Cross river NOTF/WHO-APOC CDTI PRJ : technical report submitted to the management of African Program for Onchocerciasis Control: from Jan 2007 to Dec 2007

ql: ORIGINAL : English TECHNICAL REPORT SUBMITTED TO THE MANAGEMENT OF'AFRICAN PROGRAM FOR ONCHOCRCIASIS CONTROL - APOC OUAGADOUGOU, BURKINA FASO. Hz t* rt* To: Tcc% DEADLINE FOR SUBMISSION: To APOC Management by 30rH JAN for FEB TCC meeti 2 r UEI ?.|;frl I - Ao'iI t{nli",I tl. Iiq' i*.c =EJ-*.r*-i-AFRICAN PROGRAMME FORI( I( U I\ TKUUI(AIVIIVIII ,t( L'IS. I ONCHOCERCIASIS CONTROL (APOC) i COUNTRY/NOTF : NOTF NIGERIA Proiect Name:CROSS RMR NOTF/WHO-APOC CDTI PRJ. Approval yearz 1997 Launching year: 1998 Reporting Period: From: JAN 2007 Toz DEC. 2007 , (Month/Year) ( Month/Year) Proiectvearofthisreport: (circleone) I 2 3 4 5 6 7(D9 10 Date submitted: DEC. 2007 NGDO partner:UNIPTEF WHO/APOC, 24 November 2004 i/ /csi -Bi{ esb COP AH€ BFo rc , 1,1 I {, t i'iirl i PROGRBSS PROJECT TECHNICAL REPORT iri TO APOC MANAGEMENT ENDORSEMENT Please confirm you have read this report by signing in the appropriate space. OFFICERS to sign the report: Country: NIGERIA National Coordinator Name: Mrs Ogbu Pearce Signature: ..... Date: Zonal Oncho Coordinator Name: Mr. John Eluwa Signature: ..... Date: NGDO Representative Name: Mr. Saoondo Anom Signature: ..... Date: This report has been prepared by Name : Mr. Adie, Hilary Adie Designation : Coordinator Signature : Date ii WHO/APOC, 24 November 2004 a .. Table of contents ACRONYMS DEFINITIONS......... ....VI FOLLOW UP ON TCC RECOMMENDATIONS .........1 EXECUTIVE SUMMARY SECTION 1: BACKGROUND INFORMATION 1.1. GSNBRAT. rNFoRMATIoN............. .........4 1.1.1 Description of the project (briefly) .........Erreur ! Signet non diftni. 1.1.2. Partnership Erreur ! Signet non ddJini. 1.2. Popu1erroN............... .......8 SECTION 2: IMPLEMENTATION OF CDTI....... ........9 2.1. TrvrBlrNp oF ACTrvrrrES ............ .........9 2.2. Apvocecv ..................... 10 2.3. MoellzerloN, sENSITIZATIoN AND HEALTH EDUCATIoN oF AT RISK coMMUNITtps 10 2.4. CoNaNalrlrrry rNVoLVEMENT........ ......12 2.5. CRpecrrv BUTLDTNG.. ...... 13 2.6. TRreruBNTS.............. ..... 18 2.6.1. Treatmentfigures............ .....Eteur ! Signet non dilinl 2.6.2 Wat are the causes of absenteeism?.......... ................. 19 2.6.3 What are the reasons for refusals?................ ............... 20 2.6.4 Briefly describe all lcnown and verified serious adverse events (SAEs) that ... 20 2.6.5. Trend of treatment achievementfrom CDTI project inception to the curuent year22 2.7. ORoeRntc,sroRAGEANDDELIvERvoFIVERMECTIN.............. ...............22 2.8. CouvtuNtry sELF-MoNIToRING eNp StereHoLDERS MeerrNlc ............24 2.9. SuppRvrsroN............... ......................26 2.9.1. Provide aJlow chart of supervision hierarchy ... . .................26 2.9.2. What were the main issues identified during supervision? .............................. 27 2.9.3. Was a supervision checklist used? ............. 28 2.9.4. What were the outcomes at each level of CDTI implementation supervision? 28 2.9.5. Was feedback given to the person or groups supervised?................................ 292.9.6. How was the feedback used to improve the overall performance of the project? 30 SECTION 3: SUPPORT TO CDTI 3.1. EqulrrrreNr .....................30 3.2. FrNreNcrel coNTRTBUTToNS oF THE pARTNERS AND coMMuNITIES...........................3l 3.3. Orupn FoRMS oF coMMrrNrry suppoRT............... ................32 3.4. ExpeNorruRE pER ACTIVITy .............32 SECTION 4: SUSTAINABILITY OF CDTI....... ...........33 4.1. INTTRNIL; INDEIENDENT pARTICIpAToRy MoNIToRINc; Eve1uerloN.................... 33 4.1.1 Was Monitoring/evaluation carried out during the reporting period? (tick any of thefollowingwhich are applicable)............ ...........33 4,1.2. Wat were the recommendations? ............. 33 4.1.3. How have they been implemented? ............. ................. 33 4.2. SusreNeeILITy oF IRoJECTS: eLAN AND sET TARGETS (MANDAToRv AT................34 Yn 3)........ .................34 4.2.1. Planning at all relevant levels.. ..................34 4.2.2. Funds....... ............... 34 v 2 4 30 lll WHO/APOC, 24 November 2004 ,, . 4.2.3 Transport (replacement and maintenance) . . .... 35 4.2.4. Other resources.. ...- 35 4.2.5. To what extent has the plan been implemented............... ...........-... 35 4.3. INrBcRnrIoN............ ......35 4.3.1. Ivermectin delivery mechanism,t............... ................... 35 4.3.2. Training.... ..-...........36 4.3.3. Joint supervision and monitoring with other programs........... ...... 36 4.3.4. Release offunds for project octivities ........ 36 4.3.5. Is CDTI included in the PHC budget? .............. ........... 36 4.3.6. Describe other health programmes that are using the CDTI structure and how this was achieved. What have been the achievements?............. '................... 36 4.3.7. Describe others issues considered in the integration of CDTI. ..... 37 4.4. OpenerroNAl RESEARCH ...-.37 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. ........ 37 4.4.2. How were the results applied in the project?............. .................... 37 SECTION 5: STRENGTHS, WEAKNESSES, CHALLENGES, AND OPPORTUNITIES.... SECTION 6: UNIQUE FEATURES OF THE PROJECT/OTHER MATT8RS...........39 38 lv WHO/APOC, 24 November 2004 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-DirectedTreatmentwithlvermectin CSM Community Self-Monitoring EU Prime European Union Program for Strengthening Routine Immunization LGA Local Government Area MOH Ministry of Health NGDO Non-GovernmentalDevelopmentOrganization NGO Non-Govemmental Organization NIDs National Immunization Days NOTF National Onchocerciasis Task Force NPI National Program on Immunization PHC Primary health care REMO Rapid Epidemiological Mapping of Onchocerciasis SAE Severe adverse event SHM Stakeholders meeting TCC Technical Consultative Committee (APOC scientific advisory group) TOT Trainer of trainers UNICEF United Nations Children's Fund UTG Ultimate Treatment Goal WHO World Health Organization v WHO/APOC, 24 November 2004 Definitions (i) Total population: the total population living in meso/tryper-endemic communities within the project area (based on REMO and census taking). (ii) Eligible population: calculated as 84o/o of the total population in meso/hyper- endemic communities in the project area. (iii) Annual Treatment Objective: (ATO): the estimated number of persons living in meso/hyper-endemic areas that a CDTI project intends to treat with ivermectin in a given year. (iv) Ultimate Treatment Goal (UTG): calculated as the maximum number of people to be treated annually in meso/hyper endemic areas within the project area, ultimately to be reached when the project has reached full geographic coverage (normally the project should be expicted 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 mesolhyper-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 mobilised by the community and the govemment. (ix) Community self-monitoring (CSM): The process by which the community is empowered to oversee and monitor the performance of CDTI (or any community- based health intervention programme), with a view to ensuring that the programme is being executed in the way intended. It encourages the community to take full responsibility of ivermectin distribution and make appropriate modifications when necessary. vl WHO/APOC, 24 Novemb er 2004 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 24 Number of Recommend ation in the Reoorl TCC RECOMMENDATIONS ACTIONS TAKEN BY THE PROJECT FOR TCC/APOC MGT USE ONLY 111 States and LGAs should release funds - The State CDTI project reported the continuous non payment of counterpart funds in the National review Meeting, the National onchocerciasis control progrzrm in conjunction with UNICEF has written to the Commissioner for health requesting for an audience with the Govemor, this has not been done till date. Increase number of CDDs per population -The special country initiative provided an opportunity for the training of more CDDs the numbers increased from24l2 in 2006 to 4632 in2007. Encourage involvement of female CDDs -The special country initiative also provided an opportunity for the training of more female CDDs, the number of female CDDs increased from 338 in June 2007 to 568 CDDs in2007. Continue the training of new Health staff on CDTI -The special country initiative also provided an opportunity to train more health staff on CDTI the number of health staff involved in CDTI rose to 59%o of all health staff in the proiect areain2007. Explore best way of utilizing resources from various partners for CDTI activities. - Vitamin A Supplementation exercise organized by UNICEF provided an opportunity for partners supporting CDTI in the state to share experiences on ways of effective synergy and utilization of resources for overall benefit ofall concerned. Joint work plans between the oncho unit and three CBOs ( the Great Friends of Obudu, Pacesetters Klub exclusive of Calabar and Rural Development options) were made to utilize same period and resources for field activities for the different programs to reduce cost.The benefits started been felt immediately as CDTI was one of the few cost effective ways used in delivery of Vitamin A to beneficiaries. (Please add more rows if necessary) WHO/APOC, 24 November 2004 Executive Summary ln 1997, APOC approved the commencement of the Cross River State CDTI project and in 1998 implementation of CDTI commenced in five LGAs. Cunently the project is in 930 communities in all 14 onchocerciasis endemic LGAs out of the 18 LGAs in the entire State. The 8ft year was aimed at reviewing and improving on the strategies put in place to sustain the distribution of Ivermectin to all endemic communities in the project and utilization of the CDTI structures to deliver simple Primary Health Care interventions to the populace. This entails the following: continued utilization of CDTI structures for awareness creation for control of HIV/AIDS in Obanliku, Obudu and Yakurr LGAs with inputs from the Great Friends of Obudu and USAID, ensuring the release of counterpart funds by Government, empowerment of all CDTI communities in the new North 1 Project (Yala,Boki and Ogoja LGAs) to take up services of the community eye care program by Sight Savers International (SSD, ensuring practical integration of CDTI and other add on programs into the PHC system, ensuring greater collaboration and participation of local CBOs and NGOs in CDTI implementation in 2008. Following the judgment of the international court of justice at the Hague, Bakassi LGA was ceded to Cameroon in the ruling, Cross fuver State is expected to absorb and resettle the populace in Akpabuyo which is an onchocerciasis endemic LGA by August 2008. Thus, the project is preparing to train new CDDs and start treatment in the new population. Five communities in Odukpani LGA were driven away from their homes to adjouming communities due to communal clashes; 2007 Mectizanteatment was received there. The project treated a total of 880,623 persons in 918 communities from Jan. 2007 to Dec. 2007 (therapeutic coverage of 80% and geographic coverage of 99 %). The UTG fot 2007 was 920,996, the total population was 1,096,424 persons. Data training on the new MIS was done for 28 LOCTs, this was replicated during the special country initiative training for frontline health facility staff. WHO/APOC, 24 November 2004 I ,: The APOC special country initiative training grant afforded the Project to train 5,164 CDDs, 913 health workers and 1666 community supervisors on CDTI. Presently, the CDD to population ratio is l:206. The major challenges in the CR- CDTI project are: o Ensuring the continuation of counterpart funding by Government. o Collaboration with other service providers in promoting total blindness control. o Involvement of women in CDTI activities. o Treatment of people from Bakassi that will be resettled in Akpabuyo LGA. Various ways have been employed to address these challenges: o There is a memo to policy makers for the release of counterpart funds. o The unit is collaborating with the Sight Savers International, Youthcare, Catholic Diocese of Ogoja, UCTH and Tulsi Chanrai Foundation in provision of eyecare services to the populace. o The project has used the special courtry initiative to increase women participation as CDDs. o To achieve 100% geographical coverage, other service providers who are offering community services in the rugged areas where the health service is absent were used in the delivery of Mectizan, training of CDDs and retirement of drugs. o To ensure adequate therapeutic and geographical coverage, local CBOs were approached for support to ensure that basic components of CDTI like Mectizan distribution, Supervision and Mobilization are carried out even in the face of non release of counterpart funds. Mectizanwas distributed early to all communities and frontline health workers have been mobilized to ensure that they monitor communities within their catchments to ensure that they treat and retire Mectizan on time. WHO/APOC, 24 Novemb er 2004 SEGTION {: Background information 1.1. General information 1.11 Description of the project STUDY AREA Cross River State is one of the 10 States in South Eastern Nigeria Primary Health Care (PHC) zones. The State is situated within the Cross River Basin between latitude 50 32' North, and 40 27'East. Ebonyi, Abia, and Akwa lbom States bound the State in the West, in the North by Benue State. The Southern boundary is the Atlantic Ocean and it has international boundary with the Republic of Cameroon in the East. The main occupations of the people are farming, fishing and hunting. The State is situated within the tropical rainforest, one of Africa's most dense forests found on the eastern borders with the Cameroon and the secondary forest and guinea savannah in the western and northem parts of the State. The climate is tropical, however temperate climate is found in Obudu plateau where altitudes are in the region of 1,500metres above sea level. The topography is mountainous in the Cameroon border; plain fields are found in Yala and Ogoja axis. The population is 2.8 million as by the 2006 population census figures. The State has three main languages, Efik, Ejagham and Bekwarra. One major festival celebrated in the State is the new yam festival, which takes place in the rainy season. There is a good road network, which links the State with other parts of the country. The state can be accessed through land, air and water. There is a two tier administrative structure at this level. A democratically elected Governor heads the State executive council. The local Government chairmen who are also democratically elected head the local councils. The health system operates at three levels, the primary, secondary and tertiary levels, the primary level which is community based is run by the Local Government administration in conjunction with the State Ministry of Health, while the secondary level is managed by the State Ministry of Health and takes care of referrals from the primary level. WHO/APOC, 24 November 2004 ' ' The tertiary level is managed by the Federal Government and comprise of the teaching hospital in the university college where special cases are referred to for special care. There are 296 health centers and posts in the project area. Table l: Number of health staff involved in CDTI (Please add more rows if necessary) DistricULGA 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 B2 Percentage B.:Brl B, *100 AKAMKPA 129 89 690/o AKPABUYO 122 34 28% BEKWARRA 7l 55 77% BIASE 76 65 860/o BOKI 135 103 76Yo ETUNG 48 32 67% IKOM 99 44 44o/o OBANLIKU 102 56 55Yo OBUBRA 99 48 48o/o OBUDU 98 66 67% ODUKPANI 109 76 70o/o OGOJA 148 48 32% YAKURR 175 76 43% YALA 138 121 88% Total 1549 913 59% 1.1.2. Partnership The partners in the Cross River State CDTI project are: 1. The Federal Ministry of Health 2. APOC-WHO 3. State Ministry of Health 4. The LGAs 5. The communities 6. UNICEF WHO/APOC, 24 November 2004 7. Several other NGOs which include: D South Eastern Nigeria Outreach Eyecare Services (SENOES) iD Youthcare iii) Ogoja Catholic Diocese Eyecare Services iv) Opthalmology Department University of Calabar v) Cross River National Park vi) Cross River Forestry Commission vii) Tulsi Chanrai foundation viii) Cross River University of Technology (8) The CBOs who are working in partnership include: i) Great Friends Klub of Obudu ii) Pacesetters Klub Exclusive of Calabar iiD Calabar Leo Klub iv) Catholic Nurses Guild v) Beb Rural Health Development Options The State Ministry of Health provides the manpower needs for the implementation of the project, provides counterpart funding for activities and monitor overall implementation strategy and administration. The NGDO (UNICEF) partner provides part funding, logistics and expert advice for project implementation. The local NGOs and CBOs e.g the Cross River National Park and Forestry Commission are responsible for delivery of Mectizan, training of CDDs in their catchments areas. The project has up scaled activities in eye care. People from endemic areas residing in Calabar and other major towns in the State are treated with Mectizanin churches by other CBOs like the Catholic Nurses Guild, Archdiocese of Calabar, the Great Friends of Obudu, The Pacesetters Klub Exclusive of Calabar. A good number of policy makers worship in these churches and are also mobilized during such fora to support CDTI activities. WHO/APOC, 24 November 20046 {.2, Population iod chief,autonomousinbasicdecisionmaking,anumberofcommunitiesconstituteavillage. theTable l: Commun ties and lation at risk in the entire ect area whether they are treated or not 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 A, Hyper-endemic zone in the project area A' Total in meso/hyper- endemic zone ..1. --rt,* A' Meso-endemic zone in the project area ,t, Hyper- endemic zone in the project area ,d_ Total in meso/hyper- endemic zone Ar,' ,&..* Ai Ultimate treatment Goal (urc) AKAMKPA 103,122 50 43 93 43896 59,226 103,122 84,732 AKPABUYO 47,002 29 5 32 42165 4837 47.002 37,390 BEKWARRA 67.799 38 8 46 53866 13933 67.799 54,417 BIASE 83,442 30 2 32 75842 7600 83,442 67,100 BOKI 185,012 60 69 t29 94616 90,396 l8s,0l2 r47.847 ETUNG 72,318 15 t4 29 45280 27038 72,318 58,127 IKOM 98.423 9l J 94 91 3s3 7070 98,423 79,003 OBANLIKU 46,605 4t 26 67 28513 18092 46,605 37,882 OBUBRA 49.339 15 9 24 32092 17,247 49.339 39,920 OBUDU 37,933 36 J 39 29t46 8787 37,933 28.463 ODUKPANI 51,992 52 13 65 45531 6461 51.992 40,005 OGOJA 89,192 38 t8 56 37773 51,419 89,192 73.455 YAKURR 38,364 9 5 t4 20092 t8272 38,364 29,043 YALA 125.881 151 59 210 8l 159 44722 l2s.88l 101.239 TOTAL r,096.424 655 275 930 721324 375100 1.096,424 878,623 WHO/APOC, 24 November 2003 : I tmelrne of activities fbr the areas treated in the curent year (Please add more rows if nec District/LGA Mobilization of communities Distribution of drugs and collection of treatment data from treated comms. Training of frontline health workers, community supervisors and CDDs. Training of LOCTs on data entry in the new MIS forms Supervision, monitoring and collection ofdata Vitamin A suoolementetion Community self monitoring and Stakeholders meetinss Starting month Compl etion month Starting month Compl etion month Starting month Completion month Starting month Completion month Starti ng month Completio n Month Starting month Completio n Month Starting month Completio n Month AKAMKPA Feb. 2007 July 200't Jan.2007 Nov.07 Feb.2007 May2007 Feb. 2007 Feb. 2007 Apr.2 007 Nov.2007 May 2007 May2007 luly2007 Sept.2007 AKPABUYO Feb. 2007 July 2007 Jan.200'1 Nov.07 Mar.2007 May2007 Feb. 2007 Feb. 2007 Apr. 2007 Nov.2007 May 2007 May2007 July2007 Oct.2007 BEKWARRA Feb. 2007 July 2007 Jan .2007 Aug.07 Mar.2007 May2007 Feb.2007 Feb. 2007 Apr.2 007 Nov.2007 May 2007 May2007 July 2007 Oct.200'l BIASE Apr. 2007 July 2007 Jur.2007 Nov.07 Mar.2007 May2007 Mar.2007 Apr.2007 Apr. 2007 Nov.2007 May 2007 May 2001 luly2007 Oct.2007 BOKI Feb. 2007 July 2007 Jan.2007 July .07 Feb. 2007 May2007 Feb. 2007 Feb. 2007 Apr.2 007 Nov.2007 May 2007 May 2007 July 2007 Sept.2007 ETIJNG heb. 2007 July 2001 Jart.2007 Nov.07 Feb.2007 May2007 Feb. 2007 Feb.2007 Apr. 2007 Nov.2007 May 2007 May2007 July 2007 Oct.200'l IKOM Mar.200 7 July 2007 Jan.2007 Nov.07 Mar.2007 May2007 Mar 2007 4pr.2007 Apr.2 007 Nov 2007 May 2007 May 2007 July 2007 Oct.2007 OBANLIKU May 2007 July 2007 Jan.200'7 Nov.07 Mar.2007 May2007 Feb. 2007 Feb. 2007 Apr. 2007 Nov.2007 May 2007 May 2007 Jtly2007 Sept.2007 OBUBRA May 2007 July 2007 latl..2007 Nov.07 Feb. 2007 May 2007 Feb 2007 Feb. 2007 Apr.2 007 Nov.2007 May 2007 May 2001 July 2007 Sept.2007 OBIJDU May 2007 July 2007 lur 2007 Nov.07 Mar2007 May 2007 Feb. 2007 Feb. 2007 Apr. 2007 Nov.2007 May 2007 May 2007 July 2007 Oct.2007 ODUKPANI May 2007 July 2007 lut.2007 Nov.07 4pr.2007 May2007 Mar.2007 4pr.2007 Apr.2 007 Nov.2007 May 2007 May2007 July 2007 Oct.2007 OGOJA May 2007 July 2007 Jan.2007 Nov.07 Mu.2007 May2007 Feb. 2007 Feb. 2007 Apr. 2007 Nov.2007 May 2007 May2007 luly 2007 Sept.2007 YAKURR May 200't July 2007 Jan .2007 Nov.07 Feb. 2007 May 2007 Feb. 2007 Feb. 2007 Apr2 007 Nov.2007 May 2007 May2007 luly 2007 Sept.2007 YALA May 2007 July 2007 Jan.2007 Nov.07 Mar.2007 May 2007 Mar. 2007 Apr.2007 Apr. 2007 Nov.2007 May 2007 May2007 July 2007 Oct.2007 SEGTION 2r lmplementation of GDTI 2.1. Timeline of activities Table 3 Ti i o Treatmenttook11monthsbecausethecommunitiesdecidedontheperiodtotreatandsomedoitinthedryseasonwhentheiaim WHO/APOC, 24 Novemb er 2004 2.2. Advocacy 12 Directors in the State Ministry of Health, The Commissioner for Local Government, the Provost and4management staff of the college of health technology were paid advocacy visits to acquaint them with the Cross River CDTI project and solicit for support, the College of Health Technology was approached to provide a lecture period for staff from the oncho unit to lecture the community health extension workers in training on CDTI Implementation strategy. Television and Radio programs were organizedinthe State Broadcasting service to mobilize policy makers and the general populace on CDTI, Primary eye care services and Vitamin A supplementation. The constraint faced now in mobilization which is beyond the control of the team is the high turn over of policy makers in the Local Govemment system thereby requiring remobilization of new set of policy makers, this is time and fund consuming. The National Onchocerciasis control program office should write a well worded letter to the commissioner for Local; Government reminding him of the standing order put in place by the former administration to deduct N200,000 per year from each endemic LGA for CDTI implementation. State the number ofpolrcy/decision makers mobrhzed at each relevant level during the current year; the reason(s) for undertaking the advocacy and the outcome. Describe dfficulties/constrarnts beingfaced and suggestions on how to tmprove advocacy. 2.3. Mobilization, sensitization and health education of at risk communities Mobilization of the communities was carried out in areas where treatment compliance and therapeutic coverage is still a problem. Communities with record of clashes during elections were mobilized early to enable them get treatment before the elections started. Mobilization of communities in the remaining LGAs was done according to need as diagnosed from the monitoring exercise. LOCTs carried out intensified mobilization and Health Educatiorr of endemic communities on the need for them to continue treatment even when the symptoms of the disease may have subsided. The addition of vitamin A distribution, 10 WHO/APOC, 24 November 2003 I I' HIV/AIDS awareness creation and eyecare as responsibility of CDDs were also highlighted in the health education messages. -Communities have responded positively to the health education messages, given the topography of the State, the Radio and Television station are not received in the entire state thus, mobilization is carried out in churches and market places to target the populace. The problem of high non indigene communities in Akpabuyo, Akamkpa, Biase and Odukpani LGAs has brought about low treatment compliance as observed by the recently concluded compliance study in the State, these minorities were mobilized in their group meetings and asked to select their CDDs for training during the special country initiative training, CDDs from these minority non indigene groups. Women were also specially targeted in their group meetings, though the progress is slow, there is an increase in women participation in CDTI, e.g, number of communities with female CDDs increased fromTYo in2006 to 29 Yo in2007 -The project has accomplished a lot through the health education messages; treatment compliance is good and awareness on Mectizan treatment is high in the target communities due to effective health education dissemination. - Community mobilization is the pivot for successful CDTI implementation, APOC should continue to provide minimal funds for targeted mobilization of problematic communities to ensure treatment compliance. Various methods (Radio, TV, town announcers, posters and handbills) should be employed to ensure that all communities are mobilized; and funds will be required to ensure that all the various means are employed to ensure that communities are mobilized. A proposal for stakeholders meetings for minorities in the communities with low treatment compliance found from the recent compliance study is been sent for approval by APOC. 11 WHO/APOC, 24 November 2004 DistricULGA Number of communities/villages with community members as suPervisors Number of CDDs and the communities involved Number of communities /villages with female CDDs Total no. communities in the entire project area B, Number with community members as supervisors B. Percentage Be= BJ B, *1OO Male CDDs B, Female CDDs B" Total B"= B,+B" Number of communities with female CDDs Brn Percentage Brr= B,,/Br*100 AKAMKPA 93 93 100% 4t3 27 440 23 25 AKPABUYO 32 32 r00% 268 11 279 1l 34 BEKWARRA 46 46 100% 3r9 9 328 9 20 BIASE 32 32 t00% t72 23 195 t9 59 BOKI r29 r29 t00% 572 46 618 34 26 ETI-ING 29 29 r00% 308 9 317 7 24 IKOM 94 94 t00% 236 242 810 87 93 OBANLIKU 67 67 100% 155 l2 167 t2 l8 OBUBRA 39 39 t00% 361 11 372 9 23 OBUDU 65 65 100% 4t4 29 443 27 42 ODUKPANI 24 24 t00% t62 t3 175 13 54 OGOJA 56 56 100% 227 29 256 25 45 YAKURR t4 t4 100% 336 t4 350 6 43 YALA 2r0 2t0 100% 351 63 414 46 22 Total 930 930 100,/, 4626 538 5164 328 35 . '' , 2.4. GommuniQl involvement Table 4: Communities participation in the CDTI (Please add more rows if necessary) Female attendance at meetings and health education sessions is improving, but still poor, time is needed to build confidence of the community members to elicit the participation expected from the female gender. Communities are still being constantly reminded about the importance of female participation in community activities. All forms of discriminatory practices that hinder female participation in community activities are being tackled with community members during mobilization sessions. The mobilizationhas yielded dividends, gradually; more women are seen to be involved than when the program started. 12 WHO/APOC, 24 Novembet 2004 Communities have devised various methods of rewarding the CDDs ranging from farming for them to contributing yams for them, CDDs have received tremendous support during elections as part of the dividends for their work as CDDs, this has encouraged other CDDs. The NPI program is also gradually allowing CDDs to be used as local guides during NIDs to afford them the opportunity to be paid. The methods for reward are stabilizing and are part of the community routine having done that for the past nine years. CDD attrition is still a problem, various methods are still employed to address the problem, a the health service and communities have brainstorm on the problem and review criteria for selection of CDDs, the resolutions which include preference for retired teachers as priority where they are available to women and the discouragement of using young school leavers who are seeking for jobs were suggestions on stemming CDD attrition rate. Commenl on: - Atlendance offemale members of the community at health educalrcn meetings - In general, how do you rate the participation offemale members of the community meetings when CDTI rsrues are bemg drscusses (attendance, participation in the discassion etc). - lncentives provided by commurulrcsfor the CDDs - Atlntrcn of CDDs. Is attrition a problemfor the project? IJyes, how is it addressedz - Other issues 2.5. GapaciQl building There is adequate manpower at the State and LGA levels but personnel are not always available for CDTI activities. They are rather engaged in other ventures, thinking more of the financial benefits than the work. Communities are being mobilized to select more CDDs for training to meet a ratio of 2CDDs:100. There is an agreement reached with the Local Government Service Commission concerning posting of staff involved in CDTI activities. That district officers should be posted from one CDTI area to another CDTI area. Where the health service cannot reach, efforts are being made to involve other service providers in the area, e.g the forest rangers in the Cross River National Park and Forestry commission in Obanliku, Boki and Akamkpa LGAs. In some l3 WHO/APOC, 24 November 2004 other LGAs, teachers have also been trained to provide support manpower for data processing by the CDDs and CSM implementation. - Descnbe the adequacy oJavailable lonwledgeable manpower at all levels. - llthere frequent trawfers of trained slaff occur, state what the prolect is doing, or intends to do, to remedy the situatron. Qhe most i*portalt iisue to deslribeis *hat measures were taken to ensure adequate CDTI implementatron where not enough knowledgeable ^inpor"r rot ovailable or d staflareJrequently transferred during the course of the camparyn). t4 WHO/APOC, 24 November 2004 Table 5: Training at the different levels of CDTI implementation (Please add more rows if necessary) District/LGA Number of DistrictsllGAs staff trained Number of Health center/post staff trained Number of other trainers of trainees ( TOTs) Number of CDDs trained AtrO {'r New {,-, Relr (" Total (lz+ { s ATrO (.s New Co ReIr Total l'*-- (:4+ L.C: ATrO Oq New Co ReIr Total()n- Cro. {lr ATrO ()rs New {tq ReIr (;s Total 1'.*;'(.s+ 1'r^ AKAMKPA l3 l3 l3 129 109 109 l3 l3 13 1880 285 155 440 AKPABUYO ll ll ll 122 42 42 ll ll 1l 920 175 104 279 BEKWARRA l0 l0 l0 7l 57 57 l0 l0 l0 1340 206 122 328 BIASE t2 t2 t2 76 69 69 t2 t2 t2 1620 87 108 195 BOKI 15 l5 l5 135 103 103 l5 l5 l5 3420 128 490 618 ETUNG 9 9 9 48 32 32 9 9 9 1380 246 7l 317 IKOM 9 9 9 99 152 152 9 9 9 1900 706 104 810 OBANLIKU l0 l0 l0 102 57 57 l0 l0 l0 920 6s 102 167 OBUBRA 9 9 9 98 68 68 9 9 9 940 236 136 372 OBUDU l0 l0 l0 109 78 78 l0 l0 l0 720 320 123 443 ODUKPANI t4 t4 t4 99 52 52 t4 t4 t4 960 7l 104 175 OGOJA t2 t2 t2 148 48 48 t2 t2 t2 r680 136 120 256 YAKURR 10 l0 l0 t'75 78 78 10 l0 10 640 245 105 350 YALA 20 20 20 138 121 121 20 20 20 3300 128 286 414 TOTAL 164 164 164 1549 1066 1 066 r64 164 164 21.620 3,034 2130 5164 7o Achievement 1000h 60.,h l00o/o 24 o 'New', 'Refr' , If detail not available, provide the coruesponding total only. Make sure thcrt there is no double counting. t6 WHO/APOC, 24 November 2003 lja Table 6: Type of training undertaken (Iick the boxes where specific training was carried out during the reporting period) Trainees Type of training CDDs Other Community members e.g Community supervisors Health Workers (frontline health facilities) SOCTs, MOH staff or Other Political Leaders Others(speciff) CBOs Program management How to conduct Health education Management ofSAEs CSM SHM Data collection Data analysis Report writins Computer trainins Strategies for control of HIV/AIDS Identification of simple eye defects and screening for cataract. - Any other comments t7 WHO/APOC, 24 November 2003 2.6. Treatments 7A: Treatment and SAEs by district/LcA in all areas at risk JAN - DEC. 2007 (Please add more rows District ILGA Communit esA/illages Population Numberof persons who refused the treatment Number of absentees Number ofSAEs Number of serious adverse events (SAEs) referred to the health post/hospit al Total # of communiti eV villages in the meso/hyper -endemic zlreaN 52t Annual Treatment Objective {lz Number of communiti es/villages treated 7): Geographic al coverage va l,7t $;i lttx't()ll Total population of the meso/hyper- endemic arezts I)s Annual Treatment Objective I)" Number of persons treated l)t Therapeu tic coverage (%) [V* LV/ Lr,J t{til AKAMKPA 93 93 90 97 r03.122 96,622 84,732 82 ll 339 AKPABUYO 32 32 3l 97 47,002 39,481 35,390 75 39 288 BEI(A/ARRA 46 46 46 100 67,799 56,951 54,417 80 44 122 BIASE 32 32 32 100 83.442 70,091 67,100 80 53 931 BOKI 129 129 129 100 185,012 155,410 147,847 80 104 332 ETUNG 29 29 29 100 72,318 60,747 58,127 80 32 3222 IKOM 94 94 94 100 98,423 82,675 79,003 80 83 922 OBANLIKU 67 67 67 100 46,605 39.148 37,882 8l 5 344 OBUBRA 24 24 24 100 49,339 41,444 39,920 8l 38 912 OBUDU 39 39 39 100 37.933 3 1,863 30,463 80 2 399 ODUKPANI 65 65 60 92 51,992 43,614 40,005 77 6 766 OGOJA 56 56 56 100 89,192 74.921 73,455 82 233 458 YAKURR 14 t4 t4 100 38,364 32,225 31.043 8l 22 673 YALA 210 210 207 99 125.881 105,740 101.239 80 1029 822 TOTAL 930 930 918 99,} r.096.424 920.996 880,623 80Vo t70t 10,530 Clinic Base 18,533 650lo therapeutic coverage or the coverage rate is state the reasons and the@eographicalcoverageandaminimumof65o/otherapeuticcoverageorthecoverage remedy this. l8 WHO/APOC, 24 November 2004' belng maoe rc Formula for computing therapeutic and eeographical coverages Therapeutic coverage rate Number of people treated x 100(%) Total population living in meso/hyper-endemic communities within the project area Geographical coverage rate : Number of communities/villages treated x 100(%) Total number of meso/hyper-endemic communities as identified by REMO in the project area ATO coverage rate : Number of people treated x 100(%) Annual Treatment Objective %UTG achieved : Number of people treated x 100 Total number of people to be treated in meso/tryper-endemic areas within the project area (UTG) ATO = The estimaled number of people living in meso/hyper-endemic arcas that a CDTI project intends to treal with ivermectin in a given year. UTG = The maximam number of people to be treated in meso/hyper-endemic areas within the project area, ultimately lo be reached when lhe project has reached full geographical coverage (normally the project should be eryected to reach the UTG at the end ofthe td year ofthe project). 2.6.2 What are the causes of absenteeism? The causes identified in the past are still recurring; two main reasons for absenteeism have been identified in Cross River State: a. The movement of young people to western Nigeria to work in cocoa farms in the rainy season after they have been enumerated. b. The high non indigent nature of communities in the southern senatorial district of the State. The young people that travel to western Nigeria for jobs usually come home during December for Christmas when treatment and follow up has been concluded for the year. Most of them report of having been treated in the western States where they work. Communities have been mobilizedto exclude them during census taking to reduce the huge number of absentees. t9 WHO/APOC, 24 November 2004 The problem of non indigent communities in the southern part of the State is beyond the scope of the project because migration from other states cannot be stopped and this poses a great problem in terms of community participation and mobilization' 2.6.3 What are the reasons for refusals? The communities where refusals are still many are corlmunities where there were severe adverse reactions in the beginning of treatment, the numbers are reducing now, there ate l70l refusals for 2007 as against 2,365 in2006,8121 in 2005 and 10713 persons in2004. However, mobilization is still being carried out in these communities. 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 started treatment 9 years ago, atthis period of the project life, SAEs are not common again since there is no expansion to any new area. . In case the project did not have any cases of serious adverse events (SAE) during this reporting period, please tick in the box. No SAE case to reported 20 WHO/APOC, 24 November 2004 SA{* Age Sex Village of origin Date Mectizarr was taken Date lt' symptom s appeared Symptoms Health status before taking Mectizan Date of admission in health facility Date of dismissal from health facility Results of tests (thick blood smear) Outcome of prognosis Extenuating or complicating circumstances Alcohol involveme nt or not Table 8: Cases of serious adverse events (SAEs) that occurred during the reporting period (Please add more rows if necessary) * Serial number of the patient 2l WHO/APOC, 24 November 2004 2.6.5. Trend of treatment achievement from CDTI project inception to the current year Table 9: Treatments and coverage by calendar year for the entire project area. (Pleaseftll in the required data) Please indicate the UTG for the project area: (use this figure as the denominator in all UTG coverage calculations.) YE AR Communities/Villages Population Total # of communitie s/villages in the meso/hyper -endemic areas Iir Annual Treatme nt Objectiv e II: Numbe rof commu nities/v illages treated I ) Geogr aphical covera ge (%) Slr I,:.j llr" 100 ATO cover age (%) Ils r,t/ Ur* I(} 0 Total population ofthe meso/hype r-endemic afeas r;, Annual Treatment Objective Ii" Number ofpersons treated [-r Therap eutic coverag e(n ilo- ll{,1 l:n*I 0o ATO covera ge(n ftu i..rl t:,* I 0t! UTG Cover age (%) r997 719 719 694 97 97 495374 393782 255862 52 65 6t% l 998 803 803 775 97 97 60s693 498842 420640 69 84 83% 1999 99s 995 854 86 86 734717 617409 475788 65 77 77% 2000 934 934 877 94 94 917724 700000 631016 69 90 82o/o 2001 934 934 852 9t 9r 924084 700000 649010 70 93 84% 2002 932 932 923 99 99 902544 750000 700695 78 93 92% 2003 930 930 893 96 96 93095 I 782000 732941 79 94 94Yo 2004 930 930 858 92 92 1,000,642 820,526 723.694 72 88 88% 2005 930 930 930 100 100 1,008,897 847,469 764.573 75 90 90% 2006 930 930 902 97 97 1,040,759 866,354 803,103 77 93 93% 2007 930 930 918 99 99 1,096,424 920,996 880,623 80 96 96% 2008 2.7. Orderingr storage and delivery of ivermectin Mectizan@ ordered/applied for by - (please underline the appropriate answer) MOH tr WHOtr UNICEtrE** NGDO Other (please specify): NGDO tr n Mectizan@ delivered by - Qtlease tick the appropriate answer) MOH E** WHO N UNICEF N Other (please specify) : Please describe how Mectizan@ ls ordered and how it gets to the communities NOCP orders the total drug requirement for the whole country; LINICEF facilitates clearing of the drugs from the ports and storage in the central stores in Lagos. The State Ministry of Health authorities collect the State consignment from Lagos and the drugs are stored in the 22 WHO/APOC, 24 November 2004 .( Onchocerciasis control unit stores in Calabar. The LGA councils sponsor the collection of the drugs from the central store in Calabar. At the LGA level, the drugs are stored in the LGA central drug store. The drugs are distributed to the health districts in the LGAs. The communities around the districts come to the District headquarters' to collect the drugs for the end users. Table 10A: Mectizan@ Inventory 2007(Please add more rows if necessary) - How are the remaining ivermectin tablets collected and where are they kept? All remaining tablets are collected from the communities by the Local Government oncho. Coordinators.The drugs are stored in the Local Government Drugs store if the expiry dates are still within safe limits or returned to the State Oncho unit if the drugs will expire soon. - List and briefly describe the activities under ivermectin delivery that are being carried out by health care personnel in the project area. State/District/LGA Number of Mectizan- tablets Requested Received Used Lost Waste Expired AKAMKPA 226,000 226,000 225,r47 2t 22 0 AKPABUYO 95,000 95,000 94,987 6 11 0 BEKWARRA 150,000 150,000 149,000 26 J 0 BIASE 140,000 140,000 139,655 9 7 0 BOKI 280,000 280,000 279,985 t1 4 0 ETUNG 160,000 160,000 156,349 19 ll 0 IKOM 160,000 160,000 159,788 33 4 0 OBANLIKU 90,000 90,000 89,783 2l J 0 OBUBRA 120,000 120,000 1r9,894 J 7 0 OBUDU 90,000 90,000 89,882 7 5 0 ODUKPANI 90,000 90,000 89,093 44 10 0 OGOJA 190,000 190,000 190,000 J aJ 0 YAKURR 90,000 90,000 89,854 28 4 0 YALA 260,000 260,000 259,499 8 J 0 Clinic base 50,411 50,411 50,411 TOTAL 2,lgl,4ll 2,lglr4ll 2,193,327 239 97 0 23 WHO/APOC,24 November2}}4 ,, Health personnel collect Mectizan from the State onchocerciasis control unit and ensure that the drugs get to all centers agreed by community members.Community members are intimated on the availability of the drugs and requested to send a representative to collect the drugs. Inventory of the drugs collected and usage is kept by the health personnel. Training of CDDs on dosing, filling of data forms and community self monitoring are all done by the health personnel. 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? Training of health personnel and community self monitors took place in all LGAs with UNICEF support rn2007. Table 11: Community self-monitoring and Stakeholders Meeting (Add rows if needed) Describe how the results of the community self- monitoring and stakeholders meetings have affected project implementation or how they would be utilized during the next treatment cycle. District/ LGA Total # of communities/villages in the entire project area No of Communities that carried out self monitoring (CSM) No of Communities that conducted stakeholders meeting (sHM) AKAMKPA AKPABUYO 93 32 20 20 20 20 BEKWARRA 32 20 20 BIASE 46 20 20 BOKI 129 20 20 ETI-ING 29 20 20 IKOM 94 20 20 OBANLIKU 67 20 20 ODUKPANI 65 20 20 OBUBRA 24 20 20 OBUDU 39 20 20 OGOJA 50 20 20 YAKURR t4 20 20 YALA 210 20 20 TOTAL 930 280 280 24 WHO/APOC, 24 November 2004 Communities have designed various methods of ensuring that everybody gets treatment every year through the CSM/SHM mechanisms e.g, in Edomi community, Yakurr LGA, community members have resolved that since onchocerciasis is a community disease and requires everybody to be treated before the disease can be controlled. Community members must show a card from a CDD showing that such a member has received Mectizan for the current treatment round before being allowed to go to farm. Monitors are stationed on the farm roads to enforce this. In Busi communities, the week of peace, aweek set aside for rest after harvest has been agreed upon as treatment period for the Busi communities to ensure good coverage. CDD incentives have also been tackled during stakeholders meetings, communities have devised various ways of ensuring that treatment is given to the people every year. CDDs have been rewarded by employment opportunities in the Local Government Councils, as Representatives as ward councilors for their communities and as civil defense corps. Communities have used fora created by stakeholders meetings to indict primary health workers who are not doing their jobs, since community self monitoring has indicators for monitoring health workers too and this has made health workers to wake up to their responsibilities. Stakeholders meetings have provided fora for communities to discuss on health and development activities generally. In Assiga, the stakeholders forum was used to discuss on the completion of their bridge project after all about Mectizan had been exhausted in the agenda for the day. The meetings have fostered unity amongst communities, providing a forum for resolution of conflicts and making it possible for two communities that were not at peace to talk to each other. 25 WHO/APOC, 24 November 2004 ,t 2.9 Superwision 2.9.1. Provide a flow chart of supervision hierarchy. SUPERVISION HIERACHY IN CR.CDTI PROJECT Community-Directed Treatment with Ivermectin (Community Leader(s) Village Heahh Committee, C ommunitv memhers. C D Ds) Zonal Onchocerciasis Control Team (ZC, consultants, & stafJ) State Onchocerciasis Control Team (State Coordinator, SOCT, Dir. PHC, PHC Coordinator) Local Government Onchocerciasis Control Team (LOCTs Leader, LOCT, PHC Coord., Heslth Supervisor, District Sapervisor) 26 WHO/APOC, 24 November 2004 ry@ I , ,1 2.9.2. What were the main issues identified during supervision? Routine supervisory visits are duties of the LOCTs and FLHFs at this stage of the project life but where very serious issues concerning the overall CDTI implementation were detected, the SOCTs with the LOCTs intervened to curb the problems. Such supervisory visits identified the following: The issues identified during this monitoring are of interest to the Primary Health Department in general. The supervisory checklist used had indicators on Immunization coverage, vaccine storage, reproductive health, HIV/AIDS, primary eyecare, essential drugs supply, dianhoael diseases, food and nutrition, environmental sanitation. The report of the monitoring exercise has been shared with the Director of Primary Health care and program managers of the various programs monitored. For CDTI, the following indicators were monitored in the field: INTEGRATION: In 100 Yo of the health centers / posts visited, there was a roster showing schedule for home visits by health facility staff. Only 63%o of the staff complies to the schedule. In some health facilities, some of the staff was not present. Health staff present had basic knowledge of onchocerciasis and their role as primary health workers in the onchocerciasis control program. MECTIZAN DELIYERY: Mectizan was in all communities visited. The monitoring provided opportunity to deliver Mectizan to communities that were not given Mectizan to quickly treat for the year. INCENTIVES TO CDDs: Some CDDs get material incentives ranging from money to food stuff. Others were rewarded in kind- appreciation by the community elders but the CDDs are willing to continue to help their communities. 27 WHO/APOC, 24 November 2004 RECORD KEEPING: There is an improvement in record keeping over last year. The training offered by the special country initiative for CDDs and the data management training for LOCTs provided opportunity for personnel in CDTI to be trained especially on the new reporting forms. TRAINING: All CDDs interviewed knew the key elements of CDTI implementation, dosing criteria and compilation of reporting forms. However, some CDDs still have problems with the new reporting forms. SUSTAINABILITY: The key strength of the Cross River Project is the communities who have expressed their willingness to continue to ensure the success of the project and add on simple health interventions that will improve their health. LOGISTICS: Some LOCTs have been allocated motorcycles from other PHC programs, the latest batch of motorcycles supplied by APOC were given in 2000. Most of the motorcycles supplied by APOC have broken down and this has hampered the smooth implementation of CDTI. 2.9.3. Was a supervision checklist used? Yes, an integrated PHC supervisory checklist that was developed by the unit was used and trip authorizations also contained other salient issues that were not reflected in the checklist but came up and were pertinent to be checked and they were addressed. 2.9.4. What were the outcomes at each level of CDTI implementation supervision? COMMUNITY LEVEL: CDDs were present in all the communities visited in Akamkpa LGAs, the camps in Oban district are small in Population, have one CDD each, apart from Aningeje where 3 CDDs are new,l2out of the 15 CDDs are old and have been distributing Mectizan since 1998. Mectizan was inadequate in Camp 3 and Njikoka. There was no Mectizan available in Okoyong Usang Abasi,. 28 WHO/APOC, 24 November 2004 Treatment was completed for Usung Esuk, Odukpani, New Netim and Odunyama. Treatment is ongoing in other communities; a CDD in Ikang was refused Mectizan for distributing by the Health Service, he owns a chemist shop and being a border town could sell the drug. In Ikom LGA, except for Nkim community where treatment is ongoing, all other communities visited had completed treatment for 2007.The communities in the Northern and Central part of the State are the strength of the project and are providing personnel for Mectizan, distribution and motivating them. All issues discovered during the monitoring were addressed, drugs were given where treatment had not commenced or drugs were inadequate. HEALTH FACILITY LEYEL: The performance of the health facility staff is still a far cry from the expected, at some of the health facilities; staff does not take their job seriously. Record keeping still needs improvement and more training and regular motivation to ensure adequate implementation of CDTI. The report of the monitoring was shared with the Director disease control, in a recent meeting with the Governor of the State, the issue of poor performance of frontline health workers was to be addressed in the next year budget, where increased pay for all FLHFs was proposed to stimulate FLHFs to stay in their places of work. DISTRICT AND LGA LEVEL: The staff at this level is committed to their duties, they have been assigned other portfolios of duties in Primary Health Care apart from CDTI, given some minimal motivation and logistics, and they can ensure smooth implementation of CDTI. 2.9.5. Was feedback given to the person or groups superuised? The monitoring team had a member of the LOCT in each of the LGAs visited to ensure that he got first hand information as respondents were giving their answers during questioning. 29 WHO/APOC, 24 November 2004 : a" 2.g.G. How was the feedback used to improve the overall performance of the project? The LOCT members were in the monitoring team and saw for themselves the gaps in the field; the lapses that needed immediate attention were addressed, Mectizan was carried along during monitoring, all communities that had no drugs or drugs were in short supply were given drugs, problems with data entry and general CDTI implementation were addressed with on the spot corrections and trainings for both community members and FLHFs. SEGTION 3: Support to GDTI 3.'1. Equipment Table 12: Status of equipment (Please add more rows if necessary) *C*dition 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? Government provides minimal funds for the maintenance of logistics. However, outright replacement of the logistics will be difficult because there are no concrete plans on ground to replace the existing ones. APOC has approved an additional vehicle in the 8ft year. The project is still awaiting the purchase of the vehicle. Source Type of equipment APOC MOH DISTRICT/ LGA NGDO Others Eu PRIME SSI No. Condition No. Condition No Condition No. Condition No. Condition 1. Vehicle I CNFR I CNFR 2. Motor cycle(s) t9 ll F, 6CNFR, 2WO 5 5F 3. Computer(s) 3 2F, ICNFR 4. Printer(s) J 3WO I IF 5. Photocopier (s) I IF 6. Fax Machine(s) I 1F 7. Others a) Generator I ICNFR b)Television I IF c)outboard engines 2 2F 30 WHO/APOC, 24 November 2004 t", 3.2. Financial contributions of the partners and communities 1$ = N126.50 N.B. 513,000 was amount released for vit. A supplementation in June and Dec.2007 by UNICEF' - If there are problems with release of counterpart funds, how were they addressed? Counterpart funds for 2006 were approved by the Governor but release of the funds is a problem till date, neither approval nor release has been made for 2007. The Ministry in its Middle sector health plan has made a strong case for payment of counterpart funds and the Governor promised that he was going to change the donor driven status of most PHC Programs through prompt release of counterpart funds from 2008. Additional comments The long distance of the signatory designated by UNICEF the NGDO partner for the WHO- APOC account is of great concern. Several hours are spent on the road to travel to Enugu from Calabar for approval ofproposals and signing ofcheques. The process ofapproval and signing is not delayed but the distance and time waste is still a problem. Financial contributions al for the last three Contributor Year 6 (JULY 2004 TO JUNE 2OO5) Year 7 (JULY 2005 TO JUNE 2006) Year 8 (Jan 2007 TO Dec 2007) TOTAL Budgeted russ) TOTAL Released rus$) TOTAL Budgeted (US$) TOTAL Released ruSS) TOTAL Budgeted (US$) TOTAL Released rus$) Ministry of Health (MOH) 10,869 2,560 23,715.4r 877.47s 23,715.41 2,453.36 Local NGDO(s) ( if any) NGDO partner(s)-UNICEF 12,260.86 20,083 District/LGA 20,289 870 Others a) Sight Savers In'tl 2,426.87 b)Cross River National Park 30s.67 c)Youth Care d)Great Friends of Obudu 1,069,76 142.290 142.29 Communities 1,868.00 4,743.00 4,743.00 APOC Trust Fund 27,684 27,684 7,704.00 3,850.00 I 5,150.98 15,150.98 TOTAL 5E,842 31,114 31,419.41 10,397.77 57,293.15 42,572.63 31 WHO/APOC, 24 November 2004 a,'' 3.3. Other forms of community support - Describe (indicate forms of in-kind contributions of communities if any) Communities in Yakurr (Assiga communities) have actually given land to CDDs to cultivate cassava as a form of incentive to motivate them to work. There are also a good number of communities who are giving yams to their CDDs after harvest. Other communities have excluded CDDs from communal work and levies. 3.4. Expenditure per activity - Indicate in table 14, the amount expended during the reporting period for each activity listed. Write the amount expended in US dollars using the current United Nations exchange rate to local currency. Indicate exchange rate used here-N126.50:1USD Table 14: Indicate how much the project spent for each activity listed below during the reporting period - lny comments or explanations? $13,988.f4 WAS FIINDS RELEASED BY UNICEF FOR VIT. A SUPPLEMENTATION IN JUNE AND DEC.2OO7 Activitv Expenditure ($ US) Source(s) of fundine Drug delivery from NOTF HQ area to central collection point of community Special country initiative for production of IEC materials, mobilization of communities and training of personnel in CDTI 317.54 13,470.35 9or4.MOH APOC Maintenance of *vehicles_- Training of LOCTs on new data reporting format 23s.82 i,ozs.g9 -- Govt. MOH APOC Vitamin A supplementation to under 5s and Post Partum Mothers 13,988.14 UNICEF Additional funds for CDD and village health committee training 2,118.58 I-INICEF Purchase of office stationery and ink Release of funds fot fu.ling of venicfes to coite.t tupitul iGms - from Lagos. t42.29 Great Friends 900 MOH Monitoring and supervision of CDTI 822.13 UNICEF Organization of community self monitoring and stakeholders meetings 3162 I..INICEF TOTAL 35,832.74 Total number of persons treated 758,758 32 WHO/APOC, 24 November 2004 l, 11 . SEGTION 4: Sustainability of GDTI 4.1. lnternal; independent participatory monitoring; Evaluation 4.1,1 Was Monitoring/evaluation carried out during the reporting period? (tick any of the following which are applicable) DONE IN YR 2000 Year I Participatory Independent monitoring DONE IN YR 2002 Mid Term Sustainability Evaluation DONE IN YR 2003_5 year Sustainability Evaluation LAST DONE IN YR 2005 Internal Monitoring by NOTF DONE IN YR 2005 Other Evaluation by other partners 4.1.2. What were the recommendations? The following were recommendations of the evaluation team that came to monitor the progress of implementation of sustainability' plans in2005, the activities of the project since then have been geared towards implementing the recommendations. o That the implementation of CDTI which made reasonable progress in 2003 and2004 became badly stalled in 2005 due to a dranatic reduction in funds released for the operations of the CDTI project by local partners, State, Local Government and NGDO partner (UNICEF). o That report keeping and data generated at all levels was poor. o That there was extensive turn over of staff and officials in the CDTI project. 4.1.3. How have they been implemented? o The report of the evaluation made the State Government to approve the sum of Three million Naira for activities at the LGAs, this funds have not been released till date, the project has resorted to other service providers to "piggy back" on them to ensure that activities are carried out, The Cross River University of Technology provided a forum for monitoring, the Great Friends of Obudu provided the funds for some office stationery. o Record keeping has improved at all levels with training of personnel on data management during the special country initiative and data training for LOCTs. )J WHO/APOC, 24 November 2004 r f , . The staff that are in the project now are stable; there has been training of new staff to replace the ones that left. 4.2. Sustainability of proiects: plan and set targets (mandatory at Yr 3) Was the project evaluated during the reporting period? NO Was a sustainability plan written?-YEs , IN 2003 When was the sustainability plan submitted? 2003 What arrangements have been made to sustain CDTI after APOC funding ceases in terms of? 4.2.1. Planning at all relevant levels There is joint planning for all PHC programs and an integrated monitoring checklist comprising of key indicators for PHC programs is in use in the project now. This is aimed at reducing cost of monitoring and ensuring that there is sustainability in terms of monitoring and supervision of PHC activities since any program with funds to be in the field can monitor all aspects of PHC with the integrated checklist. Joint planning on utilization of vehicles, motorcycles and other resources has been discussed in recent PHC forum in the State to encorrage sustained and reduced running cost in PHC programs. 4.2.2. Funds Resources have been got either directly or indirectly from local NGOs and CBOs, A list showing areas of collaboration where Local NGOs and CBOs can help indirectly without providing physical funds have been made and circulated. Trainings and supervision in the National Park and Cross River Forestry Commission operational area are done by the forest rangers. The Cross River broadcasting corporation is willing to air jingles at subsidized rates to mobilize the populace. There are budget line items specifically for CDTI activities at the LGA and State levels and there is a standing order by Government on contribution into an account of the sum of 200,000 Naira by all the 14 endemic LGAs in the State for CDTI activities though that has not 34 WHO/APOC, 24 November 2004 1* riII been implemented since 2005. There is need to mobilize the in coming policy makers to sustain it. 4.2.3 Transport (replacement and maintenance) APOC approved a new vehicle for the project in the current year. The vehicle is being awaited. Outright replacement of the logistics will be difficult because there are no concrete plans on ground to replace the existing ones by Government. Government has being providing minimal funds for the maintenance of existing vehicles. 4.2.4. Other resources Local CBOs have been mobilized to provide or fund some activities for the project. The Great Friends Klub of Obudu produced community mectizan retirement forms for the LGAs of Obudu and Obanliku. Training and the pilot implementation of awareness creation on HIV/AIDs control using the CDTI structures was solely funded by a local NGO, the Great Friends of Obudu. 4.2.5. To what extent has the plan been implemented The implementation of the plans are on track, there are few adjustment resulting from shortfall of funds but other sources have been used to augment funds and the project is achieving and hopes to continue achieving integration, add on of new simple health initiatives and above all ensnre at least 65%otherapeutic coverage and 100% geographical coverage for Mectizan treatment. 4.3. lntegration Outline the extent of integration of CDTI into the PHC structure and the plans for complete integration: 4.3.1. Ivermectindeliverymechanisms Plans have been made with the PHC directors of all the 14 LGAs on the need to seize the opportunity of collection of supplies for routine immunization in the first part of every 35 WHO/APOC, 24 Novemb er 2004 t. ' ;'' year to collect their Mectizafi) so Mectizan drug requirements for the following year are got by December, for proper requisition' 4.3.2. Training There is integration in training, during the reporting period, some trainings undertaken were done using fora provided by Sight Savers Eyecare Program or the HIV/AIDS awareness training by the Great Friends of Obudu. SOCTs also attended various joint training sessions organized by the Primary Health Care and Disease control Department. 4.3.3. Joint supervision and monitoring with other programs There is in place an integrated monitoring checklist which is being used for monitoring in pHC. This checklist contains supervisory indices for all components of PHC. This is to help joint supervision at the State, LGA and Community levels. 4.3.4. Release of funds for project activities The funds for onchocerciasis control have not been released since 2005. 4.3.5. Is CDTI included in the PHC budget? The current strategic frame work for Cross River State has Onchocerciasis as a component in the PHC/DC department and provisions have been made for 2006 to 2018. There is also a standing order that was put in place by the former regime that N200,000 be released into an account for onchocerciasis control activities. 4,3.6. Describe other health programmes that are using the CDTI structure and how this was achieved. what have been the achievements? Over 1,200 Cataractsurgeries have been conducted by the Tulsi Chanrai Foundation and Sight Savers international eyecare services. Community members were mobilized and screened by CDDs. The Project has used CDTI structures for distribution of Vitamin A to under 5s and post partum mothers in 18 LGAs.ll9,l74 post partum mothers and 36 WHO/APOC, 24 November 2004 \r 368,980 under 5 year children were supplemented in June 2007, currently, Dec. supplementation is ongoing. 4.3.7. Describe others issues considered in the integration of CDTI. The CDTI structure in Cross River State has integrated the following, vitamin A supplementation, Primary eyecare services, and currently awareness creation for HIV/AIDS IN 3 LGAs. A pilot on usage of the CDTI approach to enshrine a model PHC structure like the one in South Sudan and Tulsi Chaffai are being considered. Here, the community is responsible for the choice of the community health worker, payment of the fees of the community health worker in a college of health technology. After the training, the health worker returns to the community to offer basic health services to community members. Communities will be encouraged to assist CDDs achieve more training to be of greater help to them. 4.4. Operational research 4.4.1. Summarize in not more than one half of a page the operational research undertaken in the project area within the reporting period. There was an operational research by APOC consultants on Mectizan treatment compliance study during the period, the research was to document all factors responsible for poor treatment compliance and proffer recommendations to improve the process. 4.4.2. How were the results applied in the project? The study revealed that there was low treatment compliance in Akpabuyo LGA, this LGA has the same demographic characteristics as Odukpani, Akamkpa and Biase LGAs, the report of the study identified the high non indigene nature of the area. A proposal to hold stakeholders meetings with the minority ethnic groups is being proposed, an operational research proposal will also be submified by the project in 37 WHO/APOC, 24 November 2004 '. i f, conjunction with a social scientist to find the underlying causes and proffer solutions to the problems causing poor treatment compliance. SEGTION 5: Strengths, weaknesses, challenges, and opportunities SEGTION 5: Strengths, weaknesses and challenges STRENGHTS: o Commitment of some implementers at all levels . tJtilization of opportunities provided by other organization to implement CDTI activities. . Commitment of local CBOs and other organization in collaborating with the Onchocerciasis control unit. o Addition of programs that are of high premium to community members e.g the skills acquisition training for youths, Community eyecare program. o Good working relationship between the project and the NGDO partner UNICEF. WEAKNESSES o Inability of PHC structures to support CDTI activities due to inadequate manpower and absence of heatth facilities in some remote areas of Akamkpa and Obanliku LGAs. o Inadequate community participation due to Leadership and Communal clashes and distortion in population leading to poor planning. o Inadequate community participation due to weak community structures in the heterogeneous area ofthe southern senatorial area ofthe state. o Non release of approved funds from Government has stalled the plans for implementation of activities during the period. CHALLENGES AND HOW THEY WERE ADDRESSED. . To achieve lO0% geographical coverage, other service providers who are offering community services in the rugged areas where the health service is 38 WHO/APOC, 24 November 2004 rl. \otrt r absent were used in the delivery of Mectizan, training of CDDs and retirement of drugs. o To ensure adequate therapeutic and geographical coverage, local CBOs were approached for support to ensure that these basic components of CDTI like Mectizan distribution, Supervision and Mobilization. o In the southern senatorial area where stranger elements abound have had low indices in community participation generally, efforts were made to improve participation by using other organizational units like the churches to mobilize them. - List the strengths and weaknesses of CDTI implementation process - List the challenges and indicate how they were addressed. sEcTtoN 6: matters Unique features of the proiecUother The networking of local community based organizations has been of tremendous help in the face of non release of counterpart funds by Government. Identification and utilization of the services of other organizations offering community services have saved funds. 39 WHO/APOC, 24 November 2004