Mahenga focus CDTI project v/s VAS proposal submitted by National Onchocerciasis Task Force & nutrition program

NOTF/TANZANIA MAHENGE FOCUS CDTI PROJECT V/S VAS PROPOSAL SUBMITTED BY NATIONAL ONCHOCERCIASIS TASK FORCE & NUTRITION PROGRAM PROPOSAL OUTLINE Title Linking Vitamin A Distribution to Community Directed Treatment Mahenge Focus (Kilombero and Ulanga) -Tanzania Prepared by (District and partners) Submitted to The African Program for Onchocerciasis Control (APOC) Ivermectin (CDTI) in General Objectives of Programme 1. To enhance the sustainabiliÿ of the CDTI framework by demonstiating its abiliÿ to deliver Vitamin A to children 6 - 59 months and post partum women. 2. To contribute to decreased child mortality in Kilombero and Ulanga Districts by providing Vitamin A supplements to children 6 - 59 months. 3. To lay the foundations for extending CDTI+VA to adjacent communities Specific Objectives 1. Reaching postparhrm women with VAS 2. Attain >75 yo Ivermectin Treatment 3. To reach 20% of chlldren between 6 - 59 months. 4. All of the above in a sustainable manner: Target Groups: Children 6 - 59 months, post-partum women Mahenge focus CDTI (Kilombero, Ulanga) Time Period: 3 years Estimated Budget: YEAR ONE Ulanga District Tshs 43,403,500/= Kilombero District Tshs. 4 1,209,9001: Total Tshs. 84,613,4001: Definitions Community- Directed Treatment with Ivermectin (CDTI). A strategy whereby communities are empowered to make decisions on their health including selection of the place, mode and time of distribution, and support to Ivermectin distributors. Therapeutic coverage rate Number of people treated x 100 Total population living in meso- and hlper endemic communities in the project area Geographical coverage rate Number of communities/ villages treated x 100 Total number of meso- and hlper endemic communities as identified by REMO in the project area Sustainabiliÿ CDTI activities in an area are sustainable when they continue to function effectively for the foreseeable future, with high treatment covsrage, integrated into the available health care service, with strong community ownership, using resources mobilized by the communiÿ and the government." Cost per person teated with Ivermectin ( based on amount released from APOC Trust Fund only) Annual coverage with vitamin A (VA) Number children aged 6 - 59 months who have received two doses of VA in a one year period. Total number children 6 - 59 months APC. Additional person covered cAPC. Cost per additional person covered. MAITENGE CDTI PROJECT pRoposAl, FoR THE TNTEGRATION OF VTTAMIN A SUPPLEMENTATION (VAS) AND COMMUNITY DIRECTED TREATMENT WITH IVERMECTIN (CDTT) ACTIVITTES 2005-2006 1. SITUATIONAL ANALYSIS a) Demography and population at risk i. Demographic Information ULANGA DISTRICT Is situated in the South-West of Morogoro Region, is about 312km from Morogoro Municipaliÿ and 5l2km from Dar es Salaam. It is the largest district among the six Districts of Morogoro Region. The district is bounded with Kilombero district in the North which extend to West, East. with Liwale district and South with Songea district. It covers an area of 24,560 sq.km. It is the 6û in the Nation in terms of expanse area. However 75%o of this area is protected forest and wildlife sanctuaries. The distict is divided into three agro-ecological zones, which have different physical features and weather as follows; In addition, 9 villages in the floodplain are inaccessible to vehicles for 9 months;2 villages in the mountain zone have not been reached by car for the last 12 years-motorcycles have to be carried across a perennial river. Due to its high attitude, Ulanga District enjoy a cool climate around the year with temperature ranging from 17C to 32C and two rain season between October to February and March to June. The average annual rainfall is around 1700mm. Administratively the distict is divided into 5 divisions,24 wards, 65 villages and 308 sub villages. Ulanga District has a population of about204,707 people according tothe2002 National census. KILOMBERO DISTRICT Is situated in the part of Morogoro Region, is about km from the regional headquarter and km from capital ciÿ Dar es Salaam. It's bounded with Kilosa district to the Northern side, Morogoro and Rufiji districts in the Eastern, and Njombe district in the Western and Southern part is bounded by Ulanga district. The district covers an area of 24,560 sq.km.and is an area suitable for agriculture and activities. The district generally gets rainy seasons in the year, long rains between March and June (Masika) scattered shower in August and September and short rains between October and December average annual rainfall is between mm. Has a range of Udzungwa Mountains as high as 3,500 meters with land lowland srüramps forming the Rufiji basin. The district has 38 rivers. Administratively the district is divided into 4 divisions, 24 wards, 8l villages and 360 sub villages. Kilombero District has a population of about35l,207 people according tothe2002 National census. The distict is connectedbyTazaraRailway line from Dar es Salaam crosses the district from east to west. Roadways}S2 kilometers: From Kidatu to Taweta. ii. VA information Under-five mortaliÿ rate in Kilombero district is estimated at 153 per 1000 live births and L47 per 1000 in Ulanga respectively. The major causes of childhood mortaliÿ in the district are ranked as Malaria, Pneumonia, Diarrhoea, Anaemia, Malnutrition and AR[. The population at risk of Vitamin A deficiency in both district includes children under the age of five years, pregnant and postpartum women, making a total of 296,062. This may be considered as the target population for Vitamin A supplementation to be integrated with CDTI Mass vitamin A supplementation is done twice a year, with the first dose provided around the Day of African Child around June 16ü while the second dose is provided at the end of the year around World AIDS Day in December for children 6-59 months of age. a) Vitamin A supplements through mass approach is normally done by health workers at service delivery posts in the communiÿ as well as at Front Line Health Facilities. The community is mobilized by Village health workers, village govemment and social mobilisers at community level b) The main challenges/constraints encountered during mass vitamin A supplementation include inadequate funding, delay in releasing of fund from donors and qualiÿ of coverage data. To orercôme these problems, councils/districts have always been advised to incorporate the costs of the activiÿ into comprehensive council health plans (CCHP), involving communiÿ in planning and implementation of the activity and establishment ofvillage registers. c) Through these cooperate efforts VAS coverage in both districts is generally high - 92% in Ulanga 2004 and90.8% in Kilombero2004. Challenges of VAS: Since inception, mass vitamin A supplementation faced a number of challenges, includingt Late arrival of supplies (vitamin A capsules) to district level . Inadequate funds for implementation and social mobilisation. . Delayed release of funds from donor§ . poor involvement of community leaders in activities during implementation. . Inadequate incentives/allowance to service providers iii. CDTI information CDTI activities in Mahenge Focus Project are being implemented in two districts namely Kilombero and Ulanga. The project operates in I 17 communities that are defined as hyper and meso- endemic with à total population of 428,325 people. Activities are implemented with support from other parhers which are remitting funds for CDTI. These includes the Local Gôvernment Authorities, Swiss Development Cooperation (SDC), Interchurch Medical Assistance (IMA) and African Program for Onchocerciasis Control (APOC). In the year 2004 the Project received amount of 838,000 Mectizan drugs and was at once distributed to all Central Collecting Points (Hospital, Health centers and dispensaries).- The in- charges of all Central Collecting Points in the dispensaries and Health centers have been in- powàred for closer supervision of CDTI actiüties. 301,079 people were treated in the year 2004 *h"rr by coverage for Utanga v/as 680 andKitombero wasT2Yo giving an overall coverage of TAYofor Mahenge focus. Population at risk: All people living in the endemic areas that is in hlper and messo communities. In Kilombero total population is223,618 and in Ulanga is204,707 Target population: People living in the affected areas excluding under-fives, pregnant rvomen, very sick people and lactating mothers under seven day. 1. Challenges of CDTI r Fear ofside-effects especially reproduction related . PPIV were easily missed when the distribution month has elapsed . Time is needed îor transition from project support to CDDs to total integration of CDD work into the village structures . Mobilization skiilJfor Ivermectin promotion are needed at village and district levels Possibilities of integrating VAS and CDTI There is a possibility to integrate VAS with CDTI basing on the following: . Presence of skilled CDDs to implement the two interventions , Established CDTI system in the District r Presence of equipped Oncho Zonal coordinators. . Utilization of already existing heath care system such as PHC . Presence of communities that are already implementing CDTI progarm. . Govemment leaders are already sensitized on implementation of CDTI . Vitamin A capsules and Ivermectin tablets can be easily handled and delivered to the community through established health care system Anticipated challenges of integration: -Diffrculÿ in data handling for the two interventions -availability of all the supplies (vitamin A and Ivermectin) ahead of implementation -variability in targets foirhe two interventions Jimited côoperation from the community/misconception of the purpose for interventions Benefits of delivering Ivermectin and Vitamin A together. . Time serving . Considered cost effective as the two are administered by the same service proüders at the same time. r Increased incentives to CDDs. . Accessibiliÿ for VAS to PP women who could not be reached through Reproductive and Child Health Services. . Reaching under fives who could not be reached during Child Health Days and AIDS Day. ' Increase of therapeutic coverage for CDTI Main VAS challenges that may be addressed by integration . Reaching children at hard to reach areas using CDDs ' Increasing po§t partum women VAS coverage ' Improving data qualiÿ through auditing . Establishing actual target populations through head count in comparison to projection from the last census Challenges of integration . Different period of implementing of the activities. . Abilitÿ of CDDs to carryout those activities. . Community acceptability for integration. . Refusal of CDTI implementation might refrain integration eventually reduce the coverage. r Some Villages are not covered by CDTI activities. Second dose ofVA Vitamin A supplements through mass approach is normally done by health workers at service delivery posts in the community as well as at front line health facilities. Village health workers, village government and social mobilisers at community level mobilize the communiÿ. Routine VAS to children under the age of two years and post partum women is done by the health workers at front line health facilities The main challenges/constaints encountered during mass vitamin A supplementation include inadequate funding, delay in releasing of fund from donors and qualiÿ of coverage data. To overcome these problems, councils/districts have always been adüsed to incorporate the costs of the activity into comprehensive council health plans (CCHP), involving community in planning and implementation of the activity and establishment of village registers. a) How will VA be disüibuted in non CDTI areas. In non CDTI areas, vitamin A supplementation is done at front line health facilities as well as at supplementation posts by health workers with community mobilization done by üllage and sub-village governments b) Children 6- 59 months if obtain Vit A via other mechanism what will be the impact on the coverage of Child Health week. Increased opportunities for distribution of vitamin A supplements accompanied by social mobilization will result into increased coverage VAS-CDTI INTEGRATION STRATEGIES TO ADDRESS CHALLENGES CHALLENGE CONTRIBUTING FACTORS SOLUTIONS VAS SPECIFIC Late receipt of funds National level procedures Improve disbursement timins Delay of VAS stocks from MSD National level procedures Improve Inadequate Vitamin a supplies for routine PPW suoolementation National level procedures Improve Low coverage in a number of locations Diffi cult terain/topography hinders logistics of VAS Early supply of VAS stock to district to allow reaching diflïcult areas in time Demand for early reports by national level Extend time required for reporting from current two weeks to at least 4 weeks, to receive better reports from the oerioheral HFs Misconception of purpose of VAS among some communities Increase sensitization of communities by district and villases Timely and reliable reports Lack of VAS data skill collection at FLHFs Training for FLHF workers and VHrù/s CDTI SPECIFIC Poor compliance Misconception of the drug due to misplaced beliefs Mobilization skills for Ivermectin promotion are needed at village and district levels Fear of side-effects especially reproduction related To conductmore HSAM to community members Lack ofsupport for sensitization Time is needed for transition from project support to CDDs to total intesration of CDD CHALLENGE CONTRIBUTING FACTORS SOLUTIONS work into the village structures Low coverage Mectizan supplies during rain session Timely Ivermectin available at communiÿ level Poor quality reports Inadequate resources for supervision and verification Provide support for closer supervision and scrutinv of reoorts INTEGRATION FLHFs may delay implementation and reports Unaware of integration Capacity building on new intesrated processes Fluctuations of VAS and CDTI supplies Different ordering system Ensure simultaneous orderins of suoolies Likely low community resDonse to integrated services General unawareness of intesration Dumose Sensitize community on intesration soals Preparing appropriate reports reflecting both VAS and CDTI Present lack of monitoring framework that includes both VAS and CDTI Establish a joint VAS-CDTI operations monitorins mechanism Possible workload increase for CDDs Increase of number of target population due to new VAS service Increase number of CDDs CDDs unaware of siguificance of and how to administer VAS CDD training did not include VAS administration Reorienting CDDs to significance of and how to administer VAS Different timeframes for deliverv VAS and Ivermectin Compliance to national VAS timetable Change of VAS delivery resime Ivermectin timeframe determined by community seasonal characteristics Ivermectin tablets withdrawn from district after the assigned distribution month Ivermectin tablets should be available at all FLHF throughoutthe veâr <t)(l) C)(€ E cÉ bI(l) .ÉLiIU' rt) o ()(l) ,oo() b{(l) CüL. rr) EÉ Cg 1.F(o€a oÊîJRE'Efra Eo.=6Es 5(16*rlgrÊl)u,l(-tÉloos2(oÉtFÈ E EE E .1 ËE îa .-q çQ :rZ HË E{ e.É go Ë EË E = EÉ § i a âpE: 6 3Ë xisk §ü:{i 6ËBHÉg Ë EP f g'; = UH€ 6 e? g 3ÉF§E S ?Érôi,.i ;8E §0 rlÉG)Étr EgÈ ,iâ E GI è0ÉEoÈ.!.9 >.6 .E L ÿEEIa)1l= s âg Ë zô i3 EF (l) e) 6t a â è0ÉÊl (l)éea=§tsÈE è0 E;â? aol EE'E â EEâë &o t-i U Az c,É e) o à9,E.=(l)o)É()OE 6l ÊeÉn tr] jaü ZY?u t v ^ tso E*fr E EEB âg Ë iBË E E B§ Ë Kfr]H€ AÈÊ É a r€§ EâE E È'E E âx.-^x:O É xoG:, 's E É'sàü7,' É > E.gE*E .Ê'.8 s É È §EEËË = E =s$'È't E .E.E S bEE.çE *gËE : El EE3l ,-'È E .BI EEË gl=l; a E Ë +jc >. 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N c \f ÿ, <lN iÿ, a c = §t I§l olr, D ôo(=6rrroryq§l 35 .<l 6' oÉ, =5d oôô tri oo rJ)- ooo- o co ooôd o aoJ eê(c oo 'I? o ôri |rJN ooô rrt o d oâ E ,g3 o)L E c, i5 (t) i5 =I .=IË @0 G' èoco (§ ooo() ô o o)oc(§ =o: o =^JX ILÉ LOooÈ6 o-9làë!D =elz(§ 6 co EEo o) d)É. o 1r- @oo() ct @ o,oc(§ Bo: o o .9È(, o 't) E(t) 5 o)a o q, E' E .go o, ut EF a (t) G E. ah =ocoo{ U'oo(J (n .Ec6 F §, o UJ ultlilo 'Es .E €x Eic = (E o=ôÿ-=-- sÉE3 .() ô-- Ë E EE 6o(,i E(,6 .E o o EtU' ooo roôt o(1 ooq o rai r! !r, oon DNo o trl §torl îâll t,c o o e J oo u o 0- o C o u r o ïtc E ct 'ôÉoCL$o ,ÿ, ,o, o =ar oEâ o E6 o E E (,,ê otu tttct o UJIL o ot!r c»=oÉ (, Ê,:,oC' C'E o TJ ûoc, ûo(, Ëi a,(, É oL c,oe §ltl e,oG' !t o(, tq (ÿ, o a(t\t oo(, e =G e ooo^ oo ô N o ooodo oôô§l (ÿ) .JÉo ro l! ü, ,=e = tt o o o G' GÉ, o E>o- o êoq N ooqÉ ooe o oIq N e cÉ o .E oÊ o(l)oc(! =o: oJ- =x oû(! Èoc ,9(! a uÉo E .ca o: oÉ o o) o) I I cqJ q) LL Èoo .! Èoc .9 ts a a co E ,É ctl ol oÉ. oq, (1,[- Ît clF = t-(-) o (I,a, o€o7i E"go()Èr 9t .o g-=FE9 o'= .-:.9 ë .^cE (§q, o.È EËî, .o oQ) -ËE 1r, ul C., UI eo eE.bGC oP :EEE_§EEË üJ E€E ao)() v>dJo- (r,ÊE =r ËE9l o ËSlco ol 6É .91- ËEl> s atrl J o,;I; .E ULANGA DISTRICT CDTI/ VAS PROJECT: BUDGET SUMMARY BY PARTICIPATING PARTN ERS AN D ACTVITIES NO ACTIVITY APOC IMA COUNCIL TOTAL 1 1.3 2,235,000.00 2,235,000.00 2 2.3 1,222.s00.00 L,222,500.00 3 3.1 4.180.000.00 4.180.000.00 4 3.2 4,626.000.00 4.626.000.00 5 3.3 190.000.00 190.000.00 6 3.6 620,000.00 620,000.00 7 3.7 496,000.00 496,000.00 B 3.8 2.s80.000.00 2.580.000.00 9 4.3 2s.310.000.00 1.660,000.00 26,970.000.00 10 5.1 142,000.00 142.000.00 11 5.2 142,000.00 142.000.00 TOTAL 30,125,000.00 10,028,500.00 3,250,000.00 43,403,500.00 Percentage (%) contribution by each oartner 69.41o/o 23.Llo/o 7.49o/o lOO.OOo/o llr ËEtsL ?ç6? ôÂo! êÂoI o t ? utJ m o =ô () oo (, oÉt ooct H? =r9X i)c 1- tJ oô- oo o- (, oÈ- ûo(, ooo .= o6 6 o oo c? @ 6 oo Cri q + oo <? @È i oeo o@ o 6oo c: 6 oÈ ooo- oF ooo- oo c3 - o_û ooo- oN oêô @- o -5q D o oôô o'oÉ ,55iN ooo. oDNN ooq oNN ooo- o ooo o-@F ccq o oo§! Na ooo ci ooN @-È ooq o6 ooodo ÿt eoo- oo@ eoo. oo c3oiD ooq @ o ooo cio§! oood o ooo o-cq o ooq D@@ oo§+È ooo§i oo a,i 3c?0 oe <? o € ooodô F(, É,FLo oÉ. uJo =oJ Y F u.l(9 of @ zo F É.(9 !! z F cl(, U' oço rô L N N E5 N o I@F @ @ o N N @ @ @@ @@ N N o 6 e. oq oood ood oo o ooô oo 5Ii?o- Ioo- oN ood Iooÿi ôo 6 oqô oo- oq o o@ oo@ o ea oo N oo- oN oe @ o u? oq oodN oo o ood oo co oo@ é ooo oU? oocN I 6 o ct oEq 3(p oÔCEE6;q oc €oêê) q EËiÂ1 aË 'o 6 E oE5J ô Eo E c E od iD3 ô ='6§r Éô EôL ô =6o ! oÉ ,i a c6 o ,o eo EoE I b o 'Êô o EE o od Ëo6 .g Ë6o oc 'P = eI oëo = e@ o o m 6âL Iç@ =6 =ù-ol- oo .E oê =!1, EEô CL E .!PE bô o ô i6I € o, ëtt,oo d = .E 'tt§r 'o; Eô Eo Eo € bè b ô ooc6 =6 oôôo eo Ec o oÿ. E6ôq ,E = ÉI o E6E É a § cct Ëo6 .g 65L o5 c o tt, U t l, s§ËeË: =€= E.*E g,oo €E >Goo ô.Ë>ÊE5<E .E -ooo a:Ë 'Ë6E Ë€€Ë ;EE; E(, oÈQEO1= af§BÉ,.ÉʧiE o5 1r, ul Ëou eo oE -L- -=E :B;s Ë ËEË: E ;ËE§EE ?Ë6I ?ê @è =a IDÊ6T ? T o ü o ccâ (,oo I)f oocl ooC! o=ô i,,l iJcâ oo o- r@ Ldl Iû ooÈ a. r co ! D oo @ o ooe- €o eoe ooq N eoo e@o a\Î aoq o@ eoq eoq. ooqôoo oo0- o@o ooo- o oo o- o@§ ooo o o0o- @@ oo§l @ ooF c{ Icqp aaN ooo- € ooq o aoo o_@ oêo aoo ooôdo ccôicD ooo oN e ooq o ooo- oôô o a o_oo N. ooo- o@ ooo <i Qo§i ooo <teé 5cci N ooo o N ooq0oÉ N. ooo- ooê- N oc5âD Qoo- o@ ooq ooa ooo o6 N N IoN 6@ @@ @ NÈ c o I) o oo o ôo o oôôÿ; 0co o oc @ o@ ôô E cq cN oq oq oo- o ra ao oo c0 oo on cc?c3 cq 555j c D- N oq ooq oN oqIoô- oo o_ N oooN oo- o oa oo 53- c3t_ o0 6N o@ oc? aN oo eô ='6oL oc :€ e Eôü ôo FoL co Ec o o Y, Edêq c 't = coo oo coô o 6 = @o6 Ec 'ÿ, 6 = t§6 s o =6 6 =L c§o 'at eoq E6L ooo 46 E €g 6() 6 E .!9E o TL o .E 6 I ob ,.J 6 o6o !) dr Ico ,Er Io ,E I 8c6E ! Igos ! o =6 oEoËI b i5 E5l! .E EE .E -95oÉ à &ê5 G E6o U' èFoô z' o(L "t=L 6 E6ot- U' àFo z' oo o lr E 6E .g6 Èl: =c)oF ê .E Es Oêrdé ËEÈ âELdoÊ .i9ËÉË aÉ.4 o€ c oI E al EiËqEÈ ÀcctoE o I ɧl 5sEq !aI -> oË:6=L! ts( él O ê o Éé c a tô9lz2 uo LèôÊÊt €E>!ÂT 3§ ' oÊLa9É5 ,=aÈtC,g(, 3GL0.9 ôÈL di ,! E -9Ë o 6 EËËoto.â sËêts i> o I c ê É Éô E Cr ?EtI ?o i)câ o =c! o =cl rdI r6 lr!0 êoq o ct o eN F €o oc! ot-§: o o o N F r, ooq oNq N ôôô rto ooo o oood ooô +'oN oôô o ooq @ ooo .d ooô c; ooq @ N ooq oôo oIo{È ooodN oôô o@ oooêo ooN r.: oôN- oôôd oooÉt@ §t @ @ @ o o ao o ood oq o oo o o o- oo @ o@ o oo c; oo ooe o@ ooa oo oôo o@ 0o Iooo ccc§: >[Ét(l È1ÿtl ooao (,oq o!0ç{ F uJ ia tlN Fÿt N o c6eoEon o oE 6 F =Io @ G 6 oE ôoê = b ô co E a oÉ. Ë66 .g E6e oc = E. G coo b o = @ 6L c6o 'oEoâ- o Eoô C' èFo o6oqÊ ,c = E ê E o L 5 E E oÉ. J c 6ôF at àl-o E6ê oÊ = 6ê o E oo 8 oE!LÇ c o E3 aoo @É FoF o zÿ o æ Etz =IL UIY ( ,.8 - =ËsrE= EEEe :EEg sEs*s o _'cà E€E=C Ê H,Ê ui-Ê.9 E- -.=§E oÈ e?6>àEEii_ o- otsF EÏ8-E â sQ o ËÏ;**rËi;€EEgF !r!ii:L): Ê Ëç @ oE . =E =ô o 3co ro 8.EËE>ooo KILOMBERO DISTRICT CDTI/ VAS PROJECT: BUDGET SUMMARY BY PARTICIPATING PARTNERS AND ACTVITIES NO ACTIVITY APOC IMA BASKET TOTAL 1 2.L 646.000.00 646,000.00 2 3.1 4.922.400.00 4.922.400.00 3 3.2 4.176.000.00 4.176.000.00 4 3.3 10.169.800.00 10.169.800.00 5 3.4 2.816.100.00 2.816.100.00 6 3.5 1.383.000.00 1.383.000.00 7 3.6 2,900,000.00 2,900,000.00 8 3.7 2.060.000.00 2.060.000.00 o 3.8 4.160.000.00 4.160.000.00 10 3.9 2.000.000.00 2,000,000.00 11 3.1 1.920.000.00 1.920.000.00 L2 4.L 3.291.000.00 3.291.000.00 13 5.1 387.200.00 387,200.00 L4 5.2 378,400.00 378,400.00 TOTAL 24,73O,3OO,OO 4,160,000.00 12.319.600.OO 41,209,900.00 Percentage (%) contribution by each partner 60.01olo 10.09olo 29.89o/o 100.00o/o