Aerial survey of the flow of the rivers in Tamale sector: 17th and 18th May 1977

,l Bf rl/oz REVIEW OF THE, ONCHO CONTROL PROGRAMME IN THE FOREST ARE,AS OF GHANA . r\_ rll- c-Y Ol ,.i tt { (A Review with emphasis on lvermectin Distribution) DR. YAW ABOAGYE-ATTA (PU B LI C H EALTH C O NS U LTANT) ACCRA SEPT., to OCT., 1998 Il IJ J t \' 2. 3. 4. CONTENTS 1 INTRODUCTION/BACKGROUND TERMS OF REFERENCE EXECUTIVE SUMMARY RECOMMENDATIONS 5. FORMAT FOR REGIONAL REPORTS (D WESTERN REGION (II) ASHANTI REGION (III) EASTERN REGION (IV) CENTRAL REGION 6. INTERVIEW WITH NGOS INTERVIEW WITH DR. MARIAN HAGAN INTERVIEW WITH DR. KOFI AHMED, ONCHO DIRECTORATE, MOH INTERVIEW WITH THE EXECUTIVE DIRECTOR, NATIONAL ONCHO SECRETARIAT 9, ANNEXES Coverage of ivermectin and IEC in Forest Areas Ashanti Region identified Oncho Communities and Volunteers identified for Trainng Eastem Region identified Oncho Communities Addendum Itinerary Review of Literature l1 J 5 6 8 11 t2 36 51 63 77 81 8l 81 83 83 PAGES 83 85 86 88 9l 94 7 8 9 l. ll iii. iv. vi. ACKNOWLEDGEMENTS 2 INTRODUCTION EVALUATION OF IVERMECTIN DISTRIBUTION AND ONCHO IEC ACTIVITIES IN T/ft, AR, ER & CR The Onchocerciasis Control Programme (OCP) which was started in 1974 in Ghana alongside other 6 countries in West Africa, today covers 1l countries including Ghana. In Ghana, the original OCP areas cover the 3 Northern Regions including some parts of the Brong Ahafo Region. Before the start of the programme, the oncho disease was found to be most severe in the Northern parts of the country, referred to as the Savannah areas where the whole population was at risk of getting the disease , 1006 of the population was infected with the disease and about 10,000 people were found to be blind as a result onchocerciasis. As a result, the initial efforts by the OCP, International Donor Agencies and Countries were concentrated in these areas where the disease was most debilitating. After over 20 years of successful vector control and the use of Chemotherapy to treat the populations, oncho has been controlled in the original OCP areas. However, research had revealed that there was onchocerciasis in the Forest Areas of Southern Ghana but which was not as blinding as was the case of the Savannah oncho which eventually rendered its victims blind. The same family of the oncho vector was found in the Southem forest areas breeding in similar conditions as in the North. Due to the thick Forests along the major rivers and streams in these areas, vector control using helicopters and f,rxed winged air crafts was not possible as was done in the north to break the cycle of transmission of the disease, and as a result, treatment of all the oncho communities using ivermectin has been highly recommended as the most feasible alternative strategy in controlling onchocerciasis in these areas for over 10 years. As mentioned earlier, the Oncho Control Programme activities have been going on for over 20 years now in Ghana, concurrently with the other 10 West African Countries, and today the Donors say after successfully breaking the cycle of transmission of the disease in addition to the production and free supply of ivermectin to all OCP countries for as long as they will need it, they (Donors) consider that the time has now come for the oncho beneficiary countries to take over the activities of OCP and integrate them into the Public Health delivery system to be financed and managed by the Health Services in close collaboration with NGOs and the affected communities. Under the new approach to managing onchocerciasis, the oncho communities are expected to nominate a volunteer who will register all the community members with the help of the community members and give out ivermectin to eligible ones to take once every year. Record keeping is considered very essential in this programme to ensure effective coverage and accountability for the tablets given out to every community. This will J also help the Health Workers in monitoring the activities of the community volunteers in order to address refusals and side effects which may occur. The new partnership, it is hoped, will empower the communities to get involved in managing their Health needs and open up a constant and fruitful relationship with the Health Workers for the general welfare of everybody in order to make the vision of Health for all a reality in Ghana. 4 TERMS OF REFERENCE DR. Y. ABOAGYE ATTA PUBLIC HEALTH CONSULTANT AIRPORT RESID, AREA ACCRA REQUEST FOR A CONSULTANT TO REVIEW THE ONCHO CONTROL PROGRAMME The distribution of ivermectin has gone on for the past 3-4 years in some of the forest areas of the country using varied number of approaches. The Ministry has identified you as an external consultant to review this aspect of the programme. This is to be completed and report submitted by the end of October 1998. The findings would be incorporated into the country's report for the 19th JPC meeting that will be held from 11-17 December 1998 in Accra. Your terms of reference would be: 1. To review and evaluate the ivermectin distribution in Westem Region supported by SSI Eastern Region in Suhum and Kyebi districts Central in the Twifo Praso district, by TOPP and in Winneba district. Some districts in Ashanti. 2. To prepare a detailed report and make a presentation to the Ministry. A vehicle with a driver and a technician will be provided and you will have thirty-one days to complete the assignment. Yours sincerely, DR. E.N. MENSAH AG. DIRECTOR OF MEDICAL SERVICES FoT: THE MINISTER OF HEALTH Copies: FC, Dir., Oncho Control a. b. c. d. l l .l I l 5 EXECUTIVE SUMMARY The Evaluation of the coverage of ivermectin distribution and IEC activities in the Forest Zones of the Country covered 4 Regions and 56 Districts. The Regions are Western Ashanti Eastern and Central WESTERN REGION The Western Region has 11 Districts and 59 Sub-Districts. SSI is supporting the Region to distribute ivermectin in all the Districts. About 471 Communities have Community Volunteers who are doing ivermectin distribution in 11 Districts. Information, Education and Communication (IEC) activities sponsored by Helen Keller International (HKI) have taken place in 5 Districts. Furthermore, SSI has approved funds for the production of some IEC material for the Region. In the Region, there are other NGOs such as the Red Cross, Protected Areas Development Programme (PADP) and World Vision International (WVI) who have all indicated their willingness to help control Oncho. At all the levels visited, there are Community Volunteers who are working closely with the Health workers. By virtr,re of the intervention of SSI through the MOH, awareness about the Oncho Programme is very high. ASHANTI REGION Ashanti Region has 18 Districts which are Sub-divided into 91 Sub-Districts. Out of the 18 Districts, only 6 Districts had ivermectin distributed in them mainly through OCPAIOS without the direct involvement of the Regional and District Health Authorities. In terms of Oncho IEC, only 4 Districts have been covered by the HKI programme which has now prepared the grounds for ivermectin distribution using Community Volunteers with the full participation of the Regional, District and Sub-District Level Health Authorities. NGO participation in the past to control oncho has not been very visible. Presently an Italian NGO called MAC has conducted some oncho research in the Offinso District to enable it draw up a plan of assistance to control oncho in the District. 6 "1 I I ,i' I The Regional Level Authorities have admitted that in the past they have not been involved in Oncho Control but now with the integration of all health service activities, oncho has been prominently featured in the action plan. EASTERN REGION The Eastern Region has 15 Districts and 84 Sub-Districts. Oncho Control in the Region has in the past been done in some Districts by OCPA{OS. Also, the Suhum Kraboa-Coaltar District has got Volunteers established in it by an NGO called African Poverty Eradication Commission (APEC) since 1996. Lions Club also distributed some ivermectin in the same District in the past. The Regional Level authorities have stated that all the Districts have now been earmarked for ivermectin distribution and IEC activities to take place. CENTRAL REGION The Central Region has 12 District and 50 Sub-Districts. Records on ivermectin distributed in the Region was mainly undertaken by OCPA\iOS with minimum involvement of the Health Authorities. The Twifo Hemang Lower Denkyira District played a pioneering role in ivermectin distribution. It has Community Volunteers established in all the Sub-districts with the help of the Medical Offrcer in charge of Twifo Oil Palm Plantation (TOPP) clinc where oncho was first diagnosed in the laboratory. The Catholic Hospital at Assin Fosu District has been receiving ivermectin from France to do passive treatment. WVI which is in the District has indicated its readiness to support oncho activities. Plans have been put in place to extend ivermectin distribution and IEC activities to all the Districts in the Region using Community Volunteers. I 1 I I I I 7 'i { I I 2 3. RECOMMENDATIONS IVERMECTIN t:gl-"qti!:Ip_gty-!p,beeg inadequate, irregular and untimely to the needed Communities. Efforts should thereforti be made to streamline its suppty pieferabiy to coincide with the dry seasons for wider coverage. IEC IEC materials produced by the Ministry of Health with the support of HKI should be made available to the Health Workers and Community Volunteers for wider and regular Health Education to reduce refusals due to side effects. RECORDS KEEPING It is recommended that all records kept by the volunteers should be done according to households. In addition, the calculation of Yo coverage should be arrived at using the TorAL POPULATION of the community ai rhe general denominator in order to produce similar statistics. 4. DATA 1 I I l community volunteers should be encouraged, through regular supervision, to accurately record the population of their Communities in order to make it possible to determine the ivermectin requirements of the communities based on the number of those who meet the criteria to take ivermectin. 5. ACCESSIBILITY Communities in inaccessible areas should be encouraged to nominate distributors from among themselves to improve on the coverage of distribution. 6. TRANSPORTATION Transport should be provided to the Sub-District Level Staff to enable them adequately supervise the Community Volunteers. 7. INCENTIVES The communities should be educated to provide incentives of some sort to their distributors. Their economic situation may make it difficult for them toprovide any meaningful assistance and Assemblymen and NGOs have a role to play in this direction. J l 8 I _l l -i { I ! I l l J 8. TRAINING Regular training should be instituted for the Volunteers and the District/Sub- District Level Health Workers. Incentives for the Volunteers could be distributed to them at these meetings to encourage full participation. The Regions should be encouraged to seek support from NGos to train Community Volunteers in ivermectin distribution. 9. COST SHARING Communities should be consulted to determine how the Community Directed Treatment with Ivermectin (CDTI) programme can be sustained through contributions for purchasing record books, pens etc. rO. MONITORING Regional/District Level Health Workers should visit some selected volunteers on rotational basis as this helps to boost the moral of Volunteers to increase the confidence of the Community Members in them. II. I.D. CARDS Identity Cards could be given to the Volunteers for easy identification to help increase the confidence of the people in them. This should be in areas where a distributor has to cover a number of communities. 12. WORK PLANS As far as possible, Regions should prepare their co-ordinated District WORK PLANS for Onchocerciasis Control with budgetary provisions included in the Regional Budget before any activity, including GDTI is embarked upon. This will make future evaluation of programmes easier and meaningful. 9 -1 fi! .I "l I I t -r I , I REGIONAL REPORTS I '-l l0 t I I 1. 2. J. 4. 5. 6. 7. 8. FORMAT FOR REGIONAL REPORTS Introduction Role of NGOs Districts/Sub-Districts visited Communities visited Observations Conclusions Recommendations Tables: i). Persons Contacted ii). Ivermectin & IEC Evaluation Communities Covered I I l ll l l l I l l -l a 1 t -t 1 - -l WESTERN REGION 12 IWESTERNI REGION INTRODUCTION The team to review oncho IEC activities and Ivermectin distribution in the Western Region was led by Dr. Yaw Aboagye-Atta, a Public Health consultant and assisted by Oscar Kanwille, an Economist, of the National Onchocerciasis Secretariat (NOS), started the field work on the 2819198 on arrival at Sekondi from Accra at about 9.3Oam. At Sekondi, the Team was joined by Richard Amissah, Technical Officer, attached to the Disease Control Unit and who at the inception of Oncho Control in the Region was assigned to play a Focal role in the coordination of all oncho activities in the Region. During the meeting, the Western Region was described as the Wettest Region in the country and drained by the most important rivers in the country such as the Tano, Pra, Ankobra and Bia to mention a few. The undulating topography therefore makes the rivers and streams to flow swiftly with rapids and water falls creating the conditions suitable for the oncho fly to breed. Earlier surveys conducted in most of the rural areas have shown that communities closer to the coast and even along the coast have onchocerciasis through nodule assessment. Since 1992193, activities aimed at controlling oncho have been carried out in the Region largely through the support of SSI and Blue Peter of the UK. In 1998, Helen Keller International (HKI) provided the Region with IEC materials in support of Health Education activities in 5 districts to cover 24 sub-Districts where oncho endemicity is considered to be relatively high. The Red Cross Society and the Protected Areas Development Programme (PADP) are also working in the Region. During consultations at the Regional level, it became evident that Oncho Control activities have been fully integrated into the Public Health Care delivery System since all the 11 (eleven) districts in the region have oncho programmes and budgets prepared and in operation this year (1998). Last year (1997) a total of 632 communities in the Region have been covered, treating a total of 210,307 people. (The Region has an estimated population of 1.3 million). After the brief,rng session the Evaluation Team informed the meeting that it is expected to cover 8 districts and 16 or more communities in the Region to be able to give a global picture of the situation on the ground. Richard Amissah from the Regional Health Directorate accompanied the Team on its visits in the Region. I 1 1 J :l l l I) J l l3 -t '"1 '-I 1 I --r I -) I I ROLE OF NGOS IN IVERMECTIN DISTRIBUTION AND IEC ACTIVITIES IN WESTERN REGION. Non-Governmental Organisations are playing very meaningful and sustainable roles in Health care delivery in the Western Region by working closely with the Regional, District, Sub-District and community level Health Volunteers. The NGOs who are presently working in the Region are: 1. Sight Savers International (SSI) and Blue Peter of the U.K. 2. World Vision International (WVI) 3. Protected Areas Development Programme (PADP). 4. Helen Keller International (HKI). 5. Red Cross. Sight Savers International (SSI) is collaborating with the Regional Directorate of HgiontocontrolonchothroughCommunityDirected Treatment with Ivermectin (CDTI) since 1993. The support given by SSI is in the following areas: i) Transport (4 wheel drive vehicle and motorbikes). The vehicle supports drug distribution from the Region to Districts, data collection, monitoring and community level distribution back-ups. The motorbikes are for liaison activities in the Districts, Sub-Districts and for community level support to the oncho volunteers. ii) Ivermectin Supply: SSI through its National Coordinating office of the Eye Care Secretariat in Accra, ensures the adequate and timely supply of ivermectin to the Region for use in the oncho endemic communities. iii) Fundine: Funds are provided for ivermectin distribution activities throughout the Region as a Supplement to Government funding. ir) IEC Materials: Information, Education and Communication materials produced last year by Helen Keller International (HKI) have been reproduced by SSI to support intensive IEC activities in the Region prior to ivermectin distribution within the communities. Research: A pilot research of I year was funded by SSI in the Wassa West District in 1996 to review Community Directed treatment with ivermectin for replication in the other Districts in the Region. ,SrSI I v) 14 ) II I I I 1 J l J J vi) Trainins: Training and refresher courses for District and Sub-District level staff are a regular component of SSI activities to improve the quality of Health Service delivery to the communities. vii) Computer: A complete set of data processing and storage equipment has been installed at Tarkwa for Ivermectin monitoring purposes. ,WI Wqrld Vision International (WVI) used to operate from the Regional capital until a r6eni poliw-y crrangb shifted the focus of development assistanci to ,p"rifi. districts in any Region in order to maximise its limited resources to achieve the highest possible impact within the rural communities. This policy shift is in consonance with the District Assembly concept of stimulating change at the community level through grass-roots participation. Thus, in March 1998, the Western Regional Office of WVI relocated fully into the Ahanta West District to work with the Assembly. The sectors of intervention include i) Health: Assist MOH in the district to carry out its programmes of disease control, immunisation etc. ii) Education: WVI is supporting basic education through infrastructure development and improvement, the provision of equipment and teaching aids in addition to playing an advocacy role for parents to send the girl child to school. iii) Agriculture: This progralnme offers support to plantation outgrowers to improve upon the production capacities. ir) Women In Development: Women in the district are identified by their various speciality domains and given financial and technical assistance to improve their business management techniques to increase their productive returns. Palm Oil processing is one major industry which is being supported to grow. v) Transport: The Regional Directorate of Health Service and the District Health Management Teams have been supported with 4-wheel Drive vehicles to help in their outreach services to the communities. HKI Helen Keller International (HKI), through the National Oncho Secretariat (1.{OS) and the Ministry of Health (MOH) is supporting oncho IEC activities throughout the country working through the Regional Directorates of Health Services. The Western Region has received financial and material support (Flyers, posters, flip charts and video drama on oncho) for Oncho information campaigns in 5 (five) I I l l5 II "1 I I I selected oncho endemic communities. Further assistance is anticipated to cover the remaining 6 (six) districts of the Region. PADP The Protected Alea*..pgy-e-lopr_nent Programme (PADP), Western Region, is developing Miinagement Plans fdAnkLssa and Bia conservation areas, biologicatly two of the most important high forest areas remaining in Ghana. This will enhance biological diversity in the areas and so significantly contribute to sustainable development of Ghana's natural resources and the conservation of biodiversity for the benefit of future generations. The objective of PADP is to produce management plans for Ankassa and Bia Protected Areas that will ensure their biological integrity and address the conflicts of interest that arise as a result of competitive land use. Firstly the Plan is to ensure the conservation of biodiversity and secondly the plan will try to meet the development aspirations of the people who are dependent on the off-reserve areas surrounding the protected areas. The PADP is a three year planning phase with limited intervention envisaged. Implementation will take place as part of the second phase. Before the implementation phase can begin, certain structures must be set in place within the Wildlife Department and the District Assembles and amongst local communities and other associated institutions which are concerned with natural resource management. A round table meeting was organised in Takoradi (2117/98) which brought together the major agencies involved in Onchocerciasis Control Programme to investigate ways in which PADP can assist these agencies in the programme areas. PADP's collaboration in the Oncho Control Activities in the Region will be in the following areas; PADP's demographic surveys will help provide a list of community Distributors in the project area and to fix the location of the settlements with a GPS. PADPs liaison with MOH in the region will be the Regional Disease Control Officer (RDCO) on all matters concerning onchocerciasis. PADPs in socio-economic surveys will include a list of simple questions concerning Ivermectin. The number and type of questions will be decided by the MOH. The completed questionnaire from the field will be returned to the Regional Disease Control Unit (DCU). PADP will fund cross border liaison activities on Oncho Control with Cote d'Ivoire with the view to establishing links with the authorities carrying out similar work to open up avenues for possible future cooperation. I J I l I J l i l6 "t I I I PADP is exploring ways in which an ongoing mapping and GIS could be of use to the MOH in its project area. PADP, in order to effectively involve the communities, is trying to use the Traditional Authority to define the community whereas the OCP definition is broader. PADP demographic surveys in the project area has shown a large number of newly arrived migrants in the area who have not had any contact with formal or informal programmes including the current community system of ivermectin distribution. PADP and MOH are exploring ways in which health progralnmes could reach these communities. PADP envisages a workshop on onchocerciasis to explore ways in which community mobilisation and demographic recording system being set up by the project can assist the various parties involved in Onchocerciasis Control. This should show the way forward for possible mobilisation of funds to support the oncho programme. RED CROSS The Red Cross is highly present in the Western Region operating mostly in the communities where it has established Red Cross Volunteers who are also used for other Health Services delivery liaison activities. The Red Cross Volunteers are mostly trained to give First Aid emergency help whilst patients are being transported to the nearest Health facilities. By virtue of their intervention, most community members understand why they should be involved in managing their own health care needs. I J IJ .l J _i J t7 '1 sI -l DISTRICTS AND SUB.DISTRICTS The Western Region has l1 districts and 59 sub-districts. The team visited 8 districts and 12 sub-districts in the Region. Ivermectin distribution supported by SSI is going on in all the districts and the sub districts. IEC activities supported by HKI was undertaken in only 5 districts. The remaining 6 districts and 24 out of the 59 sub- districts are hopefully going to receive support from SSI and HKI in the near future. The District Assemblies, working in close partnership with the DHMT and NGOs operating within the Districts is a very healthy sign since the District action plans reflect the activities of all these partners to avoid duplication of action. In this regard, all the funding has been pooled together for maximum effect. The District Chief Executives, the Assembly members are all aware of oncho activities in their respective districts and evidence of support given to oncho prograrnmes is manifested in the allocation of substantial resources to the DHMTs who have in their action plans, clearly shown specific actions involving oncho alongside the other diseases to be controlled in the Districts. Some of the problems faced at the District levels in terms of disease control including onchocerciasis are: Inadequate staffing levels to be able to offer effective supervision of the sub-districts and the communities. The categories of staff include Doctors and Technical Officers. Lack of transport for sub-district level operations. Inadequate/lack of sufficient IEC materials. Lack of dearly defined and compatible formats for reporting on ivermectin distribution. Sources of drinking water where the oncho fly also breeds is polluted by industrial activities from the Rubber Estates (Ahanta West District). Refusals due to reactions which are mostly experienced by infected persons. Health Education can help to reverse the situation. Some of the communities in the Districts are very inaccessible due to the absence ofroads etc. I --l -l I \ - \ In some of the Districts, Church houses are used for IEC campaigns after church services. Also fees ranging from /50.00 to /500.00/person are charged for sustaining the programme and the volunteers. t8 I t -l t ICOMMUNITIES VISITED The review visit in the 12 sub-districts of the Region took the team to 20 communities located at distances ranging from 3km to 59km from the sub-district capitals. The team interacted with the Chiefs, Elders and Assemblymen in these communities who showed a high level of awareness as far as oncho control was concerned. They confirmed that they have been extensively consulted by the Health Workers in the District/Sub-Districts about oncho as a disease, the cause and its treatment. They are also aware of the side effects which they acknowledge as positive sign of the efficacy of the medicine. The community members also admitted that they selected their own Community Distributors who have volunteered to take care of the medicine and distribute it to all the community members. They also agreed that record keeping was a necessary tool to help ascertain whether the medicine has reached all the eligible community members. The modes of distribution frequently used were through "gong-gong" beating to assemble all the community members at a central location for the medicine and also by going from house to house to give it to those who happen not to be available when the "gong-gong" was beaten. Records are kept by the volunteers in all the communities. In most of them, the records were kept on household basis whilst in a few other cases, the records listed out names on first come first serve basis. The Distributors were however informed that the former record keeping plan was preferred because one could easily cross- check whether all the household members were covered during the annual excercise' On the whole, the communities have fully accepted the programme even though there are some reactions. The people are also willing to take the medicine and participate in future ivermectin distribution programmes. The people interviewed including chiefs, elders and unit committee members all attest to the fact that the medicine is effective since their health has improved through improved vision and reduction in the bodily pains formerly experienced which affected farrn work. The communities are also aware of the roles played by NGOs such as SSI, WVI and the Red Cross in helping them to get good health care delivery through financial, matterial and technical suPPort. The community volunteers on their part requested for moderate incentives in the form of boots, bicycles, T-shirts, Caps and badges. In some areas, some asked for financial remuneration. Some of the major problems that the volunteers encountered were the refusals due to side effects which they say can easily be overcome through intensive IEC campaigns. Again, the volunteers complained about the long distances that they have to cover through very difficult terrain to reach the neighbouring communities. I I l l l J t9 ) t I1 I l - .l I On the whole, one can conclude that the communities are fully involved in the programme, the Health Workers visit them from time to time to carryout health iducation. Even though there are still shortcomings in the records kept by the volunteers, this makes improvement very easy since they are aware that is the only way to keep track of what is going on to ensure a 100% coverage of the eligible population in their communities. They however appealed that the supply/distribution should not coincide with the farming season. The visit was also an opportunity for some of the communities to discuss their health needs such as: Spinal pain down to their waists suspected to be CSM. Children suffering from sore throat and pains. Frequent deaths of children in some communities.(Ahanta West District). Community members having blood in their urine. Polluted water in the streams/rivers as a result of mining or plantation activities which could be the sources of some of their ailments. Dr. Yaw Aboagye-Atta also seized the opportunity to advise strongly against self- medication whatever the circumstance, and that they should first report all cases to the Health Workers for assistance. He then touched on the self-help and mutual help concept which is the only viable alternative to self sufficiency. He concluded that if the communities are able to provide themselves with Community Clinics, the District Assemblies will readily take any person nominated by them to be trained as a full Health Worker who will return to stay and take care of all their daily health needs. 20 I I i I J I l I I OBSERVATIONS 1. Some communities are not yet covered due to low endemic rates 2. During meetings with community members, some leopard skins on the feet of some community members was observed. Some community members who are very close to the water ways complained about the black fly nuisance from bites. 4. The main problems recounted by the volunteers include: a) refusals due to severe reactions, in some cases people had to be admitted at the hospitals for treatment. inadequate IEC materials which are very useful tools in oncho campaigns, especially HKI Video Drama. b) 5 c) lack of means of transport for Health Workers and Volunteers. d) volunteers asking for incentives to motivate them There is no WORK PLAN for Oncho Control Activities including Budgetary provision in the Regional Health Budget. This will make future evaluation of the programme difficult. I J I l J I I i I CONCLUSIONS 2t i I I il {"1 -1 a "q I CONCLUSIONS There is a very high sense of awareness about onchocerciasis, its causation, the vector and availability of treatment at all the levels thanks to the annual awareness progralnmes carried out by the Health Personnel. Previous activity of oncho control goes back to 1993 at the Districts and within the Communities with the active support of SSI. The number of cycles of ivermectin treatment varies from community to another depending on the level of oncho endemicity and ranges from 3 to 5 cycles. The mode of ivermectin distribution employed in the Western Region is through active community involvement i.e. Community Directed Treatment with Ivermectin. 5. There are 5 (five) NGOs which are supporting ivermectin and IEC activities in the Region and the most active ones are SSI, WVI, PADP, Red Cross and HKI. 6 The general attitude of the communities to ivermectin treatment is very positive because despite the side effects from ivermectin, the majority of the community members are willing to participate in future programmes to help control the disease. 7 The above mentioned is a reflection of the total participation and acceptance of the programme by the Traditional Authority and other groups including local NGOs and within the communities visited as a result of the annual Health Education sessions given by the Health Workers. Ivermectin procurement for use at the community levels is based on registered eligible population submitted to the Regional level through the Sub-Districts and districts. Even though the adequacy of the drug depends on the needs of the various communities, the baseline data cannot always be said to be fairly accurate. The timely delivery of the drugs to all the levels from the Region is constrained by poor logistic support. Community distributors were selected by the communities themselves with the active involvement of the Traditional Authorities and trained in their presence by the Sub-District or District level Health Workers. 10. Ivermectin distribution in the Region is mostly financed by Government with assistance from some NGOs. At the Community level, the people are encouraged to take charge of the programme and to provide assistance to the volunteers to purchase notebooks, pens and also give them money for transportation to go to the health Facilities for the medicine or send returns to the Health Authorities when there is a delay. 22 2. aJ t 4 I t I ,). \ ,i:l- I 8 9 l I 11 t2 13 The Distributors requested for motivation in the form of boots, T-shirts or badges. In some cases some are asking for motorbikes of bicycles. The problems that most distributors faced are refusals due to side-effects but is being taken care of through Health Education talks given to the community members on every visit. The second most important problem is the distances that some have to cover on foot to reach the neighbouring communities to give the medicine. NGO performance in the Region is very encouraging since they are actively integrating their activities with that of the District Assemblies for long term sustainable development to eliminate waste and duplication. 14. In terms of the future plans of NGOs SSI wants to expand and improve on its support to the Region in partnership with Government Agencies and other NGOs operating in the Region WVI has focused its attention on the Ahanta West District for maximum impact at the community level in collaboration with all the decentralised Government Agencies of the District Assembly. PADP is focusing its efforts on conserving and protecting biodiversity at the Ankassa and Bia Forest Reserve areas seeking to actively collaborate with the Onchocerciasis Control Programme (OCP) going on in the region in partnership with the District Assembles, Traditional Authorities and the NGOs operating in the areas for effect protection of the Natural Environment. I I I -l l l J l 23 I-l RECOMMENDATIONS 1. INCENTIVES FOR VOLLTNTEERS Community Distributors could be motivated with T-shirts boldly marked "COMMUNITY HEALTH WORKERS". This could be extended to the other volunteers on either annual or bi-annual basis. The cost should however be borne by the District Assemblies and the scheme should cover the whole Region. NGOs could be approached for support. 2. TRAINING Training should be planned and organised for the volunteers either at the District or Sub-District levels with minimum cost to Government (District Assemblies). 3, IEC MATEzuALS IEC materials should be widely used to help reduce refusals and to encourage wider and immediate acceptance of ivermectin. 4. RECORDS KEEPING Community Volunteers should be taught to keep the Register according to households, instead of the first come first serve list. 5. TRANSPORT The District and Sub-District level staff should be assisted with transportation for outreach health delivery services including onchocerciasis activities. 6. DATA PROCESSING Health Workers in calculating the percentage (oh) coverage in the communities treated should use the TOTAL POPULATION of the District, Sub-District or Community as is applicable. 7. COVERAGE Neighbouring inaccessible communities should be encouraged to get a volunteer who will work with the volunteer in the accessible community. 8. FIELD TECHNICIANS Field Technicians should be posted to all the sub-Districts to give on the spot backup support to all the volunteers. 1 I 1 I I --r 24 I I I I I I I I t I l l I J I I l 9. DOCTORS In as much as possible, all the District should have a Medical Doctor to manage the Hospitals or Health Centers. l 25 -l I I I 1 l I I I I I I PERSONS CONTACTED IN WESTER]\ REGION WESTERN REGION _ TAKORADI Regional Health Management Team 1. Dr. Alhaji Mohammed Ibn Ibraham Regional Director of Health Services 2. Susana Owusu Regional Health Services Coordinator 3. Richard Amissah Oncho Focal Person PROTECTED AREAS DEVELOPMENT PROGRAMME (PADP) _ IYESTERN REGION l. Francis Hurst Project Leader, PADP SHAMA AHANTA EAST DISTRICT 1. Van Otoo District Director of Health Services (DDHS) 2. Mercy Yawson District Technical Officer(Dro) 3. Kwame Fosu Orderly BOMBA COMMUNITY 1. Nana Kumi Paul Essein Chief of Bomba Community Distributor (CD) Elder Elder Nana Kwesi Appiah Clement Badu Ntiamoah Thomas Atipoe Chief of Aprapraso Community Distributor Unit Development Committee Chairman 2. J. 4. Fosu Appiah Kwesi Nyamekye Kofi Ntim APRAPRASO COMMANITY 1 2 J 26 I4. Yaw Poku AHANTA WEST DISTRICT 1. Dr. Emmanual Asamoah 2. Dr. Boakye Agyemang AHANTA WEST _ TWI l. Jemima Amanor ELLOBANKATA COMMANITY l. Kennedy Ansah 2. P.J.E. Esshun 3. Kingsley Kwafie 4. Paning Kwadjo Kwesi 5. Francis Blay 6. Kwame Kyi Essuan l. Stephen Kweson 8. Stephen Andol BOEKROM COMMUNITY I. Mr.Kweson 2. Nana Boah V 3. Nyameassem 4. Yenynaabaho NZEMA EAST DISTRICT (AXIM) 1. Dr Godwin Afenyado 2. Anna Addo NEW ANYINAS E SUB-DISTRICT 1. Samuel Nyarko Youth Leader (6 others) DDHS Student (M.Sc U.S.T.) Area Development Programme (ADP) Manager, WVI Ellobankata Community Distributor Unit Committee Chair Unit Committee Member Elder Teacher Kingusih Unit Committee Member Carpenter Community Distributor Chief Linguist Unit Committee Member DDHS District Public Health Nurse (DPHN) I I I I J I _l ! -l 27 Disease Control Officer I 2J -t I i..1 --I 1 A'YT] KYI RE NKWAN TA C O MM UN I TY Ben Ackah Emily Ankonn 1. George Bukuro 2. David Owusu 3. Naka Akuba 4. Cecilia Kesi 5. Mathilda ASUATI COMMUNITY l. John Kobinna 2. Patric Dankwa 3. Wisdom Dankwa Principal Medical Assistant Snr. Staff Midwife - Community Distributor Community Member Unit Committee Memeber Community Member - Community Member Community Distributor t ) I Unit Committee Organiser Comm. Member 4. Joseph - Unit committee Member 5. Samuel Mensah - Community Member AMOKWANI SUAZO l William Kofi - Community Distributor 2. Nana Brewu II - Chief 3. Kofi Agyemang - Comm Member 4. P.E. Yankey - Elder JOMORO DISTRICT . HALF ASINI l. Cecilia Corney - District pub Health Nurse 2. Francis Alimah Blay - DCO 3. B.K. Quansah - DHMT Accountant ELUBO H.C. (JOMORO) l. Francisca Afful - Medical Assistant 28 I I ) I ) I I II 2. Turkson Timothy COCOTOWN - ELABO SUB-DISTRICT 1. Nana Essi Awuah I - 2. Joseph Quayson 3. P. M Addison 4. Lucas Bendor 5. Christopher Quayson WASSA WEST DISTRICT. TARKWA 1. Dr. Avotre 2. Samuel Barmes NSUAEM - NSAAEM SAB-DISTRICT 1. Ella Akor 2. Eleanor Arkorful 3. Noah Hlomey NYANSO _ NSUAEM SUB.DISTRICT 1. Richand Amoah 2. Agnes Opoku 3. George Amememah 4. Joseph Mensah ABOSO- ABOSO SUB-DISTRICT 1. Issac Mensah 2. Georgina Aquah BONSASO - BONSA- SUB DISTRICT 1. Samuel Buadu 2. Nana Dakwaa DCO Chief Assembly man Comm. Member Distributor Distributor DDHS DCO CHN CHN Environmental Health Officer Community Member Business Woman Comm. Distributor Asafohene Medical Assistant CHN/Midwife Unit Committee Member l l 1 I l I 29 Queen Mother ) -t -- 3. J.Y. Baidoo - Unit Committee Member 4. Francis Bogyan - Community Member 5. Opong Franics - Tufuhene 6. R.E.N. Owusu - Distributor ASANKRAGWA _ WASSA AMENFI DISTRICT 1. Dr. Alhaji M.B. Ibrahim - Reg. D.H.S. 2. Dr. Avotre - DDHS (Tarkwa) 3. Fred Kweku Ayisi - Clinical Attendent attached DCU WASSA AKROPONG H/C - WASSA AKROPONG SUB-DISTRICT 1. Christina Aggrey - Nursing Officer (CMB) 2. Joseph Nkrumah - Medical Records Assistant 3. Levina Asamoah - Snr. Enrolled Nurse 4. Moses Appiah - Trainee 5. Benjamin Gyadu - Laboratory Attendant 6. Agnes Ansah - Clinical Attendant WASSA MOSEASO - II/ASSA AKROPONG SUB-DISTRICT l. Yaw Osono - Community Member 2. Kofi Asante - Community Member 3. Okyeame Kweri Ayeribi - Linguist 4. Safo Adu - Distributor WAISADUNKWA - ASANKRANGWA S AB.DISTRICT 1. M.K. Baidoo - Distributor Joseph Asuah Kofi Adama Co-Distributorfunit Committee Member Community Member I - -t I I 2 J l J J J 30 -'l I I I I I I 4 5 6 Joseph Baidoo Kweku Baidoo Kwame Mreku 1. Stephen Komlaga 2. John Atramah Charles Lamptey Patrict Kwesi Morrison Kwesi Asebu Kojo Broni Kweku Akpable Francis Adombire Distributor Teacher/unit Committee Member Community Member Community Member DDHS SMO DCU Distributor Red Cross Member Unit Committee Member (a PANTOSO - ASANKRANYAW SUB-DISTRICT, I (a I i I I t 4. 5. 6. 7. 8. A .C a( a( OWIN S STRICT -ENCHI I J 2 J 4 5 6 1. Dr Francis Erskine Dr. Tachie Menson Ebenezer Tamakloe Clement Nti-Boateng Nikolas Adomako Michael Atawugye Samuel Aboagye Samuel Gyamfi Koo Bro TO TO ASANKEKROM - YIIYAB RA SUB.DISTRICT l I Dist. Coord Director 2 aJ J NYANKAMA COMM. _ ENCHI SAB-DISTRICT J J 1. Francis Newman 3l Distributor aa aa (-1 ; 2. Nana Kwesi Boah Panyin III - Chief 3. J.B. Owusu - Community Member 4. Tanor Ntuah 5. A.K. Bonya - 6. Agnes Tiboah 7. Francis Tanor - Youth Leader ABOTARIYE COMMUNITY _ ENCHI SUB.DISTRICT 1. Abena Gyebi - CommunitY Member 2. Samankina Karimu - " 3. Zenabu Salia - " 4. Abiba Karimu KWEKU ATTA COMMUNITY _ ENCHI SUB-COMMUNITY 1. Nana Ababio Yaw II - Chief 2. Juliana Osei - MIDWIFE (Clinic) 3. Kweku Samuel - CommunitY Member 4. Charles Ababio - " 5. Kojo Duah 6. Joseph Abeaku - " 7. Kojo Osei SEFWI.WAIWSO DISTRICT SEFWI-WIAWSO l. Thadius Zaason - Deputy Co-ordinating Director 2. Joseph Jumo - Ag. DDHS (Nutrition Officer) 3. Kobinna Arthur - Disease Control Officer NSUANSUA COMMUNITY - WIASO SUB-DIST. l. Nana Kwame Kyei II - Chief 32 ) (I l 2. Ama Adansi - Queen Mother 3. Nana Kwesi Arkaa - Elder Krontihene 4. Nelson Fuakye - AssemblYman 5. George Adu - Distributor 6. Kwaku Bente - (' 7. Issac Abegyina - Unit Comm. Member 8. Okyeami Yaw Fosu - Linguist 9. Simone Bediako - Pastor (Pentecost) 10. Kofi Mensah - CommunitY Member 11. Mathiew Fuakye - " NYAMEADISO COMMUNITY - WIAWSO SAB-DISTRICT 1. Nana Freeman Dzakputa - Chief I J 2. George Azameti Alfred Agbemenya E.K. Mensah 5. 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N rr)_ o cf) rO N- N @s o, co @ rO$o @s N @o t-s (oo s_ os o =EEfiot o,N F.-cf) N(o (oN tr)o @CO O tr)r.c) o IIJ 2fE E oo \r(o cf) @(o rON lr)CO o(o(o o lolr) 9.o I dI =o (O s \ir (O @ o (o (o o e.F 9,o a(U LU(! c oE o E o -c U) - 6 o) B (E c l(Ul-c l< l^ a(E LrJ (u E 0)NzI.l(o loILlo IElo ll 6o E Goa c, 3 lo co E c = o N oo =o t=t._ IElo)t' lco l,ll5tlslol>lolo E o f-- o,(o iEcq) E ooa(E =L(() I I I I I I I I I I I I I J I I ASI{ANTI REGION J'. -) I ASHANTI REGION INTRODUCTION The second phase of the evaluation visits to establish the ivermectin and IEC situation in the Forest Regions of Ghana started on the 7s of October, 1998 when the team arrived at Kumasi, Ashanti Regional Capital from Accra at 10.30 am. The Regional Director of the Health Services and his Health Management Team held a meeting with the Public Health Consultant and his Team. The New Regional Director of Health Services reiterated a mandate from the Vice President to eradicate Guinea worn in the Region in 2 years. He concluded that this is an opportunity to integrate oncho control and IEC into the Guinea worrn eradication exercise. ASHANTI REGION. KUMASI The Ashanti Region is made up of 18 Districts and 91 Sub-Districts In 1993 and 1994 Oncho control activities were undertaken in the Region through the Oncho coordinator from the National level in selected Districts in the Region without involving the Regional Level Health Authorities. The Districts in question are: Atwima Ashanti Akim South Ashanti Akim North Adansi East Adansi West Amansie East Offinso ln 1997, Helen Keller International (HKI) through the National Onchocerciasis Secretariat (NOS) and the Ministry of Health (MOH) organised a Training of Trainers (TOT) workshop at Koforidua (Eastem Region) for all Regional Disease Control and Health Education Officers. After the above workshop, the Region identified 9 Districts to be supported financially and materially for Oncho IEC (Information Education and Communication) activities to take place, but the number was reduced to 4 Districts due to resource constraints. The Regional Level Trainers trained the District and Sub- District Level Staff. In all, 20 Sub-District Staff have been trained. A total of 25 Health Workers have been trained in the use of IEC materials produced by HKI. The Districts where training has taken place are: Atwima Ahafo-Ano South Amansie West Offinso I :l 1. 2. aJ. 4. 5. 6. 7.I J _l l J I 1 2 aJ 4 "J J 5l I I s. The Focal Persons from the District Level were selected by the DHMTs who will in tum train other Sub-District Level Health Workers. The District Level training was supervised by the Regional Level Facilitators' At the District Levels, the Village Health Committee (VHC) members are usually considered and selected for training for Ivermectin Distribution because of their earlier involvement in handling Community Health issues. As stated earlier, only 2 cycles of ivermectin treatment had taken place in the Region in some selected Districts undertaken from Accra without the involvement of the Regional Authorities. As a result the Regional Level could not monitor ivermectin activities in the Districts to ensure regular supply to the needy areas. The Kumasi Central Hospital (Okomfo Anokye Hospital) has in the past recorded some reported cases of Onchocerciasis which were treated with ivermectin. The visiting team was assured that, now, Onchocerciasis Control in the Region, like any other disease of Public Health Importance has been fully integrated into the Regional Health Care delivery System and as such ivermectin distribution and Oncho IEC prograrnmes will be currently carried out in all the Districts in the Region with special emphasis on the endemic zones of the Districts. Ivermectin supply will therefore be controlled from the Regional to the District and Sub-District Levels from whence it will be given out to the communities through the Community Volunteers for distribution. In support of the above programme, OCP through the Oncho Directorate of the MOH organised in the early part of the year (1998), Rapid Epidemiological Mapping of Onchocerciasis (REMO) in the major river basins in the Region and the results from this survey will go a long way in identifying the critical oncho communities for priority treatment. Also, an Italian NGO called MAC (Movimento Apostolico Ciechi) has selected the Offinso district for support to help control oncho. The NGO supported another REMO exercise in the district in the middle of this year (1998) to help establish the level of assistance to be given to the district. Their final report is not yet available. Other NGOs operating in the Region are the WVI, Catholic Church and the Rotary Club. Care International has also indicated its interest in the Region. These are not doing any specific work on Oncho Control. Some of the problems faced by the Region in terms of Oncho control are: - the irregular supply of oncho medicine in the past which was not passed through the Region. - insufficient IEC materials produced by HKI for awareness campaign in the Region. - old and weak vehicles which cannot reach very remote areas of the Region for outreach activities. 38 l1 llll lrII - inadequate funding from central Govemment for an integrated disease control programme including oncho control. Concerning the future of oncho control and IEC activities in the Region, the Regional Health Management Team agreed that a regular supply of ivermectin and the availability of sufficient quantities of IEC materials will go a long way to control oncho in the Region. Also, the community surveillance system which has been put in place will help to improve disease control in the Region by directly involving the communities in the management of their health needs. DISTRICTS AND SUB-DISTRICTS VISITED The team visited 4 Districts and 6 Sub-Districts in the Ashanti Region. In all the Districts visited, the DHMTs briefed the visiting team on the general health activities going on in their respective Districts with particular emphasis on Oncho control. It was confirmed that in 1993 and 1994, some selected communities were treated with ivermectin with the involvement of the District Level Health Authorities. This was carried out by the then Oncho Coordinator (Dr. Emmanuel Asamoah) and the Oncho Secretariat along the endemic river basins. This year (1998) REMO was also carried out along the major river basins, which drain the Districts visited. Also, at the Atwima and Offinso Districts, it was confirmed that Oncho Training Workshops were organised by the Regional Facilitators for the District Level Health Staff who are in turn to train the Sub-District Level Staff in the use of Oncho IEC materials. The Offinso and Adansi East Districts are to benefit from NGO support from MAC (Italian NGO) and Care International respectively. Initial contacts have been made by the NGOs with the DHMTs and the final proposals are yet to be firmed-up for implementation. MAC will be involved in Oncho Control whilst Care International is interested in child health issues. ADANSI WEST DISTzuCT The Adansi West District REMO results (1998) identified some isolated places in the South of the District with Oncho cases. This area is drained by the Offinso River and its branches covering 2 Sub-Districts (Akrofuom and Amponyase Sub-Districts). Out of the 8 oncho communities, 3 were treated in 1993194. (Refer to table in page 87 for details). In the Akrofuom Sub-District of the Adansi West District, the Catholic Church (NGO) with participation of the Sikaman-Brofoyedru Community constructed a community clinic in 1991 which is presently manned by a Community Health Worker who is also the Ivermectin Distributor in the Community. Generally, the Health Workers interviewed showed interest in Oncho Control activities and are prepared to work with the communities to distribute ivermectin. The team was informed that in most communities, the volunteers made sure that the oncho medicine was taken in their presence. 39 I Some of the serious side eft-ects were swollen scrotumia, bodily pains and swollen feet, which generally did not last long. On the positive side-effects, the Health workers had reports from individuals who had their internal worms expelled and a woman whose last child was 16 years was able to get pregnant again after taking ivermectin. She recounted how all attempts to conceive a child failed until she took the oncho medicine. It is on records that she has even composed a song, recorded it and gave it to the then Oncho Coordinator (Dr. Emmanuel Asamoah). The presence of oncho flies in the rivers was also a problem to the first line communities. The communities visited were selected based on their past record of ivermectin treatment and Community Distributors installed there. In all, 7 communities were visited to interact with the community members and the Distributors. The general picture gathered was very positive and encouraging because ivermectin was widely accepted as a good drug, which they are prepared to take for as long as it will be made available to them. This reflects the fact that oncho disease is present in the communities and the people are aware that the oncho fly transmits the disease by biting them. The Oncho Volunteers (Distributors) on their part expressed the preparedness to cooperate with the community members to distribute the medicine to all community members. To make the programme a success, the Distributors asked to be trained and provided with materials for IEC activities. Schisto control is being supported by AGC, whilst the MOH is supporting yaws control; The DDHS does not see oncho as a major problems in the District even though it is confined to the Sub-Districts in the south along the Offin River. ADANSI EAST DISTRICT The Adansi East District has 5 sub-Districts and is drained in the South by River Pra. The Oncho disease is found in 16 communities in the Ataase Sub-district and 2 communities in the Akutresu Sub-Districts. The above mentioned l8 communities were supplied with ivermectin in 1995. In i996, the programme was evaluated and the second cycle of drug supply delivered. It was confirmed that the District has selected 13 communities which have oncho Distributors and note books for recording ivermectin distributed. The DDHS said oncho has been integrated into the Health care system and there are plans to retrain the Volunteers to start a permanent drug distribution exercice in the District when the go-ahead comes from the Regional Level. Since 1997 to date, no ivermectin has been received. An NGO, Care International, has indicated its interest to intervene in the District in Child Health Care. The DHMT confirmed the presence of oncho flies in the river basins and regrets that no IEC activities have taken place in the District. 40 JASHANTI AKIM NORTH DISTRICT The Ashanti Akim North District has 4 Sub-Districts and about 35 communities. The DHMT informed the Team that oncho has been recored in 3 Sub-Districts apart from Konongo Sub-District. Konongo is the District Capital. The Oncho Sub-Districts are 1. Dwease 2. Praaso The exact time that ivermectin was given in the District was not known. The treatment took place in 2 (Two) sub-Districts in the 1990s These are: 1. Dwaese Sub-District 2. Juansa 3. Agogo It was recollected that Dr. Kofi Ahmed and a Team of Specialists came to do REMO in the District recently and also treated some communities namely: 1. Huuruso 2. Otikrom 3. Nkwamkwanya In 1995 (2715195) a survey conducted at Otikrom after examining 37 people came out with only one person with modules. Since the 1990s no ivermectin has been distributed in the District. The distribution by then was done by the MOH and no Volunteers were used. Also, Oncho IEC activities have not taken place in the District. The only NGO in the District involved with Rural Health Care is the Presbyterian Church supported by Netherlands. AGOGO SUB-DISTRICT At the Agogo Sub-District, the Team visited the Hospital and were informed that they had some records of reported cases of Oncho but no drugs to treat them. Some Oncho patients however were able to get ivermectin on the open market at G5,000. The source of supply was not known. It was also mentioned that Dr. Kofi Ahmed visited some remote villages recently to assess the oncho Situation. 4l I I I DWEASE SUB-DISTRICT A visit to the Dwease Health Center confirmed that ivermectin was distributed in the Sub-District about 3 years ago. Recently, the centre received 4 cases of oncho which were referred to Konongo for Laboratory confirmation and treatment. The Health personnel lamented that they have not been well informed about oncho and the cycle of treatment. At the Methodist Primary School where ivermectin distribution took place in the past, the Head teacher said that was in 1993 and the people were treated according to their weight. The head teacher said, the oncho medicine came from the MOH. PRAASO COMMUNITY Praaso is a community in the Dwease Sub-District. The Health Centre Staff said no ivermectin has ever been distributed in that community. They did not know much about the Oncho medicine. All oncho suspected cares were referred to Konongo Hospital. ASHANTI AKIM SOUTH DISTRICT The Medical Assistant in charge of the Hospital had traveled to Kumasi for a workshop. The substantive Medical Doctor was on further training The District has 6 Sub-Districts and about 75 communities. The DHMT said Dr. Kofi Ahmed and a Team of specialists came there this year (1998) to conduct oncho Survey. From information given by the Laboratory Technician all the Sub-Districts had recorded cares of oncho which were referred to Konongo for treatment. The High endemic Sub-Districts were given as: 1. Ofoase Sub-District o DwenawenaseCommunity o Mamponteng Community 2. Kunso Sub-District At Manponteng, out of l0 people examined 8 were found to be oncho positive. The DHMT said that, even though nothing had been done on oncho in the past, the District can rely on its Village Health Communities (VHC)to distribute ivermectin in the affected communities in future. Also, no IEC activities have taken place in the District. The visiting.team advised the DHMT to liaise with Dr. Kofi Ahmed for the REMO results and use that to ask for assistance from the Regional level to undertake oncho activities including IEC. I I I I I J J J 42 CONCLUSIONS l. Oncho control activities had taken place in the Ashanti Region, without the involvement of the regional level Authorities, by the Oncho Control Programme in collaboration with the MOH (oncho coordinator). Out of the 8 District visited in the Region, two (2) cycles of Oncho treatment had taken place in 7 Districts. Only the Ashanti Akim South District reported of non-involvement in oncho activities in the past. 2. The DHMTs had very Limited participation in oncho activities. Where they did they were only informed about areas and some communities which had already been identified for treatment using Volunteers set up by the Programme However. Those who reacted to the oncho medicine later reported to the Health Facilities for assistance 3. Previous treatment was MOH directed, using community Distributors and some Health centres for passive treatment as was the care at Nyinahin in the Atwima District. 4. No NGO has been involved in oncho activities in the Region in the Past until recently when an Italian NGO know as MAC (Movimento Apostolic Quiet) has made positive moves to help control oncho in the Offinso District. 5. The Oncho Programme known as APOC and the MOH have conducted REMO in the major river basins in the Region in order to put in place a long term Programme to control Oncho in the endemic communities using the existing health care delivery structures in the Region down to the community level to use the Village Health workers in consultation with the communities themselves. 6. There was evidence of records kept by some Volunteers, e.g at Adansi East District. The community members interacted with showed interest in the oncho medicine even though they agreed that some people reacted the drug which to them was a positive sign. 7. The existing Groups at the communities where ivermectin had been distributed in the past expressed their willingness to participate fully in future oncho programmes. Ivermectin supply in the Region came straight from Accra to the Communities with out passing through the Regional, District and Sub-District levels to enable them monitor the programme. 8. Where Community Volunteers were used in ivermectin distribution, they were selected with the help of the Community members and Trained by the Programme from Accra. 9. Ivermectin delivery to the Communities was financed by the programme and it was the responsibility of the communities to distribute the drug through the Volunteers. No clear cost sharing mechanisms were established. 43 -1 I I I I I l j J Ij 10. Since the programme to distribute ivermectin was irregular where it did take place, the volunteers hadn't the opportunity to ask for incentives and the level of their commitment was not measured since there was no clearly spelt out channels for feed back (Reports). 1 1.The main problems encountered were insufficient supply of the drugs and refusals due to reactions because the people were not sufficiently educated on the side effects of the drug. l2.Presently there is no serious involvement of NGOs in oncho activities in the Region An Italian NGO called MAC is in the process of assisting the offinso District to control oncho. I .J I l 44 *1 I -'l I I I I RECOMMEMDATIONS 1. It is recommended that the Region, Districts and Sub-Districts should get involved in oncho activities in their respective level since the disease has been integrated into the Health Care System. 2. The IEC activities which have been carried in only 4 Districts should be extended to the other Districts and Sub-Districts. 3. Transportation is a vital tool if the control of the integrated diseases is to be fully realised. 4. Community Directed Approach to ivermectin distribution should be encouraged in all the Communities. 5. The Regional and District level Authorities can approach NGOs with proposals for assistance to manage their integrated disease control programmes. 6. Adequate and timely date on ivermectin requirements for the Region should be made available to the MOH oncho Directorate in Accra for the right quantities of the drug to be made available. I I I 45 PERSONS CONTACTED IN ASHANT REGION ASHANTI REGION (AR) - KUMASI Ashanti Regional Health Management Team 1. Dr. E. Appiah Denkyira Regional Director of Medical Services (RDMS) Regional Disease Control Officer (RDCO) District Director of Health (DDHS) Orderly, Nkwawie Health Centre Snr. Nursing Officer Laboratory Technician Ward Assistant Technical Officer (TO) Bio- statistics I I I ATWIMA DISTRICT (AR) _ NYINAHINI HOSPITAL1. Dr. Lutherking Zorgli Services 2. Douglas Brenya 2. Elizabeth Attaa -Mensah I l OFFINSO DISTRICT (AR)-OFFINSO 1. Dr. Joseph Oduro - DDHS 2. Samuel Baffu - Executive Officer (EO) 3. Christina Aidoo - Nursing Offrcer (pH) AKUMADAN H/C - AKAMADAN SUB-DISTRICT l. Chiriga Johnson - Medical Assistant 2. Millicent Addo - Snr. Enrolled Nurse (SEN) 3. Hannah Owusu - Community Health Nurse (CHN) NKENKANSU IYC - NKENKANSU SUB-DISTRICTl l Margaret Adjei Robert Mandari Agnes Acheampong Arhin Gyan Anthony 2. J. 4. J J I J 5. Kyei Offei 46 Leprosy Attendant -t I 1 II 1 I1 I I I ,J I ,I 4. Philip Antwi 5. K. Asare Acheampong - Assistant chief Accounts officer AKAAKU AKWEKU COMMUNITY - ATAASE SUB.DISTRICT 1. Nana Yaw Opoku - Chief 2. Yaw Nkrumah - Krontehene 3. Kwame Fosu - Unit Committee Chairman 4. J.K. Sam - youth Leader 5. Kojo Amuasi 6. Kweku Badu 7. John Adu 8. Samuel Aful - Distributor NKRAN FO-N KWANTA C O M MAN I TY - A TAAS E S U B.D I S TRI C T l. Nana Seth Addo - Chief 2. Emmanuel Bio - Distributor 3. Osei Kuffour - Unit Committee Member ADANSI WEST DISTRICT (AWD). OBUASI ADANSI EAST DISTRICT. NEW EDUBEASI l. Dr. Seth M. Ayi 2. Godwin A. Akuoko 3. Francis A. Yeboah Dr. P.C. Awuah Dr. Mensah Opiah Mensah Stephen Ampong DDHS District DCO (TO) DCU (rO) Snr. Field Technician DDHS Medical Officer DCO 1 2. J. 4. 47 DCU (r.O.rr) I I ,l I l I I SIKAMAN-BROFOYEDRU COMMUNITY . AKRAFUOM SUB.DISTRICT, I 2. Nana Anim Agyekum II Thomas Amoateng Thomas Darkwa Clement Frempong Benfo Apenteng Chief Public Health Care Worker/Distributor (PHC) aJ 4 5 (( JSS Teacher aa REGION, AS I{ANTI AKIM NOR DISTRICT. GO- ODUMASI 1. Dr. Ofori Paddy - Snr. Medical Officr 2. Abdul Asiz Abdulai - Technical Officer Community Health (CH) 3. Ben Tuffour - CH, Leprosy ASHANTI AKIM NORTH DISTRICT.AGOGO HOPITAL 1. Dr. Johanna de Graaf - Doctor In Charge 2. Dr. P. Angeletti - Ophthalmologist DI,YEASE - DWEASE SUB.DISTRICT 1. Emmanuel Yaw Asante - Medical Assistant J.K. Nifa Agartha Boateng Emmanuel Appiah Revenue Collector Orderly (ro), Head Teacher, Methodist Primary School I I J l J 2 J 4 1J I PRAASO COMMUNITY HEALTH CENTER - DWEASE SUB-DISTRICT l. Emmanuel Forkuo - Medical Assistant ASHANTI AKIM SOUTH DISTRICT. JUASO 1. Jacob Awuah - District Pharmacist 2. Abdul Razak - Assistant Disease Control Officer 48 Il J. 4. Thomas Duah Appiah Samuel Assistant Disease Control Officer Leprosy Technician l 49 (t,t o f d! d, 9,o I G, -o(!F o oo ot .o co f(1) <E o)E =EEEOEau o)co(trE}olzEo<o aoooEEoo -ccFF I ={OFtrd rr- <uloOp <t)flE s"2 'a .aP}E(! f.)lYZ EElzY lr)(o -N o^ooco rroo EEfz lz r'- .t(o lo :-aa .o .o -o -off,OE[! uJ3=oozz EEY -:Z(os '6 o = -oo Etz O) cf) oo(,) o)ccooccooYY EEiz -!z @ rf)Nr o UJ F =f = =oo c(t)'F =g(o.=lz>zz -) = .r, E_sEc:rolz .)<<z -(6 -YCoo ==_Y fz<z IaO(U= EEolzoz :f LEq) Io o co Ico E G =a o =o-ooT ^oE,PgN <(L 0)L C c)(J -c =o o)I o an of - () d. o o I dtfo co'= =o(u.=lz>zz 1)6P EE ECfq) .)a lz<z E orol9aaEooo(U(E1, ogE x'(56=<o o at o :, -) o e Lo oE = oacEL o a o LrJ aE oo ao ='6c oo -cEoz Ev c o .C,o -c f oa E = c(U -cU' zI o ]Utr c .o(,) o E. c o .Eo o ultr IU oo o UJ F =f = =oo z o F fJ LrJ o uI oz z tro lU =tr IIJ I I I I l l I I J .l _l I .J J J J I I I I I I l I I I 1 I EASTERNREGION II l I I EASTERN REGION INTRODUCTION The Evaluation Team arrived from Juaso, capital of Ashanti Akim South District, on the l2ll0l98. The Regional Health Management Team welcomed us to a meeting and briefed us on the general Health Care Progralnme of the Region with particular emphasis on Onchocerciasis Control regarding ivermectin distribution and IEC activities. Mr. Thomas Azttrago of the Disease Control Unit joined the Team on its field visits. EASTERNI REGION _ KOFORIDUA The Eastern Region (ER) has 15 Districts further broken down into 84 Sub-Districts There are about 2,6L7 communities. Surveys conducted between 1993 and 1995 identified 321 communities in which onchocerciasis was detected. The table in page 88 shows that all the Districts in the Region have recorded cases on oncho with varying prevalence rates. Around 1994, there was an uncoordinated ivermectin distribution in the Region by OCP/I{OS and some amount of passive treatment at some Hospital and Health Centres. Health Workers at the time were the only responsible agents for the distribution of the drug in the selected Districts. In 1996, REMO was carried out in the Region which confirmed the existence of oncho in all the Districts. An NGO called Africa Poverty Eradication Commission (APEC) adopted the Suhum Kroboa Coaltar District in 1996 where it installed community volunteers in the selected oncho communities to carry out the distribution of the drug within their communities. These volunteers were selected by the communities themselves. Some of the Districts in which ivermectin distribution was directed by the Health Workers (Institutional Distribution - MOH) are: l. East Akim District 2. Fanteakwa District However, it has now been recognised and accepted by all the Health Workers that Community Directed Approach to ivermectin distribution in most effective because the volunteers are always present in the communities to make sure that all the members are treated and their names recorded in a Register. The above has permanently put to rest the earlier desire by the Health Workers to do the distribution of the medicine by themselves instead of using the Community Volunteers. l I I I J I l I I J IJ l 52 1In some cases, the volunteers charge small fees to help run the programme in terms of providing note books, pens, rulers etc. with the total consent of the Community members. IEC activities took place in the Region in two Districts with material and financial support from an NGO called Helen Keller Intemational (HKI) which is supported by the Nippon Foundation of Japan. The Districts are: 1. Suhum District 2. Birim North District The Regional Health Management Team (RHMT) has also received a report from the Cocoa Research Institute of Ghana (CzuG) at Afosu of oncho cases amongst the workers who have since been treated with ivermectin provided from the Regional level. The report indicated that out of 1,200 workers 95Yo were positive but only 853 could be treated representingTl% of the positves diagnosed at Tafo Hospital. This year (1998), the Region has received a total of 60,000 tablets of ivermectin. DISTRICTS AND SUB-DISTRICTS The Birim North District has 5 Sub-Districts and about l4lCommunities. The District Health Management Team (DHMT) said that the Suhum District which is widely believed to have the highest incidence of oncho comes second to the Birim North District. For this reason, the District was selected to benefit from HKI support and Volunteers identified from some communities were trained to support the Health workers in ivermectin Distribution. The District is now awaiting drugs requested from the Regional level to start treating the people with the help of community registers. Two NGos, Ghana Association of the Blind (GAB) and the planned Parenthood Association of Ghana (PPAG) have initiated contacts with the DHMT to assist in the general Health care of the District. A stop at the Akoasi/Amuana Praso Sub-District at Akoasi Health Centre and Afosu (CRIG) revealed that some volunteers have already been identified and trained to distribute ivermectin when it becomes available. The Nursing officer at Akoasi said no treatment had taken place there in the past but they are now eagerly awaiting the arrival of the drug to distribute. She told the visiting team that she frequently gives general health talks at the Communities including oncho and the treatment available for it free of charge. At Afosu in the same dub-district, the Director of CRIG was happy to inform the Team about the dispatch with which the Region responded to the needs of 53 I I I I Ithe workers who were identified to have oncho and provided ivermectin to treat all of them. He also said that, Community volunteers have been identified and trained so that the treatment can be extended to all the community members. He assured us that he was always prepared to co-operate with the DHMT to help meet the needs of the whole Community. At the Fanteakwa District (5 Sub-Districts) the Team stopped at Osino Health Centre and Nsutan Community both in the Osino/Flemang Sub-District. The Medical Assistant in charge of the Health Centre said they have had recorded cases of oncho in the District and that treatment was on going (october, 1998) at Nsutam through an installed volunteer who is also the Health Focal Person at the Sub-district and a Teacher by Profession. The Sub- District had 2,500 tablets of ivermectin. He however regretted that IEC activities have not get taken place at his sub- District hoping that when the programme in extended to them it will help create awareness of oncho and its treatment which in free of charge. At Nsutam the Team interacted with the Distributor and inspected his register which was well kept. He confirmed receipt of 2,500 tablets he is distributing to the community members. Since the treatment started this year (1998), some reactions to the drug is discouraging others from coming forward but through his health education talks, most people are receiving the drug. The Distributor said there are reported cases of bilharzia and guinea worm in the community and the Health Workers are actively assisting in controlling the situation. He concluded by telling the Team that he uses his own bicycle in distributing ivermectin. He also made an appeal to the Regional/District Level Authorities for an ID card as a distributor to help increase the confidence of the people in him. The East Akim District has 8 Sub-Districts and about 20 communities. A total of 264 volunteers have been identified to be trained at Kibi anytime funding is made available from the Region. The DHMT has received ivermectin from Koforidua (Regional Capital) and immediately after the training, the volunteers will distribute the drug in all the 8 Sub-Districts. The DHMT said funds from the Pooled Donor Fund is awaited for the Training of the Volunteers. Also, IEC activities have not yet been extended to the District and they are eagerly awaiting it to help inform the communities about oncho and its treatment. Two cases of Guinea Worm victims has been recorded in the District at Tafo. In conclusion, they asked for means of transport (motor bikes) for the Disease Control Officers for outreach programmes to supervise at the communities. 54 2. I J Jl l .. IJ I IJ I 4 The Suhum Kraboa Coaltar District is supported by an NGO called APEC since 1996 which has put in place Community Volunteers to the Community members. The District has 6 Sub-Districts and about 363 communities. Last year (1997) 78 communities were registered for ivermectin distribution with assistance of APEC. Out of the 78 communities, only 2 of them are yet to submit their report for 1997. The 1997 treatment was proceeded by a survey which identified the 78 communities treated. This year (1998) REMO was conducted along the major river basins in the District which made it possible to conclude that all the communities in the District should be treated with ivermection. As a result a registration exercise has been carried out in all the communities but due to the limited availability of ivermectin (32,000 tablets) only 2 Sub- Districts have been targeted for effective coverage. The remaining Sub- Districts will be covered when more drugs are received from Koforidua. Passive treatment was also undertaken at the Suhum Hospital using a register to record those treated. The DHMT said there were refusals at the onset of the programme in 1996, but now due to the Health talks given on oncho, the situation has recorded a very positive out turn. Last year, (1997) APEC supported the District with some second hand clothing for the distributors and some used Hospital Equipment was also donated to the District. In addition, APEC gave some of the Distributors who had to cover larger communities token Travel and Transport allowances. Some of the Distributors are also used by the MOH for carrying out National Immunisation Day (NID) activities. They asked for some T-shirts as a motivation in carrying out their voluntary assignments. The District had received motor bikes for distribution to the Sub-Districts and will need about 2 for use from the District capital to quickly respond to the tight monitoring schedule drawn-out for the Disease Control Officers. The Team visited two (2) Sub-Districts in the Suhum District namely: 1. Anum Apapam Sub-District Suhum Sub-District 55 I I I I I I J I J J I I J J J 2. -J J I t This took the Team to Mfrata and Dawa communities where meetings were held with the Chiefs, Elders, Distributors, and Unit Committee members who are all actively involved in the ivermectin distribution progrtlmme. The people are highly satisfied with the oncho medicine and are asking for more. At Mfrata Community, leopard skin was observed on the legs of 3 people. Also, the presence of the oncho flies were felt because the meeting place was close to the river. The distributor said he had 60 tablets - 1997 which were all distributed. This visiting team recommended that the register should be kept on household basis. The Distributor at Dawa registered 266 people in 1997 and only half of the member was treated due to shortage of drugs. He said he has about 7 communities around Dawa and as such will need more medicine. The Unit Committee Chairman who was present at the meeting reiterated the readiness of the people to take the medicine when it comes despite some of the reactions recorded last year (1997). I .l l J I) 56 ,I I CONCLUSIONS The Health workers and the community members as a whole are aware of Oncho and its treatment and are prepared to take the medicine. Previous activities on oncho control were co-ordinated from Accra (OCPAIOS) with little involvement of the Regional Level Health Authorities. Two (2) cycles of ivermectin treatment have been recorded (1994 and 1996) in the Region. This years treatment (1998) will make it 3 cycles. A well coordinated approach was started in 1996 with the intervention of APEC which adopted the Suhum Kraboa Coaltar District. Before 1996, ivermectin distribution was Programme directed now, Community Volunteers have been put in place to help distribution the drug. Some Districts are yet to train their Volunteers. 2. J I t I 4. As a whole, 3 NGOs have taken part in oncho activities in the Region namely: Africa Poverty Eradication Commission (APEC) Lions Club Helen Keller International (HKI) APEC and Lions Club directly intervene to help distribute ivermectin and HKI worked through NOS/MOH to provide materials and funds for Information. Education and Communication (IEC) of the oncho disease. The attitude of the community members to the drug is very positive since they are prepared to take the medicine and participate fully in future programmes despite some recorded side effects which they the community members see as the outcome of a potent drug (ivermectin). Community participation in very high as is reflected in the composition of the people who attended the meetings at the communities visited. Even the Health Workers believe that the only way to sustainably control oncho in the Forest areas using ivermectin is by involving the communities themselves in the programme through the volunteers who will keep and distribute the medicine to all the community members. Presently the drug is received from the Districts from the Regional level, then to the Sub-Districts for distribution to the communities. The quantities are presently inadequate due to lack of census and the delivery is not set to particular deadlines. This was evidenced in the field by the Distributors and the community members who kept on asking us when the drug was coming. 57 I J 5 6 J -J J I 7J -J J I I J 89 All the Distributors so far put in place have been selected by the communities themselves with guidance from the Health Workers at the Sub-District levels. From the Regional to the Sub-District levels, the programme is financed by the State. At the community level, some cofirmunities agree to charge agreed rates for the medicine issued to them to help run the prograrnme at the community level. Remuneration for the Distributors has not been firmly established but some of them have been asking for T-shirts, ID cards. Badges etc. Their requests are directed to the District Assemblies and DHMTs. Some of the problems encountered at Regional and District levels is the lack of transportation to supply the drugs to the communities. At the community level, some volunteers have to cover other surrounding communities which calls for the use of bicycles which they do not have. Refusals due to reactions are also recorded but this is countered by health education from the Health Workers. NGO performance in the Region is not very encouraging. APEC which is in the Suhum District hasn't got the needed f,rnancial strength to go all out and direct oncho programme in the District. HKI on the other hand only intervened through NOSiMOH Lions club intervened only once to distribute ivermectin by actively involving its members but since then nothing has happened again. I I I I l I 10 11 t2. 13 l J I I l l l l 58 1RECOMMENDATIONS The Regional and District Level Authorities should consider preparing proposals to seek NGO support in the control of onchocerciasis which is a long term programme. Some of the NGOs to be considered are: Sight Savers International (SSI) World Vision Intemational (WVI) Adventist Relief and Development Agency (ADRA) Movimento Apostolico Ciechi (MAC) Helen Keller International (HKI) etc Since the Regional/District Level Health Authorities have accepted Community Directed Treatment Approach using community volunteers to treat the communities, efforts should be made to intensifu regular training programmes for the identified volunteers especially on the need to keep proper and accurate records to facilitate the regular and timely supply of ivermectin. Proper records keeping will also facilitate monitoring by the Sub-District level Health Workers. IEC activities which have been conducted in only 2 districts should be extended to all the Districts in the Region. Other diseases could be incorporated into the oncho education programmes. The Regional Level Authorities should review NGO activities in the Region with particular reference to the Suhum Kraboa Coaltar District in an attempt to get NGOs to clearly define their areas of interest and the degree of commitment of financial and material resources that they can make available to support Health Care Delivery. Community Volunteers may be considered for motivation with T-shirts, badges, caps etc., but this should be extended to all of them. The DHMTs can hold discussions with the District Assemblies for consideration for funding of these programmes on long term basis. Transportation is a vital component for monitoring and regular supervision of the communities by the Sub-Districts. Motor bikes in this case could be a very good alternative to 4-wheel drive vehicles. I I I i I I 2 J-J 4 5 6 J I _) "t I --) I 59 ( I I IPERSONS CONTACTED IN EASTERN REGION Eastern Regional Health Management Team 1. Dr. Victor Ankrah - Director, public Health 2. Emelia Okai - Head, DCU 3. Thomas Azrrago - DCU (TO) 4. Michael Adjabeng - DCU (TO) BIRIM NORTH DISTRICT (ER). NEW ABIREM 1. Tei Gyangman - DDHS 2. Abdul Rahman - DDCO 3. K. Amoah Darkwa - DCU 4. Ernestina Agyare - DCU 5. Mary Atakura - Coordinator, PPAG - Nkawkaw BIRIM NORTH DISTRICT (ER) - AKOASI 1. Faustina Mensah - Nursing Officer NEW ABIRIM DISTRICT, AFOSU 1. Ebenezer Kuntun Tei Director, CRIG FANTEAKWA DISTRICT (ER) OSINO 1. D.K. Anderson Medical Assistant I l l l 2. Kaiser Wilfred Dzigbordi EAST AKIM DISTRICT (ER). KIBI 1. Kwame Ofosuhene 2. Janet Newton TAR DISTRICT Distributor/Teacher - Nsutam (Osino/ Hemang Sub-District DCU DCU l J l. Dr. Harry Opata 60 DDMS J I2. David Agyemang - DCU (FT) 3. Narh Coffie - DCU (FT) MFRATA ANUM APAPAM SUB-DISTRICT 1. Opanyin Y.B. Kiseidu - Acting Chief 2. G.K. Dartey - Youth Leader 3. S.O. Opare - Town Secretary 4. Kofi Ayisi - Community Member 5. S.F. Atuah - Distributor 6. Samuel Kwakwa - "Gong-gong" beater DAIYA - SAHAM SUB-DISTRICT 1. Tei Gbenor - Elder 2. Kweyisi Addo - Community Member 3. Afedi Joseph - Distributor 4. Abraham Tekpeh - Unit Committee Chairman I I I I -.1 J J I ,I J J ) J I 61 I I ot o fo e, Lo EI(E oEAtrE o-cor4g: 9Et7O= I ELo -o .9 No E c)L =E 0) .9.oY ! o- rOGA tE q,E a< =dPElJ.< r.ll O9t-1<)flE z-Z ^7EUp'5b<b3Y2 lE -llltl-YlO-l-N I EE :rl -E -C =faa EEll -Y o ul F =f = =o o '0,-- sg EOG aooz E = .9o!s3E(tr =o o E,FLo I m =o ocof E AagE <(L t)c(!F=62I(trb* .=(D o -y,Oz -o Eoooo E=f-cE= <@ o a 9,o -cEoz E :=(n o =-:zoo c o LL E = a C, [.Ll oo -ooLY .Lt(E -c(I, =oac) z o lo luJlE I I '] I I I I o ult IU oo o UJ l- =:) = =oo z o F fJ tU og oz z Fo IU =t ul I J I l J l J .l l c o ao LrJ J ,: C 0 II _l I CENTRAL REGION J J J J I J J J (. I il I II I J _l J J J l J II CENTRAL REGION REGIONAL DIRECTORATEOF HEALTH SERVICES, CAPE COAST INTRODUCTION The Evaluation Team departed Accra on the 19th of October, 1998 at 6.30 am arriving at Cape Coast, the capital of the Central Region at about 8.30 am the same day. Informed ahead of our arrival from Accra, the Regional Director and his Health Management Team welcomed us to a meeting to brief us on oncho activities in the Region with specific references to Ivermectin distribution and oncho IEC activities. Mr. John Mensah of the Disease Control Unit accompanied the Evaluation Team to Twifo-Praso, capital of the Twifo- Hemang-Lower-Denkyira District (THLDD). CAPE COAST The Central Region has 12 Districts sub-divided into 50 Sub-Districts. The Regional Directorate remarked with appreciation the pioneering role played by the Twifo Oil Palm Plantation (TOPP) Clinic in the Region in detecting, treating and sustaining onchocerciasis control in the District. The Regional Team concluded with satisfaction the positive partnership between the private sector (TOPP) and Govemment. The other Districts in the Region in which oncho is a major Health problem are prepared to learn from the experiences of the outreach services delivered by the TOPP Clinic in the Twifo Hemang Lower Denkyira District (THLDD). Ivermectin Distribution in the Region started in 1991 at the TOPP Clinic which was then extended to the rest of the THLDD in 1993. The presence of Black flies has been reported along the major river basins in the Region and nuisance through the bites of these flies is a problem and the concern of all, especially the farmers. The prevalence of the oncho disease in the Region was recently confirmed by REMO conducted by the Oncho Directorate with support from OCP/APOC (1998). Oncho IEC activities in the Region was supported with materials and finance from Helen Keller International (HKI) in 3 Districts this year (1998). This was latter extended to cover all the 12 Districts bringing together 36 Health Personnel (Disease Control Officers, Public Health Nurses and Medical Assistants) were trained at Ankaful near Cape Coast by the MOH, Oncho Directorate. The District Level officials are to organise training for their respective Sub-District Health Personnel who will in turn carry out training in the communities for the community members and their selected Community Based Volunteers who will be responsible for ivermectin distribution. So far, in the Central Region, ivermectin distribution has not be well coordinated and the first line communities which have benefited from any treatment at all were 64 -rl Tit I it ll selected at random for research purposes. The only organised and well coordinated effort is in the THLDD led by Dr. C.K. Krah, the Medical Officer in charge of TOPP Clinic. The Districts have also submitted their Action Plans for Health Care Delivery which includes oncho ivermectin distribution and IEC activities. Oncho Control has therefore clearly been integrated into the plans to be carried out alongside the other disease management programmes. The only NGO in the Region, WVI, has adopted the THLDD for assistance in Health Care Management. This NGO has also offered to support oncho control activities in the District and has so far supported training workshops for Sub-District Health Personnel and Volunteers on oncho ivermectin distribution and IEC techniques. In terms of Research into other diseases of Public Health importance in the Region, the Evaluation Team was also informed about work done on Elephantiasis in the Awutu-Efutu-District. Further, it was brought to light the intention of the Region to use an Eye Care Unit at Asikuma Brakwa to conduct Research into eye problems related to oncho. Finally, the Region declared its preparedness to use Community Volunteers in distributing ivermectin in all the oncho communities in the Region. Up to date, between 4 to 8 cycles of ivermectin has been distributed in the Region. The THLDD has recorded a consistent amount of 8 cycles of ivermectin distributed in the District. It ll ll U I I I I l 65 I t_! II U U lI I Records available at the DHMT showed that a total of 5,000 tablets have been received in the District in 1995 (4,000 tablets) and in 1996 (1,000 tablets). The 1996 consignment was used at the Hospital for treating reported cases. The District also benefited from an IEC workshop at Ankaful this year (1998) and has in turn trained about 20 Health Staff from the Sub-Districts. The Districts has an action plan which include oncho control since 1996 which has not yet got the required funding for realisation. Presently, the DHMT is organising IEC activities in some corrununities with the video produced by HKI which is highly acclaimed by the community members who want to see it over and over again. Again, a regular supply of ivermectin is one of the main problems. In conclusion the DHMT requested for more financial and materials support from HKI and also to SSI to extend its assistance to the District to help control oncho. ASSIN DISTRICT The District capital of Assin is Assin Fosu with 8 Sub-Districts and about 150 communities. The District has had cycles of treatment in 1994 and in 1997. REMO conducted in 1994 by Dr. Emmanuel Asamoah, then Deputy Oncho Coordinator, identified 32 communities, established volunteers and did treatment in some of these communities. Also, in 1997,10,000 tablets were supplied from the Oncho Secretariat which have been redistributed to the oncho communities with volunteers and register. There was evidence of some retums at the District Office received from some of the Distributors (about 15 returns). In the past however, the District received its supply of ivermectin from France which was mainly used for passive treatment at the District Hospital. The District also participated in oncho ivermectin/IEC training at Ankaful. After the training, the Sub-District levels were also trained who in turn trained the volunteers. The Sub-Districts and communities visited are i) Kushea Sub-District Assin Bremang ii) Assin Breku Sub-District Atintan At Assin Bremang in the Kushea Sub-District, the Distributor made available his register for inspection which was well kept accordingly to households. At the time of the visit, the Distributor had submitted his returns to the District Disease Control Officer. Also 3 cycles of treatment has been recorded at the community rn 7994195, l J "l J 68 J1997 and 1998. In 1998, 700 tablets were used to treat 467 people. The Distributor said this was insufficient and needed more tablets for a wider coverage. The community visited was highly organised and prepared to work with the Distributor to ensure that everybody in the community is treated. Despite some reported reactions to the medicine, the community members say the medicine is very good and the need it every year. The second community visited, Atintan in the Assin Breku Sub-District, the Distributor had a register which was not kept according to the household members approach. The community recorded2 cycles of treatment. In 1995,500 tablets were distributed and in 1996,200 tablets were given to some community members. The members of this community were less enthusiastic to the treatment programme and did not cooperate with the volunteer. The Evaluation Team took time to address some of the concerns of the community members and urged them to cooperate fully in the programme to help eliminate river blindness from the community. The Distributor on his part asked for more medicine and assistance in IEC to help increase the awareness of the programme in the community. AWUTU-EFFUTU-SENYA DISTzuCT (AESD) The AESD has Winneba as its capital, 4 Sub-Districts and about 167 communities. No Oncho Control Programmes have been implemented in the District apart from a training workshop organised in 1996 by the then Oncho Coordinator, Dr. Emmanuel Asamoah, at Ankaful in which the District was represented. The training was followed by REMO which established the existence of oncho in the District especially in the Bawjiase Sub-District where in frontline communities such as Ahunten the prevalence rate was over 50% whilst in the second line villages like Papase near river Jei, the prevalence was about26oh. The DHMT informed the team that apart from some areas in the Winneba Sub- district, the remaining 3 Sub-Districts have recorded cases of oncho. Also, some Volunteers have been identified in the identified oncho communities for training to distribute ivermectin but this has not yet been done due to lack of funding. However, the DHMT is hopeful that some funding may come from Central Government for oncho and other communicable disease activities. An NGO, Plan International, is Supporting Child Survival Programmes in the District. A workshop organised for the DHMT by the NGO was going on at the District at the time of the visit. The NGO has also provided a vehicle to support its programmes in the District. J I J J I 69 I IConcerning the strategy that the District has put in place to address oncho in the District, The DHMT mentioned the following: Intensification of oncho IEC by using the oncho materials produced by HKI. Identify all the oncho communities and use the Community Directed Treatment approach to achieve a wider target. Leave some ivermectin at some Health Centres from passive treatment. Undertake selected treatment for some communities in the low oncho prevalent Sub-Districts. On the last strategy, the consultant recommended that all community members in low oncho prevalent areas should all be treated with ivermectin using their Community Volunteers. Some of the problems that the DHMT is facing is lack of ivermectin to treat students from the University and migrant workers who have oncho. To support oncho and other Disease Control Programmes in the District, a Global Positioning System (GPS) receiver will be used starting from the 28110198 to identify all the communities in the Sub-Districts to facilitate outreach disease control progranrmes. 70 ICONCLUSIONS In the Central Region, there is a general awareness of the oncho disease amongst the Health Workers such as its causation and treatment. However, the same cannot be said for the communities visited which is reflected in the refusals by community members to participate in the programme by taking the medicine. There has been previous work on oncho control in the Region especially at TOPP Clinic which was latter extended to the other Sub-District in the THLDD using Community Volunteers. In the other Districts visited the oncho activities which took place in the past were directed by OCPA{OS with little or no involvement by the DHMTs. The Region as a whole has recorded between 4 to 8 cycles of ivermectin treatment. The THLDD has a better record of consistent treatment since it started there in 1991 at the TOPP Clinic, and latter extended to the other Sub- Districts in 1993. Community Volunteers have been used at TOPP. The other Districts had oncho treatment through the OCPNOS programmes for some selected research settlements. At THLDD and Assin Districts, some Volunteers and their records were reviewed. The same could not be said for the other districts like Upper Denkyira and Awutu-Effutu- Senya. The general attitude of the communities to the oncho medicine was not encouraging because the people were not willing to participate in the present programme. Participation by Chiefs, Elders and Community Groups could improve since there is a faint awareness of the programme but not the details. The only channel of ivermectin procurement in the Region is from the NOS in Accra straight to the Districts which request for the medicine. The Regional Medicine Stores are not involved. The method of selection of the volunteers and Training is initiated from the Sub-Districts with support from the DHMTs with the full involvement of the Chiefs, Elders and all the community members. Cost sharing has been initiated at the THLDD and Assin District. They charge c500.00 per dosage and this was decided upon by the community members themselves in order to sustain the programme. The Distributors are not remunerated. The fees charged are used to buy note books and pens for record keeping. AIso, the money is used by the Distributors to go for the medicine or send returns to the sub-district heads. 2 aJ 4 5 6 7 9 71 10. 11. The main problem is unwillingness to take the medicine due to lack of adequate information about the disease and its cause. The other one is Blackfly nuisance in some communities. NGO performance especially at TOPP (THLDD has been very encouraging. Also WVI within the same District is supporting oncho prograrnmes. The other Districts which are not having any support from NGOs have all indicated their willingness to actively seek NGO support in the near future. I II I I J 72 I II I J J .J J J _1 "J J IRECOMMENDATIONS Oncho activities have been integrated into the District Action Plans which has reflected in the Regional Plan of Activities. Funding should therefore be made to support these prograrnmes in order to promote an integrated oncho control in all the Districts. IEC is highly recommended as the number one tool in oncho control if community mobilisation and direct involvement is to become a reality. At all levels, people should know about the disease, its causes and the treatment as a long term measure to prevent blindness. The Region and the individual Districts should be encourage to seek support from the NGOs. In this direction, NOS and the Oncho Directorate of the MOH can act as liaison. A central supply system for ivermectin from the Regional Stores to the Districts, Sub-Districts and then to the communities should be instituted for control and accountability. Regular and standard training should be organised for the Volunteers. Some sort of incentive or motivation should be worked out for all the Volunteers, e.g. T-shirts, caps or badges. Records should be kept at the communities based on household listening for easy monitoring by Sub-District Staff. 9 Regular visits from the National Level to the communities helps to whip-up the morale of the Volunteers who feel that their effort is recognised at higher levels. ) a) 4 1 I I I I I -l ,J l l J ) I 5 6. 7.i[( 8 I J J ,i I IJ IJ It J PERSONS CONTACTED IN CENTRAL REGTON CENTRAL REGION (CR) Regional Health Management Team l. Dr. E. K. Sory Regional Director of Medical Services (RDMS) 2. J.F. Quainoo Regional Disease Control Officer (RDCo) 3. John Mensah - Disease Control Unit (DCU) TWIFO HENANG LOWER DENKYIR DISTRICT (TI{LDD ). TWIFO PRASO Dr C.K. Krah Medical officer, Twifo Oil Palm Plantation (TOPP) 2. Ebenezer Tetteh - Nutritionist 3. Regina Langlah - Public Health Nurse GHN) 4. Kenneth Breku - Communicable Disease Control Officer (CDCO) TIYIFO HEMANG HEATH CENTRE TWIFO HEMANG SAB-DISTRICT 1. Agartha Winifred Eshun - Nursing Officer Q.{O) 2. Ernestina Boateng - Community Health Nurse (CfN) BOBI COMMUNITY - TIYIFO HEMANG SUB-DISTRICT 1. Simons Ekwam - Distributor 2. Godwin Ativo - Community Member ABAKA NKWANTA COMMUNITY - TWIFO HEMANG SAB.DISTRICT 1. Bismark Blankson Darko - Distributor/Teacher ABAKA NKII/ANTA COMMUNITY - TWIFO HEMANG SUB-DISTRICT l. Robert Djan - Distributor 2. Daniel Aquah - Unit Committee Secretary 3. Mohamed Ayensu - Elder I I .J J "J I -) 74 I , I _l I I 4. Felix Amoah ASSIN DISTRICT (AD)ASSIN FOSU 1. Dr. Kojo Sekyi Appiah 2. Georgina Asimedi Daniel Adumako Frimpong Akwesi Frimpong Kwaku Sarla DDHS Public Health Nurse GHN) Distributor Elder Community Member DDHS DCO StudentI 3. Albert Aquah - DCO ,4.S,S1N BR E MAN G C O MMUNI TY - KAS HEA S U B -D IS TRI C T 1. Stephen Brown - Distributor 2. Nana Karikari - Chief 3. Akyeampon IV - Assistant Chief ATINTAN COMMUNITY ASSIN - BREKA SUB-DISTRICT 1 2. aJ I I AWUTU- EFFUTU SENYA DISTRICT (CR) WINNEBA Dr. N.A. Adjetey Samuel Odoom 1 2 l _i _l 75 otr o fo E,FLo -c .gco-(oo-if<#o) EEo=EY Y L o E .9. d) -CEo(U(,}Y Eo ur co5eCL .LOao o)c o o- E .Elr oclz =(Eoh co€ 51<oo-'=gE@o =dPFrl.<tuo(J r-Z't) FE e"-Z o) o)CCooEEooII oo ==FF EEtz .)z ro$ EBo-t €o EE EElz fz$coNr f,f,oaoot! lJ- cc '6'6 a@ EElz -:zl-V(oN o IIJ =D = =o o (o co = Yz o .- tz _ooo-ocrl< o-Che()T AEoob.-=<o I o)c o E oL cn C(E ',,l,7 coo<o o d, a 6 Idl =o o)co E 0)I o '= F ooo (L f -:z o)Loco .P .saa =aY< o d, o o oo).=c>o .lzcc ^L o) -lJ^! -r_1o o-i = >= = 6*L o .= .Ycoo L o) o- o-f c '6 a z o o ulu C .o(r, c) E. cL c o) O o UI Ezf = =oo z o tr fJ IIJ o E oz z F o lrJ =tr lU2o IUtr uJ oo I _l I I l J I I IINTERVIEW WITH NGOs AFRICA POVERTY ERADICATION COMMISSION (APEC) APEC was started in the United States of America (USA) by a Ghanaian called Dr. Patrick A. Clerke. A branch was later opened in Ghana and managed by Major (Rtd.) A.N. Clarke who is a brother to the founder of APEC in the USA' lBefore the NGO started operations in Ghana, its mother branch in the USA had initial lofficial contacts with the OCP Headquarters in Ouagadougou in Burkina Faso, with Ithe aim to intervening in Ghana to Control Onchocerciasis. It was during these contacts that APEC was requested to contact the National Oncho Secretariat (NOS) and the Ministry of Health who could guide it in channeling its assistance to some of the most affected areas of the country' When the follow-up was made by APEC Ghana, the NOS/\4OH agreed to allow the NGO to intervene in the Eastern Region starting with the Suhum Kraboa-Coaltar District. In 1996, after laying the groundwork for operations to start in the Suhum Kraboa- Coaltar District, APEC brought together Health Workers and some identified community volunteers (87) to a 2 day training workshop which was followed by ivermectin distribution in the District. Since then, some follow-up visits have been made to supervise the activities of the volunteers, allowances paid to them and second hand clothing given to them as a motivation. Also, APEC has assisted some Health Facilities with equipment, renovated some Health Institutions (Wa Hospital, Akroping School for the Blind etc.) APEC is also in Agricultural Programmes undertaking ventures in the production of Cashew, Pineapples, mangoes, livestock/poultry etc. with the view to helping the poor to help themselves by direct participating in these projects. The sources of funding for the NGO are limited to its mother organisation in the USA and also on the returns generated from the export of its agricultural produce. Presently, APEC is being supported by Technoserve, Empretec and the World Bank. Technoserve has drawn-up a plan with APEC to help finance its Agricultural Ventures. Empretec is helping it to build its capacity financially and administratively. The World Bank on the other hand is encouraging APEC to take up environmental issues for it to consider for support. Some of the problems facing APEC are Inadequate funding from parent organisation in the USA. I ( Low returns from Agricultural ventures to support its operations. .t t Lack of co-operation from National Institutions. Concerning its future plans for Oncho Control in the Eastem Region, The NGO admjtted that !t [rasq]! got the necessary fundr to take up the wiple f-e€goilxut it is 'hopEn i that it can continue to support ivermectin distribution i4 the Suhum Kraboa- Coaltar District. troRLD VISION INTERNATIONAL (rWI) W"(a Vision International is presently operating a policy which identifies needy geographical zones for total support called Area Development Programmes (ADP) Headed by area Managers. There are 72 of such zones in all the 10 Regions of Ghana. The ADP zones are: 1) Bongo District (UER) 2) Nkwanta District (UR) 3) Sene District (BAR) 4) Kwahu District (ER) 5) Suhum/Kraboa Coaltar District (ER) 6) Dantgbe West (GAR) 7) Ahanta West (WR) 8) Twifo Praso (WR) 9) Assin District (CR) 10) Ashanti (AR) 11) Gushiegu/Karaga District (NR) 12) Nadowli District (UWR) For the next 8-10 years, WVI will be in the siune areas and then expand from there if there is the need and resources are available. WVI is also working very closely with other NGOs like the LINICEF, UNDP and wHo. As mention earlier, WVI had to move out of the Regions to needy areas for effective intervention by working closely with the District Assemblies and the District Health Management Teams (DHMTs). Concerning Oncho Control activities, the NGO could help in the Training of Trainers and participate in ivermectin distribution with limited financial support. Their major constraint is inadequate funding from their overseas partners which called for careful prioritisation of their programmes for sustainability in the ADP selected zones. I -) I -J .) t J 78 I .t :J :l SIGHT SAVERS INTERNATIONAL (SSD SSI is a British NGO which supports Govemments Health programmes with particular focus on Eye Care. The NGO has its Africa Regional Office in Accra. Its support to the National Health prografirmes is channeled through the National Eye Care Secretariat of the Ministry of Health. It is mainly a financing agency with Government as the implementor. SSI in addition to eye care activities is actively involved in the Onchocerciasis Control Programme in Ghana by providing financial, material and logistic support to the Western Region of Ghana to distribute Ivermectin in order to Control Forest Oncho. The NGO is only operating in the Western Region to control oncho with the view to maximise effect with its limited resources. It has plans for expansion to other Regions on request from MOH. Presently, the major problem which the NGO faces is the lack of capacity by the National Eye Care Secretariat to execute all its action plans approved for by SSI Ghana. As a result, financial resources made available for all such programmes are not fully utilised and simply return to chest. This situation makes it increasingly difficult for SSI Ghana to ask for more funds from the Donors to expand. Concerning its future plans, the NGO is collaborating not only with Eye Care secretariat but also with NOS and the Oncho Directorate of the MOH. HELEN KELLER INTERNATIONAL (HKD HKI is an American NGO which is support by the Nippon Foundation of Japan. The NGO started operations in Ghana in 1996 to help Control Oncho by supporting the Information, Education and Communication (IEC) component of the Oncho Programme in the country. The support so far given by the NGO has been in the areas of: l) Technical Advice from its Regional Training Officer in Niamey on regular basis. 2) Research to conduct a knowledge, Attitude and Practice surveys which guided the production of IEC materials. 3) IEC Materials like flip charts, posters, flyers and video drama produced to support oncho Health Education throughout the country. Trainine workshops have been organised for Regional, District and Sub-District Level Health Staff in the use of IEC materials. l 4) 79 l Is) Financial support to finance HKI activities in the country through NOS. HKI has produce 70 Flip Charts, 1,000 Posters, 10,000 Flyers and 50 Video Drama which have been distributed to the most endemic oncho communities throughout the country for use. All the 10 Regions have variously benefited from these materials. The NGO has future plans to produce additional materials for the rest of the communities which have not been covered in the first phase. Furthermore, arrangements are far advanced for the NGO to be registered in the country to enable it give maximum support to oncho Control and other Health programmes. NATIONAL LEVEL NGO SENTATIVES CONTACTED CAP SSI l. Major (Rtd.) A.N. Clerke National Director (APEC) il. WORLD VISION 1. Sam Asare Head of Planning/Resource Development Advisor to the National Director 2. Mrs. Dina Dsane National Health Coordinator including Cender and Development Alfred Owusu Southern Sector Coordinator Mrs. Phyllis Nyanteng Executive Assistant to National Director 1. Mrs. Verda Tarpeh Administrator HELEN KELLER INTERNATIONAL l. J.K. Fosu HKI Coordinator/ Executive Director of Oncho Secretariat V 2. Oscar Kanwille - HKI Liaison Officer NATIONAL EYE CARE SECRETARIAT 1. George Gborgli - Administrator 80 ) J 4 J oJ J ru IV SIGHT SAVERS INTERNATIONAL (SSI) ) J ) .J J ) , I1 INTERVIEW WITH DR. MARIAN HAGAN _ NATIONAL EYE CARE SECRETARIAT The Head of the Organisation at the time of the visit had travelled on an Official assignment. However, the Administrator informed the team that they have not always been able to meet set targets jointly agreed with SSI because of Inadequate supply of ivermectin from the National Level for distribution in the Western Region. INTERVIEW WITH DR. KOFI AHMED _ ONCHO DIRECTORATE, MOH. The Head of the Organisation at the time of the visit had travelled on an Officia1 assignment. INTERVIEW WITH THE EXECUTIVE DIRECTOR OF NATIONAL ONCHO SECRE,TARIAT (NOS) The National Oncho Secretariat was established on the 23'd of October, lg74 within the then Ministry of Finance and Economic Planning to Coordinate all the activities of the Oncho Control Programme (OCP) in Ghana and also to plan for the Social and Economic Development of the Oncho Freed Zones in the 3 Northem Regions (Northern, Upper East and Upper West Regions.) The Secretariat therefore has the responsibility for Servicing the National Oncho Committee which is made up of all the National Institutions and Agencies, some NGOs and Multi-lateral and Bilateral Donor Agencies which are all involved in the Programme. In terms of Socio-Economic Development, NOS through its Capital Development Budget has been able to engage the necessary services which has led to putting in place physical infrastructure in the "Overseas" area of the Oncho Freed Zone. These include; construction of 3 Health Centers, 2l Hand Dug wells, the provision of 2 Bridges and 43 km road with a British Aid. Since 1986, with the discovery of the new oncho medicine called ivermectin, NOS was responsible for placing orders for the medicine from Ouagadougou for use in treating the people in the original OCP areas in the Northern Savannah zones and also in the Forest areas of Southern Ghana. To facilitate the above, NOS in association with OCP Ouagadougou and MOH Coordinators actively carried out Training for some identified Community Volunteers in the highly Oncho endemic communities in the Volta, Eastern, Ashanti, Western and Central Regions. Another major activity carried out by NOS is annual awareness campaigns throughout the country to inform the people, especially in the rural areas, about the disease, its mode of transmission, symptoms, treatment and side effects. I I l l :l l IIt. IJ 8l -t t I I I ln 7996, an American NGO called Helen Keller International (HKI) which is supported financially by the Nippon Foundation, though the NOS and the MOH introduced Information Education and Communication (IEC) into the Oncho Control activities which culminated in the production of Flip charts, Posters, Flyers and Video Drama for use in educating the people about the disease in order to increase their participation to sustain the programme now that the Donors are facing out their support. Other NGOs which are closely collaborating with NOS are Sight Saver International(SSI) which has adopted the Western Region for Ivermectin Distribution African Poverty Eradication commission (APEC) which in charge of the Eastern Region but presently only working in one District, the Lions Club and the Twifo Oil Palm Plantation (TOPP) Clinic which is in charge of ivermectin Distribution in the Twifo Hemang Lower Denkyira District in the Central Region. Today, NOS in close partnership with the newly established Oncho Directorate within the MOH has working links with all the Regional and District level Health Authorities. Seminars and workshops have been extensively carried out for the smooth integration of Oncho activities in all the Regional and District action plans. 82 I I I I I I IVERMECTIN AND IEC DISTRICTS _ ASHANTI REGION IEC DISTRICTS L Atwima 1. Atwima 2. Ashanti Akim South 2. Ahafo-Ano South 3. Ashanti Akim North 3. Amansie West 4. Adansi East 4. Offinso 5. Amansie East 6. Offinso OFFINSO DISTRICT COMMUNITY VOLUNTEER TRAINEES FOR ONCHO CONTROL IN AKUMADAN SUB-DISTRICT Community VolunteerDapaah Christorpher Opoku Gyankeh Kofi K. Dua Ottir Rose Fosua Bonnah Peter Amadu Yussif Maxwell A Boateng JamesBulokon Community Volunteer ASHANTI REGION ADANSI WEST DISTRICT (AR) I. AKROFUOM SUB-DISTRICT ONCHO ENDEMIC COMMUNITIES IDENTIFIED BUT NOT YET TREATED 1. Kramokrom 4. Car Owner Mprakyire 5. Gromessa 6. Yawowusukrom ta Srentiatia Sraneso Nkubesa Nkwaduamo Mpaepaem Mankranso Tamo Kwaem Bosomponso aa aa l a( (a l J (a l I I) 2 J ) J Koh Gyame 83 I J I I _l IVERMECTIN DISTRICTS IaJ 4 II 1. 2. Agogoso Ahinsan Adokwai Old Edubiase ADANSI WEST D TzuCT ONCHO COMMUNITIES - REGION TRE ATED I COMMLTNITY Sikaman-Brofoyedru Kramokrom Pomposo Mprakifire Grumeso Yaw Owusu Abogooso Adukwai YES NO (( a( YEAR 1993 1993 r994 a( (( ((I aa (( aa I I l 84 I EASTERN REGION IVERMECTIN DISTRICTS 1. Suhum Kraboa Coaltar 2. East Akim 3. Fanteakwa ONCHOCERCIASIS IN 1993/95 SURVEYS DISTRICTS 2. Birim North NO. OF COMMUNITIES l0 9 15 9 t4 16 10 20 11 t2 20 45 t7 4 9 1 IEC DISTzuCTS Suhum Kraboa Coaltar I _i 1. 2. 3. 4 5. 6. 7. 8. 9. 10. 11. t2. 13 14. 15. Afram Plains Kwahu South Manya Krobo Yilo Krobo Akwapim South Akwapim North Birim South Birim North Kwaebibirem East Akim West Akim Suhum Kraboa Coaltar Fanteakwa New Juaben Asougyaman 32t l J SOURCE: MOH, DISEASE CONTROL UNIT EASTERN REGION KOFORIDUA, Oct., 1998. j l 85 l d, ADDENDUM THE ISSUES I SHALL BE ADDRESSING INCLUDE: 2. Reviewing and evaluation of the programme in the Regions/Districts with emphasis on Ivermectin distribution. Awareness in Community as a disease. Its Causation and Treatment (DHMT, Community) Previous Activity of Oncho in District/Community (DHMT, Community) Previous Treatment with Ivermectin in District/Community l1 No. of Cycles (years) Mode of Distribution - Community Directed - Ministry of Health - NGOs Sight Savers International Africa Poverty Eradication Commission Protected Areas Development Programme Lions Club Helen Keller Intemational - Industry e.g. TOPP 5. Coverage Achieved by Year Number of Districts/ Communities Eligible Population Covered by Community Keeping of records 6. Attitude of Community to Ivermectin as a drug for Treatment Acceptability Effectiveness Reactions Willingness to participate in Future Programmes 7 . Participation of other Groups at Community Level in Oncho Activities Chiefs and Elders Unit Committees DCEs Assembly-members Other Govemmental Agencies J 4 86 1 8. Channels of Ivermectin Procurement Method Adequacy Timeliness 10 Method of selection and Training of Distributors Financing of Ivermectin Distribution (Cost sharing) Remuneration of Distributors11 9 Incentives Types Responsibility 12. Problems encountered in Ivermectin Distribution 13. 14. t5 16. NGOs performance to date and future plans Interview with Dr. Marian Hagan Interview with Mr. J.K. Fosu Interview with Dr. Kofi Ahmed 8',1 II ITINERARY WESTERN REGION (No. of days 8) 1. Monday September 28th I I Depart early Morning for Sekondi and Takoradi. Discussions with Regional Director of Health Services and his team, visit Communities, interact with Chiefs and Elders, Assembly-men, Unit Committee Members. Night at Sekondi-Takoradi. 2. Tuesday September 29th Courtesy call on Regional Minister or representative, discuss programme, depart for Agona Nkwanta. 3. Tuesday September 29th The rest of the day al Agona Nkwanta, discussions with DDHS and team, DCE, Assembly-men, Unit Committee members, Ivermectin Distributors, Community members, Review records, Night at Axim. Wednesday September 30th Work in Nzema East District. Night at Half-Assini Thurseday October 1st Work in Jomoro District, depart for Tarkwa, Work in Wassa West District. Night in Tarkwa. Friday October 2nd Depart for Asankragua. Work in Wassa Amenfi District. Depart for Enchi. Saturday October 3rd Work in Aowin Suaman District. Night at Sefivi-Wiawso Sunday October 4th And morning of 5th October work in Sefwi-Wiawso 9 Monday ber 5th -t I I 4 5I J 6. 7 8 l l I J I J _l Departure for Accra 88 ASHANTI AND EASTERN REGIONS (10 days) Personalities and Institutions to contact, as well as activities as indicated for the Western Region will be the same for the rest of the Regions to visit. 1. Wednesday October 7th Accra to Kumasi. Discussions with the Region Director of Health Services and his team. Courtesy call on the Regional Minister or his representative. Work in Atwima District. Night at Offinso 2. Thursday ber 8th Work in Offinso District. Night at New Edubiase Lrldav leIqbq9!h3 4 6 7 Work in Adansi East and Adansi West Districts Kumasi. Night and weekend in 5 Monday October 12th Work in Ashanti Akim North and Ashanti Akim South Districts Night at Koforidua Tuesday October 13th Discussions with the Regional Director of Health Services and his team. Work in Birim North, Fanteakwa, East Akim and Suhum Kraboa Coaltar District Night at Koforidua. Wednesday October l4th Depart for Asamankese. Night at Asamankese. Thursday October 15th Depart for Accra 89 -t I I I CENTRAL REGION (7 DAYS) l. Monday October 19th Depart Accra for Cape Coast. Discussions with Regional Director of Health Services and team. visit fishing communities in Cape coast District, Courtesy call on Regional Minister or representative. Night at Cape Coast. 2. Tuesday October 20th Work in Twifo-Hemang-Lower-Denkyira District and hold discussions with TOPP. Wednesday October 21st Depart for Dunkwa. Work in Upper Denkyira Distrct. @ J 4. I l I l Depart for Assin Fosu. Work in Assin District Night at Assin Fosu. Friday October 23rd Depart for Winneba Work in Awutu-Efutu-Senya District Saturday October 24th Return to Accra. Monday October 26th Visit some NGOs in Accra Monda), to Friday October 26th to 30th Analysis of findings, report writing and presentation of report. I 5 6 l J _l l 8 J I -J I) 90 II l i I J ) I I I I I REYIEW OF LITERATURE 1. EVALUATION OF THE IVERMECTIN DISTzuBUTION PROGRAMMES IN LA In a study carried out by an independent team for the ONCHOCERCIASIS CONTROL PROGRAMME (OCP) Ouagadougou, the team arrived at the following: "fuluiu;. On the whole acceptability of ivermectin treatment fs excellent and interviewed people are all enthustastic and willing to conttnue to take ivermectin tablets. Recommendation i. There is a need to agree with National Co-ordtnators on the expected ge o gr aphical c ove r age and policy for tre atment.ii. Health education will be needed to reduce further, the percentage of people who refuse to take the ivermectin tablets. iii. Local health organisation must be involved in the planning and implementation and the supervision of the distribution of ivermectin tablets." COMMENT our findings confirm the above conclusion and are happy to note that the issues recommended are already in operation in the communities visited. 2. IVERMECTIN TREATMENT IN THE OCP In another ocP paper, treatment coverage was defined as the proportion of people treated out of the TorAL CENSUS POPULATION (emphasis mine). COMMENT It came to our notice that it is nor clear whether the treatment coverage in the communities visited was based on TorAL CENSUS POPULATION or ELIGIBLE POPULATION even in the same Region (e.g. WESTERN). The above quoted paper also came to the conclusion that "The patient coverage of an average of over 74% through both the mobile and community- based treatment mechanism is suficient for the prevention of ocular morbidity in the areas covered." COMMENT Even though our findings showed coverage of between 70% - 80% (in some mining communities and settler farming communities where children are not ffiony, 100% coverage was achieved, wR), there are whole communities that have not heard of ivermectin. For example the villages from the last community in Aowin Suaman District, called Kweku Atta, the Sefwi Wiawso, settler farmers mostly, through Koodwuo, Kramokrom, Quarters, Fawokabra 9t l J etc., have not benefited from the drug. Quarters is about 22 km on a good motorable road from Sefivi Wiawso. Ashanti Akim South (Juaso) refers cases diagnosed at the laboratory for treatment at the Hospitals. Ashanti Akim North (Dwease and Praaso) had ivermectin treatment about eight years ago and no more since then. Coverage in the Central Region is very low. In the Twifo Praso Lower Denkyira district where Ivermectin Distribution has been going on for a number of years spearheaded by the Twifo Oil Plam Plantation (TOPP), coverage achieved ranged from a mere 2.5%o in Jukwa to a high of 57o/o in Wawase. This was achieved only after intensive I.E.C. 3, REPORT ON THE COMMUNITY DIRECTED TREATMENT WITH IVERMECTIN (CDTI) IN GHANA. 1997 - Submitted Dr. Kofi Ahmed. MOH In this paper it was stated that in Ghana the mobile approach (to ivermectin distribution) has been the practice with health workers doing the distribution until two years ago when the CDTI was adopted and tried in some selected areas as pilot studies. An exercise was carried out, the objective of which was "to establish the Communtty Directed Treatment with lvermectin (CDTI) approach in the endemic villages." In a monitoring and evaluation meeting held ten days after the distribution of the drug had been started, the following conclusions were made. ,,BENEFITS t. The communities have seen the benefits of the drug judging from the number of people who rushed to come for treatment in some communities. The geographical coverage for ivermectin distribution has increased. The health workers have more time for other health delivery activities in the communities since the communities now do the treotment with iv er me ctin the ms e lv e s. ii. iii. L RECOMMENDATION The Regional levels should toke active part in supporting the districts with the necessary logistic to train and monitor the activities of the subdistricts and the community distributors. Accurate community population figures should be made available in order to eliminate the drug needs and monitor the coverage. The monitoring of the distributions should be made part of the routine health activities of the communities. The regional and district levels should review and use the monitoring data before forwarding to the headquarters. ii. iii iv. 92 I J .t I I 'l I I I v. vi LE.C. on lhe disease control and benefits of ivermectin should be stressed to both the health worker and the general community Other strategies to distribute the drug in the communities should be studied." Our conclusions and recommendations are in general agreement with the OCP evaluation report and those of the Director of the Oncho Programme, Ghana. We must also add that the performance of the community distributors is satisfactory and commended by communities. We support the recommendation by the Director of the Oncho Control Programme that an evaluation of ivermectin distribution coverage should be carried out yearly for the next few years. This should include the performance of NGOs. The District Director of health Services (DDHS), Suhum Kraboa Coaltar District, Dr. Harry Opata has produced a paper on "CONTINUOUS POPULATION MONITORING, May 1998". The document seel<s to "establish a mechanism of continuously, periodically registering parameters of the population of Suhum Kraboa Coaltar District with the aim of making information readily available for decision making and responding to demographic situations that call for ivermectin." This falls in line with the National Oncho Programme Directors' recommendation - " accur at e c ommunity p opulation fi gur e s .... " The document has prospects for application nationwide. It will require a lot of material, financial and organisational support and I will strongly recommend it for study and implementation. COMMENT I I I I J I l l I J ll. llt J I I I I) 93 ACKNOWLEDGEMENTS I would like to express my deep appreciation and gratitude to all those who made this consultancy possible and for their support, encouragement, their time and useful suggestions and also for their financial support. Special mention is made to the following. The Hon. Minister of Health Designate, Hon. Mr. Samuel Nuamah Donkor, and his Deputy Hon. Nana Paddy Acheampong, Dr. E.N Mensah, Ag. Director of Medical Services, Dr. Kofi Ahmed, Director, Oncho Control Programme, the Financial Controller, Mr Patrick Numoo, Mr. J.K. Fosu, Executive Director, National Oncho Secretariat, the Regional, District and Sub-District Health Management Teams. The Chiefs, Assemblymen, Unit Committee Members, Community Members and all those mentioned in the report for their cooperation, time, patience and hospitality. Lastly but not the least to Driver Mr. Addo Allotey who expertly drove me through rough roads and sometimes bush tracks, and Mr. Oscar Kanwille, Economist, National Onchocerciasis Secretariat, my dependable, hardworking and very punctual companion for accurately recording all interviews and in helping to prepare the report. 94

-1 MAY 1 t' OCP /VCU TAMALE SECTOR lt OF lTI sEcT'oR 1 trbIIowing important rain fa11s in Yendi, Salaga and. Tamale areas, alr areal survey was undertaken in order to observe the hyd.ro- logical situation mainly on the DAI(A river a"nd. also the rivers Bonalgre, Bassa, Mo1e, Kulparm and Sissili. 1. RIVm DAr"A - (t7tfr Uay, 1977) The portion of the river Daka, between Dogonkade and Sabon-Gid-a usually start flowing before the upper and lower Daka. Ttris portion was prospected and sti1l remain a scene of long pooIs. However some of them were corununicating and. five (5) smalf breed-ing sites of less significance were d.iscovered upstream of Ecumdipe and. d.or,'nstream of the Road Salag'a/Bimbila. One of them, Gite No.2 (see map No.1A) near the Komoo Confluence was positive with a few larvae and pupae of Sirmrlium d.amnosum whiLes in the Gite No.1, no aguatic stage of S .damnosum was recorded. except some empty cocons and pupae and l-arvae of S.adesi. The Komoo River was found d.ried. In connection with the existence of those breed.ing sites, thedispersal of the Ad.ult flies shov.,s an interesting picture. Tables 1 a3d. lgive the routine weekly catches on the Daka river in Mqy, 1976 and. May,1977. Obviously the flies caught d.uring the month cou1d. not be issued from new breed.ing sites which could have taken place after the prospectionsd.ates. If this is the case, suggestion can be mad.e that the origine of theflies caue!! along the Daka river, especially at Dosonkade, hglg_g5ilg(and. even Klupeni):.n laay 1975 should be ttre lreedTiffis ffiated- between Dogonkade and En:rd.ipe. 2. RIIIffiS: BASSA AND B0NAIffE - ( tTtn uay, 1977) hospected from the le,ke Volta to their respective brid.ge:at l(passa tovm and Bonalgre town. fhey were found. d.ried. 3. MOLE - (t8trr uay, 1977) - Dried. 4. SISSILI - Dried. from its Confluence with the Kulpawn River to Wiasi A=e" --('lffiMr.y, 1977). 5. KUtpAwN - (t8tir Uay, 1977) Very 1ow hydrological cond.ition. Paos frcr1 I I Pfevious areal prospections of the Daka on l8th l,lay, 1)'16, have shown more breeding sites on the same portion of the River, to the exclusion of the other portions. Ihe first breeding site (with S.d.amnosum) was then sttuated, upstream of brid.ge on the Salaga/nimbila Road.l No-low was observedin this site on the llth lvlay, 1977 (see Map No.2). Dring an other prospection, on the 2nd June, 1976 the same sites were recorded and also on the Komoo River. 0n1y one breeding site eristed. d-ownstream of Sabon-Gid.a, and. Upstream of Dogonkade, the Daka river rernained dried, - (see Map No.3). /...2 \ 0' 2 6. KULpA 1 AND SALO - (r8tn uay, 1g77) No aquatic stage of S.d.armosum was recorded.in two sampl es - one at the Water falIs and the Kuld.a 1 and the other one on the Salo River. '1 . t[r]TE voLTA - (t8tn laay, 1977) Routine assessement of the }arva1 control at: DA3OYA d,ownstream, Daboya, Daboya upstream, Lungbunga,Weni, Dipare, Sugtr, and l{ara, have shor,sn an excellent situation of the treatments except at Dipare where fewpupae of s.d.amnosum were found.. Last d.ate of treatmentlJth May, 1977 . -ffi{ > <,' "Z e. {.\sF'--o l-lt: E,tl :t;t:.""' ;"; ! | | :-'. t,\C itO. ('(: )t : i:i.,!. ;'.1 .,w,'i l,:I.ttl P. O. Do.; 2Ll, 7',l,ll..tLE -) oH C5 I o Eq a \o \o \\Lntr\ Lr\ \o oo \o F_ Lr\ cv o \o tr- tf\ o\ .a \o c- ta\ \oN 0){, .r{(Ilq+ o EOiEd ..{ dd rJ O .-lo tu(5 oP If{(0HptroB.ooodZda f'1 O.H e E \ot- lr\ .+ o \o \tr\ r C\J \o tr- tr\ U-tN tr\ a dd 'rl(5 I o .oda d H o Pi 'rt 0)Fo)!miroh)fp .d AE: qpago 6E9rH.AA trlag o oo \o{ n !- tr- \o \o \\I't Lr\\. -\ rO =f sf F-- \o \o \\ta\ Lr\ OrN(\ N.n \o \oD- tr-- Lr\n tr-@(\ (\ @o\ u HaaoE ; F. H \o^t-- \o -\ tr- -n --\\\ F\tr\\ c\.l \o v C\] N.+ h! H .rl F{t\odtr- g.1Ln d\otr-['{ r (H oo .PA Hgo .r-t .r{ +boogo) .rl qrdaooOF{tr P.p oo.cZ+ H tr o,D H \o F-\ta\ (\ \o \otr- D- l'r\rr\ Lr\tr-NN rrn F] Er H a qi o o 'rlIP9\H{lg*- &L a J4 trd E o)H J4 o c)B +$ ,v o o .d F{ rO o oB .c, H c! J1 o o)B P a M trl r4 B \o D-- o\ >r I E F-l H M e -l HHI HFfl €l z E..|I a trl () Fr O a trlH Ef l=l TABLE 2 FrrEs DmrsIrY - ItraY, 1976 0N IAKA lIlrEE STATIONS IGupeni fnPala Cross Dogonkade Erundipe Sabon-Gid.a RU{ARKSDATES CAUGHT DISSECTD PAROUS 21/5n6 25/5/15 27 /5fi6 1 1 3 1 1 3 1 1 2 25/rfi6 z6/s/te 2 4 Z 4 2 4 t /s/t e 13/5/7 5 14/5/7 6 20/5/7 6 21/5/46 27 /5n6 z8/5fi6 7 14 7 2 3 B 9 I 13 7 2 3 B 9 4 9 6 I 2 8 B 4/jfi6 11/5n 6 fi/s/t e 25/5/76 0 2 1 5 0 2 1 5 0 2 1 4 5/5fi6 6/>/t a 12/5/76 1e/5n5 26/>/t e 0 o 0 3 1 0 o 0 3 1 o o o 3 1 Ed o tuq0Pg[ad .-l H.drd B .-to o(5ord IFHpoo +.oO.r{ (dZaa l-- tr- \\lr\ La\ Lr\ ra oo tr- tr-f'- F- lr\t.\ C\J ..) oo t-- tr- \\rn l.\ O\O C\l oo cH(J J o Fq a a Q) o+d o o TD o .q o+d o o tr]p- Hg trl a o oPd C) oz o dd 14 o EO oe H a) 0) B+q)OQr .O .-l EOEgt! ..r J4dF{ oodt{H md tr1a3 O oa F- tr- \\ oo tr\tr\ rf) -+ tr- f-- \\Lr\ LN Oe rO tr- c.- \\rJ\ tr\ oo r'- @ H Ok() Fl p" tsr F-- \tr\ trtt o a o o+d o o a o oPd o o l._ F.- l.r\ oN o Ed o F{P a a. o € .rl a oq0 rCHd 'r{ JdrdHoooq0 tiO PQ O q-.1Zo a trl Fl H a F-F- tr\ \o o H E o. H t-F- L.\ rn tr- tr- o\ >-rg I E Ed HN g c t'l Itr Er o H Ha ae a Hl H1 Hi EI UIHtr.oF- 'rl c^ .. ..iJ r ulo ,140)hL o.dd oEEoO tr@Eo-- j4 o o3 {5 .+ J4 0) G) dl'rrn 11 o o)B 'di C\J J4q) 0)B P o h4 F-l Fq B EfL :!j,, :lt { ''r JT ,IL .,,1 'i '*", '&, +q t. .t * i T ,,1 t: l.. - .i. ,l a ;t 1. { t o + + t'' I \ ,i- ,.i _ :\ .:' a,1,rt.r:* t - ,.4: a l- {. .-k <i .! a'1 .1. 'a I h aa, I .r I .. \' .: :r .* 'r 1.1 .{ a .{ ..: -{11 \ .( ('t; ,l .t\ I I ! ll 1":f f ) I, \ il: ilr t '1.- 4 !"- -i1 /< :i a -rt a t. ' :/ ,..+- -.-.. {.1jL.LJ -:-r,tu',.r.I**-*i ,; _l -l +i -a I"?/ "i c \ : t',' ;! s',.{t,.' L... . :, t:r- . +': ,-i r1 Hft9 N'-g lr I/r/ P 'gsyy*$1t'9 f,' r:.-' t'"; i,"r {" H <;k^/ --+-- Hii_.- njj .1 \ e.ti+r+fL -+_: \ ( .M-I L, ,fu Lt N TAMALE .t ,,{,. IY EN OI a \\ i , Dtt e t c/) af o f \ i)Qcoof a \'" \. aaa oa .r{i l '' l .t:l ,I foe sEilrEMgR€ 1976 BEm6 sir6 4whP N13 Vilo:pe ,tuoyt2 -&^- 2-*u d,u f ;l- 1:-1ta^^.-a.,1, X.."--\ t' i I I I I t I I I I I I ri I I I i i i I : I i I I I C 1 .i.. /_.. {i'.",., -, ,i'.gi lv v 7 N la A .4. TAMALEt - '1i' 4 I[$b rrlolP.cTtoN ltt '?/ t/V7 oolr SEPTENffiE ,976 $ itu ) ) _,-+ ' I f ,>\^iN; h.^" H ffi E- I I ,eL-;*,"**!,Jr , l. -.-.r-;;--.iif-*- . -,-- .;-r,;l-''ii1rr;fla',ifili a.i T t