North Cameroon NOTF/WHO APOC project yearly technical report Mectizan distribution: November 1st, 1999 - October 31st, 2000

NORTH CAMEROON NOTF/WHO.APOC PROJECT YEARLY TECHNICAL REPORT MECTIZAN DISTRIBUTION November 1", 1999-October 31*t, 2000 GLOBAL 2OOO RIVER BLINDNESS PROGRAM MAY 2OOO EXECUTUYE SUMMARY The Northern Province covers 65 000 km2, with an estimated population of about I 200 000 inhabitants. It is divided in four administrative divisions made up of twelve Health Districts and seventy two Health Areas. The Foulbe constitutes the dominant ethnic group. The displaced population from the Extreme North Province and the refugees from chad are cause of constantly changing population figures. Another difliculty is the long distances between poorly accessible communities and the acute shortage of health personnel. Nodule prevalence surveys carried out in 1992 revealed that onchocerciasis was primarily endemic in the southern part of the province in 6 Health Districts out of twelve, namely Tchollire, Toubouro, Rey Bouba, Poli, Lagdo and Touroua. A year later, Mectizan treatment started in 1993 in 2 Health Area, under the auspices of River Blindness Foundation. During the third and the fourth year, five more Health Areas were recruited. In 1997 Global 2000 took over and the treatment was extended to 6 more Health Areas. With APOC assistance in 1998, the distribution was extended to 14 more Health Areas. Currently with the new census enumeratior\ 27 Health Areas are receiving ivermectin either through CDTI strategy or through outreach strategy in 528 communities. The government of Cameroon has adopted CDTI as National Policy and accordingly, because of field constraints, a transition plan has being implemented to use CDTI in 70 Yo of the communities.734, CDDs have therefore been trained in about 400 communities. Eventhough the period covered by this report extends from November l$,1999 to October 3l$,2000,most of our activities have been scheduled, between February and August as follows : February 29h-March 4hr2000 Procurement and shipment of Mectizan to project site/Program review at Yaounde headquarters March 6th and 7m Coordination meeting at the Provincial HQ/Retraining of trainers session. March ath-april 7th r2o00 Census enumeration/Selection of CDDs April 10tr-t76,2ooo Procurement of IEC materials and supply/Advocacy meetings April lEtr-May 8m Training of health district teamVTraining of CDDs/Nlobilization of Communities May l5s-June 306,2000 Di stributionflVlonitoring/Supervi sion July l7e-August 31il Reporting and evaluation/Estimation of Mectizan needs/IVlectizan order The achievements of the project are the expansion of CDTI to 70 o/o of the communities and the integration and readiness of activities proceeding the distribution.The strengths of the CDTI implementation process include distribution in poorly accessible communities or areas with shortage of health personnel, the empowerment of the communities, the support of the program by all tiers of the administrative structure and full integration of the program. The timely release of APOC funds and heavy APOC administrative burden on NGDOs remain the major constraints of the progra.m. 2SECTION I : BACKGROT]ND INFORMATION The CMRM2 project is located in the Northern Province of Cameroon, covering 65 000 km2, with an estimated population of about I 200 000 inhabitants. The province is divided in four adminisfiative divisions made up of twelve health districts and seventy health areas. It shares boundaries in the north with the Extreme North Province, in the east with the Chad Republic and the Central African Republic, in the west with the Federal Republic of Nigeria and in the south with the Adamaoua Province. The Foulbe constitute the dominant ethnic group and forms the indigenous population of the area with others large tribes including the Mboum, the Namji, Moundang, Mafa, and the Mbororo, who are nomadic cattle herders. The displaced population from the Exfreme North and the refugees from Chad are the cause of constantly changing population figures. This report covers the second year of disfiibution. The installments of 21 079 600, 24 140 448, 13 250 000, and 7 052 976 Frs. CFA were received respectively in November l3th' 1998, April 30n" 1999, February 2ge,2oo0 and April2000. This year, ow treatment activities are going to target the hyper/meso endemic communities, involving 6 health Districts in the southern part of the province, namely Tchollire, Touboro, Rey Bouba, Poli, Lagdo, and Touroua as shown in the Implementation plan in the annexe. 1) Number of communities in hyper and meso endemic Districts. During the last Census enumeration recommended and sponsored by APOC, the population estimate was adjusted to 290 937 and the number of hyper/mesoendemic cornmunities was noted to be 528. 3Table I : Level 2) Number of villages receiving lvermectin before and number receiving now At the beginning of the activities, to avoid late distribution during the rainy season, the activities were prefinanced by GRBP headquarters in Atlanta. The CDDs were trained only in poorly accessible communities and in communities with acute shortage of personnel. During the second year, we had planned to train CDDs in 40 Yo of communities, 30 Yonyear 3 and 30 % in year 4. This gradual increase was necessary because extended training sensitization and mobilization were needed to ensure adherence to the new sfrategy. These needs were further compounded by the fact that the project area was large, poorly accessible with a low population density and an acute shortage of health personnel. Table 2 : CDTI IMPLEMENTATION PROCESS 98 99 #of endemic communities Estimated Population #of endemic communities # Districts #of endemic Area Estimated Population 1 3 I 9r766 tt6I Touboro 8 70190 1402 Rey-Bouba 3 23294 45 27928 62Tchollire 5 44887 103 554573 120Poli 7 35350 92 39s394 s7619 675 Lagdo 3 46978 35 236 Touroua I 9173 25 18634 290937 528Total 27 229 872 431 Districts # of endemic communities # of CDTI communities 1998 # of CDTI communities 1999 Projected # of CDTI communities 2000 Tchollir6 116 8 32 82 Toubourou 140 9 58 98 Rey Bouba 62 3 23 44 Poli t20 l3 39 108 Lagdo 67 0 25 48 Touroua 23 0 5 20 Total s28 33 182 400 43) Number of times the communities/yillage in the project Area have received treatment. From 1993 to 1996, the distribution was carried out by the Minisry of Public Health, with assistance from the River Blindness Foundation (RBF). In 1996, the role of RBF was assumed by the Carter Center's Global 2000 River Blindness Program (GRBP). This partnership with the Minisfiy of Health continued until 1998, when APOC became part of it. Before the APOC Project therefore, communities were receiving Ivermectin under the oufreach system, which relies on the health center and staff for Mectizan distribution. In this case, the nursing personnel takes the drug to the villages and distributes it at a minimal cost. The communities in the project area have received treatment under the above mentioned guidelines stipulated by the MOPH five times since 1993. Under APOC sfiategy, these communities have received treatment two times since 1998. 4) Community definition A community refers to a group of persons that settle according to cultural and ethnic affinity, and that has chosen a place as a cenfial meeting point and has a leader approved by all. SECTION 2 : IMPLEMENTATION OF CDTI YEAR 2 Name : Northern Province NOTFA'IIHO-APOC Date of commencement of APOC ASSISTANCE : MAY 1998 The technical report covers the period November I't, 1999 through October 31$ 1999 In accordance with our Plan Of Action, CDTI activities were expanded to 40 Yo of our project Area, thus covering 182 communities. For the period covered by this report, our objectives are to implement CDTI strategy n 70 o/o of our communities where 734 CDDs are being frained in about 400 communities. 30 % of the remaining communities w0ill continue with the outreach strategy as explained earlier. 5TRAINING The retraining session of the Provincial team followed by the progam levr_ey were held in the local Headquarter in Yaounde from March lst to March 3'o, 2000. The provincial team, namely the Health Delegate, the Chief of Service for Community Health and the three Onchocerciasis Project Coordinators were present. The meeting was chaired by the Carter Center Project Advisor assisted by the National Onchocerciasis Coordinator- The objective of that gathering was to review and evaluate past activities and to recommend solutions for identified consfiaints and weaknesses of the program. Emphasis was also put on APOC Administrative and technical procedures and guidelines. Following the session in Yaound6, refiaining course was held at the Provincial headquarters in Garoua for the District teams on March 6ft and ln' 2OOO. From April 18ft, the reffaining session for the health area teams were scheduled followed by fiaining sessions of CDDS. The places of fiaining and the number of frainees are shown in table 3 Table 3 : Training of the different levels of staff involved in CDTI implementation. 34 retraining sessions including the provincial session were held throughout the Project zone. During these sessions, 5 trainers of trainers were frained as well as 16 districts and 32 health Area Staffs. At this moment the fiainingof 734 CDDs has been completed in all disfiicts. These CDDs were selected by their communities during the census exercise. The training sessions were centered on Districts #of taining undertaken #of TOT trained #of District Stafftrained #of Health Center Stafftrained On CDTI #of CDDs fiained Tchollire 6 I aJ 5 rcz Touboro 9 1 J 8 300 Rey Bouba 4 aJ 5 49 Poli 8 I 3 9 118 Lagdo 4 I 2 4 116 Touroua 2 2 2 I 49 Total 33 5 t6 32 734 6APOC guidetines, program o\ilnership and participation by the community, identification of the disease, Mectizan disfiibution, management of adverse reactions, and reporting. Table 4 : Implementation of CDTI Districts #of communities #of communities which selected CDDs #of communities which collected Drugs #of communities decided on method of disnibution #of communities that decided on month of distribution #tf communities which trained CDDs #of commutiltl€5 paying CDDs in King or in cash. Tchollire 116 82 82 82 82 82 Touboro 140 98 98 98 98 98 Rey Bouba 62 44 44 44 44 44 Poli 120 108 108 108 108 108 Lagdo 67 48 48 48 48 48 Touroua 23 20 20 20 20 20 Total s28 400 400 400 400 400 As you can notice the column "# of communities that decided on month of distribution" is blank because, eventhough some communities might have selected specific weeks for distribution, the month was decided in accordance with the Disffict Plan Of Action that had taken into account the field activities. Table 5 : Training of CDDs Districts #of endemic communities # of communities implementing CDTI # OF CDDs trained Tchollire lt6 82 102 Touboro 140 98 300 Rey Bouba 62 44 49 Poli 120 108 ll8 Lagdo 67 48 ll6 Touroua 33 20 49 Total s28 400 734 7The following is summary of activities carried out since November 1999 February 29th - Procurement and shipment of Mectizanto project site March I't - 3d - Program Review at Yaounde Headquarters. - Retraining session for Provincial Team. March 6tor 7" - Coordination meeting at the Provincial Headquarters. - Retraining at of District teams. March E'h - April,7'o,2000 - Census Exercise - Selection of CDDs by communities Aprit loth - lTthr2ooo - Proctrement of IEC materials and supplies - Advocacy meetings (Adminisfrative authorities) April 18th - May 8th - Reraining of Health Area teams - Training of CDDs - Mobilization of communities MAY lsth - June 3oth, 2000 Mectizan freatment to 528 communities Monitoring and supervision of the treatment Areas July llh - August 31't - Reporting and Evaluation - Estimation and Mectizan order These training sessions and meetings provided the opportunity for district teams, namely physicians, mrses and health committees to sensitize the local administrative, traditional and political authorities about CDTI strategy. Tables 6 provides details of the contents of the training sessions. 8Table 6 : Types of Training our project's Annual Training Objectives are the following : Table 7 : Annual Treatment Activities Type of training Total trained Type of Material used Facilitation team Major Constraints Provincial Training t9 Flip charts Posters Manual aild Writing materials Provincial team Long distance to cover Security perdiem and fravel cost District Training 32 Flip charts Posters Manual and Writing materials District team And OPC Long distance to cover Security perdiem and travel cost Health Area training 734 CDDs Posters, ffeatment books Tapes, measuring rods chalk Health are Nurse + OPC Insufficient resources logistics Group size ATO 7o achieved total # of training to be undertaken 33 100 % # of TOT to be trained 5 100 o/o # of District staffto be frained t6 100 o/o # of Area health centers staffto be trained 32 100 % # of CDDs to be frained 1048 70% 9The achievement rate for the training of CDDs in accordance with the Plan Of Action was anticipated though as we plan to achieve 100 % next year. IEC Materials were developed and harmonized and were used for sensitization and mobilization sessions throughout the project area. The training materials haven't been harmonized yet. APOC Manuals and tapes have been used for the fiaining of Health staff and CDDs. Some CDTI materials from Douala and Nairobi seminars have been used to infroduce the new concept to local authorities and target communities as well. [n general, the CDDs did perform well as expected. Table 8 : Mobilization and Education of Target CDIT communities Mobilization at the community level was aimed at ensuring community involvement with emphasis on their : - Attitude and acceptance of the project - Selection of CDDs by the communities - Timely collection of Mectizan from agreed points - Payments of incentives to CDDS - Decision on the mode and time of distribution - Education of the communities on the disease and its treatment. - Importance of the extended treatment. The mobilization and IEC in the endemic communities was best achieved through the involvement of adminisfiative and taditional authorities, focus groups, and outreach by Public Health mrses to the communities. Developed and harmonized materials by the NOTF namely posters, flyers, flipcharts were Districts #of communities mobilized # of communities which receive FIE about importance ofextended treatment # ofAdvocacy visits to state director of health #of MOPH staff involved in mobilization #of NGDO staff involved in Mobilization Tchollire 82 82 1 9 I Touboro 98 98 I t2 I Rey Bouba 44 44 1 8 Poli 108 108 I l3 I Lagdo 48 48 I 7 Touroua 20 20 I 5 2 Total 400 400 6 54 J t0 also utilized as tools for health education. Table 8 above details the mobilization activities that took place. The mobilization efforts were encouraging, especially the involvement of traditional and political authorities which contrnues to bring about positive affitudes and acceptance toward the program. They continue to attend mobilization meetings. The communities seem to be responding well to the new approach (CDTI), and as a result have taken charge of their own distribution. Communities continue to arrange for the collection of their drug by the CDDs and they have been deciding on the mode of distribution. The period of distribution was decided by Districiteams because of logistic and financial constraint. They were however able to decide on the weeks of distribution. Improving mobilization of target communities To finther improve mobilization of target communities there is a : - Need for more posters in both French and Arabic since Arabic is widely spoken and understood in North Province. - Need for more flyers and brochrnes targeted at local authorities and opinion leaders. - Need for flipcharts for use in health centers and target communities. - Need to increase awareness by having an onchocerciasis week. SECTION 3 : ACHIEVEMENTS Although this reporting period begins in November 1", 1999, a total of fi7778 persons were treated in the 6 districts in the Northern Province of Cameroon in 1999. Of which 42267 were fieated under the CDTVAPOC sfiategy in the districts of Lagdo, Poli, Tchollire, Toubouro, Touroua and Rey-Bouba. Treatment was gtven in 160 communities out of 177. The overall coverage rate in the CDTI area was 48 %using the estimated population. Table 9 and table 10 summarize the overall fieatment activities and the fieatment activities by the CDDs only. 1l TREATMENT ACTIVITIES BY DISTRICT NORTH Table 9 TREATMENT ACTIVITIES BY CDDS ONLY Table 10 DISTRICTS Estimated poputation Total Treated oh Coverage # of target Communities # of communities treated o/o Coverage LAGDO 36900 8294 22o/o 29 24 83o/o POLI 12782 5053 40o/o 39 36 92o/o TCHOLLIRE 10881 7113 650./0 25 24 xt% TOUBORO 1 9050 15432 81olo 58 50 860./0 TOUROUA 31 00 2558 83o/o 10 10 100Yo REY BOUBA 54EE 3E17 70o/o 16 16 100o/o TOTAL 88201 42267 4Eo/o 177 160 90% As discussed earlier CDTI has expanded to 70 Yo of hyper/meso endemic communities. All training and mobilization activities have been completed. Mectizan tablets have been delivered to all Area Health Centers by the CAPPT personnel where they will be picked up from by CDDs, according to their treatment plan and objectives. The distribution period will also be a determining factor for the pick up time. Treatments are scheduled to begin by May 15ft. I DlSTRICTS Estimated poputation ATO Total Treated o/o Coverage HRV/ARV ATO HRV/TTT ARV o/o Coverage LAGDO 42938 34350 1 5835 460/o 35 26 74o/o POLI 34817 27854 13556 48.600/6 92 87 9506 TCHOLLIRE 44887 35909 21905 61o/o 103 96 93o/o TOUBORO 65489 52392 42366 80.80% 131 131 10006 TOUROUA 10512 8410 3729 44.3oo/o 25 15 600/o REY BOUBA 22249 17799 10387 58.30% 45 30 67% TOTAL 220E92 176714 107778 50.90% 431 385 E9% ' CAPP : Provincial Drug Agency t2 Although the CDDs were selected by their own coilrmunities, some abandoned the program because they felt the level of motivation was inadequate. As a result remuneration of CDDs has gone from 25 % to 32 o/o of cost recovery funds. Given the fact that these CDDs have to give up their activities without any esffiFensatsry qdns, ghurterifiE thE distibutistl Fetisd tniuht be the sultltiutt tu ttrii broUtem. In general, all trained CDDs performed up to par despite the fact that some of them left. Some of the difficulties encountered were the lack of motorcycle in some health areas, the fluctuating census data because of steady migration of populations from the Exfieme North, in search of fertile land for farming. Progressive adhesion to the program has been noticed in spite of continued nrmors about the drug effects. The program will continue to provide the necessary health education to the communities, while seeking the support and endorsement of opinion leaders and traditional leaders. As the beginning of treatment approaches, in order to reach absentees and defaulters, wo need to ensure that the treatment coincides with when most people are home, and mop up ffeatments should be scheduled on non-farming and school days. MONITORING AND SUPERVISION Supervisions have been carried out at two different levels : - District level are supervised every 3 months by the provincial team to ensure that the procedures had been followed as plannsd and that the objectives had been reached. - The district teams in turn supervise the health area team once a month and the health area teams supervise the CDDs twice a month. SECTION 4 A . STRENGTHS OF THE CDTI IMPLEMENTATION PROCESS. Poorly accessible communities or areas with shortage of health personnel have been receiving Mectizan freatment. Communities have been taking charge of their own distribution by collecting their own drug, choosing their own distributors and the mode of distribution. The empowerment of communities through the CDTI process has strengthened local dialogue structures, rendering them more functional. l3 Local traditional, political and administrative authorities have already expressed their support of the new sfiategy, by attending most of the mobilization meetings. AII Primary Health Care personnel have been trained on the CDTI strategy and are fully involved in the training of CDDs. The CDDs are supervised by the area nurses, and the Onchocerciasis Supervisors. The health facilities are used as collection points at health area level. All the above factors make CDTI strategy easy to integrate into the PHC system. B . WEAKNESSES OF THE CDTI IMPLEMENTATION PROCESS Funding delays resulting in GRBP prefinancing unbudgeted funds for activities. Heavy APOC administrative burden on NGDOs due to reporting requirements and multiple on going unplanned activities. Poor data quality and inconsistencies may be increased as a result of irregular supervision. Inadequate supervision of CDDs due to poor accessibility to some communities or to lack of logistics. Insufficient incentives offered by the system resulting in CDDs leaving the program, which can be compounded by the lack of commitment of some communities to support their CDDs. High CDDs training cost leading to inadequate CDDs : population ratio. In summary, the major achievement of the project has been to be able to keep up with the transition plan which will allow us to implement CDTI in 70 o/o of our communities. That achievement has occurred in spite of the inaccessibility to some communities and the long distances between communities. During the first year of the program, the 33 fiained CDDs had reated 4543 persons as a result of the then existing National Policy. Today, the National policy has changed and some 700 CDDs have been fiained throughout the project area. This will result in having over 70 o/o of the eligible target population being treated By CDDs. Having the remaining 30 o/o of communities under outreach strategy will be quite a delicate task for reporting purposes. The challenges remain the continued acceptance and ownership of the progftlm by the communities including the CDDs, whose motivation system is essential to the progriun. l4 TYPES OF SUPPORT NEEDED a) From Government - Increased counterpart funding. - Involvement at the highest level for full mobilization of all tiers of government. - Ensure that project vehicles and equipment are used exclusively for the intended purpose. b) From APOC - Timely release of approved funds to enable coordinated and harmonized planning of activities. - Reduction of reporting demands and unplanned activities. - There should be fewer intermediaries for direct communication with the NOTF. c) From the communities - Communities should be more active in selecting and motivating their CDDs - There should be more personal involvement to CDTI activities. 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