NGNIG 4 project annual project technical report to Technical Consultative Committee (TCC): January to December 2003

YEAR FOUR ANNUAL PROJECT TECHNICAL REPORT ON THE NIGER STATE COMMUNITY DIRECTED TREATMENT WITH IVERMECTIN ANNUAL PROJBCT TECHNICAL RBPORT TO TECHNICAL CONSULTATIVE COMMITTEE (TCC) AFRICAN PROGRAMME FOR ONCHOCERCIASIS CONTROL (APOC) COUNTRYAIOTF: NIGERIA Proiect Name: NGNIG4 Approval vearz l99l Launch vea 2000 Reportine Period (Mo : JAITIUARY TO DECEMBER'20O3. Date submitte dz 30 11212003 NGDO partner: UNICEF WHO/APOC, 26 September 2003I JANNUAL PROJECT TECHNICAL REPORT TO TECHNICAL, CONSULTATIVE COMMITTEE (TCC) ENDORSEMENT Please confirm you have read this report by signing in the appropriate space. OFFICERS to sign the report: country : NIGERIA/LIBERIA National Coordinator Name Signature Date Zonal Oncho Coordinator Name Signature: .... Date This report has been prepared by Name : R.Y.DArrI Desisnation : STATE ONCHO. COORDINATOR.I Signature : Date ll WHO/APOC, 26 September 2003 Table of contents DEFINITIONS v FOLLOW UP ON TCC RECOMMENDATIONS.. ..........1 EXECUTIVE SUMMARY......... .......2 SECTION 1: BACKGROUND INFORMATION .............3 1.1. GENEnU TNFoRMATToN 3 l.l.l. Desuiption of the project (briefly) .....................J 1.1.2. Partnership........ ..............-3 1.2. PopulerroN AND Healru sysrEM 8 SECTION 2: IMPLEMENTATION OF CDTI....... ........10 2.1. Pnn:oo oF ACTrvrrrES 2.2. ORoeRnc, sroRAGE AND DELIVERv oF TvERMECTIN 2.3. Aovocecy nNo SeNsrrrzATroN 2.4. MonrlrzeuoN AND HEALTH EDUCATToN oF AT RJSK coMMLINITTES 2.5. COIT,IIT{T-D'ITTIESINVOLVEMENTINDECISION-MAKING 2.6. Capecrry BUTLDTNG 2.6.1. Training.... 2.6.2. Equipment and human resources.. CoNpruoN oF THE EeUIeMENT * Plsass srATE 2.7. TRenrveNrs 3.1. FmeNctm coNTRIBUTIoNS oF THE pARTNERS AND coMMUNITIES 3.2. OrHen FoRMS oF coMMlrNrry suppoRT 3.3. ExpeNorruRE PER ACTrvrrY l0 t4 t6 18 22 24 .........24 .........27 27 28 2.7.1 Treatment figures .............. 28 2.7.3. Trend of treatment achievement from CDTI project inception to the current year 332.8. SupeRvrsroN 34 SECTION 3: SUPPORT TO CDTI....... ..........39 39 40 40 SECTION 4: SUSTAINABILITY OF CDTI........ ............41 4.1. INreRNer-; INDEIENDENT pARTrcrpAToRy MoNrroRrNc; EvelueuoN 4l 4.2. CouuuNrry sELF-MoNrroRrNG eNp SrareHoLDERS MEEUNc 42 4.3. SusrerNngILITy oF IRoJECTS: eLAN AND sET TARGETS (MANDAronv er Yn 3) 44 4.4. INrecRarroN 45 4.5 OppnerroNAL RESEARCH 46 SECTION 5: STRENGTHS, WEAKNESSES AND CHALLENGES......... .....46 Apendix I MAP OFNIGER STATE SHOWING THE ADMINISTRATIVE BOLINDARIES............5l Apendix 2 PLAN OF ACTION FOR YEAR V CDTI IMPLEMENTATION IN NIGER STATE... ......52 ll WHO/APOC, 26 September 2003 Acronyms APOC ATO ATO CBO CBS CDD CDTI CSM DHS KAP LGA LOCT MIS MDP M&E MOH N/A NIDs NGDO NGO NOCP NOTF PHC RBM REMO SAE SHM SOCT TCC TOT UNICEF UTG wHo African Programme for Onchocerciasis Control Annual Treatment Objective Annual Training Objective Community-Based Organization Community Based Supervisor Community-Directed Distributor Community-Directed Treatment with Ivermectin Community Self-Monitoring District Health Supervisor Knowledge Attitude and Practice Local Government Area Local Onchocerciasis Control Team Members Management Information System Mectizan Donation Programme Monitoring and Evaluation Ministry of Health Not Available National Immunization Days Non-Governmental Development Organization Non-Govemmental Organization National Onchocerciasis Control Programme National Onchocerciasis Task Force Primary health care Roll Back Malaria Rapid Epidemiological Mapping of Onchocerciasis Severe adverse event Stakeholders meeting State Onchocerciasis Control Team Members Technical Consultative Committee (APOC scientific advisory group) Trainer of trainers United Nations Children's Fund Ultimate Treatment Goal World Health Organization lv WHO/APOC, 26 September 2003 a Definitions (v) (i) Total population: the total population living in meso/hyper-endemic communities within the project area (based on REMO and census taking). (ii) Eligible population: calculated as 84Yo of the total population in meso/hyper- endemic communities in the project area. (iii) Annual Treatment Objective: (ATO): the estimated number of persons living in meso/hyper-endemic areas that a CDTI project intends to treat with Ivermectin in a given year. (iv) Ultimate Treatment Goal (UTGI calculated as the maximum number of people to be treated annually in meso/hyper endemic areas within the project area, ultimately to be reached when the project has reached full geographic coverage (normally the project should be expected to reach the UTG at the end of the 3d year ofthe project). Therapeutic coverage: number of people treated in a given year over the total population (this should be expressed as a percentage). (vi) Geographical coverage: number of communities treated in a given year over the total number of meso/hyper-endemic communities as identified by REMO in the project area (this should be expressed as a percentage). v WHO/APOC, 26 September 2003 +FOLLOW UP ON TCC RECOMMENDATIONS Using the table below, fill in the recommendations of the last TCC on the project and describe how they have been addressed. TCC session 17 (Please add more rows if necessary) 1 Number of Recommendation in the Report TCC RECOMMENDATIONS ACTIONS TAKEN BY THE PROJECT FOR TCC/APOC MGT ASE ONLY 261(i) State should contribute funds to project - A memo was forwarded to the State Government, in request of US$30,000. The response is still awaited - A State level Stakeholders' meeting is scheduled for the first quarter of year 2004. 261(i.) Census should be done in 30olo of the LGAs using the appropriate levels of CDTI Census was updated during the last treatment and an intensive census update to be suppofted by UNICEF is scheduled for January/February 2004. WHO/APOC, 26 September 2003 Executive Summary Niger State has 25 administrative divisions known as Local Government Areas out of which 21 are implementing CDTI. The projected population for the State is 3.2 million (i.e. based on the 1991 census). There are 2,520 affected communities in these 21 LGAs with an estimated population of L,682,L57 at risk of infection and blindness from Onchocerciasis. During the period of report, 879,9LL people were treated in 1,969 communities. The ATO for the year was 1,139,606. These figures represent 52olo therapeutic and 78o/o geographic coverages respectively. The Ultimate Treatment Goal (UTG) for the project will be determined by the end of the first quarter of year 2004 when census for 4 newly added LGAs and additional communities of 7 old treatment LGAs which were found to be qualified for CDTI (as a result of REMO update and finalization of January, 2003) is completed. However, the estimated UTG for the project could be as much as 1,413,006 people. Not all of the treatment repofts were received from the LGAs at the time of submission of this repoft, however based on data available, the UTG coverage is 620/o. The population in over 40o/o of the project is very highly migratory, comprising of ethnic groups such as Gwaris, Kambaris and nomadic Fulanis. Due to the cultural beliefs and practices of the first two groups, they migrate annually both within and outside the State in search of virgin (fertile) land for growing cash crops such as yams, guinea corn, maize and millet, while in the case of the nomadic fulanis; they migrate in search of water and fresh fodder for their animals. The above phenomenon is responsible for the highly nucleated and dispersed settlement pattern that features in over 600/o of the vast land of the project. 4,L06 CDDs were trained/retrained(72o/o of ATO), at a ratio of 1 CDD to 410 population, while 10 SOCT and 733 LGA/PHC workers were trained and retrained on Community Self Monitoring as well as for improved record keeping. The later achievements represent 100o/o and 1690lo coverages of ATros respectively. The biggest challenge the project experienced within the year was achieving its' ATO of 1,139,606 in the 21 CDTI LGAs, inspite of late receipt of donor funds, and lack of State Government funding, which was compounded by unstable leadership at LGA level,and which resulted in poor funding at that level. Frequent change of political leadership, coupled with poor funding was therefore, a major constraint to the smooth conduct of CDTI activities at that level. In fact, the last leadership was dissolved during the first week of December 2003, in preparation for election of a permanent LGA council by the end of January, 2004. 2 WHO/APOC, 26 September 2003 SECTION 1: Backgrcund information 1,1. General information 1.1.1. Description ofthe project (briefly) - Geographical location, topography, climate - Population: activitds, cultures, language - Communication system (road...) - Administrationstructure - Health system & health care delivery (provide the number of health posts/centers in the project area if the information is available). 1.1.2. Partnership - Indicate the partners involved in project implementation at all levels (MOH, NGDOs -national, intemational) - Describe overall working relationship urmong partners, clearly indicating specific areas of project activities (planning, supervision, advocacy, planning, mobilization, etc) where all partners are involved. - State plans if any to mobilize the state/region/district/LGA decision-makers, NGDOs, NGOs, CBOs, to assist in CDTI implementation. L.1.2. Description of project Niger State is geographically located within the middle belt of Nigeria. It lies between latitude 3 20'East and longitude 1i 3' North. It is bordered by Zamfara State on the North, Kebbi State on the North West, Kogi State on the South, Kwara State on the South West, Kaduna and Federal Capital Territory of Abuja at the North East and South East respectively. The State shares a common boundary with the Republic of Benin on the western border i.e. at Babanna district of Borgu local government area. The location of the State gives rise to common inter-border trade with it in all directions, see Appendix 1. The topography of the State is highly undulating, while the land is traversed by several fast flowing rivers and streams such as River Niger, Oli, Kaduna, Kontagora, Gurara and several tributaries that flow into them. As a result of the topography of the State, the major rivers of Niger and Kaduna have been dammed, for production of electricity, therefore the State houses the largest number of hydro electric power stations in the country, thereby earning itself the title, 'Power State'. There are two prominent hydroelectric power dams in the State i.e. that of Kainji across River Niger, and Shiroro, across River Kaduna. Despite its meso endemicity, the State is surrounded by the hyperendemic foci on its' Northeast, Southeast, South and Southwest. These States are Kaduna, the FCT, Kogi and Kwara States respectively. The vegetation is mainly of the Guinea Savanah type with forest mosaic savanah especially in the South and South western parts of the State. The climate is of distinct dry and wet season with rainfall ranging between 1,100mm in the North and 1,600mm in the South. The J WHO/APOC, 26 September 2003 wet season ranges from 150days or more in the northern part to 210 days or more in the Southern part. The dry season commences in October and the humidity could be as low as t+0 between December and February. Temperatures rise as much as gbf between March and June, with the lowest minimal temperatures usually in December and January. Most of the Onchocerciasis endemic communities are located within the abundant flood plains of the rivers that traverse the land, and so the population is mainly agrarian in over 80o/o of the area. Among the large ethnic groups, the Gwaris', Kambaris' and nomadic Fulani's have a cultural habit of moving from place to place in search of virgin land for their crops and in the case of the Fulanis for water and fresh fodder for their animals. Common cash crops produced by these groups include yams, maize, millet and guinea corn. The Nupes' are one of the major ethnic groups in the State, and they are more stable in settlement, forming very large clustered populations who reside within the marshy alluvial rich valleys which abound in the State. The Nupes grow rice as both food and cash crop and they are also very good fishermen. While the settlement pattern in 40o/o of the State is dense and clustered, over 600lo is sparsely populated and highly nucleated with distances of up to 20 kilometers between some communities. Niger is in fact, the largest State in Nigeria, occupying about 12 million hectares of land i.e. about one tenth of the total land area of the country. The State has a fairly good road network in about 40o/o of its' area, however due to its' highly riverine nature, about 40o/o of the movement is by water using local tug boats, engine boats and ferry for movement of goods, vehicles and humans across the river Niger and neighbouring Kebbi State. Heavy flooding as a result of overflow of dams, is a major threat to fishing communities that reside along the large rivers of the State, and several communities are therefore often either submerged or they are displaced during the rainy season. The administrative structure is typical of what obtains all over the country, with a politically elected Executive Goryernor at the State capital, and 25 local administrative councils, headed also by politically elected LGA Chairmen. There are several traditional institutions headed by Emirs of various hierarchies who oversee the districts and communities. The communities are also headed by traditional rulers who pay allegiance to the top hierarchy. The State Government comprises of three arms i.e, the executive, legislative and judiciary. The health care delivery system comprises of three levels i.e. Primary (Primary Health Care), Secondary and Tertiary, all of which are quite well interlinked. The PHC system has been put 4 WHO/APOC, 26 September 2003 quite well in place, and is becoming more functional especially with the presence of a resident German government assisted PHC development project known as the GTZ (Lafia PHC project). There are over L,400 health posts/health centres in the State out of which about 1,000 exist within the CDTI project area. 1.1.2 Paftnerchip The partners involved in project implementation in the State are the MOH, APOC, UNICEF, WHO, CIZ (PHC), local NGOs, CBOs and the benefiting communities themselves. The partnership between Government, donors and the benefiting communities has grown in strength over the years; however, unfortunately, financial input from Government especially at State level has diminished over time. Political instability at LGA level, caused by delay in election of permanent governing councils, due to ongoing Local Government reforms, and reduced Federal revenue allocation to these LGAs had a very negative effective on CDTI activities. As a matter of fact, the last but one LGA executive council was dissolved during the first week of December 2003 i.e., in anticipation of elections scheduled to hold at the end of January,2004. There has been improved collaboration with UNICEF, especially in the last two years'. UNICEF supported the project with US$ 14,000 in year 2002 and it was utilized for orientation of local NGOs and CBOs, as well as for training of LGA/PHC staff for facilitation of CSM. The sum of U.S.$12,441 received from UNICEF in year 2003 was utilized for ensuring distribution of Mectizan to end users i.e support of the SOCT and LOCT in ensuring that Mectizan received by the State was released to the benefiting communities as soon as the drugs arrived the LGAs, and that communities were mobilized for immediate collection of their drugs for distribution to the beneficiaries, orientation of women groups, as well as holding of stakeholders' meetings at LGA level. As a result of this suppott, 930 local NGOs and CBOs were oriented and mobilized for support and pafticipation in CDTI, 227 LGA/PHC frontline health facility staff were trained as facilitators of CSM and SHMs, 650 Stakeholders met, and 700 women group representatives were mobilized for support of CDTI. Based on reports received so far, a total of 879,911 people were treated out of an estimated population of 1,682,157 located in 21 CDTI LGAs. Two LGAs, namely Borgu and Lavun had not submitted treatment repofts at the time of submission of this document while LGAs like Gurara, Agwara, Katcha, and R'rjau submitted only paftial treatment reports. A proposed State level stakeholders' meeting has had to be rescheduled for the first quarter of year 2004 i.e. when hopefully, the local government elections would have been held, and there is promise of continuity of governance at that level. UNICEF also pafticipated in planning of activities and in mobilization of Government at State and LGA level, through paying of 3 advocacy visits to State executives and soliciting for counterpaft funds. A 5 WHO/APOC, 26 September 2003 UNICEF official also visited two CDTI LGAs, during which the LGA executives were mobilized for suppoft. Several superuisory visits were also made to the benefiting communities by visiting UNICEF officials and the Zonal Programme Coordinator for NOCPlZone C, in company of the SOCI, LOCTs and superuising frontline PHC facility staff. UNICEF input was strengthened by the presence of the GTZ (Lafia) PHC project which supported the project with US$5,595 utilized for generation of data which helped to finalize the REMO for the State (in year 2002). GTZ also supported in year 2003 with the sum of U.S.$ 13,386 which was utilized for training of 103 LGA/PHC staff, and Health Education/Mobilization of communities in 3 out of 4 newly approved CDn LGAS of Suleja, Gurara and Agwara. Communities in Minna the State capital, were also mobilized for clinic based distribution of Ivermectin from the support received from GTZ. All of these efforts by donors have greatly helped to boost the morale of both participating government officials as well as in improving the quality of CDTI in the State. The improved partnership with UNICEF might not be unconnected with rescheduling of activities of its officials and its' identification of a focal officer for Oncho., in person of Dr. Kenneth Korue, at its'National office. The local NGOs and CBOs who were mobilized are very much involved in CDTI activities, especially at the community level, where they advocated for programme support as well as helped, to mobilize their communities for compliance with yearly treatment with Ivermectin. Local NGOs and CBOs volunteered to distribute Mectizan in several urban centres of the CDn project area this year, and they played a major role, especially in newly added LGAs like Tafa, Suleja, Gurara and Agwara, where, because of constraint on time for communities to make decisions, and the urgent need to commence treatment in those LGAs, distribution was carried out actively, by CBIT and people were mobilized to assemble at various treatment points i.e. clinics, village head houses, churches, mosques, town squares etc for administration of treatment. The most prominent (active) among the CBOs were, the youth development organizations known as Kungiyan matasa i.e. the age grades, who volunteered to serve as CDDs in old treatment LGAs where others dropped out because they were not motivated by their communities. The presence of these CBOs, might account for high retention of CDDs in 600lo of the treatment communities. Other active groups are the union of road transport workers who volunteered their vehicles for collection of drugs from district health facilities in old treatment LGAs. The tremendous Technical and Financial suppoft received from APOC, though it arrived the State in July, as in the case of other funds, did really help in the conduct of CDTI activities. APOC funds though fully received, could unfortunately, not all be utilized because of difficulties encountered with obtaining UNICEF approval for expenditures proposed, coupled with severe bottlenecks encountered (at State level) in obtaining approval for release of funds for those expenditures 6 WHO/APOC, 26 September 2003 approved. The changes at UNICEF brought in new personnel who are not familiar with APOC financial procedures and therefore tend to apply UNICEF rules to utilization of APOC funds! Some locally based international NGOs like the lions club of Borgu i.e. the female unit of Rotary international located at New Bussa, headquarters of Borgu Local Government, one of the 17 old CDTI LGAs, have even volunteered to commit funds in support of the CDTI. More effoft will be made to ensure such that funds are released. In order to ensure release of funds by Government, plans are on ground to establish Mectizan@ distribution subcommittees within proposed Stakeholders' committees at State and LGA level. If this proposal is achieved, it is hoped that it will help to support yearly drug collection and distribution, as well as in sustaining of the yearly, long-term, annual drug distribution. Women participation in CDTI in this State is velT poor mainly due to cultural and religious attitudes (in most parts of the project area) which secludes women from participating in public activities. In order to create capacity for mobilization of women groups, there has been good collaboration with the department of women affairs both at State and LGA level, where the focal persons for women affairs at LGA level, have been trained, and in fact, constitute a part of the LOCT. 700 women group leaders were recently oriented and mobilized for CDTI in the 21 pafticipating LGAs. 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SECTION 2: Imolementation of CDTI 2.1. Period of activities Insert Plan of action indicating activities by month, which were implemented PLAN OF ACTION FOR CDTI IMPLEMENTATION IN NIGER STATE. s/N Activit6s Time frame Action by Pafticapants Repofting deadline Month of Implementation 1 NOTF/APOC advocacy visits to proiect State Jan-Mar NOCP APOC sMoH, LGAs April 8h January, June, July, December. 2 Management and operational planning workshop for State Coords. Jan-April APOC NOCP 2 SOCTs 1 data officer Feb. 10th May 30th Jan/Feb. 3 Procurement of essential p@ect equipment and supplies Feb-July APOC State WHO State Coord. Feb.-July October 4 Training/Retraining of SOCT as TOT for Community Self Monitorins(CSM) 13-14 Jan NOCP zocf SOCT Feb 2nd October, January 5 Training/retraining of LOCT as superuisors and facilitators of (CSM) Jan 15 - Feb 15 NOCP SOCT LOCTs Feb 31* Jan-Mar 6 Retraining of LGA/PHC Staff on improved MIS. February SOCT LOCT, LGA/PHC staff June 30s Aug, Sept, October. 7 Mobilization of State and Local Government Public and Private sector support Jan-July NOCP SOCT LOCI/PHC staff State policy makers, LGA policy makers, Traditional leaders, opinion leaders, Reps. of CBOs, Comm. leaders and comm. members. 10th August Jan-Dec 8 Community KAP survey Maypune UNICEF G-tz zoc'f SOCT LOCT Communities July 21* Not done 9 Selection/replacemen t of CDDs by community members. Feb-June Communiti CS Community leaders/memb ers Mar 31$ July 3 Feb, Aug, Sept. October. l0 WHO/APOC, 26 September 2003 10 Training/retraining of CDDs March- July LOCTs CDDS,CBOS July 30 Jan, Aug, Sept. Nov. Dec. 11 Community registration and distribution schedule announced March- July LOCTs CDDs, communities March23- July 31 August-December 12 Community owned Mectizan distribution l*,2N,3d,4b rounds March - October LGAs CDDs and health workers CDDs Communities May-Nov 10 Aug-Dec 13 Community Self Monitori n g/su pervisio n of distribution activities. Feb- Nov Communit y Monitors, Health workers, Village heads. Communities Nov 30m October- December 2003, January 2004. t4 LOCT suppoftive monitoring/ supervision of distribution activities Feb-Dec LOCTs CBOs LGA/PHC staff CDDs Community Dec 5h Aug, Sept, Nov. 15 SOCT "spotcheck" monitoring and supervision of distribution activities. April June Sept SOCTs LOCTs/PHC staff CDDs Communities May 4b July 4s od 4u' Aug, Sept, 16 Review meetings- (a)Socr (b)zorF (c)NOTF/APOC, (d) UNICEF Mar, April, Jun, July Sept.,Dec. LGA Coords State Coord ZPC,APOC, NOTF/UNr CEF LGA/PHC personnell, SOCT; 9 State Coords. And deputies: State Coords, Deputies NOTF April 15, June 12,Jul 20, Sept 15 Dec 7. Jan(a,b),Mar(a),A pril(a),June(c),July (b,d) Nov(c), Dec(d) proj.Accts, SOCTs LOCTs/NoTF/ UNICEF L7 NOTF Quality control team visit to project site Feb Aug NOTF zoct SOCT LOCT Communities Mar 31* Sept 18 Project evaluation by NOTF/APOC (internal/external) ? APOC NOTF SOCT LOCT UNICEF Communities ? 19 Report collection/ collation, analysis. -Planning for adiustment June- Dec 10th Health workers LOCT SOCT LOCT Health workers Communities Dec 10 Sept-Dec 20 Planning for year v(2004) Dec 1lth- 13th LOCT SOCT LOCT NOTF/SOCT UNICEF Dec 15 Dec.30 ll WHO/APOC, 26 September 2003 c.t oN L() -o o) aq) a \o c..l o > c.l -:. - q va\) q) 4 ot\ \ t v q) 4 a) U t<(6 ox oLrtr C) q) tr 'oq) Cd(l)tr qdoli Cd o) l< .o cn C) o C\,(F< o q.) tr (l) F oir ol .ol CBIFI ah P q) o a 6)9 a6EE oU LI E c, o z. 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L c, -o E o) oz L o.) -o Eo oz *lI, Ea 1n * lULlo f(9 * lEL(o =o *(o L(oF 2.2. Ordering, storage and delivery of lvermectin Mectizan@ ordered/applied for by - Qtlease tick the appropriate answer) MOH ! WHOI UNTCEF 3 NGDO ! Other (please specify) Mectizan@ delivered by - Qtlease tick the appropriate answer) MOH N WHOtr UNICEF N NGDO N Other (please specify): Please describe how Mectizan@ is ordered and how it gets to the communities The quantity of Mectizan@ required by the project is calculated based on 84o/o of the previous years' population, and this is multiplied by 3 to obtain the accurate requirement. The request is submitted to the MDP through the NOCP. The State receives its allocation from the NOCP and releases to the LGAs through the LOCTS. LOCTs release drugs to district health supervisors, while the communities collect from the district health facility within their locality. In the case of very distant communities, drugs are deposited at the nearest frontline health posVfacility for convenience of collection. The delivery process is as described by the following flow chart. NOCP SOCT LOCTs CBS DHS CBS COMMUNI COMMUNI COMMUNITY l4 WHO/APOC, 26 September 2003 State/District/ LGA Number of Mectizano tablets Requested Received Uscd Lost Waste Expired Kontagora 169,500 169,500 t47,485 0 25 0 Rijau 154,000 154,000 50,634 0 160 0 Magama 220,500 220,500 200,369 0 94 0 Mariga 193,500 193,500 181,333 0 19 0 Mashegu 132,500 132,500 131,511 0 726 0 Agaie 128,500 128,500 t22,988 0 LL2 0 Lapai 272,000 272,000 252,849 0 L94 0 Mokwa 164,000 164,000 L13,344 0 14,055 0 Rafi 188,500 188,500 183,133 0 133 0 Wushishi 163,000 163,000 L27,806 0 840 0 Borqu 336,000 336,ooo N/A Lavun 82,500 82,500 N/A Shiroro 56,000 56,000 41,L74 0 0 0 Gbako 57,500 57,500 56,558 0 54 0 Katcha 220,500 220,500 85,168 0 478 0 Munya 126,500 126,500 80,548 0 0 0 Bosso 169,500 169,500 114,585 0 69 N/A Suleia 240,000 240,000 240,000 0 0 0 Gurara 150,000 150,000 37,842 0 0 0 Aqwara 129,000 129,000 129,000 0 0 0 Tafa 57,500 57,500 57,500 0 0 0 TOTAL 3,411,000 3,411,000 2,353,827 o 16,959 0 Table 3: Mectizan@ Inventory (Please add more rows if necessary) State activities under Ivermectin delivery that are being carried out by health care personnel in the project area 15 WHO/APOC, 26 September 2003 - Such activities include annual collection/allocation of Mectizan to communities, distribution at health facilities in hypo endemic foci as well as in urban centers of CDTI project area.. Training/retraining of CDDs/suppoftive mobil ization of communities. Superuision of drug distribution. Facilitation of CSM and training of monitors. Collation of treatment record and ensuring 2way feedback on yearly activities. Any other comments. None 2.3. Advocacy and Sensitization State the number of policy/decision makers mobilized at each relevant level during the current year; the reasons for the sensitization and outcome. Describe dfficulties/constraints beingfaced and suggestions on how to improve advocacy. 20 State policy makers were mobilized for awareness on CDTI, release of State counterpart funds and for their support, through advocacy for LGA release of funds. Requests were also made for release of State counter part funds by both NOCP and UNICEF during advocacy visits to the State. Pledges have been made by Government and a memo has already been submitted in request of US$30,000 for conduct of year 2004 CDn activities. The outcome of the request will be ascertained in year 2004. Several advocacy visits were made to all 21 CDTI LGAs by State officials and specifically to three LGAs by UNICEF officials, for creation of awareness on Onchocerciasis as a public health hazard in those areas, on the availability of Mectizan free of charge, for control of the disease, the safety of the drug, and the need for Government support in funding of the ongoing CDTI. 200 LGA policy makers and 1,300 traditional leaders were mobilized for support. From reports received so far, some LGAs released funds, others assisted with vehicles and fuel and even pafticipated in community mobilization. Some traditional leaders and opinion leaders provided funds for town crying and dissemination of messages on commencement of treatment. Several of them superuised distribution too!. This situation was even more pronounced in the 4 newly added LGAs of Suleja, Gurara, Agwara and Tafa, where even though PHC Personnel had been trained, and communities had been mobilized for CDTI, treatment had to be conducted actively by CBIT because there wasn't much time available for community decision making, purchase of note books, census, selection of CDDs, decision on treatment time and other CDTI requirements, t6 WHO/APOC, 26 September 2003 therefore drugs were distributed at PHC facilities, mosques, church premises, in front of the traditional ruler's residences at ward level, within the various LGAs. The distribution was conducted by CBOs, and local NGOs. The SOCT and LOCT coordinated and supervised the distribution exercise, in collaboration with the traditional leaders. On the whole, the role of traditional leaders in mobilization of the communities for acceptance of treatment was very encouraging. Generally speaking, the LGA policy makers (particularly the directors PHC and supervisory councils on health) and the community leaders fully participated in planning for the CBIT. Some community leaders even suppofted their drug distributors with funds, as incentives. Based on repofts received so far, the sum of US$1,129 only was released by 7 old treatment LGAs, because full repofts are yet to be received on all funds released at that level. Based on information on hand also, the sum of US$ 492 was released by communities of 5 old treatment LGAs. As earlier explained, funding by Government at both State and LGA level, has not been very encouraging. The poor release at LGA level was quite upsetting, although this situation is attributed to the political instability at that level, since there was constant change in leadership. As a matter of fact, the last political leadership was replaced early in December, 2003, in preparation for election of permanent Local Government councils possibly in January, 2004.In view of moves to establish better accountability at that level, several reforms are also being put in place, and these developments negatively affected release of funds from Federal revenue allocation to these LGAs, and this did in turn, take its'toll on the implementation of CDTI at that level. In order to overcome these challenges, media publicity would be intensified and radio jingles and local drama would be designed and developed for airing and awareness creation on CDTI. Various stakeholders' meetings were held at 21 LGAs. The State level Stakeholders' meeting earlier scheduled to hold in December has been rescheduled for February, 2004 i.e. in order to allow for establishment of Permanent t7 WHO/APOC, 26 September 2003 Governing councils at the LGA level, (since the leadership at that level would be major participants at the proposed meeting). Moves are already being made, to get local government administrations to release funds into a central PHC account for yearly funding of all PHC activities and it is expected that if this proposal passes through, there will be a sustainable source of funding of CDTI activities at that level. During the LGA level meetings, a total of 650 people of various groups including the interim leadership met and deliberated on the ongoing CDTI at their various LGAs. Several resolutions were made for improvement, and for ensuring sustainable annual Mectizan delivery. Among resolutions made were:- To establish Mectizan@ distribution committees that will ensure timely collection of Mectizan from the State ensure its' adequacy, and availability to all benefiting communities in the LGAs. To form pressure groups that would prompt Government at State and LGA level for annual release of counterpaft funds. To conduct fund raising activities at all levels, and to establish Oncho./CDTI accounts at the LGAs. To better monitor the commitment of frontline healthcare workers to CDTI. 2.4. Mobilization and health education of at risk communities Provide intormation on : The use of media and/or other local systems to disseminate information Mobilization and health education of women and minorities - method and response Response of target communities/villages Accomplishments We a kn e s s e s/C o ns t r ai nts Suggest ways to improve mobilization of the target communities. Before and during community mobilization and treatment, information was disseminated in some LGAs using public information vans. Local town criers were also very much engaged, church and mosque microphones were employed and information was disseminated at local meetings, ceremonies, during festivities and on market days. Radio announcements were l8 WHO/APOC, 26 September 2003 also made at some LGAS. These outlets really helped to improve on awareness and coverage especially in the 17 old treatment LGAs. At the community level, threat of CDD attrition, due to lack of motivation still poses a problem in at least 40o/o of communities. The communities are also being mobilized to reduce the burden of CDD workload by selecting more CDDs especially at ward level. The response so far is slow, but efforts to institutionalize this latter idea was initiated at the Stakeholders' meetings. Campaigns were also intensified in religious fanatic areas where people, especially women, were discouraged from accepting treatment because of rumors about the drug being used (in disguise) for birth control. Megaphones received from APOC and those for polio eradication campaigns were well utilized during community mobilization sessions, especially for reaching women in purdah in areas where religion and culture secludes women indoors, and therefore they cannot pafticipate in community mobilization activities. Four page full colour wall Calendars and T- shirts with several Oncho./CDTI Logo messages were also produced and are widely distributed during advocacy and stakeholders'meetings. These materials have indeed helped to create awareness on the programme as well as brought goodwill which would help to improve coverage. These efforts would ensure the sustainability of CDTI in the State. The major weaknesses and constraints to achieving good impact of the mobilization campaigns was late release of funds, because most of the activities held after treatment had either gone far, or in some cases, had even been completed, and therefore would only be beneficial for subsequent treatment exercises. The best way to improve mobilization of the target communities is to commence activities in January through early release of funds, and to air a lot of Health Education/Mobilization messages on media, (especially radio), since it is the cheapest and most reliable source of information dissemination. Radio also has a far greater reach than television. Interuiew/discussions programmes on both radio and television, are also very helpful, especially when the predominant opinion leaders are involved in the media discussion programmes. Other ways to improve mobilization of target communities is through formation of local drama groups. l9 WHO/APOC, 26 September 2003 700 women group leaders were oriented and mobilized for participation in the ongoing CDTI. They expressed appreciation for the efforts being made and pledged to improve on their participation. They have also resolved to mobilize their fellow women to contribute towards motivation of the CDDs. They also promised to adequately utilize the IEC materials given to them for mobilization of their men and women folk. The women received laminated pocket calendars showing the wife of the State executive Governor administering Mectizan to male and female beneficiaries, during the launching of CDTI in one of the affected LGAs. There are proposals to place billboards at all2L CDTI LGA headquafters, with the hope that this will have an impact on awareness creation. Health education messages would also be redesigned for improvement of advocacy for the programme. Over 900 CBOs and Local NGOs were oriented for participation in CDTI. Several of them are already participating at their various communities. There are also plans to mobilize school children for CDTI in the oncoming year. 20 WHO/APOC, 26 September 2003

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Ji co C.l oLJU €gE.H?HayA cto,Es€!96d20.e g PgB€E gE gE orco(l).E}J VL '=trc)rEf;3rsbu(EO=lu HEpH =-'silsEEE +UEBdE.EEE#E=Trt,tnc5d'F',=b vto'Ede'n .=Eg H.e, E; HE I3e;VLPElog=..P-oE9-6q sT€EE :EE.q!E rE gg(oYf)E9gEE €rE6E $EsEtbh.9fi; . .c1JUL' =*.9-o2.gEsga EEEEEggEE: EEEfs ErAF=(UE 5 9EE$Ei H =Bg H HEEHEHE raq) la, ta (J U,\ bo a)s Tql s u, !\t\ sI t)s u, oo q.r q) b !aSoos E)S$(JSa) -* €b Ss\€crs .lt t) *Sst ES aS .r \.<s! s' (J'SsB SR; ^.osiE€s'\". nS{ f$lYtrs r'Sll E 3.SGi.-LSS .$^r\= Elbs 1- ESEsss\)rrr o o o o o o $ o\ rr \o $ c-l \oo !!t o -t o\ r- \o -l' C.| \oo i oo r- o 6 6l\o t oo F- st t'- \o \o =f o\ o GI ol\o s € osf +ca r\ c.) \a \oca \os o6lia GI 00 C.l F- c..t6l an $ stC.l c)(.) F- <l$ oxd .o(J (d L,' (6 !4 (d o U)a o EO (d (, C,) (d (d (J (d (d 3 b0 +(d (UF FJ F oF 2.6. Gapacity building 2.6.1. Training During the period of report, the following categories of people were trained and retrained: (1) SOgf- -10 were trained and retrained on, facilitation of CSM and Stakeholders' meetings (SHMs). (2)Locr -113 were trained for facilitation of CSM and SHMs. They were also retrained on record keeping and utilization of the MIS for Mectizan@. This constitutes 90o/o of ATro. Health centre/ Post staff (3) CDDs (4) csM -620 district health workers and frontline and healthcare workers were trained for facilitation of CSM and SHM as well as on record keeping and MIS. This constitutes 1690/o of ATrO. There is adequate capacity for training and supervision of CDTI in the project area. -4,t06 were reported tra ined/retra i ned,constituti ng 7 2o/o ATrO. There is threat of CDD attrition in some LGAS, while there is very good CDD retention in others. Communities are also being mobilized to select CDDs at ward level, but the response is slow. These issues are already being addressed by CSM and SHM which are already being instituted in 332 CDTI communities of 17 LGAs. The number of trained CSM monitors is not available yet, since the CSM has just commenced. -24 -WHO/APOC, 26 September 2003 o6ltr th o o(J o Lq)E z !! ,vo -lF- l co € € c.l o coN co oo \o c.l $ o\ at t o\ rat\o $ o\ c\l $\o 6c.)N ol (.l € $ o\ r- \oo +. q c?)oo 6 c-l o aoN cO oo \o c.l s o\N $ o\ta) \o c7l$N $N o\co c.l N N oo $ o\ rr ra) \oo ? I o!+ I F c-l € o{ r- € C.l N ra c.) o $\o c.t co oo co € o\ c.l\o$ $ o\N c..l co o\o c\l \ ao ci c\ co o\ o 2q) .1Gcttfrt-x bF -i 10o q,)!9 r. 6t6)L z =6? o -+F-: I I I I o o.l I I r- q I o =! I I oN I I I r- F I oo(9 zor{ I (, ?e q) ai =cBdL 8E!s EEtr> .- G)Z2 €)o €v r:v. co r- c.l \o c.t $ \oN r-N \oco \oc.) co ca co €co \oN $c.l coco +. q co r- c\l \o co $ \o(\.l r-N \oa.) \oco €$ co co ao €ca \oc..l € c.ta.) z o o N o o o o \o o F o\ o o\c..l € $s t o\ \ool r-- \o o\ cnN q) E 6ltr ts 6l th ar) () Fl 6v ol co + a 00 6 \o oo r- $ $ to c.l t $ t +. q c.t $ € € oo \o € r-. t $ c.) c.l $ t $ z o o o o o o o o (a € 6 oo @ € € € t s $ $ t in FI q) o a d o b0d tr ov (d d 6tr (d b0(d z Cd b0 d @q) a(d (u (d b0 (6 adJ (d 3x o d& a q = bI I< o FA d -l o oI{ (t) o (ds(, d U (d M (d = c.) o c..l () .o () aoa \o N t, o Or d I N I :.t's U.) v1q) U a) U., =\ a)\ t S q) dq) er o cd tr0) q) o tr F (-) o a C) o) tr 0)lr .()E o (tt bo (€ LrF .iir orl -ol(dt FI I II I I I I I I I I I II I 6 aooo c.l o -o c) o.o v) \o o.l O o0. o > $ c.l \oo $ NF. o\ I I o\ € €- co \o c.l .oz (6 z (d z (d z t-. c.l o\ ao o o o $ c.l r-. o o (l) I o\ t co \o € I $ I I ao \o o o(! c) \ocf) (l) (l) (l) I o\ € \o c{ co c.l o a.l\o o\\o € I \o C-l to c{ o o ca c\l coN cftco c\ a.) $ cos q) Q) Q) q) -oo\ $ $ ro co o o\ c.l o o o $o\ N t co o\ rn rn r rn ta) N o tn o o € d (u cr-) (d li Cdt{ (, (dt{d 3 b0 d (dF Fl FoF o (l) €) (') -o c\ \o ol c,i) () a -a € o (! \ d I t o\ s € -: s 6 I Gt\ g * t I I I I I Table 6: Type of training undertaken (Tick the boxes where specific training was carried out during the reporting period) - Any other comments 2.6.2. Equipment and human resources Table 7: Status of equipment (Please add more rows if necessary) Trainees Type of training CDDs Other Community members e.g Community supervisors Health Workers (frontline health facilities) MOH staffor Other Political Leaders Others(speci&) Program management { { V(teachers) How to conduct Health education i ./ { { { V(teachers, NGOS,CBOS) Management of SAEs ./ { y'(") CSM { { ./ y'(") SHM { ./ { { ./ y'(" ) Data collection ./ { { { V(teachers) Data analysis ./ ./ V(teachers) Report writing ./ { Others (speci&) Source Type of equipment APOC MOH DISTRICTILGA NGDO (UNICEF) Others Condition of the equipment * Please state 1. Vehicle Functional (1) WROFF (1) wRoFF (1) 2. Motor cycle " (18) CNFR (1) 3. Computers " (2) 4. Printers " (1) 5. Fax Machines " (1) 6.Photocopier " (1) T.Bicycles WROFF (1) S.Proiector " (1) 9.Generator " (1) 10.Air conditioners * (2) -27 -WHO/APOC, 26 September 2003 * Condition of the equipment (Functional (F), Currently non-functional but repairable (CNFR), Written off (WROFF). How does the project intend to maintain and replace existing equipment and other materials? Availability of State Government funds will be of utmost importance for such issues, otherwise, equipment and other materials will be maintained within the central pool i.e. within the MOH central maintenance budget for office and field equipment. The LGA councils will be encouraged to purchase and replace obsolete motorcycles and bicycles from counterpaft funds and any other sources. - Describe the adequacy of available knowledgeable manpower at all levels. There is fairly adequate knowledgeable manpower at State and LGA level; However, low literacy at community level is a major factor in determining number of CDDs selected by the communities, because they do not have much confidence in the capability of illiterates in administering correct dosage of Mectizan@ to them. - Wherefrequent transfers of trained staffoccur, state what project is doing or intends to do to remedy the situation (The most important issue is what measures were taken to ensure adequate CDTI implementation where not enough knowledgeable manpower was avuilable or staffoften transferued during the course of the campaign). There is stability of staff at State level and at LGA level, transfers are often only within the LGAs i.e. from district to district. Where frequent transfers occur, effofts are made to train all PHC staff within the project area, and in an LGA like Borgu, where there is inadequacy of PHC staff, school head teachers were trained and incorporated as superuisors. The school head teachers have remained at their postings for over seven years since they were incorporated in the programme, and they have been participating actively since then. 2.7. Treatments 2.7.1. Treatmentfigures Treatment repofts receieved from 19 LGAs are for Mectizan distribution employing two active strategies:- CDTI in 15 old treatment LGAs and CBIT in 4 newly approved and added LGAs of Suleja, Gurara, Agwara and Tafa. 28 WHO/APOC, 26 September 2003 CBIT was also employed for distribution of drugs in new communities of old treatment LGAs like Rijau, Bosso and Katcha, since there was constraint on time to allow for community decision for conduct of CDTI. Treatment figures for LGAs like Borgu, and Lavun and complete reports for new communities of Rijau, and Katcha LGAs, were not received at the time of compilation of this repoft, however, about 200,000 additional treatments are expected from these LGAs. A total of 879,911 people have so far been repofted treated in 1,969 out of 2,520 communities. The Annual Treatment Objective for the year was 1,139,606 while the estimated Ultimate Treatment Goal is 1,413,006. These figures represent 52olo therapeutic and 78o/o geographical coverages respectively. The cost per treatment is U.S.$0.07. 29 WHO/APOC, 26 September 2003 c.too c\l Lop (.) o.(l) a \o C\l o o rJr > o c.l AtEIJss'* iEEEE9q o69 0 o q) o () -o z o o o o o o o o cEle4 AO o o o o o o as -()bg -otrE9 zd ta) € o\ta)(\l z \oco z (\] N o\ c..lo$ € co$ o \o €N I o c..l a.l o E. fie ,E E:r E E['€E N€c\ r-$ 00 r*c\ z o Nc.) \ooo\i o\o\ r-r- o Ns o CE)aop. o\ o:E o.) =aDOcd fr9 -t8F \or\ \o o\€ c.)s @€ o€ €r-. N\o o6 co€ z z o\ oo€ roc.) ? poc5gETE = o--z \o ra \O- o\ia o\ t o\ o\ r- @r- co or- € r .{ 6s \o o\ o, t \ol.- oq 6 € \oo ro^ o\o r- co r-\o s r- cO z z o\@o o\ oosrn c.l c.l\o €^ a.) ri EoE 6.25 tr:i t .u'A \oo\o^ ra\o ral\o\o € \o €\ ror- ao \o €\o r- o\ \o * ol o\r: att oo € € o\ \o ia) c..I € co (\l t-- t-- s o \o r- €t r) c..l \oo$ c..l c.lr-q o(\l o\ r-. o\c! .=-rdE E9 = o 3(d15 -?.g o-:oE = o; _oF No €r- o o C\(\l o\r- o^ oo € c.l o\\o tl\o \o o\qt ca$q. co r $ $ c.)ct @ o\ (n ro\o c.) € Nq$\o oo $ o\ coC'I o c.) o\c\ ca oo r- co tc\ *oao c{o U)(l) bI) GI U'(l) a EtHoQ I .iAs E .9 q.) =@o. !s!86&r 6o oo o oo \o € € o oo l-. ra) c.)\o to € o z z oo oo oo IB u.E [i ! -8 5 $.Htr tr= ii = E'; ! AO o rn\o \o N in \o C-.1o co N oo o o cn z z c.lr c\l\o $ oo tso d o.= =EEE c!.= < gP'FqJ rn\o \oc.) c\l\o \o co (\l oo o\ c.l cn \o r.} \o oo c\ r.} c\t\o $ia E E $-Eg *" \o \oc.l r-$ol \o r-o\ N $ o\c.t c.t \o \o€ coo c\\o t€ .E< HC? '5< (t o bI) CI, ov * cl :?& c, E crl oo Cd C\, bo Lr Cd b0 C) rn Cd a Ito d o0 ((l o. Cd Fl It F .Vo dd v) c,l) = bIk o c4 (UJ ok oL. (r', ou(d .o(J * d (J Gv -\ -. Laq q) Uq) q 1 oL a) t B q) FS q) s J1 u) CB (t) Cdo (d cd tr -l () tt) € .o t) rI] a € (d tr(l) (lt c) F #r o.ll .oldtFI ta o c.l () ,o () a()a \o c.l d o {o rJr > c.) $ s E $. OO te,IJ\ c-q)LS)9vd d\(Do rrEl(gsEEq sI * !qlsi: E$:'r .:s 3 'EHo)qr\h Et .: .l: tr {rsl € 'r=t d *n3 EEE ss .E tSb s;E .E.S_ ; EsE gE SEi ;13 : E itl I Slr' tIa S$ BEr SESOl L ll ic) €l+ ilt slE siS EIE !Ei oas Et!$cl .s6 \ €ssil E*.I $$$\ S's IEE: Ei\-hU \SU0 Es$ = 'sc\H s s*9 EESFrrttS3 isE olol -t ,xt > EI E cl5 ol =oI 0)ol E 8IELl C)oli Ll ' -8lEtrt trrl tr zl< CB o)L(! Io G) 'a L cdo9tu dI !6qo'ao LHqz olH €& ! P9're t) '.=(Dc '5 o) vL )6 ECOcv)H(D5.: JE PI Eo =l tr! .t):tr xl HC)al vi El.eK HI E>- El c)k' el! o,) pl F =lP slb.t tr =t o-*l c -al > '9t.r att9l ao .91>Et= Etpq - ddg LIV ol .Y Xl p 8l H .ul-8qli Xltrol ii- -l =il e .H5EIE EI E2l€ zt\ o ct o) boFaES oo oF o (dL 0) 6I)(! Lo oo 8a (d b0 oo o o (dL o a0(d o oo oaE5oa(B rro F U,Iol o0 cdl lil(I)l >t ol ol cdlol -clol CBILrl oll ol G)lhrl ol cl(dt <.rl €l C)l ol(dttrl ol -ql hd trl 9lJI ol EI ol :l €l cl 5l EI ol fr.l cn a dlgE O\()O\tr -9o.e Ei cn0)(tr(,c,. cq- H-ojs xc)p9PE si u -l Y !i o,tcrEE EE TE E.EE EX )..1, .!iEz*oz r o tr&r x -lZ< il o o o o o o o $$ ot (\l I clo ol \o ao o (n I r-- TQ o\ o\ ca € *\o r-r- coco \o$ €co a!to N ol a^ttt to o- ra) o r-r- € v} co r- € o\ $ o\ o\ o\F-a cn6r-$ co o\\o n"Nr- c.l ot$ € €r-o s o\00 \O^ c.l c.l *a C.l$ N o\ o\ ??li o\o$ t aoF-(\l \o € c.) oo c.toq @$ \o o\ € co O rA cl@\o oo €rr oo o oo 6r- t rn F- c.l \o co \o$ o\\o o\ ot r- F-a.) \oao \o$ oN ot \tto rr co o \o ao \o$ ar ra c{ d tr * o vt v, o FA +d (u (t') +(d (d () +d d 3b! +d cdF F.l F. oF il I - If the project is not achieving 100% geographical coverage and minimum of 65% therapeutical coverage rate or coverage rate is lluctuating, state reasons and plans being made to remedy this. 100o/o geographical coverage is not being achieved this time around because of addition of 800 treatment communities as a result of REMO finalization and approval for expansion into 4 additional LGAs as well as addition of about 500 new communities in old CDTI implementing LGAs. Not all of the communities could be covered due to constraint on time caused by late treatment. The major reason for late treatment was of lack of government funds and late receipt of donor funds. No funds were available until August and this constraint was caused by reasons explained within the earlier sections of this report. 2.7.2 What are the causes of absenteeism? Absenteeism is mainly caused by displacement of some community members during flood disasters which occurred in seven communities during the rainy season. Others relocate to stay at their farm houses in the rainy season, and do not return early for treatment. This phenomenon is mainly caused by a lack of community decision on preferred treatment time, as well as inadequate mobilization of community members on the need for them to be available during treatment period. Some members abstain deliberately from the community, in order to escape from being compelled to take the drug against their wish. As is the case in more organized communities. 2.7.3. Brietly describe all known and verified serious adverse events (SAEI and provide in table 9 the required information when available. Not Known or Reported. 2.7.4. In case the project has no case of serious adverse event (SAE) during this reporting period, please tick in the box No case to report { 32 WHO/APOC, l0 April2003 c.)oo c-l La o O" B co cn Q) o r E oo cl 6t a N\oC)ooI Es/o O I r- lt- ro \o\o c.l\o €€ $o\ c\o\o ^oO9 Eaf Oo\ () c.) c.lcn ao F-co o\r- oor- c\ia 6\ :r.,i ! o5() ,ooC)(c =oE>ooEOF oo od o\ c.l + €t$ cO rn o\ €\or- \o € .d o\r- o\ o\t.- € 'l] ! .o oi! u9o.=4-Etr z8 A c.l co oo^ \o r-N € o\q \o €N t N \f oo € r- o\o € \oo\o o\ ao tsoE 6.2 =C,ot eFFL., \o N o\\o(\.l o $ c?)t TA oo$ o.l$q \o c.t ov} o o\ N o\vl N o\ (a c?I o\\o o\ $\o\o $N (\l00\o tro Cd &o O. ts *H _ E EhS'E o ho , _os€='E.' ' a 3so c=o. H6 o O o\ co to o\ 00 € o\00 € €\o t- F- €o9teF (.)o\<8" o j'j' co $ o\o\ o\o\ 00t'- =oio-o0=E= Ee Ho 8.',: Oo.l coN r- c.) Nr-\o to+ N c..l $ co \O^ \orrr- o\\o o\ a()o'E !2 EESE 'tr E= ii5E-a15z8- € co \oo o c..l N co oo o\ r-\o lal cor-:q)E 6.2 !=c)T EFF r-, cn oo a.) oo c.l o\ o\s\o c.) o\\ o c\l c.l oq) oo(g 6q) E oO oo6 = .,3 +r>fioo> 9 aHrr.9 = >; _ E E T EE tro oo c-l ooN \ooo c{ tr-o c..l ooooN o\oo(\l o o c{ € o\ o\ o\ o\ o\ o oN oo c..l c.l oN c.lo (\l so a.l t'- o\ o\ q)s 6iq)LG c,q) oLe(l) L q) 0) tr € ti Cdo TI cdlEItrlol 631ol >l .ol o o0 CI,l< C) o() E cd a trq) tr d(DlrF ot o)l .ol cdlFI ct(D (l) a) o o o ooI q)(l) o a FA Q o {) o 6) q) 6l () 6lo o E q) tr ta r- N I J 2.8. Supervision 2.8.1. Provide a flow chart of supervision hierarchy Community Self Monitors Communities 2.8.2. What were the main issues identified during supervision. Issues identified include:- Lack of State counterpaft funds and late commencement of CDTI activities. Absence of LGA plans of action and very poor LGA funding of CDTI. Lack of census update in some communities resulting in inadequate Mectizan@. Absence of treatment summary forms in community registers. Treatment record not accurately transferred from community notebooks. Poor commitment of some of some LGA coordinators and frontline health facility personnel. Lack of posters in communities. + UNICEF NOCP SOCT LOCT DHS Comm Based Supervisors.CBS CDDs 34 WHO/APOC, l0 April2003 Large numbers of absentees and no mop-up treatment. CDDs are often not motivated Inadequate CDDs. - Large number of refusals in Borgu LGA and slow pace of treatment due to extreme disenchantment of CDDs by community members attitudes. 2.8.3. lVas supervison checklist used ? Yes. The superuision was conducted mainly by the Zonal Oncho. Coordinator for Zone C, who was funded by UNICEF. Some supervision was carried out by the SOCT and LOCT. Most of the supervision was by the frontline health facility staff. 2.8.4. What were the outcomes at each level of CDTI implementation supervised? State level - There was no counterpart fund from the State Government, therefore activities did not commence early. Treatment would commence late and communities were not given the choice to decide on treatment time since Mectizan@ had not been collected by June due to lack of funds for travel to and from the NOCP headquafters at Lagos for receipt of the drugs. LGA level - Lack of plans of action in 50o/o of LGAs and very weak and sometimes, no funding of CDTI in 600/o of LGAs visited. Lack of census update in several communities resulting in inadequate Mectizan@ supply. Ratio of CDDs to community did not meet criteria of 2 CDDs to 250 people. Household heads did not give accurate number of household members to CDDs, which resulted in inaccurate census. Several CDDs complained of work overload and poor motivation by their communities. The frontline health facility Staff were not superuising CDTI activities. 35 WHO/APOC, 26 September 2003 - Absence of treatment summary forms in community registers. Some community summary forms were in custody of superuising health staff for fear of its' being misplaced or destroyed in the communities. Treatment record not accurately transferred from community register. Figures forwarded to SOCT did not tally with data at community level eg. in Munya LGA. Lack of posters in most of the communities. Large numbers of absentees and no mop-up treatment. The drugs supplied was inadequate, and further request was not honoured The number of CDDs to population was in excess of 1:800 tn 40o/o of communities, visited and there was no community support in terms of incentives either materially or in kind (e.9. through assistance with farmwork) therefore CDDs treated only at their convenience, often at night, and go to their farms in the day time. Completion of treatment in such communities took up to two months. There was also no follow- up of absentees or refusals. Poor commitment of LGA coordinators and frontline health facility staff of two LGAs. Drugs were not released four weeks after they had been supplied to the LOCT (Borgu LGA), therefore treatment was further delayed. The frontline health facility staff in- charge of the communities, did not inform communities about arrival of drugs and the need for them to go for collection from the district health facilities (Shagunu in Borgu LGA). The treatment record for previous years was not properly kept. Large numbers of refusals leading to slow pace of treatment in Borgu LGA. The CDDs were extremely disenchanted with the poor community attitude. Some CDDS were even chased out of households and threatened with beating if they did not leave immediately (Wawa, in Borgu LGA). 2.8.5. Wosfeed-bach given to the supervised, and how was thefeedback used in improving the overall performance of the project Yes, feedback was given to the superuised and the feedback was used in improving the overall performance of the project in the following manner:- 36 WHO/APOC, 26 September 2003 At State level The issue of need for release of counterpart funds was Presented to State MOH executives like the Director PHC, Permanent Secretary, and Honorable Commissioner of Health, who doubles as deputy Governor of the State, in the presence of Senior Ministry of health officials and other political heavy weights at advocacy meetings held with visiting NOCP and UNICEF officials in April and August. The State policy makers noted the problem and pledged to address the matter in order to ensure that funds are released by Government. No funds were received but a memo was submitted in anticipation of release of the sum of US$ 30,000 for suppoft of year 2004 CDn activities. A State level stakeholders' meeting is scheduled for the first quafter of year 2004, and issues threatening the sustainability of the State CDTI will be deliberated on. LGA level The supervising SOCT were directed to guide the respective LOCT on writing of plans of action (with budgets) which were to be submitted to the LGA authorities in request of funds. The written action plans were submitted as suppofting document to a letter of request from the State MOH, for release of the sum of approximately US$784 per LGA. A State review meeting was held in September and all LOCT leaders from 17 old treatment LGAs were informed of this obseruation. They were then directed to go back to ensure that the census was updated during Mectizan@ distribution. Follow-up monitoring of the above indicated that the census had been updated in over 50o/o of communities. Additional Mectizan was then released to those requiring it, for mop-up of treatment. In order to boost capacity for drug distribution at a ratio of 1 CDD to 250 population, communities were remobilized and advised to appoint additional CDDs at ward level. Although only 7 LGAs gave updates on CDD population there is evidence of good compliance with the recommendation because the present ratio of CDD to population 37 WHO/APOC, 26 September 2003 is 1 to 410. Communities were also mobilized to suppoft their CDDs in order to motivate them for long-term seruice. The achievement made in this regard is however hard to quantify because the LOCT hardly give feedback on CDd remuneration. However, timely feedback was received for treatment in 70o/o of LGAs. The poor commitment of the participating LOCTs and health facility personnel was also addressed at LGA level advocacy meetings' held at the LGA headquarters and also at stakeholders meetings held in all 21 LGAs. The PHC staff were reprimanded by both the traditional leaders and the LGA policy makers. They have been advised to show more commitment otherwise, their salaries would be withheld, and they in return, have pledged to improve on their performance. The situation at Borgu and Lavun LGAs, who have completed 4 years of CDTI is of particular concern because no treatment reports were receieved from these LGAs up to the time of submission of this report! The impact of the actions taken to correct these anomalies can only be assessed in year 2004, because the above mentioned actions were taken only during the last two months of year 2003. As a matter of fact, the stakeholders' meetings held only in December, i.e. at the end of the years'treatment. The large numbers of refusals in Borgu LGA was said to be caused by detractors who were Islamic fanatics. These people, misinformed their communities that the drug had a very negative effect on their health, and accused America of attempting to reduce Muslim populations while camouflaging the drug as being for river blindness control. The issues were tabled and thoroughly addressed also at the LGA level Stake holders' meetings. The traditional leaders promised to go back and correct these erroneous impressions circulating in their communities. The superuising LGA/PHC Personnel were once more advised to produce duplicate copies of community summary forms and always to leave behind one copy in the community registers while keeping the other. He was directed to advised the CDDs and village heads to ensure the safety and security of all Mectizan@ treatment records, by keeping such record in a safe place, especially in custody of the village head. 38 WHO/APOC, 26 September 2003 SOCT and LOCT were trained and retrained on record keeping and transfer of data into MIS. The data received this year was very much improved. The LGA Coordinator for Munya has however not adjusted, and plans are on ground to reorganize the LOCT in that LGA because of this problem and several other administrative problems affecting the programme in that LGA. SECTION 3: SupDort to CDTI 3.{. Financial contrlbutions of the partners and communities Table 1 1: Financial contributions by all partners for the last three years Instead of US$62,120, US$70,000 was received from APOC. Not available. If there are problems with release of counterpart funds, how were they addressed? There are problems with release of State counterpart funds and several memos were written to government as reminder. Several advocacy visits were paid by both the NOTF and UNICEF {. Na Contributor Yeor | ('2000') Year 2 (2001') Year 3 Q002') Year 4 (2003) TOTAL Budgeted (us$) TOTAL Released (us$) TOTAL Budgeted (US$) TOTAL Released (us$) TOTAL Budgeted (us$) TOTAL Released (US$) TOTAL Budgeted (us$) TOTAL Released (us$) Ministry of Health (MOH) 22,725 22,725 49,000 0 43,000 0 43,000 0 Local NGDo(s) ( if any) NGDO partner(s) (UNICEF) 24,000 7,023 24,000 0 24,000 14,000 24,000 12,44L G'rz N/A 2,000 5,595 13,386 13,386 DistricVLGA 10,000 8,138 15,000 L0,42t L0,37t 9, 100 Na l,lo2 Communities 13,041 8,145 58,800 L,240 t,4L6 Na 33s APOC Trust Fund t28,940 66,715 100,700 84,597 65,000 35,000 62,L20 70,000x TOTAL 198,706 1L4,746 247,5OO 961258 t42,371 65,111 142,506 97,264 39 WHO/APOC, 26 September 2003 officials during which they solicited for Government release of counterpart funds at both State and LGA level. Funds are yet to be released at State level while US$1,102 was released by 7 old treatment LGAs. Stakeholders meetings were held in all 21 LGAs where the issue was discussed and plans are on ground for fund raising. The State level meeting will hold in February 2004 where the issue of "lack of Government funding as a threat to sustainability of CDTI'will be the theme for discussion. Further more, pressure groups are being identified through stakeholders'meetings (at all levels) to prompt Government to release the required funds. 3.2. Other forms of community support Describe (indicate forms of in-kind contributions of communities if any) Most communities suppoft CDDs with prayers, cash, foodstuff, and meals (during Mectizan@ distribution,) farming, vehicles for collection of Mectizan and superuision. Other communities (about 50), nominated their CDDs for political posts at LGA councils, some recommended their CDDs for participation in NIDs. 3.3. Expenditure per activity - Indicate the expenditure on activities below in US dollars using the current United Nations exchange rate to local currency The current UN exchange rate is US$1.00 to $ 127.50 Table 12: Indicate how much the project spent for each activity listed below during the reporting period Activity Expenditure ($ us) Source(s) of funding Drug delivery from NOTF HQ area to central collection point of community 6,902 UNICEF/LGAs Mobilization and health education of communities 18,729 APOCruNICEFIGTZI LGAs Training of CDDs Training of health rtrff ut utt trr"t, 1,569 APOC/LGAs 12,549 APOCruNTCEFIGTZ Supervising CDDs qnd distribution Internal rqonitoring of CDTI activities Advocacy visits to health and political authorities 2,343 APOC/LGAs 0 0 3,791 APOC/tINICEF/LGAs IEC materials 4,220 APOC Summary (reporting) forms for treatment 0 0 40 WHO/APOC, 26 September 2003 Vehicles/ Motorcycles/ bicycles maintenance 700 APOC/LGAs Offrce Equipment (e.g computers, printers etc) 7,96 1 APOC/LGAs Others 9,490 APOC TOTAL 62,254 Total number of persons treated 879,911 Comments Although two installments of US$70,000 was received from APOC during the period of report, the second installment could not be utilized due to its' receipt only in December, coupled with delay due to bureaucratic bottlenecks in approval for utilization of funds, by both UNICEF and the Ministry of Health. The unusually high expenditure on training was due to training of LOCTs on CSM/SHM as well as training for CDTI in the 4 newly added LGAs of Suleja, Gurara, Tafa and Agwara. SECTION 4: Sustainabilitv of CDTI 4.1. lnternal; independent participatory monitoring; Evaluation 4.1.1 Was Monitoring/evaluation ca:ried out during the reporting period? (tick where applicable) No. There was only year one participatory independent monitoring in year one of the project. Mid Term Sustainability Evaluation 5 year Sustainability Evaluation Intemal Monitoring by NOTF Other Evaluation by other partners 4.1.2 What were the recommendations? Not applicable 4.1.3 How have they been implemented? Not applicable 4t WHO/APOC, 26 September 2003 DistricU LGA Total # of communities/villages in the entire project area No of Communities that carried out self monitorins (CSIO No of Communities that conducted stakeholders meetins (SHIO Kontagora 65 20 20 20 Activity onqoinq Rijau L26 l\ Magama 51 Mariga 247 22 ll Mashegu 116 20 ll Agaie L97 20 ll Lapai 2LL 20 ll Mokwa 114 20 ll Rafi L29 20 ll Wushishi 130 22 ll Borqu 156 20 ll Lavun 86 20 ll Shiroro 103 20 ll Gbako 62 20 ll Katcha 184 20 ll Munya 140 20 ll Bosso 134 I ll Suleja 37 0 ll Gurara 150 0 0 Agwara 36 0 0 Tafa 46 0 0 TOTAL 2,52O 332 ll 4.2. Gommunityr self-monitoring and Stakeholders' Meeting Table l3: Community self-monitoring and Stakeholders Meeting (Please add more rows if necessary) Describe how the results of the community self- mon'toring and stakeholders meetings have affected project implementation or how they would be utilized during the next treatment cycle. CSM and SHM at community level commenced only in November and is still ongoing, therefore the results are not yet available. However, it is obvious from LGA level Stakeholders'meetings held in 21 LGAs, that there will be improved funding at all levels, and that the commitment of policy makers to CDTI would improve due to formation of Oncho. Control committees at that level. 42 WHO/APOC, 26 September 2003 The meeting also noted that some frontline health care staff assigned to supervision of CDTI did not show much commitment, and therefore promised to inform the LGA authorities about any of such developments. 43 WHO/APOC, 26 September 2003 4.3. Sustainabality of proiects: plan and set targets (mandatory at Yr 3) 4.3.lWhat aruangements have been made to sustain CDTI after APOCfunding ceases in terms of:- 4.3.1 Planning at all relevant levels. State and LGA plans will be made and realistic budgets will be tied to activities clearly indicating source of funds 4.3.2 Funds. State and LGAs are working in collaboration with UNICEF to make Government to release funds based on annual PHC budgets. The outcome of Stakeholders' meetings indicate that pressure groups have been formed, and these groups designated as Oncho.Control committees would ensure that government releases funds for CDTI activities. There are plans also for fund raising at all levels. The traditional leaders also pledged to see to selection of more CDDs especially at ward level, to mobilize their people for motivation of the CDDs through incentives and to advocated for female pafticipation in the CDTI. 4.3.3 Transport (replacement and maintenance) will be done centrally in MOH. i.e. if counterpart funds are not available. The LGA coordinators have been personally responsible for maintenance of project motorcycles attached to them and will continue since this is the usual practice over here. LGA administrators will be encouraged to purchase motorcycles and bicycles for the programme whenever the need arises. At State level, effofts will be made to ensure full integration of the CDTI into viable projects like AIDS control, NPI, etc. so that there would be central maintenance of all participating PHC vehicles i.e including the CDTI project vehicle. 4.3.4 Other resources- Funds raised through State and LGA level fund raising activities 4.3.5 Please provide a written plan with set targets and achievementsfor sofar. 4.3.6 To what extent has the plan been implemented Since the project is yet to be evaluated a sustainability plan has not been drawn yet, However, the proposed plan for Year V is hereby attached. 44 WHO/APOC, 26 September 2003 4.4. lntegration Outline the extent of integration of CDTI into the PHC structure and the plansfor complete integration 4.4.1. Ivermectindeliverymechanisms Ivermectin is received and delivered through the existing PHC structure of the three tiers of Government. Communities collect Mectizan@ from district health superuisors. While in hard to reach areas, from the frontline healthcare staff. The period of the NIDs is often suitable for drug delivery, because the LGA/PHC staff are often invited to the LGA headquarters for collection of vaccines. Mectizan@ is included among the items for delivery to the LGAs. 4.4.2. Training LGA/PHC Personnel have been trained as TOTs. They are directly responsible for community mobilization and training/retraining of CDDs. The LGA Monitoring/Evaluation officers who serue as disease surueillance officials are members of the LOCT and do collect Mectizan@ from State to communities. 4.4.3. Joint supervision and monitoring with other programs At the State level, plans for integration of superuision and monitoring with other programmes are on ground. LGA M&E officers are members of the LOCT, therefore they will integrate superuision of ongoing AFP surveillance with supervision of CDTI. 4.4.4. Release offunds. Already there is a budget for Oncho. within the PHC budget, and plans are on ground to prompt Govt. for joint release of funds under the PHC vote of charge. 4.4.5. Is CDTI included in the PHC budget? Yes. Describe other health programmes that are using the CDTI structure and how this was achieved What have been the achievements? 4.4.6. 45 WHO/APOC, l0 April2003 Not yet. However there are plans to integrate distribution of ITNs for RBM into CDTI Vitamin A distribution is another programme being considered for utilizing the CDTI structure. 4.4.7. Describe others issues considered in the integration of CDTI. 4.5 Operational research 4.5.1 Summarize in not more than one half of a page the operational research undertaken in the project area within the reporting period. None yel However there is a plan to sourceforfundsfrom UNICEFfioT conduct of KAP studies on ways to promote female participation in CDTI in the State. 1.5.2. How were the results applied in the project? SECTION 5: Strenoths, weaknesses and challenges List the strengths and weaknesses of CDTI implementation process Strengths 1. Release of funds from APOC, UNICEF and GTZ. 2.Improved participation of UNICEF. 4. Fairly committed LOCTs in 70o/o of LGAs. 5. Good community participation and ownership of CDTI. 6. Fairly good integration of CDTI into PHC at all levels, especially NPI programme (CBOs oriented and mobilized for pafticipation) 7. Finalized and approved REMO. This will enable us to determine UTO by March 2004 when census update would have been completed.. 8. Fairly good CDD retention in 600lo of communities. 9. Availabiliil of 225 trained LGA/PHC staff for facilitation ongoing application of CSM/SHM to 332 CDTI communities of 17 LGAs. 46 WHO/APOC, 26 September 2003 Weaknesses 1. Poor political will of Governments, as evidenced by non release of counterpart funds at State level, and poor release at LGA level. 2. Poor utilization of APOC funds due to bureaucracy (at State level) in approval for forwarding of proposals to UNICEF for approval and lengthy bureaucrary in approval for disbursement of funds even when approval is received. 3. Inadequate CDDs. The available ones are hardly motivated to continue, due to lack of community support and poor female pafticipation. 4. Inadequate Vehicles (4W.D. Vehicle, 20 motorcycles and 100 bicycles additional required) 5. Poor effort at integration with PHC by some LGA Oncho. Coordinators, and poor superuision in Such LGAs 6. Late feedback on treatment in some LGAs. Constraints 1. Lack of State counterpart funds and poor release at LGA level. 2. Late receipt of donor funds resulting in late commencement of CDTI activity and pressure of SOCT to meet up with set target. 3. Large expanse of land for CDTI (6.5.million hectares) and inadequate vehicles for superuision especially in Borgu, Mariga, Magama, Rijau, Katcha, Rafi, Agwara and Mashegu LGAs. 4. Late supply of Mectizan. The complete quantity of drug requested was not received until September, 2003. 5. Flood disasters in some LGAs leading to displaced communities. 6. Inappropriate treatment time leading to delay in treatment by some communities. Therefore treatment was carried out only at night. 7. Delayed completion of treatment and threat of CDD attrition in some communities, due to CDD disenchantment as a result of poor motivation by some communities. 47 WHO/APOC, 26 September 2003 - List the challenges and indicate how they were addressed Challenoes 1. Updating of census for determination of Ultimate Treatment Goal (UTG). Letters were written to LGAs where REMO was updated and they were guided on areas for CDTI. The list of additional communities, was compiled and communities were mobilized for the CDTI. Census is already ongoing in several communities, while UNICEF plans to fund a State wide census update early in year 2004. 2. Attaining at least 650/o of Ultimate Treatment Goal. Mectizan@ distribution commenced earlier (i.e. in August) unlike in previous years, however, the drugs supplied then covered only 9 LGAS. A Second consignment was not received until September, however all L7 LGAs had Mectizan@ in their custody for at least three months to allow for mop-up of treatment. Mass distribution of Mectizan@ was also conducted in the 4 newly added LGAs and with these efforts, 78o/o geographical coverage was achieved and the treatment data is updated, the therapeutic coverage is expected to rise to at least 70o/o. 3. Full integration of CDTI with PHC programmes like disease surueillance, M&E at State, LGA, District and Community level. - The meetings for AFP surueillance were attended by the SOCT and through that, M&E staff who are the participants were mobilized for better pafticipation in CDTI activities. 4. Mobilizing Government at State and LGA level for timely release of funds for conduct of CDTI. - Earlier efforts, as described within the repoft did not yiel much result. The stakeholders' meetings' appear to old better promise for ensuring release of government funds. 5. Updating of census for determination of Ultimate Treatment Goal (UTG) 6. Mobilizing communities for suppoft of CDDs/ Increasing number of CDDS through prompting of communities to select CDDs at ward level. Communities were mobilized 48 WHO/APOC, 26 September 2003 and urged to motivate their CDDs through either provision of incentives or reduce CDD workload through selection of additional CDDs at ward level. Several communities chose option two, while others chose both options. 7. Inclusion of females as CDDs. Orientation meetings were held wlth 700 representatives of various women groups. Because the activity held only in December, the impact could not be assessed during the period of repoft and would only be determined in the subsequent year. i.e. in terms of improved participation in CDTI and motivation of CDDs. 8. Ensuring good treatment compliance (at least 75o/o) with reduction in absentees and refusals. - In 50o/o of LGAs i.e. where treatment commenced early, there was adequate time for ensuring compliance and mop - up. 9. Prompting LGA/PHC personnel for early feedback on CDTI. Treatment commenced earlier i.e in August in 50o/o of LGAs, and this helped to ensure early feedback on treatment. Unfortunately, drugs for the other 50o/o of LGAs was received late i.e. in September, and this might have contributed to lack of feedback from two LGAs i.e. Borgu and Lavun because no repofts were received. 10. Changing attitude of some LGA coordinators towards integration with PHC. - Efforts were made through visits to the LGAs, meetings were held with LGA health team with DPHCs presiding over the meetings. Superuision schedules for LOCTs and frontline PHC staff were drawn and shared with SOCTs and the LGA teams. 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