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7,TH YEAR ANNUAL TECHNICAL REPORT FOR COMMUNITYDIRECTED TREATMENT WITH IVERMECTIN GDTD
PROTECT IN NIGER STATE.I
I
ORIGINAL: English
COUNTRYAIOTF: Nigeria Proiecl l\auqa: NGNIGS
Approvalvear: 1999 Launchinq year: 2000
Reportine Period: From: January 2006 To: December 2006
IMoNTH/YEAR) ( MONTH/rEAR)
Proiectvearofthisreport: (circleone) I 2 3 4 5 6 (7) I 9 10
Date submitted: 28th January 2007 NGDO partner: UNICEF
A}INUAL PROJECT TECHNICAL REPORTSUBMITTED TO
TECHNICAL CONSULTATIVE COMMITTEE (TCC)
DEADLINE FOR SUBMISSION:
To APOC Management by 31 Januarv for March TCC meeting
To APOC Management by 31 JuIv for September TCC meeting
AFRICAN PROGRAMME FORONCHOCERCTASTS CONTROL (
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ANNUAL PROJECT TECHMCAL REPORTTO
TECHMCAL CONSULTATIVE COMMITTEE (TCC)
ENDORSEMENT
Please confirm you have read this report by signing in theappropriate space.
OFFICERS to sign the report:
Country: MGERIA
National coordinator Name: Mrs. P. Ogbu Pearce
Signature4T)
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Zonal Oncho coordinator Name: Dr. Fayomi
Signature
ItDate: .5.1. /.t.1. ?rn't I
aeps-
Date
This report has been prepared by Name : Hajiya Rakiya.Y.Datti
Designation : Onchocerciasis coordinator
Date
NGDO representative Name: Dr (Mrs) Catherine Gana
Signature€
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DEFINITIONS, w
FOLLOIY UP ON TCC RECOMMENDATIONS, I
DGCUTIYE SUMMARY 2
SECTION I: BACKGROUND INFORMA
l.L GzttgnuINFqRMATIqN.
l.l.l Description of the project (briefly)
2.1
2.2.
2.3.
2.4.
2.5.
2.6.
2.6.1.
2.6.2
2.6.3
2.6.4
2.6.5.
2.7.
2.8.
2.9.
2.9.1.
2.9.2.
2.9.3.
2.9.4.
2.9.5.
2.9.6.
3
1.1.2 PtnnNonsarp...
1.2 POPULATION...
SECTION 2: IMPLEMENTATION OF CDTI ........... .... 12
.....3
..3-6
7-8
9-t I
TIMELNEOFACTIVITIES ....... 12-13
Aovoc.tcv. ......14-15
MoBITIz,InoII, SENSITIZATIoN AND HEALTH EDUCATION OF AT RISKCOMMUNITIES................,. 15
Couuuunv INVoLVEMENr................. ...16-18
C.tp,qcrcy nwtDrNG.......... .. 18-22
Tnnaruotns. .........22
Treatmentfigures............. ......25
ll'hot are the causes of absenteeism?........... ...............26
What ore the reasonsfor refusals? ................ .............26
Briefly describe all krnwn andverified serious adverse events (SAEI that .................26-27
Trend of treatment ochievementfrom CDTI project inception to the cunent year.............28
ORDENNG, SToRAGEAND DELIVERr oF IVERMECTIN ..29-31
CouuuNrcy sELF-MoNrroRrNG tuo SrexanotDERS MEETTNG .... 3l-33
Suponwstox ...-.....33
Provide a/low chart of supervision hierarchy. ........... 33
What were the main issues identified during supervision? .......33-33
llas a supervision checHist used? ......... .....................34
Vlhat were the outcomes at each level of CDTI implementation supervision?.............. 34-35
Was feedback given to the person or groups superuised? .............. -15
How was the feedback used to improve the overall performance of the project? ..........35-36
lll
SECTION 3: SUPPORT TO CDTI.. ------.------- 37
3.1. Egwrur,ur ......37-38
3.2. FtNtxcut coNTRtBWtoNS oF THE qARTNERS AND coMMtJNtruES.... 39-40
3.3. Orntn FqRMS oF coMMUNrry suppoRT.. ......................40
3.4. Exprttotrunt pERACTTt/rry .40-41
SECTION 4: SUSTAINABILITY OF CDTI 4I
4.1. INrrnN.u; TNDEzENDENT pARTICTpAToRy MoNIToRTNG; EvlLu.artoN 4l
4.1 .l Was Monitoring/evaluation carried out during the reporting period? (tick any of tlrc
follow ing w hic h are appl icable) ..............
4.1.2. Vlrhot were the recommendations?.
4.1.3. How have they heen implemented? -.............
4.2. Susrtnuarutry oF zRoJECTS: zLAN AND sET TARGETS (utuotrony AT yR 3) ....................
4.2.1. Planning at all relevant levels .........
4.2.2. Funds........
4.2.3 Transport (replacement and maintenance)
4. 2.4. Other resources...
4.2.5. To what extent has tlre plan been implemented
Ixrccmrtottt
Iverme ct in de I ive ry me chanisms
Training....
Joint supervision and moniloringwith other program, ..........
Release offunds for proj ect activities ....
Is CDTI inclufud in the PHC budget?
4.3.
4.3.1.
4.3.2.
4.3.3.
4.3.4.
4.3.5.
.....41
.....41
.....42
,...,42
,...,42
42-43
43
43
43
43-44
,....44
,....44
....45
....45
....45
4.3.6. Describe other health programmes thot are using the CDTI structure and how this was
achieved. What hove been tlrc achievements?.............. ..........45
4.3.7. Describe others issues considered in the integration of CDTI. .45-46
4.4. Oprntnotul RNEARCH ..........46
4.4.1. Summorize in not more thsn one holf of a page the operational research undertaken in the
project area within the reporting period. .............46
4.4.2. How were the results applied in the project? ............. ...................46
SECTION 5 : STRENGTHS, VEAKNESSES, CHAL LENG ES, AND OPP0RTUNITIES............ I 7-s0
SECTION 6: UNIQUE FEATARES OF THE PROJECT/OTHER MATTERS
lv
5L5t
Acronyms
APOC African Programme for Onchocerciasis Control
ATO Annual Treatment Obj ective
ATrO Annual Training Obj ective
CBO Community B ased Organ ization
CBS Community Based Supervisor
CDD Community Directed Distributor
CDTI Community Directed Treatment with Ivermectin
CSM Community Sel f-Monitoring
DHS District Health Supervisor
DPHC Director Primary Health Care
FOMWAN Federation Of Muslim Women Association Of Nigeria
HSAM Health Education, Sensitization, Advocacy, Mobilization
LGA Local Government Area
LOCT Local Onchocerciasis Control Team
MIS Management Information System
M&E Monitoring and Evaluation
MOH Ministry of Health
N/A Not Available
NGDO Non-Govemmental Development Organization
NGO Non-Governmental Organization
NIDs National Immunization Days
NPI National Programme on Immunization
NOCP National Onchocerciasis Control Programme
NOTF National Onchocerciasis Task Force
PHC Primary Health Care
REMO Rapid Epidemiological Mapping of Onchocerciasis
SAE Severe Adverse Event
SHM Stakeholders' Meeting
SOCT State Onchoc.erciasis Control Team (The State Programme coordinating team)
TBAs Traditional Birth Attendants.
TCC Technical Consultative Committee (APOC scientific advisory group)
LINICEF United Nations Children's Fund
UTG Ultimate Treatment Goal
wHo Wotld Health Organization
v
DeJinitions
(i) Total population: the total population living in meso/hyper-endemic communities within theproject area (based on REMO and census taking).
(ii) Eliqible populotion: calculated as 84%o of the total population in mesolhyper-endemiccommunities in the project area.
(ii i) Annual Treatment Obiective; (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) Utimate Treatment Goal (UTGI: calculated as the maximum number of people to be treatedannually in meso/hyper endemic areas within the project area, ultimately to be reached whenthe project has reached full geographic coverage (normally the project should be expected toreach the UTG at the end of the 3d year of the project).
(vi)
(v)
(vii)
(viii)
(ix)
Theraoeutic coverage: number of people treated in a given year over the total population (thisshould be expressed as a percentage).
Geographical coverage: number of communities treated in a given year over the total numberof meso/hyper-endemic communities as identified by REMO in the project area (this shouldbe expressed as a percentage).
Integration: delivering additional health interventions (i.e. vitamin A supplements,albendazole for LF, screening for cataract etc.) through CDTI (using the same systems,training, supervision and personnel) in order to maximise cost-effectiveness and empowercommunities to solve more of their health problems. This does not include activities orinterventions carried out by community distributors outside of CDTI.
Sustainabililv: CDTI activities in an area are sustainable when they continue to functioneffectively for the foreseeable future, with high treatment coverage, integrated into theavailable healthcare service, with strong community ownership, using resources mobilised bythe community and the govemment.
Community seV-monitoring (CSM\.' The process by which the community is empowered tooversee and monitor the performance of CDTI (or any community-based health interventionprogramme), with a view to ensuring that the programme is being executed in the wayintended. It encourages the community to take full responsibility of ivermectin distributionand make appropriate modifications when necessary.
vl
FOLLOW UP ON TCC RECOMMENDATIONS
Using the table below, fill in the recommendations of the last TCC on the project and describe howthey have been addressed.
TCC session I
Numberof
Recommendations in theReport
TCCRECOMMEN
DATIONS
ACTIONS TAKEN BY THE PROJECT FORTCC/APOCMGT USE
ONLY
(i) Focus on State andLGA financialcontributions.
Concerted effort was made both to the Ministry forLocal Government to obtain the proposed mandate forcentral deduction ofcounterpart contribution forthe 2lCDTI LGAs as well as to the Ministry of Finance forrelease ofUS$30,000 approved counterpart fund fortheState.
US$20,000 was released to the State but no mandatewas obtained for central deduction of LGAcontributions.
Only 2 LGAs released the sum of US$650 to theirLOCTs despite intense advocacy visits to all of the 2lLGAs
(ii) Replace and repairproject equipment.
Some project equipment were repaired and maintainedat State level, however, repair of LOCT motorcycles has
been difficult due to absence of counterpart funding atthat level.
(iii) Recruit more newfemale and maleCDDs.
Communities are continuously mobilized for inclusionof women as CDDs, but this is still difficult to achievebecause of religious and socio-cultural belief of thepeople especially the Moslems who happer to be themajority. There is a plan to collaborate with an islamicgroup known as FOMWAN, with the hope of improvingwomen participation. Absence of female CDDs does nothowever seem to have any negative effect on treatmentof females.
There is severe CDD attrition due to lack of motivation,and new ones are being selected both at ward level andalong family lines. CDDs are to be trained for integrateddisease surveillance and it is hoped that this wouldcreate opportunities for thern to be motivated alsothereby reducing threat of attrition.
(iv) Improvesupervision at alllevels.
There has been concerted effort by NOCP, UNICEF andthe SOCT to ensure that communities are adequatelysupervised, and these efforts have been quite revealing!The LOCT are highly dernoralized and hardlysupervised the lower level, therefore, drugs were notreleased to the communities on time and even whenreleased, distribution was not properly supervised anddata was not collated from the community register.
WHO/APOC. 24 November 2fi)6
Executive Sunnury
Niger State has 25 administrative divisions known as Local Government Areas (LGAs), out ofwhich 2l arc approved by APOC for implementation of CDTI. The population of the State is 3.9
million based on the recent (2006) national census. There are 2,872 affected communities with aregistered population of 1,774,333 people at risk of infection and blindness from Onchocerciasis.
At the time of submission of this report l,l53,3ll people were treated in 2,069 endemic
communities, representing65Yo therapeutic and72o/o geographic coverage respectively. Four LGAs
did not give any feedback while five of them submitted only partial reports. The Ultimate Treatnent
Goal (UTG) forthe project is 1,490,440, therefore UTG coveragewasTTYo.
The population in over 40%o of the project area is highly migratory because the State shares
boundary with several others in all directions, as well as Benin republic on its' western border.
Commonest among the migrant ethnic groups are Gwaris, Kambaris and nomadic Fulanis. Due tothe socio-cultural beliefs and practices of the aforementioned, they migrate annually both within and
outside the State in search of virgin (fertile) land for growing cash crops such as yams, guinea corn,
matze and millef, while the nomadic Fulani migrate in the dry season in search of water and fresh
fodder for their animals. The above phenomenon is responsible for the nucleated and highlydispersed settlement pattem, as well as highly dynamic community and population figure thatprevails in over 60% of the State. Niger is the largest of the 36 States in Nigeria, occupying l}Yo ofthe total area.
5,356 CDDs were trained/retrained out of an ATrO of 14,263 representing 3802, while 702 healthpersonnel were trained/retrained to increase capacity for supervision of CDTI. This achievementrepresents l22o/o cov erage.
The challenge the project experienced within the period of report was achieving its'ATO of1,490,440 people in spite of very poor funding at LGA level. Only two LGAs released funds to the
LOCT, therefore most of the teams were demoralized and commitment declined. Because ofinability of most LGAs to collect lvermectin from the State, it had to be conveyed to them, either by
the SOCT or during distribution of vaccines for mass immunization. In order to ensure that drugs
were released to all eligible communities, a comprehensive list of these communities, and their drug
allocation was compiled by the SOCT and then distributed to the LGAs as a guide. The acceptance
of Mectizan, and its' popularity, together with opportunity provided by the NIDs, helped to integrate
CDTI in PHC at all levels, while the commitment of some of the LOCT and frontline health facilitystaffensured training/retraining of CDDs as well as supervision of treatment. Intensive advocacy and
mobilization visits werc made to LGAs by the SOCT and supervision was intensified to ensure
adequate ooverage.
Frequent transfer of the heads of the PHC department at LGA level was a major set back to ensuringtimely reporting from the LGAs, despite the effort of the SOCT. UMCEFS' renewed commitment tothe programme provides a ray of hope and its' funding for focused intervention in Borgu LGA(November/December 2006) holds promise for improved coverage at the border with Beninrepublic.
) WHO/APOC. 24 November 2006
SECTION I: Backgruund information
LL General information
1.1.1 Description of the project (brielb)
- Geographical location, topography, climate
- Population: activities, cultures, language
- Communication systems (roads...)
- Administrationstructure
- Health system & health care delivery (provide the number of health posts/centers in the
project area if the information is available).
- Number of health staff in project area and number of health staff involved in CDTI activities
l.l.l. Descriotion of oroiect
Niger State is geographically located within the middle belt of Nigeria and it lies between latitude 3
20' East and longitude ll" 3' North. It is borderedby Zamfaru State on the North, Kebbi State on
the North Wesf 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 westem border i.e. at Babanna district of Borgu Local
Govemment Area. The location of the State gives rise to common inter-border trade with it in all
directions.
The topography of the State is highly undulating, while the land is traversed by several fast flowing
rivers such as Niger, Oli, Kaduna, Kontagora, Gurara and several tributaries that flow into them. As
a result of the topography, the major rivers of Niger and Kaduna have been dammed for production
of electricity, therefore, the State houses the largest number (3) of hydro electric power stations in
the country thus earning itself the title, 'Power State'. Prominent among the dams are Kainji, across
river Niger at New Bussa in Borgu LGA, and Shiroro, across river Kaduna at Shiroro LGA. Despite
its' meso endemicity, the State is surrounded by hyper endemic foci on its' northeas! southeas!
south and southwest. These foci are in Kadun4 the FCT, Kogi and Kwara States respectively.
The vegetation of the State is mainly of the guinea savanna type with forest mosaic savanna
especially in the south and south-western parts. The climate is of distinct dry and wet season with
rainfall ranging between l,l00mm in the North and l,600mm in the south. The wet sqxon ranges
from l50days or more in the northern part to 210 days or more in the southern part. The dry season
commences in October and humidity could be as low as 140'between December and February.
1 WHOiAPOC. 24 November 2006
Temperatures rise as much as 90T betrveen 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 lan{ thus the population is agrarian in over 80% of the State. Among the
large ethnic groups, the Gwaris', Kambaris' and nomadic Fulani have a socio-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 the farming groups
include yams, rice,maize, millet and guinea corn. Nupes' are one of the major ethnic groups in the
State, and they are more stable in settlement forming very large clustered populations that reside
within the marshy alluvial rich valleys, which abound in the State. The Nupes grow mainly rice as
both food and cash crop while they are also very good fishermen.
While the settlement pattern in 4OYo of the State is dense and clustered, over 60% is sparsely
populated and highly nucleated with distances of up to 40 kilometers between some communities.
Niger is in fact the largest State in Nigeri4 occupying about 12 million hectares of land, which
represents about one tenth of the total land area of the country.
There is a fairly good road network in about 40%o of the areq however, due to the riverine nature,
about 40%o of movement is by water, using local tug boats, engine boats, and ferry for movement ofgoods, vehicles and humans across the rivers, especially between communities and from the State to
neighboring Kebbi State. Heavy flooding, as a result of overflow of the hydroelectric power dams
especially after the rains, is a major threat to communities that reside along the large rivers of the
State, therefore several communities are often either submerged, dispersed or are displaced.
The administrative structure is typical of what obtains all over the country, i.e. with a politically
elected executive Governor at the State level and 25 local administrative councils headed also by
politically elected LGA chairmen. The peculiarity here is that the administrative councils are further
suMivided into 43 units with 18 ofthem known as developmental area councils each with a separate
leadership which makes coordination of activities quite difficult especially where there is poor
collaboration between the adjoining LOCT coordinators. There are several traditional institutions
headed by Emirs and chiefs of various hierarchies, who oversee the districts and communities while
the kingdoms are grouped as emirate councils. The communities within the emirates are headed by
traditional rulers who pay allegiance to the top hierarchy as is typical of the ancient feudal system ofgovernment, while all Emirs are accountable to the Executive Governor. The State government
basically comprises ofthree arms i.e., the executive, legislative and judiciary.
4 WHO/APOC. 24 November 2006
The heatth care delivery system comprises of three levels i.e. Primary, Secondary and Tertiary, all of
which are quite well interlinked. The PHC system has been put fairly well in place, and is becoming
more functional. There are over 1,400 health posts/health centers in the State out of which about
1,000 exist within the CDTI project area. There are 3,239 PHC staff, out of which, 796 are
participating in CDTI.
Out of 2l CDTI LGAs, 17 are old (i.e. have implemented CDTI for at least 4 years), while four,
namely, Suleja Tafa, Gurara and Agwara (which came about as a result of the REMO
update/approval of year 2004) have implemented CDTI for three years now. Western Borgu shares
border with Benin Republic at Babanna district and was also approved for CDTI in year 2004. It was
only in year 2006 however ,that concerted effort was made to ensure total coverage of over 200
communities in that sector.
5 WHO/APOC. 24 November 2fi)6
Table 1: Number of heahh staffinvolved in CDTI
District/LGA
Number of health staffinvolved in CDTI activities.
Total Number ofhealth staffin the
entire project areaBr
Number of health staffinvolved in CDTI
B,
Percentage
BrBzlBr *100
Kontagora 150 l3 9
Rrjau 123 50 4t
Magama 216 36 17
Mariga 202 34 17
Mashegu t14 27 24
Agaie 132 23 t7
Lapai 137 67 49
Mokwa 182 48 26
Rafi 185 6t 33
Wushishi 150 50 33
Borgu l13 69 6l
Lavun 185 23 t2
Shiroro 120 60 50
Gbako 69 2t 30
Katcha 65 45 69
Munya 194 l8 9
Bosso230 36 t6
Suleja 166 2t 13
Gurara 187 37 20
Agwara 164 24 l5
Tafa l5s 33 2t
TOTAL 3,239 796 25
('l WHO/APOC. 24 November 2fi)6
1.1.2 Portnerchip
- Indicate the partners involved in project implementation at all levels MOH, NGDOs
(national/international), communities, local organizations, etc.]
- Describe overall working relationship among par0lers, 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/LcA decision-makers, NGDOs, NGOs,
CBOS, to assist in CDTI implementation.
Partners involved in project implementation are:-
- The National Onchocerciasis Control Programme, of the Federal Ministry of Health,
- The State Ministry of Health and LGA/PHC departments
- UNICEF, APOC, WHO
- 2,872 Onchocerciasis endemic communities with their CBOs. These CBOs are mainly agricultural
cooperative groups and trade unions for both men and women, as well as various youth (age
grade) associations, which also often double as agricultural cooperative groups.
The overall working relationship among the partners is quite cordial and encouraging. Generally, all
are involved in HSAM at various levels. LINICEF has renewed its' commitment and is involved in
planning for conduct of CDTI activities like planning, training, HSAM and supervision/monitoring.
The focused intervention at Borgu LGA (December) was an outcome of the internal
advocacy/monitoring visit paid to the State by the new UNICEF consultant in October in company
of NOTF officials. Two review meetings for the 9 assisted States were also sponsored by UNICEF
in the year under report.
The Ministry of health solicited for piece-meal release of funds from the US$23,809 approved and
was successful in acquiring US$15,873 which was utilized for HSAM, supervision and monitoring
{rmong several other activities.
7 WHO/APOC. 24 November 2006
Various groups like media organizations, the Nigerian Red Cross society, Jama'atu- Nasril-Islam
(JNI) the predominant muslim organization, as well as National Union of Road Transport Workers
also pledged to continue to assist with HSAM activities.
There would be a new democratic government in 2007, and there is a plan for high level advocacy
visit involving UNICEF, NOCP and possibly APOC to the State in the middle of year 2007 to
advocate for bulk release of funds (for 3 years) from the newly elected democratic govemment.
Advocacy visit would be paid to the 2l new LGA councils by the SOCT to also solicit support for
long term release of funds for LOCT/CDTI activities.
A comprehensive list of active local NGOs and CBOs is being compiled for sensitization and
collaboration in the on-coming year, of special interest is the Federation of Muslim Women
Association Of Nigeria (FOMWAN) which would be engaged for collaboration to mobilize women
for active participation in CDTI at community level.
I WHO/APOC. 24 November 2fi)6
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2.2. Advocacy
State the number of policy/decision makers mobilized at each relevant level during the current year;
the reason(s) for undertaking the advocacy and the outcome. Describe difficulties/constraints being
faced and suggestions on how to improve advocacy.
State level.
l0 Policy makers were mobilized at this level i.e. within the Ministry of health, Finance, and Ministry
for Local Government to inform the leaders on the current status of the programme especially as
regards funding, as well as the need to ensure sustained yearly funding at both State and LGA level.
The UNICEF representative visited the State in company of two members of the NOCP, but was
unable to meet with the policy makers. The Director PHC was however met and the concerns about
the projecg especially as regards funding, was expressed to her. She pledged to convey the message to
the relevant administrators.
The advocacy to the Ministry for local Government was to follow-up on the promise by LGA leaders
during the stakeholders' meeting of December 2004, to give a mandate for central deduction of funds
for sustaining of CDTI activities at that level. While the effort at State level yielded result, same could
not be said of the Ministry for local government. The difficulties being faced at both Sate and Local
Govemment level is due to the current political environment where funds are hardly released for
activities. The local government funds are alleged to be mostly withheld by the State government
thereby frustrating conduct of activities therefore in spite of several efforts, little achievement was
been made because no mandate has been given.
It is therefore suggested that a high powered advocacy team comprising of WHO,APOC, UMCEF as
well as other NOTF personnel be made to visit the newly elected State government in June or July
2007 to help improve on the current situation.
LGA Level
A total of 632 policy makers and traditional leaders were mobilized to solicit for both moral and
financial support to the programme. The situation at Borgu, Wushishi, and Bosso LGAs was given
special consideration in view of low coverage as well poor compliance by both programme
implementers and communities. Several stakeholders' meetings were held with traditional leaders and
the LGA policy makers in attendance for ensuring improvement during the next treatrnent round.
t4 WHO/APOC. 24 November 2006
Conmunitv level
Communities were mobilized for self monitoring and stakeholders' meetings in order to check/address
problems of CDD attrition, as well as poor treatrnent compliance, which is currently the problem in
some LGAs. It would indeed be appropriate for APOC to sustain funding for conduct of such an
activity in order to check the above threat
2.3. Mobilizttion, sensitization and health education of at rtsk communities
hovide information on:
- The use of media and/or other local systems to disseminate information
- Mobilization and health education of communities including women and minorities
- Response oftarget communitieVvillages
- Accomplishments
- Suggest ways to improve mobilization and sensitization of the target communities.
A documentary was produced on Onchocerciasis control in Niger State, by the initiative of the
National Television Authority, Minna network centre, free-of-charge, and aired both locally and
nationally in several slots which lasted over five days and this helped to increase awareness on the
CDTI. Demand is high for Mectizan and we are informed that acceptance of Mectizan enhanced
acceptance of polio immunization in some communities which were initially non compliant.
Large numbers of posters and other IEC materials produced since year 2005, were distributed to
affected communities through the LOCTs.
A total of 1,331 villages were mobilized in 15 LGAs, especially in Mariga, Borgu, Bosso, Rijau,
Mokwa and Katcha where new communities were added. The mobilization activities wer€ conducted
by some SOCT, LOCT and peripheral health care staff. Mobilization and health education efforts
have ensured good compliance in about 67%o out of the 2l CDTI LGAs. There is however need for
adequate release of funds at LGA level in order to ensure better supervision of activities by the
LOCTS.
l5 WHO/APOC. 24 November 2006
Community involvement
Table 4: Communities participation inthe CDTI
* - Only partial reports were received.
N/A - Not Available.
Comment on:
- Attendance of female members of the communit5r at health education meetings
16 wHo/ApoC. 24 November 2006
District/LGA
Number of communities/villageswith community members as
supervisors
Number of CDDs and thecommunities involved
Number ofcommunities /villages
with female CDDsTotal no. Number
withcommunit5rmembers essupervisors
Bs
Percentage
Be=Bsl Bt*100
IVIaleCDDs
B1
FemaleCDDs
&
Total
Bc= B7+Bs
Number ofcommunitieswith female
CDDs
Bro
Bn=Bre/84*100
s in theentire
projectanea
BrKontagora 72 72 100 152 t52 0 0
Rijau t42 142 t00 292 0 292 0 0
Magama 52 52 100 r04 0 104 0 0
Mariga 271 270 r00 564 0 564 0 0
Mashegu t02 N/A N/A 216 0 216 0 0
Agaie 205 205 100 427 0 427 0 0
Lapai 2tt 2tt 100 596 596 0 0
Mokwa 145 N/A N/A s37 0 537 0 0
Rafi* t28 53 4t 203 0 203 0 0
Wushishi* 130 6t 47 130 0 130 0 0
Borgu* 403 230 57 470 2 472 2 0.5
Lavun 92 N/A NiA 235 0 23s 0 0
Shiroro r03 103 100 136 4 140 2 2
Gbako 62 62 100 96 0 96 0 0
Katcha* t66 145 87 257 0 257 0 0
Munya 140 140 100 283 0 283 0 0
Bosso* 154 t2t 78 218 0 218 0 0
Suleja l9 t9 r00 60 0 60 0 0
Gurara r38 lil 80 tt4 ) l16 ') 1.4
Agwara 65 N/A N/A 130 0 130 0 0
Tafa 72 72 100 t28 0 128 0 0
TOTAL2,872 2,069 72 sJ48 8 sJs6 6 0.2
In general, how do you rate the participation of female members of the community meetings
when CDTI issues are being discusses (attendance, participation in the discussion etc).
lncentives provided by communities for the CDDs
Attrition of CDDs. Is attrition a problem for the project? If yes, how is it addressed?
Other issues
Attendance of female community members at community meetings constitutes about 50% of the
total gathering in about 50% of the project area i.e. where purdah (i.e. seclusion of women indoor)
is not the practice. Where purdah is in practice the attendance is zero except where a separate
meeting is held exclusively for the women. However, even where attendance is adequate, the
participation of the women in discussion is passive, because culture inhibits them from being vocal
in public. However, as earlier explained, when separate meetings are held for the sexes, the rcverse
is the case, and the kind of issues that are discussed are quite revealing. Such issues give indication
as to community compliance with treatment, coverage, CDD performance, attitude of supervising
FLHF staff, adequacy of Mectizan@, awareness on the programme, as well problems on payment
of CDD incentives.
More often, the scenario in over 50% of the project area is one where only the elderly women are
permitted to participate and fully contribute to discussions at public meetings. The female elders
are expected to debrief the other women in the community, at another separate gathering of
women. The elderly women are often the TBAs in the community and they double as mobilizers,
since they are the women goup leaders.
The issue of provision of incentives varies with different socio-political areas of the State. In areas
where the community leadership is good, there is a system of communal contribution either in cash
or in kind which is usually handed over to the CDDs at the end of distribution. Most communities
contribute between US$0.1 to US$0.4 per household treated, with a result that CDD incentives
could be as much as US$37. Other CDDs are assisted with farm work while other communities
contribute foodstuff such as grains (millet guinea com, rice), yams, fish and several others.
Generally, all are supported with prayers. CDDs have often been elected into political posts, while
others, because of their hard work, were offered government paid jobs by their LGA councils. The
incentives paid to CDDs during the period of reporting was barely quantified by the LOCT,
however, the amount reported on from 5 LGAs was U.S.$1,025 in cash. However, in over 50%o of
the project are4 esperially where CDDs are selected along family lines, or at ward level,
incentives are not paid as a rule. This is because the communities view the CDDs role as one of the
t7 WHO/APOC. 24 November 2fi)6
usual responsibilities expected from a family member towards his kindred. Such CDDs are quite
contented with this position, and appreciate the fact that their communities vest trust on them. The
community leaders and CBOs also assist with mobilization and supervision of treatment.
CDD attrition was a major problem this year however and this resulted in incomplete geographical
coverage of some of the affected communities. Reporting was delayed as a result of which about
28Yo of community data were not received at the time of compilation of this report. Several CDDs
dropped out because of lack of incentives especially in view of the fact that other members of the
same communities benefited from participation in Polio eradication activities while they were not
incorporated. Because of attrition, the current CDD to population ratio is l: 331 in contrast to
l:271 ofyear2005.
Meetings have been held with the community leaders with the aim of addressing such concerns.
The communities have been mobilized to either select distributors along family lines or if possible
at ward level in order to overcome such unfortunate developments. They have also been advised to
identifr a sustainable source of funding for long time treatment.
2.5. Capactty building
- Describe the adequacy of available knowledgeable manpower at all levels.
- Where frequent transfers of trained staff occur, State what the project is doing, or intends to do,
to remedy the situation. (The most important issue to describe is what measunes were taken to
ensure adequate CDTI implementation where not enough knowledgeable manpower was
available or if staffs are frequently transferred during the course of the campaign).
Generally there is 650lo knowledgeable manpower at State and LGA level, however in some LGAs
where it is inadequate for facilitation/supervision of CDTI, school head teachers are trained to
complement the efforts of the district health supervisors. This is typical of Borgu and Bosso LGAs.
The school head teachers are residents of the communities and their inclusion complements the
role ofthe health supervisors since there are extremely few PHC facilities within these LGAs.
The Ministry of health has made efforts to discourage frequent transfer of staffthrough holding of
meetings with the LGA/PHC directors as well as with the LGA policy makers, and Ministry for
Local Government, however this has not yielded positive results since these transfers occurred
even during the last quarter of year 2006. The directors themselves were transferred and this has
greatly frustrated achieving any meaningful impact, especially concerning checking the negative
attitude of some of the LOCT.
l8 WHO/APOC. 24 November 2006
Three of the 8 participating State staff (SOCT), were also transferred, therefore, the supervision
schedule was neorganized to ensure that no LGA was neglected. Furthermore, new personnel
would be identified and trained on the job in order fill up the gap created and to reduce the
workload of the available staff.
Frequent transfer is a common phenomenon in some LGAs like Bosso, Rafi, Gurara and Borgu,
and this created a lot of problem with supervision, especially because such staff are replaced by
newly employed ones who have no training on the programme. The project therefore intends to
train all PHC staffwithin these LGAs as well as to institute CSM and SHM. Seminars will be held
for final year students of the schools of health technology from where such personnel are produced
in order to prepare them for supervision of CDTI wherever they are posted. Meetings have already
been held with the LGA policy makers to address such problems with the hope that such transfers
would be controlled.
LOCTs were highly constrained in movement and the district supervisors were mainly vested with
responsibility of overseeing implementation of CDTI activities within their locality.
ln view of cross border concerns with Benin republic, it is necessary to point out that although
Borgu LGA has about 6l%o of its' staff participating in CDTI, most of these personnel are
concentrated within the southern and south eastern axis, whereas the portion of that LGA that
immediately borders Benin republic, i.e. Babanna district, located in the western portion has only
13 health facilities and 15 trained PHC staffi.e. despite its' large area and long distances of up to
20 or 30 kilometers between communities. It was in view of this critical situation and the need to
ensure adequate supervision that school head teachers were trained and incorporated as supervisors
since year 2W4.lt will indeed be necessary to sustain this tempo in order fill in such resource
gaps, i.e. by retraining those on ground and training new ones. The funds for the special initiative
from APOC will help to achieve some of these objectives.
tg WHO/AFOC. 24 November 2fi)6
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Tahle 6: Type of training undertaken(Tick the boxes where specilic troining was conied out during the reporting period)
TraineesType
Of training
CDIh
OtherCommunitymembers e.gCommunitysupervisors
HealthWorkers(frontlineheelthfecilities)
MOHstafforOther
PoliticalLeaders Others(specify)
ProgrammanagementHow toconductHealtheducation
\/ \/ ,/
ManagementofSAEs
\/ \/CSM ,/ ,/SHM ,/ \/Datacollection
,/ ,/Data analysis \/ \/Reportwriting
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- Any other comments
At State level
- Training was done on the job, and 4 SOCT members were equipped with knowledge and skills
to improve on their report writing skills.
A, LGA ICVCI
- FLI{F staffwere trained/retrained by the SOCT and LOCT. CDDs were trained/retrained by the
FLHFS.
2.6. Treatments
2.6.1. Treotme nt tig ures
- If the proiect is not achieving lffio/o geographical coverage and a minimum of 650/o
therapeutic coverage or the coyerrge rate is fluctuating, state the reesons and the
plans being made to remedy this.
22 WHO/APOC. 24 Novernber 2fi)3
Based on the data available at the time of submission of this report, the project achieved 65%
therapeutic coverage, 72%;o geographical because reports for 802 communities out of the 2,872
targeted were not received. Late commencement of treatment as well as poor attitude of some
LOCT to ensuring early compilation and submission of treatnent reports are the responsible
factors. The LOCT are generally demoralized because they do not receive any moral or financial
assistance from their leaders for smooth Mectizan distribution, therefore some of them resist
collecting the drug from the SOCT and others collect but do not care to release it to the
communities.
The poor attitude of some supervising PHC staff had a negative effect on coverage because
activities were not supervised in some areas, while some PHC staff did not even care to inform
the communities on availability of Mectizan. This is particularly true of Borgu and Bosso LGAs.
Meetings were held with the policy makers of such LGAs and they promised to ensure better
supervision of drug distribution through imposition of sanctions on defaulting staff. They also
pledged to ensure release of funds for LOCT travel during supervision, as well for conduct of
other CDTI activities. The need to integrate activities in PHC was again emphasized and the
heads of health pledged to ensure that is done.
Meetings were also held with the traditional leaders of defaulting communities, and they
expressed concern that they were not earlier informed about such problems. They then pledged to
ensure that all communities in their domain were always treated.
Communities were also mobilized to select CDDs along family lines or at ward level in order to
check the problem of attrition and low coverage.
)1 WHO/APOC. 24 November 2fi)6
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2.6.2 What are the causes of absenteeism?
Absenteeism is due to either poor community mobilization for treatment or selection of inappropriate
treatrnent time, whereby some community members would have traveled out of home either for
farming and other vocations.
2.6.3 What are the reasonsfor refusals?
Refusal is often due to fear of reaction to the drug or suspicion that the drug is for birth control
especially in inadequately mobilized communities.
2.6.4 Briefu describe oll known ond verifted seriaus adverce evenls (SAEs) that occurred during
the reporting period and provide (in table 8) the required information when available
In case the project did not have any cases of serious adverse events (SAE) during this reportingperiod, please tick in the box.
No SAE case to report
I
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2.7. Ordering, storage and delivery of tvermectin
Mectizan@ ordered/applied for by - @lease tick the appropriate answer)
MOH wHotr TTI\IICEFtr NGDOE
Other (please specifu):
Mectizan@ delivered by - Qtlease tick the appropriate onswer)
MOH f] WHOtr TiNICEF NGDO!
Other (please speciff):
Please describe how Mectizan@ is ordered and how it gets to the communities
The Federal Ministry of HealthA.,lOCP office orders for drugs while UNICEF takes responsibility
for its'clearance on arrival at the Nigerian port. It is also responsible for its' storage prior to
collection.
The quantity of Mectizan@ required by the project is calculated based on 84o/o of the total census
population and that figure is multiplied by 3 to obtain the accurate drug requirement for the
project. Approval to collect drugs is obtained from the NOCP zonal office at Kaduna, and the
State collects its drug allocation from NOCP National office at the Federal Ministry of Health.
After collection, release is made accordingly to the LGAs. LOCTs release drugs to district health
supervisors, while the communities collect their requirement from the district health facility
within their locality or from other agreed collection points. In the case of very distant
communities, drugs are deposited at the nearest frontline health post/facility for convenience of
collection. It is pertinent to note that all drug requirements are determined through the same
calculation procedure as employed for drug requisition by the State. The delivery process is as
follows:-
LOCTs
COMMUNITY
,/
NOCPHEADOUARTERS
SOCT
FLHFs
COMMUNITY
DHS DISTRICT/WARI)HEADS
\i{ +
COMMUNITY
)9 WHO/APOC. 24 November 2fr)4
State/DistricULGA
Xumter of wtectizan" tabletsRequestcd Reccivcd Used Lost Wasted Erpired Remaining
Kontagora 238,000 238,000 173,103 136 0 0 64,761
Rijau 386,000 386,000 250,667 1,715 0 0 133,618
Magama 233,000 233,000 215,760 3,886 0 0 13,354
Mariga 329,075 329,075 320,306 t46t 0 7,308
Mashegu 143,000 143,000 N/A N/A N/A N/A 143,000
Agaie 194,000 194,000 180,075 I ,83 1 0 12,094
Lapai 337,000 337,000 310,979 399 0 25,622
Mokwa 210,000 210,000 N/A N/A N/A N/A 210,000
Rafit 213,000 213,000 94,084 160 0 118,756
Wushishi* 164,000 164,000 82,970 0 81,030
Borgu* 480,000 480,000 264,343 208 0 215,449
Lavun 89,000 89,000 N/A N/A N/A N/A 89,000
Shiroro 134,500 134,500 lll,223 1,406 0 0 21,871
Gbako 90,000 90,000 81,930 t2 0 0 8,058
Katcha' 164,000 164,000 I 15,860 1,619 0 46,521
Munya 155,000 155,000 145,285 55 0 9,660
Betto+ 177,000 177,000 I 18,641 398 0 57,961
Suleja 140,000 140,000 130,144 70 0 9,786
Gurara 175,000 175,000 156,784 1,710 0 16,506
Agwara I14,000 I14,000 N/A N/A N/A N/A 114,000
Tafa lll,612 1ll,612 lll,4l7 159 0 0 36
TOTAL 4?77,187 4277,187 2,863,571 15,225 0 r198"391
Toble 10: Mecltztn@ Inventory
* - Only partial reports were received.
N/A - Not yet Available.
How are the renoining tvermectin tablets collected and where are they kept?
- The remaining tablets are retrieved from the LGAs and kept at State level for subsequent
utilization.
- Remaining Ivermectin tablets are collected from the communities through the FLHFs and
submitted to the LGA Oncho. coordinators through the district PHC supervisors. The LGA
coordinators submit all remaining tablets to the State coordinator and such drugs are kept at
r{) WHO/APOC. 24 November 2006
the project office for the next distribution round i.e. if the expiry date is not close. However, if
they are required for urgent utilization by other projects or are almost expired, they are
transferred to the NOCP Zone C, officer for further action.
List and briefly describe the activities under ivermectin delivery that are being carried
out by health care perconnel in the project area.
Healthcare personnel hold regular meetings with communities and their leaders to ensure
effective conduct of CDTI activities.
They sensitize and mobilize the communities (through health education) for ownership of
CDTI.
They train the CDDs, and supervise yearly Ivermectin distribution.
They supervise distribution in order to ensure that communities receive drugs, the drugs are
properly managed, and that there is good treatment compliance, as well as ensuring that CDDs
keep accurate treatment records.
They provide feedback on Ivermectin distribution to the district health supervisors, LOCT,
SOCT and all other partners.
Health care personnel facilitate conduct of CSM and SHM through training and supervision..
Any other comments
Low morale, caused by poor funding of activities by government, is a major reason for poor
attitude to work which is exhibited by some health care personnel.
Any other comments
2.8. Community sef-monitoring and Staheholden Meeting
Has any training (of trainers) for community self-monitoring been done in the project area?
If so, When?
In years 2002, 2003, 20M.
?t WHO/APOC. 24 November 2fi)6
DistricU LGA
Total # ofcommunities/villages in the
entire project areaNo of Communitiesthat carried out selfmonitoring (CSIO
No of Communitiesthat conducted
stakeholders meeting(sHM)
Kontagora 72 l8 l8Rijau 142 24 36
Magama 52 t7 t4Mariga 270 34 46
Mashegu N/A N/A N/AAgaie 205 34 38
Lapai 2tl 26 36
Mokwa N/A N/A 0
Rafi* 53 t8 0
Wushishi* 6t 20 0
Borgu* 230 29 38
Lavun N/A N/A N/AShiroro r03 t7 52
Gbako 62 t6 2tKatcha+ 145 24 l8Munya 140 23 32Bosso* t2t 20 12
Suleja t9 6 8
Gurara lll l8 t4Agwara N/A N/A N/ATafa 72 l8 28
TOTAL 2,069 362 4tt
Table 11: Cotttnunily self-monitoring and Staheholden Meeting
Describe how the results of the community self- monitoring and stakeholders meetings have
affected project implementation or how they would be utilized during the nert treatment
cycle.
Pilot CSM and SHMs conducted in these LGAs revealed that some CDDs were discontented
about not being paid incentives by their communities, while members of communities who had
never served as CDDs were incorporated into programmes like polio+radication and guinea
worn surveillance. This informed the decision to work towards formulating a PHC directive such
that, wherever committed CDDs were pr€sent, they were also integrated into other PHC
7) WHO/APOC. 24 November 2fi)6
programmes, especially where financial or material rewards would be derived, in order to
encourage CDD retention. This action is already being applied in at least 5 LGAs and the benefits
are obvious since the treafinent coverage is quite good and there is very good CDD retention.
These LGAs are Magama, Kontagora, Agaie, Lapai and Gbako.
Information from some SHMs revealed that the communities had preference of a treatrnent
period, which did not conform with the period when drugs were usually released to them, and this
information helped to plan for Mectizan delivery at preferred treatment periods.
In the Kambari settlements (camps) there is distrust in a CDD from the same community
administering drugs to its' members, so the CDD from the main village is relied upon to visit the
neighboring wards (settlements) to administer drugs and this causes a lot of delay in completion
of treatment and reporting. These CDDs have to travel over distances of sometimes 20 to 30
kilometers apart and require assistance with bicycles from APOC.
2.9. Supervision
2.9.l.Provide aflow chart of supentision hierarchy.
2.9.2. jYhat were the moin issues identiJied during supervision?
The main issues identified include :-
(l)Drugs were being allowed to expire.
(2) There was no documentation on treatnent of some communities (especially those that are far
and hard to reach) for example, those at the border with Benin republic.
NOCP
SOCT
LOCT
DS
CDDsFLHFCSMs, Communilies,
Wllage heads
?1 WHOiAPOC. 24 November 2006
(3) Geographical coverage was low and therapeutic coverage for some LGAs like Borgu, Bosso
and Wushishi were far below 65%. Drugs released to some LGAs were also not adequately
accounted for.
(5) Late submission of treatnent reports to the State.
(6) Inconsistency in Mectizan inventory records at different levels / Poor census.
2.93. Was a supentision checklist used?
Yes. One was developed by the SOCT to address specific issues of concern while the standard
checklist was utilized by the combined team of NOCP and UNICEF.
2.9.4. What were the outcomes at each level of CDTI implementdion supervision?
State level
(l) The outcome of NOCPAJNICEF supervision indicated that there is need for adequate
supervision of the LOCT by the SOCT since drugs released for 6 months had not been
distributed in some LGAs, while year 2005 treatment report indicated that some LGAs had
very low coverage.
(2) Absence of counterpart funds at LGA level was having a severe effect on conduct of CDTIactivities.
LGA level
(l) High CDD athitior/Some CDDs wer€ not adequately trained and data entry was poorly done.
HeighVdosage calibration was also inaccurate. In one of the communities, drugs were
received by the CDD, but not distributed.
(3) Highly demoralized LOCT. There was hardly any release of counterpart funds at the LGA
level and the health statr (LOCT) did not supervise the FLHF staff in most of the LGAs.
Records were poorly kept at all levels and there was no duplication of those forwarded to
higher levels.
(4) There was frequent transfer of trained health staff leading to lack of supervision of some
communities.
(5) The directors PHC were not giving the necessary moral support to the LGA coordinators.
74 WHO/APOC. 24 November 2006
Conmunitv level
(l) Treatment fatigue was observed to be the problem with many of the communities. There was
a feeling of good health and the communities no longer had the urge to comply with
treatment.
(2)The health staff were not adequately communicating with the traditional leaders, therefore the
leaders were not aware of release of Mectizan to the CDDs.
3) Mectizan was not released to the communities by the FLHF staffand when they requested they
were informed that there were no drugs because the programme had come to an end.
(4) Opposing political parties were exploiting the issue of payment of incentives to CDDs as a
tool against the incumbent government, by insisting that the payment should be done by
government rather than the people since healthcare is a social service that is their right.
2.9.5. Wasfeedboch gtven to the penon or groups supemised?
Yes, feedback was given at all levels.
2.9.6. How was thefeedbach used to improve lhe overall petforrnonce of the pmjea?
(l) Reminders were written to both the State Ministry of Finance and the Ministry of Local
Govemment in request of release of counterpart funds. Advocacy visits were also made to
both Ministries to sensitize the leaders on need to release funds. LGA policy makers were
sensitized on the urgent need to release funds to the LOCT, and pledges were made to support
with funds. That promise was not actualized in most LGAs but is still viable and could be
redeemed. Meetings were also held with traditional leaders in Wushishi, Borgu, Bosso and
Gurara among several other LGAs and pledges were made for improvement.
(2) The State Ministry of Health released the sum of U.S.$15,873 for HSAM, supervision, as well
as for retrieval of outstanding treatment reports and drug balances that were not submitted.
(3) Meetings were held with the LGA authorities to inform them on the poor attitude of some
health workers, and action was taken to ensure that drugs were immediately released to the
benefiting communities and treatment commenced immediately. This was particularly so for
Bosso,Borgu, Wushishi,Mashegu, Mokwa ,Agwar4Lapai, and Agaie LGAs.
15 WHO/APOC. 24 November 2006
(a) In order to ensure 100% geographic and at least 84% therapeutic coverage of communities,
the SOCT compiled a comprehensive list of endemic communities and their projected
population and released Mectizan accordingly to the LGAs. This effort also helped to control
wastage.
(5) Adequate capacity was provided (for supervision of CDDs) through training and retraining of
health staff and other community supervisors like teachers (in Borgu LGA) where long
distance between communities makes supervision very difficult.
(6)The SOCT supported the LOCT to mobilize the communities for better compliance with CDTI
objectives and especially the need to sustain yearly treatment through both moral and
financial support to the CDDs.
(7) Communities were mobilized to select new CDDs i.e. where attrition had affected distribution
and all were trained, by the FLHFs and LOCT and treatment followed immediately even
though some as late as in December.
(8) Communities that had never been treated were mobilized for participation and treatment is
ongoing. There is promise of 1007o geographical md 84Yo therapeutic coverage in year 2007.
?(t WHO/APOC. 24 November 2006
SECTION 3: Srryport to CDTI
3.1. Equipment
Toble 12: Stotus of equipment
*Condition of the equipment (F:Functional, CNFR:Currently non-functional but repairable,
WO:Wriffen off).
How does the project intend to maintain and replace eristing equipment and othermaterials?
This will be done through the normal government system, i.e through the vehicle maintenance
pool. Furthennore, the project intends to intensiff request for monthly standing imprest (running
cost) from the State approved budget line for recurrent expenditure which if provided, would
serve as a source of funds for equipment maintenance as well as for maintenance of other items.
The budget line for overhead i.e. State counterpart fund would also be intensely exploited for
ensuring sustained funding of project activities by government.
Even though funding at LGA level is currently very poor, there will be sustained mobilization of
the relevant authorities for the necessary fund release, the LGA coordinators have been
responsible for maintenance of project motorcycles attached to them and will continue since this
APOC MOH DISTRICT/LGA
NGDO OthersSource
Type ofequipment
No. Condrton No. Conditon No Condrtion No. Condition No. Condition
l. Vehicle I F I wo I wo2. Motor cycle(s) 22 l0F
6CNFR6WO
l6 wo
3. Computer(s) 2 lwolF4. Printe(s) 2 lwolF5. Photocopier (s) I CNFR6. Fax Machine(s) I F7. Others
a)Megaphones l0 Fb)Writing board I Fc)Overheadproiector
I F
Video player I FBicycles 65 20wo 50 woT.V. set I F
Manual typwriter 2 F
In-focus proiector I F
UPS I wo
IIIIIIIIIIIIIIIIIITIIIIIIITIIIIIIITIIIII
IIII
?7 WHO/APOC. 24 November 2006
is the usual practice over here. LGA administrators will also be encouraged to purchase
motorcycles and bicycles for the programme i.e where ever the need arises. Furthermore, efforts
will be made to ensure integration of the CDTI with viable projects like HIV/AIDS control, NPI,
malaria control etc. so that there would be central maintenance of all participating PHC vehicles.
APOC management has also been requested to replace some capital equipment before its'f,rnal
disengagement.
JR WHOiAPOC. 24 November 2006
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(2) If there are problems with release of counterpart funds, how were they addressed?
While the State released funds, there were indeed severe problems with release of counterpart
funds at LGA level. All effort made to ensure release at LGA level was futile.
- Additional comments
It is recommended that advocacy visit be made to the newly elected government between June
and July 2007 by a high powered team of APOC,LINICEF and NOCP to solicit for bulk release
of funds, possibly for 4 years duration.
33. Aherforms of communtty support
(3) Describe (indicate forms of in-kind conhibutions of communities if any)
In-kind conffibutions by communities include assistance with farm work, prayers, supervision by
village heads and CBOs, support with community mobilization, giving of food stuff to CDDs,
provision of transport or transport fare to collect Mectizan@ from agreed points, nomination of
CDDs into politically elected posts such as local councillors or LGA council chairmen,
employment into government paid jobs, and recommendation for inclusion of CDDs for other
incentive giving social services like polio eradication and guinea wonn surveillance.
3.4. Eryenditure per acttvtty
(4) Indicate in table 14, the amount expended during the reporting period for each activity
listed. Write the amount erpended in US dollars using the current United Nations
exchange rate to local currency. Indicate exchange rate used here US 1.00 to#126.
Tahle 14: Indicate how much the project spentfor each activily listed below during the reportingperiod
ActivityExpenditure
($ us)Source(s) of
fundinsDrug delivery from NOTF HQ area to central collectionpoint of community
2,000Gov't
Mobilization and health education of communities 5,000 Gov't/UnicefTraining of CDDs 6,000 Gov't/UnicefTraining of health staffat all levels I1,000 Gov't/APOCfunicefSupervising CDDs and distribution 4,500 Gov'VAPOC/UnicefInternal monitoring of CDTI activities ? Gov't/UnicefAdvocacy visits to health and political authorities 6,000 Gov'UAPOC/Unicef
IEC materials
Summary (reporting) forms for treatment
40 WHO/APOC. 24 November 2004
(2) If there are problems with release of counterpart funds, how were they addressed?
While the State released funds, there were indeed severe problems with release of counterpart
funds at LGA level. All effort made to ensure release at LGA level was futile.
- Additional comments
It is recommended that advocacy visit be made to the newly elected government between June
and July 2007 by a high powered team of APOC,UNICEF and NOCP to solicit for bulk release
of funds, possibly for 4 years duration.
3.3. Otherforms of communtty support
(3) Describe (indicate forms of in-kind contributions of communities if any)
In-kind contributions by communities include assistance with farm work, prayers, supervision by
village heads and CBOs, support with community mobilization, giving of food stuff to CDDs,
provision of transport or tmnsport fare to collect Mectizan@ from agteed points, nomination of
CDDs into politically elected posts such as local councillors or LGA council chairmen,
employment into government paid jobs, and recommendation for inclusion of CDDs for other
incentive giving social services like polio eradication and guinea wonn surveillance.
3.1. Eryenditure per acttvtty
(4) Indicate in table 14, the amount erpended during the reporting period for each activity
listed. Write the amount expended in US dollars using the current United Nations
exchange rate to local currency. Indicate erchange rate used here US$1.00 to#126.
Table 14: Indicate how much the project spenlfor each acttvity listed below during lhe reportingperiod
ActivitvExpenditure
(s us)Source(s) of
fundinsDrug delivery from NOTF HQ area to central collectionpoint ofcommunity
2,000Gov't
Mobilization and health education of communities 5,000 Gov't/Unicef
Training of CDDs 6,000 Gov't/UnicefTraining of health staffat all levels I1,000 Gov'VAPOCfunicef
Supervising CDDs and distribution 4,500 Gov't/APOCfunicef
Internal monitoring of CDTI activities ? Gov't/UnicefAdvocacy visits to health and political authorities 6,000 Gov'VAPOCAJnicef
IEC materials
Summary (reporting) forms for treatment
40 WHO/APOC- 24 November 2fi)4
Vehicles/ maintenance 1,587 Gov't
Office e. etc 100 Gov't
Others to 2,500 Gov'VUnicef
TOTAL 38,687
Total number of persons treated I,153,311
(5) Any comrnents or qlnnotions?
The support for field activities from UNICEF was for focused attention to Borgu LGA in view of
consistent low coverage and the need to address cross border concerns with Benin republic. This was
an outcome of the monitoring visit by both UNICEF and NOCP to the State in October.
SECTION 1: Sustainability oICDTI
4.1. Internal; independent participatory monitoring; Evaluation
4.1.1 Was Monitoring/evaluation carried out during the reporting period? (tick any of the
following which are applicable)
Year I Participatory Independent monitoring
Mid Term Sustainability Evaluation
5 year Sustainability Evaluation
,/ Internal Monitoring by NOTF
Other Evaluation by other partners
4.1.2. What were the recommendations?
The recommendation of the internal monitoring by the NOTF was that:-
(l) The LOCTs should be constantly supervised.
(2) More CDDs should be selected in the larger communities in accordance with CDTI guidelines.
(3) Communities should be better supervised in order to ensure good treatment compliance
(4) Census up date should be completed in parts of the project where it had not been done.
(5) The State and LGAs should be adequately funded for susainability.
4l WHOiAPOC. 24 November 2006
4.1i. How hwethey been imPlenunud?
(l) Monitoring and supervision is being intensified to ensure compliance with CDTI objectives.
There is plan to develop and produce integrated checklists for use by the PHC department in
order to promote the required integration.
(2) The State PHC departrnent holds regular meetings with policy makers and informs them of
developments. The LGA/PHC directors have been sensitized to ensure feedback on conduct of
CDTI activities through holding of regular review meetings together with the district and FLHF
staff. Problems should be identified at all levels and successes commended.
(3) The State and LGA policy makers will continuosly be mobilized for release of counterpart funds.
(4) Communities are being mobilized for adequate support to CDDs and would continue to be, in
order to ensure good retention as well as selection of more CDDs at ward level as well as along
family lines.
4.2. Sustainability of projects: plon and set targets (mandatory at Yeor 3)
Was the project evaluated during the reporting period? No.
Was a sustainability plan written? Yes.
When was the sustainability plan submitted? July 2005
What arrangements have been made to sustain CDTI after APOC funding ceases in terms of:
4.2.l.Planning at all relevant levels
This will be done at all levels as an integrated PHC plan with clear objectives towards sustaining the
strengths, improving on the weaknesses and taking advantage of opportunities presented through
implementation of an integrated action plan. Integrated planning will be done annually within the
PHC departments at State, and LGA level as reflected in the post-APOC/CDTI plans. Plans and
budgets are already available for year 2007 activities.
4.2.2.Funds
Government would be aggressively mobilized to release counterpart funds based on the activities on
the sustainability plans. A realistic budget is already available at State level and this has received
approval of the State government. The LGA budgets are also ready and awaiting release of funds.
SHMs will be held at all levels, and the Ministry for local government will be continuously
4) WHO/APOC. 24 November 2fi)6
pressurized to ensure cenml deduction of funds for Oncho. activities in accordance with the
resolution made at the State level stakeholders' meeting held in December 2004. Unfortunately
efforts so far made have not yielded much benefit.
At State level, high level advocacy visits will be made to the Ministry of finance as recommended by
the evaluation team. Moves will be made to obtain release of monthly standing imprest as was the
past practice, as this will assist the project to carry out minimal repair/maintenance of project
vehicles and equipment as well as for general running of office.
4.23 Transport (replacencnt and maintenance)
This will be done centrally in the MOH i.e. if counterpart funds are not available. The LGA project
motorcycles will be repaired and maintained with their own counterpart funds. LGA administrators
will be encouraged to purchase motorcycles and bicycles for the programme whenever necessary. At
State level, efforts will be made to ensure full integration of CDTI into active projects like AIDS
control, NPI, malaria control etc. so that there would be central maintenance of all participating PHC
vehicles i.e including the CDTI project vehicle.
APOC management will however be requested to replace some capital equipment
4.2.4. (hher resoutces
UNICEF has renewed its' commitment to the project through appointrnent of a new schedule officer.
Govemment along with other NGOs would have to sustain support in the absence of additional
external funding. Because of the current situation at LGA level, there is a serious funding gap but it
is hoped that other sour@s would be identified that will help to ameliorate the constraints being
experienced i.e. pending the arrival of a new government that might satisfr the hope for financial
release by government at all levels.
4.2.5.7o what ef,ent has the plan been implemented
The plan was written in year 2005 and its' full implementation is expected to be by end of December
2008 since it came into effect only in the year under review. Most activities especially at LGA level
were conducted in an integrated manner taking advantage of opportunity provided by the Polio
eradication programme.
4.3. Integration
Oulline the exlent of integration of CDTI into the PHC struc'ture and the plonsfor complete
integration:
47 WHO/APOC. 24 November 2006
Planning and budgeting is done in an integrated manner and the SOCT members have other
schedules (in PHC) which enables them to integrate CDTI activities with others. Integration of
vitamin A distribution was initially proposed by the project, but because UNICEF had already
integrated it with the intensified polio immunization campaign, it was not realized. Vitamin A is also
a part of the on going routine immunization package. Polio and measles eradication activities are the
current attractions, and moves are being made to train CDDs for integrated disease control as a part
of the routine CDD training/retraining programme. A workshop has been held and laminated
photographs have been provided by WHO for distribution to the CDDs. The special initiative from
APOC will provide opportunity for orientation of the CDDs.
While deliberate efforts are being made to ensure complete integration of activities at State level i.e
starting from planning to joint supervision, it is very strong at LGA level, because all healthcare staff
at that Ievel are given schedules that compel them to participate in campaigns such as mass
immunization, disease surveillance, malaia control and several other services, because these
personnel are also in charge of the health facilities within the project area.
4.3.1. Ivermectin deltvery mec h onisms
The Ivermectin for LGAs when not collected on schedule, is distributed from the State through the
LGA/NPI managers when they come monthly to collect vaccines for immunization or through other
personnel when they come in for other PHC activities.
- Ivermectin meant for communities is delivered through already established channels like M&E
officers' outing, or collection/delivery ofNPI vaccines to districts and communities.
The M& E officers are members of the LOCT, and their position provides opportunity for visiting
the district health facilities on a monthly basis i.e. while out on AFP surveillance.
4.3.2. Training
This activity is yet to be fully integrated, however several SOCT do participate in the NPI campaigns
and they utilize these opportunities to support targeted training on CDTI. Training will however be
integrated with other add-on activities such as primary eye care outreach programmes and malaria
control. Training is proposed for PHC managers and NGOs at State and LGA level to empower them
for better collaboration and networking as well as for joint supervision and monitoring. The proposed
integrated training of CDDs for integrated disease surveillance has already been mentioned above.
44 WHO/APOC. 24 November 2fi)6
4.3.3. Joint supervision and monitoring with other progroms
During the year under reporq most of the SOCT and LOCT participated in PHC campaigns like
vitamin A distribution, malaria control, polio eradication etc, at State and LGA level, therefore
supervision of CDTI was integrated with such activities. Joint supervision and monitoring with other
PHC programmes is the current approach and these activities are already reflected in the 3-year
CDTI sustainability plans submitted. Integrated supervision checklists will also be developed for use.
4.3.4. Releose offundsfor project acttvities
Already there are approved PHC budgets with allocation for Oncho control for the current and
subsequent years. Release of funds will be effected through continuos strong advocacy meetings with
policy makers and traditional leaders. Efforts will be made to ensurc that Oncho. budgets are
continuously integrated within existing PHC budgets in order to effect release of funds.
4.3.5. Is CDTI included in the PHC budget?Ya.
4.3.6. Describe other health pmgrammes that are using the CDTI struAure and how this was
achieved What have been the achievements?
The WHO coordinated routine immunization programme is making effort to utilize a slightly
modified CDTI structure, for ensuring adequate service delivery at community level. Traditional
leaders are now involved in routine immunization activities, and health management teams are being
instituted at ward and community level to ensure self-monitoring.
4.3.7. Describe othen isszes considered in the integration of CDTI.
Other issues considered are that of conducting several more CDTI tasks at a time while out in the
field for PHC activities. There is a proposal to involve CDDs with all community based disease
confol programmes like polio eradication, community mobilization for HIV/AIDs control, home
treatment of malari4 as well as for distribution of insecticide treated bed nets.
A major issue of concern with disease control is the evident compartmentalization which is exhibited
strongly right from the top hierarchy of healthcare delivery. What often obtains is that different
programmes engage separate personnel at community level instead of the available CDDs for the
various activities, especially where incentives are involved without taking cognizance of the
available CDTI structure. In order therefore, for CDTI to serve as a vehicle for integration at
community level, there is the need for programme planners/implementers like WHO and other
45 WHO/APOC. 24 November 2006
agencies, to make conscious effort through policy formulation and advocacy for utilization of
existing resource personnel at community level.
4.4. Operotional researc h
4.4.1. Summarize in not more than one half of o poge the operational research undertaken in the
project area within the reporting period
None yet but there is the intention to undertake one, based on assessing the impact of Islamic
associations on women participation in social service delivery at community level. This proposal is
aimed at identifiing viable and effective means of ensuring better women involvement in healthcare
service at the peripheral levels with the aim of improving, as well as sustaining Mectizan delivery to
the end users for the long duration oftime required.
4.4.2. How were the results applied in the project?
Not applicable.
46 WHO/APOC. 24 November 2fi)6
SECTION 5: Strengths, weahnesses, challenges, and opportunifies
- List the strengths and weaknesses of CDTI implementation prooess.
- List the challenges and indicate how they were addressed.
Stote level
Streneths
(l) Availability of adequate Mectizan and its' popularity.
(2) Opportunity for integration of activities with other PHC programmes
campaign.
(3) Availability of State counterpart funds in the year of report.
(4) Renewed commitrnent of UNICEF.
(5) Sustained support from APOC.
Weahnesses
like immunization
(l) Very poor funding at LGA level and generally unfavourable political environment.
(2) Late commencement of treatment due to slow response by the LOCT. Drugs had to be
conveyed to most of the LGAs before treatment commenced.
(3) Late submission of treafrnent reports. Only I I LGAs submitted complete reports while 4 LGAs
did not submit any report. The SOCT had to pay several visits to the LGAs before the current
report could be obtained.
(4) Inadequate institution of CDTI at Borgu LGA which shares border with Benin republic. The
area is very large and communities very hard to reach. Human resource and transport logistics
are very inadequate.
(5) Poor attitude of some LOCT leaders to integration. Poor supervision by the FLHFs.
47 WHO/APOC- 24 November 2006
LGA Level.
Streneths
(l) Adequate Mectizan.
(2) Fairly good commitrnent of PHC staffin about 55% of LGAs
(3) Fairly good integration of CDTI with PHC
Weaknesses
(l) Very acute funding gap in all LGAV No release of counterpart funds.
(2) Delay in submission of treatment reports.
(3) Poor attitude of some PHC staff, therefore CDTI is not being fully integrated with other
activities. Wastage, due to expiry of unused drugs that were not returned after distribution.
(4) Poor supervision of FLHF staffby LOCT.
(5) Inadequate trained personnel in some LGAs e.g. at Babanna area of Borgu LGA
(6) FLHFs not adequately training or supervising CDDs.
(7) Inadequate transport logistics especially in border LGA like Borgu where distances from LGA
headquarters to some communities takes 8 to l0 hours due to extremely bad terrain.
(8) Frequent transfer of staffin some LGAs
(9) Several motorcycles are broken down and are yet to be repaired due to lack of financial release
by the LGAs.
(10) CDTI is not adequately instituted along border areas with Benin republic.
(l I ) Inadequate 2-way feedback to State and communities.
Communitv level
Strensths
(l) Good awarenesVacceptance of Mectizan.
(2) Receptive communities.
(3) Evidence of good ownership in over 55% of project area.
4R WHOiAPOC. 24 November 2006
(2) Good commitment of some traditional leaders
(3) Committed CDDs in some parts.
Weaknesses.
(t) Inadequate CDDs. High CDD attrition. The much funded National immunization programme had
a negative effect on the CDDs since only few do benefit from participation despite their long time
commitnent to distributing Mectizan to their people even when they not being paid any
incentives.
(2) Reduced commitment of some community leaders to ensuring support for CDDs.
(3) Reducing community treatnent compliance due to fatigue.
(4) Inadeq uate comm unity geographic coverage.
(5) Poorly mobilized communitiesin25%o of project area.
(6) Inadequately trained CDDs. Inaccurate transfer of treatnent data from registers.
C h alle nees/ Opoortun ifi es
(1) Meciizan delivem
Activities like training, Mectizan delivery, advocacy and supervision were largely integrated into
the polio immunization activities at LGA level, some SOCTs participated in training and
supervision, thereby utilizing the opportunity for conduct of targeted CDTI activities. All LOCT
were integrated into the National Immunization Days (NIDs) activities.
(2) Advococy to Stole Polict ruherc
Ministerial management meetings were employed to sensitize the new Honourable Commissioner
of Health for release of funds for oncho. control activities while the involvement of the State
director of Budget in PHC project monitoring helped to facilitate release of State counterpart fund
during advocacy to the Ministry of Finance.
4q WHOiAPOC. 24 November 2006
(3) Puhlic owareness for imoroved drug acceolance
Collaboration with the State unit of the National Television Authority (NTA) produced a
documentary that was produced and aired free-of-charge for further creating awareness on the
programme.
(3) Motivation of CDDs/ reduction of CDD attrition:
Some CDDs from communities that did not give incentives were incorporated to participate in
mass immunization activities from where they received some cash benefits.
- Communities with strong family aftiliation were encouraged to select CDDs along family lines
thereby increasing number and reducing demand for incentives.
(4) Egremelv delaved reoorttns bv LGAg/collection of reports bv S(rcT
Funds released by the State was utilized by the SOCT for travel to defaulting LGAs for conduct
of several activities like collection of outstanding treatment reports/drugs, advocacy to LGA
leaders, meetings with the PHC team, 'spot-check' monitoring/validation of treatment as well as
Health education/Community mobilization
SECTION 6: Uniquefeatures of the project/other mafrerc
Cross-border concetns with Benin Republic
This project is one of the largest, and this makes conduct of activities very difficult and demanding,
especially in view of gross under funding by government, coupled with the funding gap caused by
inability of the LGAs to sustain support to the project since year 2005.
Borgu LGA is of special reference here, because of cross border concerns with Benin Republic. The
support from UNICEF as well as that of the State govemment helped to address several of the
concerns about that LGA.403 communities are cumently listed with over 200 in the border district of
Babanna. Treatment commenced in several communities only in December and most of the fieatment
reports are yet to be received to determine the outcome of the effort made.
To give an insight into the enormity of the problem, it is necessary to explain here that Borgu LGA is
the largest in Niger State occupying about 25Yo of the total land area while the region of concem -
Babann4 comprises of 50%o of the whole LGA. The distances between communities range from 30
50 WHO/APOC. 24 November 2fi)6
to 40kms on an average. There is the need to boost (strengthen capacity for haining and supervision
at that level, while there is need to support the LOCT with 2 motorcycles and provide at least 40
bicycles that will help to facilitate movement by CDDs during conduct of CDTI activities.
While sincerely appreciating APOC's support, it is our sincere hope that it can assist (as a special
intervention) with the necessary funds and logistics for addressing the cross-border concerns.
5l WHO/APOC. 24 November 2006
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