t I JAF-F'AC

JAF-F'AC

I

_t

)

JOINT ACTION FORUM Office of the Chairman

JOINT ACTION FORUM Fifth session

The Hague.S-10 December 1999

FORUM D'ACTION COMMUNE Bureau du Pr6sident

JAF5/INFiDOC.4 ORIGINAL: ENGLISH September 1999

REPORT ON THE 1999 INDEPENDENT MONITORING OF CDTI PROJECTS IN TANZANIA

t

I

I

REPORT OF INDEPENDENI'

MONIf'ORTNG OF CDTI PROJECTS IN TANZANL{ : THE RUWMA PROJECT

August

16 -

^September

l(t,

1999

I

AIDS

APOC

CBTI CDTI

CDD CSD EPI

HH

IEC

IMA KAP MCH MOH

NGDO NOTF PHC

REA

REMO SODA SSI

TOl' wHo

Acquired Immune Deliciency syndrome

African Programme on Onchocerciasis Control Community Based Treatment

with

lvermectin Community Directed Treatment rvith Ivermectin Community Directed Distributors

Cornmunity Selected Di stributors Expanded Programrne on Immunisation House Hold

Information Education Communication Inter-church Medical Association Knowledge Attitude and Practice

MaternalChild

Health

Ministry Of

Health

Non Governmental Development Organisation National Onchocerciasis Task Force

Primary Health Care

Rapid Epidemiological Assessment

Rapid Epidemiological Mapping of Onchocerciasis

Songea Development association

(A

local community development agency) Sight Savers International

T'raining of Trainers World Health Organisation

I

ll

a

TABLE

^I.O

TABLE I.I TABLE

I.2

TABLE

I.3

TABLE I.4 TABLE

2. I

T ABLE 2.2

TABLE

2.3

TABLE

2.4

TABLE

2.5

TABLE

2.6

TABLE

2.7

TABLE

2.8

TABLE

3. I

TABLE

4.1

TABLE

4.2

TABLE

4,3

TABLE

5.I

TABLE

5.2

TABLE

5 3

LIST OF TABLES

Decisron making process at village _level Mode of distribution by source

of

information Who distributed _Ivermectin

Treafinent summary from household survey Refusals and absentees by village

Length of CDD training

Issuesitopics covered at

CDD

training

What the communities were told about Ivermectin treatment Horv Ivermectin dosage was determined

Existence of treatment registers Quality ^analysis of treatment registers

Communities receiving health education x form of

CDD

supervision H/Education recipients

Whether CDDs had been changed Forms

of

support received by CDDs

Activities

integrated

with CDTI

Opinions of CDDs on community response

whether community members collected the drug from a collection point Constraints in supervision

Constraints in getting the drug

Constraints in the distribution of drugs by CDDs

t

EXECUTIVE SUMMARY

The

independent nronrtorinq

of the CDTI

process

of Ivermectin distribution in

the

ltuvuma Project

area

of

Tanzania rvas

carried out by a four-man team drarvn

trom Nigeria, Uganda and Tanzania. The monitoring exercise rvas undertaken to ascertain the extent

to

rvhich _the

CDTI

process was follorved during the

first

year

of

operation

of

the programme which started

in

1998.

The monitoring exercise covered 30 endemic villages in trvo randomly selected districts- Songea and Mbinga- in the project area. Data were collected from a cross section

of

the village population including village leaders/officials, health workers

in

the communities, the CDDs, household members, the youth, _{men and} women

groups. Policy

makers and Programme Managers

at

various levels

of the

health system, the collaborating NGDOs and

the World Health

Organisation(WHO)

were also covered.

Instruments

for

data

collection included in-depth interviews, questionnaires, observations, official

records/documents and focus group disc ussi ons.

The

major

findings of the

monitoring team include

that all

the sampled

villages

were treated. This implies a coveraqe rate

of 100%.

While the

CDTI

decision-making process was largely (67%)

followed in

the selection

of

CDDs,

it

was not adhered

to in

deciding the time and mode

of

Ivermectin

distribution.

The health workers made these decisions mosl

of

the

time.

Central location was

the

prefened mode

of distribution.

The training

of CDDs

rvas

deficient

especially

in the

areas

of

census-taking, record-keeping and

proper completion of the

treatment

register.

Dosage determination

was by

height measurement

but a disturbingly high

inaccuracy rate

of 40% was found.

Severe side effects

of

the drug rvere generally not

reported.

Community education on

CD'l'l did

not

deal with the major

issues

of

programme ownership,

community responsibilitv

and material support for the

CDDs.

^'fhere was'good cooperation and collaboration among the

Ministry

of Health, WHO and NGDO partners. Shortage

of

drugs and delay

in

supply

of

drugs and funds rvere

not

experienced

during

the

vear.

There was general satisfaction

wrth and

appreciation

for the

programme

in the project

area

and the

prospects

for

sustainability is verv good.

Kev recommendations include

a) A

retraining

of both the

health personnel (trarners) and the

CDDs

before rhe next distribution.

b)

A fresh community education exercise

in

all villages before the next distribution

c)

A census

of

villages to be carried out.

d) APOC to cntically

evaluale

the

system

of

school-based

distribution fourid in

the project area and take policy _decisions on it.

e)

Elnployment

ol

an accounts of

ficer at

the NOTF t<l handle financial and accounting matters.

!

.I"ABLE

OF CONTENTS

l'ctgc

LIST

O}-

ABBRE\/IATION

LrsT oF TABLES_ __

ii

EXEC UTI

\/E

SU ]\{

I\IAR}'

_lll

I I I

I

I.O INTRODUCTION

l.

I

^Country background

1.2

Project background

1.3

Terms of refbrence

2.0 METHODOLOGY

2.1 TargetPopulation

2

2.2 Sampling---

2

2.3

Monitoring

Instruments---

4

2.4 Linitations---

5

3.0 RESULTS 3.1

Indicators--

3.2

Quality ol'implementation

of CDl'l--- ---1

3.3

Communiw

Perception--- ---1

3.4

Sustainabilitv---

3.5

Constraints---

3.6

Unique features of the

proJeo--- --- ²⁴

4.0

DISCUSSIONS

AND CONCLUSIO

5.0 RECOI\{MENDATION

₂₅

ANNEXTS

1.

Team membership

2. Time

frame

3.

Charts and Graphs

4.

[nstruments

6 0 6 8

)

1

24

t

l.l Country

Background

l'anzania has a rvell

established

Pnmary Health Care

system(PHC)

which

provtdes communiry health services and programmes such as water

&

sanitation,

Child

survival,

Family Planning and AIDS educatron. There is an

established

network for

^the

distribution of

essential drugs

from district

pharmacies,

village

health posts and health

units. The various

levels

of

Government,

the NGDOs and the

churche$ are actively

involved in both

health

and

other community development programmes

and

projects (Ruvurna Focus

CBTI

Project, 1998: 7-8)

1.2 Proiect Background

The

Ruvurna

CDTI

Project area, often refened

to

as

the

Ruvuma Focus, covers three

adjoining districts within the

southern

highland

Zone

of Taruania. The districts

are Songea

and Mbinga in

Ruvuma Region and Luderva

in lringa Region.

Songea, the headquarters of the Ruvuma Region, is located 1,000 km southwest of Dar es Salaam, the capital city.

The

Project area has a

total

population

of

761,461 inhabitants (198S census) organised

into 17 Administrative Divisions, 75 Wards and 296 Villages or

^autonomous

comtnunities.

Songea

district

has

ll9

^villages,

Mbinga has ll4 rvhile

Ludewa has 63

villages. Each village is

administered

by an

elected

village committee

headed b1- a

chainnan

Ivermectin distnbution for the treatment

of

Onchocerciasrs was started

in

the project area

in

1992

by the River

Blindness Foundation

(RBF) which

provided

financial

and other

logistical

support up

to 1995.

Operations

for

1996 and 1997 were supported

with

funds

provided by the Inter-church Medical Assistance Inc (lMA) and Sight

^Savers

lnternational (SSI)

respectively

in

cooperation

rvith the

Tanzanian

Ministry of

^Health.

APOC

flnding for

the establishment

o[the CDTI

process started

in

1998.

1.3 'ferms of

reference

'fhe

_terrns

of

ref'erence set

by APOC fbr CDTI

independent

monrtoring

teams

are

as

lollows.

l.

Succinctly document horv ivermectin treatments u,ere undertaken

in a

number

of

the communities in Ruvuma Focus.

2..

Assess

community

involvement

in drug collectron.

decisron

rnaking during

the period and the mode

of

distribution, selection

of'distributors,

and the willingness

ol'the

comrttunifv Lo lrear these responsibilitres as dcstgned rn the

CDTI

Pro.lects.

,) t-

3. Documcnt

cornrnunrlv pcrccptrons

ol'CD'l-l

l)roccsscs,

cspcciallv thc

issuc

of ownership and

expectations

for

onchocerciasis

control, and

based

on

^these

perceptions and exlrctations, detennine the degree of satistactron of

the community rvith

difttrent

pro$amme activities and outcomes.

4.

^Assess the qualrty of training received by Community Directed Distrrbutors

5

Examine

the

record books

of

the CDDs and assess the qualiry

of

record keeping and their abilrt,v to keep accurate records. The same applies to the health services

staffon

the projects.

6.

^Determine

the

number

of

community and

eligible

persons treated and compare

your findings

rvith the records

of

CDDs and the records at the other levels (e.g.

district)

7.

Determine whether health personnel participated

in

ivermectin disnrbution, and assess the degree and

quality of

supervision

by

health

staff (

_{and the}

quality of

training and/or onentation

of

such staff to CDTI).

8, ^Identify

constraints rn the distributions and rnake recommendations

to

the NOTF

and

management

ol'APOC on corrective

measures necessary

belbre the

next treatment.

9.

^L)iscuss the Project's sustainability based on the findings above

2.0 METHODOI,OC\

2.1 Target Pollulation

An

endemicity assessment

of the

Project area conducted

by

the Tanzanran

Mrnistry of Health using both REA and REMO

methods

identified a total ot'132

hyperimeso endemic

villages rvith

an estimated population

of

350,473 inhabitants (based

on

1998

census). This

constitutes

the target population. The 132 villages in the arca

are

di stributed as fol lows:

a

:

I

iI

iJ

il I

ll

rJ

.\

t

Songea

District

Mbinga

District

Ludewa District

79 vrllages 22vrllages

3 I villages

I

2.2

Samnline

A

multistage random sarrrplrng method rvas follou,ed

a)

I)istnct l-rvo

drstrrcls '.\'ere selected

for

cttYerale/assessment uslng str]l:ric random ^t sarnpling

method

^'l-he i'hosen distncts rvere Son;-ca and Mbinga

I

I

I

^t

I

tr)

Catesory

"A" villages.

Considering

that 79 out of l0l (78%) villages in the

two chosen districts are

in

Songea,

it

rvas decided that category

"A"

and

"8"

villages be sanrpled

in

the ratio

of

2:1. Consequently,

fbur

category

"A"

villages were sampled

tiom

Songea

district

rvhile hvo were sampled from Mbinga distnct.

Before

carrying out

the sampling,

all

the

villages in

each

district

were grouped by distance from health faciliry" into near

(rvithin

5 km) and far (beyond 5 km) as rvell as

by

level of endemicity _thyper or meso).

Within

each stratum, the required number

of villages

rvere chosen

by

random sampling process.

Followrng this

procedure, four category

"A"

villages (Madaba, Kilagano, Mdunduwalo and Mugagura) were chosen

from

Songea

District

"vhile two villages

(Ruanda

and Mkako) were

chosen from Mbinga

District

making the six category

"A"

villages required.

c)

"B" vil Following

the

desigr, tbur

villages _adjacent

to

each chosen category

"A" village

were selected giving a

total of 4x

6

: ₂₄

_category

"B"

villages.

The listing of

sampled

categorl' "A" and

category

"B" villages by districts

is presented in the table belorv.

Sarnpled category

"A"

and

"B"

villaqes bv Districts Districts

SONCEA

MBINGA

"A"

_villages

Madaba

Kilagano

Mdunduwalo

Magagura

Ruanda

Mkako

"B"

_villaqes

Mahanje Lilondo

Lutikila

Mkongotema Lugarara

Mungano Zomba Mtrepai

Mngazini Maposeni Litowa Parangu Mpandangindo JKT

Mlale

Masanga Litapwasi Ngahokora

Ndongosi Paradiso Kingole Litumbadrosi

Kilimani

Lipumba L.ukarasi Amanimakoro

4

d) Households.

Households (defined ^as a group

of

persons who cook and eat

from

the same

pot)

covered

in

the exercise rvere chosen

by first

going

to the 'centre' of

^the village and spinning a bottle to choose a

direction.

Each

dwelling unit in

the ^chosen direction was vrsited

until l5

households were

interviewed.

Where there were more than one household in a drvelling unit, one was chosen by balloting.

Where there rvere tw'o sets

of

inteniervers operating

in

one

village,

once a direction rvas chosen, the interviewers moved in opposite directions, one covering eight and the other seven to make the fifteen households required.

2.3 Monitorinq Instruments

Altogether eight monrtoring

instruments

provided by APOC

^rvere

^employed in

the exercise. The instruments were:

ct)

Key mformants questlonnarrefor

"A"

_villages

This

28-item questionnaire was administered

to the

chairman

of village

committees in category

"A" villages. It

^{is intended to} provide the view of the community leadership on the

CDTI

^process and also to confirm the information given

by

the health personnel and the CDD.

b1

Key tn/orntunt,\ questt<ttttzutrc.f bt'

"8"

_vtlluges

l'hrs shortened version

ot'the

above (a) instrurnent was administcred

to

thc chainnen ol

village

committees

in

category

''8"

villages

mainly to

ascertain rvhether the

CDTI

^was

irnplemented

in

those villages.

c') ^()roup

cltscttsstctn gutde tn cale4on'

"A"

vrllage.s

I-hrs gurde

was

used

to

conduct

fbcus group

discussion sesslons

alnong

communtty

members. In

each category

"A" yillage,

one male and one female adutt (25years and above) group discussions were

held, In

three category

"A"

vrllages, group discussions were also held

for

female youth

(15 - ²⁴

^years),

^{whrle in the}

remaining three vrllages they rvere held

for

male

youth.

Each group,

which

contained

6 to 8

persons discussed,

among others

^tssues,

the community

understanding

and perception of the

CDTI;

community particlpation and

^prospects

for

programme

sustainabiliry The

^village

chairmen assisted to rdentifu and assemble group members.

dl

^ln-depth tntervtcvl, gurdc

fttr

^vtlluge

"A"

(''l)D:;

Thrs instrument

*'as

adnrrnrstered

to

trvo CDDs (CSDs) rn categor)

"A" _vrllages.

_The

detarled

rnteryre\\

cor,cred such issued as lrorv the CDL) was selecied. ^r'easons

fbr

^hrs

chorce. hrs trarnrng, hcalth

sYstem

collaboratron, supervision. community

^support, perceptlon

of the

Dr(),lratnme

.

constrarnts

and

sugqeslrons

for suslatnabitity. It

also

I

3 n ,l

rl -l

I I 2

I

I t

entailed close supen'ision

ol'the

CDDs measuring device, census and treatment registers and abstraction of summary statrstics

fiom

them.

c)

^ln-deplh tntervtav, gwdc

/itr ^village "8"

('1.)l)s

This modified

and shortened version

of

instrument

(d)

above, was administered

to

two

CDDs in category "8" r'illages. The tu,o

instruments

seek

essentially

the

same information.

/)

Household Sum'cv l.-ornt

l'his

instrument was administered

in l5

selected households in each category

"A"

_village.

In

each chosen household, the head was requested

to list all

members

of

the household.

Each

member

was then called upon to

respond

to a

number

of

^questions

on

his,/her

involvement in the last ivermectin distribution. This

instrument helped

to

^estimate

coverage rates, monitor CDD training and performance as

well

as community acceptance rates, defaulter rates and incidence ofsevere side effects.

g)

_Quest ionnaire

for

Heulth Personnel

This

instrument was administered

to

selected health personnel

directly involved in

the

CDTI process. It

^sought

information on the role of health

personnel

in

community mobrlisation,

CDD

training, supervision, managernent

of

severe side effects and record keeping.

h)

lntervicy, gude.for polic), ntukers

l'his

is a guide

for

inten-rervs rvith

policy

makers

in

the

Ministry of

Health, Programme Managers and Coordinators, Representative

of

the WHO and Representatives

of

NGDOs involved

in

CDTI.

2.4 Limitations

One obvious

limitation of

the data collection exercise was the language

problem.

While

the monitonng

instruments rvere

wrinen in English, they had to be

administered in Srv36i11.

As

we moved from one

district to

another, and

from

one

village to

another,

it

became clear that the standard Srvahili translations had to be rendered (translated)

in

local dialects

for

the villagers

to follow.

In the ^process

of

translation and retranslation, there were chances of misinterpretation and misunderstanding of certain concepts and ideas.

(l

3.0

RESTII,

S

3.1 [ndicators

3.1.1 Indicators

of effect of

CDTI

In thts exercise, etl'ect indicators measure the extent to rvlrrch the

CDTI

process has been

lollowed in

ivermectin treatment

in

ihe Project

area. I'hree CDTI

^ke1; processes were used in this assessment, namely:

. How

the date or period of distribution (treatment) was decided.

.

How the mode of distribution was decided.

. How

the CDDs rvere selected.

Table 1

presents

the field

data

as rvell

as

the effect indicators on

these three

CDTI

decision-making processes:

TABLE.I.O DECISION MAKING PROCESS AT THE VILLAGE LEVEL

I

,

tJ .l

3

Process/

Data sourte

Decision

on

date/

time

of

distribution.

i)Key

^informants

(A&B) ri)CDDs (A)*

+

No.

of targct villages

1

Lerder H.

n rkcr olxnmr

Effect Indicator

8/30=

26.7%

I I t'.2- 8 3o,ir

I i/30:

36 T/o 5lt2=

4t

⁷⁹⁴

vit

viL

atcc

8 2

l0

1 _r ll

-5

9 2

I

6 4

4 5

l

2

l

')

2 J

J

I

Questions about how decision was taken on tinre and mode of distribution were not included in ^village

"B" CDD interview schedule

The table indicates that the decisron on thr: rlme or penod

of

treatment was mostli,made by the health tvorkers in the Ruvuma

fbcus

.According to the

viilagc

leaders

in l3

out ol

30

communitres (J3

3%), the

health u'orkcrs

took the

decisron;

rrhile in 9 out ol- l2

vrllagers (7594). tirc CDDs rcported thirt thr'decisron rvas nrade

by

irealth

u,orkers

^The

vit

Mc.cting

viI

cldcrs

ViL H

ittc=

Made

other

Decision on mode of distribution.

i)Key

informants

(A&B) J

I 0

ii)CDDs (A)* 2

il

5

Selection of CDDs

i)Key

informants (A&B)

ii)CDDs(A&B) 60

30 20

37

)

J

20130=

66 7%

37160=

6t 7%

rl

comm

I

I

elfect

indicators

on

horv the period

of

treatment rvas decided is therefore26.T0/o (village leaders) and8.3Yo

(CDDs).lt

was also found that only in

4

out

of

18 (22.2o2t) focus group discussion sessions that mernbers agreed that the decision on time rvas made at a village

meeting.

Three

of

those four sessions were male

groups. Majority of

the groups agreed that health workers made the decisions on time/period of treatment.

With

regard to decisrons on mode

of

distribution, the table shows that the

village

leaders agreed that more oflen, the decisions were not made at

village

and sub-village meetings.

The effect indicators on decision

on

mode

of

distribution are 36.7% accoding

to

vllage leaders and 41.75%

b1'CDDs. Five of

the eighteen group discussion sessions (27.8%) agreed that the decision was made at village or sub-viliage

meetings. Of

these

five, foui

rvere male and only one was a female group discussion session.

On the method

of

selection

of

the CDDs, the table indicates a general agreement among

both village

leaders,

the CDDs and the

^group discussants

that most of the time

the selection was at a

village meeting.

The effect indicators on selection

of CDD

are 66.7%o

(village

leaders and 61.7%

(CDDs). Twelve of

the eighteen group discussion sessions (66.7%) agreed that the CDDs were chosen at village

meetings. Eight of

these twelve groups (67%) were males rvhile four were females.

Summarv

of E

Indicators

Code

Description #of

Target vil./

#of

Vil.

meeting

decisions ^o//o

E-l Proportion and number

of

target Communities which

decided on the Period

or

method of

treatment

E-2 Proportion and number

of

target

com munitic:s where the

6community"

selected

their

ou'n CDD

30 8

30 20

26.7

66.7

3.1.2

Mode of

lvernuctin distribution

'fhe

table belorv presents data on the system

of

Ivermectin distnbution rn the Project area based

on information from

the

village

leaders

in

both

A

and

B ^villages

and

the

focus group discussion sessions.

U

TABLE

I I

^MODE OF DIS'TRIBU-TION BY SOURCE OF INI.ORMATIOI{

Mode of distribution Source

Leaders Discussion

4 (22.2%) t3 (72.2%)

s.6%

l8

The table shorvs that in 73.4% of the vrllages, the mode of distnbution was from a central

location

according

to village leaders.

Thirteen

out of the

eighteen discussion groups

(72.2%)

also indicated

that

central place

distribution

approach

was followed in

their

communities. Such central

places

for distribution included village

centers, health

facilities

and the village chairman's house.

In

many villages, distribution was also done

in

schools

for pupils

and teachers

only. This

mode

of distribution is a peculiarity of

Tanzania and

will

be further discussed under the section on unique features

of

the project area.

3.1.3

Wto

distributed the lvermectitt rc,BLE _l_2_ WHO DI STRIBUTED I VERMECTIN

The person Percentage

I

-T

h

iJ

I I

l

CDDs (CSDs)*

Village leader

CDD anct Village _leader CDD and Health Worker Not stated

l4

I I I I

u

l8

778

5.6 5.6 5.6 ,,1 5.6

TOTAL _100.0

*In the project area, CDDs are called CSDs (Community _selected distributors) to distinguish rhenr fronr family plannrng service workersrry_ha_arc-qa-llc_d cDDs (Contaceptive Drug Distributors)

The table above presents the data on rvho carried out the actual Ivermectin distnbution according

to

participants

in the

erghteen

focus goups

discussion

sessions. The

table shows that

while in

a large majoritl,

of

the cases (78%) distribution was done by CDDs,

there were

nevertheless

ferv

instances

rvhere the village leader or health

^rvorker

participated directly

in

Ivermectrn distribution.

We also found that the number

of

CDDs employed in each village varied greatly rangrng from

2 to

27. There were a total

of

73 CDDs

in

the

six

category

"A" villages. Of

this number. 39 (53.4%) were females w,hile 34 (46.60/o) rvere nrales.

3. l. 4 Comntu niq, coyerage

All

the cotnmunittes vrsited rn both category

"A''

and

"B"

_{r,rllages received lvermcctrn}

treatment

The coverage rates for ^e ategory

"A"

villages obtarned from our sample survev of horrseholds are as follorvs

t LHouse to House

2.Central Place 3 Both l&2 4 Other

4 (t3.3%) 22 (13 4%)

4 (13.i%)

TOTAL 30 000%)

a

I

TABLE I

3

I'REATMENT SUMIUARY FROM HOUSEHOD SURVEY

65 8%

50.0%

34 3%

67.0%

56 5%

74.3%

i

_TP=Total Population T..T=Total Treated R=Refusal A=Absent P=Pregnant S=Sick ^TCR=Total

Coverage Rate

When the

CDD

treatrnent records were exarnined, we found that

only in

one

of

the six category

A ^{villages (Mkako)}

^were

the

records adequate

for computing the

treatnent coverage

rates. None of the other five

villages had data

on total

number

of

^persons

treated. For Mkako village, total population was 1870 and total no

of

persons treated ^rvas

1333. This

^gives

a

coverage rate

of

71.3o/o.

This

compares

very favourably with

the coverage rate

of

^74.3o/o shorvn in the table above for the same village.

From the

above table

also, it is

possible

to

derive

the

rates

of

refusals and absentees during the last distribution.

IABI-E-!:

Dnta from HII Su Data from CDD Records

Village Population Abscnt

No.

_'h

Madaba Kilagano Mdunduwalo Magagura Rtranda Mkako

Table

1.4 shou,s a

total of

23 refusals and 42 absentees

giving

a 4.7o/o refusal rate and 8.6% absentee rate derived from the household surve),data. Only

two

villages, Kilagano (16.3%) and Mdundurvalo (12.8%) reported refusals, while

all

the other villages reported absentees ranging

from 3 (3.5%) in

Kilagano

to

12 (14.1%)

in Ruanda. On the

other hand

rvith

the

only

exception

of Mkako with a

high absentee rate

of

16.0% (299), the

CDD

records

in all

the villages

did not

include information

on

refusals and absentees.

This underscores the poor record keeping among CDDs.

85 86 70 88 85

14 160%

Village TP'

TT'

UNTREATED

<5

R'

Ar Pr sr Other

56 43 24 59 48 55

l4

l-3 IO l-,

l:i

IO

0

l4

9 0 0 0

8 J 7 5

t2

7

I 2

{

0 I I

0 2

)

1

I

0

6 8 '15

9

ll

l0

TCR'

Madaba Kilagano Mdunduwalo Magagura Ruanda Mkako

85 86 70 88 85 74

TOTAL 4EE

285 i

73 23 42 9 6 50 58.40h

Refusals

No.

^o/o

Absent

No.

^Y"

Refusals

No

^{t/" Population}

00%

t1

^t6.3%

9 lZ.fi"

0

^U/o

0

^ff/n

00%

8

9.4%

3

^3.s%

7

^10.tr/o

5

^5.7/o

t2

t4.t%

7

940h I 870

il

^o6y,

| 4as

TOTAL

23

^4.70/,

42

^8.6Vo

1t)

3.2 Oualitv of CD'tl Imnlementntion

3.2.1 CDD Training

In all

the villages (both

A

and

B)

covered, rve fbund that the CDDs had recerved some

training on the CDTI process. The

length

of training varied significantly

among the CDDs ranging from less than one day trainrne in Mugarura to seven days in Madaba.

TABLE

2.I

LENGTH OF CDD TRA]NING

/o

83 50.0

t6l

o.J 16.7 100 0

The

modal

training period

reported lvas one

day. This

rvas rather

too

short

to

ensure adequate and proper training of CDDs.

As

regards rvho trained the CDDs, eleven out

of

the twelve CDDs inrerviewed (91.7%) reported

that they

u'ere trained

by

Health Personnel/Onchocerciasis

Coordinator.

The

remaining CDD from

Irzladaba

indicated that he was trained bv an official of

the community development agency, SODA.

The table belou' sututtrarises the inlbrmation on rvhat issues and toprcs rvere covered at the training scssions as stated by the CDDs.

TAB LE 2. 2 : IS SLIEVTQPI C S COVERE D AICDD_IBAINING

I ssues # saying Yes /o

A.

Aboul Onchocerciasis

I

Cause 10. Symptoms

I

I

Socioecononric rmportance

I 2. Community nrobilrsatiorveducation 13. Ivermectin needs long time treatment

B.

About the Drug Treatment duratron Coverage of dr stri bur ion Dosage determination Drug expiration

Treatment oI AbsenteeVrefu sal s

Side effects counscl i ngy'referral Exclusion cr rlerrz,

Record keelrrrre Census talrlru_, _.

f_1

rl

)

rl il

H

r^l

I

I 2 J 4 5

6

7 8 9 :

I .1

1it

j

'1

! I l

!

lr l2

l

l0

lr

8

t2 l2

I

il

l2 l2 II

t2

917 t00 0

5E3

83i

917

667 r00 0 r00 0

83 917 100 0 r00 0

917 r00 0

_t l2

_i

No. of Davs Response

I 2

!

7

Less than I I

6 2 I 2

TOTAL _t2

TOT t00 0

;i

l'able 2.2

shou's that the

only

one issue apparently not covered during the

training

was expiration

of

Ivermectin after removing the container

seal.

Socioeconomic importance

of

Onchocerciasis ^rvas covered

only in

about

half of

the training exercises. On the whole, coverage

of

issues at

training

was good

but we

found

sufficient

reason

to worry

about how rvell some

of

the topics were covered and understopd by the CDDs.

3.2.2 CommunitT, education and

nnbilisation

Under the

CDTI

process, health personnel and the CDDS provide community education

on Ivermectin distribution. AII the health workers interviewed confirmed that

the

communities were provided with education on the importance of treatment with

Ivermectin

tablets. Similarly, 1l out l2

CDDs, (91.7%)

in category'A'villages

agreed that they provided

their

communities rvith education on Ivermectin

treatment. Only

one

CDD (8.3%) in

Magagura

village

admitted that he

did

not provide the community rvith education on Ivermectin treatment.

TABLE 2.3: WHAT TF{E COMMUNITIES WERE TOLD ABOUT IVERMECTIN

l.Taking Ivermectin treatment annually for several years 2. Benefrts of treatment

3. Community responsibility 4. Side effeos

5

Other

81.8 90.9 18.2 72.7 9.1

TOTAL CDDs 100.0

'table

_{2.3 shorvs that the} cornnrunities were least educated on community responsibiiity.

Only

l8o/o

of the CDDs

reported educating

their

communities

on this very

^important

issue. This finding

was confirmed by

village

leaders. When asked what they were told about communih-

responsibility (

see

key informant interview : village 'A'

_Question

l6c.), half of

them (509i,),

the village

leaders said

that they

were

told nothing

about

community responsibility. This, no doubt, has some adverse effects on

^the

implementation of

CDTI

in the area.

3. 2.3 Dosage

deternination

Ivermectin dosage determination is one

of

the key tasks the

CDD

must learn

to

perform

correctly.

Table 2.4 presents the data on horv the CDD performed this task.

TABLE 2.4. HOW IVERMECTIN DOSAGE WAS DETERMINED

Process ^o/o

I

By height measurement

2

^{Use weight}

3

^Visual Observation

4.

Age

5

Other (prevrous e.rpcrrence)

t2

I

I 2 I

100.0 8.3

8l

t67

8i

se # ofCDDs ^a//o

9

l0

)

8 I

t2

'Ycst

# of CDDs

l:\'f

^S t2 r00 0

!

I

i

il

I

iI

t'2

The table indrcates that

all

the CDDs (100%) use height measurement, although three ol-

the CDDs

emploved

weight

measurement, age and

visual

observation (experience) as

well. All

the CDDs have measuring devices which

in all

cases

but

one, rvere available

for inspection.

The

CDD

who

did

not present his device explained that he came

to

the

interview fiom

another engagement away

fiom

his house rvhere

the

measuring device rvas kept.

Dosage

occurlcv

check

A

dosage accuracv

check

performed

on l5 randomly

selected I{ouseholds revealed 9(60%) correct dosages and

6

(40%) incorrect dosages

of

Ivermectin

given. This is

an

alarmingly high percentage of enor.

3.2.4 Record keeping and reporting

Another rnajor task required

of

operators

of

the

CDTI

process

is

proper record keeping and

reporting.

As a form of self evaluation of this task, the CDDs were asked

if

they ^had problems

with

record keeping

(interview

schedule

for village 'A' CDD

_Quest.

39).

^In

response, 6

of

them (50%) admitted having problems

with

record keeping while the other half denied having any

problems.

As for the nature

of

problems being experienced, only two were metttioned namel-v;

insulficicnt

forms and absence

of

proper hard back big note

books to be

used as registers instead

of

^loose sheets

of

paper

being

used conectlv Horvevel, our observation is that their problem

with

record keeping

is

much deeper thalr

that. 'fhis rvill

be discussed later.

('cnsus

llccttrtls

On the

issue

of

census

taking, tive out of six (83.3%)

category

'A' _village

_leaders

indicated

that

census

of their village

was

undertaken. One village

leader denied this.

Horvever, no census register could be produced

for

inspection.

'l'reatment l?egtsler

The

treatment register

is

one

of the

most irnportant

CD'l'l record.

[nformation

on

^its

existence as obtained

from

the

village

leaders and CDDs

in

category

A & B

villages is

summarised belorv.

TABLE 2

5

EXISTANCE OF TREATMENT REGISTERS

Source of information

Stat us Village Leaders

(A & B).

N=30

CDDs (A & B)

o//o N=60 oh

I

Register seen

2

Exists but nor scen

3

Does nol exrst

23 4 J

I 6 lo/o

l]3%

I 3oto

45 8 6

16 3Yo 13.60/o

l0.lYo

TOTAL RESPONDI]NTS _{30 100%} :e r000%

The table

shows

that all

^logether

there were

three

villages which had no

treatment registers

tbr

1998 lvermectin

distribution

The villages are Ruanda, Amanimakoro and Lutumbadiosi,

all in Mbinga district. This

yields

a

defaulter rate

of

^30o/o

for

Mbinga

district and

l0o/o

for the

entire project

area. Explaining why

there

was no

treatment register, one of the CDDs for Amanimakoro said:

" _No

regtster hus becn opencd

for ^the

¹⁹⁹⁸ treatment cycle because the trealmenl

.forns

y:ere collected by the

Dtstrict

Onchocerctass Coortltnator and he has not returned them."

A

further analysis

of

the

45

treatment registers seen and inspected reveals some serious problems

in

record keeping attributable, in mosl part, to poor training and supervision.

TABLE 2.6: OUALITY ANALYSIS OF TREATMENT REGISTERS

TOTAL

More than half (53%) of the trealment

registers

were in such poor state that

no meaningful statistics could be extracted from them.

A

third of the registers however rvere

well kept. None of the 45

records examined

follorved the

recommended practice

of

organising treatnrent registers on household basis and

giving

each household a separate page. This

will

prermit updating of registers.

Side e.ffect.r records

Treatment records rvere available and inspected in 23 villages but none recorded any side

effect information

as

required.

Further,

of the four

Health Personnel seruing as CDD supervisors who rvere intervierved, none had records

of

severe side effects available

lbr

inspection. The impression given was that none suffered any side effects from the drugs.

However, dunng fbcus group discussions, partrcipants gave examples

of

individuals rvho suffered severe side

effects.

For instance a male, 25+ years discussant

in

Mdundurvalo village said,

" I

was espectally the mam

vtctim.

M1t /ace got swollen to the extent that

I

could not .see

for

^{tv,o day:;.}

^"

Another

female discussant

of

under

25

years

of

age

focus group, in Mkako

^village, Mbinga

district oted

one person who had srvelling and severe itching

of

the rvhole bod1,

rvhich

necessitated

going to

hospital

for

treatment where

lre

r.r,as

qiven

tranquiliz-ers 'l'his, accordrng to hrm, created l'ear among community members.

Assessment No. Yo

Good Fair Poor Very bad

14 7

t4 l0

3t.t%

15.6%

3t.t%

22.zYo

45 100.0%

14

3.2.5 ,Supervision

of

CDDs

Our

dau

show tlrat lourteen (23 39/o)

of

sampled CDDs in both category

A

and B vrllages had not been supervised by any

one

This means that seven villages were not supervised since

two CDDs

were taken

from

each

village.

Trvo vrllages were supervised

by

non-

health

personnel

while 2l ^villages (70%) were

supervised

by health

^{personnel as}

prescribed

by

the

CDTI

process. Table 2.7 classifies communities rvho received health education on Ivermectrn ^(see 3.2.2) by fbrm of CDD supervisron

TABLE 2 7. COMMUNITIES WHICH RECEI\ED HEALTH EDUCATION X FORM OF CDD SUPERVI S ION FI/EDUCATION RECEIPIENTS

3.2.6 Perlormance and change

of

CDDs

When asked to evaluate the performance of CDDs,

allthe

village leaders (1007i,) returned the verdict _{that the} CDDs had done rvell.

We are inclined to

agree

rvith their

assessment and

to

attribute

a number of

^lapscs

identified in their

performance,

especially record keeping, to ^{poor training}

^and

supen,isron.

As a

follow

up on the issuc

of

pertbnnance, both thc vitlage lcaders and the

CI)l)s

u,ere asked

if

there had been any,change of CDDs sincerhc last

<irugdistribution. 'fhe

result is summansed belorv.

lADr-E ^z

s ^wrcrHER cpps

[Ap_DE_ENCuaNGep

Sourte Response

l

il

:I

i^I

'l

There had been change No change

Don't know

Village Ieaderc N=30

(6 _7%) (e3.3%)

0%

CDDs

Nd0

58 I 59 2

28 0

(0ei'o)

(98 _3%)

I

^70h

096)

Reasons

given for the two

changes

repo(ed by the village

leaders

were

(a,y

Lack of

commitment and seriousness:

(b)

being

too

busy rvrth

his

other personal engagelnenrs /rvork

Supervision by 'farget _{villages CDDs} th

Health personnel Others

Not supervised

2t

2 7

42 4

l4

10.0%

6 1o/o 23.3oto

TOTAL RESPONDENTS 30 60 100 0oz6

TOTAL RESPONDENTS 30 r00.0%

tI

Summary

of

output indicators

Code Descrintion No. Ponulation

^7o

0-l

Refusels two months after

distribution 23 488

^4.7

Absentees that were later treated 0

At

risk villages treated 30 r00

0-2 0-3 0-5

0-6

0-7

0-8

M

Communities where CDDs werr Changed after the

fint

distribution Communities in n'hich the CDD ^was

Supervised by tbe health personnel Target communities which received

education about importancc of cxhnded Ivermectin treatmenL

Persons five years and abovewho Reccived Iverrrectin

2

7l

30

285

6.7

6.1

100

s8.4 42 0

30

30

30

30

4E{t

Cost per person treated $31000/122"559 = ^50.29

I_I

i {

ii ,I

16

3.0 Conrqrunity

I'crecDliett

3.3

I

Communitr perception o[

CDTI

Prograntme

o)

Ownersrp o/ l)rogruntnrc

Evidence

fiom

tntervrer.r,s

rvith village

leaders,

the CDDs

and

focus

^group discussion sessions shows that tlrroughout the project area, community members were

not

able to

distinguish the CDTI

process

from any other community health

programmes

of

the

Government.

The Programme was taken as

just

another disease

control activity of

the

Government. They did not

perceive

the

Programme

as their own but that of

the Government and perhaps the donors.

The main reason

for

failure of the communities to exhibit the expected

CDTI

perspective

was due to

inadequate

community education. In all the focus

group .sessions, the participants stressed that no one ever

told

them rvhat

their

role and responsibility

in

the programme should be.

h)

Usefulness lntportance of CDT'I

Focus group discussion participants (Women,

25+

years, Madaba, Songea

district)

put their viervs on usefulness of the CDTI Programme this way:

"ln./act

v'c ure

happvwith

this Prograntnte

andwe

thanktho.se ^u,ho gavc u,t the drugs"

Male (25+yearsl discussants in Mdunduwalo village elaborated turther

"People

arc

reultstngthe benefits of'tlrc

drug. Prior

to the u,se of tfu,r drug, they

dul not

knov, what

to do aboul

the disease,

and now tlrut

they lruve recerved

lhem]br

ntore than lwo round:;, they appreciate"

c)

(.ommuntly, c-\pe(:lat ton.

The

expectation and

the

desire

of the

communlty members rvas

that the

Programme should

not

come

to

an

end.

According

to

one

of the

group discussants, Covernment should ensure thal the drug supply continues

until

when they

know

that the disease has been completely eradicated.

d)

An apprehenstotl

Focus

group

discussants expressed some apprehension

and fear

about

tablets kept

in homes

of

CDDs rvhere sanitary conditrons n'ere

drfficult to guarantee

'l-hev feared that sonte tablets might gel contarnrnated and suggested that the unuseci drugs be kept at the nearest health lacilitres

a

a)

Communilt' usscssntent

d ('l)DtOD'l'l

When asked how rvell the CDDs had done therr rvork,

all

the

village

leaders tntervierved responded in the af firmative

-

They had done rvell.

Participants in focus group discussion sessions horvever

felt

that

it

was too early to assess the Progtamme having completed only one

year.

They agreed that

within

the year, CDDs had done well.

3.3.2

Commaniq, Responsibili$

As

shown

in

table 2.3 (see

P.l0),

community responsibility under

CDTI

^process was the least ffeated topic during community education and mobilisation and the least understood aspect

of ^the CDTI ^{process. According} to Madaba adult males group

discussion participants,

"

Community ctlucation was reslricted

to

the need

for

annual treatment

of

lvermecttn

for

^several

^years.

The contnrunily was

not

informecl

of

therr

responsibility antt how they are

supposed

to ensure they sustain

^the programme after five

yelrs."

Some key elements of community responsibility under the

CDTI

are discussed below

a)

lrnsuring contntunih' compliance

ln

most communities in the project area, communitv responsibility is understood

to

mean

"going for

treatment whenever

the drug is brought to the village." A number of

communities were prepared

to

ensure

that

every member

took part in

srvallowing the

drug.

Rules ^had been made which impose penalties on defaulters.

b)

Support./br the

(

_DD.r.

ln

the course of our investigation, CDDs rn category

A

villages were asked what

kind of

support

or

assistance they received

from their communities.

The results

is

summarised belorv

TABLE

3.I:

^{FORMS OF SUPPORT} RECEIVED BY C_DDS

ln cash or kind Provision of transport Community mobi I isation

I3xemption from communrty rvork l;nsuring compliance

None at all

'1

_-5

12

0 0 0 0 _s8.i%

41 ^7o/o

H lt/

Support

/o

TOTAL RESPONDITNTS r00 0%

Ir)

Thus as tar as the CDDs were concerned, the

only lbrrn of

assistance glven

to

^{them by}

the communitl, was using the existing administrative structure to ensure that community members

took the drug.

The absence

of

material incentives was emphasised b1, male (25+years)

group

discussants

fiom Mdunduwalo village.

Songea

District when

they stated:

"7'o _sat,the

lruth,

^u,e

don'l

^gn,e lhem even on ounce

ty'

salt."

However, group discussants from Madaba had this to say:

"7.he

only

_^support

given to

CDDs b),

the

communiyt

is

e-rentplutn

front

contmuniry,

work. However, thts

exemptton

is n()l

re.etrrcled

to

those engoged tn oncho conlrol sen)tces bul

tt

is extended to

all

tho.se tm,olved in otlrcr Prtmary Health Care (PHC)

activrlies"

From

the

foregoing, we conclude that the forms

of

community support received

by

the CDDs are

Exemption from community rvork

ii)

Ensuring compliance

i

ii)

Communit_v mobilisation

c) ^CDD

Supervision

Another aspect

of

community responsrbilrty under the

CDl'l

^is supervision

of

the CDDs

by

the conrmunity members. Unfbrrunately, community leaders and members were not

properly

educated

on this,

hence

thrs lunction was not

prcrformed

in rnost of

^the

communitics visited

Village

leaders u,ere specitically asked how they were involved in

CDTI

supervision ^(See key informant interview schedule for village

'A'

item

26). ln

response

only I

out

of

six (16.7o/o) specificallv mentioned supen'ising the activities of CDDs

in

the communit\,.

3.4 Programme Sustainabiliw

3.4.1 Communiq, sr+'r.rship

ol

the Programme

This is

also a ke-v element

in

the future sustainability

of

the

CDl'l Programme. But

as

stated earlrer

(see

3.3.1),

the

communities

had not been

educated

to

see

the

CDTI Programme as their

own. It

is ver1, important

to instill

this community perception

of

the Programme so as to ensure sustainabilrty.

3.4.2

Integration

iruo

ilrc

health system

Three

ofllcrals

tntervrerved at the natrorurl level

(MOH,

_{SSI and} NGDO rcpresentatrve at

the

NOTIr)

rndrcaled that Onchocercrirsis control is

rvell

integrated

into

the Health care system.

A

special unrt for the coordrnatron

of

eye care and Onchocerclasls activities ^lras

I

it

I

il

1

I

)i

1

I I

t tq

i

been established

at

the

MOH

headquarters and is administered under the Directorate

of

Preventive

sen,ices. The unit, which

receives

its financial and other support

from Government, has a National Onchocerciasis Control Plan in place.

At the distnct level,

integration

of

Onchocerciasis

control activities is a key

strategv being promoted as stated by one

MOH official;

"cli,ylrtcts

are

bemg empow,ered

to

conttnue the programme

by

integrating onchocercias is tttlo ^P HC act ivrt rcs"'

Of

the

four

health workers intervies,ed,

all

indicated that they were responsible

for

other

activities

besides

CDTI

^progmmme

activities.

The

table

belorv summarises

the

other activities carried out by the health rvorkers involved in

CDTI

activities;

TABLE 4.I ACTIVITIES INTEGRATED WITH CDTI

The table shows that the main

activity with

rvhich

CDTI

is being integrated

u'ith in

75%

of

respondents

is MCHiEPI. All

^the three health rvorkers

who

reported this are health personnel based in the peripheral health uruts (Health centers and Dispensaries;. The trvo health

workers.(50%) who

reported

carrying out

Eye

carelVitamin A

supplementation

activities,

are

the District

Onchocerciasis Coordinators

who are

based

in the

Songea Regional Hospital and Mbinga

District

Hospital and work in the Eye Care departments

of

these

Hospitals.

Also, the Project Coordinator

for

the Ruvuma focus, himself a

full

time employee

of the MOH, is

responsible

for

eye care services

in the

Songea Regional Hospital.

The other activities

with

which

CDTl

activities are integrated with are Curative (50%), Health education (25%) and Home visits (25%).

3.4.3 Willingness to contribute (Community Response)

Evidence of the community

response

and willingness to contribute to the

CDTI Programme was gathered dunng

our

interviews

with

the CDDs, the

village

leaders and droup discussion sessions

with

various segments of the population.

CDDs in

category

'A'

vrllages were asked

to

say what

they

t-elt about the Programme

rvith

respecl

to "community

response''

(CDD A

Questionaire, item

4l(b). Their

vietvs are summansed belorv

Activitics carried out # Yo

Curative

Eye care/Vitamin A supplementation MCH/EPI

Home visits Health Education

,)

)

3

I I

50.u/o 50.v/o 75.0%

2'5.0%

25.0%

TOTAL RESPONDENTS 4 100.0plo