SMC in Cameroon: Current status & lessons learnt Dorothy Fosah Achu – Permanent Secretary NMCP

Cameroon Operational Map Coverage areas 1. Far North Region: ( 30 HD) Surface area 34 263 km2 Population: 4 332 529 Children under five: 849530 (15.7%) 2. North Region: ( 15 HD) Surface area 66 576 km2 Population: 2 652 841 Children under five: 486 744 Total : 1 336 274 (~1 500 000, 40% children under five in the country)

Cameroon Funding Map Partner/Districts covered 2016 2017 2018 Comments Number Eligible Districts* 45 45? Based on 2006 MARA maps UNITAID WB Govt (€) 190 192 Yes/NA Contribution of some materials IDB (€) 1 269 639 985 583 Purchase of drugs GFATM (€) 2 228 469 3 424 192 EFG Total funded (€) 3 498 108 4 599 967 NA  Unfunded NA * By WHO criteria

Cameroon Targets & coverage Initial target number based on population data Target number following head count Target number of children during distribution Administrative coverage results Severe Adverse Events reported 2016 3-11 months 12-59 months Total 1 387 534 1 543 498 1 549 250 1 326 366 In total, 85.6% of eligible children received 3 doses; 8,3% received 2 doses while 3,1% received only 1 dose. The most frequent side effect reported was vomiting (mostly at the time of administration of the medications (32%) and abdominal pain or diarrhoea 18%; However these were mild symptoms.

Cameroon: Lessons learnt Training - I Numbers Trained 2016 Comments Trainers 177 8 Central trainers, 15 regional trainers and 147 district trainers Supervisors 426 Health areas supervisors Health Facility Workers 1 256 Proximity supervisors Community Health Workers 11 082 Distributors Public announcers and other mobilisation actors 7 664 2130 public announcers and 5534 mobilizers Total trained 20 605

Cameroon: Lessons learnt - Training – II Potential issues for consideration The training agenda and methodology were too dense for participants to capture the essentials; The choice of trainers and supervisors was based on duty posts rather than on competence Supervisors were often divided between several other health activities and thus not totally available Multiplicity of M&E tools Proposed solutions Training should be concise; practical (using real tools and materials), and tailored for each actor; briefing sessions are necessary before each cycle; Trainers should be selected through testing in knowledge and skills Supervisors must be engaged in the activity and free from other distracting activities during the campaign There is need for simplification and color-coding of tools to facilitate comprehension and ease of use Potential issues may include: - Minimum standards, coordination and harmonization - Key training levels / tools - Capacity gaps - Review and evaluation processes

Cameroon: Lessons learnt - Training – II Potential issues may include: - Minimum standards, coordination and harmonization - Key training levels / tools - Capacity gaps - Review and evaluation processes From complex to very simple messages and tools

Cameroon: Lessons learnt - Delivery approaches - I Number of distribution teams by approach Door to Door Fixed Others 2016 5 541 The initial strategy planned was for 200 children to be treated by each team of two CHW over 5 days. At the end of the implementation, a maximum of 1 477 698 targeted children were treated by a 2-person team of 5541 CHWs, giving an average of 267 children treated by each team. This value varied significantly depending on the density of the population involved (camps, villages or towns) Also the fixed strategy which was planned was not executed due to mobilization of health personnel into communities

Cameroon: Lessons learnt - Delivery approaches - II Potential issues for consideration High number of absences at the first round of treatment Low usage of fixed posts Inefficiency of the Mobile Money system to pay CHW leading to resignation of CHW Adjustment of strategies in insecure zones Proposed solutions Reinforce communication prior to distribution and disseminate information on all aspects of the campaign - fixed posts, dates of visits… Establish a credible community based payment system to ensure motivation of CHW through out the campaign Adopt the “Hit and Run” strategy in insecure zones to ensures more compliance and greater up take in such populations Potential issues for consideration may include: - Explanation about the choice for specific approach choices - Key constraints / challenges - Integration within existing networks / systems (CHWs / health workers) - Motivation issues - Review and evaluation processes (monitoring, supervision, daily coverage analysis)

Cameroon: Lessons learnt - Eligibility and referrals Potential issues for consideration Late arrival of AL led to many exclusions of children treated with ASAQ Late onset of the SMC campaign led to several children becoming sick and being excluded. Exclusion from treatment (including absences) decreased over time: 37291 in C1, 27470 in C2 and 18340 in C3. Common causes of exclusion include: fever (42%) and previous exposure to AQ, SP or sulfonamides (2,5%); 1,5% of children were said to be allergic to one of the components; On the other hand, there was high demand for treatment in children above 5 years Proposed solutions Initiate preparatory activities in good time so that the treatment of children can begin in time to benefit the maximum number of children Make available AL several months before onset of SMC and inform HW in time on the modalities of use Potential issues for consideration may include: - How it worked in country - Issues with age-setting - Role of health facilities - Availability of RDT and treatment - How many children were ineligible (% of target) / Common reasons

Cameroon: Lessons learnt -Pharmacovigilance and safety monitoring – I

Cameroon: Lessons learnt - Pharmacovigilance and safety monitoring – II Potential issues for consideration Low notification of side effects Insufficient management of mild and moderate side effects Non compliance of HW to guidelines on collection of samples and treatment of SE; Non-dispersible formulation of SPAQ caused many cases of vomiting Proposed solutions Strengthen the notification of SE by instituting incentives (case of EPI) Preposition lab reagents and drugs for the diagnosis & management of SE Continue the advocacy for the production of dispersible formulations of SPAQ Potential issues for consideration may include: - How it worked in country - Issues with age-setting - Role of health facilities - Availability of RDT and treatment - How many children were ineligible (% of target) / Common reasons

Cameroon: Lessons learnt - Monitoring, supervision & evaluation of reach Issues for consideration Inefficient supervision due to coinciding of health activities Insufficient feedback to HW and CHW during the campaign Multiplicity of M&E tools ( about 30 tools) Delays in transmission and consolidation of real time manually collected data Bias in conducting the rapid survey (by HW) Delay in measurement of malaria prevalence at the end of the campaign Proposed solutions Simplify and color-code the tools Strengthen the community base information and communication system to facilitate information sharing and provide feedback Put in place an electronic data transmission system Potential issues for consideration may include: - Appropriateness of tools (provide summary of key monitoring and supervision minimum tools) - Fitness-for-purpose, challenges and constraints - In-process monitoring and how data are used / not used to inform implementation - Supervision processes and gaps Quality assurance: How do you make sure children are reached 4 times? How do you assess adherence to home doses? Cross-checking age targets - Existence and reliability of coverage surveys or other surveys - Impact assessment (is there any?) and evaluation gaps

Key messages FAR NORTH REGION NORTH REGION Please consider: - Proxy measures of success (evidence of reduction of cases, feedback from health workers, etc.) - Beneficiary perceptions (positive, neutral, negative) (Quote from the end of cycle rapid surveys where available) - What key message from country on the future of SMC implementation? How to sustain financial investment? - Expected short-term and mid-term challenges - Other points to be raised / open questions / recommendations / points of advocacy

Key messages/ recommendations There is a clear reduction in the number of cases received in HF. The rapid survey showed that only 3.1% of children who received the treatment fell sick within the past two weeks. (Other age groups ???) NMCP and partners are very excited about these results and have recommended a number of actions to ensure that they are sustained: Diversify manufacturers and reduce the cost of the medication Ensure early procurement of drugs and early Implement only cost-effective strategies and use affordable tools Mobilize resources from other sectors (education, agriculture…) for implementation and evaluation activities Strengthen community based information systems Empower communities through C4D actions to improve mobilization of local resources Diversify external funding sources

Conclusion The NMCP is submitting a three year Funding request to the GF for the period 2018 – 2020. We are however worried that this intervention alone may carry a great portion of the allocation and leave little for the other complementary interventions (LLINs, IPT and case management) We hope to make wise choices on the following issues: For how long should we implement SMC, How can we cut down on costs while maintaining community engagement and who are the implementing partners both in and out of the country to support this approach

22/09/2018