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

2. Cameroon Operational Map
Coverage areas
1. Far North Region: ( 30 HD)
Surface area km2
Population:
Children under five: (15.7%)
2. North Region: ( 15 HD)
Surface area km2
Population:
Children under five:
Total : (~ , 40% children under five in the country)

3. Cameroon Funding Map Partner/Districts covered 2016 2017 2018 Comments
Number Eligible Districts* 45
45?
Based on 2006 MARA maps
UNITAID WB
Govt (€)
Yes/NA
Contribution of some materials
IDB (€)
Purchase of drugs
GFATM (€)
EFG
Total funded (€)
NA 
Unfunded NA
* By WHO criteria

4. 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
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.

5. 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 mobilizers
Total trained
20 605

6. 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

7. 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

8. 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 targeted children were treated by a 2-person team of 5541 CHWs, giving an average of 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

9. 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)

10. 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: in C1, in C2 and 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

11. Cameroon: Lessons learnt -Pharmacovigilance and safety monitoring – I

12. 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

13. 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

14. 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

15. 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

16. Conclusion
The NMCP is submitting a three year Funding request to the GF for the period 2018 – 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

17. 22/09/2018