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Table 2 Summary of challenges and solutions in form of support required for optimal performance of frontline implementers

From: Optimising the performance of frontline implementers engaged in the NTD programme in Nigeria: lessons for strengthening community health systems for universal health coverage

  Challenges Solutions
Technical support
 FLHF • Minimal training and knowledge on NTD programme implementation leave FLHF staff feeling unable to provide supportive supervision to implementers. • Lack knowledge of what to do in case of adverse event in children. • Inadequate human resources result in FLHF feeling overburdened with daily responsibilities at the clinic and limited time to move around for supportive supervision during MAM. • Inadequate number of distributers. • Medicine distribution channel through the focal people results in delay in distribution of medicines. • Medicine arriving during the raining season makes it difficult to reach some endemic communities. • FLHF staff want knowledge on how to handle children with adverse event during implementation (Kaduna). • FLHF staff request that all health workers be trained on NTD programme implementation rather than selected few (Ogun). • Government should employ more health workers. • More CDDs should be recruited and more health workers to assist in programme implementation. • FLHF staff want NTD medicines to be send to them directly and not through ward focal person to avoid delay in distribution to CDDs (Kaduna). • Medicines should arrive in the state during the dry season when all communities are accessible.
 CDDs • Training time was short and rushed, and in some cases, CDDs were only informed on dosage and how to measure on the dose pole not what is expected in their role. • Training in English hinders understanding of material (Ogun). • CDDs not confident when determining treatment dosage for rare scenarios like people living with physical disabilities that prevent them from standing beside the dose pole. • The CDDs are over-burdened with work load as they had to distribute to large populations and in more than one community (Kaduna). • Time for reporting is too short. • Not enough supervision. • Duration of training should be 3 h and facilitator should arrive on time. • Use of local language, role play and pictorial training materials during training for better understanding (Kaduna). • Training content to include how to handle side effects and determine medicine dosage for people living with disabilities to increase confidence in medicine administration (Kaduna). • Adequate time should be given for distribution and reporting to allow CDDs to do a thorough job and capture those absent during initial visit (Kaduna). • More CDDs should be recruited based on the population of the community. • Adequate supervision during implementation gives CDDs opportunity to inform supervisors of challenges and get immediate feedback on what to do. • Adequate training and time to fill the recording sheets for reporting.
 Teachers • Inadequate quality of training which is not detailed enough for teachers to understand all they need to know. In Ogun, some teachers were not trained at all. • Some trainers do not have deep knowledge about the diseases and the programme, hence unable to cascade training effectively. • Short notice of training time resulted in many teachers missing the training or arriving late (Ogun). • Training venue not always appropriate for learning. • Training was not interactive or participatory. • Only one or two teachers are trained for medicine distribution. • Lack of supervision will create mistakes. • They have challenge using the reporting tools. • Nobody from the health sector was available to support medicine administration in school. • Reporting time is too tight for them to do a thorough job. • Have regular training (once/twice every year). • School teachers should be trained rather than head teachers since head teachers can be transferred to other schools anytime (Kaduna). • Use simple training manuals to guide teachers during implementation. Should contain types of food children can eat on the day of administration. • Include training on how to handle side effects to boost confidence. • Training on how to use the record sheet for effective reporting. • More teachers to be trained to distribute medicines, the number should depend on the population of the schools. • Supervision should include access to health personnel from the Ministry of Health and the NGO supporting the programme to ensure staff are doing the right thing. • Supervision should be supportive and not for discipline which will motivate teachers to work faster and easier. • The number of days for reporting should be increased to allow adequate time to submit a detailed report.
Social support
 FLHF • CDDs imposed on communities by politicians or community leaders are not accepted by the community leading to rejection of medicines. • Acceptability of the programme is poor in some communities including non-indigenous tribes. • CDDs should be selected from within their community to enhance community acceptability of the medicines. • Traditional rulers to be involved and sensitised about the importance of the programme. • Better sensitisation of tribes by meeting with their leaders or someone that can talk to them in their language, then recruit CDDs from that tribe.
 CDDs • CDDs not from communities they served: rejection of medicines by nomadic Fulani’s. • People refused medicine due to different perceived needs; they are hungry. • Most men in the community (Kaduna) refuse male CDDs access to houses. • People refused the medicine because of side effects. • Time given for medicine administration is short. • Recruitment of CDDs from communities they serve; recruit nomadic Fulani CDDs to increase uptake of the medicines by the Fulani community (Kaduna). • Sensitisation of community on the importance and benefit of the medicine. • More female CDDs should be recruited to gain access to houses that males CDDs cannot enter. • Traditional rulers to be informed separately by means of a circular so they can use their town criers to spread the news (Ogun).
 Teachers • Some parents do not allow their children to collect the medicine because of socio-cultural beliefs (Kaduna) or they do not trust the source of the medicine (Ogun). • Teachers’ workload increases on the day of medicine administration as they must also teach on those days. • Sensitisation of parents through Ministry of Education. School-based management committee (SBMC) and PTA should also be involved in sensitisation of parents. • Increase public awareness of the programme using mass media, radio jingles, posters and sensitisation of community leaders, the mosques and churches 2–3 months before implementation of MAM (Kaduna). • Inform and seek the consent of parents for at least 2 weeks before implementation (Ogun). • Post banners in both English and Hausa languages at the school gate a week before implementation to raise awareness among parents. • Teachers assigned to administer medicine to pupils should be free from other responsibilities for that day.
Incentives
 FLHF • FLHF give their own money to CDDs for transportation, refreshments and materials like exercise books for reporting. • FLHF staff could not travel to supervise CDDs due to lack of transport. • No incentives for CDDs, other health programmes supply incentives. • Lack of incentives discourages CDDs who disengage with the programme when other health programmes offer incentives. • Adequate transportation allowance or access to a motorbike should be provided for medicine distribution in hard-to-reach areas.
 CDD • CDDs spend their own money to reach some communities, photocopy forms, transportation, purchase stationary and pure water sachets for people. • No incentives from the programme like other health programme demotivate CDDs. • Communities do not provide small incentives as they believe CDDs have been paid by government. • Medicine distribution during raining seasons prevents CCDs from working on their farms. • Lack of medicine result in CDDs being accused of marginalising some community members. • Adequate transportation allowance, registers and stationary should be provided for CDDs, especially for hard-to-reach areas to prevent out of pocket spending. • Incentives should be provided to encourage implementers, e.g. financial remuneration, provision of uniforms, ID cards, commendation from a higher authority like Ministry of Health, secure employment at the health facility (Ogun) and involvement in other health programmes. • Medicines distribution should be done during dry season (January–March). • CDDs want more medicine to be available to cater for increased population that were not captured during census update (Kaduna).
 Teachers • There is no quality drinking water in schools, so teachers find it difficult to administer medicines to pupils. • Delay in medicine distribution to schools in hard-to-reach areas. Many schools could not get medicine on time; teachers visited the medicine dispensary point several times before they could collect medicine for distribution in their school (Ogun). • Inadequate transportation allowance or delays in receiving payment. • Exam period is a poor time for medicine administration. • Medicine administration disrupts the academic activities as they must suspend lessons to give the medicines. • There are no incentives for teachers’ efforts in medicine administration. • School authority should make clean water available for pupils taking medicine or pupils could be encouraged to bring clean water from home on the day of medicine administration (Ogun). • Timely provision of the medicines, at least 1 week before implementation day (Kaduna) or on the day of training (Ogun). • Transportation allowance for teachers should be based on distance (Kaduna). • Transport allowance to be paid by cash and not into bank account (Ogun). • Medicine administration should take place within 2 weeks of resumption when academic activities have not commenced fully. • Provide incentives, e.g. financial; commendations from head teachers, parents and Ministry of Education; award of certificate of participation; provision of food on ‘Teachers’ Day’ or during festive period (Christmas and Salah).
  1. NB: The challenges and solutions outlined in the table do not always directly correlate.