1. Impact Assessment of the Community AnimalHealth System in Mandera West District, KenyaDr. Gezu Bekele and Dr. Jeremiah Akumu August 2009

2. ContentsExecutiveSummary..............................................................................................................................................i1.Introduction ........................................................................................................................................... 11.1Privateveterinarypracticeinpastoralistareas ................................................................... 11.2TheVSFSuisse/ELMTproject ............................................................................................... 12.Methods .................................................................................................................................................. 22.1 Studydesign ............................................................................................................................ 2 Financialsustainability .................................................................................................. 2 QualityofCAHWtreatments ....................................................................................... 22.2 Datacollection ......................................................................................................................... 3 Keyinformantinterviews.............................................................................................. 3 MethodswithCAHWs .................................................................................................. 3 Proportionalpilingtoestimatecasefatalityrate(CFR) ............................................ 32.3 Samplingmethodandsamplesizes ..................................................................................... 43.Results ................................................................................................................................................... 53.1 Financialperformanceofpharmacies .................................................................................. 53.2 NumberofCAHWtreatmentsandincome......................................................................... 73.3 DiseasereportingbyCAHWs ............................................................................................... 73.4 QualityofCAHWtreatments................................................................................................ 8 Casefatalityratesinsheepandgoats .......................................................................... 8 Casefatalityratesincamels .......................................................................................... 9 Casefatalityratesincattle............................................................................................. 93.5 Areasforimprovement ........................................................................................................ 114.Discussion............................................................................................................................................. 124.1 Methodologicalissues .......................................................................................................... 12Timingoftheassessment ............................................................................................ 12Diseasediagnosis,recallissuesandcasefatalityrates............................................ 124.2 Impactassessmentfindings ................................................................................................. 13FinancialsustainabilityofCAHWslinkedtoprivatepharmacies ........................ 13QualityofCAHWtreatments ..................................................................................... 14Diseasereportingandlinkstogovernment.............................................................. 16Useofveterinarydrugsbypastoralists..................................................................... 175.ConclusionsandRecommendations................................................................................................. 17AcknowledgementsThecommunityanimalhealth(CAH)systemcoveredinthisreportwasfundedbytheUnitedStatesAgencyforInternationalDevelopment(USAID)throughtheRegionalEnhancedLivelihoodsinPastoralAreas(RELPA)program,EnhancedLivelihoodsintheManderaTriangle(ELMT)activity.WithinELMT,VeterinairessansfrontieresSuisse(VSFSuisse)supportedtheCAHsystem.TheparticipatoryimpactassessmentwasconductedfollowingatrainingconductedinGarissa,Kenya.BoththetrainingandassessmentwereimplementedbytheRELPAPastoralAreasCoordination,AnalysisandPolicySupport(PACAPS)activity,implementedbytheFeinsteinInternationalCenter,TuftsUniversity.TheassessmentteamacknowledgestheintellectualcontributionsofpastoralistsandcommunitybasedanimalhealthworkersinGeder,Wargudud,KalwahilandWangaydahan,andthevaluableinformationprovidedbytheTakabaandWargududprivateveterinarypractitionersandtheVetAgroCompanyinNairobi.WealsoacknowledgethesupportofVSFSuisseexpert,Dr.SimonChuchu,andMr.AnisHassan,andthesupportoftheCARETakabaoffice.ThePIAtrainingwasassistedbyDr.DawitAbebeofPACAPSandMr.CharlesHopkinsofCAREEthiopia;Dr.AndyCatleyofPACAPSprovidedassistancewithdataanalysisandeditedthereport. 3. AbbreviationsCAH CommunityanimalhealthCAHWCommunitybasedanimalhealthworkerCBPP Contagiousbovinepleuropneumonia;CCPP ContagiouscaprinepleuropneumoniaCFR CasefatalityrateCIConfidenceintervalECHO EuropeanCommissionHumanitarianOfficeELMT EnhancedLivelihoodsintheManderaTriangleprojectFMD FootandmouthdiseaseKsh KenyashillingNSD NairobisheepdiseaseOIE OfficeinternationaldesepizootiesPACAPS PastoralAreasCoordination,AnalysisandPolicySupportprojectPPR PestedespetitsruminantsRELPA RegionalEnhancedLivelihoodsinPastoralAreasUSAID UnitedStatesAgencyforInternationalDevelopment 4. ExecutiveSummaryThisreportdescribesanimpactassessmentofacommunityanimalhealth(CAH)systeminManderaWestDistrict,Kenya,whichwassupportedbyVSFSuisse/ELMTbetweenMay2008uptothetimeoftheassessmentinAugust2009.Thesysteminvolvedthesupplyofveterinarymedicinestocommunitybasedanimalhealthworkers(CAHWs)fromprivateveterinarypharmacies,whichinturn,receivedmedicinesandcreditfromaveterinarysupplierinNairobi.ThesupportfromVSFSuisse/ELMTincluded:refreshertrainingtoCAHWsinanimalhealthcare;trainingpharmacystaffinsmallbusinessplanningandmanagement;assistancewithrenovationofpharmacies;facilitationoflinkagesbetweentheNairobibasedsupplierandlocalpharmaciesinManderaWest;provisionofpartcollateraltoloansprovidedbytheNairobibasedsuppliertothepharmacies;supporttoadiseasesurveillancesystemlinkedtolocalgovernmentveterinaryoffices.TheimpactassessmentfocusedonthefinancialperformanceandsustainabilityoftheCAHsystem,andthequalityofCAHWtreatments.Itwasrecognizedthatbothfinancialperformanceandclinicalcompetence/qualityrelatetooverallsustainability.KeyfindingsFinancialperformanceByAugust2009somekeyachievementsintermsofpharmacydevelopmenthadbeenachieved. FivepharmaciesreceivedcreditfromtheVetAgroCompanyinNairobibasedonsignedbusinessagreements,andthesepharmaciesthenactedasasourceofhighqualitymedicinesforCAHWs.Onaverage,theCAHWveterinarystockturnoverincreasedfrom19.5%beforetherevitalizationofthepharmaciesto80.5%atthetimeoftheassessment. ThemonthlytreatmentreportsfortheperiodSeptember2008toJuly2009indicatedthatmorethan51,000animalsweretreatedforvariousdiseasesbythe32CAHWswhoreportedtoVSFSuisse;eachCAHWtreatedaround177casespermonth.Althoughincomplete,financialrecordsfromshowedanaveragemonthlyprofitperCAHWofKsh2,520(US$35).ThiswasconsideredtobeasufficientfinancialincentivetokeeptheCAHWsmotivatedandworking,consideringthattheywereparttimeworkersandalsogainedincomefromothersources. Knowingthatthemajorityofthepharmacieswerefinanciallyverystable,VetAgrowasplanningtoexpandtheirmarketsinpastoralareasusingasimilarmodel.Oneofthemainchallengeswasdroughtinmid2009.ThenumberofanimalstreatedinJuneandJuly2009waslowcomparedwithpreviousmonthsandthiswasexplainedbydroughtandthemovementoflivestocktoEthiopiaandSomalia.Asherdersspentalotofmoneyonwaterfortheremaininglivestock(withinthedroughtaffectedarea),theyhadlesstospendonveterinarycare.QualityofCAHWtreatmentsCAHWtreatmentoutcomeswerecomparedwiththeoutcomesoftreatmentbyuntrainedherdowners.Thecasefatalityrate(CFR)wasmeasuredfordifferentdiseasesaffectingdifferentlivestockspeciesinCAHWtreatedandownertreatedanimals. ForthosediseasesforwhichacurativetreatmentstrategywasusedbyCAHWs,casefatalityratesinCAHWtreatedherdsweresignificantlylowerthanownertreatedherds(atthe95%confidencelevel)for9outof11diseasesassessed.Intermsofclinicalsignificance,fatalityfollowingCAHWtreatmentswaslowerforall11diseases.WhenviewedincombinationwiththequalityofthedrugswhichCAHWsweresourcingfromprivatepharmacies,thisresultshowedthatforthediseasesinquestion,CAHWtreatmentshadfarbetterimpactonlivestocksurvivalrelativetotreatmentsadministeredbyuntrainedherders. i 5. CAHWsalsoprovidedsupportivetreatments,particularlytheuseofantibiotictotreatorpreventsecondarybacterialinfectionsassociatedwithviraldiseases.Forthefiveviraldiseasestreatedinthisway,asignificantreductioninfatalitieswasevidentinCAHWtreatedanimalsforonlyonediseaseviz.Nairobisheepdisease(NSD).Thisresultwasexplainedbythelimitedbiologicalefficacyofantibioticsintermsofpreventingmortalityduetoviraldiseases.InthecaseofNSD,theuseofoxytetracyclinebyCAHWswasthoughttohavepreventedortreatedsecondarypasteurellosisorcertaintickbornediseases.Recommendations1. VSFSuisseshouldcontinuetosupporttheprivatedeliverysystem,linkingtheVetAgroCompanywiththepharmacies,veterinariansandCAHWs.Asthesystemhasonlybeenrunningforjustoveroneyear,furthermonitoringandevaluationoffinancialperformanceisneeded,probablyoverathreetofiveyearperiod,togenerateinformationforscalingupandpolicy.Incommonwiththeapproachusedsofar,VSFSuisseshouldavoiddirectmaterialorfinancialsupporttothepharmaciesorCAHWs.VSFSuisseshouldalsodevelopaclearexitstrategy2. AsdroughtisanexpectedeventintheseareasandcanimpactnegativelyonthepharmaciesandCAHWsasprivateoperators,plansshouldbedevelopedwiththeseactorstoprovideveterinarycareduringdrought.Apilotveterinaryvoucherschemeshouldbediscussedanddesignedwellinadvanceofdrought,andVSFSuisseshouldliaisewithUNagenciesanddonorstopreparepotentialdonorsoftheapproach.Thedesignprocessshouldincludewaystotargetmorevulnerablecommunitymembers,andalevelofvouchervaluewhichisagreedwithlocalstakeholders.3. Intermsofpolicyandharmonizationopportunities,VSFSuisseneedstodevelopaclearinternalorganizationalposition,andapolicystatementforpublicuseontheroleofCAHWsinthepastoralistareaswhereitoperates,includingapproachestosupplyCAHWswithveterinarymedicines.SuchastatementwillassistVSFSuissetoliaisewithotherNGOsandUNagenciesthatareoperatingveterinaryprogrammesinadjacentareas,especiallyinnorthernKenya,southernSomaliaandsouthernEthiopian(includingSavetheChildrenUSinDolloAdoandMoyale,andCAREinBorena).Togetherwiththeseotheractors,VSFSuissecouldjointlyorganizeaninternationalworkshoptosharelessonsfromthisassessmentonhowtheCAHsysteminManderaWestisoperating,includingthechallengesfacingthesystem.4. AlthoughtheCAHsystemshowedastrongimpactonlivestockmortality,thereisaneedtoreviewcertainaspectsoftheCAHWtrainingandpractice.ThisreviewshouldfocusontheuseofantibioticsbyCAHWsandcriticallyassessthejustificationfortheuseofantibioticsassupportivetherapyforviraldiseases.OtherthanNSD,thisassessmentshowednoimpactofCAHWsonviraldiseasesindicatingthatalternativestrategiesareneeded.WhilesomeveterinariansinKenyacontinuetocriticizeCAHsystems,pastoralistlivestockcontinuetobeaffectedbypreventablediseaseswithsevereimplicationsforlivelihoods.Forexample,poxdiseases,NSDandpestedespetitsruminants(PPR)canallbepreventedbywelldesignedanddeliveredvaccinationasaroutinepreventivemeasure.Furthermore,aspastoralistsarecurrentlypayingforantibiotictreatmentforthesediseases(withmixedoutcomes)itseemslikelythatpaymentformoreeffectivevaccinesisfeasible.Yettheveterinarianestablishment,overdecades,hasfailedtodeveloppreventivestrategiesfortheseandotherdiseases.Basicepidemiologicalandeconomicassessmentswithpastoralistscanclarifythedemandforeffectivevaccination,andassistgovernmenttodevelopbetterstrategies.Ifsuchstrategies ii 6. couldbedevelopedandimplemented,especiallywithprivatesectorinvolvement,theneedtouseantibioticsinresponsetooutbreaksofviraldiseaseswouldbereduced.Theroleofvaccinestoreducemortalityincamelcalvesshouldbeexamined.5. Thisassessmentfocusedonlivestockmortalityandfromalivelihoodsperspective,thesuddenorgraduallossoflivestock(financialassets).ThisapproachneedstobeexpandedtootherVSFSuisseprojectareastobuildamorecomprehensiveevidencebase,whilealsoassessingbroaderimpactsrelatedtoproductionlosses.Furthermore,futureassessmentswouldbenefitfromassessmentofequityissues,suchasuseofCAHWsbylivestockkeepersaccordingtowealthandgender.6. GovernmentsupporttotheCAHsystemseemstobeconfused,withthecurrentCAHWsallowedtopracticeandsubmitreports,butnoexpansionpermitted.Assumingthatlocalgovernmentiswilling,possiblesupporttogovernmentwouldincludeassistingthemtomonitortheperformanceofprivatepractitioners,includingpharmacystaffandCAHWs,inasystematicmanner.Similarly,thediseasesurveillancesystemmightbestrengthenedbydevelopingclearobjectivesforthesystemandtestingitagainstthemainsurveillanceindicatorsofsensitivity,specificity,timeliness,representativeness,simplicityandacceptability.However,itshouldbenotedthatasurveillancesystemwhichusesCAHWsisunlikelytobesustainedunlessgovernmentcanrespondtodiseaseoutbreaks,orideally,preventoutbreaks.7. USAIDshouldreviewtheuseoftheirlogoonprivatebusinessesandwaivebrandingrequirementsinthesesituations;similarly,VSFSuisseshouldreviewitsownbrandingpolicy.iii 7. 1. Introduction1.1PrivateveterinarypracticeinpastoralistareasItslongbeenrecognizedthateconomically,themostfeasiblemodelsforprivateveterinarypracticeinpastoralistareasinvolveurbanbasedpharmaciesorclinicswhichsupportnetworksofveterinaryparaprofessionals.Theseapproachesrecognizetherelativelyhightransactioncostsofdeliveringservicesinpastoralistareasandtherealitythatformostveterinarypharmacies,thevolumeofdrugturnoveristhemaindeterminantofbusinessviability.Fromtheperspectiveofbusinessdesignworkerssuchascommunitybasedanimalhealthworkers(CAHWs)provideaninexpensivedrugdeliverysystemandstrengthentheviabilityofprivatepracticesrunbyveterinarydiplomaordegreeholders1.In2003privatepractitionersfrompastoralistareasofEthiopia,Kenya,Somalia,Sudan,TanzaniaandUgandamettoreviewtheirexperiencesandconfirmedtheimportanceoflinkageswithCAHWsorotherveterinaryparaprofessionals2.InKenya,smallbusinessdevelopmentmodelswhichlinkurbanveterinarypharmaciestoCAHWsarenotnew.TheFARMAfricaapproachinMeruiswelldocumented3,asisthePAVESprivateveterinarypracticeinKapenguriawhichservedWestPokotpastoralistareas4.However,whenthisapproachhasbeentriedinmoreremotepastoralistdistrictssuchasTurkana,ManderaandWajirithasbeenmoredifficulttosustainforvariousphysical,economicandinstitutionalreasons.Physically,thesedistrictsarelarge,isolatedandhaveveryweakinfrastructureandtherefore,transactioncostsforserviceprovisionareespeciallyhigh.Institutionally,variousactorshavebeenslowtomoveawayfrompaternalistic,directprovisionofveterinaryservicesthroughaidprojects.Afurthercomplicationhasbeenrecurrentdroughtandtheprovisionofveterinaryinputsthroughhumanitarianprogrammes,someofwhichhavelimitedflexibilityintermsofinnovativeprivatesectorinvolvement.Tosomeextent,veterinaryvoucherschemesofferawayforwardintermsoftargetedveterinarycareduringdroughtwhichworkswithratherthanagainsttheprivatesector5.1.2TheVSFSuisse/ELMTprojectThisassessmentaimedtomeasuretheimpactofthesupportprovidedbytheVSFSuisse/ELMTprojecttothecommunityanimalhealth(CAH)systeminnortheastKenya.Itfocusesonanexaminationofthequalityandsustainabilityofthesystem.TheprojectwasimplementedintheManderaWest,Garbatula,LiasanisandWajirNorthDistrictsfromMay2008toJuly2009.Intheproject,32communitybasedanimalhealthworkers(CAHWs)weregivenrefreshertrainingsonbasicanimalhealthcare,and10stafffromfiveprivateveterinarypharmaciesweregiventraininginsmallscaleveterinarybusinessplanningandmanagementmethods.Thepharmacystaffincludedthepharmacyownersviz.threeveterinariansandtwoCAHWs.Inaddition,theprojectfacilitatedacreditarrangementtothepharmaciesthroughaprivatecompanyinNairobicalledtheVetAgroCompany.1Catley,A.,Leyland,T.andKaberia,B.K.(2002).TakingaLongTermPerspective:SustainabilityIssues.In:CommunityBasedAnimalHealthcare:APracticalGuidetoImprovingPrimaryVeterinaryServices,Catley,A.BlakewayandLeyland,T.(eds.),ITDGPublications,Rugby.2AU/IBAR(2003).PrivateVeterinaryPracticeinPastoralistAreasofEasternAfrica:ReportofaregionalworkshopheldinNakuru,Kenya,69August2003.AfricanUnion/InterafricanBureauforAnimalResources:Nairobi,Kenya.3Kaberia,B.K.(2002).Effectivenessandfinancialviabilityofaprivatizedanimalhealthdeliverysystem.In:PrimaryAnimalHealthCareinthe21stCentury:ShapingtheRules,PoliciesandInstitutions.ProceedingsofanInternationalConference(K.SonesandA.Catley,eds.),1518October2002,Mombasa.AfricanUnion/InterafricanBureauforAnimalResources,Nairobi.4Ririmpoi,B.(2002).Integrationofcommunityanimalhealthintoprivatepractice:thecaseofWestPokotDistrict.InProceedingsofthe10thDecentralisedAnimalHealthWorkshop,811September,LakeBogoriaHotel,Kenya.CommunitybasedLivestockInitiativesProgramme,Nairobi,2931.5Mutungi,P.M.(2005).ExternalevaluationoftheICRCveterinaryvouchersystemforemergencyinterventioninTurkanaandWestPokotDistricts.InternationalCommitteefortheRedCross,Nairobi. 1 8. TheseactivitieswerearesponsetoanearlierreviewwhichindicatedthatsomeofthelocalveterinarypharmaciesandCAHWswereoperatingataverylowlevelofactivity.TheassessmentwasrestrictedtoManderaWestDistrictandspecifically,theTakabainterventionsite.AtthissiteVSFSuissesupportedtheTakabaandWargududprivateveterinarypharmaciesownedbytwooftheeightCAHWswhowerelinkedtotheprojectinthoseareas.Inturn,theTakabaandWargududpharmacieswerelinkedtotheVetAgroCompanyinNairobiandalso,tosixCAHWsoperatinginthefieldinthisarea.Thespecificobjectivesoftheimpactassessmentwereasfollows. ToassesstheimpactofthesupportprovidedbytheVSFSuisse/ELMTprojectonthepreexistingCAHsystemintermsofchangestothefinancialsustainabilityofthesystem. ToassessthequalityofthetreatmentsprovidedbyCAHWs,withemphasisontheimpactonlivestockmortality. TodrawlessonstoinformfutureplanningofCAHsystemsinpastoralareas.2. Methods2.1StudydesignFinancialsustainabilityThiscomponentoftheimpactassessmentexaminedtheperformanceofprivateveterinarypharmaciesbyreviewinginformationsuchasdrugpurchasesandsales,anduseofthepharmaciesbyCAHWs.Informationwascollectedfrompharmacyrecordsandthroughstakeholderinterviews.QualityofCAHWtreatmentsThiscomponentoftheimpactassessmentusedaretrospectivecomparisonoftheimpactoftreatmentsdeliveredbyCAHWsusinglocalpharmacydrugs,versustreatmentsadministeredbylivestockkeepersusingdrugspurchasedfromothersources.Theimpactindicatorusedwasthecasefatalityrate(CFR)fordiseasestreated.ItwasassumedthatthetreatmentsprovidedbyCAHWs,usingpharmacydrugsshouldhavebeenofhigherqualitythantreatmentsprovidedbyuntrainedlivestockkeepersusingdrugsfromothersources,suchasordinaryshopsandblackmarketdealers.Therefore,forthosediseaseswhereacurativetreatmentwasused,theCFRsinCAHWtreatedherdswouldbeexpectedtobelowerthanCFRsinownertreatedherds. Adistinctionwasmadebetweencurativetreatmentsandsupportivetreatments.Curativetreatmentswerethosewherethetherapeuticapproachwasdirectedataprimarydiseaseagent.Inthecontextofthisassessment,supportivetreatmentsaimedtolimittheclinicalimpactofsecondaryinfections.Thesetreatmentsincludedtheuseofantibioticsinviralinfectionsasameanstodealwithsecondarybacterialinfections6.Dependingonthediseaseinquestion,supportivetreatmentscanbeexpectedtohavelessimpactoncasefatalitythancurativetreatments.Thisreflectstheimperfectnatureofmedicaltherapeutics,particularlyincaseswheredrugstotreataprimarydiseaseagentarenotavailable.6Supportivetreatmentscanalsoincludetheuseofrehydrationsolutionsorvitamins,butthesekindsoftreatmentsdonotapplytotheCAHsystem. 2 9. 2.2DatacollectionThedatacollectionmethodsweredesignedwithVSFSuissestaffbasedinNairobi,WajirandTakaba,whowerepreviouslyinvolvedinthedesignandimplementationoftheELMTproject.TheimpactassessmentwasconductedinAugust2009byateamofthreeveterinariansandaveterinaryassistant;aveterinarianfromPACAPS(whospokeSomaliandOromo),andthreeVSFSuissestaff.VSFSuisseprojectdocumentswerereviewedtoprovideinformationonprojectactivities.KeyinformantinterviewsKeyinformantgroupandindividualinterviewswereusedtocollectinformationasfollows. Theavailabilityofbasicanimalhealthservicesintheirarea. LivestockmovementradiusandcoverageoftheCAHWservice. LimitationsoftheCAHWservicedeliverysystemandsuggestionsforimprovement.MethodswithCAHWsInformationwascollectedfromCAHWsasfollows. Simplescoringofdrugsuppliers/sourcestoshowreplenishmentoftheirveterinarydrugsbeforeandaftertheVSFSuisse/ELMTprojectsupport. Matrixscoringofdifferentdrugsourcesagainstfourindicatorsviz.accessibility,affordability,qualityandavailability. Simplescoringofpreferencesfordifferenttypesofantibioticssourcedfromthepharmacies. InterviewstoexaminetheadvantagesanddisadvantagesofbeingaCAHW.Proportionalpilingtoestimatecasefatalityrate(CFR)Proportionalpilingwasusedwithlivestockkeeperstoestimatecasefatalityrates(CFRs)7.Themethodwasdesignedsothattheseinformantscoulddescribespecificvariablesbylivestockspecies. TheproportionoftheherdwhichbecamesickduringtheobservationperiodofSeptember2008 toJuly2009,andthen,thespecificdiseaseswhichwerediagnosedbyeitherCAHWsorowners basedonclinicalinformation. Theproportionofsickanimalstreatedbydisease,andtypeandsourceofdrugsadministeredby eitheraCAHWorlivestockkeeper. Theproportionsoftreatedanimalswhichdiedandsurvived,bydiseaseandaccordingto treatmentbyaCAHWorlivestockkeeper.TheproportionalpilingmethodwasstandardizedandadaptedfromthemethodwhichhasbeenvalidatedwithpastoralistsineastAfrica.Itusedlocaldiseasenames(Annex1)andthedatawashandledasnonparametricdata.MediandifferencesinCFRbydiseaseforCAHWtreatedandownertreatedherdswerecalculatedusingConfidenceIntervalAnalysissoftware8.However,adistinctionwasmadebetweenstatisticalsignificanceandclinicalsignificance:Statisticalsignificancetestsgiveanindicationoftheprobabilitythatobserveddifferencesbetweengroupsareduetochance.Clinicalsignificanceconcernstherelevanceoffindingstoclinicalveterinarypractice.Becausestatisticalsignificanceispartlydependantonsamplesizeitispossiblethatclinicallyimportantresultsmaybeoverlookedbecauseastudyssamplesizeistoosmall.9Therefore,althoughthedeathofonecamelinaherdmightnotregister7Thecasefatalityrate(CFR)foragivendiseaseistheproportionofsickanimalswhichdie.Therefore,CFRdiffersfrommortalityrate,whichmeasurethenumberofdeathsinthetotalpopulationduetoagivendisease;totalpopulationincludesbothsick(affected)andhealth(nonaffected)animals.8Altman,D.G.,Machin,D.,Bryant,T.N.andGardner,M.J.(2002).ConfidenceIntervalAnalysisversion2.BritishMedicalJournalBooks,London.9Thrusfield,M.(2005).VeterinaryEpidemiology,thirdedition.BlackwellPublishing,Oxford.3 10. astatisticallysignificantresultinastudy,suchalossmayhaveaneconomic,livelihoodsorwelfaresignificancetoeithertheownerortheanimal.2.3SamplingmethodandsamplesizesTheManderaWestDistrictwasselectedpurposivelyfromamongtheVSFSuisse/ELMTimplementationareas.InconsultationwithVSFSuissestaff,thedistrictwasviewedtoberepresentativeoftheproject.Figure1.MapsofKenyaandManderaDistrict4 11. Withintimeandresourcelimits,theintentionwastoconductadetailedassessmentinoneareaandcollectsystematicdataoncasefatality,ratherthanoptforamoresuperficialassessmentacrossmoredistricts.WithinthedistricttheTakabaassessmentsitewassuggestedbyVSFstaffbecauseCAHWswerelinkedtoveterinarypharmaciesfordrugreplenishment,andalso,totheDistrictVeterinaryOfficer(DVO)fordiseasereporting.TheTakabaprojectsitewaslocatedfartherfromeithertheManderaorWajirVSFSuissemainfieldofficesthananyoftheothersiteswheretheprojectwasimplemented.Therefore,theTakabasitewasconsideredanappropriatesitetodrawkeylessonsonissuesrelatedtothesustainabilityofaCAHsysteminremotepastoralareas.Fourvillageswererandomlyselectedinthedistrictviz.Geder,Kalwahil,WargudandWagadahan. Ineachvillage25keyinformantswereinterviewed(total100informants);inbothGederand Wargududtheseinterviewsweregroupinterviewswiththe25informants,whereasintheother villagestheywereindividualinterviews. AtotalofsixCAHWswereinterviewed,selectedfromallfourvillages. Proportionalpilingwasconductedwiththesame100individualinformantsselectedfromthefour villages;theseinformantsrepresented52cattleherds,77camelherdsand94smallruminant flocks.3.Results3.1 FinancialperformanceofpharmaciesVSFSuissefirstestablishedaCAHsysteminnortheastKenyain2002,usingfundsfromECHO.TheCAHWswereequippedwithakitofveterinarydrugsandequipmentvaluedatKsh40,000(US$556)intworounds.AtimelineofeventsfortheoverallCAHsystem,includingsupportprovidedbytheVSFSuisse/ELMTprojectispresentedinFigure2.Figure2.TimelineofkeyeventsintheCAHsystemTime Event2002 VSFSuissetrained60CAHWsinthegreaterManderadistrict. FollowingthetrainingeachCAHWwasgivenakitofveterinarydrugsandequipmentofvalueKsh20,000;CAHWsweregivenmorethaneightrefreshertrainingsbetween2002and2006.2006 VSFSuisseprovidedaveterinarystockofvalueKsh20,000perCAHWandalsoestablishedaveterinarydrugstorebelongingtoagroupofCAHWsinManderatown,asafinalmeansofsupporttotheCAHsystem1.2007 VSFSuisseassessedthestatusoftheCAHsystemandlearnedthatthesystemhadfailedto operateasintended,mainlyduetomismanagementofthefundsprovided. 2008 TheVSFSuisse/ELMTprojectstartedandrevitalizedtheearlierCAHsystemestablished in2002. Thenewprojectstartedadiseaseoutbreakreportingsystemincollaborationwiththedistrictveterinaryunit,usingCAHWsandprivatepractitioners. August2009 VSFSuisseassessedtheimpactoftheCAHsystemsupportedbyELMTprojectincollaborationwithPACAPS/TuftsUniversity(thisreport).Note1TheCAHWswhobecameprivatedrugsuppliersweretwinnedwithveterinaryprofessionalsatthattimemainlyforthepurposeoflicensingtheirveterinarypharmacies.ThenewVSFSuisse/ELMTprojectwhichstartedinMay2008aimedtoensurethesustainabilityoftheearliersystem.Thenewprojectincludedthefollowingsupport.5 12. Refreshertrainingto32CAHWs. Smallbusinessplanningandmanagementtrainingtofiveprivateveterinarypractitioners,beingthreeveterinariansandtwoCAHWs. Theprivatepractitionersweremobilizedtorevitalizetheirveterinarybusinessusingfundsfromtheirownsources,includingloanstockcollectedfromtheVetAgroCompany. Theprojectcoveredpartofthecostofpharmacyrenovation.TheoverallapproachusedbyVSFSuissewastosupportareliabledrugsupplysystem,mainlybyfacilitatingbusinessagreementssignedbetweentheVetAgroCompanyandtheprivateveterinarypharmacies;thiswasdoneinIsioloinMay2008.VSFSuissealsoactedascollateralforaportionoftheloanprovidedbyVetAgroCompanytothepharmacies,being35to45%oftheloan.Similarly,VSFSuissefacilitatedthesigningofagreementsbetweentheCAHWsandprivateveterinarypharmacies.Consequently,atthetimeofthisassessmentinAugust2009theTakabaandWargududveterinarypharmacieswereusingtheVetAgroCompanyinNairobiforinputswhiletheCAHWwereusingdrugsfromthelocalpharmacies.ThelocalpharmaciesweresellingdrugsatapricethatincludedtheCAHWservicechargetoindividualcustomers.ByAugust2009somekeyachievementsintermsofpharmacydevelopmenthadbeenachieved.ThepharmaciesreceivedcreditfromVetAgroCompanybasedonthebusinessagreementssignedinIsiolo.Figure3showsthevalueofthestockcollectedfromVetAgroCompanybythepharmacies(supportedbytheVSFSuisse/ELMTproject)betweenMay2008andJuly2009.Figure3.Privatepharmaciesstockreplenishmentperformance 300,000.00Total value of drugs (Ksh) 250,000.00 200,000.00 Total sales 150,000.00Total collection Outstanding 100,000.0050,000.00 0.00Takaba Wargudud Garbatula Laisamis WajirLocation of PharmaciesFigure4showsthesourcesofdrugsusedbysixCAHWsinvolvedinthisassessment,beforeandaftertherevitalizationofthepharmacies.Theirhigherpreferencefortheprice(affordability)offeredbythepharmacieswasexplainedintermsoftransportationcostsandotherpersonalexpensessuchasfoodandaccommodationwhichwereincurredwhenvisitingmoredistantsourcesinManderaandNairobi.Table1presentsCAHWpreferencesfordifferentantibioticswhichwereavailablefromthepharmacies.Onaverage,theCAHWveterinarystockturnoverratesincreasedfrom19.5%beforetherevitalizationofthepharmaciesto80.5%atthetimeoftheassessment(a61%increase).ItwasnoticeablethattheCAHWsinterviewedprioritizedtheskillgainedfromthetrainingsandthesocialrespectfromtheircommunitiesrelativetothefinancialbenefitsgainedfromtheirservices.Withregardstoeconomicbenefits,theCAHWsverymuchdisapprovedofthecompetitionfromwarejis(drugscirculatedbyblackmarketdealers)andordinaryshopssellingcheap,lowqualitydrugs.6 13. Figure4.CAHWpreferencesforveterinarydrugsuppliers7060 Median score (n=4 CAHWs)50 Accessibility40 Aff ordability30 Quality Availability20100 DukanLocalPrivatePrivateVeterinarypharmacies pharmacies pharmacies suppliersMandera MoyaleNairobiNoteforFigure4Dukanmultipurposelocalshopssellingveterinarymedicines,usuallyinsmallquantitiesandwithoutlicensesortechnicaltraining.Table1.CAHWpreferencesforantibioticsItemAveragepreference Unitprice(Ksh) Grossprofitperunit score(%)Purchase Sell Ksh%profitPenstrep20% 2728635064 22.4Oxytetracycline10%2012016040 33.3Tylosin2054060060 11.1Oxytetracycline20%LA 2728635064 22.4Deseptoprimtablet 7 810 2253.2NumberofCAHWtreatmentsandincomeTheprojecthiredtwoveterinaryparaprofessionals(aveterinaryassistantandalivestocktechnician)tocollectmonthlytreatmentanddiseaseoutbreakreportsformsfromeachCAHWandtransferthemtotheNairobioffice.ThemonitoringreportsindicatedthatCAHWtreatmentfigureswerecollectedregularlyfromthe32CAHWsthroughouttheprojectperiod.Whilethesefiguresaresummarizedbelowitshouldbenotedthatthenumberoftreatmentsarenotrelatedtothelivestockpopulationordiseaseprevalence,andtherefore,provideonlylimitedevidenceofimpact. ThemonthlytreatmentreportsfortheperiodSeptember2008toJuly2009indicatedthatmorethan51,000animalsweretreatedforvariousdiseasesbythe32CAHWswhoreportedtoVSFSuisse;eachCAHWtreatedaround177casespermonth. ThenumberofanimalstreatedinJuneandJuly2009waslowcomparedwithpreviousmonthsandthiswasexplainedintermsofdrought.Specifically,livestockmigratedtoEthiopiaandSomaliaandbecauseherdersspentalotofmoneyonwaterfortheremaininglivestock(withinthedroughtaffectedarea),theyhadlesstospendonveterinarycare. IncompletefinancialrecordsfromtheprojectwereavailablebutshowedanaveragemonthlyprofitperCAHWofKsh2,520(US$35).3.3DiseasereportingbyCAHWsTheVSFSuisse/ELMTprojectstartedananimaldiseasesurveillancesystembasedonCAHWreports.InthesystemtheCAHWswereresponsibleforcollectinginformationonoutbreaksofdiseaseslisted 7 14. bytheOfficeinternationaldesepizooties(OIE),usingreportingformsdevelopedbyVSFSuisseandsubmittingthemtotheDVOeachmonth.ThesystemstartedinMay2009anduptotheendofJuly2009theCAHWssubmittedsevendiseaseoutbreakreports.3.4QualityofCAHWtreatmentsAsummaryoftheimpactofCAHWtreatmentsonCFRsispresentedinTable2.Table2.StatisticalandclinicalreductionsincasefatalityratesinlivestockherdstreatedbyCAHWscomparedwithownertreatedherdsCurativeorSheepandgoats Camels Cattle Allspeciessupportive Statistical Clinical StatisticalClinical Statistical ClinicalStatistical Clinicaltreatmentsbyreduction reduction reduction reduction reductionreduction reduction reductiondiseaseinCFRinCFR inCFR inCFR inCFRinCFRinCFRinCFR Curative: HelminthosisYesYes Yes Yes YesYes3/3 3/3Mange YesYes Yes Yes 2/2 2/2Trypanosomosis NoYes YesYes1/2 2/2CCPPYesYes 1/1 1/1CBPP YesYes1/1 1/1Respiratorydisease Yes Yes 1/1 1/1TickbornediseaseNo Yes 0/1 1/1Total 9/1111/11 Supportive: PoxdiseasesNo Yes NoYes 0/2 2/2PPR No No 0/1 0/1NSD YesYes 1/1 1/1FMD No No 0/1 0/1Paralysis,camels NoYes 0/1 1/1Total1/6 4/6NotesCurativetreatmentsaimtokilltheprimarydiseaseagent,suchasabacterium(e.g.throughtheuseofantibiotic)orparasite(e.g.throughtheuseofanthelmintic).FormostinfectiousdiseasescurativetreatmentshouldresultinlowerCFRs(fewerdeaths)thansupportivetreatments.Supportivetreatments,inthecontextofthisassessment,mainlyinvolvedtheuseofantibioticstotreatbacterialinfectionswhichweresecondarytoviralinfections.Thisapproachisusedwhenantiviraldrugsarenotavailableandassumesthatsomedeathsresultfromthesecondarybacterialinfections.Astheprimarycauseofdiseaseisnottreated,ingeneral,supportivetreatmentsresultinhigherCFRs(moredeaths)thancurativetreatments.CasefatalityratesinsheepandgoatsCAHWsprovidedcurativetreatmentsforfourdiseasesordiseasegroupsviz.contagiouscaprinepleuronemonia(CCPP),mange,helminthosisandprotozoaltickbornediseases,andsupportivetreatmentsforthreediseasesviz.Nairobisheepdisease(NSD),sheepandgoatpoxandpestedespetitsruminants(PPR)(Table3).ForthreeoutoffourdiseaseswherecurativetreatmentswereusedbyCAHWs,CFRsweresignificantlylowerinCAHWtreatedcasesrelativetocasestreatedbylivestockkeepers.CAHWtreatedcasesofNSDalsoshowedasignificantlylowerCFRrelativetocasestreatedbylivestockkeepers.Furthermore,thesemedianreductionsinCFRweresubstantial:31.6%forCCPP;33.3%formange;21.4%forhelminthosisand33.9%forNSD.Fortickbornedisease,sheepandgoatpox,andotherdiseases,CFRswerelowerinCAHWtreatedherds.ComparedwithCFRsinownertreated8 15. herdsthesechangeswerenotstatisticallysignificant,butwereclinicallysignificant.ForPPR(supportivetreatment),CFRswerehigherinCAHWtreatedherds.Table3.ComparisonofcasefatalityratesinsheepandgoatsfollowingCAHWandownertreatmentsDiseaseCAHWtreatmentsOwnertreatmentsMediandifference MediancaseTypeofmedicine MediancaseTypeofmedicine incasefatalityrates fatalityrate(%)andstrategyafatalityrate(%)(%)(95%CI)CCPP28.5Oxytetracycline,63.4Tetracyclinecapsule 31.6(20.5,41.7)*(n=84flocks)curative (n=36flocks) Mange4.9 Ivermectin, 40.0 Diazinonspray 33.3(15.4,47.6)*(n=36flocks)curative (n=11flocks) Tickborne37.9Oxytetracycline,58.3Oxytetracycline10.6(27.5,53.3)diseaseb(n=16flocks)curative (n=6flocks) NSD 48.3Oxytetracycline,91.7Oxytetracycline 33.9(16.0,54.6)*(n=36flocks)supportive (n=14flocks) Helminthosis 10.5Albendazole,50.0Albendazoleor 21.4(12.5,50.0)*(n=29flocks)curative (n=11flocks)tetramisole PPR 59.2 Tylosin,42.9Dihydrostreptomycin 4.6(14.3,26.7)(n=50flocks)supportive (n=11flocks)tablets Sheepand 23.9 Oxytetracycline, 34.9Nottreated 11.1(25.9,2.6)goatpox (n=28flocks)supportive(n=19flocks) Otherc19.3 Various, 33.3Various2.9(31.9,11.1)(n=32flocks)supportiveand (n=15flocks)curativeNotes*Significantatthe95%confidencelevel,usingconfidenceintervalanalysis.aSupportivetreatmentsusedinviralinfectionandinvolvedtheuseofantibiotictotreatsecondarybacterialinfections.bAssumedtobebabesiosisoranaplasmosis.cOtherdiseaseswerefootrot,liceinfestation,botulism,bloat,swollenheadandnonspecificabortion.CCPPcontagiouscaprinepleuropneumonia;NSDNairobisheepdisease;PPRpestedespetitsruminantsCasefatalityratesincamelsCAHWsprovidedcurativetreatmentsforfivediseasesordiseaseformsviz.acutetrypanosomosis,chronictrypansomosis,respiratorydisease(coughing),mangeandhelminthosis,andsupportivetreatmentsforonediseaseviz.camelpox(Table4).ForthreeoutoffivediseaseswherecurativetreatmentswereusedbyCAHWs,CFRsweresignificantlylowerinCAHWtreatedcasesrelativetocasestreatedbylivestockkeepers.ThesemedianreductionsinCFRweresubstantial:25.0%forrespiratorydisease;42.9%formange;and43.2%forhelminthosis.Fortrypanosomosis(acuteandchronic),camelpox,paralysisandotherdiseases,CFRswerelowerinCAHWtreatedherds.ComparedwithCFRsinownertreatedherdsthesechangeswerenotstatisticallysignificant,butwereclinicallysignificant.CasefatalityratesincattleCAHWsprovidedcurativetreatmentsforthreediseasesviz.trypanosomosis,contagiousbovinepleuropnuemonia(CBPP)andhelminthosis.ForallthreediseasestherewasasignificantlylowerCFRinCAHWtreatedherdsrelativetoownertreatedherds(Table5).ForotherdiseasestherewasalowerCFRinCAHWtreatedherdswhichwasclinically,butnotstatistically,significant.9 16. Table4.ComparisonofcasefatalityratesincamelsfollowingCAHWandownertreatmentsDiseaseCAHWtreatmentsOwnertreatmentsMediandifference Mediancase TypeofmedicineMediancaseTypeofincasefatalityrates fatalityrate(%) andstrategyafatalityrate(%)medicine (%)(95%CI)Trypanosomosis, 3.8 Quinipyramine 10.0 Diminazine 4.0(8.0,11.0)chronic (n=40herds)sulphate,curative(n=16herds) aceturate Trypanosomosis, 31.0Quinipyramine 50.0Isometidium25.0(0.0,50.0)acute (n=44herds)sulphate,(n=15herds) chlorideorcurative diminazine aceturate Respiratory 17.2Oxytetracycline,47.2 Tetracycline 25.0(5.7,50.0)*disease(n=30herds)curative (n=12herds) capsule Mange0.0Ivermectin,42.9 Diazinonspray42.9(15.4,86.5)*(n=34herds)curative(n=7herds) Helminthosis8.6Albendazole,55.6 Albendazoleor 43.2(14.8,58.3)*(n=35herds)curative(n=11herds) tetramisole Camelpox38.5Oxytetracycline,40.0 Nottreated5.9(13.9,20.4)(n=27herds)supportive(n=17herds) Otherb 25.0Various,curative 33.3 Various1.7(26.7,5.0) (n=49herds)andsupportive(n=31herds) Notes*Significantatthe95%confidencelevel,usingconfidenceintervalanalysis.aSupportivetreatmentsusedinviralinfectionandinvolvedtheuseofantibiotictotreatsecondarybacterialinfections.bOtherdiseaseswerewounds,liceinfestation,botulism,bloat,eyeinjuriesandinfections,nonspecificabortionandplantpoisoning.Table5.ComparisonofcasefatalityratesincattlefollowingCAHWandownertreatmentsDisease CAHWtreatments OwnertreatmentsMediandifferenceMediancaseTypeofmedicineandMediancase Typeofmedicineincasefatalityratesfatalityratestrategyafatalityrate(%)(%)(95%CI)(%)Trypanosomosis 0.0Isometidiumchloride,100Isometidium 100(64.3,100.0)* (n=12herds) curative(n=6herds) chloride CBPP27.5 Oxytetracycline,62.5Oxytetracycline30.9(8.3,51.4)* (n=10herds) curative (n=9herds) Helminthosis 0.0Albendazole,40.0Albendazoleor33.3(2.5,40.9)* (n=31herds) curative (n=11herds)tetramisole FMD9.5Oxytetracycline,3.9 Nottreated 0.0(13.1,17.7) (n=13herds) preventive(n=11herds) Other33.3 Various,curativeand 40.0Various,curative 15.6(0.0,33.3)(n=31herds) supportive(n=25herds)andsupportive Notes*Significantatthe95%confidencelevel,usingconfidenceintervalanalysis.aSupportivetreatmentsusedinviralinfectionandinvolvedtheuseofantibiotictotreatsecondarybacterialinfections.bOtherdiseaseswereliceinfestation,botulism,bloatandeyeinjuriesandinfections.CBPPcontagiousbovinepleuropneumonia;FMDfootandmouthdisease 10 17. 3.5 AreasforimprovementTable6describessomeofthelimitationsoftheCAHsystemidentifiedbystakeholders,howtheselimitationsaffectedtheperformanceoftheprogram,andsuggestionsforimprovementsorbetteroptionsforfutureinterventions.TheTablesummarizescommentsbystakeholdersincludingbeneficiaries,CAHWs,privateveterinarypractitioners,VSFSuissestaffandthemembersoftheassessmentteam.Table6.StakeholderreviewofCAHsystemLimitationsSuggestionsVSFSuissehasnotbeeneffectivelyutilizing TrainVSFandgovernmentstaffoninformationfromCAHWsmonthlytreatments participatorymonitoringtechniquesaspartofreportstoprovideonthejobtrainingtothem.theirCAHWtrainingoftrainerscourse;Therefore,someoftheCAHWshadsome FurthertrainingforallCAHWsbyexperiencedknowledgegaps:veterinarianfocusingoncamelhealth usingantibioticdrugsagainstsomeuntreatableproblemsandtreatments,particularlycorrect diseases;useofantibiotics. administeringdihydrostreptomycintablets orallytoadultruminants; knowledgegapsoncameldiseases.VSFSuisseworkedwithonlyeightCAHWsoutofIncludetheotherCAHWsinfuturerefresheraround16CAHWsthatusedtheprivateveterinarytraining;pharmacies: TrainadditionalCAHWsoncostsharingbasis. thecoverageoftheCAHWsservicewasvery TheCAHWsneedtocoverthekitcostandthis poor;requiresthecommunitytolookforbetteroff consequently,pastoralistscontinuedusinglow membersduringselection10. qualitydrugsfromordinaryshopsandblack marketdealers,aswellasusingincorrect treatmentproceduressuchasadministering penicillinstreptomycinbyintravenous injection. Theprivatepharmaciesweresellinghigh Strongtrainingforprivatepractitionerson qualitydrugsfromtheEuropeancompanydrugprescriptionandhandlingmatters. NorbrookIreland.Masseducationondrugrelatedissuesto Theysoldshortactingantibioticdrugssuchaspastoralists. 10%oxytetracycline,Penstrep,Deseptoprim tabletsandTylosintogetherwith20%long actingoxytetracycline,andthishastechnical problems. Thepharmacieswereforcedtofollow pastoralistspreferenceforshortactingdrugs partlyduetothelowerprice11.ThepresenceofthedonorandVSFSuisselogoson Erasethelogosandmakeallstakeholdersthewallofthepharmaciesmeantthatthe awarethatthedrugsinthepharmaciesarecommunitiesandsomeoftheCAHWsthoughtthatpurelyprivateproperty.thepharmaciesweresellingdonated(free)drugsatcommercialpricestomakeaprofit;thisaffectedthenormalclientrelationshipstosomeextent.10ThemembersofthecommunitiesinvolvedinthisassessmentsuggestedthatanyadditionalCAHWstrainedmayneedtocoverthekitcostespeciallyofveterinarydrugs.11Thereseemstobelimitedjustificationforselling10%oxytetracyclinetoCAHWs. 11 18. 4. Discussion4.1MethodologicalissuesTimingoftheassessmentTheassessmentwasconductedduringthepeakofthelongdryseasoninAugust2009.Therefore,althoughasamplinglistofinformantswasavailableforthepurposeofmakingarandomselectionofinformants,itwasnotpossibletolocateormeetmostofthepeopleselectedfromthelist.Furthermore,itwasnotpossibletoidentifyherdswhichhadreceivednotreatmentsandwhichmighthaveactedasacontrolgroupfortheassessment.Inpart,theselimitationswereovercomebycomparingCAHWtreatedandownertreatedanimals;whenusingtheproportionalpilingmethod,informantsconfidentlyprovidedthisinformation.Inaddition,theCFRdatawashandledasnonparametricdata.Diseasediagnosis,recallissuesandcasefatalityratesTheproportionalpilingmethodforestimationofCFRpartlydependsontheabilityofinformantstodiagnoselivestockdiseaseswithreasonableaccuracy.Suchdiagnosisusestheirclinicalobservationsandrecognitionofepidemiologicalfactorssuchastheseasonaloccurrenceofdisease,contactbetweenherds,exposuretodiseasevectorsandotherfactors.Theclinicaldiagnosticskillsofpastoralistshavebeenshowntobesimilartothoseofveterinarians12.Aretrospectiveassessmentdesigncanbehinderedbyrecallbias.Hereweassumedthatanyinaccuraciesinrememberingtreatmentoutcomes(deathsandsurvivors)wouldapplysimilarlytobothCAHWtreatedandownertreatedherds.Ideally,CFRresultsfromCAHWtreatedherdswouldhavebeencrosscheckedagainstcompleteCAHWtreatmentrecordsforthoseherds,anddetailsofdrugadministrationbyspecies,disease,proportionofanimalstreatedandvolumesandroutesofdrugadministration.Thislevelofdetailedinformationwasnotavailable.AfurthermeansofcrosscheckingwasacomparisonoftheCFRsreportedbypastoralists,withtheliteratureonlivestockdiseasesinpastoralareas.Acomparisonbasedonaninitial,briefliteraturesearchisprovidedinAnnex2butaffordsonlyaveryapproximatemeansofvalidatingtheCFRdataisthisreport.ThisisbecausenoneoftheliteraturerefersspecificallytotheManderaWestareaandcasefatalityvariesaccordingtobiologicalvariationindiseaseseverityduetopathogenvirulence,andfactorssuchastheendemicorepidemicnatureofadiseaseinagivenarea.ThereforethereisnostandardCFRforagivendiseaseinaparticularspeciesandformostcases,abroadrangeofCFRs.RatherthanusingthespecificfiguresreportedintheliteratureitisprobablymoreusefultocomparethedatabycategorizingCFRsusingtermssuchashigh(e.g.CCPP,NSD,PPR,trypanosomosis),moderate(e.g.mange,sheepandgoatpox,camelpox)andlow(e.g.FMD).AnothermeansofcrosscheckingwouldbetocomparetheoutcomeofCAHWtreatmentswithtreatmentsprovidedbyveterinarians,withthelatteractingasagoldstandardtreatment.Initially,theassessmentwasdesignedtoassessherderpreferencesfordifferentanimalhealthserviceprovidersandtherefore,hadscopetocompareCAHWandveterinarians.However,itbecameevidentthattherewerenootherserviceprovidersintheareaapartfromtheCAHsystemsupportedbyVSFSuisse/ELMT,andtheprivatepharmaciesthatbelongedtotheCAHWs.12Catley,A.(2006).TheuseofparticipatoryepidemiologytocomparetheclinicalveterinaryknowledgeofpastoralistsandveterinariansinEastAfrica.TropicalAnimalHealthandProduction38,171184.12 19. 4.2ImpactassessmentfindingsTheimpactassessmentfocusedonthefinancialperformanceoftheveterinarypharmaciessupportedbyVSFSuisse/ELMTwithaviewtolearninglessonsonthefinancialsustainabilityoftheCAHsystem.ItalsoexaminedthequalityofCAHWsbymeasuringtheoutcomeofCAHWtreatmentsusingCFRestimates.Qualityalsorelatestosustainability,becauseagoodqualityservicewhichdeliversreliableoutcomesismorelikelytobeusedbyclients,especiallyifthequalityexceedsselftreatmentsbylivestockowners.IntermsofCAHWquality,thefieldassessmentcoveredonlytheTakabainterventionsite.VSFSuisseshouldconductsimilarassessmentsinotheroperationalareastogenerateacompletepictureoftheCAHWtreatmentissuesandrelatedtrainingandtechnicalsupportneeds.FinancialsustainabilityofCAHWslinkedtoprivatepharmaciesBeforethecurrentprojectstartedin2008,VSFSuissehadpreviouslyestablishedaveterinarydrugshopinManderatownwhichwasmanagedbyCAHWsoperatingaroundManderaasagroupbusiness.The60CAHWstrainedintheprojectinterventionareaswerelinkedtothedrugshopforreplenishingtheirdrugs,andin2006,weregivenadditionalstockvaluedatKsh20,000(US$278)perperson.WhenVSFSuisseassessedthesystemin2007itwasnotoperatingandthemainreasonforthefailurewasmisuseoftherevolvingfundsinjectedintothegroupbusiness,bytheCAHWswhowereresponsibleforitsmanagement.Theseexperiencesaresimilartothoseseeninotherservicedeliverymodelsbasedoncollectiveownershipofasystem.AlthoughtheVSFSuisse/ELMTprojecthadbeenoperatingforonlyayearatthetimeofthisassessment,themorecommerciallymindedapproachtakenbytheprojectwasshowinggoodresults.Forexample,32CAHWssecuredveterinarydrugswhilethefiveprivateveterinarypractitionershadinjectedasubstantialamountofstockintotheirbusinessesbyusingtheirowncapital.Onaverage,theseindependentinvestmentsamountedtobetweenKsh200,000(US$2778)andKsh400,000(US$5556),includingtheloansprovidedbytheVetAgroCompany.SomeCAHWshadcollectedastockofvalueKsh5,000(US$70)toKsh10,000(US$140)fromthelocalpharmaciesonaloanbasis.TheVSFSuisse/ELMTprojectcontributedtotherenovationcostsofthepharmacies.IntermsofCAHWmonthlyincomederivedfromveterinaryactivities,alimitedanalysisofCAHWrecordsshowedanaverageprofitofKsh2,520(US$35)permonth.Althoughamorecomprehensivereviewisneededwhichtakesaccountofseasonalvariationsinincomeanddrought,thisfigureisfarhigherthanthemonthlyincomereceivedbyCAHWsinMwingiDistrictin200413andindicatesasufficientfinancialincentivetosustainparttimeCAHWSinManderaWest.TheVetAgroCompanyinNairobiiswillingtocontinuetoprovidecreditservicestothelocalpharmaciesasrequired.Knowingthatthemajorityofthesepharmaciesarefinanciallyverystable,thecompanyaimstousetheselocalprivatepractitionerstoexpandtheirmarketsinpastoralareasincludingthesouthernpartofSomaliaandEthiopia.Inthisregard,VSFSuissehaveplayedanimportantroleinlinkingthelargercompanytothelocalpharmacies.TheprivatepharmacieswerealsosupplyinghighqualityveterinarydrugstoCAHWs,therebyassistingtheoverallqualityoftheCAHsystemintheareascovered.Overalltheseexperiencesagreewithotherfinancialassessments13Rubyogo,J.C.,Murithii,P.M.,Agumbah,G.J.O.andObhai,G.(2005).SustainabilityofaprivatizedcommunitybasedanimalhealthworkersysteminMwingiDistrict,Kenya.TropicalAnimalHealthandProduction37,253266. 13 20. andstudiesinKenyawhichexaminethefinancialsustainabilityofCAHsystemsinvolvingprivatepharmaciesasthemainlocalsourceofveterinarydrugs14.InKenya,clinicalanimalhealthservicedeliveryrequiresveterinaryworkerstosourcesinputsfromprivatesuppliers.However,themorereputablesuppliersarelocatedinthemainurbancentersandinpastoralistareasahighlyunethicaltradeinveterinarydrugsupplyhasevolved,withconsequentrisksofdrugmisuse.Duetotheabsenceofproperlyregulatedandlicensedsourcesofveterinarydrugs,variouspettytradersanduntrainedpractitionershavesteppedintofillthegap.Thisisunacceptablefromalegalandethicalperspective,yetitisclearlytheroleofgovernmentveterinariansandrelatedagenciestoensurequalitycontrolofveterinarydrugsinthecountry.IntheCAHsystemcoveredinthisassessment,theprivateveterinarypractitionersandtheCAHWsinvestedtheirowncapitaltoestablishorrevitalizepharmaciesandacquirestocksofdrugs.Thisindicatesastrongpersonalcommitmenttothesebusinesses.However,theprivatepractitionersandCAHWswereconcernedthatitmaybedifficultforthemtocompetewithotherprivatepractitioners(includingotherCAHWs)whoreceivematerialandfinancialsupportsfromNGOsoperatingintheadjacentareas.Inaddition,duringdroughttheirstocksofveterinarydrugscanexpiryaslivestockmovetoneighboringcountries,andfreedrugsthatmaybedeliveredinresponsetodroughtbyNGOs,UNagenciesortheGovernmentofKenya.ThesefindingspointtoaneedtosupporttheCAHandprivatepharmacysystemintimesofdroughtwithveterinaryvoucherschemes,whichhavealreadybeenpilotedinpastoralareasofKenyaandareabetteralternativetofreedrugdistribution15.Similarly,somepastoralistsstatedthatCAHWswerenotalwaysavailablewhereneededmost,especiallyattimesofdroughtwhenherdsmigratetoEthiopiaandSomalia.TheCAHWsindicatedtheyfollowherdstoEthiopiaduringnormalyears.WithinEthiopiathereisapromisingtrendtowardsmoreuseoflocal,privatesectorworkerstoimplementemergencyveterinaryinterventionsinpastoralareas.ThisindicatesaneedforcrossborderharmonizationofCAHsystemsinnormalperiods,plusharmonizationofveterinaryvoucherschemesorsimilarapproachesduringdrought.QualityofCAHWtreatmentsDuringthelasttwodecadestherehasbeenconsiderabledebateintheveterinaryestablishmentinKenyaovertheuseofCAHWs.OneaspectofthedebatehasfocusedontheabilityofCAHWstodiagnosediseasesanduseveterinarymedicinescorrectly.AlthoughthereisnostandardmethodofmeasuringCAHWclinicalcompetence,variousstudiesinKenyahaveshownthatwhenwelltrainedandsupervised,CAHWscanprovideasufficientlevelofclinicalcompetenceandhavepositiveimpactonlivelihoods16.Incontrast,thereseemtobenostudiesavailablewhichreachanoppositeconclusion.ThisassessmentexaminedtheimpactofCAHWtreatmentsonlivestockfatalityanddidnotmeasureproductionrelatedlossesorimpacts.TheposttreatmentfatalityratesinCAHWtreatedherdsinthis14Somekeyreferencesare:Kaberia,B.K.(2002).ibid.Ririmpoi,B.(2002).ibid.LeonardD.K.(1987).Thesupplyofveterinaryservices:Kenyanlessons.Agric.Admin.Extens.26(4),219236.OkwiriF.O.,KajumeJ.K.andOdondiR.K.(2001).AnassessmentoftheeconomicviabilityofprivateanimalhealthservicedeliveryinpastoralareasinKenya.AfricanUnion/InterafricanBureauforAnimalResources,Nairobi,80pp.15LivestockEmergencyGuidelinesandStandards(2009).http://www.livestockemergency.net16Keyreferencesinclude:OdhiamboO.,HoldenS.andAckelloOgutuC.(1998).OxfamWajirpastoraldevelopmentproject:aneconomicimpactassessment.OxfamUK/Ireland,Nairobi,23pp.Rubyogo,J.C.,Murithii,P.M.,Agumbah,G.J.OandObhai,G.(2005).AssessmentoftheTechnicalCompetenceandEthicalBehaviourofCommunitybasedAnimalHealthWorkersinMwingiDistrict,Kenya,.TropicalAnimalHealthandProduction37(4),267276.14 21. assessmentagreewithearlierstudieswhichshowthatCAHWscandiagnoseandtreatdiseasescorrectly.TheassessmentshowedthatCAHWtreatmentsarenotperfectbutthisfindingisnotsurprisingnoclinicalserviceineitheranimalhealthorhumanhealth,anywhereintheworld,willproducecompletecureratesthisisthenatureofclinicalmedicine.WhiletheveterinaryestablishmentinKenyacontinuestoblockCAHsystemsatpolicyandlegislativelevels,itwouldbeusefultoassesstheclinicalcompetenceofveterinariansandcomparethisistoparaveterinaryprofessionalssuchasCAHWs.Suchastudywouldnodoubtrevealthatclinicalcompetencenotonlyrelatestoleveloftraining,butalso,tohandsonclinicalexperience.UntiltheveterinaryprofessioninKenyaopensitselfuptosuchscrutiny,itremainsdebatablewherethetechnicalcompetencereallyresides.ThereisnosystemintheveterinaryboardinKenyaforreassessmentofveterinariansclinicalknowledgeovertime,nosystemforcontinuingprofessionaldevelopmentandfew,ifany,examplesofveterinariansbeingdisciplinedorremovedfromtheveterinaryregister.LookingspecificallyattheCFRresults,ingeneralthecurativetreatmentsprovidedbyCAHWsresultedinsignificantlyfewerlivestockdeathscomparedtotreatmentsadministeredbyherdowners(Table2).Furthermore,thereductionsinCFRarisingfromCAHWtreatmentswereoftensubstantial(Tables3to5).Forexample,CAHWhaddramaticimpactonmortalityduetotrypanosomosisincattle(Table5).ItseemsreasonabletoassumethatthislevelofCAHWperformancedidnothappenbychance,butwasduetoacombinationofknowledgeandskillsacquiredthroughtraining,andthecorrectuseofappropriateveterinarydrugs.Forcameldiseases,theassessmentfindingsagreedwithearlierstudiesinKenya.Forexample,acomparisonofcamelherdswithandwithoutveterinarycareinnorthernKenyashowedthatmortalityduetodiseaseincalveswas44.8%inuntreatedherdsbutonly5.4%intreatedherds.Inadultcamels,mortalityduetodiseasewas26.7%inuntreatedherdsand4.3%intreatedherds17.AlthoughtheassessmentdidnotaimtodirectlymeasurelivelihoodsimpactofCAHWactivities,diseasesuchastrypanosomosis,helminthosis,CBPP,CCPPandmangehavebeenreportedinSomalipastoralareassincethe1940sandareknowntohaveimportantimpactsintermsofproduction(e.g.milk,fertility)andmortality.Forpoorerhouseholdswhorelymoreonsheepandgoats,CCPP,PPR,helminthosisandNSDareimportantdiseaseswithCCPP,PPRandNSDcausinghighmortalityandtherefore,lossofkeyassets;NSDcauseshighermortalityinsheepandgoatsinAfricathananyotherinfectiousdisease.InthecaseofCBPPtherearemixedopinionsamongveterinariansconcerningtheuseofantibioticstotreatthisdisease,oftenbasedonconcernsthattheuseofantibioticsencouragescarrierstatusandmakeseradicationmoredifficultinthelongterm.Morerecentstudiescontestthisview.Forexample:thereappearstonoscientificevidencethatthetreatmentofCBPPcaseswithantibioticsresultsincarrierstatus18andantibioticshavebeenshowntobebeneficialinlimitingtheimpactofthedisease19.OxytetracyclinehasbeenusedtotreatCCPPformanyyears.IncentralSomaliainthelate1980sitwasconsideredtobeaneffectivetreatment20andmorerecentresearchhasindicatedthevalueof17Simpkin,P.S.(1985).TheeffectsofdiseaseasaconstrainttocamelproductivityinnorthernKenya.MPhil.Thesis,UniversityofLondon.18Mariner,J.C.,McDermott,J.,Heesterbeek,J.A.P.,Thomson,G.,Roeder,P.L.andMartin,S.W.(2006).AheterogeneouspopulationmodelforcontagiousbovinepleuropneumoniatransmissionandcontrolinpastoralcommunitiesofEastAfrica.PreventiveVeterinaryMedicine73/1,7591.19OttoJ.B.Huebschle,RogerD.Ayling,KevinGodinho,ObedLukhele,GeorginaTjipuraZaire,TimG.Rowan,RobinA.J.Nicholas(2006).Danofloxacin(Advocin)reducesthespreadofcontagiousbovinepleuropneumoniatohealthyincontactcattle.ResearchinVeterinaryScience81,304309.20 In 46/47 reports were information on the efficacy of oxytetracycline was available, the treatment was reported as efficacious. Thereferenceis:Baumann,M.P.O.(1990).TheNomadicAnimalHealthSystem(NAHASystem)inPastoralAreasofCentralSomaliaandItsUsefulnessinEpidemiologicalSurveillance.MPVMthesis,UniversityofCalifornia,Davis.15 22. danofloxacintotreatCCPP21.OntheseissuestheassessmentteamnotedsomemisunderstandingsinCAHWtrainingcoursesdeliveredbyveterinarians.Forexample,TylosinisadrugofchoiceforuseagainstrespiratorydiseasessuchasCCPPandCBPPbuthasneverbeenusedbyCAHWsagainstthesediseases.Insteaditwasusedagainstviraldiseases,particularlyPPR,andwithnoimpact(Table3).Thisexperienceindicatesthatwhenveterinariansareconfusedabouttheevidencesupportingaparticulartherapeuticoption,suchconfusioncaneasilybepassedontoCAHWs.OthertechnicalareasinneedofrevisionintermsofCAHWtrainingandsupervisionwereasfollows. OtherthansupportivetreatmentofNSDinsmallruminants,therewaslimitedevidencetoshowthatthesupportiveuseofantibioticstotreatviraldiseaseswaseffectiveantibioticusagehadnodemonstrableimpactonmortalitycausedbypoxdiseases,PPRorFMD. ThefindingthattheparenteraladministrationofoxytetracyclinereducedmortalityduetoNSDagreedwithexperiencesinnorthernSomalia,wherethesamedrugwasreportedtoincreasesurvivalinNSDoutbreaks;thiseffectwasattributedtopreventionortreatmentofsecondarypasteurellosisorcertaintickborneprotozoaldiseases22.FurtheractionduringNSDoutbreakscouldincludewholeherdacaricideapplicationtoreducetransmissionbythetickvector. TheCAHWsandpharmaciesweresellingvariousshortactingantibioticdrugsalthoughthecorrectadministrationofthesedrugs(e.g.dailytreatmentoverthreetofivedays)isproblematicinpastoralareas23;incompletetreatmentcanleadtotreatmentfailuresanddiscourageuseofCAHWsbypastoralists. Diarrhoeaanddeath,probablyduetoenterotoxaemia,wascommonlyreportedasacauseofcamelcalfmortality;thisneedsfurtherinvestigationandfollowup. CAHWsweretrainedtoadministerantibiotictabletsorallytoyounganimalsfordiarrhoea,anduseantibioticbolusestotreatretainedplacentaincattle;itseemsthattosomeextentthesepreparationsarebeingadministeredorallytoadultruminantsbypastoralistswithrelatednegativeimpacts.WhilesomestakeholdersmaycriticizeCAHWsforsomeoftheseweaknessesinclinicalexpertise,ultimatelyitistheresponsibilityofveterinarianstoprovidecorrecttechnicaltraining,monitorCAHWperformanceandaddressanyproblemsastheyarise.Otherthanoccasionalimpactassessments(suchasthisreport)thereappearstobenosystematicororganizedsysteminthegovernmentveterinaryservicetomonitorCAHWactivitiesortheclinicalworkofotherprivatepractitioners.DiseasereportingandlinkstogovernmentUnfortunatelytheassessmentteamwasnotabletomeettheDVOashewasnotavailable.AccordingtotheCAHWsinTakabathedistrictveterinaryunitisallowingtheexistingCAHsystemtocontinue,butopposesfurtherexpansionoftheservicee.g.byrefusingtotrainnewCAHWs.AtthesametimethereappearstobenofeasiblealternativetoCAHWsandtherefore,thegovernmentstrategywouldleavemanyareaswithoutCAHWsandallowinformaldrugsalesbypeoplewithnotrainingatall.Astheresultsofthisassessmentshows(Tables2to5),theuseofveterinarydrugsbyuntrainedpeoplehaslimitedimpactrelativetoCAHWs.21U.Ozdemir,G.R.Loria,K.S.Godinho,R.Samson,T.G.Rowan,C.Churchward,R.D.AylingandR.A.J.Nicholas(2006).Effectofdanofloxacin(AdvocinA180)ongoatsaffectedwithcontagiouscaprinepleuropneumonia.TropicalAnimalHealthandProduction38,533540.22Edelsten,R.M.(1975).ThedistributionandprevalenceofNairobisheepdiseaseandothertickborneinfectionsofsheepandgoatsinnorthernSomalia.TropicalAnimalHealthandProduction7/1,2934.23InMaasaiareasofKenyaitwasnotedthatuntrainedpastoralistsoftenadministeredonlyonedoseofshortactingoxytetraxcycline:Roderick,S.,Stevenson,P.,Mwendia,C.andOkech,G.(2000).TheUseofTrypanocidesandAntibioticsbyMaasaiPastoralists.TropicalAnimalHealthandProduction32(6):361374.16 23. WithregardstotheCAHdiseasereportingsystem,suchsystemshaveconsiderablepotentialtocontributetonationaldiseasesurveillance.InTanzaniaforexample,thosepastoraldistrictswithaCAHWreportingsystemoutperformedallotherdistrictsintermsofreportsubmissions24andthisisonereasonwhytheOIEsupportswelltrainedandsupervisedCAHWs.TheapproachinManderaisausefulstartbutcouldbestrengthenedbyreferencetothesixmainindicatorsofasurveillancesystemviz.sensitivity,specificity,timeliness,representativeness,simplicityandacceptability20.UseofveterinarydrugsbypastoralistsIngeneral,goodCAHWtrainingandsupportsystemsrecognizethatpastoralisttraineeshavestrongdiagnosticskills,andareknowledgeableontheclinicalsignsandbasicepidemiologyofmanylivestockdiseases.Incontrast,themaindeficitintheknowledgeofCAHWtraineesisthecorrectuseofveterinarymedicines.Althoughtheassessmentdidnotaimtostudythisissueinanydetail,thefieldworkindicatedthatsomeuntrainedpastoralistsweremisusingveterinarydrugs. Manyofthepastoralinformantsweretreatingtheiranimalsusing500mgoxytetracyclinecapsules,administeredbyinjection;thistreatmentwasusedparticularlyforrespiratoryproblemsmainlyingoatsandcamels,andthediluteddrugwasdirectlyinjectedintothethoraciccavitybetweenthethirdandfourthribs.Onaverage,asingledoseof12capsuleswasusedtotreatanadultcamelandthreecapsulestotreatanadultgoat,indicatingthatthedoseofthistreatmentwasaround10timeshigherthanthe20mg/kgbodyweightdosagerecommendedbydrugmanufacturersforthesespecies.Thispracticeneedsfurtherinvestigationasitswidespreaduseindicatesthatherdersperceiveittobebeneficial. Somepastoralistswereadministeringantibiotictabletsorallytoadultruminants,butalsoreportingthattreatedanimalsthenbecameemaciated.Thiswasperhapsduetodamagecausedtothenormalrumenflorabytheantibiotic. Pastoralistsmaypreferusingantibiotictabletsratherthaninjectionbecauseoraladministrationiseasierthaninjecting,andthetabletsarerelativelycheap.TheseexperiencesindicatethattheCAHsystemcouldbesupportedbymassmediainformationcampaignsorinformationdistributedthroughthepharmacies,toraiseawarenessaboutthecorrectuseofveterinarydrugs.5. ConclusionsandRecommendationsTheimpactassessmentreachedthefollowingconclusions. Theveterinarydrugsupplysystembasedonrural,privateveterinarypharmaciessupplying CAHWsofferedgoodpotentialforfinancialsustainability,particularlyifaveterinarydrug company(s)/suppliercouldservicethepharmaciesthroughnormalbusinesscontractsandcredit arrangements.TheestablishmentofaneffectiveCAHsystemwithoutdirectlyprovidingmaterial orcashinputsintoindividualbusinesses(includingCAHWskits)isanappropriateapproachboth fortheVSFSuisse/ELMTprojectandprobably,withinpastoralareasofKenyamorewidely. TheroleofVSFSuisse/ELMTasaproviderofcollateraltolocalveterinariansandCAHWsisone ofthekeylessonslearnedfromthisassessment.Itenabledveterinaryworkerswhomaynothave otherwiseaffordedtheinitialinvestmentrequired,tostrengthenprivateveterinarybusiness.This approachshouldbereplicatedbyotherNGOswithafocusonpromotionofveterinaryservice privatizationinpastoralareas.Theauthorsunderstandthatthemutualbenefitsbased collaborationbetweenthelocalprivatedrugsuppliersandCAHWsisessentialtoensurethe sustainabilityofaCAHsystem.24Allport,R.,Mosha,R.,Bahari,M.,Swai,E.andCatley,A.(2005).TheuseofcommunitybasedanimalhealthworkerstostrengthendiseasesurveillancesystemsinTanzania.Officeinternationaldesepizootiesrevuescientifiqueettechnique24(3),921932.http://www.oie.int/downld/imprimeur/pdfs%20review243/Allport921932.pdf17 24. TheplacementofUSAIDandVSFSuisselogosonthepharmacieswasinappropriateandcausedconfusionatcommunitylevel,mainlyduetoperceptionsthatveterinarydrugswhichhadbeendonatedfreeofchargewerebeingsoldforpersonalbenefit. ThedrugsandservicesprovidedCAHWsandprivateveterinarypharmacies,andsupportedbyVSFSuisse/ELMT,substantiallyreduceddiseaserelatedlivestockfatalitiesinpastorallivestockintheTakabainterventionarea.Itthereforehadapositivelivelihoodsimpact. Aswithanyveterinaryservicedeliverysystem,therewereareasforimprovement.ThesecouldbeintroducedintotheVSFSuisseprojectwithoutamajorchangeintheoveralltechnicalapproachoftheproject. ThepolicyenvironmentforprivatizedCAHsystemsinpastoralareasofKenyaremainsconfusedafterdecadesofdebateandevidencebasedresearch.AsKenyalacksaclearorevidencebasedpolicyonthesesystemsitcontinuestofallfurtherbehindothercountriesintheregion,withimportantnegativeimpactsonpastorallivelihoodsintermsofscalingupandenablingprimaryveterinaryservices,andrelatedregionalharmonizationofsystems.Futureneedsandopportunitiesinclude:1.VSFSuisseshouldcontinuetosupporttheprivatedeliverysystem,linkingtheVetAgro Companywiththepharmacies,veterinariansandCAHWs.Asthesystemhasonlybeen runningforjustoveroneyear,furthermonitoringandevaluationoffinancialperformanceis needed,probablyoverathreetofiveyearperiod,togenerateinformationforscalingupand policy.Incommonwiththeapproachusedsofar,VSFSuisseshouldavoiddirectmaterialor financialsupporttothepharmaciesorCAHWs.VSFSuisseshouldalsodevelopaclearexit strategy2.Asdroughtisanexpectedeventintheseareasandcanimpactnegativelyonthepharmacies andCAHWsasprivateoperators,plansshouldbedevelopedwiththeseactorstoprovide veterinarycareduringdrought.Apilotveterinaryvoucherschemeshouldbediscussedand designedwellinadvanceofdrought,andVSFSuisseshouldliaisewithUNagenciesand donorstopreparepotentialdonorsforsuchanapproach.Thedesignprocessshouldinclude waystotargetmorevulnerablecommunitymembers,andalevelofvouchervaluewhichis agreedwithlocalstakeholders.3.Intermsofpolicyandharmonizationopportunities,VSFSuisseneedstodevelopaclear internalorganizationalposition,andapolicystatementforpublicuseontheroleofCAHWs inthepastoralistareaswhereitoperates,includingapproachestosupplyCAHWswith veterinarymedicines.SuchastatementwillassistVSFSuissetoliaisewithotherNGOsand UNagenciesthatareimplementingorfundingveterinaryprogrammesinadjacentareas, especiallyinnorthernKenya,southernSomaliaandsouthernEthiopian(includingSavethe ChildrenUSinDolloAdoandMoyale,andCAREinBorena).Togetherwiththeseother actors,VSFSuissecouldjointlyorganizeaninternationalworkshoptosharelessonsfromthis assessmentonhowtheCAHsysteminnorthernKenyahasbeenreinitiatedandoperating, includingthechallengesindicatedearlier.4.AlthoughtheCAHsystemshowedastrongimpactonlivestockmortality,thereisaneedto reviewcertainaspectsoftheCAHWtrainingandpractice.Thisreviewshouldfocusonthe useofantibioticsbyCAHWsandcriticallyassessthejustificationfortheuseofantibioticsas supportivetherapyforviraldiseases.OtherthanNSD,thisassessmentshowednoimpactof CAHWsonviraldiseasesindicatingthatalternativestrategiesareneeded.Whilesome veterinariansinKenyacontinuetocriticizeCAHsystems,pastoralistlivestockcontinuetobe affectedbypreventablediseaseswithsevereimplicationsforlivelihoods.Forexample,pox18 25. diseases,NSDandPPRcanallbepreventedbywelldesignedanddeliveredvaccinationasaroutinepreventivemeasure.Furthermore,aspastoralistsarecurrentlypayingforantibiotictreatmentforthesediseases(withmixedoutcomes)itseemslikelythatpaymentformoreeffectivevaccinesisfeasible.Yettheveterinarianestablishment,overdecades,hasfailedtodeveloppreventivestrategiesfortheseandotherdiseases.Basicepidemiologicalandeconomicassessmentswithpastoralistscanclarifythedemandforeffectivevaccination,andassistgovernmenttodevelopbetterstrategies.Ifsuchstrategiescouldbedevelopedandimplemented,especiallywithprivatesectorinvolvement,theneedtouseantibioticsinresponsetooutbreaksofviraldiseaseswouldbereduced.Theroleofvaccinestoreducemortalityincamelcalvesshouldbeexamined.5. Thisassessmentfocusedonlivestockmortalityandfromalivelihoodsperspective,thesuddenorgraduallossoflivestock(financialassets).ThisapproachneedstobeexpandedtootherVSFSuisseprojectareastobuildamorecomprehensiveevidencebase,whilealsoassessingbroaderimpactsrelatedtoproductionlosses.Furthermore,futureassessmentswouldbenefitfromassessmentofequityissues,suchasuseofCAHWsbylivestockkeepersaccordingtowealthandgender.6. GovernmentsupporttotheCAHsystemseemstobeconfused,withthecurrentCAHWsallowedtopracticeandsubmitreports,butnoexpansionpermitted.Assumingthatlocalgovernmentiswilling,possiblesupporttogovernmentwouldincludeassistingthemtomonitortheperformanceofprivatepractitioners,includingpharmacystaffandCAHWs,inasystematicmanner.Similarly,thediseasesurveillancesystemmightbestrengthenedbydevelopingclearobjectivesforthesystemandtestingitagainstthemainsurveillanceindicatorsofsensitivity,specificity,timeliness,representativeness,simplicityandacceptability.However,itshouldbenotedthatasurveillancesystemwhichusesCAHWsisunlikelytobesustainedunlessgovernmentcanrespondtodiseaseoutbreaks,orideally,preventoutbreaks.7. USAIDshouldreviewtheuseoftheirlogoonprivatebusinessesandwaivebrandingrequirementsinthesesituations;similarly,VSFSuisseshouldreviewitsownbrandingpolicy. 19 26. Annex1.LocaldiseasenamesEnglishSomaliCCPP Renweyne/hergeb/berfurHelminthosis Goryan/shuqMange Chito/cadhoTickbornedisease Qalal/KadadhigNSD MerjaqasPoxdiseases FuruqFootrot Hoko/rafdilalLice InjirBotulismMohogoyBloat DibirAbortionSeleysaCameltrypanosomosis,chronic DhukanCameltrypanosomosis,acute GudanRespiratorydisease,camelDhugetoParalysis,camelMedahtag/shimbir/qorjabCBPP Sombeys/berfurTrypanosomosis,cattle Sumutie/gandiLSD Kuskus/burburEphemeralfeverTuqmaFMD Oyale/gandilePPR QandhoWoundsNeberEyediseases Endhahanun20 27. Annex 2. Mortality and case fatality ratesLivestockMedian case fatality Mortality and case fatality rates reported in thespecies/diseaserate reported in veterinary literature Mandera West, owner-treated herdsSheep and goatsHelminthosis 50.0%Mortality varies by type of disease and age group. Type Iostertagosis causes high morbidity and low mortality;Type II ostertagosis causes low morbidity and highmortality, and therefore, a high case fatality rate1.Mange40.0%Data not located.CCPP 63.4%Mortality from 60-100%1Case fatality in central Somalia 59% (10%-100%)2Babesiosis 58.3%No specific mortality data located. Sudden deaths can beconfused with anthrax1NSD91.7%Mortality up to 90%1PPR42.9%High mortality 77 to 90%; high case fatality1Sheep and goat 34.9%Mortality varies from 5 to 80%1poxCamelsHelminthosis 55.6%Variable depending on parasite(s), disease type, agegroup etc; case fatality can be high in some forms of acutediseaseMange42.9%Case fatality rate 69% in Turkana, Kenya; generallyreported to be high especially in calves3Trypanosomosis 10.0 to 50.0%High case fatality rate1; 68.4% case fatality, Turkana,Kenya3; death may occur after months or years;spontaneous recovery is rare4Camel pox40.0%5% to 30% case fatality rate1; case fatality up to 28.5% inSomalia5CattleHelminthosis To add As sheep and goats.Trypanosomosis To add High case fatality in both acute and chronic forms;spontaneous recovery is rare4FMD3.8% Case fatality rates:- Boran cattle, Ethiopia from 15.1% (