World Health Organisation African Programme for onchocerciasis Gontrot

Assessment of the Sustainability of the Abia State CDTI project,O Nigeria.

June 2003

VOL. 1-MAIN REPORT

Ekanem Ikpi Braide(Team Leader) Charles Franzen Yisa A. Saka Sunday Isiyaku Obinna Onwujekwe

RECU I 5 srp, eool APOC,D,R TABLE OF CONTENT

Acronyms ...... 3

Acknowledgement ...... 4

A. Executive summary ...... s

B. lntroduction...... 9

C. Methodology...... 11

D. Evaluation Findings ...... 1S 1. State level 2. LGA Level 3. DistricUHealth Facility level 4. Village level

E. Overall sustainability grading for the project ...... 31

F. SWOT Analysis ...... 34

G. Recommendations ...... 41

H, The way fonruard ....46

L Appendices ...... 49

L Time table for the evaluation of sustainability of Abia State CDTI project. ll. Agenda State level feedbacU planning meeting lll. Agenda LGA level feedbacUplanning meeting lV. List of persons interviewed. V. Participants at planning meeting, Vl. List of evaluators. Vll. Participants at planning workshop. !, ACRONYMS

APOC African Programme for Onchocerciasis Control CDD Community Directed Distributor ' CDTI Community Directed Treatment with lvermectin CHEW Community Health Extension Worker CSM Community Self Monitoring DHS District Health Supervisor FLHF First Line Heatth Facility HOD Head of Department HSAM Health Education, Sensitisation, Advocacy and Mobilisation lEC lnformation, Education and Communication LGA Local Government Area LOCT Local Onchocerciasis Control Team MOH Ministry of Health NGDO Non-Governmental Development Organisation NOCP National Onchocerciasis Control programme NOTF National Onchocerciasis Task Force PHC Primary Health Care REMO Rapid Epidemiological Mapping for onchocerciasis SHM Stakeholders Meeting SOCT State Onchocerciasis Control Team SWOT Strength Weaknesses Opportunities and Threats WHO World Health Organisation WR World Health Organisation Country Representative DPHC Director, Primary Healthcare 4

The team is grateful to the following who have contributed to the success of this mission.

The WR Lagos , and staff of WHO office in Umuahia for providing administrative . . support.

. Officials of the Abia State Ministry of Health: The Permanent Secretary, Director of

ordinator, and SOCT members, for participating effectively in the evaluation and providing necessary logistic support to the team.

. Project Administrator for Abiailmo project, GRBP/The Carter Center for providing logistic 1 support and facilitating the mission.

. Chairmen of LGA Councils, Secretaries of LGA Councils, Treasurers of LGA Councils, LGA PHC Coordinators, LGA Oncho Coordinators, members of LOCTs, and other staff of the LGAs visited (lkwuano, Ukwa East and Umunneochi), for their participation in the exercise particularly during the workshop for production of the sustainability plans.

. Leaders and members of communities visited for cooperating maximally during the exercise. A. EXECUTIVE SUMMARY

The Abia state CDTI project would have received 5 years APOC funding by September 2003. The project, jointly managed with the lmo State CDTI project as Abia/lmo CDTI project, is supported by GRBP. The project was evaluated for sustainability within the period June 16 - July 2 by a team of scientists from Nigeria and Tanzania, mandated by APOC to o Evaluate the sustainability of the project present. o Present and discuss the results of the evaluation with Government officials and NGDO . Support state level, LGA and Health area personnel in developing Post APOC sustainability plans using the guidelines for sustainability planning meeting developed by APOC and pretest the guidelines. On arrival in the state, Government and NGDO officials were briefed on the purpose of the evaluation and appropriate permission obtained to carry out the task. lnformation was gathered from interviews of policy makers and CDTI implementers at state, Local Government Area (LGA), First Line Health Facility (FLHF), and Community levels, as well as from review of relevant documents. Multistage sampling approach was applied in selecting LGAs, Districts and villages to be covered in the evaluation and information was collected using 4 standardized sustainability evaluation instruments (one for each level). Findings were made under planning, monitoring/supervising, Mectizan procuremenU distribution, HSAM, integration of support serviceg financial resources, other material resources, human resources and coverage. Each of these indicators was scored for each level by each evaluator. The scores were later discussed in evaluators meetings and an average score recorded for each indicator at each level.

At the state level, monitoring/superuision, Mectizan procuremenV distribution, HSAM, human resources, and coverage, are rated as hiqh. Rated as moderate are planning, integration and other resources while financial resources is rated as low. The team observed that, though a plan for CDTI exists within the overall plan for PHC in the state Ministry of Health, there is no evidence that plannrng is participatory done in an integrated manner with specification on the cost to be borne by each partner. Five skilled and dedicated SOCT members effectively carry out Monitoring and supervision using work plans and checklists. Reports of supervisory visits 6 exist but there is no indication of follow up activities. These visits are occasionally integrated, with officers of other health programmes participating. Problems are solved through normal administrative channel. Though there is no problem with Mectizan procurement and distribution, the drug is not stored in Government drug store because the storage facility is unsafe. Training and HSAM are carried out effectively when necessary but there is no integration of CDTI training with trainings in other health health programmes. lmplementers of CDTI in the state are skilled, committed and are not frequently transferred. Geographical coverage is 100% and average therapeutic coverage for the state is above 65%.

There are no indications that support programmes are planned and executed in an integrated manner. However, there is potential for integration as some of the SOCT members have assignments in other health programmes. Abia CDTI Project has depended heavily on APOC funding in the past five years and post APOC funding of the project has not been addressed. There is inadequate funding of the project by State Government but there is some hope that this will improve with quality of the present leadership of the State Ministry of health. The new Permanent Secretary and her principal officers participated actively in the evaluation and are now fully sensitized on the need for Government to increase support to the project. Procedure for access of funds over the years has been long because the project is operated as a joint lmo/Abia project with funds lodged in the lmo/Abia project account and managed by GRBP Zonal office in Owerri. The situation has improved with the opening in January 2003, of a bank account for APOC funds in Umuahia (The State Capital). However, there is no accountant handling CDTI account in the State. Average score for all indicators at state level is 2.7.

At LGA level, rated as hiqh are leadership, human resources and coverage. Planning, Mectizan, HSAM, and other resources are rated as moderate while monitoring and financial resources are rated as low at this level. Skilled and committed LGA Coordinators & LOCT members are fully in charge of initiating CDTI activities at this level. Coverage is impressive with 100% geographical coverage in all the LGAs visited and above 65% in two of the three LGAs visited. CDTI plans, at this level, are included only vaguely in the overall LGA PHC plan with no budget estimates specified for CDTI activities in these plans. Requests by LOCTs for Mectizan is 7 estimated from past treatment records from communities. Mectizan supply is timely and adequate but the drug is not stored in the LGA drug store. HSAM targeted. Training is conducted properly but routinely .lt is not targeted because of frequent transfer of project staff. The coordinators have motorcycles, which they maintain with personal funds, which, in most cases, are not refunded. Monitoring and superuision is done but is not targeted, no checklists are used and findings are not properly documented. Frnancial support of the project by the LGA is grossly inadequate. CDTI is funded from within PHC budget. However, this is not clearly spelt out as CDTI disbursemenf and it is not clear from which budget line disbursements are made. Average score for all indicators at the LGA level is 2.64.

At FLHF level, leadership, Mectizan and coverage arc rated as hioh, planning, HSAM and human resources are rated as moderate while monitoring, financial resources and other resources are rated as low. Officials at this level are skilled and are responsible for implementing CDTI activities, Supply and storage and distribution of Mectizan are effective at this level. Mectizan is stored in the LGA drug storage facility and controlled within PHC programme system. No written plans exist in most of the facilities. Plans seen in two FLHF are not integrated into FLHF plan. Staff at this level train CDDs routinely. Training is targeted only for CSM and SHM. HSAM is carried out but there is no indication as to how it has led to effective actions. With regards to human resources, staff members are skilled but there are frequent transfers. Monitoring, financing, and other resources are rated as low. Supervisory visits are made to each community once a year routinely. Financing is very poor . There is no budget for CDTI and no funds are disbursed for CDTI activities. The officer in charge of one of the FLHFs uses funds from drug revolving scheme, which is wrong since Mectizan is not part of the scheme. At this level, provision for transportation is highly inadequate. There are no records of maintenance of motorcycles and bicycles, where they exist, and maintenance cost is borne by staff. Average score for all indicators at FLHF level is 2.5.

The community performed best with high scores on planning, leadership, monitoring, Mectizan, HSAM, financialand coverage. The benefit of Mectizan is greatly appreciated at this level. Planning is done jointly by CDDs and community leaders, who in consultation with 8

community members take decisions on how and when to collect the drug form the FLHF as well as mode and timing of distribution. Communities are responsible for selecting CDDs and directing distribution. Monitoring is effectively done by the CDD with assistance of community leaders and members. All reports on CDTI are sent to the district health Supervisors. There is effective Mectizan requisition and distribution system with no wastage. The CDD is given one tin of Mectizan at a time and requests for more when needed. This however may result in delay in completion of distribution in some communities. Most of the CDDs do not know how to calculate the number of Mectizan tablets needed for each distribution. CDDs and community leaders effectively carry out HSAM when necessary. Some communities support the Programme financially and materially by providing transport and other incentives to CDDs. Other communities do not see the need for this. All households are covered. Therapeutic coverage is high but found to be wrongly calculated. Human resources at this level is not optimum and is scored as moderate. Though CDDs have good reporting skills and are willing to continue working in CDTI, they are ovenryorked (one CDD covers 500-600 persons). CDD attrition rate is low. Average score for all indicators at community level is 3.5.

Findings during the evaluation were presented to the SOCT and LOCT at planning meetings. These findings were exhaustively discussed, SWOT analysis conducted for each level of findings, and 3-year post APOC sustainability plans prepared (volume 3 of this report).

Resources (particularly financiaf one of the seven aspects of sustainability, is not fulfilled and is seriously blocking sustainability. Also not fulfilled is lntegration, which is moderately blocking sustainability. Funding (by Government), one of the six critical elements of sustainability, is not satisfied and is a major problem.

Based on the findings and assessment, the team agreed that the Abia State CDTI project is making progress towards sustainability but will require national and project staff to take required remedial action on the aspects not fulfilled and the critical elements not satisfied. fhe team recommends that as, a way forward, all Stakeholders should be briefed on the findings of the evaluation and requested to make concrete plans to implement required remedial actions. These include, integration of CDTI with other health programs, retraining of all implementers of CDTI on accurate calculation of coverage, selection of more CDDs, appointment of an accountant to handle CDTI accounts in SOCT, advocacy for timely release of adequate funds for CDTI, inclusion of CDTI data in health management information system, training of all health staff on CDTI, sourcing for dependable funding for replacement of capital equipment. The project should fine tune the three years post ApOC sustainability plans prepared during the evaluation period. lt is necessary for roles of LOCTs and DHS to be spelt out' Good geographical and therapeutic coverage as well as continued availability of Mectizan should be maintained. There must be close monitoring of the project by NOCp to ensure that these recommendations are implemented.

B. INTRODUCTION

Abia state is located in eastern Nigeria and shares boundaries with Ebonyi and Enugu Sates to the north, Cross River and Akwa lbom States to the east, Rivers State to the south, and Anambra and lmo States to the west. Until 1991, Abia State was part of lmo State. The population of 920,459 (1991 census) is made up of predominanily the igbo ethnic group, living in low density ditfused settlements in 17 Local Government Areas (LGAs).The climate is characterized by two major seasons , the dry and the rainy seasons with a vegetation that is mainly rain forest. There are many rivers in the State such as lmo, lgwu, ota miriand Cross River with many tributaries containing fast flowing water which serve as suitable breeding sites for Simulium, the vector of Onchocerca.

Eight (8) of the seventeen LGAs in the State are endemic for onchocerciasis (2 hyper endemic and 6 meso endemic) with the remaining g being hypo endemic. ln 1ggg, the state, submitted a proposal to the African Programme for Onchocerciasis Control (ApOC) for the control of onchocerciasis in Abia State through the use of the Community Directed rreatment with lvermectin (CDTI) strategy' The proposal was approved and CDTI commenced in the State with Global 2000 River Blindness Programme (GRBP) serving as the supporting NGD9. one local I 0__

NGDo' ltu Mbuzo Methodist Mental Rehabilitation centre has indicated interest in assisting the project in mobirization and supervision of cDTr in Bende LGA.

Five members of the state oncho control ream (socr) members, 24 Local Government - - oncho control ream (Locr) members,40 District Health staff (DHS),136 Health FacilityStaff (HFS) and 803 community Directed Distributors (cDDs) implement all components of cDTl in -- the state' Ratio of cDD to population is 1 cDD: 541 persons, cDTl activities such as health education' sensitization, advocacy, mobilization, Mectizan procuremenu distribution, monitoring -- and supervision are being implemented project. in the Training of socr members and LocTs . on community self-Monitoring (csM) and stakeHolders Meetings (sHM) has been completed. -. community self-Monitoring is being implemented in 13 of the 564 CDTI communities, communities have accepted ownership of the project and some (174 outof 564) are supporting distribution by paying transport costs for cDDs to collect Mectizan as well as providing assorted incentives' During the past treatment year (october 2001 to septem ber 2oo2) contributions from partners totaled N533,500 i.e. N260,500 from the LGAs, N171,200 from the state Government and N101'8oo from the communities. There is keen interest on the part of policy makers and project managers to integrate cDTl into other health programmes in the state. However there is yet no policy to promote integration

constraints faced by the project include, absenteeism due to rural urban migration, faith based refusals' difficult terrain, frequent transfer health of facility staff, inadequate funding by Government and row compensation of cDDs by communities.

As at september2oo2, a total of 301,165 persons population outof a of 434,g44registered in 564 hyper and meso endemic villages in 40 g health districts in LGAs had been treated using 829'415 tablets of Mectizan. Geographical coverage was 1oo% and therapeutic coverage 69'20/o' Treatment for the year octob er 2o02to september 2003 is yet to be concluded.

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C. METHODOLOGY

o Evaluation question...... How sustainable is the Abia State CDTI project ?

. Design ...... Cross sectional, participatory and descriptive

. Population...... Abia State project, including its SOCT, its NGDO partner; _ Its LGAs with their LOCTS, the project communities, project villages and their CDDs

. Sampling...... Details of the sampled districts and villages are contained in Table 1 below.

" Sampling

The sampling for the evaluation was purposively done, based on the primary criteria of coverage (geographical & therapeutic). Secondary criteria for sampling were the following:

. Endemicity level (the sample contained both hyper and meso endemic areas). . Geographical spread: sampled villages were from different areas of the project area. o Accessibility/convenience: sampled villages were selected taking into account accessibility and convenience to ensure that the state is covered within the limited period of the evaluation.

There are eight CDTI LGAs in Abia State with six of them in the north and central part of the state while two are located in the southern area. Two LGAs are hyper endemic while six are meso endemic. One LGA each was selected from the north, central and southern parts of the state one of which was hyper and two meso endemic LGAs. Considering the difficult terrain, most of the communities selected were those that are easily accessible. - .

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There is a 100% geographic coverage in all the endemic LGAs and communities. Ukwa East LGA with the highest therapeutic coverage of 81%, lkwuano LGA with the least therapeutic coverage of 640/o and Umunneochi LGA that had a medium coverage of 68% were selected. The district health facilities and villages were also selected based on the same criteria. Details of the sampled Districts, Villages and FLHF are shown in the table 1.

TABLE 1: DISTRIBUTION OF SAMPLED LGAs, HEALTH DISTRICTS & VILLAGES

S/N Health Therapeutic Endemicity Health Area CommunityA/illages District Coverage (Therapeutic (Division) Coveraoe)

1 Ukwa East High (81%) Meso Umuigubeachar 1. Umunwankwo a (82o/o) (78%) 2. Amaoba $2%\ Azumini (63.9%) 1. Obozu (55%) 2. Umuooo (83%) 2. Umunneochi Medium Hyper Ngodo (62.2%) 1. Uhude (39%) (6e%) 2. Umuada $7o/o\ Umuchieze 1. Obiagu-Lekwesi (67.4%) (91Yo) 2. Ama Oqidi $4Yo) 3. lkwuano Low (64.0%) Meso Oboro (57Yo) 1. Aroayama (96%) 2. Omuiou $0%\ Ariam/Usaka 1. Azunchayi (85%) ff7.6%\ 2. Uoa fi1%\

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Sources of information

lnformation was collected at State LGAs, FLHF and community levels from the following sources: o Verbal reports o Documents o lnterviews

management staff.

staff.

lnformation was recorded on the evaluation instrument and each indicator scored independently by each evaluator. Details of indicators scored at each level are shown in Table 2.

Table 2 lndicators scored at each level Cateoorv lndicator State LGA FLHF Communitv Plannino Leadershio X Activities & Progress Superuision which support CDTI Mectizan suoplv Traininq and HSAM lntegration X X X Funding (financial) Resource provided Other resources X (Transport etc) Human resources Results achieved Coverage ,/ = Scored X = Not scored After field visits, a one day planning meeting was conducted for State SOCT members, Budget & planning officers and DPHC. During the meeting, findings presented by the team were discussed exhaustively by the participants. Problems were identified and solutions to the

l3 14 problems proffered. Thereafter, the SOCT members and principal officers of the Ministry worked together in producing a three-year post APOC sustainability plan for the State. A two- day planning meeting was held for CDTI implementers and partners from the LGAs. Findings at LGA, FHLF and community levels were presented after which a SWOT analysis facilitated by SOCT members was conducted. Participants then worked in LGA groups to produce three-year post APOC sustainability plans for the LGAs.

Analysis Based on the information collected, each indicator was graded on a scale of 0-4, in terms of its contribution to sustainability. Team members exhaustively discussed findings and average sustainability score for each indicator at each level calculated. A graph was plotted for each the level being assessed. A SWOT analysis was also participatorily done during the planning workshop to assess the performance of the project at each level of the project. Participants from the State and LGAs developed three-year post APOC sustainability plans for the States and LGAs using the outcome of the SWOT analysis.

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D. EVALUATION FINDINGS

'1. Findings at the State level

Fig. 1: Abia CDTI Project: Sustainability at State Level

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Plannino (2.13 Moderatelv):

There is an existing plan for onchocerciasis control activities and it is part of the overall annual plan of the department of Public Health and Primary Health Care and also of the State Ministry of Health services. There are also monthly plans for core CDTI activities at the project office.

All programmes submit plans which are consolidated into an annual plan for the MoH. There is no direct evidence that planning is integrated as this is not the system within the Ministry. All programmes submit plans which are consolidated into an annual plan. The planning process is not integrated as this is not the policy within the Ministry.

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There is a written plan for CDTI activities at this level. This plan, which provides key elements of CDTI, is not a re-write of previous year's plan and is targeted at specific activities. This plan exists within the overall Ministry of Health plan, The existing plan has a bulk budget amount for all CDTI activities. However, it does not specify activities that would need to be funded by the various partners, does not specify the costs to be borne by each partner and does not indicate activities that would need to be funded post APOC. A supplementary plan for 2003 was produced just before the evaluation team arrived. There was a similar plan for 2002 which varied with respect to line item and bulk budget amount.

The team was informed that the main partners - Ministry of Health (Oncho Coordinator, Assistant Chief Planning Officer of the Ministry and State DPH/PHC) and the NGDO (Project Administrator) participate in the planning. These plans are presented and adopted at NOCP/NGDO review meetings. There are however no minutes of these meetings and no evidence that participatory planning was done. The adopted plans are consolidated into the MoH plans and sent to the State Planning Commission for approval.

The State Oncho Coordinator has produced a plan for sustainability post APOC which covers the period of October 2OO3 - January 2004. This is yet to be worked on and finalized with the MoH and the NGDO. There is no plan for the period beyond 2004. The Permanent Secretary is strongly in support of integration and plans to hold a meeting with programme officers and supporting agencies to discuss integration. She explained that sustainability plans would be fully developed after LGA Chairmen are appointed and planning meetings are held.

Monitorinq/supervision (3.0 Hiqhlv) There are 5 SOCT members and each one is responsible for monitoring and supervision in 1 or 2 LGAs. A monthly work plan, which includes monitoring and supervision, is prepared. Though monitoring and supervisory checklists are used and reports written, there are no written reports of follow up activities.

The SOCT members monitor and supervise distribution as scheduled in the plans. This is mainly at the LGA level with spot checks to communities. There is a minimum health package in the State and sometimes all programme officers work together. For example recently in

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Obingwa (UNICEF assisted LGA) all programme officers visited as a team and carry out separate interventions.

Occasionally there is integrated monitoring and supervision, but the timing is usually tied to the CDTI programme schedule because of lack of vehicles and availability of the CDTI vehicle. programme often schedule their monitoring trips to coincide with CDTI activities. :_ Other officers

The SOCT members monitor and supervise distribution. This is mainly at the LGA levelwith spot checks to communities. There is a minimum health package in the State and sometimes all programme officers work together. For example recently in Obingwa (UNICEF assisted LGA) all

The system in place for solving problems is the normal administrative procedure. lf there is a problem in an LGA the SOCT in-charge of that LGA is responsible for ensuring that the problem is solved. lf the problem persists, it is reported to the State Oncho Coordinator who

Where successes are recorded, they are noted and the officer or team is commended. For example in 2001 lsuikwuato LGA had the best therapeutic coverage and as incentive, the coordinator was nominated to attend an NOTF/APOC review meeting in Kaduna.

Mectizan Procurement and Distribution (3.0 Hiqhlv) * t"" - *,t"*f the availability of Mectizan@, the drug is collected by the State from the".* NGDO office in Owerri and kept in the Oncho Coordinator's office from where the LGAs are quickly informed to come and collect their allocations. Though this proT'ect system Of storage is seen as dependable for quick delivery to the LGAs, it is not the Sfafe drug delivery sysfem. Mectizan is not stored within the drug supply system of the Ministry. The excuse provided is that the medical store is not safe as such the drugs are often pilfered from ..there.

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Traininq and HSAM (3.0 Hiqhlv) Staff at this level have required and adequate training skills. The SOCT menbers train the LOCTs on CDTI and they in turn the CDDs. Each SOCT member handles specific topics during training using appropriate training materials like reporting forms, flipcharts, posters and brochures. New LOCT members transferred from non endemic areas are trained alongside old members. The content of the training ,therefore covers the entire CDTI aspects. The content does not change much over the years except when new aspects such as Community Self- Monitoring and Stakeholders Meetings are introduced. When this is the case, training is targeted at the new aspects. There is minimal integration of CDTI trainings with trainings carried out by other health programmes . There is no clear policy on integrated training.

Briefings are carried out from time to time for decision makers and other staff in the Ministry to advocate, health educate, sensitize and mobilize them. For example when the current Permanent Secretary was appointed, HSAM was carried out and as a result she visited some LGAs for advocacy and spot checks. ln other instances when planning division requires clarification on issues HSAM is provided. Whenever necessary, advocacy visits are made to LGA Chairmen and council members. the concept of CDTI was explained to them and support for CDTI activities solicited. lnteqration of Support Services (2.0 Moderatelvl There are no indications that support programmes are planned and executed in an integrated manner. There is , however, evidence of instances where SOCT members are involved in other programmes in the Ministry of Health. For example, one member of the SOCT is a health educator for CDTI and other programmes. Another SOCT member is primarily a staff in the budget and planning unit of the Ministry. The Data Manager also manages data for other health programmes in addition to managing CDTI data. There is, however, no policy on integration.

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Financial (1.75 Moderatelv) Budgeting is carried out following the government's procedure. There is a budget line for onchocerciasis control activities which is listed under subhead 12 in the recurrent budget of the MoH. The budget estimate for 2003 is N100, 000.00. There are other CDTI activities, which are covered under other budget lines like travel, training, stationery etc. This is to ensure that the project has other budget lines from which funds can be sourced for CDTI activities.

No amount was budgeted for 2002 Onchocerciasis control activities but the state government released N500, 500 from the 2001 budget for activities in 2002. Activities such as training, travel, stationery were covered by other sub heads within the Ministry of Health budget. This also applies to the 2003 budget.

The sum of N1.5 million was requested for from the state government for core CDTI activities in 2003, but there has been no approval yet. However the MoH has so far expended N93, 930 on vehicle spare parts, fuel and vehicle maintenance in 2003. A supplementary budget has been prepared and submitted to the government but there has not been any reaction to it yet. The situation was not different in the previous years. ln 2002 the MoH released the sum of N76, 200 for stationery, entertainment during meetings, and advocacy. The sum of N550, 500 was requested forthe project in 2001 and N370, 100was released and used forcollection of capital equipments from WHO Lagos, allowances, vehicle repairs, fuel, and other miscellaneous expenses. The reason given for low budgetary provision and release of funds is that Government financial resource has dwindled in the past years.

There are no plans to source for any dependable post APOC funding. lt is however believed that budget shortfalls or deficit could be bridged from other sub heads within the state MoH budget and from the 5% the ministry keeps from all revenue it generates. The DPH/PHC is however considering approaching the supporting NGDO to fund some core CDTI activities

The State Oncho coordinator requests for APOC funds through the DPHC. Funds from the State for Onchocerciasis control activities are approved by the Permanent Secretary and goes through the accounting system in the ministry before it is released. APOC funds are accessed

l9 20 through the NGDO office in Owerri because the project is administered as lmo/Abia project with APOC funds managed by the NGDO accountant .ln February, 2003, APOC funds were transferred from NGDO account in Owerri to a State account in Umuahia where the funds are processed and disbursed within the MoH under the supervision of the NGDO. However, there are no clear guidelines as to how this is done because there is no project accountant for the State CDTI project.

The project has depended heavily on APOC funding since inception. Government of Abia State has not provided adequate financial support. lt is difficult to make out magnitude of financial and material support provided by the NGDO since the project is jointly administered with lmo State project as Abia/lmo project. APOC financial support of the project is due to end in September 2003.

Transport and other Material Resources (2.5 Hiqhlv)

Routine maintenance is carried out for the vehicle and other equipment, but there is no record of maintenance (no maintenance book). The MoH and NGDO provide additional vehicles when needed to ensure that CDTI activities are not disrupted. The MoH provides funds for vehicle maintenance.

Transport is adequately utilized for CDTI activities at this level although authorizations for the use of the vehicle are verbal based on approved workplan. There is no abuse of vehicle usage. The vehicle is functional and will serve the project for at least the next two years. Though policy makers in the Ministry of Health are committed to replacing the vehicle and equipment when necessary, most of the officers interviewed at this level do not consider this feasible because of the prevailing financial problems in the State.

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Human Resources (4.0 Fullv) There are five SOCT members who are likely to remain in their posts for long. They are committed to the project and some of them have been in the programme for 13 years. There is a high level of team spirit. There are plans to train more officers on CDTI and replace any SOCT member transferred. Motivation is however poor due to delay in payment of salaries by Government.

Coveraqe (3.0 Hiohlv) Treatment for 2003 is still in progress and final treatment reports for 2003 are not available. Therapeutic coverage reported for 2002 and 2001 are 640/o - 81% and 61% - 81%) respectively.

It was however discovered that therapeutic coverage in most communities is wrongly calculated, using eligible population as denominator instead of total population.

2. Findings at LGA Ievel

Fig. 2: Abia CDTI Project. Susutainability at LGA level

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Planninq (2.0 Moderatelv) The plan for Oncho control activities is separate and included as part of disease control under the PHC in the overall LGA plan. The Oncho plans do not in most cases have budgets estimates for CDTI activities.

Leadership (4.0 Fullv) The LGA Oncho Coordinator is in charge of activities at this level and initiates activities. There are 3 LOCT members who assist the coordinator in implementing CDTI. However, CDTI officials are supervised by the head of Health unit.

Monitorino/Supervision (1.3 Sliqhtlv) Reporting is done on a monthly basis and sent to the State Oncho Coordinator. This is however -. not within government system; i.e. is through the monitoring and evaluation unit. Supervision is carried out at this level up to the FLHF level, with spot checks to communities. These trips are, in most cases, routine without definite schedules and are not targeted to solve problems. There are no supervisory checklists or written reports. The visits are not integrated and no deliberate efforts are being made to integrate.

It is not the practice in the LGAs to integrate monitoringisupervision. The Oncho coordinator deals with problems when they arise, but in instances where such problems cannot be solved by the officer, they are reported to the appropriate higher authorities at the LGA level, and if necessary, at the State level.

There were no evidences that successes are recognized and commended or feedback given to persons concerned.

Mectizan Procurement and Distribution (2.5 Hiqhlv) Request for Mectizan made by the LGA is based on community requests indicated in the previous year's community summary forms. Mectizan supply is timely with no shortages and wastages.

22 The LGA Coordinator goes to collects Mectizan from the State and stores it in his office. There is no clear indication that government provides transport for the collection of the drugs from the project level. The drug is not controlled within the government system.

Traininq and HSAM (2.3 Moderatelv) The Oncho Coordinators and LOCTs train the District Health Supervisors (DHS) and FLHF staff who in turn train the CDDs under the observation of the coordinator and the LOCTS.

Training is more a routine than targeted activity with set objectives because of frequent transfers within the system. New LOCTs, DHS and FLHF staff are trained annually alongside old LOCT members and the entire content of CDTI training is covered all over again during each training session. Trainings are not integrated with training by other health programmes. There are sufficient human and material resources for training at this level. Training is not integrated because this is not the practice in government, because it is not a policy.

HSAM is carried out to policy makers and decision makers at this level. This is usually targeted at new decision makers to solicit for their support and commitment. Positive impact of HSAM was noticed during interviews with decision-makers at this level.

Financial (0.5 Sliohtlv) CDTI is usually budgeted for under PHC under the health sector subhead. This is not clearly spelt in the budget as CDTI or Onchocerciasis control. There were disbursements of funds, though it could not be ascertained if these were disbursed directly from the budget. ln 2002 Umunneochi LGA spent N135, 000 for core CDTI activities. ln Ukwa East N130,000 was expended for training, transport and stationery in 2002. There is no evidence of any dependable resources to support CDTI post APOC.

No budget documentations are available with the coordinators. However the finance departments have documents showing had approved budgets as well as some records of expenditure for CDTI activities.

23 24

Transport and other Materials (2.25 Moderatelv) Functional motorcycles are available at the LGAs but these will not be functional for the next 5 years. These motorcycles are under the custody of the coordinator and not in the pool of vehicles. There is routine maintenance of motorcycles but there is no evidence of schedule or record of maintenance. The Oncho Coordinators maintain their motorcycles and submit claims to the LGA for reimbursement. Their expenditure is, in most cases, no reimbursed. The LGAs provide alternative transport when the motorcycles break down. Policy makers at this level are confident that LGAs will continue to maintain the motorcycles but cannot guarantee replacement. The motorcycles are also used by other programme officers to support activities at FLHF level. The motorcycles are under the custody of the Oncho coordinators but other programmes have access to it. There are no written authorizations to travel. This is usually verbal. Motorcycle logbook was found in only one LGA.

Human Resources (3.0 Hiohlv) Staff members, are satisfied with their work, have enough skills to undertake all CDTI activities, and are committed to their responsibilities. Motivation is however poor because salaries are delayed. There are no motivational practices because of lack of funds.

Coveraoe (3.5 Hiqhlv) Geographic coverage is 100%, while therapeutic coverages for the LGAs visited are

2002. ....680/0 (Umunneochi),64% (lkwuano) and 81%(Ukwa East). 2001. ....83% (Umunneochi) 61%(lkwuano) and 73% (Ukwa East). 2000. ....650/o (Umunneochi) 52o/o (lkwuano) and 69% (Ukwa East).

24 25

3. Findings at the First Line Health Facility (FLHF) level

Fig. 3: Abia CDTI Project. Sustainability at FLHF Level 4.5 4

$ 3.5 3 .9 o 2.5 o= C" 2 IE o 1.5

1 0.5 0 .*oe q..c a""" """"t ."""" ^t'"" ..c "..., Groups of lndicators at"""/

Planninq (2.0 Moderatelv) ln most of the FLHFs there are no written plans or time tables for CDTI activities. Two of the facilities have plans, which are not integrated into the overall plan of the area and are not part of a minimum package at this level.

Leadership (3.0 Hiohlv) Officers in charge of the FLHFs are also in charge of CDTI at these levels and are responsible for initiating CDTI activities like training of CDDs, monitoring and supervision. There are a few instances where the officers have to come from other district health facilities to initiate CDTI activities at the FLHF.

25 26

Monitorinq/Supervision (1 .7 Moderatelv) Supervisory visits are made to each community at least once a year. These visits are mainly routine, not targeted and not integrated with any other health programme. Reports are sent to LGA coordinator for collation after each treatment round. The team did not see any filed reports at this level. The reporting system is not part of the standard reporting process of the health system i. e. it is not part of the monitoring and evaluation minimum reporting package. Staff at this level deal with problems identified during visits to the communities. This is usually done in consultation with the communities. Where the problems cannot be solved, they are referred to the LGA Oncho coordinator. There is no evidence of successes recorded or actions taken based on recommendations from monitoring visits.

Mectizan@ Procurement and Distribution (3.5 Fullv) Requests for Mectizan are based on information on population generated from the community summary forms. This is used to determine the quantity of drug to order. The drug is usually available in time for distribution (January/February) and there are no reports of shortages of or late supply of Mectizan.

Mectizan is stored at the storage facility in the health centre. lt is controlled within the programme system where the drug is collected from the LGA and managed by the supervisor There are no specific transportation arrangements to collect the drugs from the LGA. Communities come to the facility to collect their drug allocations and this is recorded in an inventory for stock control. No shortages are experienced at this level.

Traininq and HSAM (2.0 Moderatelv) The staff at the facility train CDDs and these trainings are mainly routine but targeted in some instances e.g. training of new CDDs and introduction of new operation strategies like the Community Self-Monitoring. Available manpower and materials for training at this level are adequate.

HSAM is continuously carried out by the health staff based on needs after the initial HSAM carried out at the beginning of the programme. HSAM is carried out during community meetings

26 27 and Stakeholders Meetings and is mainly targeted at solving problems. There are however no clear indications as to how these have led to effective actions

Financial (0.5 Sliqhtlv) There is no budget at this level for CDTI activities. Funds are not usually disbursed from this level directly for CDTI activities. One FLHF wrongly uses funds generated from drug revolving scheme (Bamako initiative) to defray costs for CDTI activities. ln one instance application for funds by a supervisor was approved by government and funds released.

Transport and other Material Resources (1.5 Moderatelv) Transportation at this level is inadequate. There are no reliable alternatives except to hire vehicles at high costs. Government has not been forth coming in maintenance and replacement of motorcycles. There are no records of maintenance and maintenance costs is borne by the staff. No log books are used and there are no indications that authorizations are given. There are no realistic plans to replace motorcycles.

Human Resources (2.0 Moderatelv) Staff members have enough knowledge and skills to undertake CDTI activities. Staff can be transferred at any time thus cannot be said to be stable. There are no plans for in-service trainings.

Coveraqe (4.0 Fullv)

Geographic coverage is 100%.

27 28

4. Findings at community level

Fig. 4 Abia CDTI Project :Sustainability at the Gommunity Level

4.0 3.5 3.0 2.5 2.0 1.5

1.0 0,5 0.0 o) (,) c o- c 16 (6 o .= c (U 'o C,) L N = (! E =a C E c o a (! J (u o o I o E =c o C I o- ([ o h o o) O J = Group Indicators

Planninq and Manaoement (3.0 Hiohlv) On notification of the availability of Mectizan at the FLHF level, the CDDs collect the drug after consultation with community leaders and members. They also agree on mode and timing of distribution. This is usually done at community meetings and in churches. Community census is updated before distribution commences.

Leadership and Ownership (3.0 Hiohlv) ln most of the communities visited, the community leaders are responsible for distribution in their communities. There is adequate coverage (therapeutic and geographic) except in a few instances where low therapeutic coverage was found to be due to non commitment from the

28 29

CDDs. Community leaders, when informed of problems, try to solve such problems with the CDDs

Community members are involved in decision making in CDTI. They select their CDDs and decide on time and mode of distribution. There are, however, a few communities where the community leaders and council chiefs choose the CDDs without the participation of other community members. There are also a few communities that are under the illusion that the CDDs must be females. ln most cases distribution is from house to house.

The community members believe that taking Mectizan will cure them from river blindness and prevent blindness. Other advantages mentioned include good health, expulsion of worms and clearing of scabies. The communities are also aware that the drug should be taken annually but most cannot tell for how long. ln a few cases where the communities know the duration of treatment, they can not explain the reason for the need to take the drug for the specified period.

Monitorinq (3.0 Hiqhlv) At the end of treatment, CDDs coltate their treatment figures and submit to the DHS. There is usually no delay in doing this. Most communities do not provide transport for the submission of reports. The reason given for this is that the FLHFs are close to the communities.

Mectizan@ Procurement and Distribution (3.0 Hiqhlv) The right amount of Mectizan is usually received and distributed. CDDs are given one tin of Mectizan at a time to distribute and this is replenished by the DHS. Most CDDs do not know how to calculate the number of tablets of Mectizan to order for their communities and depend on the supervisors to estimate the number of tablets required. The CDDS usually collect the drug from the central collection point. ln most cases no adequate transport arrangements are made by the communities for the CDDs to collect the drugs, because the FLHF are close.

29 30

Traininq and HSAM (3.0 Hiqhlv) CDDs and community leaders are involved in HSAM particularly during community meetings and stakeholders meeting. lnformation is only occasionally provided by CDDs to persons who refuse treatment to persuade them to take Mectizan.

Financino (3.0 Hiohlv) Most of the communities provide incentives for their CDDs except in a few cases where the communities are not aware of the need for incentives and therefore do not provide any material incentives. Most communities give an average of N1,000 - N2,000 to their CDDs. ln all cases, the communities provide treatment registers and writing materials.

Human Resources (2.0 Moderatelv) The ratio of CDDs to population is inadequate. On the average, each CDD treats between 500 - 600 persons. Most CDDs have to walk considerable distances to cover all households assigned to them. Many of the CDDs have good reporting skills as reflected in their treatment registers. Exclusion criteria are known and observed, while cases of side effects are usually referred to health facilities. Communities have arrangements for selecting and training new CDDs when there is need for replacement . However replacements are not common because CDD attrition rate is low. ln all communities visit except one, the CDDs express willingness to continue distribution for a long term. The one exception is a community where the former CDD was banned from participating in community activities because she insulted the village head. The two young school leavers who have been assigned to replace her, indicate that they will leave the assignment as soon as the gain employment outside the village.

Coveraqe (3.5 Fullv)

The communities visited have treatment registers and coverage of households is 100% in most communities. However the team found that therapeutic coverage for the most communities is calculated using the eligible population instead of total population. There are also some discrepancies found between the coverage rate provided by the SOCT and those in the treatment registers in the communities. Therapeutic coverage reported for 2002 ranges between 36% and 96%.

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E. OVER.ALL SUSTAINABILIW GRADING OF ABIA STATE CDTI PROJECT.

With respect to the seven aspecfs of sustainability, attitude of staff, community ownership and effecfiyeness are found to be very much helping sustainability, while efficiency, and simplicity are moderately helping sustainability. lntegration is moderately blocking while resources (particularly financial) is found to be seriously blocking sustainability.

o lntegration: lntegration of CDTI into health system is weak at all levels (but scored only at state level). Effort at integration has been ad hoc - more of occasional collaboration than integration.

Government financial contribution to CDTI has been very poor at the state level and non existent at LGA and FLHP level. Only the communities support CDTI impressively. ' : ' ffiietiffi integrated ptanning and negtigibte integration, project stilt manages to be fairly efficient.

*) Procedure for accessing funds still not clearly defined. . Attitude of Staff: Staff very skilled and dedicated at all levels. . Community Ownership: Level of community ownership high. Deficiency funds only when community is not aware of need to act, e.g. selecting more CDDs to attain CDD population ratio etc. Effectiveness: Coverage is good with 65% treated in most communities and 100o/o coverage of all communities covered.

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Considering the six critical elements of sustainability, there is no problem with supervision, Mectizan supply and political commitment and transport (for minimal essential activities). However, there is serious problem with financial support of the programme by Government and there is no dependable plan for replacement of vehicles.

Grouping the indicators under this categories, activifies, resources, and results, the projects to seem to have achieved good results in spite of poor resources and minimal integrated planning. Average score for all levels is 2.6 for activities, 2.3 for resources and 3.5 for result.

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It is obvious that the good result cannot be sustained past APOC without adequate alternative sources of support being secured.

TABLE 3 Scoring under categories of indicators

Gategory lndicators Scores State LGA FLHF Community Planning 2.13 2 2 3 Activities and processes Leadership x 4 3.0 3 which support CDTI Supervision & Monitoring 3 1.3 1.7 3

Average overall score for Mectizan supply 3 2.5 3.5 3 category at all level 2.6 Training & HSAM 3 2.3 2 3

lntegration 2 x x X

Funding 1.75 0.5 0.5 3 Resources provided Transport & Other resources 2.5 2.5 1.5 X Average overall score for category at all level 2.6 Human Resources 4 3 2 2

Results achieved

Average overall score for Coverage 3 3.5 4 3.5 category at all level Average Score 2.7 2.64 2.5 3

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F. SWOT ANALYSIS FOR EVALUATION OF SUSTAINABILITY OF CDTI PROJECT IN ABIA

Table 4 SWOT ANALYSIS - STATE LEVEL

lndicators Strength Weakness Opportunities Threats

1 Planning Plan exists. No integration in Partners meet. No plan beyond January

planning . 2004. Plan exists for Oct No records of 03-Jan 04. meetings of oartners are keot. 2 Monitoring SOCT members visit No follow up Some integrated Bureaucracy delays And health facilities activities after monitoring and problem solving. supervision frequently. supervisory visits. supervision.

System in place for oroblem solvino. 3 Mectizan Timely and regular Drug system not Effective System for Non integration into Procurement & delivery of Mectizan. within normal procurement and Government drug Distribution government delivery of Mectizan system not good for No shortage and no procedure could be adopted by sustainability. wastage of tablets. other health programs Government may not be moved to support the project if the drug procurement system is parallelto existing system.

Government willnot appreciate the effectiveness of the svstem. 4 Training and SOCT members Minimal Briefing of MoH Routine, non targeted HSAM qualified and skilled integration of policy makers training will be boring, for training. training provides opportunity unproductive, and for advocacy for ineffective... will not lead Training materials Training of old adequate funding. to improvement in available and LOCTs not quality of implementation adequate. targeted. of the project.

Good arrangement for training of new LOCTs

Adequate briefing of MoH oolicv makers . 5 lntegration of lntegration of support lntegration does SOCT members are lntegration of support Support services. not go beyond also involved in services provides Services support activities other programmes. opportunity for practical to programme integration of CDTI with implementation. other health Droorammes. 6 Financial Budget line for CDTI No accountant at Ability to obtain Adequate funds cannot exists. state level. funds from other be gotten from other sub-heads is qood sub-heads due to

34 35

APOC account now Low budgetary for integration. competing demands by moved to State. allocation for all health programmes. CDTI.

No dependable funding source identified post APOC activities. 7 Transport & Routine maintenance No maintenance Joint use of vehicles Vehicle can last for only other Material Vehicle provided by book by health two more years. Resources MoH and NGDO for programmes good Thereafter, Supervision activities. No written and for integration and will not be regular and signed sustainability and effective. Funds available for authorizations for provides opportunity vehicle maintenance. vehicle use. for future integration at implementation No abuse of vehicles No dependable level. arrangement for Ministry provides replacing CDTI additional vehicles vehicle from other programmes for use by SOCT when necessary

I Human Skilled and dedicated None Without frequent None Resources SOCT members. transfers SOCT members can No frequent transfers consolidate of SOCT members. achievements in CDTI and effectively Plan to train more train more Ministry State Ministry of Staff on CDTI. Health staff on CDTI. 9 Coverage 100% geographical Coverage The need to retrain Coverage rates reported coverage achieved. calculated using LOCTs and CDDs by project not accurate.. eligible population on calculation of higher than real rates. Therapeutic coverage in many accurate coverage above 65% in most communities rates is an lncorrect data will result LGAs opportunity to cover in wrong assessment of other aspects of achievement of project. CDTI not yet adequately addressed e.g. SHM and CSM.

The retraining is also an opportunity to review coverage rates using total oooulation

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Table 5 SWOT ANALYSIS - LGA LEVEL

lndicators Strength Weakness Opportunities Threats

1 Planning Plans part of PHC plan. No budget Existence of CDTI With no budgets estimates in CDTI in PHC plan estimate for CDTI plans. provides included in plans, opportunity for project activities will future funding of not be adequately CDTI and is good funded for inteoration.

2 Leadership Coordinator and 3 other Reporting not within LOCT members Without checklists , LOCT members involved government system skilled and capable reports, and follow

in CDTI . (i.e.M&Eoffice). of improving on up, supervision will quality of remain routine, Coordinator deals with No supervisory supervision. ineffective and non- problems effectively. checklists and no problem solving written supervision Reports sent monthly to reports. state. Visits are not Supervision carried out at integrated with other FLHF. health programmes.

No feedback ever given on problems and successes not officially recognized and aooreciated. 3 Mectizan Mectizan supply adequate Quantity of Lack of government Procurement & And good timely. Mectizan needed control of Mectizan Distribution estimated by flow may Quantity of Mectizan LOCTs with limited discourage requisited for is based on input from CDDs Government from community need. most of who do not supporting the know how to programme. LGA Coordinator collects calculate number of Mectizan from SOCT. tablets needed. Separate storage of Mectizan from Mectizan not stored other drugs will in Government hamper integration. store. Coordinator keeps the drug in his office.

Lack of transport for collection of drug.

4 Training and District health supervisors Trainings routine LOCTs skilled and Frequent transfers HSAM effectively trained by and not integrated. able to train other of health staff will coordinator and LOCTS. health staff. hinder progress of project if training is New LOCTsFLHFstaff not integrated. trained annually

36 )t

Sufficient human and material resources exist.

Decision makers adeouatelv sensitized 5 Financial CDTI not budgeted for. Budget not clearly Placing CDTI under No evidence of spelt out. PHC which has an dependable approved budget government Disbursement of line, provides resources for CDTI funds not under opportunity for now and post- budget line. integrated planning APOC and budgeting.

6 Transport & Motorcycles available No evidence of LGA s and Motorcycles cannot other material and functional schedule or record coordinators bear last for the next five resources of maintenance cost of years. With no Routine maintenance maintenance plans for Motorcycles under No written travel replacement coordinator's custody authorization to ,supervision willbe travel hampered.

Log book present in onlv one LGA 7 Human LOCT skilled and Salaries not paid Skilland dedication Poor motivation Resources dedicated. regularly. of LOCT may dampen opportunity for morale of LOCT LOCTs stable with few improving on members transfers. quality of project imolementation. I Coverage 100% geographic Therapeutic The need to retrain Coverage rates coverage coverage is wrongly LOCTs , FLHF staff reported by project calculated using and CDDs not accurate.. Therapeutic coverage eligible population calculation of higher than real above 65% in most instead of total accurate coverage rates. villages. population. rates is an opportunity to cover lncorrect data will other aspects of result in wrong CDTI not yet assessment of adequately achievement of addressed e.g. project. SHM and CSM.

The retraining is also an opportunity to review coverage rates using total oooulation.

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Table 6 SWOT ANALYSIS - FLHF LEVEL

lndicators Strenoth Weakness Oooortunities Threats 1 Planning None No written plans To lntegrate from With no plans ,CDTI or timetables for grassroots level, activities will be CDTI activities. CDTI into other implemented only on ad health programmes hoc basis with no FLHF are the coordination. CDTI closest health units activities will be limited to the communities. to Mectizan distribution period. 2 Leadership Officers in charge are Dependence on lntensify advocacy None skilled. LOCT for in order to translate directives on awareness and Political leaders CDTI. interest of political aware and interested. leaders into Limited initiative. practical support of the oroiect. Monitoring & Staff deals with Report not part lmprove on scope LGA policy makers and Supervision problems at their level of the general of dissemination of other health staff do not and refers problems M/E package. report by know about CDTI data upward if necessary. incorporating it into and will not be No copy of generalMlS convinced to support the Reports sent to LGA reports filed at package. project. coordinator. health facilities.

Supervisory visits only once annually.

Visits routine and not targeted.

No evidence or record of cases investiqated. A Mectizan Requests based on No specific To properly None Procurement & information from transportation integrate Distribution community arrangement for procurement, populations. collection of storage, and Mectizan. distribution of Mectizan stored at Mectizan with health facilities. arrangement for other drugs used at Mectizan supply this level. timely with no reported shortage and wastaoe. C Training and Adequate manpower Training of To integrate training Routine, non targeted HSAM for training. CDDs mainly for CDTI with training willbe boring routine, not training for other and unproductive, and HSAM carried out. targeted. health programmes. ineffective... will not lead Problems discussed to improvement in during community quality of implementation meetinos of the oroiect.

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6 Financial None No budget for None With no budget for CDTI, CDTI activities there will be total dependence on funds Funds not from LGA and State. usually disbursed directly for CDTI at this level

Drug revolving scheme monies wrongly used in one FLHF Transport & FLHFs close to lnadequate None Dependence on LGA to other Material communities. transportation bring supplies . Resources for collection of materials from LGA.

No records of maintenance of available motorcycles.

8 Human Staff members are Frequent Opportunity to train Frequent transfers can Resources skilled and transfer of Staff. all staff posted to disrupt smooth running committed. facility. of project. No plans for in- service traininq 9 Coverage Geographic coverage None To use CDTI None 1000h structure for distribution of other drugs and materials.

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Table 7 SWOT ANALYSIS - COMMUNITY LEVEL

lndicators Strength Weakness Opportunities Threats 1 Planning CDDs collect drugs ln a few To apply the Community with assistance from communities, decision making ownership community. Village heads process to other threatened in take decision on developmental communities Communities decide behalf of the activities where only village mode and time of communities. heads take distribution. decisions.

Census updated before distribution commences 2 Leadership and Community leaders Most community To replicate CDTI Community Ownership responsible for members do not community members may not distribution know for how ownership in other be serious about long they should developmental taking the drug Community leaders take the drug activities. consistently solve problems and why. annually for 10-'15 years if they do Community not aware of the members have high need to and why. degree of awareness of goals of Drooramme 3 Monitoring CDDs collate lncorrect CDDs are literate Wrong calculation information and calculation of and can be easily of coverage will report on time. therapeutic taught how to affect coverage. calculate coverage effectiveness of correctlv. control. 4 Obtaining and Regular and timely CDDs given only To provide Supply of Managing supply of Mectizan. one container of adequate supply of Mectizan by Mectizan Mectizan at time Mectizan at once. installments to CDDs collect from and supply CDDs may result central point replenished in poor coverage when necessary. and delay in distribution if CDDs cannot do replenishment is proper not immediately calculation for available. requesting Mectizan 5 HSAM CDDs and None To replicate for None community leaders other programmes. involved in HSAM

lnformation orovided 6 Financial Communities provide Some To replicate for CDDs in incentives communities do other programmes. communities that not know they do not provide Communities provide should give incentives may registers and pens incentives loose interest in the assiqnment.

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7 Human Literacy level in Too few CDDs Train more CDDs CDDs willbe Resources communities high. for population overworked. CDDs skilled and size. dedicated. I Coverage Household coverage Therapeutic Use CDTI structure 100o/o coverage for implementing Wrong calculation calculated using other programmes. of coverage will eligibility instead affect of TOTAL effectiveness of POPULATION control since 65% coverage must be attained for control to be effective

G. RECOMMENDATIONS 7 State Level Recommendations lndicator Recommendation Priority Who to take action Deadline for Ratino action 1. Participatory planning High SOCT, NGDO, Director PHC, Dec 2003 should be done with other Programme officers in Health, programme managers fully BudgeUPlanning officer. involved.

Planning Produce post APOC plan for 10 years and include in High Head of ministry, Director, PHC, state health rolling plan. Director Finance, Budget and planning Officer, SOCT, NGDO, Progarmme officers in health.

2. Follow up on problem High SOCT All year rdentified during monrtoring round and Supervisor visits to LGAs. Maintain good record of visits and follow Monitoring and up actions. Supervision Put in place a policy for integrated monitoring and Medium Head of mrnistry supervision of health Dec 2003 programmes and projects

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3. Maintain good Mectizan Medium SOCT. NGDO All year requisition practice, which Round ensures no shortage and no wastage.

Mectizan Process delivery of procurement and Mectizan within High SOCT. NGDO Jan2004 distribution Government system and store Mectizan in government drug store.

Secure government drug store to prevent pilferage High SOCT, NGDO Jan 2004

4. lntegrate training on CDTI Medium Director PHC, Programme Oct 2003 into training of other health officers in Health, SOCT, programs NGDO.

Training and HSAM Conduct one seminar annually on CDTI for all Medium, SOCT. Feb of each Ministry of Health staff year members. 5. State Oncho team Medium SOCT. Oct 2003 lntegration of members should initiate support service integration since each SOCT member is involved in other health activities. 6. Financial Appoint an accountant for High Head of Ministry, Director Sept 2003 the state CDTI project. Finance.

Specify amount available for CDTI in budget lines High Director Finance, SOCT Budget Dec 2003 & planning officer. lncrease allocation for CDTI Dec 2003 7. Transport Keep a log book for vehicle Aug 2003 All year Obtain written authority for SOCT movement Round Dec 2003 Explore other services of vehicle replacement

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I LGA Level Recommendation lndicator Recommendation Priority Who to take action Deadline for Ratino Action 1 No budget estimate Do planning budget and High LOCT, HOD, Treasurer of LGA Dec 2003 Or Approved budget to indicators be released 2. Reporting is not done Pass all reports through High LOCT, M & E. Office of LGA Dec 2003 through government M & E section of LGA to system state. 3 Untargeted supervision Plan for ind carry out High LOCT, HOD and other Always targeted, planned and Programme officers Coordinated suoervision 4. Non usage of check list Use of check list and High LOCT Sept and no report after reporting post supervision supervision 5. Poor management of Outline and High HOD, LOCT Oct 2003 problem, success and institutionalize system no feedbacks. for solving problems Providing reward for SUCCESS Provide feedback to all stakeholders 6. No Mectizan storage Provide secure drug High HOD, LOCT. Jan 2003 facility storage facilities

7. No government control Pass Mectizan through High LOCT Jan 2003 of Mectizan LGA store inventory

8. No transport to collect Provide transport for High HOD, LGA chairman, Treasurer. Dec 2003 Mectizan Mectizan collection from state I Unintegrated trarning Training of staffs of High HOD and all staffs LGA Health Dec 2003 LGA Health department. dcnartmenl 10. Lack of budget line for Ensure Oncho has it's High HOD, Treasurer LGA, LOCT Dec 2003 CDTI and not clearly own budget line within spelt out. the overall budget for PHC clearlv soelt out. 't1 Lack of logbook and Provide logbook for High HOD/SOCT, LOCT Sept 2003 record of vehicle vehicles and maintenance motorcycles

Maintain good record of record vehicle/motorcycle maintenance. 12. Verbal authorization of Provide traveling Medium HOD Sept 2003 travel. authorization book, forms/movement reoister 13. Poor motivation Pay salaries regularly. High LGA chairman Always

Commend good work Medium HOD done. Dec 2003 14. Wrong therapeutic Retrain LOCT/CDD on High HOD/SOCT Sept 2003 coveraare calculation of coveraoe 15, Frequent staff transfer Ensure staff stay a Medium HOD, LGA chairman period of 5 years on job before transfer bv

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mounting effective advocacy (HSAM) to LGA commission

9 FLHF Level Recommendations lndicator Recommendation Priority Who to take action Deadline Ratino for action 1. No yearly work plan Write out yearly work High DHS/LOCT September nlan with hr rrlnct 2. Plan not integrated Plan with other staff High DHS with other health staffs September together so that CDTI is at post LOCT. oart of FLHF olan. 3. (to Supervision and Plan targeted field visit , High DHS, LOCT supervise) Monthly monitoring not send written reports to appointed staff to collate targeted, once a year LGA and retain copy at data not reported D.H office. Appoint staff asM&Eofficer. 4 Lack of transportation Provide DHS with High HOD/LGA, Treasurer LGA. September to collect Mectizan at transportation LGA. (fees/vehicle i.e. motorcvcle) 5. No budget or funding Provide work plan with High HOD, LOCT, DHS December of CDTI activities at budget. Seek for this level. approval, request and ralcase af fr rnds 6. Lack of transportation Provide motorcycles High SOCT, HOD, LGA December chairman

7. Lack of record of Provide logbook for Medium HOD/DHS August maintenance of maintenance record. matarnveles 8. Transfer of officers Ensure staff stay a Medrum HOD, Chairman LGA and August period of 5 years on job Head of personnel LGA. before transfer by mounting effective advocacy (HSAM) to LGA commission 9. No in-service training All institutions that train, Medium State Education September on CDTI. CHEW, Senior CHEW, Board/SOCT Health technologies, and CHO & Health staff to health educate on CDTI.

44 45

10 Communitvommu Level lndicator Recommendation Priority Who to take Deadline for Ratino action action 1 Planning Although a very large majority of High CDDs and LOCTs Nov. '1, 2003 communities decide on mode and time of All communities that distnbution, as well as selection of the make decisions on mode CDDs, ensure that all communities have and time of distribution, been empowered to make their own selection of CDDs and all decisions. Many of the registration books CDDs accurately fill in are well done throughout the project their registration books. area, but continue to ensure that CDDs fill out the registration books accurately. 2. Leadership and Training should immediately be High SOCTs and Sept. 1,2003 Ownershlp undertaken with LOCTs and CDDs with LOCTs the objective of impacting knowledge to Community members community members concerning how know that Mectizan is to long they should continue to take be taken for more than Mectlzan and why they should take it for 't 5 vears. such a period. 3. Monitoring Continue to improve collation of data by Medium LOCTs Dec. 3'1, 2003 All CDDs collate data CDDs and ensure all data arrives at the accurately and deliver to FLHFs on time their FLHF on time. 4. ()otarnrng and An urgent training should be undertaken High SOCTS and Sept. 1,2003. Managlng Mectizan for all LOCTS, DHSs, and CDDs to LOCTS. CDDs are able to make ensure that CDDs are able to calculate accurate requests for the proper number of tablets requested tablets based on for ach community. By the end of the population and DHSs will trainrng accurate requests can be made hand out total number of to the FLHFs which means that the tablets required at one DHSs can give total number of tablets time. required to CDDs rather than doling out supplies one bottle at a time. 5. Health Education, Essential health education, sensitization, High SOCTs and Dec. 31, 2003 Sensltlzatlon, advocacy and mobilization provided and LOCTs Advocacy & expanded to all communities throughout Mobillzatlon the life of this project. All communities fully involve and educated in all parts of HSAM. 6. Financial Training to LOCTs and CDDs should Medium LOCTs Oct. 1, 2003 All community members emphasize the need foe communities to are aware that support support their CDDs in any way they see for their CDDs is crucial. flt (not necessarilv) 7. Human Resources Every effort should be made by the High SOCTS and Dec. 3'1, 2003 Before next treatment project to improve the CDD to LOCTs round, ratio of CDDs to communig member ration of 1:250, as community members is this will improve coverage and make the 1:25O work of CDDs much easier. 8. coverage Training should be undertaken to ensure High SOCT Dec. 31, 2003. AIILOCTS and CDDs that LOCTs and CDDs understand that understand coverage to coverage is to be calculated using total be calculated using total population and not eligible population. oooulation

45 H. THE WAY FORWARD

As a way fonrvard the following remedial actions already outlined under recommendations, should be carried out: . All Stakeholders should be briefed on the findings of the evaluation and requested to hold meetings to make concrete plans to implement required remedial actions. The three-year post APOC sustainability plans prepared during the evaluation period should also be discussed and fine-tuned during these meetings.

. A policy on integration of health programs should be put in place by Government and deliberate attempts be made to integrate CDTI into other health programs. One strategy for enhancing the integration is mandatory monthly meetings of all programme managers of health programmmes during which an update is given on each programme/project by the Manager /Coordinator. Meeting regularly and discussing plans and activities will help build trust and deprogram officers from believing that integration will result in loss of some benefits and of programme/project identity. Best results will be obtained if the Permanent Secretary overseas this initiative while the DPHC facilitates. The ministry should organize trainings on networking and integration.

. All implementers of CDTI need to be trained on accurate calculation of therapeutic coverage. There is serious confusion even among SOCT and LOCT members on what should be considered therapeutic coverage... . percentage of eligible population

treated, percentage of total population treated , or percentage of people at risk treated.

. Communities should be requested to select more CDDs. Presently most communities believe that selecting more CDDs would require provision of more incentives. Experience in other projects should be shared with the communities .The explanation should be given that selecting more CDDs would in fact reduce amount of incentives to be provided by the community since each CDD (in the 2:250 ratio set up) will be treating relations.

. A State accountant should be assigned to the SOCT handle CDTI accounts.

46 47

. Government of Abia State should seriously consider increasing support for CDTI. lf need be, the issue should be presented by the Hon Commissioner for Health at the State Executive Council meeting. The SOCT and LOCTs should intensify advocacy to Executive and Legislative arms of Government for timely release of adequate funds for CDTI. lt is important for policy makers and politicians in the sate to know that APOC funding will soon cease and that the project stands a chance of collapsing if Government does not provide adequate support.

. Policy makers should make it mandatory for CDTI data to be included in Health Management lnformation System.

. Trainings on CDTI should be organized for all health Staff at all levels so that frequent transfers will not disrupt CDTI activities.

. Dependable sources of funding for replacement of capital equipment should be identified.

, The conflict in roles of LOCT members and the District Supervisors should be resolved to avoid overlap and duplication of activities.

. Good geographical and therapeutic coverage as well as continued availability of Mectizan should be maintained.

Finally, there must be close monitoring of the project by NOCP and APOC to ensure that these recommendations are implemented.

47 o, ,-

I. APPENDICES

Appendix l. Time table for the evaluation of sustainability of Abia State CDTI Project.

Davs Team I I Team ll I Team lll Sundav 15 June Allteam members arrive and settle into hotels in Umuahia Monday 16 June Briefing session on the health system structure (Director PHC) Orientation of the evaluation team on the evaluation instruments and field work. Finalizinq proqramme Tuesday 17June Courtesv call to State Ministrv of Health/Government Officials Data collection and Data collection and Data collection and interview with State interview with LGA level interview with LGA level MoH officials and official (Ukwa East LGA) officials (lkwuano LGA) State Oncho Coordinator Wednesday 18 lnterview with NGDO Advocacy visit Advocacy visit June Project Administrator Data collection and Data collection and and NOCP Zonal interview at FLHF level interview at FLHF level Coordinator (in (Umuigubeachara) and (Oboro) and two Enugu) two communities communities (Aroamaya (Umunwankwo & & Umuigu) in lkwuano Amaoba) in Ukwa East LGA LGA) Thursday 19 June Data collection and Data collection and Data collection and interview with LGA interview at FLHF level interview at FLHF level level official (Azumini) and two (Ariam/Usaka) and two (Umunneochi LGA) communities (Obozu & communities (Azunchayi Umuogo) in Ukwa East & Upa) in lkwuano LGA LGA Friday 20 June Mop up of data Data collection and Data collection and collection and interview at FLHF level interview at FLHF level interviews at State (Ngodo) and two (Umuchieze) and two level communities (Uhude & communities (Obazu - Finalize Umuada) in Umunneochi Lekwesi & Amaogidi) in arrangements for LGA Umunneochi LGA planning meeting 23 - 25 June Saturdav 21 June Data collation, analysis and report writinq Sunday 22 June Data collection analysis report writinq (produce draft report) Mondav 23 June FeedbacUPlanninq workshop for State Tuesdav 24 June FeedbacUPlanninq workshop for LGAs Wednesday 25 FeedbacUPlanning workshop for LGAs June Thursdav 26 June FeedbacUPlanninq workshop for State and LGAs Friday 27 June Feedback session with the State Ministry of Health and NGDO Work on evaluation reoort Saturday 28 - Work on evaluation report Mondav 30 June Tuesdav 1 Julv Departure 49

Appendix ll. Agenda - State level "feedback"/planning meeting

I Registration of participants 9.00 9.30 SOCT ) - Opening prayer 9:30 - 9:35 To be appointed J Welcome/Openins Remarks 9:35 -9:45 DPTYPHC 4 Introductions of particioants 9:45 - l0:00 State Oncho Coordinator 5 Aims and Objectives of meeting: What is 10.00 - 10.30 Prof. Eka Braide Sustainabilitv? 6 Coffee/Tea Brea* 10.30 - l 1.00 State Coordinator 7 Evaluation Methodolosv ll:00-ll:30 Sundav Isivaku 8 Presentation of main findings from Evaluation and I l:30 - l3:00 Prof. Eka Braide discussions (State, LGA, FLHF & Community) Dr. Y. A. Saka Charles Franzen Sundav Isivaku 9 Perspectives ofthe project and future direction and l3:00 - l3:30 Plenary session discussions Dr. Y. A. Saka/Charles Franzen to lead. l0 Lunch 13.30 - 14.00 State Coordinator ll Guideline for sustainability plan, Discussion and 14.00 - 14.30 Prof. Eka Braide/Sunday Isiyaku Identification of issues for qroup work t2 Group work for the development of State level 14.30 - 16,30 Abia State MoFVSOCT Sustainability t3 Presentation of Grouo Work and final plan 16.30 - 17.00 t4 The way forward: implementing self-sustainabi I ity 17.00 - 17.30 DPH/PHC and Facilitators (what to do now) l5 Other matters 17.30 - 17.45 State Coordinator l6 Closine Pravers 17.45 To be aooointed

49 50

Appendix !ll. Agenda - LGA level "feedback"/planning meeting

One

1. Reqistration of participants 9.00 - 9.30 SOCT 2. Openino Draver 9:30 - 9:35 To be aooointed 3. Welcome/Openinq Remarks 9:35 - 9:45 DPH/PHC participants 4. I ntroductions of 9:45 - 10:00 State Oncho Coordinator 5. Aims and Objectives of meeting: What is 10.00 - 10.30 Prof, Eka Braide Sustainabilitv? 6. Coffee/Tea Break 10.30 - 1 1.00 Oncho. Coordinator 7. Evaluation Methodoloqv 11:00 - 11:30 Sunday lsivaku 8. Presentation of main findings from Evaluation and 1 1:30 - 13:00 Prof. Eka Braide discussions (State, LGA, FLHF & Community) Dr. Y. A. Saka Charles Franzen Sundav lsivaku 9. Perspectives of the project and future direction 13:00 - 13:30 Plenary session (Dr. Y. A. and discussions Saka/Charles Franzen to lead). 10. Lunch 13.30 - 14.00 State Coordinator 11 Guideline for sustainability plan, Discussion and 14.00 - 14.30 Prof. Eka Braide/Sunday ldentification of issues for orouo work lsivaku 12. Group work for the development of State level 14.30 - 16.45 Group Leaders Sustainabilitv 13. Review of davs work 16.45 -17.00 Facilitators Close Prayers 17.00 To be aooointed Day Two 1 Reoistration of oarticioants 8.00 - 8.30 SOCT 2. Openinq Prayer 8.30 - 8.35 To be apoointed 3. lntroduction to the dav's activities 8.35 - 8.45 Facilitators 4 SWOT Analvsis 8.45 - 9. 45 State and LGAs 5 Group work continues 9.45 - 10.30 Group Leaders 6. Tea Break 10.30 - 10.4s State Coordinator 7 Group Work continues 10.30 - 13.30 Group Leaders 8 Lunch 13.30 - 14.30 9. Presentation of Group Work and final plan 14.30 - 't6.00 Grouo Leaders 10. The way forward: implementing self-sustainability 16.00 - 16.30 DPH/PHC,LGA PHC (what to do now) Coordinators & Facilitators 11 Other matters 16.30 - 16.45 State Coordinator 12 Closinq Pravers 16.45 To be aooointed

50 5l

Appendix lV.

S/N NAMES OF THOSE DESIGNATION ADDRESS o. INTERVIEWED 1. Mrs. C. P.Brown Permanent Secretarv Ministrv of Health. Umuahia 2. Dr. A. C. Oriqa Director, PHC Dept. Ministrv of Health. Umuahia 3, Mrs V. O. Chiobu Director Finance Dept. Ministry of Health, Umuahia 4. Mr. R. C. Nwala Asst. Chief Plannino officer Ministrv of Health. Umuahia 5. Mrs. Nnenna Onuoha Oncho. Coordinator Ministrv of Health, Umuahia b. Stephen Okoroii LGA Coordinator Umunneochi LGA 7. Chief Victor C. Secretary Umunneochi LGA Azumara 8. Matthew O. Obasi Plannino Officer Umunneochi LGA L Mrs Evelvn Nwaobara DHS Umuiquibeachara, Ukwa East LGA. 10. Ms Nqozi Nwichi DHs Azumiri, Ukwa East LGA 11. Beniamin Anvacho CDD Aroavama. lkwuano LGA 12. Felix Okoli CDD Obiagu -Amoji-Lekwesi, Umunneochi LGA 13. Chief S. O. Eke Umuada Communitv Leader Umunneochi LGA 14. Eze l. M. Aou Uhude Comm. Leader Umunneochi LGA 15, Chief R. O. Nwankwo Umuiqube Comm. Leader Ukwa East LGA 16. Chief N. Nwaobare Amaoba Comm. Leader Ukwa East 17. Chief J. W. Oobonnava Obozu Ukwa East LGA 18. Chief Friday Adiele Comm. Leader Ukwa East LGA 19. Edith Okeke CDD, Amaoba Ukwa East LGA 20. Ladv Patience Nwabara CDD, Umuiobeachara Ukwa East 21. Elder lsaac Nwankwo CDD, Obozu Ukwa East 22. Mrs. Uloma Fridav CDD, Umuoqo Ukwa East 23. Ms. OnvinvechiWabara CDD Umuoqo Ukwa East 24. Amaogidi Male Comm. Community Members Umunneochi LGA Members 25. Mr. James Madukwe Comm. Leader, Amaoqidi Umunneochi LGA 26. Mrs Vistoria lhemeie HHF Umunneochi 27. Miss Reioice Ude Nqodo HHF Umunneochi 28. Mrs. A. Ukanwoke Midwife Oboro, lkwuano LGA 29. Mr. Godfrev Okezie Treasurer Ukwa East LGA 30. Mr P. M. Akwumoha Transport Officer Ukwa East LGA 31 Mr. C. O. Onu LGA Oncho. Coordinator Ukwa East 32. Chief lqwe Ucho Secretary Ukwa East LGA 33. Mrs. R. N. lheadindu PHC Coordinator Ukwa East LGA 34. Mr. Friday lwundu CDD, Umuigu lkwuano LGA Kawah 35. Mr. J. O. Ekebuike PHC Coordinator lkwuano LGA 36. Community members lkwuano, LGA Umuiou 37. Community members lkwuano LGA Aroavame 38. Chief Hart Okeke Community Leader, lkwuano LGA Aromava

5l ''l

52 -'

Appendix V. Participants at planning meeting Day One - State officials 1. Mrs. C. Brown - Permanent Secretary. 2. Dr. A. C. Origa - DPH/PHC 3. Mrs. Nnenna Onuoha - SPO 4. F. N. Nwadibia - SOCU Team Leader. 5. Mrs. Meg Onwu - SOCU 6. Mr. P. C. Owabuko - Data Manager 7. Mrs. Uche Eke - SOCU 8. R. C. Nwala - Planning Officer 9. Dr. Enyinaya - GRBP Day Two - Local Government Officials 1. L. O. Meregini - PHCC/HODH Isuikwuato LGA 2. Ibe Nwafor - LOCI-/Manager Isuikwuato LGA 3. C. E. Eluwa - Chief Bende LGA 4. Okoroji Stephen - LOCT/Manager Umunneochi LGA 5. Olcwukwe Nwankwo - LOCT/Manager Ohafia LGA 6. Nwogu Gabriel - LOCT/Manager Ikwuano LGA 7. Kalu Mecha - LOCT/ManagerArochukwu LGA 8. R. C. Iheadindu - PHC Coordinator Ukwa East LGA 9. C. O. Okpom - PHC Coordinator Ukwa West LGA 10. Nworgu Ndubuisi - LOCT/Manager Bende LGA 11. Nwala R. C. - ACPO Ministry of Health 12. Onu C. U. - LOCT Ukwa East LGA 13, J. O. Ekebuike - PHC Coordinator Ikwuano LGA 14. Ugo U. Nwokoji - PHC Coordinator llcr,vuano LGA 15. Kalu Onuwabuchi - ACCT Ohafia LGA 16. Eleuwa A. O. - Admin. Officer Ohafia LGA Day Three - Local Government Officials 1. Kalu, Onuwabuchi - ACCT. Ohafia LGA 2. R. N. Iheadindu - PHC Coordinator Ukwa East LGA 3. N. Nworgu - Oncho Manager Bende LGA 4. C. E. Eluwa - PHC Coordinator Bende LGA 5. J. O. Ekebuike - PHC Coordinator Ikwuaro LGA 6. Ibe Nwafor - Oncho Manager Isu/3 LGA 7. Udo Ukpai - Oncho Manager Ukwa West LGA 8. C. O. Okpom - PHC Coordinator Ukwa West LGA 9. Nworgu Gabriel - Oncho Manager Ikwuano LGA 10. Okoroji Stephen - Oncho Manager Umuneochi LGA 11. Ezeuwa A. O. - A.O Ohafia LGA 12. S. A. Ezemba - PHC Coordinator Arochukwu LGA 13. Kalu Mecha - Oncho Manager Arochukwu LGA 14. C. U. Onu - Oncho Manager Ukwa East LGA 15. Okwukwe Nwanl$/o - Oncho Manager Ohafia LGA 16. L. O. Meregini - PHC CoordinatorlsuiKwuato LGA 17. Ugo U. Nwokoji - PHC Coordinator Ohafia LGA Godfrey O. Okezie - Treasurer Ukwa East LGA

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Appendix Vl. List of evaluators

S/No Name Address 1. Prof. Ekanem lkpi Braide Department of Zoology University of Calabar Cross River State, Nigeria, Tel:234 80 33 41 68 42 (Mobite) ekanem [email protected]

2. Mr. Charles Franzen Country Representative lnterchurch Medical Assistance c/o Christian Social Service Commission P. O. Box 9433 Dar es Salaam, Tanzania Tel:211 2918 (Off) 277 5578 (H) 07 48 231298 (Mobite) 2118552 (Fax)

cfranzen@ i ntafrica. com 3. Dr. Yisa A. Saka Deputy national Coordinator National programme for Onchocerciasis Control (NOCP) Federal Ministry of Health Federal Secretariat lkoyi, Lagos Nigeria o Tel: 234 1 4 482 12S5 (Ofr) 234 803 33 02 93 87 (Mobite) yisaasaka@hotmail. com 4. Mr. Sunday lsiyaku Sight Savers I nternational 1 Golf Course Road P. O. Box 503 Kaduna, Nigeria Tel:234 62 248360 (Off) 234 62 231216 (H) 23408 33 10 94 65 Fax: 234 62 248973 ssin g@ infoweb. abs. net sunday_isiyaku@yahoo. co. uk 5. Obinna Onwujekwe Department of Therapeutics, University of Nigeria Teaching Hospital, PMB 01129 Enugu, Nigeria. Fel:234 42457188 fax234 42259569 [email protected]

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