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