World Health Organisation African Programme for Onchocerciasis Gontrol

Assessment of the Sustainability of the Plateau CDTI project

February 2003

Eleuther Torimo (Teom Leoder) Obiomo Nwoorgu Koyode Ogungbemi Horrieth Homisi Sundoy Isiyoku Abel Eigege

I Index

Page Abbreviations/ acronyms and acknowledgements 3

Executive summary 4

Introduction and methodology 5

Findings and recommendations 9 1. State level 2. LGA level 3. District/ health centre level 11 4. Village level 16 5. Overall sustainability grading for the project and way 22 fonryard 26 6. Appendix: I Agenda, Plateau State planning Meeting 28 I1 Agenda, LGA Planning meeting (iii) State/LGA Planning meeting program. 30 (iv) State Level, Problems and solutions 31 (v) LGA level, problems and solutions 32 (vi) FLHF/Community, problems/solutions 33 (vii) List of people interuiewed. 35 (viii) List of evaluators. 36 Detailed findings 37 1. State level 39 2. Health district/ LGA level 3. Sub-district/ first line health facility level 4. CommuniW level

2 Abbreviations/ acronyms

APOC African Programme for Onchocerciasis Control CDD Community Directed Distributor CDTI Community Directed Treatment with Ivermectin CHEW Community Health Extension Worker DHS District Health Superuisor FLHF First Line Health Facility GRBP Global 2000 River Blindness Programme HOD Head of Department HSAM Health Education, Sensitisation, Advocary and Mobilisation IEC Information, Education and Communication LF Lymphatic Filariasis LGA Local Government Area LOCT L Onchocerciasis Control Team MOH Ministry of Health MOF Ministry of Finance NGDO Non-Governmental Development Organisation NOCP National Onchocerciasis Control Programme NOTF National Onchocerciasis Task Force NPI National Programme on Immunisation PHC Primary Health Care RBM Roll Back Malaria REMO Rapid Epidemiological Mapping for Onchocerciasis soc State Onchocerciasis Co-ordinator SOCT State Onchocerciasis Control Team SPO State Programme Officer UNFPA United Nation Funds for Population Activities WHO World Health Organisation zoc Zonal Onchocerciasis Co-ordinator ZOTF Zonal Onchocerciasis Task Force WR World Health Organisation Country Representative

Acknowledgements

We would like to thank the following persons for their assistance and support: . The staff at APOC Headquarters in Ouagadougou: The Director Dr S6k6t6li, Dr Amazigo, Mr Aholou, Mr Agbonton and others for overseeing and facilitating the mission. . The WR and his staff in Lagos and Jos for administrative and other support. . The NOCP Zonal Co-ordinator: Mrs. Patricia Ogbu-Pearce for her extensive support to the team . Staff of the Plateau State Ministry of Health: The Hon. Commissioner, Barrister John Magaji; Director PHC, David S. Belin; State Oncho Co-ordinator Henry Filda and his team, who despite the strike action in the State civil seruice ensured that the team was able to carry out its assignment. . GRBP Country Representative, Dr. E. Miri and his staff for providing office space and other support. . LGA Chairmen, Health workers and community members in Bokkos, Jos East and Pankshin LGAs who provided information and suggestions related to CDTL

-1 Executive Summaly

The Plateau CDTI project has been supported by APOC since April 1998 and it is in its last year of agreed funding from APOC. An evaluation of the sustainability of the project was carried out between 17th February - zno March 2003 by a team of evaluators from Nigeria and Tanzania. The evaluators were charged with the following tasks: -

1. Evaluation of the sustainability of the Plateau State CDTI project, including field assessments in selected LGAs, Districts and communities

2. Preparation and conduct of feedback/planning meetings with the State and Local Government Authorities (LGA)

3. Analysis of data and preparing a report.

Using a multistage sampling approach, information was collected using the 4 standardized sustainability evaluation instruments related to the State, LGA, FLHF and community levels.

Findings

At the Community level, geographic coverage is 100o/o while therapeutic coverage is over 650lo with an increasing trend. Communities like taking mectizan and are aware that it has to be taken annually for a long time and know its benefits. "The drug makes us feel strong, improves vision, prevents blindness and expel worms from the body". Community leaders and CDDs jointly take responsibility for distribution of Mectizan within their communities as evidenced by their active role in community mobilization, decisions on timing and treatment venue, regular consultations with CDDs and support for CDDs. Census and registration are carried out by CDDs before each registration. CDDs submit reports and drug balances to first line health facilities. Treatment of Lymphatic Filariasis (LF) has been integrated with that of Onchocerciasis and on the whole is doing well,

On the negative side CDDs were not taught how to determine amount of drugs to be requested for their communities. Lack of a rational criterion for determining quantity of drugs needed often resulted in surplus drugs in some communities and shortage in a few. Communities are aware of their roles to support CDDs and agreed to do so but have often failed to do so. Attrition rate of CDDs is high (about 50o/o). The ratio of households covered by CDDs is higher than that recommended by APOC. IEC materials for HSAM are not adequate. Finally there is some confusion among community members and CDDs, in communities where both Lymphatic Filariasis (LF) and Onchocerciasis are being co-treated, on what causes what disease and what treatment is for which. Reasons for this confusion need to identified and addressed. Integration of the training tools for the two diseases might ameliorate the situation.

At first Level Health Facility, there is a good Mectizan inventory of drugs received and balances returned. FLHFs seem to be a weak component part of the CDTI system. Most staff at this level do not have adequate knowledge and skills for CDTI. CDTI training for health workers is restricted to one per health facility, usually the District Health Supervisor, who is the most

-t senior officer. CHEWs are more stable, not often transferred out of their stations but are not trained in CDTI.

There is confusion (to evaluators as well as CDTI staff at all levels) over CDTI leadership at this level. There are five LOCTS, one in charge of each of the five health districts and there are also flve DHSs, one in each of the health districts. LOCTs are often junior in position to DHS yet they are expected to supervise CDTI in FLHFs. All health staff at this level should be trained in CDTI.

At the LGA Level, LOCT/ Oncho focal persons are skilled and knowledgeable about CDTI. But during field visits SOCTs appeared to be more informed about issues at FLHFs and community levels than LOCTS, which raises doubts about the adequacy of their (LOCTS) empowerment by the State level to direct CDTI activities at the LGA level. Ownership and leadership provided by LGA management is weak. For example PHC Coordinators and LGA Management are not fully involved in CDTI process.

There has not been a budget for CDTI activities in LGAs since the inception of the program. LOCTs did not know how to use the census figures collected from CDDs to calculate quantity of mectizan to be requested for annually. There is need for rethinking and recasting the packaging of IEC materials to avoid confusion in communities where both LF and Oncho are being treated together. CDTI data is not part of the Health Management Information System.

The State level has spearheaded the implementation of CDTI all levels. Extensive support and leadership has been provided by GRBP particularly in the early years of the program. The State has assumed increasing leadership of the project, most marked in the last year. To enhance sustainability, leadership needs to be strengthened through involvement of other partners in the State Ministries e,g. MOA, Ministry of Chieftainry and Local Government Affairs, Ministry of Planning and Finance. To enhance financial management a CDTI accountant should be appointed and trained to support the program.

Some N2m of APOC funds has been released this year (June 2002 and May 2003). Information provided during interviews show that the funds are adequate for essential CDTI activities. The 1997 "Proposal" spelled out contributions to be made by different partners. For example it is indicated that the contribution from State would increase annually as that of APOC decreases and ends at the end of the fifth year. To date the State has made no financial contribution. The State Deputy Governor, Commissioner for Health and Local Government Chairmen gave oral assurances that adequate funds will be provided to continue CDTI when APOC funding ends. The evaluation team learnt of a high level effort to obtain CDTI funds released before the evaluation team left the State but the effort was not successful. The evaluation team was informed of several initiatives to enhance integration of CDTI into PHC, including a Federal level initiative to integrate services in selected Wards. The evaluation team recommends strongly that a three-year sustainability plan be developed as a matter of urgenry, building on the one-year plan prepared during the feedbaclVplanning meeting at the end of evaluation. The evaluation team was surprised to see the extent to which many leaders particularly LGA level did not know much about CDTI. The State should issue a directive that will clearly define the roles of different levels in CDTI implementation.

5 Overall assessment of project and way-forward Using the standard four-tier schedule for ranking projects evaluated: fully, High, Moderate and low, the evaluation team judges the Plateau State CDTI to be at the level of Moderate. The project is potentially sustainable as evidenced by the excellent coverage, high level of community leadership and approval and availability of mectizan everywhere.

But this project requires rethinking and mobilization of high-level decision-makers to provide financial resources to sustain CDTI. It is intriguing to the evaluation team that at the end of the fifth year the State has not made a single annual contribution on the lines agreed with APOC. Other important issues that need rethinking and action include: High attrition rate of CDDs and empowering of LGAs, through training and decentralization of authority from the State level to LGAs and FLHFs. Using the Abuja grading of: Fully sustainable; On the way to sustainability and not on the way to sustainability, the evaluation team concludes that the Plateau program is on the way to sustainability.

Two feedback/planning meetings (of one and two days duration, for LGA and State management staff respectively) were successfully carried out.

Way forward

Recommendations of the evaluation team for each of the four levels are contained in pages 13 (State), 19 (LGA), 24 (FLHF) and 27 (Community level).

State and LGA leadership indicated that immediate and rapid action will be taken in a number of interrelated key areas. Foremost is the implementation of the one-year plan of action (developed during the briefing and planning meeting) and development of a three year CDTI sustainability plan. The process of developing the three-year plan has potentials for mobilization of all paftners.

The evaluation team recommends that APOC follow closely the development of the three-year sustainability plan and implementation of the evaluation recommendations and provide support in key areas. It is hoped that the target of completing the three-year plan by Mid April and making it available to APOC will be met.

6 Introduction and Methodology

1. Introduction

Plateau state is located in the Middle -Belt of Nigeria and it is bounded to the South West by Nasarawa state, while to the North West and North East are Kaduna and Bauchi states respectively with Taraba state to the South. The state has an estimated population of 3.2 million people.

The people of the state are predominantly farmers living in scattered rural settlements. Most of the roads are bad, rough and sometimes not passable due to flood and lack of bridges. Also, the rocky nature of some LGAs is also a serious impediment to effective transportation.

The state enjoys two types of seasons, the raining season, (May - October) and the dry season (Nov. - April). Most treatment/distribution activities in the state are preferably carried out during the dry season when farmers have less to do in their farms.

The State is divided into 17 political Local Government Areas (LGAs). CDTI program is being executed in five LGAs: Bassa; Bokkos; Jos East; Kanke and Pankshin. The remaining 12 LGAs with 313 villages are hypo-endemic and treatment is mostly carried out in health facilities at the village level with the assistance of Global 2000 and the State Ministry of Health.

APOC financial assistance to the state CDTI Project stafted in April 1998. The project is in its fifth and final year of APOC financial assistance. (June 2002 - May 2003).

According to the 1997 proposal to APOC, the project in their flfth year should have put in place adequate infrastructure and resources to sustain CDTI.

The evaluators were charged with the following tasks: -

1. Evaluation of the sustainability of the Plateau State CDTI project including fieldwork in selected LGAs, Districts and communities

2. Preparation and conduct of feedback/planning meetings with the State and Local Government Authorities (LGA).

3. Analysis of data and repoft writing.

2. Methodology

. Evaluation guestion'How sustainable is the Plateau State CDTI project . Design'Cross sectional, participatory and descriptive . Population:The Plateau State project, including: its SOCT; its NGDO partner; its LGAs with their LOCTs; the project communities/villages and their CDDs . Sampling: Details of the sampled districts and villages are contained in table 1 below.

l Sampling

The sampling was done purposively, based primarily on the coverage (geographical & therapeutic). Secondly the sampling was based on the: -

. Endemicity level (the sample contained both hyper and meso endemic areas). . Geographical spread: sampled villages were from different clusters in the project area

In Plateau State there are 5 CDTI LGAs divided in three clusters; Cluster one consists of Bassa & Jos East. Cluster two consists of Bokkos and cluster three consists of Pankshin & Kanke. One LGA was picked from each cluster based on the above sampling criteria.

The LGAs with the best average therapeutic coverage are Pankshin (96.80lo) and Kanke (85.4olo); Pankshin was picked because of its best coverage. LGAs with medium coverage are Bassa (82.4o/o) and Jos East (86.60lo); Jos East was picked because of its medium coverage. Bokkos LGA was picked because of its lowest coverage (79oh).

Details of the sampled Districts, Villages and FLHF are illustrated in the table on page 10.

Sources of information Information was collected from interuiews, verbal reports and documents. Various categories of people were interuiewed at the Zone (Co-ordinator), State (SOCT leader, team members, poliry-makers, management staff), LGA (LOCT leaders, management staff, heath technical staff), the frontline heath facility level and the community. Information was recorded on the evaluation instrument and discussed extensively before grading the performance of the relevant level on the indicator.

Analysis Based on the information collected, each indicator is graded on a scale of 0-4, in terms of its contribution to sustainability. The average sustainability score'for each group of indicators is calculated, for each level. A graph was plotted for the level being assessed, The evaluators discussed emerging problems and possible solutions and made recommendations on remedial action related to each of the four areas.

8 TABLE 1: DISTRIBUTION OF SAMPLED DISTRICTS &WLI-AGES

LGA LGAs DISTRICT VILLAGE (Rx FLHF SELECTED COVERAGE (TREATMENT COVERAGE RATE) RATE) 1 BOKKOS DAFFO (e3.3%) TOFF

LOWEST HIGHEST COVERAGE) (98.60lo)

COVERAGE KARFA

(79o/o) (80.7o/o)

MUSHERE (80.4olo) KAWEL (100o/o)

LOWEST COVERAGE SAI (47.2o/o)

2 JOS EAST FEDERE (99.8%) FEBAS (100o/o)

MEDIUM HIGHEST COVERAGE) GANDI (98.3olo)

COVERAGE FOBUR (85.9olo) NABATONG

(79o/o) LOWEST COVERAGE (100o/o)

SABON GARI

(51,8olo)

3 PANKSHIN BALANG SHIPANG (99. 5olo) KADYIS (100o/o)

HIGHEST HIGHEST COVERAGE) NYELLENG (98.60lo)

COVERAGE JIBLIK (73.6%o) JING (99.2olo)

(ee.s%) LOWEST COVERAGE TILLENG (73.60/0)

J PANKSHIN BALANG SHIPANG (99.5Vo) KADYTS (100%) HIGHEST HIGHEST COVERAGE) NYELLENG (98.6%) COVERAGE JIBLIK (13.6Vo) JrNG (e9.2%) (99.5Eo) LOWEST COVERAGE TILLENG (13.6qc)

9 FINDINGS AT THE STATE LEVEL

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

4.5 4 4

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."-. -"*" *."" ."".."* .."nd .,"c """.-t """"t* ".""t" a."* I Seriesl Group of lndicators

Planninq (2.4 Moderatelv) :

Check whether there is a year plan for onchocerciasis control appearing as part of overall plan for the health service. Whether this plan contains details of activities needed for effective oncho control. Whether all partners including government, NGDO, UN Agencies are involved in the overall process. Whether specific planning for sustainability has taken place for the period after APOC funding is withdrawn.

Control of river blindness appears as part of the annual Development Plan of Ministry of Health. In relation to APOC, MOH prepares yearly action plans based on the 5-year plan developed with and agreed by all partners (1997). The plan, June 2002 - May 2003 contain key elements for an effective CDTI program including training, advocacy, and supervision/monitoring and mectizan distribution. The plan spells out contributions to be made by different partners: MOH; APOC and GRBP. A plan for sustainability is yet to be developed. A meeting of LGA chairmen convened in January this year deliberated on this and related issues. It was agreed that each LGA should take ownership of CDTI and provide funding. Follow up of the meeting has not taken place. Few LGA staff in the LGAs knew about the meeting.

t0 Monitorinq /Supervision (2.3 Moderatelv)

Check whether state level staff is being used appropriately for monitoring and supervision. Whether M/S is being planned and carried out in an efficient and integrated manner. Whether there is routine process of management of problems and successes detected during monitoring.

Each of the five SOCTs supervises assigned LGAs quarterly. SOCTs and Global 2000 staff also carry out spot check on District Health Supervisors (DHSs) and First Level Health Facility staff. Management problems such as those related to combined treatment and dosage are dealt with promptly. While superuision of CDTI is integrated with LF and control of Schistosomiasis at LGA and lower levels, it is not the case at the State level. SOCT superuision/monitoring is not synchronized with that of GRBP. Mectizan - Procurement and Distribution (2.5 Moderatelv):

Check whether sufficient mectizan is being ordered, stored and distributed within the government system at the State level.

Ordering mectizan is done by GRBP. The system operates well. Storage and distribution is mostly within government system. GRBP delivers mectizan to SPO who in turn delivers the drug to LGA, LGA to FLHF or FLHFs collect from LGA. Census is carried out yearly but there is no clear indications or evidence that calculations of mectizan requirement are based on APOC formula.

Trainino & Health Education Sensitization, Advocaw and Mobilization (HSAM) (3 Hiqhlv):

Check whether staff at the State level is being used appropriately as trainers. Whether training is planned and carried out in an efficient and integrated manner. Whether staff at the state level are planning and carrying out HSAM activities efficiently.

Staff at State level routinely only train LOCTs. LOCT staff in turn train and supervise FLHF staff and FLHF staff train CDDs. CDTI training is provided for newly transferred staff and is carried out together with that for LF and Schisto control. Health Education, sensitization, advocacy and mobilization activities are well planned. Staff reported shoftage of IEC materials.

Inteoration of Suppoft Activities (2.5 Moderately)

Check whether various program support activities are planned and carried out in an integrated manner

CDTI activities such as supervision, monitoring and training have been mostly decentralized to lower levels - LGAs and frontline health facilities. This step helps to facilitate integration. Training for CDTI, LF and Schistosomiasis take place at the same time and place. Mectizan and Albendazole are delivered together. But integration of CDTI within the overall PHC at State level remains weak. A new Federal level initiative on Model Wards is expected to find better and eflective ways for enhancing integration in PHC.

ll Financial Resources (0.98 Sliqhtlv):

Check whether appropriate amounts are budgeted for planned oncho control activities, whether government is budgeting and disbursing sufficient amount yearly for this and if there are shortfalls whether other sources of funding are used for this gap and finally whether oncho control funds from the budget are efficiently managed.

A total of N2m has been released by APOC for this year (June 2002 and May 2003). Information provided during interuiews shows that available funding is adequate for essential CDTI activities. GRBP has supported training and logistics activities and provided bacKtopping whenever release of APOC funds is delayed. Control of APOC budget is good. The process for release of funds involves: SPO; Director PHC; Commissioner for Health; Governors office and MOF. The State has not provided flnancial contribution to the program since the inception of APOC. Other health programs like NPI, UNFPA, RBM obtain counterpart funding from MOH.

Transoort and other Material Resources (3 Hiqhlv):

Whether adequate transport and material resources are available for CDTI activities, whether they are adequately and appropriately maintained, whether appropriately managed and used and whether there are plans to replace them when APOC support comes to an end.

Two vehicles (the second one is provided by GRBP as needed) are available. Vehicles are considered adequate for the next 2-3 years provided are adequately maintained. The use of vehicles is authorized by SPO and a logbook is used. A photocopier, computer and a printer are available. There are no plans for replacement of vehicles.

Human Resources (3 Hiqhlv):

Whether adequate transport and material resources are available for CDTI activities, whether they are adequately and appropriately maintained, whether appropriately managed and used and whether there are plans to replace them when APOC su comes to an end

Staff at this level are skilled and considered adequate (six SOCTs including SPO). For sustainability an account on a part-time or full-time basis needs to be available in the program. The gap is partly filled by GRBP. The high attrition rate of CDDs is a statewide issue and it is important to document experiences and lessons from different areas as basis for future solution. Another issue the team took note of relates to the provision of top ups to salaries of selected staff in the APOC budget. The team wandered how this would be sustained and effect on staff motivation when APOC support ends.

Coveraqe (4.0 Fullv):

Check whether all in the country have a satisfactory therapeutic rate. Coverage is good, above 80% in all the communities. Concerted effort from all fronts will be necessary to maintain and preferably increase it.

12 Recommendations at this level

Recommendations Implementation

Planning The state should issue a directive to all partners Priority, HIGH indicating clearly the role to be played by different Indicators of success, A directive partners in sustaining CDTI. available to all partners. Who to take action Director PHC Deadline for completion: Middle March 2003

The State and other partners should develop a Priority HIGH three year plan for sustainability on the lines Indicators of success, Three-year agreed at the planning meeting as a matter of sustainability plan is prepared. urgency. The plan should be realistic, based on Who to take action Director PHC government resources and other sustainable Deadline for completion: Middle April sources. 2003.

The State plan should build on and respond to the needs of the LGA plan.

Monitoring and Superuision Prioritlt HIGH The State level should strengthen and empower Indicators of success, Training of LGA LGA staff to enable them to play a leading role in leaders and staff particularly at FLHFs CDTI. (Reports on training carried out) Who to take action: SOCT and LOCTS. Mectizan Priority, HIGH Training of SOCTs and LOCTs outlined above Indicators of success Calculation of should include a strong component of skills to mectizan requirement included in Training calculate Mectizan requirement. programs. Who to take action: SOCT and LOCTS. The State should ensure the early supply of Mectizan using the necessary requisition forms for early distribution to the communities.

Training & HSAM Priority High Integration of training and HSAM materials for Indicators of success, Integrated CDDs and communities. training materials for CDTI, LF and Related diseases available. A redesigning of training material to prevent Who to take adton SOCf confusion and mix up about LF and Oncho Deadline for completion: incl uding simplifi cation of traini ng information.

CDTI to be included in curriculum of school of health technologies

Integration of Support Activities Priority, Medium

t3 Incorporate CDTI as component of the Model Ward Indicators of success CDTI is one of the initiative. elements of the Model Ward initiative. Who to take action:. Deadline for completion:

Finance MOH should carry out intensive advocary to ensure Priority High that adequate funds to sustain CDTI including Indicators of success, Adequate budgets State and LGA budgets are released. for CDTI are included in State and LGA budgets. Who to take action: Commissioner, PS, PHC Director, NOCP, and SOCT. Deadline for completion April 2003 Transport and Other Resources Priority MEDIUM Indicators of success, Availability of Plan for CDTI to share use of transpoft from adequate transport. different sources. Strengthen maintenance of Who to take action: Director, PHC, PS vehicles. Deadline for completion: end of next distribution

Human Resources: Prioritln, MEDIUM An accountant should be appointed and trained Indicators of success Repoft on with the necessary skills in the MOH. This may not experiences and lessons on retention of necessarily be a full time appointment. CDDs available. Who to take action: SOC|. Identification and documentation of experiences Deadline for completion June 2003. and lessons on how to address the issue of attrition of CDDs

Coverage Maintain the high level of coverage.

1.1 FINDINGS AT LGA LEVEL

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

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Plannino (1.3 Sliqhtly):

To check whether the year plan for CDTI appears as paft of an overall written plan for activities at LGA level.

CDTI is integrated into the overall PHC written plan. Year plan prepared by LOCT and submitted to PHC Coordinator for vetting. This has provision for all key CDTI activities: Mectizan supply, training, HSAM and monitoring/superuision. Community requirements taken into consideration in plan prepared e.g. time of distributions and mobilization. LGA Chairmen and LOCTs attended a CDTI sustainability meeting in January. Issues discussed included: Advocary, assistance from LGAs and communities, counterpart funding and the coming of the evaluation team. No funds have been release for CDTI activities following request from CDTI focal person in the LGA even though CDTI is integrated into the PHC plan.

l5 Leadership (2.3 Moderatelv):

To check whether the LGA health management team is taking full responsibility of the implementation of CDTI.

In some LGAs the management team (LGA chairmen and other Leaders) are actively interested and involved in initiating key CDTI activities. Oncho Coordinator/LOCT focal person at the LGA level is the focal person for all CDTI activities at this level. PHC Coordinators, LOCTs and District Superuisors are the only individuals involve in CDTI activities in some LGAs. Oncho focal persons at the LGA level depend on the State (SOCTs) for all CDTI activities including finances. State has and continues to direct CDTI activities. State level staff have not empowered the LGA level staff.

Monitorinq and Superuision (2.3 Moderately):

Check whether routine data concerning CDTI activities are being transmitted from LGA within government system. Whether persons responsible at LGA are efficiently supervising activities at FLHL level in an integrated manner and whether there is routine management of problems and success indicated by the monitoring system.

Problems identifled during monitoring are dealt with at each level e.g. CDDs report drug shortage to village heads, village heads then report to FLHF staff, who then report to LOCT at the LGA and then LOCT report to SOCT at the State level. Successes are noted and communicated verbally to individuals concerned. All treatment summaries, Mectizan bulk transfer forms are submitted directly to SOCT at the State level. CDTI superuision is integrated with other disease programs e.g. Schisto, LF, and Malaria. LOCTs draw up monthly itineraries for this purpose. Transpoftation is shared for superuisory visits for all diseases. LOCT visits communities when there are problems e.g. CDDs not compensated by communities. Monitoring reports not available at all levels. In some Lags some of the superuisory visits by LOCTs at the FLHF level appear to be high. Transmission of data is not paft of government Health management information system i.e. does not pass through the normal MIS. Some LOCTs collect routine CDTI data directly from the FLHF level and communities (CDDs).

Mectizan (2.5 Moderatelv):

Check whether sufficient Mectizan is being ordered and received yearly and in good time. Whether Mectizan is being collected, stored and effectively administered through the government system

Census is carried out annually by CDDs before distribution process. Mectizan received from State to LGA without previous requisition order forms from FLHF or communities. SOCT supply Mectizan annually to LOCT, staff at FLHF collect Mectizan for communities from LOCT at LGA level. CDDs collect Mectizan from FLHF for their communities. Mectizan at LGA level is usually distributed within 2 days and not stored at the LGA level. Bulk receiving forms were available at all levels but ordering forms were absent. Census figures do not seem to be used in calculation of annual Mectizan requirement. Finances for transpoftation of Mectizan from LGA to FLHF provided by APOC supported. Mectizan received from State to LGAs without previous requisition order form or request from FLHF or communities. It was obserued that staff at various levels

l6 (LOCT, FLHF and CDDs) were unable to calculate quantity of Mectizan required annually based on community census. Shortages reported in 2000 due to presence of refugees from other states but in one incident, team found that about 2500 tablets of Mectizan were given out in 2002 instead of about 3800 administered in 2001. In some cases, excess Mectizan tablets were returned.

Traininq and HSAM (2.8 Moderatelv):

Check whether staff members are being used appropriately as trainers. Whether training is planed and carried out efficiently and in an integrated manner. Whether staff is planning and carrying out HSAM activities effi ciently.

LOCT trains District level personnel and occasionally assists in training at community level. Staff at FLHF train CDDs. Training is conducted annually for 2 days for new staff and retraining for old staff and CDDs (before distributions).

Health education on CDTI is integrated with that for LF and Schistosomiasis control. This takes place before, during and after distribution. LOCT undertakes advocacy visits to mobilize LGA management staff for CDTI. Training materials on CDTI were scanty at all levels. Some staff at FLHF level were not very knowledgeable about CDTI. State provides all training, supervision and monitoring and workshop materials for all workshops and training organized at all levels.

Financinq (0.08 Sliohtly):

Check whether appropriate amounts are budgeted for planned CDTI activities at the LGA level, Whether LGA government is budgeting and disbursing increasing amounts for CDTI yearly. Whether in case of a deficit between estimated costs and amount provided by government, dependable provision is being made to meet it and whether funds disbursed for CDTI from budget at LGA level are efficiently managed.

Although LGAs have no budgetary provisions, funds from APOC and other sources have been adequate for CDTI activities. Salaries of LOCTs and FLHF staff are paid by the LGA. No financial budget for CDTI program by LGA management including release of counterpart funding since inception of CDTI activities 5 years ago in LGAs. No CDTI related expenditure in the past 5 years was approved at the LGA level, all CDTI activities are funded through APOC budget. Management at LGA level is not aware of funds available to them for CDTI activities annually. Such information is available at the State level. APOC budget is used for all CDTI activities this includes payment of per diem to staff during training, monitoring/supervision, delivery and collection of mectizan at all levels and provision of Health education materials.

Transpoft and other Materials Resources (1.5 Sliqhtlv'l:

Check whether adequate and appropriate transport and materials are available for CDTI activities at LGA level. Whether transpoft at LGA level is adequately maintained. Whether transpoft available is appropriately managed and used in an integrated way, Whether there are appropriate and realistic plans for the replacement of transport and materials when APOC support comes to end.

Transport for CDTI is considered adequate for the next 2-3 years provided necessary maintenance is carried out. Transport includes 11 motorrycles (3 APOC, 8 LF) and 35 bicycles

t1 (25 APOC, 10 LF). Transport at the LGA and FLHF used in an integrated manner for all programs e.g. CDTI activities, Schistosomiasis control, LF, malaria, NPI, etc. Trips made for CDTI purposes at LGA level are authorized by the PHC Coordinator and by the District Health Superuisors at the FLHF level. Itinerary for annual planned activities by LOCTs available. Transport provided by APOC for CDTI activities and other programs e.g. LF are used in an integrated manner for all programs activities at LGA and FLHF levels. Health education materials (posters, flipcharts, leaflets) not adequate. The last time this was received was in 2001.

Replacement of motorcycle spare pafts carried out with APOC fund and minor repairs by individuals. No logbook for use of transport by LOCTs and FLHF staff available. No plans by LGA management to replace available vehicles after APOC.

Human Resources (3.45 Hiqhly):

Check whether staff at LGA level are skilled and knowledgeable regarding the implementation of CDTI. Whether they are committed to their work.

There are 5 LOCTs in each LGA. Most CDTI focal persons have been in place for at least 3 years. They acquired enough skills for CDTI activities. There is a better stability of staff at the LGA level compared with staff at FLHF level where some of the district health officers are only 6 months old. New staff at LGA level are trained annually. Staff members at the LGA level expressed satisfaction with their responsibilities. Some CDTI focal persons receive verbal praise for contribution towards CDTI programme. Cases of poor skill and inadequate skills found amongst some FLHF staff. Staft at LGA level involved in CDTI are owned 6 months salary arrears by LGA management. Instability of staff at FLHF level, some district health officers are only 6 months old at the present post. CDTI staff at LGA level receive allowances including top- ups after training and superuision of CDTI activities.

Coveraoe (4.0 Fully):

Check whether LGA has a satisfactory geographical coverage rate. Whether LGA has a satisfactory therapeutic coverage rate,

100o/o of the communities are geographically covered with CDDs selected from each hamlet/ward in their communities. Therapeutic coverage over 80o/o in all the communities. CDDs move from house to house during distribution and drug reserued for at least 5 weeks for absentees. As reported by some LOCTs coverage has been increasing by l0o/o annually due to the introduction of LF program in some LGAs.

l8 Recommendations Implementation Planning Priority High Three-year sustainability plan with a one year (2003) fndicators of success: CDTI work plan to be prepared and integrated into . Availability of year 2003 CDn sustainability the LGA/PHC work plan. The work plans to be work plan. prepared by the LGA management team, comprising . Report of workshop where plan was PHC Coordinator, Supervisory Councilor for health, developed DFS, DPM and LOCT. The plans will focus on . Report of CDTI sensitization meeting problems identified during monitoring and Who to take action supervision exercises . LOCT & PHC Coordinator Deadline for completion . March 2003

Leadership Priority High

LGA to be empowered to play leadership role at this Indicator of Success: level, PHC Coordinator to be trained on CDTI. o Document showing reconstitution of LOCT and membership Who to take action . PHC - Coordinator and LOCT. Deadline . April 2002 Monitoring and Superuision Priority Medium . All CDTI supervisors should use supervisory fndicatos ofsuccess; checklists to ensure appropriate supervision . Superuisory visit reports is carried out . CDTI data included in MIS o Include Oncho data as part of health management information system at the LGA Who to take adion level . PHC-Coordinator,LOCT . A provision should be made for the PHC Coordinator to sign CDTI reports before Deadline for completion transmission to the State. . By end of next distribution . Supervisory visits to be targeted and integrated with other health activities. Mectizan Priority High . Training of all individuals involve in CDTI at fndicatorc for success; all levels on how to determine quantity of . Training report mectizan to be ordered using the census Who to take action figures as recommended by APOC . LOCT and PHC Coordinator Deadline for completion a The LGAs should use the requisition forms o End of next distribution developed by the State for their Mectizan allocation.

Training & HSAM Priority High . PHC Coordinator to be involve in all training fndicator ofsuccess: in LGA and not to be by passed Training report available and sighed by PHC o Training should be at health facilities and Coordinator targeted Training j ustifi cations . Guideline for training should be constantly reviewed Who to take action o Individual staff s in all health facilities should PHC Coordinators and LOCT be trained in all disease (model health center

l9 spearheading). Deadline for Completion Advocacy and sensitization meeting on CDTI April - May 2003 to be conducted by management team once every year.

Finance Priority High . CDTI technical reports should be widely Indicator for Success: disseminated to the LGAs Amount of resources mobilized annually . LGAs to mobilize funds from other sustainable sources. Who to take action . Budget in sustainability plan should be PHC Coordinator and LOCTs realistic and LGA budget Deadline for completion March 30 (the inception of the new government)

Other Resources Prioritv Hioh . Log books to be provided for use of vehicles Indicator for success: . LGAs should to develop a clear plan for Availability of maintenance plans maintenance and replacement of transport Who take action PHC-Coordinator and LOCT

Deadline for completion April 2002

20 FINDING AT THE TIEALTH FACILITY LEVEL

Fig.3: Plateau CDTI Project. Sustainability at FLHF Level 4.5 4 4 3.5 \} 3 ! .9 2.5 o, o= 2 E') (E 1.5 0)

1 0.5 0

-e -o% q."'.d a""" .*te *."'t* ^*,"" ..eo o"".c "-"'- """" Groups of lndicators ""t

PLANNING (0.66 Sliohtlv):

There is a written year plan for CDTI in the FLHF area

There was no written plan for CDTI activities prior to 2002. The LOCTs and State met in 2002 for the first time to draw up a written work plan for CDTI activities for 2003. This plan has been discussed and shared with the districts and it contains key CDTI activities, duration and budget by activity.

LEADERSHIP (1.33 Sliqhtlv):

The FLHF management team is taking full responsibility for CDTI at this level, in an integrated manner.

FLHFs consider CDTI to be their program, implementation based on directives from LGAs, once they get the drugs. The district political leaders show interest in CDTI and participate in mobilizing communities. Mectizan distribution is integrated into Lymphatic Filariasis and Schistosomiasis control program but not fully into other PHC activities.

2l MONITORING AND SUPERVISION (1.8 Moderatelv):

Routine and necessary data concerning CDTI activities at this level are being transmitted entirely within the government system. Health staff at this level is routinely and efficiently supervising CDTI activity at the communities in an integrated manner and problems and successes are managed promptly and effectively.

The DHS goes round to collect treatment repofts and keeps a copy of the community treatment summary forms at the facility and often these are sent to him/her by CDDs. The DHS monitors and supervises officers in charge of facilities who in turn supervise and monitor CDTI activities in the communities. There was however no checklist to confirm this and repofts showed that some health facility staff do not supervise their communities. The DHS also use the oppoftunity of their monitoring visits to carry out other health care activities, suggesting some form of integration. They are also involved in co-treatment of LF and Onchocerciasis in their districts. Superuision is funded by the project (APOC). Sometimes, reports to the LGAs were late due to delays in submission of reports by CDDs. There was no reward system in place to encourage health workers who show outstanding commitment to CDTI in the facilities.

Mectizan Procurement and Distribution (2.7 Moderatelv):

Sufficient Mectizan is being ordered annually, and in good time. Mectizan is being collected, stored and effectively administered within the government system at this level.

There were no reported shortages in most communities. Mectizan is stored at the drug store in district health facility and issued out almost immediately to the communities. Health facility staff collects drugs for their communities, while CDDs collect drugs on behalf of their communities from the health facility closest to them. There was a good Mectizan inventory of drugs received and balances returned. There were no standard and rational means of determining the number of drugs required by communities. Instead drugs supply is based on the previous year distribution. The drugs, in most cases, were not available at the period the community requires them, which is before active farming season (January to April).

Traininq and HSAM (2.5 Moderatelv)

Training and HSAM are being planned and carried out in an efficient manner

The DHS train the Officers in charge of the FLHF who in turn train the CDDs. In most cases training was found to be routine and in instances where it was not routine, emphasis were on training new CDDs. Training was usually carried out at the district health facility. A team made of the LOCT, DHS and CDDs carried out HSAM of communities annually as routine. It was only on few occasions that HSAM was targeted at issues like refusal of treatment due to side effects. Training is integrated with LF and Schistosomiasis control program but not with other PHC activities. Most health workers at the health facilities have poor knowledge of CDTI because the

22 training for health workers was restricted to one per health facility. Training was entirely funded by the project (APOC and NGDO). Where HSAM was jointly done for LF and Oncho, Oncho becomes subsumed under LF because of perceived high burden of LF. Health education materials such as posters and flip charts were provided by APOC but not adequate

Financinq (O Not at all)

The costs involved in planned CDTI activities at this level are clearly defined and budgeted for. Sufficient funds to cover these costs are ful or increasi bei disbursed from LGA resources.

The Local Government has never provided funds for CDTI activities at this level. CDTI activities are funded through prqect budgets (APOC and NGDO) since the inception of the program.

Transoort and other Material Resources (2 Moderately):

Adequate and appropriate transpoft and materials are available for necessary CDTI activities at this level and are adequately and appropriately maintained, managed and used, in an integrated way

The transports available at this level are used for all PHC activities CDTI inclusive. The LGA carries out major repairs and maintenance when the vehicle is to be used for NID, the DHS is responsible for minor repairs from his salary and proceeds from sale of PHC drugs in the facility. The motorcycles are inadequate and IEC materials such as posters are not provided on an annual basis. Government can pay for maintenance, replacement of parts and repairs if they are committed to the program. There is no guideline for movement or trips for CDTI. No logbook or travel authorization is used at this level.

Human Resources (1.6 Sliqhtlv):

The team at this level is skilled and knowledgeable, regarding the implementation of CDTI in its area of operation.

The CHEWs at the lower cadre are more stable and not regularly transferred out of their stations. DHS are higher officers and are liable to be transferred out of the LGA at any time. Training at this level is restricted to the District Health Supervisor, who is the most senior officer. There are five LOCTs, one in charge of each of the five health districts. There are also five DHS, one in each of the health district also. The LOCTs are often junior in position to DHS they are expected to supervise.

23 Covera 4 Full The ra hical covera in the FLHF area is satisfacto

The geographical coverage is satisfactory at this level based on distribution reports. There are however, no REMO results at the FLHF level to verify this.

Recommendation at this level

Recommendation Implementation Priority: High Human Resources Indicators of success The role of LOCTs and DHS should be reviewed with LOCT members are assigned specific duties and a view to ensuring clarity and avoid duplication of are empowered to peform the assiqned duties duties. Who to take action: PHC Co-ordinator and LGA Oncho. Co-ordinator, Deadline for completion : April, 2003 Priority: High Training All the health workers at the facility levels should be Indicators of success trained adequately on CDTI All health workers at the health facility levels have good knowledge of CDTI.

Who to take action: PHC Co-ordinator and LGA Oncho. Co-ordinator

Deadline for completion: June, 2003

Priority: Medium Monitoring and Superuision All CDTI superuisors should use supervisory Indicators of success checklists to ensure appropriate supervision is Completed superuisory checklists by supervisors carried out are available.

Who to take action: LOCTS,

Deadline for completion: October, 2003

24 Fig.3 Sustainability at the community level

4.5 4:fr 4.0 3.2 3.5 the 3.0

2.5 S 2.0 1.5 1.0 0.5 0.0 o) ol C c o .9 c (6 'o(d (6 q) .c -c N (d n E U' o ct) C E L c o .= o G f o (U E c 0) I c I o- (6 o o o ir- O J = ts Group lndicators take place. Communities are willing to take the drug but some do not know how long they are expected to do so. In some villages, the leadership has not played any effective and proactive roles in solving major problems such as refusals, CDD attrition and inadequate suppoft to CDDs.

Monitorinq and Superuision (2.6 Moderatelv):

CDDs are reporting appropriately to the FLHF level.

CDDs are reporting appropriately to first line health facilities (submitting reports and drug balances). Community treatment records are available at the communities, but not properly kept in few communities. In most cases, monitoring was not carried out by the supervisor at the first line health facility and this had negative impact on the quality and timeliness of reports

Mectizan Procurement and Distribution (3.0 Hiqhly):

The right amount of Mectizan is received and the CDDs or community members themselves fetch the yearly supply of Mectizan.

Drug supply to communities is adequate. The Officer in charge of the FLHF informs the community about the availability of the drug at the central collection point, and CDDs collect the drugs for distribution. FLHF staff sometimes take the drugs to the CDDs. CDDs were not taught

25 how to determine the quantity of drugs to be requested for their communities. Lack of a rational criterion for determining quantity of drugs needed often result in surplus drugs in some communities and shortage in a few communities.

Traininq and HSAM (2.0 Moderatelv):

CDDs and community authorities continue to be engaged in HSAM of other community members.

HSAM for communities is carried out annually before distribution by a team of health workers, CDDs and community leaders. IEC materials are not usually adequate for HSAM. Knowledge of community members and CDDs about Onchocerciasis and Mectizan treatment is poor in communities that are being co-treated for LF and Onchocerciasis. There were reports of refusals as a result of inadequate health education, mobilization and sensitization at the communities.

Finance (2.3 Moderately):

The community has made arrangements to fund local costs of distribution.

Some communities provide money or non-financial incentives such as farming for the CDDS. Community support as mentioned by some CDDs is inadequate in most communities, Communities knew their roles to support the CDDs, but admitted that they had often failed to do so.

Human Resources (3.2 Hiqhlv)

There is a satisfactory ratio of CDDs to households and all CDDs have received appropriate training. CDDs are willi to continue their work in CDTI.

Registration and treatment is usually completed between two weeks to a month. Prior to last year (2002), training was mainly routine, but now training is targeted at new CDDs because of high attrition rate. The DHS at the first line health facility conducts training for CDDs at the health facility, Most CDDs are willing to continue to serue as CDDs in the long term. There was however, indication that lack of adequate incentive could lead to further CDD attrition. The ratio of CDDs to population is less than the recommended ratio of one CDD to 20 households or 2 CDDS to per 250 population. Most CDDs do not travel far from their homes to distribute Mectizan. Posters and CDD information booklets are provided to CDDs after training annually but not adequate. Attrition rate of CDDs is high due to inadequate suppott and mobile characteristics of CDDs for further education and employment in towns and cities

Coveraqe (4.0 Fullv)

The geographical coverage in the community is satisfactory and the community has a satisfactory therapeutic coverage rate.

Geographic coverage was 1000/o as all the endemic communities, wards and hamlets are being treated. Therapeutic coverage is very high, as most of the communities have attained an increasing rate of at least 650lo. There were discrepancies in therapeutic coverage given by the project and that calculated by the evaluator in some communities

26 Recommendation at this level

Recommendation Implementation Training Priority: Hiqh More CDDs should be adequately trained and Indicators of success deployed in each community. -The recommended ratio of 2 CDDs to a population of 250 people is met. CDDs should be trained on the use of the census to -The demand for incentive is less. determine the quantity of drugs required - CDDs can determine the quantity of drugs needed in their communities Who to take action: PHC Co-ordinator and LGA Oncho. Co-ordinator, Deadline for completion May, 2003 Human Resources: The Communities should develop means of providing more CDDS and provision of incentives through the use of community based organisations and village health committees HSAM Priority: High HSAM should be intensified for communities to understand and perform their CDTI activities. Indicators of success -Communities understood their roles and support their CDDs. -Communities have good knowledge of Onchocerciasis and Mectizan treatment.

Who to take action: PHC Co-ordinator and LGA Onchocerciasis Co- ordinator,

Deadline for completion July, 2003

Conclusion and way-folward Using the four-tier schedule for ranking projects evaluated: fully, High, Moderate and low, the evaluation team judges the Plateau State CDTI to be at the level of Moderate. The project is potentially sustainable as evidenced by the excellent coverage, high level of community leadership and approval and availability of mectizan everywhere.

But this project requires rethinking and mobilization of high-level decision-makers to provide financial resources to sustain CDTI. It is intriguing to the evaluation that at the end of the fifth year the State has not made a single annual contribution on the lines agreed with APOC.

Other important issues that need rethinking include: High attrition rate of CDDs and further empowering of LGAs, through training and decentralization of authority from the State level to

21 LGAs and FLHFS. Using the Abuja grading of: Fully sustainable; On the way to sustainability and not on the way to sustainability, the evaluation team concludes that the Plateau program is on the way to sustainability.

Two feedback/planning meetings (one day and two days for LGA and SGA management staff respectively) were successfully carried out, Details of issues discussed and the sustainability plans prepared are contained in report of the meeting attached.

Way forward

State and LGA leadership indicated that rapid action will be immediately taken in a number of interrelated key areas. Foremost is the implementation of the one-year plan of action (developed during the briefing and planning meeting) and development of a three year CDTI sustainability plan. The process of developing the three-year plan has potentials for mobilization of all paftners.

The evaluation team recommends that APOC follows closely and provide support in key areas particularly the development of the three-year sustainability plan, which is key to future collaboration. It is hoped that the target of completing the plan by Mid April and making it available to APOC will be met.

28 Appendix I Plateau State CDTI Planning Meeting

AGENDA

Item Acti Time Facilitator 1 Openinq prayer 10:00 - 10:05 To be appointed 2 Welcome 10:05 - 10:10 Director PHC 3 Introductions 10:10 - 10:15 SOC (Henry Filda) 4 Introduction to the workshop; 10:15 - 10:30 What are the aims and objectives of the Dr E. Tarimo meeting What is sustainability 5 Tea Break 10:30 - 10:45 6 "Feedback" on achievements, issues and 10:45 - 11:15 Prof.O. Nwaorgo lessons from the Kogi evaluation on Dr. K. Ogungbemi sustainability of CDTI 7 Identification of problems identified and 11:15 - 12:30 S. Isiyaku solutions B LUNCH 12.30 - 13.00 9 Feedback from group work 13.00 - 13.30 Group Discussions 10 Rethinking roles of the different levels and 13.30 - 14.00 Dr. K. Ogungbemi paftners 11 Planning for sustainability in this project 14.00 - 16:00 Dr. T. Tarimo Planning for the next one year 13 Tea Break 16:00 - 16:45 74 The way forward: implementing self- 16:45 - 17:15 Director, PHC sustainability (what to do now) 15 AOB t7.75 - t7.30 16 Closing Prayers t7.30 To be appointed

29 Appendix II:

Program for Plateau State CDTI Planning Meeting for Local Government Areas

"Feedback"/ Planning Meeting

1 Item Activity Time Facilitator 1 Openinq prayer 10:00 - 10:05 To be appointed 2 Welcome remarks 10:05 - 10:10 Director PHC 3 Introductions 10:10 - 10:15 SOC (Henry Filda) 4 What are the aims and objectives of the 10:15 - 10:30 Dr. E. Tarimo meetinq? 5 Tea Break 10:30 - 10:45 6 Where we are in the evaluation 10:45 - 10:55 S. Isiyaku 6 "Feedback" on issues and lessons from the 10:55 - 11:30 Dr. H. Hamisi Plateau evaluation on sustainability of CDTI Dr. K. Ogungbemi in (LGAs) Prof. O.Nwaorqu 7 Identification of problems and solutions: 11:30 - 12:45 S. Isiyaku Plenary 8 LUNCH 72.45 - 73.30 9 Rethinking roles of the different levels and 13.30 - 14.00 Dr. Ogungbemi partners 10 Planning for sustainability in this project 14.00 - 16:00 S. Isiyaku Planning for the next one year: Group Work by LGA

Day 2 1 Group Work Continue 8:30 - 10:30 2 Tea Break 10:30 - 10:45 3 Report back from group work 10:45 - 12:00 4 The way forward: implementing self- 12:00 - 12:30 LGA Chairmen sustainability (what to do now) Directors PHC 5 AOB 12:30 - 13:30 6 Closinq Prayers 13:30 To be appointed

30 Appendix III State/LGA Level Planning Meeting Program

The participants would look at problems identified by the evaluators under each indicator and agree solutions to them. a In planning for the next one year the group would:

a Group would then feed back at a plenary session for general input. a This would be the frame work within which the first plan would be produce i.e. what would be done between now and the end of the year to address the issues raised by the evaluators and to initiate the process of developing a sustainability plan post APOC funding.

3l Appendix IV State Level

Problems and Solution

AT STATE PROBLEMS SOLUTIONS LEVEL Planning No funds released for CDTI activities o The director PHC accepted that following request from CDTI focal sustainability efforts had just been person in the LGA, even though CDTI initiated recently. is integrated into the PHC plan. . That each LGA is to contribute N300, 000.00 while the State contributes 2.5m Some Chairman absent during last as counterpart funds. State sustainability meeting . That the commissioner of health had directed that an account be opened for this purpose. . Suggestion . n was made that the money be lodge in LGA accounts instead of State. . Strong and persistent advocacy especially from APOC and other NGDOs is required to get desired counterpart funds. . Interview held with the commissioner of health suggested that the NGDO should handle the money Training Training materials on CDTI were a The SPO promised to intensify training in scanty at all levels the areas where the programs are integrated Some staff at FLHF were not a CDTI activities are included in school knowledgeable about CDTI curriculum of public health schools e.g. school of health technology.

Finance Salaries of local government staff are a Suggestion made that CDTI accountant not paid by LGA even though be deployed or appointed at State level. presently they are in 6 months salary a That CDDs be empowered economically arrears. where the community failed to suppoft. a Also that the CDDs be involved in No financial budget for CDTI program programs that gives incentives like by LGAs during NPI program.

No CDTI expenditure for the past 5 years at the LGA level

The actual accounting for APOC funds falls on the State office.

Local Government Councils are not aware of funds available to them for CDTI activities annually. Monitoring Monitoring reports not available at all The director planning said the LGAs are & levels. expected to take full control of

32 supervision monitoring and supervision. In some LGAs some of the o Accepted that there was weak supervisory visit by LOCTs at the integration system in the State but effort FLHF level appear to be high. will be put in place to strengthen it.

Some LOCTs collect routine CDTI data directly from the FLHF level and communities (CDDs).

Processes of data collection are not part of government health management systems.

Mectizan Mectizan received from State to LGAs The SPO, SOCTS, LOCTS and the HLHF to train without previous requisition form or and educate CDDs on how to apply for mectizan request form HLHF or communities. by using their census figures and multiplying by factor of 3. Census figures do not seem to be used in calculation of annual mectizan requirement.

Finances for transport of mectizan from LGA to HLHF provided by APOC at the district and LGA levels.

Transport No logbooks, no plans to repair Suggestion was made that APOC help in vehicles available, fueling etc. provision of vehicle. motorcycle spare parts are carried out with APOC fund. Health H/education not adequate (posters, APOC, LGAs will help in developing education Education flipchafts, leaflets) the last time this materials. Materials was received was in 2001. Human Instability of staff at FLHF level, some Suggestion was made that LGA staff should be resources district health officers are only 6 transferred. months old at the present post Not to rely on NGDO for their data management. CDTI staffs at LGA level receive allowances including mop-ups after training and supervision of CDTI activities yet do not report to the State office in time. Coverage Distribution of mectizan is always not Coverage was high. on time for some of the communities. As reported by some LOCTS, coverage has been high by 10olo annually due to the introduction of LF proqram in some LGAs.

-r -, Appendix V LGA Level

Problems and Solutions

AT LGA PROBLEMS SOLUTIONS LEVEL Planning No funds released Directives to be given from States MOH and Ministry for Local Govt. & Chieftaincy affairs to LGA to release funds. Chairman absent during last State Another meeting is to be convened sustainabiliW meetinq Leadership 1. Only LOCTs, DHS, HHFS are trained 1. WorKhop for all LGA coordinators, for Oncho program. Why others? Directors on CDTI

None involvement of health staff at 2. Health institutions (CDn) curriculum FLHF 3. LOCTs to train DHS/H/HFS and other health 2. LOCTs depends wholly on NGDO for staff at FLHF funding 4. Organize a sort of competition LGA by LGA and District by District, DPHC to release little funds for CDTI activities.

1, LGA should come for drugs at Jos, training and 3. LGA has continue to depend on State other activities, This should be included in the LGA for CDTI activities work plan annually

Monitoring/ M & E don't know what is happening 1. HOD should ensure that correct repofting Evaluation about CDT reports procedures are adhered to. 2. Integration into PHC CDTI repofting proqram Mectizan Quantity of mectizan not properly Proper training on how to calculate mectizan calculated and inadequate or excess comparable with the census pop. total pop x 3 Training/Healt No posters on LFlOncho CDn (IEC 1. HOD, Coordinators should ensure that training h Education materials) inadequate IEC materials be conducted and provide health education materials

2. States, LGAs should print posters and other IEC materials

3. Printed posters, when distribution should be proDerly distributed and monitored. Finance No funds released by LGA, mostly Directives to be given by MOH and Ministry of Local counterpart funding (Not released) Govt. and chieftainry to LGAs to release funds (counterpart). Transport/othe No logbooks, no plans to repair vehicles Logbooks, repairs, fueling should be done by the r logistics available, fueling etc. birycles LGAs (vehicles could also be given during CDTI materials activities). Coverage Kudus

34 Appendix VI

FLHF AND COMMUNITY LEVEL

FLHF/COMM PROBLEMS SOLUTIONS UNITY LEVEL Planning DHS/LOCTS are doing the same thing Each LGA should sort out and use either (CDTI activities) DHA/LOCT or decide No funding at district level, no budget 1. The DHS should be allowed to produce their budget

2. LGA should include such CDTI budget at LGA budqet Attrition rate Attrition rate of CDDs 1. Motivation by the communities 2. Reduce the work load of CDDs Lack of support to CDDs 3. Traditional leader involvement, district heads, village heads, ward heads. Gettinq work else where 4. LGA should also contribute IEC materials No IEC offices at LGA level Directives be given to LGA to provide offices for IEC Training/Healt No posters on LFlOncho CDn (IEC 1. HOD, Coordinators should ensure that training h Education materials) inadequate IEC materials be conducted and provide health education materials

2. States, LGAs should print posters and other IEC materials

3. Printed posters, when distribution should be properly distributed and monitored.

35 Appendix vii

List of Persons Interviewed during the evaluation

State Ministry of Health 1. Barrister John Magaji - Honorable Commissioner for Health, Plateau State 2. Mr. David S. Belin - Director PHC and Disease Control, MOH Plateau State 3. Mr. Henry Filda - State Onchocerciasis Program Officer

NGDO 1. Dr. E. S. Miri - Country Representative GRBP (Carter Center) 2 Dr. Eigege Abel - Director, LF and Schistosomiasis Program 3 Mr. John Umoru - Project Officer, Onchocerciassis 4 - GRBP Project Accountant

ZONAL NOCP Mrs. Pearce Ogbu - Zonal Coordinator, NOCP

BOKKOS LGA 1. Mrs, Dorcas Wambula - Assistant PHC Coordinator 2. Azi Hamman - Oncho Coordinator 3 Mrs Nimdom C. Miri Director of Finance 4. Mr. James Dashen The Chairmankos LGA 5. John Jik - District Health Supervisor, Ikngnhap 6. Health facility staff Gara 7. Ezra Ringmen - CDD, Kawel 8, Friday Daniel CDD, Sat 9. Elizabeth Gantu - DHS, Daffo 10.Luka John - CDD, Toff 11. Bitrus Gaza - CDD, Kafa 12. Health facility staff Toff 13. Adamu Job Village leader, Kawel 14. Yoila Modik - Village leader, Sat 15. Elimon Akaya - Village leader, Toff 16. Yusuf Makabi - Village leader Kafa

PANKSHIN LGA 1. LOCT Pankshin - Josiah Dakon 2. PHC Coordinator Pankshin - Mrs. Riftatu Akins 3. LGA Chairman - Diket P. 4. District Supervisor Ballang Shipang- Mrs. Dara Gomet

Kadyis Community 1. Village member male 2. CDD male Kadyis - James Gokok 3. CDD male Kadyis - Anthony Gomwir 4. Village Head Kadyis Goger Godung

Nyelleng Community 1. CDD female Rabecca 2. Village Chief Bulus Gorap

36 a

3. Village member female Mrs, Christy Yunana 4. Village Member male 5. PHC FLHF 6. District Health Supervisor Jiblik

Tilleng Community 1. Village Member male Jacob Dabish 2. Village member female - Rosaline Christopher 3. CDD female Mrs. Christy Yunana 4. Village Chief Adamu Dariye

Jing Community 1. Mllage member male Stephen Damara 2. Vlllage leader Nanle Park

3l a

Appendix viii

List of Evaluators

S/N Name Address o 1 Dr. Eleuther Tarimo Box 33277, Dar es Salaam, Tanzania +0255 742 605025 [email protected]

2. Prof. Obioma Nwaorgu Dept. of Parasitology & Entomology Enugu State University of Science and Technology, Enugu, Nigeria Tel: 234 42 456128 (H) 234 42 2s8078 (Off) 234 42 250836 (Fax) onwaorgu@infoweb. abs. net [email protected] 3 Dr. Kayode Ogungbemi Dept of Psychiatry Ahmadu Bello University Kaduna, Nigeria. Mobile: 234 803 3230018 Tel: 234 62272844 (H) Tel: 234 62 248360 m [email protected] 4. Dr. Harriet Hamisi HKI Project Officer Tanga CDTI Project P. O. Box 5547 Tanga, Tanzania Tel: 255 27 2646217 255 27 2647880 255 744 694369 255 748 381520 lyimoha rrieth@yahoo. com 5. Mr. Sunday Isiyaku Sight Savers International 1 Golf Course Road P. O. Box 503 Kaduna, Nigeria Tel: 234 62 248360 Fax: 234 62 248973 Tel: 234 62 2312t6 (H) ssinq@infoweb. abs. net 6 Dr. Abel Eigege Carter Center, Inc (GRBP) 1 Jeka Kadima Street, Off Tudun Wada Ring Road Jos, Nigeria Tel:234 73 46t861 234 73 463870 Fax:234 73 460097 [email protected]

38