World Health Organization African Programme for Onchocerciasis Control Assessment of the Sustainability of the Enugu State CDTI Project June 16 -02 July 2003 Sebastian Olikira Baine (Team leader) F. Olamiju James Mugisha P Ogbu-Piarce C. Okoronkwo E. Alor L. Nweke J. Nwagwu 1 Index Page Abbreviations/ acronyms and acknowledgements 3 Executive summary 4 Introduction 7 Methodology 7 Findings and recommendations 11 1. National level 11 2. LGA level 19 3. First Line Health Facility level 27 4. Village level 34 5. Overall self-sustainability grading for the project 39 6. Recommendations 39 7. A Vision for the future 39 Appendix I: Feedback/planning workshops, State level 41 Appendix II: Feedback/ planning workshop, LGA level 44 Appendix III: List of participants in the workshops on CDTI 47 Appendix IV: List of people interviewed 50 Appendix V: Work plan for the evaluation team 52 Appendix VII: CDTI sustainability plan of action 53 Appendix VIII: Instruments used to measure sustainability 74 Appendix IX: Guidelines and checklist for developing a CDTI sustainability plan 157 Appendix X: Personnel and activities required for sustainability of CDTI after 5 year of APOC support 165 2 Abbreviations/ acronyms APOC African Programme for Onchocerciasis Control CBO Community Based Organization CBIT Community Based Ivermectin Treatment CDD Community Directed Distributor (of Ivermectin) CDTI Community Directed Treatment with Ivermectin CHEW Community Health Extension Worker CHO Community Health Office DC Disease Control DHS District Health Supervisor GRBP Global 2000 River Blindness Programme LF Lymphatic Filariasis LGA Local Government Authority LOCT Local Government Onchocerciasis Control Team MOH Ministry of Health NGDO Non-Governmental Development Organisation NGO Non-Governmental Organisation NPI Nigerian Programme of Immunization NOCP National Onchocerciasis Control Programme NOTF National Onchocerciasis Task Force PHC Primary Health Care PS Permanent Secretary SPC State Project Coordinator SOCT State Onchocerciasis Control Team UNICEF United Nations Children’s Fund WHO World Health Organisation ZOC Zonal Onchocerciasis Coordinator Acknowledgements We are enormously thankful to the following for their help: The staff at APOC Headquarters in Ouagadougou; Dr Sékétéli, Dr Amazigo, Mr Aholou and Mrs Vctoria Matovu. His Excellency the Deputy Governor of Enugu State, the Permanent Secretary, Director PHC/DC, Director Planning and Research, Director Finance and Staff of the Ministry of Health Enugu State as well as the Permanent Secretary Ministry for LGA and Chieftancy Affairs of the Ministry. The Global 2000 team: Mrs. C. Maduka and her team for the invaluable support to CDTI activities in Enugu State. Last but not least the health workers and community members in the Udi, Anirni and Igboeze North Local Government Authorities. 3 Executive summary The African Programme for Onchocerciasis (APOC) has been supporting the Enugu State CDTI project since 1998 and five years’ of APOC support will end in September 2003. It is the policy of APOC to evaluate CDTI projects in their fifth year of implementation to assess their progress on the road to sustainability. A six- member team conducted this evaluation: two from Uganda; and four from Nigeria. The evaluation was carried out over a period of 15 days (including one day for planning). Information was collected by document study, survey (using the instruments developed for the evaluation of sustainability of CDTI) and observation at sampled sites at the four levels i.e. State, LGA, FLHF and Community (village) levels. The following are the principal findings of the evaluation: . Planning: Planning at State level does not fully involve all stakeholders. The sustainability plans for CDTI available at the State level are for the period June 2003 upwards. The State has no specific plans for counterpart funding and no post APOC sustainability plans were seen. Most LGAs have sustainability plans that include all CDTI activities. However, these plans are not integrated into the overall health plans. Leadership: There is a State Programme Coordinator and SOCTs members at the State level and focal persons for CDTI activities at the LGA, FLHFs and community levels. The community leaders play a vital role in the leadership of their respective villages. However, there was inadequate awareness about CDTI among top management at the State and LGA levels. Although the FLHF staffs that are involved in CDTI activities have accepted CDTI philosophy, they are not yet fully empowered to initiate specific CDTI activities on their own. Monitoring and supervision: Data from the village level moves effectively to the State level through the government system. Supervision is not conducted in an efficient manner (there are too many supervisory visits e.g. supervision and monitoring at the LGA level is routine and frequent, and has implications in terms of funding) and checklists are not utilised. CDTI supervision by the SOCT is integrated with other health interventions, for instance, NPI and nutrition programmes. Appropriate channels are used to address critical issues concerning CDTI activities that are identified. The reporting process is within the government system. However, some SOCTs do carry out supervision at lower levels, which should not be the case as it interferes or hinders empowerment of the DHSs/FLHF staffs. Hence, not allowing the creation of a foundation for sustainability when APOC funding ceases. Supervisory visits are dependent on APOC funding. Mectizan procurement and distribution: This is working well, and takes place entirely within the government system. UNICEF clears the Mectizan at the port of entry and hands it over to GRBP which in turn hands it over to the State. From the State it is distributed to the LGAs for further distribution to the FLHF, and then to the CDDs and finally to the community. Training and HSAM (Health Education/Sensitization/Advocacy/Motivation): Training targets are not being attained in terms of numbers. Training and HSAM are targeted to the needs of those that lack knowledge/information about CDTI activities. At the State level, occasionally, trainings are integrated with other health programmes such as NPI and Nutrition programmes. At the LGA, training is routine, not targeted for needs for each episode and is not integrated. Finances/ funding: The government’s contribution at present is largely in the form of salaries for staff. The Enugu State released 345,000 and 250,000 Naira in 2000 and 2002. Most of the funding for CDTI activities in the Enugu State is provided by APOC. There is uncertainty as regards availability of funding 4 from the State and LGA levels for CDTI activities once APOC funding ceases. This argument is supported by the observation that State fund releases are erratic and funds released so far have been used to pay office rental and utilities. What could be established was the will of GRBF to support CDTI activities. Nonetheless, the magnitude of GRBP financial support for CDTI activities post APOC is not clearly defined or currently known. Transport and equipment: Transport facilities available for use in the CDTI activities are mainly provided by the APOC and GRBP. Maintenance and fuelling of vehicles currently depend on APOC and personal resources. The latter source is not sustainable. The use of vehicles is not well controlled and monitored by the relevant offices. Although, properly filled logbooks were available to support in part their proper utilization, there were no checks on logbooks by the in-charges. Authorisation to use vehicles were verbally made and not written. There were no documented plans to replace transport facilities during the post APOC period or when they have outlived their useful life. Human resources: Persons involved in CDTI activities were found to be well informed, rationally committed and stable. Staff participating in CDTI activities at the State, LGA and FLHF levels are employees of government and therefore on the government payroll. In that case, the government is indirectly contributing to the CDTI activities. The weakness as regards personnel is that staffs at some FLHFs/districts level have not yet been involved in CDTI activities. Nonetheless, these staffs showed interest, are trainable and will be useful once they are included in the CDTI activities. The overall judgement of the team is that the Enugu State CDTI project is potentially sustainable. There is an assurance that State and LGAs will be able to support CDTI activities in terms of availing the resources needed for the CDTI programme to function when APOC support ceases. However, this assurance needs to be diligently and persistently pursued because in most cases it ends on promises. There is need to intensify advocacy to the political leadership e.g. His Excellency the Governor was positive and strongly emphasized his support for CDTI but the promised support requires follow-up. Also intense advocacy should be extended to the technocrats. Overall, a strong advocacy targeted at policy and decision-makers in the State is significantly desired. Detailed recommendations were drawn up basing on the findings of the evaluation. The recommendations were prioritized, and indicators and deadlines were suggested for each of them. The most significant recommendations are to: . State, LGAs and FLHF/Districts planning systems to fully involve all stakeholders in CDTI, and draw up a detailed integrated sustainability health plan, which includes CDTI activities basing