World Health Organization African Programme for Onchocerciasis Control

Assessment of the Sustainability of the Nassarawa State CDTI Project

February/March 2003

Sebastian O. Baine Edith N. Nnoruka Richard Ndyomungyenyi William A.Istifanus John A. Umaru Alhaji Abbas Dalhatu

1 Index

Page

Abbreviations/ acronyms and acknowledgements

Executive summary

Introduction and methodology 1. Introduction 2. Methodology

Findings and recommendations 1. National level 2. District level 3. Health centre catchment area level 4. Village level 5. Overall sustainability grading for the project 6. A new insight

Advocacy activities and feedback/ planning workshops 1. Advocacy activities 2. Feedback/planning workshops

Appendix 1 Report on meeting with WR Appendix 2 The district level feedback/ planning workshop Appendix 3 District sustainability plans Appendix 4 Suggested changes to the ‘Sustainability’ instrument Appendix 5 Timetable of the evaluation visit

2 Abbreviations/ acronyms

APOC African Programme for Onchocerciasis Control CBO Community Based Organization CBIT Community Based Ivermectin Treatment CD Coordinating Director CDD Community Directed Distributor (of Ivermectin) CDTI Community Directed Treatment with Ivermectin CHEW Community Health Extension Worker CHO Community Health Office 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 NOCP National Onchocerciasis Control Programme NOTF National Onchocerciasis Task Force PHC Primary Health Care PS Permanent Secretary SPO State Project officer SOCT State Onchocerciasis Control Team UNICEF United Nations Children’s Fund UTG Ultimate Treatment Goal WHO World Health Organisation ZOC Zonal Onchocerciasis Coordinator

Acknowledgements

We are immensely grateful to the following persons for their help: The staff at APOC Headquarters in Ouagadougou; Dr Sékétéli, Dr Amazigo and Mr Aholou; Hon. Commissioner, Permanent Secretary, Director PHC/Disease Control and Staff of the Ministry of Health Nasarawa State as well as the Permanent Secretary Ministry for LGA and Chieftancy Affairs of the Ministry; The Global 2000 team: Dr. E. S Miri, Dr Abel Eigege and his team; Mr A. A. Umar and his State team; and Health workers and community members in the Karu, Lafia and Nassarawa Eggon LGAs.

3 Executive summary

The African Programme for Onchocerciasis (APOC) has been supporting the Nasarawa State CDTI project for the past five years. 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 an interview schedule) and observation at sampled sites at four levels: State; LGA; FLHF; and Community (Village) levels.

The following are the principal findings of the evaluation:

. Planning: Planning at State level involves all stakeholders. There is a sustainability plan for all health services at the State level. However, the sustainability plans for CDTI available are for the period June 2003 upwards. Notwithstanding, the State has no specific plans for counterpart funding and no post APOC sustainability plans. 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 Officer and focal persons for CDTI activities at the LGA, FLHFs. The community leaders also play a vital role in the leadership at 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, 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, but in some cases the FLHF is bypassed. Supervision as it is being conducted at present is not as efficient as it could be (too many visits) and there are no checklists). CDTI supervision by the SOCT is integrated with other health intervention, for instance, those against LF and Schistosomiaisis. Address to identified issues of concern regarding CDTI activities follows through appropriate channels. The reporting process is within the government system. However, a few SOCTs still carry out supervision at lower levels, which should not be the case as it does not empower the DHSs and FLHFs, hence, not creating a foundation for self sustainability when APOC funding ceases. Supervision and monitoring at the LGA level is routine and frequent, and has implications in terms of funding. 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 the State. From the State it is distributed to the LGAs for further distribution to the FLHF and then to the CDDs and finally the community.

. Training and HSAM (health education/sensitization/advocacy/motivation): Training targets are not being attained in terms of numbers because some FLHFs are not involved with CDTI activities. Training and HSAM are targeted to the needs of those that lack knowledge/information about CDTI. At the State level, occasionally, trainings are integrated with other health programmes such as LF and Schistosomiaisis. At the LGA, training is routine, not targeted for needs for each episode and is not integrated.

. Finances/ funding; transport and equipment: The government’s contribution at present is largely in form of salaries for staff. In 2001, State approved 2,000,000 Naira but the funds actually released were 340,000 Naira. Most of the funding for CDTI activities in the Nasarawa State is accrued out APOC. There is uncertainty as regards availability of funding from the State and

4 LGA levels for CDTI activities once APOC funding ceases. This argument is supported by the observation that State fund releases stagger over several years. What could be established is that GRBF might release funds for LF and Schistosomiaisis which could benefit CDTI activities since the trio is being integrated. It is not clearly defined how much GRBF will fund CDTI activities post APOC.

. Human resources: Persons involved in CDTI activities were found to well informed, rationally committed and stable. Staff participating in CDTI activities from 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 programme. 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 Nasarawa State CDTI project is not far from being sustainable. There is a sound 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.

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 relate to: . State, LGAs and FLHF/Districts planning systems to fully involve stakeholders in CDTI, and draw up a detailed integrated sustainability health plan that include CDTI activities basing on current ideas; . involving FLHFs/Districts currently not participating in CDTI activities into the project immediately, and do the necessary training in those FLHFs/Districts. . intensify advocacy to all stakeholders in CDTI especially the top level management in the States and LGAs, and the politicians at those levels respectively; and, . planning integrated supervisory visits more efficiently and effectively..

Advocacy activities were carried out at the State, LGA, and Village levels. Two feedback/planning workshops were held – one for the State and one for all the LGAs in Nasarawa State. In each workshop, the evaluation team gave feedback on its findings of the evaluation. The participants discussed these findings in detail. In these workshops, the evaluators finally guided the participants to draw up realistic plans for sustainability of the CDTI activities in their areas of jurisdiction once APOC funding is withdrawn. Drawing up a detailed and realistic plan for sustainability with the involvement of all partners/stakeholders was emphasized.

5 1. Introduction

Nasarawa State is located in central part of the Federal Republic of Nigeria. It has 13 LGAs of which 12 hyper-/Meso-edemic (i.e. Akwanga, Bassa, Bokkos, Jos East, Kanke, Karu, Kokona, Lafia, Nasarawa Eggon, Pankshin, Toto and Wamba) LGAs. It was formerly part of the Plateau State until recently when it was created into a new state. The creation of this new state entailed creation of new positions in the administration, which are being filled.

The GRBF started work in collaboration with the Ministry of Health in the old Plateau State way back in 1991. Since 1992 to March 1998, GRBP was the only NGDO funding Onchocerciasis control activities in the old Plateau State. The WHO/APOC funding started in April 1998, which coincided with the first round of Mectizan distribution in the project area. The programme reached 89% of the targeted 885 villages.

2. Methodology

The evaluation of the Nasarawa CDTI project applied the instrument used to evaluate project sustainability, and therefore presents an opportunity to test the sustainability of this project. In general, all CDTI projects receiving funding from APOC are evaluated while in their fifth year of funding as their progress towards achieving sustainability when APOC funding ceases.

The instruments used to evaluate project sustainability have been field tested and revised. A “John the Baptist” was sent to Nasarawa state a few days to the commencement of the exercise. The purpose of ‘John the Baptist was to:

• introduce the instruments to the Project team; • to select times and dates for all interviews with government officials/policy makers; • plan initial planning and feedback meetings with all relevant staff; • sample sites for the evaluation; • ensure that all necessary documentation are made available to the team; and, • select local team members.

Sampling

Sampling was done purposively as stipulated in the guidelines and sample sites were chosen. Two criteria were applied to obtain sample sites:

The primary criterion was coverage (geographical and therapeutic). This is a measure of impact and, therefore, performance of the CDTI and its sustainability.

The secondary criteria took into cognizance were endemicity to ensure that the sample contains hyper- and meso- endemic areas similar to those identified by results for the project area; and, geographic spread to ensure that the sample contains areas representing the different zone where the project operates, and communities close to urban and in isolated rural settings.

First stage: the average treatment coverage rate for three years (2000, 2001 & 2002) was computed for each of the 7 LGAs, where treatment is currently taking place. However, treatment records for 2 LGAs- Kokona and Toto for the year 2000 had been misplaced and could not be found; and so were not included in the sampling frame.

Second stage: three LGAs (one with high coverage, a second-one having medium coverage and the third with low coverage) were selected. Two health facilities were selected for each L.G.A (one

6 with high coverage, one with low coverage) and two communities were selected for each health facility chosen (one with high coverage, one with low coverage). Details of sampled sites are shown in Table I.

Table I: Details of Sampled Sites: LGA, District and villages for CDTI Sustainability Evaluation in Nassarawa State

S/N LGA Rx (Coverage District Villages (Rx Rate) Coverage Rate) 1 Karu (Hyper) High Uke 1.Ang Dorowa (98.5%) (92.6%) 2. Kutu (88.9%) Karu 1. Gitata (90.2%) 2.Guruku (86.6%) 2 Nassarawa Medium Umme 1. Umme Sarki Eggon (Hyper) (90.5%) (95%) 2. Bakyano (86.3%) Alogun 1. Kagbu A (92.6%) 2. Alogani N (70.7%) 3 Lafia ( Meso) Low Shabu 1. BAD (95.5%) (82.8%) 2. Kwandere (43%) Barkin Rijiya 1. Akuruba (91.6%) 2. Akura (24.8%)

Rx = Treatment

1.3 Basics

Research question: How sustainable is the Nasarawa CDTI project? Design: Cross-sectional, descriptive. Population: The Nasarawa project, including: its’ SOCT with relevant MOH officials; its’ NGDO partners; its’ LGAs with their LOCTs and policy makers; the project villages, their Leaders and CDDs.

Instrument

Questionnaire (see appendix: 'Detailed findings') structured as a series of indicators of sustainability. The indicators are grouped into 9 categories. The instrument assesses sustainability at 4 levels of operation. The instrument guides the researcher to collect relevant information about each indicator.

Source of information: Verbal reports from persons interviewed, supplemented by documentary evidence.

Analysis

Analysis of the data collected from the field involved several stages. The first stage entailed assembly of all the data collected at each level by document study, interviews and observations. The 7 team handled each indicator at a time. Every piece of information generated was recorded into the instrument template for each level.

Second stage: entailed grading of each indicator. Once evidence on particular indicator was generated, the team made a joint decision on the sustainability yardstick ranging from 0-4. The average 'sustainability score' for each group of indicators is calculated, for each level.

Stage three: Once the team graded all the indicators, each numerical score was graded as fully (4), Highly (3), Moderately (2), and slightly (1). These are presented graphically in the text.

Stage four: Having graded the indicators, the team summarized the factual contents. Both negative and positive findings were considered and the totality of the data is presented in this report.

1.4 Team Composition

The team was composed of the following:

1. Sebastian Olikira Baine, Makerere University Uganda, Team Leader. 2. Edith Nkechi Nnoruka, University of Nigeria Teaching Hospital, Enugu. 3. Richard Ndyomugyenyi, National Onchocerciasis Coordinator,MOH, Uganda. 4. William Aliu Istifanus Abubakar Tafawa Balewa University, Bauchi. 5. John Umaru, Plateau /Nasarawa State Project Administrator, GRBP. 6. Alhaji Abbas Dalhatu Federal Capital Territory Onchocerciasis Coordinator

This team was divided into sub teams to evaluate operations at the various levels (see Appendix 1. The team met twice to familiarize themselves with the instruments and to agree on the tentative sub team compositions and schedule. Initial meetings were also held with the State team members to acquaint them with the objectives and expected outcome of the evaluation.

1.5 Advocacy and Planning/Feedback Workshops

Advocacy visits were paid to relevant persons at the State and LGA levels. MOH officials were debriefed at the end of the field visits. Finally, planning/feedback workshops were conducted for the relevant officials at the State and LGA levels. During these planning workshops efforts were made to develop sustainability plans for handling the remaining part of the year when APOC funding ceases in May 2003. Efforts were also made to develop sustainability plans for five years post- APOC funding (see Appendix…..). A time frame of eight weeks was set by the State to enable them develop and send to APOC a five year CDTI sustainability plan; that is endorsed by all partners; State and LGA, to show their commitment to finance it.

1.6 Limitations

Some of the documentations required at the various levels were not available despite prior information.

One of the communities selected was later found to be involved in communal clashes. Some staff with the evaluation team took the evaluation as an opportunity to carry out management duties. Attempts to minimize this tendency were made.

8 Findings and recommendations

1. State level

1.1 Overall grading (on a scale of 0-4)

Sustainability of CDTI at State Level

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1.2 Main findings and recommendations

1.2.1 Planning

There are yearly written plans for the health service incorporating all health intervention programmes including River Blindness Control. Inputs are obtained from all partners. CDTI work- plans seen were mainly for the period of June 2003 upwards. There was also a sustainability plan for all health services at the state MOH level. However, the State has no specific plans for counterpart funding and no post APOC sustainability plans. There were no previous year-to-year plans that are targeted to specific needs of each year.

9 Recommendations: Planning Implementation 1. There should be intensified advocacy to Priority: the Governor, Commissioner of Health and the Commissioner of finance. The 1,2: HIGH advocacy should clearly spell out the consequences of Onchocerciasis, the need for long term treatment and what other Indicators of success partners have been contributing 1. Advocacy visits made and counterpart 2. Year to year plans should always be in funds budgeted for and released in time. place and targeted to specific needs of each 2. Year to year plans targeted to specific year needs developed. Who to take action: NGDO partner country representative, Director of PHC, SPO and SOCTs.

Deadline for completion 1. June 2003 2. May 2003

1.2.2 Monitoring /Supervision

CDTI supervision by the State Onchocerciasis Control Team (SOCT) member is integrated with other health programmes such as Schistosomiaisis and Lymphatic Filariasis (LF) interventions. Problems identified during supervision are immediately addressed However, some state personnel (SOCT) still carryout supervisory visits at lower levels like FLHF and sometimes at community level. Supervisory visits are highly dependent on APOC funds.

Recommendations: Monitoring/supervision Implementation 1. The lower levels (LGA and the FLHF) Priority: should be empowered to undertake CDTI supervision at the appropriate lower levels. 1,2: HIGH 2. Full integration of supervision of CDTI Indicators of success: with other PHC activities is necessary 1. No reports that the state level is supervising at FLHF and community levels. The state receiving supervisory reports from the lower levels. 2. CDTI supervision activities fully integrated with other PHC activities supported by government funds. Who to take action: SPO, SOCT, Director of PHC and Commissioner of Health

Deadline for completion: 1. June 2003 2. Before 2003 distribution

10 1.2.3 Mectizan procurement and distribution

Global 2000 River Blindness Programme (GRBP) uses treatment data to make estimates for Mectizan required by the project for the subsequent year. An application is written through the NOCP Coordinator to Merck Sharpe and Dorme (MSD), and when approval is granted, UNICEF facilitates the clearing in Lagos, while GRBP collects them from Lagos to Jos State.

The Nassarawa project collects the drugs from the GRBP office at Jos and keeps them in their store. GRBP collects at times Mectizan and Albendazole simultaneously at Lagos (port of entry into Nigeria) and these are sent down to State. A register is maintained for all drugs received and collected. This disbursement of Mectizan is dependent on a programme specific approach, which is user friendly, effective and dependable. However, APOC funds are utilized for the delivery of Mectizan from the State to the LGA level.

Recommendations: Mectizan supply Implementation A dependable and sustainable alternative Priority: source of funding for the delivery of Mectizan should be sought. Medium

Indicators of success:

Delivery of adequate quantities of Mectizan by use of alternative sources other than APOC funds. Who to take action: The DPHC at both state and LGA Deadline line for completion: Before the 2003 distribution

1.2.4 Training and HSAM

HSAM and training is targeted to needs of the various LGAs and Policy makers that lack knowledge on CDTI. Costs for training are shared between APOC and GRBP but exact amount contributed by each partner was not clearly shown (It was presented in the records as APOC/GRBP). Occasionally training is integrated with LF and Schistosomiaisis. However, some times training is routinely done and the staff at this level train supervisors and at times CDD. Training had not been targeted until last year.

11 Recommendations: Training/HSAM Implementation 1. Training should be targeted Priority: according to needs 1. 2: HIGH 2. Personnel at state level should not do training at FLHF and communities Indicators of success: Training conducted according to supervisory visits recommendations or after needs assessment No reports that the state level is training at FLHF and community levels. The state receiving training reports from the lower levels.

Who to take action: SPO and SOCT Deadline for completion:

Before 2003 distribution

1.2.5 Integration of Support activities

There is a clear Policy on integration at the top level (NGDO and State) but CDTI is not fully integrated with other health programmes. However, there is some element of integration in carrying out a few health activities, for instance, albendazole and mectizan delivery, and collection of reports are done in a single trip at the State level.

Recommendations: Integration of support Implementation activities

CDTI activities should be fully integrated Priority: into all PHC activities HIGH Indicator of success:

CDTI activities fully integrated with other PHC activities Who to take action: DPHC at both state and LGA levels Deadline for completion Before 2003 distribution

1.2.6 Finances and funding

Initially Carter centre funded all activities but when APOC came on board in 1998, Carter center input decreased. According to the NGDO partner (GRBP) APOC funds are usually received late due to the bureaucratic processes involved. Carter center often puts in money for CDTI activities,

12 which is reimbursed once APOC funds become available. Notwithstanding, Carter Centre is committed to support CDTI once APOC funds ceases.

APOC has got a separate bank account at the NGDO office. APOC approved the sum of $50,000 (5,75 million naira), and MOH approved 3.8 Million Naira counterpart funds in 2000 but has MOH released 340,000 Naira till date. GRBP has released the sum of 2,483,271 Naira, so far, for the period of 2002/2003.

Recommendations: Finance Implementation Adequate funds should be released to Priority: support CDTI activities yearly. HIGH Indicators of Success: CDTI activities continue effectively after APOC. Who to take action Commissioner of Health, DPHC, DP, DF, SPO. Deadline for completion On-going.

1. 2. 7 Transport and other materials resources

All vehicles and materials that are in the custody of the state team are routinely maintained with funds from the APOC. The LGAs maintain all motorcycles and bicycles in their custody. However, bicycles in the field were not adequately maintained once they became non-functional. GRBP retrieves motorcycles they have provided for major repairs. The dependable source of fueling is APOC.

Transport is used for all levels since those at the LGA level are inadequate. Its usage is with proper control and authorization by the appropriate authorities. There are logbooks and appropriate authorities are in the know of vehicle movement. However, there are no servicing/maintenance schedules. Servicing/maintenance schedules of motorcycles purchased by GRBP are kept at the GRBP head office in Jos. The argument on the latter is that it is easier for the GRBP to follow up and ensure maintenance of those vehicles.

The project presently largely relies on the transport facilities that have been received from APOC and GRBP, and there are no specific plans for replacement.

Recommendations: Transport Implementation 1. Seek for an alternative dependable and Priority: sustainable source of running costs of 1,2: MEDIUM vehicles and replacement. Indicator of success 2. Vehicles should be used in an integrated 1.Alternative dependable sources of manner running costs secured. 2. Evidence of integrated use of vehicles. Who to take action: Commissioner of Health, PS, DPHC and SPO. Deadline for completion On-going.

13 1.2.8 Human Resources

There is an adequate number of skilled health personnel who are committed to CDTI activities.

Recommendations: Human Resources Implementation This is commendable and should be Priority: maintained. LOW Indicator of success: Personnel continue to be committed Who to take action: DPHC and SPO Deadline for completion: On-going

1.2.9 Coverage

Therapeutic coverage has been high and relatively stable. Coverage was 72%, 82%, and 80% in the year 2000, 2001and 2002 respectively.

Recommendation: Coverage Implementation This is very good and should be sustained Priority: LOW Indicator of success: Continued high coverage Who to take action SPO, SOCT, DPHC and Commissioner for Health. Deadline for completion: On-going.

14 2. LGA level

2.1 Overall grading (on a scale of 0-4)

Sustainability of CDTI at LGA Level

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2.2.1 Planning

Plans are yearly made at all LGAs, in some cases from various inputs at the LGA. There were plans for CDTI activities for the year 2003 in most of the LGAs. CDTI plans had provisions for all CDTI activities and were made in a participatory manner, including community requirements in some LGAs. However, these CDTI plans were not integrated into the overall health plans.

Recommendations ‘ Planning’ Implementation 1. Make a formal integrated year Health Priority plan with key CDTI activities reflected on 1,2: HIGH it. Indicators of Success: A detailed integrated Health plan 2. It should be participatory in order to containing all CDTI activities should be include the needs of all stakeholders. available. Who to take action? Director PHC and LOCTs Deadline for completion: September 2003.

15 2.2.2 Leadership

There is a focal person in all the LGAs for CDTI (i.e. the LOCT). However, the NGDO partner (GRBP) initiates CDTI activities, and not the management team. There was inadequate awareness about CDTI by the some key officers e.g. Commissioner, Director of Primary Health Care and Disease Control, Director Personnel Management, etc. In most of the LGAs the heads of the Health Units are entirely new and had not fully grasped CDTI activities.

Recommendations: ‘Leadership’ Implementation 1. The LOCT leader should be able to Priority initiate key CDTI activities on their own. 1,2: HIGH 2. There should be system of ensuring that Indicators of Success: new Heads (particularly those of the Health 1. CDTI activities initiated by LOCTs. units) are oriented, updated or if necessary 2. New Heads fully aware of CDTI trained on CDTI activities. activities. Who to take action? 1,2: SPO, SOCT; DPHC.

Deadline for completion: May 2003

2.2.3 Supervision and monitoring

In all LGAs, the reporting process is within the established government system. However, in some cases officers at this level collect reports from the community level, thereby, not empowering district supervisors and frontline health facility staff. Supervision and monitoring of CDTI activities are routinely and frequently (in some cases up to 3 times a month) done. Notwithstanding, in some cases supervision and monitoring is integrated with environmental protection activities.

There is a system for managing problems identified in the field (particularly refusals, selection and replacement of CDDs and other causes of low coverage). The LOCT leader and his team members handle the problems as they arise depending on the staff assigned to the areas. Successes are by commendation; no special awards have been made to these areas. No evidence of written reports was seen in all LGAs visited.

Supervisory checklists are available in a few LGAs but not a shared checklist. Supervisory visits are highly dependent on outside resources.

Recommendations: ‘Monitoring/ Implementation Supervision’ 1. LOCTs should collect data and Priority reports from the FLHF only. 1,2,3: HIGH 2. 2. Funds from dependable sources Indicators of Success: within the LGA should be used for 1. DHS or FLHF staffs deliver reports supervision and data collection at to the LGA level. the lower level i.e. the FLHF. 2. Funds from dependable sources 3. Supervisions should be planned and available for these activities. targeted. 3. Reports indicating planned and targeted Monitoring and supervisions carried out. Who to take action? Director PHC and LOCTs Deadline for completion: May 2003.

16 2.2.4 Mectizan supply

Mectizan is sent down to the LGA based on request from the LGA and the returns from previous treatment cycles. The State makes Mectizan available to the LGAs. Mectizan is stored within the LGA at the Central Medical store. It is dispensed using a project designed control system that is uncomplicated, effective and dependable. There were some Mectizan inventory/registers seen in some LGAs. The forms are supplied by the State and reproduced by LGA.

Shortages of Mectizan were rare and where they were reported replenishments were effected without delays. There were no complaints as to the time the drugs are supplied. For hard to reach FLHF arrangements are in place to send across Mectizan over to them. All Expenses for collection are dependent on APOC funds.

Nevertheless, in some of the LGAs visited, the Director PHC showed lack of knowledge of the CDTI programme. In such LGAs, these officials indicated either having vaguely heard about CDTI or as a project funded by donors and independent of the health system. Mectizan order forms/register were not seen in some of the LGAs. All expenses for collection are dependent on APOC funds.

Recommendations ‘ Mectizan’ Implementation 1. LGAs should ensure that the agreed Priority counterpart funds from the LGA 1,2: HIGH commission are available to enable Indicators of Success: them collect and distribute their Mectizan available on time. Mectizan supplies. Who to take action? 2. Mectizan order/inventory forms Director PHC, LOCTs, Permanent should be made available by LGAs. Secretary Ministry of LGA and Chieftancy. Deadline for completion: September 2003.

2.2.5 Training and HSAM

LOCTs routinely train DHSs every year. In most cases training was done more than once (i.e. twice yearly) and at levels below the FLHF. LOCTs feature in all training sessions in all districts. Training is usually performed for an average of 2 days. Staffs at the FLHF are not empowered to train CDDS in some of the LGAs. Training reports were not seen or available for review but a few IEC and training materials were readily available.

Training is not targeted to needs for each episode. This training is not integrated; the initial training is for both old and new ones, and the second training is refresher training. It is routinely done for all groups i.e. for LOCTs, DHS and CDDs. In Karu LGA, CDDs are trained for Polio and this serves as an incentive, however, training for polio is independent and not integrated with CDTI. Apart from the short orientation workshops on particular programs, there is no specific in-service training for CDTI.

The Head of Department, LOCT Coordinators, and PHC technical committee of the LGA often carry out HSAM at this level annually with the politicians and technocrats. They look out for policy makers who lack knowledge on CDTI and persuade them to accept, own and support CDTI activities and to release funds needed. The Head of Department and LOCTs members at the LGA usually conduct advocacy meetings (HSAM) annually with the politicians and technocrats at this level. Training and HSAM are not integrated and training materials and IEC material are very scanty and not readily available. Notwithstanding, there is no evidence of HSAM plans/programmes nor reports and no plans to address specific problems during HSAM activities. Training /HSAM materials are in place but grossly inadequate. However, the LGA Onchocerciasis team said they carry out the HSAM activities

17 routinely and sometimes in an integrated fashion. Traditional leaders and policy makers of communities that have refused the drugs are routinely targeted and this is often done single handed by the LOCT leader or the Director of PHC.

Recommendations ‘ Training/HSAM’ Implementation 1. Training should be more focused to Priority needs. 1-4: HIGH, 5: MEDIUM 2. LOCTs should empower the FLHF to enable them carry out these Indicators of Success: trainings on their own. They need FLHF are empowered to perform their own not feature in thes training sessions. roles effectively and efficiently. 3. Training should be integrated with Evidence of integrated training. other PHC activities. Improved commitment of the various 4. HSAM activities should be properly stakeholders. planned and effectively implemented. Who to take action? 5. Appropriate HSAM materials Director PHC and LOCT Leader. should be available for use Deadline for completion: December 2003.

2.2.6 Finances and Funding

Costs for CDTI activities are neither quantified at this level nor are they reflected on the Estimates of Recurrent expenditure for each year. Most of the LGA officials have neither clear idea of how much CDTI activity costs annually nor of any cost reduction strategy. However, those involved in CDTI activities have an idea of what each activity is likely to cost. Some LGAs just make arbitrary releases for CDTI activities from service funds for health or drug revolving funds while some of the LGAs are not willing to release much money because they feel APOC/GRBP is responsible. However, in some LGAs there were no budgets, but releases are being made. Relative contributions are not clearly spelt out apart from the arbitrary contribution from LGAs. Proportion of funds for the various activities from the LGAs has remained static in some. Sometimes the amount of funds released was decreasing and in a few places non-existent.

Travel allowances and funds for maintenance of transport are paid during distribution and training by the LGA. Funds are at times released for CDTI activities by most of the LGAs. At the LGA level, the amount of money released by the partner (GRBP) is not known. No budgetary documents were seen at this level. It was not uncommon to find that funding from the NGDO partner (GRBP) was registered as APOC/GRBP, and it was difficult to identify the amount of funds obtained from APOC and GRBP. Relative contributions of the LGA and other partners to CDTI are not clearly spelt out and in most of the LGA officials are unaware of the financial contributions from different partners.

There are no specific or realistic plans on ground for the Post APOC funding period. Occasionally some LGAs were aware of the financial deficits and anticipated to fall back on the drug revolving funds to carry out basic CDTI activities if all fails. No written commitments were available.

There is a control system for approval of funds within the LGA once a proposal for a CDTI activity is made. There is some degree of accountability for funds released at this level. No budgets regarding CDTI activities were seen at LGA level.

18 Recommendations ‘ Finances’ Implementation 1. Appropriate budgeting of CDTI Priority activities should be carried out at 1,2,3 : HIGH this level and should be reflected Indicators of Success: on the section for Health in the Funds readily available and contributions yearly Estimates of Recurrent of each partner clearly spelt . expenditure. Who to take action? 2. A systematic process of regular Ministry of Local Government Commision releases should be worked by the and Chieftaincy Affairs; Director PHC, LGAs. Director Finance, Director Planning and 3. Contributions of the various LOCT leader. partners/stake holders at this level Deadline for completion: should be clearly spelt out. September 2003.

2.2.7 Transport and other material resources

Each LGA was given on an average 1 motorcycle and 5 bicycles supplied by APOC. In some LGAs GRBP also gave some bicycles and motorcycles but the exact number is not known. Motorcycles are still in good order but grossly inadequate. Spare parts of the Honda motorcycles (theses were provided by APOC) are not readily found. Some of the bicycles are out of order at most of the FLHF and need replacement to enable them accomplish further work that needs to be done. Other material resources are in place but grossly inadequate.

Maintenance and fuelling of vehicles are mainly from APOC funds complemented by funds from LGA resources and personal pockets of health workers. Maintenance schedules for the motorcycles were not available. The State in some cases does major repairs on the motorcycles in some LGA. Maintenance is not routine for the bicycles. The staff have ways of coping when vehicles breakdown, so that CDTI activities are not paralyzed or disrupted. In Koru, the motorbikes are used in an integrated manner with environment health programme.

Transport is used mainly at this level and the FLHF level, occasionally it is used at community level. Trips for CDTI activities are sometimes utilized to carry out other PHC activities. Also in Nassarawa Eggon, the LOCT leader utilizes the Schistosomiaisis motorcycle for Onchocerciasis and LF in an integrated manner. Although logbooks are non-existent, the Head of Department is always informed of the movements. Routine management in some LGAs is dependent on the user who also maintains it. There are no dependable plans to affect major repairs or make replacements when they go bad..

Recommendations: ‘ Transport/other Implementation material Resources’ Maintenance and fueling of motorbikes Priority should be properly planned with LGA 1,3: HIGH; 2: MEDIUM funding. Indicators of Success: A system of using logbooks and No shortages with transport; Well- maintenance schedules should be maintained transport. A realistic plan introduced. available for replacement of transport. Realistic plans for the replacement of Who to take action? vehicles should be made. Director PHC, Director Finance, Director Planning and LOCT Leader. Deadline for completion: June 2003.

19 2.2.8 Human resources

Staffs at most of the LGAs are new because these are newly created LGAs (politically created but not yet approved officially by Federal Government). On average there are 3 to 4 persons per LGA for CDTI activities and each is assigned a specific area to supervise. New/unskilled personnel are to be trained by SOCTs or trained on the job by the LOCT Leader.

Staff members are committed, fairly skilled, knowledgeable and respond readily once called upon for CDTI activities. They respond without delays and incentives are fairly good. Salaries are regularly paid on time in all the LGAs. FLHF staff acknowledged the commitment of LOCT coordinators (particularly in the area of training and supervision.).

Recommendations ‘ Human Resources’ Implementation A system should be developed to ensure Priority that new and unskilled personnel are 1: HIGH trained. Indicators of Success: All new and unskilled trained. Who to take action? Director PHC and LOCT leader, LOCTs. Deadline for completion: May 2003.

2.2.9 Coverage

All sub districts and communities are under treatment

In Nasarawa Eggon the therapeutic coverage was 80.9% (2002) In Lafia LGA the therapeutic coverage for 2002 was 80.1% While Karu had a therapeutic coverage of 88.1% for 2002

For the year 2001 the therapeutic coverage was 85.9% for Nasarawa Eggon In the year 2001 the therapeutic coverage was 72.4% for Lafia. Karu had a therapeutic coverage 83.5% for 2001

In 2000 it was 87.3% for Nasarawa Eggon. In 2000, Lafia had a therapeutic coverage of 88% While Karu had a therapeutic coverage of 81%

Generally, all sub-districts are under treatment. Geographic coverage has remained consistently at 100% for all the LGAs. Therapeutic coverages are increasing and stable in some of the LGAs. The values range from 72.4% - 88.1% for the years 2001 -2002 respectively.

Recommendation ‘ Coverage’ Implementation Therapeutic coverage should be improved. Priority 1: HIGH Indicators of Success: Increased therapeutic coverage. Who to take action? SPO and Director PHC Deadline for completion: ON GOING.

20 First line health facility level

This area is taken to mean:

. primarily, the in-charges of the first line health facilities; and . the District health supervisors.

3.1 Overall grading (on a scale of 0-4)

Sustainability of CDTI at FLHF

4

3.5

3 ) 4 / (

t 2.5 h g i e w

2 e g a r 1.5 e v A 1

0.5

0 . n . g ip rv a M s R R e in h e iz A ce l n ag n rs p ct S n ia a r an e u e /H a er m ve l d /S M g in t u o P a g in F a H C Le in in /M or a rt it Tr po on s M an Tr Group Indicators

3.2 Main findings and recommendations

3.2.1 Planning

Three FLHF (Bakyano, Barkin Rijiya and Karu) out of the sampled 6 FLHF were not involved in CDTI and no CDTI work plans were found at these health facilities. Some of the FLHF, which were involved, had written CDTI independent plans which were not integrated into the overall year health plans. The planning system in the LGA is top-bottom and does not call for inputs from the lower levels i.e. plans were not developed in a participatory manner. CDTI plans seen were independently made by the LOCT leaders or DHS and these were passed on to Director PHC for onwards transmission. No copies of integrated and sustainability CDTI plans were seen.

21 Recommendations ‘ Planning’ Implementation 1. Formal integrated year health plans Priority: with key CDTI activities reflected 1,2: HIGH on it should be developed for this Indicators of Success: level. A detailed integrated Health plan 2. It should be participatory to include containing all CDTI activities should be the needs of all stakeholders at this available. level. Who to take action? 3. DHSs should not make these plans DHSs, in-charges of FLHF. single handedly. Deadline for completion: June 2003.

3.2.2 Leadership

Some of the FLHF staff initiates some of the CDTI activities such as monitoring. However, in most cases FLHF staffs do not initiate CDTI activities e.g. planning, Mectizan ordering and training. Some FLHF staffs have accepted the CDTI programme and slightly integrated it into PHC activities, and a few are able to initiate some CDTI activities. Nevertheless, most FLHFs staff involved in CDTI are not empowered to initiate key CDTI activities. Management team and other health staff at the FLHF level have not fully accepted CDTI activities as their own. No senior politician at this level was involved in CDTI activities.

Recommendations ‘ Leadership’ Implementation 1. Empower FLHF staff to initiate Priority CDTI activities. 1,2: HIGH 2. The planning system should be Indicators of Success: reversed and integrated with other 1. Ability to initiate CDTI activities. PHC activities. 2. Evidence of initiating CDTI activities by all FLHF. Who to take action? LOCTs/DHS Deadline for completion: June 2003.

3.2.3 Supervision and monitoring

The FLHF staff supervises CDDs and reports are transmitted within the government system to the LGA. However, in some cases the LOCT leader goes to the communities to collect the reports.

Some of these FLHF initiate supervisory visits, which are done during the distribution of Mectizan and collection of reports. Sometimes supervision is also done during other PHC activities. In most cases supervisory checklists were not available. There was no evidence of action taken based on recommendations in previous monitoring visits.

Not all FLHFs were involved in CDTI activities and no reasonable or convincing explanation was given by FLHF staff to account for their exclusion.

Problems are tackled either through the respective community leaders or the LOCT. Problems, which cannot be resolved at this level, are referred to the LGA and to the State if they cannot be settled at the LGA level.

22 Recommendations: Implementation ‘Monitoring/Supervision’ 1. LOCT leaders should empower the Priority FLHF staff on how to collect 1,2,3: HIGH reports from the communities. Indicators of Success: 2. All Health facilities should be • Evidence of FLHF staff being able involved in CDTI activities. to collect reports in time. 3. Supervisory check lists should be a • Evidence of initiating CDTI ‘shared type’ or integrated activities by all FLHF. checklist, so that it could be used Who to take action? for most PHC activities carried out LOCTs/DHS at this level. Deadline for completion: June 2003.

3.2.4 Mectizan procurement and distribution

Adequate amounts of Mectizan were obtained and supplied to those FLHFs involved in CDTI activities for the past 3 years. However, no order forms were seen. Mectizan is kept for 2-7 days in the district stores while being distributed to the FLHF level. At these FLHFs, Mectizan is kept at the central store for about a week while being distributed to the CDDs. In rare cases, Mectizan transportation costs from LGA to the FLHF are met by the LGA.

Recommendations ‘ Mectizan’ Implementation Priority LGA or any other dependable sources HIGH should bear the cost of yearly mectizan Indicators of Success: collection and distribution at the FLHF • Funds readily available for level. collection of mectizan. • Evidence of dependable source of funds for yearly mectizan collection at this level. Who to take action? Director PHC, Director Finance LOCTs/DHS. Deadline for completion: September 2003.

3.2.5 Training and HSAM

Training is routinely carried out using training materials such as brochures, posters and training manuals. Sometimes training and HSAM are targeted, and attention is given to areas of deficiency. Training for CDTI is at times integrated with that of LF. At some FLHFs, retraining is also done for older CDDs with problems.

In some cases HSAM is carried out in specific areas of need based on reports from the field. They use posters and brochures for HSAM in specific areas of need based on reports from the field. Although HSAM activities are carried out, they are neither properly planned nor targeted in most cases. No detailed HSAM plan was seen or available for examination and in some cases the frequencies of HSAM activities were too few.

23 Recommendations ‘Training/HSAM ’ Implementation 1. Training should be more focused to Priority areas of need. 1,2: HIGH 2. HSAM should be properly planned and Indicators of Success: effectively carried out targeting the in 1. Reports of targeted training. coming policy markers. 2. Commitment from the Policy /Decision makers to support CDTI even below this level. Who to take action? Director PHC, Director Finance LOCT leader, /DHS. Deadline for completion: June 2003.

3.2.6 Financing and funding

Releases of funds for health service activities at FLHF level are based on demand and availability of funds at LGA level. There is no separate budgetary allocation for CDTI activities at the LGA level. LGAs do not control funds, however, they occasionally offer assistance to CDTI activities.

Recommendations ‘Finances ’ Implementation 1. Clear budget containing key CDTI Priority activities for the FLHF should be 1,2: HIGH made. Indicators of Success: 2. Regular fund releases for the CDTI 1. FLHF health budgets available. activities at the FLHF by the LGAs. 2. Evidence of releases made by LGAs towards CDTI activities at this level. Who to take action? Director PHC, Director Finance LOCT leader, /DHS. Deadline for completion: September 2003.

3.2.7 Transport and other material resources

Motorcycles or bicycles available at some FLHF were provided by APOC and GRBP. Most health districts had one motorcycle provided by the APOC. Motorcycles in most cases are not maintained by LGA. The officers who use them normally maintain them using their own funds. One APOC motorcycle had an accident in October 2000 and has not been repaired at the time of this evaluation exercise (2003). NPI and APOC motorcycles are used for all PHC activities. Trips are made after securing verbal approval for both CDTI and other PHC activities. No logbooks are kept.

Material resources such as posters, brochures and calendars were supplied to FLHF using APOC funds. IEC materials were also found to be inadequate.

Overall, transport and other material resources are now deemed to be inadequate and the situation is anticipated to be worse after APOC. No provision /plan to maintain or replace transport and reprint posters, etc, has been made by any LGA yet. The officers are not aware of any plans.

24 Recommendations ‘Transport and other Implementation materials ’ 1. Adequate transport and other Priority materials should be provided for by 1,2: HIGH the LGAs or any other dependable Indicators of Success: organization. 1. Availability of adequate transport 2. A realistic plan for replacement and and other materials at FLHF level. maintenance of transport should be 2. Availability of a realistic plan for developed. replacement and maintenance of transport and material resources. Who to take action? Director PHC, Director Finance LOCT leader, DHS/FLHF in-charges. Deadline for completion: December 2003.

3.2.8 Human resources

The staffs are reasonably stable. They stay at a station for 2-3years before transfer. They are adequate in terms of numbers, 4-5 staffs at each FLHF, and are skilled to perform general health service activities. Nonetheless, the greater majority of FLHF staff is not trained or skillful on CDTI activities. The job descriptions for FLHF staffs are too rigid to encourage integration of roles and responsibilities.

Recommendations ‘ Human Resources’ Implementation 1. FLHF staff should be empowered to Priority carry out CDTI activities. 1,2: HIGH 2. Job descriptions of FLHFs should Indicators of Success: be redesigned to include integration 1. All FLHF staff exhibited more of CDTI activities into other health knowledge and skills on CDTI activities. activities. 2. A revised job description for all FLHF staff. Who to take action? State MOH, Director PHC/Disease control, SPO, Director Finance, LOCT leader,DHS. Deadline for completion: June 2004.

25 3.2.9 Coverage

Most communities have been fully treated. However few communities have not been treated due to the shortage of drugs.

Recommendations ‘Coverage ’ Implementation Sustain and improve coverage. Priority HIGH Indicators of Success: All households reached and treated. Who to take action? DPHC, SPO. Deadline for completion: ON GOING.

4. Community level

4.1 Overall grading (on scale of 0-4)

Sustainability of CDTI of CDTI at Community Level

4

3.5

3 ) 4 / (

t 2.5 h g i e

w 2

e g a r 1.5 e v A 1

0.5

0 . ng ip rv an AM es s. ge ni sh pe tiz S nc e ra an er u ec H a n R ve Pl ad /S M in a o e ing F m C L or Hu nit Mo Group of indicators

4.2. Main findings and recommendations 26 4.2.1 Planning

Census update is routinely done after training and before Mectizan distribution. Registration is updated during treatment. Refusals and absenteeism are visited more than once as an attempt to help them accept and receive Mectizan.

Community leaders mobilize and sensitize the communities for distribution. However, in some communities particularly in Lafia LGA, census is not updated regularly thus leading to inaccurate estimation of the amount of Mectizan tablets required.

Recommendations: Planning Implementation Updating of census regularly and using it Priority: to order adequate amount of Mectizan HIGH

Indicator of success: Census updated and no reports of shortage of Mectizan in all the communities under CDTI

Who to take action: CDDs, In-Charge of FLHF, and village Heads/village health committees Deadline for completion: On going

4.2.2 Leadership

Community leadership is taking charge of distribution, mobilization and sensitization of the communities. Problems are identified particularly refusals, for instance, the refusals are followed up by the village leaders and encouraged to take the Mectizan. Most communities voluntarily give the CDDs between 5-10 Naira per household or in-kind contributions such as yams, maize or provide free of cost labour on the CDDs’gardens for those families which cannot afford cash incentives. The community is fully aware that the incentives provided are voluntarily made and not the determinant of receiving Mectizan.

The community members are involved in most cases with selection/changing of CDDs. The CDDs are selected based on a criteria devised by the community leader. Timing is not really determined by communities. It is dependent upon the time Mectizan arrives at the State. Generally, the decision of the community leader on the mode of distribution and selection of CDDS is taken as the final say for most of the communities.

Villagers perceive Mectizan as a very important drug for improved vision, strength, expelling worms and stopping skin rashes/itching. They were aware that the drug has to be taken for a long time (mentioned 10-15 years). In Gitata, the communities are so keen on the drug because one known barren woman had conceived and given birth after taking mectizan.

Recommendations: Leadership and Implementation

27 ownership 1. The community should decide Priority: when they want to be treated. This 1,2: HIGH decision should be adhered to. Indicator of success: 2. The community should be 1. The communities receiving empowered to take decisions mectizan treatment during their regarding CDTI activities preferred period. 2. Communities full participating in decision-making regarding CDTI activities. Who to take action: FLHF staff, Community members FLHF staff, Community leader Deadline for completion: Before 2003 distribution

4.2.3 Supervision/Monitoring

CDDs send registers to the FLHF. The registers were fairly well kept and filled by the CDDs. Reports get back to the LGAs from the communities through the in-charges of FLHF/District health supervisors. In some communities the leaders make arrangements for transportation to enable CDDs deliver the reports to the FLHF. However, in some communities in Lafia LGA, the LOCT coordinators bypass the FLHF and take Mectizan to the CDDs and collect the reports from them after treatment.

Recommendation: Monitoring Implementation The reporting should follow the established Priority: government reporting system 1: HIGH Indicator of success: LOCT staff no longer collecting reports from the CDDs. Who to take action: LOCT, FLHF staff, CDDs and village leaders Deadline for completion: Immediately after 2003 distribution

4.2.4 Mectizan procurement and management

Village leaders are aware that census update or mechanisms for determining the actual required amount of Mectizan should be in place. Calculations were based on quantity of Mectizan used on the previous treatment plus census update. This is sometimes done by the CDDs and in most instances by District Onchocerciaisis Coordinators. However, in some cases the rational basis for ordering of mectizan is not known by CDDs. In some cases, there was inadequate stock of Mectizan because the census update was not done properly.

Mectizan supplies have no fixed time of arrival to the communities since this is determined by availability of Mectizan at the LGA. Some CDDs fetch the mectizan from the FLHF but in some situations the in-charges or the LOCT coordinators deliver it to the CDDs.

Recommendations: Mectizan procurement Implementation

28 and management 1. CDDs should be trained on census Priority: update and rational basis for ordering Mectizan 1, 2: HIGH 2. Communities should be empowered Indicator of success: on the timing of treatment 1. CDDs trained on census update and using the census data to order Mectizan. 2. Communities getting Mectizan treatment at their preferred time of treatment Who to take action: FLHF and CDD FLHF Deadline for completion: Before 2003 distribution

29 4.2.5 HSAM

Community leaders and CDDs sensitize and mobilize relevant decision makers, and persuade those community members who refuse to take Mectizan to do so. Promotional materials are very scanty within the community and in some cases not available at all.

Recommendations: HSAM Implementation 1. Production of more IEC materials Priority: 2. HSAM should be targeted to 1.2: HIGH needs Indicator of success: 1. All communities having adequate IEC materials 2. Reduced refusal and absenteeism rates

Who to take action: DPHC and SPO FLHF, CDDs and Community leadership Dead for completion: 1. By June 2003 2. On going

4.2.6 Finances and funding

Communities are aware and contribute voluntarily between 5 and 10 Naira or other forms of contributions such as yams, for their CDDs. They are appreciative of the fact that resources come from outside. Some communities also provide pencils and registers to facilitate CDDs work. However, support to CDDs in form of incentives is minimal in some FLHF catchment areas largely due to the misconception that CDDs are paid by Government and, therefore, some community members are reluctant to support them but this does not influence their receiving of Mectizan.

Recommendation: Finance Implementation HSAM should be intensified at the Priority: community level. 1. HIGH Indicators of success: Increased community support to CDDs clearance of misconceptions. Who to take action FLHF and Community leader Deadline for completion As necessary .

4. 2.7 Human Resources

Some of the communities have only one CCD 100 households. In other communities, CDDs cover two additional communities i.e. more than 100 households. In some communities one CDD treats about 1700-2260 persons. On an average the CDDs travel between 1 and 2 km but in most cases the houses are in clusters.

30 CDDs are skilled as judged by their knowledge on exclusion criteria, management of side effects, and knowledge of the importance of census update in some communities. CDDs are willing to continue doing their job. In part, participation in CDTI activities helps CDDs to get political appointments and so they readily take up this job of a CDD. Some CDDs have been involved in CDTI activities for 4-9 years. However, some CDDs think that the government should assist them with incentives because what the communities contribute towards their incentives is not adequate.

Recommendation: Human Resources Implementation More CDDs should be trained to attain a Priority: ratio of 1 CDD: 20 households or 2 CDDs: 1. HIGH 250 people Indicators of success: Adequate no. of CDDs trained Who to take action: In-charge of FLHF/DHS and LOCT leader. Deadline for completion: Before the 2003 distribution

4. 2. 8 Coverage

All households and areas in some of the communities are not treated due to shortages of Mectizan. Notwithstanding, therapeutic coverage for the entire villages sampled has been impressive over years. Rates for five villages have been on steady increase from 58.8% to 95% (Alogani, Kagbu, Kwaandere, Ang.Dorowa and Kutu). Six of the villages (Umme sariki, Akruba, Akura, Shabu, Gitatata and Gurku) had the coverage values fluctuating.

Recommendations: Coverage Implementation 1. Census should be updated and used to Priority: order adequate amount of drugs 1. HIGH Indicators of success: Shortages no more experienced Who to take action: 1. FLHF, CDDs and community leaders. Deadline foe completion: 1. Before 2003 distribution.

5. Overall sustainability grading for the Nasarawa CDTI project

The team examined the situation in the project as a whole and according to the nine indicators of sustainability that were investigated in this evaluation. Following the analysis of the findings, the level of sustainability of the Nasarawa CDTI project is judged to be as follows:

Level of sustainability Description Moderate The Nasarawa CDTI project is potentially sustainable i.e. not far from being sustainable provided the project staffs undertake the recommended or remedial actions.

31 6. A vision for the future

The potential threat to sustainability will become evident after APOC funding has ended. Whatever will happen is beyond the scope of the instruments used in this evaluation. Health staffs involved in CDTI activities currently receive salaries from the government but these salaries are too small to meet their basic family needs. As a result they have to find other means to bridge the financial gaps as an attempt to meet their basic family needs. These means may range from less input into CDTI activities (in terms of time and commitment) to dropping out completely when salary top-ups from APOC cease).

Workers in the State Onchocerciasis Control Teams (SOCTs) in Nigeria were quite open about this, perceiving an opportunity for themselves in the upcoming lymphatic filariasis control programme, and planning enthusiastically to limit their future involvement in CDTI.

Top management at the State and LGA levels were aware of the extent to which this event poses a threat to sustainability, their options for countering it appear limited. Since it is not possible to maintain financial incentives indefinitely, the only alternative is to thoroughly and timely integrate CDTI programme with other PHC interventions. The importance of integration has to be emphasized.

32 APPENDIX I

Advocacy and feedback/planning meeting report.

SUSTAINABILITY OF CDTI IN NASARAWA LGAs

Feedback/Planning Meeting Report – LGA level .

The workshop started at 12.30 pm with a welcome address by the Chairman. Participants and Facilitators thereafter introduced themselves. An introduction to the feedback / planning workshop and CDTI overview was then given by Mr. A.A. Umar the SPO. After this presentation, Dr. S. O. Baine presented a paper on the background to CDTI and the concept of sustainability. The paper focused on indicators that are important for evaluating whether a CDTI project is sustainable. This presentation was followed by one presented by Dr. (Mrs.) E. Nnoruka on the methodology adopted for the evaluation of the Nasarawa project. The highlight of the paper included a “John The Baptist” visit which was to determine the areas to be covered during the evaluation. Based on indices of coverage, 3 LGAs (Karu, Nasarawa-eggon, Lafia) were chosen. From these LGAs, 6 health districts and 12 villages were selected for the exercise. Thereafter, Dr. W.A. Istifanus, Mr. John Umaru Drs. E. Nnoruka and R. Ndyomugyenyi presented summaries of findings at the community, District (FLHF), LGA and State levels respectively after which there were discussions on problems identified at the four levels. Dr. Istifanus led this. Participants then worked in three groups and solutions to the problems identified were proposed and feed back from each group was taken. Dr. Istifanus and Mr. John Umaru facilitated this exercise. The workshop was adjourned to 3.30 to allow participants a lunch break.

The afternoon session commenced at 3.30 pm after lunch with a presentation on “rethinking roles of the different levels and partners” by Dr. E. Nnoruka. The presentation mainly focused on a post APOC role of the State. It was stressed that since APOC was pulling out of CDTI activities, the LGAs needed to reconsider: the roles of the different partners; addressing the problems identified during the sustainability evaluation; and to focus on the major objective post APOC which is to maintain a geographical coverage of not less than 100% and a therapeutic coverage of not less than 65%. For these coverages to be sustained it was emphasized that the LGAs’ major role should be to make Mectizan available to the communities. To facilitate this, the LGAs’ basic activity was highlighted. A checklist of items/activities APOC would not fund after withdrawing from the project was given as well as areas where some funding may be done.

A year plan was developed and they were also asked to develop a five-year plan highlighting the key activities that must be done to get the CDTI activities going in the absence of APOC funding. They were also asked to identify alternative, dependable sources of funding for the post APOC era. Participants were also requested to develop a thorough budget justification for the activities to be undertaken. Finally, they were requested to develop a time frame suitable for them develop and present signed plans, which should be submitted to the State.

The workshop was attended by 33 people (see attached attendance list). The degree of participation was very high. Participants were fully engaged in discussing the ideas/ issues generated by the presentations and a year plan for sustainability was developed. The workshop was thereafter closed.

33 SUSTAINABILITY OF CDTI IN NASARAWA STATE

Feedback/planning meeting report – State level

The workshop started at 12.15pm with a welcome address by the Chairman. Participants and Facilitators thereafter introduced themselves. An introduction to the feedback / planning workshop and CDTI overview was then given by Mr. A.A. Umar the SPO. After this presentation, Dr. S. Baine presented a paper on the background to CDTI and the concept of sustainability. The paper focused on indicators that are important for evaluating whether a CDTI project is sustainable. This presentation was followed by one presented by Dr. (Mrs.) E. Nnoruka on the methodology adopted for the evaluation of the Nasarawa project. The highlight of the paper included a “John The Baptist” visit which was to determine the areas to be covered during the evaluation. Based on indices of coverage, 3 LGAs (Karu, Nasarawa-eggon, Lafia) were chosen. From these LGAs, 6 health districts and 12 villages were selected for the exercise. Thereafter, summaries of findings at the community, District (FLHF), LGA and State levels were presented by Dr. W.A. Istifanus, Mr. John Umaru Drs. E. Nnoruka and R. Ndyomugyenyi respectively after which there were discussions on problems identified at the four levels. Dr. Istifanus led this. Participants then worked in three groups and solutions to the problems identified were proposed and feed back from each group was taken. Dr. Istifanus and Mr. John Umaru facilitated this exercise. The workshop then closed for lunch.

The afternoon session commenced at 4.46pm after lunch with a presentation on “rethinking roles of the different levels and partners” by Dr. E. Nnoruka . The presentation mainly focused on a post APOC role of the State. It was stressed that since APOC was pulling out, the State needed to have a rethink with respect to the roles of the different partners, addressing the problems identified during the sustainability evaluation and focus on the major objective post APOC which is to maintain a geographical coverage of not less than 100% and a therapeutic coverage of not less than 65%. For these coverage to be sustained it was emphasized that the States major role would be to make Mectizan available to the communities. To facilitate this, the States basic activity was highlighted. A checklist of items / activities APOC would not fund after withdrawing from the project was given as well as areas where some funding may be done.

A year plan was developed and they were also asked to develop a five-year plan highlighting the key activities that must be done to get the CDTI activities going in the absence of APOC funding. They were also asked to identify alternative, dependable sources of funding for the post APOC era. Participants were also requested to develop a thorough budget justification for the activities to be undertaken. Finally, they were requested to develop a log-frame suitable for them develop and present signed plans, which should be submitted to APOC through the NOCP.

The workshop was attended by 21 people (see attached). The degree of participation was very high. Participants were fully engaged in discussing the ideas/ issues generated by the presentations and a year plan for sustainability was developed. The workshop was thereafter closed.

34 APPENDIX II

Sustainability of CDTI in Nasarawa State

Feedback/Planning Meeting State level

AGENDA

Item Activity Time Facilitator 1 Registeration of Participants 8.30 - 10.00 SOCT Members 2. Opening prayers 10:00 – 10:05 To be appointed 3 Introductions 10.05 – 10:15 A A Umar 4 Welcome Address 10:15 – 10:20 Director PHC/Disease Control 5 Introduction to the workshop ( an overview 10:20 – 10:40 A A Umaru of CDTI) 6 What are the objectives 10:40 – 11:00 Dr. S. Baine What is sustainability 7 Methodology 11:00 – 11:15 Dr E Nnoruka 8 “Feedback” on achievements, issues and lessons from the Nasarawa evaluation on sustainability of CDTI Summary of findings at Community level. 11:15- 11:30 Dr Istifanus Summary of findings at District level (FLHF). 11:30- 11:45 Mr. John Umaru Summary of findings at the LGA level Summary of finding at the State level 11:45 – 12:00 Dr E Nnoruka 12:00 – 12:15 Dr Ndyomugyenyi 9 Discussions on problems identified 12:15 – 12:30 Dr Istifanus . 10 What could be the solutions to these 12:30 – Alhaji Abass/ John problems to identified 1:00pm Umaru Group work Group 1: One set of problems Group 2: One Set of problem Group 3: One set of problem 11 LUNCH 1:00– 2:00 9 Feedback from group work 2.00 – 2:30 Team leaders for Group Discussions 10 Rethinking roles of the different levels and Dr. Nnoruka. partners 2:30 – 4:00 Planning for sustainability in this project

13 Plenary sessionb 4:00 – 4:30 Dr Richard N

14 The way forward: implementing 4:30 – 5:00 Director, PHC sustainability (what to do now) GRBP Rep- John Umaru, Dr. Baine 15 General matters 5:15 – 5:30 Baine/Abass 16 Closing Prayers 5:.30 To be appointed

Rappateurs: John Umaru (morning sessions); and, Dr W. Istifanus (afternoon sessions).

35 Sustainability of CDTI in Nasarawa State

Feedback/Planning Meeting LGA Level 26th Febuary 2003

AGENDA Item Activity Time Facilitator 1 Registeration of Participants 8.30 - 10.00 SOCT Members 2. Opening prayers 10:00 – 10:05 To be appointed 3 Introductions 10.05 – 10:15 A A Umar 4 Welcome Address 10:15 – 10:20 Director PHC/Disease Control 5 Introduction to the workshop ( an overview 10:20 – 10:40 A A Umaru of CDTI) 6 What are the objectives 10:40 – 11:00 Dr. S. Baine What is sustainability 7 Methodology 11:00 – 11:15 Dr E Nnoruka 8 “Feedback” on achievements, issues and lessons from the Nasarawa evaluation on sustainability of CDTI Summary of findings at Community level. 11:15- 11:30 Dr Istifanus Summary of findings at District level (FLHF). 11:30- 11:45 Mr. John Umaru Summary of findings at the LGA level Summary of finding at the State level 11:45 – 12:00 Alhaji Abbass 12:00 – 12:15 Dr Ndyomugyenyi 9 Discussions on problems identified 12:15 – 12:30 Dr Istifanus . 10 What could be the solutions to these 12:30 – Alhaji Abbass problems to identified 1:00pm Mr. John Umaru Group work Group 1: One set of problems Group 2: One Set of problem Group 3: One set of problem 11 LUNCH 1:00– 2:00 9 Feedback from group work 2.00 – 2:30 Team leaders for Group Discussions 10 Rethinking roles of the different levels and Dr. Nnoruka. partners 2:30 – 4:00 Planning for sustainability in this project

13 Group work for Sustainability Planning. 4:00 – 4:30 Dr Richard N

14 The way forward: implementing 4:30 – 5:00 Director, PHC sustainability (what to do now). GRBP Rep- John Umaru, Dr. Baine 15 General matters 5:15 – 5:30 Baine/Abass 16 Closing Prayers 5:.30 To be appointed

Rappateurs: John Umaru (morning sessions); and, Dr Istifanus (afternoon sessions).

LGA level workshop programme

36 Facilitators for small groups in Session 10

Group 1: Planning, Training, Mobilization and Mectizan Dr Istifanus John Umaru

Group 2: Monitoring, Supervision, Leadership Dr Baine Alhaji Abass

Group 3: Finance, other Resources, and Transport

Dr Richard Ndyomugyenyi Dr Nnoruka

Assignment: Group work: Identify solutions to the problems Identify resources needed for these solutions Identify resources available Identify other dependable sources for resources Identify Time Frame

FACILITATORS FOR LGA GROUPWORK: NASARAWA STATE. Session 13

Group I

LGAs

Akwanga Karu Toto Facillitators:

Dr Richard Ndyomugyenyi Mr John Umar Mr Jacob Damboi

Group II

LGAs

Kokona Lafia

Facillitators

Dr Baine Alhaji Abass Mrs Saratu Mbaratan

Group III

LGAs

37 Nasarawa Eggon Wamba

Facillitators

Dr W Istifanus Mr A A Umar Mr Patrick Obele

38 APPENDIX III

List of people interviewed

LGA NAME DESIGNATION LAFIA Alh. Umaru Bako Village head of Shabu Elizabeth Abimuku FLHF i/c Kwandere PHC Ibrahim Alakayi DHS Alh. Abubakar Habu Madawakin Kwandere Mohammed Galadima CDD Shabu Aliyu S. Agbo “ Abubakar Umar “ Isa Galadima CDD Kwandere Mohammed Isa “ Ibrahim O. madaki “ Umaru Mairiga “ NASARAWA-EGGON Mr. Ishsya O. Idamaku Village Head Kagbu-A Alh. Mohammadu Dauda DH Alogani Mr. Victor Allu DHS Alogun Health District Mrs. Paulina Agushaka FLHF i/c Kagbu-B Mr. Yohanna Alahupu CDD Kagbu Mr. Obadiah bala CDD Alogani Mr. Anthony Peter “ Mr. Alogakho Wahda “ KARU Mal. Baba Makeri Village Head Kutu Mal. Ibrahim haruna Village Head Ung. Dorwa Mr. Chindo Mohammed DHS Uke PHC District Mr. Aminu Auta CDD Kutu Mr. Sarki Danjuma “ Mr. Maikwato “

39 APPENDIX IV

LGA Workshop CDTI 25th February 2003

S/N NAMES POSITION STATE/LGA SIGN. 1 Alh. A. M. Kauara DPM/SHG LAFIA MINICIPAL 2 Alh. Aris Musa DFS - - - 3 S.H. Envulunzaa D. DPHC AGIDI LGC 4 Abdullahi Moh'd Umar LOCT LAFIA 5 Joshua D. Bawa LOCT TOTO LGC 6 Jerry Y. Aimiku LOCT AKUN LGC 7 Ambi A. Azagaku DDPM AGIDI LGC 8 Sguaibu A. Ojah DPM/SEC LAFIA NORTH 9 Aliyu A. Sabasu DPHC LAFIA CENTRAL 10 Isa M. Mohammed A.DC LAFIA CENTRAL 11 Hojio H. Danjuma DPHC TOTO 12 Mrs C.L. Atama DPHC PANDA 13 Jamila Bai DPHC KOKONA 14 Godwin S. Otso SLOCT KOKONA 15 Habiba Abdullahi DFS AKW. WEST 16 Sunday Esson I. LOCT N/EGGON 17 Haj. Hauwu A. Idris DPHM/SEC GADABUKE LC 18 Esson A. Yerima CO/DCO GRBP OFFICE LAFIA 19 Musa Dangana DPHC/DC MOH LAFIA 20 Sunday Ogah SOCT MOH 21 Gladys Ogah DESK OFFICER LF/SCH., MOH LAFIA 22 Emma B. Nanar SLET MOH LAFIA 23 Patrick B. Obele SOCT N/STATE MOH LAFIA 24 Francis Akwash DPHC MLGC LAFIA 25 Chris Shabaya DDPHC/SEC MOH LAFIA 26 Yarima Engom SLET MOH LAFIA 27 Jacob DANBOYI MOH/SOCT 28? 29? 30? 31? 32? 33?

40 APPENDIX V

CDTI SUSTAINABILITY PLAN OF ACTION FOR NAASARAWA STATE 2003

S/N ACTIV. OBJ. PERS DUR REQUI. COST PER UNIT INDIC. FOR TOTAL SOURCES OF FUND RESP SUCCESS COST STATE G OTHERS R B P 1 Planning To develop SPO, 18TH Jan. 12 Biros, 15 x 12 = N180 Availability of scheduled CDTI SOCTs, 2003 12 10 x 12 = N120 Complete out activities to be DPHC, 1 Day pencils, 500 x 2 = N1, 000 line of CDTI N3,340 N3,340 - carried out in the DPRS, 2 A4 30 x 24 = N720 activities. Plan year 2003 DAT, paper 50 x 12 = N600 of action DIR. 1 crate of 60 x 12 = N720 FIN. mineral 16 meat pie 12 bottles of swan water 2 Advocacy (a) To solicit for NOCP, 7th – 10th 2 Video 200 x 2 = N400 Adequate support to the NGDO April films support, programme from Hon. 2003, Flyers budgeting and N92,020 N30,000 N state executives Com., 3 Days Leaflets release of funds 62 (b) To create PS, Handouts. 1 x 3 x 5000 = N15, 000 for CDTI ,0 awareness among DPHC 1 NOCP 1 x 3 x 5000 = N 15,000 implementation 20 the existing LGA 1 NGDO 1 x 3 x 5000 = N15, 000 executives SPO, 1 COMM. 1 x 3 x 5000 = N15, 000 (c) To advocate SOCT 1 PS 1 x 3 x 5000 = N15, 000 all newly elected 1 DPHC 1 x 3 x 2000 = N6, 000 political figures 6th – 8th 1 SPO 1 x 3 x 1500 = N4, 500 on CDTI August 1 SOCT 60 x 30 x 3 tanks = N5, 400 programme 2003 Fuel 1 x 30 x 24 = N720 NOCP 3 Days Refreshm NGDO ent

41 3 Training (a)To train new SPO, March 10- 2 D/paper 400 x 2 = N800 List of programme staff SOCT 14 2003 35 Biro 15 x 35 = N525 participants and on CDTI 35 pencil 10 x 35 = N350 report of training strategies. 35 Erasers 5 x 35 – N175 (b) To train all 35 5 x 35 = N175 LOCT, DHS, Sharpener 10 x 35 = N350 N42,575 N10,000 N32,575 HFS on CSM and ‘’ s 30 x 35 x 4 = N4,200 SHM. SOCT 35 Files Refreshm 20 x 35 x 4 = N2,800 ent (Mineral) 1 x 4 x 2000 = N8,000 Biscuits 3 x 4 x 1500 = N18,000 PERDIE 60 x 30 x 4 Tanks = N7,200 M: 1 SPO 3 SOCTs Fuel Flip charts Handouts 4 Collection and To collect SPO, 29th -30th Vehicle Availability of Storageof 2,138,173 tablets March Fuel 50 x 60 2 x 50 = N6, 000 Mectizan in the Mectizan tablets of Mectizan from 2003 Perdiem 4100 x 2 = N8, 200 state store. N14,200 N14,200 - - NGDO partner for Personnel the state. Store storage 5 Supervision & To carry out spot SOCTs 12th – 16th Vehicle High coverage monitoring check on the April- Fuel 50 x 60 3 x 50 = N9, 000 and accurate activities of May Per diem 1500 x 3 x 4 = N18, 000 records of N27,000 N27,000 - - LOCT, DHS and 4 day treatment report visit few communities for quality control. 6 Production of To produce IEC SPO, 12th – 31st 500 200 x 500 = N100, 000 Availability of IEC materials materials and SOCTs May 2003 Bronchure 250 x 200 = N50, 000 IEC materials and procure all 200 flip 200 x 150 = N30, 000 and stationeries N180,000 N100,00 N80,000 procurement of necessary chart in the project. 0 stationeries. stationeries 200 required by the calendar project.

42 7 Maintenance of To keep all MOH Jan.-Dec. 5 tyres 5 x 12,000 = N6, 000 Vehicle in good vehicles vehicles road 2003 5 tubes 5 x 2,500 = N2, 500 condition for worthy for 12 2 gakkon engine oil utilization N52,300 N50,000 N2,300 - effective servicing 1200 x 2 12 = N28, 800 utilization. In the 12 x 250 = N3, 000 field. Fuel filter 1000 x 12 = N12, 000 Workman ship 8 Stake Holders’ To carry out stake SPO, 18th June 12 pencil 12 x 120 = N1, 440 List of meeting holders’ meeting DPHC 2003 3 Biro 3 x 750 = N2, 250 participants and with all CDTI 1 day 5 crates 5 x 60 = N3, 000 minutes of implementing Fuel 180 x 50 = N9, 000 meetings. N19,690 N19,690 - - partners in the SPO 1 x 2000 = N2, 000 state to discuss DPHC 1 x 2000 = N2, 000 sustainability. 9 Annual State To review CDTI SPO, 15th 18th 2 D/paper 400 x 2 = N800 List of CDTI Review implementation in DPHC July 35 Biro 15 x 35 = N525 participants and meeting the state with the 3 DAYS 35 pencil 10 x 35 = N350 report of the LGAs and NGDo 35 Erasers 5 x 35 – N175 review meeting. N29,675 N29,675 - - partners 35 5 x 35 = N175 Sharpener 10 x 35 = N350 s 1 x 3 x 5000 = N15, 000 35 Files 1 x 3 x 4100 = N12, 300 1 DPHC 1 SPO Funds, stationary 10 APOC/ZOTF To attend all SPO 15th – 16th 1 SPO 2 x 4100 x 1= N8, 200 Availability of Review APOC and zonal April Fuel 60 x 50 x 2= N6, 000 reviewed meetings CDTI review & Biro 1 x 1 x 15 = N15.00 technical reports N14,410 N14,410 - - meetings to 22nd - 23rd Pencil 10 x 1 x 1 = N10.00 for submission to present reports. October Erasers 1 x 5 x 1 = N5.00 APOC 2003 Sharpners 1 x 5 x 1 =N5.00 Joter 250 = N175

11 Treatment of To ensure at least SOCTs, 19th – 20th Forms 60% of those conflict areas in 60% treatment % March Mectizan living in conflict the state coverage in 2003 2 x 50 x 45 x 3 = N7, 500 areas treated N10,500 N10,500 - conflict LGA of Motorcycl 1 x 60 x 50 = N3, 000 Toto es Vehicle

43 12 Communication To enable no State On-going Nitel N55, 000 Functional State - access to the Nipost of the Facilities N57,000 N57,000 donor Fax N2, 000 13 Procurement of To ensure buying SPO 30th 7 m/c 1x120,000 x 7 = N840, 000 logistics of motorcycles & SOCTs August 17 1x20, 000 x 17 =N340, 000 Bicycles for the 2003 B/cycles 1,180,000 180,000 1,000,00 LGA 0 TOTAL 1,247,500 20,000 55,000

OVER ALL TOTAL 1,722,710 488,815 1,233,89 5

______- ______Alh. Musa Dangana Abubakar A. Umar John A. Umaru DPHC/DC State Project Officer Project Administrator MOH-Nasarawa State Nasarawa State Global 2000/River Blindness Program.

Date:…………………… Date:…………………… Date:……………………

44 APPENDIX VI

Instruments used to measure sustainability.

Instrument 1: national/State level

NOTE: This instrument is for national level which coordinates programme implementation in the country. It could also be used (modified slightly if necessary) for another level of support other than the main implementation level (district/ LGA). An example of this level is the ‘State’ in Nigeria.

The focus of this level’s activities in CDTI The main function of this level is to develop, revise as necessary, and oversee implementation of CDTI Policy. This level also provides support to the level below it: Providing targeted training, HSAM and monitoring/ supervision. Arranging for an adequate supply of Mectizan.

Country: NIGERIA: NASSARAWA STATE

Researcher: DR. S BAINE and DR.E. NNORUKA

Date: 17TH FEBRUARY 2003

Abbreviations/ acronyms CDD community directed distributor CDTI community directed treatment with ivermectin FLHF first line health facility HSAM health education, sensitisation, advocacy, mobilisation – i.e. activities which are aimed at getting all the key players to participate wholeheartedly in the programme NGDO non-governmental development organisation NOTF national onchocerciasis task force

45 1. Indicators of activities and processes: planning

Check whether there is a year plan for Onchocerciasis control, appearing as part of an overall written plan for the health service at this level. This indicator assesses whether the programme has become integrated into the health service, and whether management is accepting ownership of the programme – both good for sustainability.

Characteristics of the indicator Sources of information Onchocerciasis control should be integrated into Examination of: the overall written year plan of the health service Written plans: yearly, quarterly, at this level. Note that this plan is usually not very monthly etc. detailed. Minutes of planning meetings. Interview with health service staff at this level.

Findings Describe the present situation: There are yearly written plans for the health service incorporating all health intervention programmes including River Blindness Control. Inputs are obtained from all partners. CDTI workplans seen were mainly for the period of June 2003 upwards, at the state MOH there was also a sustainability plan at this level.

If planning and implementation of CDTI is not part of the overall year plan: Why is this?

Which steps are being taken to improve the situation?

Analysis When writing the report you have to summarise: The evidence about how well this indicator is being achieved. Reasons for poor performance (if any); steps being taken to improve it; and how this is likely to affect sustainability. Your overall judgement: is this indicator for sustainability being achieved? Fully Highly Moderately Slightly Not at all Not applicable

46 Check whether there is a year plan containing details of all activities needed for effective onchocerciasis control activity at this level. This indicator assesses whether the project is functioning effectively, and whether management accepts ownership of the programme – both good for sustainability.

Characteristics of the indicator Sources of information This more detailed plan should make provision for all key Examination of written elements of onchocerciasis control: Mectizan supply; plans: yearly, quarterly, targeted training; targeted HSAM; targeted monitoring/ monthly etc. supervision. Interview with health The plan varies from year to year, showing that it is service staff at this level. targeted to the specific needs of each year.

Findings Describe the plan for the present year:

These CDTI year plans for 2003 upwards seen, had outlined key activities, timeframe and persons responsible for carrying out these activities. There were no previous year to year plans to assess the level of focus of these plans.

Describe the plan for the previous year:

If the plan is incomplete, or simply a re-write of previous plans: Why is this?

Which steps are being taken to improve the situation? Uses comments from TCCs to re write the plan.

Analysis When writing the report you have to summarise: The evidence about how well this indicator is being achieved. Reasons for poor performance (if any); steps being taken to improve it; and how this is likely to affect sustainability. Your overall judgement: is this indicator for sustainability being achieved? Fully Highly Moderately Slightly Not at all Not applicable

47 Check whether all partners (government, UN agencies, NGDOs) are meaningfully involved in the overall planning process. This indicator assesses whether the programme is functioning effectively and efficiently – if each partner is clear about its role, this is good for sustainability.

Characteristics of the indicator Sources of information All partners should contribute to the routine Examination of: planning of a project. Plans: yearly, quarterly, monthly etc. Partners should be clear about their own Minutes of NOTF meetings. roles, and those of the other partners. Interview with staff at this level (government, relevant UN agencies and NGDOs)

Findings Describe the present situation: These yearly plan have contributions from all partners following a stake holders meeting. The plan is routine and some partners are not fully aware of their roles. In some cases they feel Global 2000 and APOC are the same because there is no distinction between financial contributions from Global 2000 and APOC. . If partners are not meaningfully involved in planning: Why is this? Which steps are being taken to improve the situation?

Analysis When writing the report you have to summarise: The evidence about how well this indicator is being achieved. Reasons for poor performance (if any); steps being taken to improve it; and how this is likely to affect sustainability. Your overall judgement: is this indicator for sustainability being achieved? Fully Highly Moderately Slightly Not at all Not applicable

Check whether specific planning for sustainability has taken place, for the period after APOC funding is withdrawn. This assesses whether the programme is functioning effectively, and that management has begun to take ownership of it and can mobilise the resources it needs.

Characteristics of the indicator Sources of information Staff members have made plans for this period, which will enhance Examination of the programme sustainability. This planning should include: identifying written sustainability resource gaps; strategies to cut expenditure; and strategies to find plans. dependable sources. Interviews with staff at There should be written evidence that such planning has taken place. this level (government There should be evidence that the plans are being successfully and NGDO). implemented.

Findings Describe the present situation: Sustainability plans for the year 2003 upwards have been made but the dependable sources and 48 strategies have not yet been identified by the State. State has no specific plans for counterpart funding from Government but hopes Federal Government may approve deduction from source for sustainability at some point in time. Specific plans for sustainability have been attempted by the NGDO partner but no Sustainability plan has been put up for Post APOC period. However because of the other Health programs using the CDTI strategy e.g. Loa Loa, NGDO partners are confident that they would be able to sustain the Nasarawa CDTI project post APOC. There is no written commitment to this effect.

If there has been little or no planning for sustainability: Why is this?

Which steps are being taken to improve the situation?

Analysis When writing the report you have to summarise: The evidence about how well this indicator is being achieved. Reasons for poor performance (if any); steps being taken to improve it; and how this is likely to affect sustainability. Your overall judgement: is this indicator for sustainability being achieved? Fully Highly Moderately Slightly Not at all Not applicable

2. Indicators of activities and processes: monitoring/ supervision

Check whether staff at this level is being used appropriately for monitoring/ supervision. This indicator assesses whether the programme is functioning efficiently.

Characteristics of the indicator Sources of information Staff members at this level should routinely only Examination of: supervise the level immediately below them. Staff Supervisory checklists, plans and should not supervise the FLHF or community levels. reports. ‘Spot checks’ may however be done from time to time. Visitor’s books at all the levels below Staff members at this level should have empowered staff this one. Interviews with: members at the level below them to supervise activities at Staff at this level. their own level, as well as levels further down. Staff at levels below this one.

Findings Describe the present situation:

SOCTs and NGDO partner have carried out routine monitoring and supervision at all levels and in some instances up to 3 x monthly for the SOCTs. Reports from the State coordinator indicate that a policy has been made to address the issue of SOCTs supervising below the levels they are supposed to. The LGA is to be responsible for super vising the FLHF while the District Health supervisors supervise the CDDs. However findings, in the field indicate that they still go beyond and these supervisory visits are highly dependent on APOC funds.

49 If staff members are not being used appropriately for monitoring/ supervision: Why is this?

Which steps are being taken to improve the situation?

Analysis When writing the report you have to summarise: The evidence about how well this indicator is being achieved. Reasons for poor performance (if any); steps being taken to improve it; and how this is likely to affect sustainability. Your overall judgement: is this indicator for sustainability being achieved? Fully Highly Moderately Slightly Not at all Not applicable

Check whether monitoring/ supervision is being planned and carried out in an efficient and integrated manner. This indicator assesses whether the programme is functioning efficiently.

Characteristics of the indicator Sources of information One routine supervision visit per year must be done to each Examination of: project (as a separate entity, or as a district). Supervisory checklists, plans Supervision visits for CDTI should be integrated where appropriate and reports with supervision of other programmes. Visitor’s books at the level Resources for supervision (human, transport etc.) should be immediately below this one efficiently used: .Interviews with: Using as few staff members as possible. Staff at this level. Planning trips to cut down on distance travelled. Staff at the level immediately Not spending unnecessarily many nights out etc. below this one. Supervision visits should be thorough, using a checklist.

Findings Describe the present situation: Supervisory visits are planned in some instances but in majority of cases it is routinely done. Frequent supervisory vists are embarked upon per year per LGA for training purposes and during drug distrbution. These visits are up to 2-3 x per month during distribution. Check lists are being used by SOCTs to keep track with visit schedules. Supervisory visits are often done alongside schistosomiasis and Loa Loa. However integeration with PHC is minimal. Describe the situation the previous year:

If monitoring/ supervision is not being done efficiently: Why is this?

Which steps are being taken to improve the situation?

Analysis When writing the report you have to summarise: The evidence about how well this indicator is being achieved. Reasons for poor performance (if any); steps being taken to improve it; and how this is likely to affect sustainability.

50 Examine the trend in monitoring/ supervision activity: is it becoming more efficient?

Your overall judgement: is this indicator for sustainability being achieved? Fully Highly Moderately Slightly Not at all Not applicable

Check whether there is a routine process of management of problems and successes, which are indicated by the monitoring system. This indicator assesses whether the programme is running efficiently and effectively, and whether management is beginning to accept ownership of the programme.

Characteristics of the indicator Sources of information As soon as problems are identified as a result of Examination of the following documents: supervision visits, or from coverage data (i.e. areas with low Plans: yearly, quarterly, monthly etc. coverage) the appropriate manager should deal with them. Minutes of staff/ planning meetings. Such problems should usually be passed on to the Reports of previous monitoring exercises. appropriate managers at the next level below to deal with, Letters of commendation. with the necessary support – thus empowering these Interviews with: persons. Staff at this level. Successes should be noted and reported, and appropriate Staff at the levels below this one. feedback given. There should be evidence of action taken based on recommendations in previous monitoring exercises.

Findings Describe the present situation:

When a problem is identified, measures are taken by the SOCT in charge of the LGA, and the SOCT does this even at a level lower. The leadership in the MOH occasionally help out in solving problems if their attentions are required.

Global 2000 has a system of recognizing successes related to good management of data for Guinea worm (Carter Award) and has been proposing its extension to Onchocerciasis. However, in other areas successes are just reported back.

If the system of managing problems/ successes is weak: Why is this?

Which steps are being taken to improve the situation?

Analysis When writing the report you have to summarise: The evidence about how well this indicator is being achieved. Reasons for poor performance (if any); steps being taken to improve it; and how this is likely to affect sustainability. Your overall judgement: is this indicator for sustainability being achieved? Fully Highly Moderately Slightly Not at all Not applicable

51 3. Indicators of activities and processes: Mectizan® procurement and distribution

Check whether sufficient Mectizan is being ordered, stored and distributed within the government system at this level. This indicator assesses whether the programme is functioning efficiently, its processes are simple, and it is becoming more integrated into the government system.

Characteristics of the indicator Sources of information The Mectizan supply should be controlled within a government system. This does Examination of all not have to be the system routinely used for the supply of other drugs. Mectizan ordering and The system should be effective, uncomplicated and efficient. stock control This system should use dependable, sustainable resources for its operation. It is documentation at this desirable that these resources should be supplied by the government. level. The system should supply sufficient Mectizan for the needs of all the projects Interviews with staff at concerned. this level (government and NGDO).

Findings Describe the situation the previous year: In accordance with the NOCP arrangement for the country, Global 2000 uses treatment data to make estimates for Mectizan required by the project for the subsequent year. An application is written through the NOCP Coordinator to Merck Sharpe and Dorme (MSD), and when approval is granted, UNICEF facilitates the clearing in Lagos, while Global 2000 collects them from Lagos.

The Nassarawa project then collects the drugs from the Global 2000 office at Jos and keeps them in their store. At times Mectizan and Albendazole are collected simultaneously at Lagos by Global 2000 and these are sent down to State. A register is maintained for all drugs received and collected. This disbursement of Mectizan is dependent on a programme specific approach which is user friendly, effective and dependable. APOC funds are utilized for this purpose. Describe the situation the year before that:

If the government system is not fully responsible for all sections of the Mectizan supply system: Why is this?

Which steps are being taken to improve the situation?

Analysis When writing the report you have to summarise: The evidence about how well this indicator is being achieved. Reasons for poor performance (if any); steps being taken to improve it; and how this is likely to affect sustainability. What has been the trend in Mectizan supply?

Your overall judgement: is this indicator for sustainability being achieved? Fully Highly Moderately Slightly Not at all Not applicable

4. Indicators of activities and processes: training and HSAM

Check whether staff members at this level are being used appropriately as trainers. This indicator assesses whether the programme is functioning efficiently.

52 Characteristics of the indicator Sources of information Staff at the national level should Examination of training materials, plans/ programmes, reports: routinely only train staff at the At this level. level immediately below it. At the levels below this one. Staff members at this level should Interviews with: have empowered the level Staff at this level (the trainers). Staff at the very next level below (the trainees). immediately below them to train Staff at the district/ LGA level. lower levels. Staff at the FLHF level.

Findings Describe the present situation:

Training is routinely done. Staff at this level train LOCTs, supervisors and at times CDD respectively. Training had not been targeted up until last year. Shared costs between APOC and Global 2000 but exact amount contributed by each partner were not shown. Finding of the evaluation team at the lower levels is that training still extends right down to community level. HSAM is targetted out to LGAs and Policy makers that lack knowledge. APOC provides funds for this. Describe the situation the year before:

If staff members are not being used efficiently as trainers: Why is this?

Which steps are being taken to improve the situation?

Analysis When writing the report you have to summarise: The evidence about how well this indicator is being achieved. Reasons for poor performance (if any); steps being taken to improve it; and how this is likely to affect sustainability. Examine the trend in the way in which staff are being used as trainers:

Your overall judgement: is this indicator for sustainability being achieved? Fully Highly Moderately Slightly Not at all Not applicable

4.2 Check whether training is being planned and carried out in an efficient and integrated manner. This indicator assesses whether the programme is functioning efficiently.

Characteristics of the indicator Sources of information There should be an objective need for each episode of training. This Examination of training materials, plans/ means there should be evidence that staff to be trained lack knowledge programmes, reports: and skills to perform the job, and the training should then focus on this At this level. deficiency only. Repeat training of already skilled staff should not At the levels below this one.

53 happen. Interviews with: If circumstances permit training for CDTI should be integrated with other Staff at this level (the trainers). training, e.g. in in-service training programmes. Staff at the very next level below (the Resources for training (human, transport etc.) should be efficiently trainees). used: Staff at the district/ LGA level. Using as few staff members as possible. Staff at the FLHF level. Using as little time as possible (without sacrificing quality) Choosing the most cost-effective site etc.

Findings Describe the present situation:

Initially, training had been routinely done in the past but recently training according to the State Programme officer was reported to be targeted according to needs of the various LGAs. However, there was no plan for this at the state level. Occasionally training is integrated with Loa Loa and shcistosomiasis In the field however there were indications that training was still routinely carried out at the lower levels.

Describe the situation the year before:

If training is not being carried out in an efficient and integrated manner: Why is this?

Which steps are being taken to improve the situation?

Analysis When writing the report you have to summarise: The evidence about how well this indicator is being achieved. Reasons for poor performance (if any); steps being taken to improve it; and how this is likely to affect sustainability. Examine the trend in training activities – is it becoming more efficient and integrated?

Your overall judgement: is this indicator for sustainability being achieved? Fully Highly Moderately Slightly Not at all Not applicable

54 Check whether staff at this level is planning and carrying out HSAM activities in an efficient manner. This indicator assesses whether the programme is functioning efficiently and effectively, and whether managers are taking ownership of the programme.

Characteristics of the indicator Sources of information Staff members identify situations where decision makers lack Examination of HSAM plans/ information about/ commitment to CDTI, and undertake activities to programmes and reports. inform and persuade these persons. Interviews with: HSAM activities are properly planned. They are only carried out Staff (programme and where there is an objective need for them, and not as a matter of management) at this level. routine. Civil authorities at this level. Such activities should only be carried out at the national level, Staff and civil authorities at the and at times at the level immediately below (but only when staff next level down. at that level asks for help). There is evidence that these HSAM activities have been effective and have led to action.

Findings Describe the present situation (in relation to efficiency and outcome): HSAM is planned for at this level in some cases. The State has carried out some key activities with a view of increasing awareness and sensitisation of decision makers and other stake holders. These activities included: Advocacy visits to key personalities at both the state and LGA level and traditional leaders. Airing of television ,video recordings and radio jingles on CDTI activities Celebration of the yearly Oncho Day activities in the state. Production of IEC materials of different kinds, few samples of these were seen. However, these were inadequate and the people are not yet fully aware of the disease and its impact if treatment is not provided. Organizing of the Stakeholders’ meetings. . Describe the situation the year before (in relation to efficiency and outcome):

If HSAM activities are not being carried out efficiently: Why is this? Which steps are being taken to improve the situation?

Analysis When writing the report you have to summarise: The evidence about how well this indicator is being achieved. Reasons for poor performance (if any); steps being taken to improve it; and how this is likely to affect sustainability. Examine the trend in HSAM activities – is it becoming more efficient and effective? Your overall judgement: is this indicator for sustainability being achieved? Fully Highly Moderately Slightly Not at all Not applicable

5. Indicators of activities and processes: integration of support activities

Check whether the various programme support activities are being planned and carried out in an integrated manner. This indicator assesses whether the programme is functioning efficiently.

55 Characteristics of the indicator Sources of information Staff combines two or more tasks on a single Examination of documents: trip trip: authorisations, log books, trip reports. Monitoring / supervision for CDTI and other Interviews with staff from this level projects. (managers, administrators, drivers). Training for CDTI and other projects. Interviews with staff from the next level below. HSAM. Fetch records or to deliver Mectizan.

Findings Describe the present situation:

There is a clear Policy on integration at the top level (NGDO, National) but CDTI is not fully integrated with other health programmes. However there is some element of integration in carrying out a few health activities (Lymphatic filariasis, Schistosomiasis) with Oncho. At State level, albendazole and mectizan, and reports are also collected in a single trip.

Describe the situation the year before:

Same as above.

If integration between support activities is poor: Why is this? Which steps are being taken to improve the situation?

Analysis When writing the report you have to summarise: The evidence about how well this indicator is being achieved. Reasons for poor performance (if any); steps being taken to improve it; and how this is likely to affect sustainability. Examine the trend in the integration of activities – is it becoming more common? Your overall judgement: is this indicator for sustainability being achieved? Fully Highly Moderately Slightly Not at all Not applicable

56 6. Indicators of resources: financial

Check whether appropriate amounts are budgeted for planned onchocerciasis control activities at this level This indicator assesses whether the programme is functioning efficiently.

Characteristics of the indicator Sources of information The costs for each onchocerciasis control activity in the year plan at Examination of the this level should be clearly spelt out in a budget. budget documents. There is evidence of a cost reduction/ containment strategy (e.g. Interviews with the health targeted training, HMAS and monitoring/ supervision; training service managers at this conducted at the next level below etc). level. Project managers should have a clear estimate of the funds that will be available to them for onchocerciasis control in the coming year, and should be able to justify this belief. The total amount budgeted for in the year plan should fall within this estimated income.

Findings The budget and estimated income: For this year: Initially Carter centre funded all activities but when APOC came on board in 1998, Carter center input decreased. According to the NGDO partner APOC funds are usually late due to the bureaucratic processes. Carter center puts in money for CDTI activities, this is refunded once APOC funds arrive. Notwithstanding Carter Centre is committed to support CDTI once APOC funds ceases. APOC has got a separate account at the NGDO office.

APOC approved the sum of $50,000 (5,75 million naira) MOH approved 3.8 Million Naira counterpart funds in 2000 but has released 340.000 naira till date. Global 2000 has released so far for the period of 2002/2003 the sum of 2,483,271 Naira

For the previous year: APOC released $85,069(9,78 million Naira) MOH released nothing. Global 2000 released (6, 940, 083 Naira) If budgeting has been inappropriate: Why is this?

Which steps are being taken to improve the situation?

Analysis When writing the report you have to summarise: The evidence about how well this indicator is being achieved. Reasons for poor performance (if any); steps being taken to improve it; and how this is likely to affect sustainability. Examine the trend in the budgeted amount and the expected income:

Your overall judgement: is this indicator for sustainability being achieved? Fully Highly Moderately Slightly Not at all Not applicable

57 NB at this level it is difficult to get information on budgetary allocation for each line activity of CDTI (at the MOH) because the budgetary system usually lumps up all activities per program under a particular heading. This enables the year plans to reflect the various health programs for the State.

Check whether the government is budgeting and disbursing sufficient amounts for onchocerciasis control yearly. This indicator assesses whether the programme is becoming integrated, and whether management is accepting ownership of the programme and can mobilise the resources it needs.

Characteristics of the indicator Sources of information The relative budgetary contributions of the government and other Examination of: partners to onchocerciasis control should be clearly spelt out. Budget documents The amount that the government has budgeted in one or more specific (government and NGDO) onchcerciasis control budget lines (e.g. current and capital) should be Records of disbursement increasing yearly, as a proportion of total expenses. By the end of Year and expenditure (ledgers, 5 of APOC funding the bulk of onchocerciasis control expenses at orders, approvals for national level should be met from government funds. expenditure etc.) The amounts actually disbursed from such budget lines should be Interviews with managers at increasing yearly, as a proportion of total expenses. (Note that actual this level (government and disbursement is more important than budgeting, and is a real sign of NGDO). political commitment).

Findings The budget and disbursements: For this year: APOC approved the sum of $50,000 (5,75 million naira) MOH approved 3.8 Million Naira counterpart funds in 2000 but has released 340.000 naira till date. Global 2000 has released so far for the period of 2002/2003 the sum of 2,483,271 Naira

For the previous year: APOC released $85,069(9,78 million Naira) MOH released nothing. Global 2000 released (6, 940, 083 Naira)

For the year before that: APOC released $90,828(10,445,220 Naira) MOH released approximately N140,000 Global 2000 released 4,202,723 Naira. If the government proportion of expenditure is not increasing proportionately: Why is this. Government releases are dependent on availability of funds.

Which steps are being taken to improve the situation?

Analysis When writing the report you have to summarise: The evidence about how well this indicator is being achieved. Reasons for poor performance (if any); steps being taken to improve it; and how this is likely to affect sustainability. Examine the trend in government budgeting and disbursements:

Your overall judgement: is this indicator for sustainability being achieved? Fully Highly Moderately Slightly Not at all Not applicable

58 Check whether in case of a deficit between estimated costs and the amount provided by the government, dependable provision is being made to meet it. This indicator assesses whether management is able to mobilise the resources it needs, as well as its commitment to ownership.

Characteristics of the indicator Sources of information Project management at national level should be aware of the Inspection of: shortfall, if one exists, and of its size. The budget documents. (government Project management should have specific and realistic plans to and NGDO). bridge the shortfall. Records of expenditure (ledgers, If it is planned that non-government sources of funding are to orders, approvals for expenditure be used after APOC funding ends, written commitment for this etc.). should have been obtained at the highest level in these donor Letters of agreement. organisations. Projects in their third year of APOC funding Interviews with managers at this level should also be well on the way to achieving such commitment. (government and NGDO).

Findings Describe the present situation:

Funds from Government are not sufficient nor are they regular. The Community contributes towards CDTI activities and it is clearly understood by the communities that treatment is not dependent on payment. At State level they are not fully aware of the shortfall; Government approved 3.8million Naira but has released only 340,000 naira till date. NGDO partner realises that once APOC pulls out there shall be a huge deficit. One of the dependable sources that they hope to approach is Lions International, but may not be to the level of APOC. However, evidence from the field show that CDTI activities will function better if additional resources.

Describe the situation the previous year: Same as above

If the shortfall cannot be met: Why is this? Which steps are being taken to improve the situation?

Analysis When writing the report you have to summarise: The evidence about how well this indicator is being achieved. Reasons for poor performance (if any); steps being taken to improve it; and how this is likely to affect sustainability. Examine the trend in shortfall and how it is to be supplemented: Your overall judgement: is this indicator for sustainability being achieved? Fully Highly Moderately Slightly Not at all Not applicable

59 Check whether funds disbursed for onchocerciasis control from the budget at this level are efficiently managed This indicator assesses whether the programme is functioning efficiently.

Characteristics of the indicator Sources of information The budget holder should be using a control system with the following Inspection of: elements: The budget documents (government Approval of each item of expenditure. and NGDO). Allocation of expenditure against specific budget headings. Financial control records (ledgers, Regular calculation of residual amounts under budget headings. orders, approvals for expenditure All the funds released yearly should be spent as budgeted. etc.). Interviews with managers at this level (government and NGDO).

Findings Describe the present situation: Approval of expenditure:

There is a system of management of funds in place. Proposals are initiated by the SPO and submitted to the Project administrator, who inturn submits it to the Perm Sec. for approval, after approval it goes to the NGDO accountant who then writes a cheque. There are three signatories to the CDTI account. After expenditure accountability is done.

State counterpart funds are accessed directly form MOH through the Director of Finance without NGDO involvement and accountability is to the State. Accounting for all funds collected from APOC/Global 2000 are properly done and communicated to the NOCP and WHO accountants in Nigeria for vetting and prompt submission to APOC office in Ouagadougou.

Allocation of expenditure:

This is done according to specified budget headings.

Regular insight into budget line balances:

If the funds are not being well managed: Why is this?

Which steps are being taken to improve the situation?

Analysis When writing the report you have to summarise: The evidence about how well this indicator is being achieved. Reasons for poor performance (if any); steps being taken to improve it; and how this is likely to affect sustainability. Your overall judgement: is this indicator for sustainability being achieved? Fully Highly Moderately Slightly Not at all Not applicable

60 7. Indicators of resources: transport and other material resources

7.1 Check if adequate and appropriate transport and other material resources are available for necessary CDTI activities at this level. This indicator assesses whether the programme is functioning effectively, and whether it is able to mobilise the resources it needs.

Characteristics of the indicator Sources of information There are adequate numbers of functional vehicles available Inspection of: for necessary CDTI activities. Each vehicle in the pool, each piece The vehicles are appropriate for the purpose they are intended of equipment: its source; its functional to fulfil – tough but not luxurious. status. There is sufficient office equipment available, in working order: Training materials and stationery computers, printers, photocopiers – also stationery and stocks. materials for training and HSAM. Interviews with managers at this level The running costs for these vehicles and equipment are met (government and NGDO). from dependable, sustainable sources.

Findings Describe the present situation: Type of vehicle No. Source* Functional status and adequacy for CDTI tasks** Toyota Hilux 1 APOC In very good condition was given in 2000. Motocycle(Honda) 7 APOC One is non functional Motocycle(Suzuiki) 18 GRBP 8 are non functional. Type of equipment No. Source* Functional status and adequacy for CDTI tasks** Desk top computer 1 APOC Problematic Photocopier 1 APOC Functional Generator 1 APOC Functional Sharp TV 1 APOC Functional Video machine 1 APOC Functional Telephone 1 GRBP/ Functional APOC Ceiling Fan 1 State Functional Bicycles (Raleigh) 35 APOC All are functional Bicycles (Raleigh) 16 GRBP All are functional * APOC, MoH, NGDO, other (specify) ** Is it working, and is there enough of it for the job? Describe the adequacy/ functionality of the present vehicles, equipment and materials, considering the work still to be done in the coming 5-10 years:

Presently most of the vehicles and equipment are still functional, but there is need to replace the non-functional. The brand of the Honda (Hero) motorcycles was noted to be very troublesome for them and there is lack of spare parts. If transport, equipment and materials are inadequate and/or funded from sources which are not dependable: Why is this?

Which steps are being taken to improve the situation?

61 Analysis When writing the report you have to summarise: The evidence about how well this indicator is being achieved. Reasons for poor performance (if any); steps being taken to improve it; and how this is likely to affect sustainability. Your overall judgement: is this indicator for sustainability being achieved? Fully Highly Moderately Slightly Not at all Not applicable

Check if transport and other material resources in use at this level are adequately and appropriately maintained. This indicator assesses whether the programme is functioning effectively and efficiently.

Characteristics of the indicator Sources of information There is a routine maintenance schedule for each vehicle, which is Inspection of: adhered to and recorded. This includes weekly driver maintenance, Vehicle and equipment scheduled garage servicing, and replacement of worn tyres. maintenance schedules. Equipment such as photocopiers and generators is regularly Vehicle and equipment maintained according to a schedule, and this is recorded. maintenance records. Staff members have ways of coping when vehicles break down or are Interviews with managers at not available, so that CDTI activities are not disrupted. this level (government and The costs for vehicle and equipment maintenance and repair are met NGDO). by from dependable/ sustainable sources. Repairs to vehicles and equipment are rapidly and efficiently done.

Findings Describe the present situation:

All vehicles that are in the custody of the state team are maintained with funds from the APOC. These vehicles and equipment are maintained adequately and on routine basis. The LGAs maintain all motorcycles and bicycles in their custody. However, in the field bicycles were not adequately maintained once they become non-functionaly. Global 2000 retrieves motor bikes provided; for major repairs while LGA maintain APOC donated vehicles The dependable sources of fueling is APOC.

If the vehicles and equipment are not being well maintained, and/ or funded from sources which are not dependable: Why is this?

Which steps are being taken to improve the situation?

Analysis When writing the report you have to summarise: The evidence about how well this indicator is being achieved. Reasons for poor performance (if any); steps being taken to improve it; and how this is likely to affect sustainability. Your overall judgement: is this indicator for sustainability being achieved? Fully Highly Moderately Not at all Not Slightly applicable

62 7.3 Check if the transport available at this level is appropriately managed and used. This indicator assesses whether the programme is functioning efficiently.

Characteristics of the indicator Sources of information Transport is used at this level, and to undertake support activities at the Inspection of vehicle control next level. It should not be used for CDTI implementation activities at documents: lower levels. Copies of trip authorities The use of transport is properly controlled: (also noting destination and Trips made for CDTI purposes should be properly authorised in writing purpose). by the relevant official. Log books. Each trip undertaken for CDTI purposes should be recorded in a log Interviews with managers at book. this level (government and Trip authorities and log book entries are regularly reconciled, and action NGDO). taken if there are discrepancies.

Findings Describe the present situation:

Transport is used for all levels since those at the LGA level are inadequate. Its usage is with proper control and authorization by the appropriate authorities. There are log books but no servicing/maintenance schedules; however appropriate authorities are in the know of vehicle movement.

If the transport is not being well managed: Why is this?

Which steps are being taken to improve the situation?

Analysis When writing the report you have to summarise: The evidence about how well this indicator is being achieved. Reasons for poor performance (if any); steps being taken to improve it; and how this is likely to affect sustainability. Your overall judgement: is this indicator for sustainability being achieved? Fully Highly Moderately Slightly Not at all Not applicable

63 Check if there are appropriate and realistic plans for the replacement of transport and other material resources, when APOC support comes to an end. This indicator assesses whether the programme managers are taking ownership of the programme, and are able to find resources for it.

Characteristics of the indicator Sources of information Management should know that replacements will be needed before Inspection of letters of the end of the programme, and have specific, realistic plans to meet agreement. the need at that time. Interviews with: It should be planned that the government will: Programme managers at this Provide replacements for vehicles and equipment. level (government and NGDO). Maintain existing vehicles and equipment. High-ranking Ministry officials Provide stationery and materials for training and HSAM. and politicians at this level. If it is planned that replacement will be from non-government sources, written commitment for this should have been obtained at the highest level in these donor organisations.

Findings Describe the present situation:

The project presently relies on the available transport that they have received from APOC and there are no specific plans for replacement.

If the plans for replacing vehicles, equipment and materials are unsatisfactory: Why is this?

Which steps are being taken to improve the situation?

Analysis When writing the report you have to summarise: The evidence about how well this indicator is being achieved. Reasons for poor performance (if any); steps being taken to improve it; and how this is likely to affect sustainability. Your overall judgement: is this indicator for sustainability being achieved? Fully Highly Moderately Slightly Not at all Not applicable

64 8. Indicators of resources: human resources

Check whether staff at this level is skilled, knowledgeable and committed, regarding the implementation of CDTI in its area of operation. This indicator assesses whether the programme has been able to develop sufficient resources for itself. Characteristics of the indicator Sources of information The number of staff members in the government health service at this level Inspection of: should be appropriate to the task in hand: not too many or too few. Staff files. Team members should have enough knowledge and skill to undertake all the Reports and timetables. key CDTI activities themselves, without help: Interviews with Planning Data management Managers and other staff Report writing Computer skills at this level (government Training and HSAM Mectizan ordering/ distribution and NGDO). Monitoring/ supervision Staff at the next level There should be evidence that the team is committed to the success of the below. programme (from the evidence of the partners, as well as workers at the next level below; from written reports and timetables).

Findings Describe the present situation: Particulars of current staff Area of skill No. of skilled Level of skill: is it adequate to perform the job? persons Planning 5 Informed about skills according to State Ocho Cordinator. Report writing 2 Adequate skills to perform task Training and HSAM 4 Adequate skills to perform task Monitoring/ supervision 4 Adequate skills to perform task Data management 1 Adequate skills to perform task Computer skills 2 One skilled Mectizan ordering/ distribution 4 Adequate skills to perform task Evidence of commitment/ lack of it: Working extra hours when necessary Willing to accept and attempt to emergency situations as it affects CDTI implementation.

If the staff at this level lack skills and commitment: Why is this? Which steps are being taken to improve the situation?

Analysis When writing the report you have to summarise: The evidence about how well this indicator is being achieved. Reasons for poor performance (if any); steps being taken to improve it; and how this is likely to affect sustainability. Your overall judgement: is this indicator for sustainability being achieved? Fully Highly Moderately Slightly Not at all Not applicable

65 Check whether staff at this level is stable, and whether provision is made for passing on CDTI skills when a trained person moves away. This indicator assesses whether the programme has been are able to maintain its resources.

Characteristics of the indicator Sources of information Staff at this level should remain in one post for at least five years. Inspection of staff files. There should be immediate orientation (in CDTI) of new, unskilled The table in 8.1. project staff members. Interviews with managers and other staff at this level.

Findings Describe the present situation:

The team is made up 4 SOCTs which are all on ground and stable. There is a mechanisms for orientation on ground.

Describe the situation two years ago:

Same as above.

Describe the situation when APOC funding started being given:

If the staff is not stable, and new staff is not being trained: Why is this?

Which steps are being taken to improve the situation?

Analysis When writing the report you have to summarise: The evidence about how well this indicator is being achieved. Reasons for poor performance (if any); steps being taken to improve it; and how this is likely to affect sustainability. What is the trend in the number and quality of staff?

Your overall judgement: is this indicator for sustainability being achieved? Fully` Highly Moderately Slightly Not at all Not applicable

66 9. Indicators of impact: coverage

9.1 Check whether all projects in the country have a satisfactory therapeutic coverage rate. This indicator assesses whether the programme is effective – if the rates are poor the project is clearly struggling, and less sustainable.

Characteristics of the indicator Sources of information All projects in the country should have a Interviews with staff at: therapeutic coverage rate of 65% or This level. higher. The next level below. These rates should be stable or increasing. Inspection of distribution reports and statistics at project level, for the past 3 years.

Findings The therapeutic coverage situation in districts/ LGAs: At the last distribution: Therapeutic coverage 79.6% for 2002

The year before: Therapeutic coverage 81.7% for 2001

The year before that:

Therapeutic coverage 71.8% for 2000

If the therapeutic coverage rates are poor: Why is this? Therapeutic coverage has been relatively stable in Nassarawa State due to recent communal clashes and the issue of nomadic movements.

Which steps are being taken to improve the situation? (if such steps are already being taken that is good for sustainability)

Analysis When writing the report you have to summarise the reasons for poor performance (if any); steps being taken to improve it; and how this is likely to affect sustainability. What is the trend in therapeutic coverage?

Your overall judgement: is this indicator of sustainability being achieved? Fully (100% of projects have a Highly (90- Moderately Slightly (70- Negligibly therapeutic coverage rate ≥65% - 99% of (80-89% of 79% of (<70% of stable or increasing) projects) projects) projects) projects)

67 Instrument 2: district/ LGA level

NOTE: This instrument evaluates the level which actually takes responsibility for implementing CDTI in its area of operations. It is that level where health services are planned and provided. We are going to refer to it as the district/ LGA level . The level below this one is the one where the health centres/ clinics/ dispensaries are located. We are going to refer to this level as the ‘FLHF’ (front line health facility) level.

The focus of this level’s activities in CDTI The main function of this level is to take responsibility for the implementation of CDTI in its area of operation. However its function is still largely one of support of the FLHF level: Providing targeted training, HSAM and monitoring/ supervision. Arranging for an adequate supply of Mectizan. The FLHF level is the one that is finally responsible for working with the CDDs in the communities.

Geographical name of this district/ LGA: NASSARAWA EGGON, LAFIA and KARU LGA

Project: NASSARAWA STATE

Researcher: Dr. Sabastian O. Baine, Dr. Edith Nnoruka, Dr. Richard Ndyomungyenyi.

Date: 18th February 2003

Abbreviations/ acronyms CDD community directed distributor CDTI community directed treatment with ivermectin FLHF first line health facility HSAM health education, sensitisation, advocacy, mobilisation – i.e. activities which are aimed at getting all the key players to participate wholeheartedly in the programme NGDO non-governmental development organisation

68 1. Indicators of activities and processes: planning

Check whether the year plan for CDTI appears as part of an overall written plan for the activities of the district/ LGA. This indicator assesses whether the programme has become integrated into the health service, and whether management is beginning to accept ownership of the programme – both good for sustainability.

Characteristics of the indicator Sources of information CDTI should be integrated into the overall written plan (showing Inspection of: that staff at this level consider CDTI to be part of their yearly The written year plans. routine, like any other programme). Minutes of planning meetings. The plan should make provision for all key activities: Mectizan Interviews with: supply; targeted training; targeted HSAM, targeted monitoring/ Staff at this level: managers and supervision. others (pharmacist, transport officer Year plans should be drawn up in a participatory way. etc.). Year plans must take into account community requirements for Staff at FLHF level. the timing of distribution.

Findings Describe the present situation: Plans are yearly made at all LGAs, in some cases from various inputs at the LGA. However, the CDTI plans were not integrated into the overall health plans. CDTI plans had provisions for all CDTI activities and were made in a participatory manner, including community requirements in some cases.

If planning and implementation of CDTI is not part of the overall year plan: Why is this? Which steps are being taken to improve the situation?

Analysis When writing the report you have to summarise: The evidence about how well this indicator is being achieved. Reasons for poor performance (if any); steps being taken to improve it; and how this is likely to affect sustainability. Your overall judgement: is this indicator for sustainability being achieved? Fully Highly Moderately Slightly Not at all Not applicable

69 2. Indicators of activities and processes: leadership

Check whether the district/ LGA health management team is taking full responsibility for the implementation of CDTI at this level. This indicator assesses whether management is taking ownership of the programme.

Characteristics of the indicator Sources of information It should be the management team at this level, and not Inspection of year plans. higher levels/ NGDO leadership, which is initiating the key Interviews with: CDTI activities: planning, targeted monitoring/ supervision, Management team at this level. targeted training and HSAM, Mectizan ordering/ Staff at the project level distribution. NGDO leadership. There should be a focal person for CDTI activities. Staff at FLHF level.

Findings Describe the present situation:

In all the LGAs, there is a focal person for CDTI (LOCT). However, CDTI activities are initiated by the NGDO partner (Global 2000) and not the management team. There was inadequate awareness on CDTI by the some key officers e.g. Director of Primary Health Care and Disease Control, Director Personnel Management, etc.

If leadership at this level is not taking the initiative in implementing CDTI: Why is this?

Which steps are being taken to improve the situation?

Analysis When writing the report you have to summarise: The evidence about how well this indicator is being achieved. Reasons for poor performance (if any); steps being taken to improve it; and how this is likely to affect sustainability. Your overall judgement: is this indicator for sustainability being achieved? Fully Highly Moderately Slightly Not at all Not applicable

70 3. Indicators of activities and processes: monitoring/ supervision

Check whether routine data concerning CDTI activities are being transmitted from this level, entirely within the government system. This indicator assesses whether the programme has become more integrated into the government system, and is functioning effectively.

Characteristics of the indicator Sources of information The reporting process should take place within the Examination of reports and report forms. government system, not using other resources. Data being Interviews with: transmitted includes: coverage reports; Mectizan statistics; Managers and staff at this level. training reports; distribution reports; financial reports. Staff at the project level.

Findings Describe the present situation:

In all LGAs, the reporting process is within the established government system. However, in some cases officers at this level collect reports from the community level, thereby, not empowering district supervisors and frontline staff. Monitoring was observed to be much i.e. 2-3 times a month.

If data are not being transmitted within a government system: Why is this?

Which steps are being taken to improve the situation?

Analysis When writing the report you have to summarise: The evidence about how well this indicator is being achieved. Reasons for poor performance (if any); steps being taken to improve it; and how this is likely to affect sustainability. Your overall judgement: is this indicator for sustainability being achieved? Fully Highly Moderately Slightly Not at all Not applicable

71 Check whether the responsible persons at the district/ LGA level are efficiently supervising CDTI activity at the FLHF level in an integrated manner. This indicator assesses whether the programme is functioning efficiently.

Characteristics of the indicator Sources of information Staff at this level should routinely only supervise the FLHF, and not the Examination of: community level. ‘Spot checks’ may however be done from time to Supervisory checklists, plans, time. itineraries and reports. Although one routine supervision visit per FLHF per year is necessary, Visitor’s books at FLHF level. supervision visits should focus more on FLHFs where there are proven Interviews with: Staff at this level. problems – each supervision visit must be justified. Staff at the FLHF level. Supervision visits for CDTI should be integrated with supervision of other programmes (e.g. through a shared checklist). Transport for supervisory visits should be shared with other programmes.

Findings Describe the present situation:

Supervision of CDTI activities are routinely done, frequent (in some cases up to 3 times a month) but in some cases integrated with environmental protection activities.

If supervision is not being done in an integrated and efficient manner: Why is this? Health facility staff may not supervise CDDs because of to much work at their clinics.

Which steps are being taken to improve the situation? Plan to ask LGA to increase staff to help ease work load at the FLHF.

Analysis When writing the report you have to summarise: The evidence about how well this indicator is being achieved. Reasons for poor performance (if any); steps being taken to improve it; and how this is likely to affect sustainability. Your overall judgement: is this indicator for sustainability being achieved? Fully Highly Moderately Slightly Not at all Not applicable

72 Check whether there is a routine process of management of problems and successes, which are indicated by the monitoring system. This indicator assesses whether the programme is running efficiently and effectively, and whether management is beginning to accept ownership of the programme.

Characteristics of the indicator Sources of information As soon as problems are identified as a result of Examination of the following documents: supervision visits, or from coverage data (i.e. areas with Year plans and annual reports. low coverage) the appropriate manager should deal with Minutes of staff/ planning meetings. them. Reports of previous monitoring exercises. Where relevant such problems should be passed on to Letters of commendation. the appropriate FLHF staff to deal with, with the Memos. necessary support – thus empowering these persons. Interviews with: Successes should be noted and reported, and Staff at this level. appropriate feedback given. Staff at the FLHF level. There should be evidence of action taken based on recommendations in previous monitoring exercises.

Findings Describe the present situation:

There is a system for managing problems identified in the field (particularly refusals, selection and replacement of CDDs and other causes of low coverage). The LOCT leader and his team members handle the problems as they arise depending on the staff assigned to the areas. No evidence of written reports were seen in all LGAs visited. Successes are by commendation, no special awards have been made to these areas.

If the system of managing problems/ successes is weak: Why is this?

Which steps are being taken to improve the situation?

Analysis When writing the report you have to summarise: The evidence about how well this indicator is being achieved. Reasons for poor performance (if any); steps being taken to improve it; and how this is likely to affect sustainability. Your overall judgement: is this indicator for sustainability being achieved? Fully Highly Moderately Slightly Not at all Not applicable

73 4. Indicators of activities and processes: Mectizan® procurement and distribution

Check whether sufficient Mectizan is being ordered and received yearly, and in good time. This indicator assesses whether the programme is functioning effectively.

Characteristics of the indicator Sources of information The order forms for the district/ LGA exist, and should be based on Examination of all Mectizan FLHF and community requests. ordering and stock control The Mectizan s`hould be available at this level in time for distribution documentation at this level. at the time requested by the communities. Interviews with staff at this level There should be no reports of shortages and/ or late supply. If there (managers and pharmacist). have been shortages, there should be specific plans to remedy them.

Findings Describe the situation with Mectizan supply at the last distribution:

Mectizan is sent down to the LGA based on request from the LGA and the returns from previous treatment cycles. The State makes Mectizan available to the LGAs. No shortages have been reported. There are no complaints as to the time the drugs are supplied. There were some mectizan inventory/ register seen in some LGAs. In some of the LGAs visited the DPHC have shown lack of knowledge of the CDTI programme and even admit they do not know how the drug looks.

Describe the situation the previous year:

Same as above.

Describe the situation the year before that:

Same as above.

If there are problems with obtaining the Mectizan that is required: Why is this?

No problems as of yet.

Which steps are being taken to improve the situation?

Analysis When writing the report you have to summarise: The evidence about how well this indicator is being achieved. Reasons for poor performance (if any); steps being taken to improve it; and how this is likely to affect sustainability. What is the trend in Mectizan supply at this level?

Your overall judgement: is this indicator for sustainability being achieved? Fully Highly Moderately Slightly Not at all Not applicable 74 Check whether Mectizan is being collected, stored and effectively administered within the government system at this level. This indicator assesses whether the programme is functioning efficiently, its processes are simple, and it is becoming more integrated into the government system.

Characteristics of the indicator Sources of information The Mectizan should be controlled within a government Examination of: system. This does not have to be the system routinely used All Mectizan ordering and stock control for the supply of other drugs. documentation at this level. The system should be effective, uncomplicated and efficient Vehicle log books and/ or trip authority The district/ LGA level should fetch its Mectizan from the forms. project level itself, by means of transport supplied and paid Interviews with staff at this level for by government at this level. (managers, pharmacist, drivers).

Findings Describe the present situation:

Mectizan is stored within the LGA at the Central Medical store. It is dispensed using a project designed control system that is uncomplicated, effective and dependable. The forms are supplied by the State and reproduced by LGA. Mectizan is supplied from the State on the basis of request from the LGA Oncho Co-ordinators. For hard to reach FLHF arrangements are in place to send across Mectizan over to them. All Expenses for collection are dependent on APOC funds.

If the Mectizan supply is not being administered within a government system: Why is this?

Which steps are being taken to improve the situation?

Analysis When writing the report you have to summarise: The evidence about how well this indicator is being achieved. Reasons for poor performance (if any); steps being taken to improve it; and how this is likely to affect sustainability. Your overall judgement: is this indicator for sustainability being achieved? Fully Highly Moderately Slightly Not at all Not applicable

5. Indicators of activities and processes: training and HSAM

Check whether staff members at this level are being used appropriately as trainers. This indicator assesses whether the programme is functioning efficiently.

75 Characteristics of the indicator Sources of information Staff should routinely only train staff at the FLHF level, Examination of training materials, plans/ and not at the community level. programmes, reports: Staff should have empowered staff at the FLHF level to At this level. see to their own training needs as much as possible, and to At the FLHF level. conduct training activities at the community level Interviews with: Staff at this level (the trainers). independently. Staff at FLHF level (the trainees). Wherever possible staff at this level should conduct their CDDs. own training for CDTI, if they have need for such training.

Findings Describe the present situation:

DHSs are routinely trained every year by LOCTs and in most cases training is done more than once and at levels below the FLHF. LOCTs features in all training sessions at all districts. Staff at the FLHF are not empowered to train CDDS in some of the LGAs. Training reports were not seen but a few IEC and training materials were readily available. Describe the situation the year before:

Same as above.

If staff members are not being used appropriately: Why is this?

Which steps are being taken to improve the situation?

Analysis When writing the report you have to summarise: The evidence about how well this indicator is being achieved. Reasons for poor performance (if any); steps being taken to improve it; and how this is likely to affect sustainability. Examine the trend in the way in which staff are being used as trainers:

Your overall judgement: is this indicator for sustainability being achieved? Fully Highly Moderately Slightly Not at all Not applicable

76 Check whether training is being planned and carried out in an efficient and integrated manner. This indicator assesses whether the programme is functioning efficiently.

Characteristics of the indicator Sources of information There should be an objective need for each episode of training. This Examination of training means there should be evidence that staff to be trained lack knowledge materials, plans/ and skills to perform the job, and the training should then focus on this programmes, reports: deficiency only. Repeat training of already skilled staff should not happen. At this level. If circumstances permit training for CDTI should be integrated with other At the FLHF level. training, e.g. in in-service training programmes. Interviews with: Resources for training (human, transport etc.) should be efficiently used: Staff at this level (the Using as few staff members as possible. trainers). Using as little time as possible (without sacrificing quality) Staff at FLHF level (the Choosing the most cost-effective site etc. trainees). CDDs.

Findings Describe the present situation:

Training is not targeted to needs for each episode. Training is done twice yearly and is routinely done. This training is not integrated, the initial training is for both old and new ones and the second training is a refresher training. It is routinely done for all groups i.e. for LOCTs, DHS and CDDs. In Karu LGA, CDDs are trained for Polio and this serves as an incentive, however their training are independent and not integrated with CDTI. Apart from the short orientation workshops on particular programs, there is no specific in - service training for CDTI.

Describe the situation the year before:

Same as above.

If training is not efficient and integrated: Why is this?

Which steps are being taken to improve the situation?

Analysis When writing the report you have to summarise: The evidence about how well this indicator is being achieved. Reasons for poor performance (if any); steps being taken to improve it; and how this is likely to affect sustainability. Examine the trend in training activities – is it becoming more efficient and integrated?

Your overall judgement: is this indicator for sustainability being achieved? Fully Highly Moderately Slightly Not at all Not applicable

77 Check whether staff at this level is planning and carrying out HSAM activities in an efficient manner. This indicator assesses whether the programme is functioning efficiently and effectively, and whether managers are taking ownership of the programme.

Characteristics of the indicator Sources of information Staff members identify situations where decision makers lack Examination of: information about/ commitment to CDTI, and undertake HSAM plans/ programmes and activities to inform and persuade these persons. reports. HSAM activities are properly planned. They are only carried out Year plans and annual reports. where there is an objective need for them, and not as a matter Minutes of planning meetings. of routine. Interviews with: Such activities should only be carried out at this district/ LGA Staff (programme and level, and at times at the FLHF level (but only when staff at that management) at this level. level asks for help). Civil authorities at this level. There is evidence that these HSAM activities have been Staff and civil authorities at the effective and have led to action. FLHF level.

Findings Describe the present situation:

They look out for policy makers that lack knowledge on CDTI and persuade them for release of funds. The HOD, and LOCTs members at the LGA usually conduct advocacy meetings (HSAM) annually with the politicians and technocrats at this level. There is no evidence of HSAM plans / programmes nor reports. However the LGA Oncho team said they carry out these HSAM activities routinely and sometimes in an integrated fashion. In Karu the LOCT leader does no mobilization at this level. Routinely targeting Traditional leaders, and policy makers of communities that have refused the drugs are often done single handed by the LOCT leader or the Director of PHC.

Describe the situation the year before:

---Same as above.

If planning and implementation of CDTI is not part of the overall year plan: Why is this?

Which steps are being taken to improve the situation?

.

Analysis When writing the report you have to summarise: The evidence about how well this indicator is being achieved. Reasons for poor performance (if any); steps being taken to improve it; and how this is likely to affect sustainability. Examine the trend in HSAM activities – is it becoming more efficient?

Your overall judgement: is this indicator for sustainability being achieved? Fully Highly Moderately Slightly Not at all Not applicable

78 6. Indicators of resources: financial

Check whether appropriate amounts are budgeted for planned CDTI activities at this level. This indicator assesses whether the programme is functioning efficiently.

Characteristics of the indicator Sources of information The costs for each CDTI activity in the year plan at this level should be Examination of the budget clearly spelt out in a budget. documents. There is evidence of a cost reduction/ containment strategy (e.g. targeted Interviews with health training, HMAS and monitoring/ supervision; training conducted at FLHF service and local level etc). government managers at Managers at this level should have a clear estimate of the funds that will this level: be available to them for CDTI in the coming year, and should be able to Technical managers. justify this belief. Treasurer/ administrator. The total amount budgeted for in the year plan should fall within this estimated income.

Findings The budget and estimated income: At the previous distribution:

Costs for CDTI activities are neither quantified at this level nor are they reflected on the Estimates of Recurrent expenditure for each year. Most of them have neither clear idea of how much CDTI activity costs annually nor of any cost reduction strategy. Some LGAs just make arbitrary releases for CDTI activities from Service funds for health or Drug revolving funds. While some of the LGAs are not willing to release much money because they feel Global 2000/APOC is responsible. Managers at the LGA Oncho office have an idea of what each activity is likely to cost. In some areas there were no budgets, but releases are being made I For the previous year: ---- Same as above.

For the year before that:

---- Same as above.

If budgeting has been inappropriate: Why is this?

Which steps are being taken to improve the situation?

Promises have been made for funds for CDTI activities in the next LGA budget line to be deducted from source for all LGAs by Ministry of Local Government and Chieftaincy affairs.

Analysis When writing the report you have to summarise: The evidence about how well this indicator is being achieved. Reasons for poor performance (if any); steps being taken to improve it; and how this is likely to affect sustainability. Examine the trend in the budgeted amount and the expected income:

Your overall judgement: is this indicator for sustainability being achieved? Fully Highly Moderately Slightly Not at all Not applicable 79 Check whether the government at this level is budgeting and disbursing increasing amounts for CDTI yearly. This indicator assesses whether the programme is becoming integrated, and whether management is beginning to accept ownership of the programme and can mobilise the resources it needs.

Characteristics of the indicator Sources of information The relative budgetary contributions of the local government and Examination of: other partners to CDTI should be clearly spelt out. Budget documents (government and The amount that the government has budgeted in one or more NGDO) specific CDTI budget lines should be increasing yearly. By the Records of disbursement and end of Year 5 of APOC funding the bulk of CDTIexpenses at this expenditure (ledgers, orders, level should be met from local government funds. approvals for expenditure etc.) The amounts actually disbursed from such budget lines should Interviews with health service, local be increasing yearly, as a proportion of total expenses. (Note that government and NGDO managers actual disbursement is more important than budgeting, and is a at this level: real sign of political commitment). Technical managers. Treasurer/ administrator.

Findings The budget and disbursements: For this year:

Relative contributions are not clearly spelt out apart from the arbitrary contribution from LGAs. Proportion of funds for the various activities from the LGAs has remained static in some. Sometimes the amount released is decreasing and in a few places non - existent.

Travel allowances and funds for maintenance of transport are paid during distribution and training by the LGA. At this level amounts released by other partner (Global 2000) are not known. No budgetary documents were seen at this level.

For the previous year: ---- Same as above.

If the government proportion of expenditure is not increasing proportionately: Why is this? ---- Political commitment varies with each LGA Chairman.

Which steps are being taken to improve the situation? --- Advocacy (HSAM) will be carried out immediately telling them their responsibilities/roles as APOC is soon withdrawing.

Analysis When writing the report you have to summarise: The evidence about how well this indicator is being achieved. Reasons for poor performance (if any); steps being taken to improve it; and how this is likely to affect sustainability. Examine the trend in government budgeting and disbursements:

Your overall judgement: is this indicator for sustainability being achieved? Fully Highly Moderately Slightly Not at all Not applicable

80 Check whether in case of a deficit between estimated costs and the amount provided by the government, dependable provision is being made to meet it. This indicator assesses whether management is able to mobilise the resources it needs, as well as its commitment to ownership.

Characteristics of the indicator Sources of information If there is a shortfall the management Inspection of: should have specific and realistic plans The budget documents (government and NGDO). to bridge it. Records of expenditure (ledgers, orders, approvals for If it is planned that non-government expenditure etc.). sources of funding are to be used after Letters of agreement. APOC funding ends, written commitment Interviews with health service and local government for this should have been obtained at the managers at this level: highest level in these donor Technical managers. organisations. Treasurer/ administrator.

Findings Describe the present situation:

There are no specific or realistic identifiable plans on ground for Post APOC funding. Occasionally some are aware of deficit and hope to fall back on the drug revolving funds to carry out basic CDTI activities if all fails. No written commitments were available. Describe the situation the previous year:

Same as above.

If the shortfall cannot be met: Why is this?

Which steps are being taken to improve the situation? Serious thoughts are yet to be accorded to these issues now that they know that there shall be a post APOC phase for real.

Analysis When writing the report you have to summarise: The evidence about how well this indicator is being achieved. Reasons for poor performance (if any); steps being taken to improve it; and how this is likely to affect sustainability. Examine the trend in shortfall and how it is to be supplemented:

Your overall judgement: is this indicator for sustainability being achieved? Fully Highly Moderately Slightly Not at all Not applicable

81 Check whether funds disbursed for CDTI from the budget at this level are efficiently managed. This indicator assesses whether the programme is functioning efficiently.

Characteristics of the indicator Sources of information The budget holder should be using a control Inspection of: system with the following elements: The budget documents (government and NGDO). Approval of each item of expenditure. Financial control records (ledgers, orders, Allocation of expenditure against specific budget approvals for expenditure etc.). headings. Interviews with health service and local Regular calculation of residual amounts under government managers at this level: budget headings. Technical managers. All the funds released yearly should be spent as Treasurer/ administrator. budgeted.

Findings Describe the present situation: Approval of expenditure:

There is a control system for approval of funds within the LGA once a proposal for a CDTI activity is made. There is some degree of accountability for funds released at this level. No budgets were seen in regards to CDTI activities at LGA level.

Allocation of expenditure:

Regular insight into budget line balances:

No evidence seen.

If the funds are not being well managed: Why is this?

Which steps are being taken to improve the situation?

Analysis When writing the report you have to summarise: The evidence about how well this indicator is being achieved. Reasons for poor performance (if any); steps being taken to improve it; and how this is likely to affect sustainability. Your overall judgement: is this indicator for sustainability being achieved? Fully Highly Moderately Slightly Not at all Not applicable

82 7. Indicators of resources: transport and other material resources

Check whether adequate and appropriate transport and materials are available for necessary CDTI activities at this level. This indicator assesses whether the programme is functioning effectively, and whether it is able to mobilise the resources it needs.

Characteristics of the indicator Sources of information There are adequate numbers of appropriate, functional Inspection of: vehicles available for necessary CDTI activities. Each vehicle in the pool: its source; its The running costs for these vehicles are met by the functional status. government. Stocks of materials for training and HSAM. There are sufficient materials available for training and Interviews with managers at this level: HSAM. transport officers, programme managers.

Findings Describe the present situation: Type of vehicle No. Source* Functional status and adequacy for CDTI tasks** Bicycles 5 APOC In fairly good order but Not enough for job. Motorcycles 1 APOC Functional but not enough for the job.

Training/ HSAM No. Source* Functional status and adequacy for CDTI tasks** material Flipcharts, training --- Grossly inadequate for the job. Manuals IEC materials --- Grossly inadequate for the job. TV/video 1 LGA * APOC, MoH, NGDO, other (specify) ** Is it working, and is there enough of it for the job? Describe the adequacy of the present vehicles and materials, considering the work still to be done in the coming 5-10 years: Each LGA is given on an average 1 motorcycle and 5 bicycles supplied by APOC. In some LGAs , GRBP gave some bicycles and motor cycles but the exact number is not known. Motorcycles are still in good order but grossly inadequate. Spare parts of the APOC Honda motorcycles are not readily found. Some of the bicycles are out of order at most of the FLHF and need replacement to enable them accomplish further work that needs to be done at that level. Materials are in place but grossly inadequate. If transport and materials are inadequate and funded from non-government sources: Why is this?

Which steps are being taken to improve the situation?

Analysis When writing the report you have to summarise: The evidence about how well this indicator is being achieved. Reasons for poor performance (if any); steps being taken to improve it; and how this is likely to affect sustainability. Your overall judgement: is this indicator for sustainability being achieved? Fully Highly Moderately Slightly Not at all Not applicable

83 Check whether transport at this level is adequately and appropriately maintained. This indicator assesses whether the programme is functioning effectively and efficiently.

Characteristics of the indicator Sources of information There is a routine maintenance schedule for each vehicle, which is Inspection of: adhered to and recorded. This includes weekly driver maintenance, Vehicle and equipment scheduled garage servicing, and replacement of worn tyres. maintenance schedules. The costs for vehicle and equipment maintenance and repair are met Vehicle and equipment by the government. Repairs are rapidly and efficiently done. maintenance records. Staff have ways of coping when vehicles break down or are not Interviews with managers at this available, so that CDTI activities are not disrupted. level: transport officers, programme managers.

Findings Describe the present situation:

Maintenance and fuelling are mainly from APOC funds complemented by funds from LGA resources and personal pockets of health workers. Maintenance schedule was not available. State in some cases does major repairs on the motor bikes in some LGA. Staff have ways of coping when vehicles breakdown, so that CDTI activities are not paralysed or disrupted. Maintenance is not routine. In Karu ,the motorbikes are used in an integrated manner with environment health programme.

Make particular enquiries about the ability of the government to pay for maintenance, repairs and tyre replacement:

LGA Treasury occasionally releases funds for maintenance and repairs of Motorcycles. However plans for replacement will actually depend on the level of commitment of the Policy makers in power.

If the vehicles are not being well maintained, and/ or the government is not paying: Why is this? Currently, LGA claim they have financial constraints and can only perform within the limits of what they get.

Which steps are being taken to improve the situation?

Continued HSAM, emphasizing their roles/responsibilities.

Analysis When writing the report you have to summarise: The evidence about how well this indicator is being achieved. Reasons for poor performance (if any); steps being taken to improve it; and how this is likely to affect sustainability. Your overall judgement: is this indicator for sustainability being achieved? Fully Highly Moderately Slightly Not at all Not applicable

84 Check whether the transport available at this level is appropriately managed and used, in an integrated way. This indicator assesses whether the programme is functioning efficiently.

Characteristics of the indicator Sources of information Transport is used at this level, and to undertake support Inspection of vehicle control documents: activities at the FLHF level. It should not be used for CDTI Copies of trip authorities (also noting implementation activities at the community level. destination and purpose) Trips made for CDTI purposes should be properly Log books. authorised in writing by the relevant official. Each trip The supervision plan/ matrix. undertaken should be recorded in a log book. Interviews with managers at this level: Transport provided for CDTI, and that provided for other transport officers, programme managers. programmes, should be combined as a pool to be used for legitimate activities of all programmes at this level.

Findings Describe the present situation:

Transport is used mainly at this level and the FLHF level, occasionally it is used at community level. Trips for CDTI activities are sometimes utilized to carry out other PHC activities. Also in Nassarawa Eggon, the LOCT leader utilizes the Schisto motorbike for Oncho and Lymphatic filariasis in an integrated manner. Although log books are non existent, the HOD is always informed of movements. Routine management in some LGAs is dependent on the user who also maintains it.

If the transport is not being well managed: Why is this? Transport is reasonably managed at this level even though there are no documentary evidence to show this.

Which steps are being taken to improve the situation?

Analysis When writing the report you have to summarise: The evidence about how well this indicator is being achieved. Reasons for poor performance (if any); steps being taken to improve it; and how this is likely to affect sustainability. Your overall judgment: is this indicator for sustainability being achieved? Fully Highly Moderately Slightly Not at all Not applicable

85 Check whether there are appropriate and realistic plans for the replacement of transport and materials when APOC support comes to an end. This indicator assesses whether the programme managers are taking ownership of the programme, and are able to find resources for it.

Characteristics of the indicator Sources of information Management should know that replacements will be needed before Inspection of letters of agreement. the end of the programme, and have specific, realistic plans to Interviews with: meet the need at that time. Programme managers at this It should be planned that the government will: level: administrators, technical Provide replacements for vehicles. managers. Maintain existing vehicles. NGDO project managers. Provide stationery and materials for training and HSAM. High-ranking local government If it is planned that replacement will be from non-government officials. sources, written commitment for this should have been obtained at the highest level in these donor organisations.

Findings Describe the present situation:

No plans yet for this but LGA contributes to maintenance of vehicles- motorbikes mainly.

If the plans for replacing vehicles and materials are unsatisfactory: Why is this?

Not yet tackled as an issue.

Which steps are being taken to improve the situation?

Yet to be considered.

Analysis When writing the report you have to summarise: The evidence about how well this indicator is being achieved. Reasons for poor performance (if any); steps being taken to improve it; and how this is likely to affect sustainability. Your overall judgement: is this indicator for sustainability being achieved? Fully Highly Moderately Slightly Not at all Not applicable

86 8. Indicators of resources: human resources

Check whether staff at this level is skilled and knowledgeable, regarding the implementation of CDTI in its area of operation. This indicator assesses whether the programme has been able to develop sufficient resources for itself.

Characteristics of the indicator Sources of information Staff should have enough knowledge and skill to undertake all Inspection of: the key CDTI activities themselves: planning, training, HSAM, Staff files. ensuring Mectizan supply, monitoring/ supervision. Monitoring reports. Staff at this level should remain in one post for at least five Activity reports. years. Interviews with There should be immediate training (in CDTI) of new, unskilled Managers and other staff at this level. project staff members who have CDTI responsibilities. Staff at the project level Staff at the FLHF level.

Findings Describe the present situation: Particulars of current staff Area of skill No. of skilled Level of skill: is it adequate to perform the job? persons Planning 4 - Adequate to perform the job. Training and HSAM 4 - Adequate to perform the job. Monitoring/ supervision 4 - Adequate to perform the job. Mectizan ordering/ 1 - Adequate to perform the job. distribution Information about staff stability and in-service training:

Staffs at most of these units are new because of the newly created LGAs (politically created but not yet approved officially by Federal Govt). On an average there 3 to 4 persons per LGA unit for Oncho and each is assigned a specific area for supervision. New/unskilled personnel are to be trained by SOCTs or trained on the job by the LOCT Leader.

If the staff at this level lack skills, and are often transferred: Why is this?

Which steps are being taken to improve the situation?

Analysis When writing the report you have to summarise: The evidence about how well this indicator is being achieved. Reasons for poor performance (if any); steps being taken to improve it; and how this is likely to affect sustainability. Your overall judgement: is this indicator for sustainability being achieved? Fully Highly Moderately Slightly Not at all Not applicable

87 Check whether staff members at this level are committed to their CDTI work. This indicator assesses whether the programme has been able to develop sufficient resources for itself.

Characteristics of the indicator Sources of information Staff members express satisfaction with their present Inspection of: responsibilities Staff files (for performance records There is evidence of specific motivational practices and and awards). rewards within the programme: awards, financial incentives, Documentation about incentive compensation in cash or kind. schemes. Salaries/ wages and allowances are paid regularly. Interviews with Staff members mention non-financial rewards inherent in CDTI Managers and other staff at this level. work. Local government officials. There is evidence from partners and workers at the FLHF level NGDO project staff. that staff members are committed to their CDT work. Staff at FLHF level.

Findings Describe the present situation:

Staff members are committed and respond readily once called upon for CDTI activities. They respond without delays and incentives are fairly good. Salaries are regularly paid on time in all the LGAs. FLHF staff acknowledges the commitment of Oncho LGA coordinators (particularly in the area of training and supervision.). I If staff members appear to have little commitment to CDTI work: Why is this?

Which steps are being taken to improve the situation?

Analysis When writing the report you have to summarise: The evidence about how well this indicator is being achieved. Reasons for poor performance (if any); steps being taken to improve it; and how this is likely to affect sustainability. Your overall judgement: is this indicator for sustainability being achieved? Fully Highly Moderately Slightly Not at all Not applicable

88 9. Indicators of impact: coverage

9.1 Check whether the district/ LGA has a satisfactory geographical coverage rate. This indicator assesses whether the programme is effective – if the rate is poor the project is clearly struggling, and less sustainable.

Characteristics of the indicator Sources of information All sub-districts and communities Inspection of: identified by the latest REMO Distribution reports and statistics at community level, for this should be under treatment (i.e. the district/ LGA, for the past 3 years. geographical coverage rate is REMO list of endemic communities for this district/ LGA. 100%). Interviews with: This rate should be stable or Staff at district/ LGA level. increasing. Staff at FLHF level.

Findings The geographical coverage situation in the district/ LGA: At the last distribution:

All sub districts and communities are under treatment.

The year before:

Same as above.

The year before that:

Same as above. While in some no information was available

If the geographical coverage rate is poor: Why is this?

Which steps are being taken to improve the situation?

Analysis When writing the report you have to summarise the reasons for poor performance (if any); steps being taken to improve it; and how this is likely to affect sustainability. What is the trend in geographical coverage?

Your overall judgement: is this indicator of sustainability being achieved? Fully (100% of Highly (95-99% of Moderately (90-94% Slightly (85-89% of Negligibly communities are communities – of communities – communities – (<85% of doing CDTI) stable or increasing) stable or increasing) stable or increasing) communities)

89 9.2 Check whether the district/ LGA has a satisfactory therapeutic coverage rate. This indicator assesses whether the programme is effective – if the rate is poor the project is clearly struggling, and less sustainable.

Characteristics of the indicator Sources of information All communities in the district/ Inspection of: LGA should have a therapeutic Distribution reports and statistics at community level, for this coverage rate of 65% or higher. district/ LGA, for the past 3 years. These rates should be stable or REMO list of endemic communities for this district/ LGA. increasing. Interviews with: Staff at district/ LGA level. Staff at FLHF level.

Findings The therapeutic coverage situation in the communities in the district/ LGA: At the last distribution: In Nassarrawa Eggon the therapeutic coverage was 80.9% (2002) In Lafia LGA the therapeutic coverage for 2002 was 80.1% While Karu had 88.1% for 2002

The year before: For the year 2001 the therapeutic coverage was 85.9% for Nassarawa Eggon In the year 2001 the therapeutic coverage was 72.4% for Lafia. Karu had 83.5% for 2001

The year before that: In 2000 it was 87.3% for Nasssarawa Eggon. In 2000, Lafia had 88% While Karu had 81%

If the therapeutic coverage rate is poor: Why is this?

Which steps are being taken to improve the situation?

Analysis When writing the report you have to summarise the reasons for poor performance (if any); steps being taken to improve it; and how this is likely to affect sustainability. What is the trend in therapeutic coverage?

Your overall judgement: is this indicator of sustainability being achieved? Fully (100% of communities have Highly (90- Moderately (80- Slightly (70- Negligibly a therapeutic coverage rate ≥65% 99% of 89% of 79% of (<70% of - stable or increasing) communities) communities) communities) communities)

90 Instrument 3: first line health facility (FLHF) level

NOTE: This instrument evaluates the level which finally interacts with the villages and communities, in ensuring that CDTI takes place in all the communities in its area of operations. This level has different names in different countries. In most countries there is a health centre – a clinic, or health centre, or dispensary, which we call a ‘first line health facility’. The health workers who work there are the ones who are responsible for training and supporting the CDDs in the villages. When we speak of a FLHF we therefore mean: The health facility and its staff. The accompanying political/ administrative mechanisms between the district/ LGA and community levels. By ‘FLHF team' is meant the group of persons working in the first-line health facility and in its catchment area. The level below this one is of course the community, the villages. Here the CDDs – ‘community directed distributors’ – live and work. We refer to this level as the ‘community’ level.

The focus of this level’s activities in CDTI The main function of this level is to work with the village communities, so that CDTI is established in them: Mobilising them to become involved in CDTI, by selecting CDDs. Training the CDDs and supporting them in their work. Arranging a dependable supply of Mectizan for them, at the right time each year. Helping them to collect and forward the coverage data for their community.

Geographical name of this FLHF: BARKIN RIJIYA, BAKYNO, GURUKU,KARU, UKE AND ALOGANI

Project: NASARAWA

Researcher: ALL TEAM MEMBERS

Date 18th – 20th FEBRUARY 2003

Abbreviations/ acronyms CDD community directed distributor CDTI community directed treatment with ivermectin FLHF first line health facility HSAM health education, sensitisation, advocacy, mobilisation – i.e. activities which are aimed at getting all the key players to participate wholeheartedly in the programme NGDO non-governmental development organisation

91 1. Indicators of activities and processes: planning

1.1 Check if there is a written year plan for CDTI in the FLHF area. This indicator assesses whether the programme is being planned in an effective and integrated manner, and whether management is beginning to accept ownership of the programme.

Characteristics of the indicator Sources of information There should be a written plan or timetable in existence, for the Inspection of: most recent round of CDTI (this is recommended). The written year plans. Ideally the plan should be integrated into the overall year plan for Minutes of planning meetings. the FLHF area. Interviews with staff at this level. Ideally CDTI should form part of the ‘minimum’ or ‘recommended’ package for this level

Findings Describe the present situation: Three FLHF (Bakyano, Barkin Rijiya and Karu) out of the 6 were not involved in CDTI and therefore no CDTI work plans. Some of the FLHF, which were involved had written CDTI independent plans which were not integrated into the overall year health plans. Sometimes the CDTI plans seen were independently made by the LOCT leaders or DHSs and these were passed on to Director PHC for onwards transmission. No copies of the plans were physically seen.

If there is no written plan for CDTI: Why is this?

Are any steps being taken to improve the situation?

Analysis When writing the report you have to summarise: The evidence about how well this indicator is being achieved. Reasons for poor performance (if any); steps being taken to improve it; and how this is likely to affect sustainability. Your overall judgement: is this indicator for sustainability being achieved? Fully Highly Moderately Slightly Not at all Not applicable

92 2. Indicators of activities and processes: leadership

2.1 Check whether the FLHF management team is taking full responsibility for CDTI at this level, in an integrated manner. This indicator assesses whether the CDTI project is integrated into the health system, and whether management is beginning to accept ownership of the programme.

Characteristics of the indicator Sources of information The FLHF management team and all health staff at this level Inspection of year plans. consider the program as theirs and are initiating the key CDTI Interviews with: activities: planning, monitoring/ supervision, training, HSAM, Management team at this level. Mectizan ordering/ distribution. Senior political figures at this level. The political head/ senior politician at this level should know Staff at the district/ LGA level. about CDTI and have participated in some CDTI activities.

Findings Describe the present situation: Some of the FLHF staff initiates some CDTI activities like monitoring. However in most of the cases FLHF staff do not initiate CDTI activities like planning, mectizan ordering and trining. No senior politician at this was involved in CDTI activities.

If DMT is not taking full responsibility for CDTI: Why is this? The planning system in the LGA is top-bottom and does not call for inputs from the lower levels.

Are any steps being taken to improve the situation?

Analysis When writing the report you have to summarise: The evidence about how well this indicator is being achieved. Reasons for poor performance (if any); steps being taken to improve it; and how this is likely to affect sustainability. Your overall judgement: is this indicator for sustainability being achieved? Fully Highly Moderately Slightly Not at all Not applicable

93 3. Indicators of activities and processes: monitoring/ supervision

3.1 Check whether routine and necessary data concerning CDTI activities at this level are being transmitted entirely within the government system. This indicator assesses whether the programme is becoming more integrated into the government health system.

Characteristics of the indicator Sources of information The reporting process should be within the government Examination of reports and report forms. system, not using other resources. Data being Interviews with: transmitted includes: coverage reports; distribution Managers and staff at this level. reports; Mectizan statistics; training reports. Staff at the district/ LGA level.

Findings Describe the present situation: The FLHF staff examines the CDD reports writes his own and this is transmitted within the government system to the LGA. However in some cases the LOCT leader goes to the communities to collect the reports.

If CDTI data at this level are not being processed within government system: Why is this?

Are any steps being taken to improve the situation?

Analysis When writing the report you have to summarise: The evidence about how well this indicator is being achieved. Reasons for poor performance (if any); steps being taken to improve it; and how this is likely to affect sustainability. Your overall judgement: is this indicator for sustainability being achieved? Fully Highly Moderately Slightly Not at all Not applicable

94 Check whether health staff at this level is routinely and efficiently supervising CDTI activity at the communities on site in an integrated manner. This indicator assesses whether the CDTI programme is being implemented efficiently.

Characteristics of the indicator Sources of information Although one routine supervision visit per community per year Examination of: is necessary, supervision visits should focus more on Supervisory checklists, plans, communities where there are proven problems – each itineraries and reports. supervision visit must be justified. Log books. During visits to communities FLHF staff should turn their Interviews with: attention to as many health related programmes and problems Staff at this level. as possible. Village heads and CDDs.

Findings Describe the present situation: Some of these FLHF intiate supervisory visits, which are done during distribution of drugs and collection of reports. Sometimes supervision is also done during other PHC activities. In most cases supervisory checklists were not available.

If health staff persons are not routinely and efficiently supervising CDTI: Why is this?

Not all health facilities were noted to be involved and no reasonable explanation could be put up by the health staff themselves for this exclusion.

Are any steps being taken to improve the situation?

Analysis When writing the report you have to summarise: The evidence about how well this indicator is being achieved. Reasons for poor performance (if any); steps being taken to improve it; and how this is likely to affect sustainability. Your overall judgement: is this indicator for sustainability being achieved? Fully Highly Moderately Slightly Not at all Not applicable

95 3.3 Check whether there is a routine process of management of problems and successes, which are indicated by the monitoring system (coverage data, visits and reports) This indicator assesses whether the programme is being implemented efficiently and effectively, and whether management is beginning to accept ownership of the programme.

Characteristics of the indicator Sources of information As soon as problems are identified through supervisory Examination of the following documents: visits, coverage data etc. (e.g. communities with low Year plans and annual reports. coverage) health staff at this level should deal with them. Minutes of staff/ planning meetings. Where relevant such problems should be passed on to Reports of previous monitoring the relevant community to deal with, with the necessary exercises. support – thus empowering communities to make Letters of commendation. decisions on CDTI and cope with problems. Interviews with: Successes should be noted and reported, and Staff at this level: in-charge and others. appropriate feedback given to communities. Community leaders and CDDs. There should be evidence of action taken based on recommendations in previous monitoring exercises.

Findings Describe the present situation: Problems are tackled either through the community leader or the LOCT. Reports on problems from the field are forward to LGA and State. No evidence of action taken based on recommendations in previous monitoring visits.

If there is no routine process of managing problems and successes: Why is this?

Are any steps being taken to improve the situation?

Analysis When writing the report you have to summarise: The evidence about how well this indicator is being achieved. Reasons for poor performance (if any); steps being taken to improve it; and how this is likely to affect sustainability. Your overall judgement: is this indicator for sustainability being achieved? Fully Highly Moderately Slightly Not at all Not applicable

96 4. Indicators of activities and processes: Mectizan® procurement and distribution

Check whether sufficient Mectizan is being ordered annually, and in good time. This indicator assesses whether the programme is functioning effectively.

Characteristics of the indicator Sources of information The order forms for the FLHF area exist, and orders should be Examination of all Mectizan based on the requests from the community. ordering and stock control The Mectizan should be available at this level in time for documentation at this level. distribution at the time requested by the communities. Interviews with: There should be no reports of shortages and/or late supply. If Staff at this level (managers and there have been shortages, there should be specific plans to pharmacist). remedy them. Village leaders and CDDs.

Findings What happened at: The last round of treatment? Adequate amounts of Mectizan have been obtained and supplied to those FLHFs involved in CDTI activities for the past 3 years. However, no order forms were seen. At these FLHFs, Mectizan is kept at the central store for about a week while being disbursed.

The round of the year before?

The round the year before that?

If sufficient Mectizan is not being ordered annually: Why is this?

Are any steps being taken to improve the situation?

Analysis When writing the report you have to summarise: The evidence about how well this indicator is being achieved. Reasons for poor performance (if any); steps being taken to improve it; and how this is likely to affect sustainability. What is the trend in Mectizan ordering and suppky?

Your overall judgement: is this indicator for sustainability being achieved? Fully Highly Moderately Slightly Not at all Not applicable

97 4.2 Check whether Mectizan is being collected, stored and effectively administered within the government system at this level. This indicator assesses whether the programme is functioning efficiently, its processes are simple, and it is becoming more integrated into the government system.

Characteristics of the indicator Sources of information The Mectizan should be controlled within a government system. This Examination of: does not have to be the system routinely used for the supply of other All Mectizan ordering and drugs. stock control The system should be effective, uncomplicated and efficient documentation at this The FLHF level should fetch its Mectizan from the district/ LGA level level. itself, by means of transport supplied and paid for by government at Vehicle log books and/ or this level. trip authority forms. Communities should fetch their Mectizan from the FLHF themselves. Interviews with staff at this However in situations where villages are very far from health centres, level (managers, or where it is easy/ practicable for FLHF staff to deliver the Mectizan, pharmacist, drivers). they may help with the delivery.

Findings Describe the present situation: Drugs are kept for 2-7 days in the district stores while being distributed to the FLHF level. The drugs from the State to the LGA level are transported using APOC funds. In rare cases from LGA to the FLHF transportation costs are met by the LGA.

If Mectizan is not being received and stored within the government system : Why is this?

Are any steps being taken to improve the situation? State Coordinator has discussed with LGAs to collect the drugs from State using their own money after APOC

Analysis When writing the report you have to summarise: The evidence about how well this indicator is being achieved. Reasons for poor performance (if any); steps being taken to improve it; and how this is likely to affect sustainability. Your overall judgement: is this indicator for sustainability being achieved? Fully Highly Moderately Slightly Not at all Not applicable

98 5. Indicators of activities and processes: training and HSAM

Check whether training is being planned and carried out in an efficient manner. This indicator assesses whether the programme is functioning efficiently.

Characteristics of the indicator Sources of information There should be an objective need for each episode of training. This means Interviews with: there should be evidence that CDDs to be trained lack knowledge and skills Staff at this level (the to perform the job, and the training should then focus on this deficiency only. trainers). Resources for training (human, transport etc.) should be efficiently used: CDDs (the trainees). Using as few staff members as possible. Examination of training Using as little time as possible (without sacrificing quality) materials, plans/ Choosing the most cost-effective site etc. programmes, reports at this level.

Findings Describe the present situation: Training is carried out using training materials such as brochures, postures, training manuals with some attention to areas of deficiency and it is combined with LF. However, some times training and HSAM are targeted. Retraining is also done for older CDDs with problems.

Describe the situation the year before:

If training is not efficiently done in an integrated manner: Why is this?

Are any steps being taken to improve the situation? Training and HSAM will be more targeted from 2003.

Analysis When writing the report you have to summarise: The evidence about how well this indicator is being achieved. Reasons for poor performance (if any); steps being taken to improve it; and how this is likely to affect sustainability. What is the trend in the way training is done – the method and content?

Your overall judgement: is this indicator for sustainability being achieved? Fully Highly Moderately Slightly Not at all Not applicable

99 Check whether staff at this level is planning and carrying out HSAM activities in an efficient manner. This indicator assesses whether the programme is functioning efficiently and effectively, and whether managers are taking ownership of the programme.

Characteristics of the indicator Sources of information Staff members identify situations where decision makers lack Interviews with: information about/ commitment to CDTI, and undertake Staff at this level. activities to inform and persuade these persons. Civil authorities at this level. HSAM activities are properly planned. They are only carried Community leaders and CDDs. out where there is an objective need for them, and not as a Examination of: matter of routine. HSAM plans/ programmes and There is evidence that these HSAM activities have been reports. effective and have led to action. Year plans and annual reports.

Findings Describe the present situation: HSAM activities are carried out but not with a detailed plan. They use posters and brochures for HSAM in specific areas of need based on reports from the field. However in some cases the frequencies of HSAM activities were too few.

Describe the situation the year before:

If staff is not engaged in HSAM: Why is this?

Are any steps being taken to improve the situation?

Analysis When writing the report you have to summarise: The evidence about how well this indicator is being achieved. Reasons for poor performance (if any); steps being taken to improve it; and how this is likely to affect sustainability. Examine the trend in HSAM activities – is it becoming more efficient?

Your overall judgement: is this indicator for sustainability being achieved? Fully Highly Moderately Slightly Not at all Not applicable

100 6. Indicators of resources: financial

6.1 Check whether the costs involved in planned CDTI activities at this level are clearly defined and budgeted for. This indicator assesses whether the programme is functioning efficiently.

Characteristics of the indicator Sources of information The costs for each CDTI related activity in the year plan Examination of the budget documents should be clearly spelt out in a budget. These activities (government and NGDO). include monitoring/supervision, training, HSAM, and Interviews with: arranging Mectizan supply. FLHF team managers (leader, The staff should be able to justify the amount they plan to treasurer). use. There should be evidence of cost containment (e.g. Local government managers at this level by targeting training, HMAS and supervision). (chairperson, administrator, treasurer).

Findings What happened at: The last round of treatment? Releases for Health services activity at FLHF level are based on demand and availability of funds at LGA level. There is no separate budgetary allocation for CDTI activities as this level as it does not control funds, but some assistance is occasionally provided from the LGA. The round of the year before? Same as above

If costs involved in CDTI related activities are not clearly defined Why is this? This level does not budget nor control funds.

Are any steps being taken to improve the situation?

Analysis When writing the report you have to summarise: The evidence about how well this indicator is being achieved. Reasons for poor performance (if any); steps being taken to improve it; and how this is likely to affect sustainability. What is the trend in the way costing for CDTI related activities is done?

Your overall judgement: is this indicator for sustainability being achieved? Fully Highly Moderately Slightly Not at all Not applicable

101 Check whether sufficient funds to cover these costs are fully or increasingly being disbursed from FLHF and/or district/ LGA resources. This indicator assesses whether the programme is becoming integrated, and whether management is beginning to accept ownership of the programme and can mobilise the resources it needs.

Characteristics of the indicator Sources of information Funding disbursed is enough to Examination of: enable targeted, essential CDTI Budget documents (government and NGDO) activities at this level to be carried Records of disbursement and expenditure (ledgers, orders, out. approvals for expenditure etc.) The relative contributions of all Interviews with: sources of funding should be clearly District/ LGA level managers (technical and administrative). spelt out. NGDO managers at this level. The proportion provided by the FLHF team managers (leader, treasurer). government (FLHF and/ or district/ Local government managers at this level (chairperson, LGA levels) should be the major one administrator, treasurer). by now.

Findings How much was provided by the government: Last round of treatment? No special funds are available at this level.

The round of the year before? Same as above.

The round the year before that?

Same as above.

If the proportion supplied by the government is not the major one by now: Why is this?

Are any steps being taken to improve the situation?

Analysis When writing the report you have to summarise: The evidence about how well this indicator is being achieved. Reasons for poor performance (if any); steps being taken to improve it; and how this is likely to affect sustainability. What is the trend in the relative proportion of resources contributed by the official health service?

Your overall judgement: is this indicator for sustainability being achieved? Fully Highly Moderately Slightly Not all Not applicable

7. Indicators of resources: transport and other material resources

102 Check whether adequate and appropriate transport and materials are available for necessary CDTI activities at this level. This indicator assesses whether the programme is functioning effectively, and whether it is able to mobilise the resources it needs.

Characteristics of the indicator Sources of information There are adequate numbers of appropriate, functional Inspection of: vehicles (of any type) available for necessary CDTI Each vehicle being used: its source; its activities. functional status. The running costs for this transport are met by a Stocks of materials for training and dependable source (e.g. the government). HSAM. There are sufficient materials available for training and Interviews with the FLHF management HSAM. team.

Findings Describe the present situation: Type of transport No. Source* Functional status and adequacy for CDTI tasks** Yamaha 1 NPI Functional SUZUKI 1 APOC Non Functional HONDA 125 1 APOC Functional Training/ HSAM No. Source* Functional status and adequacy for CDTI tasks** material IEC materials Inadequate

* APOC, MoH, NGDO, other (specify) ** Is it working, and is there enough of it for the job? Describe the adequacy of the present vehicles and materials, considering the work still to be done in the coming 5-10 years: Most Health districts had one motor cycle from APOC. This transport was considered inadequate after APOC. IEC materials were also found to be inadequate.

If transport and materials are inadequate and funded from non-government sources: Why is this?

Which steps are being taken to improve the situation?

Analysis When writing the report you have to summarise: The evidence about how well this indicator is being achieved. Reasons for poor performance (if any); steps being taken to improve it; and how this is likely to affect sustainability. Your overall judgement: is this indicator for sustainability being achieved? Fully Highly Moderately Slightly Not at all Not applicable

103 Check whether transport at this level is adequately and appropriately maintained. This indicator assesses whether the programme is functioning effectively and efficiently.

Characteristics of the indicator Sources of information There is a routine maintenance schedule for vehicles (where Inspection of: relevant), which is adhered to and recorded. Vehicle and equipment The costs for vehicle and equipment maintenance and repair are met maintenance schedules. by dependable sources (e.g. the government). Vehicle and equipment Repairs are rapidly and efficiently done. maintenance records. Staff have ways of coping when transport breaks down or is not Interviews with the FLHF available, so that CDTI activities are not disrupted. management team.

Findings Describe the present situation: Motorcycles in most cases are not maintatined by LGA. The officer who use them normally maintain them using their own funds. One APOC motorcycle had an accident in October 2000 and uptill now it has not been repaired.

Make particular enquiries about the ability of the government to pay for maintenance, repairs and tyre replacement:

If the vehicles are not being well maintained, and/ or the government is not paying: Why is this?

Which steps are being taken to improve the situation?

Analysis When writing the report you have to summarise: The evidence about how well this indicator is being achieved. Reasons for poor performance (if any); steps being taken to improve it; and how this is likely to affect sustainability. Your overall judgement: is this indicator for sustainability being achieved? Fully Highly Moderately Slightly Not at all Not applicable

104 Check whether the transport available at this level is appropriately managed and used, in an integrated way. This indicator assesses whether the programme is functioning efficiently.

Characteristics of the indicator Sources of information Trips made for CDTI purposes should be properly Inspection of vehicle control documents: authorised in writing by the relevant official. Each trip Copies of trip authorities (also noting undertaken should be recorded in a log book. destination and purpose) Transport provided for CDTI, and that provided for Log books. other programmes, should be combined as a pool to The supervision plan/ matrix. be used for legitimate activities of all programmes at Interviews with the FLHF management team. this level.

Findings Describe the present situation: NPI and APOC motorcycles are used for all PHC activities. Trips made after securing verbal approval for both CDTI and other PHC activities. No logbooks are kept.

If the transport is not being well managed: Why is this?

Which steps are being taken to improve the situation?

Analysis When writing the report you have to summarise: The evidence about how well this indicator is being achieved. Reasons for poor performance (if any); steps being taken to improve it; and how this is likely to affect sustainability. Your overall judgement: is this indicator for sustainability being achieved? Fully Highly Moderately Slightly Not all Not applicable

105 Check whether there are appropriate and realistic plans for the replacement of transport and materials when APOC support comes to an end. This indicator assesses whether the programme managers are taking ownership of the programme, and are able to find resources for it.

Characteristics of the indicator Sources of information Management should know that replacements will be needed before the Inspection of letters of end of the programme, and have specific, realistic plans to meet the agreement. need at that time. Interviews with: It should be planned that the government will: The FLHF management Provide replacements for vehicles. team. Maintain existing vehicles. NGDO project managers. Provide stationery and materials for training and HSAM. High-ranking local If it is planned that replacement will be from non-government sources, government officials. written commitment for this should have been obtained at the highest level in these donor organisations.

Findings Describe the present situation: The officers are not aware of any plans.

If the plans for replacing vehicles and materials are unsatisfactory: Why is this?

Which steps are being taken to improve the situation?

Analysis When writing the report you have to summarise: The evidence about how well this indicator is being achieved. Reasons for poor performance (if any); steps being taken to improve it; and how this is likely to affect sustainability. Your overall judgement: is this indicator for sustainability being achieved? Fully Highly Moderately Slightly Not at all Not applicable

106 8. Indicators of resources: human resources

8.1 Check whether the team at this level is skilled and knowledgeable, regarding the implementation of CDTI in its area of operation. This indicator assesses whether the programme has been able to develop sufficient resources for itself.

Characteristics of the indicator Sources of information Staff should have enough knowledge and skill to Interviews with undertake all the key CDTI activities themselves: Managers and other staff at this level. planning, training, HSAM, ensuring Mectizan supply, Staff at the district/ LGA level. monitoring/ supervision. Village leaders and CDDs. Staff at this level should remain in one post for at least Inspection of: five years. Staff files. There should be immediate training (in CDTI) of new, Monitoring reports. unskilled project staff members who have CDTI Activity reports. responsibilities.

Findings Describe the present situation: Particulars of current staff Area of skill No. of skilled Level of skill: is it adequate to perform the job? persons Planning Training and HSAM Monitoring/ supervision Mectizan ordering/ distribution Information about stability and in-service training:

.The staff are reasonably stable 2-3yr before transfer. They are adequate (4-5) at FLHF and they are skilled in the above activites.

If the staff at this level lack skills, and are often transferred: Why is this?

Which steps are being taken to improve the situation?

Analysis When writing the report you have to summarise: The evidence about how well this indicator is being achieved. Reasons for poor performance (if any); steps being taken to improve it; and how this is likely to affect sustainability. Your overall judgement: is this indicator for sustainability being achieved? Fully Highly Moderately Slightly Not at all Not applicable

107 9. Indicators of impact: coverage

9.1 Check whether the geographical coverage in the FLHF area is satisfactory. This indicator assesses whether the project is effective – if the rate is poor the project is clearly struggling, and less sustainable.

Characteristics of the indicator Sources of information All villages identified by the latest Inspection of: REMO should be under treatment (i.e. Distribution reports and statistics at community level, for geographical coverage should be this FLHF area, for the past 3 years. maintained at 100%). REMO list of endemic communities for this FLHF area. The rate should be stable or Interviews with staff at FLHF level. increasing.

Findings The geographic coverage situation: At the last distribution: Most communities have been fully treated. However few communities have not been treated due to the shortage of drugs.

The year before: Same

The year before that: Same

If geographical coverage is poor: Why is this?

Are any steps being taken to improve the situation?

Analysis When writing the report you have to summarise the reasons for poor performance (if any); steps being taken to improve it; and how this is likely to affect sustainability. What is the trend in geographical coverage?

Your overall judgement: is this indicator of sustainability being achieved? Fully (100% of Highly (95-99% of Moderately (90-94% Slightly (85-89% of Negligibly communities are communities – of communities – communities – (<85% of doing CDTI) stable or increasing) stable or increasing) stable or increasing) communities)

Instrument 4: community level

108 NOTE: This instrument evaluates the CDTI programme at the level of villages and communities, where the actual distribution of Mectizan takes place. We use the term ‘community’ to refer to both villages (in societies where there are well-defined villages) and communities where family groups are fairly isolated from each other, and do not live in a ‘village’ in the accepted geographical sense of the word. In these communities we find the following persons are involved in the CDTI programme: The community or village leadership – both traditional and elected. The community directed distributors (CDDs) – the persons who have been selected by the community to do the distribution of Mectizan. The other, ‘ordinary’ community members, who take the Mectizan yearly. In this document these persons will be referred to as ‘community members’. When collecting information from ‘ordinary’ community members discussion groups should be conducted.

The focus of this level’s activities in CDTI The main function of this level is to distribute the Mectizan yearly to the community members: Communities select CDDs, who are supported by the leadership and the other community members. The CDDs update the community census every year; distribute the Mectizan appropriately; and send a report on the distribution to the FLHF level.

Geographical name of this community/ village: GURKU, GITATA, AKURA, BAKYANO, AKURBA, ANG DOROWA, KUTU, KWANDERE, KAGBU A, UMME SARIKI,SHABU,ALOGANI.

Project: NASARAWA STATE

Researcher: ALL TEAM MEMBERS

Date: 19th FEBRUARY 2003

Abbreviations/ acronyms CDD community directed distributor CDTI community directed treatment with ivermectin FLHF first line health facility HSAM health education, sensitisation, advocacy, mobilisation – i.e. activities which are aimed at getting all the key players to participate wholeheartedly in the programme NGDO non-governmental development organisation

109 1. Indicators of activities and processes: planning and management

Check whether CDDs are planning and managing their CDTI work efficiently. This indicator assesses whether the programme is efficient and simple. The more streamlined and time-efficient the job, the higher its sustainability.

Characteristics of the indicator Sources of information CDDs should plan their work efficiently, e.g. by: Community treatment Carrying out census and distribution during the same visit (using this registers. census data for the following year’s order). Interviews with: Arranging with the community leadership for help with specific CDDs. problems, such as families who are not willing to participate in the Community members. programme. Community leaders. Choosing visiting times and routes which will make the work less FLHF staff. burdensome.

Findings Describe the present situation:

Census update is routinely done after training before distribution, while in some registration is updated during treatment. Refusals and absenteeism are visited more than once. Community leaders mobilize and sensitize the communities for distribution. However in some communities particularly in Lafia LGA, census is not updated regularly thus leading to inaccurate estimation of the amount of tablets required.

If CDDs are not working efficiently: Why is this?

Are any steps being taken to improve the situation?

Analysis When writing the report you have to summarise: The evidence about how well this indicator is being achieved. Reasons for poor performance (if any); steps being taken to improve it; and how this is likely to affect sustainability. Your overall judgement: is this indicator for sustainability being achieved? Fully Highly Moderately Slightly Not at all Not applicable

110 2. Indicators of activities and processes: leadership and ownership

Check whether community leadership is managing problems with the distribution. This indicator assesses whether the programme is effective, and whether the community is taking ownership of it.

Characteristics of the indicator Sources of information The community leadership should be taking responsibility for Inspection of minutes of community/ the distribution of Mectizan within the community. council meetings (where available). If coverage (geographical and therapeutic) is not adequate or Interviews with: not being maintained, the leadership should understand the CDDs. reasons for this. Community members. Together with the community at large, the leadership should Community leaders. identify and solve problems related to the distribution. FLHF staff.

Findings Describe the present situation: Community leadership is taking charge of distribution, mobilization and sensitization of the communities. Problems are identified particularly refusals and CDD incentives are handled within the communities. For instance the refusals are followed up by the village leaders and encouraged to take the drugs.Most communities voluntarily give the CDDs between N5-N10 per household or an alternative such as yams for those who could not afford cash incentives to CDDs.

If the community leadership is not involved in the distribution: Why is this?

Are any steps being taken to improve the situation?

Analysis When writing the report you have to summarise: The evidence about how well this indicator is being achieved. Reasons for poor performance (if any); steps being taken to improve it; and how this is likely to affect sustainability. Your overall judgement: is this indicator for sustainability being achieved? Fully Highly Moderately Slightly Not at all Not applicable

111 Check whether the community at large has been involved in taking decisions on the distribution process. This indicator assesses whether the community is taking ownership of the programme.

Characteristics of the indicator Sources of information The community should have Inspection of minutes of community/ council meetings taken responsibility for decisions (where available). such as: Interviews with: The selection/ changing of CDDs. CDDs. The timing and mode of Community members. distribution. Community leaders. The persons supervising CDDs: FLHF staff, lay supervisors etc.

Findings Describe the present situation:

The community members are involved in most cases with selection/ changing of CDDs. The CDDs are selected based on a criteria devised by the community leader. Timing is not really determined by communities. It is dependent upon the time Mectizan arrives at the State. Generally the decision of the community leader in regards to mode of distribution and selection of CDDS is taken as the final say for most of the communities.

If the community is not sufficiently involved in taking decisions: Why is this? Culturally, in this area, the decision of the village leader is considered final. Although this is culturally acceptable, it is not in line with the principle of CDTI where community members should be empowered to take decisions concerning the distribution.

Are any steps being taken to improve the situation?

Analysis When writing the report you have to summarise: The evidence about how well this indicator is being achieved. Reasons for poor performance (if any); steps being taken to improve it; and how this is likely to affect sustainability. Your overall judgement: is this indicator for sustainability being achieved? Fully Highly Moderately Slightly Not at all Not applicable

112 Check whether the community members value and accept long-term annual treatment. This indicator assesses whether the community is taking ownership of the programme.

Characteristics of the indicator Sources of information Community members should be able to mention one or Interviews with: more advantages of taking Mectizan. CDDs. Community members should express the need for annual Community members. treatment with Mectizan. Community leaders. People should show understanding of the need for, and The persons supervising CDDs: FLHF express interest in long term treatment with Mectizan. staff, lay supervisors etc.

Findings Describe the present situation:

Villagers perceive Mectizan as a very important drug for improved vision, strength, worm expeller and skin rashes. They are also aware that the drug should be taken for a long time- upwards of 10- 15 yrs. In Gitatata, the communities are so keen on the drug because one known barren womwn had conceived and given birth after taking mectizan.

If community members do not value and accept the treatment: Why is this?

Are any steps being taken to improve the situation?

Analysis When writing the report you have to summarise: The evidence about how well this indicator is being achieved. Reasons for poor performance (if any); steps being taken to improve it; and how this is likely to affect sustainability. Your overall judgement: is this indicator for sustainability being achieved? Fully Highly Moderately Slightly Not at all Not applicable

113 3. Indicators of activities and processes: monitoring

Check whether CDDs are reporting appropriately to the FLHF level. This indicator assesses whether the programme is effective. If such reporting is not taking place Mectizan supply will be compromised, which is bad for sustainability.

Characteristics of the indicator Sources of information Reports to the FLHF level should get there on time. Reports Inspection of community distribution may be summary reports, or the original community reports. distribution record, depending on the level of skill of the CDD. Interviews with: Adequate transport should have been arranged for CDDs. distribution records/ reports to be handed to the appropriate The persons supervising CDDs: FLHF person. staff, lay supervisors etc.

Findings Describe the present situation:

Registers are sent back to village FLHF. These registers appear fairly well kept and filled out by the CDDs. Report get back to the LGAs from the communities through the incharges / District Health supervisors. In some communities their leaders can make arrangements for transportation to enable them deliver their reports at the FLHF but in some cases they deliver by themselves. However, in some communities in Lafia LGA, the LGA co-ordinator by passes the FLHF and takes the drugs to theCDDs and collects the reports after treatment. Village leader also monitors their distribution through a “Jakada”.

If the reporting by CDDs is poor: Why is this?

Are any steps being taken to improve the situation?

Analysis When writing the report you have to summarise: The evidence about how well this indicator is being achieved. Reasons for poor performance (if any); steps being taken to improve it; and how this is likely to affect sustainability. Your overall judgement: is this indicator for sustainability being achieved? Fully Highly Moderately Slightly Not at all Not applicable

114 4. Indicators of activities and processes: obtaining and managing Mectizan

Check whether the right amount of Mectizan is received. This indicator assesses whether the programme is effective. If the right amounts are received it will foster community ownership, which is good for sustainability.

Characteristics of the indicator Sources of information All community members who were eligible Inspection of treatment register for the community (held for treatment got it, and some Mectizan was by CDDs; or at higher levels) left over for absentees and those who were Interview with: temporarily non-eligible. CDDs. There should be a rational explanation about Community members. how the amount ordered for the community Community leaders. is calculated (on the basis of population). The persons supervising CDDs: FLHF staff, lay supervisors etc.

Findings What happened at: The last round of treatment?

In some cases there were not adequate stock of mectizan as the census update was not done properly. Some eligible are given the drugs apart from those that refused. In most cases the rational basis for ordering of mectizan is not known by most of these CDDs. Village leaders are aware that census updates or mechanisms for determining the actual required doses of Mectzan should be in place. Calculations were based on quantity of drugs used on every previous treatment plus census update. This is done sometimes by the CDDs and in most instances by District oncho Coordinators.

The rounds before that?

Ditto

If the wrong amount of Mectizan was received: Why is this?

Are any steps being taken to improve the situation?

Analysis When writing the report you have to summarise: The evidence about how well this indicator is being achieved. Reasons for poor performance (if any); steps being taken to improve it; and how this is likely to affect sustainability. What is the trend in Mectizan supply?

Your overall judgement: is this indicator for sustainability being achieved? Fully Highly Moderately Slightly Not at all Not applicable

115 Check whether the CDDs or community members themselves fetch the yearly supply of Mectizan. This indicator assesses whether the project fosters community ownership.

Characteristics of the indicator Sources of information The CDDs or community members fetch the Mectizan they Interview with: need every year, from a designated and mutually acceptable CDDs. place. Community members. Adequate transport should have been arranged for Mectizan to Community leaders. be collected from such a place. The persons supervising CDDs: In the case of remote communities, the district/ LGA, in FLHF staff, lay supervisors etc. collaboration with FLHFs, should ensure that supplies reach District/ LGA staff. such groups.

Findings What happened at: The last round of treatment?

Mectizan supplies have no fixed time for arrival. Some CDDs fetch the mectizan from the FLHFs while in some the in-charges or the LGA coordinator delivers the drugs to CDDs. Communities assume that their monetary contributions are used for transportations well. It is acceptable to the communities. Adequate quqntities are normally received.

The rounds before that?

Same as above

If community members or CDDs have not been collecting the Mectizan: Why is this?

Are any steps being taken to improve the situation?

Analysis When writing the report you have to summarise: The evidence about how well this indicator is being achieved. Reasons for poor performance (if any); steps being taken to improve it; and how this is likely to affect sustainability. What is the trend in CDDs or community members fetching the Mectizan they need?

Your overall judgement: is this indicator for sustainability being achieved? Fully Highly Moderately Slightly Not at all Not applicable

116 5. Indicators of activities and processes: HSAM

Check whether CDDs and community authorities continue to be engaged in HSAM of other community members. This indicator assesses whether the project is effective, and whether the community has taken ownership of it.

Characteristics of the indicator Sources of information CDDs/ community authorities identify situations where Interview with: community members require information. Community leaders. CDDs/ community authorities take necessary steps to provide Community members. required information; encourage community members to CDDs. provide resources; promote acceptance and ownership The persons supervising CDDs: FLHF (meetings, sanctions, community by-laws). staff, lay supervisors etc.

Findings Describe the present situation:

Community leaders, stake holders and CDDs continue to sensitize and mobilize relevant decision makers as well as persuade refusals within the community, which is very rare in these cases. Promotional materials are very scanty within the community and in some cases not available at all.

If CDDs and community leaders are not involved in HSAM: Why is this?

Are any steps being taken to improve the situation?

Analysis When writing the report you have to summarise: The evidence about how well this indicator is being achieved. Reasons for poor performance (if any); steps being taken to improve it; and how this is likely to affect sustainability. Your overall judgement: is this indicator for sustainability being achieved? Fully Highly Moderately Slightly Not at all Not applicable

117 6. Indicators of resources: financing

Check whether the community has made arrangements to fund local costs of distribution. This indicator assesses whether the project can mobilise the resources it needs, and fosters community ownership.

Characteristics of the indicator Sources of information The community should support individuals who Interview with: are providing CDTI services for them. Community leaders. The community should make provision for the Community members. supply of record books, pencils, transport and CDDs. other expenses incurred during CDTI. The persons supervising CDDs: FLHF staff, lay supervisors etc.

Findings Describe the present situation:

Communities are aware and contribute voluntarily between N5-N10 or alternatives such as yams, as incentives for their CDDs. They are appreciative of the fact that resources come from outside. Some communities also provide pencils and registers.

If the community is not supporting or helping to defray costs: Why is this?

Are any steps being taken to improve the situation?

Analysis When writing the report you have to summarise: The evidence about how well this indicator is being achieved. Reasons for poor performance (if any); steps being taken to improve it; and how this is likely to affect sustainability. Your overall judgement: is this indicator for sustainability being achieved? Fully Highly Moderately Slightly Not at all Not applicable

118 7. Indicators of resources: human resources

Check whether there is a satisfactory ratio of CDDs to households. This indicator assesses whether the project can mobilise the resources it needs, and whether the community has taken ownership of the programme.

Characteristics of the indicator Sources of information A ratio of at least one CDD to 20 Interview with: households (or 2 CDDs per 250 Community leaders. population) is recommended. Community members. The households for which CDDs are CDDs. responsible should be close to their own The persons supervising CDDs: FLHF staff, lay homes. supervisors etc.

Findings The present ratio in the community:

Some of the communities have only 1 CCD, which is not adequate . In some cases the CDDS covers two other additional communities. In some communities one CDD treats about 1700-2260 persons. Some treat more than 100 households.

The average distances that CDDs have to walk to get to homes:

On an average the CDDs travel between 1-2 km and in most cases the houses are in clusters.

If the ratio of CDDs is too low: Why is this?

Are any steps being taken to improve the situation?

Analysis When writing the report you have to summarise: The evidence about how well this indicator is being achieved. Reasons for poor performance (if any); steps being taken to improve it; and how this is likely to affect sustainability. Your overall judgement: is this indicator for sustainability being achieved? Fully Highly Moderately Slightly Not at all Not applicable

119 Check whether all CDDs have received appropriate training. This indicator assesses whether the project is effective.

Characteristics of the indicator Sources of information CDDs should be skilled at their work: doing the Interview with: census; giving the right dose; knowing who is not Community leaders. eligible; knowing what to do with side-effects Community members. There should be a plan in place for training CDDs to CDDs. replace those who drop out, or when new ones are The persons supervising CDDs: FLHF staff, elected for other reasons. lay supervisors etc. Observing CDDs at work.

Findings Describe the present situation:

CDDs are skilled based on their knowledge on exclusion criteria, management of side effects, and knowledge of the importance of census update in some communities.

If CDDs appear unskilled, or if there is no proper plan for training replacements: Why is this?

Are any steps being taken to improve the situation?

Analysis When writing the report you have to summarise: The evidence about how well this indicator is being achieved. Reasons for poor performance (if any); steps being taken to improve it; and how this is likely to affect sustainability. Your overall judgement: is this indicator for sustainability being achieved? Fully Highly Moderately Slightly Not at all Not applicable

120 Check whether CDDs are willing to continue their work in CDTI. This indicator assesses whether the programme has mobilised the resources it needs, and whether it fosters community ownership.

Characteristics of the indicator Sources of information CDDs should express willingness to continue Interview with: with distribution in the long term, given the Community leaders. conditions which prevail in the community. Community members. Few CDDs in this community have dropped CDDs. out from the distribution work. The persons supervising CDDs: FLHF staff, lay supervisors etc.

Findings Describe the present situation:

Cdds are willing to continue ther job. In most cases it helps them get political appointments and so readily take up jobs as CDDs. Some CDDs have been working as distributors for 4-9 years without dropout. However, some CDDs think that the government should assist them with incentives because what the communities contribut towards their incentives is not adequate.

If some CDDs are doubtful or unwilling to continue, or have dropped out: Why is this?

Are any steps being taken to improve the situation?

Analysis When writing the report you have to summarise: The evidence about how well this indicator is being achieved. Reasons for poor performance (if any); steps being taken to improve it; and how this is likely to affect sustainability. Your overall judgement: is this indicator for sustainability being achieved? Fully Highly Moderately Slightly Not at all Not applicable

121 8. Indicators of impact: coverage

8.1 Check whether the geographical coverage in the community is satisfactory. This indicator assesses whether the project is effective – if the rate is poor the project is clearly struggling, and less sustainable.

Characteristics of the indicator Sources of information All households and areas in the Inspection of: community are being treated. This CDDs’ treatment registers. includes the hamlets for which the Yearly distribution reports for that community. community has agreed to be Interview with: responsible. Community leaders. If this geographical coverage is not Community members. 100%, it should be improving. CDDs. FLHF level staff.

Findings The geographic coverage situation: At the last distribution: All households and areas in some of the communities are not treated due to shortages of the drug.

The year before: Same areas are also covered.

The year before that:

Same areas are also covered.

If geographical coverage is poor: Why is this?

Are any steps being taken to improve the situation?

Analysis When writing the report you have to summarise the reasons for poor performance (if any); steps being taken to improve it; and how this is likely to affect sustainability. What is the trend in geographical coverage?

Your overall judgement: is this indicator of sustainability being achieved? Fully (100% Highly (only nomads Moderately (the Slightly (some Negligibly (no-one coverage of all in the surrounding outlying hamlets wards of the got treated, or only households) area were missed) were also missed) community were a few families) also missed)

122 8.2 Check whether the community has a satisfactory therapeutic coverage rate.

This indicator assesses whether the programme is effective – if the rate is poor the project is clearly struggling, and less sustainable.

Characteristics of the indicator Sources of information The community overall has a therapeutic Inspection of: coverage rate of 65% or higher. CDDs’ treatment registers. This rate should be stable or increasing. Yearly distribution reports for that community. Interview with: Community leaders. Community members. CDDs. FLHF level staff.

Findings The therapeutic coverage situation in the community: At the last distribution:

Therapeutic coverage for the entire village sample has been impressive over years. Rates for 5 villages have been on steady increase from 58.8% to 95% (Alogani, Kagbu, Kwaandere, Ang.Dorowa and Kutu). 6 of the villages (Umme sariki, Akruba, Akura, Shabu, Gitatata and Gurku) Had the coverage values fluctuating.

The year before:

The year before that:

If the therapeutic coverage rate is poor: Why is this?

Which steps are being taken to improve the situation?

Analysis When writing the report you have to summarise the reasons for poor performance (if any); steps being taken to improve it; and how this is likely to affect sustainability. What is the trend in therapeutic coverage?

Your overall judgement: is this indicator of sustainability being achieved? Fully (the community has a Moderately (the therapeutic Negligibly (the therapeutic therapeutic coverage rate ≥65% - coverage rate is ≥65%, but it is coverage rate is <65%) stable or increasing) unstable or decreasing)

123 APPENDIX VII

WORK PLAN FOR THE EVALUATION TEAM

Team 1 Team 2 Team 3 Days

Sunday 16th All team members arrive and settle into hotels (at Jos/Lafia). February Orientation of the Plateau/ Nassarawa Evaluation team members on the Monday 17th Evaluation Instruments in Jos. February Courtesy call to State MOH by all team members upon arrival at Lafia, Nassarawa State. Tuesday 18th February Later teams disperse for Data Collection on same Day.

Data collection Data collection Data collection from SMOH H/Q from LGA H/Q from LGA H/Q & SOCT leader (Karu) (Nassarawa Eggon)

Wednesday 19th Interview with the Data collection from Data collection from February Country FLHF and two FLHF and two Representative of communities communities GRBP/Carter Center (Karu) (Nassarawa Eggon) Thursday 20th ± other NGDO & Data collection from Data collection from February Zonal Officer in Jos. Second FLHF and two Second FLHF and two communities communities (Karu) (Nassarawa Eggon) Friday 21st Data collection at Data collection from Data collection from February LGA level (Lafia- FLHF and two second FLHF and two 3rd LGA) communities. communities.(Lafia) ( Lafia) Saturday 22nd Feb Mop up Data collection & debriefing of LGA authorities & invitation of participants to the feedback planning meeting. Sunday 23rd Feb Collation of Data & report writing. Preparation for debriefing of State and Planning meetings for workshops on 24th and 25th February. Monday 24th Feed back/Planning workshop (State level) & Tuesday 25th Feedback/Planning workshop (LGA level) Wednesday 26th- Finalizing Report 28th February.

Nassarawa State Evaluation Team Composition

Team One Dr Baine (Team Leader) Dr E Nnoruka SPO Leader - A A Umar

Team Two Dr Richard. N

124 Alhaji Abbas. One SOCT member- Mr. J Danboyi

Team Three. Dr Istifanus Mr J Umaru One SOCT Member- Mrs S Mbaratan

125 1 LIST OF PEOPLE INTERVIEWED

Nasarawa State MOH Honourable David Gimba Commissioner of Health (Courtesy Call) Alhaji Musa Dangana Director PHC/ Disease Control Director Planning

Nassarawa Eggon LGA

Mr. Azhen Lasson Director Personnel Management/Secretary of Nasssarawa Eggon LGA. Alhaji Bawa Ajigena Director PHC Mr Sunday Esson Idi LOCT leader

LAFIA LGA

Alhaji Mohammed Kaura Abubakar DPM/Secretary TO Lafia LGA. ( Courtesy Call)

Alhaji Ari Musa Director Finance. Hajia Jemila Dalhatu Director PHC/Disease Control Mallam Abdulahi Moh’d Senior LOCT (Leader)

KARU LGA

Mr. Danjuma Y Daudajika Director Finance Mr. Yunusa Director PHC/Disease Control Mr Yerima Musa LOCT leader

1 Should be re-allocated. 126 GUIDELINES AND CHECKLIST FOR DEVELOPING A CDTI SUSTAINABILITY PLAN

The aim of the guidelines and checklist is to highlight key elements of a CDTI sustainability plan. The guidelines and checklist is intended to help evaluators and National Coordinators to facilitate a meeting of stakeholders to develop a three-year CDTI post-APOC sustainability plan for submission to the management of APOC.

A checklist for the personnel/staff and their functions required for Mectizan delivery post-APOC era has been included.

Remember: The aim of the planning meeting should NOT be to replace APOC financing with another donor external to the APOC partnership. It is for government and communities to take charge.

To develop a CDTI sustainability plan it is crucial to adopt the recommended Process

What is the recommended process?

All partners supporting a CDTI project should attend the meeting and jointly develop the plan. A plan should not be developed by only a segment of the supporting partners, the NOTF or the district/ State Oncho Control team. The District / LGA/State Health Management Team should chair the meeting to develop a plan. Partners at each level - National (NOTF), State (SOCT) Local Government (LOCT), and District (DOCT) – members, should discuss and have a good understanding of the significance of the sustainability Plan. The following should be made available to the meeting: The past and current State/LGA/District comprehensive health plan Letter of Agreement and information on the financial contribution of government and other partners The sustainability evaluation report After a plan has been developed all partners should endorse, in writing, their commitment to finance the plan. The SIGNED copy should be forwarded to APOC HQ The partners should fully understand the need to develop a five or ten - year CDTI sustainability plan almost immediately after this exercise.

Membership of the group to develop CDTI sustainability plan at the country level: At the State level- The Commissioner of Health, Director of Disease Control (PHC), 5 States Control Team members, Director of Finance NGDO partner

At the LGA level The meeting identified about 5 persons per LGA who should attend the meeting on post-APOC CDTI sustainability plan. These are: Chairman of LGA or Director of Personnel.

127 Director of PHC, 2 LOCT members, Councilors of Health, Finance Director

It is expected that subsequently at the meetings for States/regional/provincial and LGA/district staff, a joint sustainability plan will be developed.

B. Checklist of KEY information that should appear in a post-APOC (after 5th Year) sustainability plan.

Background information of the project REMO map APOC funding period CDTI implementation- achievements and challenges Training of Health personnel and CDDs – Annual Training Objectives and Results (1st to 5th Year) Coverage (Geographic and therapeutic) – Annual Treatment Objectives and Results (1st –5th Year)

Defining the Role of each supporting partner in the post-APOC era. It would be necessary at the meeting to discuss/review the roles different partners have played in the past five years and to determine whether there is need for modification. The roles should be clearly stated in the plan: Role of the community – their tasks should remain unchanged Role of the Health Centre/FLHS, Districts/LGAs Role of the Provincial /State/Regional authorities. Role of the NGDO supporting partner (if any)

The plans should show evidence that all critical issues raised in the evaluation report are being addressed by government at all levels.

The plans should conform with the conditions for further support by APOC stated in paragraph D (iii) below.

Written agreement that the three-year MOH and supporting NGDO contributions to the CDTI budget will be released by government (State and LGA/ Province and District) NGDO respectively.

The State/District /LGAComprehensive health plan. Check whether onchocerciasis control activities have been included and budgeted for in the State/LGA/District plan (Comprehensive Health Plan). If not, this error should be amended in the current and subsequent plans Please note the CDTI sustainability plan should be an integral part of the Comprehensive Health Plan. This means, CDTI activities should appear in the State/LGA/District Comprehensive Health Plan and the signed sustainability plan should be submitted to APOC management with the Comprehensive Health Plan.

C. CDTI Sustainability Plan Budget

128 The first and most important step is for the partners to determine the BASIC AMOUNT required annually to maintain ivermectin distribution at 100% geographic coverage and treatment coverage of more than 65% of total population. Time should be taken during the meeting to determine and agree on the minimum financial support required. Study and comprehend APOC’s criteria for further support, before proceeding to develop the budget. The criteria are presented below for reference. The Plan should be at least a three-year sustainability plan Insert in the year Plan a table showing amount project received from APOC Trust Fund during each of the preceding 5 year life span of the project (1st, 2nd, 3rd, 4th and 5th years) and the total. Budget justification of the 3-year sustainability plan should be adequate and detailed.

CRITERIA FOR FURTHER APOC SUPPORT i. After the fifth project year, APOC should NOT support programmatic activities. This includes: Salary top ups Routine CDTI activities such as CDD training, monitoring and supervision and distribution of Mectizan Running cost for motor vehicles Cost of consumables Internal procurement and transport of Mectizan ii. The costs of the above activities should not feature in the APOC column of the sustainability Plan but should be taken up primarily by government or NGDO. iii. APOC could provide further support for up to three additional years of CDTI implementation if the projects meet the following conditions: There should be a 3 year, post-APOC plan for sustainability Government has released the entire budget for the preceding year. Ample evidence that the issues raised during the mid-term evaluation have been (and are being) thoroughly and systematically addressed. Evidence that resources have been used for planned activities as intended. Evidence that 100% geographic coverage and an acceptable (higher than 65%) therapeutic coverage has been attained Written commitment that the 3 year post-APOC plan shall be followed by a ten- year post-APOC plan for sustainability. iv. APOC COULD support the following activities APOC may consider providing technical assistance and advocacy support after the fifth year, for the years 6-8, only if certain criteria are met. Such support, for projects after the fifth year includes:

Replacement of capital equipment Capacity building to strengthen project sustainability especially regarding effective management of scarce resources, advocacy and local resource mobilization as well as leadership development, and data/information management Advocacy aimed at fostering commitment of government to continue to support CDTI Technical assistance for external monitoring and evaluation REMO Mapping Operational research to improve implementation of sustainability of CDTI

129 There should be no column in the budget for APOC, unless absolutely necessary (for example - capital equipment NOT replaced in the 5th year; high level advocacy and activities listed above). Facilitators should guide the meeting and ensure that items listed conform with the criteria for further support.

PERSONNEL AND FUNCTIONS FOR CDTI SUSTAINABILITY

The personnel at the National Level are deliberately left out in the list below. After the sixth year of CDTI implementation the personnel required to maintain CDTI activities at each level and their functions are as follows:

State / Provincial/ Regional level

Personnel: Mectizan Store officer/Coordinator 4 others at this level Functions Ordering and collection of Mectizan based on census data Account for previous years allocation of Mectizan tablets Add up population data from the LGA treatment summary form to obtain the State census Multiply the State census by a factor of 3 to determine the number of tablets required Complete the application form Submit the application form to the Zonal Coordinator Plan how to collect the State batch of Mectizan supplies from the Zonal office (wait until there is information that Mectizan is available for collection) Send advance message to all LGAs to come for their Mectizan supplies (please take note of the date the supplies form the zone will arrive) Travel to collect Mectizan (one person with a driver)

Storage and Delivery of Mectizan Issue the Mectizan according to LGA request (please write LGA names on their allocation for easy delivery) Store Mectizan in a secure space (and wait for LGA representatives to come for their allocation) Register the name of LGA representative, status, quantity allocated, signature of receiver and date received.

One-time Community Self Monitoring orientation of LGA staff Plan for community self-monitoring Write to inform the Stakeholders (Chairman, PHC Director, Oncho Coordinator) about the community self monitoring orientation meeting Study the manual on Community Self-Monitoring of Ivermectin Treatment Mention that the Oncho. coordinator should invite the LOCT and community leaders to the CSM orientation meeting Give date of meeting, venue (in the LGA not in the State capital) Rehearse the role play of what to do with the team at the state before departure Pay respects to the chairman and those in authority at the LGA (Councillor for health, Director of personnel etc) Commence the orientation meeting on schedule Orientate the Stakeholders on CSM

130 Discuss what CSM is, why it is necessary and the reason for the state team’s visit to the LGA (to orientate the LG team to carry out CSM). Mention those who will carry it out at the community level (community leaders) Mention those who will train them to carry out CSM (LGA staff) Demonstrate how to carry out community self monitoring (please use role play as much as possible) Request the participants to take turns to role-play

Data collation, processing and management Send message to the LGA (verbal, written, radio) requesting them to send Treatment summary forms Training activity (number participating, number of training meetings) Mobilization Others Enter the data on treatment summary to the computer Add up data from the treatment summary forms from each LGA to obtain a STATE summary. Compare data on each of the indicators with subsequent years data (increasing/decreasing coverage, missing tablets, etc) Note the LGA performance on geographic and therapeutic coverage Identify the LGAs that are not performing well and those with outstanding performance, and the reasons for it. Provide feedback to the LGAs and make suggestions on what they should do

Technical and financial reporting Write a first draft of the technical report using the guideline The guideline has been followed strictly All activities are included in the draft Give a copy of the draft to the NGDO partner ( if any) to review

Collect the reviewed copy from the NGDO partner (verbal feedback is also very useful) Discuss the feedback with the team Rewrite the first draft and check Consistency of figures Syntax It may be helpful to ask someone to edit the final draft Print final draft and submit to the National Coordinator

Advocacy, information, education, communication and motivation Make a compilation of influential people in the State (politicians, businessmen) who could support the programme Approach them to solicit for specific support Mention what the programme is about and the benefits from it to the people Discuss the assistance received from partners Mention what remains to be done (provision of bicycles for dispensaries, replacing a motorcycle, institute prizes ands awards for good performance etc) State how the individual making contribution will be acknowledged (inscription of name on donated item, name on honours list in State office, citation in NOCP newsletter etc) Check for availability of IEC materials Identify the materials that are in shortage Produce IEC materials Distribute to the LGAs

131 LGA/DISTRICT LEVEL

Composition:

LGA/DISTRICT level Coordinators District Health Supervisors/4 others Functions

Planning by the team and use of plans at this level LGA coordinator to notify members of date of planning meeting. Documents required for the meeting: previous years LGA plan with key CDTI activities, previous years integrated PHC plan, Budget and actually releases from the various partners and Evaluation report. Identify venue for the meeting. Develop 3 years sustainability plan. Agree on frequency and timing of meetings for each year. Review previous year’s activity for every year. Identify lapses based on geographic and therapeutic coverage, weaknesses, etc. Review current years plan taking into consideration the above. Copies of plans should be circulated to all members. Use developed plans for implementation of activities of CDTI.

One-time CSM/SHM training of CHEWS/District Health supervisors Identify training materials required for CSM/SHM. Identifying venue for the training.

Monitoring of CDTI activities at FLHF (or District) Verification of updating of census using District summary forms. Accountability of Mectizan tablets received. Adequacy of Mectizan tablets. Collection of remaining tablets (unused tablets). Geographic coverage (100%) Therapeutic coverage > 65% Storage of Mectizan. Safety of Mectizan. CSM/SHM instituted. Feedback to the DOS/CHEWS. Supervisory checklist in use.

Data collation (collection and summary) Collection of Treatment summaries from all Districts/Frontline Collation and addition of treatment summaries. Submission of report to State Coordinator.

Accountability for Mectizan use

132 Collection of remaining tablets (unused tablets). Submission of unused Mectizan tablets to State.

Census-based delivery of Mectizan Annual updating of census. Collation of census population from community summary. Calculation of Census population Use of updated Census figures from community summary forms for calculation of Mectizan tablets required/ issued.

Advocacy, information education and communication and motivation. Advocacy to policy makers at the LGA. Meeting with Traditional/Opinion leaders Meeting with community leaders. New Flip charts/Posters emphasizing the need for compliance and duration of treatment. Advocacy materials for policy makers on the need for continued support and funding for sustainability. Jingles Feedback Commendation Awards: Best data-record keeping/collation, best coverage (Geographic and Therapeutic), best maintained vehicle and logistic support, best LGA exhibiting E spirit de corp (least complaint). ------

District level (FOR NIGERIA ONLY) District Health Supervisors

FUNCTIONS

Meeting with FLHF staff to develop work plan for next treatment cycle Identification of new FLHF staff for the meeting Review previous year’s performance of FLHF Review of previous year’s work plan Identify areas of need to improve CDTI implementation

Mectizan collection based on census Account for previous year’s Mectizan Collection of population figures of communities from CHEWs Adding up the population figures received from FLHF (District dispensary and health posts) from summary forms Ordering of Mectizan for next treatment cycle based on census figures Collection of Mectizan from LGA drug store

Storage and Supply of Mectizan to CHEWs Mectizan is stored in a safe place Mectizan is stored in adequate condition Mectizan collected has been recorded in an inventory form Supply of Mectizan to CHEWs based on community population figures

Collection of summary forms for reporting Summary forms for reporting of treatment by CHEWs and CDDs for next cycle collected

133 One-time CSM/SHM training of CHEWS in FLHF Meeting with CHEWs three months before distribution of Mectizan by the community Training of CHEWs on Community Self Monitoring (CSM) Training of CHEWs on Stake Holders’ Meeting (SHM) Supervising randomly selected CHEWs on facilitation of CSM Supervising randomly selected CHEWs on facilitation of SHM Collection of report on CSM from all the CHEWs Compilation reports on CSM for the District Submission of District CSM report to the LGA Collection of report on SHM from all the CHEWs Compilation reports on SHM for the District Submission of District SHM report to the LGA

Data collation from FLHF Collect data on the year’s treatment from CHEWs Cross-check data on the year’s treatment register with CHEWs Compilation of treatment data for the District Submission of the year’s treatment data on the District to the LGA

Accountability for Mectizan used by FLHF Collection of summary form on Mectizan used from the CHEWs Cross-check the data on Mectizan used with the CHEWs Collate Mectizan used for the District Submission of report on Mectizan used to the LGA

Targeted training of FLHF and CDDs Identification of areas of weakness among the FLHF staff Training of FLHF staff on the areas of weakness Compilation of reports on targeted training of FLHF staff Submission of reports on targeted training of FLHF staff to LGA Identification of areas of weakness among trained CDDs Training/retraining of CDDs on the areas of weakness Compilation of reports on targeted training/retraining of CDDs Submission of reports on targeted training/retraining of CDDs to LGA

Advocacy Identification of advocacy needs Identification of District opinion leaders and groups Meeting District opinion leaders to advocate for further support for CDTI Meeting District groups to take on responsibilities for the sustainability of CDTI Compilation of reports on advocacy meetings Submission of reports on advocacy meetings to the LGA

Targeted Supervision of FLHF Staff Identification of areas of weakness among the FLHF staff for supervision Identification of poor performing communities Supervision of poor performing communities with FLHF staff Compilation of reports on targeted supervision of FLHF staff in poor performing communities Submission of reports on targeted supervision of FLHF staff in poor performing communities to LGA

134 ------

Frontline Health Facility (Health centers/posts)

Personnel Community Health Extension Workers (CHEWs)/ Health Surveillance Assistants or their equivalent in other countries

Functions Mectizan collection and delivery Plan Obtain the community population from the register Multiply the community population by a factor of 3 to determine the amount of tablets required Send the request for Mectizan to the Health District/LGA Collect the amount of drugs allocated to the FLHF Deliver the drugs to the CDD

Supervision of CDDs, distribution and census update Use one supervisory checklist form for every community

135 APPENDIX VIII

PERSONNEL AND ACTIVITIES REQUIRED FOR SUSTAINALBILITY OF CDTI AFTER 5 YEAR OF APOC SUPPORT

Done Undone After the fifth year of CDTI implementation the personnel required to maintain CDTI activities at each level and their functions are as follows:  

A . State Level Personnel: Mectizan Store Officer/Coordinator 4 others   Activities i. Ordering and collection of Mectizan based on updated census data

· Accounting for previous years allocation of Mectizan tablets   · Summation of population data from the LGA treatment summary form to obtain the State census  

· Calculation of number tablets required (Multiplication of the State census by a factor of 3 to determine the number of tablets required)   · Completion of the application form   · Submission of the application form to the Zonal Coordinator/NGDO   · Planning collection of State batch of Mectizan supplies from the   Zonal office (wait until there is information that Mectizan is available for collection)  

· Informing LGAs of availability of Mectizan tablets (Send advance messages to all LGAs to come for their Mectizan supplies)   (please take note of the date the supplies form the zone will arrive)   · Collection of Mectizan (One Person with a driver)  

136 (please take note of the date the supplies from the zone will be received)   ii. Storage and Delivery of Mectizan Issuing the Mectizan according to LGA request (please write LGA names on their allocation for easy delivery)   Storage of Mectizan in a secure place (and wait for LGA representatives to come for their allocation)   Completion of inventory (name of LGA representative, status, quantity allocated, signature of receiver and date received).   iii. One-off Community Self Monitoring orientation of LGA staff   Planning for community self-monitoring   Writing to inform the Stakeholders (Chairman, PHC Director, Oncho Coordinator) about community self-monitoring orientation meeting   Studying the manual on Community Self-Monitoring of Ivermectin Treatment   Invitation of the LOCT, Community leaders to the CSM orientation meeting by Oncho Coordinator.   Stating date and venue of meeting, (in the LGA not in the State capital)   Rehearsing role play by state before departure   Courtesy call on Chairman and other policy makers at the LGA   Commencement of the orientation meeting on schedule   Orientation of Stakeholders on CSM   Discussion on CSM importance and reasons for state team’s visit to the LGA (to orientate the LGA teams on CSM).   Mentioning persons to undertake to carry out CSM at the community level (community leaders)   Mentioning persons to undertake CSM training (LGA staff)   Demonstration of community self monitoring (please use role play as much as possible)   Role play by participants   iv. Data collation, processing and management   Sending messages to the LGA (verbal, written, radio) requesting them to submit:   treatment summary forms   training activities (number participating, number of training meetings)   Mobilisation  

137 Others   Data entry of treatment summary forms   Collation of data from the treatment summary forms from each LGA to obtain a STATE summary.   Comparison data of each of the indicators with subsequent years data (increasing/decreasing coverage, missing tablets, etc)   Noting performance on basis of geographic and therapeutic coverages   Identification of the LGA performance (outstanding, adequate and the reasons for the performance).   Feedback to LGAs and making suggestions on what should be done   v. Technical and financial reporting   Writing a first draft of the technical report using the following guidelines:   Strictly using the TCC guidelines   Including all activities in the draft   Giving a copy of the draft to the NGDO/ partner for review   Collection of revised copy from the NGDO/ partner (verbal feedback is also very useful)   Discussion of feedback with the team   Correction of the write the first draft and checking for:   Consistency of figures   Syntax   Editing of final draft.   Submission of final draft to National Coordinator   vi. Advocacy, information, education and communication and motivation   Compilation of influential people in the State (politicians, businessmen) who could support the programme   Approaching influential people to solicit for specific support   Discussions on the programme and it’s benefits  

138 Discussions on the assistance received from partners   Mentioning outstanding support required (provision of bicycles for dispensaries, replacing a motorcycle, institute prizes ands awards for good performance etc)   Stating how individuals who make contributions will be acknowledged (inscription of name on donated item, name on honours list in State office, citation in NOCP newsletter etc)   Checking for availability of IEC materials   Identification of the materials in shortage   Production IEC materials   Distribution to LGAs

Done Undone   B . LGA Level Personnel : Coordinators District Health Supervisors / 4 others

Activities i. Team planning and use of plans by team members Notification of members of date of planning meeting by LGA Coordinator   Documents required for the meeting: previous years LGA plan with key CDTI activities, previous years integrated PHC plan, Budget and actually releases from the various partners and Evaluation report.  

Identification of venue of the meeting.  

Development of 3 years sustainability plan.   Agreeing frequency and timing of meetings   Review of previous year’s activity for every year.   Identification of lapses based on geographic and therapeutic coverage, weaknesses, etc   Review of current years plan taking into consideration the above.   Circulation of copies of plans to all members.  

139 Using developed plans for implementation of activities of CDTI.     ii. One-off CSM/SHM training of CHEWS/District Health supervisors Identification of training materials required for CSM/SHM.   Identification of venue for the training.     iii. Monitoring of CDTI activities at FLHF (or District) Verification of updating of census using District summary forms.   Accountability of Mectizan tablets received.   Adequacy of Mectizan tablets.   Collection of remaining tablets (unused tablets).   Geographic coverage (100%)   Therapeutic coverage > 65%   Storage of Mectizan.   Safety of Mectizan.   Institution of CSM/SHM   Feedback to the DOS/CHEWS.   Use of supervisory checklist   iv. Data collation (collection and summary) Collection of Treatment summaries from all Districts/Frontline   Collation and addition of treatment summaries.   Submission of report to State Coordinator.     v. Accountability of Mectizan used

140 Collation and addition of treatment summaries   Submission of unused Mectizan tablets to State.  

vi. Mectizan delivery based on community census Annual updating of census.   Collation of census population from community summary forms.   Calculation of updated census population   Use of updated census figures from community summary forms for calculating number of mectizan tablets to be issued  

vii. Advocacy, information education and communication and motivation. Advocacy to policy makers at the LGA.   Meeting with Traditional/Opinion leaders   Meeting with community leaders.   Production of Posters emphasizing the need for compliance for duration of treatment.   Production of Advocacy materials for policy makers on the need for continued support and funding for sustainability of CDTI   Production and use for Jingles ( radio and TV)   Feed back to policy makers and CHEWs / Supervisors   Commendation of SOCT/CHEWs/supervisors/communities   Award of prizes: LGA with best data - record keeping / collation, LGA /community with best coverages   (Geographic and Therapeutic), supervisor/LGA/State with best maintained vehicle and logistic support,   LGA/ District/State with exhibiting est spirit de corp  

C. District level Personnel: District Health Supervisors Other Supervisors

141 Activities i. Meeting with FLHF staff to develop work plan for next treatment cycle Identification of new FLHF staff for the meeting   Review of previous years performance of FLHF   Review of previous years work plan   Identification of ways of improvement of CDTI implementation  

ii. Mectizan collection based on census Accounting for previous year’s Mectizan tablets allocation   Collection of population figures of communities from CHEWs   Summation of the population figures received from FLHF (District dispensary and health posts) from summary forms   Ordering of Mectizan tablets subsequent treatment cycle based on census figures   Collection of Mectizan from LGA drug store

iii) Storage and Supply of Mectizan to CHEWs   Assessment of safety of Mectizan storage facilities   Assessment of adequacy of storage facilities   Assessment of use of inventory forms for receipt and issuance of Mectizan tablets   Assessment that Mectizan is issued to CHEWs on the basis of updated community census  

iv. Collection of summary forms for reporting Summary forms for reporting of treatment by CHEWs and CDDs for next cycle collected  

v. One-time CSM/SHM training of CHEWS in FLHF Meeting with CHEWs three months before distribution of Mectizan by the community   Training of CHEWs on Community Self Monitoring (CSM)   Supervision of randomly selected CHEWs on facilitation of CSM   Supervision of randomly selected CHEWs on facilitation of SHM   Collection of report on CSM from all the CHEWs   Compilation of reports on CSM for the District  

142 Submission of District CSM report to the LGA   Collection of reports on SHM from all the CHEWs   Compilation of reports on SHM for the District   Submission of District SHM report to the LGA     vi. Data collation from FLHF Collection of previous year's treatment data from CHEWs   Cross-checking the current year’s treatment figures in community registers with CHEWs   Compilation of treatment data for the District   Submission of the year’s treatment data on the District to the LGA   vii Accountability for Mectizan used by FLHF Collection of summary form on Mectizan tablets used from the CHEWs   Cross-checking the data on Mectizan tablets used with the CHEWs   Collation of Mectizan tablets used for the District   Submission of report on Mectizan used to the LGA     viii. Targeted training of FLHF and CDDs   Identification of areas of weakness among the FLHF staff   Training of FLHF staff on the areas of weakness   Compilation of reports on targeted training of FLHF staff   Submission of reports on targeted training of FLHF staff to LGA   Identification of areas of weakness among trained CDDs   Training/retraining of CDDs on the areas of weakness   Compilation of reports on targeted training/retraining of CDDs   Submission of reports on targeted training/retraining of CDDs to LGA   viii. Advocacy Identification of advocacy needs   Identification of District opinion leaders and groups   Compilation of reports on advocacy meetings   Meeting District opinion leaders to advocate for further support for CDTI  

143 Submission of reports on advocacy meetings to the LGA   ix.Targeted Supervision of FLHF Staff Identification of areas of weakness among the FLHF staff for supervision   Identification of poor performing communities   Supervision of poor performing communities with FLHF staff   Compilation of reports on targeted supervision of FLHF staff in poor performing communities   Submission of reports on targeted supervision of FLHF staff in poor performing communities to LGA  

Done Undone D. Firstline Health Facility  

Personnel CHEW(s)

Activities i.Mectizan collection and delivery Planning collection and delivery of mectizan tablets   Obtaining the community population from the register   Multiply the community population by a factor of 3 to determine the amount of tablets required   Requesting from Mectizan to the Health District/LGA   Collect the amount of drugs allocated to the FLHF   Collection of mectizan tablets by CDDs / Communities   ii) Supervision of CDDs, distribution and census update Use of supervisory checklist form for every community  

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