l- World Health Organization African Programme for Onchocerciasis Control FINAL RËPOftî ,i ={ Evaluation of the Sustainability of the Niger State CDTI Project, Nigeria N ove m ber- Decem ber 2004 Elizabeth Elhassan (Team Leader) Uwem Ekpo Paul Kolo William Kisoka Abraraw Tefaye Hilary Adie f'Ï 'rt\ t- I I I TABLE OF CONTENTS I Table of contents............. ..........2 Abbreviations/Acronyms ................ ........ 3 Acknowledgements .................4 Executive Summary .................5 *? 1. lntroduction ...........8 2. Methodology .........9 2.1 Sampling ......9 2.2 Levels and lnstruments ..............10 2.3 Protocol ......10 2.4 Team Composition ........... ..........11 2.5 Advocacy Visits and 'Feedback/Planning' Meetings........ ..........12 2.6 Limitations ..................12 3. Major Findings And Recommendations ........ .................. 13 3.1 State Level .....13 3.2 Local Government Area Level ........21 3.3 Front Line Health Facility Level ......27 3.4 Community Level .............. .............32 4. Conclusions ..........36 4.1 Grading the Overall Sustainability of the Niger State CDTI project.................36 4.2 Grading the Project as a whole .......39 ANNEXES .................40 lnterviews ..............40 Schedule for the Evaluation and Advocacy.......... .................42 Feedback and Planning Meetings, Agenda.............. .............44 Report of the Feedbacl</Planning Meetings ..........48 Strengths And Weaknesses Of The Niger State Cdti Project .. .. ..... 52 Participants Attendance List .......57 Abbrevi ations/Acronyms APOC African Programme for Onchocerciasis Control CDD Community Directed Distributor CDTI Community Directed Treatment with lvermectin FLHF Front Line Health Facility - GCR Geographical Coverage Rate HSAM HealthEducation/Sensitization/AdvocacylMobilization , IEC lnformation, Education, Communication LGA Local Government Area LOCT Local Government Onchocerciasis Control Team MoH Ministry of Health NGDO Non-Governmental Development Organization NGO Non-Governmental Organization NOCP National Onchocerciasis Control Programme NOTF National Onchocerciasis Task Force PHC Primary Health Care REMO Rapid Epidemiological Mapping of Onchocerciasis SOCT State Onchocerciasis Control Team SOPAC State Onchocerciasis Programme Advisory Committee SWOT Strengths, Weaknesses, Opportunities and Threats TCC Technical Consultative Committee TCR Therapeutic Coverage Rate UNICEF United Nations Children's Education Fund WES Water, Environment and Sanitation WHO World Health Organization ZOTF Zonal Onchocerciasis Task Force Acknowledgements We would like to thank the following persons for their cooperation and assistance: . The staff at the Headquarters of the African Programme for Onchocerciasis Control (APOC) in Ouagadougou: Dr. Sékétéli, Dr. Amazigo, Dr. Noma, Ms. Matovu, Mr. Aholou and Mr. Zoure. His Excellency, Dr. Shem Nuhu Zagbayi, Deputy Governor of Niger State; Dr. (Mrs.) Hadiza Mohammed, Acting Director of Primary Health Care, Ministry of Health; Mr. Pius Kolo, Director of Finance, Ministry of Finance, and other top policy makers in the State. Hajiha Rikiya Datti, State Coordinator, Niger State CDTI Project, other SOCT members, drivers and other staff of Ministry of Health, Minna, for undertaking all the arrangements. Political and traditional leaders, health workers and community members of areas visited in Lavun, Raffi and Wushishi Local Government Areas (LGAs). Executive Summary The Niger State Community-Directed Treatment with lvermectin (CDTI) Project was approved in 1999 and commenced implementation of activities in 2000 in 17 local government areas. Following the refinement of the Rapid Epidemiological Mapping of Onchocerciasis (REMO) in 2003, four additional endemic LGAs were identified for implementation of CDTI. These commenced CDTI implementation in 2003. Even before APOC support, Mectizan@ distribution had been going on in the state since 1991 with UNICEF support. However, the distribution had been inconsistent. There were complicated bureaucracy and delays in requesting and approval of funds from UNICEF. This led APOC management to send a TCC to the state. The state has since built on the recommendations of the committee and has shown improvement in both geographic and therapeutic coverage rates. The evaluation of the Niger State CDTI project took place between lBth November and 5th December 2004. The team, using the instruments and guidelines developed by APOC management visited three LGAs (Lavun, Rafi and Wushishi), six front line health facilities and twelve communities, two from each FLHF. Policy makers, opinion leaders, community leaders and health workers from the four levels were interviewed, and supporting documents examined. The sustainability evaluation also provided the team with good opportunities to advocate for funding by policy makers at the state and LGA levels. The advocacy at the state level led to an immediate success as the sum of N1, 000,000 was released by the state to the project during the evaluation period. Data were collected on ten indicators: planning, integration, leadership, monitoring and supervision, Mectizan@ supply, training and HSAM, finance, transport and material resources, human resources, and coverage rates at the state, LGA and FLHF levels. The data at the community level were based on eight indictors as integration and transport were not considered separately. The generated data were analysed quantitatively on a scale of 4; they were also analyzed qualitatively. Ihe project was judged to be making progress towards sustainability having scored an overall average of 2.62 and fulfilled five of the seven aspecfs of sustainability of integration: simplicity, attitude of staff, community ownership and effectiveness. Resources and efficiency were the indicators blocking sustainability at the State, LGA and FLHF levels. The project also fulfilled three of the five critical elements of sustainability: supervision, Mectizan@ supply, and political commitment. Only the community level fulfilled all the critical elements of sustainability. At the state level, the average score was 2.84. ln seven of the ten indicators, the state level performed well, while in three it did not. Those indicating good performance were integration of support activities, leadership, monitoring and supervision, Mectizan@ supply, training and HSAM, human resources, and coverage rates, while those showing poor performance badly were planning, finance as well as transport and material resources. The leadership was functioning effectively and had taken ownership of the programme. Monitoring and supervision activities were planned, integrated into the health service and they were effective. Mectizan@ was ordered in sufficient quantities and distribution to LGAs was timely and operating within the health service. Training and HSAM were undertaken effectively resulting in awareness and ownership of the programme at all levels although in some cases the latter did not result in financial commitment. Human and material resources were adequate, the staff being stable and committed. Coverage rates were satisfactory. Some indicators showed poor performance; there was no evidence that onchocerciasis was integrated into the health service at this level and some activities were not targeted. Financial resources were precarious. Of the US$399,418 approved for field activities by APOC, only US$280,000 was released due to delays in accounting. Of the sum received, the project utilised only US$1 19,418 as a result of delays in requesting for funds and or approval of proposals by UNICEF. Transport was inadequate and it was not certain that sufficient resources could be mobilised to meet the need. The LGA level scored an average of 2.28. Only four of the ten indicators were judged adequate. The four indicators were integration of support activities, Mectizan@ supply, human resources and coverage rates. CDTI activities were well integrated into the health services. The opportunities offered by other programmes were used for CDTI activities i. e. Mectizan@ supply alongside monitoring and supervision. The health personnel were also involved in other programmes. Aspects of monitoring and supervision such as monitoring reports and non-use of checklists made such visits ineffective and inefficient. Planning was done at the state level and non-participatory. The leadership did not initiate activities and funding was poor due to inadequate release of funds to the LGAs by the state. The latter made the possible provision of the currently inadequate transport and material resources uncertain. Training was not targeted and HSAM activities did not appear to have led to action from policy makers. The FLHF was the weakest link in the health service. lt scored an average of 2.17 and showed good performance only in terms of Mectizan@ supply, human resources and coverage rates. Mectizan@ supply was within the health system. Supplies were timely and adequate. The human resource was well informed and stable. Coverage rates were well over 65%. Training was targeted but HSAM did not appear to have been targeted. Transport was inadequate and the users maintained the two bicycles provided. There were no funds provided to this level. Staff used their personal funds when there was need. Planning for onchocerciasis was not part of the overall plan. lntegration of CDTI activities into other programme was by coincidence, as it was not planned for. The leadership depended on the LGA for their plans and to initiate activities.