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Evaluation of the Sustainability of the Ebonyi State CDTI Project, Nigeria

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Evaluation of the Sustainability of the Ebonyi State CDTI Project, Nigeria World Health Organization African Programme for Onchocerciasis Control FINAL REPORT Evaluation of the Sustainability of the Ebonyi State CDTI project, Nigeria Ausust 2003 Eleuther Tarimo (Team Leader) Mary Alleman Cyrille Evini Uwem Ekpo Chukwu Okoronkwo ' * t)c**'*""' 1, r! &? v{r"r'T,;-;l -.i,), .,.(vJ i lt r .. ii,,-"".'_ ! --4 L. Introduction...... ,...................... 8 2. Methodology........ .......................9 2.1 Sampling ........9 2.2 Levels and instruments.......... ..........10 2.3 Protocol.... ......................10 2.4 Team composition ............... ............ 11 2.5 Advocacy visits and 'Feedback/Planning' meetings... .........12 2.6 Limitations .....................12 3.Evaluation Findings And Recommendations..... ........13 3.1 State lrvel ....... 13 3.2 Local Government Area Level ............17 3.3 Front Line Health Facility Level .........23 3.4 Community Irvel ..............27 4. Conclusions........... ..........33 4.1 Grading the overall sustainability of the Ebonyi State CDTI project.... ......33 4.2 Grading of project as a who1e................ .................. 36 ANNEXES 37 Interviews ................38 Schedule for the Evaluation, advocacy. .......40 Feedback and planning meeting agenda ......41 Report of the feedback/Planning meetings ....................45 Abbreviations/acronyms APOC African Programme for Onchocerciasis Control CBD Community Based Distributor (of Ivermectin) CBIT Community Based Ivermectin Treatment CDD Community Directed Distributor (of Ivermectin) r : CDTI Community Directed Treatment with Ivermectin FLHF First Line Health Facility fYQ Headquarters HIC Health Centre IVP Health Post HSAM HealthEducation/Sensitization/Advocacy/Mobilization IDP Ivermectin Distribution Programme IEC Information, 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 NID National Immunization Day NOCP National Onchocerciasis Control Programme NOTF National Onchocerciasis Task Force PHC Primary Health Care PRS Personnel Research and Statistics RBP River Blindness Programme REMO Rapid Epidemiological Mapping of Onchocerciasis SHM Stakeholders'Meeting SOCT State Onchocerciasis Control Team TCR Therapeutic Coverage Rate WHO World Health Organization ZOTF Zonal Onchocerciasis Task Force Acknowledgements We would like to thank the following persons for their help: . The staff at the Headquarters of the African Programme for Onchocerciasis Control (APOC) in Ouagadougou: Dr S6k6t6li, Dr Amazigo, Mr Agboton, Dr Noma, Ms Matovu, Mr. Aholou & Mr. Zoure . His Excellency, Dr Sam Egwu, the Executive Governor of Ebonyi State, Chief F. O. U. Mbam Permanent Secretary, Ministry of Health, and other top policy makers in the State. Mr Stephen Orogwu, State Coordinator, Ebonyi State CDTI Project, other SOCT members, drivers and staff of MoH, Abakiliki for undertaking all the arrangements. Mrs Chinyere Maduka, Project Administrator, Global 2000 Anambra/Enugu/Ebonyi CDTI Project, for her kind assistance in facilitating arrangements for travels. Political and traditional leaders, health workers and community members of areas visited in Ikwo (Ikwo Central & Ikwo South), Izzi (Izzi & Nnodo) and Onicha (Onicha & Ohaozara East) LGAs. Executive Summary The Ebonyi State CDTI Project, supported by the African Program for Onchocerciasis Control (APOC) since August 1998, is now in its 5th and final year of support. The project was evaluated by an independent team from 4-18 August 2003 using guidelines developed by APOC. The main finding from the evaluation is that CDTI has been a success in the state. There are, however, areas that need improvement to ensure sustainability of the project. Funds provided by partners (Ebonyi State, APOC and Global 2000) have been adequate to carry out planned activities. The State has released funds for CDTI as follows: $30,000 (1999); $32,000 (2000); $30,000 (2001) and $37,000 (2002). The evaluation team was pleased to note the high level of political commitment to CDTI by the state as evidenced by enthusiasm, knowledge of onchocerciasis and related issues, and support to activities. It is hoped that the state's commitment will be maintained as APOC support declines. The project leadership has actively sought supplementary funds from other sources. For example, for the period 2003-2006 support for a number of activities has been secured from the Ebonyi State Health System Project (assisted by The World Bank). The rolling Health Plan at the state level includes onchocerciasis control. A detailed CDTI annual plan and a "Sustainability Plan of Action" also exist. The sustainability plan was an important input to the Feedb ack/Plannin g meetin g after the ev aluati on. Health education, sensitization, advocacy, and mobilization (HSAM) has been quite successful. Innovations have been made in the designs of posters, calendars, brochures, and fliers providing CDTI messages. Radio and television jingles are equally used to provide CDTI messages. However, educational materials were sometimes inadequate in the field. The Mectizan@ supply is within the government system at all levels and is effective and uncomplicated. Supply was reported as good, and rarely were there reports of shortages received. When such reports were received, prompt action was taken. Supervision and training activities for CDTI (e.g. training and HSAM) are well integrated. However, integration of CDTI with activities of other disease control programs remains weak. This is because each program has its own system. The initiative for integration of CDTI and other disease control programs needs to come from the PHC Director. To enhance efficiency, the State Onchocerciasis Control Team (SOCT) policy in the last two years has been to supervise and train staff only at the next level immediately below (i.e. LGAs), while the Local Government Onchocerciasis Control Teams (LOCTs) have been empowered to monitor, supervise and train FLtIFs staff. However, findings in the field show that there is a gap between this policy and practice; the SOCT and LOCTs at times supervise and train FLFIFs and CDDs. Many supervisory visits are made by the team of six SOCTmembers (6 including the state coordinator) in a month. These visits need to be coordinated and targeted. The roles and size of the SOCT also need to be reviewed in view of the project's policy to increase skills and empower LOCTs to manage CDTI in their LGAs. The State has plans for replacement of vehicles, equipment, and materials and to provide motorcycles and bicycles to new LGAs and FLHFs, respectively. All units visited had good therapeutic and geographic coverage. The state has consistently maintained greater than 65Vo therapeutic coverage in each of the 10 endemic LGAs since 2000, except for Ebonyi LGA which reported a therapeutic coverage of 63.77o in 2000. Overall therapeutic coverage for year 2OO2for the state was7l.L%o. Most LOCTs are technically competent but are too dependent upon the SOCT for initiative to plan and implement annual activities. Very few LGAs have budgets, and the funds released in most cases have been erratic and small. Most LOCTs visited had a written plan containing the key CDTI activities, but no LGA had an overall health plan. Approximately one-half of LOCT staff seem to be transferred to other LGAs every year. Despite a lack of resources for the CDTI project and delays in the payment of salaries, all LOCT staff expressed satisfaction with their involvement in the program and commitment to CDTI. Often, LOCT staff that have worked hard are commended for their efforts by the LGA during meetings. CDTI does not have an organized process for recognizing and awarding good perfonnance. The evaluation team recommends that such a system based on sustainable rewards (financial and non-financial rewards be initiated for individuals or institutions (e.g. FLF{F staff or village). The evaluation shows that FLIIFs are the weak link in the CDTI chain, often seen as conduit or post-office. Staff at this level have not been empowered or encouraged to plan, though most are relatively skilled in training, HSAM, monitoring, and supervision for CDTI. Many FLI{F staff are relatively new to the program or to their present positions. Only in a few cases had FLIIF staff been in position for more than 4 years. It has become an accepted practice by FLIIF staff to conduct training before every distribution cycle. Such training should be more targeted. There appear to be no specific guidelines on supervision which FLHF staff are expected to follow. Community ownership/leadership is evidenced by selection of and changing of CDDs (in all villages visited). The time and mode of distribution were not always determined by the villages but were generally accepted. Some villages, however, expressed preference for different times from the period they currently receive treatment. Villages are also involved in encouraging compliance with Mectizan@ treatment, providing writing materials, registers and occasionally CDD compensation. Village members expressed willingness to continue taking Mectizan@ annually, however long it takes and mentioned improvement in sight, clearer vision, passage of worms, and an overall feeling of being healthy as benefits of taking Mectizan@. In some villages, members are aware of the length of time they would be taking the drug while in some they are not. CDD compensation is an issue everywhere, only about half of
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