I I World Health Organization African Programme for Onchocerciasis Control Monitoring report on the implementation of Kogi State CDTI sustainabilitY Plan. June 2005 MARGARET A. MAFE JOSEPH C. OKEIBUNOR STEVE O. OROGWU CHRISTOPHER S. OGOSHI , 2 CONTENTS Page Executive Summary J Monitoring Team 7 Acronymns 8 1. Introduction 10 1.1 Background Information 10 1.2 Terms Of Reference 13 2. Methodology 14 2.1 Sampling t4 'r) Selection of villages t4 2.3 Instruments 16 2.4 Data Analyses t6 3. Findings, Discussion, Recommendations and Conclusions t7 3.1 State Level t7 3.2 Local Government Level 20 3.3 First Line Health Facility Level 24 3.4 Community Level 26 General Recommendations 29 Annex 39 Instruments 40 2 3 EXECUTIVE SUMMARY Monitoring of the implementation of the sustainability plan of the CDTI project in Kogi State was undertaken between 13ft and 23'd June,2005 using the APOC's tool [Tool for Monitoring the Implementation of CDTI Project Sustainability Plan, APOC, May 20051. Six randomly selected villages, 2 in each of the 3 randomly selected LGAs were visited for the collection of information using indepth interviews, detailed questionnaires, Focus Group Discussions (FGDs), documentation citing and observation notes. Questionnaires instruments were also employed at the State level with implementations and key staff at the State and Local Government levels and with the Supervisors at the FLHF. Kogi State is one of the 36 States of Nigeria. It has 21 LGAs all of which are endemic for onchocerciasis. The State headquarters is located at Lokoja. Onchocerciasis was first reported in present day Kogi State in Lokoja in 1907 by Blacklock Subsequent surveys revealed that the disease was endemic in the State and also indicated that the State is one of the most highly endemic in the country. The State has over 1 million persons at risk of the infection. Mectizan distribution started in the late 1980s in parts of the present Kwara and Kogi State, with support from Africare. Sight Savers Intemational (SSI) was invited to support Ivermectin distribution in the State in 1997 following the withdrawal of Africare from Nigeria. SSI is still the NGDO supporting CDTI activities in the State. The State received approval on African Programme for Onchocerciasis Control (APOC) Trust Fund support for the implementation of Community Directed Treatment with Ivermectin (CDTI) in 1998. The 5 LGAs of Idah, Ofu, Olumaboro, Yagba East, Yagba West, Igalamela were those initially funded by APOC. Others were later included. 2,403 communities (with a total population of 1,294,237) are endemic for onchocerciasis, 1,034 of which are hyper-endemic (with a population of 529,801) while 1,369 (with a population of 744,450) are meso-endemic. Majority of the LCAs (20 out of 2l) have therapeutic coverage rates above 650/o. 1,153,753 persons were treated out of the population of 1,294,237 in the 2,403 communities. The annual treatment objective (ATO) for year 2004 was 1.2 million representing 89% therapeutic coverage and 100% geographic coverage while the ultimate treatment goal (UTG) was l, 1000,000 representing 95.3Yo. J 4 The partners involved in CDTI implementation in the State are Sights Savers lnternational, National Onchocerciasis Control Programme (NOCP), the State Government, the various Local Governments (LGAs) and the endemic communities. The State has approved a sum of N5 million as counterpart fund for CDTI activities this year but no release has been made so far as is the case generally for all other activities in the State as the 2005 budget is yet to be released. The State obtains its Mectizan supply from the NGDO (SSI) in Kaduna. There is adequate supply at the State level and there are no delays. The supply is stored in the State's Central Medical Store and released to the LGAs through the LOCTs. The LOCs in turn release it to the District Health Supervisors (DHS) or Health Facility (HF) staff from whom the endemic communities receive their supplies. There are focal persons for the CDTI implementation at the State level and in each LGA and FLHF visited. There is no comprehensive health plan either at the State, LGA or FLHF levels although detailed sustainability work plan for CDTI activities developed during the APOC sponsored sustainability planning in 200212003 were available at the State and FLHF levels. The FLHF health staff are also conversant with the key CDTI activities although they only execute when informed by the LGA authorities. HSAM is well directed and advocacy efforts have been very effective. In year 2002, the State released a total sum of two million Naira ($*2,000,000.00). This is some fractions above the amount earmarked in the sustainability work plan and APOC/State agreement for the implementation of CDTI activities in the State for that year. In year 2005, the Governor approved the sum of five million Naira ($*5,000,000.00) for the implementation of CDTI activities in the State although this is yet to be released because the State budget for the current fiscal year has not been approved by the State Assembly. The level of advocacy needs to be maintained given the high turnover rate of commissioners of Health and other Politicians in the State. The new set of policy makers in the LGAs have been well sensitized on the problem of the disease and efforts taken to address the situation in their respective LGAs. The advocacy efforts of the LOCTs has also been effective as the LGA authorities are not only releasing funds for the distribution of Mectizan@ in their LGAs but also providing the LOCT Coordinators with monthly imprest account for effective monitoring and supervision. At the FLHF level, HSAM activities are well 4 5 side reactions directed although large number of refusals result from previous experience of which adversely affect coverage. the officers at The LOCT members do not use the checklist during monitoring and supervision of the next lower levels and there are no monitoring reports. The concepts of "weakness" and out on ..strength,, are also not understood nor appreciated. Monitoring and supervision are carried forms and routine basis and are not integrated with other health problems neither are supervisory back to the checklists in use although few copies were seen and most FLHF staffdo not give feed community. delivery Adequate quantities of Mectizan@ tablets are supplied to the State and timely too but the is through the NGDO based in Kaduna and not integrated within the State's drug delivery planned systems. The drugs are also ordered by the NGDO instead of the State. This is however to change in year 2006 because the NGDO has indicated its willingness to devolve the ordering the NGDO and procurement of Mectizan@ to the State such that the State will be empowered by This to calculate its coverage rates and determine its mectizan requirements at the different levels. ought to reduce the inaccuracy in the State's CDTI data as many LGAs had coverage rates of above 90%. There is sufficient and timely supply of Mectizan@, which is kept within the government system until it is distributed to the communities at the LGA although the process of procuring Mectizan@ is not integrated. Supply of Ivermectin at the community level has been suffrcient and timely although time of supply is dictated by its availability at the LGA/FLHFS' pick The system is simple, reliable and uncomplicated though Communities need to be allowed to up their supplies from the FLHFs. Training was satisfactorily conducted and based on clear justification for the training of supervisors of CDDs at the different LGAs and the supervisors demonstrated good knowledge of the CDTI operations. The objectives of training at the FLHF level are justified and the activity is carried out to increase knowledge and skills of programme personnel, using appropriate training materials. Some of these materials were however in short supply. There is no integration of CDTI training with other health programme activities. 5 6 There is a level of integration of resources and members of the SOCT participate in other health programmes such immunization and one of the SOCT members is the State's coordinator of the Primary Eye Care programme while another is in charge of Leprosy control. Transport facilities are also used in an integrated manner. However, the activities of different programmes are vertically implemented and not integrated. Integration of resources such as transport among the different programmes is also practiced in the LGA. However, the integration of activities is a concept that needs to emanate from the higher levels, such as the State although programmatic demands and timing may not promote integration of health activities in the LGA. Financing of CDTI activities in the State is excellent because for 2OO4 the State released a little more than earmarked from for the implementation of CDTI in State and in line with the sustainability plan developed in 2O022OB. The level of advocacy needs to be sustained to ensure release of the sum eannarked for year 2005. The LGAs are releasing funds for the implementation of CDTI. In all the LGAs visited at least 50o/o of the funding requests of the LOCTs were released. There is however, need for intensified advocacy in recognition of the transitory nature of the political office holders. Record keeping above the community level appears poor. Coverage rates seemed to be on the high side with most of the LGAs reporting therapeutic coverage of 90o/o and above. In one LGA there were conflicting figures. The SOCT does not collate its data to determine its coverage rates and Mectizan@ requirement which weakens its capability for data handling.