World Health Organisation African Programme for Onchocerciasis Control
Assessment of the self-sustainabitity of the Taraba CDTI project
i:'
: . ,,i,1, ::'ir May 2002
Oladele Akogun Yemi Fayomi Edith Nnoruka Joseph Okeibunor Chulcwu Okoronlrwo Detlef Prozesky i. Phittip Sanlrwai Index
Abbreviations/ acronyms and acknowledgements J
Executive summary 4 lntroduction and methodology 6
Findings and recommendations 1. State level 9 2. LGA level t4 3. Disrict/ health centre level 18 4. Village level 2l 5. Overall self-sustainability grading for the project 23
Advocacy activities and planning workshops 24
Appendix 1 State level workshop programme 27 Appendix 2 The SOCT and LGA workshop processes 29 Appendix 3 State level plan for self-sustainability 32 Appendix 4 LGA level workshop prograrnme 37 Appendix 5 LGA level plans for self-sustainability 40 Appendix 6 Detailed findings 56 1. State level 56 2. Health district/ LGA level 60 3. Sub-district/ first line health facility level 63 4. Communiw level 66 . Abbreviations/ acronyms
APOC African Programme for Onchocerciasis Control CBIT Community Based Ivermectin Treatment CBM Christoffel Blindenmission . CDD Community Directed Distributor (of Ivermectin) CDTI Community Directed Treatment with Ivermectin CHEW Community Health Extension Worker - CHo Community Health Offrcer LG local government LGA Local Government Authority LOCT Local Government Onchocerciasis Control Team MITOSATH Mission to Save the Helpless 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 SOC State Onchocerciasis Co-ordinator SOCT State Onchocerciasis Control Team WHO World Health Organisation ZOC Zonal Onchocerciasis Co-ordinator UTG Ultimate Treatment Goal
Acknowledgements
- We would like to thank the following persons for their help: -r . The staffat APOC Headquarters in Ouagadougou: Dr S6kdteli, Dr Amazigo, Mr Aholou . StaIf of NOCP/ MoH in Lagos and Abuja, for undertaking all the arrangements - . Staffof the MoH in Bauchi and Taraba: Princess Ogbu-Pearce, Dr Apake and the SOCT . The CBM team: Mr Ogoshi and the Jalingo branch staff; the MITOSATH staff: Mrs Olamiju and her administrative assistant . Staffat the WHO offices in Lagos, Abuja and Taraba . Health workers and community members in the Takum, Yorro and Ardo Kola LGAs. 4
Executive summary
The Taraba CDTI project has been supported by APOC for the past 4 years, and is in its last year of agreed funding from APOC. An evaluation of the self-sustainability of ttre project was carried out in ApiU May 2002, by a team of seven evaluators (six form Nigeria and one from South Africa). The evaluators were charged with three tasks: . Evaluating the self-sustainability of the project. ' Working with local stakeholders to plan for self-sustainability, based on the findings of the evaluation. ' Advocacy with local political and civil service leaders, regarding their future role in the self-sustainability of the project.
The evaluation was carried out over a period of eleven days. Information was collected by document study, interview and observation, at sampled sites at four levels of the health service: State, LGA, district/ health centre, and village/ community.
The overall judgement of the team is that the Kaduna CDTI project is not far from being sustainable. Regarding the six elements of sustainability, the situation is broadly as follows: ' Effectiveness: The project is effective at all levels (although some geographical areas are performing less well).. ' Effciency/financing: Many activities are not properly targeted, resulting in ineffrcient use of scarce resources. Lower levels (LGA and district/ health centre) are not yet fully empowered to carry out tasks at their level, and such tasks are often carried out by higher level staff. ' Simplicir): Routines are generally simple and easy to carry out (except the key area of village census). ' Integration:The programme is by now well integrated into the official health system. ' Attitude: Although stakeholders have accepted the project as part of their routine work, some key players have not yet accepted the fact that they will have to cope without outside resources in the near future. ' Resources: In this key area the project still relies too heavily on APOC. There are however cases were altemative sources are being used, but this is not yet the rule.
Regarding the position of the different levels of the project, the CDTI activities of the most peripheral level (the village) appear to be sustainable, even now. The three higher levels however will have to sort out the key issues of planning, funding, transport, and delegation of responsibility, if they are to be self-sustaining.
Detailed recommendations were drawn up, based on the findings of the evaluation at the four levels. The recommendations were prioritised, and indicators and deadlines were suggested for each. The most important recommendations concern: ' Determining the exact funding that will be available, and mobilising additional sources of funding if necessary. ' Tailoring activities (mainly training and supervision) to fit the budget. ' Empowering the LOCTs and district level staffto take full charge of activities at their levels - all in all, rationalising activities to achieve maximal efficiency. Advocacy activities were carried out at the level of the State (Deputy Govemor, Commissioner for Health and other senior MoH civil servants) and LGAs. Particular attention was paid to the State Onchocerciasis Co-ordinator, Ers a key player in future remedial action.
Three feedback/ planning workshops were held - one for the SOCT, and two for teams from each LGA/ LOCT (six such teams attending each workshop). In each case the evaluation team gave feedback on its findings, which were discussed in depth. The evaluators and other facilitators then guided the participants to draw up realistic'Plans for self-sustainability' for their respective areas of operation.
The workshop process worked well and considerable enthusiasm was generated. There is considerable agreement between the plans produced in this way, and the recommendations that the evaluators have made in this report. However most of the plans still need to be refined, and possibly adapted, in the light ofthe evaluators' recommendations. Finally, the plans need to be meticulously implemented, if the self-sustainability of the Taraba project is to be assured. National, zonal and State level staffhave ayear in which to work with local stakeholders, to take the necessary action. Introduction and methodology
l. Introduction
The African Programme for Onchocerciasis Conhol (APOC) approved the Taraba State Project for funding of CDTI implementation in July 1997. The project has however been distributing Mectizan since 1994, using the mobile system and later the Community Based Ivermectin Treatnent (CBIT) shategy. When APOC funding for the project was agreed, the Community Directed Treatment with Ivermectin (CDTI) strategy was finally adopted. Treatments have risen from a few thousands to over 880,000 persons by 2001 with the Ultimate Treatment Goal (UTG) currently put at 980,000.
The State contains hyper endemic foci with high prevalence of blindness. The project was initially supported by A&icare, and after its withdrawal by CBM and a local NGDO, MITOSATH. The two supporting organisations have an exciting relationship, in which the intemational NGDO mentors the local one and agrees to transfer certain responsibilities to the indigenous NGDO within a given timeframe - as a way of promoting progftlmme sustainability. This has resulted in the devolution of support for three LGAs by CBM to MITOSATH during 2001, and will later result to the transfer of support for the entire project area to the local NGO.
As part of its plan to achieve sustainability of programme operations APOC management commissioned a team of consultants to develop an instrument to assess the self-sustainability of projects. This having been completed, it was decided that all projects in or about to enter their fifth year of APOC funding should be assessed, to find out their levels of self- sustainability. Hence the current assessment of the self-sustainability of the Taraba project.
2. Methodology
2.1 The'John the Baptist'visit
Building on the Kaduna experience where the instruments were field tested and revised, a 'John the Baptist' was sent to the Taraba Project a few days to the commencement of the exercise to: . [ntroduce the instrument to the Project team . Negotiate times and dates for all interviews with government offrcials . Plan initial planning and feedback meeting with all relevant staff . Sample sites for the evaluation . Ensure that all necessary documentation are made available to the team . Select local team members
2.2 Sampling
Sample sites were chosen according to the guidelines using coverage rates and where needed accessibility as parameters. Three LGAs were selected (one with high coverage, another having medium coverage and the third with low coverage). Two health facilities were selected for each L.G.A (one 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). This resulted in the selection of the following:
S/no. LGA Health facilitv Communitv I Yono (high Lankaviri Lankaviri'E' coverage) Napu'B' Kajong Kaione Shompah'B' 2. Ardokola Tau Answan Sauda (medium Gadaguru coverage) Ardo-Kola Ardo-Kola Kasakuru 3. Takum (low Fete Fete'II' coverage) Aeba Dogongawa Campo Ilcyor Total 3 LGAs 6 Health Facilities L2 Communities
It was pointed out by some team members that this sample was not representative of endemic communities in the State as a whole, since it did not reflect the level of endemicity. Since appointments had already been made which would be difficult to change, the team leader decided to continue with the present sample. It was accepted however that this aspect of representativeness be strongly considered in sampling in future evaluations, in addition to the coverage rate.
2.3 Protocol
, Research question: How self-sustainable is the Taraba CDTI project? . Design: Cross-sectional, descriptive. . Population;T"be Taraba 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: * A record sheet, structured as a series of indicators of self-sustainability. The indicators are grouped into 9 categories. * The instrument assesses self-sustainability at 4 levels of operation. * The instrument guides the researcher to collect relevant information about each indicator. . Source of information;Yerbal reports from persons interviewed, supplemented by documentary evidence and observations. . Analysis: * Data from all sources is aggregated, according to level and indicator (Appendix 6) * Based on the information collected, each indicator is graded on a scale of 0-4, in terms of its contribution to self-sustainability. * The sunmary findings for each group of indicators were given at the end of each group. * The average'self-sustainability score'for each group of indicators is calculated, for each level. * A qualitative description of problem areas is given. 2.4 Team composition
The team was composed of the following:
l. Detlef Prozesky, University of Pretori4 South Africa (team leader) 2. Edith Nnoruka, University of Nigeria Teaching Hospital, Enugu. 3. Oladele Akogun, Federal University of Technology, Yola. 4. Joseph Okeibunor, University of Nigeri4 Nsukka. 5. Yemi Fayomi, NOCP 'C' Znnal Office, Federal Ministry of Health, Kaduna. 6. Phillip Sankwai, Ministry of Health, Kaduna State, Kaduna. 7. Chukwu Okoronkwo, NOCP, Federal Ministry of Health, Lagos.
This team was divided into three sub-teams to evaluate operations at the various levels. 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.
2.5 Advocacy visits and 'Feedback/ planning' workshops
Advocacy visits were to be paid to relevant persons at each level (State, LGA, community) and officials were to be debriefed at the end of the field visits.
Finally, planning meetings were to be conducted for State and LGA levels which involved relevant officers at those levels. During these planning meetings the evaluation team would give feedback on its findings; based on these sustainability plans were to be developed and agreed on.
2.6 Limitations
The routine data collected at project level did not contain aggregations for the health facility level, which made sampling for communities and the health facilities a little bit difficult. a The documentations required in an LGA were not available despite prior information. ! ln spite of initial briefings some project staffwith the evaluation team took the evaluation as an examination and were expressly concemed when they felt the necessary information and/or documentation was not forthcoming. Treatments in some areas were huniedly concluded in order to pass the 'examination'. A community in Takum had to be substituted as it was reportedly deserted following inter-ethnic clashes. Another community in Ardo-Kola also had to be substituted due to the deliberate absence of the CDD and unavailability of the community records. The problem with representativeness of the sample is discussed above. 9
Findings and recommendations
1. State level l.l Overall grading (on a scale of 0-4)
Taraba project: selfsustainability at State/ project level
3.5
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1.2 Main findings
The situation regarding self-sustainability is fair, but there are significant problem areas. The major findings are:
. Coverase is high and well maintained. Coverage figures are being incorrectly calculated though.
' Planning is thorough and detailed at project level, because of the APOC requirements. All partners participate in the planning, and are allocated clear responsibilities. At State level CDTI is planned for like other programmes, but the plan is not detailed. There has been no specific planning for sustainability, although managers are aware of the problem.
' Leadership: there is a senior official allocated to the onchocerciasis control programme, and he has enough time for this task. He has an adequate team of field workers. There is evidence of political commitment, but only up to the level of the Commissioner for Health. There have been no disbursements from the State for two years running. 10
Supervision and monitoring takes place within the government system. NGDO partners also carry out monitoring, but this is not always integrated with that of the State. Supervision/ monitoring is routine but not always targeted, and is sometimes carried on to lower levels than the LGA. Successes and problems are identified but not always noted and dealt with.
Mectizan ordering, storage and dishibution are dependent on activity and funding from NGDOs and APOC. Stock control is mainstreamed and effective, using a unique system which is an improvement on the Ministry procedure. The NGDO involvement in Mectizan supply, while not ideal for sustainability, is probably dependable.
Training and sensitisation activities are conducted more or less appropriately. However mobilisation is not fully targeted, and SOCTs are inappropriately involved in training at district and community level: delegation/ empowe(ment of LOCTs and CHEWs (to take charge fully of training and mobilisation) remains to be completed.
Finances and funding: budgeting for CDTI is routinely done in detail. Adequate but inappropriate amounts are budgeted - inappropriate in the sense that the current level is not sustainable. The proportion of funds released by the State is decreasing. Management is not fully awareof the size of the shortfall and has no specific plans to remedy it - there is a sense however that partner NGDOs will not wholly abandon their investment of the years, and may probably be depended on for targeted assistance in critically important areas. The financial control system is excellent.
Transport and material resources: transport is plentiful but dependent on APOC. It is well managed but used below LGA level. Other material resources are sufficient, but staffis sometimes obliged to use the resources of other programmes. There is no dependable plan for replacement of transport or equipment, although there is little doubt that partner NGDOs will continue a measure of support forthis aspect.
Human resources: staff at this level are skilled and knowledgeable, but their number is too great. Personnel are stable and replacements could easily be trained on the job. The NGDO input in human resources is constant and significant.
1.3 Recommendations
Recommendation Implementation Planning: Priority; HIGH r { plan and budget must be drawn up, Indicators of success: for the 2003 round of distribution. Each r I detailed plan and budget exists fof 2003, activity has to be specified and fully as described on the left. costed, and the total budget has to fall r I detailed 5 year plan exists, as described. within the amount that will be available . Attendance register of the plannins exercise. (see'Financial resources' below). . Who to take action: As part of the same exercise, a 5 year . State PHC Coordinator - Dr Ajai plan of the same kind must prepared. . be ' SOC - Dr Apake These planning exercises must be . ZOC - Princess Ogbu-Pearce participatory, including SOCT members . NGDO partners (CBM and MITOSATH) and NGDO staff. De adl ine for comple t ion: . November 2002 ll
Financial resources: Prioritv: HIGH . The funds that will be available for the Indicators of success: 2003 distribution must be accurately l. Written breakdown of assured frurds for determined (from the State; from 2003. remaining APOC funding; from 2. The fundraising plan exists. NGDOs, from the public - any realistic 3. Official documents exist which pledge the source). amount and duration of future financial . If there is not going to be enough money suoport from outside. for the minimwn number of activities Who to talce action: that need to be caried out during 2003, . State PHC Coordinator- Dr Ajai the same planning team (see 'Planning' . SOC -DrApake above) must make a very specific plan . ZOC - Princess Ogbu-Pearce for raising additional funds. . NGDO oarbrers (CBM and MITOSATH) . This plan must be implemented, Deadline for completion: resulting in firm promises of additional 1. May 2002 funds from other sources being obtained 2. May 2002 as soon as possible, in writing. 3. November 2002 . The same must be done for each of the remainins vears,of the proiect. Providine leadership: PrioriU: HIGH : ftl order to secure political commitment Indicators of success: to CDTI at the top level, there should . A report of the advocacy events that were be targeted and innovative, high- conducted powered advocacy at the level of the . Adequate counterpart funds have been Governor of Taraba State released. Who to take action: . APOC management at Ouagadougou . NOCP (involving SOC and his team, NGDOs- State MoH manasement) De adline for completion: . December2002, repeated as needed (e.g. when Govemor shanges, or when counterpart fundins is not forthcomine) Transport and other material resources: Priority: HIGH r I specific, realistic, dependable plan must Indicators of success: be made for ensuring the continued l. A realistic written plan exists for provision of adequate transport, once APOC assuring fufure transport as described on funding comes to an end. This plan should the left. include a strict maintenance schedule, and 2. A written document from APOC, funds for it; funds for fuel and repairs; speciffing the nature and timing of the replacement of present project vehicles 'alimony' that mav be orovided. when these come to the end of their life (and Who to talce action: considering cheaper altematives); using . State PHC Coordinator - Dr Ajai altemative forms of transport (e.g. public . SOC - Dr Apake transport). . ZOC - Princess Ogbu-Pearce . APOC must be requested to consider . NGDO partners (CBM and MITOSATH) meeting some pressing capital needs (in , APOC HO manasement t2
transport and equipment) which are Deadline for completion: expected to exist at the end of the funding l. May2002 period - this as a form of 'alimony' for 2. December 2002 when the proiect has to soldier on by itself. Monitoring and supervision: Priority: MEDIUM . Monitoring data from 2001/ 2002 must be Indicators of success: used to identiff LGAs with low coverage 1. A supervision timetable for 2003,which and other problems. When planning for the takes account of all the requirements on 2003 distribution these LGAs should the left. This timetable should be part of receive particular supervision, and not those the overall detailed year plan. which are going well. 2. A report of the steps taken to commend . LGAs which are doing well should be LGAs which perform well. publicly commended for the good job they 3. A report of the successfully completed are doing - e.g. by receiving a letter of LOCT training, as described on the left. commendation signed by the State 4. Written guidelines on problem Govemor. identification and management (for . LOCTs should receive practical training in LOCTs) exist. problem identification and management, in Who to takc action: order to empower them to supervise the . SOC - Dr Apake - and his team lower levels more effectively, and to . ZOC - Princess Ogbu-Pearce identifu and deal with problems at district Deadline for completion: level as they crop up. 1,2,3 Dec,ember2002 . Guidelines on problem identification and 4. July 2002 management (for LOCTs) should be drawn up, for use during the above-mentioned training and afterwards. Human resources: Priority: MEDIUM r fu view of the fact that SOCT activities Indicators ofsuccess: overall are being targeted and decreased, the r I report describing the redeployment of number of SOCT members should be SOCTs rationalised. Their number could be pruned Who to take action: to 4-6, or alternatively the present number . SOC - Dr Apake could and be given other responsibilities to . PHC coordinator - Dr Ajai occupy them when they are not involved in . Permanent Secretary- Dr Mohammed CDTI. D e adl ine for c o mpl e t i on: December 2002 Trainine and sensitisation/ mobilisation: Priority: MEDIUM . Training conducted by SOCT members must Indicators of success: continue to be targeted. Only LOCT members 1. A training timetable for 2003, who clearly lack skills, or who are new to the job, which takes account of all the should be trained. LOCT members who are requirements on the left. known to be performing well do not need further 2. A mobilisation/ advocacy timetable training. for 2003, which takes account of r fu particular LOCT members should receive the requirements on the left. training, where needed, to be able to train 3. Reports on the training and CHEWs at the district level entirely by mobilisatio nl adv ocacy visits themselves, and to conduct mobilisation within conducted during 2003 the districts entirely by themselves. Note: the timetables should be part of . Training should move to the LGA level. SOCT the overall vear plan for 2003. 13
members should travel to a given LGA to Who to take action: supervise the training there - this will be cheaper . SOC - Dr Apake and his teamMr than bringing LOCT members to Jalingo. Sankwai . Mobilisation/ advocacy conducted by SOCT . ZOC - Princess Osbu-Pearce members must be targeted, to include only LGAs D e adl ine for c o mpl e t ion: known to be in need of advocacy, or districts/ 1,2 December2002 communities for which LOCTs request help. 3. December 2003 Mectizan procurement and distribution: Priority: MEDIUM The responsibility for fetching Mectizan Indicators of success: annually from the UNICEF store in Lagos, and 1. The plan and budget mentioned distributing it to the LGAs, must be transferred to under'Planning' above must show the SOCT. The costs of this exercise must be met that the State will do the from self-sustainable resources - preferably from transporting mentioned on the left, State counterpart funds. If other resources are to using self-sustainable resources. be used written pledges must be obtained. 2. Signed pledges of non-State, self- The responsibility for ordering and storing sustainable resources being used. Mectizan should be devolved to the State as soon 3. A report of training empowering as possible, while maintaining the present unique SOCT to order Mecrtizan annually. system of stock control: 4. A letter indicating that the State has * CBM and MITOSATH should immediately provided a suitable room, or from start teaching the SOCT to do the annual NGDOs pledging their provision of ordering, so that the June 2003 order will be the same. * made by the SOCT independently. Who to tal@ action: The State should provide an adequate, lock-up . SOC - Dr Apake room for storing Mectizan. Altenratively, , NGDOs - CBM and MITOSATH NGDOs must provide written confirmation Deadline for completion: that they will do so for the foreseeable future. December 2002 t4
,, LGA level
2.1 Overall grading (on a scale of 0-4)
Taraba projecfi self-sustainability at LGA level
S3
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2.2 Main findings
The situation regarding self-sustainability at this level is reasonably good, although there is considerable variation in LG support, from area to area. The main findings are:
' Coverage: Both geographical and therapeutic coverage are affected by numerous inter- and intra-communal conflicts in several parts of the State. Some LG teams do not have a list of communities they should be treating. In some cases the therapeutic coverage is being incorrectly calculated (using the eligible population as denominator) - as a result coverage rates are spuriously high.
' Planning: There is no documented routine planning at the LG level, and they only start planning when prompted by the SOCT. [n one case plans were written, contained all the necessary elements and were drawn up in a participatory way, but in others one or more of these desirable aspects of planning was lacking.
. Leadership: [n each LG the LOCT was in place, and had a designated team leader. Some LOCT leadership was rather passive, depending on SOCT stimulation to galvanise it into action. The level of political commitment of LG leadership appeared satisfactory, although there was some local variation.
' Monitoring and supervision: [n some LGA areas the LOCT does 2-3 visits to each community during each distribution; in others it is not clear how many visits take place (if any). Routine data collection takes place within the PHC system, but in some instances 15
LOCTs have to go to the village level to collect it (which is less sustainable). Visits for monitoring/ supervision at this level are not documented in report form, nor are supervisory checklists used. However problem solving by LOCTs appears satisfactory.
Mectizan supply: Mectizan is stored in acceptable space at this level. The State team delivers Mectizan to the LGs. However this is not the method of procurement of other drugs by the LG and is therefore not sustainable.
Training and mobilisation: CFIEWs are actively involved in CDD training and mobilisation, but LOCTs still do a lot of mobilisation. Training and mobilisation activities do not have any specific larget or focus and therefore are routine and ineffrcient. The CDTI raining manual is not available at the LOCT level.
Finances/ funding: In many instances (but not all) LGAs make some funds available for CDTI activities at this level. The LOCTs do however depend on the small yearly disbursement from APOC. [n some cases funding is inadequate, and as a result some LOCTs occasionally use some of their own money. There is no specific LGA budget for CDTI, thus making annual planning difficult.
Transport: In general this is adequate, although some instances were reported where distribution was delayed due to lack of transport. LG funds are commonly made available for fuel and maintenance, and in most cases transport at this level is used in an integrated fashion. Maintenance of vehicles is not systematically carried out.
Human resources: LOCTs are stable and well trained. Their level of motivation varies.
2.3 Recommendations
Coverage Priority: MEDIUM 1. SOCT must make special arrangements to Indicators ofsuccess: treat those displaced by communal strife, 1. Update of absentees in the register who are now returning. 2. All LOCTs have lists of communities they 2. SOC must ensure that all LOCTs have an should treat up-to-date list of the communities they 3. Rates are calculated with the correct should be treating denominator 3. SOC must ensure that the therapeutic Who to take action: coverage rates are being correctly . Dr Apake and SOCT members calculated, using the total population as Deadline for completion: denominator (not the eligible population) . July 2002 Plannins Prioritv: HIGH . LGA PHC co-ordinators, LOCT leaders Indicators of success: and Supervisory Councillors for Health . Availability of written plan (as described draw up a detailed plan and budget for on the left) at the LG office CDTI in the LGA, for 2003. Who to take action: . The plan contains a timetable of all . LOCTs (leaders and members); LG PHC activities, and details of all resources co-ordinators; Supervisory Councillors for needed (human, material, financial). Health . The plan addresses local needs . SOC Dr Apake and SOCT members specifically and systematically. encourase and enable LOCTs t6
Deadline for completion: . December2002 Leadership Priority: HIGH . The leadership at LGA level needs to be Indicators ofsuccess: informed more fully about CDTI, and . LGA leadership ensures that CDTI is motivated to take a more active interest in properly resourced and supported. it. ('Leadership'means political - the ll'ho to take action: health councillor, and technical - the PHC . SOC Dr Apake and the SOCT members co-ordinator). . LGA Supervisory Councillors for Health . Such sensitisation should be targeted to De adl ine for c o mpl e tion: those LGs where leadership is known not . December20l2 to take an active interest in CDTI - LGs which are not allocatine fundine to CDTI. Financing/ funding Priority: HIGH . LOCTs must be helped to obtain the funds Indicators of success: needed for the yearly distribution: making . Written confirmation of financial support application firstly to their LGs, but also if from donors (LG, NGDOs etc.). necessary to parhrer NGDOs and other Who to take action: local philanthropic groups. , LOCT leaders, LG PHC co-ordinators, LG Supervisory Councillors for Health D e adl ine for c ompl e t ion: . December20A2 Traininq and mobilisation Priority: MEDIUM 1. The LOCT should be enabled to train the Indicators of success: CFIEWs at the district level. SOCT 1. 2003 training and mobilisation of district members should only support and level stafffully undertaken by LOCTs supervise such training. 2. LOCTs are not involved in the 2003 2. LOCT members should restrict their training of CDDs/ mobilisation of training and_mobilisation activities to the communities district level, unless CHEWs specifically 3. Clear operational need exists for all ask them to attend to problems at training conducted by LOCT in 2003 community level. 4. Each LOCT Dossesses a trainins manual 3. Such training and mobilisation should be Who to take action: targeted - i.e. particularly focused on 1,4 SOC Dr Apake and SOCT members those districts which really need it. 2.3 LOCT - leader and members 4. SOC must ensure that every LOCT De adl i ne for c ompl e tion: has at least one copy of the CDTI training . December2002 manual. Supervision and monitoring Prioritv: MEDruM 1. Statistics must be aggregated in such a Indicators of success: way that it is possible to get coverage l. Availability of coverage drtaaggregated at figures for each district. district level 2. The 2001/ 2002 statistics must be used to 2. 2003 year plan shows that monitoring is identift districts with low coverage. When targeted, with problem districts receiving planning for the 2003 distribution these special attention districts should receive targeted 3,5 2003 year plan shows that LOCTs focus supervision. their monitoring at the district level 3. LOCTs should not routinely visit 4. Supervision reports exist which show that communities - that is the responsibilitv of LOCT members are usins the checklist t7
the health centre CHEWs. Who to take action: 4. LOCTs should use the prescribed . SOC Dr Apake and SOCT supervisory checklist systematically, at . LOCT - leader and members each visit. D e adl ine for c o mp I e tion: 5. Health centre CHEWs (not LOCTs) 1. July 2002 should be primarily responsible for 2,3,4 December 2002 collecting community level reports/ 5. June-July 2002 statistics Mectizan procuremenU distribution Prioritv: MEDIUM LGs should arrange to collect their own Indicators ofsuccess: batch of drugs from the State office using ' LG collects Mectizan from Jalingo along the same system for procurement of other with the collection of other essential drues drugs (such as the essential drugs.) Who to takc action: , LOCT leader. LG PHC co-ordinator Deadline for completion: . December2002 Transport Priority: HIGH 1. LOCTs must be enabled to negotiate for Indicators of success: sufficient hansport to conduct the yearly l. Written undertakings by partners to distribution - negotiating for the use of support transport needs of CDTI for each vehicles, and for the funds to operate LG, for 2003 them. The following may need to be 2. Written evidence of the control system approached: other programmes at the 3. Written evidence of systematic LGA level (for use of their vehicles); the maintenance LG (for fuel and maintenance); partner 4. A written plan for replacement of transport NGDOs (for fuel and maintenance). exists; written undertaking from partners 2. A system of strict control of the to assist when the present vehicle needs prograrnme motorcycle needs to be reolacement instituted: authorisation of every trip and Who to take action: every expenditure (fuel, tyres and . SOC Dr Apake and SOCT repairs); a log book; and monthly ' LOCT - leader and members reconciliation of trip authorisations and . LG PHC co-ordinator logbook entries. Deadline for completion: 3. LOCTs must be enabled to carry out . December2OO2 vehicle maintenance systematically. 4. A specific, realistic, dependable plan must be made for transport, for when the present programme motorcycle comes to the end of its life. This could be finding funds for a new vehicle; using public transport: usins LGA pool vehicles etc. Human resources Prioritv; MEDIUM . SOCTs must ensure that new LOCTs Indicators of success: members are adequately trained and . All LOCT members are fully trained orientated.. Who to take action: . SOC Dr Aoake and SOCT Deadline for completion: . December 2002 l8
3. Health centre/'district' level
3.1 Overall grading (on a scale of 04)
I i faraba proiect: self-sustainability at health centre level
i
3.5 {3 E ,C E!2 o P r.s o .E
0.5
.r4"" od {o""" ..r"--*--.":"-""-:""'"t """"t,""^"."""j.? """' group of indicators
3.2 Main findings
It is clear from the diagram above that much more needs to be done to safeguard self- sustainability at this level. The core ofthe problem is that LOCTs tend to do too much at community level themselves, rather than empowering/ enabling health centre staff to take over. In two out of three areas the district level staff was at least involved in the progftunme, which is good for sustainability. In the third however they were hardly involved at all, with LOCT members taking almost all the initiative.
. Coveraqe: Generally health centres succeed in covering the communities allocated to them. In some districts the staffdo not know how many villages they should be covering, nor do they know the therapeutic coverage rate that has been achieved in their catchrnent area - there is no documentation on coverage rates at this level.
. Plannins: This is done by the LOCT and passed on of the health centre staff- it does not therefore address the specific needs of the health centre area. Planning is not written but ommitted to memory by the staff.
' Leadership: Although health centre staffare willing to play their part, there is little room for them to take the initiative - it is the LOCT that takes the lead throughout. t9
Supervision and monitorins: [n two LG areas health centre staffare performing well: actively supervising and monitoring community level activity; collecting CDDs' statistics and reports; and solving the problems that arose at community level. [n the third LG area health centre staff was hardly involved in these activities at all.
Mectizan procurement and distribution: Generally this is working well. In most cases there is adequate storage spirce for the Mectizan at the distribution centres, and the CDDs themselves fetch the drug from there. In a few cases it is the LOCT members (not the local CHEWs) who work out how much Mectizan in needed for a given area. [n one case it was even reported that the SOCT delivers Mectizanto villages.
Training and sensitisation/ mobilisation: In most cases training of CDDs is primarily undertaken by LOCT (and even SOCT) members, with the local CtIEWs in attendance. CDD training takes place routinely, and is not targeted at all. Local CHEWs are routinely involved in commtrnity mobilisation however, and have suffrcient IEC materials for this purpose.
Financine and fundine: Financing of CDTI activities at this level is adequate and there is integration into other health centre activities. There is no budget for CDTI at this level, but none is really required.
Transport: Accessibility of the health centre to the catchment communities is generally good. However in some cases this is a major problem, affecting effective supervision of communities around the health facility area. There is some integration, where the same limited transport available is used for different programmes.
Human resources: Generally personnel at the health facility are willing to participate in CDTI and there is some stability at this level.
3.3 Recommendations
Coveraqe Prioritv: HIGH . Copies of records from the health Indicators ofsuccess; centre area should be retained by the . Copies of community and district level CDTI health center. data exist at the health centres. . LOCTs should enable district staff . District staffare able to interpret the data from to calculate the coverage rates for their area and to use it for plannine. their areas, as a tool for monitoring Who to take action: their own performance and planning . LG PHC co-ordinator and LOCTs their work. . District level staIl D e adline for c ompl e t i on: . December2OO2 Planning Priority: HIGH . LOCTs should enable health centre staffto Indicators ofsuccess: compile written year plans for CDTI in their . The plan exists, as detailed on the left. catchment areas. Who to tql@ action: . Such plans should contain a timetable of all . LG PHC co-ordinator and LOCTs activities; details of all resources needed . Health centre staff (human, material, financial); and take local De adl ine fo r c o mpl e t i o n: realities and problems into account. , December200? Leadership Priority: HIGH . LOCTs should Indicators of success: enable health centre , Health centre stafftake charge of 2003 distribution in their areas staff to assume Who to take action: responsibility for ' LG PHC co-ordinator and LOCTs managing the CDTI , CHEWs in charge of health centres prograrnme in their D e adl ine for c ompl e ti on: catchment areas. . December2002 Supervision and monitoring Priority: MEDIUM . CFIEWs in charge of CDTI at health centres must Indicators of success: analyse village coverage figures for 2001/ 2002, . Each district has a supervision and identiff those that are struggling. When timetable for 2003, which takes planning for the 2003 distribution these villages account of the requirements on should recrive particular supervisiorq and not those the left. This timetable should be which are going well. part of the overall year plan. . LOCTs must identifu districts where health centre Wo to toke action: staff is not taking responsibility for supervising and , LG PHC co-ordinator and LOCTs monitoring CDDs (collecting statistics and reports; . CHEWs in charge of health visiting communities during distribution). ln these centres districts staffneeds (and to be encouraged trained if De adl ine for c omple tion: necessary) to perform this function effrectively. ' December2002 Mectizan procurement and distribution Priority: HIGH . LOCTs must identify districts where health Indicators of success: centre staffare not taking fi.rll responsibility . Health cenhe staffmake correct orders, for ordering and supplying the correct based on census results ofthe previous arnounts of Mectizan for their communities. year . In these districts the staff needs to be Who to take action: encouraged (and ifnecessary trained) to . LG PHC co-ordinator and LOCTs perform this function effectively (estimating . CHEWs in charge of health centres amounts based on previous census results; Deadline for completion: making the order accordingly). , December 2002 Training and sensitisation/ Priority: MEDIUM mobilisation: Indicators ofsuccess: ' Training of CDDs should be l. There is a training plan for the year conducted by CHEWs working in 2. Sub-district CFIEWs are in charge of the training. the health centres, not by higher 3. Training is only done for CDDs who really need it levels (e.g. SOCT members). Who to take action: LOCT members may be present to . LG PHC co-ordinator and LOCTs support and supervise. . CI{EWs in charge of health centres . Yearly training of CDDs should be De adl ine for c ompl e tion: targeted - i.e. particularly focused 1. December 2002 on those who really need it. 2,3 knmediately before the 2003 distribution Transport and material resources Priority: MEDIUM . LOCTs must identiff districts Indicotors ofsuccess: where the distribution is being . Availability of means of transport durins supervision hampered by a lack of Who to take action: transport, and must work with . LG PHC co-ordinator and LOCTs the local CHEWs to plan . CFIEWs in charge of health centres effectively to overcome this Deodline for completion: problem. . December2002 4. Village level
4.1 Overall grading (on a scale of 0-4)
Taraba proiect self-sustainability at community/ village level
4
3.5
t 3
2.5 -9o 3 2 o ED .E 1.5 o 1
0.5
0 e& .@' odr a*o'"" "*."a.." -!*.r-:..""..:"""."" "-."ta+o ""t' Group indicators
4.2 Main findings
Overall, the programme appears highly sustainable at this level. Communities appreciate the cost and benefit of the drug and accept that distribution will continue for a very long time. They are willing to meet their responsibilities within the resources available at the community level.
. Coveraqe: Generally therapeutic coverage is good (although in some cases it is falsely high, since'eligible population'was used as denominator). A few communities have low rates, indicating major problems.
. Planning: Universally the census is done separately from, and preceding, the distribution. This effectively doubles CDDs' workload.
. Leadership: [n almost all communities the local leadership actively supports the distributioru and helps to solve problems as these appear.
. Monitoring: In the majority of cases community reports were submitted in time to the district. In about half of the communities the village register was not well kept.
. Mectizan procurement and distribution: In the majority of cases enough Mectizan is received, on time. In a few cases CDDs are only given small amounts at a time, and have to fetch more as the distribution progresses. 22
Mobilisation/ sensitisation: In almost all communities this is proceeding satisfactorily, although IEC materials are sometimes lacking.
Finances/ fundine: tn the majority of cases villagers appreciate the programme, and support CDDs in cash or in kind. Some few still remain apathetic though, leaving CDDs to struggle by themselves..
Transport: All communities visited collect their Mectizan from collection centres themselves. No cases were reported where lack of transport led to the drug not being collected.
' Human resources: CDDs are well traine4 and new CDDs easily get the faining and orientation they need. Communities and CDDs are generally prepared to continue supporting the programme in the long terrn, although this motivition depends to some extent on how much a community has suffered from the disease.
4.3 Recommendations
Planning: Priority: HIGH . CDDs undertake only one visit to Indicators of success; each family during each distribution - l. CDDs combine the census and distribution in a i.e. the census and Mectizan single home visit in the 2003 distribution. distribution are done at the same time. 2. The reports of the refresher training in the new . LOCTs and health centre staffshould method exist. suggest this way of doing CDTI to Wo to take action: CDDs and villagers - since in the . SOC and SOCT spirit of CDTI they have to make the . LOCT and district Ievel staff decision . De adl ine for c ompl e t ion: This new method needs to be l. February-April 2003 included in refresher CDD haining. 2. December 2002 Mectizan ordering and distribution Priority: HIGH . The amount of drug required should be Indicotors of success: estimated on the basis of the community , District staffmake the 2003 order based on population that is updated during each the 2002 updated census. annual treatment. This is done from 2003 Wo to take action: onwards. . SOC and SOCT . LOCT and district level staff Deodline for completion: . December2002 Mobilisation/ sensitisation Priority: HIGH . Where the programme is not doing Indicators of success; well (low coverage rate, poor support . Reports of specific mobilisation of .problem' for CDDs etc.) LOCTs and district villages exist. level staffneed to conduct specific Wo to take action: and focused mobilisation of ' LOCT and district level staff. communities, to improve their Deadline for complet ion: support for CDDs. . December 2002 23
5. Overall self-sustainability grading for the Taraba project
Following on the analysis above, the level of self-sustainability of the Taraba project is judged to be as follows:
Level of Description sustainabilitv High This project is not far from being sustainable. With feedback from the team before departure, the project staffshould be able to undertake the required remedial action.
Reasons for this judgement: . Money - there should be sufficient money available to undertake strictly necessary tasks . Transport -it should be possible to make provision for the running, maintenance, repair and eventual replacement of vehicles. . Supervision - it should be possible to conduct the necessary monitoring and supervision at all levels. . Mectizan supply - the supply system is currenfly dependable, and should continue to be so. . Political commit?nenr- although there are some gaps, it should be possible to remedy these with intensive advocacy. 24
Advocacy activities and planning workshops
The team planning the evaluation and APOC management decided together that each evaluation team would have two tasks: . Assessing the self-sustainability of the project concerned. . Using the findings of the evaluation in apractical way, to help local stakeholders to plan for optimal sustainability of their projects. It was felt that this would b much more powerful than sending yet another report a few weeks later. This section describes how the evaluation team went about frrlfilling the second task.
l. Advocacy
The team undertook the following advocacy activities:
1.1 State level
Involving the State Onchocerciasis Co-ordinator Throughout the evaluation there was constant communication with the SOC, and he was encouraged to be involved with all steps of the evaluation. This was done to make him fully aware of the issues around self-sustainability, and to increase his commitment to the changes which he and his team would have to plan and implement in the near future. He used this opportunity to the full, and appeared to have gained a clear vision of the present situation and futtre needs. [n order to strengthen this motivation, he was approached to become a member of the evaluating team for the Cross River (the same had been done with the Kaduna SOC, who was now a member of the Taraba evaluation team). He agreed enthusiastically.
Visits to officials of the State Department of Health * Courtesy calls were made at the beginning of the evaluation, to the Hon. Commissioner for Health, Permanent Secretary and the Director of Disease Control/ PHC. The purpose of the evaluation was explained to them, and their co-operation was requested. * At the end of the evaluation meetings were held with the same persons. The findings were surlmarised to the Commissioner, who was delighted at the evaluation and promised renewed commitment. He promised to make attempts to fix an appointment with the Governor to meet the team of evaluators. He noted that the State had not made plans for sustainability acknowledging it as an oversight which would be put aright immediately by the MoH.
Visit to H.E. the Deputv Governor of Taraba State * The evaluation team had met the Commissioner for Health, whose political commitment for the sustainability of the programme was explained. The State however has not met its obligations despite the requests to the govemment for counterpart funding. The Commissioner for Health arranged an appointment for the team to meet the State Govemor but the Governor delegated the Deputy Govemor to receive the team. * The Evaluation team visited the Deputy Governor in company of Commissioner for Health, the Permanent Secretary, Director of Disease Control and representatives of 25
the NGDOs working in the State oncho control. The Deputy Governor expressed appreciation for the reminder effect that the visit has had on the government and promised to ensure that the State meets its obligations and pay the counterpart funds. He also promised to persuade the LGs to pay their own counterpart fi.rnds as well.
1.2 LGA level
In each of the three LGAs where field work was done, efforts were made to inform and motivate the authorities. This was done in three ways: . Courtesy visits upon arrival in the area: to LGA offrce bearers (whoever was available); Supervisory Councillor for Health; Director of PHC. . Collecting information about the programme from these persons. . Giving detailed personal feedback to these persons, at the end of the data collection period.
2. Feedback/ planning workshops
2.1 State level
This workshop was held on Monday 6ft May, at the CBM office in Jalingo. In attendance were: the evaluation team; the SOC Dr Apake and the whole SOCT; the Director of PHC for Taraba State, Dr Aji; the zonal onchocerciasis coordinator Dr Ogbu-Pearce; and local staff of the two NGDO partners, CBM and MITOSATH.
The full programme is given in Appendix 1, and the detailed proceedings in Appendix 2. The following is a summary of the workshop process:
. Introduction to the workshop process . Presentation: what is self-sustainability? . Brief report of evaluation team's findings at the community, health facility/ district and LGA levels . Detailed report of the evaluation team's findings at State/ project level. . In-depth open discussion on the findings and their implications. . Group work: 'Preparing broad recommendations for action at State/ project level'. Each small group made suggestions conceming two of the nine groups of indicators. This was followed by group report back and discussion. . Group work: 'Planning for self-sustainability at State/ project level'. Groups had two tasks: making a plan for 2003, and identifuing resources for 2003. Again this was followed by group report back and discussion. . Open discussion: 'The way forward: implementing self-sustainability in the Taraba CDTI proiect'.
Since time ran out before the plan thus produced could be finalised in detail, it was decided that half the SOCT would meet on the following day, assisted by team member Mr P Sankwai, to complete the task. The resulting plan is given in Appendix 3.
The workshop process was successful. There was a lively exchange of views throughout the day, with the final plan being very much a consensus document. It was therefore decided to use the same process at the LGA level workshop on the following day. 26
The 'Taraba State self-sustainability plan' now exists - but it clearly still needs to be put into practice. This is primarily the responsibility of the SOC and local NGDO staff, and these persons need to be actively encouraged by the NOC, ZOC and national NGDO coordinators. In particular, the project leaders need to look critically at the evaluation team's recommendations as they appear in this report. They may wish to incorporate some of these in the 'Taraba State self-sustainability plan' which was prepared at the
2.2 LGA level
Two identical workshops were held, on Tuesday 7tr and Wednesday 8ft May 2002. The locale was the conference room at the State secretariat. In attendance were: . As facilitators: the evaluation team; the SOC Dr Apake and the whole SOCT; the zonal onchocerciasis coordinator Dr Ogbu-Pearce; local staffof the two NGDO partners, CBM and MITOSATH. . LGA representatives: LOCTs (kaders and teams); LG PHC co-ordinators; LG Supervisory Councillors for Health. Six LGAs attended on the first day, and six on the second (this was done so that the workshops would not be too large to give individual attention to each LGA). The mix of persons attending varied from LGA to LGA, but all were represented.
The full programme is given in Appendix 4, and more details of the proceedings in Appendix 2.Tlte workshop process closely followed that of the State level workshop held on 6n May, except that of course the focus was on the LGA level. LGA/ LOCT teams participated actively throughout, and prepared detailed plans (of varying quality) with the assistance of their facilitators. These plans are given in Appendix 5, exactly as they were produced.
Again, twelve 'LGA self-sustainability plans' now exist. Several need more work to be done on them though, to be of practical use, and all need to be put into operation. This is primarily the responsibility of the LOCTs and their leaders, but they will need the support and encouragement of the SOCT. Again, LGN LOCT teams need to look critically at the evaluation team's recommendations for their level, as they appear in this report. They may wish to incorporate some of these into the plans that they prepared at the workshop. It is suggested that SOCTs encourage the LGAs to improve on their plans in this way. 27
Appendix I State level workshop programme
Assessment of the self-sustainability of the Taraba CDTI Project
PLAI\IMNG WORKSHOP FOR STATE/ PROJECT LEVEL MAY 6,2002
AGENDA
S/II ACTIVITY TIME [.ACILITATOR 1. Openins Dravers 10.00 - 10.0s Pastor Skwaila 2. General introduction 10.05 - 10.r5 Dr. Anake 3. lntroductory remarks t0.15 - 10.20 PHC Director 4. Aooointment of scribe 10.20 - 10.2s 5. lntroduction to the workshoo Drocess 10.25 - 10.3s Prof Akosun 6. Evaluation obj ectives : 10.35 - 10.50 Prof. Prozesky What is self-sustainabiliW? 7. Methodolosv & limitations 10.50 - l,1.00 Mr Okoronkwo 8. Brief summary of findings: ' Community level 11.00 - I t.0s Dr Fayomi . Health facility/ district level 11.05 - I1.10 Mr Sankwai . LGA level 11.10-1t.15 Dr. Okeibunor (followed bv time for ooen discussion) II.I5 - 1,,.25 9. Summary of findings: . State/ project level 11.25 - 11.45 Dr. Nnoruka (followed bv time for ooen discussion) 11.45 - 12.00 10. BREAK 12.00 - 12.20 11. Where do we go now? - preparing broad recommendations for action at State/ project level (group work) . Group l: Planning, Finances 12.20 - i,3.20 ProfProzesky . Group 2: Training,Mectizarr . Group 3: Supervision, Leadership . Group 4: Manpower, Transport Each group appoints a scribe to report back 12. Report back from group work 13.24 - 14.00 Prof. Akogun (followed bv time for ooen discussion) 13. LUNCH 14.00 - 15.00 14. Planning for self-sustainability at State/ project level (group work) . Group l: What will our resources be for 2003? * Identifu dependable sources of firnding 15.00 * 16.00 Dr Okeibunor * Estimate likely amounts involved * Rank sources in order of 'dependability' . Group 2: What needs to be done during 2003? * Listing essential activities * Costing each activi8 (roughly) 28
15. Report back from group work 3.45 - 4.45 Dr Fayomi (followed bv time for ooen discussion) 16. The way forrvard: implementing self- sustainabitity in the Taraba CDTI project 4.45 - 5.30 Prof. Prozesky ' Practical steps to take the process forward (open discussion in the whole sroup) 17. General matters/ administrative information 5.45 - 6.00 Dr. Apake 18. Conclusions/ closing 6.00 - 6.15 Mr. Oeoshi
Facilitators for small groups in Session ll
Group l: Planning. Finances * Mr Okoronkwo * Dr Apake * Dr Ajai Group* 2: Training. Mectizan * Prof Akogun Mrs Olamiju , * Mr Sankwai Group 3: Supervision- Leadership " DrNnoruka * Princess Ogbu-Pearce * Dr Okeibunor Group 4: Manpower. Transport * Dr Fayomi * Mr Ogoshi * Prof Prozesky
Facilitators for small groups in Session 14
Group 1: What will our resources be for 2003? * Dr Fayomi * Mr Ogoshi * ProfProzesky * Mr Okoronkwo * Princess Ogbu-Pearce * Dr Ajai
Group 2: What needs to be done during 2003? * Prof Akogun * Mrs Olamiju * Mr Sankwai * Dr Nnoruka * Dr Apake * Dr Okeibunor 29
Appendix 2 The SOCT and LGA workshop processes
The SOCT worksho
The following is a record of &e process of this workshop:
1. Introductions and summary of findings of lower levels
. The Evaluation team leader introduced the elements of sustainability: effectiveness, efficiency, simplicity, integratiorl attitude and resources. . Reasons for evaluating the Taraba CDTI project was discussed. ' The general method was to attempt to get the participants to relax and to contribute to discussions without feeling shy or inhibited. . The methodology (low coverage, high coverage, peripheral health) used for the evaluation exercise was discussed and the limitations to the procedure were identified. . The State teagn was presented with a summory offindings at levels below the State (the community, health facility, and LG levels). This was just to acquaint them with the situation at these levels. . The meeting then discussed the findings together. There was enthusiastic discussion on the sunmary of findings at the levels below the State, with the evaluation leader facilitating discussions on each of the issues raised. The group arrived at the following conclusions: * Although these findings were discussed it was noted that they mainly fall within the level below the State. Creativity was mentioned as a thing that was lacking at that level. * For example, the devolution of documentation (records) between LG and health facility and the collection of drug from the State by LG would be included in the next plan.
2. State/ project level findings
. These were presented for discussion (see report for details). Coverage is high and well maintained, planning is thorough and detailed in line with APOC request. There is political commitment at level of the health centres, and routine supervision at the LGs. The concerns are: * No work-plan for sustainability at the Project level and MoH. * No funds released by the State for two years. * Numerous visits to LG and below but not targeted to particular issues. * Problems identified in the field were not addressed. * APOC funds solely support supervision and there are no other identified sources of support. * Training, mobilisation and sensitisation was done at inappropriate levels. * Management has no plans to remedy shortfall. * Well managed vehicle and equipment but no plans for maintaining and replacing them. * The size of the team is large and may need to be trimmed down to a small size. 30
. The following issues were raised in the discussion which followed: * The team size will need to be reduced. Staffwill be deployed to other areas such as blindness prevention, which is about to take offin the State. * Activities at the LG level ar€ a concern to the SOCTs and they had to do the work themselves rather than wait for the LOCT. The role of the LOCT in the progftrrnme is well acknowledged but the fact that the CDTI is mainly a local community progftrrnme was emphasised. Education was identified as a major factor. Community educatiott, sensitisation and mobilisatio,n suggested as the key factor.
3. Group work I: Making recommendations for sustainability on the basis of findings
. The SOCT was divided into four groups each with evaluation team members as facilitators. Each group was given the task of deliberating on particular findings (planning and finances, training and Mectizan, supervision and leadership, manpower and transport) and making recommendations on howto address them in a sustainable manner. Teams had the following ground rules: * SOCT member should be nominated by the goup as rappoteur, evaluator as facilitator' * Suggestions must come form the SOCT members while the facilitators guide the discussion towards addressing sustainability. This is best done by asking questions and seeking clarifications until a recorrmendation that addressed sustainability is made. * At the end of the deliberations each team presents the recommendations using the following format: recommendation; Action by; indicators for assessing outcome; start date/deadline. . Each group's recommendation was presented and discussed during the plenary that followed. The recommendations were very similar to those made in the draft report by the evaluators and its participatory nature and process of arriving at them made the SOCT to regard the outcome as their recommendations.
4. Group Work II: Planning self-sustainability at the State/ project level
. After lunctr, participants were divided into two groups each with a number of evaluators as facilitators. The teams were to develop a plan of action to address realistically the recommendations made in the first group session. These topics were: a. Planning for Resources for 2003 (identification of dependable resources, estimate likely amounts to be required for activities, rank sources in order of dependability) b. What needs to be done during 2003, the following distribution period (list essential activities, requirements and costs). The teams came up with very impressive plans, which were realistic and practicable within the system. . After presentation it was jointly agreed that the SOCT continue to work on the plan of action for 2003 the following day for presentation to MOH decision-makers as their own plan for addressing sustainability. r I member of the evaluation team worked with the SOCT to further develop the State draft plan of action which will be implemented during the following year. 3l
The LGA/ LOCT works
Attendance at Workshop l: Takum, Zing,Yono, Sardauna, Ussa, Kurmi LGAs/ LOCTs Attendance at Workshop 2: Ardo-Kola" Bali, Donga, Gashaka, Ibi, Karim-t amido LGAs/ LOCTS.
The following is a record of the proceedings of these workshops:
1. Introduction and presentation of findings
. Introductions were made - including a welcome address by the Director of the Epidemiology unit. . The aim of the workshop was mentioned and the method of evaluation explained. The reasons for the workshop (to assist LGAs make their own plan for sustainability) were explained. . The findings at the community level, health district and LG levels were explained and discussed with LGA participants taking the lead in the discussions and suggestions, under the guidance of the evaluators. . [t was noted that few Directors of Finance and Supervisory Councillors were present - none at Workshop 2.
2. Analysing the situation and making plans
. Members of the State team and the NGOs took part in the facilitation. . The aspect of findings at the State level was skipped - members mainly discussed the LG level findings: * , Some participants had misgiving about the collection of drugs since Mectizan is expensive and treated like money it should be sent to LGs using the existing method. One important training need that the participants noted was compilation and record-keeping. One participant at Workshop 2 observed that the selection method did not reflect the entire state profile and wished that the evaluators take into consideration the endemicity of the areas such as Gashaka LG which was not selected for visitation. The participants were delighted about the arrangement and regarded advocacy and fund-raising as the most important factor. It was suggested that a trust account be opened and the signatories be the highest traditional leader in the area and the PHC Director. Realistic presentation of budgets was mentioned as an important factor. * There was enough time to discuss the findings and make recommendations on what to do. The recommendations were highly innovative and constructive. Thereafter the group broke into six LG groups. Every LG group had at least two facilitators: the SOCT responsible for the LG and another person (SOCT member or evaluator or NGDO partner). At the end of the group work, the rapporteur for each group presented the 2003 LG plan of action. The groups discussed the plan and the use to which the plan will be put. The general decision is that the plan of action will be useful, but will need moral and material support from LGA political leadership. \o oo (Jr H { o\ 5 UJ N) oz t9 tr- E EO (D \_< +i ? HrO,1 AF CT E oo 8> ,a t, A8 o X' (- ho 9,P E (D 5Fl 5< x(D t(, o? ts TJO 91 F a ! Uco a (Ds. 6'P. r-t ts.o Fl. - FtEsts Ft i< (D t CQ iao g U) rd 7L ts+r F) s ET Fl HiJ 0a A) F! o, tiO ts. 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U) BSsS 96 o o5(D5-59d ra9€ 8.3 s5(D rn4 80=ts B s rsE 6',r - la) )atlLh + u)=p qts SFHd9U) (D Fl(D EP o -a J E U)V) >aa H oo aoo HA E'OO H -'- ta Fi" u a-o V) ?l{ A J"'? 9"7 g o zo o O oU ,sE td ,SE N> EEi?D (9 -q) 'U Oqe ?HE 5EE{6X -lE i'o- ^ !1 FD ,a "o H) oad H) (DH u!1tr.]e(a g.e EE 3 i5E s. E5 -P)(-DE{ -A)ra3{ oa H. |J5 UH (D C0d (D5 (n ag. fg p t F5 (la +0a (D (D N) qi N) L{ otr o otr H t+ 8F tJ BF O 3r O o oq UJ o .\) Y Y (rr O Y "o P O O N O O c\ O (, .r (rrUJ Appendix 4 LGA level workshop programme Assessment of the self-sustainability of the Taraba CDTI Project PLAIINING WORKSHOP X'OR LGA LEVEL MAY 7-8.2002 AGENDA SAI ACTIVITY TIME FACILITATOR 1. Openine Drayer 10.30 - 10.i5 SOCT member 2. Welcome 10.35 - 10.40 Dr. Apake 3. Introductions 10.40 - 10.45 Mr Sankwai 4. Introduction to the workshop: t0.4s - 10.s0 Prof Akogun Whv are we here. and what are we olannins to do? 5. Background about the evaluation: 10.55 - I1.05 Prof. Prozesky Whv it was done: what is 'self-sustainabilitv'? 6. Background about the evaluation: 11.0s - il.1s Mr Okoronkwo How it was carried out 7. Brief summary of findings: . lntroduction: LGA achievements 11.15-11.20 ProfProzesky . Community level 11.20 - 11.25 Dr Fayomi . Health facilityldistrict level I1.25 - 11.30 Mr Sanlaryai ' State/ project level 11.30-11.35 Dr. Nnoruka (followed bv time for ooen discussion) r r.35 * il.40 SOCT member 8. Summary of findings: . LGA level I1.40 - 11.50 Dr. Okeibunor (followed bv time for open discussion) I 1.50 - 12.1s SOCT member 9. BREAK t2.15 - r2.30 t0. Where do we go now? - preparing broad recommendations for action at LGA level Group work - mixing the different LGAs . Group l: Planning ' Group 2: Finances 12.30 - 13.30 Dr Nnoruka , Group 3: Training and Human resources SOCT member . Group 4: Mectizan . Group 5: Supervision and monitoring . Group 6: Leadership . Group 7: Transport Each sroup aopoints a scribe/ rapporteur 11. Report back from group work 13.30 - 14.00 Mr Sankwai (followed bv time for open discussion) SOCT member t2. LUNCH 14.00 - 15.00 38 13. Planning for self-sustainability at LGA level Group work - members from each LGA work by themselves. Each group has thefollowing tasks: . What do we need to do, between now and the 15.00 - 16.00 Dr Okeibunor end of this year? SOCT member . What will our resources be for 2003, for CDTI? . What will our CDTI prosramme be for 2003? t4. Report back from group work 16.00 - 16.30 Dr Fayomi (followed by time for open discussion) SOCT member 15. The way forward: implementing self- sustainability in each LGA CDTI project 16.30 - 17.00 Prof. Akogun . Practical steps to take the process forward SOCT member (open discussion in the whole srouD) 16. General matters/ administrative information 17.00 - 17.10 Dr. Apake 17. Word of thanks and closing 17.t0 - 17.20 LGA member Facilitators for small groups in Session l0 . Group l: Planning Group 5: Supervision and monitorins Dr Nnoruka, Mrs Olamiju Dr Okeibunor, Mr Ogoshi . Group 2: Finances Group 6: kadership Prof Akogun, SOCT member Princess Ogbu-Pearce, Prof Pro zesky . Group 3: Training and Human resources Group 7: Transport Mr Okoronkwo, SOCT member Dr Fayomi, SOCT member . Group 4: Mectizan Mr Sankwai, SOCT member Facilitators for small groups in Session 13 . LGAI . LGA4 DrNnoruka Mrs Olamiju, SOCT member Mr Okoronkwo, SOCT member LGA2 LGA 4 Prof Akogun, Mr Sankwai, SOCT member Dr Okeibunor, Mr Ogoshi, SOCT member LGA 3 LGA 6 Princess Ogbu-Pearce, Prof Prozesky, Dr Fayomi, Prof Prozesky, SOCT member SOCT member 39 Details of tasks for group work in Session 13 . What do we need to do, between now and the end of this year? From the group work earlier, it is clear that we need to perform some additional tasks this year, if we want CDTI to continue properly. This means we have to work out: * What are each of these tasks we have to undertake? * Who will have to perfiorm each of these tasks? * By when does each task have to be done? * How will we know that we have performed the task? . What will our CDTI programme be for 2003? From the group work earlier, it is clear that our CDTI progralrrme next year will be different from the one we have been carrying out in former years. This means we have to work out: * What are each of these tasks we have to undertake? * Who will have to perform each of these tasks? * By when does each task have to be done? * How will we know that we have performed the task? . What will our resources be for 2003, for CDTI? To carry out our work programme for 2003 need to have resources: staff, transport, money, stationery etc. * What exactly are the resources we will need? 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I (I d Ei ,f FD (D FE o E o,f EtD o as p t-t p a ;h o't rt F { bJ rr rr r- o-F @ t- - o oH 9 o o o o o rrr o HQ bJ o o o o rn rn o o (.1 OFU -.1 *l il F.l -J Ei -l rr r{ -FU o ND iS: o o OE O. *{ r{ v) u) !D ti !i'o o g) S) ) .) o C)o (! o. s) o. o o -l *J -l P. Eo. t? a. FU t_l 6 o (D o. o. O tr D) oE' EI F! ) (D tso t? rJi o r{ o rli CT & () pQ 5 lrj U o o o o o rt(D U c) .J o r_t EF U) U) A TD }J -J E rt o. A* b,J v) Fi(D 7 11 t, tsIl Lr Lr v:'$ ,d 7 o o (D s) P S) Fl FO C' (t (f P ()Ft H E E d g O) s) (! P !D !0 (f o !: r-i .2 q a Lr o z t o (D T 2 o iJ CJ t (D d E (D o (D (? qr' (D (D p!J d |.t d (D (D ts Fl o H 7 5 !9 (D 4F o (D u o g o Fc' aio o |dP ()o ()o o s) U t9 o :o d B r-i (D Ft Ft o o (D N N B (Do p o) 6 d (D (D U) b k { A o o. d s) o SD !) 6 H (D ,'f - o { g) o (D n !0 p 9; U' Ft O U) o o s) F) s rA C' (t clt (D o ttl o (D l, E ts o F U t- r, { D) d (D (D A) !D Fio iJ E o6' t () o (Da A E (D B o) o E. >p. a o () r-r { E AP o .) o (D t! (D :1 (D !D C' o U Fn Ft B (! E !t a. tr04 o (D (D o (D E 9+ oa o U .) o- (D DO { o U) IA o o U Fl 11 oi o o' {A 9) () U Ft d tf :' 0Q tal @ V) (D ) () o r-t (D E u) 9 o (n o o) oF.t o ) ar) o H -l D: (D FOp oa ? p) o- d!D Y (D o oE o (D e O e p- (rrs Appendix 6 Detailed findings 1. State/ project level No. Indicator Findings Position/ scale 1.1 Therapeutic I 82o/o 3 coverage r MITOSATH is still calculating therapeutic coverage with'elieible pop.' as denominator 2.1 CDTI plan . CDTI is reportedly planned for like all other disease 3 part ofoverall control progmrnmes at State level, but there was no plan written evidence except one line in a budget. . There is a detailed APOC style plan at project level - this is different from other progftlrnmes , Review meetings at the end of distribution - followed by planning. That plan is sent to the State for counterpart funding. . NOTE the MITOSATH initiative to add Vit A distribution to CDTI 2.2 Plans contains . The plan submitted to APOC is highly detailed, and 4 all elements of was seen. CDTI . There is a2002 project timeline of activities 2.3 Participatory . The plan reflects input from all partners, but not all J planning participate in actually compiling it. . The review meeting is a good forum though, and leads directly into the planning. . All partners clear on their respective roles. 2.4 Planning for . They are aware of the need for a plan but haven't 1 sustainabilitv actually made one. 3.1 Specific CDTI . Dr Apake is officially allocated and recognized, but 4 leadership without documentation. The documentation is really not needed in this case. . He has enough time for his CDTI work - so does the PHC Director. . MoH has seconded programme officers to both NGDOs (some of whom are too busy to cope, since they retain MoH responsibilities) 3.2 Evidence of ' The Permanent Secretary and PHC Director are 2 political commiffed, even the Commissioner, but all they can commitnent do is write memos for release of frrnds. These are not responded to. . There have been 3 allocations in 5 years. The last was in 2000 and was influenced by external factors. There has been nothing for 2 years. 4.t Routine data I It takes place in the govemment system, but APOC 3 collection funds and registers are used for collecting the data. mainstreamed I NGDOS are involved though- SOCTs appear to give it to them, then it goes to SOC. 57 4.2 Only , The use the approved NOTF format. Everything is 4 necessary data necessary and useful. collected 4.3 Routine . Each LGA is visited at least once by relevant staff 2 supervision by during distribution - but also for mobilisation, right person training, advocacy. . The visits by SOCTs are routine and numerous, and not targeted. ' NGDOs also visit LGAs and do spot checks (on Mectizan, SOCTs) - use checklist; also do advocacy at that level. 4.4 Efficient . SOCTs routinely supervise belowthe LGA level, and 2 supervision thereby some LOCTs are not firlly empowered. . APOC funds pay for supervision visits by SOCTs . SOC and PHC director supervision visits appear to be integrated. . There should be fewer SOCTs, therefore fewer visits. . Supervision visits have specific goals. 4.5 Routine . Usually they deal with problems identified, but at 2 process of times SOCTs do not- some problems are left to problem and NGDOs to solve. success . NGDO reports looking out for low coverages, and management dealing with those. Generally they seem to tackle observed problems actively. . We are not clear about their plans to deal with areas oflow coverage. . Successes are sometimes noted and verbal feedback given. Feedback on coverage data is routinely given. . The LOCTs pass on problems that are beyond them to SOCTs - but SOCTs are still doing things that LOCTs are capable of. 5.1 All aspects of . Mectizan is stored by the NGDOs. It is administered/ I Mectizan controlled by Ministry staff, and uses its own control supply system (which is better for sustainability). mainstreamed . NGDOs (both) are responsible for ordering, and APOC pays for the distribution up to LGA level. 5.2 Alternative . Both NGDOs depend on outside funding - they may 2 mechanisms cease to operate in due course. At present however dependable they are available to help. This is dependable. . APOC contributions are ending. . State contibution is not dependable. 5.3 Import . Not applicable clearance arransed 6.1 Only . Up to 2001 they trained all LOCTs routinely, but not J necessary in2002 - firnds arrived late and this made them training being realise that the haining wasn't needed. done . NGDOs did separate training on CSM. MITOSATH also reports doing targeted training on issues observed durine supervision. 58 6.2 Training done . LOCTs are trained by SOCTs and NGDOs - but 2 by appropriate SOCTs also participate in training CHEWs and staff CDDs. 6.3 Continued . SOC, PHC director, Permanent Secretary, 4 sensitisation/ Commissioner for Health, SOCTs are all involved mobilisation appropriately. . There is routine mobilisation of all 1500+ communities before every distribution. . NGDO is mobilising CBOs to help in practical ways; uses any available opportunity for advocacy, e.g. annual dinner 7.t Cost . The costs are fully detailed in the APOC style budget. J implications By the time it gets to the Ministry it is reduced to one are quantified figure. Recurrent and capital costs are separated in the in the LGA APOC budget. budget 7.2 Appropriate . The amounts budgeted are adequate but not 2 and adequate appropriate - they don't take the previous year's amounts activities into account, and budget is based on past budgeted routine. . The amount budgeted for SOCT daily allowances (for training and supervision especially) is inappropriate. ' Programmes without external funding get by with far less (but also achieve less) 7.3 Funds ' Relative contributions are clearly spelt out in the I increasingly APOC style budget. being supplied . The amount supplied by the State is not the major one by State currently, and the proportion is getting less. The State resources is not puling itd weieht 7.4 Deficit met by . State managers are not frrlly aware of the size of the 0 dependable shortfall. provision . There are no specific plans to make good the shortfall (although there are good intentions). . There is no written commitment of any kind. HoweverNGDO verbal commitrnent is there: to continue helping with transport especially. They will be there to bridge important gaps. 7.5 Funds ' Every criterion is met. 4 efficiently managed. 8.1 Sufficient . There is more than sufficient transport available. 2 transport for There has never been any report offailure to carry oul necessary activities (although there has been, at LGA level - visits to LGA twice). Howevertransport is dependent on APOC. for CDTI 8.2 Transport well . Trips are all authorised, but not always in writing. 2 managed . No logbooks in the State system. NGDOs use them. . The vehicles are being used to some extent below LGA level. . Only NGDOs service/ maintain vehicles. 59 8.3 Sufficient . They have the stationery they need. J other material , They are borrowing a computer from another resources programme, and go to the Ministy for photocopying. . NGDOs provide bicycles and motorbikes . Some APOC money is used to print material. 8.4 Dependable . Management may be aware but there are no really I replacement specific plans for replacement. plan . The lower order State managers are aware, and are happy to share resources between programmes, if these should become available. There are no written commitrnents. . NGDOs are going to be helping - not clear how muctr, but they won't just do nothing. But they will insist on specific requests and motivatons. 9.1 State team , The team is excellent and knowledgeable, but the J skilled and number is too large for current level of operations. knowledseable 9.2 Personnel . All staffat this level are stable (except the Permanent 4 stability at the Secretary, but he is not actively involved) State level . Replacements can be easily trained on the job 60 2. Health district tLc[level Yorro Ardo Kola Takum No. Indicator Findings Position /scale 1.1 Geographic . Ardo Kola has no record of endemic communities or 2+4+2 coverage total number of communities in the LGA :2.'l r ftl Takum there are 103 endemic communities in 13 health centres and all were covered . 11 communities were under treatrnent but the number of communities are not known in Yorro t.2 Therapeutic . Takum 7l.l% 2+3+3 coverage . ArdoKola is 8l.l % :2.7 . Yorro is78.2Yo 2.1 Written yearly . There is a plan in Takum 2+2+2 plan r fu Ardo Kolathere is a plan :2 . Yorro has a plan which is not documented 2.2 Plans contain . Takum has elements needed for CDTI 4+1+l elements of . ArdoKola does not have a plan -2 CDTI . Yorro has no written plan but it falls within the general PHC 2.3 Participatory . Ardo Kola plans are participatory 4+4+l planning r ftl Takum plans are participatory _J_a r fu Yorro the director draws up the plan 3.1 Allocated . Ardo Kola depends on the SOCT for everything 4+3+l leadership for r fu Takum the leadership initiates all key CDTI :2.7 CDTI activities . In Yorro the LOCT is fully responsible for CDTI 3.2 Evidence of r fu Ardo Kola the leadership is committed and firnds 4+4+2 political proposals brought to the LG _J.J commitment r ftl Takum the Vice Chairman and the Supervisory councillor know enough about CDTI and are committed . Supervisory Councillor for Health in Yorro is committed 4.1 Routine . There is no evidence or record of monitoring or l+4+4 supervision at situation supervision in Ardo Kola _J_a the LGA r fu Takum the LOCT visits twice every year to supervise . [n Yorro the LOC visits thrice 4.2 Routine data . LOCT collects and sends data to LOCT in Takum 4+l+4 collection and . No evidence of reports sent to higher level in Ardo :3 transmission Kola , Data are sent routinely within the PHC framework 6l 4.3 Routine . The LOCT manages distribution problems in Takum. 4+4+4 process of . The CHEWS are responsible for managing problems 4 problem and of the CDDs in Ardo Kola success r fu Yorro they manage problems during routine management suoervision and then they give verbal commendation. 5.1 Order of . Mectizan procured from the State and taken to LGA in 4+2+4 Mectizan Takum :3.3 every year and . The State sends an estimated quantity of drugs to Ardo in good time. Kola . Suffrcient amount of drug is received every year to Yorro 5.2 Storage of r ftl Takum it is stored at the LG main store along with 4+3+4 _a1 Mectizan other drugs -). I within r fu Ardo Kola Mectizan is stored in the central store government . At Yorro it is stored in a health cenhe at the sub level district level 5.3 Distribution to . The drugs are collected during training in Ardo Kola 4+4+4 the sub-district r fu Takum the health centres are delivered by the 4 LOCT . Distribution by LOC using goverrment vehicle 6.1 Only . Takum training is routine and not targeted 3+4+4 :3-7 necessary . ft1 Ardo Kola old CDDs are separated from new ones training being for training done . Yorro trainine is vearlv and new CDDs are given skills 6.2 Training done . LOCT trained CHEW and CFIEWs tained CDDs in 4+4+4 at appropriate Takum :4 level by . fu Ardo Kola there are 9 training centres for CDD appropriate training staff . Yorro: CDDs are trained at the subdistrict only 6.3 lntegration of This is not applicable inNigeria Instead it should be CDTI training asked if CDTI is an integral part of CFIEW training into in-service curriculum trainine. 6.4 Staffinvolved : ftl Takum the CHEWS and the CDDs take part in 4+4+4 in sensitisation and mobilisation in the communities 4 sensitisation/ . Ardo Kola CHEWS and LOCT take part in mobilisation mobilisation of decision . Yorro relevant decision makers enlightened makers 7.1 Cost . No written budget in Takum but proposals are 4+3+3 implications approved by policymakers in the LG :3.3 are quantified . fu Ardo Kola there is no microplan for CDTI in the LGA . Yorro there is no specific budget for CDTI activities budset but funds made available . No written budget in Takum but amount is appropriate 4+3+0 7.2 Appropriate :2-l and adequate and adequate amount . Supervision and maintenance done within the budgeted for government sYstem CDTI . Yorro there is no budget or doctrment on costs and activities adequacy 62 7.3 Funds to cover r ftl Takum the amount being supplied by LG increaseJ 4+4+0 costs with time =2.7 increasingly . Ardo Kola this is being covered being supplied . No budget for oncho specifically by LG resources 7.4 Deficit met by . No deficit budgeting in Takum 4+0+0 dependable . Ardo Kola not applicable =1.3 provision . Yorro there is no budget 7.5 CDTI in LGA ' Funds sufficient when released in Takum and shared to 4+4+0 sufficient meet the needs :2.7 managed. ' Ardo Kola funds are efficiently managed when released . Yorro there are no records 8.1 Sufficient . There are 5 well maintained PHC motor bikes in 4+4+4 transport for Takun 4 necessary ' LG used to provide transport in Ardo Kola visits to sub- . Yorro adequate transport is made districts for . NOTE: LGA reports that there have been 2 instances CDTI where distribution was held back due to transport 8.2 Tips and . LG pays for all the trips and all trips are integrated to 4+4+0 journeys for all other PHC activities in Takum :2.7 CDTI are . It is integrated into other activities in of the LG integrated to r fu Yorro there is no log book other activities 8.3 Management I In Takum there are routinely managed by the LG 4+4+4 of vehicle I ln Ardo Kola it is well managed by the user-ofhcer 4 I ln Yorro they are well managed 9.1 LG team . Takum team is well skilled and knowledgeable 4+2+4 skilled and _J.J ' Ardo Kola team is not skilled but have knowledgeable -aa knowledgeable about CDTI . Yorro team skilled and knowledgeable 9.2 Personnel . All staffare stable in Takun and when transfened they 4+4+4 stability at the are moved to endemic areas -4 LG level : fu Ardo Kola the staffare stable : fu Yorro the staflare very stable oEr . Sustainability of CDTI in Takum by LG is feasible .q r fu Ardo Kola the LG does not seem to be in the best position to sustain CDTI at the moment r fu Yorro CDTI may be sustained at the LG level 63 3. Sub-districUfirst line health facility level Ardo Kola Tau Lankaviri Kanjong Dongawa Lufu No. Indicator Findings Position /scale 1.1 Geographic . All eleven villages are treated in Tau but the 2+4+4 coverage denominator is not known :3.3 r fu Kanjong and Lankaviri 100% coverage . fu Lufu and Dosonsawa coverage is 100%. 1.2 Therapeutic . The number of villages are not known and the 0+2r-0 coverage number of people teated are not known. =0.7 r ft1 Kanjong &3.2%treated . There are no records in Lufu and in Dogongawa 2.1 Official plan of . There is no planning and the in charge has never 0+2+4 the centre attended any meeting -2 . No documentation of the plan in Kanjong and Lankavid . There are no documents in Dogongawa but there is some plan 2.2 Written year . No written planning 0+2+2 plan , No written plan but it is well understood :1.3 . No written plan but activities carried out in sequence and there is a plan 2.3 Content of the . Not applicable 0+2+4 plan . The content is well known -2 . Not applicable in Dogongawa and in Lufu 3.1 Full . Very little involvement in management there is no 1+3+2.5 responsibilrty of orientation, no opportunity to provide leadership :2.1 local leaders . Based on information from communities the plans are made . Initiative begins in the health facility and in Lufu the instructions come from the LG 3.2 Political . Personnel is willing to perform but does not know 0+0+2 commitment what is expected of him :0-7 ' No evidence of political commitrnent . Communities are happy and involved in Dogongawa and in Lufu there is no commitment 4.1 Routine and . No routine supervision 0+3.5+4 efficient . There is some supervision but it is not routine in :2.5 supervision of Kanjong in Lankaviri the villages on r ftl Takum Supervision and monitoring are regularly site done by CHEW 4.2 Collection and . Not at all 0+4+4 transmission of . Collection and reporting within govemment system :2.7 routine data in Lankaviri and Kajong within system . There is no documentation but collection and transmission done at this level 64 4.3 Routine . Not at all 0+4+4 management . There is routine monitoring in Kanjong and :2.'l process of l,ankaviri successes and . Routine processes of management of problem and challenges joint solution of problems in Takum 5.1 Sufficient . CDDs estimate of requirement is used to get supply 4+3.5+3 orders for . LOCT decides on quantity in Yorro :3.5 Mectizan . Tally sheets used to determine number of drugs required in Dogongawa but in Lufu they come for more when the allocation is fininshed 5.2 Mectizan . Not at all 0+4+4 regarded as free . The people knowthe drug prevents blindness and it :2.7 but essential is good for them drug , Mectizan is acknowledged as free and community affair in Takum 5.3 Storage and . No document regarding this 0+4+2 administration . Mectizan is stored in the health centre :2.0 . Stored in the health centre in Dogongawa but in Lufu there is no storage facility 5.4 Appropriate . The people get the drug 4+4+4 distribution to ' The village sends the CDD to collect the drug and is 4 villages effectively distributed to the villages . Distributes drugs to all villages in Dogongawa and in Lufu drugs are shared to all CDDs after trainine 6.1 Only necessary . In-charge does not take part in training 2+4+4 training is being . In Lankaviri the in charge is trained to enhance their _J.J done knowledge and in Kanjong they retrain every year r fu Lufu and Dogongaw4 CDDs are trained annually since some do forget and new CDDs come. 6.2 Training is done . LOCT and SOCT staffdo training 3+4+4 by appropriate . CDD is trained by the supervisor and the LOCT -). I staff members . The in-charge has what is required in the health centre for training 6.3 Materials for . One-on-onecorlmunitymobilisation 2+4+4 IEC available . There are materials for training in Kanjong and in _J.J_aa Lankaviri . There are adequate IEC materials including charts in Takum 6.4 Personnel . Not at all 0+4+4 continue to be : ftl Kanjong and Lankaviri the staff still go for :2.7 engaged in mobilisation and sensitisation sensitisation . Staffroutinely go to check ongoing work in Dogongawa and in Lufu 7.1 Adequate . Not at all 0+4+0 provision of the . Fuel and vehicle is provided by the LG in Lankaviri :0.8 cost of CDTI and Kanjong . There is no budget and not applicable 65 7.2 Available costs . Not at all 0+4+0 of CDTI at this . Funding and assistance comes from the LG to the :0-8 level ommunities . Not aoolicable 8.1 Transport for . No transport means but has a bicycle l+4+0 necessary visits . There is a means of travel. Transportation is adequate :1.'l in Yorro . There is no vehicle at this level commercials vehicles are often used 8.2 Integration of . Somewhat integrated into the processes l+4+4 _J processes ' There is integration since the personnel also do other -a things such as NID in Yorro . There is some intesration in both health district 9.1 Skill of the sub- ' More CDDs are required 2+4+3.5 district team . The staffis skilfirl and knowledgeable inn t ankaviri :3.2 and in Kanjong . There is some skill available in both health disticts 9.2 Stability of . They are very stable 4+4+3 personnel . There is stability of staffin Yorro :3.7 ' Staffremain in one station for a long time in both health districts 9.3 Satisfactory . Staffhave not been paid for three months 2+3+2 work conditions . Salaries are paid for two months out of four in Yorro :2.3 and there is enough working materials . Salaries have not been paid for nine months in Takum t{ !) . The first line Health system in Ardo Kola is not oP involved beyond being a collection centre and it is therefore not sustainable . The first line hedth system in Yorro is well involved and has clearly defined responsibilities. The program is sustainable at this level r fu Takum the first line health system is very much involved and has clearly defined responsibility. The Drosftrm is sustainable at this level 66 4. Community levet No. Indicator Findings Position /Scale 1.1 Geographic r fu Napu, Kanjong, Shompa B, Lankaviri B in 4+3.5+4 coverage Yorro coverage is 100% :3.8 r ftl Alheri company the number of households are not known and the denominator is not calculable, Ardo Kola (86.30/o), Tau Galadima every segment was treated (L00%),In Lapo the number is not determinate . Tampo l00yo,Ikyor 100%, Agba l00yo,Fete2 rca% r.2 Therapeutic r fu Napu itis29.5o/a, Kanjong 88.6yo, Shompa 23+3.5+2.7 coverage 7 5.3Yo, Lankaviri E 88.5% :2.8 : fu Alheri C 81.7 Yo, Ardo Kola 91.5olo, Tau 86.lYo,Lapo 95.7Yo . Tampo 6l.2yo,Ikyor 81.73Yo, Agba9g.7yo, FeteII 80.9 % 2.t Census update r ft1Napu and Kanjong , Shompa B, Lankaviri 4+2.5+3.5 done at time of CDD updates census by moving house to house :3.3 distribution . In Alheri, Ardo Kola the register is updated but in Tau and Lapo no register was seen but he said he updates the register regularly, , Tampo and Ikyor census is well done in Agab census is done sometimes but in other times no! in Fete II census is updated 3.1 Leadership/ . In Napu, Kanjong, Shompa B, Lankaviri the CDD 4+3+4 community takes part in community mobilisation those who -)-I problem react report to the chief who motivates them to management take the drug r fu Alheri and Ardo Kola and Tau community contributes funds for feeding CDD and takes part in the arrangement. In Lapo there is no indication of leadership. . In Tampo,Ikyor, Agbq Fete tr leaders take responsibility and solve problems as they come, mobilisation, education absentees follow-up. 4.1 Maintenance of r fu Nup,l Kanjong, Shompa B village register is 3.5+2.5+4 village level kept accurately and updated but in Lankaviri _J.J-aa register update was not properly done and underage not changed. r fu Alheri, Ardo Kola, Tau the register is kept but not accurately entered but in [,apo register is poorly kept . In Tampo lkyor Agba and Fete lkegister is complete and filled bv CDD, 67 4.2 CDD report to . fu Nup,t Kanjong, Shompa B and l,akaviri the 4+2+4 sub-district report is submitted to the nearest health facility. :3.3 r fu Alheri report is sent to the health district, in Ardo Kola the report is not sent to the health centre, in Tau the report was not available but sent before, during and after dishibution, in Lapo there is no evidence of reporting . fu Tampo, Ikyor, Agba and FeteII there is an inventory for drug and the summary forms are submiued to the health facilitv 5.1 Receipt of r ft1Nup,l Kanjong, Shompa B, Lakanviri quantity 4+2+3.5 required requested received on time due to refusals :3.2 amount of . In Alheri, and Ardo Kola dugs that are given to drugs him by the SOCT, so the CDD does not determine the number of drugs required, Tau and Lapo the nomads are treated but there are no rational means of detennining the number required. r ftl Tampo,Ikyor, Agbq Fete II the drug Mectizan is given to everyone in the village, drug is given to everyone livins in the villase. 5.2 Accuracy and r ft1Napu and Shompa B it is based on the 3.5+1.8+3 rationality of population of people in the village but Kanjong :2.'l drug estimate and Lankaviri based quantity required on the amount requested in the previous year , In Alheri, Ardo Kola, Tau and Lapo whatever the CHEW gives is used and there is no rationale for entries ' The drug is given by the health stafl in Tampo and Ikyor the CDD collects 500 at a time and replenishes when he has finished, in Agba and Fete the number of elisibles is used to determine 5.3 Required r fu Nup.u Kanjong, Shompa B and Lankaviri it 4+4+4 amount was received at the time the community wanted 4 received on and called for it time . Alheri, Ardo Kola, Tau and Lapo the drugs arrive at the time they like and they are happy. . Tarrpo and Ikyor mectizan arrives when the distribution period is around. In Agba and Fete II the number requested is received at the time needed. 6.1 CDD and . In Napu, Kaqiong, Shompa B, [,ankaviri the 4+3+4 Community people are mobilised, sensitised with and without -J-I leaders carry on IEC materials any time the drug arrives. sensitisation . Alheri, Ardo Kola, Tau the CDD informs and and sensitises the villagers on their role using IEC mobilisation materials. There was no evidence of sensitisation and mobilisation of the community r ftl Tampo,Ikyor, Agba and Fete II take part in sensitization and mobilisation and advocacy 68 7.1 Villagers r ft1Napu, Kanjong, Shompa B and l,ankaviri we 4+3+4 appreciation know the drug is costly and that the finance involved :3.7 offinances is much and distributed free. involved in . They appreciate the problem in Alheri, Ardo Kola, CDTI Tau and contribute money to the CDD, village head feeds the workers and pay N5 per household for the CDD's incentive. In l,apo they abuse him and do not give me any support. r fu Tampo and Ikyorthe communities appreciates the finances involved, in Agba and Fete [I the villagers are aware of the cost of the drug and appreciate the finances involved 7.2 Community r fuNup,r, Kanjong, Shompa and Lankaviri the 4+2.5+4 arrangement community has no arrangement to compensate CDD :3.5 to meet but provide transporf provides goods and food such local costs as groundnuts and yams as incentives to compensate for CDD time and effort. r fu Alheri there is a sustainable system of supporting CDDs, Ardo Kola govemment is required to support CDD, in Tau there is an zurangement for funding local costs but in [,apo there is no evidence of community support of the CDD . In Tampo, community provides pencils and writing materials but the CDD provides these in lkyor and Agbq in Fete II there is a community contribution to motivatine the CDD (farmins) 8.1 Community r fuNapu, Kanjong, Shompa B and Lankaviri the 4+4+4 access of drugs are always collected in spite of the transport 4 transport to difficulties, there are no problems of access and collect collection mostt often the collection centre is near. Mectizan . The CDD goes to collect the drug from the health centre in Alheri, Arodo Kola Tau and Lapo r fu Tampo and Ikyor they promise to give money and to support his collection of the drug. In Agba and Fete there is no oroblem with communitv access 9.1 CDDs have r fu Napu, Kanjong, Shonpa B and l,ankaviri the CDD 4+4+4 received has been trained to treat and manage side effects 4 appropriate r ft1Alheri, Ardo Kola and Tau and Lapo receives training training every year, r fu Tampo, Ilryor, Agbq Fete II the CDD has been trained in the past six years some up to nine years and this shows- 9.2 System for r fuNapu, Kanjong, Sompa B and Lankaviri there is a 4+3.5+4 acquisition plan to replace absent CDDs and train new CDDs :3.8 of skills by . Alheri, Ardo Kola" Tau there is a system on ground new CDDs for the training CDDs using older ones. There is no system on ground for training in Lapo. . In Tampo, Ikyor, Agba and Fete II there is routine yearly training at the community level and to send another CDD for trainine. 69 9.3 Willingness . fu Napu, Kanjong, Shompa and Lankaviri the CDDs 4+4+4 of CDDs to are willing to continue to help their people. -4 continue . In Alheri, Ardo kola Tau and Lapo: 'We continue to with CDTI do the work even if there is no community support' , CDDs are willing to support the community and to continue to serve in Tamoo.Ikvor. Asab and Fete II 9.4 Appreciatio . In Napq Kanjong, Shompa B and Lankaviri there is a 4+3.5+4 n ofannual lot of refusals but the people like it since the wonns :3.8 t treatment by are removed. There is a general appreciation of the community importance of annual fieatment of the itching and the worns. . In Alheri and Ardo Kola" Tau the villages appreciate the benefits of the drug for skin and sight. There is some interest in the drug in Lapo . Communities appreciate the improvement in the skin, worn expulsion and value the treatment in Tampo, Ikyor. Aeba and Fete II 9.5 Community r fu Napu, Kanjong, Shompa B and Lankaviri the 4+3+4 acceptance villagers want the CDTI to continue and accept their :3.7 ofneed for role in the distribution for the next 15 years long- term r ft1 Alheri, Ardo Kola" Tau the community accepts the treatment need for long term treatment. The community does not feel the impact of the problem and does not have much interest. . The community members accept the treatment for a lone time in all the communities for a long time i Self-sus- . In Yorro the community meets their responsibilities o rrt tainability at and are capable of sustaining CDTI () community r fu Ardo Kola there is no sustainability but could be ()o level turned around if there is sensitisation and mobilisation as well as training and education of the communities and CDDs r fu Takum the performance is very good and the Drocess is sustainable I