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World Health Organisation African Programme for Onchocerciasis Control

Assessment of the Sustainability of the Imo CDTI project, Imo State Nigeria – Year 5

June 2003

Martin Ogbe – Team Leader Danny Haddad Karoli Malley Obioma Nwaorgu Joseph Okeibunor Veronica Okeke 1

TABLE OF CONTENT

TABLE OF CONTENT ...... 1

ABBREVIATIONS/ ACRONYMS ...... 2

EXECUTIVE SUMMARY ...... 4

1.0 INTRODUCTION ...... 7

2.0 METHODOLOGY ...... 8 2.1 SAMPLING ...... 8 2.2 SOURCE OF INFORMATION ...... 9 2.3 ANALYSIS ...... 9

3. EVALUATION FINDINGS ...... 10 3.1 SUSTAINABILTY AT THE STATE LEVEL: ...... 10 3.2 SUSTAINABILITY AT LGA LEVEL ...... 16 3.3 SUSTAINABILITY AT FLHF LEVEL ...... 20 3.4 SUSTAINABILITY AT THE COMMUNITY LEVEL ...... 24

4.0 CONCLUSION ...... 28 4.1 GRADING THE OVERALL SUSTAINABILITY OF IMO CDTI PROJECT. ... 28 4.2 FEEDBACK/PLANNING MEETINGS: ...... 30 4.3 THE WAY FORWARD ...... 31

APPENDIX ...... 32 STATE & LGA LEVEL WORKSHOP PROGRAMME ...... 32 IMO STATE CDTI EVALUATION TEAM ...... 33 2

ABBREVIATIONS/ ACRONYMS

4WD Four Wheel Drive APOC African Programme for Onchocerciasis Control CDD Community Directed Distributor (of ivermectin) CDTI Community Directed Treatment with Ivermectin DAGS Director of Administration and General Services DPHC/DC Director of Primary Health Care/Disease Control FLHF First Line Health Facility FO Finance Officer GRBF Global 2000 River Blindness Foundation HSAM Health Education Sensitisation Advocacy and Mobilization Km Kilometres LCIF Lions’ Club International Foundation LG Local Government LGA Local Government Area LOCT Local Government Onchocerciasis Control Team LSC Local Government Service Commission MOH Ministry of Health NGDO Non-Governmental Development Organisation NOCP National Onchocerciasis Control Programme NOTF National Onchocerciasis Task Force PA Project Administrator PHC Primary Health Care SOCT State Onchocerciasis Control Team SPO State Programme Officer WHO World Health Organisation 3

ACKNOWLEDGEMENT:

We would like to thank the following persons and organisations for their contributions and assistance towards the successful execution of this assignment: . The Director, Dr. A. Seketeli and staff at APOC Headquarters in Ouagadougou for making available the necessary financial and logistic requirements for the success of this assignment. . The WR, Lagos and his staff contributed to the smooth functioning of the evaluation team. . Dr. Jiya and his team facilitated the smooth take off of the exercise in Nigeria . Staff of the Ministry of Health Owerri: They provided information and prompt support. . Country Representative, Global 2000, Dr. Miri, and his staff, Health workers and community members in Isiala Mbano, Obowo and Ikeduru LGAs provided information and contributed to the success of the mission. . Dr. Uche Eyinnaya, PA, Global 2000 Owerri, participated worked tirelessly in ensuring the success of the exercise 4

EXECUTIVE SUMMARY

Introduction

The Imo CDTI project was launched in October 1998 and is therefore in its fifth year of agreed funding from APOC. A team of external evaluators from Nigeria, Tanzania, and the Netherlands carried out an evaluation of the sustainability of this project between June 16 and 30, 2003.

The evaluators were charged with three tasks: . To evaluate the sustainability of the project. . To present and discuss the results with the MOH authorities and NGDO partner . Support the State level, and endemic LGA personnel in developing post APOC sustainability plans, using the guidelines for sustainability planning meeting developed by APOC.

Information was gathered from the review of relevant documents and reports. Interviews were held with the MOH team, LGA Health Management Teams, and FLHF staff, community leaders and members as well as CDDs. The evaluation team also held community meetings in all the communities sampled. Field observation at four levels (the State, LGA, FLHF and village levels) provided additional source of information.

Findings:

Geographical coverage is good and commendable. All the LGAs visited had geographical coverage of 100%. However, only 13 (81.3%) of the 16 APOC assisted LGAs in the State had therapeutic coverage of 65% or higher. All the same the therapeutic coverage is on the increase. Communities expressed willingness to continue with treatment for as long as it is necessary. The drug has been associated with a number of health benefits such as deworming, improved sight and being energizer. This attitude has potentials for creating demand for continuation of the project and thus enhances sustainability.

Communities have been empowered to play a leading role in CDTI. For example, communities have been informed of their roles and responsibilities in supporting CDDs as most respondents were aware of their responsibilities. However, the ratio of CDDs to population is very high and the communities argued that the number of CDDs represent what they could adequately support. Further more, apart from the selection of CDDs and choice of method of treatment, the period of treatment is mostly dependent on the availability of drugs, over which communities lack control. All the same community ownership of the programme is strong. It was obvious, from the meetings evaluators held with communities, that practical steps have been put in place to ensure sustainability of the CDTI at the community level. The evaluation Team concludes that CDTI at the community level is sustainable. Therapeutic coverage of all communities visited is 74.2% for 2002 with a range from 54.0% to 93.0%. The low coverage in some communities resulted from the inclusion of non-permanent residents in the registers. To 5 reverse this situation only permanent residents of the communities should be included in community treatment registers.

Funding for CDTI by government (at the State and LGA levels) has been minimal and mainly for payment of salaries, provision of stationeries. The financial contribution of the State Government towards the implementation of CDTI is particularly small. The trend over the years is also unclear though the latest move indicates an improvement. In 2003, the State budgeted 2 million and released N70,000.00 as against N410,000 expected by June 2003. In 2002, no record for separate budget for the recurrent cost of onchocerciasis control but N10,000.00 was released, whereas in 2001, N99,350.00 was released. Major funding for CDTI implementation is from external sources, specifically APOC and Global 2000. The two agencies have provided technical and financial support of about US$174,816.32 and US$52,559.85 respectively over the past five years. In addition APOC has provided vehicles and capital equipment including one 4WD Land Cruiser vehicle, motor cycles, generator, computer, among others in the past 5 years. Over dependence on external sources of funding does not guarantee project sustainability. It is the belief of the evaluation team that sustainability can only be ensured when government funding constitute at least 75% of the required financial inputs by the 5th year of CDTI implementation, though it is argued that Government will meet its responsibility when it becomes obvious that there is no external support. Examples were sighted of the Imo Health and Population programme and the Leprosy Control Programme previously supported by World Bank. These programmes have been sustained by the State, without any external support.

There is high-level political commitment as evidenced of the involvement of the State Ministry of Health and other policy makers in the CDTI programme. The different departmental heads in the Ministry were informed about the programme.

The staff attitude and level of supervision are satisfactory. There are enough financial resources to carry out activities but these are mostly from APOC and Global 2000 funds. This would have been considered to be seriously blocking sustainability for a fifth year project, but again, it is argued that since the funds were given from these sources they had to be used without placing much pressures of the Government. However, steps should be taken to secure counterpart funding from government from the sixth year budget. The Local Government Service Commission is currently disposed to getting the LGAs to release counterpart funds for CDTI implementation. This spirit is contained in the recent directive to all LGAs to released counterpart funds of not less than N100,000.00. This should be pursued and sustained.

Regarding transport and Mectizan supply, there are no plans for the replacement of vehicle and motorcycles in the future because the present vehicles are still functioning well. The current Mectizan supply system is good for sustainability of the project. There is a good sense of community ownership of the programme. Communities sponsor CDDs to collect their Mectizan requirements from designated point. Furthermore, the project is effective. Treatment coverage is on a stable rise, with therapeutic coverage of 74.2% in 2002. 6

Evaluating the project against the seven aspects and six critical elements of sustainability, the evaluation team concludes that the Imo CDTI is MAKING SATISFACTORY PROGRESS TOWARDS SUSTAINABILITY.

On examining the six critical elements the evaluation team found five would very much help sustainability because they were present in the project. The only critical element lacking in Imo CDTI project is ‘money’. Though there is enough money to undertake the absolute minimum residual activities in CDTI implementation, the evaluation team holds that the source may not be sustainable. The funding for CDTI implementation is mainly from APOC funds while government contribution is very minimal, in spite of the series of advocacy visits on the policy makers. The government needs to make more deliberate and tangible contributions to CDTI implementation in the State.

With respect to the seven aspects of sustainability, the evaluation team found that five, namely efficiency, simplicity, attitude of staff, community ownership and effectiveness were very much helping sustainability of the project. However, integration and resources were found to be moderately and slightly, respectively, blocking sustainability because monitoring in CDTI is not fully integrated into the M&E system of the health system and government funding for the programme is very minimal.

Way Forward:

MOH should ensure that the sustainability plans developed during the briefing and planning meeting is finalized and implemented as a matter of urgency. MOH should monitor closely implementation of decisions reached to address the deficiencies identified by the evaluation team and the overall sustainability plan and should take prompt corrective action. The issue of integration needs to be further addressed. For instance the integration of CDTI monitoring and evaluation into the mainstream of the State MOH M&E system could be addressed by the State developing its own monitoring and evaluation process that incorporates all health programmes.

On the ratio of CDDs to population the project plans to intensify its current efforts at mobilizing the communities to select CDDs based on their kindred. This has the potentials of not only achieving proper ratio of CDDs to population, but of reducing the workload and demand for compensation for CDDs.

Effort will be made to include CDTI as a budget line in the next State budget session coming up in August/September and when this is done it would be sustained in the future. Both the MOH and the LSC would endeavour to work out modalities for including onchocerciasis control in the M&E formats to make for easy entry of CDTI monitoring activities in the same format as other diseases. The LSC would also monitor the release of counterpart funds by the LGA Chairpersons.

APOC should follow closely implementation of decisions and activities for the sustainability plan. 7

1.0 INTRODUCTION

Imo State is located in the Southeastern region of Nigeria. The state lies between latitude 4°45’ and 6°15’ North and Longitude 6°30’ and 8°09’ East. Abia and Anambra States boarder it on the North, on the South, are Rivers and Bayelsa States, East is Abia State while Anambra State is on the West. Imo State has an estimated total population of about 3.4 million persons, with 27 Local Government Areas, out of which 16 LGAs are implementing APOC supported CDTI strategy for the control of Onchocerciasis. It is estimated that over 1.1 million persons are at risk of Onchocerciasis in these 16 LGAs. The facilitating NGDO for the implementation of CDTI in these 16 LGAs is GRBP.

The major Rivers are, Imo River, Otamiri River and the Ogochia, Nbaa, Uramiriukwu Rivers. The climate of the State consists of the dry season (November – March) and the wet season (April – October).

The main occupation of the people is farming, fishing, and trading. The people are mostly indigenes living in villages. Community leaders in consultation with the elders and community members make decisions.

Mectizan® distribution started in Imo State in 1993 in 4 LGAs – Okigwe, Ahiazu, Ihitte- Uboma and Ezinihitte LGAs. A total of 114,157 persons were treated in these LGAs by then. In 1998, a proposal made to APOC for Onchocerciasis Control in Imo and Abia States was approved, with Global 2000 Nigeria as technical partner. The five-year APOC funding support is intended to facilitate the institution of structures for the long- term sustainable distribution of Mectizan® in the State.

The project is in its fifth year of funding from APOC, and is undergoing a fifth year evaluation of the sustainability of the programme in the State. After the evaluation sustainability-planning meetings were held with the State MOH and LGA Health Teams respectively and the NGDO to develop sustainability plans for the different levels of CDTI implementation in Imo CDTI project using guidelines for sustainability planning developed by APOC management. 8

2.0 METHODOLOGY

. Evaluation question: How sustainable is the Imo State CDTI project? . Design: Cross-sectional, descriptive. . Population: The Imo State CDTI project, including: MOH, its NGDO partner, its LGAs with their LGA Health Teams, FLHF, the project communities/villages, their CDDs and the project’s finance officer. . Sampling: Details of the sampled LGAs, FLHFs and communities/villages are given in Table 1 below.

2.1 SAMPLING

A multi stage sampling approach was adopted in selecting the sample for the evaluation. First the average treatment coverage rate for three years was computed for each of the sixteen LGAs, with an APOC supported CDTI programme. Njaba, which is under treatment because of its meso endemicity level but not supported by APOC was excluded in the sample.

Next, the average coverage rates of the sixteen LGAs were sorted in an ascending order from lowest to highest. These were put into three strata of low, medium and high coverage rates. From each stratum, a mixture of balloting and purposive sampling techniques was employed in selecting one LGA. The selection took into consideration treatment coverage as well as geographical distribution. Where more than one LGA had the same characteristics, one was selected by a simple random sampling process. The sampling thus gave Isiala Mbano, Obowo and Ikeduru LGAs for the evaluation. From each of the three sampled LGAs, two communities were randomly sampled, based on their treatment coverage rate, one community with low coverage and another with high coverage. From each community two villages were randomly selected.

Table 1: Distribution of Samples in LGAs, Communities/FLHF and Villages: S/N LGA Rx (Coverage Community/ Villages (Rx Coverage Rate) FLHF Rate) 2002 1 Isiala Mbano Low (56.4%) Oka 1. Umudururie (23.8%) 2. Ndiama (49.4%) Ibeme 1. Umuchoko (31.3%) 2. Ezealaodu (83.1%) 2. Obowo Medium Umuagu 1.Umuchukwu (71.7%) (62.3%) 2. Umunkwoko (46.9%) Umuariam 1. Umunebi (94.6%) 2. Umuatonti (68.3%) 3. Ikeduru High (72.3%) Iho 1. Umuokoro (51.4%) 2. Umuoshioke (43.4%) Attah 1. Ntu (62.6%) 2. Ogada (59.5%) 9

2.2 SOURCE OF INFORMATION

Information was collected from interviews, verbal reports and documents. Various categories of people were interviewed at the State (MOH Management Team members), NGDO (project finance officer, PA), LGA (PHC Coordinator, Oncho Manager, LG Management and Political heads) and at the frontline heath facility/Community level (Health staff). In the communities the evaluation team interviewed community chiefs, community members, CDDs and held community meetings.

Information was recorded on the evaluation instrument and discussed extensively within the evaluation team before grading the level of performance on the indicator.

2.3 ANALYSIS

Based on the information collected, each indicator was graded on a scale of 0-4, in terms of its contribution to sustainability. The average 'sustainability score' for each group of indicators was calculated, for each level. A graph was plotted for the level being assessed. The evaluators discussed qualitative description of problems, and likely suggestions for solving the problem were deliberated upon and listed as recommendations. 10

3. EVALUATION FINDINGS

3.1 SUSTAINABILTY AT THE STATE LEVEL:

Fig. 1: Imo CDTI: Sustainability at State Level 4 4 4 4 3.7 3.8 3.3 3.5

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Planning (Fully; 4.0)

There is a general plan of action for the health system, which includes CDTI related activities. It was also observed that the plan was in place in the finance and planning units of the Ministry of Health.

There is a five-year plan from where annual plans were extracted. The detailed year plans for 2000, 2001, 2002 and 2003 contained all the elements of CDTI implementation. The year plans varied from year to year. The year 2004 plan contain aspects of sustainability.

All partners were involved in the planning process. The minutes of these committee meetings exist. The minutes show that various partners made contribution to the planning of activities. The roles of each partner is clearly defined, and partners are aware of their respective roles. There were elements of sustainability in the overall plan.

Advocacy activities for sourcing of funds, in partnership with Global 2000 and other stakeholders, were included in that plan. The 2004 budget for the MOH made provisions for the replacement of capital equipments for CDTI implementation. There is targeting of activities to reduce cost. 11

Monitoring and Supervision (Highly; 3.7)

SOCTs only monitor/supervise LOCTs using clear checklist. Plans for monitoring and supervision are contained in the monthly work plans, which are approved by the Director of PHC/Disease control. Monitoring and supervision is not carried beyond the level immediately below (LOCT). The LOCTs are empowered to supervise the level below them (FLHF).

In cases of special problems in the communities, the SOCT and SPO make spot checks to the communities and the reports are contained in the notebooks of the SOCTs and SPO. Staff are adequately used for monitoring/supervision. The SPO supervises SOCTs on a monthly basis. Monthly work plan is vetted by the PA and is passed through the SPO to the Director of PHC for approval by the Hon. Commissioner or Perm. Secretary. Visitors’ book, signed by a number of persons exists. Logistics assistance is received from Global 2000.

Problems arising from the LG are effectively managed by the SOCTs and reported to the SPO. Reports exist of the management of such problems. Reports come from LOCT to SOCT to SPO. SOCTs are empowered to deal with problems at their own level of operation. Problems of late supply of drugs as identified from previous monitoring exercises have been addressed.

There is no integrated supervisory checklist for CDTI with other disease control programmes, however, there is integrated supervision and shared logistics for supervision to reduce cost in MOH. Only CDTI has a checklist for supervision. The M&E unit collates monthly data on other health programmes but not on CDTI. However results collected on CDTI by SOCT are submitted to the M&E unit and the annual report for the MOH incorporates information on CDTI. The State has planned an award for high performing officers. Before now recognition of good performance was only verbal.

Mectizan® Ordering, Procurement and Distribution (Highly; 3.0)

The process of Mectizan® ordering, procurement and distribution in the project is simple. Global 2000 procures drug with government approval. Global 2000 orders the drugs and facilitates the movement of the drugs to its zone of operation nearest to the State. The State comes to collect the drugs from Global 2000 office in the zone of operation.

Supply of drugs to the state is based on the request of the State. There is evidence for stock control using an ordering form, which was sited in the PA’s office. The Government is fully responsible for the process described. Mectizan® is stored within the Government system.

Collection of drug from National level is dependent on the NGDO. 12

Training and HSAM (Highly; 3.3)

The SOCTs only train LOCTs who are empowered to train DHS/FLHF staff. The training is targeted at specific needs such as new information, and involvement of new LOCTs. The training of LOCTs is integrated with training for Schistosomiasis control. However, this integration is NGDO driven.

HSAM was undertaken this year to solicit funding support from the State government. This involved the Director PHC, NGDO and SOCTs. There is evidence of increased fund release for CDTI activities in comparison with last year’s release.

Integration of CDTI Activities (Fully; 4.0)

There was evidence of the collection of information on other health programmes during CDTI visits. Opportunities of visits for any activity was used to address other issues

Financing/Funding: (Moderately; 2.3)

The budget document shows that onchocerciasis control activities were budgeted for, and there is an approved budget by the authorities. There is also targeting of activities and not going beyond their level to reduce cost. The SOCT lacks a clear picture of what to expect in the coming year.

The financial contribution of Government towards the implementation of CDTI is very minimal. The trend over the years is also unclear though the latest move indicates an improvement. In 2003, there was 2 million Naira budgeted, but only N70,000.00 was released as against N410,000 expected by June 2003. In 2002, there was no record for separate budget for onchocerciasis control. But N10,000.00 was released. In 2001, the release was N99,350.00.

In spite of series of advocacy visits by teams constituted by APOC and NOTF/Nigeria, which involved Prof. Ransome Kuti in some cases, government funding has been very minimal.

There was a general economic depression in year 2002, being the reason for the small amount released. The reason why so far only small amounts have been released, is, according to the SPO, that: “the government seems to believe that there are funds from external sources. In fact CDTI is better. If APOC pulls out CDTI will be taken over. For instance Imo Health and Population project is still functioning after the withdrawal of World Bank”.

There is awareness of the short fall in funding. There are high-level advocacy activities in the plan to improve funding. There is also a plan to sign an MOU with Global 2000. 13

The appropriate officers approve expenditure according to the approved work plan. Funds are allocated according to approved budget. Records are kept on budget line items. The ledger shows what has been spent on every budget line item and what is left. Funds released are spent as budgeted.

This however, refers to the situation with State government budget estimates. The handling of APOC funds is outside the State control because there is no project accountant for the State CDTI project. The NGDO accountant handles the APOC finances for the project.

Transport and other Material Resources (Highly; 3.8)

The vehicles are functional, but the photocopier is not. They may not serve for the next 5-10 year. They would require replacement. The running cost of the vehicle is met with APOC funds. “I have not demanded money for running the vehicle since APOC funds are there. If APOC fund is not there then I would ask the State to provide” (SPO).

There is a regular maintenance of vehicle and generator, which is recorded and the cost is met with APOC funds. The MOH and Global 2000 provide support vehicles, when CDTI activities are to be carried out. The vehicle is used for CDTI activities just to the LGA level, the level immediately next to them.

Each trip is authorized and recorded in a logbook. Government helps with the provision of stationeries for the production of HSAM materials. In the 2004 budget there is an indication of provision made for the replacement of capital equipment. Government indicated preparedness to replace vehicles and other capital equipments post APOC.

Global 2000 also expressed the same preparedness to replace vehicles and other capital equipment.

Human Resources (Fully; 4.0)

Staff is very committed and stable. The staff at this level has been in the same location for more than five years

Coverage: (Moderate; 2.0)

Coverage is very low for a fifth year project. Only 13 out of the 16 (81.3%) LGAs had therapeutic coverage of 65% or higher, though therapeutic coverage is on the increase. The low coverage is due largely to the registration system where people who are not permanent residents in communities are registered for treatment as well. This creates a situation of high rates of absentees. 14

Recommendations at this level

Recommendation Implementation Monitoring & Supervision: Priority: MEDIUM • There should be a supervisory checklist for Indicators of success: all health programmes in the MOH, • Existence of MOH disease including CDTI supervisory checklist. • M&E unit should collate data on CDTI as it • CDTI data collated by M&E unit. is done for other health programmes • List of persons rewarded for good • State should put in place, a mechanism for performance rewarding good performance Who to take action: DPHC/DC Deadline for completion: January 2004 Mectizan Ordering, Procurement & Priority: MEDIUM Distribution: Indicators of success: State MOH should take responsibility for collecting Mectizan collected by the State MOH Mectizan from the National level Who to take action: DPHC/DC and SPO Deadline for completion: January 2004 Training & HSAM: Priority: MEDIUM The State should take responsibility in ensuring that Indicators of success: the training of LOCTs on CDTI should be CDTI training integrated with training in integrated with training on other health other health programmes programmes. Who to take action: DPHC/DC and SPO Deadline for completion: January 2004 Financing/Funding: Priority: HIGH • Government should increase its financial Indicators of success: contribution for the implementation of the Funds released CDTI programme. Who to take action: • Government should release approved funds Commissioner for Health • A CDTI project accountant should be Permanent Secretary trained to handle the funding of the CDTI DPHC/DC project. Deadline for completion: • Project manager should have a clear January 2004 estimate of the funds available to the project. Transport and other Material Resources: Priority: HIGH State government should put in place funds meeting Indicators of success: the running costs and maintenance of project Amount of funds released for CDTI vehicles and other capital equipments Who to take action: DPHC/DC 15

Deadline for completion: January 2004 Coverage: Priority: HIGH • Only permanent residents of the Indicators of success: communities should be included in Names of non resident removed from community registers for annual treatment. register Who to take action: SPO Deadline for completion: January 2004 16

3.2 SUSTAINABILITY AT LGA LEVEL

Fig. 2: IMO CDTI: Sustainability at the LGA Level 4 4 4 3.8 4 4 3.7 3.7 3.5 ) 4

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Planning (Fully; 4.0)

There is a general plan of action for all health activities and CDTI activities were included. The plan was drawn by the budget committee comprising of all the HODs of the various departments in the LGAs. The District Development Committees (DDC) were also involved in the planning and they brought community interests in the plan.

Leadership (Fully; 4.0)

LGA Health Management team takes full responsibility for the implementation of CDTI. There is a focal person for CDTI in the LGA.

Monitoring/Supervision (Highly; 3.7)

CDDs submit report to health facility staff, then to DHS, to LOCT, to Onchocerciasis control programme manager and then to SOCT. CDTI reports are submitted within the government system but do not use the routine M&E channel.

The staff at this level supervises up to the District/FLHF level. When there is problem in some communities, such communities are visited. Supervision is integrated. There is a checklist for different programmes but when supervising for Onchocerciasis, other programmes are looked into as well.

Transport for supervision is also shared. When there is a problem (e.g. refusals, reluctance of CDDs and CDD compensation) the LOCTs meet with the Eze, his Cabinet 17 and other influential people in the village to resolve the problem. The Local Govt writes to communities with success stories to commend them. Some are commended verbally.

Mectizan® Procurement and Distribution (Fully; 4.0)

LGA collected Mectizan® from Owerri with LGA vehicle. The required quantity was received. No report of shortage. Mectizan® is stored at the LGA drug store. Mectizan® is ordered and delivered within the government system. There is no bottleneck.

Training and HSAM (Highly; 3.7)

The Oncho Manager in the LGA trains the LOCT and DHS. DHS train FLHF staff who train CDDs. The training is sponsored by the LGA. Only weak and new personnel or those who transferred from non-onchocerciasis endemic LGAs were trained. There are enough training materials. In-service exist in some of the LGAs.

Training on CDTI is not integrated into other trainings in the LGA. HSAM is conducted as need arises. Training materials have been produced in both English and the local language. Health education and mobilization at community level, sensitization at the LGA level and advocacy to decision makers and stake holders at the State level were carried out.

Financial (Moderately; 2.5)

Adequate amounts were budgeted for CDTI activities and these were targeted to reduce cost. In some LGAs, there is no specific budget for Oncho control but the Government supported all Oncho related activities. In some LGAs there is an integrated budget for all health programmes, while in others there is specific budget for onchocerciasis control. In all the LGAs, letters authorizing the release of counterpart funds were sited however no funds were released to meet the counterparts funding requirements. In some of the LGAs there is increasing trend in financial support for CDTI activities but these are still minimal. Moreover the managers at this level had no idea at the beginning of the year of how much would be released for CDTI activities. All CDTI activities are funded with whatever government provides and through out of pocket expenditure, which is claimed later.

The LGA staff members have various cost containment strategies, which include reduction cost and expenditure on other line items is used. For instance, to bridge short falls the quantity of snacks could be reduced.

Documents used for approval of expenditure were seen. Allocation of expenditure was based on approved budget. There is a control system through audit unit. Vouchers are provided and signed by audit unit before cheque is released. The amount is given as cash advance, which has to be retired after spending. There are no regular insights into balances. 18

Transport and other Material Resources (Highly; 3.8)

There were adequate functional vehicles and suitable HSAM materials for CDTI tasks, however, these may not be adequate for the next 5-10 years. Vehicles in the LGA were used in an integrated manner for all health programmes and the LGAs plan to get more vehicles. There is adequate schedule for vehicle maintenance by LGA. Staff members apply for transport money to make trips in the absence of vehicles.

LGA services, maintains, fuels, replaces damaged parts and pays for registration and renewal of documents of vehicles. Trips are authorized in writing using the monthly- approved movement schedule.

The Council is in a position to provide vehicles and bicycles because they appreciate the programme but no tangible plan was sited. There is need therefore for the LGAs to take deliberate steps towards the provision of vehicles.

Human Resources (Fully; 4.0)

The staff is stable and most of the members of staff at this level have been in the same place for between 5 to 15 years. Most of the Councils also sponsored staff to training programmes to improve certificates. The workers demonstrated good sense of commitment to CDTI work. The LG authorities give assistance to the LOCTs for the implementation of CDTI and salaries are paid by the LGA. Coverage (Moderately; 2.5)

Geographical coverage has remained 100% for the past three years.

Therapeutic coverage for communities visited in each LGA for 2002, 2001 and 2000 were 61-74%; 56-75%; and 51-68% respectively. Though therapeutic coverage is on the increase, only 78.2% of the communities visited had therapeutic coverage of 65% or higher. This is due to high number of absentees. Those who are not permanently resident were registered in the communities as well. 19

Recommendations at this level

Recommendation Implementation Monitoring and Supervision: Priority: HIGH The monitoring and supervision of CDTI should be Indicators of success: included in the routine M&E in the PHC system CDTI included in the M&E checklist Who to take action: PHC Coordinator Deadline for completion: January 2004 Training and HSAM: Priority: MEDIUM Training for CDTI should be integrated into training Indicators of success: for other health programmes CDTI training integrated with training for other health programmes Who to take action: PHC Coordinator Deadline for completion: January 2004 Transport and Other material Resources: Priority: MEDIUM Replacement of vehicles should be included in the Indicators of success: overall 5 year plan of action of the LGA Five year plan Who to take action: LGA Chairman/DASS Deadline for completion: January, 2004 Coverage: Priority: HIGH Only permanent resident of communities should be Indicators of success: included in the community registers for treatment Revised treatment registers Who to take action: Oncho Managers Deadline for completion: January 2004 Financial: Priority: HIGH • Government should release the approved Indicators of success: counterpart funds. Counterpart funds released • Onchocerciasis control manager should have a Who to take action: clear estimate of the funds available to the PHC Coordinator project. Oncho Managers DAGS, LGA Chairperson Deadline for completion: January 2004 20

3.3 SUSTAINABILITY AT FLHF LEVEL

Fig. 3: IMO CDTI: Sustainability at the FLHF Level 4 4 4 4 4 3.7 3.7 3.5 3.5 3 ) 4

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Planning (Fully; 4.0)

There is an integrated written plan/timetable, which has CDTI activities along with the activities of other health programmes.

Leadership (Fully; 4.0)

The FLHF staff takes full responsibility and initiative on when to meet community members and CDDs, for example, once informed that Mectizan is available in the LGA. The same applied to other health programmes.

Monitoring and Supervision (Highly; 3.7)

Reports on Mectizan® were submitted to the District Health Supervisors. For other health programmes, reports were submitted to the Unit heads at the LGA. Reports were handled within the government system, but not using the M&E structure as in other health programmes.

DHS supervises FLHF staff, who supervises CDDs periodically together with community monitors. Sometimes the DHS and FLHF staff visit communities with special problems. Routine visits to villages for CDTI are integrated with supervision of other health activities. Problems are reported to the Chairman of the Village Health Committee. 21

Successes were recognized verbally. The people were often commended during their community meetings for giving compensation to the CDDs.

Mectizan® Procurement and Distribution (Highly; 3.5)

The required quantity of Mectizan® was received and on time. In many communities quantity required was collected in batches. “It is because I do not want the drugs to remain here for a long time”, (FLHF staff, Ikeduru LGA).

Mectizan® is stored with other drugs in the FLHF storage system. There is adequate storage space in these government facilities. The drug is fetched from with government funds.

Training and HSAM (Fully; 4.0)

This year there was no training was conducted. CDDs are trained on need. HSAM is undertaken on a need basis only. In most of the communities there is a one-day re- orientation or refresher course for the already trained staff. Only two health personnel were trained in Umuariam because they were new. The people are already fully trained. We only train now based on need.

Situations of poor attitude to Mectizan® were identified and addressed. HSAM was undertaken in some communities because of change in the community leadership and the new leadership gave support for the programme. CDDs were compensated and encouraged for their work. There is already a good awareness of CDTI at this level.

Financial (Moderately; 2.5)

Staff has no idea in some communities of the financial requirements for the implementation of CDTI. The relative contribution of all partners is not clearly spelt out and staff at this level lack knowledge of where funds come from for CDTI implementation. In the others, communities support the programme and the FLHF staff had no need for a budget. In some communities the cost of each CDTI related activity in the year plan was spelt out in a budget. There were just enough funds from both the LGA and APOC for collection of drugs, training and mobilization

Transport and Other Material Resources (Highly; 3.7)

There are enough HSAM materials. Allowances were provided in lieu of transport in some FLHFs. There is a need to replace transport facilities for the work that has to be done in the coming 5-10 years.

The LGA maintains vehicles, which are used for all health programmes. In some cases the FLHF staff maintains bicycles. If the motorcycle breaks down public transport is used and refund paid for by government. Government is able to pay for maintenance, repairs and tire replacement. 22

Transport is used in an integrated way. Staff has to get authorization from head of facility to use transport facilities. This is however not in writing and there were no logbooks. There are no plans for replacement of vehicles because the present vehicles are still functioning well.

Human Resources (Fully; 4.0)

Staff are often sent on in-service training for health and officers’ courses in some LGAs.

Coverage (Highly; 3.0) In one of the communities visited, there were two villages (out of 11) that did not treat in 2002. The reason was a lack of compensation for the CDDs in these villages. 23

Recommendations at this level

Recommendation Implementation Monitoring and Supervision: Priority: MEDIUM CDTI reporting should be included in M&E structure Indicators of success: with other health programmes Inclusion of CDTI in M&E system Who to take action: PHC Coordinator Deadline for completion: January 2004 Mectizan, Procurement & Distribution: Priority: HIGH LGA should put in place a mechanism to ensure that Indicators of success: drugs are collected once. Once batch collection of Mectizan Who to take action: PHC Coordinator/Oncho Manager Deadline for completion: January 2004 Financing/Funding: Priority: HIGH The cost implication for CDTI activities should be Indicators of success: clear to staff at this level and stated in a budgeted plan Cost plan of action of action Who to take action: FLHF staff Deadline for completion: January 2004 Transport and & other Material Resources: Priority: MEDIUM • Log books should be provided for vehicle as Indicators of success: well as written authorization for use Vehicles provided • Provision should be made for replacement for Who to take action: vehicles by the LGA PHC Coordinator/DAGS Deadline for completion: January 2005 Coverage: Priority: HIGH Communities should ensure that CDDs are adequately Indicators of success: compensated No. of CDDs compensated Who to take action: LOCT/FLHF staff Deadline for completion: January 2004 24

3.4 SUSTAINABILITY AT THE COMMUNITY LEVEL

Fig. 4: IMO CDTI: Sustainability at Community Level 4 4 4 4 4 3.7 3.5 3.7

) 3.5 4

/ 3 ( 3 t h g

i 2.5 e

W 2

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e 1 v

A 0.5 0 g ip g n M e n e in h rin za A nc a g nn rs o ti S a m ra la e it ec H in u ve P ad on M F H o Le M C Groups of Indicators

Planning (Fully; 4.0)

The CDDs visit households in the evening or early in the morning to meet the people. At these times of the day the people are most likely to be found at home. The CDDs go to village leadership to mobilize people for treatment.

In some communities census update is undertaken before distribution to estimate the required quantity of drugs, while in other communities, census update is conducted during treatment. “I prefer it that way. I made agreement. These are my people. Without them, who would marry me? They are my people” (CDD, Umuagu community, Obowo LGA)

Leadership (Highly; 3.7)

So far there has not been problems. Hardly anybody refuses to take the drug. The community leadership tries to educate those who refused at the initial stage, after which most people will accept it. When coverage was low the leadership in Ogada redirected the CDDs to treat by going from house-to-house. This also applies to other communities. Furthermore when drugs are insufficient the community leaders go to the FLHF to collect more drugs.

The community took all decisions, through village meetings and selected their CDDs. However, the timing of distribution depends on when drugs are available in some communities. Some of the communities do not feel that they have a say in the period/time of distribution. They will take it when they are told that it is available. 25

The most commonly mentioned advantages of Mectizan® is that it expels worms and improves sight. The drug strengthens the body. The community is ready to take the drug for a long time. “Since it is our ‘national cake’, we shall continue to take it. If they stop bringing it then we would stop.” “As long as we are alive.” “As Oliver Twist, we would like to take it more than once a year.” “The first time I took the drug I noticed great difference in my eyes.” “The medicine is good for us.”

Monitoring (Fully; 4.0)

The CDDs submit their reports to the FLHF staff on time. The community has a monitoring committee, made up of the Eze (community leader) and his Nzes, for monitoring the distribution. The CDDs are supported with some token amount to aid their transportation for submission of reports and collection of drugs.

Obtaining and Managing Mectizan® (Highly; 3.5)

The quantity of Mectizan® demanded was received. The quantity demanded was based on the population of eligible persons registered multiplied by three in some communities. However in others there was no knowledge on how the quantity needed is calculated. Some make demands based on the quantity distributed the previous year. All members of the communities who were eligible for treatment got it. Absentees were treated later.

The CDDs collect the drug for their respective community from the FLHF. Funds were given to CDDs from community purse for transportation to the health facility to collect drugs for the community. In some cases CDDs go with their community leaders to collect the drugs

HSAM (Fully; 4.0)

The people in the communities have been well educated. “Everybody wants the drug” (Community Leader, Umuagu, Obowo LGA). Community provides funds for transportation and compensation of CDDs. Community members who refused are educated by the CDD with the help of the community leader if necessary.

Financing (Highly; 3.0)

The community provides transport for CDDs. The Town Union gives financial and material incentive to CDDs. In some communities the community had engaged the CDD in the health centre. The CDD in Umuatonti is sometimes given palm fruits from the community yield to help her without paying her in cash in recognition of the work she does for the community through the distribution of Mectizan®. In other communities CDDs are given 1000 naira annually. In another, the people work on the farm of the CDD for three days. The community provides notebooks for the community registers. However, some communities still find it difficult to compensate their CDDs. 26

Human Resources (Highly; 3.7)

The ratio of CDDs to the population is not satisfactory. In some communities, the number of CDDs that the community can afford to compensate caused this. It takes CDDs an average of 10-15 minutes to cover the farthest distance in their community. The CDDs were adequately trained. The community would normally assemble to elect a new CDD to be trained in place of any CDD that drops out. The CDDs are interested. “The CDD job has helped me. It has given me paid employment which will help me to train my children” (a female CDD in Umuchukwu). “I love the job because I want to help my people” (a male CDD in Umunkwoko). The CDDs were happy associating with health officers. “For nine years I have been distributing it”. The MOH has a policy of involving VHWs in NID to compensate them. “I like to continue because it is a part of the ‘corporal work of mercy’ I am doing for my people.”

Coverage (Fully; 4.0)

The therapeutic coverage of all communities visited is 74.2% for 2002 with a range from 54.0% to 93%. The low coverage in some communities is a result of the inclusion of non-permanent residents in the register books. It should be noted that the therapeutic coverage is generally on the increase. All the villages in the communities visited are under treatment in 2003. 27

Recommendations at this level

Recommendation Implementation Leadership: Priority: HIGH Communities should be empowered to decide for Indicators of success: themselves the best time for the distribution of Communities deciding on time for Mectizan® distribution Who to take action: Oncho Manager Deadline for completion: January 2005 Mectizan® Ordering, Procurement and Priority: HIGH Distribution Indicators of success: Training of CDDs should include the proper way of Correct calculation of tablets needed calculating and requesting the quantity of tablets Who to take action: required for their communities Oncho Manager/FLHF staff Deadline for completion: January 2004 Financing and Funding: Priority: HIGH Communities should ensure that CDDs are adequately Indicators of success: compensated either in cash or kind. All communities compensating CDDs Who to take action: Oncho Manager Deadline for completion: January 2004 Human Resources: Priority: HIGH Communities should ensure that they keep to the Indicators of success: recommended ratio of 1:20 households or 2 CDDs per Increased number of CDDs 250 population. Who to take action: Oncho Manager/Community leaders Deadline for completion: January 2004 Coverage: Priority: HIGH Only permanent resident of communities should be Indicators of success: included in the community registers for treatment Revised treatment registers Who to take action: Oncho Managers/Community leaders/CDD/FLHF staff. Deadline for completion: January 2004 28

4.0 CONCLUSION

4.1 GRADING THE OVERALL SUSTAINABILITY OF IMO CDTI PROJECT.

Making a judgment of the project in terms of the seven aspects of sustainability.

(a) Make a judgment of the project, in terms of each of the seven ‘aspects’ of sustainability:

Judgment: to what extent is this aspect Aspect helping or blocking sustainability in this project? Integration Moderately blocking sustainability Resources Slightly blocking sustainability Efficiency Very much helping sustainability Simplicity Very much helping sustainability Attitude of staff Very much helping sustainability Community ownership Very much helping sustainability Effectiveness Very much helping sustainability

• Integration: Reports on CDTI activities are handled within the government structure, however there is no integration into the Monitoring and Evaluation system. Training of staff is not done in an integrated manner.

There is an integrated use of logistics and involvement of CDTI in other disease programmes such as the use of CDDs, LOCTs and SOCTs in NID. Routine visits to villages for CDTI are integrated into supervision of other health programmes.

• Resources (Human, financial and material): The government contribution has so far been very minimal, in spite of serious advocacy visits. The management of funds for the project is not within the government system. Transport is available and at the state level there is a plan for the replacement of transport and other material resources. Government does not meet the running costs for transport. There are enough human and material resources. Vehicles and other material resources are used in an integrated manner.

• Efficiency: Programme support activities are being planned and integrated for efficient management of resources. Examples are sharing of logistics and cost reduction to achieve goals.

• Simplicity: The project uses simple and uncomplicated procedures for the implementation of CDTI activities. 29

• Attitude of Staff: At all levels, the evaluation team rated the attitude of staff towards CDTI to be very positive. For example, staff used personal resources in the acquisition of CDTI activities where there is a delay in the provision of the required resources from project funds.

• Community Ownership: Communities make most of the decisions in the implementation of CDTI as well as monitor the distribution of Mectizan®. In many communities there is an established process of compensating CDDs. However in a few communities the timing of distribution is dependant on the availability of Mectizan®

• Effectiveness: Although some community registers have non permanent residents included in their registered, the coverage for the communities visited was 81.3% (13 out of 16) of the LGAs had a therapeutic coverage of 65% or higher. This is on a steady increase. The geographical coverage has for the last three years been 100%. (b) Next, the evaluation team examined the six key aspects of the project – ‘critical elements’ of sustainability. If these are not present it is unlikely that the project will be sustainable:

. Money: Is there sufficient money available to NO; though APOC funds are undertake strictly necessary tasks, which have available to undertake absolute been carefully thought through and planned? minimum residual activities, (Absolute minimum residual activities). government funding of CDTI activities is minimal . Transport: Has provision been made for the YES: There is plan in the year 2004 replacement and repair of vehicles? Is there a budget to replace capital equipments reasonable assurance that vehicles will continue to be available for minimum essential activities? (Note that ‘vehicle’ does not necessarily imply ‘4x4’ or even ‘car’). . Supervision: Has provision been made for YES continued targeted supportive supervision? (The project will not be sustained without it). . Mectizan supply: Is the supply system YES dependable? (The bottom line is that enough drugs must arrive in villages at the time selected by the villagers). . Political commitment: Effectively YES demonstrated by awareness of the CDTI process among policy makers (resulting in tangible support); and a sense of community ownership of the programme. YES . Human resources? 30

In line with the guideline for grading the whole project using the seven aspects and six critical elements of sustainability the evaluation team concludes that the Imo CDTI project is MAKING SATISFACTORY PROGRESS TOWARDS SUSTAINABILITY.

4.2 FEEDBACK/PLANNING MEETINGS:

Feedback/planning meetings were successfully organized for the State MOH and LGA teams respectively. After presentation of findings by the evaluation team, a number of keys issues were raised, discussed and recommendations made on the lines indicated below:

Issues discussed include sourcing of funds for sustaining the programme as well as strategies for cost reduction. According to the participants, “if we have limited resources all we do is to reduce the material requirements for carrying out activities. For example, reduce snacks during training”. The participants also resolved to target activities as well as intensify the integration of activities within CDTI on one hand, and programmes in the health system on the other hand. They also concluded that meaningful justification of activities through targeting of the most necessary activities would help to reduce cost. These were brought to bear on the sustainability plans, which were developed during the meetings. The LGA teams also indicated their resolve to solicit support from community organizations to fund CDTI. According to one of the FLHF staff, who participated in one of the meetings, “the people love the drug so much and would not want to miss it. The women groups in one community came to support the CDD when the secretary to the Traditional Ruler, refused to assist the CDD with transport in collecting the drug because of his religious belief”.

With regard to reference in the report that the government has not made tangible financial contributions for CDTI on the lines outlined in the project proposal the participants argued that government’s financial disposition to CDTI is not a true reflection of Government’s attitude to the programme. It was further stressed that government holds the same attitude towards other externally funded programmes and government would surely support the programme when APOC withdraws. However, the Permanent Secretary and other policy makers in the MOH noted that with the recent advocacy visit which went up to the State Planning Commission, the programme would be included in the budget in August/September as a line item and when this is achieved, it will become a permanent feature in the State budget.

Regarding Mectizan procurement and distribution, deliberate effort should be made from the fourth year of the project to avoid shortages of Mectizan. The project should evolve more reliable systems of Mectizan requirements computation and timely requisition to MDP and NOTF should facilitate the prompt release of Mectizan tablets to the project level. The project level should utilize the existing government established channels of drug delivery to the districts and Health Areas. 31

Regarding the sustainability planning meeting, the agenda and list of participants are attached. The sustainability plans (State and LGA), budgets and justification notes will be forwarded in the next few days.

4.3 THE WAY FORWARD

APOC should follow closely implementation of decisions and activities for the sustainability plan. 32

APPENDIX

STATE & LGA LEVEL WORKSHOP PROGRAMME

Sustainability of Imo CDTI Project “Feedback”/Planning Meeting AGENDA Day One Item Activity Time Facilitator 1 Opening prayer 10:00 – 10:05 To be appointed 2 Welcome 10:05 – 10:10 Director of PHC 3 Introductions 10:10 – 10:25 SOCT Coordinator 5 Official Opening 10.25 – 11.00 6 Presentation of Evaluation instruments 11:00 – 11:20 Dr Okeibunor 7 Presentation of findings from 11:20 – 12:20 Prof Ogbe Evaluation and discussions 8 Perspectives of the project and future 12:20 – 1:00 Director of PHC direction and discussions 9 LUNCH 1.00 – 2.00 10 Guideline for sustainability plan, 2.00 – 3.30 Dr. Okeibunor Discussion and Identification of issues for group work 11 Group work for the development of 3.30 - 5.00 Director of PHC State level Sustainability 12 Closing Prayers 5.30 – 5.35 To be appointed

DAY TWO Item Activity Time Facilitator 1 Opening prayer 10:00 – 10:05 To be appointed 2 Welcome 10:05 – 10:30 Director PHC Introduction to the day’s activities 3 Continuation of group work 10.30 – 12:30 4 Presentation of report on group work 12.30 – 1.00 Prof. Nwaorgu 5 LUNCH 1.00 – 2.00 6 Incorporation of comments and 2.00 – 4.30 Team leader consolidation of plan 7 Presentation of final plan 4.30 – 5.00 Team 8 Next steps 5:00 – 5:15 Director PHC Global 2000 Rep Prof Ogbe 9 General matters 5.15 – 5.30 SOCT Coordinator/ Dr. Okeibunor 10 Closing Prayers 15.30 – 5.35 To be appointed 33

IMO STATE CDTI EVALUATION TEAM

NAME ADDRESS Dr. Danny HADDAD P.O. Box 34424 Dar es Salaam Tanzania +255 744 566057 [email protected] Dr. Veronica OKEKE Department of Sociology/Anthropology University of Nigeria, Nsukka Enugu State, Nigeria 042 770050 [email protected] Mr. Karoli MALLEY National Institute for Medical Research Tukuyu Research Station P.O. Box 538 Tukuyu, Tanzania 255 025 255 2214 [email protected] Prof. Martin OGBE Delta State University P.M.B. 1 Abraka 054 66026 cell: 080330113825 [email protected] Prof Obioma NWAORGU Global Health and Awareness Research Foundation S/34 Chief Edward Nnaji Park New Haven, Enugu, Nigeria 234 42 258078 (O) 234 42 456128 (H) Fax: 234 42 250836 [email protected] [email protected] [email protected] Dr. Joseph Chukwudi OKEIBUNOR Department of Sociology/Anthropology University of Nigeria, Nsukka Enugu State, NIGERIA Tel.: 234 42 771169 (Home) Email: [email protected]