Monitoring of the Implementation of CDTI SustainabititY Plan in ,

June 2005

Richard Ndyomugyenyi (Team Leader) Luc Mebenga Tamba Sunday Isiyaku

@v (@ WORLD HEALTH AFRTCAN PROoRAMTAE FOR OR6ANIZATION ONCHOCERCIASI5 CONTROL

I TABLE OF CONTENTS

Abbreviations/acronyms and acknowledgments ...... 3 J Acknowledgements

Executive Summary ...... 4 Introduction and MethodologY .....6 .....6 l. Introduction . 2. Methodology ,.....6 Findings and Recommendations ...... 8 ...... 8 l. State level l4 2. LGA level 3. FLHF..... 26 4. Village level ... 27 Debriefing 29 Overall Conclusion and Recommendations ...29 ... Appendix l: Summary table of problems and solutions 3l Appendix 2: List of people interviewed ...... 34 Appendix 3: List of monitors 35

2 Abbreviations/ acronYms APOCAfricanProgfttmmeforonchocerciasisControl CDD Community Directed Distributor CDTICommunityDirectedTreatmentwithlvermectin CHEWs Community Health Extension Workers FLHF First Line Health FacilitY GRBP Global 2000 River Blindness Programme HOD Head of DePartment HSAM Health Education, sensitisation, Advocacy and Mobilisation LF LYmPhatic Filariasis LGA Local Government Area LOCT Local Onchocerciasis Control Team MOH Ministry of Health NGDONon.GovernmentalDevelopmentorganisation NOCP National Onchocerciasis Control Programme NOTF National Onchocerciasis Task Force NIDs National Immunisation DaYs PHC Primary Health Care RBM Roll Back Malaria SOCT State Onchocerciasis Control Team UNFPAUnitedNationFundsforPopulationActivities WHO World Health Organisation WR World Health Organisation Country Representative

Acknowledgements assistance and support: We would li-t

3 Executive SummarY in March 2003 at the end of its fifth Plateau CDTI project was evaluated for sustainability were developed following the year of implementation. Thereafter, sustainability plans of the sustainability plans, evaluation recommendations. After two years of impiementation tasks: APOC management commissioned a team with the following particularly at the LGAg' FLHF and 1.0. To determine the extent to which program partners, in their sustainability plans community levels are implementing thI proposed activities of the sustainability plans and the 2.0. provide technicai ,upport for achiEvingthe objectives implementation of CDTI.

Findings activities despite advocacy to policy At the state level, no funds have been released for cDTI as stakeholders and review meetings makers and for this reason, some planned activities such continue to be implemented and this could not be conducted. However, some GDTI activities malaria in a project initiated and has been possible iu.Jo int.gration of CDTI with LF and the state to LGA is not integrated in funded by the NGDO partner. Mectizan delivery from funds from Global 2000/Carter the drug delivery ryt,!. and its delivery is deiendent 9n project is highly dependent on extemal Center, the NGDO The implem"ntt ion of *," ;;;".. the policy makers with the funding (NGDO partner). High power delegation uOro*y to state to release funds for participation of epOC *unui",n"nt is urgJnt[ needed for the i"pf"ri""t"tion of CDTI activities as detailed in the sustainability plan' not used for implementatigl At the LGA level, CDTI sustainability plans are available but LGAs released some funds for GDTI due to delayed and inadequate funding. ehhough all the effective implementation of the activities in 2004,the funds released are still i-nadequate for this has enabled CDTI planned activities. CDTI is integrated with I-f and malaria and based on annual activities to continue. Treatment coverage is high but it is calculated -calculated total population like in other treatment objective. coverage should be based on Advocacy to policy makers by APOC supported projects for easy comparison across projects' and adequate release of funds for SOCT and NGDO pi.tn", shouli continue to ensure timity also be integrated timely implementaiion of the planned activities. CDTI activities should LF and malaria in NGDO with other programmes in the ministry of health in addition to partner funded Project. in an integrated manner with LF At the FLHF level, health workers are implementing CDTI has disrupted timely and malaria control. However, massive iransfer of health workers need for LGAs to train implementation of CDTI activities in some LGAs. There is an urgent train all health workers in the all the new health workers on CDTI. It is also important to LGAs on CDTI so that when ever there are transfers; there is always somebody knowledgeable to continue with CDTI implementation' is being implemented At the community level, health education and mobilization on CDTI nets (ITNs) for malaria and integrateo wiitr LF and the distribution of insecticide treated in some communities' control. However, ivermectin collection from the FLHF is delayed

4 reasons for These communities need to be followed up by the health workers to establish exercise books, some delayed collection and solutions worked out. Registers are in form of LGAs together with which are in a poor state and difficult to use to calculate coverage. The page for each ApOC and the NGDO partner need to print standardized registers with a recorded at each household and the number of tablets received by each household member round of treatment. This will help in monitoring individual long-term compliance'

lack The overall conclusion Thekey CDTI activities continue to be implemented, despite This has been of funding from the State and inadequate and delayed funding at LGA level. partner funded project' possible d-r. to integration of CDTI *itn tf and malaria in the NGDO CDTI is However, its sustainability is doubtful if the NGDO partner funded projects where high-powered currently being integrated comes to an end. APOC .anug"."nt should send a and state delegatiln thaiwoui

5 1.0. Introduction plateau state is located in the Middle -Belt of Nigeria and it is bounded to the South West by Nasarawa state, while to the North West and North East are Kaduna and Bauchi states respectively with Taraba state to the South. The state has an estimated population of 3.2 miilion people and is divided into l7 political Local Government Areas (LGAs)

The Plateau State Ministry of Health is structured in line with the Nigerian health structure which is based on the concept of the Alma Ata declaration of 1978 which states:

"Primary health care as essential health care based on practical, scientifically sound and socially acceptable methods and technologt made universally accessible to inqividuols and their participation and at a cost that the community -andfamiliis in tie community through full country can afford to maintain at every stage of their development in the spirit of self reliance and self determination".

Based on the above the national health care delivery system is structured into primary, secondary and tertiary levels. Health Care is the responsibility of the lo-cal, state and federal gor"*-Lnts. The Piateau State Ministry of Health is responsible for the provision of Lcondary health care and supervises LGAs to provide primary health care services to its population. The FLHF which are also known as the PHC centres are manned by trained tommunity health extension workers (CHEWs) and are located in the communities with each PHC centie serving/providing services to communities within a radius of 5 kilometres. The staff centres superviie and implement health care activities in the communities under them and this is where CDTI is supervised.

The activities of the Ministry and health services provided are funded from budgetary allocation from the state government.

CDTI is being implemented in five LGAs namely Bassa, , Jos East and , CDTI implem-entaiion in the state started in 1998 with APOC financial assistance and the 2000lCater Center and the State Ministry of Health. 'pt#uuproject is in partnership with Global CDTi project was evaluated for sustainability in March 2003 at the end of its fifth year of implementation. Thereafter, sustainability plans were developed following the evaluation rlcommendations. APOC management commissioned a team with the following tasks:

l. To determine the extent to which program partners, particularly at the district, FLHF and community levels are implementing the proposed activities in their sustainability plans.

Z. Provide technical support for achieving the objectives of the sustainability plans and the implementation of CDTI.

2.0. Methodology Design: Cross sectional, participatory and descriptive popilation: SOCT; NGDO partner, LGAs and their LOCTs, Village leaders and CDDs

6 Sampling 80%o, Moderate with The five LGAs were divided into three categories (good with coverage> Them one LGA was randomly coverage between 65o/o-79Yo and bad with ioverag" .65%). an LGA with good coverage selected from each category by balloting. Bassa was selected as of 680/o' (83%),Jos East u, nloaJ.ut"

summarized in table 1 The distribution of the LGAs, FHLF and communities visited are

Table 1: List of LGAso FLHF and villages visited in Plateau state

LGAs FLHFS Villages (Communities) I- BASSA LGA l.l- Binchin FLFIF 1.1.1- 1.2- Zagun FLHF 1.2.1- 2.1.1- Shere Dabo Jankasa 2- JOS EAST LGA 2.1- Shere Ekan FLHF 2.2- Angware FLHF 2.2.1- 3.1 .1- 3- KANKE LGA 3.1- FLHF 3.2-Myet FLIIF 3.2.1- Nemel

2.l.Dztt collection categories of people Information was collected from interviews and review of documents. The Project interviewed included the Deputy Country Representative of GRBP and the LGA level, the Administrator, GRBp DPHC and socr in the Stati Ministry of Health. At the while the focal person LOCT leaders or the representative and the DPHC were interviewed cDDs and for GDTI was interviewed at the FLHF. At the community level, village leaders, in the implementation the community members were interviewed according to their function of CDTI sustainability plan (see the list of interviews/contacts, Appendix III)

2.2. Data AnalYsis each indicator at The team members met every evening to assemble the data collected for the team members each level using the study instrumenti and the observation notes. Then foi each indicator at each level. When the members were unable to agreed on the irndings"of u[r"" on one point reporting, discussions were created within the full team members available at the associated to some particuiar key-actors of implementation of CDTI activities the State level. These discussioni increased more knowledge needed to understand implementation of CDTI sustainability plan'

7 3.0. Findings and Recommendations

State Level state 3.1. Implementation of GDTI Sustainability Plan in Plateau REMARKS S/N ACTIYITY PERFOR]VIANCE 2004 Sustainability I PLANNING: PrePare a Done Plans available comprehensive Plan for CDTI for 1 into 2. ADVOCACY: High powered Done Resulted of N 1.4 advocacy to solicit for commitment are government suPPort/fu ndin g although funds not released Resulted in approval 2. ADVOCACY MEETINGS: Done funds bY Advocacy meetings with the of some policy makers and keY officers LGAs from the 5 endemic LGAs 3 MECTIZAN@ COLLECTION: Not Done Collect Mectizan from NOCP Zonaloffice Bauchi Lack of funds 4 OPERATIONAL RESEARCH Not Done To conduct a repeat KAP study in the five focus LGAs Lack of funds 5 TRAINING: i. To use KAP Not Done result to redesign training materials and health messages ii. Conduct targeted training of health staffin the 5 focus LGA levels iii. To train 16 state level officers on CDTI implementation iv. To train I data clerk on data management v. To train state APOC accountant on accounting of APOC Done with support 6. MONITORING AND Done SUPERVISION: i. To ensure from NGDO Partner efficient and effective rePorting of activities at all levels ii. To visit defaulting LGAs and activities.

E Lack offunds 7 COMMUNITY SELF Not Done MONITORING AND STAKEHOLDERS MEETING: To ensure that}5o/o of endemic communities in all LGAs hold stakeholders and imPlement self Not approved bY 8. PURCHASE OF NEW Not Done APOC VEHCILE AND 5 MOTORCYCLES: Purchase I new 4WD vehicle and 5

Done with financial 9 RUNNING COST OF 2 Done NGDO TOYOTA HILUX VEHICLES: support from There is a functional vehicle to partner CDTI activities. Supported by NGDO 10. MANAGEMENT OF SIDE Done REACTIONS: To ensure that partner side effects are rePorted and

11. REPORT WRITNG: TO Done present progress rePorts on the

t2 REVIEW MEETINGS: TO Not Done Lack of funds discuss and review CDTI sustainability components and lementation Lack offunds 13. PPIC REVIEW MEETNG: TO Not Done present progress rePorts on the

2005 I PLANNING: PrePare a Not Done Lack of funds comprehensive Plan for CDTI for 2 Lack of funds 2 ADVOCACY MEETINGS: Not Done Advocacy meetings with the policy makers and keY offtcers from the 5 endemic LGAs by NGDO J MECTIZAN@ COLLECTION: Done Supported Collect Mectizan from NOCP partner Zonaloffice Bauchi by NGDO 4 TRAINING: To conduct Done Supported targeted training of health staff partner at the 5 LGA levels. Supported by NGDO 5 MONITORING AND Done partner SUPERVISION: i. To ensure

9 efficient and effective rePorting of activities at all levels ii. To visit defaulting LGAs and spot-check activities. 6 COMMLINITY SELF Not Done Lack of funds MONITORING AND STAKEHOLDERS MEETING: To ensure that50Yo of endemic communities in all LGAs hold stakeholders and imPlement self 7 PURCHASE OF NEW Not Done Lack of funds VEHCILE AND 5 MOTORCYCLES: Purchase t new 4WD vehicle and 5

by NGDO 8 RUNNING COST OF Done Supported VEHICLES: To ensure that partner here is a functional vehicle to CDTI activities. 9 MANAGEMENT OF SIDE Done Supported by NGDO REACTIONS: To ensure that partner all side effects are rePorted and effecti 10 REPORT WRITING: TO Done present progress rePorts on the programmes _ funds 11 REVIEW MEETINGS: i. To Not Done Lack of discuss and review CDTI sustainability components and implementation strategies. ii. PPIC review meeting to discuss and review CDTI sustainability comPonents and implementation strategies

l2 PROCUREMENT OF CAPITAL Not Done Lack of funds EQUIPMENT: To Purchase I UPS, I TV, I Printer and I video recorder for office use.

l0 3.2. Implementation of Key CDTI activities

Findings at the State Level Planning: There is a health plan in the ministry of health where Oncho (CDTI) is integrated. The sustainability plan prepared by the state in 2003 is the plan used for CDTI at this level' planning foi itre piogru.rn. is done in collaboration with the supporting NGDO who that continuJs to providi lidership for the programme. Howevet, there was no clear evidence is the state has complete ownership of ihe prograrntn". Implementation of CDTI activities initiated by the NGDO in an integrated manner with LF and malaria control using insecticide treated nets.

Advocacy: at the The NGDO partner together with SCOT carried out an advocacy visit to policy_makers state Ministry of Healiir after development of the sustainability plan. The State-Commissioner of Health piesented the issue at tha State executive council meeting. The objective of the plan. tn advocacy was to get the state government to provide funding for the sustainatility November 2004, the state govemment approved the sum of N1.4 million for the programme due to and a cheque was issued t6 tne Ministry of Health. The cheque has not been cashed unavailabiiity of funds from the State. The state has written to APOC management requesting support to for a high po*". delegation advocacy team to the state policy makers to solicit for the programme but there has been no response from APOC management'

Mectizan@: Mectizan@ is ordered and received by the supporting NGDO. The current process of procurement is used by the state to avoid delays in release of the drugs from the store as a The result of the bureaucracy and protocol inherent in the drug delivery system in the country' NGDO delivers Mectizan@ to the state which in turn delivers the drug to the LGAs. The LGAs then send the drug to FLHF where the communities collect the drug at time of distribution. The drug is iot delivered through the essential drug delivery system from the on state to lower levels.-Currently Mectizan@ delivery from the state to LGAs is dependent NGDO funds, which has a negative long-term implication on sustainability when Global 2000lCmter Center support comes to an end.

Integration: Traini"ng, monitoring and supervision of CDTI activities is integrated wi!! t-{ and malaria control CDTI. This integration however is the initiation of the supporting NGDO and not as a policy of the state miniJtry of health. The CDTI vehicle is used for all the three programmes since there are no other functional vehicles in the ministry, except the one donated by UNFPA to for reproductive health, and its usage is restricted to Reproductive Health activities due donoris instructions. There is no integration of CDTI activities with other health progralnmes within the Ministry of health a part from with LF and malaria in GRBP project'

ll Finance: It is on record that since the inception of the programme, the state has not contributed was counterpart funds to the programme apart from staff salaries and allowances' It of APOC anticipated that with the development of the sustainability plan and the cessation the programme, A funding, the state government would release funds for the continuation of in the sustainability sum of Nl, 406,280 ($10,190) was approved by government (as budgeted was plan for the state) in Novemb er 20b4 and a cheque was issued. However, the cheque has however never cashed due to unavailability of funds from government. The project for the 2005 budget continued to budget for CDTI urrually. The state is yet to make a request the state, of N833, 670 (SZ,04l). However, alihough funds are not provided for CDTI by project on implementation CDTl'activities has continued through Global 2000 integrated Oncho, LF and malaria. progrommq support "The states hqve not been forthcoming in the release of funds for the the development of the from the LGAs and co*iunities have however improved since sustainability plans " (NGDO Representative)

Record Keeping: and reports made There are up t; date CDTI data, which are entered by the state control team and available to the Director of PHC and the supporting NGDO. The data are analysed on utilised for planning and implementation of CDTI. Coverage is still being calculated based integrated into the state annual treatment odjective but not on total population. The data is not health management information systems.

Coverage: population There is 100% geographical coverage and the therapeutic coverage based o! tgtul LGA for the 2004 treatmeni ranged fum?gx - 86%. The highest coverage was in Pankshin (86%),Bassa (83%),Jos East '78yo, Bokkos -71% and Kanke - 68%'

Conclusions and Recommendations at State Level: Conclusion: o Although advocacy was done to policy makers to release counterpart funds for CDTI the state activiry-as detailed in the sustai;bility plan, no funds have been released by since the sustainability plans were developed in 2003' o CDTI activities continue to take place despite no funds released by the state. This has ^of by heen possible due to integration CDTI with LF and malaria in a project funded the NGDO Partner. o Mectizan delivery is not integrated in the normal drug delivery system and its delivery from the state to LGA level is dependent from the NGDO partner. Recommendations: . High-powered delegation advocacy team to the. state policy makers with the paiicipation of ApOC managemeni is urgently needed to solicit for release of funds for CDTI activities as planned in the sustainability plan' drug c Mectizan@ delivery from the state to the LGAs should be integrated with the delivery system for sustainability.

t2 Implementation of Sustainabitity Plan at LGA level

Bassa LGA

REMARKS SAI ACTIVITY PERFORMANCE 2004 Done SustainabilitY Plans 1 PLANNING MEETING: TO were develoPed and develop a CDTI sustainabilitY available plan at the local government level Integrated with LF and 2 ADVOCACY: To improve Done malaria; suPPorted bY CDTI sustainabilitY at level NGDO Integrated with LF and J MOBILIZATION: To facilitate Done malaria; suPPorted bY the communities to collect NGDO Mectizan@ Lack of funds 4 TRATNING AND Not Done REORIENTATION: TO tTAiN all LGA Directors, suPervisory councillors, LOCT, DHS, HFS and new CDDs on CDTI

Supported bY NGDO 5 pnocunr,MENT OF Done partner MECTIZAN@: To Procure Mectizan@ from state Supported bY the 6. MECTIZAN@ Done communities DISTRIBUTION: To enable all communities get their Mectizan@ on time Integrated with LF and 7 Done malaria; suPPorted bY MONITORING AND NGDO partner COLLECTION OF REPORTS: i. To sPot check and ensure CDTI activities are carried out effectivelY ii. To collect Supported bY NGDO 8 MAINTENANCE OF Done partner MOTORCYCLES AND BICYCLES: To maintain the effectiveness of motorcYcles and Integrated with LF and 9 tvteNACgMENT OF SIDE Done malaria by FLHF EFFECTS: To ensure all side effects are ProPerly managed

l3 Lack offunds 10. STAKEHOLDERS Not Done MEETING: To discuss and review CDTI sustainabilitY components and

Lack of funds l1 PRINTING OF SUMMARY Not Done FORMS AND REPORT WRITING: i. To effect documentation of Mectizan@ treatment' ii. To make proPer rePorting on CDTI activities 2005 Done Lack of funds 1 PLANNING MEETING: TO Not develop a CDTI sustainabilitY plan at the local government level Integrated with LF 2. ADVOCACY: To improve Done CDTI sustainabilitY at commun level Integrated with LF J MOBILIZATION AND Done HEALTH EDUCATION: TO facilitate the communities to collect Mectizan@ Integrated with LF 4 CENSUS UPDATE: To uP- Done date communitY registers at the level Lack of funds 5 TRAINING AND Not Done REORIENTATION : To uPdate the knowledge of all concern on in the LGA on CDTI

Delivered by the state 6. PROCUREMENT OF Done and supported bY MECTIZAN@: To Procure Mectizan@ from state NGDO Integrated with LF 7 SUPERVISION, Done MONITORING AND COLLECTION OF REPORTS: To sPot check and ensure CDTI activities are carried out

14 8 COLLECTION OF Not Done REPORTS: Ensure high coverage and retrieval of Mectizan@ treatment funds 9 MAINTENANCE OF Not Done Lack of MOTORCYCLES AND BICYCLES: To maintain the effectiveness of motorcYcles and 10. MANAGEMENT OF SIDE Not Done EFFECTS: To ensure all side reactions are treated accord yet done due to 11. STAKEHOLDERS Not Done Not MEETING: To discuss and lack of funds review CDTI sustainabilitY components and t2 REPORT WRITING: TO effect Not Done Distribution not Yet proper reporting and completed documentation of CDTI activities yet done due to 13 ONCHO DAY: To celebrate Not Done Not and give awareness to the lack of funds public

15 Jos East LGA

S/N ACTIVITY PERFORMANCE REMARKS 2004 plans I PLANNING MEETING: TO Done Sustainability prepare a sustainabilitY available activities for the 2004 and 2 ADVOCACY: To inform and Done Integrated with LF create awareness on the CDTI malaria sustainability programme to the people (policy makers at LGA) a J STAKEHOLDERS Not Done Lack offunds MEETING: To discuss and review activities within the last one year and plan for the next year to identiff Problems in implementation. 4 SOCIAL MOBILIZATION Done Integrated with LF and AND H/EDUCATION: TO malaria create awareness and sensitize the communities towards participation and involvement in CDTI programme and 5 CENSUS UPDATE: To uP- Done Integrated with LF date community registers at malaria the village level 6. TRAINING: To train new Done Integrated with LF and CDDs and FLHF staff on malaria CDTI implementation 7 COLLECTION OF Done Delivered by the state with MECTIZAN@ FROM STATE support from NGDO TO LGA: To ensure that partner Mectizan@ is collected from the state to LGA 9 DISTRIBUTION OF Done Integrated with LF and MECTIZAN@: To ensure malaria availability of drugs to the beneficiaries

t6 10 SUPERVISION, Done Integrated with LF and MONITORING AND malaria COLLECTION OF REPORTS: i. To ensure proper recording, distribution and integration of CDTI into other health related programmes ii. To ensure correct treatment and to identiff problems encountered in the field. 11 COLLECTION OF Done lntegrated with LF and SUMMARY REPORTS malaria FROM FIELD: To ensure proper reporting t2 MOP UP TREATMENT: TO Done follow up on absenteeism and refu sals for compliance. 13. REVIEW MEETINGS: i. To Not Done Lack of funds strengthen the efforts of health workers and community members on the task of CDTI programmes. ii. To identifr problems encountered during monitoring and supervision of CDTI activities and to review and improve workplan for the year.

t7 14. REPORT WRITNG: To Done ensure proper comPilation of data from the communitY to LGA to state. 2005 Lack offunds I PLANNING MEETING: TO Not Done prepare a sustainabilitY activities for 2005 Lack of funds 2. MOBILIZATION AND Not Done FVEDUCATION: To assess rate of awareness on CDTI activities and health related Lack offunds J TRAINING: To train 20 new Not done CDDs and 10 FLHF staff that have not been trained Delivered bY the state with 4. COLLECTION OF Done fromNGDO MECTIZAN@ FROM support partner STATE TO LGA: To ensure that Mectizan@ is collected from the state to LGA Integrated with LF and 5 DISTRIBUTION OF Done MECTIZAN@: To ensure malaria availability of drugs to the beneficiaries Integrated with LF and 6. CENSUS UPDATE: TO Done by the identiff 2004 defaulters and conducted communities e Integrated with LF and 7 COLLECTION OF Done SUMMARY REPORTS malaria FROM FIELD: To ensure

Integrated with LF and 8 SUPERVISION AND Done MONITORING: To ensure malaria that all eligible PoPulations are treated. Not yet done due to lack of 9 ONCHO DAY: To celebrate Not Done Oncho funds Not yet done due to lack of 10. STAKEHOLDERS Not Done MEETING: To discuss and funds review activities within the last one year and Plan for the next year to identiff Problems ln

l8 Kanke LGA REMARKS SAt ACTIVITY PERFORMANCE 2004 Not Done 1 PLANNING MEETING To ascertain and develop CDTI activities so as to sustain the Programme at the LGA level Integrated with LF 2 ADVOCACY MEETING: To solicit Done for support from LGA on sustainability of CDTI activities at LGA level 3 MOBILTZATION AND Done FYEDUCATION: To create awareness and facilitate distribution of drugs

l9 4. ONCHO DAY: Boost mobi lization Not Done Lack offunds and create acceptability of Mectizan@ communities and the 5 TRAINING AND Not Done Lack of funds REORIENTATION: To train old CDDs, DHS, HHFS and other health personnel on targeted suPervisory skills and Mectizan@ calculations 6. CENSUS REGISTRATION: To uP- Done Conducted by date community registers at the CDDs level 7 PROCUREMENT AND Done Integrated with LF DISTRIBUTTON OF MECTZAN@: To ensure that there is earlY and adequate Mectizan@ to communities and community members treatg{- Integrated with LF 8. S UPERVIS IONA{ONITORING OF Done MECTIZAN@ DISTRIBUTION: TO carry out spot checks on FLHF and CDDs during distributior/treatment.

9 COLLECTION AND ANALYSING Done Integrated with LF OF MONTHLY REPORTSA{OP UP: i. To ensure that ffeatment results from all communities are collected and collated for submission to LGA/state. ii. To ensure that all communities are treated 10. STAKEHOLDERS Not Done Lack of funds MEETING/COMMUNITY SELF- MONITORING: To discuss and review CDTI sustainability and community monitoring and Plan for the following year. ll TRANSPORTA4AINTENANCE : TO Done maintain 3 motorcycles, 10 bicycles, fuel and cost of 12. REPORT WRITING: To know the Done Integrated with LF ATO of each community, PoPulation treated and coverage and submit same to state. l3 MANAGEMENT OF SIDE Not Done Integrated with LF EFFECTS: To ensure those with side effects are treated

20 2005 Done Lack of funds 1 PLANNTNG MEETING: TO develop Not CDTI activities at this level ) ADVOCACY: LGA to suPPort the Done Integrated LF makers Integrated with LF J MOBILIZATION AND Done H/EDUCATION: Mobilise communities to suPPort CDTI activities Lack of funds 4 ONCHO DAY Boo st mobilization Not Done Lack of funds 5 TRAINING AND Not Done REORIENTATION: Targeting of CDTI activities Conducted by 6. REGISTRATION: TO up-date Done community registers at the CDDs level Integrated with LF 7 PROCUREMENT AND Done DISTRIBUTION OF MECTZAN@: For early and adequate distribution of

yet done. Will 8 SUPERVISIONA{ONITORING: To Not Done Not after carry out spot checks on FLHF and be done CDDs during distribution/treatment. completion of treatment be done after 9 COLLECTION OF REPORTS/MOP Not Done Will UP: Treatment results collected and completion of collated treatment l0 STAKEHOLDERS Not Done Lack of funds MEETING/COMMUNITY SELF- MONITORING: Review CDTI and sustain the 11 TRANSPORT A,IAINTENANCE: TO Done maintain 3 motorcycles, 10 bicycles, fuel and cost of after 12. REPORT WRITING: To know the Not Done Will be done ATO of each communitY completion of treatment l3 MANAGEMENT OF SIDE Not Done EFFECTS: To ensure those with side effects are treated

2t 5.0. Implementation of Key CDTI activities at Local Government Level

Planning: In the ttrree lCAs visited, CDTI is integrated into the overall PHC written plan (budget up to 2005), the figures were however the figures were different from what is contained in the local govemments; sustainability plan. The local government coordinators have CDTI iustainability plans with a Oetaitea list of activities. There was no evidence however, that the plans were being used for implementation of CDTI due to inadequate and delayed funding.

Training: During thi visit, the team was confronted with a difficult situation in which most of the staff of thJprogramme had been transferred as part of a mass transfer by the local government service-commission. Over 90%o of the stafftrained on CDTI had been transferred to other local governments. However, the team was informed that trainings had been conducted as part of an integrated training for LF and malaria control. State team and the supporting NGDO conducted the trainings with sessions on LF CDTI and malaria. The programme will have to make arrangements to train the new staffs on CDTI at this level to replace those transferred.

IISAM (Sensitization and Advocacy): Various udro"u.y and sensitization visits had been made to local governments by state control team and the supporting NGDO. These visits were targeted at policy makers and political officer holders (chairmen and councillors). The objectives of the advocacy and sensitization were to create awareness and get government to solicit for support (release of funds) for CDTI activities. Advocacy and sensitization were not limited to a number but at every opportunity they were carried out. The advocacy resulted in the approval and release of some funds for CDTI activities. It is note worthy that the Chairman of Jos East LGA approved the sum of N30, 000 ($217) for CDTI activities after the advocacy by the monitoring team.

Monitoring and Supervision: The programire staff af the local government level interviewed informed the team that they oul monitoring and supervision but reports of these visits were not seen by the team. "urryThe monitoring and supervision is integated with LF and malaria control. The main strengths identified *".e th. integration of personnel and resources for the CDTI, LF and malaria. This integration is thought to have incieased compliance to ivermectin treatment and appreciation of the p.ogra-mJ. The lack of incentive for CDDs continues to be a problem to the p.og.*-". There was no evidence of feedback to the communities or persons concerned and checklist was not used, which were identified as weaknesses.

Mectizan@ Supply: Mectizan@ supply was adequate in all the local governments visited. Mectizan@ is delivered by the state to-the local governments and then the LGAs deliver the drug to FLHF where communities collect the drug based on community census. Mectizan@ is not supplied through

22 to the LGAs is the drug delivery system in the local governments although the delivery. that the drug generally timely. Hlwever, there were-complaints from some communities had not reached the arrived late. For instance in Kanke local government, the drug people Mectizan@ tablets in January communities at the time of monitoring. prefer to receive since it was - March, during tn. J.y season. fnJOetayid drug delivery may affect coverage already a rainy i"uton and people busy in their farms'

Human Resources: this level' Supervisors who There are focal persons (coordinators) responsible for CDTI at for the LGAs agrtt with the fo.ui p..rons make up the local onchocerciasis control teams the focal persons had been ,u"ppon", the focal p.rronr. During the monitoring visit, most of good skills and transferred out of their stationr. fh" few whom ih" t.un, met demonstrated like NlDs, LF, knowledge of CDTI and they are also involved in other health activities of salaries arrears owed by malaria etc. The morale of most staffs was however, low because government (up to 17 months in Bassa LGA)'

Integration: be pointed out CDTI is integrated with LF and malaria control at this level. It must however, attempt by the that this integration is an initiation of the NGDO partner but not a deliberate control are used local governments to integrate programmes. Resources for LF, and malaria training and mobilisation)' for thJimplementation orborfa"tiuities (monitoring/supervision,

Finance: budgets for cDTI In the LGAs visited, the team was able to see documentary evidence of Funds budgeted' activities (sustainability plans) including requests, approval and released' that in Kanke Local approved and released ar" ,urnn1arizedln table 2. [t was noteworthy Ministry for Local Government Area, zustainability funds were only approved after the State the funds Govemment and Chieftaincy Affairs directed-th;-LcA to do so' However' CDTI activities as approved and released are inadequate for effective implementation of detailed in the sustainability plans.

23 Egi EO F Fl X 19 F E (r) p G 3,4 o s x !9 rc (D o G b.) ^\ EE G z s.i I t-) e3 sd - t\) EE Lat O\ ii 0e 6 O,\ u) "^ (D il NJ a ? 5 v\O oq (D F} oo v) z e4 e1 p s3 SE !d -t'o (rr -e a tJr -o o E O o at! b.J a e4 @z- F 5 ah z N?B o P SE (D F O -l "o v"o t)D o o O p(D (o tD UJ A r.t E i p 5 (D s a @ 5 (D E -o D 0q s o\ s o o ao F o

ar) z gj1 EE e3\o ,oo a 5 -s 0e tJ "sUJ o O oo S-r 5 lr z. ?84 g 5 6l- (Jr e1 -@ alo Ft bJ Lh .v^ eF o O o UI I [J o z, e1 z, F UI 5 NJ (, o 6 o Ur rlo tr tuo O O o

L'I u) -o !, :J o\ 60ags @ \oUl DOQ s o\ 8g

o Ar ar-() t.Jrll xa -ll (D (D g8r o(D =liD o 8.6* ua) o tJ sr.C?g:- '82 o o E3_r BE o= L'I o o o +) Ft =px (D F < i iE E .<5 o '_-xx, (! F) o a A) !j+l E o ts +EYBis N o { p8ae.o6H rt EOoo TD 9?6 ds a q8??Bo :1 tJ N< 5 o' EO, I .g=8"ia='

Transport: two Transport was found to be available in the LGAs. Each LGA had at least motorcycles; one donated by APoc and the other by the NGDO for the integrated programmes (LF and Malaria control) and they were functional and adequate'

Coverage: be over There *ur IOOX geographical coverage and therapeutic coverage was found- to -oreruge Treatment 90%o inthe local gor"in*"rts visted. is calculated based on Annual Objectives (ATd) and not on the overall total population' In Kanke LGA treatment .oi.rug" was discovered to be as low as 4lYo due to inflation of the population-

"The low coverage in some communities in Kanke LGA is due to inJlated population by the communities in order to get more insecticide treated nets for their communities" (LGA Oncho Coordinator, Kanke LGA)

Conclusions and Recommendations at LGA Level:

Conclusions: a CDTI sustainability plans are available and implementation of CDTI activities (training, monitoring and supervision) is integrated with LF and malaria' is a elthough the LGAs released some funds for CDTI activities in 2004, there delayei release of funds and activities could not be executed on schedule. Secondly, the funds released are still inadequate for effective implementation of CDTI activities as detailed in the sustainability plans. a Treatment coverage calculation is based on annual treatment objective but not on the total population as recommended by the TCC-

Recommendations: a SOCT together with NGDO partner should continue with advocacy to policy makers to ensure timely and adequate release funds for CDTI activities as planned. a Treatment coverage should be calculated based on the total population like in other APOC supported projects for easy comparison of coverage across projects.

25 6.0. Findings at the First Line Heatth Facility Level

Planning: met were There *uJ ro list of CDTI activities at this level, but the few staff the team carried quite knowledgeable and clearly remembered the key CDTI activities that were participants. out and the dates, including location of training and estimated number of

Training: CDDs *i. t*in"d on treatment exclusion criteria, dosage determination and record malaria keeping and these trainings were done as part of an integrated training for LF and control. The CDDs arJ responsible for delivering these services (treatment with Albendazole for LF and distribution of insecticide treated nets) in their communities. The resources used were from the LF programme. There was no indication that these trainings were actually targeted to solve identified CDTI problems/issues.

IIASM (Sensitization): The few staff interviewed at this level informed the team that they conducted on sensitization sessions for community leaders. They also sensitised the communities was side effects and provided support supervision to CDDs. The objective of sensitisation to create awareness on ivermectin ireatment and support for CDDs by the communities. Some of the sensitization meetings were carried out in the village leaders' compounds, of with all the leaders in attendant" (b"t*.", 50 - 100 people depending on the number communities). There were however no written reports of these meetings'

Monitoring and SuPervision: Monitoring uid .up.*iiion was reportedly canied out regularly (before, during and after distributioi) in an integrated manner with LF and malaria control. The main strength identified was the integ[ation of personnel and resources for the CDTI and other control activities, which are reportedly to be ensuring high compliance to ivermectin treatment. However, the lack of incentive for CDDs and feedback to the communities or CDDs was seen in identified as the major weakness affecting CDTI. Supervisory checklists were not any of the FLHF visited, which was another weakness.

Mectizan@ Mectizan@ supply was adequate and its requisition was based on the Mectizan@ inventory. Meciizan@ is delivlred before the rains (January - April) but it is not ordered and delivered within the health care drug delivery system. The drug is delivered with Albendazole for LF and insecticide treated nets for malaria control.

Human Resources: In all the FLHF visited, there was a focal person who is responsible for CDTI in a number of communities. Most of them had however been transferred and the replacements had not reported. The few the team met had been trained and they demonstrated good knowledge of CDTI activities although some did not know how to calculate Mectizan@ requirement based on census.

26 Integration: Activities at this level are integrated with LF, malaria and NID. The LF resources are used for CDTI at this levet 6y the same staff, while government and other donor organizations provide support for NID using the same staffs.

Coverage: Geographical coverage was 100% in the FLHF visited. Therapeutic coverage (coverage based on total populition) was more than 95o/o in some communities and this could be attributed to pobr census. For example there was a village where eligible population was higher than the total poPulation.

Conclusions and Recommendations at FLHF Conclusions: o Health workers are implementing CDTI in an integrated manner with LF and malaria. o Massive transfer of health workers has to some extent disrupted timely implementation of CDTI activities. For instance, treatment had been delayed in fanke LGA due to lack of staffs to coordinate and supervise ivermectin distribution.

Recommendations: o All health workers particularly the newly posted should be trained on CDTI- o Targeted training/reoriented should be conducted for old staff to address issues like determining quantity of Mectizan@ to be ordered.

7.0. Findings at CommunitY Level

HSAM (IIeaIth Education and Mobilization): Most of the communities visited had health education and mobilization sessions in 2004 as part of an integrated health education for LF and malaria control. The supervisors and CDDs conducted these sessions.

Mectizan@ Supply: Drug supply to co-munities was found to be adequate. The communities collect their arugi from the FLHF and when the drug is not enough, additional tablets are collected from the FLFIF. However, there was one village in Bass4 which had not collected the drug, despite timely delivery to the FLItr and the reason for the delayed collection were not known. Such villages need to be followed up by health workers to establish reasons for delayed collection of Mectizan for the distribution to take place during the preferred period by the community members. Mectizan@ is distributed along side Albendazole- The communities in Kanke LGA, which had not received Mectizan@, wished that the drug could be supplied early (January - March) as against April - June when they have to go to their farms.

27 Human Resources: visited. All the CDDs were Most communities had 2 - 4 CDDs for the communities the CDDs is a female' males except in one community (Zagun,Bassa LGA) where one of been agreed by the Attrition rate was about 25% indtLugh some form of incentive had CDDs' However' communities, this was not fulfitled thus affecting the morale of the to be established other factors may Ue responsible for this high attriiion rate, which need and addressed accordinglY-

Record Keeping: all the communities This was found to be poor in all the LGAs visited. Registers found in Most of them visited were exercise Looks purchased by either the viltage leader or CDD' which had only had treatment of 2004 and 2005. Some of the registers' makes it ,or"rug" from 2000, were"or".ug. mlissing some years in betwe-en 2000 and 2005,which One difficult to calculate and individual long- term compliances from those registers' helps CDD interviewed had no register. He chlmed that ths sister-in-law who sometimes in distribution was keeping the register-

Coverage: was Most of-the households in the communities visited were treated but coverage quality of difficult to determine particularly in Bassa and Jos east LGAs because of poor coverage over records. The summary forms found in these communities had therapeutic 90Yo andthis was attributed to integration with malaria control-

,,There has been high treatment coverage due to the integrotion with distribution af to increased Albendazole and insecticide treated *tt 7o, maloria control, which hqs led compliance" (Community Leader Gurguvillage, Jos Eost LGA)

conclusions and Recommendations at community Level

Conclusions: a Health education and mobilization on CDTI is being implemented and integrated with LF and malaria control. o Ivermectin collection from FLHF is delayed in some communities despite timely arrival and reasons for this are not known' to o Registers used are exercise books, some of which are in poor state and difficult use to estimate treatment coverage. Recommendations: o Communities which delay to collect ivermectin on time for distribution to take place during period ugr""i upon by the community members need to be followed and up bV heah[ workersio establistred reasons for delayed collection of the drug solutions worked out.

28 NGDO partner need to print o The LGAs together with APoc management a1d th9 The number of tablets standardised iegisters with a page fJr each household' be recorded' This will help received by eacf, household *..6.. each year should in determining long- term compliance'

8.0. Debriefing: State: of health' Permanent The debriehng was attended by the team members; Commissioner Center/Global 2000' DDPHC and Secretary, MOH; Programme Administrator, Carter included lack of tunding at the socr. The team hdhrghi;Jihe main key finding.s,_which Timely release of.funds was state level and delayed and inadequate funding ut LCe-t"vel' planned activities' The Commissioner of emphasized fo. ti..fy itnpf"ln"rrLtion of tfrl 2000 RBP for the support Health expressed gratitude to Apoc and cartei center/Grobal He promised commitment of rendered to the State in controlling river blindness' ge DPHC to draw a programme of government to the health of its peopti. directed the of health workers' He also training new health workers after ihe recent mass transfer be opened where the Ministry will directed that an account for the Programme should deposit its counter-Part funding.

NGDO: CARTER CENTER/GLOBAL 2000 presented to the technical staff of Findings of monitoring in Plateau and Nasarawa were in the two states' Some of the Global 2000. fne ,iieigths and weakness were highlighted ptace and integrated with LF and strengths were that COff activities continue to Lte were high' The weaknesses malaria and both g"-offihi"al and therapeutic coverage Mectizan supply' included inadequate"tiAing by the state and LGAs and delayed

Reactions/discussion new and were the same According to Oi-p.-anuel Miri, the findings were not of the two projects in findings identified during the evaluation of GD-TI sustainability or no funding by the state ZO03.All the proUt"-, i'dentified are based on inadequate wofTn eradication and LGAs. High-level advocacy to the president for Guinea APOC should use the same programme yietfied good results ir-O n was iuggested that for CDTI activities if approach. States *i tt" LGAs have to irif,.orre funding lack of flexibility in the sustainability is to be achieved. other reactions included health system of Nigerian CDTI sffategy and failure of integrating GDTI within the PHC in Nigeria is weak and Federal Health Minittry,. ft ** ulro o|'served that the and be sustainable' The therefore CDTI cannot be integrated within weak structures CDTI programme' staffhoped that APOC management would continue to fund g.0Theoverallconclusionandrecommendations: have continued to be It is the overall conclusion of the monitors that CDTI activities therapeutic coverage, despite implemented in Plateau state with high geographical and funding at LGA level' This lack of funding from the State; and iriadJqua:te a,O delayed integration of GDTI with LF continued implementation of cDTI has been possible due-to project has high treatment and malaria in the NGDO partner funded project. The but there are no resources from coverage with strong ownership at the community level

29 sustainability of GDTI is government or the community to ensure the sustainability. The where CDTI is currently being therefore doubtful if the NGDO partner funded projects from the findings of last integrated comes to an end. The situation has not really changed of sustainability by evaluation and as the project has only partia[y furflrlled the definition APOC i.e. effec-tivelyfor ,,CDTI activities in an areo are sustainable when they continue tofunction coverage, integrated into the ovailable health the future, with high treatment foreseeable mobilized by the care service, with strong comiunity ownership, ,iing r"tources community snd the government."

Consequently the monitoring team recommends that: aim at reaching o APOC management-sends a high-powered delegation that would to advocate for the highest level of government ut tt national and state levels " Nigeria has many goverrrments supportl The national level is important because go a long way APOC supported^projects and government support at this level will in boosting sustailability of the all the projects in Nigeria.

be the weakest o The FLHF level (primary health care clinics) was discovered to CDTI link in tfr" i.fi".entation of CDTI after many years of implementation; recommends that the has not U".n rutfy integrated into the PHC system' The team should be pursued integration of C6ft in-the Nigerian Federal Ministry of Health This would to ensure that CDTI activities are integrated into all PHC activities. as a package not only reduce costs but it would also harmonise control activities that for community health and strengthen the PHC system' The team recognise of not this may take a while to be achleved; it is a strong path to sustainability only CIiTI, but also other community directed control programmes'

supporting e The monitoring recommends that APOC management should consider health core CDTI u"Iiuiti., like targeted training, monitoring and supervision, the fact that education and adrocacy for th'is project. ftris is crucial considering some of the there has been mass transfer of health staff across the LGAs and government cannot staffs are not knowledgeable on GDTI. It is also apparent that the poor at this time train thes-e staffs because of the high cost involved and 5 17 funding as all local governments visited owed staff salary arrears of - on the months. The non-traiiing of these staff would have a negative impryt should be a implementation of the sustainability plans. Thellgmmended support onl offsupport to ensure the sustainability of CDTI in Plateau State.

and chieftaincy o The team observed that the State Ministry of Local Government uffui.. play a crucial role in ensuring the release of funds in the LGAs' This GDTI' The Ministry if however not been carried ulong in the implementation of meetings with the team retommends that NOTF Nigeria should hold stakeholders Local Commissioners and Directors of pffC from the States' Ministry for Government and Chieftaincy Affairs. Appendixl. summary of Problems and solutions at each Level

30 A. State Level

State level Problems Solutions Planning Lack of ownership of the The NGDO partner should program by the state. The empower the state to own program activities are the progfttm. This will initiated by the NGDO ensure capacity building at partner this level. Advocacy Advocacy seem to be weak High-powered delegation and it has not made any advocacy with the impact on release of funds participation of APOC for CDTI activities management should be conducted to solicit for release of funds. Mectizan@ Delivery Mectizan@ delivery is not Mectizan should be integrated in drug delivery integrated with the drug system. Currently it is delivery system from the dependent on funds from state to the lower levels for the NGDO partner. This has sustained delivery. a negative implication on sustainability of Mectizan delivery when the NGDO funding comes to44 J!4:_ Integration CDTI is integrated with LF CDTI should be integrated and malaria in the NGDO with other Ministry of partner funded project, but health programs such as not in other programs in the EPI, home based Ministry of Health. management of malaria and reproductive health where feasible in addition to LF and malaria in GRBP funded project. Finance No funds have been High-powered delegation released for CDTI activities advocacy is urgently needed since the inception of APOC Record keeping Treatment coverage is Coverage should be calculated based on annual calculated based on total treatment objective. population like in other APOC tunded CDTI projects for easy comparison

3l B. LGA Level

LGA level Problems Solutions policY makers for Planning CDTI sustainabilitY Plans are not Advocacy to used for implementation due to timely release of funds and in delayed funding sufficient amount for implementation of CDTI activities is needed. Training Massive transfer of health o Training of new health workers has created a vacuum in workers staff,rng a Training of all health workers in the LGAs on CDTI so that there is always somebodY to take over CDTI activities whenever there is a transfer. HSAM Advocacy resulted into release Continued advocacY by of some funds though the funds NGDO partner and SOCT to are still inadequate policy makers at this level for release of funds. list Mon itorin g/supervision o No supervisory check list A supervisory check o No feedback to the should be used and feed back communities on findings on the findings given to the of the supervlslon. lower levels Mectizan@ a Mectizan@ is not a Mectizan should be delivered through the integrated in the drug drug delivery system delivery system. a Delayed delivery of o Timely delivery of for ivermectin to somer Mectizan@ LGAs communities to receive the drug during the period agreed upon bY the communities Finance a The approved and Regular advocacy to PolicY released funds are makers for timelY and inadequate sufficient release of funds for o release of funds CDTI activities is required. Coverage Treatment coverage ls Coverage should be calculated calculated based on annual based on total poPulation as treatment objective recommended by TCC for easy comparison with other APOC funded

32 C. FLHF Level

FLHF Problems Solutions There should be a list ofCDTI Planning There is no Iist of CDTI activities activities with time frame of

on Some staff did not know how to Training of the staff Training and how to calculate Mectizan requirements elements of CDTI calculate Mectizan@ uirements should be done a suPervisory Monitoring and o No supervisory check list Develop check list supervision o No feed back to the the communities and CDDs a Give feed back to communities on the of Training of all health workers Resources Focal persons for CDTI available Human on CDTI so that but all were knew and not Yet in the LGAs are transfers, trained on CDTI whenever there there are some staffs knowledgeable on CDTI for timely implementation of the activities. was Update of village census Coverage Treatment coverage which calculated based on total annually population was more than 95% in some villages indicating Poor census date

D. CommunitY Level

level Problems Solutions reasons for Mectizan@ suPPlY Delayed collection of Mectizan@ Establish and by some communities delayed collection ide solutions. reasons for Human Resources ftigh attrition rate of 25%o Establish attrition and address them

Partners to print keeping Registers used are exerclse Record for all books, some of which are in a standardized registers state communities in Update of census annually Coverage Coverage figures unreliable record some communities due to Poor and improving on census update and record keePing keeping bY Providing standardized sters

33 Appendixll..ListofPersonslnterviewed/]VletinPlateauState

Level Name Country Representative Carter I State Dr. E. I. Miri Center/Global Deputy Country Representative & 2. Dr. Abel Eigege Director Plateau/ Nassarawa Programmes, Carter Center/Global 2000 Programme Administrator, Carter 3 Mr. John Umaru Center/Global 2000, Director of PHC MOH 4. Mr. Yohanna Oncho Coordinator Plateau State 5 Mr Fildan Deputy Director of PHC 6 Bassa LGAJFLHF/ Mr. Joel Nshem Communities Oncho Coordinator BASSA LGA 7 Mr. F Karo LOCT Bassa LGA 8. Mr. tbrahim Dabo Samuel Oncho FLHF 9 Mr. Abdulrahaman Oncho Binchin FLHF 10 Mr. Michael John CDD of I l. l4r. Vturtala M. Garba Community Youth Leader ofZagan 12. Mr. Sunday Adisa CDD of 13 Mr. Adikaba leader of t4. IvIr Jos East LGA Chairman 15. Jos East LGA /f'LHF/ Mr.Ishaya T. Usaini Communities Asst. PHC Coordinator and HIViAIDS 16. Mr. Samuel Angam Officer Cold Chain Officer t7. Mrs. Victoria Pam Oncho Coordinator 18 ttrtr. librin B.Ibrahim Commun leader of Shere Dabo Jankasa 19 Mr Azi Mr CDD of Shere Dabo Jankasa 20. of 2l I\rIr N leader 11 Mr. J Dabo CDD of PHC A 23 Mr. Daniel Sati Director of PHC 24 Kanke LGAJFLHF/ Mr. Boniface B. Miri Communities Oncho Coordinator Kanke LGA 25 Mr. Musa Clinic FLHF 26. Mrs. Nenrit Lar CDD of 27 Mr. Goladi Community leader ofDungung 28 Mr. Gideon Goki

leader ofNemel 29. MI CDD ofNemel 30 Mr Atukum

34 Appendixlll.. LIST OF IVIONITORS FOR PLATEAU STATE

No. Name Address I Mr. Sunday Isiyaku Sight Savers International Data Analyst-SSl I Golf Course Road P. O. Box: 503 Kaduna, Nigeria Tel:234 62248360 234 62231216 (H) Fax;234 62248973 E-mail : sisiyaku@ww/kad.com ssi n g@i n foweb.abs.net sunday [email protected]

I 2 Dr Luc Mebenga Tamba University of Yaounde Anthropology Social Anthropologist Department of Sociology and P. O. Box: 755 Yaounde, Cameroon Mobil lsl 1 +(237) 9973392 E-mail : [email protected]

Uganda, 3 Dr Richard Ndyomugyenyi Ministry of Health Medical Doctor P.O. Box 1661, Kampala, Uganda Tel +(256) 41 348332 Fax:256 41 348339 E mail: [email protected]

35