World Health Organisation African Programme for Onchocerciasis Gontrol Assessment of the Sustainability of the Plateau CDTI project February 2003 Eleuther Torimo (Teom Leoder) Obiomo Nwoorgu Koyode Ogungbemi Horrieth Homisi Sundoy Isiyoku Abel Eigege I Index Page Abbreviations/ acronyms and acknowledgements 3 Executive summary 4 Introduction and methodology 5 Findings and recommendations 9 1. State level 2. LGA level 3. District/ health centre level 11 4. Village level 16 5. Overall sustainability grading for the project and way 22 fonryard 26 6. Appendix: I Agenda, Plateau State planning Meeting 28 I1 Agenda, LGA Planning meeting (iii) State/LGA Planning meeting program. 30 (iv) State Level, Problems and solutions 31 (v) LGA level, problems and solutions 32 (vi) FLHF/Community, problems/solutions 33 (vii) List of people interuiewed. 35 (viii) List of evaluators. 36 Detailed findings 37 1. State level 39 2. Health district/ LGA level 3. Sub-district/ first line health facility level 4. CommuniW level 2 Abbreviations/ acronyms APOC African Programme for Onchocerciasis Control CDD Community Directed Distributor CDTI Community Directed Treatment with Ivermectin CHEW Community Health Extension Worker DHS District Health Superuisor FLHF First Line Health Facility GRBP Global 2000 River Blindness Programme HOD Head of Department HSAM Health Education, Sensitisation, Advocary and Mobilisation IEC Information, Education and Communication LF Lymphatic Filariasis LGA Local Government Area LOCT L Onchocerciasis Control Team MOH Ministry of Health MOF Ministry of Finance NGDO Non-Governmental Development Organisation NOCP National Onchocerciasis Control Programme NOTF National Onchocerciasis Task Force NPI National Programme on Immunisation PHC Primary Health Care RBM Roll Back Malaria REMO Rapid Epidemiological Mapping for Onchocerciasis soc State Onchocerciasis Co-ordinator SOCT State Onchocerciasis Control Team SPO State Programme Officer UNFPA United Nation Funds for Population Activities WHO World Health Organisation zoc Zonal Onchocerciasis Co-ordinator ZOTF Zonal Onchocerciasis Task Force WR World Health Organisation Country Representative Acknowledgements We would like to thank the following persons for their assistance and support: . The staff at APOC Headquarters in Ouagadougou: The Director Dr S6k6t6li, Dr Amazigo, Mr Aholou, Mr Agbonton and others for overseeing and facilitating the mission. The WR and his staff in Lagos and Jos for administrative and other support. The NOCP Zonal Co-ordinator: Mrs. Patricia Ogbu-Pearce for her extensive support to the team . Staff of the Plateau State Ministry of Health: The Hon. Commissioner, Barrister John Magaji; Director PHC, David S. Belin; State Oncho Co-ordinator Henry Filda and his team, who despite the strike action in the State civil seruice ensured that the team was able to carry out its assignment. GRBP Country Representative, Dr. E. Miri and his staff for providing office space and other support. LGA Chairmen, Health workers and community members in Bokkos, Jos East and Pankshin LGAs who provided information and suggestions related to CDTL -1 Executive Summaly The Plateau CDTI project has been supported by APOC since April 1998 and it is in its last year of agreed funding from APOC. An evaluation of the sustainability of the project was carried out between 17th February - zno March 2003 by a team of evaluators from Nigeria and Tanzania. The evaluators were charged with the following tasks: - 1. Evaluation of the sustainability of the Plateau State CDTI project, including field assessments in selected LGAs, Districts and communities 2. Preparation and conduct of feedback/planning meetings with the State and Local Government Authorities (LGA) 3. Analysis of data and preparing a report. Using a multistage sampling approach, information was collected using the 4 standardized sustainability evaluation instruments related to the State, LGA, FLHF and community levels. Findings At the Community level, geographic coverage is 100o/o while therapeutic coverage is over 650lo with an increasing trend. Communities like taking mectizan and are aware that it has to be taken annually for a long time and know its benefits. "The drug makes us feel strong, improves vision, prevents blindness and expel worms from the body". Community leaders and CDDs jointly take responsibility for distribution of Mectizan within their communities as evidenced by their active role in community mobilization, decisions on timing and treatment venue, regular consultations with CDDs and support for CDDs. Census and registration are carried out by CDDs before each registration. CDDs submit reports and drug balances to first line health facilities. Treatment of Lymphatic Filariasis (LF) has been integrated with that of Onchocerciasis and on the whole is doing well, On the negative side CDDs were not taught how to determine amount of drugs to be requested for their communities. Lack of a rational criterion for determining quantity of drugs needed often resulted in surplus drugs in some communities and shortage in a few. Communities are aware of their roles to support CDDs and agreed to do so but have often failed to do so. Attrition rate of CDDs is high (about 50o/o). The ratio of households covered by CDDs is higher than that recommended by APOC. IEC materials for HSAM are not adequate. Finally there is some confusion among community members and CDDs, in communities where both Lymphatic Filariasis (LF) and Onchocerciasis are being co-treated, on what causes what disease and what treatment is for which. Reasons for this confusion need to identified and addressed. Integration of the training tools for the two diseases might ameliorate the situation. At first Level Health Facility, there is a good Mectizan inventory of drugs received and balances returned. FLHFs seem to be a weak component part of the CDTI system. Most staff at this level do not have adequate knowledge and skills for CDTI. CDTI training for health workers is restricted to one per health facility, usually the District Health Supervisor, who is the most -t senior officer. CHEWs are more stable, not often transferred out of their stations but are not trained in CDTI. There is confusion (to evaluators as well as CDTI staff at all levels) over CDTI leadership at this level. There are five LOCTS, one in charge of each of the five health districts and there are also flve DHSs, one in each of the health districts. LOCTs are often junior in position to DHS yet they are expected to supervise CDTI in FLHFs. All health staff at this level should be trained in CDTI. At the LGA Level, LOCT/ Oncho focal persons are skilled and knowledgeable about CDTI. But during field visits SOCTs appeared to be more informed about issues at FLHFs and community levels than LOCTS, which raises doubts about the adequacy of their (LOCTS) empowerment by the State level to direct CDTI activities at the LGA level. Ownership and leadership provided by LGA management is weak. For example PHC Coordinators and LGA Management are not fully involved in CDTI process. There has not been a budget for CDTI activities in LGAs since the inception of the program. LOCTs did not know how to use the census figures collected from CDDs to calculate quantity of mectizan to be requested for annually. There is need for rethinking and recasting the packaging of IEC materials to avoid confusion in communities where both LF and Oncho are being treated together. CDTI data is not part of the Health Management Information System. The State level has spearheaded the implementation of CDTI all levels. Extensive support and leadership has been provided by GRBP particularly in the early years of the program. The State has assumed increasing leadership of the project, most marked in the last year. To enhance sustainability, leadership needs to be strengthened through involvement of other partners in the State Ministries e,g. MOA, Ministry of Chieftainry and Local Government Affairs, Ministry of Planning and Finance. To enhance financial management a CDTI accountant should be appointed and trained to support the program. Some N2m of APOC funds has been released this year (June 2002 and May 2003). Information provided during interviews show that the funds are adequate for essential CDTI activities. The 1997 "Proposal" spelled out contributions to be made by different partners. For example it is indicated that the contribution from State would increase annually as that of APOC decreases and ends at the end of the fifth year. To date the State has made no financial contribution. The State Deputy Governor, Commissioner for Health and Local Government Chairmen gave oral assurances that adequate funds will be provided to continue CDTI when APOC funding ends. The evaluation team learnt of a high level effort to obtain CDTI funds released before the evaluation team left the State but the effort was not successful. The evaluation team was informed of several initiatives to enhance integration of CDTI into PHC, including a Federal level initiative to integrate services in selected Wards. The evaluation team recommends strongly that a three-year sustainability plan be developed as a matter of urgenry, building on the one-year plan prepared during the feedbaclVplanning meeting at the end of evaluation. The evaluation team was surprised to see the extent to which many leaders particularly LGA level did not know much about CDTI. The State should issue a directive that will clearly define the roles of different levels in CDTI implementation. 5 Overall assessment of project and way-forward Using the standard four-tier schedule for ranking projects evaluated: fully, High, Moderate and low, the evaluation team judges the Plateau State CDTI to be at the level of Moderate. The project is potentially sustainable as evidenced by the excellent coverage, high level of community leadership and approval and availability of mectizan everywhere. But this project requires rethinking and mobilization of high-level decision-makers to provide financial resources to sustain CDTI. It is intriguing to the evaluation team that at the end of the fifth year the State has not made a single annual contribution on the lines agreed with APOC.