Assessment of the Sustainability of FCT CDTIProject, Abuja, Nigeria

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African Programme for Onchocerciasis Control

Assessment of the

Sustainability of FCT CDTI Project, Abuja,

Nigeria

August - September 2003

Prof M Homeida (Team Leader) Prof O Nwaorgu

Dr. J Jiya

Dr. V Okeke

Dr. E Nnoruka

Mr. P Mabuba

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Abbreviations/Acronyms

APOC African Programme for Onchocerciasis Control CDD Community Directed Distributor

CDTI Community Directed Treatment with Ivermectin CHO Community Health officers

CHEW Community Health Extension Worker

CDD Community Directed Distributor of Ivermectin CDTI Community Directed Treatment with Ivermect CSM Community Self Monitor

DHS District Health Supervisors

DDPHC/DC Deputy Director of Public Health and Disease Control.

DDP Deputy Director Planning

DPRS Director Planning Research and Statistics FLHF First Line Health Facility

HA Health Area

HOD (Health) Head of Department of Health.

HSAM Health Education Sensitization Advocacy and Mobilisation LF Lymphatic Filariasis

LOCT. Local Government Onchocerciasis Control Team LGA. Local Government Area

M & E Monitoring and Evaluation MDP Mectizan Donation Programme MCH Maternal and Child Health

MFCT Ministry of Federal Capital Territory

NGDO Non-Governmental Development Organisation NPI National Programme on Immunization

NOCP National Onchocerciasis Control Programme NOTF National Onchocerciasis Task Force

PHC. Primary Health Care.

SOCT. State Onchocerciasis Control Team.

SPO State Programme Officer SAE Serious Adverse Event WHO World Health Organization

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Acknowledgement

We would like to thank Dr Azo Seketeli and APOC Management for asking us to evaluate this project. Our appreciation also goes to Dr. J Jiya the National Oncho Co- ordinator, and the Deputy Director of Public Health division of the Health and Social Services Department (MFCT) Dr A K Mohamed for his assistance as well as for providing us with an office space; Mr Chris Ogoshi, the Christoffel Blinden Mission Country Representative, Alhaji Abass Dalhatu, the FCT coordinator, the SOCTs and drivers for their services. Dr Edith Nnoruka, the Scout for preparing the ground for the evaluation which has assisted us greatly. Dr Nuha Mamoun who joined as a volunteer was helpful in assisting the team. Gwagwalada Area council for providing their hall for the sustainability planning workshop.

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Executive Summary

The African Programme for Onchocerciasis Control (APOC) is supporting 29 projects in 32 States in Nigeria, covering 20 million at risk population. The first control efforts started in 1991 when Mectizan was launched in Niger State. Mectizan distribution was assisted by the NGDOs and the mode of distribution was clinic or community based.

With APOC’s support these programmes reoriented their activities of control to CDTI.

Many of these projects are in their 10^th round of distribution.

The FCT (Federal Capital Territory) was established by a presidential decree 1976, while government occupation took place in 1991 to house the new Federal Capital: Abuja.

Unlike the other budding States which are often carved from existing States, FCT was created in an area where there were only a few villages with a population of not more than – 5000 people. There were no Oncho Control activities in this area before the capital was moved.

Between 1991 -1998 onchocerciasis control activity was carried out by CBM on rather a smaller scale. The CDTI programme in FCT supported by APOC started in 1998 and was assisted by CBM. It is thus in its 5^th year. The 5^th year evaluation was carried out in the period 24^th August to 7^th September 2003 by 7 evaluators; 5 externals and 2 internals. The Scout, Dr Nnoruka prepared the ground well for the evaluation. The FCT CDTI program suffered from two main negative forces:

• The unique and new structure established in the Capital Territory to run the health services which in certain aspects is different from what is seen in other states(see Health structure- annex III).

• The massive influx of people from all over Nigeria to FCT all competing to establish a new prosperous life. Making money is their main interest. The immigrants/settlers (as they are so called) brought to the area, new customs and tradition. They formed non homogenous communities that do not resemble communities in other States

These factors have largely disturbed the running of CDTI in FCT. The following are the principal findings of the evaluation:

The Health structure created two levels of authorities, the State and the Area Council (LGA as is referred to in other States of Nigeria, for purposes of simplicity we adopted the same term.) The responsibility of the programme lies on both, with heavy reliance on the Area councils. In some instances these authorities are seen as separate with a line of dermacation when it comes to the execution of the Oncho control activities. This situation has created some resistance on the side of the SOCTs (in the State) to effectively supervise the LOCTs (in the Area) and monitor the programme activities.The commitment and attitude of the staff at State and LGA levels especially towards the FLHF need to be improved. The first line health facilities (FLHF) which play a crucial role in CDTI activities are very weak and not empowered in the FCT programme. The personnel manning these centres are not of the appropriate professional caliber or training that will enable them to monitor and supervise the CDDs adequately. It is thus highly recommended that this level should be looked into, strengthened and empowered to take full responsibility.

The programme is also weak at the community level. Twenty five per cent of the communities visited did not receive Mectizan in the last 2 years either because the CDDs

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abandoned the programme and were not replaced or they were no longer interested in carrying out the job. In two communities visited, the CDDs declined to see the evaluators despite repeated visits and insistence from the evaluators.

The communities in all areas visited were not involved in selection or in deciding the time or mode of distribution of Mectizan. In most communities, the members thought that Mectizan distribution is a government project and that CDDs are government employes.

However, they are willing to appoint their CDDs when the evaluators explained their role in the programme. The State level was not aware that treatment was stopped in these communities.

Determination of quantity of Mectizan required: Staff at all levels were unable to establish the rationale behind the calculations of quantity of Mectizan required annually.

Coverage, consequently is low in most areas where treatment is still going on. In 90% of the communities there is no reliable census. Many mistakes in dosing and calculations were noted. The use of measuring sticks to determine dosing is not well practiced. Since, there is no on-going programme activities in the immigrants (settlers) community,our evaluation was restricted to the original indigenous population. Nevertheless geographic coverage is not more than 75%.

If the estimated total population is used (data obtained from the village leaders), the actual therapeutic coverage will be far below the 65% mark. The problem of immigrants (settlers) should be addressed in more depth. They are representing 60-80% of the total population of the at-risk population in FCT. They have a unique situation and form very heterogenous communities. Moreover many of the old villages are now urbanizing.

Operational research is to assess the feasibility of establishing CDTI programme among the settler’s communities and habits of simulium fly in the urbanized settings of FCT.

Specific Remarks.

Planning: There are plans of Oncho-control activities in the State and some LGAs but not integrated in the overall PHC plan. The 6-8 years –Post APOC plan of oncho activities prepared by FCT project does not qualify as a sustainability plan as it has not followed APOCs guidelines. Adequate explanation of how to develop such a plan was made clear to all the concerned in the programme, both at the State and LGA levels.

Effort in the feedback /planning workshop was made to help them develop a 3years sustainability plans

Monitoring and Supervision: This area is still weak in the programme. Monitoring and supervision should follow a specified plan and should respond to needs. Currently, failures pass unnoticed e.g suspension of treatment for 2 years. Spot checks should be carried out by SOCTs and a proper system of feedback should be established from the communities to the FLHF and the LGAs.

Mectizan Procurement and Distribution:The flow of Mectizan is satisfactory.

However, it is dependent on the NGDO system. For mature projects as in Nigeria and a strong NOCP, Mectizan handling should be entirely the responsibility of the government.

Ordering of the drug by the communities, the LGA and FCT oncho co-ordinator is not based on needs. It is distributed on quota basis to the communities and many members pass untreated. It is highly recommended that the programme should have census of all the communities under treatment and the need for Mectizan should be calculated based

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on the eligible population. The communities and CDDs should play a pivotal role in deciding the amount required and should collect the drug from the nearest health post where they should also present their treatment sheet and summary.

HSAM and Training: The need for a well thought out detailed, HSAM plan targeted to solve the problems encountered is a high priority. The high attrition rate of CDDs, communities unaware of programme and failure to support it,the low geographic and therapeutic coverage, all call for HSAM activities. The NGDO has been active in producing good HSAM materials, but they were not seen nor referred to in the

communities. Training of CDDs is very deficient, as evidenced by the lack of census, poor motivation and errors in distribution. There is no formal training of staff at FLHF level, who should shoulder the responsibility of training the CDDs. The recent transfer of most staff at the LGAs, handicapped the programme and disturbed the CDTI activities.

Training and retraining should therefore be intensified.

Human Resources: There is knowledgeable staff at the State and LGA levels but not in the FLHFs. However, some of the staff need to change their attitude and convictions on CDTI. The integration of activities in the health system is limited to Oncho, NPI and blindness prevention with reasonable integration. However, the need may arise in FCT to integrate other diseases of similar programmes such as LF and schistosomiasis.

Transport: At present reasonable number of project vehicles and motorcycles both from APOC and MFCT are available. Remote FLHFs require motorcycles for activities at this level. There is no provision for replacement of vehicles or motorcycles at any of the levels. The office equipment are adequate and in good condition. However there is sharp shortage of consumables, paper, overhead sheets etc. The government at all levels should make available enough consumables and be able to maintain these equipments.

Financing/Funding: The state and LGA carries a handsome budget, however funds were only released in the first 3 years of the programme. No funds were released in the last 2 years at both State and LGA levels. This is a real set back as these are the times when the government should be committed to release funds and take responsibility of CDTI activities. The situation was made worse by the fact that most communities are not contributing anything in kind or cash to support the running the programmes including incentives to CDDs.

Detailed recommendations were drawn up based on the findings of the evaluation. The recommendations were prioritized and indicators of success and deadlines were

suggested for each. Concerted advocacy and activities were carried out at various levels in FCT, the LGAs and in the communities. The feedback/planning workshop which was held at Gwagwalada Area Council was an important exercise and it seems that such meetings for bringing together staff at State and LGA are not held often.

The evaluators had a difficult job of steering the discussion into how the project can be improved. In the group work, participants, brought out the weaknesses, strengths, opportunities and threats in the programme and were able to draw recommendations.

Furthermore, 3 year sustainability plan was developed of both FCT and LGA levels. In conclusion: Based on the analysis of findings in the field for both State and LGA, the evaluators came to the conclusion that the CDTI project in FCT is not making progress towards sustainability.

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1.0 INTRODUCTION

Nigeria has a population of over 100 Million people and several fast flowing Rivers that is suitable for breeding of the Simulium-blackfly. Remo has now been Completed in all of Nigeria and CDTI projects are well defined with at risk population of 20 million.

The Federal Capital Territory (FCT) of Nigeria was established in 1991 to provide a new capital for the country. It comprises 8,000 square Kilometers, located in the geographical center of the country. The FCT is divided into 6 administrative divisions (Local

Government Councils) comprises 28 districts (the smallest peripheral unit) Geographical location of FCT in relation to the rivers:

The FCT lies in the centre of Nigeria, just north of the hot and humid low-lands of the Niger- Benue Trough, but South of the drier area North. It lies north of the plains

farmed by the confluence of the Niger and Benue rivers. Four major rivers flow through the area. All of them flowing roughly from North to South and draining into River Niger.

The rivers flow swiftly through rocky gorges providing an ideal place for breeding simmulum flies.

Oncho- endemicity:

The results of recent mapping of Onchoerciais demonstrated that the area is hyperendemic. Indeed onchocerciasis endemicity was an important issue and a real concern when the capital Abuja was selected. Oncho-endemicity was used as an argument against its selection as the capital. Hence the area was sprayed before construction of the capital was started.

The Population:

Before the construction of Abuja the population comprising the FCT was 498,000, while recent estimate provide a figure of 6 million. This influx of people had a great negative impact on the control of Onchocerciasis in the area which will be highlighted in

the present report. Moreover the known problem of Fulani nomads visiting the area remains an obstacle to proper control of onchocerciasis.

Onchocerciasis Control in FCT:

Mectizan distribution was started in 1995 by CBM when 56,083 people were treated by clinic based /Community based system (CBTI).

APOC approved a CDTI project for FCT in 1998. According to reports submitted to APOC treatment under CDTI was proposed to increase from 162,709 in 1998 to 234895 in the 4^th year of implementation. APOC management conducted two independent monitoring exercises of FCT CDTI project in August 1999 and March 2001.

The Present evaluation : In accordance with APOC management decision to evaluate CDTI projects for sustainability at 3^rd and 5^th year, the present team (see annex I) was asked to evaluate FCT CDTI project on its 5^th year along the lines of the tested instruments( updated March 2003 version) and following the guidelines provided by APOC management( March 2003).

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1.1 PROJECT BACKGROUND AND HEALTH STRUCTURE OF FCT ABUJA Abuja is the Federal Capital City of Nigeria. Constitutionally the City is Governed by the office of the President who appoints a Minister to oversee the affairs of the city on his behalf. There is therefore the Ministry of the Federal Capital Territory (MFCT) under which is the Federal Capital Development Authority (FCDA). The FCDA is the works parastatal of the ministry; it carries out all the development aspects in the Capital City.

This includes health Services, water supply and construction of physical structure with the provision of services.

The Health Services delivery in the Federal Capital Territory comes directly under the supervision of the Honorable Minister of the FCT. There is a Department of Health Services Headed by a Director who reports to the Minister through the Permanent Secretary in the Ministry. While the Minister is the political head, the Permanent Secretary is the Administrative Head and Accounting officer for the Ministry.

The Director Public Health and Social Services has under him various divisions such as Hospital Services, Public Health and Disease Control, Nursing, Food and Drugs, Planning and Finance and Accounts. These divisions in the Department run similar activities as their counterparts in the Health Ministries at State level. The difference being that in the state, they are full departments under the leadership of a Director while in the MFCT the divisions are headed by Deputy Directors. Onchocerciasis control in the Federal Capital Territory is in the division of Public Health and Diseases Control.

Abuja Federal Capital Territory has six area councils administered similarly with the Local Government Areas found in other states in the Federation. The Council areas are administered by Council Chairmen who report to the Local Government Services Commission of the FCT. The Council Chairmen are elected officials while the Minister is appointed by the President. Within the Councils are health departments under the leadership of Health Department of Health (HOD); they supervise and operate the Primary Health Care facilities, (PHC) First line health facilities (FLHF) and community clinics within their areas of Administration. Within the Area Councils are District Health supervisors, Community Health Workers/Officers and Environmental Health Workers. A large proportion of the area council health workers are made up of the following professionals:

(a) Community Health Officers (CHO) (b) Environmental Health Officers (EHO)

(c) Community Health Extension Workers (CHEWS) (d) Community Midwives

(e) Nurses and (f) Health Attendants.

There is no direct linkage between the Health Department at the Ministry and those in the councils. Programme managers can communicate with their counterparts at the council level, using the authority of the Deputy Director who links directly with councils Chairmen and to the Head of Division of Health.

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1.2 Terms of reference:

The evaluation team was charged with the following:

• Evaluation of the current functioning status of FCT CDTI project and to determine if it has established sustainable elements in the course of its 5 years span.

• Determine if FCT CDTI project is fully sustainable or not making progress to wards sustainability.

• Organize a feedback/planning meetings with the project personnel at State and LGAs (Area councils) , to enable them improve performance of project activities to reach full sustainability and develop a post APOC sustainability plan.

• To analyse the data collected and present a report to the project, NOTF and APOC management.

1.3 Team Composition (Annex I)

Professor Mamoun Homeida (Team Leader) Professor Obioma Nwaorgu

Dr Jonathan Jiya Dr Veronica Okeke

Dr Edith Nnoruka Mr Pius Mabuba Alhaji Abass Dalihatu 2.0 METHODOLOGY

Evaluation question: How sustainable is the FCT CDTI, Project?

Design: Cross-sectional, descriptive.

Population: The FCT Abuja project, including: HM FCT, its NGDO partner; its Area council (LGAs) with their Health Teams; the Health Areas, the project communities/villages, their CDDs and the project’s finance officer.

Sampling: Details of the sampled Districts, health areas and communities/villages are contained in Table 1 below.

2.1 SAMPLING

A multi stage sampling approach was adopted in selecting the sample for evaluation.

This was purposively done and the sample sites were chosen according to the stipulated guidelines. The primary criterion was the coverage rate (geographic and therapeutic coverage) which assessed the performance of the whole system; while the secondary criterion took into cognizance endemicity, geographic spread and accessibility /convenience.

Firstly the average treatment coverage for three years was computed for each of the six Area Councils (LGAs). Since treatment is currently taking place in communities to the results of the fifth year distribution were not available for use by the evaluators. The

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average coverage rates of the six LGAs were sorted in an ascending order from lowest to highest. These were put into three strata. Three LGAs were then selected out of the six Area councils of FCT Abuja project where CDTI activities are being carried out in accordance to the primary criterion (one with high coverage, another medium coverage and the third low coverage).

Secondly, two health areas were selected for each LGA (one with high coverage and the other with low coverage) and two communities were selected for each health area chosen (one with high coverage, one with low coverage). The secondary criterion was satisfied in each case before coming up with the final choice. This resulted in the selection of the following samples reflected in table 1 below.

Table 1: Details of Sampled Sites:

LGA, Health Areas and Villages for CDTI Sustainability Evaluation in FCT Abuja, Nigeria.

S/

N

LGAs Rx(Coverage Rate) Districts/Health Areas.

Villages (Rx

Coverage Rate) 1 Abuja Municipal

Council (Hyper)

High (89.4%)

Gwagwa (94.1%) 1. Kadon Hausawa (95.6%) 2. Tasha I (87.2%) Kabusa (86.6%) 1. Ajatta (89.7%)

2. Kabusa I (80%) 2 Kuje (Hyper) Medium

(82.1%)

Kuje (58.1%) 1.Damakusa(59.4 2. Sauka Kuje (57.3%)

Rubochi (36.5%) 1. Tikka (64.2%) 2. Ubo Bassa (39%)

3 Gwagwalda ( Hyper)

Low (79.5%)

Gwagwalada (81.5%)

1. Ung Dodo I (91.3%)

2. Passo (73.1%) Ibwa (77%) 1. Ibwa Pada

(68.9%)

2.Ung Bassa Paiko (58.5%)

The evaluation team members were divided into sub teams to evaluate operations at the various levels according to the work plan (see Appendix II). The team met twice to familiarize themselves with the instruments and to agree on the tentative schedule. Initial meetings were also held with the State team members to acquaint them with the objectives and expected outcome of the evaluation.

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2.2 SOURCE OF INFORMATION

Information was collected through interviews, verbal reports and documents. Various categories of people were interviewed at the MFCT (Ministry of the Federal Capital Territory namely: Deputy Director (Public Health & Disease Control, FCT Oncho Coordinator, Project Finance officer, Deputy Director Planning, Director Finance- Budgetary), NGDO Partner (CBM), LGAs (Council Secretary, HOD Health, LOCT leader, LGA planning, Finance and Transport officers respectively), the frontline heath facility/health areas level (District Health Officers) and at the community. In the communities the evaluation team interviewed community Heads, members, CDDs and in some instances held community meetings.

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

2.3 ANALYSIS:

Based on the information collected, each indicator is graded on a scale of 0-4, in terms of its contribution to sustainability.

The summary findings for each group of indicators were given at the end of each group.

The average 'sustainability score' for each group of indicators is calculated, for each level and a qualitative description of problem areas is given. Recommendations are made, prioritized, implementers specified and time frames given.

2.4 Limitations

• Transfer of most of the staff at the Area Councils as well as inability to locate the previous staff during our interviews, was one of our major handicap for data collection in majority of the sampled areas.

• Most of the documentation required at the LGA and FLHF/Subdistrict level were not available despite prior information.

• Acessibility to Tude, one of the communities in Kuje LGA was so poor that it had to be substituted with Tikka, which was the next community with similar characteristics (i.e same high therapeutic coverage) whilst in the field.

2.5 Advocacy Visits

Advocacy visits were paid to the director of FCT health Services, deputy director of FCT planning, Deputy director of Public Health and Diseases control at State levels.

Similar visits were paid to secretaries and HOD Health at the Area Councils.

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3.0 EVALUATION FINDINGS

3.1 SUSTAINABILTY AT STATE LEVEL

3

2 1 1

2 2 2

3

2

0 0.5 1 1.5 2 2.5 3 3.5 4

Average Weight (/4) Planning Monit/Super Mectizan Train/HSAM Integrated Sup Finances Transp/Mat Res Human Res. Coverage

Group of Indicators

Fig 2: FCT Project: Sustainability at State level

PLANNING [HIGHLY (3)]

There is a plan for onchocerciasis control at the project office. The plan is in form of a workplan with specified dates and duration for the various activities. There is a similar workplan which was developed by the LGAs. The plan is not integrated in the overall PHC workplan, but it contains all the CDTI elements. No evidence that other partners other than MOH staff took part in the development of these plans. There is a plan for

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years 6-8 Post-APOC which does not take account of APOC’s guideline for development of sustainability plans.

Recommendations ‘ Planning’ Implementation 1. A specific sustainability 3 year plan

(Post APOC) should be developed using the guidelines provided by APOC.

2. All concerned partners, at all levels and the NGDO partner should be involved in preparation of this plan.

Priority: HIGH Indicators of Success:

A detailed, well thought out, integrated sustainability plan containing all CDTI activities is available. The plan should indicate the budget lines and the sources of the financial support.

Who to take action?

Deputy Director PHC/Disease control, State Coordinator, SOCTs, LOCTs, DHS and NGDO partner(CBM)

Deadline for completion:

December 2003.

MONITORING AND SUPERVISION [MODERATELY (1.6)]

The SOCTs from HQ supervises the LOCTs at the LGA. Supervision is done as a routine and not in response to need or solving problems. The system does not use a checklist. The LOCTs supervise and monitor below the FLHF level. No spot checks are carried out. The SOCTs do not carry out supervision below LOCT level because they believe that this will not encourage sustainability. Feedback of problems at lower levels are not passed up to the SOCTs, hence problems are not solved effectively and in due time. No reports of monitoring or supervision were seen at this level.

Recommendations ‘ Monitoring and Supervision’

Implementation 1. The sense of two separate authorities

governing the program, State versus LGA should be corrected.

2. The link and flow of information from up to down and bottom to up should be revisited. The DHS and LOCTs role in monitoring and supervision should be activated and the LOCT should alert the SOCTs to any problems that require their support.

Priority: MEDIUM Indicators of Success:

1. Flow of information is easy and the program is reviewed as one

program.

2. Improved performance of CDTI activities is noticed in the next round of distribution.

3. Availability of integrated checklist.

State coordinator, SOCTs, LOCTs, HOD Health, DHS.

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3. Spot checks by the SOCTs should continue using checklists. The feedback to LOCTs and HOD Health by the SOCTs is mandatory.

4. Supervision and monitoring should be integrated.

Before next round of distribution.

August 2003.

MECTIZAN SUPPLY [SLIGHTLY (1) ]

The yearly order is done by CBM (NGDO partner). The order is not based on dependable census of people needing the drug. The drug is collected by CBM from Lagos and then delivered directly to FCT. The State then delivers the drugs to the LGAs, from where it is distributed to the communities by the LOCTs. This system does not follow the government system of distribution of Mectizan which is in practice for some states( e.g those assisted by UNICEF).

Recommendations ‘ Mectizan’ Implementation 1. Mectizan ordering, procurement, storage

and disbursement should be the entire responsibility of the government.

2. The programme should ensure that the right quantity of Mectizan is ordered and gets to the communities well ahead of time of distribution without any shortage.

1. Mectizan is ordered through the NOCP, collected by NOCP and delivered to the Zonal offices, from where FCT collects it in enough quantity to meet the need of the community.

FCT coordinators, NOCP, Zonal, NOCP coordinator, FCT coordinator.

January 2004

TRAINING AND HSAM [ SLIGHTLY (1)]

There has been no training in the last 2 years. The reason given is because the field officers have been well trained and there was no need for further training. This is despite the evaluation team’s observation that most of the LGA staff have been changed recently.

The training of LOCTs are done by SOCTs. However, it was noted that SOCTs also take a crucial part in training the CDDs. Training materials and posters are available and in sufficient quantities. There is no integration with other control programmes in the training or HSAM activities.

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Recommendations ‘ Training /HSAM’ Implementation 1. Training should be more focused to

needs especially when LGA and FLHF staff are new to the jobs.

2. Training should be integrated with other PHC activities.

3. HSAM activities should be properly planned and effectively implemented as frequently as necessary and at all levels.

Priority: MEDIUM

Indicators of Success:

1. Improved performance of the various workers of the programme.

2. Training arranged in integrated fashion for newly posted staff.

3. Improved coverage in the next round of treatment.

FCT Oncho coordinator, SOCTs and LOCTs.

Before the next round of distribution.

(March 2004)

INTEGRATION OF SUPPORT ACTIVITIES [MODERATELY (2)]

There is some well defined form of integration with NPI and the Blindness Prevention programme.

Recommendations ‘ Integrated Support’

Implementation 1. More integration with other Disease

Control program in the FCT e.g Malaria control, HIV/AIDs and other PHC activities.

Oncho integrated with other diseases.

DD PH/DC, FCT Coordinator.

January 2004.

FINANCES AND FUNDING [MODERATELY (2)]

Although budgetary provision were made for onchocerciasis control in the last 5 years release of funds was effected in the first 3 years and it was in an increasing manner.

However, there was no release of funds in the last 2 years. Funds when released were well managed according to a good system. No provision is made to meet any deficit that may arise in case of short-falls of government funds.

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Recommendations ‘Finances/Funding’ Implementation 1. Budgeted funds should be released every

year in time to be used for a successful program.

Availability of funds and reports of budget releases, in time for the activities of the programme

Director Health Services FCT, DD PH/DC FCT Oncho coordinator, FCT Planning officers.

May 2004.

TRANSPORT AND MATERIAL RESOURCES [ MODERATELY (2) ]

There are adequate numbers of functional vehicles and motorcycles for necessary activities at this level provided by APOC and government. There is also sufficient office equipment available as well as materials for training and HSAM. The vehicles are regularly maintained by APOC and Government. The use of the vehicle is restricted to program activities, however there are no log books or travel authorization books. No plans have been put in place for replacement of vehicles and other material resources post APOC.

Recommendations ‘ Transport and Material resources’

Implementation 1. Ministry of FCT should make provision

for replacement of cars and motorcycles when broken.

2. Ministry of MFCT and Area councils should budget for maintenance of cars and motorcycles.

3. Ministry of MFCT and Area councils should replace office equipment if broken and maintain them when necessary.

Priority: MEDIUM

1. Vehicles and office equipments are maintained and repaired as necessary.

2. Plans for replacement of non-functioning vehicle and office equipment are in existence and replaced ones should be seen.

FCT Ministry , Area Council, DDPHC/DC,FCT Oncho-coordinator Deadline for completion:

January 2006.

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HUMAN RESOURCES [HIGHLY (3)]

There are enough personnel at this level, though some of them require further training.

The staff is committed and stable.

Recommendations ‘Human

Resources’

Implementation Training of SOCT should be carried out in

an integrated fashion. Targeted training should take place when problems arise.

SOCTs well trained Who to take action?

NGDO Partner, NOCP, DD PH/DC, FCT Oncho co-ordinator.

August 2004.

COVERAGE: [MODERATELY (2)]

People treated in this program according to the record at this level rose from 177,695 in 1999 to 238,895 in 2002.ie. from 78% to 87% coverage of the total population. However the record sheets show incomplete calculations in some of them. The FCT personnel indicate that geographical coverage is 100%. It is clear that total population figures quoted are lower and consequently eligible figures are also lower than actual. There are errors in calculations.

Recommendations ‘ Coverage ’ Implementation 1. The programme should put in place a

plan to carry out census in all communities;

this should be updated every year before distribution.

2. The programme should adopt calculating coverage based on total number treated to the total population at risk.

3. No community should be left untreated for any length of time.

Priority: HIGH

All communities including immigrant population are treated with Mectizan.

Coverage is 65% or above in 100% of the communities.

NOTF, FCT Oncho coordinator, SOCTs and LOCT,DHS and CDDs.

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4.The programme should ensure the delivery of mectizan to all the communities at risk

5. Immigrant population should be included as an extension of the program and a new CDTI program should be established.

6. Steps should be taken to see that Therapeutic coverage is over 65% in all the communities and should be increasing every year.

• Deadline for indigenous

communities: before next round of distribution i.e March 2004.

• Deadline for Immigrant communities: April 2005

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3.2 SUSTAINABILTY AT LGA LEVEL

1.6 1.7 2.3

1.7 1.7

2 2 2.2

2 0 0.5 1 1.5 2 2.5 3 3.5 4

Average Weight (/4) Planning Leadership Mon/Sup Mectizan Train/HSAM Financial Trans/Mat.Res Human Res Coverage

Fig 3:FCT Project: Sustainability at LGA Level

PLANNING [MODERATELY (1.6)]

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In one out of the 3 LGAs visited, CDTI plan is integrated into the overall PHC plan.

There is a separate CDTI annual plan with all key oncho activities. In the rest of the LGAs visited there were incomplete time schedule and the overall health plan did not reflect Oncho activities. They were lumped under the communicable diseases annual plan. Community requirements for timing of distribution were taken into account and all plans were not developed in a participatory manner.

Recommendations ‘ Planning’ Implementation 1. There should be an annual CDTI plan in

all the LGAs, integrated into the overall PHC health plan.

2. Plans should be drawn in a participatory manner.

1. Annual CDTI plan is available at each LGA.

2. Availability of integrated PHC Plan drawn up in a participatory manner.

HOD Health , LOCTs Deadline for completion:

January 2004.

LEADERSHIP [MODERATELY(1.7)]

LGA Health management team including the HOD Health does not initiate CDTI activities at this level. The LOCTs carry out these activities once the go ahead has been given by the Project office. There are focal persons in charge of CDTI activities in all the LGAs.

Recommendations ‘ Leadership’ Implementation There is need to advocate for involvement

of Senior LGA management team in CDTI implementation.

Reports showing advocacy carried out.

HOD Health , FCT Oncho coordinator, SOCTs

November 2003.

MONITORING AND SUPERVISION [ MODERATELY(2.3)]

CDTI data are transmitted within the government system but does not follow the normal M and E system. The LOCTs in some LGAs take the data from the FLHF and communities directly to the SOCTs at the State level. Supervisory visits are routinely done at the community level and not targeted at specific problems. Thus staff at FLHF are not empowered for supervision and management of problems as the need arises. No

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supervisory checklists are used and there is no integration with other diseases. Spot checks are also not carried out in communities by LOCTs. In some LGAs, rewards are given for outstanding performance and successes. There is a process of management of problems in some LGAs.

Recommendations

‘Monitoring/Supervision’

Implementation 1. The LGA Health Management team

should be involved in supervising and reporting of CDTI activities.

2. CDTI monitoring and supervision should be integrated with other diseases.

3. Supervision should be targeted towards problem solving and staff at FLHF empowered adequately for supervision and problem management. Supervisory checklists should be provided

1. LGA Health management team is involved in supervisions and reporting of CDTI activities.

2. Supervisory checklists showing CDTI activities are integrated with other diseases.

HOD Health, FCT Oncho coordinator, LOCTs

August 2004.

MECTIZAN PROCUREMENT AND DISTRIBUTION [MODERATELY (1.6)]

Ordering of Mectizan is not based on census. Staff at this level do not understand how to calculate quantity of Mectizan to be ordered. Mectizan is controlled within the government system at this level but transportation is dependent on APOC funds.

Recommendations ‘ Mectizan ’ Implementation 1. LOCTs should know the rationale

behind the quantity of Mectizan ordered annually.

2. LGA( Area Council) should take full responsibility for transporting Mectizan from LGA to FLHF.

• LOCTs can explain correctly how to calculate quantity of mectizan required.

• Mectizan is available at the FLHF.

HOD Health, FCT Oncho coordinator, LOCTs, DHS.

April 2004.

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TRAINING AND HSAM ACTIVITIES [ MODERATELY (1.7) ]

In some of the LGAs visited, SOCTs train LOCTs at the LGAs while in the others SOCTs and LOCTs train DHS and CDDs at the LGAs. Training is routine and not targeted to needs. No training manuals were seen. HSAM activities were carried out routinely, not directed to need. No HSAM reports were seen. HSAM was carried out mainly during distribution periods.

Recommendations ‘ Training and HSAM’

Implementation 1. There is urgent need to provide

training and HSAM materials at this level.

2. Training and HSAM activities should be targeted to need.

• Training and HSAM materials available.

• Reports of training and HSAM activities carried out

HOD Health, FCT Oncho coordinator, LOCTs, DHS.

February /March 2004

FINANCE AND FUNDING [Highly (2.6)]

Costing of CDTI activities was appropriate in 2 out of the 3 LGAs visited. 80% of their budgeted amounts were released except in the past 2- 3 years. Amounts released were increasing annually in some LGAs and decreasing in others while some LGAs had no idea of amounts released. In AMAC ( Abuja Municipal Area Council),N 400,000 was approved in 2002 but none was released while in Kuje N650,000 was approved but not released for CDTI activities. However, no provision is being made for alternative source of funding to take care of shortfall. In one LGA visited there is evidence of proper control of funds disbursed and accounted for.

Recommendations ‘ Finance’ Implementation 1. There is need to advocate to top

management LGA Staff for approval and release of funds for CDTI activities.

2. Efforts should be made to identify other sources to bridge the shortfalls in funding of CDTI activities.

1. Advocacy at LGA top management level taking place.

2. Alternative sources of funding identified.

3. Budgeted funds are released for CDTI activities.

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HOD Health, FCT Oncho-coordinator, SOCTs

Jan 2004

TRANSPORT AND OTHER MATERIAL RESOURCES [MODERATELY (2)]

Transport, training and HSAM materials are inadequate. There are no maintenance schedules in some LGAs. The LGAs provide funds for maintenance of transport but there are no log books and HODs Health are not always aware of Oncho vehicle movements.

Vehicles are utilized in an integrated manner but there are no plans for replacement of old vehicles.

Recommendations ‘

Transport/Material Resources ’

Implementation 1. There is need to provide motorcycles

especially for remote areas.

2. Log books should be provided and used for the movement of vehicles. There should be long-term plan for replacement of old vehicles.

1. Plans for procurement of additional vehicles made.

2. Log books available and used.

HOD Health , FCT Oncho coordinator, NOTF, DD PHC/DC.

March 2004

HUMAN RESOURCES [MODERATELY (2.2)]

There are reasonable numbers of staff for CDTI activities. Many of them are CHEWs.

There is no stability since last year due to transfers. Staff are committed and Staff salaries are paid regularly including field allowances.

Recommendations ‘ Human Resources’ Implementation There is need to have sufficiently qualified

staff for proper implementation of key CDTI activities.

1. Sufficiently qualified staff are available.

2. In service training for CHEWS conducted.

FCT Oncho-coordinators; HOD Health, LGA Secretary.

October 2004.

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COVERAGE [ MODERATELY (2)]

Four out of twelve communities visited did not have treatment in the last two years.

Therapeutic coverage is not properly calculated because of not using correct census data.

In addition immigrants in the communities are not treated.

Recommendations ‘ Coverage ’ Implementation 1. Proper census figures should be used for

calculation of coverage annually.

2. LOCTs should train and supervise FLHF staff to ensure that appropriate census is carried out in all communities.

3. LOCTs should spot check mectizan distribution in communities annually.

4. Steps should be taken to include immigrants in the CDTI programme.

1. Proper census is carried out and annually updated.

2. Coverage is calculated annually using correct census data.

3. All communities including the immigrants are receiving treatment.

FCT Oncho Coordintor, SOCTs, LOCTs, DHS

January 2004

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3.3 SUSTAINABILTY AT FLHF LEVEL

0 0

1 0 0 0

1.6 1

2

0 0.5 1 1.5 2 2.5 3 3.5 4

Average Weight (/4) Planning Leadership Mon/Superv Mecitizan Train/HSAM Financial Trans/Mat Res Human Res. Coverage

Fig 4: Sustainability at FLHF level

PLANNING [NOT AT ALL (0)]

Most of the FLHF had no annual plan for Oncho activities but plans exist for other diseases and public health activities e.g. NPI and Maternal and Child Health. One FLHF had a work plan, but this was not integrated into the overall Health plans.

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Recommendations ‘ Planning’ Implementation 1.FLHF should have a plan for Oncho

activities integrated with other health activities. DHSs should not make these plans single handedly.

Priority Medium

A detailed integrated Health plan containing all CDTI activities available.

DHSs/in-charges of FLHF, LOCTs Deadline for completion:

January 2004.

LEADERSHIP [NOT AT ALL (0)]

In most of the health facilities the FLHF staff at these posts are LOCTs who are mainly CHEWs and assistant CHEWs, without sufficient experience needed for carrying the programme forward to sustainability. They are not capable of initiating and supervising CDTI activities, nor have they been fully empowered for this purpose. SOCTs are involved in training of CDDs.

Recommendations ‘ Leadership’ Implementation 1.Staff at the FLHF should be of

reasonable caliber and should be empowered.

2. SOCTs should not be involved in the training of CDDs.

Priority : HIGH Indicators of Success:

1. Availability of CHOs at the FLHF.

2. LOCTs taking full charge of trainings.

HOD Health at LGA, FCT Oncho coordinators, DHS

February 2004.

MONITORING AND SUPERVISION [SLIGHTLY(1)]

In most FLHF, data are transmitted through this level to higher levels. However in some cases,LOCTs collect data directly from CDDs, bypassing the FLHF. Transmission of data is entirely within the government system.

Some FLHF staff are involved with supervision but not in an integrated fashion with other health programmes. There are no checklists, and log books; nor were there monitoring reports. Management of problems in most FLHF is poor, particularly with regards to coverage. Successes often pass unnoticed.

Recommendations

‘Monitoring/Supervision’

Implementation 1. All FLHF staff should be actively Priority: Medium

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utilized for receiving CDTI data from the community for immediate transmission to higher levels.

2. There is also the need for

integration with other diseases since this is the lowest level.

3. Checklists and log books should be available for supervisory activities.

4. FLHF should be empowered to manage CDTI problems e.g poor coverages

1.CDTI data are transmitted from communities through the FLHF to the LGAs.

2. Monitoring and supervison activities are integrated.

3. Availability of supervisory checklists and log books.

4. FLHF staff are appropriately trained to manage problems.

FCT Onch coordinator, HOD Health, LOCTs

Deadline for completion: June 2006

MECTIZAN PROCUREMENT AND DISTRIBUTION [NOT AT ALL (0)]

FLHF are unaware of how the number of Mectizan tablets is calculated or ordered. When shortages are reported, they do not take action. FLHF wait for the drug to be brought to them by the LOCTs. The FLHF level is by-passed LOCTs take the Mectizan straight from the LGAs to the communities. Both LGA and APOC funds are used for transportation of Mectizan.

Recommendations ‘ Mectizan Procurement’

Implementation 1. Mectizan ordered should be based on

census.

3. FLHF staff should be involved in the ordering and movement of the drug.

4. This level should be strengthened to deal with supervision and treatment of side effects as they arise.

Priority : HIGH Indicators of Success:

FLHF staff are trained on how to calculate quantity of Mectizan required by communities and on how to manage side effects once they arrive.

FCT Oncho-cordinators, DHS,LOCTs Deadline for completion:

January 2004

TRAINING AND HSAM [ NOT AT ALL(0)]

LOCTs at FLHF and LGAs are involved in training of CDDs. But in some facilities FLHF staff who are not LOCTs are rarely involved. SOCTs are also involved in training of CDDs. Staff at this level are not involved in HSAM activities.

Recommendations ‘ Training and HSAM’

Implementation Staff at this level should be empowered and Priority : HIGH

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involved in training, supervision and HSAM activities.

FLHF staff adequately trained in supervision and HSAM activities.

FCT Oncho coordinator, DHS,LOCTs Deadline for completion:

March 2004

FINANCE [ NOT AT ALL (0)]

Both budgeting and funding of oncho activities are not handled at the FLHF level.

Recommendations ‘ Finance’ Implementation There is need to set aside some funds from

LGA for FLHF Oncho activities e.g for side effect management.

Funds are available for Oncho activities from LGA to FLHF.

HOD Health, FCT Oncho Coordinator, LOCT.

June 2004.

TRANSPORT AND MATERIAL RESOURCES [MODERATELY(1.6)]

Vehicles are not adequate; of those available, a few are out of order. There are no training or HSAM materials at this level. There is no regular system for maintenance of vehicles.

In some LGAs individuals are responsible for maintaining their motorcycles. Transport is utilized in an integrated manner and in some facilities trips are authorized, but no log books were seen. Staff at this level do not know about plans for replacement of transport and HSAM materials.

Recommendations ‘ Transport /Material Resources’

Implementation 1. Motor cycles should be provided at this

level especially for FLHF in remote areas.

2. HSAM materials should be provided.

Priority: Medium Indicators of Success:

Availablity of motorcycles and HSAM materials.

FCT Oncho coordinator, HOD Health, DHS, LOCTs.

Oct 2005.

HUMAN RESOURCES [SLIGHTLY(1)]

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Most of the FLHF staff are new and so the system could not be properly assessed.

However, some staff at this level are skilled and knowledgeable about CDTI activities.

Recommendations ‘ Human Resources’ Implementation 1. The newly transferred FLHF staff

should be trained.

2. Staff at this level who are involved in CDTI activites should remain at their posts for at least 5 years or when transferred they should be engaged in Oncho-control in their new positions.

Priority:: HIGH Indicators of Success:

1. Stability of staff and newly transferred staff trained.

2. Staff transferred to other LGAs are involved in the Oncho-control activities in their new posts.

FCT Oncho coordinator, LGA Secretary and LGA Service Commission.

March 2004

COVERAGE [MODERATELY (2)]

All communities are covered but there is no treatment taking place in the immigrants household. No treatment records were seen at this level in almost all the health facilities visited.

Recommendations ‘ Coverage’ Implementation 1. Treatment records should be

available at the FLHF.

2. Both indigenous and immigrant communities should be treated.

Priority:: HIGH Indicators of Success:

1. Treatment data are available.

2. Indigenous and immigrant communities are receiving Mectizan.

. FCT Oncho coordinator, DHS,CDDs Deadline for completion:

Marcg 2004.

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3.4 SUSTAINABILTY AT COMMUNITY LEVEL

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2.4

1.5

2.4 1.2 1 1

1.3 0 0

0.5 1 1.5 2 2.5 3 3.5 4

Average weight (/4) Planning Leadership Mon/Superv Mectizan HSAM Finance Human Res Coverage

Fig 5: Sustainability at Community Level

PLANNING [MODERATELY (2.4)]

The CDDs modify the time of distribution and they work together with the village leader.

Census update was carried out only in one village while there was no proper census in the other villages.

Recommendations ‘Planning’ Implementation

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CDDs should be trained in performing census. Mectizan requirements and distribution should be based on proper census of total population and number of eligibles.

Priority: HIGH

Indicators of success:

Census is carried out in all communities Mectizan requirements and application based on current census.

SOCTs, LOCTs, DHS and CDDs Deadline for completion:

Before next round of distribution i.e. before March, 2004.

LEADERSHIP AND OWNERSHIP [MODERATELY (1.5)]

In 50% of the communities the leaders are involved in problem solving while in the other 50% the leaders are not involved. In all cases community leaders are not aware of the pattern of distribution or coverage within their communities.

Village leaders and elders are responsible for selecting CDDs, timing and mode of distribution. The communities are not involved while in some areas the people thought that the CDD is a government employee. A lot of value is placed on Mectizan and in all areas there is willingness to take it for as long as necessary despite the fact that a large number of the community members think that the tablets should be taken for 5 years only.

Recommendations: ‘Leadership’

Implementation 1. Communities should be sensitized to

their central role in driving the programme.

2. The programme staff should advocate for community meetings being held to select CDDs, determine time and mode of distribution.

3. The community should also be fed back with successes and problems encountered to solicit support for the programme.

Priority: HIGH

Indicators of Success 1. Community meetings held.

2. Communities are better informed about the programme

3. Communities select their CDDs.

4. Minutes of meetings are presented to FLHF, LGA and State authorities.

CDDs, LOCTs, DHS Deadline for Completion:

Before the next round of distribution i.e.

before March, 2004.

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MONITORING [MODERATELY (2.4)]

Reports of distribution are collected by LOCTS and brought up to the FLHF/LGA. There were no community treatment summary reports seen in almost all communities visited.

Recommendations ‘Monitoring’ Implementation 1. CDDS should submit Mectizan

distribution records to FLHF in time.

2. Community treatment summary reports should be available at FLHF and in the LGA Office- LOCTs

Priority: MEDIUM.

Reports of treatment activities are available at FLHF and LGA office after completion of distribution.

Who to take action:

CDDs and LOCTs.

Deadline for Completion;

August, 2004.

OBTAINING AND MANAGING MECTIZAN [SLIGHTLY(1.2)]

Mectizan is not ordered on the basis of needs but supplied to the communities by LOCTs on quota basis through CDDS and village leaders. Generally, village leaders feel that their members get the drug but they have no rational basis for the assumption.

In cases of shortage no plans were made to remedy this. Drugs are sent down to the communities sometimes by-passing the FLHF.

Recommendations: ‘Mectizan Procurement’

Implementation 1. The order of Mectizan should be based

on actual census.

2. All efforts should be taken by the CDDs to treat all eligibles.

2. CDDs should collect their Mectizan from the nearest FLHF.

1. Order of Mectizan is based on census and no shortage of Mectizan is observed.

2. Mop-up treatment is carried after each distribution.

3. All nomads and immigrants are treated.

CDDs, LOCTs, SOCTs Deadline of Completion:

Next round of distribution i.e. next March, 2004.

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HSAM [SLIGHTLY (1)]

Community leaders and CDDs are involved with HSAM only during distribution.

HSAM is not targeted to areas of need.

Recommendations: ‘HSAM’

Implementation 1. HSAM should be carried out well before

and during distribution to all communites.

2. HSAM should be targeted to solve problems encountered e.g. low coverage, refusals, etc.

All community members are taking Mectizan with high and increasingly annual coverage rate.

CDDs, DHS, LOCTs and SOCTs, Community Leaders

Deadline for Completion:

Before next round of distribution i.e. before March, 2004.

FINANCING [SLIGHTLY (1)]

Most communities do not support the CDDs in any aspect because they feel it is government responsibility.

Recommendations: ‘Financing’

Implementation 1. Communities should be sensitized to

their responsibilities to support the CDDs.

2. Advocacy visits to stakeholders should be intensified and regular stakeholders meeting should be convened.

Priority:MEDIUM Indicator of success:

Communites are supporting the CDDs and taking are active participation in distribution and providing the CDDs with the necessary resources.

DHS, LOCTs, SOCTs, Community Leaders.

Next round of distribution i.e before March 2004

HUMAN RESOURCES [SLIGHTLY (1.3)]

Four out of the twelve communities visited have no CDDs and the attrition rate is quite high. In some instances there is one CDD to 400 households.

Assessment of the Sustainability of FCT CDTIProject, Abuja, Nigeria

African Programme for Onchocerciasis Control