CDTI Abia

World Health Organisation

African Programme for onchocerciasis _Gontrot

June 2003

VOL. 1-MAIN REPORT

Ekanem

Ikpi

Braide(Team Leader) Charles Franzen

Yisa A. Saka Sunday Isiyaku Obinna Onwujekwe

RECU

Assessment of the

Sustainability _of the Abia

State CDTI

Nigeria.

project,

O

TABLE OF CONTENT

Acronyms

. .. ... ...3

Acknowledgement

. ... ... ... ...4

A.

^Executive

summary

...s

B. lntroduction...

_...9

C. Methodology....

_...11

D.

Evaluation

Findings

...1S

1.

^{State level}

2.

^{LGA Level}

3.

DistricUHealth Facility level

4.

^{Village level}

E.

Overall sustainability grading for the

project

.. ... .. .31

F.

^SWOT

Analysis

. ...34

G. Recommendations

...41

H,

^{The way}

fonruard

....46

L Appendices

...49

L

Time table for the evaluation of sustainability of Abia State CDTI ^project.

ll.

Agenda State level feedbacU planning meeting

lll.

^Agenda LGA level feedbacUplanning meeting

lV.

^List of persons interviewed.

V.

Participants at planning meeting,

Vl.

List of evaluators.

Vll.

Participants at planning workshop.

!,

ACRONYMS

APOC

^{African Programme} for Onchocerciasis Control

CDD

Community Directed Distributor

' CDTI

^{Community Directed} Treatment with lvermectin

CHEW

Community Health Extension Worker

CSM

Community Self Monitoring

DHS

^District Health Supervisor

FLHF

First Line Heatth Facility

HOD

^Head of Department

HSAM

Health Education, Sensitisation, Advocacy and Mobilisation

lEC

lnformation, Education and Communication

LGA

Local Government Area

LOCT

Local Onchocerciasis Control Team

MOH

Ministry of Health

NGDO

Non-Governmental Development Organisation

NOCP

National Onchocerciasis Control programme

NOTF

National Onchocerciasis Task Force

PHC

Primary Health Care

REMO

Rapid Epidemiological Mapping for onchocerciasis

SHM

Stakeholders Meeting

SOCT

State Onchocerciasis Control Team

SWOT

Strength Weaknesses Opportunities and Threats

WHO

World Health Organisation

WR

World Health Organisation Country Representative

DPHC

Director, Primary Healthcare

4

The team is grateful

to

the following who have contributed to the success ^of this mission.

The WR Lagos , and staff of WHO office in Umuahia for providing administrative

.

.

^support.

.

Officials of the Abia State Ministry of Health: The Permanent Secretary, ^{Director of}

ordinator, and SOCT members, for participating effectively in the evaluation and providing necessary logistic support to the team.

.

Project Administrator ^for Abiailmo ^project, GRBP/The Carter Center for providing logistic

1

^{support and} facilitating the mission.

.

Chairmen of LGA Councils, Secretaries of LGA Councils, Treasurers of LGA Councils, LGA PHC Coordinators, LGA Oncho Coordinators, members of LOCTs, and other staff of the LGAs visited (lkwuano, Ukwa East and Umunneochi), for their participation in the exercise particularly during the workshop for production of the sustainability ^plans.

.

Leaders and members of communities visited ^for cooperating maximally during the exercise.

A. EXECUTIVE SUMMARY

The Abia state CDTI project would have received 5 years APOC funding by September 2003.

The project, jointly managed with the lmo State CDTI project as Abia/lmo CDTI project, is supported by GRBP. The ^project was evaluated for sustainability within the period June 16

-

July 2 by a team of scientists from Nigeria and Tanzania, mandated by APOC to

o

Evaluate the sustainability of the project ^present.

o

Present and discuss the results of the evaluation with Government officials and NGDO

.

Support

state level, LGA and

Health

area

^personnel

in

developing Post APOC sustainability ^plans using the guidelines for sustainability planning meeting developed by APOC and pretest the guidelines.

On arrival in the state, Government and NGDO officials were briefed on the purpose of the evaluation and appropriate permission obtained to carry out the task. lnformation was ^gathered from interviews

of

policy makers and CDTI implementers

at

state, Local Government Area (LGA), First Line Health Facility (FLHF), and Community levels, as well as from review of relevant documents. Multistage sampling approach was applied in selecting LGAs, Districts and

villages

to

be covered in the evaluation and information was collected using

4

standardized sustainability evaluation instruments (one for each level). Findings were made under ^planning, monitoring/supervising, Mectizan procuremenU distribution, HSAM, integration

of

support serviceg financial resources, other material resources, human resources and coverage. Each

of

these indicators

was

scored

for

each level

by

each evaluator. The scores were later discussed in evaluators meetings and an average score recorded for each indicator at each level.

At the state level, monitoring/superuision, Mectizan procuremenV distribution, HSAM, human resources, and coverage, are rated as hiqh. Rated as moderate are planning, integration and other resources while financial resources is rated as low. The team observed that, though a plan for CDTI exists within the overall ^plan for PHC in the state Ministry of Health, there is no evidence that plannrng is participatory done in an integrated manner with specification on the cost to be borne by each partner. Five skilled and dedicated SOCT members effectively carry

out Monitoring and supervision using work plans and checklists. Reports of supervisory visits

6

exist but there is no indication of follow up activities. These visits are occasionally integrated, with officers of other health programmes participating. Problems are solved through normal administrative channel. Though there is no problem with Mectizan procurement and distribution, the drug is not stored in Government drug store because the storage facility is unsafe. Training and HSAM are carried out effectively when necessary but there is no integration of CDTI

training with trainings in other health health programmes. lmplementers of CDTI in the state are skilled, committed and are not frequently transferred. Geographical coverage is 100% and average therapeutic coverage for the state is above 65%.

There are no indications that support programmes are ^planned and executed in an integrated manner. However, there

is

potential for integration

as

some

of the

SOCT members have assignments in other health programmes. Abia CDTI Project has depended heavily on APOC funding in the past five years and post APOC funding of the project has not been addressed.

There is inadequate funding of the project by State Government but there is some hope that this will improve with quality of the present leadership of the State Ministry of health. The new Permanent Secretary and her principal officers participated actively in the evaluation and are now fully sensitized on the need for Government to increase support to the project. Procedure for access of funds over the years has been long because the project is operated as a joint lmo/Abia project with

funds

lodged in the lmo/Abia project account and managed by GRBP Zonal office

in

Owerri. The situation has improved with the opening in January 2003, of a bank account for APOC funds

in

Umuahia (The State Capital). However, there

is

no accountant handling CDTI account in the State. Average score for all indicators at state level is 2.7.

At

LGA level, rated as hiqh are leadership, human resources and coverage. Planning, Mectizan, HSAM, and other resources are rated as moderate while monitoring and financial

resources are rated as low at this level. Skilled and committed LGA Coordinators & LOCT members are fully in charge of initiating CDTI activities at this level. Coverage is impressive with 100% geographical coverage in all the LGAs visited and above 65% in two of the three LGAs visited.

CDTI plans, at this level, are included only vaguely in the overall LGA PHC plan with no budget estimates specified

for

CDTI activities in these plans. Requests by LOCTs

for

Mectizan is

7

estimated

from

^past treatment records from communities. Mectizan supply

is

timely and

adequate

but the

drug

is

not stored

in the

LGA drug store. HSAM targeted. Training is conducted properly but routinely .lt is not targeted because of frequent transfer of ^project staff.

The coordinators have motorcycles, which they maintain with personal funds, which, in most cases, are not refunded. Monitoring and superuision is done but is not targeted, no checklists are used and findings are not ^properly documented. Frnancial support of the project by the LGA is grossly inadequate. CDTI is funded from within PHC budget. However, this is not clearly spelt out as CDTI disbursemenf and it is not clear from which budget line disbursements are made.

Average score for all indicators at the LGA level is 2.64.

At FLHF level, leadership, Mectizan and coverage arc rated as hioh, planning, HSAM and human resources are rated as moderate while monitoring, financial resources and other resources are rated as low. Officials at this level are skilled and are responsible for

implementing CDTI activities, Supply and storage and distribution of Mectizan are effective at this level. Mectizan is stored in the LGA drug storage facility and controlled within PHC

programme system. No written plans exist in most of the facilities. Plans seen in two FLHF are

not integrated into FLHF plan. Staff at this level train CDDs routinely. Training is targeted only for CSM and SHM. HSAM

is

carried out but there is no indication as to how it has led to effective actions.

With regards to human resources, staff members are skilled but there are frequent transfers.

Monitoring, financing, and other resources are rated as low. Supervisory visits are made to each community once a year routinely. Financing is very poor . There is no budget for CDTI and no funds are disbursed for CDTI activities. The officer in charge of one of the FLHFs uses funds from drug revolving scheme, which is wrong since Mectizan is not part of the scheme. At this level, provision for transportation is highly inadequate. There are no records of maintenance of motorcycles and bicycles, where they exist, and maintenance cost is borne by staff. Average score for all indicators at FLHF level ^is 2.5.

The community ^performed best with high scores on planning, leadership, monitoring,

Mectizan, HSAM, financialand coverage. The benefit of Mectizan is greatly appreciated at this level. Planning is done jointly by CDDs and community leaders, who in consultation with

8

community members take decisions on how and when to collect the drug form the FLHF as well as mode and timing of distribution. Communities are responsible for selecting CDDs and directing distribution. Monitoring is effectively done by the CDD with assistance of community leaders and members. All reports on CDTI are sent to the district health Supervisors. There is effective Mectizan requisition and distribution system with no wastage. The CDD is given one tin of Mectizan at a time and requests for more when needed. This however may result in delay in completion of distribution in some communities. Most of the CDDs do not know how to calculate the number of Mectizan tablets needed for each distribution. CDDs and community leaders effectively carry out HSAM when necessary. Some communities support the

Programme financially and materially by providing transport and other incentives to CDDs.

Other communities do not see the need for this. All households are covered. Therapeutic coverage is high but found to be wrongly calculated. Human resources at this level is not

optimum and is scored as moderate. Though CDDs have good reporting skills and are willing to continue working in CDTI, they are ovenryorked (one CDD covers 500-600 persons). CDD attrition rate is low. Average score for all indicators at community level is 3.5.

Findings during the evaluation were presented to the SOCT and LOCT at planning meetings.

These findings were exhaustively discussed, SWOT analysis conducted for each level of findings, and 3-year ^post APOC sustainability plans prepared (volume 3 of this report).

Resources (particularly financiaf one of the seven aspects of sustainability, is not fulfilled and is seriously blocking sustainability. Also not fulfilled is lntegration, which is moderately blocking sustainability. Funding (by Government), one of the

six

critical elements of sustainability, is not satisfied and is a major ^problem.

Based on the findings and assessment, the team agreed that the Abia State CDTI project is making progress towards sustainability but

will

require national and project staff to take required remedial action on the aspects not fulfilled and the critical elements not satisfied.

fhe

team recommends that as, a way forward, all Stakeholders should be briefed _{on the} findings of the evaluation and requested to make concrete plans to implement required

remedial actions. These include, integration of CDTI with other health programs, retraining of all implementers of CDTI on accurate calculation of coverage, selection of more CDDs,

appointment of an accountant to handle CDTI accounts in SOCT, advocacy for timely release of adequate funds for CDTI, inclusion of CDTI data in health management information system, training of all health staff on CDTI, sourcing for dependable funding for replacement of capital equipment. The project should fine tune the three years post ApOC sustainability plans prepared during the evaluation period. lt is necessary for roles of LOCTs and DHS to be spelt out' Good geographical and therapeutic coverage _as well _as continued availability of Mectizan should be maintained. There must be close monitoring of the project by NOCp to ensure that these recommendations are implemented.

B. INTRODUCTION

Abia state is located in eastern Nigeria and shares boundaries with Ebonyi and Enugu Sates _to

the north, Cross River and Akwa lbom States

to

the east, Rivers State

to

the south, and

Anambra and lmo States

to

the west. Until 1991, Abia State was part

of

lmo State. The population of 920,459 (1991 census) is made up of predominanily the igbo ethnic group, _living

in

low density ditfused settlements

in

17 Local Government Areas (LGAs).The climate is

characterized by two major seasons , the dry and the rainy seasons with a vegetation that is mainly rain forest. There are many rivers in the State such as lmo, lgwu, ota miriand Cross River with many tributaries containing fast flowing water which serve as suitable breeding sites for Simulium, the vector of Onchocerca.

Eight (8) of the seventeen LGAs in the State are endemic for onchocerciasis (2 hyper endemic and 6 meso endemic) with the remaining g _{being hypo endemic.} ln 1ggg, the state, submitted a

proposal

to

the African Programme

for

Onchocerciasis Control (ApOC)

for the

control of onchocerciasis

in

Abia State through

the

use

of

the Community Directed rreatment with lvermectin (CDTI) strategy' The proposal was approved and CDTI commenced in the State with Global 2000 River Blindness Programme (GRBP) serving as the supporting NGD9. one local

I 0__

NGDo' ltu Mbuzo Methodist Mental Rehabilitation centre has indicated interest _in assisting the project in mobirization and supervision of cDTr in Bende _LGA.

Five members

of

the state oncho control

ream (socr)

_members,

₂₄

_Local Government ^{- -} oncho control ream

(Locr)

members,40 District Health staff (DHS),136 Health FacilityStaff (HFS) and 803 community Directed Distributors (cDDs) _implement all components of cDTl in -- the state' Ratio of cDD to population is 1 cDD: 541 persons, cDTl activities such as health education' sensitization, advocacy, mobilization, _Mectizan procuremenu distribution, monitoring -- and supervision are being implemented in the project. Training of

socr

members and

LocTs

^.

on community self-Monitoring (csM) and stakeHolders Meetings (sHM) _{has been} completed. -.

community self-Monitoring

is

being implemented

in 13 of the 564 _CDTI

communities, communities have accepted ownership of the project and some (174 outof 564) are supporting distribution by paying transport costs for cDDs to collect Mectizan as well as providing _assorted incentives' During the past _treatment year (october 2001

to

septem ber 2oo2) contributions

from partners totaled N533,500

i.e.

N260,500 from

the

LGAs, N171,200

from the

state Government and N101'8oo from the communities. There is keen interest on the part of policy makers and project _managers

to

integrate

cDTl

into other health programmes in the state.

However there is yet no policy to promote integration

constraints faced by the project _include, absenteeism _due to rural urban migration, faith based refusals' difficult terrain, frequent transfer

of

^health facility

staff,

inadequate funding _by Government and row compensation of cDDs by communities.

As at september2oo2, a total of 301,165 persons outof a population

of

434,g44registered _in 564 hyper and meso endemic villages in 40 health districts in g LGAs had been treated using

829'415 tablets

of

Mectizan. Geographical coverage

was

1oo% and therapeutic coverage 69'20/o' Treatment for the year octob er 2o02to september 2003 is yet to be concluded.

IO

C.

METHODOLOGY

o

Evaluation question...How sustainable is the Abia State CDTI project ?

. Design

...Cross sectional, participatory and descriptive

_ . Population...

^... Abia State project, including its SOCT, its NGDO partner;

Its LGAs with their LOCTS, the project communities, project villages and their CDDs

. Sampling...

... Details of the sampled districts and villages are contained in

Table 1 below.

"

_Sampling

The

sampling

for the

evaluation

was

purposively done, based

on the

primary criteria of coverage (geographical & therapeutic). Secondary criteria for sampling were the following:

.

Endemicity level (the sample contained both hyper and meso endemic areas).

.

Geographical spread: sampled villages were from different areas of the project area.

o

Accessibility/convenience:

sampled villages were selected taking into

^account

accessibility and convenience to ensure that the state is covered within the limited ^period of the evaluation.

There are eight CDTI LGAs in Abia State with six of them in the north and central ^part of the state while two are located in the southern area. Two LGAs are hyper endemic while six are meso endemic. One LGA each was selected from the north, central and southern parts of the state one of which was hyper and two meso endemic LGAs. Considering the difficult terrain,

-

.

most of the communities selected were those that are easily accessible.

ll

t2

There is

a

100% geographic coverage in all the endemic LGAs and communities. Ukwa ^East LGA with the highest therapeutic coverage of 81%, lkwuano LGA with the least therapeutic coverage of 640/o and Umunneochi LGA that had a medium coverage of 68% were selected.

The district health facilities and villages were also selected based on the same criteria. Details of the sampled Districts, Villages and FLHF are shown in the table 1.

TABLE 1: DISTRIBUTION OF SAMPLED LGAs, HEALTH DISTRICTS & VILLAGES S/N Health

District (Division)

Therapeutic Coverage

Endemicity Health Area CommunityA/illages (Therapeutic

Coveraoe)

1 Ukwa East High (81%) Meso Umuigubeachar

a ^(82o/o)

1.

Umunwankwo (78%)

2.

Amaoba $2%\

Azumini ^{(63.9%) 1.}

2.

Obozu (55%) Umuooo ^(83%) 2. Umunneochi Medium

(6e%)

Hyper Ngodo (62.2%) 1. Uhude ^(39%) 2. Umuada $7o/o\

Umuchieze (67.4%)

1. Obiagu-Lekwesi (91Yo)

2. Ama Oqidi $4Yo) 3. lkwuano Low (64.0%) Meso Oboro ^(57Yo) 1. Aroayama ^(96%) 2.

Omuiou

$0%\

Ariam/Usaka ff7.6%\

1. Azunchayi (85%) 2. Uoa fi1%\

t2

l3

Sources of information

lnformation was collected at State LGAs, FLHF and community levels from the following sources:

o

Verbal reports

o

Documents

o

lnterviews

management staff.

staff.

lnformation was recorded on the evaluation instrument and each indicator scored independently by each evaluator. Details of indicators scored at each level are shown in Table 2.

Table 2 lndicators scored at each level

,/

_{= Scored}

X

= Not scored

After field visits, a one day planning meeting was conducted for State SOCT members, Budget

&

planning officers and DPHC. During

the

meeting, findings presented by

the

team were discussed exhaustively

by the

participants. Problems were identified and solutions

to

the

Cateoorv lndicator State LGA FLHF Communitv

Activities & Progress which support CDTI

Plannino

Leadershio X

Superuision Mectizan suoplv Traininq and HSAM

lntegration X X X

Resource provided Funding (financial) Other resources (Transport etc)

X Human resources

Results achieved Coverage

14

problems proffered. Thereafter,

the

SOCT members and principal officers

of the

^Ministry

worked together in ^producing a three-year post APOC sustainability plan for the State. A two- day planning meeting was held for CDTI implementers and partners from the LGAs. Findings at LGA, FHLF and community levels were presented after which a SWOT analysis facilitated by SOCT members was conducted. Participants then worked in LGA groups to produce three-year post APOC sustainability ^plans for the LGAs.

Analysis

Based on the information collected, each ^indicator was ^graded on a scale of 0-4, in terms of its contribution to sustainability. Team ^members exhaustively discussed findings and ^average sustainability score for each indicator at each level calculated. A graph was plotted for each the level being assessed. A SWOT analysis was also participatorily done during the ^planning

workshop to assess the performance ^of the project at each level of the project. Participants from the State and LGAs developed three-year ^post APOC sustainability plans for the ^States and LGAs using the outcome of the SWOT analysis.

t4

l5

D. EVALUATION FINDINGS

'1.

Findings at the State level

Fig. 1: Abia CDTI Project: Sustainability at State ^Level

3.5 sf, vJ .Eo) ^-

'd

^z'5

o2

= o)(o L

9

^1s

1

0.5

0

*."* _.".'c

.t"--"

..-.

...un"t'oo

(.e"&t

..no.

"r"t*

o,s' ""tt'"

f ^s-b'I

Group of lndicators

Plannino

(2.13

Moderatelv):

There is an existing ^plan for onchocerciasis control activities and it is part of the overall annual plan of the department of Public Health and Primary Health Care and also of the State Ministry of Health services. There are also monthly plans for core CDTI activities at the project office.

All programmes submit ^plans which are consolidated into an annual plan for the ^MoH. There is no direct evidence that planning is integrated as this is not the system within the Ministry. All programmes submit ^plans which are consolidated into an annual plan. The planning process is not integrated as this is not the ^policy within the Ministry.

l6

There is a written ^plan for CDTI activities at this level. This ^plan, which provides ^key elements of CDTI, is not a re-write of ^previous year's plan and is targeted at specific activities. This ^plan exists within the overall ^Ministry of Health plan, The existing plan has a bulk budget ^amount for all CDTI activities. However, ^it does not specify activities that would need to be funded by the various partners, does not specify the costs to be borne by each partner and does not indicate activities that would ^need to be funded ^post APOC. A supplementary ^plan for 2003 was produced just before the evaluation team arrived. There was a similar ^plan for 2002 which varied with respect to line item and bulk budget amount.

The team was informed that the main ^partners

-

^Ministry of Health (Oncho Coordinator, Assistant Chief Planning Officer ^of the Ministry and State DPH/PHC) and the ^{NGDO (Project} Administrator) participate in the ^planning. These plans are presented and adopted at

NOCP/NGDO review meetings. There are however no minutes of these meetings and no evidence that participatory ^planning was done. The adopted plans are consolidated ^{into the} MoH plans and sent to the State Planning Commission for approval.

The State Oncho Coordinator has ^produced a ^plan for sustainability ^post APOC which ^covers the ^period of October 2OO3

-

^{January 2004. This is yet to be worked on and} finalized with the MoH and the ^NGDO. There is no plan for the ^period beyond 2004. The Permanent Secretary ^is strongly in support of integration and plans to hold a meeting with programme officers and supporting agencies to discuss integration. ^She explained that sustainability ^plans would be fully developed after LGA Chairmen are appointed and planning meetings are held.

Monitorinq/supervision ^(3.0 Hiqhlv)

There are 5 SOCT members ^{and each} one is responsible for monitoring and supervision in ¹ or 2 LGAs. A ^{monthly work plan,} which includes monitoring ^and supervision, is prepared. ^Though monitoring and supervisory checklists are ^used and reports written, there are no written reports of follow up activities.

The SOCT members monitor ^and supervise distribution as scheduled in the ^plans. This is

mainly at the LGA level with spot checks to communities. There ^is a minimum health package ⁱⁿ the State and sometimes all programme officers ^work together. For example recently ⁱⁿ

l6

t7

Obingwa (UNICEF assisted ^LGA) all ^programme officers visited as a team and carry out separate interventions.

Occasionally there is integrated monitoring and supervision, but the timing is usually tied to the CDTI programme schedule ^because of lack of vehicles and availability ^of the CDTI vehicle.

:_

^Other programme officers often schedule their monitoring trips to coincide with CDTI activities.

The SOCT members monitor and supervise distribution. This ^is mainly at the LGA levelwith spot checks to communities. There ^is a minimum health package in the State and sometimes all programme officers work together. For example recently in Obingwa (UNICEF assisted ^{LGA) all}

The system in ^place for solving problems is the normal administrative procedure. ^lf there is a

problem in an LGA the SOCT in-charge of that LGA is responsible for ensuring that the problem is solved. lf the problem persists, it is reported to the State Oncho Coordinator who

Where successes are recorded, they are noted and the officer or team ^is commended. For example in 2001 lsuikwuato ^{LGA had} the best therapeutic coverage and as incentive, the coordinator was nominated to attend an NOTF/APOC review meeting in ^Kaduna.

Mectizan Procurement and Distribution ^(3.0 Hiqhlv)

".* * t"" ^- *,t"*f

the availability of Mectizan@, the drug is collected by the State from the NGDO office in Owerri and kept in the Oncho Coordinator's office from where the LGAs are quickly informed to come and collect their allocations. Though this ^proT'ect system

Of storage is seen as dependable for quick delivery to the LGAs, it is not the Sfafe drug delivery sysfem. Mectizan is not stored within the drug supply system of the Ministry. The excuse provided is that the medical store is ^not safe as such the drugs are often pilfered from

..there.

18

Traininq and HSAM (3.0 Hiqhlv)

Staff at this level have required and adequate training skills. The SOCT menbers train ^the LOCTs on CDTI and they in turn the CDDs. Each SOCT member handles specific topics ^during training using appropriate training materials like ^reporting forms, flipcharts, posters ^and

brochures. New LOCT members transferred from ^non endemic areas are trained alongside old members. The content of the training ,therefore covers the entire CDTI aspects. The content does not change much over the years except when new aspects such as Community Self- Monitoring and Stakeholders ^Meetings are introduced. When this is the case, training is targeted at the new aspects. There is minimal integration of CDTI trainings with trainings carried out by other health programmes

.

^{There is no} clear policy on integrated training.

Briefings are carried out from time to time for decision makers and other staff in the Ministry to advocate, health educate, sensitize and mobilize them. ^For example when the current

Permanent Secretary was appointed, ^HSAM was carried out and as a result she visited some LGAs for advocacy and spot checks. ln other ^instances when planning division requires

clarification on issues HSAM is ^provided. Whenever necessary, advocacy visits

are

^{made to}

LGA Chairmen and council ^members. the concept of CDTI was explained to them and support for CDTI activities solicited.

lnteqration of Support Services ^(2.0 Moderatelvl

There are no indications that support programmes are planned and executed in an integrated manner. There is _, however, evidence of instances where SOCT members are involved ^{in other} programmes in the Ministry of Health. For example, one member of the SOCT is a health educator for CDTI and other programmes. Another SOCT member is primarily ^a staff in the budget and planning unit of the Ministry. The Data Manager also manages data for other ^health programmes in addition to managing CDTI data. There is, however, no policy on integration.

l8

t9

Financial ^(1.75 Moderatelv)

Budgeting is carried out following the government's procedure. There is a budget line for onchocerciasis control activities which is listed under subhead 12 in the recurrent budget of the MoH. The budget estimate for 2003 is N100, 000.00. There are other CDTI activities, which are covered under other budget lines like travel, training, stationery etc. This is to ensure that the project has other budget lines from which funds can be sourced for CDTI activities.

No amount was budgeted for 2002 Onchocerciasis control activities but the state government released N500, 500 from the 2001 budget for activities in 2002. Activities such as training, travel, stationery were covered by other sub heads within the Ministry of Health budget. This also applies to the 2003 budget.

The sum of N1.5 million was requested for from the state government for core CDTI activities ⁱⁿ 2003, but there has been no approval yet. However the MoH has so far expended N93, 930 on vehicle spare parts, fuel and vehicle maintenance in 2003. A supplementary budget has been prepared and submitted to the government but there has not been any reaction to it yet. The situation was not different in the ^previous years. ln 2002 the MoH released the sum of N76, 200 for stationery, entertainment during meetings, and advocacy. The sum of N550, 500 was

requested forthe project in 2001 and N370, 100was released and used forcollection ^{of capital} equipments from WHO Lagos, allowances, vehicle repairs, fuel, and other miscellaneous expenses. The reason given for low budgetary provision and release of funds is that Government financial resource ^has dwindled in the past years.

There are no plans to source for any dependable ^post APOC funding. lt is however believed that budget shortfalls or deficit could be bridged from other sub heads within the state MoH budget and from the 5% the ministry keeps from all revenue it generates. The DPH/PHC is however considering approaching the supporting NGDO to fund some core CDTI activities The State Oncho coordinator requests for APOC funds through the DPHC. Funds from the State for Onchocerciasis control activities are approved by the Permanent Secretary and goes through the accounting system in the ministry before it is released. APOC funds are accessed

20

through the NGDO office in Owerri because the project is administered as lmo/Abia project with APOC funds managed by the NGDO accountant .ln February, 2003, APOC funds were

transferred from NGDO account ^{in Owerri} to a State account in Umuahia where the funds are processed and disbursed within the MoH under the supervision of the NGDO. However, ^there are no clear guidelines as to how this is done because there is no project accountant for the State CDTI ^project.

The project has depended heavily on APOC funding since inception. Government ^of Abia State has not provided adequate financial support. lt is difficult to make out magnitude ^of financial and material support provided by the NGDO since the project is jointly administered with lmo State project as Abia/lmo project. APOC financial support of the project is due to end in September 2003.

Transport and other Material Resources ^(2.5 Hiqhlv)

Routine maintenance is carried out for the vehicle and other equipment, but there is no record of maintenance (no maintenance ^book). The MoH and NGDO provide additional vehicles ^when needed to ensure that CDTI activities are not disrupted. The MoH provides funds for vehicle maintenance.

Transport is adequately utilized for CDTI activities at this level although authorizations for the use of the vehicle are verbal based on approved workplan. There is no abuse of vehicle usage.

The vehicle is functional and will serve the ^project for at least the next two years. Though ^policy makers in the Ministry of Health are committed to replacing the vehicle and equipment ^when necessary, most of the officers interviewed ^at this level do not consider this feasible because of the prevailing financial problems ⁱⁿ the State.

20

21

Human Resources ^(4.0 Fullv)

There are five SOCT members who are likely to remain in their ^posts for ^long. They are

committed to the project and some of them have been in the programme for 13 years. There is a high level of team spirit. There are plans to train more officers on CDTI and replace any SOCT member transferred. Motivation is however poor due to delay in ^payment of salaries by Government.

Coveraqe ^(3.0 Hiohlv)

Treatment for 2003 is still in progress and final treatment reports for 2003 are not available.

Therapeutic coverage reported for 2002 and 2001 are ^640/o - 81% and 61% - 81%) respectively.

It was however discovered that therapeutic coverage in most communities is wrongly calculated, using eligible population as denominator instead of total population.

2.

Findings at LGA Ievel

4.5 4 3.5 3 2.5 2 1.5

1

0.5 0

t

.9o

}

o

E')(!

o

-""""-."'" _*.o'd tr.""'" ^-"" -.-""-""""

Groups of

tndicators ^d'd'

Fig. 2: Abia CDTI Project. Susutainability at LGA level

22

Planninq ^(2.0 Moderatelv)

The ^plan for Oncho control activities ^is separate and ^included as part of disease control under the PHC in the overall LGA plan. The Oncho plans do not in most cases have budgets

estimates for CDTI activities.

Leadership ^(4.0 Fullv)

The LGA Oncho Coordinator is in charge of activities at this level and initiates activities. ^There are 3 LOCT members who assist the coordinator in implementing CDTI. However, ^CDTI officials are supervised by the head of Health unit.

Monitorino/Supervision ^(1.3 Sliqhtlv)

Reporting is done on a monthly basis and sent to the State Oncho Coordinator. This is

however _-.

not within government system; i.e. is through the monitoring and evaluation unit. Supervision is carried out at this level up

to

the FLHF level, with spot checks to communities. These trips are, in most cases, routine without definite schedules ^and are not targeted to solve problems. There are no supervisory checklists or written reports. The visits are not integrated and no deliberate efforts are being made to ^integrate.

It is not the practice in the LGAs to integrate monitoringisupervision. The Oncho coordinator deals with problems when they arise, but in instances where such problems cannot be solved by the officer, they are reported to the appropriate higher authorities at the LGA level, and if necessary, at the State level.

There were no evidences that successes are recognized and commended or feedback given to persons concerned.

Mectizan Procurement and Distribution ^(2.5 Hiqhlv)

Request for Mectizan made by the LGA is based on community requests indicated in the previous year's community summary forms. Mectizan supply is timely with

no

shortages and wastages.

22

The LGA Coordinator ^goes to collects Mectizan from the State and stores it in his office. There is no clear indication that government provides transport for the collection of the drugs from the project level. The drug is not controlled within the government system.

Traininq and HSAM (2.3 Moderatelv)

The Oncho Coordinators and LOCTs train the District Health Supervisors (DHS) and ^FLHF staff who in turn train the CDDs under the observation of the coordinator and the LOCTS.

Training is more a routine than targeted activity with set objectives because

of

frequent transfers within the system. New LOCTs, DHS and FLHF staff are trained annually alongside old LOCT members and the entire content of CDTI training is covered all over again during each training session. Trainings are not integrated with training by other health programmes.

There are sufficient human and material resources for training at this level. Training is not integrated because this is not the practice in government, because it is ^not a ^policy.

HSAM is carried out to policy makers and decision makers at this level. This is usually targeted at new decision makers to solicit for their support and commitment. Positive impact of HSAM was noticed during interviews with decision-makers at this level.

Financial ^(0.5 Sliohtlv)

CDTI is usually budgeted for under PHC under the health sector subhead. This is not clearly spelt in the budget as CDTI or Onchocerciasis control. There were disbursements of funds, though it could not be ascertained if these were disbursed directly from the

budget.

ln 2002 Umunneochi LGA spent N135, 000 for core CDTI activities. ln Ukwa East N130,000 was expended for training, transport and stationery in 2002. There is no evidence of any dependable resources to support CDTI ^{post APOC.}

No budget documentations are available with the coordinators. However the finance departments have documents showing had approved budgets as well as some records of expenditure for CDTI activities.

24

Transport and other Materials ^(2.25 Moderatelv)

Functional motorcycles are available at the LGAs but these will not be functional for the next 5 years. These motorcycles are under the custody of the coordinator and not in the ^pool of vehicles. There is routine maintenance of motorcycles ^but there is no evidence of schedule or record of maintenance. The Oncho Coordinators maintain their motorcycles ^and submit claims to the LGA for reimbursement. Their expenditure is, ^{in most} cases, no reimbursed. The LGAs provide alternative transport when the motorcycles ^break down. Policy makers at this level are confident that LGAs will continue to maintain the motorcycles ^but cannot guarantee

replacement. The motorcycles are also ^{used by} other ^programme officers to support activities at FLHF level. The motorcycles are under the custody of the Oncho coordinators but other programmes have access to it. There are no written authorizations to travel. This is usually verbal. Motorcycle ^logbook was found in only one LGA.

Human Resources ^(3.0 Hiohlv)

Staff members, are satisfied with their work, have enough skills to undertake all CDTI activities, and are committed to their responsibilities. Motivation is however poor because salaries are delayed. There are

no

motivational practices because of lack of funds.

Coveraoe ^(3.5 Hiqhlv)

Geographic coverage is 100%, while therapeutic coverages for the LGAs visited are

2002.

^....680/0 (Umunneochi),64% (lkwuano) and 81%(Ukwa East).

2001.

^....83% (Umunneochi) 61%(lkwuano) and 73% (Ukwa East).

2000.

^....650/o (Umunneochi) 52o/o (lkwuano) and 69% (Ukwa East).

24

25

3.

^{Findings at} the First Line Health Facility (FLHF) level

Fig. 3: Abia CDTI Project. Sustainability at FLHF Level

$

.9_o

=o

C"

IE

o

4.5

4 3.5 3 2.5 2 1.5

1

0.5 0

.*oe

""""t ."""" q..c ^t'""

Groups of lndicators

..c

at""

"/

a"""

"...,

Planninq ^(2.0 Moderatelv)

ln most of the FLHFs there are no written plans or time tables for CDTI activities. Two of the facilities have plans, which are not integrated into the overall plan of the area and are not part of a minimum package at this level.

Leadership ^(3.0 Hiohlv)

Officers in charge of the FLHFs are also in charge of CDTI at these levels and are responsible for initiating CDTI activities like training of CDDs, monitoring and supervision. There are a few instances where the officers have to come from other district health facilities to initiate CDTI activities at the FLHF.

26

Monitorinq/Supervision ⁽¹ .7 Moderatelv)

Supervisory visits are ^{made to} each community at least once a year. These visits are mainly routine, not targeted and not integrated with any other health programme. Reports are sent to LGA coordinator for collation after each treatment round. The team did not see any filed reports at this level. The reporting system is not part of the standard reporting process of the health system i. e. it is not part of the monitoring and evaluation minimum reporting package. Staff at this level deal with problems identified during visits to the communities. This is usually done in consultation with the communities. Where the ^problems cannot be solved, they are referred to the LGA Oncho coordinator. There is ^no evidence of successes recorded or actions taken based on recommendations from monitoring visits.

Mectizan@ Procurement and Distribution ^(3.5 Fullv)

Requests for Mectizan are based on information on population generated from the community summary forms. This is used to determine the quantity of drug to order. The drug is usually available in time for distribution (January/February) and there are no reports of shortages of or late supply of Mectizan.

Mectizan is stored at the storage facility in the health centre. lt is controlled within the

programme system where the drug is collected from the LGA and managed by the supervisor There are no specific transportation arrangements to collect the drugs from the LGA.

Communities come to the facility to collect their drug allocations and this is recorded in an inventory for stock control. No shortages are experienced at this level.

Traininq and HSAM (2.0 Moderatelv)

The staff at the facility train CDDs and these trainings are mainly routine but targeted in some instances e.g. training of new CDDs and introduction of new operation strategies like the Community Self-Monitoring. Available ^manpower and materials for training at this level are adequate.

HSAM is continuously carried out ^by the health staff based on needs after the initial HSAM carried out at the beginning of the programme. HSAM is carried out during community ^meetings

26

27

and Stakeholders Meetings and is mainly targeted at solving problems. There are however no clear indications as to how these have led to effective actions

Financial ^(0.5 Sliqhtlv)

There is no budget at this level for CDTI activities. Funds are not usually disbursed from this level directly for CDTI activities. One FLHF wrongly uses funds ^generated from drug revolving scheme (Bamako initiative) to defray costs for CDTI activities. ln one instance application for funds by a supervisor was approved by government and funds released.

Transport and other Material Resources ^(1.5 Moderatelv)

Transportation at this level is inadequate. There are no reliable alternatives except to hire vehicles at high costs. Government has not been forth coming in maintenance and replacement of motorcycles. There are no records of maintenance and maintenance costs is borne by the staff. No log books are used and there are no indications that authorizations are given. There are no realistic ^plans to replace motorcycles.

Human Resources ^(2.0 Moderatelv)

Staff members have enough knowledge and skills to undertake CDTI activities. Staff can be transferred at any time thus cannot be said to be stable. There are no plans for in-service trainings.

Coveraqe ^(4.0 Fullv)

Geographic coverage is 100%.

28

4.

Findings at community level

Fig. 4 Abia CDTI Project :Sustainability at the Gommunity Level

4.0

3.5 3.0 2.5

2.0 1.5 1.0 0,5

0.0 o)

.=E

c(u

o-

o-

=

^a

Eo_([

Jo)

(,)c

Lo

=

_c

o

=

c(U

N

oo

= a I

16'o

C(!

h

C

c(6

E

I

J

o

C,)(!

o Oo Group Indicators

Planninq and Manaoement ^(3.0 Hiohlv)

On notification of the availability of Mectizan at the FLHF level, the CDDs collect the drug after consultation with community leaders and members. They also agree

on

mode and timing of distribution. This is usually done at community meetings and in churches. Community census ^is updated before distribution ^commences.

Leadership and Ownership ^(3.0 Hiohlv)

ln most of the communities visited, the community ^leaders are responsible for distribution ⁱⁿ their communities. There is adequate coverage (therapeutic and geographic) except in a few instances where ^low therapeutic coverage was found to be due to ^non commitment from ^the

28

29

CDDs. Community leaders, when informed of problems, try to solve such problems with the CDDs

Community members are involved

in

decision making in CDTI. They select their CDDs and decide on time and mode of distribution. There are, however, a few communities where the community leaders and council chiefs choose the CDDs without the participation of other community members. There are also a few communities that are under the illusion that the CDDs must be females. ln most cases distribution is from house to house.

The community members believe that taking Mectizan will cure them from river blindness and prevent blindness. Other advantages mentioned ^include good health, expulsion of worms and clearing

of

scabies. The communities are also aware that the drug should be taken annually but most cannot tell for how long. ln a few cases where the communities know the duration of treatment, they can not explain the reason for the need to take the drug for the specified ^period.

Monitorinq ^(3.0 Hiqhlv)

At the end of treatment, CDDs coltate their treatment figures and submit to the DHS. There is usually no delay in doing this. Most communities do not provide transport for the submission of reports. The reason given for this is that the FLHFs are close to the communities.

Mectizan@ Procurement and Distribution ^(3.0 Hiqhlv)

The right amount of Mectizan is usually received and distributed. CDDs are given one tin of Mectizan at a time to distribute and this is replenished by the DHS. Most CDDs do not know how to calculate the number ^of tablets of Mectizan to order for their communities and depend on the supervisors to estimate the number of tablets ^required. The CDDS usually collect the drug from the central collection point. ln most cases no adequate transport arrangements are made by the communities for the CDDs to collect the drugs, because the FLHF are close.

30

Traininq and HSAM (3.0 Hiqhlv)

CDDs and community leaders are involved in HSAM particularly during community meetings and stakeholders meeting. lnformation is only occasionally provided by CDDs to persons who refuse treatment to ^persuade them to take Mectizan.

Financino ^(3.0 Hiohlv)

Most of the communities provide incentives for their CDDs except in a few cases where the communities are not aware of the need for incentives and therefore do not provide any material incentives. Most communities give an average of N1,000

-

N2,000 to their CDDs. ln all cases, the communities provide treatment registers and writing materials.

Human Resources ^(2.0 Moderatelv)

The ratio of CDDs to population is inadequate. On the average, each CDD treats between 500

-

⁶⁰⁰ persons. Most CDDs have to walk considerable distances to cover all households assigned to them. Many of the CDDs have good reporting skills as reflected in their treatment registers. Exclusion criteria are known and observed, while cases of side effects are usually referred to health facilities. Communities have arrangements for selecting and training new CDDs when there is need for replacement . However replacements are not common because CDD attrition rate is low. ln all communities visit except one, the CDDs express willingness to continue distribution for a long term. The one exception is a community where the former CDD was banned from participating in community activities because she insulted the village head.

The two young school leavers who have been assigned to replace her, indicate that they will leave the assignment as soon as the gain employment outside the village.

Coveraqe ^(3.5 Fullv)

The communities visited have treatment registers and coverage of households is 100% in most communities. However the team found that therapeutic coverage for the most communities is calculated using the eligible population instead of total population. There are also some discrepancies found between the coverage rate provided by the SOCT and those in the treatment registers in the communities. Therapeutic coverage reported for 2002 ranges between 36% and 96%.

30

E. OVER.ALL SUSTAINABILIW GRADING OF ABIA STATE CDTI PROJECT.

With respect to

the

seven aspecfs

of

sustainability, attitude

of

staff, community ownership and effecfiyeness

are

found

to be

very much helping sustainability, while efficiency, and simplicity

are

moderately helping sustainability. lntegration

is

moderately blocking while resources (particularly financial) is found to be seriously blocking sustainability.

o

lntegration:

lntegration

of

CDTI into health system is weak at

all

levels (but scored only at state level). Effort

at

integration has been ad hoc

-

^more

^of

occasional collaboration ^than integration.

Government financial contribution to CDTI has been very poor at the state level and non existent at LGA and FLHP level. Only the communities support CDTI impressively.

:

' '

ffiietiffi

integrated ptanning and negtigibte integration, project stilt manages to be fairly efficient.

*)

_Procedure for accessing funds still not clearly defined.

.

Attitude of Staff:

Staff very skilled and dedicated at all levels.

.

Community Ownership:

Level of community ownership high. Deficiency funds only when community is not aware of need to act, e.g. selecting more CDDs to attain CDD population ratio etc.

Effectiveness:

Coverage

is

good with 65% treated

in

most communities and 100o/o coverage

of

all communities covered.

31

32

Considering the six critical elements of sustainability, there is no problem with supervision, Mectizan supply and political commitment and transport ^(for minimal essential activities).

However, there is serious ^problem with financial support of the programme by Government and there is no dependable plan for replacement of vehicles.

Grouping the indicators under this categories, activifies, resources, and results, the ^projects to seem to have achieved good results in spite of poor resources and minimal integrated

planning. Average score for all levels is 2.6 for activities, 2.3 for resources and 3.5 for result.

32

33

It is obvious that the good result cannot be sustained ^past APOC without adequate alternative sources of support being secured.

TABLE

3

Scoring under categories of indicators

Gategory lndicators Scores

State LGA FLHF Community

Activities and ^processes which support CDTI

Average overall score for category at all level 2.6

Planning 2.13 2 2 3

Leadership

x

^{4 3.0} 3

Supervision & Monitoring 3 1.3 1.7 3

Mectizan supply 3 2.5 3.5 3

Training & HSAM 3 2.3 2 3

lntegration 2

x x

X

Resources ^provided Average overall score for category at all level 2.6

Funding 1.75 0.5 0.5 3

Transport & Other resources 2.5 2.5 1.5 X

Human Resources 4 3 2 2

Results achieved

Average overall score for category at all level

Coverage 3 3.5 4 3.5

Average Score 2.7 2.64 2.5 3

34

F. SWOT ANALYSIS FOR EVALUATION OF SUSTAINABILITY OF CDTI PROJECT ^IN ABIA Table

4

^{SWOT ANALYSIS} - STATE LEVEL

lndicators Strength Weakness Opportunities Threats

1 Planning Plan exists. No integration in planning .

No records of meetings of oartners are keot.

Partners meet.

Plan exists for Oct 03-Jan 04.

No plan beyond January 2004.

2 Monitoring And supervision

SOCT members visit health facilities frequently.

System in ^place for oroblem solvino.

No follow up activities after supervisory visits.

Some integrated monitoring and supervision.

Bureaucracy delays problem solving.

3 Mectizan Procurement &

Distribution

Timely and regular delivery of Mectizan.

No shortage and ^no wastage of tablets.

Drug system not within normal government procedure

Effective System for procurement and delivery of Mectizan could be adopted by other health

programs

Non integration into Government drug system not good for sustainability.

Government may not be moved to support the project if the drug procurement system is

parallelto existing system.

Government willnot appreciate the effectiveness of the svstem.

4 ^{Training and} HSAM

SOCT members qualified and skilled for training.

Training materials available and adequate.

Good arrangement for training of new LOCTs Adequate briefing of MoH oolicv makers ^.

Minimal integration of training Training of old LOCTs not targeted.

Briefing of MoH policy makers provides opportunity for advocacy for adequate funding.

Routine, non targeted training will be boring, unproductive, and ineffective... will not lead to improvement in quality of implementation of the ^project.

5 lntegration of Support Services

lntegration of support services.

lntegration does not go beyond support activities

to ^programme

implementation.

SOCT ^{members are} also involved in other programmes.

lntegration of support services provides opportunity for practical integration of CDTI with other health

Droorammes.

6 ^Financial Budget line for CDTI exists.

No accountant at state level.

Ability to obtain funds from other sub-heads is qood

Adequate funds cannot be gotten from other sub-heads due to

34