Evaluation of the sustainability of Liberia CDTI projects at the national level

World Health Organization/African Programme for Onchocercias is Gontrol LTBEItTy 1 t' .1 -- i,-\ !iRrt Evaluation of the Sustainability of Liberia GDTI Projects at the national level IIE:l I tr t {Evaluation Team DRAFT REPORT, August 2011 Team Prof. Oladele AKOGUN Dr Richard NDYOMUGYENYI Dr Andrew Nude ATABE Dr Emmanuel Nwabueze AGUWA Mr Lazarus NWEKE Mr Nicholas Norbert A. OGWENG Secretariat: NocP/MoH: Anthony Bette (National coordinator), Thomas Nagbe (NTD Manager), WHO/APOC: Ukam Oyene, 2 TABLE OF CONTENTS ABBREVIAT!ONS/AC RONYMS ACKNOWLEDGEMENT EXECUTIVE SUMMARY THE WAY FORWARD 1.0 INTRODUCTION 2.0 METHODOLOGY 2.1 Sampling 2.2 Sources of lnformation 2.3 Analysis 3.0 EVALUATION FINDINGS IN LIBERIA - NATIONAL LEVEL 3.1 Conclusion and Grading the County project Sustainability J Acronyms APOC CDD CDTI CHC CHDD CHO CHSW CHT CM COS DHOs EPI FLHF gCHVs GOL HSAM MOHSW NA NDS NGDO NOCP OlCs SSI African Program on Onchocerciasis Control Community Directed Distributors Community Directed Treatment with lvermectin Community Health Committee Community Health Department Director County Health Officer County Health and SocialWelfare County Health Team Certified Midwife Cou nty Onchocerciasis Supervisor District Health Officers Expanded Program on lmmunization Front Line Health Facility general Community Health Volunteers Government of Liberia Health education, sensitization, advocacy and mobilization Ministry of Health and SocialWelfare Nurse Aide National Drug Services Non-governmental Developmental Organization National Onchocerciasis Control Program Officer in Charge SightSavers I nternational 4 ACKNOWLEDGEMENT We wish to express our sincere appreciation to all those who made contributions to the successful accomplishment of the evaluation task, especially: . The Director, APOC, Dr. Paul-Samson Lusamba-Dikassa and staff in Ouagadougou for their confidence in the team and for providing the necessary support for the success of this assignment. . The WHO Representative in Liberia, Dr. Nester Ndayimerije, ltlr Ukam Oyene, Technical Officer and Dr Peter Clement, and for providing the wherewithal for the evaluation. . Deputy Ministers and Assistant Ministers, The NTD programme manager and the National Onchocerciasis Control Programme Coordinator for an assured environment for the assignment. . County Health Officers and their staff at all levels in Maryland, River gee and Grand Gedeh for making providing evaluation information and lastly . Health personnel and community members in Maryland, River Gee and Grand Kru Counties whose time and knowledge contributed to the success of the mission. 5 EXECUTIVE SUMMARY Overuiew ln Liberia there are three CDTI projects sponsored by APOC. These are the North west (1999), the south East (2002) and the south west lzoozj. rne 2003 war disrupted the project and by 2005 all were re-started. lt then follows that by 2011 all CDTI projects would have gone on for at least 6 years and need to be evaluated for sustainability for period when APOC funding will stop. Though there were three regional WHOiAPOC projects involving onchocerciasis control, indeed the operational levels of the CDTI activities were at the counties. There is no South East, South West nor North West project supervisor. Coordination of onchocerciasis control activities is at the national level. Procedures The national ministry of health and social welfare plays crucial role in coordinating and providing technical support for the activities at the counties. Hence all key staffs involved in onchocerciasis activities (NOTF) were interviewed. Also interviewed were partners like WHo/ApoC, Merlin and Sightsavers. Relevant documents like HSAM materials, Supervisory checklist, Budgetary documents, written year plan, minutes of meetings, log books, trip reports, treatment summary records, etc were sought for. Also examined were availability of transport. These were then scored and presented as qualitative and quantitative variables. Findings 6 At the national level, performance of most of the indicators of sustainability like planning, integration of activities, leadership, supervision and monitoring, mectizan distribution, training and HSAM and coverage for 2010 were good. However, there are still challenges involved in the critical sectors like transport and financing. Though these are in a pool with other health programmes, some vehicles are in need of repair and there are no documented agreements to replace or maintain these vehicles by either the government or the partners. No clear budgetary document was seen and hence, no evidence that excess fund requirement will be taken care of by dependable sources. Conclusion Despite challenges in critical sectors like financing and transport, the overall conclusion of the evaluation team is that the Liberia CDTI is makinq proqress towards sustainability at the national level. Recommendations The following suggestions are made for putting this project on the path towards sustainability and moving it rapidly fonruard: 1, APOC tO a. Extend funding of programmes within the Liberia projects for a further 3- year period to enable it seize opportunity provided by the current policy of devolution and decentralisation of authority to counties, integration of health activities at the national level and county levels. Not to do this may harm the programme 7 b. Provide equipment, vehicles and other capital equipment to enable national and counties carry out diligently the CDTI activities in the entire country 2. NOTF to ensure that a. Transport is available and well maintained. This will facilitate supervision and monitoring especially in the distant and hard to reach counties. b. Have budgetary document that explains yearly budget and containment measures. Dependable sources of funding should also be stated. c. They supply mobilisation and advocacy materials in adequate quantity and give support to counties to raise awareness, mobilise communities and advocate local support for CDTI activities. 8 INTRODUCTION Liberia is founded on July 26, 1847 and is one of the West African countries with an area of 111,369 square kilometres. lt has an annual rainfall of 4,000 mm (one of the highest in the world) and most of it is equatorial rainforest. Liberia has fifteen counties and some of these counties are very far away and could take up to sixteen hours drive through very challenging and difficult roads especially during wet season. Some counties are even inaccessible by road during the wet and have to be reached by using canoe. The African Programme for Onchocerciasis Control (APOC) in collaboration with Sightsavers is supportihg three Community Directed treatment with lvermectin (CDTI) projects in Liberia. The North West, South West and South East CDTI Projects. First Project in North West was approved for five years' funding by APOC from Decemeber 1999 to November 2004 for four counties of Lofa, Bong, Nimba and Montserrado, and two more Projects South West and South East CDTI Projects were approved in 2002 (Master plan for integrated neglected tropical diseases program. Minister of Health and Social welfare. Republic of Liberia. 2011) The civi! war of 1990 - 2003 adversely affected all health programmes. By 2005 these WHO/APOC sponsored CDTI activities were resumed. This means that effectively all these projects have been on for at least six years. Though there were three regional WHO/APOC projects involving onchocerciasis control, indeed the operational levels of the CDTI activities were at the counties. There is no South East, South West nor North West project supervisor. Coordination of 9 onchocerciasis control activities is at the national level. The organogram for part of the Ministry of Health and Social welfare involved in CDTI activities from national to the lowest community level is presented below (Appendix 8) in its simplest form. Over the years there have been changes in the Ministry of Health and Social Welfare towards sustainability of control of onchocerciasis and other NTDs. ln 2007, the Ministry of Health and Social Welfare established the Basic Package of Health Services (BPHS) in order to establish equitable access to health services. There was also a National Health Policy and Plan to decentralize responsibilities to the lower levels of health care. The BPHS did not include onchocerciasis and other NTD but rather other conditions that were perceived as being most critical e.g. maternal, newborn and child health. Realising the need to sustain the control of NTDs when donor support stops in 2009 the Ministry in collaboration with partners developed NTDs master plan to be included in National Health Plan of 2012 - 2021. This involves integrating the activities of NTDs (onchocerciasis, schistosomiasis, lymphatic filariasis and soil transmitted helminthes). The current shift from vertical to integrated approach in control of NTDs is due to its cost effectiveness and sustainability (Republic of Liberia. Ministry of Health and SocialWelfare. 2011). l0 METHODS Data Collection: The Ministry of Health and SocialWelfare plays crucial role in coordinating and providing technical support for the activities at the counties. Hence all key staffs involved in onchocerciasis activities (NOTF) were interviewed. Also interviewed were partners like WHO/APOC, Merlin and Sightsavers. Relevant documents like HSAM materials, Supervisory checklist, Budgetary documents, written year plan, minutes of meetings, log books, trip reports, treatment summary records, etc were sought for. Also examined were availability of transport. All the information collected were entered into an evaluation instrument 1 specially designed to collect information at this level. Both the external and internal evaluators were involved at all stages. The NOTF were eventually debriefed on the findings at the lower level facilities and their comments noted. Data Analysis lnformation was recorded on evaluation instrument 1 which had been validated. Each indicator was graded on a scale of 0-4, in terms of its contribution to sustainability. The average 'sustainability score' for each group of indicators was calculated, for each level. A graph was plotted for the level being assessed. The evaluators took note of the fact that the project has been on in all the three project site for at least 6 years i.e. excluding the war times. These were then scored and presented as qualitative and quantitative variables. 1l 3.0 EVALUATION FINDINGS 3.1 SUSTAINABILTY AT THE NATIONAL LEVEL: Liberia: Sustainability of CDTI at the national level 4.5 4 3.5 3 2.5 2 1.5 I 0.5 444 3.3 4 3.6 l I -t 3.5 3.5 2.7 o, o ttl 1.3 0- *o*..,"""" ff .*."--t .'C ^"""-" .c."d t"t" lndicators Planning: (FULLY: 3.6) 12 There is a 10 year (2011 2012) overall health plan which includes onchocerciasis control activities. This plan was drawn last year, 2010 by NOTF in collaboration with counties and partners. Previous health plan did not include onchocerciasis activities. Some of the partners e.g. WHO/APOC have been given a copy of the health plan. This plan can be viewed at www.moh.qov.lr. This planning was within the overall national health policy of Liberia. There was no separate detailed plan specifically for onchocerciasis control. The over all plan was integrated with LF elimination, EPI and family planning. The other partners decide the aspects of the activities and which counties to assist in e.g. Sight Savers concentrate their activities in the South East Liberia. The over all plan varied from year to year. lntegration: (FULLY: 4) Staff involved in onchocerciasis control also carry out other health activities e.g. EPl. Other programme staff (schistosomiasis, LF and malaria) also routinely participate in CDTI activities and are knowledgeable about CDTI activities. There is an NTD manager who coordinates all activities involving CDTI, LF and Schistosomiasis. Staff combines two or more activities in a single trip e.g. training for CDTI and HSAM activities. Before now (2010) though CDTI was carried out it was not as part of national health plan. l3 Leadership (FULLY: 4) The leadership is up to date with reports. lt delegates appropriately to colleagues. There seems to be a fraternal working atmosphere with evidence of team work. lnstitutional capacity has increased e.g. the MOH is more involved in CDTI activities. NOTF meets regularly - quarterly. There is inter-sectoral collaboration with other departments of MOH. Monitoring/Supervision: (HIGHLY: 3.5) There is no M&E plan/policy for onchocerciasis/NTDs. There is however, a national M&E plan that will be adapted to cater for CDTI. This activity is in the master plan. Treatment summary records for 2010 and 2009 were available. Financial records and Technical reports were also available. Reports are of good quality and look trustworthy. Data and reports are kept both in hard and soft copies. NOTF Staff and partners (Sight savers, CHAL) participate in monitoring and supervision. Though not documented, supervision at this level is limited to the county level about twice a year and is based on need e.g. if there are new COSs or just before mectizan distribution. lnternal monitoring is also done using questionnaires. APOC internal monitoring tools were used last year (2010). The first one has been done for 2011 and a second one is being planned. Supervision is done in integrated manner using the checklist. lntegrated checklist is available t4 and includes supervision for all NTDs. County level staff have been empowered to monitor and supervise FLHF. Two routine supervision visits are done annually and is based on need e.g. if there are new COS or just before mectizan distribution. There is no evidence of more visits. There was an integrated (with other health activities) supervision checklist available. Resources are well utilised for supervision. APOC provides logistics to government and maintains vehicle. Feedback is said to be given to the COSs after supervision: they are told about observed problems and successes. These are however not documented. Mectizan Procurement and Distribution: (FULLY: 4) Mectizan stock for the country is cleared by WHO in collaboration with Sightsavers and delivers it to MoH at an official ceremony. National Drug Service (NDS) stores and supply on approved request by the national onchocerciasis coordinator. The county makes a request to the NOCP which when approved is sent to the NDS. The county health team funds the collection of Mectizan from Monrovia. Mectizan is collected annually. However there was a shortage in 2009 because an order was not made in 2008 for 2009. There was a change in leadership at the NOCP and no one could place an order for the 2009 supply of l5 Mectizan. An integrated approach in the ordering of Mectizan, albendazole and praziquantel has been adopted. Subsequently, changes witl not affect ordering of drugs. Training and HSAM: (HIGHLY: 3.3) Training is cascaded and staffs at this level routinely train those below them. They use local media e.g. radio stations in the different counties. ln 2010 national training program was organized for the counties. Staffs at the counties are empowered to train those at the FLHF. Training is done according to staff need e.g. when there is shortage of staff. Two members of staff are strained per facility so that when one leaves the other will be there to replace. ln 2009 and before only one staff member was trained per facility hence when that person left there was no immediate person knowledgeable on CDTI to replace him/her. Occasionally, already trained staffs are included in the training which is targeted. Training resources were efficiently used. Budgets are done depending on how many to be trained. The high geographical coverage and therapeutic coverage for 2010 is evidence to the effective HSAM activities carried out. Financial: (MODERATELY: 2.7) l6 Budget documents were not seen. Budgetary expenditure is highly controlled by office of financial management (OFM). NOC claims there is cost reduction and containment; this cannot be proven since no budget document was seen. There is a pool fund from where all activities of NTDs, etc are funded. There is no separate budget for CDTI activities. The NOC said that there is no problem with budget since the fund is in a pool and accessible for CDTI activities. Also though it is claimed that the budgetary contributions of the government is increasing, this cannot be verified. Also, the actual amount disbursed is not known. Common basket approach reduces cost since APOC sends limited amount of money. Every project has its money in the pool and a code. Sightsavers are presently involved with assisting in CDTI in the South East Liberia (Letter of Agreement was not seen). Transport and Material Resources: (SLIGHTLY: 1.3) Vehicles are all broken down. However, as part of integrated service, NOC can obtain vehicles from the LF and Schistosomiasis control projects. Activities are not stopped because of lack of vehicles. Funds are not available to repair broken down equipment. There is no evidence of any maintenance / replacement plan for vehicles or equipment. This has created challenges for supervision. A Toyota land cruiser 2007 jeep has been grounded since February 2011 because of t7 $15,000 to repair it. The project is expecting APOC to fund the repairs of this jeep. The NOC hopes that since onchocerciasis control is in the national plan, government will allocate resources to support this. Human Resources: (HIGHLY: 3.5) All staff in the onchocerciasis control office are all new; less than 5 years in their job. The staffs seem to be well orientated in CDTI, although they are new. The policy makers (CMO and deputy ministers) are well orientated in CDTI activities. The CHOs also seem wel! orientated and committed in their job. Coverage: (FULLY: 4) The geographical coverage for 2010 was 99.0% (i.e. average of SE, SW and NW geographical coverage) while therapeutic coverage was 81.0% (i.e. average of SE, SW and NW therapeutic coverage). This is a remarkable improvement to 2009 values where there was shortage of mectizan. l8 Recommendations at the National leve! Recommendation lmplementation Finance There should be clear budget for CDTI activities and amount disbursed spelt out. There should be Letter of Agreements with partners assisting in CDTI activities. Priority, MODERATE lndicators of success: Budget for CDTI activities developed. Letters of Agreernent from partners written. Who to take action: NOTF Dead li ne for co mpletio n: November 30 ,2011 Transport There should be a written vehicle maintenance/replacement agreement. Running cost of transport e.g. fuel taken care of by reliable source i.e. government. Priority: HIGH lndicators of success: Vehicle Maintenance/replacement agreement signed with government and/or partners. Evidence of government taking care of running cost of transport present in budget. Who to take action: NOTF Deadl i ne fo r co mp I etio n November 30,2011 t9 ASPECT JUDGEMENT: TO WHAT EXTENT IS THIS ASPECT HELPING OR BLOCKING SUSTAINABILITY OF THIS PROJECT? (1) !ntegration There is adequate integration at the national level. Resources are shared by various health programs This is helplng the sustainability of the project(2) Resources At the national level there is adequate human resources. Though most are less than 5 years in their job, they are skilled in CDTI activities. There is however, no clear evidence that they have enough resources for cDTl activities because the funding is in a pool for all health programmes. Cost containment cannot therefore be determined and there are no Letters of Agreement with partners to cover excess financial costs. Transport is also most non functional and no maintenance or replacement agreement. This is blockinq the sustainability of the project. (3) Efficiency ln all levels cDTl activities are done efficiently. The implementation of Core CDTI activities such as training and HSAM are often done in time of greatest need (ust before mectizan distribution). supervision checklist is integrated with those of other health programs and was available with the COS. This is helpinq sustainabil rty of the project (4) Simplicity The CDTI project implementation process is simple and is done using the government system. Mectizan is managed using the national drug supply chain approved by the National Drug Service (NDS). This is helpinq sustainabil ity of the project(5) Attitude of staff The attitude of the staff at national level is very positive. Though most are relatively new to the cDTl activities, they are dedicated to their job. This is helplng sustainability of thegqJegt(6) Community Ownership Not Applicable at this level (7)Effectiveness The implementation of CDT I is effective as there is full participation of NOTF staff and there is a remarkable improvement in coverage in 2010. There is also coping mechanism in place to take care of resource (transport) shortage. Ilfgf9 hg.lping_sustainability of the project Conclusion and Grading the Overall Sustainability a) Judgment of the project, in terms of each of the seven ,aspecfs, of sustainability: 20 NOT KNOWN There is no evidence of budgetary allocation for CDTI activities. As part of integration, funds are in a pool that takes care of all health S NO There is no dependable availability of transport hence staff resort to coping mechanisms in times of need. Also there are no maintenance or replacement agreement for the vehicles seen. YES Supervision has been systematic and targeted at solving specific CDTI activities e.g. immediately before and during mectizan distribution. YES The supply system is dependable and sufficient drugs get to the communities on time. Policy makers are aware of CDTI and expressed their commitment to the programme. The CMO and other top health personnel are committed to the CDTI activities and have included it in ten year plan. YES Money.ls there sufficient money available to undertake strictly necessary tasks, which have been carefully thought through and planned? (Absolute minimum residual activities). Transport Has provision been made for the replacement and repair of vehicles? ls there a reasonable assurance that vehicles will continue to be available for minimum essential activities? (Note that 'vehicle' does not necessarily imply '4x4' or even 'car'). Superuision. Has provision been madefor continued targeted supportive supervision? (The project will not be sustained without it). Mectizan supply: ls the supply system dependable? (The bottom line is that enough drugs must arrive in villages at the time selected by the villagers). Political commitment: Effectively demonstrated by awareness of the CDTI process among policy makers (resulting in tangible support); and a sense of community ownership of the programme. Human resources? f I I YES. Most staff in all key areas are highly commltted, competent and willing to continue to carry out their tasks. Thosein other programs are also knowledgeable and willing to assist in CDTI activities. The evaluation team examined the six key aspects of the project - 'critical elements' of sustainability. lf these are not present at is unlikely that the project will be sustainable: 21 I AVERAGE CDTI SUSTAINABILITY ORE AT NATIONAL LEVEL, LIBERIA T,J PE ur u'l ?s frtr IU o tr IJJ o o z =DI Ftr o o.oz E, oz oz z l! z h= r.. ZT lU,y =tr B2 e5 tr= =Ett, o- otr IIJo ulJ 2 o tr E, o UJFz 4 (9 z zz IL AVERAGE FOR NATIONAL 3.6 4 3.5 4 3.3 2.7 1.3 3.5 4.0 3.39 LIBERIA IS MAKING SATISFACTORY PROGRESS SUSTAINABILITY OF CDTI AT THE NATIONAL LEVEL TOWARDS 22 REFERENCES 1. Republic of Liberia. Ministry of Health and Sociat Welfare. Country Situational Analysis Report, 2011. 2. Master plan for integrated neglected tropical diseases program (NTDs) Ministry of health and social welfare. Republic of Liberia. 2011 23 LIBERIA NATIONAL CDTI APPENDICES Appendix 1. Li of Evaluators a) Phone details in Liberia and Home country b) Addresses of Evaluation Team Members 1. Prof. Oladele B. Akogun, Team Coordinator Parasite and Tropical Health, Federal University of Technology, Yola, Nigeria T et: +234-7 5627 281 (offi ce), +2348037 220460 (M ob) E-mail: akoquno@vahoo.com 2. Dr Richard NDYOMUGYENYI Tel: 0880967799 E-mail : richardndvm uqvenvi@vahoo.com 3. Dr Andrew Nude ATABE +237 7 8403038, +23 1 880907 7 84 E-mail: atabe andv@vahoo.co.uk 4. Dr Emmanuel Nwabueze Aguwa Department of Community Medicine University of Nigeria Enugu Campus Enugu, Nigeria Tel. +234803 4873064 Email: enaquwa@vahoo.com 5. Mr Lazarus NWEKE Ministry of Health, Enugu Enugu, Nigeria Tel: +2348065586659 E-mail: nnabuikelaz vahoo.com 6. Mr Nicholas Norbert A. OGWENG Tel: 0880454634 E-mail: nicholasoq@yahoo.cont 24 Appendix 2: Liberia Nationa! CDTI Time Table Date Morning 7- 12 Afternoon 12.00- 16.00 AUGUST Mon 1tr Meeting WR and MoH Tues 2nd lnterviews Team orientation Logistics planning Wed 3to Travel to various project sites (counties) Sat 13th Travel back to Monrovia Sun 14tn Report writing finalization Report writing Mon 15tn lnterview with other NOTF and partners (APOC, Sightsavers and Merlin) Discuss overview of all projects Report editing and printing briefing Tue 16tn Debriefing WR Debrief NOTF Submit draft report to WR Wed 17th Departure Thu 18tn Departure 25 Appendix 3: Minutes of the Feedback meeting and sustainability evaluation to W4Liberia - Dr Nestor Ndayimirije (16h August, 2011) Attendance 1. Dr Nestor Ndayimirije (WR/Liberia) 2. Dr Peter Clement 3. Mr Ukam Ebe Oyene - APOC Technical Adviser (ovene@lr.afro.who.int 4. Prof. Oladele AKOGUN 5. Dr Richard NDYOMUGYENYI 6. Dr Andrew Nude ATABE 7. Dr Emmanuel Nwabueze AGUWA 8. Mr Lazarus NWEKE 9. Mr Nicholas Norbert A. OGWENG 26 APPENDIX 4: PARTIGTPANTS' Ltsr: MtNtsrRy oF HEALTH AND soctAL WELFARE, AUGUST''6, 2011 No Name Position Cel l#/ Email Address I Dr Bernice T.Dahn Deputy Minister of Health Services and Chairman of NOTF/Liberia bern icedahn59@yahoo.com 2 Dr Moses Pewu Assistant M inister Curative Health Services and Co- Chair of the NOTF , Liberia m.pewu@vahoo.com 3 Dr Anthony K. Bettee National Onchocercrasis Coo rd i n ato r, M O H/Li b eri a tbettee@yahoo.com 4 Mr Ukam Ebe ne APOC Technical Adviser ovene@l r.afro.who. int 5 Dr Peter Clement 6 Prof Oladele un 7 Dr Richard Nd mu n 8 Dr Andrew N Atabe I Dr Emmanuel N uwa 10 Mr Lazarus Nweke 11 Mr Nicholas N WE 12 13 14 15 16 17 18 19 20 21 22 23 27 APPENDIX 5: PRESENTATION AT MINISTRY OF HEALTH AND SOCIAL WELFARE, AUGUST 16, 2011 During debriefing, the following are the SWOT analysis and recommendation of the summary of the three projects as presented to the Ministry of Health and Social Welfare on August, 16,2011: COUNTYLEVEL: STRENGHTS . Integration of CDTI into other Health Programs . Reporting of CDTI activities are within the government system . Availability of pool transport . CDTI focal persons are well committed COUNTY LEVEL : WEAKNES SES . No financial work plan and budget at county level ' Absent of integrated written work plan . Delay in vehicle maintenance due to lack of funds . High tumover of staff . Absent of supervision and monitoring reports FRONT LTNE HEALTH FACILITY LEVEL:STRENGHTS . Existence of HF Staff . All CDTI activities are carried out by the facility using government system . CDTI activities are carried out in an integrated manner FRONT LINE HEALTH FACILITY LEVEL:WEAKNESSES . There is no written health plan in all FLHF. . CDTI plans are not written . There is frequent turnover of FLHF staff' . Record keeping is poor. . Do not plan and budget for CDTI . Gross inadequate of transportation in most facilities. . Inadequate IEC materials COMMUNITY LEVEL : STRENGHTS . Community involvement in selection of CDDs . Willingness of the community to take the mectizan . CDDs are knowledgeable in all CDTI activities. . Commitment by CDDs (Collection of drugs, distribution and reporting). Positive effect (benefits) of mectizan treatment COMMUNITY LEVEL :WEAKNESSES Inadequate number of CDDs (resulting to High CDD/population ratio) Low motivation of CDDs by community members. Community leadership is not aware of their roles and responsibility. a a 28 I. Community not aware of its ownership of CDTI ' Recording more than one househord on one page of the register RECOMMENDATIONS l. Project staff should be trained for good and prompt recordings and reporting.2' Government counterpart funding for project activities should be made morevisible. i All appropriate staff at the FLHF level should be trained on GDTI.4 All county oncho supervisors shourd be provided witrr motorcycres.5. More CDDs need to be trained.6' lmprove quality of monitoring and supervision using supervision checklist 29 Cote d'lvolrc , Appendix 6: Map of Liberia Gulnea Slier'ra Leone ATLANTIC OCEAn, 0 3l 4? Milca -+. 30 IAppendix 7: REMO map of Liberia, showing nodule prevalence (pie charts) and treatment priority areas (red zones) Nodules (%) 0 1-9 10-19 20-39 40-100 Rivers Lakcs.shp Parkr CDTI priority areas I N"cDTlarcas Atler to rctinc o o o o exffiI *+,N s 31 aoo a I Appendix 8: Organogram of onchocerciasis control activities Assistant Minister for Preventive Services NTD Program Manager Onchocerciasis Coordinator County Onchocerciasis Supervisor District Health Officer CDD + + + + + Minister of Health and Social Welfare County Onchocerciasis Supervisor Community )Z