Assessment of the sustainability of the Bauchi CDTI project: February-March 2003

World Health Organisation African Programme for Onchocerciasis Control Assessment of the Sustainability of the Bauchi CDTI project February-March 2003 Elizabeth Sara Francis Runumi (Team Leader) Joseph Okeibunor Kenneth Korve Mariam Atty Martin Ogbe v :ir 'y'er,;icit c l-o \=--e1- SDLi L'r:ir, \i,,i)C l-1 '\'1! r\Ir 1 I t II

1TABLE OF CONTENT ABBREVIATIONS/ ACRONYMS .. ACKNOWLEDGEMENTS.. EXECUTIVE SUMMARY I.INTRODUCTION 2.METHODOLOGY 2.1 SAMPLING 2.2 SOURCE OF INFORMATION ...... 2.3 ANALYSIS .......... 3. EVALUATION FINDINGS 3.2 SUSTAINABILITY AT THE LGA LEVEL..... 3.3 SUSTAINABILITY AT THE FIRST LINE HEALTH FACILITY L8V8L........... 4. Overall Self-sustainability grading for Bauchi State.... 5. WAY FORWARD ,2 .J ,4 6 .6 6 ,7j ..8 t4 l9 26 Advocacy Visits to the Policy Makers and Sustainability Planning Meetings. .29 APPENDIX 1. STATE LEVEL WORKSHOP PROGRAMME..... ..............30 Appendix 2: Sustainability of CDTI for LGAs in Bauchi State......... ...........31

2ABBREVIATIONS/ ACRONYMS African Programme for Onchocerciasis Control Community Directed Distributor (of ivermectin) Community Directed Treatment With lvermectin Community Health Extension Worker First Line Health Facility Health Facility Staff Local Government Local Government Authority LGA Onchocerciasis Control Team Non-Governmental Development Organisation National Onchocerciasis Task Force Primary Health Care State Onchocerciasis Coordinator State Onchocerciasis Control Team United Nations Children's Fund World Health Organisation Zonal Onchocerciasis Coordinator APOC CDD CDTI CHEW FLHF HFS LG LGA LOCT NGDO NOTF PHC SOC SOCT UNICEF wHo ZOC JACKNOWLEDGEMENTS We would like to thank the following persons and organisations for their help: . The staff at APOC Headquarters in Ouagadougou: The Director Dr S6k6t6li, is recognised specially for making available the necessary financial and logistics requirements for the success of this assignment. Dr Amazigo, Mr Aholou, Mr Agboton and the others are also recognised for facilitating the smooth running of the mission. . The WR, Lagos and his staff contributed to the smooth functioning of the evaluation team. . Staff of the Ministry of Health in Bauchi State; Princess Patricia OgbuPearce and her zonal team; the State Onchocerciasis Control Team, the LGA and LOCTs provided the enabling environment for the work. . Health workers and community members in the Torg Alkaleri and Gamawa LGAs contributed to the success of the mission. 4 EXtcuTrvE SUMMARY The Bauchi CDTI project has been supported by Apoc for the past 3 years, and is in themid-term or agreed rrr;;; ffi"xlgc. ai ;;j;,r;, of tle ,rrtunruJiifi or tb lJlffi:"X"',JffiX.:'l,ffJtrt]1,t'**.v ",a-'i6"ilru..r, 2003 by u i"u, or sixevaluators *".. .hu.ged with tt r.. turti,t' namely Nigeria, Tanzania uia -uiuraa. The . Evaluating the r.fr:?ir3i'ri_rTir,,e project.' B:[3iJf l:ff : il';?:H#:* j'##[ f .;,m il 1#$# c L G A s pers. n ne, The evaluation was ltlr*Tl:,?dl,,.;,",#Hl.#t#r#::5J*#trllxfi ,Tt';.J.*lil, ffil,,l.ll'"X ffiH[',,'"'rf#, ln]l ^ l:,^ r,,en tia,y . s u s ta i n a bre. rh e rea m h a sjl,,'fi*'ffi :;';g';iy*;;HHf ffi ":ifl fi fff;l#ru**i:i;,33;;g;,.; In line with the O?uru,meeting classification of fifth year,irr?)i#)ilrrlo, o" aiimi, sni,iilii6iir?;;?#I; ",,r,t;):ff;, .""8#;i:,,::,iT,'.''ff :rTT:H;li,;*;,,!i,lxJ3,T!,,broad,vasforows: . Effi:;:::;;;:::::;;v6i:1i,il.1.,";;d; ro'*l'' doth reported therapeutic and use of t.ui.. ..;r?;;;.Jffiilffi: are not properlv targeted, resurting in inerficientr, *, i ",,.' t; ffi ;;l;,il{ ts:'+: 1'.fl rjrj ;nyt uto ry r *, r. i"" i. r ive r c D rrand first line health a.iii,ylij;;; [:lir:"","-:^?] l!: community er.r. ir," r_ca' s i mp I ic,,a,, nortir".;;"':::""::l: 1lt n9t adeq uately empowered. ' ! rig,o;;;'ffi T,:;::,TfiTj'L:if ilffi#;* :f,':; ",, i,:-mg;l*""n**:#1c;,*,1il#'Jffi :xl,1:#[,,'fi:.[;]:iintegrated. ::, -".""'rrrelrulrollor assisted projects i",rr.'r-Car'ir'iot rury lr!::u/e: Stakeholders have accepre, ,",T::Itii:.:,:r.r,ri,t,i.yffi il;;iflti{",!.;:f, ;,,,:ilfl i[H#H:]:"IJf; success und rrrtu-iliilitr,il:riflf,fi;:Y o'".roprlri ,." ,"r,,,very disposJi to rheResources: Resour wirrirglo mui;;:t"t ate available in the state and LGo,ulg the poricy makers aeaccessresources;{lffi i'I,:?l:ff Jil,Ji[',:fj1;;tt;i''H"*.,I.,'ir,'...1]".atoMeuizan: rhe suppJy ;i M;;#iliJ,li.r..o and UNTGEFsmooth delivery of Mectizar,;;;;r offices. has undertaken ro promote "1 aT 6I 1. INTRODUCTION Mectizan @ distribution started in the late 1980s in the former Bauchi State. With funding from African Programme on Onchocerciasis Control (APOC) the Community Directed Treatment with Ivermectin (CDTI) strategy was adopted in 1999 for the delivery of onchocerciasis. United nations Children's Fund (UNICEF) provides support to the Bauchi State CDTI project where 571 communities in l3 LGAs are under treatment and a total population of 384,399 out of an estimated target population of 470,312. The project, which is now in the third year of funding from APOC, is being evaluated by APOCAIOTF Nigeria constituted team of consultant for its midterm sustainability as agreed among the representatives NOTFs and APOC management during the meeting of the representatives of NOTFs in Abuja Nigeria in June 2002. Furthermore, planning meetings are to be held with the State and LGA teams respectively to develop post APOC sustainability plans fp. the different levels of CDTI implementation in the State. 2. METHODOLOGY Evaluation questionz How sustainable is the Bauchi State CDTI project as it marks its mid-term of implementation? Designz Cross-sectional, descriptive. Population: The Bauchi State project, including: its SOCT; its NGDO partner; its LGAs with their LOCTs; the project communities/villages and their CDDs. Sampling: Details of the sampled Communities and villages are contained in Table I below. 2.1 SAMPLING A multi stage sampling approach was adopted in selecting the sample for the evaluation. First the average treatment coverage rate for three years was computed for each of the thirteen endemic LGAs, where treatment is currently taking place. The average coverage rates of the l3 LGAs were then sorted in a descending order from lowest to highest. These were divided into three strata of seven LGAs each. One LGA was then picked from each stratum by balloting in order to determine the three LGAs that will be used for the evaluation. Toro, Alkaleri and Gamawa LGAs were thus selected. A similar approach was used to select two Districts from each of the LGAs except that in this case the districts were first divided into two categories of coverage rates. One community with low coverage and another with high coverage were Iikewise selected in each of the districts. -I 7Table 1: Distribution of Samples in LGAs and Districts: 2.2 SOURCE OF INFORMATION Information was collected from interviews, verbal reports and documents. Various categories of people were interviewed at the Zone (Coordinator), State (SOCT leader, team members, policy-makers, management), LGA (LOCT leaders, management staff, heath technical staff), the frontline heath facility level and the community. 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 average 'selflsustainability score' for each group of indicators is calculated, for each level. A graph was plotted for the level being assessed. The evaluators discussed qualitative description of problems, and likely suggestions for solving the problem deliberated upon. SA[ LGA R* (Coverage Rate) District Villages (R* Coverage Rate) I Gamawa Low (47.6%;o) Kubdiya (2e.0%) I Kore (45.9%) 2. Ariya(46.6%) Raga (2s.2%) 1. Agodo (46.8%) 2. Shalim (46.4%) 2. Toro Medium (83.8%) Leme (99.6%) 1 . Ririwai-D alma (82.3o/o) 2. Tulu (62.5%) Jamaa (e8.4%) 1. Zagshi (86.7%) 2. Gandi (62.8%) J Alkaleri High (84.4%) Gwana (82.6%0 l. Gobirawa (82.6%) 2. Kwalkwal (94.4%) Duguri (el.3%) l. Shafa (91.2%) 2. Geii (93.3%) 83. EVALUATION FINDINGS 3.1 SUSTAINABILITY AT THE STATE LEVEL Bauchi State: Sustainability at State Level t .9 o; o ED(! o 4 3.5 3 2.5 2 1.5 1 0.5 0 I TI e.od\".'*s\".r0'".*'"ii*r**|.*""\5f"*"""i"r"tr Groups of lndicators PLANNING An annual integrated Health Plan is said to exist in the Finance Department at the headquarters. SOCT has an annual work plan reflecting planned activities but does not indicate the required resources and their sources. As a result, accessing funds from the State has not been smooth and regular as required. The work plan is a roll over of last years work plan. The work plan does not reflect stakeholder participation. It is made by the SOCT only. No sustainability elements are considered yet. Concern revolves on what routine activities can take place. No funding commitments from stakeholders to the work plan. MONITORING AND SUPERVISION The SOCT monitors and supervises the LOCT especially around the Mectizan distribution time. The ZOCT regularly interacts with SOCT to discuss issues at hand and offer guidance where required. 9The Monitoring and Supervision does not have checklists. Reports made by the team are not regular and by all team members. Visits are often hampered by lack of Iogistics (transport and funds) MECTIZAN Procurement of Mectizan is done through an independent system approved by Govemment. The drug is distributed to LGAs and Community on time. Last year had cases where returns were absent and inaccurate leading to utdersupply of required amounts to the LGAs. Pilferage was also reported and checked. Another round of supply had to be organized for the affected communities. TRAINING aNd HSAM The SOCT was centrally trained at state level but may benefit from a refresher course to enhance skills on in planning, data management and report writing. Training of LOCTs is done as a routine. Training Needs Assessment needs to be done at all delivery levels targeted training at the right people. So far nothing has been planned and no records or reports to rely on. HSAM is not fully or regularly done. Stewardship requires beefing up and advocacy expanded to bring all key players on board. INTEGRATION The plan and execution of onchocerciasis control activities do reflect integration with other health activities. The project has a vertical programme management approach. LGA leadership is not yet fully involved in promoting the programme as they do to other health activities. The ministry of Local government is yet to be involvedeffectively in promoting control activities. FINANCIAL The programme has received funds from APOC to run project-planned activities. In 2000101 planned funds were released to start the project. However, fund flow did not continue in 2002 due to accountability concerns from the state Coordination team. This hampered project activities since counterpart funds could not be released as well. The project receives complementary support from UNICEF on submission of a plan by SOCT. Logistical support in form of a vehicle and other office items has also been offered. The Govemment has continued to support the programme with provision of counterpart funds, catering for personnel and providing basic office running costs. Budgets, however, lack clear plans and need to be formulated with well thought out plan that captures all project needs. On the whole funding for all project activities is possible when the planning and budgeting processes are streamlined. It is after this step that analysis of financial flows could be determined. l0 TRANSPORT The project has 3 four-wheel drive (4WD) pick-up vans and one motorcycle at the State level provided by UNICEF and APOC. Two cars facilitate activities of the SOCT while the Zonal office utilizes one. Two of the cars, ore for the State and Zonal teams respectively, are new and in good running condition while the one is old and soon requiring replacement. The project has l3 motorcycles at LGAs provided by APOC in good running condition. The LGAs received 26 bicycles for ue by the FLHF and CDDs. The project is about to supply 20 more bicycles. The State and LGAs have so far maintained the vehicles in good running condition. Vehicles are managed with logbooks well filled but trip authorization letters do not exist. The project received an assortment of equipment including 3 computers with accessories, 2 photocopiers, 2 generators, Video set and screen, Video Camera, air conditioners shared between the State and Zonal teams. All equipments are well maintained and functioning well save for one photocopier that is old and needs replacement. HUMAN RESOURCES The SOCT is composed of 7 qualifies, knowledgeable, and committed people but is relatively new having replaced a year ago the first team. The team, however, requires strengthening in all management fields to give it confidence to do their work and supervise lower levels. The SOCT works under the supervision of the ZOCT, which is equally well staffed with 4 skilled people. COVERAGE Coverage is difficult to determine due to lack of reliable data. From the records available, out of l3 LGAs under treatment,4 reported therapeutic coverage above 100% while another 4 reported an average of 65%o. Nine out of the l3 LGAs with rates below 100% gave an average therapeutic coverage rate of 333%. These are small coverage rates by any standards. lt was reported that figures reported could have been affected by cultural practices where the majority male CDDs could have failed to record female numbers because they are not allowed to enter hamlets to meet them. Poor supervision and facilitation contributed to failure to obtain accurate statistics in some LGAs. ll Recommendations at this level Recommendation Implementation Planning The state and other partners should jointly develop a comprehensive costed and sustainable 3-year plan for CDTI. The plan should be realistic, based on government resources and other sustainable sources Priority: HICH Indicators ofsuccess; . 3-year plan available Who to take action . SOCT Deadline for completion , March 2003 Training: ascertain the actual training needs of the different implementers within this level and the level immediately below it through training on HSAM Priority: tll(lH Indicators ofsuccess: List of training needs and justification Training report, agenda, participants list), Who to take action: . SOCT . Director PHC Deodline for completion March 2003 Monitori ng and supervision: previous monitoring and supervision activities in place problems Priority: MIrl)lLlM Indicators of success: List of identified areas of weakness Report on supervision List of beneficiaries Who to take action; NOCP/SOCT Deadline for completion: Three months after the next distribution Mectizan Ordering. Procurement & Supply: communities should be undertaken drugs based on census the purchase of drugs from medicine stores staff should fully involved in retrieval of reports from the lower levels with a view to over come the difficulties involved in onetime allocation of Mectizan to LGAs according to time chosen by communities Priority: lll(ill Indicotors of success: Detail census of all communities Existence of requisition forms Evidence of campaign Collection of reports through the normal government system Prioritised list of time for allocation of Mectizan to communities Wo to take action: PS, PHC Director, NOCP, SOCT Deadline for completion August 2003 Indicators of success; Policy on this available t2 PrioriU: N,ll t)lt IM Who to take Action PHC Director De adli ne for Co mpletion : End of next distribution period Integration: members of the PHC department in CDTI. programmes should be used in an integrated manner Indicators of success: CDTI staff is involved in other programme Vehicles for other health programmes are used for supervision and monitoring of CDTI Priority: I I l( il I Who to toke Action: ZOC. SOCT, PHC director De adline fo r C omple tion : End of March 2003 Indicators ofSuccess: Amount of funds released for CDTI by the State Existence of Budget linked with specific CDTI activities Financing: to definite activities release ofbudgeted funds and counterpart funds for the funding of CDTI activities Priority: Ml:l)lt lM Who to take Action: PHC Director, ZOC, SOC Deadline for Completion : End of 2003 distribution period Transport and other Material Resources: capital equipment authorized and authori zation properly documented Indicotors of Success: Existence of written plans/undertaken for the replacement of capital equipment. Letters of authorization Priority: lll(ill Who to take Action: ZOC,NOCP, PHC Director De adline for C o mple tion : End of 2003 treatment period number and commitment to CDTI but thy lack necessary skills especially on record keeping, report writing and planning. The staff thus needs training in these areas Human Resources Indicators of Success: Good records and well-written reports. Priority: lll(itl Who to take Action: SOC, ZOC, PHC Director Coverage: with therapeutic coverage rates of less that 650/o to increase treatment. Deadline for Completion : End of 2003 Treatment period stered treatment l3 registered for treatment Indicators ofSuccess: Increased Geographical and Therapeutic coverage rates of 100% and>65%o respectively l4 3.2 SUSTAINABILITY AT THE LGA LEVEL Bauchi State: Sustainability at LGA Level t E ED '6 I o EDG o 4 3.5 3 2.5 2 1.5 1 0.5 0 I "*l*'11--$$.""-"'"."".* Groups of lndicators PLANNING (0 Not at all) There was no evidence of plans for CDTI activities for Years 2000, 2001 and 2002 in any of the LGAs visited. The plans are merely part of the annual budgets for the PHC department drawn by the Coordinator. No evidence of the participation or inputs of different PHC units in the budget formulation. The LGAs had not got any workplan. The major problem here is the lack of planning at this stage. LEADERSHIP (2 Moderate) There are CDTI Management teams (LOCT) in some of the LGAs. They are responsible for both supervision of the frontline health facility level and management of the activities at the LGA level. In some LGAs the LOCT seemed to be a oneman show with decisions of the LOCT leader passed down to the numerous supervisors (health personnel) in the frontline health facility and CDDs in the communities. The result is an undefined and indistinguishable role definition between the LOCT and the health personnel at the peripheral health facility. l5 MONITORING (1.7 Moderate) Reports are submitted by the CDDs to the Supervisors at the FLHF, but at times collected by the Supervisors themselves who in turn submit them to the LOCT leader. Government system is utilized for onwards transmission of information to the State level in a few cases while in others there is a vertical submission of reports making the process more expensive. In a few cases the PHC coordinator carries out spot checks at the health faci lities and communities. Supervisory checklist is hardly used. Supervision is therefore routine and is not integrated into normal supervision in the PHC. The LOCT members visit the communities thus taking over the responsibility of the frontline health facility. There is a system for managing problems ilentified in the field (particularly refusals and other causes oflow coverage). MECTIZAN (2.5 Moderate) Mectizan is sent to the LGA on request and on receipt of the returns from previous treatments cycles. Adequate Mectizan is made available to the LGAs from the State but this is not based on any calculation. Drugs are given in batches and shortages at the LGA level are common but shortages are later covered. Mectizan order forms were not seen in most of the LGAs. In most of the LGAs Mectizan is stored at the LGA Medical stores. TRAINING AND HSAM (1.3 Slight) LOCT leaders and SOCT routinely train supervisors every year. It is not focused to needs. Training is also carried out at levels below the FLHF.LOCT leaders feature in all training sessions in all the districts. Training is not integrated and training materials and IEC materials are very scanty and not readily available. Supervisors/staff at the FLHF are not given free hand to train CDDs. This is partly due to the perception of the LOCT that th FLHF staff would be unable to accomplish these tasks. LOCT leaders and the PHC technical committee of the LGA routinely do HSAM. There is no evidence of HSAM plans or objectives and the outcome could therefore not be assessed. FINANCING (2 Moderate) Costs for CDTI activities are not quantified at this level nor are they reflected on the estimates of recurrent expenditures for each year in the LG books. Some LGs have made releases but these were arbitrary estimates independent of systematic plan. The funding releases by LGs are mostly dependent on prompting from the State and not on any budget. Relative contributions of the LGA and other partners to CDTI are not clearly spelt out. Funds released are justified and accounted for as part of other govt. expenditure in some LGAs. Many LGs do not have documented cost of CDTI activities and the exact expenditure is difficult to compute. I I t6 TRANSPORT AND OTHER MATERIAL RESOURCES (1.5 Moderate) Motorcycles and bicycles are used by LG personnel who are involved in nonitoring and supervision of programmes such as CDTI and NPI and the use of this transport is integrated in such a way that the same NPI motorcycle is used for both CDTI and NPI activities. In some LGAs, LG maintain and fuel motor cycle for CDTI activities while in some others the user of the transport facility is responsible for maintenance and fuel since they are used for personal activities as well. Some LGs provided bicycles for the CDDs Logbooks are nonexistent but the HODs are always informed of movements. There are no dependable plans to effect major repairs or make replacements when they go bad. In effect, available logistics are not effectively managed in some LGAs. In one LGA motor cycle meant for CDTI is permanently allocated to an officer in the Department for agriculture while in another UNICEF donated motorcycles are left to rot away for fear that when repaired other departments will take them over. Training and HSAM materials are in place but grossly inadequate HUMAN RESOURCES (3 High) Personnel are skilled, knowledgeable and stable. Morale for CDTI assignment is high. However, some CDTI staff at this level kept CDTI to the chest and lack the spirit of integration and participation COVERAGE (1.5 Moderate) More than 94 per cent of the communities are under treatment. Therapeutic coverage is however poor with only 50 per cent of the communities recording therapeutic coverage of 65 per cent and above l7 Recommendations at this level Recommendation Implementation Planning: plan beginning with 2003 CDTI work-plans, developed before being integrated into an LGA/PHC work-plan. Such work-plans to be made by LGA coordinator with other members of the LOCT should focus on problems identified during the monitoring and supervision as well as the current evaluation exercises. Priority: I-llGH Indicotors of success'. CDTI workplan. plan was developed Who to take action: . LOCT and PHC Coordinator Deadline for completion; . End of March 2003 Leadership: activities at this level. role of the LOCT visi-vis the role of the lower levels Priority: t llGH Indicators ofsuccess: Document showing role definition between the LOCT and the FLHF. Who to take action: PHC Coordinator and LOCT Deadline for completion: End of March 2003 Monitoring and Supervision: integrated with other health activities. focuses on key sustainability issues such as targeted training and supervision needs to be developed and used. and supervise CDDs Priority: MEDIUM Indicators ofsuccess: Supervisory visit reports, and iustifi cation for supervision Who to toke action; PHC Coordinator, LOCT Deadline for completion: End of next distribution Training: based on need. CDDs Priority: lligh Indicators of success: Training report, justification for training Who to take action: LOCT De adline for comple tion; June 2003 Financing: targeting new council members, LG authority and other sources to give financial support to CDTI activities at this level as they gglqg l4. Priority: llit!'l Indicators of success: Amount of resources mobilized Wo to take action: PHC Director 18 in relation to resources realistically expected to be available. Deadline for completion: August 2003 Other Resources: realistic and well-costed plan for operation, maintenance and replacement of transport. repairs should be attended to. other departments should be reassigned to the CDTI but could be borrowed for other health department activities. for use by the CDTI unit for CDTI implementation during yearly distribution periods Priority: I ligh Indicators of success; Availability of Log Books/ movement Registers, Maintenance schedules, documented plan for maintenance. All vehicles maintained and put to use during distribution Suffi cient transportation during distribution Who to take action; PHC Coordinator, LOCT Deadline for completion: End of 2003 distribution Mectizan ordering, Procurement & Supply: recording of the populations of the communities using Mectizan order form should be submitted promptly to the next higher level Mectizan needed once from the State leakage to commercial stores Mectizan in line with each community request Priority: lll(;ll Indicators of success: Existence ofupdated census of communities Existence of reports at the higher levels and this level Evidence of sufficient Mectizan supplied to the lower levels Evidence of no leakage of Mectizanto the commercial stores Who to take oction: PHC Coordinator, LOCT, SOCT Deadline for completion : Three months after the 2003 distribution period Coverage: be hyper/meso endemic should be enunprated for treatment geographic coverage (all households) coverage rates in all the registered communities Priority: lll(;ll Indicator of success: All identified communities enumerated and treated Increase in therapeutic coverage to >65%0 W'ho to take action: LOCT, PHC Coordinator, SOCT, FLHF staff Deadline for completion: End of 2003 treatment period l9 3.3 SUSTAINABILITY AT THE FIRST LINE HEALTH FACILITY LEVEL BauchiState: Sustainability at FLHF Leve! 4 3.5 3 2.5 2 1.5 1 0.5 0 - lf .9o =o E')g o *$*$"-'\".*l-'1}"'{"^"$"".'"-i""r ''oSOo' Groups of !ndicators PLANNING (0 Not at all) There are no written plans or timetables for CDTI activities at this level. LEADERSHIP (0 Not at all) Awareness of roles and responsibilities among the personnel is very low. There is high dependence on the LG for directive MONITORING/SUPERVISION (2 Moderately) CDDs submit reports of distribution to the FLHF, who in turn report to the LOCT leader, Data is routinely collected and transmitted within the government system in some cases. Also depending on the season, CDTI data reports are at times submitted together with other health reports. Supervision is not integrated. Supervisory checklists are not used in many cases for visits for CDTI activities are frequent but not based on any proven need. Copies of treatment reports are usually not retained at this level. There is no documentary evidence of visits (reports/checklists) 1 20 MECTIZAN (2.5 Moderate) Yearly orders are based on quantity of tablets used in previous cycles and update of community census in some cases. The Supervisors in collaboration with LOCT leader fetch the Mectizan from the LGA, while the CDDs collect them from the FLHF. Mectizan tablets are usually adequate and available at periods acceptable to the villages. Where shortages occur fresh supplies are made. The drugs are stored in the FLHF and dispensed from there. Stock control system is simple but records are not left there. Copies of order forms were not seen at the FLHF level. In some cases this level is bypassed by the LOCT Coordinator in supplying drugs to communities. The staff at this level finds no problem with this as they argued that,"the drug belongs to the community". TRAINING (1 Slight) Training is undertaken every year but it is routinely done and not based on definite need. Training activities are not justified or based on findings from the supervisory checklists. The CDTI supervisors have not been given free hand to conduct CDD training.Training and promotional materials are not available in sufficient quantities. TRANSPORT AND OTHER RESOURCES (1.3 Slightly) Transport at this level is generally insufficient. The Bicycles are well out of order in many cases and where available are inadequate. ln some cases where the supervisors are allowed to use the transport facility for personal activities, they take up the responsibility for maintenance and minor repairs. There are no dependable sources for replacement of transport facilities. In many LGAs the transport facility is used for several health services delivery at that level and is therefore integrated. Integrated trips are carried out and are dependent on personal transport of the Health worker in most LGAs. Human Resources (2 Moderate) The manpower at this level are hardly stable as they move out of the interior and prder to work in their own communities. They also lack knowledge of their roles in the CDTI process. However, where they are involved they are enthusiastic to work for the success of CDTI Coverage (1 Slightly) This is poor because only about 85 per centof the communities in the LGAs visited were under treatment 2l Recommendations at this level Recommendation Implementation Planning: Priority: []lGH Indicators of success'. Availability of a yearly plan Who to take action: . FLHF Staff and LOCT Deadline for completion; . March 2003 Training: be based on need. through appropriate training to undertake CDTI implementation activities at this and lower levels Priority: l-ll(l tl Indicotors of success; Report of training indicating need for the training Wo to take action; FLHF StAff, LOCT, PHC COOrdiNAtOr Deadline for completion: April2003 Monitoring and Supervision: staff should be based on identified need. Priority:HI(;ll Indicators of success: Supervisory checklist Who to take action: FLHF Staff De adl i ne for comple t ion: November 2003 Leadership: involved in CDTI implementation activities in the LGAs undertake CDTI implementation activities at this level Priority: lll(itl Indicators ofsuccess: Reports of activities of FLHF in CDTI implementation Who to take oction: PHC Coordinator, SOCT, LOCT Deodline for completion November 2003 Mectizan ordering, Procurement & Supply: recording of the populations of the communities using Mectizan order form should be submitted promptly to the next higher level the catchment' s communities Priority: I ll(il I Indicators of success: Availability of Log Books/ movement Registers, Maintenance schedules, documented plan for maintenance. All vehicles maintained and put to use during distribution S uffi cient transportation during distribution Who to take action: FLHF Staff, PHC Coordinator, LOCT 22 Mectizan needed once from the LGA leakage to commercial stores Mectizan in line with each community request Deadline for completion: November 2003 Coverage: be hyper/meso endemic should be enumerated for treatment geographic coverage (all houselnlds) coverage rates in all the registered communities Priority: I II( il I Indicators of success: All identified communities enumerated and treated Increase in therapeutic coverage to >65% Who to take action: FLHF Staff, LOCT Deadline for completion: November 2003 Other Resources: made for the implementation of CDTI at this level training materials for CDTI implementation at this level Priority: N,l I:I )l t I Nl Indicqtors of success: Availability of transport Availability of HSAM and training materials Who to take action: LOCT, PHC Coordinator, SOCT Deadline for completion April 2003 Iz3 3.4 SUSTAINABILITY AT THE COMMUNITY LEVEL Bauchi State: Sustainability at the Community Level Groups of lndicators PLANNING (3 Highly) Census update is routinely done after training just before distribution, while in a few communities they are done alongside distribution. According to some CDDs and community leaders *it will be practically impossible to undertake census update and treatment simultaneously. This will increase the time spent during treatment and make the exercise more tiring" LEADERSHIP (3.7 Highly) Community leaders mobilize and sensitize the communities for distribution. Leadership is aware of problems (low coverage and inadequate incentive to CDDs) and is involved in management through mobi I izationlsensitization. MONITORING/SUPERVISION (2 Moderately) Reports are sent in reasonable time to health facility using local resources Registers are poor kept and appear incomplete. MECTIZAN (1.5 Moderately) Mectizan tablets are received at convenient time for the communities Mectizan supplies are not based on any calculations nor on past treatment records and population update. In many cases the quantity is insufficient. t E .9 o 3 oE'(! o 4 .5 3 .5 2 .5 3 2 o*"'-l**""is*'*y' \$."",""' ".* 1 5 0 0. 24 TRAINING AND HSAM (3 Highly) Community leadership and CDDs are routinely engaged in sensitization of relevant persons where problems have been identified. Promotional materials are very scanty within the community. FINANCING (3 Highly) Many ccommunities show understanding and appreciations of the costs involved in CDTI and are aware that such costs are met from external sources. Most communities are willing to contribute and, in some cases, have made arrangements to sustain local costs of distribution. Some communities provided registers and incentives to their CDDs. HUMAN RESOURCES (2.7 Highly) CDDs demonstrated that they have received appropriate training and are willing to continue. Villagers value Mectizan due to perceived help in expelling worms and restoring vision and increasing their strength as well as killing lice on their heads. They express willingness to continue treatment. For this enthusiasm on the part of the community members, CDDs are willing to continue to serve even when they given no incentives. However, they lack necessary skills in record keeping and census taking. Some communities have made no efforts in supporting their CDDs Coverage (2.5 Moderately) Geographic coverage rates ofmany communities visited are high with very few areas left untreated either because they are refugees who came after registration and commencement of treatment or the CDDs were not aware that those areas should be covered. However, the therapeutic coverage is poor. Only 50 per cent of the communities visited had therapeutic coverage rate 65 per cent and above, which is not even stable. 25 Recommendations at this level Recommendation Implementation Monitoring: treatment summary form. Priority: MEDIt IM Indicators of success: Availability of treatment summary form at the community level Who to take oction: CDD, Supervisor, Village Leader Deadline for complet ion'. . November 2003 HSAM: incorporate CDTI in their usual festivities and use opportunities provided by community gatherings for appraising and recognising those who contribute towards the CDTI promotion in the locality. gatherings in order to motivate them. Priority: MEDITJM Indicators of success; : Feedback from CDDs, community leader Wo to take action; Community Leader Deadline for completion: December 2003 Training: census update, and recording of treatment Priority: lll(;ll Indicators ofsuccess Correct records Wo to take action'. FLHF staff Deadline for completion: April 2003 Mectizan Ordering and Distribution: from FLHF communities once based on census and demand Priority: Ill(ill Indicators of success; Availability of suffi cient Mectizan Who to take action: Community leader and CDD De adl i ne fo r comple tion April 2003 Coverage: the latest REMO should be enumerated for treatment and all treated Priority: I I l( il I Indicotors of success: I 00% geographic and -.65%o therapeutic coverage achieved Wo to take action: Community Leader and CDD Deadline for completion November 2003 ! 26 4. Overall Self-sustainability grading for Bauchi State. Most of the communities that have been identified as needing treatment are reeiving it. Therapeutic coverage of the l3 LGAs undergoing treatment was however below 65%. The absence of reliable data set on the therapeutic coverage made it impossible to ascertain the actual rate. The CDDs' registers were not helpful as they containedmainly the names of treated adult members of the communities and not a total census. Ivermectin treatment has become part of the culture of communities who expressed willingness to continue with treatment for as long as it is necessary. Communities have been empowered to play a leading role in CDTI at the local level. The current satisfaction of communities with CDTI has potentials for creating demand for continuation of the project and thus enhances sustainability. The relative neglect of the role of [CAs is a weakness of great concern in the support chain. Most neglected has been the lower level of LGAs, FLHFs. This deficiency is mostly due to inadequate empowerment of LGAs through training and devolution of authority to this level. Recommendations of the evaluation team call for LGAs to take leadership and ownership of CDTI and develop realistic and costed plans. Funding for CDTI by LGAs has also been minimal and not linked to any plan of activities. Funds for CDTI are released based on prompting fromthe State and not on the needs of the LOCT. Correction of these and related deficiencies will enable LGAs to provide adequate support to CDTI at the community level. The State level has spearheaded the development and implementation of the project. APOC has provided technical and financial support in the past three years of the project. UNICEF has also provided some logistic SSI support and has pledged to continue to do so. In 2001 the State Ministry of health released three million $13,000,000.00) as its counterpart funding contribution. Althoughin2002, no counterpart fund was released by the State adequate provision was made to release funds for the implementation of CDTI as the need arose. To this effect, approved and paid vouchers to the tune ofN250,000.00 were observed by the evaluating team. Moreover, the State has run the project for one full year without APOC funds. The Commissioner of Health promised that with the reconstituted SOCT, the State is prepared to address the issues of sustainability of the project through committed and efficient implementation of the programme in the State. The policy makers in the Ministry also promised to be guided by the recommendations of the evaluating team. Similar commitment was elicited from the Department of Local Government and Community Development. Political leaders and decision makers at different levels indicated their intention to launch an advocacy programmed aimed at raising additional resources, both financial and materials for the project. Some LGAs have already embarked on the provision of bicycles for the CDDs as incentives for the CDTI. 27 Using the four tier schedule of: Excellent; High; Moderate and Low, the evaluation team judges Bauchi State CDTI to be at the level of 'HIGH' meaning that the project is potentially sustainable, but will require remedial action to be taken following the feedback from the evaluation team. The State team demonstrated preparedness to do just that. Using the Abuja schedule (Fully sustainable; On the way to srctainability and not on the way to sustainability), the evaluation team concludes that the Bauchi project is on the way to sustainability. I28 5. WAY FORWARD Finding in Bauchi State shows that all levels of implementation except the community remain weak. The FLHF level is particularly wanting because it has been generally ignored and often by-passed yet that level has a great potential for the sustainability of CDTI. APOC should develop a process of strengthening that level especially as many programmes plan to add onto the CDTI. It is also observed that the newly reconstituted SOCT is just beginning to find its feet. Sometimes Mectizan is not readily available from the UNICEF among other logistics problems. o The Ministry of Health expressed its desire that APOC CDTI should not fail in the State and are committed to meeting the demands on the State for success of the programme. There will be a re-strategization in the State to position the programme for success o UNICEF representative promise to ensure prompt delivery of Mectizan to the NOCP zone D drug store in future o The Local Government Service Commission promise to participate in getting the Local Governments to meet their counterpart funding requirements . Conclusion from the evaluation o Facilitation of ttre process of implementing sustainability plans o Capacity building especially at the LG level to form the main pillar of CDTI activity o The Department of Local Government has to be involved in CDTI implementation in the State because there is a general position that nothing happens in the Local Governments unless the Directives come from the Department of Local Governments o A presentation on APOC/CDTI activities in the State should be made to the Department of Local Government and Community Development. Follow-up by the State and LG to make realistic and feasible plans which would be used. 29 Advocacy Visits to the Policy Makers and Sustainability Planning Meetings As part of the fulfilment of the second task of the evaluation team, the team paid advocacy visits to the Commissioner for Health. The team leader briefed the Commissioner on the activities of the team before and after the evaluation data collection exercise and the planning of the sustainability meetings. The Commissioner pledged his support for the programme. The team also made advocacy visit to the Permanent Secretary, Department of Local Government Affairs. The Director of Finance and Administration received the Team on behalf of the Permanent Secretary. Here, again the team leader briefed the Department on the CDTI programme and the mission of the team in the State. The support of the Department for the successful implementation of CDTI in the endemic LGAs was solicited. In his response, the Ag Permanent Secretary pledged his support and promisd to get the LG Policy makers to give the necessary support to the programme. Earlier, a representative of the Permanent Secretary in the State level debriefing and sustainability planning meeting noted that the Department of Local Governments is\involved in all other health programmes implemented in the LGAs with the exception of CDTI. He was worried that his Department knew very little about the programme yet the Department has enormous potentials for making the LG leaders meet the needs for the successful implementation of the programme in the LGAs. It was on this note the team decided to pay advocacy visit to the Permanent Secretary. His representative at the forum mentioned earlier made this possible. The Office of the Permanent Secretary requested comprehensive briefing and documentation on APOC/CDTI activities in the State. He noted that they could use the opportunity of the seasoned civil servants serving as Chairmen of Care Taker Committees of LGAs to institutionalise a structure of CDTI implementation that the forthcoming elected Chairmen would find in place and work with. Sustainability planning meetings with the SOCT and the LGAs respectively were also undertaken as part of the mandate of the evaluation team. 30 T APPENDIX 1. STATE LEVEL WORKSHOP PROGRAMME Sustainability of CDTI in Bauchi State "Feedback"/Planning Meeting AGENDA Registration l0:00 - l0:05 To be appointedI Opening prayer Director PHC2 Welcome l0:05 - l0:10 l0:10 - l0:15 ZOCJ Introductions l0: l5 - l0:30 Dr Runumi4 lntroduction to the workshop; What are the objectives What is sustainability l0:30 - I l:00 Drs. Runumi ard Okeibunor 5 "Feedback" on achievements, issues and lessons from the Bauchi evaluation on sustainability of CDTI Mariam Ally6 Discussions on problems identified ll:00-ll:30 7 What could be the solutions to these problems to the problems identified Group work Group l: One set of problems Group 2: One Set of problem Group 3: One set of problem l 1.30 - 12.30 Mariam Ally r 2.30 - 13.00 ZOC8 LUNCH 13.00 - 13.30 Dr Korve9 Feedback from group work by group leader Prof. Ogbe10 Planning for sustainability in this proiect 13.30 - l5:00 l5:00 - l5:45 Prof. Ogbell Report back from group work t2 The way forward: implementing self sustainability (what to do now) l5:45 - l6: l5 Director, PHC, UNICEF Rep Dr. Runumi ZOC SOC r6.r5 - 16.30 ZOCl3 General matters 14 Closing Prayers r 6.30 To be appointed Itcrn Activity Tirne Fac ilitator 3l Appendix 2: Sustainability of CDTI for LGAs in Baucli State "Feedback"/Plan nin g Meeting AGENDA ) Registration I Opening prayer l0:00 - 10:05 To be appointed 2 Welcome l0:05 - l0:10 Director PHC J Introductions l0:10 - l0:15 ZOC 4 Introduction to the workshop; What are the objectives What is sustainability l0:15 - l0:30 Dr Runumi 5 "Feedback" on achievements, issues and lessons from the Bauchi evaluation on sustainability of CDTI 10:30- l1:00 Drs. Runumi and Okeibunor 6 Discussions on problems identified and solutions I 1:00 - l2:00 Mariam Ally and Dr Korve 7 LUNCH 12.00 - 13.00 ZOC 8 Planning for sustainabilitv in this proiect 13.00 - l6:00 Prof. Ogbe 9 Report back from group work l6:00 - 16:45 Prof. Ogbe l0 The way forward: implementing self- sustainability (what to do now) 16:45 - 17:15 LG Chairman PHC Coordinator UNICEF Rep Dr. Runumi ZOC SOC 1l General matters 17.15 - 17.30 ZOC 10 Closing Prayers 17.30 To be appointed Itcnr Activi Tirne Fac ilitator €)IL oa Q Fr .l rn oo OtN z turiU z -i O oo z j $ oo ca\o z * o t!.(a O + z F-$r- z eh U 6, tr N z s oo ca\o z \a) oo O,N z r- s(-- Z o 4)L Evt - lt) c)x -CJEa EcnElo(a'r= Et!6).;- ()A?P =oc =(so)ti.EE E HE€ o\OOE - .9 :.o .9 EEF,A$ .r b0 /\r Cg o) .i I u .\ r'Y(l)trXoq. Oocd= L) aX AHF(tt6ttroqY 6-li,a trF6 e 60 L--:.-t- = o_LJO O0c- (-OE.= o L(d It) (.) -va (l) olr 5()il \o s!€oE>EcrEa 'E !,1- g # [E I caEt+r-E?: sE=.,H.- - v,SEird :{ LAraJ O)VYq- o. u) El L vt.O s(l)-tar- E{Ir I s =.eHit a4 a O5:iEg E I "Eq Ed",v 5 OOO) H "8 _ F.= E .=F = h ='= x E H E [E = E E L 0) ll €aZ c.t .' co c'o =zc\ .ca L^ <X bEr<9 C\ ca' FU a .orro- 9 irar.I ..Xoo 5; FU a o o oN (, o z ah 0) I ,chEfrbod EaEE 3b su= g * € 6 E.E I\t3aOaO rYOr=c) I E H;; E E Be!:gHryH-,EE 5 B3E ASEp E g o0 o tr.:EALLoo- > o ^^ll^-?\w 'EFr6.e .E? E; B -Lv;iC OF7) tr (dJZ dz o.l co + I \o co z O + o.l z -{ \o \.} o.l .+ z ,i $ o.lF-6l z ,d r- o\ r-N z CJ oo o{ N z \ot- \o z ,r;N00 $(n z I o + € ao\o z \o co z A N O, oo co z -{ ta) t-- ol00 z .{ O o .f on z .o o\ UGI - C)-o C) E €,h X g,6E;EE .- b0 /\r ag o! 8E E ts<. bodE o F -E O! \v9;-.- I -r: o.Y tre.cB (,- 0)tsk raF F E:€=O 6q - 6) r\ ^S E X: H Vl&-.-r- (h .9(,) =5oo i: c-L ll)-EOtr LP-.7H er-=5 oO =O EU.E (Htrco'; .g €^tr(J (!90 EEQ EiH- bA:l--;=^ ItrJzi- E - Cr) \) .; t P.9(n aj -X.:d o)- trE oF 9 .Y 0)n E!--iiP.:Ui. =6 X trEr*.i Lc'(!C)?t oo. -k oo,iqi d djE= 9? * ut =.9 trir !.rd96.U5.=o!. >Er,nJ I F olr E d u;c.!ii = ?.9L.:ir)'C-rL .oo5_d(ga)F F r L E L-O E <=N i; tsN.yci s! H I E r fio 3 E g &i € H lal 7)EqH\O o) HvL€G a -6'FooF'-. =tr.YF tr 9 r-X Hl 0)\-/ otr. o.7) O L&3 aCO- Ztr'L e 8"< < 3 r\ /h Ltal\1V ii *:l:J Q ^! caooqECCU(o '5ra .-.i o)a(!t<b *xAY; lrn L C)Ao-0)x<ox L^ <x iH co '; C.t co r6.t cd tr- !iZ I c..r ;:E;q t- O-!!-H g; EZ R ss:; FO oa +)5a 8EEEqtE b0trco li cn tr0)oE o-<E5Zdu) (! , (Li ': -c cg L6oo(o -C0.)-l (dO o _l- o (!F ca tr. .: ootrtr E9 -E.:2 Xc- EI eg: qA E .EOY-E Eooll r- o.r 2 LYAF 'E=5 6 '= s3E $:; (l) c)troFE o_cEo) .;> 20 (.| \o r-. oo O, t oo z C..l z O € z N z (H .9 f,,3a ='= FEHEQ! 6-j'=o) LAL 7a A9Vtta =ESEHEEtrE'4.!EEooS E E $E.SE ,,(D >'C () -o!q=dN= e8E <> I (Ho o^evE oOVP;; LV6 o'7 '=EF-aF b 5 d<: gog ta(/) =E NE] rocaf tr 9tE cB'- =Hts:O '- c)*-c 6JEtr(! bo;iUECX-O .iv-F ,;E O tr v -d = doE .'j.: r':EE oo.Z il F'c SH.g!?X5;> =.8 EZ,!.d.= .'ca . + dUJUiiO (.)OZ (-.l Er c\ lc. E s=<ax ,c\ --Yc.)2,t)o E- -.iOO t)o; oU E€< €E F E;aE.,H FU a o cdo oU *r € v)C .^t i!J;=.)6)cg=&-tE o LPd=N-O PL(-) ajau) >o N r I ra \0 N z ,j Nr-(.)\o N z ia ?.) F* o\ z oo € co z l,o\o(o roNN z ,i \o o\r- ca z \o tt ?a z n? .9tr o= {l(H O}( v .:Jo-fiEE c E 8q ts 8- E3 i.x 0 B= !E;E' -O:i < I gd.Ec.l.E IEE:d -G H€ u+I rtrof& o.oJ 6l Er L U tan() ;-i0)>< oa( EgEHEsHfr=Es.q .^tr>a itv.L - 6 ra= EggEe,y.= k s oo E€ e HEt ca at q)()L a U o oo00r- z r-$t-- z $6l z o\ z tr f-lU -z D € € \o++Zo - oE2 I Nir) o\ Z tt) Q cll oF O O oo oot- z r- *r- z +N z $ oo ca\o z o\ z tr E,a 611? -aJEa ca ^L )tb3h.=EEr)'= 9rt€rv -(rL- _9.; &E <6 tr gu)69AA !!(l)e.^ E ol i.l .-(/)() .n :) ,*99EE E6.E E G, =a .Y (.) EE J0)tr. > (!O6dr F PE a Is: Fgdalt 7 E: E(!O>t o e:.: 9-l- EEHETtr o-= tr :J < d I5s q) ot- (Dil .Vd -PxL6,Vgs;E A€H€ : ^(.) (d6+E.= =EE [E .o dsl L0)O':- d() =6Ht IL C') ^! rnootrEECg(d '5ga .a .; 0)a(ttl- -u 88.v) , t) ;; rE*iE'Ei:5:., E E€3' BB tr-!oo o oL.l(, LV(rrr1i-) E - V b-o3.9Jpeo. b I r e 6oA!.2!=O=g -(JLV-g .= -r r2 o.ttE Es-gra 3i.iLPH!tYE-E Gi O Oq5J o Lq) Fr s N .i() IL $ N ild z s I o.l i^. ti q.r2LL + I c..,1 d< $O c.l d z ' h tr o P! . o :.B.g Hood8. U) UE r-6()o .=< odE =I- P d{Y;' O.() -o\J(1)o-.!o-9O^- > E E."€ e E I r- -.! ct;i, o.ci .<)L/OO*.i aEe"3E,i ahq) I (-)? E9B6) ^ C)r+=rE€{E 99!rtiF - H k ^ -,\t-t9.r -v 6 ii qscg6)G)r-o €=LANaEo-86 L(l)Eoo o(tQ! qr o oo (! 6-e s6 q< o o,L E.Q€=FL €seu>: ats d ! .l:---.-i, . H'E'E 6€ -9-;\=r'A-tr c, E X.= tr 1..= .5T;i lEEE dz N c.) $ tr) \o o\ c\ z O sN z ra) \o ca Zo N z .i O ra) oola) z oo c\ z \o o\C\ z -; ra) o\ z +N z 'E."q ?. $ = E.X; f N€ rL---a'-O ts E e?'= I I E "5 E fi $ ig E E (* o o 7,3,n EEA a! 6- .:fo)IJT (' L (, 0.)Er-Eo)C)i !* -,t.-'aEi:I- OI)- P rnbE9E6" ()HLFA .= 9.P .- H d5{ g d-L = o)!r iD !sG)^ o- <E<.-'.E 5 d € 0') ox0) ooo :i Er\JE O rt '3 eZ '= Yjl) ats ho<AV:; a t>3 C-}l -(tr'r"- v ii ,*9X bi-o t)O E\J O-= - OOO) EEi2'.:lE:fB =s9=3AEE=Ee b -bootr -r=d= l-1 L Er <-E= '; c\ + a{i€vl Zlc.l $ a.l bb A .r, Nx *;j o.r2rJ- rr o.O!-H e; EZ R EEo<ol()€ o.O r-He eZ RqZ tr o) Lr + 0.)L=E q:U(d oE C, .tsroil .O '.= # or <.r(DE= o.t;U o o oUc E .9 u)Cr-- 0) d^9.d8:.:s FFXtr:A f;€BES6}E>E >r bO ,(!trOH trgPoi E .=E r. EEA \o t-- € o\ IO I ra) sf z ra) 00 ra) z O c-.Zo OoO Zo caz z z la)$ z (n @(a) z o >' -i c.,^ -o .9ES -c H'r '== o o);E€E<.-q C) tr (l) U EO) v6 9A -y,ciXautOtrtr F =E()ir = O75 - U3EJ o.:Z o o- !o -vp(,=oo /a d'= -trc)L.,) o! ?Ou;t € =E E q€ ", Fr^(ULt tE >,6i " o tr_o_Yflet s i e;, r\ -.\JlLEq, EHts= E B x- 0 .3j_v Cg a.,.E EiceEHrE€isf a),H!rt694 c. >.8 5 !P-6L 'E b- Es€J gr\ AnHtr-YJo2- = ()9= c C.r.r'5Er e.E.=d(,J OE.EEJ tr)O\o?(!vbco -*,FA6,7) >\ .;t- 6!(J! bO.oO.J X .+ It" z. lN $ N $ Ocl o.oa $ N Lr 60 t- L)ir OX.i7eE Ut-8Bh€6 ^c,-r-L9 'EEE u)a.2 H? E-5q7e7, LA -€ PoE = d.= irE9EE o =.- cq rUH-I G) O.E FC) EtsEE bA oo0- U E ,n h! .=-E g I E.'r sHE€gEB (F oc aOE6 =-'-0)v ^+.F.E A .=!q c- cNl-i J-Lr-FlF -.o=e= € E so EZ o =c.l o Eo) €xE (g ,r L IEdo. -dooo= rnCEQ o'E'6. dR.F 8 6\JEJ() N ca o\ cn z rtA N6 ra N z 6fo t.l66l z 6l t-\o z O o\ ca z I o F- ta ?oia !az 13q =JP(,xoo A .r Lo F'6- -trc)\-./ o lz >\tr .=s €6<iY 0) rr szJtt.= 6l F GItr f:t (aO\OO <-o6c. aX8..3.!u! bOcrO.J X oo t; EE€.:E !Lr^- G#\ F.-ZH-TL(g 9'- .ij F N 00,) ^ t).= .i\-!il.= r .t'1f (,!?ox-E :EZEg $ N () t I C.l tj.{dx >d qa.2 QU6 v ., v ^ -JqC,E6a u)a.2 U(J6 -a-fqZ97, oo OQ ooBtr-Y x.E=l-] 6 ;\o!5rr O O g! <ti=N! PL()ir(.)t) >o .t rn Q Fr q)Ptr =Hot-,A- zD oEa I oo co N z O $ z 00 +\o z s \o (n z OoQ cl Fr Oq cO N z @ .+ c.l z $ \oOtr) z o t- Evt61?c)x ia F a.9 .9-^ E ri €wP -LJXErj LYH.r-L.=i- o C.) EE E X E€ E5 E U.E.= I ScZ-tEE -o c) EE."e$ '= bo o\ !s iD X $,F, € e 2. <B .E O-a FL -E P E.F5 E +o L./ O 7)U q) q,) L o& d 60.,o-no6 E'ts 5 '.E E9 ikEEr-E FU E EB rg'-[ts.= .; O aE 9E hE _r o.= EII >E Cd o]f uL^=!'-6L(J.lrd P-U E E i -Ef EiS:Ir- >!f)AE E Lotr ca N .c; C) tJ. \.) rl HA I .t SEz o.t 'la ,<€e9 HE.- R SE85HE ;tHsg Q..i,bE dd , (JX: oooEjF E,qESasssH U) 6) I .- u) thlb o0 .9 .9.i .!!v = .= .E _E J.o = o = =_(--E .= tr eE o-l9E c = = ctr=< SESE 5= E EES trbo ch* (.)EQO =trcD< 1a N ca I I Io\ lr) * a.t z I Fr a F- z \o z I $c\ z N z ot F-?a o\ z o\ \o c.) z I I O + c.l z N z o o\ int\o z qH O tt) o.9 CB ''E.=e6 -Jd ,, c) >r c 0.) €N= E8E <> 8 t .9 €L(!(t(r: Etr,^G) .9[i EEEtr t'.)E H)^. O- =6H qlr. > L, .= qr o o .- a =u)6 ='= iiHEXa! 6- .5=o)t+th, F< E L -thL. ^l-..c .=r\ (nI E5.tI \ ;rJ^!v ,; E3.EVL.,!E X.r Ag -o 6.; taA E 8ci € q- Ec,^ ooH:trtr'"trd '5 9pFi q .'E E 9h ar o-oJ#,E I * -A H X(Jzez 'H "t*S Eg la) c.li z ra) ON il z ta) r1 -:oh,q '- l-.1 oo l-J lv,r c69 9o> ir NEXr o ts Eo FU a (t E.8doou 5< FQ a 3 o) ='SCA) cU r. O0 (JUIioo qU)J H o(n= N-O oijao >o oo cl o)EEg c)(i >E o (! o tr o() .+ ra) \o t-- f-lQ& a a&ri *rF o t-llr Fa () Fl O tr) ru c- o\ ru o\ x N ru J-1; EQ lr} ru r- o\ ru o\ ru N ru fr orA\U)q, k)FOAU ^az (k-o u! 3? -8EH3REtr (! o.E v.-c)= o.L.,2 .Ef=E=EXtrho56dEl o." cB bo Iot E €.U t.:-=0)E c) = cd.d :/, v)a d aL.=c)+^XcY c! .=4 *Z E I E;\ =;^ o= iF 5-H E c H :1 0-v o.- EL -i)A 'hta (r()OE PHF(L) --ePE S$E .-9r*lVCqoI! >0) Fzri 2 riil ori& U)(,) tro o CB a G).'r Y s6f s?E sgs E E= .frre *n (! -q- o.:Or u) bD,.' oE .a a) $ E'9e ; eE E E; ? E *A n ilriL Es(t0 >N Es(!O >N P8 5 c.t LO0J -*cntr oo c! O..J =r C)-zta o 't0 C') rL ti 0J() -o5erG) (r') tr 0)U€OH1 0.) cn F c;)L) ,oOEl 0.) U) rI] F FQ oo cd o. tt) p(g =A.,.-HE -, I ...rho\ u- r- .! <.r=dtr'tr = !* .H€JGE.F r) sFIJI(/) L.L .=.o o = -H (-) A =THFE o -C.=E-O d c!XQC)E ,Ya{a5UEI;(,,) -")e0 -.- OH =d.N€; C) PiO7)(!, >i5e o c-l ca $ ritr FO H *r U D tr Fl v N z z F Fz f-] =a Fl Fl t3a Fr a UI tr z o tr U tu o z I t (f) (\l T 2oq N x O o\ x o\il O 6l ru o\ ru o\ ru rr o\ (o x s(!tr} o\o oE EqEg,d." E E H.E '= o'r lr0 * !g ai *o o.o:i >YO (.) C F Oa- OOcdE o Ca(h ALVa .= 7a'E. o.=Gl'= -o !l !'EAE E H OEET-: o trx : o (d!>oo u q- o aEe o.= o.&Es -o o F- o\ (a ru chL+ E 3! ",q;R EL8E-f= c0O .- a! IJ I o.,t6G)h"'U tJ- k ElrndF s8. 'i c) t8.o)(,a tse s,fi E r(,o!o(hPvc EEE$a{ GI tr LO6)P-o 9b(Bor< o') Esdc) >N O6) 96 cdo <r (.)z.a th Fc)U€OHrC) t< o t- cd;. c AE JO O L o LCdir tr A'O JOoO botr k.9 q EbV\V)) .'r t- !Y LtraiSrq)o o.;l > =5FOZ th.= c) (* o 8E =c)P>,botro 6db 2tr do oO (n \o r- El Uil a a& ri F o frl t< 3a rll '] O lr) x \o x. x c.) x ca x Nru 3a (, j F oF O r) ru O \o x O O il c.lx. OO cOil Nx. h -A\aHri _ku Ara z (5 ?- EE'; h *v_.EV.E 3 E Hs'' XEEEU ..-aEE.g .-.- () Eacd -o aq.CgN_ S 8=<>f ts o.lE€ E oE o = c6.d s1, vta \oo\ .o8a* - o\o o EEEA$ '= b0- !q o) * oE h >Y()CFO<. oo(iE o t cl) r< .= o) Xd (d .=4rJ E P Eu 5h 9E ir o-t- E c El = O-\J o).- tr 4) t'ra ACl- =z1sil C') o) rro o cl a L ^o ^-oL AE(S)o <g d '94Y aOA2 = tro 'w (l)ov=E5,-E !tJ- sr !- dc) -CAoHCL 3ts HE(.) oi5E * ,dtr6So.E ^UTN\ = cB/Oln9t .!v-vL E=e.xgIB&[flae cl, oF n o & ri Esdc) >N *=x s3F Es(dO >c.r -C .: cao XogdR Esdc)>N o B ce l.lLioo9! t-L EFt ;.: ..Lr\LV E 85 8o Ho.(JJQJc, F(J oJ F() oJ FQ oJ FU oJ qti F FQ .h =a,rY Pbo G) CT cd rtFo. 56 o CdEN= ()Haz zn q-'- v(d o0 ir. EUiS -[a E 6 b.= oo tr ';itro6 , OL tr c)=!Ho o-::E -tvLvA 6L a (r-troo c,cah;^ o:).= .r! N.g Et .t;tF -!-/.r u F.- €€Eg<tro3zoo@ a N ca $ rn N F Fa H Q le tr I F] aa z Z Fr 3 zritra ri t]trr-a tr ltIil otr z o FU t= o z Fl Er ?.) N rdQ& oa aIt{ F o\ ru lr)Nil ri Er Fra \ox (J Fl q OO ra) n \o ru \o x O O O \o x rn ru o alil l.1.; YU trlil \ox O o^- ra) il O \o Z $(a) ru =N ru -O5Ei8\JD ^aZ6 EE=9F- EEHER.gtr (n o.= v.30).a o.) a, ? .E t=.E i EXtrhb=c0[J.1 Q'u (o oo .= ct a - cgi q., '= N Cq'5 -.-6).!d rl; -- 'Fg; g ..2EU-d<*- o .! arEE 3 oE o = d.(d ,.y (r) a \o -o\d la)o\o oE E.XEs,6." E E ES 'Io\ OO* !g o) 'cixH9(D< L-9<,- bOcdE o ov)L'50)! -o d -.'5tsIrE-H'EEhEE;E9 HU 0.,.: ELi^LH -JEA 66-: tr(J Iri =zs= I .t)(,) o o d a b ^!*o- e)- k E E== E E t; (o0) -.cAoHCLaC):o. EEoo ':E O,[lEca .CdESE B*r s;:' F o I rdtr Es(dO >N *tn s3= Es(go >N aa N o o) I ot<(€ Es >c.r > m ffoo dnL EFE : r\ tr r\ ,r :Y E 85 8o EO.QJ(JJ7) FO J FQ oJ F(J o .l FU J U)ri t- F Q ,a =u)dl c.)cbo 0) .E .Z =ohEeE Eb -.9 N= 6t; ZE :o bO t! EUE - ;J. (' E o.E ho tr ';-itr'o E L ol.L C 6)=!H 9*.i! ZaL'a oo c ah ^ C).= iE --'= .oN.Y = c! .---F - L - H .- L F'- -o0)=!qo! tr E Zaou) a N ca $ rn cO frlF tra Hrl Q FE? o tS Fl B -2 () z -z o F tr z rd -2ri Fl Fr -2 3 aUil tr z Fr U tr z Fl Fr ra N oozfl! lr. o ul otf oo U)tr LrJ -Fo oo$- o,lo oot- CDto LUF F U) ooo o(o oo e- o(e oJ oo o- NN oo o_ ros ooo olr) oo s^ @ ooo c\i oot^ c)(v) s6boFO ooo c.iN oo o_ r{)s oo .t- o)(f) N oo s- @ ooo c.i oo €- @G't uJ = .r (Y)6o = .r (f)6-o (f)o I o = l(o =o- #8 = U' o lJ. otootso <uJoo o-q =a rOo0) *aEoE oo9o Egoc 'io UJ E- p.O -oEE *od =E &o€ q o9 Hi P eBilEI or@ O<f o)A o o Itr o o ! fiu -c: EE 'ro6E ! =o o o *-cb- >..= EfrS :g=R (r:Yoo<>e gE EtEr i\PE Ob F- 6EXEae 8Bg EE*; ES 8 gH oz lJlf o ultrIL (f) N $ o f o. = o 0)oc o 3o o) .oE o oalr N oo+o(,,N 8p -L6o >ao6(6, J.= AEE6lIgo o o o oL o o =jo)II U' ooc o =o o .o -c o) j oaII o - = m oI(L P ooo :E -CD9b68 or(Lot'=99(5= .=oPO $cro+ .eb9b68 L o .o z o o- =U)t' o oc €Eoocooo lJ-IJlrj o .12 z o o-la L. o oc .eEoocoO(J o -_ o-_h PE6.= Eg eb68 E o (,, .Ecc o(L o)C o .=c o = o, ._c .E o F coc -e OELoo = .N\ 5 E 8pE > o-(E0 ooo o E z o N (f) $ lf) $ IIJF Fo =of olr o (9 J =IIJJ m F z z o F Fz!! =IIJJ o- =Fo ot olr z o F o lr o z J o. (Y)ooN o o 'E oco .E o U) ooz ,l! l! o uJ ot D oo o o TL oo o- o o, oo o- o o, ooo olo a E. tuIFo o) ooo 1r) ooN.(o ooo o(o (f) oo o- f.t P8 oo o- r.r) oo ry(O ooo o(o cf) oo o- oo o- o o) oo o- o o, ooo o rr) o Hul) ra 2r tE EEao E_= -or.>'xE6 tu o-(E so-oo -.9 ^.o E;.EEH, €rtEs< oo- o -c =Ep LPA E-6'g 'v(E(J6-o8 Aa = 5.01 a'I i: '^ (tr.i: 6.N -c EEE .E ol o_tac=6'd oREAv-Y c EEg.; E HE >-= .= x_oE:(U ^=ltrc(l)tro(E =E96d8u; EPo'= (, o6oPE 9.E5: .E=9 EgE o ot uJ o- (f,o I (u = (f)o I o- sgR (r) o I o- (r)o I o (.)o I o o lGz iooo o,c .E c q o o) 'E(, oE:o .e= a6(r'Jo- a ooc o =o o) =lr j9u 'iSajo\t 'Csge 9oFC) -()o)cc(E 'E3 '6o F< E o .N o o ui o) o o o o =jof LL od tt, g o o o- fir,hP os E_a6< !oElJ od o E .q! c)(L o (E o- U) od o .= o o- E o,c '6 E€ool/)a- oI =dt o oT a g.E bEo9JE o e8 otnc):> c. e8OE/1 O:= a e8(JE 11(D := od 9.fl8r-tJ EO eE8 oU Lfl8r qEH LIo a.Eio9b68 o) .Ecc .g(L o)E o = alr) 0)\t= b'6 or€ .g .c E EEl-.c(, (f) E o =Er-fO)6c EEo o':;g 5to o-ooy > o-(E $ o9E .=! c 'ap"o 3E 6 9o(, 9.= =ar (l) o-(,) =-ocHC(D(l)(J O-Y () ,J) = =-o>J (E =e (Ei 9.6EolE! o OOaoo6 @ $q,ooc>\o9h9 =o(E- >b N lr) IJJF Fo of o lJ. o (9 J o u oF z z o F Fz IIJ =UJJ o. =F o ot oII z o F o lr o z J o. CDooN oo o_ to F- ooodto(Y) o oo(\td a9 oo o- lo F* oo(\t oi(\ Ao = 5.4) g':'6 = E.Ei6.Nc oY(u A5.P :9.'9? s8H E' o(L o E .(1, o e8OE a.l c):> .e6o'F z.eo'cgfr ao o o, o o \o olr) oE bg >b o =0s I ! o;8>o o rr) s (L o oz 06 o E o o- oL o c .9 Io a.cEp9658 c .o oo .E f E E @ oozfl! lr o UJotrl oo o o(L oo @(o\r -o oo @(o$ oJ oot--$N ooo o$ oo o_ @ f,6boF(J oot- tN oo(o- (O o, ooo o\i ooo(o Lrl E o lr o tr o o o rOoo *rr:>oE oo9o Egoc'xo l.JJ O. o o, oc .9 o a s €s, ,.(E sE I oov - .9.9 r-CE t gH Ese od o o o .EEooccL(E -tq6 IJ. (E o ! o Eo o ! =o o) -c E'OLL YJ(/,u- uiso(E !2=E: Eq uf EEo(,) s,P g .=(E(D c>L '6 6e Foo c SUo.=c):<(J<(E o<at:o -o -c -Qoq5 <.9 o E .qo o o- od bf lJ. o I =dl o Eg L:coc E3Ppo aooxo 58 EE LL -J .o lJ- L .o6p.9 ;Zir (D g o 5.9JU'A .o .o6p.o r-Zir 0)69JA Fo oJ E =tro o) .EEE o(L c .9o .!q o) ego0)o->30 u) .) Dg .=(UbE =c,ECo'->9 ctoa.0ozlro 'r o_ -.i=to s(Doo 9rE .= -ccc '6o F.e E o Eo fcoo9=o-5 c'E(E; .!t o-oy =6z o N (f) $ F- ltJF Fo =C)f olr o oJ oN t o =z o F Fz UJ =IJJJ o. =Fo ot o 1r z o F o lr o z J o- G'ooN oozfE lr o IJJotl o u, U) E, tIJ -Fo tuF Fa oo o- o r oo o_ roN oo o_ roN oo o- ro oJ oo o- o ooo ro c! oo o- o$ oo o_ roN oo o_ lo f6 s8 oo o- oN ooo olo oo o- os ooo oto ooo o uJ = p6 LL cf, o) 06E!a -= lDEqE ry€ h EEE L oE olq o P.nLL(f)o odE ?a L oE ofo o l! otool-o <uloo6qzii tooo *a:Eo5 oo9o EPU'C 'io LJJ o- E8, .C(u =boA € .e5zE=-;<Ocog:.9 Eg E fi atr Po :E8E;P.- AoU)9' -oo9,(tr'E !Y E* s' <Eo C) *rto-68,^ o?iii il hFoE 6s=8, tcYg)oo- EPeo=t cFC .o 60iol E o e*gt o f o.z oo oc .o o a o_ eSE €€t;dE e o o c 'C(L Eod'tr(/)qo .9k6!vt'-(5S O O /, O EE U'I3oEfoLL> o =dl g_ o o .EoL9oOLo8 oo 5t>E- o(L E -o .L.bEur YE cE+ ol(L.E!.^E3.Ee"dtUq EE= gE BE :l v (E :- f ().o Eto I E I = E E ^L]-EtsCOYOLJO- d) O (tr () E () 5 o o Eo o) oD ooo o -(L @FooJ 5e6g .ca Eoo8po8 I o6()(J (J L_l_5Oo-6 E tro =o C(Eoc)!>r .E or o_! Eb :9 -D ,rD o.9bE * e,E i -so(DCas .s,.E h(, o;ocFoo = c .9 o ,9 -oo E .=cf E Eoo EoU) oQ E_qE 6 HeE= 8 o, s 9Eo€ 5'tr F .-5Vo.S = o c) E6 gs;lzc (E; o E EEEE P8 =o b(EE o! o9o U^= E!;oxtgE Eg EgBEF.= o- o (,)! eb E ,ff 96-> o-; >.Pq6-o g: o(Qo_-f gE il E 3E EI !2 () 0E .!2 c -c -Yhfo0) ^q,ococLoo(, z o (f)c\l \i @ IIJF Ftt, =of olr o (9 J a u =z z o F Fz IIJ =l,tJJ o. =Fo ot oll z o F o lI. o z J o. (Y)ooN o\ ]C o al,,FC '6o 6 n.to E:= o6'E t -lcotr(5 =Ea,)68A o q, ozfl! ]L o ulotl oa o o(L oo$- N oot- N ad T!IFo ooo c.)s oo o-(9t oJ oso (f, oo o- @ oo s- N oo(o c.) oolr). $ oo o- cf,s 0ts{ (Y,(D 2 f6 P8 o$o-(o ooo @ oo@ c\is oo(o CO oolo $ oo o-(o @ ot(o tjto IJJ E tr ooo r(f) COooaN (r)o Iool! (f) o I o = (f) o Ic f - (f)o I o = (O o Iq, l o o lI. o troo1-(/, < IJJoo69 =a ! 0)Cc oa I o o- o oooco(E'E -o.2. xi) LIJ (E s €g ,.(E xE 8 o(Ev - .o.9 tg* Egg E o) oE o- =O6 a6 boof =aoa e8 .Eco o! € E.:gf ETEH= -. c o oLE o:= o '=,^lZ 9-C g i;Es;t -'=o-o.r',it # *aH aE .c C o .Nia6.9 <=1- *'6o(E 5ooo .-!9o <= .gE; .F U'q. q)be€ .,Eb ZoEo 6 >'o EEEE =- E O -ots trE9S 6o2 (/) Or U' f o- = a 0) (E c .9 o U) o oAg,E EE 6tt =1r)(e od 8tE9 Egoo(ro -oa= .qb E ".EOe(h'E?i o(E =.t6=E otr €o) -=oYfo,lJ- o otr .od -=OYfc)lJ- O- oI =dt € - Ogo oo EEEEO Q oro o E.c 9l o(J c =c- o PO o- E-E oFooJ I 8E e5 "- @. lD e aE sxkj o.9 oFo oJ od oQ. UH EE 8gJO q EptE8ioe oE 9E-t qs g3 =o o) .EcE o o- odc o)o .='6 b'E .Eob+>6 q) o!_ io(,)(5 -L46 ;i o,6E o o;o6 q)'o- .EEZEZ .sEaqe ro.o !++ !+Fu (,, o (, !c o coc -cOo (1)= .N =_6x ;i'E6 5i; = o.E : oEeg(E -.Y AE E(5 (!E o N^A:9E€;< E5 z(t N (r) (o $ l() c'l IJJF Fo =of olr o oJ e IIJJ YJ z z o F Fz ]U =UJJ o- =Fo o tr oll z o F o lr o z J o. cl,ooN