Monitoring the implementation of CDTI sustainability plans for Edo CDTI project, Nigeria

"t a- World Health Organization African Programme for Onchocerciasis Control Monitoring the implementation of CDTI sustainability plans for Edo CDTI project, Nigeria Olamiju Francisca Eluwa John I ,.a Table of Contents Abbreviations------- J Acknowledgement- --------3 Executive Summary--- 1.0 Introduction---- I .1 Team membership--------- ------------6 Methodology------- ----------------7 2.1List of Objectives 2.ZMonitoring visit ------ -------------7 2.3 Sampling procedure------ ----------8 2.4 Sources of Information-- 2.5 Monitoring itinery---- -------------9 3. Findings and Recommendations-- -------10 3.1 State Level----- --------10 3 .2 Local Government-------- -------- I 5 3.3 Health Centre / Front Line Health Facility ------------23 3.4 Community----- --------28 4. Review of the implementation of CDTI sustainability plans 4.1 State- --------------33 4.2 LGA- -------------38 4.3 FLItr -------------45 4.4 Community----- -------------55 5. Conclusiorrs------ ----------- 58 6. Some qualitative da 7. Debriefing /provision of technical support ----------63 8. List of people met------- --------66 0 2 Ia. Abbreviations APOC CBIT CBO CDD CDTI CHEW CHO DHS LG LGA LOCT MOH NGDO NGO NOCP NOTF PHC PS SOC SOCT UTG African Programme for Onchocerciasis Control Community Based Ivermectin Treatment Community Based Organization Community Directed Distributor (of Ivermectin) Community Directed Treatment with [vermectin Communitv Health Extension Worker - - """ -"'-J Community Health Officer District Health Supervisor local government Local Government Authority Local Government Onchocerciasis Control Team Ministry of Health Non-Governmental Development Organization Non-Governmental Organization National Onchocerciasis Control Programme National Onchocerciasis Task Force Primary Health Care Permanent Secretary State Onchocerciasis Coordinator State Onchocerciasis Control Team Ultimate Treatment Goal Acknowledgement We thank the Director of APOC, Dr Uche Amazigo and all the staffof APOC Headquarters in Ouagadougou in the provision of the logistics and support for this exercise. We are also grateful to the Staff of NOCP and WHO for their kind support and interventions especially with release of fund for this activity. Our appreciation also goes to the Staff of the Edo State Ministry of Health,Estako west,Owan East,Uhunmwode and The Carter Center Zonal offtce for their support at ensuring that our work was easy and our stay, comfortable . We want to thank specially Mr. Abudu Abu, the State Coordinator who was our main local guide and the Mr. John Eguagie, the Carter Center Edo/Delta P.A for their commitment and time while we were carrying out the exercise. J Thank you all and God bless you. a-a Executive Summary APOC support to Edo CDTI project started in June 1999. By the fifth year of APOC supporl which was yew 2004, the project was evaluated to determine it's sustainability potentials. Some of the key conclusions of the Evaluation team were: Firstly, CDTI at the Community/Village level is making satisfactory progress towards sustainability and will become sustainable provided appropriate and adequate support continues to be given by higher levels. Secondly, that over dependence on external sources of funding does not enhance project sustainability. Government sourced funding needs to be the main source of funding for these activities. Thirdly, integration remains a big problem in the Edo State health system. This is often blamed on a number of factors, namely attitude of donor agencies and limitation in skilled manpower. There is also a total absence of an integrated health sector plan across the different levels of CDTI operation. However, most of the activities, such as Mectizan@ procurement and supply, monitoring and supervision as well as management and use of logistics, are within the government system and the Evaluation Team considers this to be helping sustainability of the CDTI project. In evaluating the project on the basis of the seven aspects and five critical elements of sustainability, the Evaluation team concluded that the Edo CDTI project was making satisfactory progress towards sustainability. At the end of the evaluation, the evaluation team guided the project at State and LGA level in developing sustainability plans in order to sustain the programme, post -APOC period. In September 2007, a monitoring team was sent by APOC to Edo CDTI project to determine the extent to which programme partners, particularly at the district, FLHF and village levels are implementing the proposed activities in their sustainability plan. The monitoring exercise was carried out over a period of nine days, during which information was collected from documents and interviews at the state, LGA, Health Centre and community levels. Findings were recorded and recommendations made on the indicators specified in the four instruments provided. In addition, a review of the project with regards to the evaluation report and sustainability plans prepared was carried out. 4 tThe monitors found out that at the state level, some aspects of the sustainability plan (HSAM, Mectizan procurement and planning) have been addressed. The state team is equally making effort to implement the other recommendations in the sustainability plan. However aspects like need assessment training, improvement of monitoring and supervision skills, census updating which will improve the quality of CDTI implementation in the state were yet to be addressed. Copies of LGA sustainability plans were not seen at any of the LGAs visited. It was however available at the state and was used to check the extent of implementation. The LGA programme implementers seem to have forgotten there was a sustainability plan. Overall health service plan exist which in cooperates Onchocerciasis control activities. This ensures that Mectizan is given and reported annually. However most of the recommendations in the sustainability plan were yet to be addressed. Sustainability plan was not seen at the FLHFs visited. Most of the CDTI activities are controlled at the LGA .The poor implementation of sustainability plan at the LGA level affected implementation at the FLHF. Community sensitization on their roles in. CDTI implementation, which was one of the key recommendations of the evaluation team was yet to be implemented in most of the communities visited, resulting to reduced compliance to treatment. However the communities themselves have implemented a substantial number of recommendations made in their sustainability plans. Distribution by elderly CDDs is going on in most communities visited with accurate treatment records and summaries. On the average the ratio of at risk people treated by a CDD is about l:850 The monitors concluded that a good number of recommendations of the evaluators which were incorporated in the sustainability plans were yet to be implemented especially at the LGA and FLHF levels and therefore recommends that urgent steps be taken to address this. Aspects like training on need assessment, improvement of monitoring and supervision skills, census updating should be given priority attention. The project should also explore the possibility of involving CBOs and age-grades in CDTI implementation. These issues need to be addressed before year 8 distribution period in view of sustainability and effective utilization of fund. 5 l1.0 INTRODUCTION Edo CDTI project was approved for funding by APOC in 1999. The State is made up of l8 LGAs. Out of these, 12 are meso/hyper endemic for Onchocerciasis. However, the project has been distributing Mectizan since 1992. From 1992 to 1994, the River Blindness Foundation (RBF) funded the programme in collaboration with the State Ministry of Health and benefiting LGAs. Between 1995 and May 1999, funding was provided by Lions Clubs International, District 404, with the technical support of Global 2000/The Carter Center and Ministry of Health. The strategy used then was CBIT. APOC sponsorship started in 1999 and extended up to year 2004.8y the fifth year of APOC sponsorship, which was year 2004, the project was evaluated to determine its sustainability potentials. The Evaluation team concluded that in evaluating the project on the basis of the seven aspects and five critical elements of sustainability, the Edo CDTI project is making satisfactory progress towards sustainability. In addition, the evaluators guided the project in developing sustainability plan to sustain the project post APOC period. In order to determine the extent to which programme partners, particularly at the disfrict, FLHF and Community levels are implementing the proposed activities in their sustainability plan, APOC decided to monitor. A team of Monitors were sent to the Edo CDTI project in September 2007 to monitor the implementation of the Plan. 1.1: Team Comnosition l.Mrs Francisca Olamiju---Team Leader Executive Director, MITOSATH 605 Hospital place, opposite Green valley suites. Jos. Plateau State Emai l-mitosath@hotmai l. com 2. Mr. John Eluwa----Team Member Zonal Coordinator, A Zone NOCP. Federal Ministry of Health Enugu. Enugu State Emai I : nocpazone@yahoo.com 3. Mr. Abudu Abu-Local guide/Edo State Onchocerciasis Coordinator E mai l-abudu abu2000 @y ahoo. co. uk. 6 t2.0 Methodology 2.l Objectives l. To determine the extent to which program partners, particularly at the district, FLHF and Community levels are implementing the proposed activities in their sustainability plans. 2. To provide technical support for achieving the objectives of the sustainability plans and the implementation of the CDTL 2.2 Monitoring visit The Monitoring team met in Benin.The Policy makers at the Ministry of Health comprising of the Honourable Commissioner and the Director of Disease Control were visited and briefed on the purpose of the mission. The NGDO partner was also visited at their Edo/Delta Zonal office and equally briefed' After the briefing meetings, the Monitoring team met with the State Onchocerciasis team and requested for reports needed for the exercise. Monitors went through the various reports given and agreed with the State team on when to meet for discussion on sample selection and other logistics. The Monitors familiarized themselves with the tool for monitoring and met with State team and selected sites to be visited. 2,3 Sampling procedure Based on performance of the LGAs, the team divided them into three groups namely: good, moderate and bad as shown below: Good Moderate Bad Owan East Esan Southeast Esan West Ovia Southwest Akoko Edo Ovia Northeast Etsako West Etsako East Uhunmwode Owan West Esan Northeast Igueben From each category, one LGA was randomly selected, giving a total of three LGAs. From each of the selected LGAs, two Health facilities were randomly selected, giving a total of six Health facilities. From the selected Health facilities, a village was randomly selected, giving a total of six villages. Selected LGAs. FLHF and Villases LGA FLHF Village 7 IEtsako West Ikabigbo Iyora Ibienafe Iyereku Owan East Otuo Ikao Emai Ovbiomu Uhunmwode Igieduma Iguovbiahiamwen Ugieghudu Ugieghudu After site selection, the Monitors were guided by the State team on how to mobilize the selected communities and the LGAs. Logistics were provided and mobilizztion commenced the next day. 2.4 Sources of information/Instruments Used State Level Before the interviews commenced, using the monitoring tools, Monitors went through the documents provided by the State team. These documents included the following:- a) Annual reports, 2004 -2006. b) Monthly reports for year 2007. c) 5ft year APOC Evaluation report. d) Sustainability plans for both State and LGAs. e) Extracts from TCC concerning the project. 0 Financial contribution record by NGDO. g) Treatment data with list of treated communities for the selected LGAs. h) SOCT outing report file. The information obtained from the above documents helped to source for update and access performance from the various people that were interviewed. The Instrument I - for State level was used at this level as well.The following persons were met and interviewed. l. The Hon. Commissioner for Health 2. Director, Disease Control 3. The State Coordinator 4. The Programme Administrator, Edo/Delta project 5. Project Accountant. LGA Level In two out of the three LGAs visited, the Director of PHC were met and interviewed using instrument 2 for LGAs.The LOCTs of the three LGAs were interviewed as well as other policy makers available. Presently in Edo State, the local government is manned by the Head of civil service. Other documents requested for by the team at this level included: 8 I. List of endemic villages and their treatment data . Work plan for CDTI activities. o Record of financial support by LGA or other partners for CDTI o Mectizan inventory. Health Facilitv level The Front line health facility staffs that were met were mainly District Health Officers (DHS). They were interviewed using instrument 3 for FLHF . Documents requested from them included: o Mectizan inventory r List of communities under their area o Workplan for CDTI activity e Availability of IEC materials was also checked. Communitv level At the Community, the village leaders were interviewed as well as the CDDs using instrument 4 for Community level. Their community registers were looked at for accuracy and coverage. In addition, the team held community meeting with most of the Communities visited. 2.5 Monitoring Itinery Date Activity tS-iZ* September 2O07 Arrival of the Monitors from their different locations Tuesday, the 1Eh September 2007 Pre -monitoring Mobilization of LGA, FLHFs and Community @ptember2ooT Monitoring at Estako West/Debriefi ng ftrnrsaay, tne 20fr September 2007 Monitoring at Owan East/Debriefing Friday the 2l't September2007 Monitoring at Uhunmwode/Debriefing Saturday 22nd-Sunda y 23* September 2007 Report Writing Monday 24fr- Tuesday 25n September 2007 Report writing continues/Debriefing at State level Wednesday 26m September 2007 Departure 9 I3.0 FINDINGS AND RECOMMENDATIONS 3.1 sTA LEVEL Post APOC main findings At the state level some aspects of the sustainability plans on HSAM, Mectizan procurement and planning rnade have been addressed. The state team is equally making effort to implement the other recommendations in the sustainability plan. However aspects like need assessment training, improvement of monitoring and supervision skills, census updating which will improve CDTI implementation in the state is yet to be addressed. 3.1.I. PLANNING: CDTI is integrated into the overall health service plan. The plan is usually reviewed and updated annually The one currently in use is the updated one for the year 2007.Recently, the Primary Health Care/Disease Control of the Ministry of Health was split into two. The two new divisions are Primary Health Care and Disease Control. Onchocerciasis control now falls into the Disease Control Unit of the Ministry. Disease control unit Work plan /budget were shown. It is from this budget if approved and released by govemment that Onchocerciasis activities are supposed to be funded. The State Onchocerciasis coordinator told the team that he made input into the budget based on his sustainability plan. The SOCTs are currently using the sustainability plan as their work plan. There is no detailed written activity schedule with implementation date, emerging issues and actions taken for the state level implementers. However a lO-year rolling plan/budget for each of the endemic LGAs has been developed and the SOC is currently seeking its approval by Ministry of Local Government and Chieftaincy affairs. 3.1.2:IISAM On HSAM , Advocacy and Health Education were the components that have received close attention and yielded results post APOC period. a) Advocacy: The Ministry of Local Government and Chieftaincy Affairs were advocated to. The State Coordinator applied some innovative skills by: i) Not calling the fund needed by the LGA 'counterpart fund' but "participating fund" which is more appealing to the policy makers. This move was successful .An approval was received l0 afor each endemic LGA to contribute N463, 000.00.00 annually. Some have already released theirs. b) Health Education The Edo team also commenced Health education by distributing health education materials on market days.This activity was suspended because IEC materials have been exhausted. Community mobilization/sensitization was planned but not implemented due to financial constraint' The project has funds for the production of IEC materials from APOC. According to the Project Administrator of The Carter Center they were asked to wait until the messages for the IEC materials are agreed upon. 3.1.3: MECTIZAN The NGDO partner is the one responsible for the supply of Mectizan tablets to the State. Requests however are from the CDD through the HFS and LOCTs to the SOCTs. The SOCTs then request from the Carter Center and deliver to the LGA. This channel of distribution is effective and guarantees adequate supply of Mectizan. None of the partners sees the need for any change in the distribution channel, as they all agreed is that is effective and reliable. In the year 2007, Mectizan supply to the State did not arrive on time. The delay was explained to have come from the donation programme and not the NGDO. 3.1.4.: INTEGRATION There is no written plan on integrated use ofresources (vehicles and motorcycles) at the disease control unit. The State Onchocerciasis Coordinator however informed the team that when he is going out for field activities, other staff is encouraged to join him for their report collection or any other field aetivity. Aside the joint use of vehicles, there was verbal discussion with the Nutrition Unit on possible distribution of Vitamin A using the CDTI structure. The Director of disease control was involved and willing to support the integration. The modalities however have not yet been worked out and documented. The NGDO has the intention of integrating Malaria, Vitamin A and Schistosomiasis as from year 2008. This initiative is awaiting endorsement by the Government. Detailed plan on how the integration will occur is yet to be developed. The reason being mainly due to Health workers poor understanding of integration benefits. 3.1.5. F'INAI\CE There has been no counterpart contribution from the state since the CDTI implementation started in 1999, mainly due to lack of commitment by the former administration .Year 2007 budget of the Disease control ll tunit of the Ministry has been submitted to the State Government for funding . The SOC had an input into this budget. The Honorable Commissioner said is quite optimistic that if the State team take the proactive steps in putting together a reasonable realistic budget the present administration will ensure release of the fund. The NGDO budgeted fund to support CDTI activities post-APOC, has been released to the SOC. A total of N594, 000 was released in 2005, and Nl 16, 902 in 2006. ln 2007 a total of N504, 657 was released. This support was given for field activities. APOC also supported some activities like advocacy and sensitization. In 2005 no money was released by APOC. In 2006 N422,579.88 were released and in 2007 N348, 138.00 have been released so far. Measurable outputs for the use of the above fund were not ageed upon before its release. The fund for IEC materials and vehicle insurance totaling N439, 866.00 from APOC is yet to be released to the SOC. 3.1.6: RECORD KEEPING CDTI data are available at the state Ministry of Health. They are however not properly stored because of accommodation constraints. The State team is sharing a one room office with more than six other PHC staff, making seating space, privacy and storage extremely diffrcult. The analysis and utilization of data for planning of CDTI activities is not done in an efficient manner, due to manpower and skill constraints of the team. According to the state team, treatment data received from the field is accepted but reliability ofthe data is a concern as the State team said they are constrained by manpower and resources needed for supervision and monitoring. Post treatment monitoring and supervision is usually carried out routinely by the NGDO. The last one was carried out in 2006. List of endemic villages and their health facilities were recently submitted by LOCTs. Verification is yet to be carried out by the state team. The SOC shares his data with the Planning Unit of the Ministry which have the responsibility of keeping health record. The State team all agreed that there is need for more thorough data verification to cross check census updates, coverages and community compliance. 3.1.7: COVERAGE Geographic coverage over the past two years has been 100% according to data received by the state team. Therapeutic coverage was 68.7%o in year 2004,80.8yo in 2005 and75.4o/o in 2006. There is however, a concem that by year 7, the ATO of the project is yet to become their UTG and still less than 84%. It was also observed that list of meso and hyper endemic communities have not been verified post-APOC period. t2 3. 1.8:Recommendations Recommendations Action by whom PLANNING a The State team should develop annually a detailed Implementation Plans, using the Sustainability Plan as a guide. The implementation plans should include activities to be carried out to ensure that each item in the sustainability plan is effectively addressed and documented. The implementation plans should also be time-bound with names of the responsible persons. a Report of field visit should be written, highlighting the purpose, achievement and necessary follow up actions. a Issues identified and documented during field visit should be fed into plins for subsequent year. SOC, PA and Director, Disease Control SOC, PA and Director, Disease Control HSAM o The SOC should sustain the innovative advocacy drive a The State should follow up on the messages for IEC materials and ensure their early production. a There is need for intensive community mobilization and sensitization before year 2008 distribution exercise, in order to address issues like refusals, absenteeism and fear of side-reaction. SOC.SOCTS SOC, PA and zonal coordinator of NOCP SOCTs and LOCTs MECTIZAN l3 aI a Efforts should be made by the state team to ensure that adequate number of Mectizan needed by the communities are available and received by the communities as early as they desire. a LOCTs need to be empowered on how to calculate Mectizan need for their area of coverage .This should be incorporated into the next training plan as most of the health workers are new. Although the management and supply of Mectizan is efficient at the moment, Government should meet the cost of the supply of Mectizan to the LGAs as earlier recommended by the Evaluation team a SOC,SOCT and PA. SOCTs and LOCTs INTEGRATION . The NGDO in collaboration with the State should organize a CDI workshop with relevant stakeholders at State and LGA. At this meeting, benefits of Integration should be highlighted and implementation plan agreed upon. PA, DDC, SOC FINANCE a SOCT should follow up on amendment of Onchocerciasis control activities budget sent to the state govemment to ensure approval and release. a NGDO and APOC should ensure that measurable output is agreed upon( like number of CDDs to be trained, monitoring of refusals in particular LGAs, etc) before funds are released . SOC and DDC SOC, PA,ZC and DDC RECORD KEEPING o In view of sustainability, the State government is encouraged to ensure that a bigger office space is provided for the Onchocerciasis control programme to allow for proper storage of data and coordination. SOCT, DDC and PS. t4 a The SOCT will need to be trained on data management skills as well as monitoring. A data processor is recommended to join the State team to further enhance their capacity. The State can equally explore the possibility of engaging youth corpers as state implementation team. a The State team should veriff the data on list of endemic communities before the next distribution period, in order to verif, coverages. SOC,SOCTs and DDC SOCTs COVERAGE SOCTs should have a plan for coverage data verification post- treatment period, in order to confirm coverage figures. The State team should carry out a verification exercise on list of endemic villages before the next distribution exercise SOCTs 3.2 LGA LEVEL 3.2.0: Post APOC findings Copies of LGA sustainability plan was not seen at any of the LGAs visited. It was however available at the state and was used to check the extent of implementation. The LGA programme Implementers seem to have forgotten there was a sustainability plan. Overall health service plan exist which in cooperates Onchocerciasis control activities. This ensures that Mectizan is given and reported annually, however most of the recommendations in the sustainability plan were yet to be addressed. 3.2.1:PLANNING CDTI is integrated in the overall health service plan because the Onchocerciasis control unit is under the department of disease control led by the PHC coordinator. Sustainability plan was not seen in the 3 LGAs visited. l5 tLOCTs are aware that distribution time is early in the year; plans were mainly verbal aimed at sending drugs to the community through the FLHF and collection of treatment record. 3.2.2:Trainine Training was carried out in the three LGAs visited for the new LOCTs during the last distribution exercise. This was done because most of the old ones left the disease control unit. LOCTs trained the FLHFs and the CDDs at the Health facilities. Most of the LOCTs claimed that refreshment and transport cost for the training were paid from their personal funds. Training was routinely done without due consideration of capacity need of the FLHF and the CDDs 3.2.3:HSAM(Sensitization and advocacy) LGA policy makers were sensitized on the need to support CDTI and other health programmes in the three LGAs visited. The PHC Directors said this was very important during the last distribution exercise because the policy makers were new. The key policy makers targeted were the Chairmen and supervisory councilor for health . State Ministry of Local Government and Chieftaincy Affairs has given approval for each endemic LGA to contribute the sum of N463,000 annually to support CDTI. The LGA team are following up on this to ensure release of fund. During the monitoring exercise none of the three LGAs visited have released fund. Uhunmwode LGA released N25, 000.00 after year 2007 distribution exercise has been concluded. 3.2.4: Monitorins and supervision Monitoring and supervision was carried out according to the LOCTs. Report of the monitoring activities was not seen, it seems like the main aim was report collection. This was done once or twice during the distribution period. Check list were not used, Problem identified like missed Communities were not reported to the higher level. Most monitoring report was given verbally to the LOCT leader. LOCTs especially the new ones lack monitoring and supervision skills. 3.2.5: Mectizan supplv Mectizan supply was adequate .However, last distribution supply was not received by the LGA as early as they used to. Management of drug is efficient in all the LGAs visited, for instance in l6 aOwan East, the PHC coordinator said they have different sources of drugs like the Bamako initiative drug resolving fund, vaccines, Mectizan etc. They don't merge the management of the drugs because of the different systems of use and reporting requirements by the donors. So he said they remain separately handled by the different officials in the PHC unit and management has been effective. 3.2.6: Iluman resource LOCTs were present in all the LGAs visited. Their average number was three including their team leader. Most of the LOCTs team were new .This is due to the creation of Environmental Unit. Most of the former LOCTs who were environmental health Officers had left the health unit for the environment unit. Recently training was conducted by the SOCTs for the new LOCTs. The new team are all involved in other health activities like Polio Education, TB/Leprosy Control and other programmes. The unpleasant development was that most of the former LOCTs left with the Onchocerciasis control programme fi le. 3.2.7:INTEGRATION:- CDTI activities are fairly integrated into other health activities in the LGAs visited. LOCTs involved in other health programmes use the opportunity of report collection or training to follow up on issues with their other interventions. Resources of other programmes like NPI, TB /Leprosy Motor-cycles are equally used for CDTI activities.CDTl Motorcycles equally used for other interventions in the health unit. 3.2.8:FINANCE: - In Owan East, we were told that N370,000 has been approved which the LOCT said was yet to be released to them. In Estako West N25, 000.00 was released after distribution exercise has been completed. Each of the endemic LGAs agreed to contribute the sum of N463, 000.00 annually to support CDTI. None of the three (3) LGAs visited has complied. In the previous years the LGA's PHCC met said their LGAs has been supporting CDTI implementation by releasing fund to the LOCTs, although most the time the support is received when activities must have been concluded. Onchocerciasis files were unavailable to confirm their claims and the amount given. 3.2.9:RECORD KEEPING t7 t aIn two of the three LGAs visited, the CDTI file seen had only treatment record which shows annual treatment summary for the entire state shared with them by the state team. One LGA (Estako West ) said that their file was with the former LOCT leader who have moved to the Ministry of Environment. Data are not analyzed and used for planning because some missed out communities were not noticed. The records are not integrated into the LGA record system. Record of fund released, training and supervision were not seen. when asked, most LOCTs claimed it was with the former LOCT leader .Treatment record seen at LGA for some villages did not tally with village record 3.2.10 NSPORT APOC provided Motorcycle for the LGAs. Presently an average of one is available and functional per LGA. This was found to be inadequate. The LGAs used to have more than one but poor maintenance made them loose some of the Motorcycles. Request for bicycles was made to APOC which was approved and purchased .Some of the LGAs visited were yet to come to the state to collect these bicycles. 3.2.11:COVERAGE In all the three LGAs visited, treatment data were available.LGA and FLHF summary forms were not used to summarize treatment data for the various LGAs. List of endemic communities was not available; it was therefore difficult to crosscheck geographic coverages. They said geographic coverage has beenl0}oh for the past 2 years. According to the treatment data seen, therapetrtic coverage for Owan East was 80.5% in year 2005,845yo in 2006 and 83.5% in20A7 .Estako West was 58.1%in2005,67.8%oin2006 and 64.2% in 2007.In Uhunmwode therapeutic coverage was92.2%o in 2005,85.6%oin 2006 and 9l.l%in2007. 3.2. 12 :Recommendations RECOMMENDATION ACTION BY WHOM Plannins: LOCTs should develop annually detailed plans using the sustainability plan as a guide .They should specify strategies to be adopted in order to achieve the desired results. LOCTs 18 LOCTs should guide the FLHS in developing a detailed work plan with list of activities to be canied out and time line .ln view of sustainability the FLHF staff in charge of Onchocerciasis should be empowered financially and technically to plan and implement CDTI activities as a very important level and the one closest to the community. Trainins: There is need to build the capacity of the LOCTs and FLHFS through training but before then their Capacity need should identified .The training should be focused to address the identified needs. FLHF staff training should be conducted separately, focused on areas of weaknesses, like community sensitization, skill improvement in monitoring data verification LOCT leader/LOCTS Monitoring and Supervision LOCTS should develop a monitoring and supervision plan using the sustainability plan as a guide. Monitoring checklist should be developed and used. Report of monitoring activities should be written and documented. The FLHFS need to be trained on monitoring and supervision in order to improve their skills in problems identification and possible SOCTs and LOCTs l9 solution Monitoring and supervision should target on weak areas and should be result oriented. Mectizan Supplv LOCTs should request early for Mectizan to avoid delays rather than wait for notice by the State team. New FLHFS need to be trained on how to calculate Mectizan need of their area. LOCTs Human Resource Effort should be made to ensure that Onchocerciasis control file is retrieved from the former LOCT team. The new team will need more focused training to be able train the lower level effectively. In view of this training need assessment is recommended before the training activity. PHCC/LOCT leader/LOCTS 20 t Effort should be made to have focused effective training to address identified skill gaps of the FLHFS. Integration There is the need to develop an integration plan especially as the project might be adding on other interventions to CDTI. There is also the need for a written maintenance plan for jointly used capital equipments for it to last longer. The FLHFS will need to be made aware of the benefits of integration in order to ensure effective utilization of the available resources. PHCC and LOCTs Ernance Effort should be made by the LOCTs through the PHC Coordinator to ensure that the approved annual support is released on time to the LOCT team. Plans should also be made for judicious use of this fund. FLHFS should be funded to enable them carry out key CDTI activities like monitoring, training and supervisions of CDDDs. PHCC,/LOCT leader 2t Record keepins Effort should be made to retrieve file from former LOCT team. Report on training, monitoring and supervision should be written and documented. LOCTs should have LGA treatment summary,a copy of which should be retained by them rather than wait for the state to finish data entry and share report with them. PHCC/LOCT leader Transport Request for additional Motorcycles should be made by the LOCT team to the higher level. Maintenance plan should be made and strictly adhered to. Effort should be made by the LGA to collect the donated bicycles from the State. PHCC/LOCT leader coverage Effort should be made by the LOCTs to summarize the LGA treatment and ensure that copy is retained by the LGA. Leadership at the LGA level should ensure that Onchocerciasis control file is returned to the Onchocerciasis control unit. PHCC/LOCT leader 22 , a 3.3.0:FLHF LEVEL Post APOC Findings Sustainability plan was not seen at the FLHFs visited. Most of the CDTI activities are controlled at the LGA .The poor implementation of sustainability plan at the LGA level affected implementation at the FLHF. 3.3.1:Plannine At the six FLHFs visited, list of CDTI activities carried out was not seen. In one, Ikao FLHF of Owan East, list of CDDs trained during the last distribution exercise was seen. The Health facility in charge also had some experience on CDTI .Others said they were new and had little experience on CDTI activities. Planning is mainly dependent on the LOCT in charge of their area. 3.3.2:Trainine Most of the newly appointed FLHF staff has been trained by the LOCTs. They were trained along with the CDDs during the last distribution exercise. Content of training included disease symptoms, dosage and data management. None of the FLHF staffs trained CDDs they were all trained by the LOCTs. It was only in Ikao FLHF that list of CDDs trained was seen .LOCTs also claimed to have taken care of training expenses from their personal fund as the Local Government promised to reimburse them later on. 3.3.3 : HSAM (sensitization) The FLHF staff that were met were aware that they needed to sensitize the communities under their areas but were unable to do so due to financial constraint. They said they were only able to carry out minimal sensitization when they went for report collection. Their focus was mainly to encourage the community to continue to comply with treatment and to compensate their CDDs. 3.3.4:Monitorine and Suoerrision The FLHFS monitored the CDDs at least twice during the distribution exercise. Monitoring checklist was not used. There was no integrated monitoring plan. FLHFS lack monitoring and 23 rt supervision skills .This made the objectives of the monitoring to be just report collection rather than monitoring. Strengths and weaknesses were not documented but shared verbally some times with their supervisors. 3.3.4:Mectizan: - Mectizan supply in all the facilities visited was adequate. Mectizan was supplied on time and distributed to the FLHF by the LOCTs . FLHFS said drugs were collected by the CDDs at the end of the CDD's training which took place at their facilities. 3.3.5:Human Resources:- At the FLHF there was a designated person for Onchocerciasis control. They were fairing knowledgeable about CDTL Most them were DHS and were involved in other community based health interventions like Polio, Roll Back Malaria, TB/Leprosy. 3.3.6:Inteqration : Trainings and monitoring of CDTI activities were not carried out alongside other health programme activities. The CDTI activities at this level were carried out separately. Resources like bicycle, Motor cycles are however jointly used by Onchocerciasis control and other programmes. There was no integration plan given by the higher level except joint use of transport and storage facilities. FLHFS said they always recommend CDDs as local guides during the immun i zation activities. 3.3.7:Coverase: - Treatment data available at the FLHFs visited were not summarized according to each health facility area of coverage. The data available listed all the treated villages in the LGA alphabetically and their treatment record. List of endemic villages was not seen. It was difficult therefore to verify geogaphical and therapeutic coverages. The FLHFs seen claimed to have 100% geographic coverage but avisitto ovbiomu, one of the selected villages under Emai health facility of Owan East revealed that the village have not been treated for the past three years. Coverage data were not verified because the health staff lack data verification skills and fund to go out for monitoring. 24 3.3.8:Recommendations RECOMMENDATTON ACTION BY WHOM Plannine FLHS should develop a detailed work plan with list of activities to be carried out and time line. Steps to be taken in solving problems identified in previous distribution should be in cooperated into the plan. FLHFS Trainins FLHFS should identify training need of the CDDs and ensure that this is addressed. Efforts should be made to ensure that CDDs are trained in their communities or nearby communities to reduce transport cost and improve community involvement. FLHFS HSAM(Sensitization) FLHFS should carry out sensitization and sensitization. The sensitization should be focused in order or to address issues like missed out communities, high refusal and absentees rate ,CDD incentive among others. CSM and SHM should be initiated in the endemic villages FLHFS 25 Mon itorins and Supenrisial The FLHFS should carry out monitoring and supervision in order to help CDDs address problems identified during the distribution and also to verify treatment data. There is need for follow upon actions on the recommendations made by the villagers during the village meetings with the monitors. FLHFS Mectizan Mectizan supply and storage is effective and need to be maintained. FLHFs should ensure that Mectizan is received by the communities as early as they require. FLHFS Intesration FLHFS should ensure effective and integrated use of resources (capital equipments, fund for training and supervision etc) in order to be more effective. Recommendation on the involvement of CDDs in other programmes already started by some FLHFS is a commendable effort which more FLHFS can emulate. FLHFS 26 Coverage FLHF staff should compile the list of endemic villages and as well as their geographic coverages .Health facility level treatment summary forms should be compiled and shared with higher level while they retain a copy for data verification and planning. Treatment of Ovbiomu village should be done immediately. FLHFS 3.4.0 Commu itv level Post APOC Findines One of the key recommendations of the Evaluation team which was that the communities should be sensitized on their roles in CDTI implementation was yet to be implemented in most of the villages visited, resulting in reduced compliance to treatment. However the communities themselves have implemented a substantial number of recommendations made in their sustainability plans. Distribution by elderly CDDs is going on in most communities visited with accurate treatment records and summaries. On the average the ratio of at risk people treated by a CDD is about 1:850 3.4.1 :[ISAM(Health Education and mobilization) In most villages visited the last intensive health education and mobilization was canied out in year 2003 . LOCTs in charge of the area carried out the health education and sensitization .This was done by face to face contact. The village leader is usually the first contact person during the visit. A request to for him to help mobilize his village for a village meeting is made At a village meeting about 20-25 community members are usually present. According to the CDD compliance was higher leading to higher coverage when effective sensitization and health 27 t education was done. Compliance dropped due to the long gap from the last mass sensitization which took place about 4 years ago. CDDs said they try to health educate as they distribute Mectizan but this is not very effective given the long gap. Health Education and sensitization has not been effectively carried out due to poor funding of CDTI activities especially at the FLHF level. 3.4.2:Mectizan Supplv: - lvermectin supply was sufficient in the villages visited. Mectizan was collected by the CDDs at the health facility at the end of their training . Although at some of the village meetings during the monitoring exercise, the community said they would have preferred to take Mectizan earlier in the year to avoid clash with their farming activities. 3.4.3:Human Resources In the villages visited, they have an average of 2 CDDs per village, there was a fair mix of both sexes among them. Most of the CDDs especially the males were quite old, some more than 65 years old. Though they are still willing to distribute ,the workload of going round is too much for them. CDDs motivation by the villagers is poor, that was the main reason Ovibiomu village in Owan east was not treated for about 3 years. In Estako west LGA, treatment is going on in lyaraku village of Ikadigbo FLHF but the leaders agreed that CDDs should not give Mectizan to any household who refuses to contribute the N20 levy for the distribution exercise, this led to low coverage. [n ovbiomu village where treatment had stopped for sometime now the villagers apologized at a village meeting with the monitors for serving as reservQir for microfilaria to the other neighboring villages .They requested the LGA to come and train more CDDs and bring drugs for them before the year ends. They all agreed during the meeting that kindred existed and was quite willing to select more CDDs along that line. They equally agreed that it will address the issue of CDD incentive. Age grade associations were also seen as a very active social activity in the area and might be willing to support CDTl.Generally, it was observed that most CDDs that are still active are committed, with good treatment record and summaries. They were still willing to continue as CDDs but some are quite old. 3.4.4:Record keepine: All the relevant CDTI data that were supposed to be available at the village level were available with the CDDs. CDTI treatment information were properly recorded 28 ,in the community register and kept either in the chief s house or with the CDDs. From the data CDDs were aware of low coverage and the reasons for it but were unable to address them by themselves alone. The community data seen were reliable. Community uses this data only for CDTI activity. Some registers were already full. In Ikao village the CDD said the former LOCT in charge her area collected her register and did not retum it. After so many efforts which did not yield result she had to ask the community to buy another one and she complained bitterly that she has lost a lot of past valuable data. 3.4.5:Coverase: A reasonable number of households were not treated during the last distribution exercise in the villages visited, and some eligible peopte were equally not treated. In Iyora about 30% of eligible population were not treated. In Iyaraku only about 50%o of household were visited and treated. In Ikao coverage was good about 80% of the eligible were treated. In Ovbiomu no one was treated .ln Ugieghudu and lguovbiatuarwen coverage was about 70%o of eligible population. The reasons for low coverage in some communities were mainly poor CDD incentive and poor community sensitization/Health Education. Some were also missed because they were involved in farming activities during the distribution exercise. 3.4.62 Recommendations RECOMMENDATION ACTION BY WHOM HSAM(Health Education and Mobilization) Community leaders should organize a community sensitization meeting on CDTI in collaboration with the FLHFS and CDDs. Community leaders and CDDs Mectizan supplv Effort should be intensified at ensuring that Mectizan is available when needed by the endemic villages. CDDs 29 lfuman Resources Additional CDDs need to be selected for training along the kindred systems. Community leaders should involvement age grade associations in the implementation of CDTI as this might improve performance. Community Leaders/CDDs Record Keepins Effort should be made at ensuring that the community registers currently available are well stored especially those that are full. Villages that their registers are full should be encouraged to replace them. Health workers at the higher level should be discouraged from taking registers away from the villages. Community leaders, CDDs and FLHFS 30 Coverage Average therapeutic coverage in most of the villages visited was about 677o. In lyereku village it dropped from 90% in the year 2005 to 43%o in year 2007 . Intensive community sensitization should be canied out to revamp treatment compliance. More CDDs should be selected along the kindred line to reduce demand for incentive. CSM and SHM should be initiated. Community leaders, CDDs ,FLHFs and LOCTs 3l 4.0: Review of the Implementation of Edo State CDTI sustainability Plan 4.1:State Level: s/No Evaluation Recommendations in 2004 FindingB in September 2007 Recommendations in 2007 32 4. 1.1 Planning a CDTI is integrated into the overall health service plan. The plan is usually reviewed and updated annually The one currently in use is the updated one for the year 2007 Recently, the Primary Health Care/Disease Control of the Ministry of Health was split into two. The two new divisions are Primary Health Care and Disease Control. Onchocerciasis control now falls into the Disease Control Unit of the Ministry. Disease control unit Work plan /budget were shown. It is from this budget if approved and released by govemment that Onchocerciasis activities are supposed to be funded.The State Onchocerciasis Coordinator told the team he made input into the budget based on his sustainability plan. The SOCTs are currently using the sustainability plan as their work plan. There is no detailed written activity schedule with implementation a a a a . The State team should develop annually a detailed Implementation Plans, using the Sustainability Plan as a guide. The implementation plans should include activities to be carried out to ensure that each item in the sustainability plan is effectively carried out, and documented. The implementation plans should also be time- bound with names of the responsible persons. a Report of field visit should be written, highlighting the purpose, achievement and necessary follow up actions. a Issues identified and documented during field visit should be fed into plans for subsequent year 33 D a Develop a short and long term sustainability plan showing strategies for cost reduction and dependence on reliable sources of funding date, emerging issues and actions taken for the state Ievel implementers. However a l0-year rolling plan/budget for each ofthe endemic LGAs has been developed and the SOC is currently seeking its approval by Ministry of Local Govemment and Chieftaincy affairs. a 4.1.2 Monitoring and Supervision a Monitoring and supervision was carried out according to the SOCTS. a Written reports were not seen. Treatment figures were available a CSM and SHM is yet to be implemented. a Report of field visits should be written highlighting the specific purpose, achievement and needed follow up actions. a Effort should be made to implement CSM and SHM. This can be started in a few pilot communities and expanded subsequently. a Proper documentation of CDTI activities in the State 4.1.3 Training & HSAM a Training need assessment is yet to be carried out. Most trained staffat LGA and FLHF has been moved away from Health to Environment unit since year 2006. Most of the old staff did not hand over CDTI documents to the new staff. a Training need to be carried out at all levels. The recommended training need assessment by Evaluation team is very important to ensure that training build the capacity of staffin all aspects of CDTI and help them to address problems. a Training should not be done in a routine manner, The SOC should sustain the innovative advocacy drive. a a Conduct training need assessment and focus future plans for training on these needs Identify communities that need sensitisation and sensitise them a Some communities that needed sensitization were not identified. The reason being poor supervision at the a SOCTs, LOCTs and DHS need to be trained on effective supervision. That way their skill on prob lem identification o 34 higher levels and way out will be built. a The State should follow up on the messages for IEC materials and ensure their early production. a There is need for intensive community mobilization and sensitization before year 2008 distribution exercise, in order to revamp treatment compliance and address refusals, absenteeism and fear ofside-reaction. The project might consider producing and airing radio jingles in the local dialects a 4.1.4 Inteqration a Most activities are still routinely carried out. Integration and need assessment is yet to be carried out. a The NGDO in collaboration with the State should organize a CDI workshop with relevant stakeholders at State and LGA. At this meeting, benefits of Integration should be highlighted and implementation plan agreed upon. Need assessment, integration and effective monitoring is needed to ensure judicious use of available fund a Project should integrate and target activities on essentials for reduction in cost 4.1.5 Financial Resources Govemment should assume a major role in funding CDTI activities by increasing its budgetary allocations and releases for CDTI implementation a Efforts have been made by the State team to ensure release of counterpart by State and LGA. . SOCT should follow up on amendment of Onchocerciasis control activities budget sent to the state govemment to ensure approval and release. NGDO and APOC should ensure that measurable output is agreed upon( like number of CDDs to a 35 o be trained, monitoring of refusals in particular LGAs, etc) before funds are released . a A top level APOC advocacy team should be sent to the State government to get it to support CDTI implementation Top-level APOC advocacy recommended by the Evaluation team is yet to be carried oul a The State team should follow up on this recommendation, through theZonalNOCP offrce to ensure it's implementation. a a An MOU should be signed between APOC and the State government showing clearly the funding requirements of the State The issue of MOU still came up as the Monitoring team met the policy makers. They are aware that the Federal Ministry of Health rushed an agreement on behalf of the State. The State team, however want an MOU to be written between APOC and State, aside the sustainability Plan. a APOCNOCP should look into the MOU issue and see if it can be resolved. If resolved, it might change the State's commitment to the provision of counterpart fund. a 4.1.6. Transport and Material Resources The vehicle and other capital equipment supplied by APOC are wellmaintained. However, the Bicycles supplied by APOC is yet to be collected by the benefiting LGAs. The bicycles need overhauling. Because of the number, the cost of coupling, overhauling and transportation is high and the State is unable to shoulder it. a The State team should open up discussion with its partners, to source for support to make the bicycles provided by APOC functional, and release it to their beneficiaries, in order to achieve the purpose ofthe donation. a Government should budget and release funds for the running and maintenance of transport and other capital equipment. Govemment should provide Transport for the implementation of CDTI at the lower levels 4.1.7. Human Resources 36 a The SOCT should be trained on computer skills The SOCT computer skill has improved. The state team still lack a dataprocessor that can assist them in data analysis needed for monitoring. a The State team should explore the possibility of getting someone skilled in data processing to join the team. a 4.2: LGA LEVEL s/No Recommendations 2004 Findings in September 2007 Recommendations in 2007 4.2.1 Planning a CDTI is integrated in the overall health service plan because the Onchocerciasis control unit is under the department of disease control led by the PHC coordinator. - Sustainabil ity plan was not seen in the 3 LGAs visited. LOCTs are aware that distribution time is early in the year, plans were mainly verbal aimed mainly at sending drugs to the community through the FLHF and collection of treatment record. a a a LOCTs should develop annually detailed plans using the sustainability plan as a guide .They should specifi strategies to be adopted to achieve results. LOCTs should guide the FLHS in developing a detailed work plan with list of activities to be carried out and time line In view of sustainability the FLHF staff in charge of Onchocerciasis should be empowered financially and technically to plan and implement CDTI activities as a very important level and the one closest to the community. a a a Team should produce year plans that take into account community' requirement 37 4.2.2a Training and HSAM o Conduct a training need assessment of FLHF staff. r Train staffat the next level only on areas, where they are weak or lack skills a Training of the LOCTs was carried out for the new LOCT team in the three LGAs visited. This was done because most of the old ones left the disease control unit. LOCTs trained the FLHFs and the CDDs at the Healthcentres. Most of the LOCTs claimed that refreshment and transport cost during the training were paid for from their personal funds. a a Training was routinely done without due consideration of capacity need ofthe FLHF and the CDDs. o There is need to build the capacity of the LOCTs and FLHFS through fraining but before then their Capacity need should identified .The training should be focused to address the identified needs. a FLHF staff training should be conducted separately, focused on areas of weaknesses, like community sensitization, skill improvement in monitoring and data verification 38 4.2.2b HSAM(Sensitization and advocacy) o LGA policy makers were sensitized on the need to support CDTI and other health programmes in the three LGAs visited. o The key policy makers targeted are the Chairmen and supervisory councilors for health. o State Ministry of Local Government and Chieftaincy Affairs has given approval for each endemic LGA to contribute the sum of N463,000 annually to support CDTI. o As at the time of monitoring exercise none of the 3 LGAs visited have released fund. Sensitization and advocacy should continue especially as new policy makes are expected to take over next year. Efforts should be made to ensure that FLHF staffs are funded to be able to carry out sensitization and verification of coverages. Sensitization should be focused to address issues like missed out communities, high refusal and absentees rate, CDD incentive among others. o a 39 LOCTs should develop a monitoring and supervision plan using the sustainability plan as a guide Monitoring checklist should be developed and used. Report of monitoring activities should be written and documented. The FLHFS need to be trained on monitoring and supervision in order to improve their skills in problems identification and how to solve it. Monitoring and supervision should target on weak areas and should be result oriented. a a a a Monitoring and Supervision Monitoring and supervision should target on weak areas. DHS should be encouraged to supervise at their own level a a Monitoring and supervision was carried out once or twice during distribution according to the LOCTS. Report of the monitoring checklist were not seen, it seems like the main aim was report collection. Problem identified like missed Communities were not reported to the higher level as most monitoring report were given verbally to the LOCT leader. LOCTs especially the new ones lack monitoring and supervision skills. a o a a 4.2.3 LOCTs should request early for Mectizan to avoid delays rather than wait for notice by the State team. New FLHFS need to be trained on how to calculate Mectizan need of their areas. a a Mectizan Supply Government should meet the cost of the supply of Mectizan to the LGAs. LGAs should collect their Mectizan@ from the State level. Mectizan supply was adequate . During the last distribution supply was not received by the LGA as early as they used to. Management of drug is efficient in all the LGAs visited. Government is yet to start meeting the cost of the supply of a a a a 4.2.4 40 Mectizan to the LGAs. o Mectizan is still been sent to the LGAs by the State a Although the management and supply of Mectizan is efficient at the moment, LGA should ensure that they collect their Mectizan supply from the state as earlier recommended by the Evaluation team. 4.2.5 IIUMAN RESOURCE An average of three LOCTs are present in all the LGAs visited. Most of the LOCTs are new because with the creation of Environmental Unit Most of the former LOCTs who were environmental health Officers left the health unit for environment. Most of the former LOCTs left with the Onchocerciasis control programme file. Recently training was conducted by the SOCTs for the new LOCTs. The new team are all involved in other health activities like Polio Eradication and TB/Leprosy Control. a a Effort should be made to ensure that Onchocerciasis control file is retrieved from the former LOCT team. The new team will need more focused training to be able train the lower level effectively. Training need assessment is recommended before the training. a Effort should be made to have focused effective training to address identified skill gaps of the FLHFS. 4.2.6 Integration o CDTI activities are fairly integrated into other health activities in the LGAs visited. o There is the need to develop an integration plan especially zts the project might be 4t LOCTs are involved in other health programmes, they use the opportunity of report collection or training to follow up on issues with their other interventions. o APOC motor-cycles are equally used for others interventions in the health unit. Logbooks were not seen. adding on other interventions to CDTI. Joint use of resources at the LGA is a good idea but there is need for a written maintenance plan to ensure that these resources last longer. a 4.2.7 tr'inancial Resources In Owan East, we were told that N370,000 has been approved which the LOCT said was yet to be released to them. In Estako West N25, 000.00 was released after distribution exercise has been completed. Each of the endemic LGAs agreed to contribute the sum of N463, 000.00 annually to support CDTI. None of the three (3) LGAs visited has complied. a a a a a Effort should be made by the LOCTs through the PHC Coordinator to ensure that the approved annual support is released on time to the LOCT team. Plans should also be made for judicious use of this fund. FLHFS should be funded to enable them carry out key CDTI activities like monitoring, training and supervisions of CDDs. a Develop plans to target only the essentials for CDTI implementation. a Government funding of CDTI should be increased 4.2.8 RECORD KEEPING o In the two of the three LGAs visited the CDTI file seen had only treatment record which shows annual treatment summary for the entire state shared with them by the o Effort should be made to retrieve file from former LOCTs. . Report on training, monitoring and supervision should be written and documented. 42 state team. One LGA (Estako West ) said that their file was with the former LOCT leader who have moved to the Ministry of Environment. Record were not analyzed and used for planning because some missed out communities were not noticed. o The records are not integrated into the LGA record system. Record of fund release, training and supervision were not seen. When asked most LOCTs claimed it was with the former LOCT team leader. o Treatment record seen at LGA for some villages did not tally with village record. LOCTs should have LGA treatment summary ,a copy of which should be retained by them rather than wait for the state to finish data entry and and share with them. 4.2.9 Transport and other Material Resources a Government should fund the maintenance and running of vehicles and equipment. lntroduce the use of logbook for the control of motorcycles a a APOC provided Motorcycle for the LGAs visited. Currently they have an average of one that is functional. This was found to be inadequate. They used to have more than that but poor maintenance made them loose some of them Request for bicycleso a Request for additional Motorcycles should be made by the LOCT team to the higher level. o Maintenance plan should be made and strictly adhered to. Effort should be made by the LGA to collect the a 43 :l was equally made by the state to APOC last year which was approved and purchased .Some of the LGAs visited were yet to come to the state to collect these bicycles. donated bicycles from the State. a Log books should be used to control the use of motorcycle. 4.2.10 COVERAGE: o Increase HSAM in communities with low compliance with Mectizan@ treatment. a Increase therapeutic coverage to 65%o or more In all the three LGAs visited, treatment data were available.LGA and FLHF summary forms were not used to summarize treatment data for the various LGAs. List of endemic communities was not available; it wns therefore difficult to crosscheck geographic coverages. They said geographic coverage has beenlO0% for the past 2 years. According to the treatment data seen, therapeutic coverage for Owan East was 80.6% in year 2005,84.5Yo in 2006 and 83.5%o in 2O07 .Estako West was 58.1% in 2005,67.8Yo in 2006 and 64.2% in 2007.1n Uhunmwode therapeutic coverage was 92.2% in 2005,85.60/o in 2006 and 9l.l% in2007. Effort should be made by the LOCTs to summarize the LGA treatment and ensure that a copy is retained. Leadership at the LGA level should ensure that Onchocerciasis control file is returned to the Onchocerciasis controlunit. a 4.3.0. FLHF LEVEL SAIO Recommendations 2004 Findings in September 2007 Recommendations in 2007 4.3.1 Planning . Plannine is 44 o a Written health plan should integrate all health programmes at this level. Minutes for the planning meetings should be documented a mainly dependent on the LOCT in charge of their area. o At the 6 FLHFs visited list of CDTI activities carried out was not seen. In one ,Ikao FLHF of Owan East, list of CDDs trained during the last distribution excercise was seen.She also had some experience on CDTLOthers said they were new and had little experience on CDTI activities. o FLHS should develop a detailed work plan with list of activities to be carried out and time line. o Steps to be taken in solving problems identified in previous distribution should be in cooperated into the plan. 4.3.2. Integration a Trainings and o FLHFS should 45 Train staff at this level on record keeping monitoring activities were not carried out alongside other health programme activities , the CDTI activities at this level were carried out separately. o Resources like bicycle, Motor cycles are however jointly used by Onchocerciasis control and other programmes o There is no integration plan given by the higher level except joint use of transport and storage facilities. o FLHFS said they always recommend CDDs as local guides during the immunization activities. ensure effective and integrated use of resources (capital equipments, fund for training and supervision etc) in order to be more effective. o Recommendation on the involvement of CDDs in other programmes already started by some FLHFS is a commendable effort which more FLHFS can emulate. 46 r] 4.3.3 Monitoring and Supervision o Target supervision on problem areas Use checklist for supervision a Keep copies of monitoring report in the FLHF o The FLHFS monitored the CDDs at least twice during the distribution exercise. o Monitoring checklist was not used. There was no integrated monitoring plan. o FLHS lack monitoring and supervision skills, this made the objectives of the monitoring to bejust report collection rather than monitoring. Strength and weaknesses were not documented but shared verbally some times with their supervisors. a The FLHFS should carry out monitoring and supervision in order to help CDDs address problems identified during the distribution and also verify treatment data. o There is need for follow upon actions on the recommendations made by the villagers during the village meetings with the monitors. 47 r] FLHFS should identify training need of the CDDs and ensure that this is addressed. Efforts should be made to ensure that CDDs are trained in their communities or nearby communities to reduce transPort cost and improve community involvement. a a Most of the newly appointed FLHF staff has been trained by the LOCTs. They were trained along with the CDDs during the last distribution exercise. Content of training included disease symptoms, dosage and data management. None of the FLHF staffs trained CDDs they were all trained by the LOCTs. It was only in Ikao FLHF that list of CDD trained was seen .LOCTs also claimed to have taken care of training expenses from their personal fund as the Local Government promised to reimburse them later on. a a 4.3.4 Training 4.3.5 Transport & other Material Resources Government should provide transport and training materials for CDTI irnplementation Transport o At the Health facilities visited LGA is yet to take over the responsibility of ensuring that adequate transport and a LOCTs should ensure that the needed transport and training materials are budgeted for and made available for use by FLHFS. a FLHFS should request for transport 49 support and training materials from the LGA to enable them carry out CDTI activities in the LGA they support. o Human resources is adequate but need focused, effective training to address identified skill gaps. o FLHFS should identify CDD attrition where it exist and ensure that it is addressed. o FLHFS should encourage communities to select CDDs along the kindred system and ensure that they are trained. The FLHFS will need to develop a plan to train new CDDs to take over from the elderly CDDs who though committed lack strength to do the work effectively. training materials are made available for the FLHFS to carry out CDTI activities. Human Resources o At the FLHF there is a designated person for Onchocerciasis control. They are fairly knowledgeable about CDTI . o Most them are DHS and are involved in other community base health responsibilities like Polio, Roll Back Malaria, TB/Leprosy. 50 r] 4.3.6 HSAM (sensitization) o The FLHF staff that were met are aware that they needed to sensitize the communities under their area but were unable to do so due to financial constraint. They said they were only able to do carryout minimal sensitization when they went for report collection. Their focus was mainly to encourage the community to continue to comply with treatment and to compensate their CDDs. a FLHFS should carry out sensitization and Health Education. The sensitization should be focused to address issues like missed out communities, high refusal and absentees rate , CDD incentive among others. a CSM and SHM should be initiated in the endemic villages. 4.3.7 Mectizan: a Mectizan supply in all the facilities visited was adequate. Mectizan is supplied on time and distributed to the FLHF. FLHFS said drugs were collected by the CDDs at the end of the CDD's training which took place at their facilities. o Mectizan supply and storage is effective and need to be maintained. FLHFs should ensure that Mectizan is received by the communities under them as early as they require. a 5l FLHFS should ensure effective and integrated use of resources (capital equipments, fund for training and supervision etc) in order to be more effective. Recommendation on the involvement of CDDS in other programmes already started by some FLHFS is a commendable effort which more FLHFS can emulate. a a o Trainings and monitoring activities were not carried out alongside other health programmes, It was carried out separately . o Resources like bicycle, Motor cycles are howeverjointly used by Onchocerciasis control and other programmes. o There is no integration plan given by the higher level except joint used oftransport and storage facilities. FLHFS said they always recommend CDDs as local guides during the immunization activities. 4.3.8 Integration 52 4.3.8 Coverage Treatment data available at the FLHFs visited were not summarized according to each health facility area of coverage. The data available listed all the treated villages in the LGA alphabetically and their treatment record. List of endemic villages was not seen. [t was diflicult therefore to verify geographical and therapeutic coverages. The FLHFs seen claimed to have 100% geographic coverage but a visit to ovbiomu, one of the selected villages under Emai health facility of Owan East revealed that the village have not been treated for the past three years. Coverage data were not verified . because the health staff lack data verification skills and fund to go out for monitoring. a FLHF staff should compile the list of endemic villages and as well as their geographic coverages. o Health facility level treatment summary forms should be compiled and shared with higher level while they retain a copy for data verification and planning. a Treatment Ovbiomu should be immediately. of village done 53 4.4:Community Level s/No Recommendations 2004 Findings in September 2007 Recommendations in 2007 4.4.1. Human Resources a Sensitise communities to their roles in CDTI Encourage communities to support CDDs. a Encourage communities to select more CDDs and reduce work load for the existing CDDs. o In the villages visited, they have an average of two CDDs per village. there is a fair mix of both sexes among them. Most of the CDDs especially the males are quite old, some more than 65 years old. while they are still willing to distribute the workload of going round is too much for them. CDD's motivation by the villagers is poor, that was the main reason ovibiomu village in Owan east was not treated for about 3 years. [n Estako west LGA, treatment is going on in Iyaraku village of Ikadigbo FLHF but the leaders agreed that CDDs should not give Mectizan to any a Additional CDDs need to be selected for training along the kindred systems. a Community leaders should involvement age grade associations in the implementation of CDTI this might improve performance. 54 Ia household who refuses to contribute the N20 levy for the distribution exercise, this lead to low coverage. Generally, it was observed that most CDDs that are still active are committed, with good treatment record and summaries. They were still willing to continue as CDDs but some are quite old. 4.4.2 Mectizan supply a Ivermectin supply was sufficient in the villages visited. Mectizan was collected by the CDDs at the health facility at the end of their training . Although at some of the village meetings during the monitoring exercise, the community said they would have preferred to take Mectizan earlier in the yeff to avoid clash with their farming activities. o Effort should be intensified at ensuring that Mectizan is available when needed by the endemic villages. 4.4.3 HSAM HSAM(Health Education and mobilization) . [n most villages visited the last intensive health Community leaders should organize a community sensitization meeting on CDTI a 55 education and mobilization was carried out in year 2003 . LOCTs in charge of the area usually carry out the health education and sensitization .This is done by face to face contact. The village leader is usually the first contact person during the visit. A request is then made to him to help mobilize his village for a village meeting.Atavillage meeting about 20-25 community members are usually present. According to the CDD compliance was higher leading to higher coverage when effective sensitization was done. Sensitization has not being effectively carried out in the recent past due to poor funding of CDTI activities especially at the FLHF level, a in collaboration with the FLHFS and CDDs. 4.4.5 RECORD KEEPING o All the relevant CDTI datz that were supposed to be available at the village level were available with the CDDs. CDTI treatment information were o Effort should be made to ensure that the community registers currently available are well stored especially those that are full. o Villages that their registers are full 56 should be encouraged to replace them. Health workers at the higher level should be discouraged from taking registers away from the villages. properly recorded in the community register and kept either in the chief s house or with the CDDs. From the data CDDs were aware of low coverage and the reasons for it but were unable to address them by themselves alone. o The community data seen are reliable. Community uses this data only for CDTI activity. o Some registers were already full. o At Ikao village the CDD said the former LOCT in charge her arca collected her register and did not return it. After so many efforts which did not yield result she had to ask the community to buy another one and she complained bitterly that she has lost a lot of past valuable data. a Average therapeutic coverage in most of the villages visited was a4.4.6 Coverage: A reasonable number of households were not treated during the last distribution exercise in a 57 a the villages visited, and some eligible people were equally missed. The reason were mainly CDD incentive and poor community sensitization .Some were also missed because they were involved in farming activities during the distribution exercise a about 67%o. In Iyereku village it dropped from 90o/o in the year 2005 to 43Yo in year 2007. Intensive community sensitization should be carried out to revamp treatment compliance. More CDDs should be selected along the kindred line to reduce demand for incentive. CSM and SHM should be initiated a a 5.0: Conclusion The monitors found out that at the state level some aspects of the sustainability plan (HSAM, Mectizan procurement and planning) have been addressed. The state team is equally making effort to implement the other recommendations in the sustainability plan. However aspects like need assessment training, improvement of monitoring and supervision skills, census updating which will improve the quality of CDTI implementation in the state were yet to be addressed. Copies of LGA sustainability plans were not seen at any of the LGAs visited. It was however available at the state and was used to check the extent of implementation. The LGA programme implementers seem to have forgotten there was a sustainability plan. Overall health service plan exist which in cooperates Onchocerciasis control activities. This ensures that Mectizan is given and reported annually, however most of the recommendations in the sustainability plan were yet to be addressed. Sustainability plan was not seen at the FLHFs visited. Most of the CDTI activities are controlled at the LGA .The poor implementation of sustainability plan at the LGA level affected implementation at the FLHF. s8 a ICommunity sensitization on their roles in CDTI implementation, which was one of the key recommendations of the evaluation team, was yet to be implemented in most of the communities visited, resulting to reduced compliance to treatment. However the communities themselves have implemented a substantial number of recommendations made in their sustainability plans. Distribution by elderly CDDs is going on in most communities visited with accurate treatment records and summaries. On the average the ratio of at risk people treated by a CDD is about 1:850 The monitors concluded that a good number of recommendations of the evaluators which were incorporated in the sustainability plans were yet to be implemented especially at the LGA and FLHF levels and therefore recommend that urgent steps be taken to address this. Aspects like training on need assessment, improvement of monitoring and supervision skills, census updating should be given priority attention. The project should also explore the possibility of involving CBOs and age-grades in CDTI implementation. These issues need to be addressed before year 8 distribution period in view of sustainability and effective utilization of fund. 59 6.0 Oualitative Data Comments bv some of the persons met l."Ignoronce, is a disease and a big one that some of my community members are suffering fro*." Mr. Peter Ikelebo - CDD of Iyora village commenting on why some members of his community is refusing Mectizan. 2 "lrIy sight was fading before we started taking Mectizan and I was using glasses. Now can't you see I don't use it ony more" Mr Alufa Paul speaking at a village meeting in Iyora village. 3."1 have been a CDD since 1994, why some families don't take Mectizan is that they said they are not sick" - Mr Yahaya Enakare- Iyerekou Village CDD 4."1 used to be a CDDf but stopped because community were not helping in any way, but I still talre the drug .Those that are not taking it are ignorant of the gain and are illiterates". Mr. Lawal Iyale,Representative of Iyereku village leader. 5 "We used to thinkyou people pay the CDDs but now that you have explained ,we will take it up as our responsibility. We don't need to tell you what we will dofor them, you know in our place when a child is crying and asking for alcara, ,f you give him any other thing he will not talre it and the cry will not stop Eeh! We btow the akara they want we will give it to them. I*ave that to zs". Chief Daniel Azari community leader of Iguovbiatuarwen. 6."we have other problems aportfrom blindness especially that one that make part of the body of parelyzed on waking up "from skep. please help us tell government ' '-Cotnmunity respondent al a community meeting in Ugieghudz-community view of integration. 60 aMr peter ikelebo - CDD of Iyora Community with his register he said he is proud of his work Mr Yahaya Enakare-CDD Iyaraku Village with a female CDDs he trained to help him with the work 6l I t: , i I & !l t T .{-!',. ^'r.l: { |, 1u{5 I tCommunity respondent at Iyora community meeting An opinion leader at Ovbiomu community stressing the need to involve the elites of the community and association in CDTI implementation during a community meeting at the chiefs palace.(Recall that this community stopped taking Mectizan 3 years ago) 62 .q A t i ,t f, \ t b 4 .1", * I' l\ @/'\t 0 *rt; i' tlr.r - t\ : .]r L ; tChief Daniel Azari community leader of Iguovbiatuarwen listening to Mr Obakpolor LOCT of Uhunmwode as he gives explanations to some of the issues he raised at a community meeting 7.0 Debriefins notes /provision of some technical support 7.1 State Level: Two different feed back meetings were held at the state level.The first one was for the state implementation team and the second with the policy makers. State implementation team feed back Participants at this meeting were the SOCTs,SOC ,P.A,Finance officer and the data offrcer. The feedback provided opportunity for the monitors to debrief the implementation team on their findings especially at the lower levels.Strenghths and weaknesses were highlighted. Reaction of the state team Some of the findings were not exactly new to them but they were overwhelmed by it and complained of very poor commitment of the Healthworkers at the lower level. Monitors advice l. The monitors advised the team to make sure every support given at any level has a kind of shopping list. Giving fund for undefined field activities was discouraged. Finance officer and 63 ,dt il s* TB F 'r, . " #E.. .:i { *:'n 4ffidF -P.A were advised to ensure that for any fund release, expected measurable list of achievement is attached. Same should apply at the lower level. 2.The state team was equally advised to do a need assessment at all the levels using the recommendations of the evaluation team, TCC and the monitoring reports. 3. Develop action plans with time line. Prioritize them according to their importance and implement in order of priority based on fund availability. Finally the team was asked to explore the option of requesting for help from the Carter Center for training and guidance in carrying out the need assessment and development of action plan in order revamp the programme. Action: The SOC agreed to have a meeting with his team in order to start implementing the recommendations. Debriefins of the Policv makers The commissioner was out of the state but had delegated the Permanent Secretary to receive the monitors. Others present were the Director Disease Control, P.A and the SOCTs. Findings in the state and the executive summary was used to brief them. A few remarks on findings at the lower level were given as well. Response and Actions: The P.S commended the monitors and appreciated APOC for the exercise. The issues he responded are as follows Integration: Clarity on why CDTI should be used for Vitamin A distribution instead of the current system was requested. When explanations were given he requested the DDC to follow up on it immediately and ensure it commences as soon as possible knowing its benefit to the children. Human Resources: He agreed to request for youth corpers with good computer and data knowledge to join the team. He also advised SOC to look around for a competent person in the ministry and get back to him for possible posting to the Onchocerciasis unit. At the LGA and FLHF he agreed to write to the Ministry of Local Government and Chieftaincy affairs copying the Head of service in order to retrieve the files from the former team members. 64 a at Finance:He said with the new administration in place ,he would follow up to ensure counterpart fund is paid by the Government. At his level imprest will equally be released if the SOC request for it. The monitors thanked the policy makers for their time and commitment and requested SOC to follow up. 7.2LGA Level Feedback were given to the policy makers at this level after visit to the communities and facilities. They were briefed on findings in FLHFs and communities feedback that was used was findings in their respective FLHFs and communities. None of the highest decision makers (currently the Head of Service)were on seat as they were said to be at a meeting in Benin. The PHC Coordinators and the other senior officers that received the monitors assured the team that the recommendations will be implemented. 7.3 TECHNICAL SUPPORT AT THE FLHF Most of the FLHF met served as local guides for the team at team during the community visits, so they saw the issues with the monitors and advice was given to them on the spot. Some are aware of the problems and willing to solve them but unable to due to poor funding. 7.4 TECHNICAL SUPPORT AT COMMUNITY LEYEL Community meetings were held especially in communities with high refusals, absentee and non compliance. Details of this are in the community findings. The meeting provided opportunity for the monitors to help re sensitize the community, correct some of their misconceptions and also guide the Health workers on key messages and some communication skills. The communities were very good meetings, and with appropriate follow up will yield the desired result because the communities are very willing. Two things that came out of the community meetings: l. Health workers are always in a hurry when they are carrying out community meetings and d o not allow the community enough time to assimilate what they are saying and ask their relevant questions. 2. The Health workers lack communication skill and list of the very important key messages that community needed to know. 65 a, 8.0 PERSONALITIES MET DURING THE EVALUATION 8.la State level (i) (ii) (iiD (iv) (v) (vi) (vii) (viii) (ix) (x) Dr. Wilson Imogan -Honourable Commissioner Edo State Ministry of Health Sir.P.Odine-Permanent Secretary,Edo State Ministry of Health Dr. Sam Aigberior- Director Laboratory Services. Dr. Victor lyekekpolor-Director, Disease Control. Mr. A. O. Abu-Edo State Coordinator. Mr. S.A. Kadiri-Assistant Coordinator, Mrs. D. Akpata-SOCT. Mr John Eguagi e -Proj ect Admninistartor, Carter Center,Edo/Delta Proj ect Mr ClementJackson tkogho -Finance officer. Mr Paul Ugbaadamu -Project Secretary Carter Center S.lb.Etsako West LGA.Local Government Area (i) (ii) (iii) (iv) (v) (vi) (vii) (viii) (ix) (x) (xi) (xii) (xiii) (xiv) Mrs. O. Aperima,Assistant PHC Director/Director Nursing Services' Barrister. O.A. Ogedengbe. Head of Department Legal Unit Mr .A.Success SOCT representing Oncho Coordinator. Mr. Mohammed Kasim Mr. Salami Sule, Former Oncho Coordinator Mrs Victoria Azetah,lkadigbo Health Facility in-charge Mrs Aigbirio Ebimarlu Ibienefa Health Facility in-charge Mr peter ikelebo - CDD of Iyora Community Mr. Egr+aghadelmi Mob-epinion l€adcr tyera -Village Mr. Alufa Paul -Opinion leader Iyora Village Mr Yahaya Enakare-CDD Iyaraku Village Mrs. Isa Fumilayo - female CDD [yaraku village Mr. Lawal Iyale-Iyaraku Village Leader Representatve Alhaji Umaru Enakele-Chief Daudu Of lyereku (paramount leader) 8.lc i Dr M.H. Iraoya -PHC Coordinator -Owan East ii Mr. A.O Atokhai -LOCT Leader iii Mrs.Ogeagbade C.O -Otuo FLHF iv Chief John Oyibo - Ovie of lkao village v Chief Monday Aide - Ovibomu Village leader vi Mr Felix Aigbekhai-Ovibomu village CDD that stopped distribution 66 !,lc i 8. ld.Uhunmwode Local Government Area i IvIr. C. Momoh - Senior Admin Officer ii Mr. C. Emwanta - Establishment Officer iii Ivlr.W. Obakpolor LOCT leader of Uhunmwode iv Mr. Friday Ikpon Mwosa Aiguohiam -LOCT v Mrs. E. A. Osakue lgieduma'Health Facility in charge vi Mrs. Mary Ucho -Ehor FLH S vii Chief Omorodion Egbarevba-Paramount chief of Ugieghudu viii Mr Joseph Ehide -CDD of Ugieghudu ix Mr. John Ekhator CDD - Iguovbiatuarwen village x Chief Daniel Azari-Opinion leader Iguovbiatuarwen village 67 ?.r,