Community Directed Treatment with Ivermectin (CDTI) 4th and 5th year sustainability plan for Gewata Woreda (district) Kaffa-Sheka CDTI project: project period 2004-2005

Ethiopian Program for Onchocerciasis Control Community Directed Treatment with Ivermectin(cDrI) 4th and 5th Year Sustainability PIan For Gewata Woreda (District) Kaffa-Sheka CDTI Project Project Period: 2004-2005 i '- t 0 I DEC, 2003 i: "'-r '" , t\ [ Y" ,t ,., .. / l-,t [r. I ti ll Table of Contents Part I 1. Introduction.................... 2. Background Information Part tr 1. Rapid Epidemiological Mapping of Onchocerciasis Part Itr 1. CDTI implementation and Results ........ 2. CDTI training achievements .................. 3. Treatment coverage... Part IV 1. Financial Management of APOC Trust Funds..... 2. REMO Maps of Gewata woreda...... Part V Sustainability of Issues of Gewata woreda CDTI Planning Leadership Monitoring ano Supervi;i;" . :...... :..... :. Mectizan supply and distribution...,..... Training/lIESAM....... Project Budget Financing/Funding ...... Transport and other Material Resource Human Resources Coverage 10. Sustainability plan frame framework for Gewata woreda 1 1. List of Available Resources for program support 12. List of Materials, Supplies and Equipment Required for CDTI Activities ......... Part V 1 . Budget justification (Explanation ............... 2. Budget Summary Year IV..... 3.Budget Summary of Sustainability plan for year V ... 1 1 2 2 2 J J 4 5 1 2 J 4 5 6 7 8 9 .5 .5 .5 .6 .6 .7 .7 .8 .8 ,9 .11 .12 13 15 16 a t q IIntrodu.ction Gewata is one of the ten wordas (districts) of Kaffa zone, located about 450kms away Southwest of Addis Ababa. Gewata has a population of around 65,087. The woreda comprises 30 kebeles (smallest admin units), whose inhabitants mainly depend on subsistence agriculture. The climatic zones of the woreda, in most places, are that of highland with longer annual rainfall period (6-8 months). In this woreda, there are three, health stations and two community health posts. The infrastructure in the woreda is underdeveloped; no continuous electric power supply, poor telephone service, inadequate roads connecting the kebeles (rural communities) to the capital town, etc. The woreda is well known for its diversified cultural and ethnic composition, although Kaffecho is the most dominant one amongst others. Background Information Onchocerciasis control program was launched through cornmunity directed treatment with ivermectin strategy in the year 2002. The project was initiated with a strong partnership between APOC, affected communities, regional, zonal, woreda admin councils and health departrnents, Federal Ministry of Health and an NGDO parlner (The Carter Center). The program was initially designed and implemented as Kaffa-Sheka CDTI project rvith the overall coordination role assumed by the zonal health department. However, Kaffa- Sheka was later on split as two distinct zones and the leadership role was then shifted to each zonal health office. Again, very recentiy, in accordance to the decentralization policy of the govemment of Ethiopia, there was a paradigm shift of power and authority from zonal to woreda levels. It was at this juncture that the midterm CDTI sustainability evaluation of Kaffa-Sheka project undertaken. In line with this development, it was recommended that the CDTI plan be worked out at woreda level. After the midterm evaluation of CDTI sustainability, there was SWOT analysis done for each level of health delivery structure. As a result, coverage, Mectizan order and supply, monitoring and supen'isiott, as well as trair-ring and HESAM rvere considered relatively 2as strong points at woreda and front line health facility levels. On the other hand, Financial Resources, Planning, Leadership, Transport and other materials and Human Resources were considered as weak points at this level. Efforts have been made to address these weak points in this action plan. Rapid Epidemiological Mapping of Onchocerciasis (REMO) The rapid epidemiological assessment carried out in selected communities in 1997 indicated that Gewata woreda is hyper and meso-endemic for Onchocerciasis. CDTI Implementation and Results Although the woreda was known for its endemicity of Onchocerciasis, there was no mass treatment activity conducted before the launching of CDTI. However, clinic-based treatments have been going on with diethylcarbamazine (DEC) in some of the health health institutions of Gewata Woreda. As mentioned earlier, CDTI was implemented for the first time in the woreda during the year 2002. The major partners were APOC, FMOH, respective health authorities, local governments, affected communities, and the partner NGDO (Carter Center). The mass treatment had 100 percent geographic coverage of the communities in the woreda right from the beginning. CDTI Training in Gewata Woreda, Kaffa zone Year Health Personnel Others CDDs 2001 2002 8 36 226 2003 10 24 226 JTreatment Coverage, Gewata Woreda, Kaffazone Financial Management of APOC Trust Funds The financial management of CDTI projects used to be carried out by zonal health departments in the past two years. It was, therefore, not possible to come across correct figures for each woreda by year. Moreover, due to the restructuring process in the country (which is still underway) and frequent change of staff (CDTI coordinators), it was not easy get access to the financial documents. However, efforts were made to extract some data from the existing financial documents at zonal levels. Year Funds Received Other Sources Comments APOC NGDO* 2001 2002 3,606.93 ,t< None All approved budget from APOC was received! 2003 1,371.56 739.88 None Only the 1" advance was received from APOC Total 4,978.49 739.88 * NGDO support was mainly through material and technical support. New Leadership Role and Integration of CDTI ln view of the recent decentralization policy, devolution of power and authority has been made to the woreda level structure. As a result of this change, CDTI has been considered as integral part of the overall three-year strategic health plan for Gewata woreda. During the CDTI sustainability-planning workshop, all stakeholders have participated and have expressed their commitment to assuming the leadership role in the implementation of CDTI in their respective areas. CDTI has been included in the malaria and other vector borne diseases prevention and control unit in the strategic woreda health plan. 4 rl Year Total Nbr. of villages ATO Nbr. of Villages Treated Geogra phic Coverag e (%) ATO Coverage (%) Total Popn. ATO Nbr. of persons treated Therapeutic Coverage (%) ATO Coverage 2001 2002 248 248 248 100 100 60,290 48,232 45,836 76.03 95.03 2003 248 248 248 100 100 63,253 50,602 46,457 73.4 91.8 .n 4 REMO Map, Gewata woreda, Kaffa zone , : t:ri i1tr:,tra# i'a I ".r,i:;";'i' ,i}r'r;q "iil - -.. -) )!- : I "iii, ';. h -. \,'. 5Sustainability Issues in Gewata Woreda CDTI Planning This is ^ ut"u identif,red as weakness during the midterm evaluation that requtres immediate corrective action. The CDTI is incorporated in the overall three-year strategic health plan of the woreda. However, in the past, the woreda health office and FLHFs were not actively involved in drawing up the CDTI proposal and annual plans of action. It was mainly the zonal health department that was responsible for planning CDTI activities in particular. Following the midterm CDTI sustainability evaluation, however, it has been decided that all stakeholders at woreda and FLHF levels will assume the responsibility of working out their respective periodic plans of action from tliis time on. Short training course will be necessary to develop the planning skills of the health personnel working in these institutions. Efforts will be made to implement the botiom-up planning approach with the assistance of the NOTF in the remaining two project years. Leadership As introduced earlier, currently there is a paradigm shift in the admin structure and organizational set up of the overall management of health and other development programs in the country. The general trend is to empower the woreda level structures and build capacities in all aspects of program management. The CDTI, being one of the recognized and integrated health programs of the woreda, will receive ieadership and close guidance from the woreda admin council and the taskforce organized at this level. Monitoring and Supervision Monitoring and supervision is very critical to the success of CDTi if it is done in a timely and effective manner. However, it was understood during the evaluation that the frequency and coverage was inadequate. Supervisory checklists were not used regularly and feedbacks were not comrnunicated in writing. In most cases, supervisory visits were not problerl oriented and targeted to improving poor performance of FLHFs and CDDs. During the sustainabiiity-planning workshop, it was agreed that the rveak points identified would be addressed very critically although shortage of health persout.iel and ir {fi 6q ,i other competing health priorities at both woreda and FLHF levels could be possible threats in the implementation process. Mectizan Supply and Distribution This activity is considered as a strong point during the evaluation process. Mectizan procurement and distribution is fully integrated into the government health care delivery system. Every effort will be made to maintain the good achievement obtained thus far. Ordering Mectizan in good time and in sufficient quantity is indeed a commendable job favoring sustainability. However, there are areas that need fine tuning at FLHF and CDD levels. Minimizing wastage, proper record keeping and timely and complete reporting are some of the areas requiring attention in the remaining project period. Training/I{ESAM Organization and management of CDTI training programs were the responsibilities of the zonal program coordinator in the past three years. The woreda health office is not fully empowered to handle this responsibility. The future direction is however to build the capacities of the woreda health staff so that they can be in a position to plan and implement training sessions after carrying out needs assessment at FLHF levels. Efforts will be made to make CDTI training sessions focused on identified weaknesses of the health personnel and other partners including CDDs. Similarly, the woreda health office will be making proper use of its meager resources by integrating training programs to the best of its capacity. Health education, sensitization and community mobilization has been very effective in enhancing CDTI awareness to the general public. The perceived benefits of Mectizan are foundational grounds for the sustainability of CDTI in the woreda. There will be a need to produce more powerful health education and sensitization materials in order to enhance further the active involvement of communities in decision-making process. Moreover, the beneficiary communities will need to be nrobilized to provide effective support for the CDDs serving their respective villages. This is believed to be one of the comerstones for the effective sustenauce of the prograrn in the rvoreda. 7Financing/Funding During the first three CDTI years, there has been no specific budgeting for onchocerciasis control activities in this woreda. Very recently, however, the woreda admin council has started allocating funds in block for all health programs in an integrated manner. Obviously, the amount of money is much smaller compared to the diverse needs of the woreda health office. Whatever the amount may be it is indeed a commendable start and it is hoped that it could be increasing over the remaining project period. Since the woreda health system functions in an integrated manner, it is hoped that CDTI could also benefit from funds coming from other sources like Global Fund, EPI, etc. At this rudimentary stage of the woreda, however, more support will be required from APOC. Transport and other Material Resources In this woreda, at it is the policy of the Ethiopian government in general; available transport facilities are used in an integrated manner. ln the midterm evaluation, means of transport is one of the most important limitations identified at both woreda and FLHF levels. Ideally, it would be appropriate if a pick up could be provided for the woreda health service and at least one motorcycle for each FLHF. The evaluation team has recommended immediate replacement of the motorcycles that are found to be worn out and non functional in the woreda that were evaluated. it is strongly recommended that each FLHF would need one motorcycle for effective monitoring and supervision of CDTI activities. At this juncture it is very important to underscore the need to consider building the capacities of the woreda and FLHFs inorder to be able enslrre the sr.rstainability of CDTI in this particular woreda. This woreda health office lacks important office equipment like computer, printer, photocopy machine, etc. These deficiencies need to be tackled as soon as possible. Other CDTI material resources like treatment registers, reporting booklets, training manuals, posters, flip charts, T-Shirts, stationery, etc. should be supplied in sufficient quantities for the effective continuance of CDTI in the woreda. I rt 8Human Resources It is known beyond any grain of doubt that the availability of skilled and motivated human resource is very critical to the success of CDTI. The midterm evaluators noted that there was a very high tumover of health personnel at both woreda and FLHF levels. It was also noted that most of the FLHFs are understaffed. In the coming couple of years, however, these shortcomings need to be addressed as much as possible. During the planning workshop, the woreda admin council and other authorities at higher levels promised to do their best in this respect. Plans have also been made to motivate health personnel and CDDs by means of rewarding best performing individuals and institutions. As stated above, training workshops will also be organized to fill the gap of knowledge, skills and competence of the available health personnel in planning and management of CDTI activities. Coverage This woreda has already achieved 100 percent geographic coverage and therapeutic coverage of well over 65 percent during the past three years. Participants of this planning workshop believe the fact that if all other aspects and indicators of sustainability are well taken care there won't be a problem to maintain the current geographic coverage and improve further the therapeutic coverage levels. 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No. Description of item Unit Quantity Comments 1 * Health Station * Com. Health Post No. No. 3 2 2 Health Personnel No. 10 J Motorcycle No. I 4 Megaphone No. 1 5 Regular Health Budget USD 1 2 )000 Salary and operational cost for woreda health staff and FLHF supervisors. Woreda coordinator will spend about 25%, and other health staff including FLHF supervisors will spend about 10% of their working time for CDTL il 4 o GII rE U) h fiHH *a tk =ot1 'v; €E eor!i<O-6 o. f;caL -bo+rtro.tr -o!9(.)tr otrx6I*tsA -aE tb9E'E =<)=o.naq)= ^E tr .etroFc,() tr o 6 -oo x =tr E oo }r o frr otroN o , o (n o tr oo ti o Ir{ t) o od C)L (l) U)Lro (rl Cd N oq) z (!(.) l< oF al0)l o1 0.) li(Dcx 0) C)t)tro €(B d N o(.) (n 0)Lr oF TA a() Bo (.) H ,9 an (c a)(! F t-lO h L (.) F -l(.)l tr tr () (.) 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EE a r gH q it; s & I5 st R X F et) ll N o a t-.1 a(J o0 F € t<og tn C) -o a o a.p. a Lr C) A/^ EO(l r\ r" -o) \t. .=o or* -6) =ri ;9 'o- T,9cc)do e (L;()^ oc0()OE 0ELOOl-aaiB|:a o-x ok ts F.l r& $ lr o o.a ! (J () tt o N -oo a (J ! =o6() & ch tr. 'Jrtl trr $ (n ah d c) LE(B .9n .e 7i>-beo--3\o oD c'l €ui dbi oo'. il()oo- )a o$ >e (B(, EAtr t-Jo ii >v t_ 19 qi or h o.l aY >=i-oOJE )a Hci J5 (r)d(.)Q f()Ei a* aotrrr -6J:.+r,.{.) o-61,-U/^ >kHx \Q,^o>- a'-()orHa X il.E E v-L* *La -(gC)i,o d trt = t-. cac o!L-tr>F: < 3C H a a C) OO tr o a oH a- @ - *ri 15 Budget Summary for Year MDTI in Gewata Woreda, Kaffa zone S.No lnuaget Line Item APOC MOH Carter Center Total Allocation 1 lPersonnel 0 12,000 290 12,290 2lCapital Equipment ,13,000 0 4s0 13,450 3lSupplies t25 t75 7000 7,300 4lTraining 3621.08 1 19.18 79.9 3 ,820 5lMonitoring and lsupervision 3202.8 438.14 0 3,64 1 6lResource Mobilization 0 89.48 0 89 TIHESAM 2543.4 199.08 2r3.t8 2,956 8lAru:ual Review Meeting 0 0 961.42 961 glProvision of Awards 0 0 300 300 rOiTotal Budget 22,492.28 13,020.88 9,294.50 44,807.66 1 I|NGDO overhead (7.5%) r,686.92 0,00 0.00 r,686.92 l2lGrand total 24,179.20 13,020.88 9,294.50 46,494.58 1 3lEstimated Treatments 59,887 59,887 59,887 59,887 l4lCost per treatment 0.40 0.2? 0.16 0.78 151% Input of Partners 0.52 0.28 0.20 1.00 ) 16 Budget Summary of sustainability plan for Year v CDTI in Gewata Woreda, Kaffa zone t t S.No lnuOget Line Item APOC MOH 1 lPersonnel 0 73,200 290 13,490 2iCapital Equipment 0 0 0 0 65 200 5000 5,265 alTraining I 800 150 120 2,070 5lMonitoring and lSupervision 1600 1000 3,080 6lResource Mobilization 0 100 0 100 TIHESAM t430 200 200 1,830 SlAnnual Review tvteeting 0 0 96r.42 961 giProvision of Awards 0 0 300 300 t0lrotal Budget 4,895.00 27,096.42 l,lNGDO overhead (7.5%) 367.13 0.00 0.00 367.t3 l2lGrand total 5,262.73 14,330.00 7,871.42 27,463.55 I Treatments 59,997 59,887 59,887 59,887 1 per treatment 0.09 0.24 0.13 0.46 tSlZ tnput of PartneiJ 0.19 0.52 0.29 1.00 lCarter Center lfotal Allocation 3lSupplies 48ol 14,330.001 7,s71.42,, 3lEstimated