Report on the evaluation of the sustainability of the West Equatoria CDTI Project

World Health Organization AFRIGAN REGION African Programme for Onchocerciasis Control (APOC) 01 B.P. 549, Ouagadougou 01, Burkina Faso Tel: (226) 50 34 29 53; 50 34 29 59; 50 34 29 60, 50 34 36 45i46 Fax: (226) 50 34 28 75; 50 34 36 47 In reply please refer to SDD/APOC|4Il/201llGF/pm Southern Sudan Onchocerc iasts Task Force (SSOTF) Secretariat Ministry of Health Juba Southern Sudan Attention: Dr Lucia Kur E-mail: luciaku55@yahoo.com Ouagadougou, Dear Dr Kur, Re: Reporl on the Evaluation of the Sustainability of the West Equatoria CDTI Project The West E,quatoria CDTI project has been supported by APOC since 2005 and is in sixth year funding from APOC. It is routine and necessary that after five years of treatment service to the endemic communities the project be evaluated to identifo its strengths and weaknesses, oppoftunities and threats, its adequacy, impact, effectiveness and effi ciency. In June 20 I I (six years later) APOC constituted a team of evaluators with a mandate To evaluate the sustainability performance of the project. To support the implementers of West Equatoria CDTI project in developing sustainability plans. The overall conclusion of the evaluators West Equatoria CDTI project was basis of the 7 aspects and 5 critical elements of sustainabiliqt;5 NoT MAKING SATISFACTORY PROGRESS TOWARDS SASTAINABILITY. THE WAY FORWARD Integrate CDTI activities into overall health plans at all levels 0 9 DEC 2011 a a a Explore innovative ways of engaging new staff and building the capacity of hurnan resource at all levels in the CDTI strategy. Improve efficiency of implementation of core CDTI activities such as training, HSAM, monitoring and supervision into other health programmes and based on needs. Strengthen financial management at all levels lmprove HSAM to raise awareness on CDTI, educate, mobilise and promote community ownership lmprove programme effectiveness and ensure progress towards 100% and 84oh geographic and therapeutic coverages. The evaluation team examined the'six critical elements'of sustainability in the project. If these are not present, it is unlikely that the project will be sustainable. The analysis of the indicators at each level (State, Counfy, Payams, and Bomas) shows the following results: PLANNING: The concept and practice of programme planning does not exist in the project. Annual action plans were not prepared for implementation. Only the Project Coordinator (PCO) had a plan for 2010. The entire project is perceived an APOC project and government involvement is low. The ..t rl initiative for development of action plan for the state comes from the national level which is handed down to the project to implement. At the county, plans were single programme activity based and highly limited in scope. Community involvement in CDTI is poor. Roles and responsibilities of each partner in CDTI activities should be clearly delined and adhered based on the prevoiling programme challenges. The 3 year plans developedfor the state and county activities should be implemented effectively through out the specified period. INTEGRATION: There is no integration at the project level; CDTI activities are not , into the health system and the project is not included the department's general annual plan and budget. The PCO runs the programme with minimal or no involvement of the Ministry of Health because funding for project activities come directly from APOC, and expended without due authorization from his superior officers in the Ministry of Health. County supervisors were involved to some extent in other health related activities like the E,xpanded Programme on immunization (EPI), Maternal and Child Health services (MCH), etc. Logistics and equipment are not pooled. Integrate CDTI activities into PHC system Le. Guinet worm eradication programme, malaria, lymphaticfilariasis control etc. nt all levels. LEADERSHIP: Programme leadership is weak especially at the state and county levels. Initiative of activities rvas mostly from the central level (SSOTF). The leadership operate.s alone with no involvement of other personnel at other levels, in key activities like monitoring and supervision, training, health education, sensitization, advocacy and mobilization. CDDs are selected by payam staff. SSOTF and projecl level sltould devolve responsibilities and empower lower levels to implement CDTI. Constituted traditional aulhority members should be involved matters of CDTI implementation within their communities. MONITORING AND SUPERVISION: There is occasional monitoring and supervision visits to the counties with spot checks at the payam level. Sometimes data were been transmitted through the existing government system but there was no evidence for this. Problems identified have been consistently given due attention. Supervision is routine, recurrent and not targeted to address challenges at lower levels. Participation of community members in CDTI is poor. Supervisory visits should be plonned, targeted and integrated with other PHC programmes and checklist shoultl be used. . All healtlr workers should be involved in CDTI activities Funds from dependable sources available for these activities, especially governments own Community Self Monitoring (CSM) should be introduced. a a a a a a MECTIZAN@ PROCUREMENT AND DISTRIBUTION: Mectizan@ tablets are stored within government facilities. Supplies were not based on realistic community census figures but from national census figures. There were no inventory forms in use for management of tablets. Communities have not been involved in Mectizan collection and uptake. c Procurement and supply of Mectizan@ tablets should be based on community censusfigures. APOC technical assistant should empower the state project and national coordinators as well as lower levels on supply and management of Mectizan tablets a 2 a o TRAINING AND HSAM: There is no evidence that training and HSAM activities have not resulted in improved capacity at all levels and community awareness about the disease, and their roles in programme support, decision making and uptake of Mectizan@ tablets. CDTI training of lower level staff (county staff) was a yearly routine, and not targeted on specific knowledge gaps or weaknesses. In most cases, the state staffwould undertake training to the payam leve[. Training materials were unavailable. The levelof involvement of the NGDO partner, and APOC technical assistant to the project during training of lower level workers could not be acertained. Planned HSAM activities and reports could not be provided. Training/HSAM should be more focused to needs. HSAM activities should be properly planned, and appropriate HSAM materials provided FINANCE: Government financial inputs into the project were mainly in the areas of payment of salaries, provision of office accommodation and facilities for storage of Mectizan@ tablets. Even that, most of the health workers depend entirely on APOC's top up for their monthly remuneration. Funds are mainly from APOC and CBM paftner. Government financial contribution over the years has been lacking at all levels; because of resource constraint and other serious competing needs. Financial transactions are by cash and control systems are rveak. Additional signatories and skilled personnel are required. Appropriale Jinancial planning and budgeting of CDTI activities should be corried out at oll levels and included the annuul PHC budget. Skilled jinance personnel should be deployed to the programme. Contributions of the partners/stake holders should be clearly spelt out, including supply of equipment, materials, money and technical assistont. SSOTF and APOC Technical Assistontfacilitate should a realistic and less complicatedfund monagenrent system. HUMAN RESOURCE: There is a shortage of human resource at all levels. Current staff are commiffed and have been stable for average period of about 5 years with minimal or no incentives. Technical competency in key CDTI activities is poor. Improve technical staff and supporling to at least 2 eoch (accountant and administrstive secretary). Explore innovative woys of improving CDD: population ratio. TRANSPORT AND MATERIAL RESOURCES: Logistic support is inadequate and maintenance is a challenge at all levels. Log books are not utilised. Essential materials including equipment for the smooth programme implementation are and the project depend entirely on APOC/NGDO support. Existing vehicles should be replaced after 5 years given the bad terrain snd maintenonce systems put in place. COVERAGE: The project is yet to achieve 100% geographic coverage, due partly to some episodes of security situation and attendant internal displacement. Therapeutic coverage could not be ascertained due to poor record keeping especially at the poor community level. . Updote census population annually during treotment. o Improve geographic and therapeutic coverage increased to 100% and 80% respectively o Explore innovative ways of engaging volunteers and improve CDD: population ratio. a a a J a 5 The evaluation revealed several strengths Improved disbursement of APOC funds for CDTI activities. Involvement of some health officers in other health programmes. Integration of supply and dishibution of Mectizan@ tablets into government drug delivery system. Willingness of FLHF staffto facilitate CDTI activities and address issues in implementation of CDTI. Participation of community members in CDTI. Weaknesses o Over dependence on APOC funding available. . Lack of transport for effective implementation of CDTI activities. o Poor census to enable determination of adequate Mectizan@ tablets not population. . Inadequate staff/lack of planning skills at all levels. o Lack of awareness among policy makers on the philosophy of CDTI has resulted into inefficiency and ineffectiveness of the project. . Poor community participation and ownership of CDTI. . SSOTF's delayed response to the needs of CDTI at lower levels has negatively affected implementation of the project. Opportunities . Health system strengthening. o Integration of CDTI into other health programmes. . NTDs. . Benefits of CDTI. . Benefits of control of Onchocerciasis. o Unskilled staff. o Poor geographic and therapeutic coverages. . Over dependence on APOC and donor funds. . Non involvement of community leaders in CDTI. o Inadequate Mectizan@ tablets. Sincerely yours, a a a a a Threats Thank you and we look forward to further collaboration with you on the matter tfrL- ,4{,1n" cc Dr Paul-Samson Lusamba-Dikassa, Director, APOC - The Head of Office, WHO Southern Sudan Office, E-mail: mohameda@nbo.emro.who.int; whossudan@nbo.emro.who. int: drabdi_9@hotmail.com - Dr Aston Benjamin Afwine, APOC Technical Adviser, Southern Sudan - E-mail: atwinebenj am in@hotamil.com - Ms Agnes Wanyoike, APOC Finance Administrative Assistant, Southern Sudan, E-mail: aggien ien gi na@ gmai l. co m - COORD - CSD - CEV- BIM - COP - TO - CAO - BFO - FO 4