Monitoring the implementation of Kafa Sheka CDTI project sustainability plan

MONITORING THE IMPLBMtrNTATION OIi KAFA SHEKA CDTI PROJECT SUSTAINABILITY PLAN : a'I @,y January-February, 2006 AKOGUN, Oladele JIMA, Daddi MATAGI, Leon REPORT AFRICAN PROGRAAA/I,IE FOR ONCHOCERCIASIS CONTROL He .'. rl iv6d 200;l -- hES F..,- To; I 3 FEV, ',ii a CIcft[r t'i0f ,1r iri i,tr t) for lnfornotlon i To' U-'i t I COORD/ A PO L tt Map showing Federal Democratic Republic of Ethiopia (A) and the Kafa Zone (B) with districts that were visited (pink). 1 2 IIi. ACRONYMS APOC African Prograrnme for orrclrocerciasis colltrol CDD Cornmunity Directed Distributor CDTf Community Directed Treatment with lvennectin FLHF F-rontline Health Facility HSAM Health Education, Sensitization, Advocacy and Mobilization MoH Ministry of Health NID National Immunization Days NOCP National Onchocerciasis Control Programme NGO Non-government organization NOTF National Onchocerciasis Task Force WHO World Health Organization WR WHO Representative , 3 2frECUTIVE SUMNIARY lckground: Kaffa-Sheka CDTI project located in the Southenr Ethiopia, withiu hrthenr Nation Nationalities and People's l{egional State (SNNPR) coverirrg 13 Joredas and 2 recently created adminishative towns started receiving APOC support in IilO and commenced disfribution of ivermectin to onchocerciasis endemic communities Itr in 2001. The 2006 estimated population that reside in the project area is about L039,154 all of wltom are at risk of the disease. The project is also supported by Carter 0cntre- Ethiopia. In October 2003, as part of its plan to achieve sustainability of F0gramme operations, APOC management commissioned a team of consultants to mluate the level of sustainability of the Kaffa-Sheka CDTI project which was then in its id year of funding by APOC. Evaluators ad.iudged the project as making satisfactory fogress towards sustainability. The evaluation team was particularly impressed by the rdent of integration of CDTI activities at both the national and regional levels. A two- par sustainability plan was developed, the implementation of which APOC management ommissioned this assessment team to monitor and report. The report presented here tscribes the process, observations and recommendations of the assessors of this mission. Iethodolory: The team made up of internal and external monitors briefed officials offt Federal Ministry of Health (MoH) about the mission before field visits to the zone rhere the process was repeated before leaving for the districts. Officials of the tlree dected districts: Bitta, Chetta and Gimbo were first briefed, then discussions held with talth officials about the implementation of their sustainability plans. Two randomly dected Frontline Health Facilities (FLHF) and two of their catchment communities were lcn visited in each district. An interactive session was held with the in-charge of the H.HF regarding implementation of the sustainability plan using pre-designed tools. ftndings: In Kafa, at the zonal, dislrict, FLHF and community level there has been a -ar-perfect integration of CDTI into the health system making it higlrly sustainable rithout external support. The procedure for planning, resource allocation, monitoring and npervision of the health system (and indeed the local administrative services) is such tat CDTI activities are integral part of all seryice sectors including education. Resources re shared with malaria, immunisation, HIV/AIDS, tuberculosis and the educational rctors such that activities are carried out irrespective of whether funds had arrived for tat activity or not. There are very few staff and even fewer health facilities but the little Gsources available to them had been so creatively applied that the Kafa zone can serve as r model for others in sustainability. The communities are so well mobilised that a &mand had been created which is demonstrated by one comlnunity that had to report to fie police when the drugs to the community was delayed by a couple of days. Cornmunities appreciate the additional value of ivennectin in ectoparasite removal and deworming. The health officials openly commend the reduced rate of scabies in the community. ln all the FLFIF and district health offices, records and charts are displayed for the past three years indicating a decline in the prevalence of reported intestinal helminths from the first position (2001) to the fourth positiorr in 2005. The communities eftest to this. The challenge is to ensure that drugs continue to reach these communities despite the few available health facilities and the poor fiansport systern. Opportunities. The Kafa zone CDTI is clearly a show-case in integrated health services delivery with cotnmunity participation. It provides an opportunity for APOC to study in ? I 4 a. details the factors that support tlte success story in Kala and identify those factors that can be replicated in other countries even if, with rnodifications. The ongoing administrative and health system reshucturing in the region is an opportunity for ensuring the enrbedrnent of CDTI into the process. The irnplementers are cornrnitted, meticulous in their documentation and highly rnotivated by the community appreciation of their efforts. Coverage calculation was based on the census population at all levels. Challenges: The main challenge to the project is the lack of transport facility. The commonest mode of tansport is the horse and the dorkey. Health facility personnel use animal hansport in most cases and their work could be enhanced further by the provision of motor vehicles in this highly mountainous area of Southern Ethiopia. [n most districts there are only about four motorcycles shared by all sectors including health and education. In some cases these include one donated by APOC for which the personnel are very grateful. Conclusion: The Kafa Sheka CDTI (Kafa zone) is addressing rnost diligently all the issues raised in the evaluation reports and implementing the sustainability plans that were drawn in 2003. The project is clearly the most sustainable that I (Tearn [rader) have ever visited. The project can be supported with motorcycles to fi,rther enhance monitoring and supervision and strengthen the health system's ability to transport supplies and personnel in these highly mountainous and poorly served areas. Recommendations The following actions are recommended to the zone l. Solicit the collaboration of partners (including NGOs and APOC) for the provision of hansport means for the health facilities in order to ensure a rnore effective communication. 2. Sustain current process of system struchring and upgrading of the health facilities, human resource development, integrated and intersectoral project . irnplementation. 3. Develop partnership with the university in Jimmh for research into some basic aspects of the project such as the added values of ivermectin delivery (ectoparasite reduction, intestinal helminth decline) which are so frequently mentioned by the health personnel and community members. The availability of records over a long period makes such study very appropriate at this time. ? a 5 c! sACKNOWLEDGIl.NIENI'S We are grateful to all those who had contributed to the fulfihnent of the rnission's objectives especially the National Coordrnator of the control programme Dr Daddr Jrma, the Zonal llead of llealth, Mr Negaliga Birhanu and the Zonal Coordinator for onchocerciasis conhol, Mr Bekele Kidane. And their district level counterparts. We appreciate the assistance of the World health Organisation Country Representative (Ethiopia) Dr Olusegun Babaniyi and his staff. We appreciate the diligence of the Adrninistratvie Olilcer and the Travels Oflier Mr Tatek Mekonnen. The Head of the Disease Prevention and Conhol Departrnent and the NOTF Chairman in the Federal Ministry of Health Dr Alemayehu Seifu was very helpful in providing advice for which we are grateful. We appreciate the opportunity provided by the Drector, APOC, Dr Uche Amazigo for us to serve on this mission. a t 6 at .I'ABLIi OF CON'T'EN'I'S EXECUTIVE SUMMARY ACKNOWLEDGEMENTS I.INTRODUCTION l.l Background 1.2 Objectives 1.3 Focus of implementatlon 2.0 MONITOPJNG PROCESS 2.1 Team Composition 2.2 Meetings 2.3 Team Orientation 2.4 Site Selection and samphng 2.5 Information Collection and Feedback Process 2.6Data Analysis and Report writing 3.0 FINDINGS, DISCUSSION AND RECOMMENDATTONS 3.1 Situation at each level 3.2 Strengths, weaknesses and opporhrnities 3.3 Technical Support that was offered to the Project 4. CONCLUSION 5. RECOMMENDATIONS LIST OF TABLES Table l: Team members and their contact Details Table 2: Schedule for Monitoring the Implementation of Kafa zone CDTI Sustainability Plans Table 3: List of Distircts, FLHF and Villages visited LIST OF APPENDICES Appendix l. Debriefing Notes Appendix 2. Persons that were met Appendix 3. Documents that were seen Appendix 4. Completed Monitoring tools 4 6 8 8 8 9 2t 23 24 25 9 9 l0 ll ll t2 l3 l3 l3 l8 l9 9 l0 t2 20 20 a I 7 aa I I.O IN-TRODUCI'ION l.l Background Kaffa-Slreka CDTI project is found in the southern part of Ethiopia, about 447 km away from Addis Ababa, the capital city in Southern Nations, Nationalities and Peoples' Regional State. Formerly, the project was located in one administrative zone called Kaffa-Sheka, but after few months of the start of the project the zone split into two independent zones, Kaffa and Sheka. The project area constitutes 13 Woredas and 2 adminisfrative .towns (recently formed). The project was approved in 2000 and commenced dishibution of ivermectin to endemic communities later in 2001 in four Woredas and attains the ultimate teatment goal on the third year. The 2006 estimated population that reside in flre project area is about 1,039,154 and all are at risk of onchocerciasis. The Carter Centre/Ethiopia is the supporting NGDO. The project area has 23 health posts, 4l health stations, t health cenlres and I hospital. In October 2003, as part of its plan to achieve sustainability of programnre operations, APOC management commissioned a team of consultants to evaluate the level of sustainability of the Kaffa-Sheka CDTI project which was then in its 3rd year of funding by APOC. Evaluators adjudged the project as making satisfactory progress towards sustainability and suggestions were geared towards strengthening the project. The evaluation team was particularly impressed by the extent of integration of the CDTI activities at both the national and regional levels. On the basis of this report and discussions during the feedback meetings, a two year sustainability plan was developed. fu a follow up to that evaluation, APOC management has commissioned this assessment team to determine if the activities proposed in the sustainability plans are being implemented as proposed; particularly by the Woredas, frontline health facilities and communities. The report presented here describes the process, observations and recommendations of the assessors of this mission. 1.2 Objectives The specific objectives of the mission are to a) Determine the extent to which program parhrers, particularly at the district, FLHF and community levels are implementing the proposed activities in their sustainability plans. b) Provide technical advice to programme partners, particular the dish'ict, frontline health facility (FLHF-) and community levels on the implementation of the CDTI 8 !lJ Focus of implementation IteKafa Sheka CDTI covers l3 districts, ten of which are located in Kafa Zone and tlre other three in Sheka zone. The project is in a highly nrountainous area with very poor tansport system that is wholly dependent on horses and donkeys. All levels within the irnplementation chain were visited, from the Znne and dishicts. The main focus of the assessors' activity was the "level where planning and funds' allocation decisions are made for health service delivery in the Zonal level and where actual CDTI implementation is done. Using pre-designed tools for collecting information at each level, fte team assessed the following indicators of sustainability: Planning, Health educatior/ Sensitization/Advocacy/ Mobihzation (HSAM), Training Finance, Transport, Mectizan Procurement, Delivery and Distribution, Monitoring and supervision, Human Resource md coverage. Record keeping had been identified as an important but inadequately addressed point in CDTI projects and was therefore included among those items to be assessed during the visit. ZO MONITORING PROCESS 1l Team Composition The team was made of two external monitors and one internal monitor (the National Coordinator) (Table l) Trble l. Team members and their contact Details The Znnal CDTI Coordinator served as guide to the dishicts but within the district, the Dishict Coordinator guided the team. The team went through the guidelines and tools for assessing the implementation of sustainability plans and the reports and recomlnendations a 9 Nrmcs Address PhonelFax Email Prof AKOGT'N Oladele Parasite and Tropical Health, Federal University of Technology, Yola, Nigeria Tel +234-8037220460 Cell+234 8052526622 olaakosun@vahoo.com MTLeonMATAGI Makere University, Institute of Psychology, PO Box 7062,Kampala Uganda +25671800186 mataiileon@vahoo.com Dr Daddi JIMA Federal Ministry of Health, National Malaria and other Vector-borne Diseases Prevention and Conhol Team, P.O.Box 1234, Addis Ababa, Ethiopia +251 l 515 0993 Cell: +251 9l-1405722 daadhii@yahoo.corn n ,a I J of previous APOC evaluation teattrs to the Kafa Sheka CDTI project. Tasks r+,ere allocated to teatu mernbers according to previous experiences, skills and interests. 2.2 Meetings 2.2.1 The Meetins with the WHO and Ministry of Health Officials The team assernbled at the WHO office where coordination and security matters were discussed with the tearn. Administrative issues were also addressed at the WHO office before meeting with the MoH officials. A meeting was held in the Minishy of Health between the team and the health officials soon after the team had reported at the WHO office and received briefing. The team leader explained the team's mission, its duration, and the process and then negotiated feedback appointments with Dr Alemayehu Seifu the Head of Disease Prevention and Control Deparhnent and NOTF Chairman. The team agreed on a time schedule for the monitoring exercise (Table 2). Table 2. Schedule for Monitoring the Implernentation of Imo CDTI Sustainability Plans: 23 F 2006 Project Dav DATE TIME ACIIVITY I Monday 23d January 2006 Meeting offrcials at the WHO olfice and the NOTF ollice. AM Security bricfing 2 Tuesday 246January PM Departure for Jimma city AM Arrival in Jimma cityInformation to selected sites. Briefing Zone o{Iicials3 Wednesdav 256 January PM Arrival in Kafa Sheka. Team haining, selection of sites and logistics AM pepart for Kafa. District olfice contacts4 Thursday 266 January PM District I Visitto- I FLHF - I Village AM Visitto- 2FLHF - 2 Village5 Friday 27h tanuary PM District 2, Visit to- I FLHF - I Village AM visitto-2FLHF - 2 Village6 Salunday 28m January PM District 3 PHC level interviews. Visit to - I FLHF - I Village AM Visitto-2FLIiF 2 Village Debriet Dislrict 3 7 Sunday 29n January PM Travel AM Travel 8 Monday 30n January PM Anatysis AM Anatysis 9 Tuesday 3 I st lanuary PM Report writfurg AM Debrief WHO l0 Wednesdaylr February PM AM Debrief NOTF !9p.4ureu Thursday 2d Fcbruary PM l0 it, 2.2.2 Meetine the District. FLIIF and Communitv officials At the distnct (Woreda), the Head of health was the first to be contaoted and briefed, then the Head of Adrninistration. The CDTI coordinator was in all cases also the Coordinator for nralaria, TB, leprosy arrd IIIV/AIDS and was responsible for explaitting the CD'l'l activities to the tearn. fhe tearn's mission was explafured and a staff of the dishict led the team to the selected FLHF sites and communities. 2.3 Team Orientation The monitors met on arrival in Bonga town, Kafa zoue studied tlre tools and guidelines and agreed on a monitoring plan. Reports of previous evaluation were also studied and attention paid to recommendations and challenges that were pointed out in them. During the team's orientation emphasis was placed on the approach and the terms of reference which included provision of technical support to the project. A schedule was drawn for the exercise and team members were enjoined to make notes of all observations and relevant comments and to include those made during feedback as part of the information received. The team worked as a single goup since this has advantage of collating rnore information from different perspectives which could be synthesised into one single tool of observation at that level. However it was agreed that only one person would speak to the respondent at any particular period. The permission to make notes was received before the commencement of the interview and when pictures were required, permission was also received before doing so. 2.4 Site Selection and sampling lnformation was collected on each district performance in the past two years (2004, 2005). It was noted on arrival that Kafla sheka project had been split into two zones- Kafa and Sheka each with its own adminisfration and health service delivery system. Kafa had ten endemic districts but Sheka had tlree endemic districts and was located two hundred kilomehes from the Kafa district. This change had not been envisaged during planning. The tearn noted that it will require either two additional team members or five additional days in order to cover the two zones. Communication was difificult and on discussion the team opted for selecting all tlree districts form Kafa zone rather than repeating the exercise in both zones which are now separate administrative entities. Kafa zone has ten dishicts all of which were onchocerciasis endemic and had coverage of over 65%o.lt was not necessary to use performance differences as basis for selection since performance was the same. The dishicts nalnes were listed on pieces of paper and three were randomly selected as representative sample. A list of the FLHFs in the selected dishict was made and two FLHFs were randomly selected. A list of the cornrhunities in each of the selected FLHF was made and two communities were rardomly selected therefrom. Altogether, tlree districts, six FLHFs and six communities were visited during the exercise (Table 3) , il a) aa Table 3: List of Districts FLI{F and Vil visited 2.5 Information Collection and Feedback Process 2.5.1 Interviews flnd information collection Every interaction for information collection comrnenced with srnall inforrnal chats about lhe official's work and other familiar things before reference to the CDTI project in the rea and the work plan that was made. The conversation was natural and was allowed to mature through probing until the desired issues of sustaiuability are addressed within the requirements of the tools. The Woreda (District) Onchocerciasis control team leaders (DOCT) in each district were irterviewed, documents checked and other members of the health team such as the Head of Health were interviewed. In each case the FLHF health officer was furterviewed while another team member irteracts with the community leaders and the CDDs. At each level, documents and cvidence of claims were requested as required by the tool. h each case and at each level the experiences of other projects were shared with the implementers. Lessons learned from them were recognised and commended immediately, opportunities were identified and the strengths and challenges discussed. Considerable efforts were made in each case to encourage the irnplernenter to identify how the challenges could be addressed and in almost all cases the approach worked well. Opportunity was given for inforrnal chat when the monitor shared experiences of other projects with the implernenter. Every interview or interaction ended with an opportunity for the implementer to make inquiries, share concerns or raise issues which may af;[ect srstainability of CDTI. 2.5.2 Feedback Meetines Feedback was given at every stage. At the FLHF it was done on the spot since the information collection process was made fairly informal to allow a natural flow of conversation. The pattern of feeding back to the respondent was the same at every level. The respondent was encouraged to identify what would be done to improve the situation. The decisions made were noted. In closing the feedback session, the team leader repeated the entire aim of the mission and the importance of sustainability to the overall outcome. At the zonal level, the feedback followed a similar pattern. The Zonal debriefing meeting was chaired by the Zonal Head of Health Department. The conversations and opinions during the feedback were noted as part of the report. The debriefing meeting was used as a forurn for exchanging information, education and comrnunication. TXSTzuCT FLHF I .l .Wushwush Flealth Station 1.2. Diri l{ealtlr Station L l.l Wushwush Village 1.2.1 Diri I. GIMBO 2.1. Oda Health Post 2.1.1 Kofra2.BITTA 2.2. Anderacha 2.2.2 Gedech 3.1. Shama 3.3.1. Keyi3. CHETA 3.2. Oia 3.3.2.Kora Total 6 6 ? l2 aa 2.6Data Analysis and Report writing The tearn nrade daily summaries of the received information and took note of observations and their irnplication for project sustainability. All the data collected at eaclr level were pooled into a single instrurnent as representing observations at that level. 'Ihe overall project sustainability at each level was then discussed with reference to the pooled data and the outcorne of the discussions constituted the report which addressed the project opportunities, weaknesses and the strengtlrs. Suggestions and recommendatiorrs were made on how the project implernentation could be further shengthened. 3.0 FINDINGS AND THEIR IMPLICATION FOR SUSTAINABILITY 3.1 Situation at each level ZONAL LEVEL Planning The zone has a health plan which reflects CDTI activities among other health care service delivery. The Coordinator is in charge of disease prevention and control team of the zone. All programs are planned first by the Dishict and then an annual review meeting is held at the zonal level. The annual review of each district's activities is carried out and plaruring for the next cycle is done. Heads of the Dishict administration is present and is able to determine what is required for health. The opportunity is used to allocate budget for health and for CDTI activities. The Head of District government takes on the issue of allocation with the cabinet since he is present at the review and planning meeting. HSAM Since Heads of Administration in each Dishict are present at the annual planning and review meeting, advocacy is assured beyond the Health Department. T'he programme is integrated other health programmes and one HSAM assists the other. Advocacy is very powerfully done through the involvement and participation of the Heads of Administration in the reviews. The arrangement is holistic involving all the sectors from education, works, agriculture and civil society leaders and politicians. In the words of the Head of Health which was found to be true for all levels "All sectors are involved in HSAM. It is not only a health issue but it is political, educational, agricultural, etc. The drug itself is mobilising by its benefits. People take it and see its relief and do not need to be told. For example, scabies used to be a major problem here and so were wonns. But now scabies rate has drastically declined and the people observe these things. We hope that in a few lnore years scabies will be in the dustbin of history" During an interactive session in a comrnunity (Diri, Gimbo District), a policeman informed tlte team that a goup once tnade a civil report that their drugs did not arrive at the expected tilne. The police had to assure thern to avert problems. ? t3 ra a llectizan llectizan supply is adequate and tirnely and is highly integrated into the delivery of other lugs and supplies ffom the region to the zone. The rnain problern is the transportation to h Districts which they solve by integrating into the other supply deliveries. 'Ihey used b sarne rnethod for the all resources. .lilegration f,csources such as transportation is integrated and so is the personnel. There is only one person involved in the coordination for two years before additional person was posted to te team. CDTI vehicles are used for all hea[th programmes and it used other sectors rhicle for programme implementation. Activities such as supply delivery, supervision, nonitoring and evaluation are integrated. finance Being integrated it was easy to carry out CDTI activities even when money allocated has mt arrived. ln 2005, government spent 87,900Brr on CDTI. Zonal government and District allocate. Since there are other programmes with funds it is possible to run the Fogramme with funds from other programmes. Resources are allocated at this and at the hwer level. Record keeping Records are available, organised and meticulously maintained as charts on the wall and in rccords. Summaries are available for every District, health facility and communities. They are stored in the office and used for planning. For example they were able to note fre cause of 57%o coverage in Bonga city which was lower than the zonal average Coverages Geographic coverage was 100 o/o and zonal therapeutic coverage was 760/o with a range from 7l and 84%. DISTRICT (WOREDA) LEVEL Planning CDTI is integrated to the overall health plan, in such a way to create syrergy between CDTI activities such as malaria, surveillance, HIV/AIDS, polio and TB/leprosy. The detailed activities for all diseases including CDTI are conspicuously displayed on the walls of the dishict health office. This is easy because the same person is responsible for the other diseases. Planning at this level conforms to that of the zoue and it is sustainable. Training Training was mainly to orientate the new CDDs. Both the contents and the objectives of the trainings are predetennined to respond to need and cut down waste. T'he CDD ? t4 aa fainings were carried out by the health rvorkers, agricultural developrnent agents and school teachers in collaboration witlr the Woreda health office. IISAM Sensitisation has been done in the previous years in such an extent that a district-wide demand had been created making periodic sensitisation umecessary. When drugs do not arrive at the expected time to the communities, there is a general agitation. In one community police is contacted to ensure that they are not bypassed. This picture was seen in every visited community. Monitoring and Supervision Monitoring and supervision was done by all the members of tlre health team in an integrated manner. This is a policy in the zone that integrates plans, finance and human resources for health care delivery. Resources on monitoring and supervision are used for planning and addressing challenges in irnplementation. Mectizan Supply Quantity of ivermectin collected from the zonal level is usually sufficient and tirnely. Upon arrival to the zone the Woredas in charge are invited to come for their supplies. The woredas collect the ivermectin using the existing drug delivery mechanism by integrating the delivery with the other medicines and health equipments. Human Resource For each Woreda, there is an officer responsible for onchocerciasis, educated and quite knowledgeable and also handles other health activities such as rnalaria and other vector- borne diseases. All district health staff have adequate knowledge and actively participate in CDTI. lntegration Training, monitoring & supervision as well as advocacy visits are integrated with other health activities like malaria, disease surveillance, maternal and childcare. Staff, Transport (motor bikes) and other resources such as olfice equiprnents are shared in an integrated manner. Finance Like all other health activities, ahnost all the CDTI activities are carried out in an integrated way and there is no separate budget allocated merely for onchocerciasis. However, CDTI activities are included in overall health plan and based on this physical activity, the pooled money is used. l5 a aa a Record Keeping At this level, records are properly kept and analysed and the surnmaries are posted on the walls. Transport Transport, like other resorrces, is shared. There is at least one vehicle for health activity and during intense activities which require rnore vehicles; Woredas rnobilise the transportation from other sectors (such as education, agriculture). However, for some of the health facilities in some Woredas, fransportation can only be done by horses or on foot. lntegration has made it possible for activities to be sustained irrespective of the Eansport situation at this level. Coverage All the villages in the districts are undergoing arurual treatment (100%). The therapeutic coverage ranges fronT3o/o in 2004 to 84o/o in 2005. Therapeutic coverage is diligently calculated using the total census as a denominator. FRONTLINE TIEALTH FACILITY Planning AII the FLHF visited had written plans of their activities. All key CDTI activities are integrated with other health care progralnmes. These were displayed on the wall. These plans are carried out in an integrated manner. Training All the CDDs are trained. New ones receive fresh training and old ones retrained. Training is linked to the need. Training materials are available in all health facilities eg charts, posters, booklets etc. the health staff are assisted on training by community supervisors, teachers and agricultural development agents. In some FLHF- CDDs are responsible for their own Eansportation and lunch during the haining. Training is done in batches of 20-30 CDDs. HSAM AII stakeholders are involved. It is not only a health issue. HSAM has been adequately carried out in a holistic manner involving religious leaders, cornmunily leaders, health workers, teachers, agricultural development agents etc. Demand has already been created. Monitoring and Supervision The same process of training is used for monitoring and supervision. t6 aMectizan Supply All the health facilities had adequate and tirnely supply of Mectizan Human Resource Although there is some one responsible for CDTI, all the staff within the FHLF have the required and the sarne skill and knowledge to carry out CDTI activities. Integration The same staff is responsible for clinical and outreach services. All the resources and CDTI activities are integrated in the general health plan. Coverage All the villages in the catchment areas of the health facilities visited are covered with the heatment (100%). The therapeutic coverage is also very high (range from73%o- 84%). COMMUNITY HSAM All communities had received HSAM and are well mobilised for the drug. At the initial stage there was reluctance because of side reactions. However this quickly gave way to complete acceptance as the people observed the added valuae of the drug in removing ectoparasites (scabies, lice) as well as in deworming children. The communities are higllly proactive with respect to the drug arrd did not have to be rerninded of the time of dishibution. Mectizan Supply Mectizan supplies are always adequate in all the communities and are timely. ln a few cases of slight delay the communities agitate for it. One community had to make a report to the police when the drug was delayed by a couple of days. The collection is by the community supervisors who ensured that the CDDs give to the community members. Human Resources There is an average of 4 CDDs for every community, with equal representation of rnale and females except in Bitta where rnajority are males while their supirvisors are females. In others over 80olo of CDDs are educated females. Athition was alrnost nil and in a few cases where we recorded some, the reasons were that the CDD went to jail (l case in !1mbo), or had gone for further studies or got promoted to the position of supervisor. TheCDDs were very delighted to serve their communities and but for an initial grumble when payment was stopped, all of them understand that it is a comnrunity service for which no payments would be made. The paynrent of a stipend for poilio guides had tended to lead to another cornplaint since all CDDs cannot be accommodated in the poilo campaign. However this has not reduced the level of the CDDs' enthusiasm and comrnilment. a l7 aa o Record keeping Treatment registers are meticulously rnaintained with eutry of all household rnernbers and not just the eligible as often seen in olher projects. Sunrrnaries are rnade and calculated orr the basis of the census of the comurrurity. Coverage In all the cornmurities that were visited alrnost all eligible persons received lreatment. There were refusals in the beginning of the programme but since the second year there were demands for more fiequent treatments. 3.2 Strengths, Weaknesses, Opportunities and Threats 3.2.1 Strengths There are many strengths to this programme. The programme personnel are highly knowledgeable, confident and foot-sure of how they will sustain the project. They are highly committed in spite of the challenges of the resources with which they have to work. There is a system of documentation and understandirrg of the project demands and expectations which is meticulously adhered to by staff. The project is being implemented within a population of people that easily appreciate the benefits of the drug and are quick to take advantage of its benefits for holistic wellbeing. 3.2.2 Weaknesses 'I'he main weakness of the prograrnme is the inability to carry out basic operational or descriptive or qualitative research that will place in the public domain the factors that are responsible for this highly successful project. Specific challenges are the few persomel in the health system. It is delightful to note that these are being addressed currently. Another challenge for which there is no clear indication of how it is being addressed is the transport system within the districts (health care delivery service) which is highly dependent on animals in a highly mountainous region. 3.2.3 Opportunities There are several opportunities for sustainfurg the current hend and success. First is the ongoing adrninistrative and health system structuring, upgrading of the health facilities and establishing of newer health facilities. Another is the recruitment and training of new health personnel for the new projected facilities. The demand that has been created in the communities will keep the health personnel on their toes and ensure annual delivery of ivermectin for a very long time (beyond onchocerciasis and perhaps as long as there are other helminthes on which the drug has noticeable effect). 3.2.4 Threats There are llo visible tlrreats to the prograrnrle. The paynrent of guides during the polio carnpaigns will need to be addressed before it affects not only onchocerciasis but all other I8 progralnmes that rnay wartl to use the cornnruruly parlicipalory approach. One way lnay be to put money rneant for 3.3 Technical Support that was offered to the I'roiect Ihere was very little teclurical support required by this project besides advice on research and collaboration to access resources from partners l. Advice to collaborate with the Univeristy in Jirnrna for operational research 2. Resolving the issue of polio carnpaign guides being paid while CDDs are not. a !, a l9 aa 4.0 CONCLUSION The Kafa Sheka CDTI (Kafa zone) is addressing rnost diligently all the issues raised in dre evaluation reports and implernentirrg the sustainability plans that were drawrt in 2003. The project is clearly the most sustainable that [ (Tearn leader) have yet visited. The project can be supported with motorcycles which will fi.rther enltance ntonitoring and supervision and strengthen the health system's ability to transport supplies and personnel in these highly mountainous and little served areas. 5. RECOMMENDATIONS The following actions are recolnmended to the zone l. Solicit the collaboration of partners (including NGOs and APOC) for the provision of transport means for the health facilities in order to ensure a more effective communication. 2. Sustain current process of systern structuring and upgrading of the health facilities, human resource development, integrated and intersectoral project implernentation. 3. Develop partnership with the university in Jimma for research into some basic aspects of the project such as the added values of ivennectin delivery (ectoparasite reduction, intestinal helminth decline) which are so frequently mentioned by the health personnel and community members. The availability of records over a long period makes such study very appropriate at this time. ta 20 t , APPENDIX I- DEI}RIEFING NO'[[,S ITOR WIIO REPRESENTA'I'IVB AND'I'IIE I-EDERAL MINISI'RY Oi- IIEALTII I.I NOTES .ldroduction Kaffa-Sheka CD-l'l project located in the Southenr lithiopia covering l3 Woredas started dclivery of ivennectin since 2001. In October 2003, evaluators adjudged the project as making satisfactory progress towards sustainability. A two year sustainability plan was developed, the implementation of which APOC monitors wish to now provide some feedback. The monitors visited three districts Bitta, Chetta and Gimbo; six frontline heatth facilities and six comrnunities checking docurnents and collecting information on ,. fre project implementation. findings: The team noted that r There is an integrated health care service delivery. o I good plaming system (bottom up) with resource allocated to all health activities. . CDTI project created a very high demand for the dnrgs at the community level-with experience of deworrning, ectoparasite removal . Highly motivated CDDs. o Timely and adequate dmg supply. The Kafa zone CDTI is clearly a show-case in integrated project delivery with community participation. It provides an opportunity for APOC to identifu those factors that can be replicated in other countries even if with modifications. Challenges: The main challenge to the project is the lack of transport facility. In most disricts there are only about four motorcycles shared by all sectors including health and education. ln some cases these include one donated by APOC for which the personnel are very grateful. Conclusion: The Kafa Sheka CDTI (Kafa zone) is addressing most diligently all the issues raised in the evaluation reports and implernenting the sustainability plans that were drawn in 2003. Recommendations The following actions are recommended to the zone . Solicit the collaboration of partners (including NGOs and APOC) for the provision of transport means for the health facilities. . Diligently maintain current process and prepare to share success with other projects elsewhere o Develop partnership with the University in Jimrna for operational researclr Acknowledge We appreciate the hospitality of all those that we have had the opportunity of interacting with during the course of this mission from the WHO/Addiss Ababa to the Ministry of Health and the communities O. Akogun, J. Daddi, L. Matagi WHO/APOC Monitoring Team 2t Addiss Ababa, l'r February,2OO6 at t I.2 WT{O REPRESENTAT'IVE WR/trthiopia, Dr Olusegun Babaniyi was delighted at tlre visit and the report. He mentioned why the initial plan to evaluate had to be postponed and no(ed that Ethiopia, an ancient country, had a lot to share to outsiders especially the ability to creatively use rninirnal resouces for maximtrm benefits. He was especially delighted that comrnitment is still a virtue in Ethiopia and that monetization was not yet the norm. Regarding sharing the successes with the public, he noted that it was the usual practice in WHO/Ethiopia and that WHO will provide support for the publication of the activities of the Kafa CDTI project. He noted that flrere is a website which will host a summary of the monitors report. I.3. DIRECTOR, FEDERAL MINISTRY OF HEALTH The Director expressed delight at the report and promised to continue to strengthen th sustainability of the projects flrough integration and partnership with communities. 22 APPENDIX 2- List of I'ersons i\Iet NAI\IE OF AREA PERSONS I\{ET POSITION a o i LEVEL NATIONNI ADDIS ARABA I Dr. Alcnra,r'ehu Serhr 2. Dr. Daddr Jrnra Clrarrman. Na(ional Oncho Task Force (NOTF). and Head ol l)rsease Prer errtron aud ('ontr ol Deparhnent. National Orrcho Coordinator, and Acting llead of Malaria and other Vcctor Borne Diseases Deparhent. ZONE KAFFA REGION I Dr. Negalign Birharn 2. Mr. Tsegaye Bekelre Kidane Head of Healtlr Departrnent, Ka[a Region Onchocerciasis Coordiuator, Kalfa Region DISTRICT GIMBO l. Mr. Legesse Haile 2. Mr. Dejene Alemu 3 Mr. Gebreyes Hailu Head of Heath Departnren! Gimbo Wareda Oncho Coordinator Head of Disease Prevention aud Control Desk CHETA l. Mr. Shinreles Abebe 2. Addisu Alernayehu Head of Disease Prevention and Conhol Desk Oncho Coordinator. and Head of Cheta Health Otfice BITTA l. Mr. GerEnreo Takele 2. Bizayehu Getachew 3. Aslragracherv Siyounr Head of Health Department, Bitta Wareda Wareda Oncho Coordinator Environment Heal0r Coordinator FLHF Dru l. Mr. Zeeeye Bekele Health Assistant wtJSHW1JSH l. Mr. Dcsalegu Shukur 2. Mr. Wondimagegu Kibret 3. Ademe Haile Clinical Nurse Clinical Nurse CDD OJA l. Michulu Mengesha Head ofOja FLHF SHAMA L Ms. Mihiret Bekele Clilical Nurse ODA L Mr. Zerilrhun Getabun Senior Clinical Nurse and Head of Health Station BITTA l. Mr. Kikdu Geshere Clinical Nurse and Head o[the Clinic COMMUNITY DIRI l. Mr. Alemayehu Gelo 2. Mr. Agide Haile 3. Mr. Derese Gebre Marianr 4. Mr. Teshome Gebre CDD CDD Comnrunity lrader Eldcr WUSHWUSH l. Mr. Wachalo Gabre 2. Sister Mulinata Community [eader Religious l,eader KORA L Mr. Birhanu Wolde Manam Comnrunity Member KEYI l. Mr 2.Mr 3.Mr 4. Mr 5. Mr Admasu Agito Jihad Ababulgu Ashebir Alemu Giji Belete Tibo Wolde Michael CDD Corumunity Member Cornmunity Member Comrnunity Membcr Conrnruuity Mernber KOFRA l. Alemu Haile 2. Mr. Asfan Haile Mariam 3. Mr. Cebrernichael Gebre Comruunity Supervisor Community Member Conrnrunity Member GEDECH l. Mr. Dests Tare 2. Mr. Gebre Beyene 3. Mr. Kelay Tsegaye 4. Mr. Getu Wase CDD Community Member Cournrurrity Mernber Community Member 23 't t a APPENDIX 3-List of documents that were seen hy the Monitoring team l. CDTI Annual Technical Report of Kaffa Regiorr/Zone for 2006. 2. Regional/Zonal Surnmary Report -2005.3. CDTI Perfonnance Sumtttaries for 2003-2005 (including census and treatrnent data). 4. Girnbo Wareda Oncho Budgets for 2003-2005. 5. Diri FLIIF Out Reach Plan 2006. 6. Training Materials at all FLFIF (e.g. Charts, Booklets). 7 . Comrnunity/Village Treatrnent Registers. 8. Annual Work Plans for 2006 (Oncho activities included). I : 24