Assessment of Sustainability: Morogoro CDTI Proiect, Tanzania

tWorld Health Organization African Programme for Onchocerciasis Control v Assessment of Sustainability: Morogoro CDTI Proiect, Tanzania ( Fourth Year) October 2008 ,t u - (feam Leader)llpof" Ohiqmg Dr. Abel Mwakafrvila ',Dr, Rehma Mr; Prince Er, George It{s,Rosema o Acknowledgements We are grateful to the following persons and organisations for their cooperation, contributions and assistance towards the successful execution of this assignnrent The Director, Dr. Uche Amazigo, and staff at APOC Headquarters in Ouagadougou for making available the necessary financial and logistic requirements for the success of this assignment. Dr Kirumbi, Acting National Onchocerciasis Coordinator for facilitating the smooth take off of the exercise in Tanzania. The Ministry of Health and Social Welfare for facilitating the smooth running of the evaluation and for providing useful information. The Regional Adminstrative Secretary, the Regional Planning Offlcer and the Regional Medical Officer for their assistance and in providing useful information. The Morogoro and Mvomero district Councils for facilitating the conduct of the evaluation and providing relevant information. The District Health Staff, FLHF staff and community members in the study communities, who provided important information and contributed to the success of the mission, Last but not least immense gratitude to the team of accommodating drivers who drove the Evaluation Team over kilometres of roads and terrain under rough conditions, I t Y ta 1lvlorogoro C DT I Evaluation Reporl Abbreviations/Acronymns a AIDS APOC CDD CDTI CCHP CHMT DDO DNO DHO DP DLT DHS DMO DED EPI FLHF GCR HSAM HIMS IMCI IEC LF LGA RHMT MOH MOU MSD NOC NOCT NOTF NGDO OC PC PPM RPO RAS REMO RMO RIIS SSI TSH TMOHSW TCR wHo Acquired Immune Defi ciency Syndrome African program for Onchocerciasis control Community directed distributors Community directed treatment with Ivermactin Comprehensive council health plan Council health management team District dental officer District nursing officer District health officer District Pharmacist District lab technician District health secretary District medical officer District executive director Expanded program of immunization First line health facility Geographical coverage rate Health education, sensitisstion, advocacy, mobilization, Health information management system Integrated management of child health illness Information, education and communication Lymphatic filariasis Local government authority Regional health management team Ministry of health Memorandum of Understanding Medical store department National Onchocerciasis Coordinator National Onchocerciasis control team National Onchocerciasis task force Non governmental development organization Other charges Project coordinator Plan preventive maintenance Regional planning officer Regional administrative secretary Rapid epidemiological mapping for Oncho Regional medical offi cer Regional health secretary Sight savers international Tanzania shillings Tanzaniaministry of health and social welfare Therapeutic coverage rate World Health Organisation 3Morogoro CDTI Evaluation Reporl a EXECUTIVE SUMMARY INTRODUCTION Morogoro region is located in the eastern part of Tanzania. Morogoro Rural CDTI project is spread over Morogoro and Mvomero districts and serves 146 communities and a population of 524,495. This includes the Luguru, Kaguru, Kwere and Masai, settled and nomadic population. The mountainous areas are much densely populated than the low land. The main occupation of the community is farming of foods and cash crops, cattle herding, small scale fishing and timbering. The region has 4 other districts all covered by three previous CDTI projects namely Ulanga, Kilombero and Kilosa. The project commenced in 2003 but actual implementation of CDTI activities started in 2004. The project is currently in its fourth year of drug distribution having missed one year due to delay in fund disbursement from APOC . In 2007, after two years of drug delivery to the communities and three years of the inception of the project; APOC management appointed a 7-person monitoring team, a facilitator and observer for independent monitoring of the project. The Morogoro CDTI focus covers the district of Morogoro rural and Mvomero. The later being a newly created district carved out of the previous Morogoro rural district in May 2002. The two districts lie between latitude 8o and l0o south of Equator and between longitude 37" and 38o East of Greenwich. The evaluation in the field was carried out over a period of one week. During this period, information were gathered from desk review of relevant documents and reports, interviews with implementers and key stakeholders as well as field observation of CDTI implementation activities in sampled sites at the Regional, District, First Line Health Facility and village levels. Focus group discussions were also held with community members. This was followed by two days feedback and workshop for the development of their five-year sustainability plan by individuals responsible for the project implementation at the Regional and District Levels. The collation and analysis of information gathered from the field evaluation activities in Morogoro CDTI project area and planning of the feedback and sustainability planning workshop took another one week of intense work by the evaluators. SPECIFIC FINDINGS Planning CDTI activities are integrated into the overall Comprehensive Council Health Plan (CCHP). The plan varies from year to year according to specific needs of each year as more activities were being introduced. For exampl e, in 2007 , LF was included as part of Onchocerciasis control programme. A participatory approach is applied in the routine planning for the Morogoro CDTI project. Apart from government, the NGDO partner is actively involved and all partners are clear about their own roles, and those of the others. The minutes of the meetings of such meetings are available. The regional level is not involved in the planning process but is fully informed, as it is responsible for the approval of plans before they are funded. A written plan for 2007 CDTI plan was available in all the FLH facilities visited. This included training of ward development committee members and a a 4Morogoro CDTI Evaluation Reporl health education for CDDs. The plan was prepared by health staff at this level and it is integrated into the overall year plan for the facilities. At the community ievel, the community leaders are fully involved in CDTI activities. These include collection of Mectizan from the FLHF with the CDDs, going from house to house with CDDs during Mectizan distribution and involvement in HSAM activities. Community members not only take decision on mode, time and place of distribution but select their CDDs. Integration All health programmes are carried out in an integrated manner and it is in written form. There is a written work plan which shows co-implementation of CDTI with Lymphatic Filariasis Elimination program in an integrated manner. Moreover, supportive supervision is done for more than two iasks. Staff combines two or more CDTI activities on a single trip. In all the FLH facilities visited a check-list for this purpose is in place. Leadership Health and government officials at all levels are fully aware of progress, success and problems of the program and consider it as theirs. Community members and leadership support Mectizan distribution; they value and know that treatment will be for long time for at leost lSyeors they reported. Monitoring and Supervision Monitoring and supervision of CDTI activities are integrated with other routine/supervisory activities by RHMTs and CHMTs. This is usually carried out during the Mectizan distribution time. Data generated are compiled and submitted to the district authorities. Important records are readily available at various levels showing treatment summary records, inventories of equipment, financial records and periodic reports including the annual technical reports for three years. They are of good quality with clear and accurate contents. Based on the minutes of weekly CHMT meetings, problems identified during monitoring and supervisory visits are discussed and solutions are initiated to solve them. Feed back is sent to staff concern at the appropriate level. Mectizan Ordering and Supply Supply of Mectizan follows the government procurement and supply procedures. Mectizan is received through the District with other drugs through a transport system supplied and paid for by the government up to the health facilities which is the collection point for CDDs in various communities. Annual Mectizan need for communities is collected by the CDDs and Community leaders from the FLHF nearest to them by walking or use of their bicycles. In other cases where communities are remote, staffs in the FLHF supply Mectizan to the community during training of CDDs before distribution commences. a 5lvlorogoro CDTI Evaluation Report Training and HSAM Training of staff at lower levels is routinely carried out by staff at levels above them. For example staff members at the national level conduct training for staff at the regional level, and staff at the district level are trained by staff at the regional level while staff at the FLHF level is trained by staff at the district level and at Communities level, CDDs and Community Leaders are trained by FLHF staff. Training is carried out when there is deficiency as it relates to CDTI activities. This is usually when new staff, new CDD, or new decision makers are employed and when there is a new programme to be integrated with e.g. LF. Training is also conducted as a means of solving identified problems/gaps during Monitoring and supervision, such training are carried out as need arises and not on routine basis and in a cost effective manner. HSAM activities have been effective and have resulted to the inclusion of CDTI activities in the CCHP.HSAM also conducted during ward development quarterly meetings comprising of ward leaders, village leaders, sub-village leaders, extension workers including FLHF staff and influential leaders, so as to increase knowledge and commitment to CDTI activities. HSAM activities are properly planned and carried out to help in minimizing misconceptions about Mectizan and to improve coverage by reducing the number of refusals. This has been responsible for annual increase in coverage in communities. All these will make the project to be sustainable. Finance The annual budget in the CCHP available at the Regional level clearly spelt out the cost for each onchocerciasis control activity, and the Project Coordinator do not always have clear estimate of funds available for Onchocerciasis control in the coming year since the fund from the NGDO is added later. There is evidence of cost reduction since all activities are carried out in an integrated manner. Government funding is steadily increasing and always clearly spelt out in the CCHP. All funds released yearly are spent as budgeted, however even though the amount budgeted by government is increasing annually it is not up to half of the NGDO and APOC contribution for a project in the third year. Few of the communities compensate the CDDs through exemption from community activities while other do not compensate them either by cash or in-kind. Reason for non compensation of CDDs as reported by community leaders is: due to poverty, which makes CDDs to loose moral. This in a way will make the programme not to be sustainable .This is coupled with the fact that government support to the programme is still meager. Transport and Other Material Resources Presently, transport is available and adequate for CDTI activities at all levels. The project presently has one 4WD Toyota double cabin vehicle supplied by APOC. APOC also supplied, desk computer, Lap top computer, photocopying machine, fax machine and printers while SSI provided them with air-conditioner, and office furniture. C 6Nlorogoro CDTI Evaluation Repttrt The vehicles available from the govemment are the main transport means for CDTI at the district and FLHF levels. Government has been bearing the cost of maintenance and fueling of vehicles. This is carried out immediately and efficiently. All vehicles are in the pool. There is a routine maintenance schedule for vehicles at all levels by Planned Preventive Management (PPM) Servicing is carried out accordingly every three months or based on number of kilometers. Budgets for maintenance are reflected in the CCHP .The vehicle maintenance records are kept by the transport officers. Travel authorization is usually obtained for CDTI support activities by programme staff through the transport officer. Trips made for CDTI purposes are authorized in writing based on route matrix prepared by the transport officer. There is a log book stating joumey dates, quantity of fuel utilized, journey route and status of vehicle at the end of the trip. The log-book also shows name of oflicer, the driver, location of activity and number of kilometers covered. Transport is available for supervisory activities at the next level. With the current integration of activities at all levels, transport is shared among all programmes. The Evaluators were assured of likelihood of transport remaining stable until the duration of the project. Staff members have ways of coping when vehicles break down or are not available, so that CDTI activities are not disrupted. This is because more than one vehicle is usually allocated for health activities. If one vehicle used for CDTI breaks down any available vehicle could be used for this purpose. This is an evidence for the sustainability of the project. Though there is no written evidence to show replacement of vehicles and equipment for CDTI activities, the evaluators were informed that there will be support from other vehicles in the pool when the need arises since all health programmes are carried out in an integrated manner. So far all capital equipment used for the implementation of CDTI activities is from non govemment sources. However since the photocopying machine and other equipment are used for other activities apart from CDTI activities, they are in the hospital management schedule for maintenance. However government has been responsible for provision of stationery and materials for haining and HSAM. HSAM materials were however reported to be inadequate in most FLHF and communities. Human Resources There is staff stability at all levels and salaries are regularly paid. The numbers of staffs at various levels are adequate for CDTI activities. They have appropriate, knowledge and skill to undertake all CDTI activities. They are also committed to the success of the programme. Staff transfer at all levels is not frequent Since project inception, there has been no transfer of programme staff. They have remained the same and on their posts for more than three years. This will help improve the quality of CDTI programme activities and thereby sustainability. On recruitment of new staff, he/she is oriented immediately on CDTI activities. Staff attitude is satisfactory. Most CDDs expressed willingness to continue working without receiving compensation. This shows some level of sustainability. The ratio of CDDs to households is also appropriate in most of the communities visited. Though the district level staff member's commitment to CDTI is high, there has been low motivation for them. No award, financial and or material rewards or recognition of their post by the Central Government System. Also new professional health workers in the country are yet to be provided with up-to date knowledge and skills in the field of CDTI 7illorogorc CDTI Evaluation Re porl Generally, CDTI activities are integrated into the government system in carrying out the following activities namely: Management and use of transport/logistics, Monitoring and supervision, Retrieving of data especially at the FLHF level and Storage of mectizan. The Evaluation Team felt that all these are helping in the sustainability of Morogoro CDTI project. Coverage Also the therapeutic coverage situation in the project is remarkably increasing annually even though there was no significant difference between 2007 and 2006 but this has been stable In 2007 it was 75%o, in 2006 it was 75.3oh and it was 67%o in 2004. On the other hand, geographical coverage has remained at l00o/o in all three years. Evaluating the project on the basis of the seven aspect and five critical elements of sustainability, the Evaluation Team concluded that the Morogoro CDTI Project is making satisfactory progress towards sustainability. Some of the odds identified which has set the project back included finance and ownership. With regard to the five critical elements, the Evaluation Team found that three elements - Transport, Mectizan Supply and Supervision were present in the project. The elements of Money and ownership were not satisfactory in the project. Resources were mainly from outside even though there is political commitment at the other levels, there is no complete ownership at the community level. Communities are not involved in the provision of census register, pens and pencils to CDDs and most communities do not compensate their CDDs either in cash or kind. With regard to the seven, aspects of sustainability, the Evaluators found that five namely: Integration, efficiency, simplicity, attitude of staff and effectiveness were helping the project attain sustainability. Resources and community ownership were found to be blocking sustainability. This is because govemment funding for the programme is very minimal even though the programme is in its fourth. The programme has been dependent on non-government sources for three years. The quantitative scale of 3.6 for the project in its fourth year shows that the project is however makin g satisfactory progress towards sustaina bility. It is therefore the view of the Evaluation team that based on the qualitative aspects that the Morogoro CDTI project is making progress towards sustainability During the feed back meeting the implementers and stakeholders at the regional and district levels commended the findings and recommendations at each level. They appreciated the need for more fund to be allocated to the Morogoro CDTI project through recommendation from the district level to the regional level. Also it was their view that a process for an operational research on behaviour/ attitudinal study should be put in motion to determine why there is low therapeutic coverage at the sub -urban levels when compared with the rural sub villages and the level of misconception in various sub-villages on Mectizan. The team thereafter proceeded to develop the five year sustainability plan based on the recommendations and bearing in mind the weaknesses identified. The team also discussed ways of moving the project forward. Some of their suggestions on how to move the Morogoro CDTI project forward are listed below. 8illorogoro C DTI Eval ualion Reporl THE WAY FORWARD As Morogoro GDTI project moves into the 5th year, the Evaluation Team, programme ,unug.r.-und policy makers at the Regional and district levels appraised appraised the critical issues=that wilienable The Morogoro CDTI project to be sustainable post APOC and came up with the following recommendations. l. planning: There should be an integrated annual work plan at all levels. .Communities should be involved in planning and implementation of CDTI activities. Planned health activities in CCHp shouid take into account community priorities/needs. There should be a policy on how to motivate CDDs and other CDTI implementers at all levels. Z. HSAM: HASM on the CDTI activities should be carried out continuously at all levels especially at the community level to promote acceptability of and participation in the prtgru-1n" including community ownership. Advocacy visits should be paid at all levels in"tuOing ward and community leaderships for commitment to the CDTI programme' Appropriate IEC materials should be used for this purpose. Training of community leaders und ctmmunity members should be carried out regularly in order to minimize misconception and hence increase coverage. 3. Resource Mobilization: Government should be sensitized for commitment to the CDTI programme especially as it relates to increase funding of the CDTI programme. There is ,..I for high level advocacy at the regional level to ensure increased budget for CDTI activities in the CCHP. 4. Integration: In the process of integrating CDTI activities with other programmes the roles and iesponsibilities ihould be clearly stated. This is to remove any form of bottle necks that ,uy u.ir. leading to unforeseen delays in programme implementation. The present delay in 2008 mectizan distribution due to co-implementation of CDTI with LF was sighted as a good example of one of the probles of integration 5. Involving more NGDOs and Other Agencies: There is need to identify potential NGDO to provide additional support and carry out advocacy visits to them. 6. Stakeholders' Review Meetings: There should be regular stakeholders review meetings to give feedback on CDTI activities, coverage, reports constraints, etc. to individuals involved in CDTI activities. 7. Simplicity: The Government should ensure a rapid and smooth delivery of Mectizan to districti.The system of drug collection and reporting should be kept as simple as it is. The MSD system presently being used for transportation of drug to the FLHF should be maintained. 9lv'lorogoro C DT I Eva luation Retrtrtrl 8. Reporting and Documentation: Reporting and documentation of all CDTI activities (training, monitoring, supervision etc) at all levels of implementation. This will facilitate efficient planning and provision of efficient feedback to stakeholders. 9. Operational Research: The difference in therapeutic coverage between the sub-urban and rural communities was of great concern to the stakeholders. Also were the issue of refusal due to misconceptions in some sub villages on Mectizan and the willingness of the CDDs to continue with Mectizan distribution even with no support from the sub-villages. Both the stakeholders and the team were of the view that an operational research on behaviour and attitude of community as it relates to Mectizan distribution should be instituted to answer some of these questions Llorogoro CDTI Evaluotion Report l0 TABLE OF CONTENTS Acknowledgements Abbreviations/Acronyms ............ Executive summary l.O INTRODUCTION l.l Background to the Morogoro CDTI Project Evaluation """ 1.2 Evaluation Objectives .. 2.0 METHODOLOGY .......... 2.1 Design 2.2 P opulation ............ 2.3 Sampling and Selection Communities 2.4 Sources of Information ...'..'.'... 2.5 Analysis ................ 3.0 EVALUATION FINDINGS ., ....3 .4 13 .13 l5 Sustainability at Project/Regional Level Sustainability at the District Level Sustainability at FLHF Level ..'....' Sustainability at the Community Level Comparative Analysis of the Sustainability of the Four Levels .'..'..'. t9 t9 26 3.1 3.2 3.3 3.4 3.5 ..3 I ..36 .41 4.0 CONCLUSION 4.1 Grading the Overall Sustainability of Morogoro CDTI Project. ...."" 4.2 Sustainability /Ieedback workshop at the regional and district levels Morogoro CDTI project 4.3 The Way Forward ............ APPENDIX I: Morogoro CDTI Project: Evaluation Team Composition .....'.... II Morogoro CDTI project: Name of Respondents at various levels III Morogoro CDTI ...project.... IV Programme of activities for 2 days feedback/sustainability plan development V Roles of different levels and partners feedback/sustainability plan. VI Regional level-SWOT Analysis. VII Address for Morogoro CDTI Evaluation team members....'........ VIII National Onchorceciasis Control Programme Morogoro CDTI Sustainability Feedback meeting (Registration) .'............ 44 44 ,.,.........49 ,...........54 \\ .............55 ..............56 ............. 58 .............59 ...... ..61 .62 .69 .70 h{orogoro CDTI Et,aluation Reporl l1 ........... l6 ...........16 t6 ....17 .....17 LIST OF TABLES Table I Table2 Table 3 Table 4 The geographic and therapeutic coverage in Morogoro CDTI project from 2004 -2007. Study villages and communities Sustainability Score of the different Groups of Indicators by levels of CDTI Implementation in Morogoro CDTI project Financial contribution of various CDTI partners between 2004 to 2008 Pages 15 l7 4l 45 !l[ o rogoro C D'l I Eval uat io n Re p ort t2 LIST OF FIGURES Figure 1: Morogoro CDTI: Sustainability at State Level Figure 2: Morogoro Sustainability at District Level Figure 3: Morogoro CDTI: Sustainability at FLHF Level Figure 4: Morogoro CDTI: Sustainability at Community Level Figure 5: Average Performance at various levels Figure 6: Sustainability Score of the Groups of Indicators and Level of CDTI Implementation in Morogoro CDTI Project Figure 7: AveragePerformance of Each Group of Indicators in the Entire Project Pages t9 26 3l 36 4l 42 43 lvlorogoro CDTt Evalualion Report 13 1-.0 INTRODUCTION 1.1 Background to the Morogoro CDTI Project Evaluation The Morogoro CDTI focus covers the districts of Morogoro Rural and Mvomero which are among of six districts found in Morogoro region.The Morogoro CDTI project was launched in 2003. CDTI activities were implemented in 146 villages, 76 in Morogoro rural and 70 in Mvomero with a total of 146 sub-villages. In 2006, there were a total of 871 endemic communities (hyper 558 and meso being 313 communities). There are atotal of 424 endemic communities in Morogoro (345 mesoendemic and 79 hyper endemic) and 447 endemic commuities in Mvomero (213 meso endemic and 234 hyperendemic). The two districts lie between latitude 8o and l0o south of Equator and between longitude 37" and 38o East of Greenwich Morogoro region is located in the eastern part of Tanzania. The region comprises of six districts namely; Morogoro Rural, Kilosa Ulanga, Morogoro urban, Kilombero and Mvomero. The region is inhabited by Luguru, Kaguru, Kwere and Masai tribes. These communities consist of indigenous and nomadic population; the mountainous areas being much more densely populated than the low land. The young people keep on migrating to look for employment in towns and to areas or neighboring regions where there are newly discovered mines. The main occupation of the community is farming of foods and cash crops, cattle herding, small scale fishing and timbering. Topography The two districts are divided into three geographical zones:- (a) Mountainous or Highland Zone (25Yo) This zone covers the Uluguru Mountains located at an altitude of 1200 - 2000 m, above sea level with the clay type of soils. The zone is suitable for the production of maize, beans and horticu ltural particularly Mediterranean types of fruits. (b) Semi-Mountainous/Low Land Zone (20%) This zone covers most of the Southern part of Morogoro/Mvomero districts, at an altitude of 800 - 1200 m above sea level with sandy clay loam type of soils. The zone is suitable for the production of maize, cassava and sorghum as staple food crops. (c) Savannah Zone (55Yo) This zone is located at the altitude of 600 - 800 meters above sea level; with same clay loamy type of soils. The zone is suitable forpaddy, maize and cassava, for both food and cash crops; and also suitable for sugarcane, cotton and sisal as cash crops. Part of South East of the zone falls under Selous National Park, further the district has big valleys and numerous fast running rivers such as Mgeta, Ruvu and Wami-Luhindo rivers. Climate The temperature ranges between 20oc up to 28oc. Rainfall ranges from 600mm in the savannah areas and up to 1600 mm in the mountainous areas. It has two clear seasons namely: rainy season from February to May and dry season from ]une to January. Morogoro CDTI Et,aluation Reporl t4 Communication The total road network in the district is 1168 km. The roads are divided into the following categories:- -National truck roads - 188 km - Regional roads - 343 km - District roads - 295 km - Village feeder roads - 342km Most of the road network is passable during the dry seasory but some feeder-roads to the villages are impassable during the rainy season. Administrative Structure Administratively the two districts are divided into 10 (ten) divisions,42 wards and207 registered villages. They also constitute 3 parliamentary electoral constituencies. Health System The Morogoro CDTI Project area has 3 hospitals. One owned by the Government one (1) by Parastatal organization and the third by a Religious organization. There are seven (7) Rural Health Centers (6) being Government owned and one (1) belonging to Parastatal organization and eighty two (82) dispensaries of which 58 are owned by the Govemment, twelve (1'2) by NGO's, ten (10) by Parastatal organizations and two (2) by individual/private organizations. There also 59 (fifty nine) village health Posts of which 50 (fifty) are owned by the Government and 9 (nine)by NGO's. There is a total of.S4}health staff in the entire project area (286 in Morogoro and 256 in Mvomero) out of these, 327 are involved in CDTI activities (181 in Morogoro and 146 Mvomero). There are 7996 CDDs involved in Morogoro CDTI projec! comprising 1005 males and 991 females. Out of these, 973 CDDs are from Mororogoro sub project (473 males and 464 females) while 1059 CDDs (532 males and527 females) are from Mvomero sub project' The total number of communities treated between 2004 and 2007 and their geographical and therapeutic coverage are shown in table 1 Morogoro CDTI Evaluation Reporl l5 Table 1: Showing the geographic and therapeutic coverage in Morogoro CDTI project from2004-2007 Year No of endemic communities No of endemic communities treated Geographic coverage (%) Therapeutic coverage (%) 2004 146 136 92.5 67.0 2005* 2006 828 828 100 75.3 2007 871 871 100 75.0 * Late funding from APOC led to no treatment 1.2 Evaluation Objectives 1.3 Funding of the Morogoro CDTI project by APOC and SSI started in 2003. An Independent Monitoring Team was constituted by APOC to visit the Morogoro Community Directed Treatment with Ivermectin (CDTI) project from 30ft July to 12ft August 2007 (Third year of project). A copy of the monitor's report with their recommendations was cited by the evaluators. As is usual for all APOC supported projects, APOC management has therefore delegated a team of six evaluators from Nigeria and Tanzaria to evaluate the Morogoro CDTI project for sustainability. This activity was carried out from the I Oft to 24h of October 2008. The main objective of the evaluation exercise was to determine the sustainability of the Morogoro CDTI project which is presently at its fourth year and also assist programme staff and other implementers in developing a post APOC sustainability plan. The specific objectives therefore were: a) To assess the performance of the individual groups of indicators of sustainability in the Morogoro CDTI project. b) To identify the factors that may block or help the sustainability of the project c) To discuss the outcomes of the evaluation exercise with the relevant stakeholders and partners in the Morogoro CDTI project d) To develop a3year Sustainability plan for the Morogoro CDTI project post-APOC. e) To De-brief the WR in Tanzania on the outcome of the Evaluation of Morogoro CDTI Project. Morogoro CDTI Evaluation Report l6 2.0 METHODOLOGY 2.1Design A cross-sectional descriptive design was employed as the process for data collection. In doing this the evaluation objectives and questions were answered, and data was collected in order to provide the analysis required 2.2. Population The total population in the entire project a(ea is of 594,066, comprising of 297,864 for Morogoro and 296,202 for Mvomero. 328,81.4 for a total population are in meso/hyperendemic zones (227,454 mesoendemic and 89,059 hyper endemic). A total 152, 712 for a population in in hyper/mesoendemic in Morogoro district (123,988 as meso endemic and.28,724 hyper endemic) while a total of.176,'1.02 of the population are in the meso/hyper endemic zone in Mvomero district (770,366 meso endemic and 68,744 hyper endemic). 2.3. Sampling and Selection of Communities Morogoro CDTI Project comprises of two endemic districts, Morogoro and Mvomero. A multi slage sampling techniques was adopted for the selection of six villages with First Line Health facilities (three each from each of the two districts), out of which twelve sub villages (two from each village) were randomly selected through balloting. Thus a total of twelve sub-villages were selected Information was sent across to selected FLH facilities and sub-villages and appointment made for their visit by the evaluators. The District Onchocerciasis Coordinators played a crucial role in the passing this information and as guides to the team members. The data output of the selected villages and sub-villages are shown in Table 2. N{orctgoro CDTI Evaluation Reporl t7 SAI District Village Sub Villaee/community I Morogoro Rural(75%) Kizinga (65%) Mikese Mjini (81%) Polepole (35%) Mkuyuni (48%) Nzawa (61%) Misala (76%) Tawa (69.9%) Mgembe (90%) Dikoni (73%) 2 Mvomero (74.e%) Mhonda (85%) Mvaii (83%) Diyagaya (78%) Langali(80%) Lolo(81%) Mgini (80%) Kanga (70%) Lukindu (85%) Chalongwe (89o/o) Table 2: Showing study villages and communities Prior to the field visit, one day tools orientation training was held for the team. This included introduction of the CDTI concept with emphasis on the strategy, partnership and responsibility sharing. Monitoring was then discussed particularly the need for monitoring and the use of monitoring outcomes. 2.5 Sources of Information Information was collected from interviews, verbal reports and documents. Various categories of people were interviewed in the State. These included the Regional Administrative Secretary (RAS); Regional Medical Officer (RMO); Regional Planning Officer (RPO); Project Accountant; Project Coordinator at the regional level. At the district level, the District Executive Director; District Medical Office; District Pharmacist; District Transport Officer and District Oncho teams in each district were interviewed. Other individuals interviewed included the Frontline Health Facility staff (FLHF District health Supervisors) and in the sub-villages/communities, community leaders, CDDs, and community members form selected communities. Information from the community members was through a focus group discussion. Information was recorded on evaluation instruments. 2.6 ANALYSIS Based on the information collected, each indicator was graded on a scale of 0-4 (worst to best) in terms of its contribution to sustainability. Summary statistics for the scores were calculated for each level, and for each group of indicators, and tables and graphics from these results were plotted. The average 'sustainability score' for each group of indicators was calculated, for each level, and a graph was plotted. This was presented at the feedback workshop. The quality of the overall project was also assessed using the different aspects and critical elements of sustainability present in the project. Morogoro CDTI Evaluotion Retrtort 18 The five critical elements and the seven aspects of sustainability in the project were qualitatively discussed and results agreed to by the team. The project was graded using these aspects and elements in accordance with APOC guidelines. The evaluators discussed qualitative description of problems, and deliberated on likely suggestions for solving the problems identified. Thus judgment about the sustainability potentials of the project was based on the quantitative assessment of the average sustainability scores of the groups of indicators as well as the qualitative assessment of the critical elements and aspects of sustainability of the project. Recommendations were generated based on the format recommended by APOC' fvlorogoro CDTI Evaluation Report 19 3.0 EVALUATIONFINDINGS 3.1 Sustainability at ProjecURegional Level Planning: (Fully:4) There is an overall written year plan of the health service at the Regional level. Onchocerciasis is routinely listed in this Comprehensive Council Health Plan (CCHP) which is presented to CHMT members annually with other diseases. As reported by the Regional Planning Officer (RPO), this is because the disease is of notional importance to the country. There is also a more detailed onchocerciasis plan containing the key elements of CDTI. Various stakeholders comprising of government officials and other partners (SSI) participate in the development of this plan. According to the RPO, "According to our budget guidelines, all stakeholders are supposed to be involved in budget planning meetings duing which donors repori what they are going to support. ftis process is usuatty pafticipato{. He also reported that in 200712008, SSI provided some funds and IEC materials for Onchocerciasis implementation activities. The participation of all stakeholders and partners was documented in minutes of the CHMT meeting where the plans were developed. Fig l.Morogoro GDTI: Sustainability at State Level 3.5 3 2.5 2 1.5 1 0.5 t s E" o =o E') a! o "*ue snt" ,"..u n'f ss" ort "*"o- ^.d. C "rdGroup of lndicators h'lorogoro CDTI Evaluation Report 20 This plan varies from year to year since it is targeted at specific needs of each year' For example, in2007,LF was included as part of Onchocerciasis control programme. Integration: (Highly: 3.2) There is evidence of integration of all health programme activities. There is a written work plan which shows implementation of CDTI and Lymphatic filariasis activities in an integrated manner' Staffcombine tasks during training, supervision/monitoring and HSAM in a single trip. Staff also combine CDTI activities with that of other health programmes when it becomes necessary' Leadership: (Fully: 4.0) All regional leaders (Regional Administrative Secretary, RMO, RPO etc) are fully aware of progress, success and problems of the programme. If there is a problem e.g. low coverage in pr.rio6 year, during the next Mectizan distribution year, the Regional Commissioner is involved in SASM activities during Mectizan distribution launching. The Regional Commissioner openly swallows the drug . On the other hand, in districts as part of HSAM, district commissioner will do same. The leadership is up to date with her reports and targeted activities. Leadership delegates responsibilities appropriately to colleagues at this and lower levels. Leadership also has a sound and collegial relationship with junior colleages and keeps them fully informed. For example.after compiling the reports, feed backs are given to District Oncho co-ordinators. There is a good working relationship between project coordinator and district oncho team members who share same office with her. NOTF meetings are held quarterly during which progress, challenges and current issues as it relates to CDTI progrqmme is discussed Monitoring and Supervision: (Highly: 3.8) Important records are readily available at this level showing treatment summary records, inventories of equipment, financial records and periodic reports including the annual technical reports for three years. The records are ofgood quality, content is clear and accurate. Staff is empowered to work in an integrated manner and using a well planned route matrix for joint supervision. A good functional supervisory cascade system is in place for this purpose. The Project Co-ordinator with RHMT members usually supervise the District Oncho- team Members below them. In problematic cases they supervise up to the FLHF. Also District Oncho team supervises staff at the FLHF level. Monitoring /supervision is being planned to make use of efficient resources. This carried out in an integrated manner according to RHMT (Regional Health Management Team) matrix. This is usually on quarterly basis but more when problem arises e.g. discrepancy in the completion of forms. During supervisory visits, two to three RHMT members are involved. Supervisory visits take 2 to 3 Days. Integrated Supervisory Checklists are used for this purpose. Morogoro ODTI Evaluation Reporl 21 As soon as problems are identified e.g. low therapeutic coverage, the problem is addressed in a very systematic manner. Usually the Regional Authority seats with District Oncho-team members discuss with them and find out reason for the identified problem and how the problem will be tackled. Feed back from such meetings are passed on to the appropriate officers who deals with them. Successes are identified and recognized and feed back is given systematically e.g. in Districts with high coverage, District managers are congratulated and letters of commendation are sent to them. a. Mectizan Procurement and Distribution: (Highly: 3.0) Mectizan supply is controlled within a government system. Mectizan received annually at the MOH is deposited in the medical store department (MSD) from where it is distributed to the District Health Centers and Dispensaries. Sometimes the MSD as sole distribution system creates a problem. This is due to delay in release of drug. The system is however effective, uncomplicated and efficient. The system is simple since government provides the transportation for movement of mectizan with other drugs to various health facilities. There is always sufficient supply of mectizan for the needs of the project. However mectizan distribution for 2008 is yet to arrive. As reported by the programme co-ordinator, in previous yeors ordering of Mectizan is carried out by the Oncho- coordinator at the National level but following the integration of Oncho with LF this function is now the responsibility of LF coordinator at the National level. Training and HSAM: (Fully: 4) Training is planned and undertaken in an efficient manner. Training of staff at lower levels is routinely carried out by staff at levels above them. For example staff at the district level is trained by staff at the regional level. Staff at the FLHF level is trained by staff at the district level while staff at the national level conducts training for staff at the regional level. Training is carried out when there is deficiency as it relates to CDTI activities. This is usually when new staff is employed and when there is a new programme to be integrated with e.g. LF. Training is also conducted when there is an identified problem during supervision. Project coordinator and one RHMT member are responsible for the training of the district staff. This takes I to 2 days and usually takes place in the district office/locality. Training materials e.g. training manuals and leaflets are available for the trainings at this level. Health education, Sensitization, Advocacy and Mobilization (HSAM ) is properly planned and carried out based on perceived need. Before Mectizan distribution commences, HSAM is carried out at Regional level. This also involves the use of senior government officials especially in areas were problems were identified. For example during the launching for Mectizan distribution, the Hon Commissioner and Regional Administrative Secretary (RAS) are usually invited. These individuals swallow the drug openly as a means of ensuring the community members that mectizan is safe and non poisonous. This helps in minimizing the number of defaulters. Morctgoro CDTt Evaluation Report )') Health education, Sensitization, Advocacy and Mobilization (HSAM) activities has been effective and has resulted to the inclusion of CDTI activities in the CCHP Finance: (Moderately: 2.8 ) The budget in the CCHP available at the Regional level clearly spelt out the cost for each onchocerciasis control activity. Project coordinator has a clear estimate of funds available for onchocerciasis control in the coming year as well as the excepted sources and made budgets for CDTI to fall within the expected income. The financial contribution by all partners and govemment for the last four years is clearly spelt out. In 2008, APOC contribution was US$51,543; NGDO contributed US$. 17,221.85 and MOH (District) US$ 26,667.47.In 2007 MOH contribution was US$ 9,496, NGDO contributed US$ 18,353 and APOC US$60,436 and in 2006 MOH contribution was US$ 0, NGDO contributed US$ 18,353 and APOC US$60,436. However even though the amount budgeted by government is increasing annually; it is not up to half of the NGDO and APOC contribution for a project in the third year. The project Accountant is responsible for release of funding for CDTI activities- from APOC and NGDO while the district accountant is responsible for release from Council and CCHP. He knows what have been budgeted from government resources for CDTI activities but does not know the amount budgeted from other sources eg APOC and NGDO. APOC and NGDO funds are released in two installments. There is an itemized activity budget description for each of the District area( Mvomero and Morogoro) with only government sources indicated. All amounts itemized in government budget are usually released. There is evidence of approval of expenditure and expenditures are allocated according to approved plan of actions. Funds disbursed for onchocerciasis activities are efficiently managed through a well established control system. For each CDTI activity the coordinator writes a letter to the project account quoting the activity number and amount required. At the end of the activity, the amount spent is retired by the project coordinator to the project accountant. All the funds released yearly is spent as budgeted. The Project Coordinator is not aware of the existence of residual amounts under different budget headings. Deficit is seldomly experienced because financial plans are clearly discussed before documentation. Transport and Other Material Resources: (Highly:3.9) Transport and materials at this level are available and adequate for CDTI activities at this level. The project presently has one 4WD Toyota double cabin vehicle supplied by APOC. APOC also supplied, desk computer, Lap top computer, photocopying machine, fax machine and printers while SSI provided them with air-conditioner, and office furniture. So far all capital equipment used for the implementation of CDTI activities is from non government sources. However govemment has been responsible for provision of stationery and materials for training and HSAM and bearing the maintenance cost of the vehicles and their fueling. However occasionally this is also provided by APOC and SSI All vehicles are in the pool and a maintenance schedule is available for this purpose. Servicing is carried out accordingly based on number of kilometers by the Plan Preventive Maintenance (PPM). Since the photocopying machine and other equipment are used for Morogorrt O DTI Evaluati on Reporl 23 other activities apart from CDTI. They are therefore in the hospital management schedule for maintenance. Staff members have ways of coping when vehicles break down or are not available, so that CDTI activities are not disrupted. This is because there is more than one vehicle allocated for health activities. If one vehicle used for CDTI breaks down any available vehicle could be used for this purpose. All vehicles and equipment are maintained and repaired through government fund and this is carried out immediately and efficiently. Transport is available for supervisory activities at the next level. Travel authorization is usually obtained for CDTI support activities by project coordinator through the transport officer. There is a log -book available showing name of officer, the driver, location of activity and number of kilometres covered. Though there is no written evidence to show replacement of vehicles and equipment, the CDTI activities the evaluators were informed will have support from other vehicles in the pool when the need arises since all health programmes are carried out in an integrated manner. Government also has a system in place for maintenance of vehicles and equipment. Human Resources: (Highly: 3.5) The number of staff is adequate and they have appropriate, knowledge and skill to undertake all CDTI activities. They are also commiued to the success of the programme even though no evidence was obtained from the NGDO partner Since project inception, programme staff has remained the same. There has been no transfer of programme staff. On recruitment of new staff, there is immediate orientation on CDTI activities. New professional health workers in the country are yet to be provided with up-to date knowledge and skills in the field of CDTL Coverage: (Highly: ) Geographical coverage (GCR) has remained at 100%o from 2004 to 2007 while the average therapeutic coverage rates (TCR) for the 3 years 2004-2007 has remained at 72.4Yo.Even though TCR did not increase coverage has howeverbeen stable. In2007 TCR is 75Yo;ln 2006 TCR is 75.3% and in 2004 TCR is 67%. This therefore confirms that people are beginning to show more interest in the drug and communities are beginning to demand for the drug. Morogoro CDTI Eva]uation Reporl 24 Recommendation: tPlanningt Implementation APOC activities. Priority: = tligh = Iligh Indicalors o;f success : :e Stakeholders aware of their roles and implement them. - Sustainability plan in Place. :) Comprehensive annual plan include CDTI activities = Evidence of CDTI activities taking place. llho lo tahe action: + Oncho Management Team + PC,NOTF :+ DOM,NGDO Deadlin e for complelion : + 3l't March 2009 Recommendations: "Integration" integated manner will be achieved Priority = Iligh Indicalors ofsuccess: = Annual work-plan showing clear evidence of integration llho to take action: + Oncho Management Team = PC,NOTF Deadline for completion 3 1" March 2009 Recommcndations:' Leadership' Implementarion) Regional leadership should continue to get involved in HSAM annually > NGDO partner to continue empowering regional leadership on their role in CDTI processes. Priority: Indicators of successt + DMT members fully aware of the CDTI programs and their role. ll/ho to tahe aclion: :+ PC, Regional Oncho team + ONCHO Management tgCq NqPq D e a d lin e for c o mp I etio nt? 30s April 2005 Recommcndations:'Monitoring And Supervision' Implementation F Introduce a feedback system for improving and solving problems identified. D Evidence ofsuccess reported should be included be documented in previous monitoring reports. Priorityz + Iligh = Iligh Indicalors of successi + Availability of document showing successes + Feedback is given and necessary action taken. llho to take aclion: 3PC - DOC Deadline for complelion = 30h June 2009 Recommcndations:'Mectizan Procurement and Distribution' Implemenlaion: minimize delay as being experienced for 2008 Priorityz + Iligh Indicalors of success'. lltorctgoro C DT I Et,a I u a t io n Re porl 25 llho to tahe action: + RegionalOnchoteam =) NOTF D e a d lin e fo r c o mp lelio n I = January3l"t 2009 Rccommendation 'Training & HSAM' Implementation led to action at this level should be documented. Priority: = tlediunt Indicators of success. :? HSAM activities and result documented = lltho to tahe aclion: + RMO Deadline for completion: As soon as identified Recommendations :'Financial Rcsources' Implementation : hiority: and this should be at least halfofthe amount coming from non- government sources amounts budgeted headings Indicators ofsuccessz = Realistic budgets made for CDTI activities by government, = Funds released in time. llho lo take action: + Programme Accountant -PC = SMT Deadline for completion: 30n April,2004 Rccommendations:'Transport and Other Material Rcsources' Implemenlation replacement of vehicles and other materials required for carrying out CDTI activities Priorily: = llish Indicalors of success: :) MOU in place for continuous vehicles and other materials supply. lltho to lake actionz + P.C :) DPO + DOM =) RMO + RAS D eadline fo r completionz When the need arises Rccommendations: Coveraqc Implemenlation annually. Priorityt = tligh + lligh Indicators otsuccessz + TCR>67Yy lYho to take action. +PC D e a d I i n e for c o mp letio nt 30s Sept. 2009 lvl o rctgoro C DT I Eva I u at i o n Re pctr! 26 3,2 SUSTAINABILITY AT DISTRICT LEVEL Planning: (Fully: 4) CDTI key activities are integrated in the Comprehensive Council Health Plan (CCHP). This includes the Stakeholders of Health, CHMT members and personnel from all levels of health. The mode of planning is usually participatory and is based on community requirements. The written yearly CCHP and minutes of the planning meetings exist in all two districts. Integration: (Fully: 4) Thetistricts program activities are planned in an integrated manner and it is in a written form. However, rupportir" supervision is done for more than two tasks. Districts are co implementing CDTI with Lymphatic Filariasis Elimination program. Fig 2. Morogoro Project: Sustainability at District level tf E" ,6 3 o E)g o (E t u? ar) (? ro ci N q ro e; o od*dsc O) """t C "-C^.-- .-""/q,s Group of lndicators il'lorogortt C DT I Evaluation Report 27 Leadership: (Fully: 4) The project which covers Morogoro and Mvomero, districts has a Project Coordinator who oversees CDTI activities at the project level (Region), The Council Health Management Team(CHMT) in each district among others oversees all CDTI activities. Monitoring and Supervision: (Moderately: 2.3) APOC standards of reporting are used in the CDTI reporting process. Data generated during monitoring/ supervision is yet to be integrated into the Tanzania's Health Information Management system ("MTUHA"). This is because Onchocerciasis is a focal disease and among the Neglected Tropical Diseases. Currently the Tanzania Ministry of Health and Social Welfare is reviewing HMIS to include focal diseases in its disease data base. There is therefore need for HSAM at the National level to ensure Onchocerciasis is listed among diseases in the HMIS. The focal persons for CDTI at the district level and the CHMT among others conducts supervisory activities to the FLHF .Spot checks take place at community level when need arises. Staff at the FLHFs supervise their respective communities and work hand in hand with the community leaders. According to the minutes of weekly CHMT meetings, arising problems identified during monitoring and supervisory visits are discussed and solutions are initiated to solve such problems. Feed back are sent to appropriate FLHF staff to initiate action. Mectizan Procurement and Distribution: (Highly: 3.5) The supply of Mectizan smoothly follows the government procurement and supply procedures. When Mectizan arrives at the National level, the project coordinator is informed. He /she inform the district coordinators. The National office arranges for MSD to transport Mectizan to respective districts. Special routes are created to ensure that there is no delay in Mectizan arriving at the FLHF on time if the routes are already closed. The cost of storage at the Tanzania Medical Stores Department and its transportation is paid for by the Central Government that is the Tanzanian Ministry of Health and Social Welfare (TMOHSW) Training and HSAM: (Highly:3.7) Training is carried out objectively and all CHMT members are equipped with knowledge on different diseases and their control .Targeted training of FLHF staff are carried out as a follow up to gaps identified during the monitoring and supervision. The training is cost effective, takes 2 days and takes place at the district headquarters. Usually 3 staff at the district level is involved. L'lorogoro C DTI Et'al uation Report 28 HSAM activities are conducted where new decision makers and or health staffs are enrolled in order to equip them with information about CDTI, such training in done on need and not on routine basis. Inauguration of annual Mectizan distribution is carried out through selection of district with low .orriug. during which District Commissioners swallow the drug as a means of sensitizing community member and persuade them to take the drug. Finance: (Highly: 3) CDTI activities were clearly spelt out in the year plan for the two districts as shown in the CCHP with the budget for various activities. There is evidence of cost reduction since all activities at this level are carried out in an integrated manner. The budgetary contribution from the government has been clearly spelt out but not for APOC and the NGDO partners at the District level. Government funding is steadily increasing and always clearly spelt out in the CCHP. There is no regular calculation of residual amounts under budget headings. All funds released yearly are spent as budgeted Transport and Other Materials: (Fully: 4) The vehicles available from the government are the main transport means for CDTI at the district level. With the current integration of activities, at this level transport will be shared for all programmes. There is likelihood that transport will remain stable until the duration of the project. th.re is a routine maintenance schedule for all district vehicles by Planned Preventive Management (PPM). Budgets for maintenance are reflected in the CCHP, Vehicles are serviced based on mileage. The vehicle maintenance records are kept by the transport officer of the respective districts. Human Resources: (Highly: 3) At this level transfer is not frequent; staff has been on same post for more than 5 years. This will help improve the quality of CDTI programme activities. Thougtr the district level staff member's commitment to CDTI is high, there has been low motivation for them. No award, financial and or material rewards or recognition of their post by the Central Government SYstem. COVERAGE While the geographical coverage for the previous three years has remained at 100%o, the TRC has been above 65Yo for that particular period' h'lorogoro C DTI Evaluati on Reltorl 29 Recommcndation:'PIanning' effectively. Recommendations:'Intesration of suooort activities Recommendations:' Leadership' levels which initiate the key CDTI activities: planning, targeted monitoring/ supervision, targeted training and HSAM, Mectizan ordering/ distribution. Rccommcndations:'Monitoring And SuDcrvisiont Recommendations:'Mectizan Procurement and Distribution' delivery of Mectizan to districts. Im entation hiority: =Il Indicators ofsuccess: = Comprehensive written work plan Vl/ho to take aclion: 3 DED,DMO,DOC + DOT, District Planning Team, CHMT = NGDO D ead I i n e fo r comp I etio n : = 3l't March 2009 hiority: =) Medium Indicators ofsuccess: resources ll/ho to tahe aclion: = DED,DMO,DPLO,DOC :) DOT. District Planning Team, CHMT =, NGDO D e o dl in e fo r c o mpleti o n : + 31" March 2009 Priority: Indicalors ofsuccess: = The CHMT manages CDTI activities at district level at DMOs office, initiating all key CDTI activities =) Focal person for CDTI - DOC and DOT exists at district level. llho to tahe action: :) DMO, DOC - CHMT Deadlin e lor comp letion =On Priorityt =Indicators ofsuccess: + Transmission of reports through government system. + Inclusion of CDTI data in the Tanzania Health Information llho to lahe aclion: = NOCP Coordinator, NOI'F', PC, DOCs +DM CIIMT Deadline for completion: = 30ft June 2009 Implemenlation Priority: =ll Indicators ofsuccess: + del of ll/ho to tahe actionz = NOCP Coordinator, MSD D eadline lor completion: + 306 October 2008 + And June 30th annuall' ll'lorogoro C DT I Evaluati on Report 30 a &) Training should be appropriately needs. gned to address specific Recommcndations : tFinancial Resources' budget headings. 'l-he Govemment should commit more funds to CD'II activities because donor lund is decreasing. There should be regular of residual amounts under Recommendations: 'Transport and Other Material Resou rcest aOequate numbers of appropriate, functional vehicles available for necessary CDTI activities. govemment. HSAM. Recommcndations :'Human Rcsources' The district level staff member's commitment supported by motivation through awards, financial and or material rewards D The CDTI designations should be recognized by the Central Government System in the Ministry of Health and Social affairs. should be Recommendations: be maintained TCR and should be maintained Indicators ofsuccess: + The district Focal persons for CDTI train the FLHF Priority: staffs in case need l4/ho to lake action: + DMO,DOC CHMT D e adli n e fo r co mP l eti o n: I mp leme nlalio n : Prio rilY : Priorily: Indicalors of success: :) Incrcased budgct fiom thc Goverrunent. + Regular calculation of residual amounts under the itemised ll/ho to take aclion: - DMO, Health Accountant = DOC + CHMT D eadline for completiont Continuous Implemenlation Priority: h Indicators ofsuccessz + MOU in place for continuous vehicles and other materials supply. - The vehicles are aced the once needed ll/ho to take action: + NOCP Coordinator, NOTF = DMO D eadline for complaion: When the need arises Implcmentation Priority Indicators ofsuccessz +Ah motivated health staff Who to take aclion: - Director ol Preventive Services, NOCP Coordinator, NO'[-F' DMO CHMT +l D ea dlin e lo r c o mp I etio n : June 30s 2009 Implementation Priofity: = Iligh Indicators ofsuccessz + TCR>67Yy = GCR>95% llho to take aclionz - DOC,DOT + CHMT lllorogoro CDTI Evaluation Repor! D e adlin e lo r c o mp I etio n z December 30rh 2008 3l 3.3 SUSTAINABILITY AT FLHF LEVEL Fig 2. Morogoro Project: Sustainability at FLHF t .C .91 o; o ED E o (E t lo ci (t, tO N N rq U? o o o*s-.P" -C .*."od g."--e^....' dnd Group of lndicators Planning: (Fully:4) There is a written plan for 2007 CDTI activities in all the FLH facilities visited. This plan was prepared by health staff at this level. The plan included all other activities pertaining to health in the facility. Integration: (Fully: 4) Health Personnel combine two or more CDTI activities on a single trip. In remote sub villages, Mectizan is delivered after training of CDDs. There is a monthly immunization table showing staff itinerary to communities during which all other activities are carried out. Thus all activities are carried out in an integrated manner. Leadership: (Highly: 3) The FLFH staffs in the facilities visited considered the program as theirs and are initiating key CDTI activities. These included -training of CDDs, carrying out health education campaigns in Morogoro CDTI Evaluation Report 32 sub-villages, compilation of CDD reports and forwarding them to the districts, taking care of side effects when they occur, ordering of Mectizan for the cascade as well as supervising the distribution of Mectizan in communities. Monitoring and Supervision: (Highly: 3) Monitoring and supervision of CDTI activities are usually carried out during Mectizan distribution. Data geneiated are compiled and reports (reports for distribution, training and Mectizan statistics) are submitted to the disirict authoriiies. This is within the govemment system. Supervisory visits to sub-villages are to solve problems identified during monitoring visits to sub-villages. Problems identified during supervisory visits e.g. refusals due to misconception about Mectizan and CDD drop out are usually dealt with through continuous health education with both the sub- village leaders and other relevant authorities. Despite lacking compensation or any form of cash or in kind incentives; most CDDs have continued to carry out their CDTI activities in an excellent manner. However, the officer in-charge of the FLHF in Langali reported that CDDs are exempted from payment when they visit the health facility and in other sub- villages they are exempted from ioutine works in their localities such as construction of health facilities and schools. Mectizan ordering and Supply: (High: 3.5) Order forms for Mectizan do not exist at the FLHF. However the officers' in-charge in the facilities visited; send written requests to the Districts indicating the quantity their facility will require during the next distribution season. CDD census data are also included in some cases. This request is baied on estimates from the CDDs' report. The facilities have never experienced any Mectizan shortage. However arrangements are made to supply more drugs to any sub-village where shortage was reported. Mectizan is available on time for distribution even though the 2008 Mectizan is yit to be riceived. Mectizan is controlled within a government system that is effective, uncomplicated and efficient. Mectizan is received through the District with other drugs through a transport system supplied and paid for by the govemment. This is signed for by the officer in- charge of the facility and it is stored in the general drug store. CDDs come to the FLH facility to colleit their drugs where sub-villages are close to the facility. However in situations where health facilities are far from the communities, the FLHF staff sign out the drug and deliver to the sub- villages themselves. Training and HSAM: (Fully: 4) Training of CDDs is carried out from l-2 days depending on need. Where CDDs are new this is for two days other wise it will be for only one day. This usually is before commencement of Mectizan disribution. This activity is carried out by the health staff at the FLHF. Training is carried out in the sub-villages even though in some cases this takes place in the health facility due to lack of adequate space in the sub-villages or in some cases at the ward level. Furthermore, in order to increase knowledge and commitment to CDTI activities among ward leaders, village leaders, sub- viltage leaders, extension workers including FLHF staff and influential leaders, TIASM is sometimes carried out during ward development quarterly meetings. This helps in reducing the misconceptions about Mectizan thereby reducing the number of refusals and on the other hand improving annual treatment coverage for the community by reducing the number of refusals. Morogoro CDTI Et'aluation Reporl JJ Financial: (Highly:3) There is budget for CDTI related activities in the year plan. Though all CDTI activities were clearly spelt out in the budget not all of amount budgeted was released. In 2007 govemment provided two million Tshs out of 7.46 million that was requested for Langali Health facility (Mvomero District). Moreover, the amount released was effectively utilized to CDTI related activity and has been enough to enable the facility to carry out essential CDTI activities. The only source of funds established was the government. Districts provide the fund for all activities at this level especially as it relates to training. Training of CDDs was sponsored through fund received from the District and supervision and monitoring of all health programmes at this level is carried out in an integrated manner.The budget for 2007 was higher than that for 2006. Transport and other Material Resources: (Highly: 3.5) Transport at this level is adequate. Most of the transport facilities are in good condition for use during supervision and other activities. Government is responsible for maintenance and fuelling because there is a routine maintenance schedule. Vehicles are sent for maintenance after every 3 months or after certain kilometres have been covered. This has been rapid and efficient. When vehicle breaks down onchocerciasis office using APOC fund provide alternate source of transport. Trips made for CDTI purpose are authorised in writing based on route matrix prepared by the transport officer. There is a log book stating journey dates, quantity of fuel utilized and journey route. Since all transports are in a pool, supervision is carried out monthly in an integrated manner with other diseases. Replacement of the vehicles comes in place upon the available report from the district engineer and the old one is maintained by the govemment. For example a new vehicle has been approved for Langali FLHF to replace the existing old land rover. Required stationary and materials at this level are supplied by the government. | +Human Resources: (Highly: 4) All the Staffs have been in the same facility for at least four years and there have been annual refreshing courses to the FLHF on CDTI activities level during which problems identified during monitoring and supervision are dealt with. Coverage: (Fully: 4) The average TCR has been going up for the past three years, it was TlYo in 2004, (no distribution in 2005),72%oin 2006 and 76Yoin2007. Moreover, the Geographical coverage recorded in the FLHF is 100% for 2004,2006 and2007 as there was no distribution in 2005. Morogont CDTI Evaluation Report 34 Recommendations: Planning Implementation Planning: l. Develop strategies to cut expenditure. l. Devise strategies to find dependable sources of resources. 2. Provide evidence of successful implementation of CDTI plans. Priority:: IIIGTI Indicators of success'. l. Written strategies for cost reduction or cost minimisation developed. 2. Dependable sources of resources and written commitments attained. 3. Records showing successful implementation of CDTI available. llho to action NOTF DOC Proiect Coordinator Deadline for complelion Continuous. Rccommendation :Leadership Implementation Planning: Health Plans at FLFH levels should reflect CDTI activities in the CCHP and take on community priorities. Health Personnel should combine two or more CDTI activities on a single trip Priority:: HIGH Indicators of success'. Availability of written plan which Oncho activities is included ll/ho to take action: NOTF DOC Proiect Coordinator Deadline for completion: Continuous. l. Improve monitoring and supervision beyond the existing state. 2. Workout means to sustain the existing monitoring and supervision quality. Priority: lligh Indicators of success: = Availability of monitoring and supervision checklist. l. Availability monitoring and supervision monthly plans ll/ho to take action: NOTF NOC Proiect Coordinator Deadline for completion: 1,2. Continuous Mcctizen procuremcnt and supplv: Strengthen the govemment system of delivering drugs (including mectizan). Avoid/minimise delays to deliver and distribute drugs. FLHF should have Order forms for Mectizan ordering Priority: lliph Indicators of success'. l. Mectizan free from any form of taxation. 2. Mectizan being delivered efficiently and in time. 3. No regular delays reported. ll/ho to take aclion NOTF NOC Deadline for completion: Before next distribution. .trainingand-rrW: Integrate CDTI training with other health services trainings. Intensiff HSAM activities. Supply more IEC materials. Priority: lligh Indicators of success'. l. CDTI training integated with other trainings. 2. Increased awareness and coverage. i. IEC materials available. Who to take action'. Proiect coordinator and DOTs Deadline for comp letion'. Before next distribution and therefore a continuous process. Morogoro CDTI Evaluation Reporl 35 Financial resourccs: Clearly spell out the costs of CDTI plans. activities in the health Develop specific and realistic plans to bridge the financial gaps when APOC funds end. Priority: lllGll Indicalors ofsuccess: l. Itemized CDTI activities well spelt out in the 2. Strategies for cost containment present. 3. Plans to bridge financial deficits present. annual budgets. llho to take action: Project Coordinator and DOTs Deadline for completion'. Before the next Council budget Transoort and other material resources: L Develop feasible specific and realistic plans to replace and maintain transport and other materials. Appropriate transport should be provided and maintained. Maintenance and fuel be provided by the govemment I{IGI-I Who lo lake action'. Proiect Coordinator, Transport officer and DOTs Deadline for completion'. Continuous Human resources: l. Strengthen the existing incentive system. Prioritv: llish Indicalors of success'. Staff motivated and committed to provided CDTI services. llho to take action: Proiect Coordinator and DOTs Deadline for completion: Continuous Rccommendations: Coverage Increase therapeutic coverage. Improve and strengthen by-laws with respect to CDTI activities Implementation Priority: IIICII . lndicatorsofsuccess: Availability of annual treatment reports for all endemic communities from CDDs registers Evidence of distribution is on-going in all communities. Evidence of community ownership. Increasing TCR and GCR. l{ho to take aclion'. Project Coordinator and DOTs Morogoro CDTI Evalualion Report 36 Indicators ofsuccess: Availability of functional transport Existence of maintenance schedule Fig 4. MorogoroCDTl Project: Sustainability at Community level \t .s, o =o E"g o G \t lO ri .(, lo c.i N q? u, ct o "*ue ES "9C) o) v """' *** "-C --" "r"' \: Group of lndicators 3.4 SUSTAINABILITY AT COMMUNITY LEVEL Planning and Management: (Fully: 4) Time and Mode of distribution is chosen by Community members with their Leaders during community meetings. CDDs carry out census and distribution together. Community Leaders and CDDS visits families that are not willing to take Mectizan, to encourage them to take drugs. Leadership and Ownership: (Highly: 3.7) In all the communities, leadership actively supports Mectizan distribution, and help to solve all problems as they arise within the community. Community members value and accept long-term treatment. Community members are responsible for the selection of CDDs, mode and time of distribution. Community members reported benefits of taking Mectizan. This included: not allowing Oncho woffns inside the body to multiply, Mectizan improve human health; Mectizan hlorogoro CDTI Et'aluation Reporl JI minimizes/reduces scratching and skin disease; Mectizan makes children expel worms in their body and LF improvement. However community members in some sub-villages exempt CDDs from communal work while in some communities no support or incentive is provided. Monitoring/Supervision : (Fully: 4) In all communities reports were submitted in time to the FLHF through CDDs or Community leaders. In most of the communities the village registers are well kept. However no transport is arranged for CDDs for collection, distribution and submission of reports to FLHF. In some communities, FLHF staff collects summary reports during their routine monitoring and supervision visits where the FLHF are far from communities Obtaining and Managing Mectizan: (Highly: 3.7) CDDs carry out census before or during distribution. Some Mectizan are left in the community of at the FLHF for those who are temporarily non-eligible e.g. pregnant and other drugs are returned to FLHF. The quality of the census data in the CDDs records are good for an accurate calculation of the amount of Mectizan that needs to be ordered The CDDs and Community leaders collect Mectizan they need every annually from the FLHF nearest to them by walking or using their bicycles. In other cases, where communities are remote, staffin the FLHF supplies Mectizan to the community during training of CDDs. HSAM :(Highly: 3) HSAM is targeted and is mainly carried out by CDDs and community leaders on effect of disease on community, merits of taking the drugs and correction of misconceptions about the disease and also that the drug is free and safe. This is carried out during community meeting before distribution. Names of refusals in spite of intensified HSAM are submitted to the Village Executive officer. No resources are provided by the community members eg pens, CDD registers etc Financing: (Moderatelyz 2) In most communities, community members appreciate the programme. Few communities support CDDs in kind by exempting them from communal work while most only thank them without any form of in kind or cash incentive. The reason for not given cash or in kind incentive as reported by these community leaders/members is due to poverty. They also argue that CDD work is voluntary and that other community members involved as volunteer in other activities are not paid. Secondly that volunteers in other programmes eg AIDS and national programme on immunization receive stipend from their programmes. Human Resource: (Fully: 4) Morogoro CDTI Evaluation Reltorl 38 All villages visited had adequate number of CDDS with each sub-village having at least 2 CDDs' Most of the sub-village fall within the 250 residents recommended with the exception of few communities where 2 CDDs covered 556 residents. There is already a plan in such villages to select more CDDs by the community members. The average distance covered by the CDDs is between to3 k.m. In almost all the sub-village visited, CDDs took 4 to 7 days to complete their distribution. House to house is the common method of distributions in all the sub-villages visited In most cases the village leader visit various households with the CDDs. CDDs are trained annually for I to 2 days before drug distribution commences by FLHF staff CDDs ire generally willing to continue supporting the distribution in their community even though there are no cash or in kind incentive given to them by communities and they have complained about this. This is because they are serving the community where they are living. All the CDDs have worked at least for 3 years. There are few CDDs drop out. However in communities where this was experienced, replacements were selected by community members. Coverage: (Fully:4) The average coverage from 2004 to2OO7 is between 760/oto 8l%, which is increasingly il'lot'ogorct C DT t Eval uali on Reporl 39 Rccommendations:'Planning AND Management' Implementation for themselves CDDs Priority: = Ixnv Indicators ofsuccess: 3 CDTI activities are continue to be planned community. llho lo take action: = Community Leadership and Members D eadline for completion : + On-going Recommendations: Lcadership and Owncrship Implementation > HSAM to Community members and Leaders to support CDDs PrioriEz Indicalorc ofsuccess: CDTI process. = Leadership organize support for CDDs. llho lo tahe actiont = FLHF Staff, DOTs, Community Leaders D eadline for completion: = Dec2008 Recommendations : Monitoring Implementation > CDD should be provided with transport Priority: MEDII.]M Indicators of success'. l. Highcoverage. 2. Committed CDDS. Who to take action: Community leaders. Deadline for complelion January 2009 Rccommendations: Obtaining and Managing Mcctizan Implcmentation transport to CDDs Priority: + \'Icdiunt Indicalors ofsaccess: :) CDDs use =) CDDs collect drug from FLHF Easly ll/ho lo lake actionz + CDDs + Communiry Leadership Deadline for compleliont Recommendations:'HSAM' Implemcntation ) Community members to provide resources Prioity + \lediurn il'lorogoro CDTI Evaluation Repor! 40 Recom mendations: Indicators ofsuccess: = Availability of resources provided by community members Who to lake actionl Deadline for completionz January 2009 Implemenlation )Community members should support CDDs Priority: II Indicalors of successz CDDs are supported fully ll/ho to take actionz Community Leaders Deadline for complelion: Nexl Dislribution Recommendations: Human Resources Implemenlation Community Leaders and members should increase the number of CDDs Priority: Mcdiurn Indicalors ofsuccess: Increase number of CDDs ll/ho to lake aclionz Community Members and Leaders Deadline lor completion: Next distribulion Rccommendations: Coveragc Implementation: Coverage should be maintained Priority: l.ow Indicalors ofsuccess: Therupeutic coverage maintained above 65% ll/ho lo lake actionz CDDs and Community members D ead I i n e fo r c omp letio n : On-soins lltorogoro C DTI Evaluation Report 4l Fig 6 is a graphical representation of values from Table 2. The regional/ project level was weak in finance(2.8). The District level was weakest in monitoring and supervision (2.3). The community level's weakest area was finance (2.0). Generally, finance is the weakest of all the groups of indicators. Fig. 6: Sustainability Score of the Groups of Indicators and Levels of CDTI Implementation in Moro goro CDTI project Sustainability scores of groups of indicators and levels of CDTI implementation in Morogoro CDTI Project o oL o o o =-ct(E .E o3a 5 4 3 2 1 0 w Region I District tr FLHF o Community I Alerage .-$e$.*'$$.'1"$"$,'- lmplementation levels Mean sustainability scores for the groups of indicators for the Morogoro CDTI project are shown graphically in Figure 7. The weakest group of indicators, overall, were the provisions of Finance (2.7), followed by Monitoring / Supervision (3.3), Morogoro CDTI Evaluation Report 43 Figure 7: Showing average performance of each group of indicators in the entire Morogoro Project Average performance of each group of indicators in the entire project 4.5 4 3.5 E3L oo ? z.s =llEz '6 6 o 1.5 1 0.5 0 {g" $.d.r" .u$ ,.C ^..C a""" "-"-"_a..". .o' o* Performance indicators Morogoro CDTI Et'qluation Report 44 . J 4.0 CONCLUSION 4.1 Grading the Overall Sustainability of Morogoro CDTI Project- (a) Make a judgment of the project, in terms of each of the seven 'aspects' of sustainability: Aspect ]udgment: to what extent is this aspect helping or blocking sustainability in this proiect? Integration HELPING Itesources Efficiency Simplicity BLOCKING HELPING HELPING Health Staf f Accepta nce (Atritude of staff) Community ownership HELPING BLOCKING Iiffectiveness HELPING o Integration Integration of CDTI activities with other diseases under CCHP was ongoing at all levels . The programme co-ordinator at the regional level is also doubling as co-ordinator for Lymphatic htaiiasis control programmes. The Evaluation Team considers this as a good indication that sustainability is in place. o Resources (Human, Financial and Material): Since 2004 government have been releasing certain amounted annually for CDTI activities while in the two Oncho districts- Morogoro and Mvomero, there are annual releases from 2006 for CDTI activities. Project manager at all regional levels do have a clear estimate of funds available for CDTI activities annually from all sources. However none of the project managers at the two levels were aware of shortfall and how to bridge the financial gap. Sources of funding are therefore not reliable since it is not based on budget. There is no written commitment to show that funding will be obtained from other sources. Also even though the project is in its third year annual funding from govemment sources did not equate to half of the amount released from non governrnent ,orr."i as shown in table 4. The Evaluation Team considers that over dependence on external ll'l orctgoro C DT t Eva I u at i o n Re p orl 45 CONTRIBUTORS APOC trust Fund NGDO Partner(SSl) MOH Year Total Budgeted (us$) Total Released (us$) Total Budgeted (US$) Total Released (us$) Total Budgeted (us$) Total Released (us$) 2004 140,613 72,000 19,740.088 21,740.881 34,24.65 43,24.65 2005 2006 89,254 40,000 34,000 18,652 2007 60,436 60,436 19,479 18,353 9,496 9,496 2008 51,543 17,221.85 26,667 TOTAL sources of funding for all CDTI activities does not enhance project sustainability and that government sourced funding need to be increased. Table 4 : Showing financial contribution of various CDTI partners between 2004 to 2008 Presently, there are reasonable numbers of vehicle at the regional, districts and FLHF levels. These are adequate. Maintenance and fueling is through both APOC fund and State government. Management at all levels is optimistic that government will replace vehicles when they are old. However, vehicles at all levels are utilized in an integrated manner, showing evidence of sustainability. At the regional, district and FLHF levels, travel authorization are usually given. Logbooks are kept for all travels undertaken at these levels too. There is staff stability at all levels and salaries are regularly paid. Staff attitude is satisfactory. Most CDDs expressed willingness to continue without receiving compensation form their communities. This shows some level of sustainability. Presently the ratio of CDDs to households in communities visited is adequate. Generally, CDTI activities are integrated into the govemment system in carrying out the following activities namely: Management and use of transport/logistics, Monitoring/ supervision, retrieving of data especially at the FLHF level and Storage of Mectizan. However the Evaluation Team considers that over dependence on external sources of funding for all CDTI activities does not enhance project sustainability and that government sourced funding need to be increased. Efficiency: There is a rational use of resources. Programme support activities are planned and shared in an integated manner, which results in lower cost and efficient management of resources. Examples are sharing of logistics. Iu[orogrro C DTI Eval uation Report 46 o Simplicity: Morogoro project uses simple and uncomplicated procedures for the implementation of CDTI activities. a Attitude of Staff: At all levels, there is ample evidence that staff members are positively disposed to continue CDTI implementation. The Evaluation Team rated the attitude of staff at all levels towards CDTI to be very positive. o Community Ownership: Communities make most of the decisions in the implementation of CDTI and gave sound rationale for their decisions on CDTI activities within their respective domains. In most communities there is no established process of showing appreciation to CDDs for their CDTI work except by saying "thank you" even though a few exempt the CDDs from other communal assignments. Also Community members do not provide materials (note books, ruler, pencils etc ) required by the CDDs during Mectizan distribution. The Evaluation Team is of the view that an important aspect of CDTI process is not in place. This is therefore blocking the sustainability of Morogoro CDTI project. r Effectiveness: Every village identified as qualified for mass treatment with mectizan treatment is receiving treatment. However, the average therapeutic coverage over three years (2004, 2006 and 2007) at regional level was 72.5%. The coveragein2004was67%o,in2006, this increasedto75.3.7Yo and in2007 it was 75o/o.Even though distribution is delayed for 2008, geographical coverage rate has remained 100 per cent since inception of the programmes at all levels. Morogoro CDTI Evaluation Reporl 47 (b) Next, the Evaluation Team examined the five key aspects of the project - 'critical elements'of sustainability. If these are not present it is unlikety that the proiect will be sustainable: Money: Is there sufficient money available to undertake strictly necessary tasks, which have been carefully thought through and planned? (Absolute minimum residual activities). Transpott: Has provision been made for the replacement and repair of vehicles? Is there a reasonable assurance that vehicles will continue to be available for minimum essential activities? (Note that 'vehicle' does not necessarily imply '4x4' or even 'car'). Superaision: Has provision been made for confinued targeted supportive supervision? (The project will not be sustained without it). Mectizan@ xryply: Is the supply system dependable? (The bottom line is that enough drugs must arrive in villages at the time selected by the villagers). Political commitmenf: Effectively demonstrated by awareness of the CDTI process among poliry makers (resulting in tangible support); and a sense of community ownership of the programme. I NO YES YES YES NO Evaluating the project on the basis of the seven aspect and five critical elements of sustainability, the Evaluation Team concluded that the Morogoro Project is Making satisfactory progress towards sustainability. With regard to the five critical elements, the Evaluation Team found that three elements - Transport, Mectizan Supply and Supervision were present in the project. The elements of Money and Political Commitment were not satisfactory in the project. Resources were mainly from outside and political commitment was not fully there especially at the community level. There is no ownership at the community level. ll'lorogoro CDTt Evaluotion Report 48 With regard to the seven, aspects of sustainability, the Evaluators found that five namely: Integratiin, efficiency, simplicity, attitude of staff, and effectiveness were helping the project attair sustainability *trit. -community ownership and resources were found to be blocking sustainability. Thii is because government funding for the programme is very minimal. The programme has been dependent on non-government sources for three years. There is also no written commitment from the NGDO partner that this will continue or for how long. Cpommunity members do not supply the census materials and incentive to CDDs working in their community' These materials are instead provided by the FLHF. The quantitative scale of 3.6 for the project in its third year shows that the project is making satisfactory progress towards sustainability. It is therefore the view of the Evaluation team that based on the qualitative aspects that Morogorro project is making progress towards sustainabilify. lllorogoro CDTI Evalualion Report 49 4.2 SUSTAINABILITY/ FEEDBACK WORKSHOP AT THE REGIONAL AND DISTRICT LEVELS MOROGORO CDTI PROJECT FEEDBACI?SUSTAINABILITY PLAN DEVELOPMENT DAY ONE REPORT The meeting was officially opened at 10.51 am by Regional Medical Officer (RMO) on behalf of Regional Administrative Secretary (RAS). The RMO urged participants to participate fully and be committed in the CDTI activities. She thereafter welcomed the NOTF representative, Dr Kurumbi to give his opening remarks. Dr Kurumbi in his opening remarks emphasized the importance of this meeting which includes feedback of the ten days evaluation of Morogoro CDTI project and the development of their sustainability plan. He welcomed the participants on behalf of the Minister for Health. He extended his thanks to APOC management for sponsoring the mission to the Morogoro CDTI project and also gave an insight on the reason for delay in the arrival of Mectizan in communities in 2008. This he said is due to the integration of CDTI and LF programmes and the shifting of mectizan ordering to the LF coordinator. This was followed by self introduction from participants while the members of the Evaluation team were introduced by the team leader, Prof O. C. Nwaorgu. Sessions: The first presentation was on objectives of the evaluation which included the following: . To assess the preparation of projects for post-APOC sustainability . To assist the project to develop its sustainability plan for the project post APOC support Other presentations as indicated in the time table attached (see Appendix IV) followed. This included presentation of the feedback and the following recommendations at various levels namely. Regional level . There should be an increase of govemment funds budgeted and disbursed in correlation with APOC and other NGDO funds . There should be sensitization and advocacy to all members at the regional level and provision of IEC materials so as to increase knowledge on CDTI programme . Integration should be kept in place to minimize resource and time. . Mectizan should be delivered to the community in time as agreed by community District level o Integration should consider other health problems in the district. o CDTI data should be included in the HIMS (MTUHA). o Training should be appropriately designed to address specific needs. o The MOHSW should ensure a rapid and smooth delivery of Mectizan to districts. . TCR and GCR should be maintained o The district should motivate the staff who are committed to CDTI and performing well . There should be regular calculation of residual amounts under budget headings. il'lorogorc CDTI Evaluation Reytrt s0 The District Council should commit more funds to CDTI activities because donor fund is decreasing. FLHF level o Reflection of health activities in CCHP at FLFH levels should take into account community prioriti es/needs. o Combining two or more CDTI activities on a single trip by health personnel should be adhered to as it minimizes costs and controls time . There should a clear checklist for in during monitoring and supervision. o Training should be carried regularly with leaders and community members in order to minimize misconception and hence increase coverage. . Appropriate IEC materials should be provided. o FLHF should have Mectizan ordering forms . Appropriate transport should be provided and maintained. o FLHF ensure that all endemic communities receive Mectizan annually Community Level Community members should plan on how to support CDDs HSAM should be conducted to Community members and Leaders to support CDDs Community Leaders and Members to arrange transport to CDDs Community members should provide resources for census (Registers, pen etc) Community Leaders and members should increase the number of CDDs Participants were thereafter divided into three groups namely, Morogoro, Mvomero and Regional for the SWOT analysis of Morogoro CDTI project. The presentation from group work was as follows: a O Morogoro CDTI Evaluation Report 5l REGIONAL LEVEL Strengths Weakness Opportunities Threats - Presence of regional health plan framework - Health policy of the year 2007 . - Elaborate infrastructure - Presence of buildings which serve as offices. - Presence of skilled personnel - Presence of health guideline - Planning and budgeting are in place. - MandEsystem - Strong political will and support - Committed regional leaderships - Availability of data and information for planning - Traditional healers policy Inadequate planning skills ( for some RS/RHMT) Inadequate working facilities e.g ICT materials Inadequate involvement of RHMT members in supportive supervision of CDTI Inadequate finance for M and E. Inadequate transport for supervision. Inadequate integration of CDTI activities. Delay of funds for supervision. Delay of distribution of drug by MSD Lack of training schedules for CDTI. Inadequate planning of health education package according community affitude. - Presence of donors like APOC and Sight Savers International - Presence of MSD. -Readiness of the community(leadership) to provide for Oncho activities. - Elaborate structure from regional to village level. - Existence of other projects - Delay supply of drugs from MSD - Misconception due to social cultural issues in use of Mectizan -Delay of fund release. - Geographical coverage such as hard to reach areas eg During rains which make some areas hard to reach. lvlorogoro CDTI Evaluotion Report 52 MOROGORO DISTRICT Strength l. Project activities are intergraded into comprehensive council health budget 2. Funds allocation is increasing yearly 3. Committed staff at all level 4. Interpreted support supervision is well done. 5. Availability of working tools eg stationary and other accessories' 6. Availability of transport materials Weakness 1. Disbursement of funds to support allthe project activities 2. Inadequate IEC materials 3. No motivation policy to support CDTI implementers Opportunity l. Community is willing to take the drugs 2 The projecl is well accepted as there is an overwhelming support at all level 3. Free delivery of Mectizan Threats l. Community negligence especially at sub urban areas 2. Failure of the community to reward the CDDs in their areas 3. Oncho data format is incompatible in the HMIS 4. Inadequate number of CDDs in some community' 5. "In case we shift to Morogoro Head Office quarter" as a premise MVOMERO DISTRICT STREGTH . CDTI activities at the district level are planned in the CCHP and are integrated . Awareness of CDTI programme to the community . GCR and treatment coverage rate is above 70o/o . Leaders participation at all levels on CDTI . Political commitment to CDTI programme WEAKNESSES . Inadequate funds for CDTI activities . Delayment of Mectizan drugs from MSD . Misconception of the drug use by some community . Irregular transport on CDTI programme in the district at all levels . Shortage of trained health staff in some health facilities . Drop out of CDDs in some areas every year lvlorogoro C DTI Et'aluation Report 53 OPPORTUNITIES: . Integrated Mectizan drug distribution and supportive supervision . Trained staff implementing CDTI activities . Cascade system of monitoring and supervision . Planned Preventive Maintenance of motorcycle and vehicle of CDTI programme . Possibility of being acceptable at all political levels in the districts THREAT: . Negative attitude of the community towards Mectizan use . Absence of Mectizan drugs at the community level . Delayment of budgeted funds for CDTI activities . Poor infrastructure . Opposition from politician (Multipanism) . Other vertical programme paying their volunteers at high rate compared to CDDs After presentation participants went into groups to discuss problems and solutions to the problems identified in SWOT Analysis. The day one sessions came to an end at 07.10 following a closing remark by the RMO who thanked the participants for their patient and the importance they placed on the programme hence the presence and participation of RAS. She however appealed to the participants to endeavour to come early the next day since a lot is yet to be done to complete the assignment. Some of the key questions from participants include the following: o Reason for poor coverage especially in sub urban areas o Reason for delay in 2008 mectizan distribution in various sub villages o Reason for community inability to reward CDDs o Reason for non inclusion of Onchocerciasis in the HMIS Day Two This was chaired by one of the District Medical Officers (DMOs). Participants were put through how to develop their sustainability plan after a recap of the previous day activities. There after five year post APOC sustainability plan was developed at two levels- Regional and District ( Mvomero and Morogoro). Participants went through the plan developed by each team in a plenary and corrections were made. Participants reached an agreement that the sustainability plans put together with the necessary accompanying documents will be forwarded to APOC management by the project through the NOCP within two weeks. il| orctgoro C DT I Et'a I ua t i o n Rc' p orl 54 4.3 THE WAY FORWARI) As Morogoro CDTI project moves into the 5th year, the Evaluation Team, programme managers and policy makers appraised the critical issues that will enable the project to be sustainable post APOC and came up with the following recommendations. l. Planning: There should be in an integrated annual workplan at all levels. Communities should be involved in planning and implementation of CDTI activities. 2. HSAM: HASM on the CDTI activities should be intensified and carried at different levels to promote acceptability of and participation in the programme. Advocacy visits should be paid at regional, district, ward and community levels for increased commitment to the CDTI programme. Programme Officers having spent more than three years on their posts means that number of days required for training will be reduced. Money accruing from this should be channeled to Health Education, Advocacy, Sensitization and Mobilization. Use of Bill-boards for HSAM 3. Resource Mobilization: Government should be sensitized for commitment of more funds to the CDTI programme especially at the district level 4. Reporting and Documentation: Reporting and documentation of all CDTI activities (training, monitoring, supervision etc) at all levels of implementation. This will facilitate efficient planning and provision of efficient feedback to stakeholders. Inclusion to onchocerciasis in the health management information system was discussed. 5. Mectizan distribution: The problem created by integration and co-implementation of CDTI with LF leading to the lateness in Mectizan distribution in the sub-villages was fully discussed and stakeholders felt there is need to put in mechanism that is free from beaurecratic bottle neck. Also the need to include CDDs in other community health projects as a means of motivating and compensating them was agreed on. In his final conclusion speech the RHO who represented the RMO, appreciated the effort of APOC in ensuring that Morogoro CDTI project is sustained. Finally he promised that the findings will be used to improve the project and that CDTI will continue to be included in the CCHP He stressed the need for operational research to raise some of the issues raised as it related to misconception about mectizan and low coverage rate in sub-urban villages. He assured the team that a process will be put in place to ensure that the 5 year sustainability plan is completed and submitted within the next two weeks to APOC. lvlorogoro CDTI Evaluation Report 55 APPENDIX I Morogoro CDTI Proiect: Evaluation Team Composition/Workplan. APPENDIX I Morogoro CDTI Project: Evaluation Team Composition Sub-Team A Prof.O Nwaorgu (Team Leader) lWs Rosemary Nguruwe Dr Debora Kabudi Mr Lugata V. Elias Sub-Team B Dr.George .M.Kassiga Dr.Abel.A.Mwakafwila Mr Jairo E. Jayambo Sub-Team C Dr.Rehmah.Maggid Mr. Prince.P.Mutalemwa Dr Hussein Sewando ill o rctgoro (- ) DT I Ev a I u at i <t n Re port 56 sa{ NAME DESIGNATION I Godfrey Ngaleya Regional Administrative Secretary 2. Mr. Kikwesha Officer 3 Dr. Frida Mokiti Medical Officer 4. Dr. Debora Kabudi Pro Coordinator 5 Emillian SanguSangu Accountant 6. Sara Linuma District executive Director - Mvomero 7 Dicolus Chiduo District Medical Officer - Mvomero 8. Yohan Sulley District Transport Officer - Mvomero 9 Neema Michael Health accountant - Mvomero 10 Dr. Omary Mbena Focal Person for CCHP Mvomero l1 Dr. Hussein Sewando District Oncho Team - Mvomero t2 Mr.Jairo E. Jayambo District Oncho Team - Mvomero t3 Ande Malango District Executive Director - Morogoro t4 Dr. Pascal Mbena District Medical Officer - Morogoro 15 Philben Mgwasa District - Health 16 Willa Matika District Pharmacist - 17 Mr. Lugatta Valley District Ocho Team - Morogoro 18 Abraham Simwela District Health Accountant - Morogoro t9 Ms. Magreth Songelaeli Cascade leader Turian 20 Ms. Grace Ougito FLHF ilc Kanga Dispensary - Mvomero 21 Albogast Mkude FLHFs Turian 22 Masumbuko Igembya FLHFs - Turiani 23 Sr. Hurbentina Kibua FLHFS Mhonda Catholic Mission Dispensary 24 Dr.Twaha Ngalawa Cascade supervisor - Morogoro 25 Christopher David Matwarame FLHFs - Mkuyuni - Morogoro 26 Dr. Abdalah Mbalazi FLHFS - Langali 27 Mr. Anselmi John Village Executive Officer - Kanga village 28 Shabani Seif Mugumu Community leader - Chalongwe 29 Juma Homahed Community leader - Lukindu 30 Ms Adolfina Selafin Community leader - Mvaji 3l Mr. Emmanuel Matei Community leader - Diagay a 32 Adauti Rafael Mokiwa CDD - Chalongwe JJ Ms. Habiba Hashim Madinga CDD - Chalongwe 34 Mr.Seif Mussa Dilema CDD - Chalongwe 35 Ms. Beasina Machange CDD - Lukindu 36 Antoni George CDD - Mvaii 3',l Antonia Edmund CDD - Mvaji 38 John Willium CDD - Diagaya 39 Ms. Anna John CDD - Diagaya 40 Maiko Dimoso CDD - Lolo 4t Emelda Pascal CDD - Lolo Appendix 2 Morogoro CDTI proiect: NAMES OF RESPONDENTS at Various Levels lv'lorogoro C DT I Et'al u ati on Re pttrl 57 42 Nikodemus Alex CDD - Mgini 43 Revina Leo CDD - Mgini 44 Nzita Mpina CDD - Mikesse mjini 45 Sefu Rashid Chamumi CDD - Polepole 46 Salum Hussein Mtatamale Community Member -Polepole 47 Ramadhan Abdallah Ulanga Community Member - Polepole 48 Issa Hamadi Mgama Community Member - Polepole 49 Ramadhani Salum Shomary Community Member - Polepole 50 Waziri Hussein Mtatamale Community Member - Polepole 5l Mahudhumula Maleta Community Member- Mikesse mjini 52 Abdallah Yange Community Member -Mikesse Mjini 53 Mbaragalddy Comola Community Member- Mikesse Mjini 54 Zainabu Kimilila Community Member- Mikesse Mjini 55 Moshi Iddy Mbegu Community Member- Mikesse Mjini 56 Nasira Alfani Community Member - Mikesse Miini 57 Watende Ammani Community Member- Mikesse mjini 58 Semindu Comola Community Members - Mikesse Mjini 59 Asha Beny Community Member- Mikesse Miini 60 Tekla Fabian Community Member -Mgini 6t Tekla Selestini Community Member - Mgini 62 Anna Mbiki Community Member - Mgini 63 Maria Leo Community Member - Mgini 64 Tekla Richard Community Member - Mgini 65 Scolastica Chuma Community Member - Mgini 66 Shafiwi Iddi matanza CDD - Mkuyuni 67 WemaAli Kipilipili CDD - Mkuyuni 68 Maua Ramadhani CDD - Mgembe 69 Iddi Rashid Community leader Mgembe 70 Juma R. Maogila Community Member Mgembe 71 Hayawi yahaya Community Leader - Mkuyuni 72 Sheilla Juma Community Member - Mkuyuni 73 Fatuma Hamidu Community Member - Mkuyuni 74 Kadiri ALLy Community Member - Mkuyuni 75 76 illorogoro C DTt Et'aluation Re port 58 APPENDIX III MOROGORO CDTI PROIECT CURRENT ADMINIS TRATIVE STRUCTURE MTNISTRY OF RE ONAL ADMINIS TION AND LOCAL MINIS OF HEALTH ---TREGIONAL MEDICAL OFFICER LOCAL GOVERNMENT (REGTONAL)REGIONAL ADMINISTRATIVE SECRETARY DISTRICT ADMINISTRATIVE SECRETARY J I J I J I DISTRICT HEALTH MANEGMENT TEAM DISTRICT EXECUTIVE DTRECTOR (DED) DISTRICT HOSPITAL DIVISION SECRETARY HEALTH FACILITY COMMUNITY WARD EXECUTIVE OFFICER VILAGE EXECUTIVE OFFICER <- SUB-VILLAGE LEADER il'lorogorct C DTI Eval uati on Report 59 Appendix IV PROGRAME OF ACTIVITIES FOR THE 2 DAYS PLAN DEVELOPMENT DAY ONE FEEDBACIgSUSTAINABILITY ITEM ACTIVITY TIME FACILITATOR I Registration of Participants 8.00-9.00 JJlPC 2 Introduction ofParticipants 9.00-9.10 PC J Welcome and remarks 9.10-9.20 RMO;NOTIF 4 Introduction to the work What are the objectives? What is sustainability? Methodology for evaluation 9.20-10.00 Prof. O.Nwaorgu/ Prince I I 6 Feedback on achievements issues and lessons from the Evaluation Regional level District level FLHF Level Community level 10.30 Rose Dr.A.Asilia Prince Dr.R.Maggid 7 SWOT Analysis 12.30-1.30 Prince/Rose/Rehma Abel I I 9 Group work Discussion on problems identified and solution to these problems using SWOT Analysis in groups I .Planning /integration 2.Leadership/Monitoring & supervision 3.Mectizan/Finance 4.Training &HSAM 5.Transport/Human resources/Coverage 6. Reports from Groups and Discussion 2.30-3.30 All l0 Roles of different levels and partners 3.30-3.40 Rose lllorctgoro C DT I Eva luation [?e pt rl 60 ll Steps in planning for sustainability 3.40-4.00 Dr.R.Maggid t2 Group work(Development of sustainability plan for Regional and District levels 4.00-5.00 Prince/Abel l3 General matters 5.00 All I I DAY TWO ITEM ACTIVITY TIME FACILITATOR I Registration of Participants 8.00-9.00 JJ/PC 2 Review of previous days activities 9.00-9.10 All Participants J Introduction of day's activities 9.10-9.20 Rose 4 Development of Sustainability Plan continues 9.20-l1.00 All Participants I 6 Development of Sustainability Plan Continues l 1.30-1.30 All I I 8 Presentation of Group work 2.30-3.30 Group Leaders 9 Group work to incorporate correction 3.30-4.00 Group Leaders l0 Way forward APOC NDGO Partners MOH(Regional &District levels) NOTF 4.00-4.30 APOC NOTF DED NGDO RMO ll Closing remarks 5.00 RAS lll orogoro (- ) DT I Et'al ua t i o n Re port 6l I] t.l T It APPENDIX V: ROLES OF DIFFRENT LEVELS AND PARTNERS FEEDBACI(SUSTAINABILITY PLAN National Level: . To supervise and Monitor CDTI activities . Is the link between national and APOC . To ensure free entry of drugs in the country and in time . To conduct training to project coordinator at national level NGDO a a a a Training and monitoring of CDTI activities Additional of other resources Provides financial and accounting services to all APOC supported project To collaborate with MOHSW to ensure all affected communities are covered internationally and Local Regional Level: . Compile report and submit national Office . Supervision and monitoring of CDTI programme at district level . Conduct HSAM at district Level . Conduct setup and Evaluation meeting . Technical advise during planning . To interpret national guide and policy District Level: . To receive the project and ensure sustainability of it . To provide staff and working materials . To allocate funds for CDTI activities . Monitoring and distribution of drugs . Supervision on Mectizan distribution and to ensure all eligible swallow Mectizan . Record keeping . Planning and budgeting of CDTI FLHFL: . To take care of the side effect . Training of CDDs and other community leaders . Record keeping . To compile report . Planning and budgeting of CDTI activities Community Level: o Community decide how to supporVcompensate the CDDs either in-kind or cash . Community collect Mectizan from the nearest health facility lvlorctgoro C DT I Evaluat ion Re port 62 Community decide how and when to distribute Mectizan Community collectively select distributors APPENDIX: VI SWOT ANALYSIS REGIONAL LEVEL-SWOT ANALYSIS Strengths Weakness Opportunities Challenges - Presence of regional health plan framework - Health policy of the year 2007 . - Elaborate infrastructure - Presence of buildings which save as offices. - Presence of skilled personnel - Presence of health guideline - Planning and budgeting are in place. - MandEsystem - Strong political will and support - Committed regional Ieadership - Availability of data and information for planning - Traditional healers policy Inadequate planning skills ( for some RS/RHMT) Inadequate working facilities e.g ICT materials lnadequate involvement of RHMT members in supportive supervision of CDTI Inadequate finance for M and E. Inadequate transport for supervision. Inadequate integration of CDTI activities. Delay of funds for supervision. Delay of distribution of drug by MSD Lack of training schedules for CDTI. Inadequate planning of health education package according community attitude. - Presence of donors like APOC and Sight Savers Intemational - Presence of MSD. -Readiness of the community(leadership) to provide for Oncho activities. - Elaborate structure from regional to village level. - Existence of other projects - Delay supply of drugs from MSD - Misconception due to social cultural issues in use of Mectizan -Delay of fund release. - Geographical coverage such as hard to reach areas eg During seasons rains which make some areas hard to reach. Morogoro CDTI Evalualion Reporl 63 htorogoro CDTI Evaluation Reporl 64 MVOMERO DC.SWOT ANALYSIS Strengths Weakness Opportunities Threats a CDTI activities at the district level are planned in the CCHP and are integrative Awareness of CDTI programme to the community GCR and treatment coverage rate is above 70Yo Leaders participation at all levels on CDTI Political commitment to CDTI programme a Inadequate funds for CDTI activities Delayment of Mectizan drugs from MSD Misconception ofthe drug use to some community Irregular transport on CDTI programme in the district at all levels Shortage of trained health staff in some health facilities Drop out of CDDs to some areas every yeat a a a Integrated Mectizan drug distribution and supportive supervision Trained staff implementin g CDTI activities Cascade system of monitoring and supervision Planned Preventive Maintenanc eof motorcycle and vehicle of CDTI programme Possibility of being acceptable at all political levels in the districts a a a a Negative attitude of the community towards Mectizan use Absence of Mectizan drugs at the community level Delayment of budgeted funds for CDTI activities Poor infrastructure Opposition from politician (Multipartism) Other vertical programme paying their volunteers at high rate compared to CDDs a a a a a O a a a a o a Strengths Weakness Opportunities Threats o Project activities are intergraded into comprehensive council health budget. . Funds allocation is increasing yearly o Committed staff at all level o Interpreted support supervision are well done. o Availability of working tools eg stationary and other accessories. . Availability of transport materials l. Disbursement of funds to support all the project activities 2. Inadequate IEC materials 3. No motivation policy to support CDTI implementers l. Community is willing to take the drugs 2 The project is well accepted as there is an overwhelming support at all level 3. Free delivery of Mectizan 3. Community negligence especially at sub urban areas 4. Failure of the community to reward the CDD'S at their areas 3. Oncho data format is incompatible in the HMIS 4. Inadequate number of CDDs in some community. 5. In case we shift to Morogoro Head Office quarter premises i MOROGORO DC-SWOT ANALYSIS lvlorctgoro CDTI fualuation Report 66 Morogoro District SWOT Analysis REGIONAL LEVEL: Weaknesses and proposed solution Issues Weakness Strategies Planning Inadequate planning skill at RS/RHMT Inadequate integration of CDTI activities Delay of drug distribution by MSD a a o Train RS/RHMT on planning CDTI activities to be included in regional health plans Intensify coordination between regional level and MSD. Finance o o Inadequate budget for CDTI activities Delay of release of funds for supervision Increase the budget for CDTI activities at regional level during planning and budgeting Timely release of funds for supervision a Transport and human resource a a Inadequate working facilities Inadequate transport Training a a Inadequate training schedules for RS/RHMT on HSAM and advocacy. Inadequate health education and promotion strategies and IEC materials Train HSAM RS/RHMT on - Conduct situational analysis to identify hindrance of the programme. -Develop educational messages and IEC materials following the locally identified issues eg. Cultural aspects - Disseminate available policies and health education materials Monitoring and Evaluation a a Inadequate involvement of RHMT in supportive supervision of CDTI activities The current M and E in use (checklist) is not user friendly. Ie it has a lot of things. Involve RSiRHMT in CDTI activities supportive supervision Develop user friendly M and E tools lllorogoro CDTI Evalualion Reporl 67 MVOMERO DISTRICT SWOT ANALYSIS Misconception of the drug use to some community STRATEGIES/ To conduct HSAM to all levels/ Incorporate other stakeholders such as Influential people (Religious leaders and Community Own Resource persons) r' Mass Media participation such as Radio, TV and Newspaper. leaders, Political Inadequate funds for CDTI activities STRATEGIES ,/ District planning team to increase fund in the CCHP annually and mobilize other donors to support CDTI programme (Advocacy to policy makers) ./ To integrate CDTI activities with other activities in the District Delay of Mectizan drugs from MSD STRATEGIES/ To liaise with the MOH&SW to deliver Mectizan on time to the District ,/ District to distribute Mectizan to the HFs/Community timely Irregular transport on CDTI program in the district at all level STRATEGIES ,/ To facilitate reliable for CDTI Programme in the District at all level ./ To facilitate regular maintenance of transport system Shortage of trained health staff in some health facilities STRATEGIES ,/ To increase number of trained staff in the District r' To equip with knowledge/skills on CDTI to health workers in the health facilities Drop out of CDDs to some areas evety year STRATEGIES ,/ To establish the cause of CDDs drop outs ,/ To build capacity to new CDDs Inadequate supportive supervisions/monitoring to CDTI activities at the cascades and health facility level STATEGIES ,/ To facilitate cascades leaders on supportive supervision illorogoro C DT I Eva lua t i on Re port 68 MOROGORO DISTRICT COUNCIL PROBLEM AREA WEAKNESSES STRATEGIES Planning integration and No oncho office for DOTs when we shift to a new District HQ - Budget for construction of a new office at the new district HQ Leadership, Monitoring supervision and Failure of the community to reward the CDDs Encourage community support/reward CDDs the to their Oncho data format is incompatible in the HIMS - Incorporate oncho data in other problems in HIMS Inadequate number of CDDs in some communities Convince the community to select more CDDs according to their need Training of new CDDs No motivation of policy to support CDTI implementers Advise the partner and support on it NGDO Dc to MectizanlF inance Late disbursement of funds to support all project activities - Early reporting and retirement of utilized fund to APOC office Training and HSAM Inadequate IEC materials Budget to prepare and distribute IEC materials Community negligence especially at sub urban areas Increase efforts HSAM on lll orogoro ( ) DT I Eval u at i on Re ltorl 69 SN NAME ADDRESS E.MAIL ADRESS I Prof. Obioma Nwaorgu Department of Parasitology &Entomology, Nnamdi Azikiwe University Awka, NIGERIA. obinwaorgu@yahoo.com 2 Dr.Abel A.Mwakafivila Tukuyu CDTI Focus(Regional Office) Box259, Mbeya, TANZANIA. abkafiarila@yahoo.com 3 Prince P.Mutalemwa Box 9653, Dar es salaam, TANZANIA. pmutal emwa@nimr.org.tz 4 Dr.Rehmah Maggid Tanga CDTI Focus Box 452, Tanga, TANZANIA. nidugae@yahoo.com SFDDH P.O.Box 337 ,lfakara, MOROGORO, TANZANIA. 5 Dr. George M.Kassiga gkassiga@yahoo.com 6 Rosemary Nguruwe Kilosa CDTI Focus Box l4,Kilosa, MOROGORO, TANZANIA. cdtikilosa@yahoo.com APPEITIDIX: VII ADDRESSES FOR MOROGORO CDTI -EVALUATION TEAM MEMBERS TELEPI 234803?- +255784 +255754 0784308 0715318 0715381 0784402 tllorogoro C DT I Et'al uat i on Re lsort 70 APPENDIX: VIII DOCUMENTS SIGHTED REGIONAL LEVEL l.Work Plan 2.Comprehensive Council Health Plan(CCHP) 3.Annual Technical Reports for three years( 2004,2006 and2007) 5.lnventory report-Equipments 6.Supervision Matrix T. Supervision Checklist 8.Log books 9.Financial Records/Retums DISTRICT LEVEL 1.Work Plan 2.Comprehensive Council Health Plan(CCHP) 3. Supervision Checklists 4.Supervision Matrix 5.Mectizan Ordering forms 6.Ledger for Mectizan FLHF LEVEL I .Treatment Summary Records 2.Treatment Registers 3.Census Registers COMMUNITY LEVEL l.Treatment Registers 2.Mesuring sticks ! lllorogorrt O DTI Evaluati on Report 7t N c- ( Y' \.i L , ? fr d c.c U)/F\l .rr *fr z o F E 1r1 6 u,E s2 =Es5(!lvoorsd8rH OErJl 2coE' lrlF(,) 1aEfOlrrEEq3fx6B _86z,= i \ & i}{) -!\ !U t- 1-fo X a | -- vV tr ( *i.{ .. .,/, l] s U c,fF z(, ,'t i\3\* N ( F1 E j \) z-\(,) $ $t:#g 7 r--l f-.1 l _\I\ u IS Id 1.. ') 'r4 '2) +jlUc,o a \4 \0{ C v & '-.J \ i:.) (\./1 n = xU N M r] 11 x .a { $ en clj k 0' 0 N'l il il rl I x :, ,< ..,'i E E, $5' 141 (, s :L .t tjJia ; .! 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tWorld Health Organization African Programme for Onchocerciasis Control v Assessment of Sustainability: Morogoro CDTI Proiect, Tanzania ( Fourth Year) October 2008 ,t u - (feam Leader)llpof" Ohiqmg Dr. Abel Mwakafrvila ',Dr, Rehma Mr; Prince Er, George It{s,Rosema o Acknowledgements We are grateful to the following persons and organisations for their cooperation, contributions and assistance towards the successful execution of this assignnrent The Director, Dr. Uche Amazigo, and staff at APOC Headquarters in Ouagadougou for making available the necessary financial and logistic requirements for the success of this assignment. Dr Kirumbi, Acting National Onchocerciasis Coordinator for facilitating the smooth take off of the exercise in Tanzania. The Ministry of Health and Social Welfare for facilitating the smooth running of the evaluation and for providing useful information. The Regional Adminstrative Secretary, the Regional Planning Offlcer and the Regional Medical Officer for their assistance and in providing useful information. The Morogoro and Mvomero district Councils for facilitating the conduct of the evaluation and providing relevant information. The District Health Staff, FLHF staff and community members in the study communities, who provided important information and contributed to the success of the mission, Last but not least immense gratitude to the team of accommodating drivers who drove the Evaluation Team over kilometres of roads and terrain under rough conditions, I t Y ta 1lvlorogoro C DT I Evaluation Reporl Abbreviations/Acronymns a AIDS APOC CDD CDTI CCHP CHMT DDO DNO DHO DP DLT DHS DMO DED EPI FLHF GCR HSAM HIMS IMCI IEC LF LGA RHMT MOH MOU MSD NOC NOCT NOTF NGDO OC PC PPM RPO RAS REMO RMO RIIS SSI TSH TMOHSW TCR wHo Acquired Immune Defi ciency Syndrome African program for Onchocerciasis control Community directed distributors Community directed treatment with Ivermactin Comprehensive council health plan Council health management team District dental officer District nursing officer District health officer District Pharmacist District lab technician District health secretary District medical officer District executive director Expanded program of immunization First line health facility Geographical coverage rate Health education, sensitisstion, advocacy, mobilization, Health information management system Integrated management of child health illness Information, education and communication Lymphatic filariasis Local government authority Regional health management team Ministry of health Memorandum of Understanding Medical store department National Onchocerciasis Coordinator National Onchocerciasis control team National Onchocerciasis task force Non governmental development organization Other charges Project coordinator Plan preventive maintenance Regional planning officer Regional administrative secretary Rapid epidemiological mapping for Oncho Regional medical offi cer Regional health secretary Sight savers international Tanzania shillings Tanzaniaministry of health and social welfare Therapeutic coverage rate World Health Organisation 3Morogoro CDTI Evaluation Reporl a EXECUTIVE SUMMARY INTRODUCTION Morogoro region is located in the eastern part of Tanzania. Morogoro Rural CDTI project is spread over Morogoro and Mvomero districts and serves 146 communities and a population of 524,495. This includes the Luguru, Kaguru, Kwere and Masai, settled and nomadic population. The mountainous areas are much densely populated than the low land. The main occupation of the community is farming of foods and cash crops, cattle herding, small scale fishing and timbering. The region has 4 other districts all covered by three previous CDTI projects namely Ulanga, Kilombero and Kilosa. The project commenced in 2003 but actual implementation of CDTI activities started in 2004. The project is currently in its fourth year of drug distribution having missed one year due to delay in fund disbursement from APOC . In 2007, after two years of drug delivery to the communities and three years of the inception of the project; APOC management appointed a 7-person monitoring team, a facilitator and observer for independent monitoring of the project. The Morogoro CDTI focus covers the district of Morogoro rural and Mvomero. The later being a newly created district carved out of the previous Morogoro rural district in May 2002. The two districts lie between latitude 8o and l0o south of Equator and between longitude 37" and 38o East of Greenwich. The evaluation in the field was carried out over a period of one week. During this period, information were gathered from desk review of relevant documents and reports, interviews with implementers and key stakeholders as well as field observation of CDTI implementation activities in sampled sites at the Regional, District, First Line Health Facility and village levels. Focus group discussions were also held with community members. This was followed by two days feedback and workshop for the development of their five-year sustainability plan by individuals responsible for the project implementation at the Regional and District Levels. The collation and analysis of information gathered from the field evaluation activities in Morogoro CDTI project area and planning of the feedback and sustainability planning workshop took another one week of intense work by the evaluators. SPECIFIC FINDINGS Planning CDTI activities are integrated into the overall Comprehensive Council Health Plan (CCHP). The plan varies from year to year according to specific needs of each year as more activities were being introduced. For exampl e, in 2007 , LF was included as part of Onchocerciasis control programme. A participatory approach is applied in the routine planning for the Morogoro CDTI project. Apart from government, the NGDO partner is actively involved and all partners are clear about their own roles, and those of the others. The minutes of the meetings of such meetings are available. The regional level is not involved in the planning process but is fully informed, as it is responsible for the approval of plans before they are funded. A written plan for 2007 CDTI plan was available in all the FLH facilities visited. This included training of ward development committee members and a a 4Morogoro CDTI Evaluation Reporl health education for CDDs. The plan was prepared by health staff at this level and it is integrated into the overall year plan for the facilities. At the community ievel, the community leaders are fully involved in CDTI activities. These include collection of Mectizan from the FLHF with the CDDs, going from house to house with CDDs during Mectizan distribution and involvement in HSAM activities. Community members not only take decision on mode, time and place of distribution but select their CDDs. Integration All health programmes are carried out in an integrated manner and it is in written form. There is a written work plan which shows co-implementation of CDTI with Lymphatic Filariasis Elimination program in an integrated manner. Moreover, supportive supervision is done for more than two iasks. Staff combines two or more CDTI activities on a single trip. In all the FLH facilities visited a check-list for this purpose is in place. Leadership Health and government officials at all levels are fully aware of progress, success and problems of the program and consider it as theirs. Community members and leadership support Mectizan distribution; they value and know that treatment will be for long time for at leost lSyeors they reported. Monitoring and Supervision Monitoring and supervision of CDTI activities are integrated with other routine/supervisory activities by RHMTs and CHMTs. This is usually carried out during the Mectizan distribution time. Data generated are compiled and submitted to the district authorities. Important records are readily available at various levels showing treatment summary records, inventories of equipment, financial records and periodic reports including the annual technical reports for three years. They are of good quality with clear and accurate contents. Based on the minutes of weekly CHMT meetings, problems identified during monitoring and supervisory visits are discussed and solutions are initiated to solve them. Feed back is sent to staff concern at the appropriate level. Mectizan Ordering and Supply Supply of Mectizan follows the government procurement and supply procedures. Mectizan is received through the District with other drugs through a transport system supplied and paid for by the government up to the health facilities which is the collection point for CDDs in various communities. Annual Mectizan need for communities is collected by the CDDs and Community leaders from the FLHF nearest to them by walking or use of their bicycles. In other cases where communities are remote, staffs in the FLHF supply Mectizan to the community during training of CDDs before distribution commences. a 5lvlorogoro CDTI Evaluation Report Training and HSAM Training of staff at lower levels is routinely carried out by staff at levels above them. For example staff members at the national level conduct training for staff at the regional level, and staff at the district level are trained by staff at the regional level while staff at the FLHF level is trained by staff at the district level and at Communities level, CDDs and Community Leaders are trained by FLHF staff. Training is carried out when there is deficiency as it relates to CDTI activities. This is usually when new staff, new CDD, or new decision makers are employed and when there is a new programme to be integrated with e.g. LF. Training is also conducted as a means of solving identified problems/gaps during Monitoring and supervision, such training are carried out as need arises and not on routine basis and in a cost effective manner. HSAM activities have been effective and have resulted to the inclusion of CDTI activities in the CCHP.HSAM also conducted during ward development quarterly meetings comprising of ward leaders, village leaders, sub-village leaders, extension workers including FLHF staff and influential leaders, so as to increase knowledge and commitment to CDTI activities. HSAM activities are properly planned and carried out to help in minimizing misconceptions about Mectizan and to improve coverage by reducing the number of refusals. This has been responsible for annual increase in coverage in communities. All these will make the project to be sustainable. Finance The annual budget in the CCHP available at the Regional level clearly spelt out the cost for each onchocerciasis control activity, and the Project Coordinator do not always have clear estimate of funds available for Onchocerciasis control in the coming year since the fund from the NGDO is added later. There is evidence of cost reduction since all activities are carried out in an integrated manner. Government funding is steadily increasing and always clearly spelt out in the CCHP. All funds released yearly are spent as budgeted, however even though the amount budgeted by government is increasing annually it is not up to half of the NGDO and APOC contribution for a project in the third year. Few of the communities compensate the CDDs through exemption from community activities while other do not compensate them either by cash or in-kind. Reason for non compensation of CDDs as reported by community leaders is: due to poverty, which makes CDDs to loose moral. This in a way will make the programme not to be sustainable .This is coupled with the fact that government support to the programme is still meager. Transport and Other Material Resources Presently, transport is available and adequate for CDTI activities at all levels. The project presently has one 4WD Toyota double cabin vehicle supplied by APOC. APOC also supplied, desk computer, Lap top computer, photocopying machine, fax machine and printers while SSI provided them with air-conditioner, and office furniture. C 6Nlorogoro CDTI Evaluation Repttrt The vehicles available from the govemment are the main transport means for CDTI at the district and FLHF levels. Government has been bearing the cost of maintenance and fueling of vehicles. This is carried out immediately and efficiently. All vehicles are in the pool. There is a routine maintenance schedule for vehicles at all levels by Planned Preventive Management (PPM) Servicing is carried out accordingly every three months or based on number of kilometers. Budgets for maintenance are reflected in the CCHP .The vehicle maintenance records are kept by the transport officers. Travel authorization is usually obtained for CDTI support activities by programme staff through the transport officer. Trips made for CDTI purposes are authorized in writing based on route matrix prepared by the transport officer. There is a log book stating joumey dates, quantity of fuel utilized, journey route and status of vehicle at the end of the trip. The log-book also shows name of oflicer, the driver, location of activity and number of kilometers covered. Transport is available for supervisory activities at the next level. With the current integration of activities at all levels, transport is shared among all programmes. The Evaluators were assured of likelihood of transport remaining stable until the duration of the project. Staff members have ways of coping when vehicles break down or are not available, so that CDTI activities are not disrupted. This is because more than one vehicle is usually allocated for health activities. If one vehicle used for CDTI breaks down any available vehicle could be used for this purpose. This is an evidence for the sustainability of the project. Though there is no written evidence to show replacement of vehicles and equipment for CDTI activities, the evaluators were informed that there will be support from other vehicles in the pool when the need arises since all health programmes are carried out in an integrated manner. So far all capital equipment used for the implementation of CDTI activities is from non govemment sources. However since the photocopying machine and other equipment are used for other activities apart from CDTI activities, they are in the hospital management schedule for maintenance. However government has been responsible for provision of stationery and materials for haining and HSAM. HSAM materials were however reported to be inadequate in most FLHF and communities. Human Resources There is staff stability at all levels and salaries are regularly paid. The numbers of staffs at various levels are adequate for CDTI activities. They have appropriate, knowledge and skill to undertake all CDTI activities. They are also committed to the success of the programme. Staff transfer at all levels is not frequent Since project inception, there has been no transfer of programme staff. They have remained the same and on their posts for more than three years. This will help improve the quality of CDTI programme activities and thereby sustainability. On recruitment of new staff, he/she is oriented immediately on CDTI activities. Staff attitude is satisfactory. Most CDDs expressed willingness to continue working without receiving compensation. This shows some level of sustainability. The ratio of CDDs to households is also appropriate in most of the communities visited. Though the district level staff member's commitment to CDTI is high, there has been low motivation for them. No award, financial and or material rewards or recognition of their post by the Central Government System. Also new professional health workers in the country are yet to be provided with up-to date knowledge and skills in the field of CDTI 7illorogorc CDTI Evaluation Re porl Generally, CDTI activities are integrated into the government system in carrying out the following activities namely: Management and use of transport/logistics, Monitoring and supervision, Retrieving of data especially at the FLHF level and Storage of mectizan. The Evaluation Team felt that all these are helping in the sustainability of Morogoro CDTI project. Coverage Also the therapeutic coverage situation in the project is remarkably increasing annually even though there was no significant difference between 2007 and 2006 but this has been stable In 2007 it was 75%o, in 2006 it was 75.3oh and it was 67%o in 2004. On the other hand, geographical coverage has remained at l00o/o in all three years. Evaluating the project on the basis of the seven aspect and five critical elements of sustainability, the Evaluation Team concluded that the Morogoro CDTI Project is making satisfactory progress towards sustainability. Some of the odds identified which has set the project back included finance and ownership. With regard to the five critical elements, the Evaluation Team found that three elements - Transport, Mectizan Supply and Supervision were present in the project. The elements of Money and ownership were not satisfactory in the project. Resources were mainly from outside even though there is political commitment at the other levels, there is no complete ownership at the community level. Communities are not involved in the provision of census register, pens and pencils to CDDs and most communities do not compensate their CDDs either in cash or kind. With regard to the seven, aspects of sustainability, the Evaluators found that five namely: Integration, efficiency, simplicity, attitude of staff and effectiveness were helping the project attain sustainability. Resources and community ownership were found to be blocking sustainability. This is because govemment funding for the programme is very minimal even though the programme is in its fourth. The programme has been dependent on non-government sources for three years. The quantitative scale of 3.6 for the project in its fourth year shows that the project is however makin g satisfactory progress towards sustaina bility. It is therefore the view of the Evaluation team that based on the qualitative aspects that the Morogoro CDTI project is making progress towards sustainability During the feed back meeting the implementers and stakeholders at the regional and district levels commended the findings and recommendations at each level. They appreciated the need for more fund to be allocated to the Morogoro CDTI project through recommendation from the district level to the regional level. Also it was their view that a process for an operational research on behaviour/ attitudinal study should be put in motion to determine why there is low therapeutic coverage at the sub -urban levels when compared with the rural sub villages and the level of misconception in various sub-villages on Mectizan. The team thereafter proceeded to develop the five year sustainability plan based on the recommendations and bearing in mind the weaknesses identified. The team also discussed ways of moving the project forward. Some of their suggestions on how to move the Morogoro CDTI project forward are listed below. 8illorogoro C DTI Eval ualion Reporl THE WAY FORWARD As Morogoro GDTI project moves into the 5th year, the Evaluation Team, programme ,unug.r.-und policy makers at the Regional and district levels appraised appraised the critical issues=that wilienable The Morogoro CDTI project to be sustainable post APOC and came up with the following recommendations. l. planning: There should be an integrated annual work plan at all levels. .Communities should be involved in planning and implementation of CDTI activities. Planned health activities in CCHp shouid take into account community priorities/needs. There should be a policy on how to motivate CDDs and other CDTI implementers at all levels. Z. HSAM: HASM on the CDTI activities should be carried out continuously at all levels especially at the community level to promote acceptability of and participation in the prtgru-1n" including community ownership. Advocacy visits should be paid at all levels in"tuOing ward and community leaderships for commitment to the CDTI programme' Appropriate IEC materials should be used for this purpose. Training of community leaders und ctmmunity members should be carried out regularly in order to minimize misconception and hence increase coverage. 3. Resource Mobilization: Government should be sensitized for commitment to the CDTI programme especially as it relates to increase funding of the CDTI programme. There is ,..I for high level advocacy at the regional level to ensure increased budget for CDTI activities in the CCHP. 4. Integration: In the process of integrating CDTI activities with other programmes the roles and iesponsibilities ihould be clearly stated. This is to remove any form of bottle necks that ,uy u.ir. leading to unforeseen delays in programme implementation. The present delay in 2008 mectizan distribution due to co-implementation of CDTI with LF was sighted as a good example of one of the probles of integration 5. Involving more NGDOs and Other Agencies: There is need to identify potential NGDO to provide additional support and carry out advocacy visits to them. 6. Stakeholders' Review Meetings: There should be regular stakeholders review meetings to give feedback on CDTI activities, coverage, reports constraints, etc. to individuals involved in CDTI activities. 7. Simplicity: The Government should ensure a rapid and smooth delivery of Mectizan to districti.The system of drug collection and reporting should be kept as simple as it is. The MSD system presently being used for transportation of drug to the FLHF should be maintained. 9lv'lorogoro C DT I Eva luation Retrtrtrl 8. Reporting and Documentation: Reporting and documentation of all CDTI activities (training, monitoring, supervision etc) at all levels of implementation. This will facilitate efficient planning and provision of efficient feedback to stakeholders. 9. Operational Research: The difference in therapeutic coverage between the sub-urban and rural communities was of great concern to the stakeholders. Also were the issue of refusal due to misconceptions in some sub villages on Mectizan and the willingness of the CDDs to continue with Mectizan distribution even with no support from the sub-villages. Both the stakeholders and the team were of the view that an operational research on behaviour and attitude of community as it relates to Mectizan distribution should be instituted to answer some of these questions Llorogoro CDTI Evaluotion Report l0 TABLE OF CONTENTS Acknowledgements Abbreviations/Acronyms ............ Executive summary l.O INTRODUCTION l.l Background to the Morogoro CDTI Project Evaluation """ 1.2 Evaluation Objectives .. 2.0 METHODOLOGY .......... 2.1 Design 2.2 P opulation ............ 2.3 Sampling and Selection Communities 2.4 Sources of Information ...'..'.'... 2.5 Analysis ................ 3.0 EVALUATION FINDINGS ., ....3 .4 13 .13 l5 Sustainability at Project/Regional Level Sustainability at the District Level Sustainability at FLHF Level ..'....' Sustainability at the Community Level Comparative Analysis of the Sustainability of the Four Levels .'..'..'. t9 t9 26 3.1 3.2 3.3 3.4 3.5 ..3 I ..36 .41 4.0 CONCLUSION 4.1 Grading the Overall Sustainability of Morogoro CDTI Project. ...."" 4.2 Sustainability /Ieedback workshop at the regional and district levels Morogoro CDTI project 4.3 The Way Forward ............ APPENDIX I: Morogoro CDTI Project: Evaluation Team Composition .....'.... II Morogoro CDTI project: Name of Respondents at various levels III Morogoro CDTI ...project.... IV Programme of activities for 2 days feedback/sustainability plan development V Roles of different levels and partners feedback/sustainability plan. VI Regional level-SWOT Analysis. VII Address for Morogoro CDTI Evaluation team members....'........ VIII National Onchorceciasis Control Programme Morogoro CDTI Sustainability Feedback meeting (Registration) .'............ 44 44 ,.,.........49 ,...........54 \\ .............55 ..............56 ............. 58 .............59 ...... ..61 .62 .69 .70 h{orogoro CDTI Et,aluation Reporl l1 ........... l6 ...........16 t6 ....17 .....17 LIST OF TABLES Table I Table2 Table 3 Table 4 The geographic and therapeutic coverage in Morogoro CDTI project from 2004 -2007. Study villages and communities Sustainability Score of the different Groups of Indicators by levels of CDTI Implementation in Morogoro CDTI project Financial contribution of various CDTI partners between 2004 to 2008 Pages 15 l7 4l 45 !l[ o rogoro C D'l I Eval uat io n Re p ort t2 LIST OF FIGURES Figure 1: Morogoro CDTI: Sustainability at State Level Figure 2: Morogoro Sustainability at District Level Figure 3: Morogoro CDTI: Sustainability at FLHF Level Figure 4: Morogoro CDTI: Sustainability at Community Level Figure 5: Average Performance at various levels Figure 6: Sustainability Score of the Groups of Indicators and Level of CDTI Implementation in Morogoro CDTI Project Figure 7: AveragePerformance of Each Group of Indicators in the Entire Project Pages t9 26 3l 36 4l 42 43 lvlorogoro CDTt Evalualion Report 13 1-.0 INTRODUCTION 1.1 Background to the Morogoro CDTI Project Evaluation The Morogoro CDTI focus covers the districts of Morogoro Rural and Mvomero which are among of six districts found in Morogoro region.The Morogoro CDTI project was launched in 2003. CDTI activities were implemented in 146 villages, 76 in Morogoro rural and 70 in Mvomero with a total of 146 sub-villages. In 2006, there were a total of 871 endemic communities (hyper 558 and meso being 313 communities). There are atotal of 424 endemic communities in Morogoro (345 mesoendemic and 79 hyper endemic) and 447 endemic commuities in Mvomero (213 meso endemic and 234 hyperendemic). The two districts lie between latitude 8o and l0o south of Equator and between longitude 37" and 38o East of Greenwich Morogoro region is located in the eastern part of Tanzania. The region comprises of six districts namely; Morogoro Rural, Kilosa Ulanga, Morogoro urban, Kilombero and Mvomero. The region is inhabited by Luguru, Kaguru, Kwere and Masai tribes. These communities consist of indigenous and nomadic population; the mountainous areas being much more densely populated than the low land. The young people keep on migrating to look for employment in towns and to areas or neighboring regions where there are newly discovered mines. The main occupation of the community is farming of foods and cash crops, cattle herding, small scale fishing and timbering. Topography The two districts are divided into three geographical zones:- (a) Mountainous or Highland Zone (25Yo) This zone covers the Uluguru Mountains located at an altitude of 1200 - 2000 m, above sea level with the clay type of soils. The zone is suitable for the production of maize, beans and horticu ltural particularly Mediterranean types of fruits. (b) Semi-Mountainous/Low Land Zone (20%) This zone covers most of the Southern part of Morogoro/Mvomero districts, at an altitude of 800 - 1200 m above sea level with sandy clay loam type of soils. The zone is suitable for the production of maize, cassava and sorghum as staple food crops. (c) Savannah Zone (55Yo) This zone is located at the altitude of 600 - 800 meters above sea level; with same clay loamy type of soils. The zone is suitable forpaddy, maize and cassava, for both food and cash crops; and also suitable for sugarcane, cotton and sisal as cash crops. Part of South East of the zone falls under Selous National Park, further the district has big valleys and numerous fast running rivers such as Mgeta, Ruvu and Wami-Luhindo rivers. Climate The temperature ranges between 20oc up to 28oc. Rainfall ranges from 600mm in the savannah areas and up to 1600 mm in the mountainous areas. It has two clear seasons namely: rainy season from February to May and dry season from ]une to January. Morogoro CDTI Et,aluation Reporl t4 Communication The total road network in the district is 1168 km. The roads are divided into the following categories:- -National truck roads - 188 km - Regional roads - 343 km - District roads - 295 km - Village feeder roads - 342km Most of the road network is passable during the dry seasory but some feeder-roads to the villages are impassable during the rainy season. Administrative Structure Administratively the two districts are divided into 10 (ten) divisions,42 wards and207 registered villages. They also constitute 3 parliamentary electoral constituencies. Health System The Morogoro CDTI Project area has 3 hospitals. One owned by the Government one (1) by Parastatal organization and the third by a Religious organization. There are seven (7) Rural Health Centers (6) being Government owned and one (1) belonging to Parastatal organization and eighty two (82) dispensaries of which 58 are owned by the Govemment, twelve (1'2) by NGO's, ten (10) by Parastatal organizations and two (2) by individual/private organizations. There also 59 (fifty nine) village health Posts of which 50 (fifty) are owned by the Government and 9 (nine)by NGO's. There is a total of.S4}health staff in the entire project area (286 in Morogoro and 256 in Mvomero) out of these, 327 are involved in CDTI activities (181 in Morogoro and 146 Mvomero). There are 7996 CDDs involved in Morogoro CDTI projec! comprising 1005 males and 991 females. Out of these, 973 CDDs are from Mororogoro sub project (473 males and 464 females) while 1059 CDDs (532 males and527 females) are from Mvomero sub project' The total number of communities treated between 2004 and 2007 and their geographical and therapeutic coverage are shown in table 1 Morogoro CDTI Evaluation Reporl l5 Table 1: Showing the geographic and therapeutic coverage in Morogoro CDTI project from2004-2007 Year No of endemic communities No of endemic communities treated Geographic coverage (%) Therapeutic coverage (%) 2004 146 136 92.5 67.0 2005* 2006 828 828 100 75.3 2007 871 871 100 75.0 * Late funding from APOC led to no treatment 1.2 Evaluation Objectives 1.3 Funding of the Morogoro CDTI project by APOC and SSI started in 2003. An Independent Monitoring Team was constituted by APOC to visit the Morogoro Community Directed Treatment with Ivermectin (CDTI) project from 30ft July to 12ft August 2007 (Third year of project). A copy of the monitor's report with their recommendations was cited by the evaluators. As is usual for all APOC supported projects, APOC management has therefore delegated a team of six evaluators from Nigeria and Tanzaria to evaluate the Morogoro CDTI project for sustainability. This activity was carried out from the I Oft to 24h of October 2008. The main objective of the evaluation exercise was to determine the sustainability of the Morogoro CDTI project which is presently at its fourth year and also assist programme staff and other implementers in developing a post APOC sustainability plan. The specific objectives therefore were: a) To assess the performance of the individual groups of indicators of sustainability in the Morogoro CDTI project. b) To identify the factors that may block or help the sustainability of the project c) To discuss the outcomes of the evaluation exercise with the relevant stakeholders and partners in the Morogoro CDTI project d) To develop a3year Sustainability plan for the Morogoro CDTI project post-APOC. e) To De-brief the WR in Tanzania on the outcome of the Evaluation of Morogoro CDTI Project. Morogoro CDTI Evaluation Report l6 2.0 METHODOLOGY 2.1Design A cross-sectional descriptive design was employed as the process for data collection. In doing this the evaluation objectives and questions were answered, and data was collected in order to provide the analysis required 2.2. Population The total population in the entire project a(ea is of 594,066, comprising of 297,864 for Morogoro and 296,202 for Mvomero. 328,81.4 for a total population are in meso/hyperendemic zones (227,454 mesoendemic and 89,059 hyper endemic). A total 152, 712 for a population in in hyper/mesoendemic in Morogoro district (123,988 as meso endemic and.28,724 hyper endemic) while a total of.176,'1.02 of the population are in the meso/hyper endemic zone in Mvomero district (770,366 meso endemic and 68,744 hyper endemic). 2.3. Sampling and Selection of Communities Morogoro CDTI Project comprises of two endemic districts, Morogoro and Mvomero. A multi slage sampling techniques was adopted for the selection of six villages with First Line Health facilities (three each from each of the two districts), out of which twelve sub villages (two from each village) were randomly selected through balloting. Thus a total of twelve sub-villages were selected Information was sent across to selected FLH facilities and sub-villages and appointment made for their visit by the evaluators. The District Onchocerciasis Coordinators played a crucial role in the passing this information and as guides to the team members. The data output of the selected villages and sub-villages are shown in Table 2. N{orctgoro CDTI Evaluation Reporl t7 SAI District Village Sub Villaee/community I Morogoro Rural(75%) Kizinga (65%) Mikese Mjini (81%) Polepole (35%) Mkuyuni (48%) Nzawa (61%) Misala (76%) Tawa (69.9%) Mgembe (90%) Dikoni (73%) 2 Mvomero (74.e%) Mhonda (85%) Mvaii (83%) Diyagaya (78%) Langali(80%) Lolo(81%) Mgini (80%) Kanga (70%) Lukindu (85%) Chalongwe (89o/o) Table 2: Showing study villages and communities Prior to the field visit, one day tools orientation training was held for the team. This included introduction of the CDTI concept with emphasis on the strategy, partnership and responsibility sharing. Monitoring was then discussed particularly the need for monitoring and the use of monitoring outcomes. 2.5 Sources of Information Information was collected from interviews, verbal reports and documents. Various categories of people were interviewed in the State. These included the Regional Administrative Secretary (RAS); Regional Medical Officer (RMO); Regional Planning Officer (RPO); Project Accountant; Project Coordinator at the regional level. At the district level, the District Executive Director; District Medical Office; District Pharmacist; District Transport Officer and District Oncho teams in each district were interviewed. Other individuals interviewed included the Frontline Health Facility staff (FLHF District health Supervisors) and in the sub-villages/communities, community leaders, CDDs, and community members form selected communities. Information from the community members was through a focus group discussion. Information was recorded on evaluation instruments. 2.6 ANALYSIS Based on the information collected, each indicator was graded on a scale of 0-4 (worst to best) in terms of its contribution to sustainability. Summary statistics for the scores were calculated for each level, and for each group of indicators, and tables and graphics from these results were plotted. The average 'sustainability score' for each group of indicators was calculated, for each level, and a graph was plotted. This was presented at the feedback workshop. The quality of the overall project was also assessed using the different aspects and critical elements of sustainability present in the project. Morogoro CDTI Evaluotion Retrtort 18 The five critical elements and the seven aspects of sustainability in the project were qualitatively discussed and results agreed to by the team. The project was graded using these aspects and elements in accordance with APOC guidelines. The evaluators discussed qualitative description of problems, and deliberated on likely suggestions for solving the problems identified. Thus judgment about the sustainability potentials of the project was based on the quantitative assessment of the average sustainability scores of the groups of indicators as well as the qualitative assessment of the critical elements and aspects of sustainability of the project. Recommendations were generated based on the format recommended by APOC' fvlorogoro CDTI Evaluation Report 19 3.0 EVALUATIONFINDINGS 3.1 Sustainability at ProjecURegional Level Planning: (Fully:4) There is an overall written year plan of the health service at the Regional level. Onchocerciasis is routinely listed in this Comprehensive Council Health Plan (CCHP) which is presented to CHMT members annually with other diseases. As reported by the Regional Planning Officer (RPO), this is because the disease is of notional importance to the country. There is also a more detailed onchocerciasis plan containing the key elements of CDTI. Various stakeholders comprising of government officials and other partners (SSI) participate in the development of this plan. According to the RPO, "According to our budget guidelines, all stakeholders are supposed to be involved in budget planning meetings duing which donors repori what they are going to support. ftis process is usuatty pafticipato{. He also reported that in 200712008, SSI provided some funds and IEC materials for Onchocerciasis implementation activities. The participation of all stakeholders and partners was documented in minutes of the CHMT meeting where the plans were developed. Fig l.Morogoro GDTI: Sustainability at State Level 3.5 3 2.5 2 1.5 1 0.5 t s E" o =o E') a! o "*ue snt" ,"..u n'f ss" ort "*"o- ^.d. C "rdGroup of lndicators h'lorogoro CDTI Evaluation Report 20 This plan varies from year to year since it is targeted at specific needs of each year' For example, in2007,LF was included as part of Onchocerciasis control programme. Integration: (Highly: 3.2) There is evidence of integration of all health programme activities. There is a written work plan which shows implementation of CDTI and Lymphatic filariasis activities in an integrated manner' Staffcombine tasks during training, supervision/monitoring and HSAM in a single trip. Staff also combine CDTI activities with that of other health programmes when it becomes necessary' Leadership: (Fully: 4.0) All regional leaders (Regional Administrative Secretary, RMO, RPO etc) are fully aware of progress, success and problems of the programme. If there is a problem e.g. low coverage in pr.rio6 year, during the next Mectizan distribution year, the Regional Commissioner is involved in SASM activities during Mectizan distribution launching. The Regional Commissioner openly swallows the drug . On the other hand, in districts as part of HSAM, district commissioner will do same. The leadership is up to date with her reports and targeted activities. Leadership delegates responsibilities appropriately to colleagues at this and lower levels. Leadership also has a sound and collegial relationship with junior colleages and keeps them fully informed. For example.after compiling the reports, feed backs are given to District Oncho co-ordinators. There is a good working relationship between project coordinator and district oncho team members who share same office with her. NOTF meetings are held quarterly during which progress, challenges and current issues as it relates to CDTI progrqmme is discussed Monitoring and Supervision: (Highly: 3.8) Important records are readily available at this level showing treatment summary records, inventories of equipment, financial records and periodic reports including the annual technical reports for three years. The records are ofgood quality, content is clear and accurate. Staff is empowered to work in an integrated manner and using a well planned route matrix for joint supervision. A good functional supervisory cascade system is in place for this purpose. The Project Co-ordinator with RHMT members usually supervise the District Oncho- team Members below them. In problematic cases they supervise up to the FLHF. Also District Oncho team supervises staff at the FLHF level. Monitoring /supervision is being planned to make use of efficient resources. This carried out in an integrated manner according to RHMT (Regional Health Management Team) matrix. This is usually on quarterly basis but more when problem arises e.g. discrepancy in the completion of forms. During supervisory visits, two to three RHMT members are involved. Supervisory visits take 2 to 3 Days. Integrated Supervisory Checklists are used for this purpose. Morogoro ODTI Evaluation Reporl 21 As soon as problems are identified e.g. low therapeutic coverage, the problem is addressed in a very systematic manner. Usually the Regional Authority seats with District Oncho-team members discuss with them and find out reason for the identified problem and how the problem will be tackled. Feed back from such meetings are passed on to the appropriate officers who deals with them. Successes are identified and recognized and feed back is given systematically e.g. in Districts with high coverage, District managers are congratulated and letters of commendation are sent to them. a. Mectizan Procurement and Distribution: (Highly: 3.0) Mectizan supply is controlled within a government system. Mectizan received annually at the MOH is deposited in the medical store department (MSD) from where it is distributed to the District Health Centers and Dispensaries. Sometimes the MSD as sole distribution system creates a problem. This is due to delay in release of drug. The system is however effective, uncomplicated and efficient. The system is simple since government provides the transportation for movement of mectizan with other drugs to various health facilities. There is always sufficient supply of mectizan for the needs of the project. However mectizan distribution for 2008 is yet to arrive. As reported by the programme co-ordinator, in previous yeors ordering of Mectizan is carried out by the Oncho- coordinator at the National level but following the integration of Oncho with LF this function is now the responsibility of LF coordinator at the National level. Training and HSAM: (Fully: 4) Training is planned and undertaken in an efficient manner. Training of staff at lower levels is routinely carried out by staff at levels above them. For example staff at the district level is trained by staff at the regional level. Staff at the FLHF level is trained by staff at the district level while staff at the national level conducts training for staff at the regional level. Training is carried out when there is deficiency as it relates to CDTI activities. This is usually when new staff is employed and when there is a new programme to be integrated with e.g. LF. Training is also conducted when there is an identified problem during supervision. Project coordinator and one RHMT member are responsible for the training of the district staff. This takes I to 2 days and usually takes place in the district office/locality. Training materials e.g. training manuals and leaflets are available for the trainings at this level. Health education, Sensitization, Advocacy and Mobilization (HSAM ) is properly planned and carried out based on perceived need. Before Mectizan distribution commences, HSAM is carried out at Regional level. This also involves the use of senior government officials especially in areas were problems were identified. For example during the launching for Mectizan distribution, the Hon Commissioner and Regional Administrative Secretary (RAS) are usually invited. These individuals swallow the drug openly as a means of ensuring the community members that mectizan is safe and non poisonous. This helps in minimizing the number of defaulters. Morctgoro CDTt Evaluation Report )') Health education, Sensitization, Advocacy and Mobilization (HSAM) activities has been effective and has resulted to the inclusion of CDTI activities in the CCHP Finance: (Moderately: 2.8 ) The budget in the CCHP available at the Regional level clearly spelt out the cost for each onchocerciasis control activity. Project coordinator has a clear estimate of funds available for onchocerciasis control in the coming year as well as the excepted sources and made budgets for CDTI to fall within the expected income. The financial contribution by all partners and govemment for the last four years is clearly spelt out. In 2008, APOC contribution was US$51,543; NGDO contributed US$. 17,221.85 and MOH (District) US$ 26,667.47.In 2007 MOH contribution was US$ 9,496, NGDO contributed US$ 18,353 and APOC US$60,436 and in 2006 MOH contribution was US$ 0, NGDO contributed US$ 18,353 and APOC US$60,436. However even though the amount budgeted by government is increasing annually; it is not up to half of the NGDO and APOC contribution for a project in the third year. The project Accountant is responsible for release of funding for CDTI activities- from APOC and NGDO while the district accountant is responsible for release from Council and CCHP. He knows what have been budgeted from government resources for CDTI activities but does not know the amount budgeted from other sources eg APOC and NGDO. APOC and NGDO funds are released in two installments. There is an itemized activity budget description for each of the District area( Mvomero and Morogoro) with only government sources indicated. All amounts itemized in government budget are usually released. There is evidence of approval of expenditure and expenditures are allocated according to approved plan of actions. Funds disbursed for onchocerciasis activities are efficiently managed through a well established control system. For each CDTI activity the coordinator writes a letter to the project account quoting the activity number and amount required. At the end of the activity, the amount spent is retired by the project coordinator to the project accountant. All the funds released yearly is spent as budgeted. The Project Coordinator is not aware of the existence of residual amounts under different budget headings. Deficit is seldomly experienced because financial plans are clearly discussed before documentation. Transport and Other Material Resources: (Highly:3.9) Transport and materials at this level are available and adequate for CDTI activities at this level. The project presently has one 4WD Toyota double cabin vehicle supplied by APOC. APOC also supplied, desk computer, Lap top computer, photocopying machine, fax machine and printers while SSI provided them with air-conditioner, and office furniture. So far all capital equipment used for the implementation of CDTI activities is from non government sources. However govemment has been responsible for provision of stationery and materials for training and HSAM and bearing the maintenance cost of the vehicles and their fueling. However occasionally this is also provided by APOC and SSI All vehicles are in the pool and a maintenance schedule is available for this purpose. Servicing is carried out accordingly based on number of kilometers by the Plan Preventive Maintenance (PPM). Since the photocopying machine and other equipment are used for Morogorrt O DTI Evaluati on Reporl 23 other activities apart from CDTI. They are therefore in the hospital management schedule for maintenance. Staff members have ways of coping when vehicles break down or are not available, so that CDTI activities are not disrupted. This is because there is more than one vehicle allocated for health activities. If one vehicle used for CDTI breaks down any available vehicle could be used for this purpose. All vehicles and equipment are maintained and repaired through government fund and this is carried out immediately and efficiently. Transport is available for supervisory activities at the next level. Travel authorization is usually obtained for CDTI support activities by project coordinator through the transport officer. There is a log -book available showing name of officer, the driver, location of activity and number of kilometres covered. Though there is no written evidence to show replacement of vehicles and equipment, the CDTI activities the evaluators were informed will have support from other vehicles in the pool when the need arises since all health programmes are carried out in an integrated manner. Government also has a system in place for maintenance of vehicles and equipment. Human Resources: (Highly: 3.5) The number of staff is adequate and they have appropriate, knowledge and skill to undertake all CDTI activities. They are also commiued to the success of the programme even though no evidence was obtained from the NGDO partner Since project inception, programme staff has remained the same. There has been no transfer of programme staff. On recruitment of new staff, there is immediate orientation on CDTI activities. New professional health workers in the country are yet to be provided with up-to date knowledge and skills in the field of CDTL Coverage: (Highly: ) Geographical coverage (GCR) has remained at 100%o from 2004 to 2007 while the average therapeutic coverage rates (TCR) for the 3 years 2004-2007 has remained at 72.4Yo.Even though TCR did not increase coverage has howeverbeen stable. In2007 TCR is 75Yo;ln 2006 TCR is 75.3% and in 2004 TCR is 67%. This therefore confirms that people are beginning to show more interest in the drug and communities are beginning to demand for the drug. Morogoro CDTI Eva]uation Reporl 24 Recommendation: tPlanningt Implementation APOC activities. Priority: = tligh = Iligh Indicalors o;f success : :e Stakeholders aware of their roles and implement them. - Sustainability plan in Place. :) Comprehensive annual plan include CDTI activities = Evidence of CDTI activities taking place. llho lo tahe action: + Oncho Management Team + PC,NOTF :+ DOM,NGDO Deadlin e for complelion : + 3l't March 2009 Recommendations: "Integration" integated manner will be achieved Priority = Iligh Indicalors ofsuccess: = Annual work-plan showing clear evidence of integration llho to take action: + Oncho Management Team = PC,NOTF Deadline for completion 3 1" March 2009 Recommcndations:' Leadership' Implementarion) Regional leadership should continue to get involved in HSAM annually > NGDO partner to continue empowering regional leadership on their role in CDTI processes. Priority: Indicators of successt + DMT members fully aware of the CDTI programs and their role. ll/ho to tahe aclion: :+ PC, Regional Oncho team + ONCHO Management tgCq NqPq D e a d lin e for c o mp I etio nt? 30s April 2005 Recommcndations:'Monitoring And Supervision' Implementation F Introduce a feedback system for improving and solving problems identified. D Evidence ofsuccess reported should be included be documented in previous monitoring reports. Priorityz + Iligh = Iligh Indicalors of successi + Availability of document showing successes + Feedback is given and necessary action taken. llho to take aclion: 3PC - DOC Deadline for complelion = 30h June 2009 Recommcndations:'Mectizan Procurement and Distribution' Implemenlaion: minimize delay as being experienced for 2008 Priorityz + Iligh Indicalors of success'. lltorctgoro C DT I Et,a I u a t io n Re porl 25 llho to tahe action: + RegionalOnchoteam =) NOTF D e a d lin e fo r c o mp lelio n I = January3l"t 2009 Rccommendation 'Training & HSAM' Implementation led to action at this level should be documented. Priority: = tlediunt Indicators of success. :? HSAM activities and result documented = lltho to tahe aclion: + RMO Deadline for completion: As soon as identified Recommendations :'Financial Rcsources' Implementation : hiority: and this should be at least halfofthe amount coming from non- government sources amounts budgeted headings Indicators ofsuccessz = Realistic budgets made for CDTI activities by government, = Funds released in time. llho lo take action: + Programme Accountant -PC = SMT Deadline for completion: 30n April,2004 Rccommendations:'Transport and Other Material Rcsources' Implemenlation replacement of vehicles and other materials required for carrying out CDTI activities Priorily: = llish Indicalors of success: :) MOU in place for continuous vehicles and other materials supply. lltho to lake actionz + P.C :) DPO + DOM =) RMO + RAS D eadline fo r completionz When the need arises Rccommendations: Coveraqc Implemenlation annually. Priorityt = tligh + lligh Indicators otsuccessz + TCR>67Yy lYho to take action. +PC D e a d I i n e for c o mp letio nt 30s Sept. 2009 lvl o rctgoro C DT I Eva I u at i o n Re pctr! 26 3,2 SUSTAINABILITY AT DISTRICT LEVEL Planning: (Fully: 4) CDTI key activities are integrated in the Comprehensive Council Health Plan (CCHP). This includes the Stakeholders of Health, CHMT members and personnel from all levels of health. The mode of planning is usually participatory and is based on community requirements. The written yearly CCHP and minutes of the planning meetings exist in all two districts. Integration: (Fully: 4) Thetistricts program activities are planned in an integrated manner and it is in a written form. However, rupportir" supervision is done for more than two tasks. Districts are co implementing CDTI with Lymphatic Filariasis Elimination program. Fig 2. Morogoro Project: Sustainability at District level tf E" ,6 3 o E)g o (E t u? ar) (? ro ci N q ro e; o od*dsc O) """t C "-C^.-- .-""/q,s Group of lndicators il'lorogortt C DT I Evaluation Report 27 Leadership: (Fully: 4) The project which covers Morogoro and Mvomero, districts has a Project Coordinator who oversees CDTI activities at the project level (Region), The Council Health Management Team(CHMT) in each district among others oversees all CDTI activities. Monitoring and Supervision: (Moderately: 2.3) APOC standards of reporting are used in the CDTI reporting process. Data generated during monitoring/ supervision is yet to be integrated into the Tanzania's Health Information Management system ("MTUHA"). This is because Onchocerciasis is a focal disease and among the Neglected Tropical Diseases. Currently the Tanzania Ministry of Health and Social Welfare is reviewing HMIS to include focal diseases in its disease data base. There is therefore need for HSAM at the National level to ensure Onchocerciasis is listed among diseases in the HMIS. The focal persons for CDTI at the district level and the CHMT among others conducts supervisory activities to the FLHF .Spot checks take place at community level when need arises. Staff at the FLHFs supervise their respective communities and work hand in hand with the community leaders. According to the minutes of weekly CHMT meetings, arising problems identified during monitoring and supervisory visits are discussed and solutions are initiated to solve such problems. Feed back are sent to appropriate FLHF staff to initiate action. Mectizan Procurement and Distribution: (Highly: 3.5) The supply of Mectizan smoothly follows the government procurement and supply procedures. When Mectizan arrives at the National level, the project coordinator is informed. He /she inform the district coordinators. The National office arranges for MSD to transport Mectizan to respective districts. Special routes are created to ensure that there is no delay in Mectizan arriving at the FLHF on time if the routes are already closed. The cost of storage at the Tanzania Medical Stores Department and its transportation is paid for by the Central Government that is the Tanzanian Ministry of Health and Social Welfare (TMOHSW) Training and HSAM: (Highly:3.7) Training is carried out objectively and all CHMT members are equipped with knowledge on different diseases and their control .Targeted training of FLHF staff are carried out as a follow up to gaps identified during the monitoring and supervision. The training is cost effective, takes 2 days and takes place at the district headquarters. Usually 3 staff at the district level is involved. L'lorogoro C DTI Et'al uation Report 28 HSAM activities are conducted where new decision makers and or health staffs are enrolled in order to equip them with information about CDTI, such training in done on need and not on routine basis. Inauguration of annual Mectizan distribution is carried out through selection of district with low .orriug. during which District Commissioners swallow the drug as a means of sensitizing community member and persuade them to take the drug. Finance: (Highly: 3) CDTI activities were clearly spelt out in the year plan for the two districts as shown in the CCHP with the budget for various activities. There is evidence of cost reduction since all activities at this level are carried out in an integrated manner. The budgetary contribution from the government has been clearly spelt out but not for APOC and the NGDO partners at the District level. Government funding is steadily increasing and always clearly spelt out in the CCHP. There is no regular calculation of residual amounts under budget headings. All funds released yearly are spent as budgeted Transport and Other Materials: (Fully: 4) The vehicles available from the government are the main transport means for CDTI at the district level. With the current integration of activities, at this level transport will be shared for all programmes. There is likelihood that transport will remain stable until the duration of the project. th.re is a routine maintenance schedule for all district vehicles by Planned Preventive Management (PPM). Budgets for maintenance are reflected in the CCHP, Vehicles are serviced based on mileage. The vehicle maintenance records are kept by the transport officer of the respective districts. Human Resources: (Highly: 3) At this level transfer is not frequent; staff has been on same post for more than 5 years. This will help improve the quality of CDTI programme activities. Thougtr the district level staff member's commitment to CDTI is high, there has been low motivation for them. No award, financial and or material rewards or recognition of their post by the Central Government SYstem. COVERAGE While the geographical coverage for the previous three years has remained at 100%o, the TRC has been above 65Yo for that particular period' h'lorogoro C DTI Evaluati on Reltorl 29 Recommcndation:'PIanning' effectively. Recommendations:'Intesration of suooort activities Recommendations:' Leadership' levels which initiate the key CDTI activities: planning, targeted monitoring/ supervision, targeted training and HSAM, Mectizan ordering/ distribution. Rccommcndations:'Monitoring And SuDcrvisiont Recommendations:'Mectizan Procurement and Distribution' delivery of Mectizan to districts. Im entation hiority: =Il Indicators ofsuccess: = Comprehensive written work plan Vl/ho to take aclion: 3 DED,DMO,DOC + DOT, District Planning Team, CHMT = NGDO D ead I i n e fo r comp I etio n : = 3l't March 2009 hiority: =) Medium Indicators ofsuccess: resources ll/ho to tahe aclion: = DED,DMO,DPLO,DOC :) DOT. District Planning Team, CHMT =, NGDO D e o dl in e fo r c o mpleti o n : + 31" March 2009 Priority: Indicalors ofsuccess: = The CHMT manages CDTI activities at district level at DMOs office, initiating all key CDTI activities =) Focal person for CDTI - DOC and DOT exists at district level. llho to tahe action: :) DMO, DOC - CHMT Deadlin e lor comp letion =On Priorityt =Indicators ofsuccess: + Transmission of reports through government system. + Inclusion of CDTI data in the Tanzania Health Information llho to lahe aclion: = NOCP Coordinator, NOI'F', PC, DOCs +DM CIIMT Deadline for completion: = 30ft June 2009 Implemenlation Priority: =ll Indicators ofsuccess: + del of ll/ho to tahe actionz = NOCP Coordinator, MSD D eadline lor completion: + 306 October 2008 + And June 30th annuall' ll'lorogoro C DT I Evaluati on Report 30 a &) Training should be appropriately needs. gned to address specific Recommcndations : tFinancial Resources' budget headings. 'l-he Govemment should commit more funds to CD'II activities because donor lund is decreasing. There should be regular of residual amounts under Recommendations: 'Transport and Other Material Resou rcest aOequate numbers of appropriate, functional vehicles available for necessary CDTI activities. govemment. HSAM. Recommcndations :'Human Rcsources' The district level staff member's commitment supported by motivation through awards, financial and or material rewards D The CDTI designations should be recognized by the Central Government System in the Ministry of Health and Social affairs. should be Recommendations: be maintained TCR and should be maintained Indicators ofsuccess: + The district Focal persons for CDTI train the FLHF Priority: staffs in case need l4/ho to lake action: + DMO,DOC CHMT D e adli n e fo r co mP l eti o n: I mp leme nlalio n : Prio rilY : Priorily: Indicalors of success: :) Incrcased budgct fiom thc Goverrunent. + Regular calculation of residual amounts under the itemised ll/ho to take aclion: - DMO, Health Accountant = DOC + CHMT D eadline for completiont Continuous Implemenlation Priority: h Indicators ofsuccessz + MOU in place for continuous vehicles and other materials supply. - The vehicles are aced the once needed ll/ho to take action: + NOCP Coordinator, NOTF = DMO D eadline for complaion: When the need arises Implcmentation Priority Indicators ofsuccessz +Ah motivated health staff Who to take aclion: - Director ol Preventive Services, NOCP Coordinator, NO'[-F' DMO CHMT +l D ea dlin e lo r c o mp I etio n : June 30s 2009 Implementation Priofity: = Iligh Indicators ofsuccessz + TCR>67Yy = GCR>95% llho to take aclionz - DOC,DOT + CHMT lllorogoro CDTI Evaluation Repor! D e adlin e lo r c o mp I etio n z December 30rh 2008 3l 3.3 SUSTAINABILITY AT FLHF LEVEL Fig 2. Morogoro Project: Sustainability at FLHF t .C .91 o; o ED E o (E t lo ci (t, tO N N rq U? o o o*s-.P" -C .*."od g."--e^....' dnd Group of lndicators Planning: (Fully:4) There is a written plan for 2007 CDTI activities in all the FLH facilities visited. This plan was prepared by health staff at this level. The plan included all other activities pertaining to health in the facility. Integration: (Fully: 4) Health Personnel combine two or more CDTI activities on a single trip. In remote sub villages, Mectizan is delivered after training of CDDs. There is a monthly immunization table showing staff itinerary to communities during which all other activities are carried out. Thus all activities are carried out in an integrated manner. Leadership: (Highly: 3) The FLFH staffs in the facilities visited considered the program as theirs and are initiating key CDTI activities. These included -training of CDDs, carrying out health education campaigns in Morogoro CDTI Evaluation Report 32 sub-villages, compilation of CDD reports and forwarding them to the districts, taking care of side effects when they occur, ordering of Mectizan for the cascade as well as supervising the distribution of Mectizan in communities. Monitoring and Supervision: (Highly: 3) Monitoring and supervision of CDTI activities are usually carried out during Mectizan distribution. Data geneiated are compiled and reports (reports for distribution, training and Mectizan statistics) are submitted to the disirict authoriiies. This is within the govemment system. Supervisory visits to sub-villages are to solve problems identified during monitoring visits to sub-villages. Problems identified during supervisory visits e.g. refusals due to misconception about Mectizan and CDD drop out are usually dealt with through continuous health education with both the sub- village leaders and other relevant authorities. Despite lacking compensation or any form of cash or in kind incentives; most CDDs have continued to carry out their CDTI activities in an excellent manner. However, the officer in-charge of the FLHF in Langali reported that CDDs are exempted from payment when they visit the health facility and in other sub- villages they are exempted from ioutine works in their localities such as construction of health facilities and schools. Mectizan ordering and Supply: (High: 3.5) Order forms for Mectizan do not exist at the FLHF. However the officers' in-charge in the facilities visited; send written requests to the Districts indicating the quantity their facility will require during the next distribution season. CDD census data are also included in some cases. This request is baied on estimates from the CDDs' report. The facilities have never experienced any Mectizan shortage. However arrangements are made to supply more drugs to any sub-village where shortage was reported. Mectizan is available on time for distribution even though the 2008 Mectizan is yit to be riceived. Mectizan is controlled within a government system that is effective, uncomplicated and efficient. Mectizan is received through the District with other drugs through a transport system supplied and paid for by the govemment. This is signed for by the officer in- charge of the facility and it is stored in the general drug store. CDDs come to the FLH facility to colleit their drugs where sub-villages are close to the facility. However in situations where health facilities are far from the communities, the FLHF staff sign out the drug and deliver to the sub- villages themselves. Training and HSAM: (Fully: 4) Training of CDDs is carried out from l-2 days depending on need. Where CDDs are new this is for two days other wise it will be for only one day. This usually is before commencement of Mectizan disribution. This activity is carried out by the health staff at the FLHF. Training is carried out in the sub-villages even though in some cases this takes place in the health facility due to lack of adequate space in the sub-villages or in some cases at the ward level. Furthermore, in order to increase knowledge and commitment to CDTI activities among ward leaders, village leaders, sub- viltage leaders, extension workers including FLHF staff and influential leaders, TIASM is sometimes carried out during ward development quarterly meetings. This helps in reducing the misconceptions about Mectizan thereby reducing the number of refusals and on the other hand improving annual treatment coverage for the community by reducing the number of refusals. Morogoro CDTI Et'aluation Reporl JJ Financial: (Highly:3) There is budget for CDTI related activities in the year plan. Though all CDTI activities were clearly spelt out in the budget not all of amount budgeted was released. In 2007 govemment provided two million Tshs out of 7.46 million that was requested for Langali Health facility (Mvomero District). Moreover, the amount released was effectively utilized to CDTI related activity and has been enough to enable the facility to carry out essential CDTI activities. The only source of funds established was the government. Districts provide the fund for all activities at this level especially as it relates to training. Training of CDDs was sponsored through fund received from the District and supervision and monitoring of all health programmes at this level is carried out in an integrated manner.The budget for 2007 was higher than that for 2006. Transport and other Material Resources: (Highly: 3.5) Transport at this level is adequate. Most of the transport facilities are in good condition for use during supervision and other activities. Government is responsible for maintenance and fuelling because there is a routine maintenance schedule. Vehicles are sent for maintenance after every 3 months or after certain kilometres have been covered. This has been rapid and efficient. When vehicle breaks down onchocerciasis office using APOC fund provide alternate source of transport. Trips made for CDTI purpose are authorised in writing based on route matrix prepared by the transport officer. There is a log book stating journey dates, quantity of fuel utilized and journey route. Since all transports are in a pool, supervision is carried out monthly in an integrated manner with other diseases. Replacement of the vehicles comes in place upon the available report from the district engineer and the old one is maintained by the govemment. For example a new vehicle has been approved for Langali FLHF to replace the existing old land rover. Required stationary and materials at this level are supplied by the government. | +Human Resources: (Highly: 4) All the Staffs have been in the same facility for at least four years and there have been annual refreshing courses to the FLHF on CDTI activities level during which problems identified during monitoring and supervision are dealt with. Coverage: (Fully: 4) The average TCR has been going up for the past three years, it was TlYo in 2004, (no distribution in 2005),72%oin 2006 and 76Yoin2007. Moreover, the Geographical coverage recorded in the FLHF is 100% for 2004,2006 and2007 as there was no distribution in 2005. Morogont CDTI Evaluation Report 34 Recommendations: Planning Implementation Planning: l. Develop strategies to cut expenditure. l. Devise strategies to find dependable sources of resources. 2. Provide evidence of successful implementation of CDTI plans. Priority:: IIIGTI Indicators of success'. l. Written strategies for cost reduction or cost minimisation developed. 2. Dependable sources of resources and written commitments attained. 3. Records showing successful implementation of CDTI available. llho to action NOTF DOC Proiect Coordinator Deadline for complelion Continuous. Rccommendation :Leadership Implementation Planning: Health Plans at FLFH levels should reflect CDTI activities in the CCHP and take on community priorities. Health Personnel should combine two or more CDTI activities on a single trip Priority:: HIGH Indicators of success'. Availability of written plan which Oncho activities is included ll/ho to take action: NOTF DOC Proiect Coordinator Deadline for completion: Continuous. l. Improve monitoring and supervision beyond the existing state. 2. Workout means to sustain the existing monitoring and supervision quality. Priority: lligh Indicators of success: = Availability of monitoring and supervision checklist. l. Availability monitoring and supervision monthly plans ll/ho to take action: NOTF NOC Proiect Coordinator Deadline for completion: 1,2. Continuous Mcctizen procuremcnt and supplv: Strengthen the govemment system of delivering drugs (including mectizan). Avoid/minimise delays to deliver and distribute drugs. FLHF should have Order forms for Mectizan ordering Priority: lliph Indicators of success'. l. Mectizan free from any form of taxation. 2. Mectizan being delivered efficiently and in time. 3. No regular delays reported. ll/ho to take aclion NOTF NOC Deadline for completion: Before next distribution. .trainingand-rrW: Integrate CDTI training with other health services trainings. Intensiff HSAM activities. Supply more IEC materials. Priority: lligh Indicators of success'. l. CDTI training integated with other trainings. 2. Increased awareness and coverage. i. IEC materials available. Who to take action'. Proiect coordinator and DOTs Deadline for comp letion'. Before next distribution and therefore a continuous process. Morogoro CDTI Evaluation Reporl 35 Financial resourccs: Clearly spell out the costs of CDTI plans. activities in the health Develop specific and realistic plans to bridge the financial gaps when APOC funds end. Priority: lllGll Indicalors ofsuccess: l. Itemized CDTI activities well spelt out in the 2. Strategies for cost containment present. 3. Plans to bridge financial deficits present. annual budgets. llho to take action: Project Coordinator and DOTs Deadline for completion'. Before the next Council budget Transoort and other material resources: L Develop feasible specific and realistic plans to replace and maintain transport and other materials. Appropriate transport should be provided and maintained. Maintenance and fuel be provided by the govemment I{IGI-I Who lo lake action'. Proiect Coordinator, Transport officer and DOTs Deadline for completion'. Continuous Human resources: l. Strengthen the existing incentive system. Prioritv: llish Indicalors of success'. Staff motivated and committed to provided CDTI services. llho to take action: Proiect Coordinator and DOTs Deadline for completion: Continuous Rccommendations: Coverage Increase therapeutic coverage. Improve and strengthen by-laws with respect to CDTI activities Implementation Priority: IIICII . lndicatorsofsuccess: Availability of annual treatment reports for all endemic communities from CDDs registers Evidence of distribution is on-going in all communities. Evidence of community ownership. Increasing TCR and GCR. l{ho to take aclion'. Project Coordinator and DOTs Morogoro CDTI Evalualion Report 36 Indicators ofsuccess: Availability of functional transport Existence of maintenance schedule Fig 4. MorogoroCDTl Project: Sustainability at Community level \t .s, o =o E"g o G \t lO ri .(, lo c.i N q? u, ct o "*ue ES "9C) o) v """' *** "-C --" "r"' \: Group of lndicators 3.4 SUSTAINABILITY AT COMMUNITY LEVEL Planning and Management: (Fully: 4) Time and Mode of distribution is chosen by Community members with their Leaders during community meetings. CDDs carry out census and distribution together. Community Leaders and CDDS visits families that are not willing to take Mectizan, to encourage them to take drugs. Leadership and Ownership: (Highly: 3.7) In all the communities, leadership actively supports Mectizan distribution, and help to solve all problems as they arise within the community. Community members value and accept long-term treatment. Community members are responsible for the selection of CDDs, mode and time of distribution. Community members reported benefits of taking Mectizan. This included: not allowing Oncho woffns inside the body to multiply, Mectizan improve human health; Mectizan hlorogoro CDTI Et'aluation Reporl JI minimizes/reduces scratching and skin disease; Mectizan makes children expel worms in their body and LF improvement. However community members in some sub-villages exempt CDDs from communal work while in some communities no support or incentive is provided. Monitoring/Supervision : (Fully: 4) In all communities reports were submitted in time to the FLHF through CDDs or Community leaders. In most of the communities the village registers are well kept. However no transport is arranged for CDDs for collection, distribution and submission of reports to FLHF. In some communities, FLHF staff collects summary reports during their routine monitoring and supervision visits where the FLHF are far from communities Obtaining and Managing Mectizan: (Highly: 3.7) CDDs carry out census before or during distribution. Some Mectizan are left in the community of at the FLHF for those who are temporarily non-eligible e.g. pregnant and other drugs are returned to FLHF. The quality of the census data in the CDDs records are good for an accurate calculation of the amount of Mectizan that needs to be ordered The CDDs and Community leaders collect Mectizan they need every annually from the FLHF nearest to them by walking or using their bicycles. In other cases, where communities are remote, staffin the FLHF supplies Mectizan to the community during training of CDDs. HSAM :(Highly: 3) HSAM is targeted and is mainly carried out by CDDs and community leaders on effect of disease on community, merits of taking the drugs and correction of misconceptions about the disease and also that the drug is free and safe. This is carried out during community meeting before distribution. Names of refusals in spite of intensified HSAM are submitted to the Village Executive officer. No resources are provided by the community members eg pens, CDD registers etc Financing: (Moderatelyz 2) In most communities, community members appreciate the programme. Few communities support CDDs in kind by exempting them from communal work while most only thank them without any form of in kind or cash incentive. The reason for not given cash or in kind incentive as reported by these community leaders/members is due to poverty. They also argue that CDD work is voluntary and that other community members involved as volunteer in other activities are not paid. Secondly that volunteers in other programmes eg AIDS and national programme on immunization receive stipend from their programmes. Human Resource: (Fully: 4) Morogoro CDTI Evaluation Reltorl 38 All villages visited had adequate number of CDDS with each sub-village having at least 2 CDDs' Most of the sub-village fall within the 250 residents recommended with the exception of few communities where 2 CDDs covered 556 residents. There is already a plan in such villages to select more CDDs by the community members. The average distance covered by the CDDs is between to3 k.m. In almost all the sub-village visited, CDDs took 4 to 7 days to complete their distribution. House to house is the common method of distributions in all the sub-villages visited In most cases the village leader visit various households with the CDDs. CDDs are trained annually for I to 2 days before drug distribution commences by FLHF staff CDDs ire generally willing to continue supporting the distribution in their community even though there are no cash or in kind incentive given to them by communities and they have complained about this. This is because they are serving the community where they are living. All the CDDs have worked at least for 3 years. There are few CDDs drop out. However in communities where this was experienced, replacements were selected by community members. Coverage: (Fully:4) The average coverage from 2004 to2OO7 is between 760/oto 8l%, which is increasingly il'lot'ogorct C DT t Eval uali on Reporl 39 Rccommendations:'Planning AND Management' Implementation for themselves CDDs Priority: = Ixnv Indicators ofsuccess: 3 CDTI activities are continue to be planned community. llho lo take action: = Community Leadership and Members D eadline for completion : + On-going Recommendations: Lcadership and Owncrship Implementation > HSAM to Community members and Leaders to support CDDs PrioriEz Indicalorc ofsuccess: CDTI process. = Leadership organize support for CDDs. llho lo tahe actiont = FLHF Staff, DOTs, Community Leaders D eadline for completion: = Dec2008 Recommendations : Monitoring Implementation > CDD should be provided with transport Priority: MEDII.]M Indicators of success'. l. Highcoverage. 2. Committed CDDS. Who to take action: Community leaders. Deadline for complelion January 2009 Rccommendations: Obtaining and Managing Mcctizan Implcmentation transport to CDDs Priority: + \'Icdiunt Indicalors ofsaccess: :) CDDs use =) CDDs collect drug from FLHF Easly ll/ho lo lake actionz + CDDs + Communiry Leadership Deadline for compleliont Recommendations:'HSAM' Implemcntation ) Community members to provide resources Prioity + \lediurn il'lorogoro CDTI Evaluation Repor! 40 Recom mendations: Indicators ofsuccess: = Availability of resources provided by community members Who to lake actionl Deadline for completionz January 2009 Implemenlation )Community members should support CDDs Priority: II Indicalors of successz CDDs are supported fully ll/ho to take actionz Community Leaders Deadline for complelion: Nexl Dislribution Recommendations: Human Resources Implemenlation Community Leaders and members should increase the number of CDDs Priority: Mcdiurn Indicalors ofsuccess: Increase number of CDDs ll/ho to lake aclionz Community Members and Leaders Deadline lor completion: Next distribulion Rccommendations: Coveragc Implementation: Coverage should be maintained Priority: l.ow Indicalors ofsuccess: Therupeutic coverage maintained above 65% ll/ho lo lake actionz CDDs and Community members D ead I i n e fo r c omp letio n : On-soins lltorogoro C DTI Evaluation Report 4l Fig 6 is a graphical representation of values from Table 2. The regional/ project level was weak in finance(2.8). The District level was weakest in monitoring and supervision (2.3). The community level's weakest area was finance (2.0). Generally, finance is the weakest of all the groups of indicators. Fig. 6: Sustainability Score of the Groups of Indicators and Levels of CDTI Implementation in Moro goro CDTI project Sustainability scores of groups of indicators and levels of CDTI implementation in Morogoro CDTI Project o oL o o o =-ct(E .E o3a 5 4 3 2 1 0 w Region I District tr FLHF o Community I Alerage .-$e$.*'$$.'1"$"$,'- lmplementation levels Mean sustainability scores for the groups of indicators for the Morogoro CDTI project are shown graphically in Figure 7. The weakest group of indicators, overall, were the provisions of Finance (2.7), followed by Monitoring / Supervision (3.3), Morogoro CDTI Evaluation Report 43 Figure 7: Showing average performance of each group of indicators in the entire Morogoro Project Average performance of each group of indicators in the entire project 4.5 4 3.5 E3L oo ? z.s =llEz '6 6 o 1.5 1 0.5 0 {g" $.d.r" .u$ ,.C ^..C a""" "-"-"_a..". .o' o* Performance indicators Morogoro CDTI Et'qluation Report 44 . J 4.0 CONCLUSION 4.1 Grading the Overall Sustainability of Morogoro CDTI Project- (a) Make a judgment of the project, in terms of each of the seven 'aspects' of sustainability: Aspect ]udgment: to what extent is this aspect helping or blocking sustainability in this proiect? Integration HELPING Itesources Efficiency Simplicity BLOCKING HELPING HELPING Health Staf f Accepta nce (Atritude of staff) Community ownership HELPING BLOCKING Iiffectiveness HELPING o Integration Integration of CDTI activities with other diseases under CCHP was ongoing at all levels . The programme co-ordinator at the regional level is also doubling as co-ordinator for Lymphatic htaiiasis control programmes. The Evaluation Team considers this as a good indication that sustainability is in place. o Resources (Human, Financial and Material): Since 2004 government have been releasing certain amounted annually for CDTI activities while in the two Oncho districts- Morogoro and Mvomero, there are annual releases from 2006 for CDTI activities. Project manager at all regional levels do have a clear estimate of funds available for CDTI activities annually from all sources. However none of the project managers at the two levels were aware of shortfall and how to bridge the financial gap. Sources of funding are therefore not reliable since it is not based on budget. There is no written commitment to show that funding will be obtained from other sources. Also even though the project is in its third year annual funding from govemment sources did not equate to half of the amount released from non governrnent ,orr."i as shown in table 4. The Evaluation Team considers that over dependence on external ll'l orctgoro C DT t Eva I u at i o n Re p orl 45 CONTRIBUTORS APOC trust Fund NGDO Partner(SSl) MOH Year Total Budgeted (us$) Total Released (us$) Total Budgeted (US$) Total Released (us$) Total Budgeted (us$) Total Released (us$) 2004 140,613 72,000 19,740.088 21,740.881 34,24.65 43,24.65 2005 2006 89,254 40,000 34,000 18,652 2007 60,436 60,436 19,479 18,353 9,496 9,496 2008 51,543 17,221.85 26,667 TOTAL sources of funding for all CDTI activities does not enhance project sustainability and that government sourced funding need to be increased. Table 4 : Showing financial contribution of various CDTI partners between 2004 to 2008 Presently, there are reasonable numbers of vehicle at the regional, districts and FLHF levels. These are adequate. Maintenance and fueling is through both APOC fund and State government. Management at all levels is optimistic that government will replace vehicles when they are old. However, vehicles at all levels are utilized in an integrated manner, showing evidence of sustainability. At the regional, district and FLHF levels, travel authorization are usually given. Logbooks are kept for all travels undertaken at these levels too. There is staff stability at all levels and salaries are regularly paid. Staff attitude is satisfactory. Most CDDs expressed willingness to continue without receiving compensation form their communities. This shows some level of sustainability. Presently the ratio of CDDs to households in communities visited is adequate. Generally, CDTI activities are integrated into the govemment system in carrying out the following activities namely: Management and use of transport/logistics, Monitoring/ supervision, retrieving of data especially at the FLHF level and Storage of Mectizan. However the Evaluation Team considers that over dependence on external sources of funding for all CDTI activities does not enhance project sustainability and that government sourced funding need to be increased. Efficiency: There is a rational use of resources. Programme support activities are planned and shared in an integated manner, which results in lower cost and efficient management of resources. Examples are sharing of logistics. Iu[orogrro C DTI Eval uation Report 46 o Simplicity: Morogoro project uses simple and uncomplicated procedures for the implementation of CDTI activities. a Attitude of Staff: At all levels, there is ample evidence that staff members are positively disposed to continue CDTI implementation. The Evaluation Team rated the attitude of staff at all levels towards CDTI to be very positive. o Community Ownership: Communities make most of the decisions in the implementation of CDTI and gave sound rationale for their decisions on CDTI activities within their respective domains. In most communities there is no established process of showing appreciation to CDDs for their CDTI work except by saying "thank you" even though a few exempt the CDDs from other communal assignments. Also Community members do not provide materials (note books, ruler, pencils etc ) required by the CDDs during Mectizan distribution. The Evaluation Team is of the view that an important aspect of CDTI process is not in place. This is therefore blocking the sustainability of Morogoro CDTI project. r Effectiveness: Every village identified as qualified for mass treatment with mectizan treatment is receiving treatment. However, the average therapeutic coverage over three years (2004, 2006 and 2007) at regional level was 72.5%. The coveragein2004was67%o,in2006, this increasedto75.3.7Yo and in2007 it was 75o/o.Even though distribution is delayed for 2008, geographical coverage rate has remained 100 per cent since inception of the programmes at all levels. Morogoro CDTI Evaluation Reporl 47 (b) Next, the Evaluation Team examined the five key aspects of the project - 'critical elements'of sustainability. If these are not present it is unlikety that the proiect will be sustainable: Money: Is there sufficient money available to undertake strictly necessary tasks, which have been carefully thought through and planned? (Absolute minimum residual activities). Transpott: Has provision been made for the replacement and repair of vehicles? Is there a reasonable assurance that vehicles will continue to be available for minimum essential activities? (Note that 'vehicle' does not necessarily imply '4x4' or even 'car'). Superaision: Has provision been made for confinued targeted supportive supervision? (The project will not be sustained without it). Mectizan@ xryply: Is the supply system dependable? (The bottom line is that enough drugs must arrive in villages at the time selected by the villagers). Political commitmenf: Effectively demonstrated by awareness of the CDTI process among poliry makers (resulting in tangible support); and a sense of community ownership of the programme. I NO YES YES YES NO Evaluating the project on the basis of the seven aspect and five critical elements of sustainability, the Evaluation Team concluded that the Morogoro Project is Making satisfactory progress towards sustainability. With regard to the five critical elements, the Evaluation Team found that three elements - Transport, Mectizan Supply and Supervision were present in the project. The elements of Money and Political Commitment were not satisfactory in the project. Resources were mainly from outside and political commitment was not fully there especially at the community level. There is no ownership at the community level. ll'lorogoro CDTt Evaluotion Report 48 With regard to the seven, aspects of sustainability, the Evaluators found that five namely: Integratiin, efficiency, simplicity, attitude of staff, and effectiveness were helping the project attair sustainability *trit. -community ownership and resources were found to be blocking sustainability. Thii is because government funding for the programme is very minimal. The programme has been dependent on non-government sources for three years. There is also no written commitment from the NGDO partner that this will continue or for how long. Cpommunity members do not supply the census materials and incentive to CDDs working in their community' These materials are instead provided by the FLHF. The quantitative scale of 3.6 for the project in its third year shows that the project is making satisfactory progress towards sustainability. It is therefore the view of the Evaluation team that based on the qualitative aspects that Morogorro project is making progress towards sustainabilify. lllorogoro CDTI Evalualion Report 49 4.2 SUSTAINABILITY/ FEEDBACK WORKSHOP AT THE REGIONAL AND DISTRICT LEVELS MOROGORO CDTI PROJECT FEEDBACI?SUSTAINABILITY PLAN DEVELOPMENT DAY ONE REPORT The meeting was officially opened at 10.51 am by Regional Medical Officer (RMO) on behalf of Regional Administrative Secretary (RAS). The RMO urged participants to participate fully and be committed in the CDTI activities. She thereafter welcomed the NOTF representative, Dr Kurumbi to give his opening remarks. Dr Kurumbi in his opening remarks emphasized the importance of this meeting which includes feedback of the ten days evaluation of Morogoro CDTI project and the development of their sustainability plan. He welcomed the participants on behalf of the Minister for Health. He extended his thanks to APOC management for sponsoring the mission to the Morogoro CDTI project and also gave an insight on the reason for delay in the arrival of Mectizan in communities in 2008. This he said is due to the integration of CDTI and LF programmes and the shifting of mectizan ordering to the LF coordinator. This was followed by self introduction from participants while the members of the Evaluation team were introduced by the team leader, Prof O. C. Nwaorgu. Sessions: The first presentation was on objectives of the evaluation which included the following: . To assess the preparation of projects for post-APOC sustainability . To assist the project to develop its sustainability plan for the project post APOC support Other presentations as indicated in the time table attached (see Appendix IV) followed. This included presentation of the feedback and the following recommendations at various levels namely. Regional level . There should be an increase of govemment funds budgeted and disbursed in correlation with APOC and other NGDO funds . There should be sensitization and advocacy to all members at the regional level and provision of IEC materials so as to increase knowledge on CDTI programme . Integration should be kept in place to minimize resource and time. . Mectizan should be delivered to the community in time as agreed by community District level o Integration should consider other health problems in the district. o CDTI data should be included in the HIMS (MTUHA). o Training should be appropriately designed to address specific needs. o The MOHSW should ensure a rapid and smooth delivery of Mectizan to districts. . TCR and GCR should be maintained o The district should motivate the staff who are committed to CDTI and performing well . There should be regular calculation of residual amounts under budget headings. il'lorogorc CDTI Evaluation Reytrt s0 The District Council should commit more funds to CDTI activities because donor fund is decreasing. FLHF level o Reflection of health activities in CCHP at FLFH levels should take into account community prioriti es/needs. o Combining two or more CDTI activities on a single trip by health personnel should be adhered to as it minimizes costs and controls time . There should a clear checklist for in during monitoring and supervision. o Training should be carried regularly with leaders and community members in order to minimize misconception and hence increase coverage. . Appropriate IEC materials should be provided. o FLHF should have Mectizan ordering forms . Appropriate transport should be provided and maintained. o FLHF ensure that all endemic communities receive Mectizan annually Community Level Community members should plan on how to support CDDs HSAM should be conducted to Community members and Leaders to support CDDs Community Leaders and Members to arrange transport to CDDs Community members should provide resources for census (Registers, pen etc) Community Leaders and members should increase the number of CDDs Participants were thereafter divided into three groups namely, Morogoro, Mvomero and Regional for the SWOT analysis of Morogoro CDTI project. The presentation from group work was as follows: a O Morogoro CDTI Evaluation Report 5l REGIONAL LEVEL Strengths Weakness Opportunities Threats - Presence of regional health plan framework - Health policy of the year 2007 . - Elaborate infrastructure - Presence of buildings which serve as offices. - Presence of skilled personnel - Presence of health guideline - Planning and budgeting are in place. - MandEsystem - Strong political will and support - Committed regional leaderships - Availability of data and information for planning - Traditional healers policy Inadequate planning skills ( for some RS/RHMT) Inadequate working facilities e.g ICT materials Inadequate involvement of RHMT members in supportive supervision of CDTI Inadequate finance for M and E. Inadequate transport for supervision. Inadequate integration of CDTI activities. Delay of funds for supervision. Delay of distribution of drug by MSD Lack of training schedules for CDTI. Inadequate planning of health education package according community affitude. - Presence of donors like APOC and Sight Savers International - Presence of MSD. -Readiness of the community(leadership) to provide for Oncho activities. - Elaborate structure from regional to village level. - Existence of other projects - Delay supply of drugs from MSD - Misconception due to social cultural issues in use of Mectizan -Delay of fund release. - Geographical coverage such as hard to reach areas eg During rains which make some areas hard to reach. lvlorogoro CDTI Evaluotion Report 52 MOROGORO DISTRICT Strength l. Project activities are intergraded into comprehensive council health budget 2. Funds allocation is increasing yearly 3. Committed staff at all level 4. Interpreted support supervision is well done. 5. Availability of working tools eg stationary and other accessories' 6. Availability of transport materials Weakness 1. Disbursement of funds to support allthe project activities 2. Inadequate IEC materials 3. No motivation policy to support CDTI implementers Opportunity l. Community is willing to take the drugs 2 The projecl is well accepted as there is an overwhelming support at all level 3. Free delivery of Mectizan Threats l. Community negligence especially at sub urban areas 2. Failure of the community to reward the CDDs in their areas 3. Oncho data format is incompatible in the HMIS 4. Inadequate number of CDDs in some community' 5. "In case we shift to Morogoro Head Office quarter" as a premise MVOMERO DISTRICT STREGTH . CDTI activities at the district level are planned in the CCHP and are integrated . Awareness of CDTI programme to the community . GCR and treatment coverage rate is above 70o/o . Leaders participation at all levels on CDTI . Political commitment to CDTI programme WEAKNESSES . Inadequate funds for CDTI activities . Delayment of Mectizan drugs from MSD . Misconception of the drug use by some community . Irregular transport on CDTI programme in the district at all levels . Shortage of trained health staff in some health facilities . Drop out of CDDs in some areas every year lvlorogoro C DTI Et'aluation Report 53 OPPORTUNITIES: . Integrated Mectizan drug distribution and supportive supervision . Trained staff implementing CDTI activities . Cascade system of monitoring and supervision . Planned Preventive Maintenance of motorcycle and vehicle of CDTI programme . Possibility of being acceptable at all political levels in the districts THREAT: . Negative attitude of the community towards Mectizan use . Absence of Mectizan drugs at the community level . Delayment of budgeted funds for CDTI activities . Poor infrastructure . Opposition from politician (Multipanism) . Other vertical programme paying their volunteers at high rate compared to CDDs After presentation participants went into groups to discuss problems and solutions to the problems identified in SWOT Analysis. The day one sessions came to an end at 07.10 following a closing remark by the RMO who thanked the participants for their patient and the importance they placed on the programme hence the presence and participation of RAS. She however appealed to the participants to endeavour to come early the next day since a lot is yet to be done to complete the assignment. Some of the key questions from participants include the following: o Reason for poor coverage especially in sub urban areas o Reason for delay in 2008 mectizan distribution in various sub villages o Reason for community inability to reward CDDs o Reason for non inclusion of Onchocerciasis in the HMIS Day Two This was chaired by one of the District Medical Officers (DMOs). Participants were put through how to develop their sustainability plan after a recap of the previous day activities. There after five year post APOC sustainability plan was developed at two levels- Regional and District ( Mvomero and Morogoro). Participants went through the plan developed by each team in a plenary and corrections were made. Participants reached an agreement that the sustainability plans put together with the necessary accompanying documents will be forwarded to APOC management by the project through the NOCP within two weeks. il| orctgoro C DT I Et'a I ua t i o n Rc' p orl 54 4.3 THE WAY FORWARI) As Morogoro CDTI project moves into the 5th year, the Evaluation Team, programme managers and policy makers appraised the critical issues that will enable the project to be sustainable post APOC and came up with the following recommendations. l. Planning: There should be in an integrated annual workplan at all levels. Communities should be involved in planning and implementation of CDTI activities. 2. HSAM: HASM on the CDTI activities should be intensified and carried at different levels to promote acceptability of and participation in the programme. Advocacy visits should be paid at regional, district, ward and community levels for increased commitment to the CDTI programme. Programme Officers having spent more than three years on their posts means that number of days required for training will be reduced. Money accruing from this should be channeled to Health Education, Advocacy, Sensitization and Mobilization. Use of Bill-boards for HSAM 3. Resource Mobilization: Government should be sensitized for commitment of more funds to the CDTI programme especially at the district level 4. Reporting and Documentation: Reporting and documentation of all CDTI activities (training, monitoring, supervision etc) at all levels of implementation. This will facilitate efficient planning and provision of efficient feedback to stakeholders. Inclusion to onchocerciasis in the health management information system was discussed. 5. Mectizan distribution: The problem created by integration and co-implementation of CDTI with LF leading to the lateness in Mectizan distribution in the sub-villages was fully discussed and stakeholders felt there is need to put in mechanism that is free from beaurecratic bottle neck. Also the need to include CDDs in other community health projects as a means of motivating and compensating them was agreed on. In his final conclusion speech the RHO who represented the RMO, appreciated the effort of APOC in ensuring that Morogoro CDTI project is sustained. Finally he promised that the findings will be used to improve the project and that CDTI will continue to be included in the CCHP He stressed the need for operational research to raise some of the issues raised as it related to misconception about mectizan and low coverage rate in sub-urban villages. He assured the team that a process will be put in place to ensure that the 5 year sustainability plan is completed and submitted within the next two weeks to APOC. lvlorogoro CDTI Evaluation Report 55 APPENDIX I Morogoro CDTI Proiect: Evaluation Team Composition/Workplan. APPENDIX I Morogoro CDTI Project: Evaluation Team Composition Sub-Team A Prof.O Nwaorgu (Team Leader) lWs Rosemary Nguruwe Dr Debora Kabudi Mr Lugata V. Elias Sub-Team B Dr.George .M.Kassiga Dr.Abel.A.Mwakafwila Mr Jairo E. Jayambo Sub-Team C Dr.Rehmah.Maggid Mr. Prince.P.Mutalemwa Dr Hussein Sewando ill o rctgoro (- ) DT I Ev a I u at i <t n Re port 56 sa{ NAME DESIGNATION I Godfrey Ngaleya Regional Administrative Secretary 2. Mr. Kikwesha Officer 3 Dr. Frida Mokiti Medical Officer 4. Dr. Debora Kabudi Pro Coordinator 5 Emillian SanguSangu Accountant 6. Sara Linuma District executive Director - Mvomero 7 Dicolus Chiduo District Medical Officer - Mvomero 8. Yohan Sulley District Transport Officer - Mvomero 9 Neema Michael Health accountant - Mvomero 10 Dr. Omary Mbena Focal Person for CCHP Mvomero l1 Dr. Hussein Sewando District Oncho Team - Mvomero t2 Mr.Jairo E. Jayambo District Oncho Team - Mvomero t3 Ande Malango District Executive Director - Morogoro t4 Dr. Pascal Mbena District Medical Officer - Morogoro 15 Philben Mgwasa District - Health 16 Willa Matika District Pharmacist - 17 Mr. Lugatta Valley District Ocho Team - Morogoro 18 Abraham Simwela District Health Accountant - Morogoro t9 Ms. Magreth Songelaeli Cascade leader Turian 20 Ms. Grace Ougito FLHF ilc Kanga Dispensary - Mvomero 21 Albogast Mkude FLHFs Turian 22 Masumbuko Igembya FLHFs - Turiani 23 Sr. Hurbentina Kibua FLHFS Mhonda Catholic Mission Dispensary 24 Dr.Twaha Ngalawa Cascade supervisor - Morogoro 25 Christopher David Matwarame FLHFs - Mkuyuni - Morogoro 26 Dr. Abdalah Mbalazi FLHFS - Langali 27 Mr. Anselmi John Village Executive Officer - Kanga village 28 Shabani Seif Mugumu Community leader - Chalongwe 29 Juma Homahed Community leader - Lukindu 30 Ms Adolfina Selafin Community leader - Mvaji 3l Mr. Emmanuel Matei Community leader - Diagay a 32 Adauti Rafael Mokiwa CDD - Chalongwe JJ Ms. Habiba Hashim Madinga CDD - Chalongwe 34 Mr.Seif Mussa Dilema CDD - Chalongwe 35 Ms. Beasina Machange CDD - Lukindu 36 Antoni George CDD - Mvaii 3',l Antonia Edmund CDD - Mvaji 38 John Willium CDD - Diagaya 39 Ms. Anna John CDD - Diagaya 40 Maiko Dimoso CDD - Lolo 4t Emelda Pascal CDD - Lolo Appendix 2 Morogoro CDTI proiect: NAMES OF RESPONDENTS at Various Levels lv'lorogoro C DT I Et'al u ati on Re pttrl 57 42 Nikodemus Alex CDD - Mgini 43 Revina Leo CDD - Mgini 44 Nzita Mpina CDD - Mikesse mjini 45 Sefu Rashid Chamumi CDD - Polepole 46 Salum Hussein Mtatamale Community Member -Polepole 47 Ramadhan Abdallah Ulanga Community Member - Polepole 48 Issa Hamadi Mgama Community Member - Polepole 49 Ramadhani Salum Shomary Community Member - Polepole 50 Waziri Hussein Mtatamale Community Member - Polepole 5l Mahudhumula Maleta Community Member- Mikesse mjini 52 Abdallah Yange Community Member -Mikesse Mjini 53 Mbaragalddy Comola Community Member- Mikesse Mjini 54 Zainabu Kimilila Community Member- Mikesse Mjini 55 Moshi Iddy Mbegu Community Member- Mikesse Mjini 56 Nasira Alfani Community Member - Mikesse Miini 57 Watende Ammani Community Member- Mikesse mjini 58 Semindu Comola Community Members - Mikesse Mjini 59 Asha Beny Community Member- Mikesse Miini 60 Tekla Fabian Community Member -Mgini 6t Tekla Selestini Community Member - Mgini 62 Anna Mbiki Community Member - Mgini 63 Maria Leo Community Member - Mgini 64 Tekla Richard Community Member - Mgini 65 Scolastica Chuma Community Member - Mgini 66 Shafiwi Iddi matanza CDD - Mkuyuni 67 WemaAli Kipilipili CDD - Mkuyuni 68 Maua Ramadhani CDD - Mgembe 69 Iddi Rashid Community leader Mgembe 70 Juma R. Maogila Community Member Mgembe 71 Hayawi yahaya Community Leader - Mkuyuni 72 Sheilla Juma Community Member - Mkuyuni 73 Fatuma Hamidu Community Member - Mkuyuni 74 Kadiri ALLy Community Member - Mkuyuni 75 76 illorogoro C DTt Et'aluation Re port 58 APPENDIX III MOROGORO CDTI PROIECT CURRENT ADMINIS TRATIVE STRUCTURE MTNISTRY OF RE ONAL ADMINIS TION AND LOCAL MINIS OF HEALTH ---TREGIONAL MEDICAL OFFICER LOCAL GOVERNMENT (REGTONAL)REGIONAL ADMINISTRATIVE SECRETARY DISTRICT ADMINISTRATIVE SECRETARY J I J I J I DISTRICT HEALTH MANEGMENT TEAM DISTRICT EXECUTIVE DTRECTOR (DED) DISTRICT HOSPITAL DIVISION SECRETARY HEALTH FACILITY COMMUNITY WARD EXECUTIVE OFFICER VILAGE EXECUTIVE OFFICER <- SUB-VILLAGE LEADER il'lorogorct C DTI Eval uati on Report 59 Appendix IV PROGRAME OF ACTIVITIES FOR THE 2 DAYS PLAN DEVELOPMENT DAY ONE FEEDBACIgSUSTAINABILITY ITEM ACTIVITY TIME FACILITATOR I Registration of Participants 8.00-9.00 JJlPC 2 Introduction ofParticipants 9.00-9.10 PC J Welcome and remarks 9.10-9.20 RMO;NOTIF 4 Introduction to the work What are the objectives? What is sustainability? Methodology for evaluation 9.20-10.00 Prof. O.Nwaorgu/ Prince I I 6 Feedback on achievements issues and lessons from the Evaluation Regional level District level FLHF Level Community level 10.30 Rose Dr.A.Asilia Prince Dr.R.Maggid 7 SWOT Analysis 12.30-1.30 Prince/Rose/Rehma Abel I I 9 Group work Discussion on problems identified and solution to these problems using SWOT Analysis in groups I .Planning /integration 2.Leadership/Monitoring & supervision 3.Mectizan/Finance 4.Training &HSAM 5.Transport/Human resources/Coverage 6. Reports from Groups and Discussion 2.30-3.30 All l0 Roles of different levels and partners 3.30-3.40 Rose lllorctgoro C DT I Eva luation [?e pt rl 60 ll Steps in planning for sustainability 3.40-4.00 Dr.R.Maggid t2 Group work(Development of sustainability plan for Regional and District levels 4.00-5.00 Prince/Abel l3 General matters 5.00 All I I DAY TWO ITEM ACTIVITY TIME FACILITATOR I Registration of Participants 8.00-9.00 JJ/PC 2 Review of previous days activities 9.00-9.10 All Participants J Introduction of day's activities 9.10-9.20 Rose 4 Development of Sustainability Plan continues 9.20-l1.00 All Participants I 6 Development of Sustainability Plan Continues l 1.30-1.30 All I I 8 Presentation of Group work 2.30-3.30 Group Leaders 9 Group work to incorporate correction 3.30-4.00 Group Leaders l0 Way forward APOC NDGO Partners MOH(Regional &District levels) NOTF 4.00-4.30 APOC NOTF DED NGDO RMO ll Closing remarks 5.00 RAS lll orogoro (- ) DT I Et'al ua t i o n Re port 6l I] t.l T It APPENDIX V: ROLES OF DIFFRENT LEVELS AND PARTNERS FEEDBACI(SUSTAINABILITY PLAN National Level: . To supervise and Monitor CDTI activities . Is the link between national and APOC . To ensure free entry of drugs in the country and in time . To conduct training to project coordinator at national level NGDO a a a a Training and monitoring of CDTI activities Additional of other resources Provides financial and accounting services to all APOC supported project To collaborate with MOHSW to ensure all affected communities are covered internationally and Local Regional Level: . Compile report and submit national Office . Supervision and monitoring of CDTI programme at district level . Conduct HSAM at district Level . Conduct setup and Evaluation meeting . Technical advise during planning . To interpret national guide and policy District Level: . To receive the project and ensure sustainability of it . To provide staff and working materials . To allocate funds for CDTI activities . Monitoring and distribution of drugs . Supervision on Mectizan distribution and to ensure all eligible swallow Mectizan . Record keeping . Planning and budgeting of CDTI FLHFL: . To take care of the side effect . Training of CDDs and other community leaders . Record keeping . To compile report . Planning and budgeting of CDTI activities Community Level: o Community decide how to supporVcompensate the CDDs either in-kind or cash . Community collect Mectizan from the nearest health facility lvlorctgoro C DT I Evaluat ion Re port 62 Community decide how and when to distribute Mectizan Community collectively select distributors APPENDIX: VI SWOT ANALYSIS REGIONAL LEVEL-SWOT ANALYSIS Strengths Weakness Opportunities Challenges - Presence of regional health plan framework - Health policy of the year 2007 . - Elaborate infrastructure - Presence of buildings which save as offices. - Presence of skilled personnel - Presence of health guideline - Planning and budgeting are in place. - MandEsystem - Strong political will and support - Committed regional Ieadership - Availability of data and information for planning - Traditional healers policy Inadequate planning skills ( for some RS/RHMT) Inadequate working facilities e.g ICT materials lnadequate involvement of RHMT members in supportive supervision of CDTI Inadequate finance for M and E. Inadequate transport for supervision. Inadequate integration of CDTI activities. Delay of funds for supervision. Delay of distribution of drug by MSD Lack of training schedules for CDTI. Inadequate planning of health education package according community attitude. - Presence of donors like APOC and Sight Savers Intemational - Presence of MSD. -Readiness of the community(leadership) to provide for Oncho activities. - Elaborate structure from regional to village level. - Existence of other projects - Delay supply of drugs from MSD - Misconception due to social cultural issues in use of Mectizan -Delay of fund release. - Geographical coverage such as hard to reach areas eg During seasons rains which make some areas hard to reach. Morogoro CDTI Evalualion Reporl 63 htorogoro CDTI Evaluation Reporl 64 MVOMERO DC.SWOT ANALYSIS Strengths Weakness Opportunities Threats a CDTI activities at the district level are planned in the CCHP and are integrative Awareness of CDTI programme to the community GCR and treatment coverage rate is above 70Yo Leaders participation at all levels on CDTI Political commitment to CDTI programme a Inadequate funds for CDTI activities Delayment of Mectizan drugs from MSD Misconception ofthe drug use to some community Irregular transport on CDTI programme in the district at all levels Shortage of trained health staff in some health facilities Drop out of CDDs to some areas every yeat a a a Integrated Mectizan drug distribution and supportive supervision Trained staff implementin g CDTI activities Cascade system of monitoring and supervision Planned Preventive Maintenanc eof motorcycle and vehicle of CDTI programme Possibility of being acceptable at all political levels in the districts a a a a Negative attitude of the community towards Mectizan use Absence of Mectizan drugs at the community level Delayment of budgeted funds for CDTI activities Poor infrastructure Opposition from politician (Multipartism) Other vertical programme paying their volunteers at high rate compared to CDDs a a a a a O a a a a o a Strengths Weakness Opportunities Threats o Project activities are intergraded into comprehensive council health budget. . Funds allocation is increasing yearly o Committed staff at all level o Interpreted support supervision are well done. o Availability of working tools eg stationary and other accessories. . Availability of transport materials l. Disbursement of funds to support all the project activities 2. Inadequate IEC materials 3. No motivation policy to support CDTI implementers l. Community is willing to take the drugs 2 The project is well accepted as there is an overwhelming support at all level 3. Free delivery of Mectizan 3. Community negligence especially at sub urban areas 4. Failure of the community to reward the CDD'S at their areas 3. Oncho data format is incompatible in the HMIS 4. Inadequate number of CDDs in some community. 5. In case we shift to Morogoro Head Office quarter premises i MOROGORO DC-SWOT ANALYSIS lvlorctgoro CDTI fualuation Report 66 Morogoro District SWOT Analysis REGIONAL LEVEL: Weaknesses and proposed solution Issues Weakness Strategies Planning Inadequate planning skill at RS/RHMT Inadequate integration of CDTI activities Delay of drug distribution by MSD a a o Train RS/RHMT on planning CDTI activities to be included in regional health plans Intensify coordination between regional level and MSD. Finance o o Inadequate budget for CDTI activities Delay of release of funds for supervision Increase the budget for CDTI activities at regional level during planning and budgeting Timely release of funds for supervision a Transport and human resource a a Inadequate working facilities Inadequate transport Training a a Inadequate training schedules for RS/RHMT on HSAM and advocacy. Inadequate health education and promotion strategies and IEC materials Train HSAM RS/RHMT on - Conduct situational analysis to identify hindrance of the programme. -Develop educational messages and IEC materials following the locally identified issues eg. Cultural aspects - Disseminate available policies and health education materials Monitoring and Evaluation a a Inadequate involvement of RHMT in supportive supervision of CDTI activities The current M and E in use (checklist) is not user friendly. Ie it has a lot of things. Involve RSiRHMT in CDTI activities supportive supervision Develop user friendly M and E tools lllorogoro CDTI Evalualion Reporl 67 MVOMERO DISTRICT SWOT ANALYSIS Misconception of the drug use to some community STRATEGIES/ To conduct HSAM to all levels/ Incorporate other stakeholders such as Influential people (Religious leaders and Community Own Resource persons) r' Mass Media participation such as Radio, TV and Newspaper. leaders, Political Inadequate funds for CDTI activities STRATEGIES ,/ District planning team to increase fund in the CCHP annually and mobilize other donors to support CDTI programme (Advocacy to policy makers) ./ To integrate CDTI activities with other activities in the District Delay of Mectizan drugs from MSD STRATEGIES/ To liaise with the MOH&SW to deliver Mectizan on time to the District ,/ District to distribute Mectizan to the HFs/Community timely Irregular transport on CDTI program in the district at all level STRATEGIES ,/ To facilitate reliable for CDTI Programme in the District at all level ./ To facilitate regular maintenance of transport system Shortage of trained health staff in some health facilities STRATEGIES ,/ To increase number of trained staff in the District r' To equip with knowledge/skills on CDTI to health workers in the health facilities Drop out of CDDs to some areas evety year STRATEGIES ,/ To establish the cause of CDDs drop outs ,/ To build capacity to new CDDs Inadequate supportive supervisions/monitoring to CDTI activities at the cascades and health facility level STATEGIES ,/ To facilitate cascades leaders on supportive supervision illorogoro C DT I Eva lua t i on Re port 68 MOROGORO DISTRICT COUNCIL PROBLEM AREA WEAKNESSES STRATEGIES Planning integration and No oncho office for DOTs when we shift to a new District HQ - Budget for construction of a new office at the new district HQ Leadership, Monitoring supervision and Failure of the community to reward the CDDs Encourage community support/reward CDDs the to their Oncho data format is incompatible in the HIMS - Incorporate oncho data in other problems in HIMS Inadequate number of CDDs in some communities Convince the community to select more CDDs according to their need Training of new CDDs No motivation of policy to support CDTI implementers Advise the partner and support on it NGDO Dc to MectizanlF inance Late disbursement of funds to support all project activities - Early reporting and retirement of utilized fund to APOC office Training and HSAM Inadequate IEC materials Budget to prepare and distribute IEC materials Community negligence especially at sub urban areas Increase efforts HSAM on lll orogoro ( ) DT I Eval u at i on Re ltorl 69 SN NAME ADDRESS E.MAIL ADRESS I Prof. Obioma Nwaorgu Department of Parasitology &Entomology, Nnamdi Azikiwe University Awka, NIGERIA. obinwaorgu@yahoo.com 2 Dr.Abel A.Mwakafivila Tukuyu CDTI Focus(Regional Office) Box259, Mbeya, TANZANIA. abkafiarila@yahoo.com 3 Prince P.Mutalemwa Box 9653, Dar es salaam, TANZANIA. pmutal emwa@nimr.org.tz 4 Dr.Rehmah Maggid Tanga CDTI Focus Box 452, Tanga, TANZANIA. nidugae@yahoo.com SFDDH P.O.Box 337 ,lfakara, MOROGORO, TANZANIA. 5 Dr. George M.Kassiga gkassiga@yahoo.com 6 Rosemary Nguruwe Kilosa CDTI Focus Box l4,Kilosa, MOROGORO, TANZANIA. cdtikilosa@yahoo.com APPEITIDIX: VII ADDRESSES FOR MOROGORO CDTI -EVALUATION TEAM MEMBERS TELEPI 234803?- +255784 +255754 0784308 0715318 0715381 0784402 tllorogoro C DT I Et'al uat i on Re lsort 70 APPENDIX: VIII DOCUMENTS SIGHTED REGIONAL LEVEL l.Work Plan 2.Comprehensive Council Health Plan(CCHP) 3.Annual Technical Reports for three years( 2004,2006 and2007) 5.lnventory report-Equipments 6.Supervision Matrix T. Supervision Checklist 8.Log books 9.Financial Records/Retums DISTRICT LEVEL 1.Work Plan 2.Comprehensive Council Health Plan(CCHP) 3. Supervision Checklists 4.Supervision Matrix 5.Mectizan Ordering forms 6.Ledger for Mectizan FLHF LEVEL I .Treatment Summary Records 2.Treatment Registers 3.Census Registers COMMUNITY LEVEL l.Treatment Registers 2.Mesuring sticks ! lllorogorrt O DTI Evaluati on Report 7t N c- ( Y' \.i L , ? fr d c.c U)/F\l .rr *fr z o F E 1r1 6 u,E s2 =Es5(!lvoorsd8rH OErJl 2coE' lrlF(,) 1aEfOlrrEEq3fx6B _86z,= i \ & i}{) -!\ !U t- 1-fo X a | -- vV tr ( *i.{ .. .,/, l] s U c,fF z(, ,'t i\3\* N ( F1 E j \) z-\(,) $ $t:#g 7 r--l f-.1 l _\I\ u IS Id 1.. ') 'r4 '2) +jlUc,o a \4 \0{ C v & '-.J \ i:.) (\./1 n = xU N M r] 11 x .a { $ en clj k 0' 0 N'l il il rl I x :, ,< ..,'i E E, $5' 141 (, s :L .t tjJia ; .! 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