Sustainability plan implementation monitoring visit to Arua district, Uganda

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I) {.'l Wbfld Health Organisation African Program for Onchocerciasis Control SUSTAINABILITY PLAN IMPEMENTATION MONITORING VISIT TO ARUA DISTRICT, UGANDA REPORT SUBMITTED TO: THE DIRECTOR AFRICAN PROGRAM ON ONCHOCERCIASIS CONTROL/WHO SUBMITTED BY: GEOFFREY EZEPAE, MBBS, MPH _ TEAM LEADER JOSEPH WAMANI SEPTEMBER 2OO5 :AIDS APOC CAO CDD CDTI DDDHS DDHS DHE DHT DOC EPI FLHF HBMF HIV HSAM HSD IEC MoH NGDO NOCP NOTF wHo WR ABBREVIATIONS Acquired Immune-Deficiency Synd rome African Programme on Onchocerciasis Control Chief Administrative Officer Commun ity Directed Distributor Community Directed Treatment with Ivermectin Deputy District Director of Health Services District Director of Health Services District Health Educator District Health Team District Onchocerciasis Coordinator Expanded Program on Immunization Front Line Health Facility Home Based Malaria Fever Human Immune-deficiency Virus Health Education Sensitization, Advocacy and Mobilization Health Sub-District Information, Education and Communication Ministry of Health Non-Governmental Development Organ ization National Onchocerciasis Control Program National Onchocerciasis Task Force World Health Organization WHO Representative I Arua District Implementation of Sustainability work plan monitoring report. September 2005 Table of Contents ABBREVIATIONS. Table of Contents ... 1. Background. 2. Findings 2.1 District Leve|.............. 2.2 Health S u b-districts 2.3 Frontline Health Facility 2.4 Community ............. 3. Strengths, Weaknesses, Opportunities and threats 3.1 Strengths 3.2 Weakness 3.3 Opportunities.............. 3.4 Threats 3.5 Actions proposed 4. Conclusions and Recommendations 4.1 Conclusions ......... 4.2 Recommendations ....................... 5. Annexes ........ I I 1 ..............,..2 ...............,.2 5 7 8 9 9 9 9 l0 l0 l0 l0 .10 .12 Arua District Implementation of Sustainability work plan monitoring report. Septembcr 200s u 1. Background Arua district is one of the old districts located in the western part of Uganda with an estimated total population of 855,055 people. The district is bordered by the Republic of Sudan and Yumbe district in the north, Democratic Republic of Congo (DRC) in the west, Nebbi district in the south, Moyo and Adjumani districts in the north- east and Gulu district in the east. Arua town, the administrative capital of the district, is situated about 520 kms from Kampala, the capital of the nation. Administratively, the district comprises of 7 counties, 36 sub-counties,225 parishes and 2030 villages / communities. Although recently one of the counties (Koboko) has been made a full fledge district. Most parts of the district are flat but with a lot of fast flowing rivers/streams, which provide a good breeding ground for the Onchocerciasis vectors. The district has a total of 7 health sub-districts each of which has a number of sub-county health units. There are four hospitals in the district. One of the hospitals is the regional referral hospital while the other three are NGO/mission run hospitals. Onchocerciasis control program started in 1998 in the district by an organization working with Kuluva mission hospital. In 1999 the progrcm merged into the present APOC supported CDTI program. Onchocerciasis is not found in all parts of the district but found in only 5 health sub-districts. Again in these health sub-districts, it is not found in all the health facility areas and villages. Currently CDTI activities are carried out in l8 Sub counties, I 15 Parishes which comprise a total of 1046 villages. Recently, Koboko county (health sub- district) was made a full district. However, administratively they have not started operating fully and still rely on Arua Health Directorate for their programs. The CDTI is carried out in 5 Health Sub districts (HSD) namely; Koboko, Marach4 Terrego, Ayivu and Vura. All these HSDs coordinate CDTI activities in their respective catchments. According to the decentralization program, each health sub-district is responsible for planning health activities in their respective areas. The district only provides guidance in planning and supports them through supportive supervision. Therefore, the sub-districts are responsible for budgeting and implementing health activities. Table 1. List of Communities, FLHF and Sub-districts visited Sub-district FLHF Village or Community l. Terrego l.l Omugo I .l.l Ariabo 1.1.2 Noa 1.2 Wandi 1.2.1 Oraa 1.2.2 Obauze 2. Ayivu 2.1Aroi 2.1.1 Nyaru North 2.1.2 Alivu 2.2Pajtilu 2.2.lMite 2.2.2Odovu I Arua District Implementation of Sustainability work plan monitoring report. September 2005 Methodology The methodology of the assessment is described in the overall report 2. Findings 2.1 District Level A. Meetings 1. District Chief Administrative Officer On arrival the team met with the District Chief Administrative Officer (CAO) Mr. Stanley A. Adrabo in his office. The purpose of the mission was explained to him. He welcome the team and explained that the major health problems facing the district were sleeping sickness, plague and Onchocerciasis. 'Unfortunately the district has limited financial base and most finances we receive are donor funds which are directed to specific projects and hence difficult for us to plan for other activities', he continued. He went on to say that the District was one of the first districts to develop district development plan. They included control of endemic diseases such as Onchocerciasis in the plan. He mentioned that he raised the issue of Onchocerciasis in various fora such as regional meetings and donor meetings. 2. Vice Chairman, Arua District Local Government Council - Mr. Kamilo Sabo Later on a courtesy call was made to the office of the Chairman of the District Local government council. In his absence we were received by the Vice Chairman. The purpose of the mission to the district was again discussed with the chairman. Following this the chairman explained that Onchocerciasis affects 18 sub-counties of the district in five health sub-districts. In addition, sleeping sickness and plague were other major problems in the district. He however, mentioned that the treatment with ivermectin was really having effect in the district. He argued that one no longer saw people with severe symptoms of itching and skin changes in the district. He went on to say that the successes could be attributed to the fact that the treatment was simple and did not require the direct involvement of the health workers but the community members went straight to the CDDs to receive their drugs. Moreover, the drugs were free and are not found in the open market hence they were not easy to be pilfered. In addition the drugs were at the health facility level so it was accessible to the CDDs for collection and did not require long traveling and huge expense to collect. He however, emphasized the importance of supervision to the CDDs to ensure that the drugs they distribute are not expired and to ensure that the storage is properly done. He said that the district does not receive enough funds to implement projects and that over 97o/o of the money the district receives is from donor which are tied to specific projects. So, they have very little free funds to allocate to unfunded activities. He went on to appreciate the importance of continuation of activities when the donors pulled out. He mentioned that when MSF was supporting sleeping sickness control, the disease prevalence was brought down to about 0.3%. But 4 years after they stop funding, the prevalence has again risen to lZYo. He called on donors to ensure continue support for funding. He mentioned that they have started training Village and Parish Health Teams as to ensure continuation of health services at the community level. Arua District Implementation of Sustainability work plan monitoring report. September 2005 2 The District Onchocerciasis Coordinator, contributing to the discussion said that the Drug distribution has been on-going for the past 5-6 years. The communities are highly motivated and they take their drug regularly which has resulted in lowering of prevalence of the diseases. However, he mentioned the following as constraints to the program 1. Insufficient funding 2. Inadequate manPower 3. Staff transfer: the district spends time to train staff in the counties and sub- counties where Onchocerciasis exist. These staff are often transferred to other areas that do not have Onchocerciasis resulting in having untrained personnel carrying out duties. 4. Integration: Theoretically integration is possible but practically it is difficulf Some staff that are expected to carry out some of the integrated services do not have the required knowledge and experience and hence fail to do the work well. For instance a trained nurse may not be able to work in the community because he is not trained to do so. 5. Voluntarism: Most of the work is expected to be done by volunteers. However, in practice it is difficult for the work to be well done as the people continue to expect payment or incentive for the services. 3. Meeting with the District Director of Health (DDHS) - Dr. Patrick Anguzu and other information on the district The DDHS explained that the government is implementing a decentralization program such that the implementation of health activities is now handed over to the Health Sub-Districts and no longer in the hands of the District. Therefore, it is the different health Sub-Districts that budget for health activities in their areas. The District can only advise them during planning to include Onchocerciasis activities in their plan. He identified the following as the major health challenges in the district: Bilhazia, Onchocerciasis, Plague and sleeping sickness. Unfortunately these diseases are not found in all parts (sub-counties) of the district and therefore may not be paid attention globally but focused by counties and sub-counties where they exist. He went on to say that the money they receive as a department was mainly for supervision of the health Sub-district. The HSD were properly sensitized. The District has a plan for all health activities in the district. During planning each of the program and department bring together their plan. These plans are then put together as the district work-plan. He told us that they were meeting later that day to finalize the work-plan for 2005/06. As such we never saw the plan but were able to see the work-plan for 2004/05. There was a plan for control of endemic diseases including Onchocerciasis in the plan. In addition, the district conducts an integrated supervision to all health facilities during which they check activities related to Onchocerciasis. We saw their supervision report file. The last report in it was a supervision report dated I September 2005. Advocacv for Oncho was conducted last year where they sensitized the district leaders on Onchoceiciasis and the sustainability of the program. -The sensitization resulted in the district leaders participating in commlrnity mobilizltion. [t also _h"!p"4 them understand the problem of On'chocerciasii in the District. They hope_ to includl Onchocerciasis in the hainine of Village Health Team that is being pllnned for the district. The Village Health Team fi,itt Ue inv"olved in mobilization of cominirnities on health issues. Arue District Implementation of Susteinability work plan monitoring report September 2005 3 The Mectizan collection was integrated with the other district supply system. For instance the mectizan for this year was collected with funds from Schistosomiasis program when they had gone to Kampala to collect materials for the program. However, the DDHS wondered if it was not possible for the Mectizan to be stored at the National Medical Stores. In this way they could easily pick them up whenever they go to collect other things instead of going around to the NOCP for the collection. (This is an issue that the NOCP should look into and determine the constraints in doing so). Mectizan for 2005 distribution has been collected but the district is short of 300,000 tablea such that 3 sub-counties have not received any drug. However, DOC explained he was still going to request for more tablets. The District Development plan 2005-2008, contained a budget of about Sh20,000,000 for Onchocerciasis control program for 200516. As the fiscal year started in July we did not ascertain if any of the money has been released for the activities' Record keeping was poor at the district level. The district does not have a copy of the sustainability evaluation report of last year and claimed they have not received a copy of the sustainability work plan they developed in Kampala last year. The reports from the sub- districts are not properly kept. However, we saw a copy of 2004 distribution report sent to the national office. In addition, the report making process was not clear as the DOC said he sometimes receives treatrnent registers from the CDDs to make the report. On the other hand, there was no clear distribution period or guide on distribution period. The DOC said the distribution period was October to November while the different sub-counties distribute at different times ranging from April to September. The Mectizan for this year was registered in the District stock card as received on the 7* June 2005. However, some sub- counties started distributing Mectizan in April. The team wondered where and when the FLHF received the mectizan they were distributing. Some villages claimed to have finished distribution for 2005. The DOC was surprised with the situation. There are about 1880 - 2000 trained CDDs in the district. However, the DOC does not have the list of the trained CDDs. On the other hand, CDTI is fully integrated with other District programs such as EPI, Schistosomiasis and HOMAPAK. The CDDs are being used to distribute HOMAPAK in the villages and they share resources. The District EPI Officer collects information from the villages on CDTI and often receives village report forms on behalf of the DOC. This person has been trained and is very useful in the activities. The district received one motorcycle from APOC in 1999 which has broken down since last year. The district viewed the motorcycle now as a liability as it cost so much to maintain iL They prefer it replaced rather than spending much money in repairing it. However, the DOC, who also is the District Schistosomiasis Coordinator, has another motorcycle from the program which he uses for all activities including CDTI. Bicycles were present at the sub- counties levels for the activities of CDTI. According to the 2004 distribution report by the DOC, the geographical coverage was 100% for the district while the therapeutic coverage was 78.6Yo. However, we were not satisfied with the data as the sub-districts and the Frontline health facilities could not explain their prooess of sending reports to the DOC. Arua District Implementation of Sustainebitity work plan monitoring report. September 2005 4 The District officials identiff the following as the strengths and weaknesses of CDTI program in the district: o Strengths o CDD concept is working well and is now being adopted for other community-based health programs such as home management of malaria. o It is one of the programs appreciated by the communities as they own and manage it. The communities now demand for the drug- o The sub-counties used to budget for Onchocerciasis activities when they used to collect tax directlY. Challenges o Restructuring and decentralization of health services. All implementation of health services are transferred to the Health Sub-district but most times they do not have the capacity to plan for activities. o Need for organization at the district and sub-district level. The human resources are not adequate and therefore the little available need to be re- organized to meet the challenges of health care delivery. o Training: Many of the staffare not well knowledgeable on CDTI and need to be trained. The trained ones are often transferred to other sub-district where Onchocerciasis is not a problem. o Onchocerciasis is not found in all parts of the district hence planning becomes difficult. o Lack of resources hampers activities Opportunities o The creation and training of village health teams. They will be a way of sustaining the program at the village levels. ln general, leadership at this level is not very involved in the Oncho programs. It is disturbing that the sustainability work-plan is not at the district level and the last sustainability evaluation report has not been received by the district. A computer, reported to have been provided by APOC to the district since last year is not yet collected. The reason for not collecting it was not clear as it was said that the NOCP secretariat told the DOC not to collect it when he requested for it. But there was no further attempt made to follow up the collection. 2.2 Health Sub-districts The Health sub-districts normally receive information on the availability of Mectizan from the DOC. Then they made arrangements to collect the drugs whenever they had reasons to be in the District office. When the drugs were received the Health facility staff were informed and drugs sent to them. It was the health facility staff that train the CDDs and Parish supervisors. The problem of Onchocerciasis is not found in all parts of the district. Therefore, it was only the sub-counties where the diseases were found that normally made plans for Oncho activities. Hence, at the County level (health sub-district) they did not plan a o Arue District Implementetion of Susteinebility work plen monitoring report September 2005 5 for it but incorporate the sub county plans So far, all the budgeted money by the sub- counties *ere releused for them last year. This was verified in the release voucher in some of the sub-counties. [n another sub-county the in-charged informed the team that she had received the money and was going to start training the following week. Mostly what they budget for was rifresher/annual meeting with the CDDs and supervisors. During this *""tirg the CDDs were once again reminded on how to calculate the dosages for distribution and the reporting format. They also inform them about the need to update their census figures and return their reports. Monitoring and supervision was integrated in all community monitoring activities. However, there was no budget for monitoring cited. Sensitization activities were usually done at the county level. Last year the counties invited the local leaders and discussed with them the problem of Onchocerciasis, the socio- economic consequences and the need for them to assist the health units to mobilize the communities. In the last sensitization about 70 people participated' The sub-districts receive Mectizan the same way they receive other drugs. However, Mectizan was not included in their inventories and stock cards as they felt it was a special drug distributed directly to the CDDs. Some other sub-districts claimed that the Frontline Health Facilities received the drug directly from the DOC and hence they did not know how much they received and therefore could not monitor the distribution. Some sub-districts have focal persons in charge of the Oncho program while others said because the disease was not found in the entire district they did not have a focal person. It was up to the FLHF with the disease to appoint a focal person. This lack of focal persons affected the sub-district perception and supervision of CDTI activities. Moreover, most sub- district staff do not seem to be knowledgeable on CDTI activities. When the person knowledgeable was absent things seemed not to work. For instance, where the former in- charge, who incidentally was the knowledgeable person, went for further studies others were unable to say anything about the program. They could not even find documents. Record keeping was poor. They did not have any copy of the previous year report in any of the sub-districts. They claimed that the FLHF did not send reports to them but sent directly to the DOC. The sub-Districts have vehicles and motorcycles. These vehicles and motorcycles were used in integrated activities and could be used for Onchocerciasis activities. The sub-districts could not provide us with their coverage. The coverage report we could record was that obtained from the district report. The District report showed there was a IOOYI geographical coverage in the sub-districts. The therapeutic coverage was reported as 73.7% for Terrego and79.5%o for Ayivu Arua District Implementation of Sustainability work plan monitoring report. September 2005 6 2.3 Frontline Health FacilitY The activities at the Frontline heatth Facilities were better organized. They had work plans that included Oncho activities. Most of their plan was for training of CDDs and the supervisors. They gave a token of Sh1000 to the CDDs for their lunch during the training. So far some of the FLHF had conducted training for this year while another one said it had received money for training and will conduct it during the coming week. The objective of their training included height measurement, record keeping and census update. Last year one FLHF refreshed about 50 CDDs out of 72 in their catchment area and 78 in another. One other HF planned to train 64 CDDs in the first phase out of 132 planned for in their budget. Visual Aids for training of CDDs and the communities were found at some of the health facilities. However, health education posters were not pasted in the FIF. [n one sub-district visited they had the posters but were dumped at the back of a cupboard. After the first few visits the DOC had to take some posters from his office as they had so many of them lying in the district store. The FLHF normally sensitized the CDDs and supervisors who in turn were expected to sensitize their communities. No sensitization of the village sub-county leaders had been conducted. Supervision was provided during distribution period. The FLHF supervised the parish supervisors and some CDDs while the parish supervisors provided supervision to all the CDDs. This was said to be done but the observation on the ground did not suggest that the CDDs received adequate supervision. The FLHF received Mectizan sometimes directly from the District and other times from the Sub-district depending on which was nearer to them. The quantity received was enough for their distribution. The main issue was that the different sub-districts and frontline health facilities reported different distribution period so it was hard to ascertain if the drug was received timely for distribution. Most frontline health facilities had designated individual for the Oncho progtam. In most cases it was the Health Assistant that did the coordination. The focal person was tasked to provide training to the CDDs and their supervisors and to collect reports from the CDDs. Most of these people have other activities which they combine with Onchocerciasis such as Schistosomiasis control program and EPI. They also combined transport for these activities. However, some of them were new to the program and lack adequate knowledge in CDTI. In addition, most FLHF stafflacked knowledge on CDTI. The data for coverage at the FLHF level was not obtained from them. None of them had records of their activities nor record of their coverage. Some complained that CDDs sent reports directly to the DOC. Reporting was really a problem. The team felt that the accusation of sending reports directly to the DOC was a cover or lack of proper record keeping and reporting. Arue District Implementetion of Susteinebility work plen monitoring rcporL September 2005 7 2.4 Community Most of the villages distributed their drugs at a central point such as community center or in the churches. Others changed their distribution methods when the community members did not come to the central place to receive their drugs. [n such situations they started house to house distribution. The method of calculating the quantity of drugs to give varied from one CDD to another. Some reported they gave according to the Age; others gave according to the height while others gave by their imagination of how much the individual should receive. The community members were normally sensitized about the drugs in churches or at the meeting places before distribution. The community members were able to recall the following things as the things the CDDs told them . They should swallow the drug and should not throw them away. . They should not drink alcohol after taking the drug o Children, pregnant and lactating mothers and very ill people should not take the drug. All the villages reported having received enough Mectizan for distribution. However, some newly arrivals in the village might not have received. They were advised to constantly update their village register so that nobody will be left out. Most villages had 2 trained CDDs. The communities were full of praise for the work of the CDDs and scored them very highly. The CDDs themselves loved their work. Most communities were still continued with the first CDDs that started the program. In one community one of the CDDs had left for the town while in another the CDD was sick. In all these situations the communities had replaced the concerned CDD. Some communities expressed that the CDDs were not enough for their communities. The communities were said to be demanding for their drugs. In one community that has not started distribution for this year the CDD said that the community members were already asking for their drugs. The communities reported that the drug was very good. They mentioned the following as the benefits of the drug . Body lice disappeared after taking the drug. o Cough disappeared after . Body pains disappeared after taking the drug Record keeping was fairly good in most of the communities. In communities that had treatment registers, the registers were well kept and maintained. In others that used exercise books the information were kept but not complete. The CDDs had not been able to record their village summaries. Every household in the villages were said to have been treated. There were no reported refusals. But in one village the CDD reported that some were asking him why they should take ffeatment when they were not sick. However, after explanation the people went ahead to receive their treatment. There was evidence that the communities were motivated and ready to continue receiving their drugs. Arue District Implementation of Sustrinebility work plen monitoring reporL September 2005 8 3. Strengths, Weaknesses, Opportunities and threats 3.1 Strengths l. CDDs were highly motivated and eager to continue their activities. CDD attrition was very low hence CDDs have many years of experience and confidence of the communities. 2. The communities were highly motivated and most times demanded for their treatment from the CDDs. 3. Concept of CDDs has been borrowed by other community programs such as HOMAPAK. The same CDTI CDDs were now involved in other community based programs. 4. Record keeping at community level was good despite lack of proper registers- 5. Availability of written work plans at the FLHF that included CDTI activities. 6. Shared available resources including transport and human 7. Budget for CDTI were found at health facility level 3.2 Weakness l. Sustainability plan was not yet absorbed into the district health work plan. 2. CDDs knowledge and practices were inconsistent. Some used age to calculate drug dosage while others used heights. 3. Most CDDs did not have proper registers and therefore did not record all the necessary information required in their improvised notebooks. 4. No established period of treatment. Different health facilities areas talked of different treatrnent period different from what the DOC said was agreed. This created confusion in supervision. 5. Inadequate supervision to the communities. 6. Poor record keeping at District, Health Sub-District and Health Facility levels. 7. Health staff not sufficiently knowledgeable on CDTI 8. Community and FLHF directly reporting to the DOC. The process of making report was not clear. 9. Drugs were sometimes sent to FLHF without passing through the sub-district. They therefore claimed ignorance of the program. 3.3 Opportunities l. Existence of other progmms like Schistosomiasis and HOMAPAK provides avenue for sharing resources and personnel. 2. Use of CDDs for distribution of Homapacks and Bilhazia treatments. 3. Availability of transport at the sub-district and FLHF levels 4. Availability of computers at the sub-district level could facilitate record keeping and reporting. 5. The multiple responsibilities of the focal persons create opportunity for integration and sharing of resources. 6. Integrated supervision for monitoring of distribution. 7. Monthly staffmeeting at FLFIF can be used for training and refreshing staff. Arua District Implementation of Susteinebility work plen monitoring reporL September 2005 9 3.4 Threats 1. Community understanding and participation in CDTI 2. Commitment of District |eadership to the continuation of the project 3.5 Actions proposed l. lnvolve all heatth staff at FLHF in all health activities so that they could be conversant with what is going on in the health facility and hence can supervise activities when they visit the communities. 2. Use the existing opportunities of monthly staff meetings to provide training and information sharing on CDTI activities so that all health staffwill have some level of knowledge on CDTI program. 3. CDDs are invited on annual basis for collection of drugs and it is budgeted for. Use this opportunity of their visit to train them on proper methods of calculating drug dosages and administration and proper record keeping, 4. Open files at district, subdistrict and health facilities levels for the filing of project information for easy access of all people including outside supervisors. 5. DOC to make immediate plan to meet with FLFIFs identified to be doing very poorly. In addition plan to orient all Oncho focal persons in the district through supportive supervision as to remedy some ofthe anomalies identified. 4. Conclusions and Recommendations 4.1 Conclusions The CDTI sustainability plan of Arua District was monitored. The District has not received a copy of the sustainabiliry plan nor a copy of the sustainability evaluation report done in July 2004. The sustainability plan has not been integrated in the district work plan. However, the Frontline Health Facilities where Oncho is endemic have included CDTI activities in their work plans. The communities are highly motivated and have noted the benefits of the treatment in their communities and therefore are very eager to continue receiving the drugs. The communities have demonstrated ability to sustain the program. Inadequate commifinent of district leadership could threaten the continuation of the program. 4.2 Recommendations 1. District and subdistricts leadership to show more interest in CDTI activities even when the disease is not found in all parts of the district and sub-districts. 2. All Mectizan requests by the health facilities to pass through established sub-district health offices channel for recording and follow up later. 3. FLHF should be responsible for collating and synthesizing village summaries for submission to the HSD and subsequently to the DOC. 4. Empower Supervisors and CDDs to prepare reports in their respective areas. Arua District Implementrtion of Susteinebility work plen monitoring reporL September 2005 10 5. Include CDD supervision in the work plan of FLI{F. Constant follow up is required especially during distribution to ensure that established norms are being followed. 6. Oiient ai healtli facility staff on CDTI concepts and activities. In this way they can provide supportive supervision to the CDDs and their parish supervisors. 7. irrovide triinings manuals and community registers to the Frontline Health Facilities and the CDDs. 8. The NOCP Secretariat to study the possibility of storing/integrating Mectizan into the National Medical store for easy collection of drugs by the districts. Arua District Implementetion of Susteinability work plen monitoring rcport. Scptember 2005 11 5. Annexes Annex 1: List of people interviewed and met District level l. Kamilo Sabo 2. Stanley Adrabo 3. Dr. Patrick Anguzu 4. Daniel Obiga 5. Bayoru Margaret Health Sub-District level l. Abindu Modest 2. Jimmy E. Andama Terrego 3. Stephen Moro 4. Thompson Aliyu Vice Chairman, District Local Government Council District AG. Chief Administrative Officer District Director of Health Services District Onchocerciasis Coordinator District Store Keeper Deputy Dishict Director of Health Services, Ayivu Acting Deputy District Director of Health Serices, Terrego Sub-District Onchocerciasis Focal person Account Assistant, Terrego Sub-district Aroi Health Center Pajulu Health Center Pajulu Health Center Omugo Health Center Omugo Health Center Omugo Health Center Waddi Health Center Waddi Health Center Health Facilities l Josephine Lakuru 2. Nyai Sammy 3. Simon Eyoga 4. Stephen Moro 5. Andama E. Jimmy 6. Charles Onzima 7. Micheal Alindru 8. Erphas Azabo Communities SAI Name of Village Name of Yillage Chairman Name of CDD Number of other participants Male Female I Ariabo Peter Akora t4 7 2 Noa Stephen Anguna Peter Badunga 16 4 J Oraa Joseph Amagwo Sam Izati 23 l0 4 Obauze Henry Apangu l. Epiphan Turuma 2. Micheal l5 9 5 Nyaru North David O. Feni 1. David Feni 2. Driwaru Lucia 6 T2 6 Alivu Charles Adia l. Charles Adia 2.Milika Amaniyo l5 15 7 Mite Bazirio Ebere 1. Fideri Karia 2.Bazirio Ebere 3. Grace Agia 5 6 8 Ojovu 6 2 Arue District Implcmentetion of Susteinebility work plen monitoring report September 2005 t2 Annex 2: Documents cited District Onchocerciasis workplan for 2003104 Arua District Annual report for 2003104 District lntegrated Supervision Report file CDTI2004 Annual Report to the National Coordinator Arua District Local government, Directorate of health Annual Workplan for 200415 FY Arua District Development Plan 2005106-2007108: Annual work plan 2005106 District Supervision Checklist Village Summary forms Letter to all Health Sub-Districts on CDTI sustainability to include it in their budgets November 2002 t. 2. J. 4. 5. 6 7 8 9 10. CDTI file in two Health Facilities 1 l. Health Facility work plans for all health facility visited 2005106 12. Terrego Sub-District work plan for 200415 and2005106 13. Payment Vouchers in Terrego sub districts Arua District Implementation of Sustainebility work plen monitoring report September 2005 13 MONITORING IMPLEMENTATION OF CDTTI SUSTAINABILITY PLANS INSTRUMENT 1 (Stete/Region/Province) COLTNTRY UGANDA PROJECTNAME UGANDA PHASE III CDTI PROJECT NAME OF TTIE STA ARUA DATE OF COMMENCEMENT OF CDTI 1999 DATE OF EVALUATION JLTNE/JULY 2OO4 DATE OF COMMENCEMENT OF SUSTAINABILITY PLANIMPLEMENTATION 2004 DATE OF ASSESSMENT OF SUSTAIN ABILITY PLAN IMPLEMENTATION SEPTEMBER 19 _ 30,2OO5 NAME OF MONITOR DR. GEOFFREY EZBPW MR. JOSEPHWAMANI Arua District Implementation of Sustainability work plan monitoring reporL September 2005 l4 TOOL FOR MONITORTNG OF CDTI SUSTAINABILITY PLANS Instruction: Check implementation of sustainability plan and verify whether constraints earlier identified are being rectified. Also check if key CDTI activities (Training, Monitoring and Supervision, HSAM and Mectizan procurement and distribution) are being implemented as planned. STATE/ REGION/PROVINCE 1.1 PLAIYNING Cha racteristics of the indicator Sources of information B Is CDTI integrated into the overall health service plan? Not really tr Does a detailed list of CDTI activities exist including the dates when they will be carried out? No Interviews with policy makers and managers at this level Inspection of CDTI plans.a Findings: Describe the situation (*comment on leadership at this level) CDTI is not fully integrated in overall district health service. Oncho was only mentioned in one area where they said they were going to control diseases. However, District development Plan budgeted lbr Oncho control but it rvas not reflected in the health work plan seen. The leadership of the District Health department did not seem to have shown enough interest in the CDTI activities. They developed a work plan in Kampala in July 2004 but to date (September 2005) they have not collected a coPY. If planning was not doene give reasons why Inadequate funding Suggest steps to be taken to improve situation Leadership to show more interest and deve lop sustainability plan Arue District Implementetion of Susteinebility work plen monitoring reporl September 2005 15 a 1.2 HSAM (AdvocacY) 1.3 MECTIZAN Sources of informationCharacteristics of the indicetor o Interviews with officials responsible for onchocerciasis at this level (managers etc.) o Inspection ofthe technical activity reports What was the objective? To mobilize the leadership on sustainability of CDTI Who was targeted for this advocacy? Political leadership of the district What approach was used? A meeting was called and the problem of Oncho explained to them. They were also sensitised to take the message to the communities What was the outcome? Increase awareness and cl lon ln commun mobilization Findings: Describe situation The advocacy seemed to have effect as the District Local government Council seemed to be well aware of Onchocerciasis program and could give insights of the program. Moreover' the Chief Administrative officer said he normally raised the issue of oncho in donor meetings and other regional ent anIn effect, there was a for the in the district was not done reasonsIf Suggest steps to be taken to improve situation The District Health Directorate to be more involved in the and follow up the resolutions and s ofthe ad meetings Chsracteristics of the indicator Sources of information Is ivermectin supply sufficient (adequacy)? Not adequate. Shortfall of 300.000 tablets Is the delivery of ivermectin timely (for distribution)? Timely delivery' Is it integrated into d-g d"lit"ty tytt" e Interviews with officials responsible for onchocerciasis at this level (managers etc.) o Inspection oftechnical Findings: Describe the situation The drug delivery has been integrated into the normal district drug delivery svstem. lt is recorded into the stock cards However. the q uantity for this year was insufficient If ivermectin is not available (sufficient, timely, integrated) give reasons why The quantity was insufficient due to insufficient supply from the national secretariat. The DOC claimed the secretariat did not have enough in stock Suggest steps to be taken to improve situation The DOC should make attempts to order for more drugs. Meanwhile he should make efforts to collect back the remaining drugs from all villages and health facilities. ln addition. he should not havc supplies all the health facility adequate numbers and completely leaving three sub- counties without any drug Arua District Implementation of Sustainability work plan monitoring report. September 2005 t6 I.4INTEGRATION Characteristics of the indicator Sources of information Resources Mention the resources (e.g. transport staff) that are shared between CDTI and other health programme activities (e.g. EPI, malari4 HIV/AIDS) Activities List the activities (e.g. Mectizan procurement and supply, supervision and monitoring and training of lower level staff) carried out in an integrated manner with CDTI o tr Interview of at this level Inspection ofreports, plans, budgets etc Findings: Describe situation The DOC also coordinates other program such as Schistosomiasis' He uses the available motorcycle from Schistosomiasis to supervise CDTI. Moreover. he is also member of the DHT that performs integrated supervision with all the available district resources. Ifthere is no evidence ofintegration give reasons Suggest steps to be taken to improve There is need tbr further integration and inclusion of the CDTI activities in the general supervision checklist Arua District Implementetion of Susteinability work plan monitoring reporL September 2005 t7 l.sFINANCE Characteristics of the indicator Sources of information o Are resources allocated at this level for the continuation of CDTI? tr Are resources released for CDTI activities? tr What proportion of allocated funds was released? o Interviews with officials at this level o Inspection ofthe plans, budgets, documents showing disbursement, for year of reference Findings: Describe the situation Resources are al located in the district development plan' There was no resources seen in 20o4lo5 Health work plan. 200-5/6 work plan was not ready. No funds was released for cDTl last year. It appears it was not particularly high priority forthe district as it is not a disease found in all parts of the district. but not rel glveIffinances are reasons why lnadequate financial base ofthe district Most of the money received by the district is tied to project by donors and hence not able to get enough resources for other unfunded activities. Suggest steps to be taken to improve situation The DOC and DDHS need to plan further together and put the CDTI sustainability as important as other project with funds. Arua District Implementation of Sustainability work plan monitoring report. September 2005 1E 1.6 RECORD KEEPING Characteristics of the indicator Sources of information o Is data on CDTI available? Not easily available o Are they properly recorded and stored? No o Are they analysed and utilized for planning CDTI activities? Yes. annual treatment report used for ordering mectizan o Are they reliable? Not reallY. The treatment report is not reliable as the nlanner and method of compilation is doubtful. Are they integrated into the normal health record system at this level? Oncho is one ofthe diseases reported in the HMIS diagnosis report . Interviews with officials at this level o lnspection ofrecords and records system Findings: Describe situation The DOC has a very torn flat file which has information fot 200212003. There is no recent information in it except the report to the National Coordinator written in March this year- Moreover, this file seemed to be in a paper bag that he carries to work and therefore not available in the office for everybody. There was no data on the list of villages in the office nor names of CDDs in the district' Ifrecord keeping is poor give reasons why Probably general lack of knowledge on the importance of data keeping and the ahility to maintain proper data Suggest steps to be taken to improve situation DOC to take immediate steps in updating the list of villages and names of CDDs in the computer' A file should be created where all Oncho information should be kept. Such file should remain in the office available to all district health staff. Arua District Implementation of Sustainability work plan monitoring report. September 2005 t9 I.7 COVERAGE Characteristics of the indicator Sources of information What is the geographic coverage ? l00co What is the therapeutic coverage for the last treatment cYcle? 78.6oto a a o Interviews with oflicials responsible for Onchocerciasis at this level Inspection ofrecords for previous year Findings: Describe situation The therapeutic coverage has been good in the last 4 years over 7-57o.and lOOozit geographical coverage. The data compilation needs much to be desired to ensure that all data are captured and no estintation made. Ifgeographical coverage rates are below 100% and therapeutic coverage rates less than65%o, give reasons why Suggest steps to be taken to improve situation Arua District Implementetion of Sustainability work plan monitoring report. September 2005 20 MONITORING IMPLEMENTATION OF CDTI SUSTAINABILITY PLANS INSTRUMENT 2 (DistricULGA) COUNTRY UGANDA PROJECTNAME UGANDA PHASE III CDTI PROJECT NAME OF THE DISTRICT/LGA TERREGO AND AYIVU TMALTH SUB- DISTRICTS DATE OF COMMENCEMENT OF'CDTI 1999 DATE OF EVALUATION JUNE/JULY 2OO4 DATE OF COMMENCEMENT OF SUSTAINABILITY PLAN IMPLEMENTATION 2004 DATE OF ASSESSMENT OF SUSTAINABILITY PLAN IMPLEMENTATION SEPTEMBER 19 - 30, 2OO5 NAME OF MONITOR DR. GEOFFREY EZEPIJE MR. JOSEPH WAMANI Arua District Implementation of Sustainability work plan monitoring report. September 2005 2t TOOL FOR MONITORING OF CDTI SUSTAINABILITY PLAIIS (District/LGA) Instruction.. Check implementation of sustainabilitl plan and verify whether constraints earlier identiJied are being rectilied. Also check if key CDTI activities (Training, Monitoring and Supervision, HSAM and Mectizan procutemenl and distribution) are being implemented as planned. 2.l PLANNING 2.2 TRAINING Characteristics of the indicator Sources of information Is CDTI integrated into the overall health service plan Yes Is there a detailed list of the key CDTI activities (monitoring, training, etc.) including their timing? Yes but no dates stated. However. activities have started. a a a a Interviews with policy makers and managers at this level Inspection of the written Plans Findings: Describe situation The HSD has an integrated work plan for the year. However. most of the CDTI were budgeted under the health facilities that have Oncho endemic in their areas. These activities are already being implemented. Last year the funds were released for the activity' If there is no plan give reasons whY Suggest steps to be taken to improve situation Characteristics of the indicator Sources of information o What was the objective of the training? o What was the content of the training? o How was the need for training determined? o Who conducted the training? o Where was the training done? o Were training resources efliciently used? o Interviews with policy makers and managers o Inspection of training programme Findings: Describe situation No training was conducted The level of knowledge of staff were low and when one person is absent others did not know what is going on' Iftraining is not done give reasons why Oncho is not endemic in all sub-district so on !y FLHF with the disease budget and conduct training Suggest steps to be taken to improve situation To orient all staff on CDTI using the existing DHT meetings and budget to conduct this. Arua District Implementation of Sustainability work plan monitoring report. September 2005 22 2.3 HSAM (Sensitisation and Advocacy) 2.4 MONITORING AND SUPERVISION Characteristics of the indicator Sources of information . Was there sensitization of officials, opinion leaders about Onchocerciasis at this level? r How was it done (apProach)? o What was the result? r How many people were sensitized? a Interviews with officials responsible for onchocerciasis at this level Inspection of activity/technical reports Findings: Describe situation Sub-county and parish leaders have been sensitised in some counties. The sensitisation has improved political support and mobilization in the communities. The awareness of oncho has improved and the community now demand the drug' Ifsensitization was not done give reasons why? Suggest steps to be taken to improve situation Characteristics of the indicator Sources of information Was there supervision and monitoring? When were CDTI suPervisions and monitoring activities carried out? How frequently? (at least once a year) Is there a checklist on oncho. activities? Is it integrated into other health care supervisory forms' checklist? Were strengths and weaknesses identified? Were weaknesses redressed? Were there reward sYstems? Was there feedback to those a a a a a a a a a Interviews with officials responsible for onchocerciasis at this level Inspection ofactivity and technical reports as well as monitoring and supervision reports Findings: Describe situation Supervision was said to be done on monthly basis to all the health facilities' We met one of the sub-district in charge on his way to supervise the health facility. They use a checklist developed at the MOH which does not have CDTI in it. However. the supervisors claimed they ask questions on CDTI and supervise what they do. Horvever. the level of insufficient knowledge and improper practices makes one wonder if the su ision provides technical suPPo rt to the facilities and workers If supervision and monitoring were not done give reasons Suggest steps to be taken to improve situation CDTI should be included in the supervision checklist to ensure that it is not forgotten during supervision. A supervision report should be written to show what was discovered duri the on Arua District Implementation of Sustainability work plan monitoring rePorL SePtember 2005 23 5 a a 2.5 MECTIZAN SUPPLY 2.6 HUMAN RESOURCE Characteristics of the indicator Sources of information o Was ivermectin sufficient for last distribution cycle? o Was ivermectin delivered in a timely manner from the state to the Districtl LGA? o Is ivermectin supply integrated into the normal drug management component of the health system? o Interviews with officials responsible for onchocerciasis and drug supplies at this level o Inspectionofactivity/technicalreports o Inspection ofdrug delivery inventory records Findings: Describe the situation Mectizan was sufficient in all the sub-districts. They received it timely depending on their distribution period. Sometimes lvermectin goes directly to the health unit without the knowledge of the sub-district. This creates problem in monitoring and ownership of the program. Moreover. there was no clear understand on agreed distribution Period If ivermectin was not sufficient, timely and its not integrated ve reasons why Suggest steps to be taken to improve situation All mectizan should be sent through the health sub-district for normal reception and recording. The sub-district should remember it is their responsibility to onitor and supervise all activities and should not fern ignorant of of what is on Characteristics of the indicator Sources of information o Is there an officer responsible for onchocerciasis o Is s/he trained/knowledgeable in CDTI? o Is s/he responsible for other health projects or activities? Interviews with officials responsible for onchocerciasis at this level Inspection of activity records a a Findings: Describe the situation In some places there were focal persons. The focal persons and the staffare not sufficiently knowledgeable on CDTI. They coordinate other health activities such as Shistosomiasis and E,pl. There was also the HOMAPAK program in the community which is also supervised by some of these focal persons. If responsible officer is not available or knowledgeable, give reasons whY The staff are not trained in CDTI' Former focal person that was trained has gone lor further studies. Suggest steps to be taken to improve E,nsure that all sub districts have a trai staffofsub district should be trained ned focal staff. All Arue District Implementation of Sustainability work plan monitoring report. September 2005 24 2.7 INTEGRATION 2.SFINANCE Characteristics of the indicetor Sources of information a Which activities (e.g. training, monitoring) a are carried out jointly with other health programme activities? Which resources (e.g. staff, transport) are shared between CDTI and other health malaria etc. o Interview of staff o Inspection ofrepofis, log-books etc Finding: Described the situation supervision is done jointlY. The activities in the sub district are transport available is used for a carried out in integrated manner. The .ll activities including CDTI. If CDTI acti and resources are not well integrated with other health programmes give r€asons Suggest steps to be taken to improve the situation Characteristics of the indicetor Sources of information a Are resources allocated at this level for the continuation of CDTI? Are resources released for CDTI activities in time? What proportion of allocated resources is released a r Interviews with officials at this level o Inspection ofthe plans, budgets, documents showing disbursement, for year ofreference Findings: Describe the situation The work budget has budget for CDTI in the last two vears. There was sufficient evidence to show that all the budgeted money was released If proportion of resources budgeted, allocated and released is inadequate give reasons why Suggest steps to be taken to improve situation Arua District Implementetion of Susteinability work plan monitoring reporL September 2005 2.9RECORD KEEPING 2.TOTRANSPORT Characteristics of the indicator Sources of information o Are data on CDTI available? o Are they properly recorded, stored and easy to retrieve? o Are they analysed and used for planning,? o Are they reliable? r Are they integrated into record system at this level? o Inspection records, records system o Interviews with offrcials at this level Findings: Describe situation Record keeping is very poor There was no reaso nable record obtained. One saw a file that contained f'ew documents for 2002/3 but no recent information. None of the sub district has coverage report or summary of any report written in the past. Ifrecord keeping is poor give reasons why Lack of knowledge and not attaching importance to record keeping are contributing to the situation. Some reporting is said to go direct to the DOC. Suggest steps to be taken to improve situation Focal persons to immediatelY oPen files for all CDTI activity. Take steps to document and file activity reports. Ensure thjat reports from FLHF pass through sub district offices. Characteristics of the indicator Sources of information o Is transport available for CDTI activities? o Is it functional, adequate, and used in an integrated way with other health care activities? a Interviews with officials responsible for onchocerciasis transport at this level Inspection of records, reports, vehicles log-booksa findings: Describe situation There were vehicles and motocycles in all the sub-districts. There rvere also bicycles at health unit level including the some parish supervisors having bicycles. Iftransport is not available (as stated above) give reasons why Suggest steps to be taken to improve situation E,nsure maintenance of the available resourses Arua District Implementation of Sustainability work plan monitoring report. September 2005 26 2.llCOVERAGE Cheracteristics of the indicator Sources of information a What is the Geographic coverage for past two years? What is the therapeutic coverage for last two years? a a Interviews with officials responsible for onchocerciasis at this level Inspection of summary records for ivermectin treatment and rePorts. Findings: Describe situation Geographical coverage reports from them hence therapeutic coverage col However. the Dislrict report showed the therapeutic 73.7o/o for Terrego and79.5o/o fbr Ayivu. S SA id to be I 00%. But we d d not get any u d not be deter,m ned wl rh rhe report S coverage for the SU b di stricts we SI ted AS Ifcoverage rates are below expected (-100o/o geographical and 650/o therapeutic-) give reasons why Suggest steps to be taken to improve situation Empower sub district to calculate their coverage rate and make proper annual report to the DOC Arua District Implementation of Sustainability work plan monitoring report. September 2005 27 a MONITORING IMPLEMENTATION OF CDTTI SUSTAINABILITY PLANS INSTRUMENT 3 (Fronttine Health Facility - FLHF) COUNTRY UGANDA PROJECT NAME UGANDA PHASE III CDTI PROJECT NAME OF DISTRICT/LGA TERREGO AND AYIVU SUB DISTRICTS OF ARUA DISTR]CT NAME OF THE FLHF PAJURU, AROI, WANDI AND OMUGO DATE OF'COMMENCEMENT OF CDTI 1999 DATE OF EVALUATION JI-INE/JULY 2OO4 DATE OF COMMENCEMENT OF SUSTAINABILITY PLAN IMPLEMENTATION 2004 DATE OF ASSESSMENT OF SUSTAINABILITY PLAN IMPLEMENTATION 19 _ 30 SEPTEMBER 2OO5 NAME OF MONITOR DR GEOFFREY EZEPUE AND JOSEPH WAMANI Arua District Implementation of Susteinability work plan monitoring reporl Septcmber 2005 28 MONITORING IMPLEMENTATION OF CDTI SUSTAINABILITY PLANS (FLHF) INSTRUMENT 3 Instruction.. Chech imptementalion of sustainabiliy plan and verify whether constraints earlier identilied are being reailied- Also check if key CDTI activities (Training, Monitoring and Supervision, HSAM and Mectizan procufement and distribution) are being implemented as planned 3.T PLANNING Characteristics of the indicator Sources of information a a Is there a list of the key CDTI activities (monitoring, training, etc) including dates? Where and when were theY conducted? Interviews with officials responsible for onchocerciasis at this level Inspection of charts on walls, work plan, list of things to do. a Describe situation AII the Ft,HF visited had workpl ans that included meeting with CDDs and their supervisors. These activities are conducted at the health unit. So far sonle had done their meeting while another one plans to do it in the coming week as the money has been received. If planning was not done give reasons why Suggest steps to be taken to improve situation To ensure that supervision and sensitisation ofsub-countl' leaders are included in their budgets Arua District Implemcntation of Sustainability work plan monitoring rcport. September 2005 29 a 3.2 TRAINING 3.3 HSAM (Sensitization) Sources of informationCharacteristics of the indicator onchocerciasis at this level Inspection of training manuals, training reports, notes etc. a Interview with officials in charge, of justification for the training? tr What was the content of the training tr How manY CDDs were trained? B Were training resources efficiently used? tr What were the ectives/ their skills in height measurement; importance of updating census and proper record keeping Majority of the CDDs do attend as there was a little lunch allowance of Shl000 paid. So many believe it is during this meeting they receive their pay for the work done. The training is normally conducted at the health facility level' s with main objective of increasingFindings: Describe situation There is annua I meeting/refresher for the CDD If training was not done give reasons whY Suggest steps to be taken to improve situation Sources of informationCharacteristics of the indicator onchocerciasis at this level Inspection of activity/technical reportsa Interviews with official s responsible for opinion leaders about oncho. at this level? r What was the objective of the HSAM? o How was it done (approach) o What was the result? r How many people were sensitized? o Who were sensitized? Was there sensitization of communitya and sensistize the cDDs and request thetn to sensistize their communities done at this level. TheYsensitisation is not commonlYFindings: Describe situation Community leaders lnadequate funds. lack ofplanning knowledge that they should do it. for it and possibility lack ofIfsensitization was not done give reasons why To includ" sensitisation of the community To budget for it and recognise it is part oftheir responsibilitl' leaders in their Plan.Suggest steps to be taken to improve situation Arua District ImPlementation of Sustainability work plan monitoring reporL September 2005 a o 3.4 MONITORING AND SUPERVISION Characteristics of the indicator Sources of information o Was monitoring and supervision (lWS) carried out for CDTI regularly (how many times in ayear)? o Is there a M/S checklist? . Were M&S activities integrated with M&S activities of other health programmes? o What were the strengths and weaknesses identified? o Was there feedback to those supervised? EI tr Interviews with persons in charge at this level Inspection of documented reports and supervisory checklist etc. Findings: Describe the situation The Health Assistance supervises the parish supervisors and some CDDs It is expected that the parish supervisors should now supervise the CDD. It is however' doubtful if the supervision is done. No record of supervision was obtained. If monitoring or supervision was not done as planned give reasons why Poor attitude towards supervision Suggest steps to be taken to improve the situation HA to intensify supervision to the CDD. The in- charges to take interest in the supervision as the cost drugs handed over to the CDD is high. The in charge and the other staffto change attitude towards community supervision as many other activities are going onto the communities now. Arua District Implementation of Sustainability work plan monitoring report. September 2005 3r 3.5 MECTIZAN Char acter i sti c s of the indic at or Sources ofinformation w ith regard the supplyto tr Are the supplies adequate? tr Is it delivered on time for dates of planned distribution? tr Is it ordered and distributed to the FLHF and the communities within the regular health care system? Records of ivermectin ordering and stocko tr control Interview with nurse or health staff in charge Findings: Describe the situation Mectizan delivery is good. They receive their drug timely and in adequate quantity. However, some issues of concern was that some health facility receive drug directly from the district which results in the sub district saying they do not know if they have received. Secondly, some health facility had started distributing drugs even before the district received their consignment for the year, We do not then know how this came about and the source of the Mectizan they were distributing. The Mectizan in most FLHF were not recorded in the stock cards' If ivermectin supply and delivery was inadequate or untimely, give reasons why Suggest steps to be taken to improve the situation All supply should pass through normal sub district delivery system the district should establish proper inventory and reception of Mectizan not distributed to avoid confusion. Stock cards should be opened fbr Mectizan received as any other drugs and supplies of the Health unit. Arua District Implementation of Sustainability work plan monitoring report. September 2005 32 3.6 HUMAN RESOURCE 3.T INTEGRATION Characteristics of the indicator Sources of information a Is there a designated Person for onchocerciasis control? Is the designated person trained and knowledgeable in CDTI? Is the person able to effectively combine CDTI with his other community-based health responsibilities? a a Interview with the Head of the Health Department Inspection of documents Findings: Describe the situation All the health units have design ated persons nrostlY the Health Assistant. Some are trained but most are not knowledgeable on CDTI. They would require nrore training and supervision. 'l'hey combine the activity with other responsibility such as EPI. Schistosomiasis If the use of human resources is inappropriate or unsatisfactory, identifu the weak points and give reasons Suggest steps to be taken to improve the situation Training of focal persons and health staff are needed. Use the forum of monthly staff meeting to train the staff on CDTI. Characteristics of the indicator Sources of information a Which activities (e.g. training, monitoring) are carried out jointly with other health programme activities? Which resources (e.9. staff, transport, space, time etc.) are shared between CDTI and other health programme activities (e.g. EPI, malaria etc.) o Interview ofproject staff o Inspection ofreports, log-books etc. Findings: Describe the situation Some level of integration e.xists especially in use of available motorcycles and bicycles for activities. However, transfer out of persons delay the taking up of activities by other staff as they are not know ledgeable. Ifintegration is not effective give reasons why Lack of proper training Suggest steps to be taken to improve the situation To training all staff on CDTI. To inc lude CDTI in all check list Arua District Implementation of Sustainability work plan monitoring report. September 2005 33 5 3.8 COYERAGE Characteristics of the indicator Sources of information What was the Geographic coverage for past two years? What was the therapeutic coverage for the last treatment cYcle? a a a Interviews with offi cials responsible for onchocerciasis control at this level Inspection of summary records for ivermectin treatment and reports for previous years. Findings: Describe situation Geographioc al coverage was reported to be 100%o But all the units had no report to establish their therapeutic coverage. If coverage rates are below expected (-100% geographical and 65%o therapeutic-) give reasons why Suggest steps to be taken to improve situation Arua District Implementation of Sustainability wo rk plan monitoring report. September 2005 34 a MONITORING IMPLEMENTATION OF CDTTI SUSTAINABILITY PLANS INSTRUMENT 4 (Community) COUNTRY UGANDA PROJECTNAME PHASE III PROJECT NAME OF DISTRICT/LGA ARUA NAME OF SUPERYISORY FLHF ALOI. PAJURU. OMUGO AND WANDI. HEALTH CENTERS NAME OF THE COMMUNITY NYARU NORTH. ALIVU. MI TE. OJOVU. NOA, ARIAMBO. OBAUZE AND ORAA DATE OF COMMENCEMENT OF CDTI 1999 DATE OF EVALUATION JUNE/JULY 2OO4 DATEOF COMMENCEMENTOF SUSTAINABILITY PLAN IMPLEMENTATION 2004 DATE OF ASSESSMENT OF SUSTAINABILITY PLAN IMPLEMENTATION I -30 Sept 2005 NAME OF MONITOR DR EZEPUE. C AND WAMA NI JOSEPFi Arua District Implementation of Sustainability work plan monitoring report. September 2005 35 MONITORING IMPLEMENTATION OF SUSTAINABILITY PLANS (Community) INSTRUMENT 4 Instruction.' Check implementation of susfainability plan and verdy whether constraints earlier identiJied arc being rcctified. Also check if key GDTI activities (Training, Monitoring and supervision, HSAM and Meciizan procurement and distfibution) are being implemented as planned' 4.1 PLANNING NOT CRUCIAL AT THIS LEVEL 4.2 TRAINING NOT CRUCIAL AT THIS LEVEL 4.3 HSAM (Health Education and Mobilisation) Sources of informationCharacteristics of the indicator Interviews with CDDs and communitY members. Inspection of village-kept records a a leaders and mobilisation of the communitY? o How was it done (aPProach)? o What was the result? o How many people received health education ? a Was there health education and has been through churches and also house to house during treatment exerclse' Most communities were aware of CDTI activities and mentioned most of the values of ivermectin such as deworming. killing of body Iice, treatment of other diseases. They are willing to continue taking iveYmectin ed out at a low level and itHealth education and mobilisation has been carriFindings: Describe situation done give reasons whYIf sensitization was not CDDS and Sub-county supervlsors are community meetings. They should also utilise the existing LC or any other community meetings to integrate CDTI' advised to holdSuggest steps to be taken to improve situation Arua District ImPlemcntation of Sustainability work Plan monitoring report. September 2005 36 4.4. MONITORING AND SUPERVISION NOT CRUCIAL AT THIS LEVEL 4.5 MECTIZAN SUPPLY 4.6 HUMAN RESOURCES Sources of informationCharacteristics of the indicator Inspection of drug delivery inventory records a a Interviews with CDDs and community members. I distribution cycle? Was ivermectin made available at the FLIIF when needed? Was ivermectin collected in a timely manner from the FLTIF? a a a Was ivermectin suPPlY sufficient for last timely in most health facilities except in Araimbo village. There is no uniformity in their mode of distribution (some use house to house or central place)' cycle, available andIvermectin distribution was su fficient for the distributionf indings: Describe the situation mode of distribution not determined by community give reasons whY If ivermectin was not timely and its Communities to suPport the CDDs.Suggest steps to be taken to improve situation Sources of informationCharacteristics of the indicator Interview with CDDs and community memberso How many trained CDDs are community? tr Is there a fair mix of both sexes among the CDDs? tr Is the workload for each CDD compatible? with eflicient distribution of ivermectin ? tr Are the CDDs well motivated ? tr What is the attrition rate among CDDs ? there in the dosages. method of determination. Each village has at least two CDDs. The CDDS were highly motivated and their communities appreciate the work they do very much' Some CDDS were not trained and they not fully knowledgeable on theFindings: Describe the situation This due to inadequate supervlslon from the HSDS and FLHF If CDDs are not available or are not trained, give reasons why Suggest steps to be taken to improve situation Arua District Implementation of Sustainability work Plan monitoring rcport. September 2005 37 4.7 INTEGRATION NOT CRUCIAL AT THIS LEVEL 4.8 FINANCE NOT CRUCIAL AT THIS LEVEL 4.9RECORD KEEPING 4.10 TRANSPORT NOT CRUCIAL AT THIS LEVEL Characteristics of the indicator Sources of information . Are data on CDTI available? o Are they properly recorded, properly stored and easy to access? o Are they analysed and used for planning,? o Are they reliable? o Are they integrated into record system at this level? o Inspection records, records system o Interviews with officials at this level Findings: Describe situation Community registers were available but most registers were properly recorded. Most of the registers seen were used for ivermectin distribution. Some did not have proper registers hence the records were incomplete. CDD not making summaries of their treatment records. Ifrecord keeping is poor give reasons why Due to lack of proper registers. Moreover, knowledge on record keeping seemed insufficient. In addition supervision was not systematic and regular Suggest steps to be taken to improve situation Most of the CDDS require training in reco rd keeping. Arua District Implementation of Sustainebility work plan monitoring report. September 2005 38 Ii 4.lTCOVERAGE I Sources of informationCharucteristics of the indicator lnspection of summary records for ivermectin treatment and rePorts. a Interviews with CDD and communitY members.. distribution cycle? Were all eligible persons treated in the last distribution cycle? a a Were all households treated in the last and some registers were not accessible due to poo. record keePingd not establish the community coverageFindings: Describe situation The team coul therapeutic cov€rage rates are below expected give reasons why coverageIf Most of the CDDS require t the importance ofraining on records. Srggest steps to be taken to improve situation Arua District ImPlementation of Sustainabitity work plan monitoring report. September 2005 39