Assessment of sustainability of the Kisoro CDTI project: final report

World Health Organisation African Programme for Onchocerciasis Control (APOC) Assessment of sustainability of the Kisoro CDTI Project Final Report June 2002 Authors: Geoffrey Tukahebwa Xavier Nsabagasani Asaph Turinde 2 3TABLE OF CONTENT TABLE OF CONTENT... Abbreviations/ acronyms. Introduction and methodology..... l. Introduction........... 3 ,.4 2. 7 7 7 8 Methodology........ 3. Adapting the instrument.. Findings and recommendations .......... District level Health centre/'sub-district' level ..... Village level..... Overall sustainability grading for the Kisoro project. Advocacy activities and planning workshops... 1. District.... 2. Sub-district/ first line health facility level. .....','..9 ..........9I 2 3 4 T2 t4 15 t6 23 26 26 34 40 Appendix 1: Program for "Feedback / planning" workshop at District & Sub-county Levels ..........18 Appendix 2 The District and Sub-county workshop processes.........1e Appendix 3 District level plan for sustainability ....................21 Appendix 4 Sub-County Level Plans for Sustainability, July 2002- June 2003 23 I. BUSANYA SUB.COUNTY CDTI SUSTAINABILITY PLAN FOR JULY 2OO2 TO JUNE 2OO3 2. KIRUNDO SUB.COUNTY CDTI SUSTAINABILITY PLAN FOR JULY 2OO2 TO JT]NE 2OO3 ,.,.24 3. NYABWISHENYA SUB.COUNTY CDTI SUSTAINABILITY PLAN (JULY 2002 - JUNE 2003) ..................2s DETAILED FINDINGS 3. Community level 4Ag. APOC CAO CBG CDD CDTI CFO DHE DMT DMO/DDHS DOCT DOC PAF LCI LCM LCV LGDP NGDO NOTF PHC wHo Abbreviations/ acronyms Acting African Programme for Onchocerciasis Control Chief administrative o ffi cer Capacity building grant Community directed distributor (of ivermectin) Community directed treatment with ivermectin Chief finance officer District health educator District medical team District medical officer/District director of health services District onchocerciasis control team District oncherciasis coordinator Poverty alleviation fund Village level authority Sub district level authority Local council level 5 (District Government) Local goverrrment development progtamme Non- governmental development organisation National onchocerciasis task force Primary Health Care World Health Organisation 5Executive Summary Kisoro District CDTI, one of the four Phase I projects supported by APOC in Uganda is in its fifth year of the five-year agreed funding support from APOC. An evaluation of the sustainability of the project was carried out in May/June 2002, by a team of three evaluators to execute the following: . Evaluate the sustainability of the project. . Working with local stakeholders to plan for sustainability, based on the findings of the evaluation. . Advocacy with local political and civil service leaders, regarding their future role in the sustainability of the project. The entire exercise was carried out over a period of thirteen days. Information was collected by document study, interview and observation, at sampled sites at three levels of the health service, namely, District, Sub-countyftrealth centre and village/community. The overall judgement of the team is that the Kisoro CDTI project is not far from being sustainable. Regarding the six elements of sustainability, the situation is broadly as follows: . Effectiveness: The project is effective at all levels. About 90 per cent of the people in the affected communities are receiving treatment. . Efficiency/financing: Many activities are not properly targeted, resulting in inefficient use of scarce resources. Supervision and training, for instance, are being carried out as routine activities or as motivation of CDDs and the supervisors. The lower level sub- county/health centre personnel are not yet fully empowered to carry out tasks at their level, and the DOC often carries such tasks alone or with the lower personnel. . Simplicify; Routines are generally simple and easy to carry out.t Integration: The programme is by now well integrated into the official health system at the District level. The same cannot be said of the Sub-county health centre level activities. Some activities are still prosecuted vertically at the health centre level. . Attitude: Some of the stakeholders have accepted the project as part of their responsibilities. However, some key players have not accepted the fact that they will have to cope withgut outside resources in the near future. t Resources; The project still relies too heavily on APOC. At the village/community level, CDTI activities appear sustainable. The sustainability potentials appears weak at the Sub-county/trealth centre level both because of lack of committed trained health centre staff and the heavy dependence on APOC resources for the vertical implementation of CDTI activities. The Sub-county/health centre and the District levels have to sort out the key issues of planning, funding, transport, and delegation of responsibility, if they are to be sustained. Detailed recommendations were drawtr up, based on the findings of the evaluation at the three levels. The recommendations were prioritised, and indicators and deadlines were suggested for each. These included: 6Identification of funds that will be available for the 2003 distribution and their respective sources. Also there should be clear identification of dependable alrangements for meeting deficits. High level advocacy involving the NOTF and MOH officials to the District level political and administrative machinery Rationalise the use of volunteer-supervisors and identify ways of sustaining them when APOC pulls out The evaluation team carried out advocacy activities at the level of the administrative leadership of the District. The newly elected LCV Vice Chairman was also met. She promised that if challenged the District will meet up with its responsibilities. ln the past, she argued APOC did everything, hence the District never bordered. Particular attention was also given to the DDHS, DHE and DOC as key players inn future action to ensure sustainability of the programme. One feedback/planning workshop was held for both the District and sub-county level stakeholders. The team gave feedback on its findings, which were discussed in depth. The evaluators and other facilitators then guided the participants to draw up realistic 'plan for sustainability' for their respective areas of operation. The workshop process worked well and considerable enthusiasm was generated. There is considerable agreement between the plans produced in this way and thee recommendations that the evaluators have made in this report. This may be attributed to the fact that the evaluators' recommendations were based on the findings, which were given as feedback to the workshop participants upon which they drew their plans. All the same the plan still needs to be thoughfthrough, refined and adapted to a participatory plan, involving all stakeholders, in the light of the recommendations made by the evaluators. Finally, there has to be a mechanism of ensuring that plan is meticulously implemented and not treated as 'business as usual' if the sustainability of the Kisoro project is to be assured. 7Introduction and methodology 1. Introduction Kisoro District, which lies in southwestern Uganda and borders Rwanda and the Democratic Republic of Congo, is one of the districts affected by Onchocerciasis in the country. The disease is prevalent in the northern sub-counties, which are at the fringes of Bwindi impenetrable forest. It is estimated that the disease affects 8 per cent of the population of Kisoro district in 31 villages. The affected sub-counties are Nyabwishenya, Kirundo, Busanza and Bukimbiri. The last district has only onchocerciasis endemic village. Kisoro is one of the first phase districts that started the CDTI programme inl997, under APOC funding iurangement. The Carter's Centre (Global 2000 River Blindness Programme) is the implementing NGDO in the area. The CDTI programme has greatly improved coverage in Kisoro, which is currently about 93 per cent. The communities where mass treatment is being carried out are enthusiastic about the CDTI and pledge support to the programme. However, the individual community members indicate that they are unable to financially support or sustain the programme allegedly due to poverty. The local governments however, that is thee district and the sub-counties have shown willingness to support that programme financially. However, this commitment is yet to be realised in terms of budgetary allocations and incorporation of CDTI activities in the district and sub-county plans. There is an obvious need to sensitise the politicians at the sub-county and district levels since the councils are new. It is their committment in terms of budgetary allocations, that will be sustain CDTI. 2. Methodology This is given in detail in the document: 'Using the instrument to determine the sustainability of APOC projects'. . Research question: How sustainable is the Kisoro CDTI project? . Design: Cross-sectional, descriptive. . Population: The Kisoro project, including its DOC; its NGDO partner; its Districts with their project villages and their CDDs. . Sampling; * All the three health units in the affected part of Kisoro district were selected. All the health units are located in Bufumbira North Health Sub district where the disease is prevalent. Four sub-districts (one with high coverage, one with low coverage and two with medium coverage). These were selected according to the level of the past three years perforrnance and the levels of endemicity and geographical locations of the sub districts in the main District were used for further stratification, to ensure good representation of the different segments in the population. Thus the following villages were selected. In Kirundo subcounty, Higabiro and Kashaka; in Nyabwishenyi sub 8I county we went to Kikomo and Nyarutembe; in Busanza sub-county Gakenke and Kinanira were visited. In Bukimbiri sub county Nyamasinda village was visited. Instrument: * Questionnaire (see appendix: 'Detailed findings') structured as a series of indicators of sustainability. The indicators are grouped into 9 categories. * The instrument assesses sustainability at 3 levels of operation within the district. * The instrument guides the researcher to collect relevant information about each indicator. Source of information:Yerbal reports from persons interviewed, supplemented by documentary evidence. Analysis: * Based on the information collected, each indicator is graded on a scale of 0-4, in terms of its contribution to sustainability. * The average 'sustainability score' for each group of indicators is calculated, for each level. * A qualitative description of problem areas is given. 3. Adapting the instrument Overall the instrument (as designed in Ouagadougou and subsequently operationalised in Pretoria) worked well. The interviews and document study were easy to carry out and did not take long. The instruments were highly effective in identifying problem areas and user friendly. 9Findings and recommendations L. District level 1.1 Overall grading (on a scale of 0-4) Kisoro district: Slef-sustainabilaty at district level 4.5 4 3.5 3 IoI'u oo$z lSsriesl ,| 0.s 0 Coverage Planning Leadership fironiloring l\,lectian TEining / Funding Materials Mobilisation Group of lndlcators Human Rgsources 2.1 Main findings included in the planning. the technical staff, not because of political leadership or commitment. problems and is empowering others to manage their own problems but there is evidence of excessive supervision system runs parallel to normal drug distribution and depends on one man. involved in training to the level of CDD with no evidence of in-service training for other medical personnel. funding in the future but there are no clear budget lines, no evidence of the district 10 progressively taking over CDTI and no evidence of plans to make up the shortfall in the future. maintenance of the vehicles but there is no evidence of a plan to sustain the vehicle after APOC. stable but he has no support and there may be problems with replacing him. Recommendations Recommendations Implementation Leadership. r { detailed plan of CDTI activities and requirements for the year should be developed. . There should more be more advocacy among the politicians among the top management Priority: HIGH Indicators ofsuccess: . Detailed plan produced ' Should be reflected in the budget and work plans. Wo to take action . DOC . DMT Deadline for comp letion: End June 2002 Supervision. r I detailed plan needs to be developed for the DOC, making optimal use of available resources and focusing activities. The oncho coordinator should desist from supervising beyond the health facility level (sub-county level). Priority: HIGH Indicators ofsuccess; . New year plan developed . Activity plans and monitoring schedules are limited to the health facility sub-county. . Supervision activities should be reflected in the detailed plan. Who to take action . DOC r DMT Deadline for completion; Dec2002 Mectizan. A plan for distribution of Mectizan needs to be developed, in co-operation with all DMT members, channelling it through normal district distribution mechanisms. Priority: MEDIUM Indicators ofsuccess: . Plan for distribution of Mectizan . More than one DHT staff involved in the distribution . Stock cotrol cards at the center should reflect another person doing the deliveries Wo to take action: . DDHS . DMT . DOC Deadline for completion: . December 2002 Fundine. Priority: HIGH 11 The district has to be strongly motivated to accept responsibility for funding CDTI activities planned for above. Explore possibilities of accessing other sources of funds Indicators ofsuccess: . Indicators of CDTI activity included in budget or increased budgetary allocation for areas of CDTI activity. r Proposals submitted elsewhere for funding Who to take action: . DMT . DMO . The CAO . The planner Deadline for completion: End July 2002 Training. DOC should limit training to sub county/facility level and the plan should be developed for other district staff about CDTI Who should take action . DMT . DOC Indicators ofsuccess t Increased Involvement of other staff in the CDTI activities . Reflected in the detailed plan . Training manuals developed End of the planning year Materials. r { detailed and realistic plan needs to be developed for the sustained use of transport after the termination of program funds. This plan may include complementary funding or inclusion in the budget. Priority: MEDIUM Indicators ofsuccess: r I detailed plan Wo to take action: . DDHS Deadline for comp letion . December 2002 Human Resources. r { plan must be developed for the in- service training of other district health workers and . Other personnel must be integrated into the CDTI activities. Priority: MEDIUM Indicators ofsuccess: r { training timetable . Inclusion in other personnel's work plans of CDTI activities. r I training manual developed Who to take action; . DMO . DMT Dead|ine for completion; December 2002 I 12 2. Healthcentre/'sub-districtrlevel 2.1 Overall grading (on a scale of 0-4) 2.2Nlain findings evidence of systematic planning. network. up to the village level and the reporting is parallel to the district system. problem is that the DOC does most of the training. working conditions are not conducive. Kisoro district: Self-sustainability at health centre level 45 4 3.5 E,u T{6t o 1.5 1 0.5 0 CoveBge Planning Leadership Monitoring Mectian TEining / Mobilislion Funding [,laterials Human Resources Group of lndlcatort 13 2.3 Recommendations Recommendations Implementation There is need for systematic systematic planning for CDTI activities together with other health activities. There is need for more CDTI advocacy at this level. Priority: HIGH Indicators of success: Workplans reflecting CDTI activities and the related budgetary allocations. Who to take action: DOC Sub-county Government . Focal person ln-charge of CDTI Deadline for completion: . September 2002 Distribution of ivermectin should be integrated in the drug distribution system of the health centre. The reporting system should be integrated within the district and facility reporting system. Priority: Indicators of success; . Distribution of ivermectin being championed by the in-charges and anyother facility staff. . CDDs reporting to facility staff not the DOC. Who to take action: . Health Unit In-charge . DOC Deadline for completion; . ByJanuary2003 The Health Unit Focal persons should supervise the lower levels and should the ones to train CDDs DOC should build capacity for the Focal persons and supervisors to handle supervision and training of CDDs. CDDs and Supervisors should be facilitated particularly during distribution of ivermectin. Priority: Indicators ofsuccess: Reports of training and supervision of CDDs conducted by supervisors and focal persons. Reports of CDDs acknowledging receipt of money for distribution of money. Work-plan reflecting the above activities. Number of supervisorsffocal Persons trained as trainers. Developed Training Guidelines Who to take action; Focal Persons and Supervisors DOC Sub-county govemment DMT Deadline for completion By January 2003 I I E Z.J .9o 'oED'G- o 4.5 4 3 .5 0.5 3.5 0 t4 3. Village level 3.1 Overall grading (on a scale of 0-4) 3.2 Main findings Kisoro district selfcustainability at community level Coverage Hannhg Leadership [tibnitoring ]vbctizan Training / lvbbilisation Funding lt/aterials Group of lndlcators financial contribution due to biting poverty. l-funsn Resources 15 3.3 Recommendations 4. Overall sustainability grading for the Kisoro project The potentials for sustainability in this district is high for the following reasons: 1. Both treatment and geographic coverage rates are high 2. There is a commendable level of commitment from the implementers at this level. The political leadership also demonstrated some commitment when sensitised to the problem and CDTI philosophy. Recommendations Implementation Priority: Indicators ofsuccess; Who to take action: I Deadline for completion; Tick one correct assessment Level of sustainability Description Excellent This proiect is completely sustainable Hish This project is not far from being sustainable. With feedback from the team before departure, the project staff should be able to undertake the required remedial action. Moderate This project is potentially sustainable, but will require rethinking and mobilization of high-level support to get it on the road again. Low This project is seriously unsustainable - there is some doubt as to whether it ever will be. It needs a lot of immediate expert guidance from outside. t6 Advocacy activities and planning workshops This section describes how the evaluation team went about fulfilling the second task of this current assignment, which was to . LJse the findings of the evaluation in a practical way, to help local stakeholders to plan for optimal sustainability of their projects. It was felt that this would b much more powerful than sending yet another report a few weeks later. 1. Advocacy The team undertook the following advocacy activities within the District: . Visit to the LCV Vice-Chaimerson: The evaluation team paid a courtesy call on the leadership of the local govemment (LCV). The Vice Chairperson received the team on behalf of the Chairman, who absent. The Vice Chairperson was informed that APOC funding and assistance will come to an end in November 2002, and the District will be expected to sustain the gains made so far in ensuring mass treatment with Mectizan in control of onchocerciasis in the endemic communities. Unfortunately, the Vice-Chairperson expressed ignorance first of the disease and the CDTI programme. This was attributed to the fact that she is new in office and she comes from the hypoendemic region of the District. She however, noted that attention would be given to the disease if it is their problem. Meanwhile, she rhetorically asked if you would expect anyone to be committed to an unknown issue. It is however heartwarming to note that she attended and participated in the planning meeting, and made meaningful contribution. She also indicated that with the new understanding she thinks the District is in a good position to support the programme. In the past, according to her, "the District was not challenged. The programme was supported by APOC. If challenged the LCV administration will live up to expectation". Visits to the Leadershio of the District: The team met with administrative machinery of the District, represented by the Ag. CAO, and his colleagues. The team briefed the District administrator on the findings from the evaluation exercise and requested the support of the administration in ensuring that CDTI is sustained in the District. 2. Feedback/ planning workshops 1.1 District and Sub-county levels A combine workshop for the two levels was held on Saturday Sth June, in Mubanu Hotel, Kisoro. The workshop for the two groups was combined because the District health team was too small to justify a workshop for it alone. Moreover the sub-county participants operated almost at the same level with those at the District. However, District and sub-county participants did the actual planning separately. Furthermore sub-county had its planning conducted by people from the same sub-county, after the brain-storming session on solutions to the problems identified by the evaluators and discussed at plenary. In attendance were: the t7 evaluation team; the DOC and the District health team, the Ag. Chief Administrative Officer, among others. The full programme is given in Appendix 1, and the detailed proceedings in Appendix 2. The following is a summary of the workshop process: . Introduction to the workshop process . Presentation: what is sustainability? . Brief report of evaluation team's findings at the district and community levels. ' Detailed report of the evaluation team's findings at health facility and district levels . In-depth open discussion on the findings and their implications. . Group work: 'Preparing broad recommendations for action at the District/ project level and sub-county level'. Each small group made suggestions conceming three of the nine groups of indicators. This was followed by goup report back and discussion. ' Group work: 'Planning for sustainability at DistricV project level and Sub-county'. Groups had wo tasks: making a plan for 2003, and identifying resources for 2003. However, it was noted that the plan period for the District and Sub-counties is usually July-June. Moreover due to time constraints, only one of the tasks could be completed while others argued that it would be more rewarding to go back with the new knowledge and involve more technocrats in the planning for sustainability. . Again the draft plans for sustainability was followed by group report back and discussion. . Open discussion: 'The way forward implementing sustainability in the Kisoro District CDTI proiect'. The workshop process was successful. There was a lively exchange of views throughout the day, with the final plan being very much a consensus document. It is hoped that the plans will be fused into the impending District plan. The District planner, who was present at the workshop requested that copies be made available to him for incorporation into the district rolling which they are in a process of producing. The 'Kisoro District sustainability plan for the next one year-fiscal year' now exists - but it clearly still needs to be put into practice. This is primarily the responsibility of the DOC and local NGDO staff, and these persons need to be actively encouraged by the NOC, and national NGDO coordinators. In particular, the project leaders need to look critically at the evaluation team's recommendations as they appear in this report. The new political leadership needs to be adequately sensitized because a good number come from Onchocerciasis hypo-endemic areas of the District. 18 Appendix 1: Program for "Feedback / planningo' workshop at District & Sub-county Levels AGENDA 09:30 - 10:00BREAK TEA. To be appointed10:00 - 10:05Opening prayerI DMO/DOC10:05 - 10:10Welcome2 NOC/DOC10:10 - 10:15IntroductionsJ Dr. Ndyomugyenyi10:15 - l0:20Introduction to the workshop; what are the obiectives 4 Dr. Okeibunor10:20 - 10:30Background: what is sustainability5 Team Leader for the District project 10:30 - I l:00Brief summary of the report; How was it done Summary of findings 6 Dr. Ndyomugyenyi:00 3011 - 1l7 Brainstorm; what could be the solutions to these problems. Group 1: Finances, monitoring and supervision Group 2: Planning, training and mobilisation. Group 3: Transport and leadershiP 11:30 - 12:00 Team leader8 Feedback from group work Dr. Okeibunor12:00 - 12:30e(a) Planning for sustainability in this project. Group work. Plan CDTI activities for the year Identify resources for these activities. 12:30 - 13:1510 LUNCH Dr. Okeibunor13:15 - l4:15e(b) Continue planning for sustainability in this project Dr. Okeibunorl4:15 - 14:4511 Report back from group work Dr. Ndyomugyenyi14:45 - 15:00t2 The way forward: implementing sustainability (what to do now) Dr. Ndyomugyenyil5:00 - 15:1513 General matters and closure Itcnr Activit Time Fac ilitator t9 I Appendix 2 The District and Sub-county workshop processes The following is a record of the process of this workshop Introductions and summary of findings . The Evaluation team leader introducedthe elements of sustainability: effectiveness, efficiency, simplicity, integration, attitude and resources. . Reasons for evaluating the Kisoro CDTI project was discussed. . The general method was to attempt to get the participants to contribute to discussions. . The District and sub-county teams were presented with a summary offindings at dffirent levels. This was just to acquaint them with the situation at these levels. . The meeting then discussed the findings together. There was enthusiastic discussion on the summary of findings at the different levels, with the evaluation leader facilitating discussions on each of the issues raised. The group arrived at the following conclusions: * There is need for more sensitization and publicity. Many people do not know about the disease because it is in small focus. For instance, in one of the endemic sub-counties only one Parish has the disease. According to the DMO only 8 per cent of the people in the District are infected. " The Vice Chairperson noted that even though the vector is not in some areas, it is necessary to plan against the transmission of Onchocerciasis because the vector may learn to move to other areas. * On training, it was noted that health workers were not easily available hence it became necessary tto train community members. With the increasing involvement of community members, there was a demand for more CDDs, so now the District has 372 CDDs. It was also argued that they train to get enough to run the programme when APOC moves out; to get people on standby, and to replace CDDs that move out. Community members were also trained as supervisors because the endemic areas are under-staffed. " The Sub-County Chairpersons and Chiefs present undertook to sustain the supervisors to carry out CDTI activities if they are rationalized to fit into the resources of the sub-county. * Trainings will be targeted to reduce cost * The components of the LGDP fund and PAF which deal with training and capacity building will be exploited to cover CDTI trainings.. * The District planner also hinted that the CDTI issue would be mentioned in the Donors'Forum. * Generally, the findings were taken as the correct picture of what is on ground. They however, noted that though they have been forewamed of APOC withdrawal they never new it will be so soon. 2. Group work I: Making recommendations for sustainabitity on the basis of findings Owing to the small number of participants, the problem areas were discussed in the plenary. The participants were the main discussants while the NOC, leader of the team that evaluated 20 Kisoro district and Dr. Okeibunor acted as facilitators, ensuring that the sustainability issues were covered. 3. Group Work II: Planning sustainability at the DistricU project and Respective Sub- county levels Before adjourning for lunch the participants were divided into two groups, namely the District and sub-county groups. Further, the sub-county groups was subdivided into seven groups, putting every body from one sub-county in one group. The groups were asked to develop a plan of action to address realistically the recommendations made in the first group session. These topics were: a. Planning for Resources for 2003 (identification of dependable resources, estimate likely amounts to be required for activities, rank sources in order of dependability) b. What needs to be done during 2003, the following distribution period (list essential activities, requirements and costs). The teams came up with their plans, which were discussed and considered realistic and practicable within the system. The outcome of these activities were presented and discussed in plenary after lunch. !o Lq)tr lro o a o)aJC\ =o;N (\tOo c.l Lr 0,) (DE = 0:)ji> oooz c.l N o bo) I =:- oH C! z o hI"o d(Jts- (\ o ,an ^aDi5 q) .Eg EI' E - _i() !O'€otr(:o =ooo8E EE r - t ti-o '^ Eis?.E-aEoEr .F.- V i-.J'- \.-!.)L____Ar E E E E E.E#:EgEPSgEEE 0)oLr T,E > YEE '5(Do) € a *E :t-*LUE=fi -F96H9V.- Qtoo0) V9ec (B'= cgd=.=! bo (.) o.=tr tr cB.= 'E 6- s!--HH +b Ea.=az (t o 00)A00trctO :a .o 0)( o-' r'I8B ooo HE B'rr E(l) L- 6689ar arl .ao olr a a a E acB 8.9(l)lr E,Z H ! r-.' 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GT N h -ErA -(J L E q)IL o C,)q)i - e.t cr.l 6lI(t, (t) la c) L +J rt) n o Lr o(n E 23 Appendix 4 Sub-County Level Plans for Sustainability, July 2002- June 2003 1. BUSANYA SUB-COUNTY CDTI SUSTAINABILITY PLAN FOR JULY 2OO2 TO JUNE 2OO3 Busanya Sub-county sustainability Resource for CDTI, July 2002- June 2003 No. Activity Objective To be carried out by Indicator of success Period I Community mobilization and sensitization of councilors from oncho-endemic areas. To make the councilors aware of oncho-disease and the current situation ofCDTI CDDs, DOC, LCIII and sub- county chiefs Well informed councilors willing to take over the CDTI programme July- September 2002 2 Meeting community leader and training of new CDDs To get the leaders informed on the new CDTI arrangement Supervisors, sub- county chiefs, health workers in oncho endemic villages Active participation of leaders and trained CDDs to take over from dropouts October- December 2002 3 Planning and budgeting for CDTI implementation To have well programmed activity plan and resources. Sub-county councils, with DOC's technical assistance Well developed and documented budget tailored to the resources ofthe sub- county January- March 2003 4 Supervision, and monitoring in problem areas To ensure compliance with the rules of CDTI in oncho areas. Health workers, LCIII chiefs and councillors Smooth implementation of CDTI April- March 2003 No. Activity Resources Needed Sources of Resources How to Obtain these Resources How sure are the sources 1 Community mobilization and sensitization of councilors from oncho-endemic areas. Technical resources Sub-county and District District support Because of govt.'s commitment 2 Meeting community leader and faining of new CDDs Funding Sub-county, District and Central govt. Being included in sub-county and district budget It will be integrated into sub-county and district annual budget and work plan 3 Planning and budgeting for CDTI implementation Training and IEC materials Sub-county and District Seeking help from the higher levels ofgovt. With its reflection in sub- county budget and the commitment of the central govt. 4 Supervision, and monitoring in problem areas Transport Subcounty, District and Central govt. From the district and individual efforts The sub-county is committed. 24 2. KIRUNDO SUB.COUNTY CDTI SUSTAINABILITY PLAN FOR JULY 2OO2 TO JUNE 2OO3 Kirundo Sub-county sustainability Resource for CDTI, July 2002- June 2003 No. Activity Objective To be carried out by Indicator of success Period 1 Sensitize council To ensure the awareness of the councilors on CDTI Sub-county chiefs and LCIII chairperson Councilors will be better informed and take responsibility for funding CDTI Jtne2002 2 Planning, budgeting and rationalization of supervisors To streamline the number of supervisors and allocate funds to CDTI Council and LCM Oncho control will be funded by the sub-county and the supervisors reduced to manageable number June 2002 J Drug distribution Disease control CDDs, and health workers Higher coverage rates January - February, 2003 4 Supervision and reporting Proper implementation of CDTI in the sub-county CDDs and supervisors Record of success and failure February- April 2003 No. Activity Resources Needed Sources of Resources How to Obtain these Resources How sure are the sources 1 Sensitize council Personnel LCIII and District Selected from the existing staff of the sub-county and District The personnel is already there. 2 Planning, budgeting and rattonalization of supervisors Technical District (Doc) Requesting the DOC to assist The DOC is committed to the success of CDTI 3 Drug distribution Financial Sub-county, LGDP, APOC, District Lobbying and assessing the LGDP funds The funds are already there 4 Supervision and reporting Financial Sub-county, LGDP, APOC, District Lobbying and accessing the LGDP funds The funds are already there 25 3. NYABWISHENYASUB.COUNTYCDTISUSTAINABILITY PLAN (JULY 2002 - JUNE 2003) Nyabwishenya Sub-county sustainability Resource for CDTI, July 2002-June 2003 No. Activity Objective To be carried out by Indicator of success Period I Mobilization and sensitization of all stakeholders in the sub-county To create awareness for everybody on the need to support CDTI and also create political will LCm chief, chairperson and sub-county chief Increased support for CDTI December, 2002to January 2003 2 Sensitization of the religious sect that refuse treatment To get them to accept treatment LCUI chairperson, DOC, DDHS and chiefs The religious sect will now accept treatment January to February, 2003 3 Rationalization of supervisors from 17 to 8. To get the number the sub- county funds can support DOC, sub- county chief and LCIII The support of manageable number of supervisors will be reflected in the budget January to February 2003 4 Collection of all sub-county local revenue. Fulfilling LGDP minimum requirements. Assessing and utilizing capacity building grant To enhance the sub-county's ability to finance the whole budget The capacity building grant will help in training CDDs. Sub-county chief and LCIII Extra funds sourced for CDTI activities On-going No. Resources Needed Sources of Resources How to Obtain these Resources How sure are the sources I Money LCIII council, APOC, LGDP, CBG, PAF Budgetary allocation, Donation. Approved budget, LGDP and CBG are there. We only need to qualify for them 2 Personnel LGDP, MOH. LCM council Delegation of staff from MOH, Recruitment by the LCIII This routine civil service operation 3 Stationary LCm council Budgetary allocation Budget approved 4 Equipments LCUI, MOH, Govt., APOC, CBG, LGDP Proposal writing The funds are there for accessing. 26 DETAILED FINDINGS 1 District f.fiai,P'tUvehaBe .f :i.",.; '-:,'.-..';-"'i-, ..' ,' 1.1 Check whether the geographical coverage in the health district/ LGA is indicator of effectiveness 1.2 Check if all sub-districts and villages have a satisfactory therapeutic coverage rqte indicator o f effectiveness t; '' Platnlng 2.1 Check if the year planfor CDTI appears as part of an overall written planfor the health district's activities (it may appear under another name, e.g. 'onchocerciasis indicator of and effectiveness Fully (100% coverage). (All the 3l affected villages were reported under treatment. This was evidenced review of and interviews with DDHS and DOC.) Findings:All sub-districts and villages identified by the latest REMO are under treatment (i.e. the geographical coverage rate is 100% and stable). This should be confirmed by comparing coverage records with the REMO list of endemic villages Slightly (many villages/ hamlets not covered) Moderately (a few villages/ hamlets not covered) Is this good for sustainability? Highly (problem with nomads onl Findines: Fully (>90o coverage) Some people few were reportedly not taking drugs due to; sickness, pregnancy and migrant labourers. There were also religious sects which refuse the drug. The therapeutic coverage rate should be: . 65(% or higher . stable or increasing. Moderately (65- 79o/o covetage) Slightly (less than650/o coverage) Is this good for sustainability? Highly (80-89% coverage) )rogramme' CDTI should be integrated into the overall plan (showing that the DMT members consider CDTI to be part of their yearly routine, like any other programme). It should not be separate. Findines: Fully integrated. Onchocerciasis control is an integral part of health plans and falls in the section of control of communicable diseases. Moderately Sliehtly Not at all Not applicableIs this sood for sustainability? 25 3. NYABWISHENYASUB-COUNTYCDTISUSTAINABILITY PLAN (JULY 2002 - JUNE 2003) Nyabwishenya Sub-county sustainability Resource for CDTI, July 2002-June 2003 No. Activity Objective To be carried out by Indicator of success Period 1 Mobilization and sensitization of all stakeholders in the sub-county To create awareness for everybody on the need to support CDTI and also create political will LCm chiel chairperson and sub-county chief Increased support for CDTI December, 2002to January 2003 2 Sensitization of the religious sect that refuse treatment To get them to accept treatment LCM chairperson, DOC, DDHS and chiefs The religious sect will now accept treatment January to February, 2003 3 Rationalization of supervisors from 17 to 8. To get the number the sub- county funds can support DOC, sub- county chief and LCIII The support of manageable number of supervisors will be reflected in the budget January to February 2003 4 Collection of all sub-county local revenue. Fulfilling LGDP minimum requirements. Assessing and utilizing capacity building grant To enhance the sub-county's ability to finance the whole budget. The capacity building grant will help in training CDDs. Sub-county chief and LCIII Extra funds sourced for CDTI activities On-going No. Resources Needed Sources of Resources How to Obtain these Resources How sure are the sources 1 Money LCm council, APOC, LGDP, CBG, PAF Budgetary allocation, Donation. Approved budget, LGDP and CBG are there. We only need to qualify for them 2 Personnel LGDP, MOH. LCM council Delegation of staff from MOH, Recruitment by the LCIII This routine civil service operation J Stationary LCIII council Budgetary allocation Budget approved 4 Equipments LCIII, MOH, Govt., APOC, CBG, LGDP Proposal writing The funds are there for accessing. 26 DETAILED FINDINGS 1 District 1. Coverage 1.1 Check whether the geographical coverage in the health district/ LGA is indicator of 1.2 Check if all sub-districts and villages have a satisfactory therapeutic coverage rate indicator of effectiveness 2. Planning 2.1 Check if the year plan for CDTI appears as part of an overall written plan for the health district's activities (it may appear under another name, e.g. 'onchocerciasis of inte and effectiveness Fully (100% coverage). (All the 31 affected villages were reported under treatment. This was evidenced review of and interviews with DDHS and DOC.) Findines:All sub-districts and villages identified by the latest REMO are under treatment (i.e. the geographical coverage rate is 100% and stable). This should be confirmed by comparing coverage records with the REMO list of endemic villages Slightly (many villages/ hamlets not covered) Moderately (a few villages/ hamlets not covered) Is this good for sustainability? Highly (problem with nomads Findinss: Fully (>90o/o coverage) Some people few were reportedly not taking drugs due to; sickness, pregnancy and migrant labourers. There were also religious sects which refuse the drug. The therapeutic coverage rate should be . 650% or higher . stable or increasing. Slightly (less than 650/o coverage) Is this good for sustainability? Highly (80-8e% coverage) Moderately (65- 79o/o coverage) )rogramme'. CDTI should be integrated into the overall plan (showing that the DMT members consider CDTI to be part of their yearly routine, like any other programme). It should not be separate. Findines: Fully integrated. Onchocerciasis control is an integral part of health plans and falls in the section of control of communicable diseases. Is this for Moderately Sliehtlv Not at all Not applicable Fully (100% coverage) Fully (>90% coverage) HiehlvFully 27 2.2 Find out if the yearly plans were drawn up in a participatory way (the overall district/ LGA and the CDTI lan indicator of effectiveness 2.3 Check if the plan contains all the elements needed for CDTI to work well of effectiveness 3. Providing leadership 3.1 Check if the district management team (DMD is taking full responsibility for CDTI of and attitude 3.2 Check if there is evidence of political commitment to CDTI in the district/ LGA indicator of and attitude In both cases planning should involve all relevant staff (e. g. sub-district, pharmaceutical staffl preferably in a worl<shop situation. Findines: Highly. Lower plans feed into the district plan. During planning period, the different departments and NGDOs meet and draw up an overall district plan taking into account priorities of each department/stakeho lder. Is this good for sustainability? Fully Moderately Slightly Not at all Not applicable The plan should make provision for all key elements. Checklist of key activities: Mectizan supply; targeted training; targeted mobilisation/ sensitisation; monitoring and supervision Findines: Moderately. The plan is integrated. It is up to the department concerned to specify priorities. Hence it is difficult to discern whether the key oncho activities are catered for in the plan. Is this good for sustainability? Fully Not at all Not applicable It should be the DMT which is initiating the key CDTI activities: planning, monitoring/ supervision, training, Mectizan ordering/ distribution. The DMT should no longer depend on the State/ regional/ NGDO leadership to carry out CDTI. Findines: Slightly. Most of the activities are initiated from the national APOC offices. The DMT merely implements prescriptions from the headquarters. Resources are the major constraints to the districts taking initiatives Is this good for sustainability? Fully Hiehly Moderately t1i$filbl..d#fl Not at all Not applicable The senior person (politician/ civil servant) in charge of health matters at district/ LGA level lcnows about CDTI and appears committed to it. There is evidence of specific past budgetary allocations and disbursements for CDTI, and the amounts are increasing. Findines: Slightly The Acting. LC 5 chairperson confessed not having heard about onchocerciasis and did not know the CDTI initiative. She has never had any matters concerning oncho being discussed in the council. Even though, there has been increasing budgetary allocation to CDTI, this has been under the push of the district health technical staff. The realisation of the magnitude of the problem remains I 28 4;rri!,""'siipelvlsionandmonitorlng i- " : 4.1 Check if the relevant person at the LGA/ district level is routinely and fficiently supertising the CDTI activity of the sub-districts on site (indicator of effectiveness and effici 4.t Check if routine data concerning CDTI activities at this level are collected and transmitted entirely within the government system (indicator of the concern of the technical staff who have to lobby a lot to have oncho taken care of in the budgetary allocations. In principle, the coordinator should stop at the supervision of the supervisors of CDDs. However due to the latter's deficiencies Fully Highly MNotatall Not applicable Findines: Slightty The DOC tries his level best to reach all the onchocerciasis communities' .The DOC efforts are'onchocerciasis hampered by the mountainous terrain that makes his movement difficult. Hence the success of the program is solelY depends on that. In addition to running CDTI, he runs other Programmes in the whole district and yet he is alone). In principle, the coordinator Should stop at the supervision of the Supervisors of CDDs. However due to the latter's deficiencies he goes beyond. There should be evidence that each sub- district is visited at least once around the time of distribution. There should not be unnecessarily many visits - here should be clear justification for each one. Only the sub-district is routinely visited, not the villages. I I Not applicableFully Highly Moderately E NotatallIs this good for sustainability? Findines: Highly. (The data is stored and handled together with other vector control data. The issuing of Ivermectin is the same as other drugs from the same store. Stock and dispatch cards are available within the filing system). The reporting process should be within the government system, not using other resources Not at all Not applicableModerately SlightlyIs this sood for sustainability? Fully 29 4.3 Check whether there is a routine process of management of problems and successes, which are indicated by the monitoring system (coverage data, visits and of effectiveness and attitude 5. Ordering md distributing Mectizan 5.1 Check if sfficient Mectizan is being ordered yearly, and in good time indicator of effectiveness 5.2 Check if Mectizan is being stored and administered within the government at this level of As soon as problems are identified in this way, the appropriate manager deals with them. Planning must include activities, which will improve coverage in areas where it is unsatisfactory. Successes are noted and reported, and appropriat e feedb ack giv en. The CDTI co-ordinator should be empowering the next level to cope with problems. Checklist of key activities: sensitisation/ mobilisqtion ; training; improving Mectizan supp ly ; effective/ supportive supervision Findines: Highly. (The DOC makes regular visits to communities and discusses local problems with the CDDs, supervises the oncho focal persons at the Facilities. The supervisors and CDDs reported that they are in regular contact with the oncho Coordinator. Sliehtlv Not at all Not applicableIs this good for sustainability? Fully Moderately . The orderforms for the health district/ LGA exist, and are based on the sub- district orders. . The Mectizan is availablefor the LGAs in timefor distribution at a time which is convenient to villagers. . There are no reports ofshortages. . If there have been shortages, there are specific plans to remedy them. Findines: Highly. There were no reported cases of shortages of ivermectin both at the district, the facility and the village levels. Stock cards at the DDHS' office verified this. Fully Moderately Sliehtlv Not at all Not applicableIs this good for sustainability? The Mectizan: . Should be orderedfrom the next level using forms supplied by the government. . Should be stored in a room made available by the government at this level - preferably in the same room as the other drugs. . Should be controlled within the government system, preferably using the same stock control system as for other drugs. Findines: Moderately. (Other than being kept in the same store amongst other items and handled by the same storekeeper, the stock control cards and order forms are those not supplied by government. The cards/forrns are specifically designed for CDTI drug) Fully Not at all Not applicableIs this good for sustainability? I I I Highly Hiehl Hiehlv SliehtlvModerately 30 5.3 Check if Mectizan is being distributed appropriately and effectively to the sub- districts indicator of effectiveness td*'i;'ia::i'rt?dlhlng end sensltlsatlon/ mobillsetlon NOTE: ' This refers to training and sensitisation activities performed by officers working at this level, for the next level. 6.1 Check if only necessary training is being done (indicator of efficiency and done the indicator of efficienc and 6.3 Check if in-service trainingfor CDTI is being integrated with other health e at this level indicator of and Findines: Slightly (Ivermectin was reportedly in all cases delivered from the district to the facility by DOC himself using APOC funds. Without this effort, it is doubtable as to whether communities or local govemments can transport this drug to the target goup. The sub-districts should obtain the Mectizan by means of transport supplied and paidfor by the government at the district/ LGA level Preferably the sub-district shouldfetch the Mectizanfrom the district/ LGA level store. a Not applicableModerately E Not at allFully HighlyIs this for urrpuur[, I There should be an objective needfor each episode of training: * There must be evidence that staff to be trained lack lcnowledge and skills to perform the job. * Training to motivate staffis not a suffi cient reas on for training. The evaluator must be satisfied that the duratton of training was justified. Findines: Highly. The training carried out is either refresher usually before distribution of ivermectin or orienting new supervisors and CDDs in CDTI. No respondent reported training being conducted for purposes of motivating staff. Is this good for sustainability? Fully Moderately Slightly Not at all Not applicable Findinss: Moderately. This is because the staff does not stop at training health workers at facility level. Even during training of CDD, he is part of the training team). Staff of this level only trains the level immediately below it, and notfurther down. Not at all Not applicableFullyIs this good for sustainability? Findines: Not at all. (It is targeted training for only CDTD Training for CDTI should be integrated into the yearly plan for in-service training in the health district. Slishtly E Not applicableFully Highly ModeratelyIs this good for sustainability? 6.2 Check that training conducted at this level (i.e. training of sub-district staff) rs r( Hiehlv Moderately Slishtlv 31 6. Financlns/ fundipg , .: - 7.1 Check whether the cost implications of each CDTI related activity (monitoring/ supervision, training/ mobilisation, Mectizan distribution) are quantified in the the health district/ LGA indicator of effectiveness 7 .2 Check whether appropriate and adequate amounts are budgeted for the anned CDTI related activities of effectiveness and 7.3 Check whetherfunds to cover these costs are increasingly being suppliedfrom district/ LGA resources of 7.4 Check if in case of a deficit between estimated costs and the amount provided by the government, dependable provision is being made to meet ir (indicator of effectiveness and The costs for each CDTI related activity in the year plan should be clearly spelt out in the budget. Recurrent and capital costs (tf any) should be separated in the budget. I (It is block budgeting without specifying costs for individual activity such as those related to cDTr). Findines: Not at all. Moderately Sliehtlv lar,ffilfiW Not applicableIs this good for sustainability? Fully Highly The amounts budgeted should be neither excessive nor too small - managers should be able to justify the need for each amount, in relation to: . The outcomes resultingfrom the previous year's CDTI expenditure . The cost of similar activities for other programmes. Findines: Is this good for sustainability? Fully Highly Moderately Slightly Not at all Findinss: Slightly. There is no clear indication that the funds from the district were increasing and those from APOC decreasing. The relative contributions of the district/ LGA and other partners should be clearly spelt out The proportion provided by the fficial health service should be the major one by now. This proportion offunds is increasing yearly. I a Is this good for sustainability? Fully Highly Moderately I Slightly I Not at all Not applicable Management is aware of the size of the shortfall, and has specific and realistic plans to bridge it. If it is planned that non-government sources offunding are to be used after APOC funding ends, written commitment for this must have been obtained at the highest level in these donor organisations (e.s. a Memorandum of Understanding). a (No reliable source to meet shortfalls has yet been identified. Only plans to solicit funding from other donors were noted after APOC Funding ends). Findines: Not at all. Is this good for sustainability? Fully Highly Moderately Slightly hffiffi&fuU Not applicable I I 32 7.5 Check whether CDTIfunds in the health district/ LGA budget are fficiently indicator of effectiveness and efficienc 8. Transport and other materlal resources 8.1 Check if there is sufficient transport for necessary visits to the sub-district level CDTI related activities indicator of effectiveness 8.1 Check if trips/ journeys undertaken for routine CDTI purposes are integrated with those made for other programmes or purposes (indicator of integration and effici (Each expenditure is approved and allocation Based on health budget). Findines: Highty. The budget holder uses a control system with the following elements : . Approval ofeach item ofexpenditure . Allocation of expenditure against specific budget headings . Regular calculation of residual amounts under budget headings. Not applicableModerately Sliehtly Not at allFullyIs this good for sustainability? Highly. (Instances of where CDTI transport was broken and repaired by the district were noted. Also cases of having used other transport means and fuel for CDTI were noted). Findines:There are no reports offailure to undertake necessary CDTI activities at sub-district level, due to transport not being available or affordable. Transport provided by the State/ central government level is no longer is usedfor routine CDTI activities at LGA/ district level. Checklist of activities : monitoring/ supervision, tratning/ mobilisation, Mectizan distribution I t Not applicable Moderately Slightly Not at allIs this good for sustainability? Fully Findines: Highly. (DOC is at the time in-charge of other programmes that include malaria, disease surveillance, etc. Sometimes while on other progpmmes, he also executes CDTI activities and vice versa). Where CDTI is involved. trips are authorised/ undertakenfor more than one purpose. Means of transport provided by specific programmes are usedfor other programmes as well. Checklist of activities: monitoring/ supervision, training/ mobilisation, Mectizan distribution I I Not at all Not applicableModerately SlightlyIs this good for sustainability? Fully Highly I JJ 8.2 Check if the transport made availablefor CDTI is being adequately managed indicator of 8.3 Check if adequate provision is being made for the future, to replace existing means when it wears out indicator of effectiveness 9. Hluan resources . ,tl 9.1 Check whether the health district/ LGA team is skilled and knowledgeable, regarding the implementation of CDTI in its area of operation (indicator of effectiveness 9.2 Checkwhether personnel at the health district/ LGA level is stable, and whether provision is madefor passing on CDTI skills when a trained person moves of effectiveness (The authorisation of the trips is based on approval of fuel and repairs by the relevant authority. There is no use of logbook in place) Findines: Moderately. Trips madefor CDTI purposes are properly authorised in writing by the relevant fficial. Each trip undertaken for CDTI purposes is recorded in a log book. Not at all Not applicableIs this good for sustainability? Fully (Approval of funds to replace a spare part of the motorcycle was reported, though it was not based on clear plan to replace the parts). Findinesr Moderately. The district authority/ LGA has a clear plan for replacing the present vehicle used for CDTI work, when eventually it becomes necessary to do so. Not at all Not applicableIs this good for sustainability? Fully LGA/ health district team members ltave enough htowledge and skill to undertake all the key CDTI activities themselves, without help: . Planning . Training and sensitisaton/ mobilisation . Mectizan ordering/ distribution . Monitoring/ supervision. Findines: Moderately. Other than the DOC and DDHS, there is no other district health staff keen about the program. Not at all Not applicableIs this good for sustainability? Fully Staff should remain in one post for at least five years. There should be immediate training (in CDTD of new, unskilled district/ LGA staff members who have CDTI responsibilities. Highly There were no reported cases of attrition oncho focal persons. It was reported that for the CDDS who drop out they are easily replaced and retrained. Communities have the potential to train more CDDs in case some dropout. Fully Moderately Slightly Not at all Not applicableIs this good for sustainability? Hishlv SlishtlvModeratelv Hishlv SlishtlvModemtely Hishlv SlishtlvModerately Hrghly 34 2. Sub-district/ first line health facility level 1.2 Check whether the geographical coverage in the sub-district is satisfactory indicator of effectiveness 1.3 Check if all villages have a satisfactory therapeutic coverage rate (indicator of effectiveness 2. Plannlng 2.1 Check if CDTI is an fficial part of health service activities at this level, or is included in the 'basic package of activities' for ir (indicator of integration and attitude Findines: Fully (>90o coverage). All identified villages were reported under treatment. The respondents could name the areas affected but not tell the level of endemicity. All villages identified by the latest REMO are under treatment (i.e. the geographical coverage rate is I 00% and stable). This should be confirmed by comparing coverage records with the REMO list of endemic villages a I Slightly (many villages/ hamlets not covered) Is this good for sustainability? Highly (problem with nomads onl Moderately (a few villages/ hamlets not covered) Findines: Fully (>90Vo coverage) Majority of the people were reportedly taking drugs except the migrant labourers, the sickly and a few who refuse due to religious beliefs. The therapeutic coverage rate should be . 65(% or higher . stable or increasing. Moderately (65- 79o/o coverage) Slightly (less than65%o coverage) Is this good for sustainability? Highly (80-89% coverage) There should be an fficial document locally available, making clear that CDTI is a sub-district responsibility. Sub-district staffshould perceive CDTI to be one of their routine responsibilities. Findines: Highly CDTI included on the list of services offered by the facility. Not applicableSlightly Not at allIs this good for sustainability? Fully P 90% coverage) Fully (290o/o coverage) I 35 ')) Check if there is a written year plan for CDTI in the sub-districf (it may appear under another name, e.g. 'onchocerciasis programme') (indicator of and effectiveness 2.3 Check if the plan contains all the elements neededfor CDTI to workwell of effectiveness 3. Provi{ing leadership Not applicable at this level. 4. Supenision Bnd m.gnitoring 4,1 4.2 Check if members of the sub-district team are routinely and efficiently supervising the CDTI activity of the villages on site (indicator of effectiveness and efficienc Check if routine data concerning CDTI activities at this level are collected and transmitted entirely within the government system (indicator of Findines: Stightly. CDTI focal persons at the facility reported it being included in the yearly workplans, there was no written documentation to confirm this. There should be a written plan or timetable in existence, for the most recent round of CDTI. Ideally the plan should be integrated into the overall year plan for the sub-district. It should not be separate. I Not applicableIs this good for sustainability? Fully Hiehly Not at all Findines: Not applicable. No plan seen. The plan should make provisionfor all key elements. Checklist of key activities: Mectizan supply; targeted training (for CDDs); targeted mobilisation/ sensitisation ; monitoring and supervision Is this good for sustainability? Fully Highly Moderately Slightly Not at all Findinss: Highly. It was reported that staff at this level routinely visit. However, no documentation for this. There should be evidence that each village is visited at least once around the time of distribution. There should not be unnecessarily many visits - here should be clear justification for each one. I Is this good for sustainability? Fully Moderately Sliehtly Not at all Not applicable The reporting process should be within the government system, not using other resources. Findines: Highly. Records of CDDs were available at the facility. Fully Moderately Slightly Not at all Not applicableIs this good for sustainability? Moderatelv Sligh0v a Norapplicable I Highly 36 4.3 Check whether there is a routine process of management of problems and successes, which are indicated by the monitoring system (coverage data, visits and of effectiveness and attitude si'rffinryfng and distributlng Mectlzan 5.1 Check if sfficient Mectizan is being ordered yearly, and in good time (indicator of effectiveness 5.1 Check if Mectizan is regarded as a free but essential drug at the sub-district level of inte and attitude Findines: Highly. Ihey handle problems within their means and report those they are enable to handle to the next level (district). ln one community closc to the boarder with Zaire. CDDs have starled extending treatnlent to their ncighoLrrs irt Zairc As soon as problems are identified in this way, the appropriate manager deals with them. Planning must include activities which will improve coverage in areas where it is unsatisfactory- Successes are noted and reported, and appropri at e feedb a c k giv en. The CDTI co-ordinator should be empowering the next level to cope with problems. Checklist of key activities: sensitisation/ mobilisation; training; improving Mectizan supp ly ; effectiv e / sup p o rt ive s up ervis i on Sliehtly Not at all Not applicableFully ModeratelyIs this good for sustainability? Findines: Fully. Orders are based on CDD returns and sufficient amount of ivermectin was reportedly available before distribution. No cases of shortages were reported. The order forms for the sub-district exist, and are based on the village orders. The Mectizan is available for the sub- districts in time for distribution at a time which is convenient to villagers. There are no reports ofshortages and/ or late supply. If there have been shortages, there are specific plans to remedy them. I Not at all Not applicableModerately SlightlyIs this for Findines: Highly. No official document available but the staff appreciate that ivermectin is an essential drug. There should be an fficial document locally available, making clear that Mectizan is an essential drug at this level. Sub-district staff should perceive Mectizan to be an essential drug at this level. Slightly Not at all Not applicableFully ModeratelyIs this good for sustainability? I I Hiehly Fully 37 5.2 Check if Mectizan is being stored and administered within the government at this level indicator of 5.3 Check if Mectizan is being distributed appropriately and effectively to the vil of effectiveness 6. Training and sensitisation/ mobilisation NOTE: This refers to training and sensitisation activities performed by officers working at this level, at this level, for the next level. 6.1 Check if only necessary training is being done (indicator of efficiency and 6.2 Check that training conducted at this level (i.e. CDD training) rs done by the of efficienc and The Mectizan: . Should be orderedfrom the next level using forms supplied by the government. . Should be stored in a room made available by the government at this level - preferably in the same room as the other drugs. . Should be controlled within the government system, preferably using the same stock control system as for other Findines: Highly.. Stored at the health facility, delivered by the govemment staff. However, there are speciall stock-cards specifically for ivermectin. Is for Not at all Not The villages shouldfetch the Mectizanfrom the sub-dtstrict health facility themselves Findines: Highly. lvermectin is either fetched by the supervisors or CDDs selected by the community. Is this good for sustainability? Fully Moderately Slightly Not at all Not applicable There should be an objective need for each episode of training: * There must be evidence that CDDs to be trained lack knowledge and skills to perform the job. * Training to motivate CDDs is not a sfficient reason for training. The evaluator must be satisfied that the duration of training was .justified. I I Findings: Highly The training clcpcnds on whether there CDDs who drop out. Tlrc new ones have to undergo training. There may also be need for training whencver new problenrs emcrge or when the approach changes. For instance the we lound training for cornnrunity self-monitoring going ot]. Is this good for sustainability? Fully Moderately Sliehtly Not at all Not applicable Only sub-district staff should be involved in training of CDDs Findines: Moderately. There instances when the DOC goes down to the community to train CDDs especially when there are peculiar problems or when the CDTI focal persons are incompetent or when someone CDDs is transferred to another facility. Not at all Not applicableIs this good for sustainability? Fully Fully Moderately Slishtlvllighly Highly Iiehly Hishlv SlishtlvModerately 38 6.3 Check if adequate and appropriate materials are available for the necessary health education and mobilisation (of villagers) and training (of CDDs), related to CDTI indicator of effectiveness 7. Flnancing/ funding 7.1 Check whether adequate provision is made for the costs involved in each CDTI relqted at this level indicator of effectiVENCSS 7.2 Check whetherfunds to cover these costs arefully or increasingly being supplied from own (sub-district) and/ or district/ LGA resources (indicator of ffiffi?rfrengptfft'rrnd oth6r ifatel{nl r336tfcii3 " j " '" " 1;i; ::ilrl'1",;1;;1;iffi;';1'l{'1;: 8.1 Check tf there is sfficient transport for necessary visits to the sub-district level CDTI related activities indicator of effectiveness Findinss: Highty There were IEC materials at the facilities that are used for health education. The materials should be easy to use. The materials should be locally relevant. There should be sfficient materials. It should be possible to get new stocl<s of materials when needed. I Not at all Not applicableSlightlyIs this good for sustainability? Findinss: Not all Respondents at this level confessed that they have never included CDTI in their budgets The costs for each CDTI related activity in the year plan should be clearly spelt out in the budget. The staff should be able to iustify the amount they plan to use Checklist of items to be costed: monitoring/ supervision, training/ mobilisation ; arrangtng Mectizan supply I Sl,shttt - Not applicableFully Hiehly ModeratelyIs this good for sustainability? Findines: Not applicable The relative contributions of all sources of funding should be clearly spelt out. The proportion provided by the fficial health service (district or sub-distrtct) should be the major one by now. This proportion offunds is increasing yearly. Sliehtly Not at allFully Highly ModeratelyIs this good for sustainability? Findines: Highly. Supervisors are chosen from their communities. There should be no reports offailure to undertake necessary CDTI activities at village level, due to transport not being available or affordable. Checklist of activities: monitoring/ supervision, training/ mobilisation, arranging Mectizan supply Not applicableSliehtly Not at allFully ModeratelyIs this for Fullv Hishl] I Not applicable Hiehly 39 8.2 Check if trips/ journeys undertaken for routine CDTI purposes are integrated with those made for other programmes or purposes (indicator of integration and 9. Human resources 9.1, Check whether the sub-district team is skilled and lcnowledgeable, regarding the implementation of CDTI in its area of operation (indicator of effectiveness 9.2 Check whetherpersonnel at the sub-district level is stable, and whether provision is madefor passing on CDTI skills when a trained person moves indicator of effectiveness 9.3 Check whether the working conditions of sub-district staff are satisfactory indicator of effectiveness Were CDTI is involved. trips are authorised/ undertakenfor more than one purpose. Means of transport provided by specific programmes are usedfor other programmes as well. Checklist of activities : monitoring/ supervision, training/ mobilisation, arranging Mectizan supply Moderately. There are instances where transport provided by APOC is also used for other purposes. Findinss: Is this eood for sustainability? Fully Not at all Not applicable Sub-district team members have enough lorcwledge and skill to undertake all the key CDTI activities themselves, without help. Checklist of activiites : planning, monitoring/ supervision, training / mobilisation, aruanging Mectizan supply. ! Findines: Highty. There was evidence from the interviews and the records that were available that team members at this level were knowledgeable. Is this sood for sustainability? Sliehtly Not at all Not applicable Staff should remain in one postfor at least five years. There should be immediate training (in CDTD of new, unskilled sub-district staff members who have CDTI responsibilities. t Findines: Highly. There were provisions that those who drop out are replaced and trained immediately. There were also refresher training every year. Not at all Not applicableIs this good for sustainability? Slightly Findines: Moderately Although most of the health workers did not express disatisfaction, there was a case in one of the health units whereby the focal person spent 8 months without salary pay The staff should at least receive their salaries regularly. Also to be considered are stffing level, medical equipment (for vital signs), medical supplies, stationery ! Is this good for sustainability? Fully Hiehly Slightly Not at all Not applicable I ! I E Slightly Fully Highlv ! Fullv Hiehlv 40 3. Community level 1. Coverage 1.1 Check that the ical is 10096 indicator of effectiveness I.2 Check that adequate therapeutic coverage is being maintained (indicator of effectiveness 2. Planning . , ,,rii',la,1ii-:,";tfu;,,;;,". ': ). .i,.i' i ;+*,-*+'i,r- .,,rI; 'hril'lir'i,:' I ',;;l:' r 2.1 Check if the census update is routinely done at the same time as the distribution of and YIJ All quarters/ wards and hamlets are being c ov ered s at isfact ori ly. Findine: Fully (100% coverage). All the identified area./communities are under treatment. Is this good for sustainability? Highly (problem with nomads Moderately (a few villages/ hamlets not covered) Slightly (many villages/ hamlets not covered) Finding: Highly (80-89% coverage) Some people during the time of distribution are either sick, pregnant and a few refuse to swallow the drugs due to religious beliefs. Therapeutic coverage of 65% should be maintained or improving Validate the responses from the register/summary forms - Slightly (less than 650/o coverage) Moderately (65- 79%o coverage) Is this good for sustainability? Fully (>90% coverage) Findines: Fully. Distributors keep registers where all names of household members are recorded and usually updated during each distribution. CDDs are asked to describe the steps of the distribution. This should make clear whether they do the census and the distribution at the same visit. The CDDs should visit each family only once a year (except tofollow up absentees/ refusals). Also ask about previous years - what is the routine? Not applicableModerately Sliehtly Not at allIs this for Fully (100% coverage) Highly (80-89% coverage) I I I 4l 3, , . Pr$ddlugJnf,dpHhip,*' . -',i *o ,; . 3.1 Check if community leadership gets involved in managing problems and successes with distribution of attitude and effectiveness 4. IVlonitqring . i; I 1 rrttr 'l,i 4.1 Check whether village level distribution registers are being kept accurately indicator of attitude and effectiveness 4.2 Checkwhether CDDs are reporting to the sub-district appropriately (indicator of effectiveness 5. MectizaR supply 5.1 Check that the required amount of Mectizan is received (indicator of effectiveness Findinss: Highly At the village level, all the communities Local Council leaders have been deeply involved in the mobilization and distribution of Ivermectin. Some of the LCs are supervisors and distributors. ln instances where some people have refused to swallow, CDDs report to the local councils who try to use their positions to do more mobilisation. The LCs have also tried to mobilize few funds for the distributors. The community leadership takes responsibility for the distribution of Mectizan within their village. If coverage (geographical and therapeutic) is not adequate or not being maintained, the leadership understands the reasons for this. The leadership identifies and solves problems with distribution at this level. Not at all Not applicableFully Highly SlightlyIs this good for sustainability? Fully All the CDDs keep registers that are well recorded. Many of them have basic education. Register should be complete and accurate. The register may befilled in by the CDD and/ or a village helper. Veryfy by examining the register.I Moderately Slightly Not at all Not applicableIs for Fully All the CDDs submit their treatment retums to the supervisors who in turn submit them to the focal person at the supplying health unit. These records are available at the health facilities. Reports to sub-district should get to the sub-district on time. Reports may be summary reports, or the original village record, depending on the level of skill of the CDD I Not applicableModerately Slightly Not at all@itiryz IHighly Findines: Fully There was enough Mectizan for all the eligible persons. There were a few left due to the people who were sick, refused and those who at the time of distribution.were in the The CDDs / villagers report that all villagers who were eligible for treatment got it, and that there was little or no stock left over after completing treatment round Moderately Sliehtlv Not at all Not applicableIs this for I HiehlvFullv 42 5.2 Check that calculations for the required quantities of Mectizan are accurate indicator o f effectiveness 5.3 Check that the required amount of Mectizan is received on time (indicator of effectiveness 6. Training Not applicable at this level - CDDs are trained, but do not conduct training. 7. Financing 7.1 Check that the villagers appreciate the financial and non-financial costs involved in CDTI indicator of attitude 7.2 Check that the community has made arrangements tofund local costs of distribution of atti Not Not There must be a rational explanation about how the amount ordered for the village is calculated (on the basis of population). The calculation may be done by the CDD or the health centre nurse, depending on the CDD's level of skill. I Findines: Highly. The calculations for the amount ordered for is based on previous use/distributions. Sliehtlv Not at all I applicIs this good for sustainability? Fully Moderately The CDD and the villagers report that the Mectizan aruives at a convenient and acceptable time of the year. Findinss: Fully Mectizan arrives before distribution, convenient time. No reported delays at all at the time of distribution. Moderately Sliehtly Not at all I applicIs this for Briefly tell villagers (including the village head) what the component activities of CDTI are: mobilisation; training; collecting drugs; the actual distribution, supervision. Then ask them where they think resources for these activities comefrom. They should show an understandtng that tlte resources comefrom outside andfrom the work of the CDD, and express their appreciation. Findinss: Fully. Communities appreciate the costs involved in CDTI are too enorrnous to be afforded by them. Unless an external agent continues to supply mectizan , the do not see themselves able to caffy on. Sliehtlv Not at all Not applicableModerately The community makes provision for the supply of record bool<s, pencils, transport and other expenses incuted (including possible remunerattonfor CDDs) Findines: Moderate. In some communities there was commitment to provide some small Contribution within their means by where necessary providing transport, stationery and pens. Is this good for sustainability? Fully Not at all Not ble Hichly Fullv Hish v Is this good for sustainability? I Hieh 43 8. Transport and other material resources . , Not applicable at this level. 9. Huma4 resources 9.1 Check that all CDDs have received appropriate training (indicator of effectiveness 9.2 Check that there is a system in place for new CDDs to acquire the appropriate skills of effectiveness 9.3 Check whether CDDs are wil, to continue with CDTI indicator of attitude 9.4 Check whether villagers value annual treatment (indicator of attitude and effectiveness 9.5 Check whether villagers accept the need for long term CDTI (indicator of attitude and effectiveness Not Not Findinss: Fully. All CDDs were knowledgeable about CDTI CDDs report that they have received training and demonstrate understanding of the work. Checklist: doing the census; doing the reports, giving the right dose; lcnowing who is not eligible; knowing what to do with side-effects I Moderately Sliehtly Not at all I applicIs this for More than one CDD is trained per village. In case of drop out, the new selected CDD gets training/orientation from the remaining CDDs in the same village. There are refesher courses before distribution. Findines: Fully. There should be a plan in placefor training CDDs to replace those who drop out, or when new ones are electedfor other reasons. Sliehtlv Not at all Not applicableModeratelyIs this for Findine: Fully. CDDs expressed over willingness to continue with their work, though they are not paid. CDDs should express willingness to continue with distribution in the long term, given the conditions which prevail in the community. Not at all I applicModerately SlightlyIs this for The communitlt members should mention one or more advantage of Mectizan, and express the needfor the annual treatment. Not applicableModerately Slightly Not at allIs this for Findine:People show understanding and express interest in long term treatment with Mectizan. Moderately Sliehtly Not at all Not applicableIs this for HiehI HishlvFullv HiehlvFully Findins: Fully. Reported that it removes intestinal worrns, smoothens the skin and increases appentite. HiehlvFully HishFully II I I I I I I I I I I I