Assessment of sustainability of the Hoima CDTI Project : May - June 2002

World Health Organisation African Programme for Onchocerciasis Control .l l ^' . , Assessment of sustainability of the ,,, :,,,,, Hoima CDTI Project MaylJune 2002 Authors: PauI Bukuluki Denis Muhangi Samuel Mugisha 2 JTable of Content Abbreviations/ acronyms 4 Acknowledgements 5 Introduction and methodology......... 2 aJ. Adapting the instrument. Findings and recommendations........ 1. Districtlevel.......... 2. Health centre/'sub-district' level... 3. Villagelevel......... APPENDIX 5: DETAILED FINDINGS. l. District.... 2. Sub-district/ first line health facility level 3. Community level 9 9 9 10 11 11 t4 t7 Overall sustainability grading for the Hoima project. ............20 Advocacy activities and planning workshops 2t Appendix 1: Program for "Feedback / planning" workshop at District & Sub-county Levels.. ...................23 Appendrxz The District and Sub-county workshop processes Appendix 3 District level plan for sustainability 27 Appendix 4 Sub-County Level Plans for Sustainability ..........20 .37 37 45 50 4Ag. APOC CAO CDD CDTI CFO DHE DMT DMO/DDHS DOCT DOC LCI LCM LCV NGDO NOTF PHC wHo Abbreviations/ acronyms Acting African Programme for Onchocerciasis Control Chief administrative offi cer 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 oncherciasi s coordinator Village level authority Sub district level authority Local council level 5 (District Govemment) Non-governmental development organisation National onchocerciasis task force Primary Health Care World Health Organisation 5Acknowledgements First and fore most the research team would like to thank the DHT of Hoima District especially, the DMO Dr. Emer and Mr. Fred Byenume for their support and commitment to the evaluation exercise. We would also like to thank the CDDs and LCs of the communities visited for their active participation and support in mobilising study participants. Special thanks also go Dr. Joseph Okeibunor for the technical input given to our team in the planning and writing of the research report. Last but not least, we would like to thank Dr. Ndyomugyenyi for providing support and a good working environment without which the evaluation exercise would have been an uphill task. 6 7Executive Summary APOC support for the Hoima District CDTI project is in its last year of the five-year agreed funding. An evaluation of the sustainability of the project was carried out in May/June 2002, by a team of three evaluators. The three-fold task of the include to: . 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-county/health centre and village/community. The overall judgement of the team is that the Hoima 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. Geographic coverage is quite high as 125 of the 127 endemic villages are under treatment. The two villages not yet under treatment were discovered last year through REA exercise. . Eficiency/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- countyftrealth 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.t Simplicifl; Routines are generally simple and easy to carry out. . 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; 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 without outside resources in the near future. Some health centre staff do not see Mectizan as essential drug since it is not included in the essential drug kit supplied to themt 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/health 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/trealth centre and the District levels have to sort out the key issues of planning, funding, transport, ffid delegation of responsibility, if they are to be sustained. Detailed recommendations were drawn 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: 8Facilitation of the lower level to organise for the treatment of the two communities discovered to be endemic. Identification of funds that will be available for the 2003 distribution and their respective sources. Also there should be clear identification of dependable arrangements for meeting deficits. High level advocacy involving the NOTF and MOH officials to the District level political and administrative machinery The evaluation team carried out advocacy activities at the level of the administrative leadership of the District. The newly elected LCV Chairman was also met and coming from a background where onchocerciasis constituted a major public health concern, he promised to pay attention to CDTI in the district. 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 Hoima project is to be assured. 9Introduction and methodology 1. Introduction Onchocerciasis control programmes started to be implemented in Hoima district in 1990. The major actor who was supporting these control programmes was Sight Savers Intemational. The major approach that was employed to control this disease was the Community Based Invermectin Distribution, where communities were relative passive in their participation in the control programme. ln 1997, APOC started supporting the control of Onchocerciasis in Hoima using the CDTI approach. This approach emphasises the need to maximise community participation in the collection and distribution of Mectizan. CDDs, selected by the communities are playing an active role in the distribution of Mectizanto the endemic communities. The CDTI project is in its fifth year of implementation in Hoima district. APOC is supposed to end its mainstream funding of this programme in November 2002. This was the major motivation for undertaking an evaluation study to establish the extent to which the programme activities will continue to be implemented when it stops to provide resources to the CDTI project in the district. 2. Methodology This is given in detail in the document: 'Using the instrument to determine the sustainability of APOC projects'. Study Design: The design that underlined the study was a cross-sectional descriptive design. The qualitative paradigm formed the overall approach to the study. The major research question that the study sought to answer is: How sustainable is the Hoima CDTI project? The study population of Hoima district project, included: DMO, DOC, NGDO partner; project villages and their CDDs. Sampling: Four sub districts/ first Health units (one with high coverage, one with low coverage and two with medium coverage) were selected. The last three years ayerage coverage was used to determine coverage of the health units that suit the respective categories earmarked above. Endemic levels and geographical locations of the sub districtsftrealth units were further used as a stratification variable to ensure good representation of the different segments in the population. The following Health units were selected: Kyabasengya, Mparangasi, Kigorobya, and Kisabagwa. In each first line health unit catchment area, two villages (one with high, one with low coverage) were selected. These were: 10 Level ofCoverage Health Unit Selected Villages High Kyabasengya 1. Kiryangobe (High coverage) 2. Nyakabaale (low coverage) Medium Kisabagwa 1. Kasokero (high) 2. Kigawa (low) Mparangasi l. Kibegenya (high) 2. Mparangasi (low) Low Kigorobya 1. Kamugambe II (hish) 2. Haibale (low) The key instruments of data collection included: Questionnaire (see appendix: 'Detailed findings') structured as a series of indicators of sustainability. The indicators are grouped into 9 categories. The instrument assessed sustainability at 3 levels of operation within the district. It guided the researchers to collect relevant information about each indicator. The main sources of information were verbal reports from persons interviewed, supplemented by documentary evidence. Analysis was based on the information collected; each indicator was graded on a scale of 0-4, in terms of its contribution to sustainability. The average 'sustainability score' for each group of indicators was calculated, for each level. A qualitative description of problem areas was also given. Limitations of the study were found to be the following: The therapeutic coverage for the sub-counties had not been computed. It was a daunting task to compute them and relate them to health unit catchment areas. 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. 11 Findings and recommendations l. District level 1.1 Overall grading (on a scale of 0-4) Uganda/Hoima District CDTI Project Self-sustai n abi I ity at DistricUProject Level 4 tt ED o =o E')(! o (! 3.5 2 3 .5 2 .51 1 0 .5 0 ."-.1-$".$u.t".*1.")ffi {"t"t-.S Group of indicators 1.2.Main findings Coverage District geographical coverage is quite high, with 125 out of 127 endemic villages being reached with Mectizan mass treatment. The two villages not yet treated were discovered last year through a REA exercise. The average therapeutic coverage for the district was reported at 73.3o/o. Planning The District Development Plan document includes specific CDTI activities. The district plan was formulated in a bottom-up and participatory manner through planning workshops attended by stakeholders from different levels. Providing Leadership While the district takes initiative for some key CDTI activities such as Mectizan collection and distribution, some activities tend to depend much on NGDOs, in this case the Sight Savers. These include activities such as planning workshops and the REA exercises. The senior leadership of the district is fairly aware and committed to CDTI, but have not committed any funds to CDTI activities. Supervision and Monitoring The first line health facilities are visited routinely as required by the CDTI programme. However, due to the high level of integration, the district staff even visit the village level. t2 Reports are on CDTI submitted to the District Director of Health Services (DDHS). This is in line with the govemment reporting system. Although there were isolated cases where anomalies were identified, in most health units, the collection and distribution of Mectizan is managed well. There were quick response mechanisms to problems identified. Ordering and Distributing Mectizan On the whole, there was evidence that orders for Mectizan are on time based on population estimates i.e.3o/o projected increment yearly. This is also complemented by the up dating of registers that takes place during the time of distribution of Mectizan. The ordering, storage and collection of the drugs at this level was integrated within the government system. The stock cards are uniform and supplied by the goverrlment. There was no evidence for a parallel system established to cater for only CDTI. However, it was noted that although the sub- district/health units fetch the drugs including Mectizan, the facilitation to undertake this activity from the district is inadequate and irregular. Training and Sensitisation/lVlobilisation No training needs assessment had been carried out but there were satisfactory reasons for every training episode. It was observed that although training for motivation of staff was a minor reason, it was one of the background reasons. District staffs are still involved in training at the village level. This implies that adequate capacity has not been built among the supervisors to handle CDD trainings independently. Some IEC materials on CDTI exist but they have not been optimally displayed. Advocacy at the district level is still wanting. Financing/Funding Apart from the district committing staff to work on the CDTI activities, the district has no budgetary allocations for CDTI activities. The APOC funded budget at the district level was satisfactory and realistic. There was no evidence of formally written plans to cover deficits when APOC stops it's funding. Financial procedures of the district are clearly spelt out and followed in the management of APOC funds. Transport and other Material Resources It was observed that the district has sufficient pool of transport (vehicles and motor-cycles). The level of integration in the use of transport facilities was high. There were no reports of failing to undertake CDTI activities because of lack of transport at this level. Proper procedures are rarely followed in the requisitioning and authorization of the use of the transport facilities. The authorizations were sometimes verbal and the logbooks are rarely filled. Human Resources Offrcials at the district, especially those responsible for CDTI activities were knowledgeable and skilled in all the CDTI activities. They have been attending quite a number of refresher courses to this effect. Most of the district staff responsible for CDTI activities had been working in the district for more than five years. There was however, no clearly spelt out plans for the replacement with equally trained persons in case anything happens to one of the staff members. It was reported and observed that the relevant equipment is in place and functional. Salaries are regular with fair allowances. 13 1.3 Recommendations Recommendations: Implementatton (this is in relation to specitic recommendation) Geosraphical Coveraee . The district should facilitate the lower levels to organise for the treatment of the 2 communities not yet reached. Priority: Higll Indicators of success; Treatment undertaken, Wo to take action: DOC Deadline for completion November 2002 Therapeutic Coverase . More targeted support supervision and sensitisation should be implemented for the communities that have a coverage of less than 65% Priority: Hish Indicators ofsuccess: All villages have a therapeutic coverage of not less than 65% Wo to take action: DOC, DMT members Deadline for completion November,2003 Leadership . Advocacy meetings with the senior political and technical leadership of the district should be organised. Facilitators should be invited from NOTF and MOH to ensure increased support ofthe leadership for CDTI.. Priority: llisll Indicators of success: District leaders more aware of CDTI and commit financial resources to CDTI activities Who to take action: DDHS, DOC Deadline for comp letion: November,2002 Trainine r I training needs assessment should be carried out amongst district staff involved in CDTI activities. Future trainings should be targeted to respond to identified training needs . More IEC materials should be procured for distribution to the lower levels, and for sensitisation and advocacy at district level Priority: McdiLrrn Indicators ofsuccess: Training needs identified, trainings tailored to identified needs Wo to take action: DDHS, NGDO, Senior Personnel Officer, DOC Deadline for completion August 2003 Financine/Fundine . Advocacy to the district decision makers to make budgetary allocations should be done. ' There is also need to identify other dependable sources of financing including other NGDOs. Priority; lliuh Indicators ofsuccess: District budget allocations to CDTI activities, increasing allocations Who to take action: DDHS, DHT members Deadline for completion; November,2002 t4 2. Healthcentre/'sub-district'level 2.1 Overall grading (on a scale of 0-4) Uganda/Hoima District CDT! Project: Self'sustainability at First Line Health Facility/Sub'district Level 3.5 { .9o =o E"G o G 2. 3 5 2 I .5 1 0.5 0 *-."1-$$..'t...{..ff ".11}."d *t'\'f" Group of indicators 2.2 Js.[.ain finding: Coverage All endJmic villages in the catchment area of the sampled health units are being reached by CDTI programme activities. Most villages (55 out of 63) in the same area have a therapeutic coverage above 65Yo. Planning CDTI activities are considered part of the responsibilities of staff at this level. However, there is no official document that shows CDTI as a responsibility of the health facility level. There are no written plans for CDTI but staffs at this level know the sequence of CDTI activities. Leadership The health facility and sub-county staffs are not yet taking full responsibility for initiating CDTI activities. Some activities such as planning and training are initiated from the district. Activities, which are initiated by the health facility staff and CDTI supervisors, do not involve the senior leadership at this level. S u p e rvis i o n/1VIo n ito rin g The Health Team at this level routinely supervises CDTI activities. The supervision visits are integrated with those for other health activities. While reports on CDTI activities are submitted regularly, they are submitted separately from other health activity reports. 15 Problems identified in the implementation of CDTI are reported and staffs at this level respond to address identified problems such as refusals. Ordering and Distributing Mectizan Users do not pre-determined the specific time for treatment and often, treatment is ca:ried out when the Mectizan is brought. Even where orders from villages are placed, they are based on estimates rather than actual population figures. There is no official document that prescribes Mectizan as an essential drug at the health facility level. However, in some of the health units, staff recognise it as an essential drug. The storage and management of Mectizan is fully within the government system that exists for other drugs. The villages organise the collection of Mectizan from the health units. Training and Sensitisation The supervisors at this level conduct training of CDDs once every year. The yearly training of CDDs is justified because of the need to equip new CDDs with the necessary knowledge and skills, and also to facilitate sharing of experiences ,rmongst all CDDs. However, this training is also perceived as a means of motivation to the CDDS. Sometimes the district staffs also participate in the training of CDDs. Staff have only a few IEC materials and there were no tangible plans to acquire more. While the decision makers were sensitised about CDTI activities in the past, the newly elected leaders for the sub-counties have not yet been sensitised. Financing/Funding The sub-counties do not budget for CDTI activities. The health units do not have budgets, as they do not control any finances since the abolition of cost-sharing. Transport and Other Material Resources Although most health units and most supervisors (particularly those that work as government extension workers [health assistants and community development assistants] have motor cycles, they do not have adequate fuel. Some health unit staff reported that they use their personal money to supplement fuel necessary for undertaking their work including CDTI activities. Available transport is used for all health activities including CDTI. Human Resources Some key staff at this level such as health unit in-charges did not have sufficient knowledge about CDTI activities, as they are not usually involved in implementation apart from collection and distribution of Mectizan. Most staff have been stable on their jobs. Salaries are inadequate but they are paid regularly and promptly. Field allowances and fuel allocations are irregular and the latter usually inadequate. 2.3 Recommendations Recommendations Implementation Coverage . There should targeted mobilisation and sensitisation to increase the therapeutic coverage in communities currently with coverage rates of less than 65% Priority: lligh Indicators of success: All communities have coverage above 65%o Who to take action; Supervisors, CDDs and LCI leadership of communities with coverage rates of lessthan650/o. t6 Deadline for completion; August 2003 Plannine . There is need to seek the facilitation of the district to build capacity for formulating development plans. Plans for sub-county and health units should include all intended CDTI activities. The planning process should be participatory involving all stakeholders in CDTI at this level. Priority: High Indicators of success: Existence ofplans incorporating all the elements of CDTI Who to take action; Sub-county Chief, In-charges of Health Units, Supervisors Deadline for completion; Novenber,2003 Supervision r Plans should include targeted supervision. A guideline for identifying problem areas which need focused supervision should be developed. . There is need to select a team leader for supervisors in each sub-county to make coordination on advocacy planning and other CDTI activities more easier. Priority: Higl't Indicators ofsuccess: l. Evidence of targeted supervisory visits. 2. Existence of guidelines for identifying areas with special supervisory needs 3. Team Leaders in place and playing a leadership role amongst Wo to take action: DOC & Supervisors Deadline for completion: December 2002 Trainine . Training events should only be arranged in response to training needs. r Staff at this level should seek guidelines for identifying training needs amongst CDDs. Priority: Mediunt Indicators ofsuccess; 1. Training no longer follows routine schedule, but based on identified needs 2. A checklist of training needs which inform any training undertaken Wo to take action: Supervisors Deadline for completion; November 2002 Financine . There is need for targeted advocacy to make the leaders at sub-county level more responsive to CDTI activities. . The leaders should be persuaded to make budgetary allocations and release of funds for CDTI activities. Priority: lligh Indicators ofsuccess: Money allocated to CDTI activities and accompanied by proportionate disbursements Wo to take action: DOC, Supervisors & I D eadline for completion; May 2003 t7 3. Village level 3.1 Overall grading (on a scale of 0-4) Uganda/Hoima District CDTI Project Self-sustainability at t s .9o! o C')(U L o (E 4 3.5 3 2.5 2 1.5 1 0.5 0 ,"s$$.-'$w Group of indicators 3.2 Main findings Coverage The geographical coverage was 100%. All households were reached with Mectizan treatment. The therapeutic coverage was above 65oh in most of the villages. Only two villages (Haibale and Kigawa) had coverage rates below 650lo. Planning Planning and implementation of CDTI activities is done during the same period. Update of Census and distribution of Mectizan is done at the same time to avoid unnecessarily keeping CDDs occupied for a long time. Providing Leadership The level awareness by local leaders about the problem of CDTI is relatively high. The leaders are actively participating in the CDTI programmes. They have been instrumental in mobilising and sensitising the communities. They also support the work of CDDs and are very conscious of replacing vacant post of CDDs who drop out of the CDTI programme. Some leaders also double as CDDs. In a few villages, the local leadership has put in place arrangements to give a minimum token from the village revenue (25% allocation from the sub-county). Village Level 4 18 Monitorin g/Supervision Generally, the village treatment registers are kept well by all CDDs with annual updates on the number of people in each household. There are however cases of incomplete registers by some CDDs who are either unable or have not had time to fill them. The reports are regularly submitted to the CDTI supervisors who most times pick them from CDDs as they carry on routine supervision and monitoring, usually at the end of each round of CDTI activities. Obtaining and managing Mectizan The supply of Mectizan is quite well in the villages. Overall there are no major shortages at the end of each exercise. Where cases of shortages are reported in some villages, the supervisors draw more Mectizan tablets from areas with excess. A standard calculation using a3o/oincrease of the projected population in the next round of treatment is used and has proved effective to avoid shortages. The remaining tablets are handed back to the supervisors and then to the district drug store. Time of distribution was reported to be convenient and each household or individual members is given the liberty to choose the time and day of the week on which to receive treatment. Training & Sensitisation Apart from annual training where CDDs and some selected local leaders are trained by supervisors, there is no training conducted at community level. However, CDDs and some community leaders have continuously mobilised communities in case of need to elect new CDDs. Community leaders use for a like churches, village meetings and other village ceremonies to sensitise the communities about the need for taking Mectizan treatment. Financing Community members did not know the exact sources of funding for the CDTI activities. They perceived it as monetary support from the government. While there were no arrangements for providing stationary, transports to CDDs, there are a few villages, which are payrng minimal allowances to the CDDs from the 25o/o of income that remains at the Local Council level I. Transport & Other Materials Movements by CDDs are within the villages and each village has an average four CDDs. There are no big distances to travel that could require transport facilities. Human Resources The CDDs have sufficient knowledge for CDTI activities they are carrying out. Where they are not sure like in the case of managing side effects, they have been making referrals to the qualified health workers. The local residents reported that participating actively in selecting new CDDs with the guidance of village leaders. The CDDs indicated willingness to continue serving communities. Likewise the communities showed interest in continued treatment with Mectizan even for a longer time until Onchocerciasis is completely wiped out in their areas. 9I 3.3 Recommendations Recommendations Implementation Therapeutic Coveraee . There is need to intensify mobilisation and sensitisation especially in the villages of Haibale and Kigawa where the therapeutic coverage rates were found to be low. Priority: lligl't Indicators ofsuccess; . Increased therapeutic-above 65%o Wo to take action; Supervisors, LCs and CDDs Deadline for completion : November,2002 Monitorins/Supervision . Training of CDDs should focus on appropriate filling of registers and preparing summaries. This will reduce the need for more frequent visits to CDDs by supervisors. Priority; l1igh Indicators ofsuccess: . Complete and accurately filled village treatment registers, with complete summaries Who to take action; Supervisors Deadline for completion; November,2002 Financine Village Local Councils should commit some money from the 25oh of income that remains at the Local Council level I for CDTI activities. Priority: His.l.l Indicators ofsuccess; . Formal allocations of funds from the LCI in place for CDTI activities in the communities. Wo to take action: Village Local Council and the Community Members Deadline for completion; November,2002 S en s iti s ati on/lVl o b il i s atio n . There is need to produce and distribute IEC and CDTI promotional materials to the CDDs and community members Priority: Mcdiunr Indicators ofsuccess: . Existence of IEC and CDTI promotional materials at this level. Who to take action; NOTF, DMO, DOC and supervisors. Deadline for completion; End of November,2002 20 Overall sustainability grading for the Hoima project The potential for sustainability of the CDTI project in Hoima District is high. Though some levels of shortfalls were noticed in the area of participation of sub-county leadership in CDTI and the release of funds for CDTI activities, these were attributed to some realities on ground. First, the current sub-county leadership is new in the district with some level of sensitisation and mobilisation there is a promise for increased commitment to CDTI. Secondly, the poor funding had been attributed to the fact that CDTI is a sponsored project. Thus the simple logic of resource rationalisation demanded that scarce resources should be channelled to areas without external sponsorship. This does not however translate into low recognition for Onchocerciasis in relation to other major concems of the project area. It is observed that with the present level of political will, the feedback from this evaluation will ensure steps being taken to remedy the current situation in this district. Tick one cofiect assessment Level of sustainability Description Excellent This project is completely sustainable {. !t rt 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 mobilizationof high-level support to get it on ttrg rqq4 €4n. 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. I I2l 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 ' Use 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 Chairman: The evaluation team paid a courtesy call on the LCV Chairman at the end of the fieldwork. This could only be done after the fieldwork because throughout the period of the fieldwork the LCV Chairpersons were in a retreat with the Vice President of Uganda. During the courtesy call the team intimated the Chairman on its findings from the evaluation exercise. The strengths and weakness of the District with respect to sustaining CDTI in the District were enumerated. He was reminded 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. In his response, the Chairman mentioned that he is very familiar with the programme and its workings because he had being the LCIII Chairman for a sub-county that is highly endemic with onchocerciasis. He also noted that though the disease is not easily associated with high mortality its devastating effects cannot be over-emphasized, thus calls for serious attention. The Chairman promised that in spite of budgetary constraints, he would support the control of onchocerciasis in the District as he settles down to work. He indicated willingness to sit and plan with the health unit to "push things forward". He further directed the DOC comejoin him to discuss with the DDHS, who was out attending a workshop in Kampala when he returns the following week. He noted that it would be necessary to give CDTI a proper place in the District planning as APOC pulls out. Visits to the Administrative Leadership of the District: The team met with administrative machinery of the District, represented by the Ag. CAO, Mr. Kiiza Harmington 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. In their response, the administrators remarked that it would be necessary to make CDTI a component of the sub-county budget while the District will supplement whatever the sub- county can mobilize in support of CDTI as APOC pulls out. The Ag. CAO noted that in the past "we depended solely on the funders. The District and sub-county were not encouraged to put it in budget". He further noted that they have they have District development support programme. According to him, this is Belgium funded programme for Agriculture. It embraces the health and nutrition issues. The DDHS will be mandated to cover onchocerciasis as one of its health activities to benefit from the fund. I I 22 2. Feedback/ planning workshops 1.1 District and Sub-county levels A combine workshop for the two levels was held on Thursday 6th June, Hoima Kolping Hotel, Hoima. 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 evaluation team; the SOC and the District health team, the Ag. Chief Administrative Officer, among others. The full programme is given in Appendix l, and the detailed proceedings in Appendix 2. The following is a summary of the workshop process: 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 was therefore decided to use the same process at the sub-county levels to developed detailed long-term plans that will involve the sub-county technocrats, who are in the process of developing a plan for the respective sub-counties. It is hoped that the plans will be fused into the impending District plan. I I Introduction to the workshop process Presentation: what is sustainability? Brief report of evaluation team's findings at the community. 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 District/ project level and Sub-county'. Groups had t'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 Hoima District CDTI t The 'Hoima 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. ln particular, the project leaders need to look critically at the evaluation team's recommendations as in this I I ! I I I I 23 Appendix 1: Program for ooFeedback / planning" workshop at District & Sub-county Levels AGENDA 09:30 - 10:00BREAK TEA. 10:00 - 10:05 To be appointedI Opening prayer 10:05 - 10:10 DMO/DOC2 Welcome J lntroductions l0:10- 10:15 NOC/DOC 10:15 - 10:20 Dr. Ndyomugyenyi4 Introduction to the workshop; what are the objectives 10.20 - 10:30 Dr. Okeibunor5 Background: what is sustainability 10:30 - 1 l:00 Team Leader for the District project. 6 Brief summary of the report; How was it done Summary of findings 7 Brainstorm; what could be the solutions to these problems. Group l: Finances, monitoring and supervision Group 2: Planning, training and mobilisation. Group 3: Transport and leadership 1l:00 - 1l:30 Dr. Ndyomugyenyi 8 Feedback from group work I l:30 - 12:00 Team leader l2:00 - 12:30 Dr. Okeibunore(a) Planning for sustainability in this project. Group work. Plan CDTI activities for the year Identify resources for these activities. 12:30 - 13: l510 LLINCH e(b) Continue planning for sustainability in this proiect 13:15 - 14:15 Dr. Okeibunor Dr. Okeibunor11 Report back from group work 14:15 - 14:45 14:45 - 15:00 Dr. Ndyomugyenyit2 The way forward: implementing sustainability (what to do now) 13 General matters and closure 15:00 - l5:15 Dr. Ndyomugyenyi Iteur Time FacilitatorActivity

25 Appendix 2 The District and Sub-county workshop processes The following is a record of the process of this workshop 1. Introductions and summary of findings . The Evaluation team leader introducedthe elements of sustainability: effectiveness, efficiency, simplicity, integration, attitude and resources. . Reasonsfor evaluating the Hoima CDTI project was discussed. . The general method was to attempt to get the participants to relax and to contribute to discussions without feeling shy or inhibited. . The District and sub-county teams were presented with a summary offindings at different 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: * * The findings were the correct picture of what is on ground. They however, noted that though they have been forewarned of APOC withdrawal they never new it will be so soon. The participants also noted that in some areas it would be practically impossible to carry out census update simultaneously with household treatment because it will make estimation and requisition of Mectizan difficult. It was argued that the population is highly mobile and there is a lot of population movement in the area. Again, it was noted that in the past, the programme has tried to by-pass health in-charge as the District team move straight to the CDDs and supervisors. Reports were submitted to the District and not through the Health in-charge. This tends to make integration difficult and present CDTI as a parallel programmme to the Sub-county health programme. It was therefore demanded that deliberate effort should be made by the District health team to ensure full integration of CDTI in the sub-county health programme. It will start by including CDTI in the Health Management Information System (HMIS). As the way forward, they mentioned that they will want to go back with the new ideas on planning, meet with the technocrats and plan for the future. They also noted that a way forward it will be good to incorporate the plan into the District plan, which is still in the process of development as well as harmonize the sub-county and district plans for sustainability. * * 2. Group work I: Making recommendations for sustainability on the basis of findings The participants were divided into three groups each with evaluation team members and the NOC as facilitators. Each Soup was given the task of deliberating on particular findings (planning and finances, training and Mectizan, supervision and * 26 leadership, manpower and transport) and making recommendations on how to address them in a sustainable manner. Teams had the following ground rules: * A member of each should be nominated by the group as rappoteur, evaluator as facilitatorA.{OC * Suggestions must come form the other team members while the facilitators guide the discussion towards addressing sustainability. This is best done by asking questions and seeking clarifications until a recommendation that addressed sustainability is made. * At the end of the deliberations each team presents the recommendations using the following format: recommendation; Action by; indicators for assessing outcome; start date/deadline. Each group's recommendation was presented and discussed during the plenary that followed. The recommendations were very similar to those made in the draft report by the evaluators and its participatory nature and process of arriving at them made the SOCT to regard the outcome as their recommendations. 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). 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L GI)o Z r- 00 coN I I 29 Appendix 4 Sub-County Level Plans for Sustainability Budget (Ushs) No. Activity Objective To be carried out by Indicator of success Period District support Sub- counties SSI 1 Sensitization of the communities on the withdrawal ofAPOC funds To ensure that communities appreciate the need to sustain CDTI Technical team No. of sensitization meetings carried out and reports July- August 2002 200,000 100,000 300,000 300,0002 Planning and budgeting To come up with an action plan. Sub-county council, Budget made. June - July 2002 J Distribution of ivermectin Continous treatment of eligible population to achieve 80% R* coverage rate. Supervisors and CDDs 80% R* coverage rate achieved July- Sept. 2002 680,000 100,000 4 Feed back on distribution in27 villages To assess community performance Supervisors, LCM Chairman and health ilc No of villages met and reports of meetings. Oct to Dec., 2002 100,000 100,000 300,000 Total 1,980,000 1. I 30 No. Activity Objective To be carried out by Indicator of success Period Budget (Ushs) District support Sub- counties SSI I Taking of inventory of available CDDs To ascertain the number of active and effective CDDs Health assistant, Oncho supervisors Inventory reports July, 2002 300,000 200,000 2 Identification of training need of CDDs To design targeted training Health assistant, Oncho supervisor Inventory of training needs July, 2002 500,000 J Sensitization and advocacy To solicit support of sub-county council DOC, Sub county Oncho Chief Report on advocacy efforts July, 2002 200,000 50,000 4 Training of health workers To build capacity District Oncho team Reports on training August, 2002 100,000 5 Targeted Training of CDDs Capacity building Oncho supervisor Reports on training Sept., 2002 200,000 6 Distribution of Mectizan Control measures CDDs Reports and R* registers On- going 7 Procurement of IEC materials Raising awareness of the affected communities. Health workers, Oncho. Supervisor, DOC No. of IEC materials procured. July- Dec. 2002 200,000 500,000* 8 Monitoring and supportive supervision To maintain quality Monitoring and supervisory reports On- golng 200,000 100,000 300,000 9 Data collection and report writing To evaluate successes and failure and to re- plan As above Reports On- going 200,000 100,000 Total 3150000 :l: "3't:.!*!!ii rr, !],:iir' Oncho. Supervisors and Health staff. I I I 31 3. BUGAMBE SUB-COUNTY No. Activity Objective To be carried out by Indicator of success Period Budget (Ushs) District support Sub- counties SSI 1 Planning and budgeting for CDTI To include CDTI activities in sub-county budget LCM council Amount of money allocated to CDTI in sub-county budget June- July 50,000 200,000* (by APOC) 2 Mobilization and sensitization of the communities and new local leaders. To motivate the people to take the drug and support CDTI activities. Health assistants, CDDs, LCIII council members Increased number of people treated. June- Dec. 100,000 50,000 100,000* (bv APOC) J REA To identify new infected communities SSI, DOC New areas identified for mass treatment July 150,000 4 Targeted training of CDDs Equip them with skills on CDTI Supervisors No of people trained August 200,000* (by APOC) 5 Targeted supervision and monitoring To ensure the unskilled CDDs conform with CDTI requirements LCM leadership, Supervisors and sub- county chief Reports on supervisory visits June- Dec., 200,000 100,000 Total 1,150,000 32 No. Activity Objective To be carried out by Indicator of success Period Budget (Ushs) District support Sub- counties SSI 1 REA To identify new infected areas DOC Report on new infected areas July 100,000* (by APOC) 2 Mobilization and sensitization of new local leadership To create awareness among the policy makers Health stafl DOC The increased level of awareness among the new local leadership. August- September 50,000 100,000 J Targeted training of CDDs To cary out CDTI activities effectively Health assistants and i/c of health centres Improved performance of previously weak CDDs October 140,000 4 Targeted supervision and monitoring To assess activity 3 above Health center i/c and assistants Report of supervision and monitoring December 200,000 Total 590,000 5. BUSERUKA SUB.COUNTY No. Activity Objective To be carried out by Indicator of success Period Budset (Ushs) District support Sub- counties SSI 1 Workshop for village and parish leaders To agree on the way forward on CDTI as APOC withdraws DOC, and sub- county health authorities Minutes of workshop July 200,000 2 Targeted training, supervision and monitorinng To ensure success of CDTI Health i/c Reports on these activities August to October 150,000 J Evaluation and planning meeting Assess CDTI impact Health staff in the sub- county Reports on evaluation November 2002 to Feb. 20003 30,000 Total 380,000 33 34 6. KIZIRANFUMDI SUB.COUNTY No. Activity Objective To be carried out by Indicator of success Period Budget (Ushs) District support Sub- counties SSI 1 REA To identify new infected communities DOC and health staff at the sub- county A list of new infected areas. July 100,000 100,000 2 Mobilization of communities To increase R* LCIII, II, I leadership Increase acceptance of the drug August- September 150,000 J Training of CDDs with poor performance rating To increase efficiency and effectiveness of CDDs Health assistants Improved performance of CDDs October- December 140,000 4 Targeted supervision of communities with identified problems To assess SUCCESSES and failures Sub- county chiefs Improvement in the performance of CDDs December 300,000 Total 690,000 35 r ,;:i.liffi*ii No. Activity Objective To be carried out by Indicator of success Period Budqet (Ushs) District support Sub- counties SSI 1 Updating of registers To determine the target population for treatment CDDs and Oncho supervisors A compilation of target population July 60,000 60,000 2 Sensitization of community leaders and LCIII To create awareness on CDTI and lobby LCIII new leadership DOC and sub-county health staff Leaders' increased participation in CDTI activities July 60,000 60,000 J Sensitization of Parishes To create awareness and build capacity among Parish leaders Oncho supervisors Increased support from the leaders August 70,000 200,000 4 Targeted sensitization of villages in CDTI To increase community participation Oncho supervisors Improved performance September 40,000 60,000 5 Targeted training of CDDs To equip CDDs with knowledge ofCDTI process Oncho supervisors Improved performance September 200,000 6 Targeted support supervision during distribution To improve performance Hish coverage October- November 150,000 Total 960,000 Oncho supervisors

37 APPENDIX 5: DETAILED FINDINGS 1. District 1.1 Check whether the geographical coverage in the health district/ LGA is satisfactory indicator of effectiveness 1.2 Check if all sub-districts and villages have a satisfactory therapeutic coverage rate indicator of effectiveness m 2.t 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 indicator of and effectiveness 2.2 Find out if the yearly plans were drawn up in a participatory way (the overall district/ All sub-districts and 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 ! Findinss: 'fwo out of thc 127 cndcnric villages were rcccntly' discor. crccl and ltave not bccn under trcatnrcnt. Thcy w'crc discovered in last year's REA. 'fhc rcnrainirrg 125 are undcr treatntenl. Slightly (many villages/ hamlets not covered) Is this good for sustainability? Fully (t00% coverage) mffi (problem with nomads only) Moderately (a few villages/ hamlets not covered) Findines: Thc coverage rate lor 2001 was reported as 73.3"1, The therapeutic coverage rate should be: . 650% or higher . stable or increasing. Is this good for sustainability? Fully (>90% coverage) Highly (80-89% coverage) Moderately (65- 79o/o coverage) Slightly (less than65%o coverage) 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: Although CDTI activities arc integrated in the district plan. thcrc is an attitude that it is an extemally hrndccl programme hence conrrnittin-* no nroney direct to the programme activities.. Is this good for sustainability? Fully Highly Moderately Slightly Not at all Not applicable Findines: l-lrc drstrict do'clopnrcnt plan of 1997-2001 irrtlicatcs all Oncho activities. In both cases planning should involve all relevant staff (e. g. sub-dis trict, pharmaceutical stafl) preferably in a workshop situation. Fully Highly Moderately Slightly Not at all Not applicableIs this good for sustainability? LGA and the CDTI of effectiveness 1. Coverage 2. I 38 2.3 Check if the plan contains all the elements needed for CDTI to work wel/ (indicator of effectiveness 3. Providing leadership 3.1 Check if the district management team @MD is takingfull responsibilityfor CDTI indicator of and attitude 3.2 Check if there is evidence of political commitment to CDTI in the district/ LGA indicator of and attitude 4, Supervision and monitoring 4.1 Check if the relevant person at the LGA/ district level is routinely and fficiently supervising the CDTI activity of the sub-districts on site (indicator of effectiveness and Findines: Some key actors were invited to plan workshops br.rt there is no evidence in the plan to show their input. The plan should make provision for all key elements. Checklist of key activities: Mectizan supply ; targeted training; targeted mobilisation/ sensitisation ; monitoring and supervision Moderately Slightly Not at all Not applicableFully HighlyIs this good for sustainability? Findines: Some key activities like the annual planning workshops and the REA are still initiated by the NGDO. But on the supply oI Mectizan. monitoring and supervision, the district of ficials are in lead. 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. I Not at all Not applicableFully Highly Moderately SlightlyIs this good for sustainability? Findinss: Thc senior district offlcials are fairly cornrnittcd to ('DTI activitics but have not conrrlittetl or disbursccl any ntoney lbr CDTI The senior person (polilician/ 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. I Slightly Not at all Not applicableFully Highly ModeratelyIs this good for sustainability? Findines: The health units are visited routinely. But clue to high level of integration, the DOC visits and operates up to the village levcl. 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 iustification for each one. Only the sub-district is routinely visited, not the villages. I Not applicableModerately Slightly Not at allIs this good for sustainability? Fully Highly a 39 4.2. Check if routine data conceming CDTI activities at this level are collected and transmitted within the indicator of 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 reports) indicator of effectiveness and attitude "..,;-.Iftffi,m+,' 5.1 Check if sfficient Mectizan is being ordered yearly, and in good time (indicator of effectiveness Findines: At this lcvel rcporls by the DOC are submitted to the DMO, which is the normal channel of .qovcrnnrent reporling. The reporting process should be within the government system, not using other resources Fully Highly Moderately Slightly Not at all Not applicableIs this good for sustainability? 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 appropriate feedback given. The CDTI co-ordinator should be empowering the next level to cope with problems. Checklist of key activities: sensitisation/ mobilisation; training; improving Mectizan supply ; effective/ supportive supervision I Findines: In rnost of'thc villagcs visitecl. collection and tlistrihution ol'Mcctizan arc going ort qLritc w,cll. In ol'problcrrs, thcy are reponed and rcspr-rnclecl to quickly. There n'ere howevcr ancrnralics in sontc isolatcd cases. Not at all Not applicableIs this good for sustainability? Fully Highly Moderately Slightly . The orderformsfor the health district/ LGA exist, and are based on the sub- district orders. . The Mecttzan 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: 'fhc ordcrs arc clonc in tinrc based on thc population ligurcs. Shortagcs wcrc reported crncc whcn thc consi-qnnrcnt had not reached Kanrpala. so it rvas not the lault of the district. Not applicableIs this good for sustainability? Fully Highly Moderately Slightly Not at all 40 5.2 Check if Mectizan is being stored and administered within the government system at this level indicator of 5.3 Check if Mectizan is being distributed appropriately and effectively to the sub-districts of effectiveness NOTE: . This refers to training and sensitisation activities performed by officers working at this level, for the next level. . In Nigeria the LGA oncho coordinator forms part of the LOCT team. S/he does her/ his raining at the next level, together with the other CHEWS. 6.1 Check if is bei, done of efficienc and 6.2 Check that training conducted at this level (i.e. training of sub-district staff) is being done the indicator of and Findines: Thc drugs etre storcd and adntinistcred in thc govt.'s systent. The storc card ttsecl are urrilornr and supplietl by the -qovernntent. 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. Slightly Not at all Not applicableFully Highly ModeratelyIs this good for sustainability? Findines: In sorne cases lacilitatiort front tlte clistrict is inadequatc and irregular. The hcalth ccntre lV is lully participating in Oncho prograntltle. 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 should fetch the the district/ LGA level store,Mectizanfrom Not applicableSlightly Not at allFully Highly ModeratelyIs this good for sustainability? Findines: Whereas there are good reasons for each episode ol'training, there has been traitrittg assessment camied out. But also training ltas bccrr scert as a tnotivation. There should be an obiective 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 staff is not a sdficient reason for training. The evaluator must be satisfied that the duration of trainingwas justified. I Slightly Not at all Not applicableFully Highly ModeratelyIs this good for sustainability? Findines: The district staff are involved in training at village level, implying that supervisors have not been enrpowered enouglt to conduct the train irrg, Staff of this level only trains the level immediately below it, and notfurther down Not at all Not applicableFully Highly Moderately SlightlyIs this good for sustainability? I 4t 6.3 Check if in-service trainingfor CDTI is being integrated with other health programme traini, at this level indicator of and 6.4 Check that staff at this level continues to be engaged in the sensitisation/ mobilisation the relevant decision makers in their areas m 7.1 Check whether the cost implications of each CDTI related activity (monitoring/ supervision, training/ mobilisation, Mectizan distribution) are quantifi.ed in the yearly the health district/ LGA indicator of effectiveness 7.2 Check whether appropriate and adequate amounts are budgetedfor the planned CDTI related activities indicator of effectiveness and Trainingfor CDTI should be integrated into the yearly planfor in-service training in the health district. Findinss: Therc is no training plan and each health actil ity likc inrnrunization has its own tinretat"rlc. Is this good for sustainability? Fully Highly Moderately Slightly Not at all Not applicable Staff routinely identify situations where decision makers lack information about commitment to CDTI, and undertake activities to inform and persuade these persons. Staff have promotional materials at their disposal for this purpose (fliers, posters etc) I I Findines: Although thcre arc sonre promotional materials existing thcy have not been properly displayed ancl put to good usc. Advocacy is still lacking at district level. Is this good for sustainability? Fully Highly Moderately Slightly Not at all Not applicable The costs for each CDTI related activity in the year plan should be clearly spelt out in the budget. Recurrent and capital costs (f any) should be separated in the budget. Findines: Costing for CDTI activities is irregular and sornetimes not tlrcrc at all. Thc district is running two parallel budgets. Thc overall district budget does not have a break down of CDTI activities. But the APOC firndirrg budget lras all the key elements of the CDTI activities. Slishtly Not at all Not applicableIs this good for sustainability? Fully Highly Moderately The amounts budgeted should be neither excessive nor too small - managers should be able to justtfy the need for each amount, in relation to: . Tlte outcomes resultingfrom the previous year's CDTI expenditure . The cost of similar activities for other programmes. Findines: Thc artrount budgctcd is adequatc Is this good for sustainability? Fully Highly Moderately Slightly Not at all Not applicable Financing/ funding Findinss: 'l'hc clistrict clocs not nrakc attv llnancial contrihution to ('I)-l'l activitics. 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 maior one by now. This proportion offunds is increasing yearly. t Not applicableModerately Slightly Not at allFully HighlyIs this good for sustainability? 42 7 .3 Check whether funds to cover these costs are increasingly being supplied from district/ LGA resources indicator 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 7.5 Check whether CDTIfunds in the health district/ LGA budget are efficiently managed of effectiveness and efficienc 8.1 Check if there is sfficient transport for necessary visits to the sub-district level for CDTI related activities indicator o f effectiveness Findines: No new agreement in place and no plan has been put in place by the district to cover any deficits. However tltere assurance of support fronr sonte NGDOs in the area. Management is aware of the size of the shortfall, and has specific and realistic plans to bridge it. If il 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). I Not at all Not applicableFully Highly Moderately SlightlyIs this good for sustainability? Findines: Financial procedures of the district are clcarly followed in handling APOC money. 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 Slightly Not at allFully HighlyIs this good for sustainability? Findines: The directorate ol'health has sufficient facilities and are available lor CDTI activities whenever they are required. 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 be used for routine CDTI activities at LGA/ district level. I 8. Transport and other material resources I 43 8.2 Check if trips/ journeys undertakenfor routine CDTI purposes are integrated with those made other mes or indicator of and 8.3 Check if the transport made availablefor CDTI is being adequately managed (indicator of 8.4 Check if adequate provision is being made for the future, to replace existing means of when it wears out indicator of effectiveness 9. Human resources m 9.1 Check whether the health district/ LGA team is skilled and lorcwledgeable, regarding the ementation CDTI in its area indicator of effectiveness Checklist of activities : monitoring/ supervision, training/ mobilisatton, Mectizan distribution Is this good for sustainability? Fully Highly Moderately Slightly Not at all Not applicable Findines: Transport is usually used l'or other activities inclucling CDTI. water & sanitation, PHC inspcction antl nutritiort. 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 Fully Highly Moderately Slightly Not at all Not applicableIs this good for sustainability? Trips madefor CDTI purposes are properly authorised in writing by the relevant fficial. Each trip undertakenfor CDTI purposes is recorded in a log book. Findines: Thc requisitions antl authorizations are verbal. The lo-q book is filled rarely and fonnat has no option fbr date. Is this good for sustainability? Fully Highly Moderately Slightly Not at all Not applicable 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. Findinss: Is this good for sustainability? Fully Highly Moderately Slightly Not at all Not applicable Findines: Ofllcials arc krtou lctlgcablc and skilled on all CDTI activities according to repoft lronr the DMO. -l'hcy halc bccn attending refresher coursei scnr inars. LGA/ health district team members have enough lcnowledge and skill to undertake all the key CDTI activities themselves, without help: . Planning . Training and sensitisaton/ mobilisation . Mectizan ordering/ distribution . Monitoring/ supervision. Moderately Slightly Not at all Not applicableIs this good for sustainability? Fully Highly t I 44 9.2 Check whetherpersonnel at the health district/ LGA level is stable, and whether provision is made for passing on CDTI sktlls when a trained person moves away (indicator of Thc DOC has bccn in thc district lbr ntorc thatt fir c years. 'l'ltcre is no guarantee fbr inrntediatc replacernent with an equally trained persoll. Staff should remain in one postfor at least five years. There should be immediate training (in CDT| of new, unskilled district/ LGA staff members who have CDTI responsibilities. I Not applicableModerately Slightly Not at allFully HighlyIs this good for sustainability? effectiveness 45 2. Sub-districU first line health facility level 1.1 Check whether the geographical coverage in the sub-district is satisfocrory (indicator of effectiveness 1.2 Check if all villages have a satisfactory therapeutic coverage rate (indicator of effectiveness m 2.1 Check if CDTI is an oficial part of health service activities at this level, or is included in the'basic activities' indicator of inte andit Check if there is a written year planfor CDTI in the sub-districr (it may appear under another niune, e.g. 'onchocerciasis programme') (indicator of integration and effectiveness 2.2 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 I Findines: All the conrrnunitics unclcr the sub-districts visitcd irre unclcr treatnrcnt. Slightly (rnany villages/ hamlets not covered) Is this good for sustainability? il(> eo% coverage) Highly (problem with nomads only) Moderately (a few villages/ hamlets not covered) The therapeutic coverage rate should be: . 65% or higher . stable or increasing. Findines: 55 out of the (r3 villages in the sampled health tunits have coverage rates of nrore than (r5 per cent. Slightly (less than 65Yo coverage) Is this good for sustainability? Fully (>90% coverage) Highly (80-89% coverage) Modetarcly (65-790/o coverage) There should be an fficial document locally available, making clear that CDTI is a sub-district responsibility. Sub-district staff should perceive CDTI to be one of their routine responsibilities. I Findines: Thcrc arc no oflrcial docunrcnts at this level I-l on'cvcr q ual i tat i vc i ntcrvi cws indicate that thc hcalth unit stafl-parlicipate in Oncho activrtics anrl pcrceivc thenr as their nsihilit Is this good for sustainability? Fully Highly Moderately Slightly Not at all Not applicable Findinss: No eviclencc ol'a written plan although verbally they know thc sequence of activities as thcy planned in the workshop at the district level. 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 planfor the sub-district. It should not be separate. I Fully Highly Moderately Slightly Not at all Not applicableIs this good for sustainability? 1. Coverage Planning I Findines: No r,r,rittcn plan The plan should make provision for all key elements. Checklist of key activities: Mectizan supply; targeted training (for CDDs); targeted mobilisation/ sensitisation ; monitoring and supervision ! Not at all Not applicableFully Highly Moderately SlightlyIs this good for sustainability? 46 2.3 Check if the plan contains all the elements needed for CDTI to work well (indicator of effectiveness ffirurGr.ffircmp', Not applicable at this level. 4.1 Check if members of the sub-district team are routinely and efficiently supervising the CDTI the vil, on site indicator of effectiveness and 4.2 Check if routine data concerning CDTI activities at this level are collected and transmitted within the ent indicator of 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 reports) of effectiveness and attitude Findinss: Health ur-rit teanr routitrely supervises and integrates CDTI activities with other health activities (PHC). This level of integration nrake the health unit staff to supervise CDTI activity even outside targeted CDTI supervisory visits. 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. Not at all Not applicableHighly Moderately SlightlyIs this good for sustainability? Fully Findines: Reporls about CDTI activities are prepared regularly but submitted parallel to the district with othcr repons. The reporting process should be within the government system, not using other resources Slightly Not at all Not applicableFully Highly ModeratelyIs this good for sustainability? Findines: Ihe CDTI supervisors are involved in the management ol' problems (e.g. handling refusals, deployment of CDDs etc) in the villages. Feedback on successes was not properly handled. As soon as problems are identified in this way, the appropriate manager deals with them. Planning must include activities, whtch will improve coverqge in areas where it is unsatisfactory. Successes are noted and reported, and appropri at e feedb a ck given. The CDTI co-ordinator should be empowering the next level to cope with Supervision and monitoring I I a I 47 5.1 Check if sufficient Mectizan is being ordered yearly, and in good time (indicator of effectiveness 5.2 Check if Mectizan is regarded as afree but essential drug at the sub-district level indicator of and attitude 5.3 Check if Mectizan is being stored and administered within the government system at this level indicator of inte 5.4 Check if Mectizan is being distributed approprtately and ffictively to the villages I problems. Checklist of key activities: sensitisation/ mobilisation; training; improving Mectizan supply ; effective/ supportive supervision Is this good for sustainability? Fully Highly Moderately Slightly Not at all Not applicable Findines: Thc aspcct ol'villa-qcrs' convenicnce is not bcing atlherccl to. Sonretitnes the ordering ol- Mectizan is not hased ort clearly known population o['villagcs as registers are updated cluring tlre trcatnrcnt. The orderforms for the sub-district exist, and are based on the village orders. The Mectizan is availablefor the sub- districts in timefor 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 Fully Highly Moderately Slightly Not at all Not applicableIs this good for sustainability? There should be an official document locally available, making clear that Mecttzan is an essential drug at this level. Sub-district staff should perceive Mectizan to be an essential drug at this level. ! Findinss: There is no oftrcial document. However, there is a perception anrong a lew staff that Mectizan is cssential clrug in the area. For some, they receive a kit of cssential which does not contain Mecctizan. hencc they lail to see it as an cssential drug. Not applicableIs this good for sustainability? Fully Highly Moderately Slightly Not at all Findines: The storage and aclnrinistratiort is integrated in tlrc govenrrncnt systeln. 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. Fully Highly Moderately Slightly Not at all Not applicableIs this good for sustainability? Findines: 'Ihc villagers tltrough CDDs or an elected rncrnhcr ick thc clnr lronr tlre health units The villages shouldfetch the Mectizanfrom the sub-district health facility themselves Fully Highly Moderately Slightly Not at all Not applicableIs this good for sustainability? of effectiveness 5. Ordering and distributing Mectizan I I I 48 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 ,s done indicator of and 6.2 Check that training conducted at this level (i.e. CDD training) is done by the appropriate indicator of and 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 ator of effectiveness 7.1 Check whether adequate provision is made for the costs involved in each CDTI related at this level indicator of effectiveness Findines: Training is done once every year, mainly to train new CDDs and share experience although motivation was one of the nrinor reasons lor training. The ntajor reason fbr training is the attrition rate ol-CDDs. which is relatively high and the ability of the CDDs to retain knowledge. There should be an objective needfor each episode of training: * There must be evidence that CDDs to be trained lack lcnowledge and skills to perform the job. * Training to motivate CDDs is not a sufficient reason for training. The evaluator must be satisfied that the duration of trainingwas justified. Slightly Not at all Not applicableFully Highty ModeratelyIs this good for sustainability? Findings: Although supervisors carry out training, the DOC is also participating in the training of CDDs Only sub-district staff should be involved in training of CDDs Slightly Not at all Not applicableFully Highly ModeratelyIs this good for sustainability? Findines: 'l'hc nratcrials are verv linrited on the groutttl ancl therc are no tangible plans to get nlorc. 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 stocks of materials when needed. I Not at all Not applicableFully Highly Moderately SlightlyIs this good for sustainability? Findines: The suh-county docs not really budget fbr CDTI activities and so there are no detailed sections. Health urrits do not have budgets as tlrey ltavc rto luncls The costs for each CDTI related activity in the year pan should be clearly spelt out in the budget. The staff should be able to justify the amount they plan to use Checklist of items to be costed: monitoring/ supervision, training/ mobtlisation ; arranging Mectizan supply I Not at all Not applicableFully Highly Moderately SlightlyIs this good for sustainability? 6. Training and sensitisation/ mobilisation 7. Financing/ funding I I 49 7 .2 Check whether funds to cover these costs are fully or increasingly being supplied own and/ or district/ LGA resources indicator of 8.1 Check if there is sufficient transport for necessary visits to the sub-district level for CDTI related activities indicator of effectiveness 8.2 Check if trips/ journeys undertakenfor routine CDTI purposes are integrated with those madefor other programmes or purposes (indicator of integration and 9. Human resources 9.1 Check whether the sub-district team is skilled and knowledgeable, regarding the ementation CDTI in its area of effectiveness The relative contributions of all sources of funding should be clearly spelt out. The proportion provided by the official health service (district or sub-district) should be the major one by now. This proportion offunds is increasing yearly. Findinss: 'fhc sub-county ancl hcalth units do not supply any lirncls [o run CDTI activitics Slightly Not at all Not applicableIs this good for sustainability? Fully Highly Moderately Findines: In nrost health units they have motor cycles. There are prohlerls ol-getting luel. Some health unit stall'usc their personnal money for lirel. There should be no reports offailure to undertake necessary CDTI activities at village level, due to transport not being av ai I abl e or affu rdab I e. Checklist of activities: monitoring/ supervision, training/ mobilisation, arranging Mectizan supply Fully Highly Moderately Slightly Not at all Not applicableIs this good for sustainability? 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, arranging Mectizan supply Findines: In all cascs thc nrotor-cyclcs are uscd for other activitics that arc gcncral lbr the hcalth unit. Not applicableIs this good for sustainability? Fully Highly Moderately Slightly Not at all Findines: Some kcy staff at the sub-county level and health i/c have no sufficicnt knowledge and skills on CDTI. They are not participating in training. Sub-district team members have enough lcnowledge and skill to undertake all the key CDTI activities themselves, without help. Checklist of activiites : planning, monitoring/ supervision, training / mobilis atton, aruanging Mectizan supp ly Fully Highly Moderately Slightly Not at all Not applicableIs this good for sustainability? Transport and other material resources I I I I 50 9.2 Check whetherpersonnel at the sub-district level is stable, and whether provision is made for passing on CDTI skills when a trained person moves away (indicator of effectiveness 9.3 Check whether the working conditions of sub-district staff are satisfactory (indicator of effectiveness 3. Community level 1. Coverage I .l Check that the cal is 100% 1.2 Check that adequate therapeutic coverage is being maintained (indicator of effectiveness of effectiveness Findinss: Most nrenrbcrs ol'the staff have been in the place lbr rrrore than five years. There is also arrnual trairring of CDDs. Staff should remain in one post for at least five years. There should be immediate training (in CDTD of new, unskilled sub-district staff members who have CDTI responsibilities. ! Slightly Not at all Not applicableFully Highly ModeratelyIs this good for sustainability? Findines: "Whilc the physical workirrg conditions arc satislactory ancl tratrsport I'acilities are available. allowances ancl lirel allocatiotts arc not crtough neithcr arc' tltcy rcgular. Salarics arc not adequate but rcgular" The staff should at least receive their salaries regularly. Also to be considered are stffing level, medical equipment (for vital signs), medical supplies, stationery Slightly Not at all Not applicableFully Highly ModeratelyIs this good for sustainability? Findins: All parls/zones/household were covered with treatnrent. All quarters/ wards and hamlets are being covered s at i sfoct orily. Moderately (a few villages/ hamlets not covered) Slightly (many villages/ hamlets not covered) Fully (100% coverage) Highly (problem with nomads only)Is this good for sustainability? Findine: Most villagcs visited had coveragc ratcs of (r,5%r and above. cxccpt two villages (Kigawa and Haibale) which werc bclow 65%,. Therapeutic coverage of 65% should be maintained or improving Validate the responses from the re gis t er/ s ummary .form s. I I Slightly (less than 657o coverage) Moderately (65-79% coverage) Is this good for sustainability? Fully (>90% coverage) Erigfil? (80-8e% coverage) a 51 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? t Findines: Rcgistcrs arc uptlatccl a1 tltc sanrc tintc ol distribution in all tlrc villagcs visitcd Is this good for sustainability? Fully Highly Moderately Slightly Not at all Not applicable 2.1 Check if the census update is routinely done at the same time as the distribution indicator of and m 3.1 Check if community leadership gets involved in managing problems and successes with distribution of attitude and effectiveness ffi 4.1 Check whether village level distribution registers are being kept accurately (indicator of attitude and effectiveness 4.2 Check whether CDDs are reporting to the sub-district appropriately (indicator of effectiveness The community leadership takes responsibility "for the distribution of Mecttzan 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. Findinss: In nrost of thc villages visited the LCI leadership was highly parlicipating in nrobiIizing and scnsitizirrg conrmunities. They also help selecting new CDDs. There are some LCI olficials who are at the same time CDDs. Is this good for sustainability? Fully Highly Moderately Slightly Not at all Not applicable Register should be complete and accurate, The register may befilled in by the CDD and/ or a village helper. Verify by examining the register. Findines: Thcrc arc rcgistcrs lor each of the CDDs, thoLrgh some are not complete on the part of codcs and sumnraries. Is this good for sustainability? Fully Highly Moderately Slightly Not at all Not applicable 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 Findines: 'l'hcrc \\ crc no conrplaints fionr supcrvisors ahout rcports and ('DDs rcporlcd sending thcir rcport to supcrvisors in tinrc, which is usually ckrne at thc cncl ol'thc distribution exercise. No ical evidcncc Slightly Not at all Not applicableIs this good for sustainability? Fully Highly Moderately 3. Providing leadership 4. I a 52 5.1 Check that the amount Mectizan is received indicator of 5.2 Check that calculations for the required quantities of Mectizan are accurafe (indicator of effectiveness 5.3 Check that the required amount of Mectizan is received on time (indicator of effectiveness 6. Training 7.1 Check that the villagers appreciate the financial and non-financial costs involved in CDTI of Findines: The villages which expericnced shortages could get nlore ltom supervisors by collecting fiom areas which had excess. 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 Not at all Not applicableHighly Moderately SlightlyIs this good for sustainability? Fully Findines: It was reported that a 3 per cent irrcrease in the population is used to calculate the amount required fbr the next round of Mcctizan supply. It is also said that supervisors help on the calculations in areas where CDDs are not able. 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 I Not applicableModerately Slightly Not at allFully HighlyIs this good for sustainability? Findines: Although communities clid not complain abotrt the time drugs are given. it was noted that their participation on the specific period of the year lbr drug distribution was tninimal, except otr S illc da s and tinre The CDD and the villagers report that the Mectizan arrives at a convenient and acceptable time of the year. Not at all Not applicableHighly Moderately SlightlyIs this good for sustainability? Fully Findines: Apart liom CDDs the rest did not know the resources came fiorn donor. They reported that the money comes fionr government and it is part of their taxes. 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 come from. They should show an understanding that the resources comefrom outside andfrom the work of the CDD, and express their appreciation- Not applicableSlightly Not at allFully Highly ModeratelyIs this good for sustainability? 5. Mectizan supply Not applicable at this level - CDDs are trained, but do not conduct training. rci' 1fn-:rp+i'%{:;{'f+ I I 53 7.2 Check that the community has made arrangements tofund local costs of distribution of attitude Not applicable at this level m 9.1 Check that all CDDs have received tra of effectiveness 9.2 Check that there is a system in placefor new CDDs to acquire the appropriate skills of effectiveness 9.3 Check whether CDDs are wi, to continue with CDTI indicator of 9.4 Check whether villagers value annual treatment (indicator of attitude and effectiveness Findines: Thcrc are no an'angcnlent for transport, stationary, books. ancl pens. In two out of eight villages tlre conrmunities are paying some allowances to CDDs The community makes provisionfor the supply ofrecord books, pencils, transport and other expenses incurred (including possible remunerationfor CDDI Highly Moderately Slightly Not at all Not applicableIs this good for sustainability? Fully CDDs report that they have received training and demonstrate understanding of the work. Checklist: doing the census; doing the reports, giving the right dose; lvtowing who is not eligible; lcttowing what to do with side-effects Findines: Thc C'DI)s wcre' lound to be lbllowing the guirlclincs and they rlcnronstrated lull knorvlcdgc ol'tlrc work thcy arc doing. Is this good for sustainability? Fully Highly Moderately Slightly Not at all Not applicable There should be a plan in place for training CDDs to replace those who drop out, or when new ones are elected for other reasons. Findines: Thcre is no plan irr placc to train new CDDs lionr tlrc routinc annual trainin Is this good for sustainability? Fully Highly Moderately Slightly Not at all Not applicable CDDs should express willingness to continue with distribution in the long term, given the conditions, which prevail in the community. Findine: -fhc C'DDs arc proud that thcy are giving thc nruch ncctlcd scn'icc to thcir conrnrunitics. Is this good for sustainability? Fully Highly Moderately Slightly Not at all Not applicable The community members should mention one or more advantage of Mectizan, and express the needfor the annual treatment. Findine: ('onrrrunity rncnrbers appreciate the valuc of Mcctizan eurcl wcrc ablc to nrention that thc drtr also krlls othcr cliseases. Is this good for sustainability? Fully Highly Moderately Slightly Not at all Not applicable resources 9. Human resources I 54 9.5 Check whether villagers accept the needfor long term CDTI (indicator of attitude and People expressed interest in continued trcatnrent ancl therc were itttention expressed of' lt trcatnrcnt People show understanding and express interest in long term treatment with Mectizan. Not at all Not applicableHighly Moderately SlightlyFullyIs this good for sustainability?