Evaluation of the Sustainability of Ruvuma CDTI Project: 26th September - 12th October 2012

1World Health Organisation African Programme for Onchocerciasis Control Evaluation of the Sustainability of Ruvuma CDTI Project 26th September - lzth Octob err 2012 Mrs. Mary ADENIGBA (Team leader/Scout) Dr. Elizabeth ELHASSAN (Team member) Dr. Michael MUNGA (Team member) Mr.Eric MGINA (Team member) Ms. Jubilate BERNARD (Team member) Ms. Latifa KALINGA (Team member) Ruvuma CDTI Sustainability Evaluation, 2012 Page ,TABLE OF CONTENT l. INTRODIrCTION.......... 1.1 Population Activities, Cultures and Language.... 1.2 Communication System,. 1.3 Administration Structure .,.............. 1.4 Health System Structure & Health Care Delivery....... 2. MAIN OBJECTM OF THE EVAL[rATION..................... ...........12 2.1 The Specific Objectives..... ........12 3.2 Sampling........ .......1 3 3.3 Source of Information .......13 3.4 Analysis.......... ........13 ,.......................1 I , . ... .. ... . .. . .. .... ..1 1 . .. ... . .. .... .. .... .. ..1 1 .......................11 .....................12 6. Overall sustainability grading of Ruvuma Region............ .......,..............,.31 9. ADVOCACY VISITS TO THE POLICY 10. FEEDBACK MEETING. ..35 - 36 ll. DOCLIMENTATION ON NEGLECTED TROPICAL DISEASES (NTDs) PROGRAMME....................37 - 4l APPENDIX l: EVALI-IATION IT1NERARY.................. .......42-43 APPENDIX 2: PARTICIPANTS LIST... .43 APPENDIX 3: AGENDA OF REGION FEEDBACK MEETING ..................44 APPENDIX 4: LIST OF PERSONS INTERVIEWED.................. Table 1: LIST OF DISTRICTS, FLHFs AND VILLAGES EVALIrATED...... .................45 - 48 ......................13 Ruvuma CDTI Sustainability Evaluation, 2012 Page 2 APOC CDD CDTI CHMT CSM DED DMO EPI FLHF FLHFS FLHFW GCR HIV/AIDS HSAM IDSR MDA MOF MDP MOH NGO NGDO NTDs NOTF ONCHO PHC RAS RC RHO RHMT RMO SAE SHM SHT ABBREVIATIONS/ ACRONYMS African Programme for Onchocerciasis Control Community Directed Distributor Community Directed Treatment with lvermectin Community Health Management Team Community Self-Monitoring District Executive Director District Medical Officer Expanded Programme on Immuni zation Front Line Health Facility Front Line Health Facility Staff Front Line Health Facility Worker Geographic Coverage Rate Human Immuno-defi ciency Virus/Acquired Immunity Defi ciency Syndrome Health Education, sensitization, Advocacy, Mobilization Integrated Disease Surveillance & Response Mass Drug Administration Ministry of Finance Mectizan Donation Programme Ministry of Health Non Governmental Organization Non-Governmental Development Organization Neglected Tropical Diseases National Onchocerciasis Task Force Onchocerciasis Primary Health Care Regional Administrative Secretary Regional Commissioner Regional Health Officer Regional Health Management Team Regional Medical Officer Severe adverse event Stakeholders meeting School Health Teacher Ruvuma CDTI Sustainability Evaluation, 2012 Page 3 SWOT TB TCR TOT WHO WR Strength Weakness Opportunity and Treath Tuberculosis Therapeutic Coverage Rate Training of Trainers World Health Organisation WHO Country Representative Ruvuma CDTI Sustainability Evaluation, 2012 Page 4 ACKNOWLEDGEMENTS The team members wish to appreciate the kind opportunity given us by the Director of APOC, Dr. Paul-Samson Lusamba-Dikessa and his able team at Ouagadougou, Burkina Faso, to participate in this evaluation. Profound thanks go to the WHO Country Representative - Dr. Chatora Rufaro, WHO Operations manager, and the Admin / Finance Team, Dar-Es-Salam, the Sightsaver Finance manager, the National Coordinator of NTDs/CDTI, Dar-Es-Salam - Dr. Upendo Mwingira and her team are acknowledged for ensuring that the evaluation is a huge success. We acknowledge the Regional Medical Officer Ruvuma, Dr. D.A Malekela and the Region NTDs/CDTI Team, for providing the enabling environment for the evaluation. The DMOs, CDTIA{TDs coordinators, Zonal CDTI coordinators, FLHF staff, village leaders, the CDDs and village members in Songea, Namtunbo and Mbinga districts who contributed immensely to the success of this evaluation are acknowledged. Ruvuma CDTI Sustainability Evaluation, 2012 Page 5 EXECUTIVE SUMMARY INTRODUCTION The Ruvuma CDTI project was launched in 1998. It is in the l4th year of funding from APOC, and the l4s round of mass treatment with Ivermectin. An evaluation of the sustainability of the project was carried out between26'h September and 12ft October 2012by 6 evaluators (2 externaland4 internal). The main objective of the evaluation exercise was to determine the sustainability potentials of Ruvuma Region CDTI project at its 14th year and come up with recommendations that will enhance sustainability The specific objectives were: . To assess the performance of the individual groups of indicators of sustainability in Ruvuma Region CDTI Project . To identify the factors that may block or help the sustainability of the project . To analyze the data collected and present a report including recommendations to the project, NOTF and APOC management . To discuss the outcome of the evaluation exercise with the relevant stakeholders and partners in Ruvuma Region CDTI project On Monday,24'n September 2012, the team leader (Mrs. Mary Adenigba) paid courtesy visit to WHO and the NationalNTDs office, Dar Es Salaam where all planning towards the evaluation were finalized. She was in Ruvuma Region from 26th of September, 2Ol2 to prepare the ground for the evaluation. The three CDTI Regions ( Songea, Namtunbo and Mbinga) were automatically chosen for the evaluation exercise in the region. The team of evaluators met on the 1't of Octob er,2012 for orientation on the evaluation guidelines and instruments and also discussed and approve the evaluation itinerary. Advocacy visit was paid to the Regional Medical Officer (RMO) during which the team leader briefed him on the mission and activities of the team before and after the data collection exercise and the debriefing meetings. The RMO pledged his support for the exercise. The first week of the evaluation was for collection of informationldataby studying of documents, interviews and observation at the region, 3 districts, 6 FLHFs and 12 villages. The second week was for data analysis/harmonization, report writing, and feedback meeting. Below is the situation with reference to the indicators of sustainability l.Planning There was detailed plan of activities for NTDs which included essential CDTI activities at Regional and district levels. CDTI was included in the overall written plan of the districts but was only mentioned in terms of personnel and logistic at regional level. The plans were developed in a Ruvuma CDTI Sustainability Evaluation, 2012 Page 6 participatory manner but there was no written plan for CDTI activities at FLHF and community levels Partners were involved in the overall planning and were clear about their roles. Integration CDTI activities were implemented in an integrated manner and were carried out with other health programmes. CDTI data followed the government system of reporting, from the community level to national level. CDTI was also implemented in an integrated manner with other NTDs e.g there was integrated plan of activities for the NTDs while IEC materials and the Community treatment register were developed to reflect the NTDs Leadership Findings revealed that there was great awareness among leaders and existence of strong leadership support for CDTI activities at all levels. The activities of CDTI at regional and district levels were coordinated in a cascaded fashion whereby there was one regional coordinator under whom, there were coordinators in each CDTI district. At the FLHF, the in-charge of health facilities were CDTI coordinators for all communities in the catchment areas of health facilities. Generally, community and religious leaders were aware of CDTI activities and fully support the work of CCDs. They were well involved and were willing to support CDDs tasks such as community mobilisation, sensitisation, and drug distribution. Monitoring Most important reports at regional, district and FLHF were in place and they captured good quality data for CDTI activities. It was only one district (Mbinga) which had a vehicle designated to CDTI activities, the other two depended on pooled vehicles under their DEDs and DMOs. CDDs at community level faced transport problem and community members did not have any provision to solve this problem. The submission of CDTI data at all levels was through the government reporting system whereby CCDs submit their reports to the in-charge of health facilities who submit theirs to the district CDTI coordinator before it is sent to the regional coordinator who finally forward the reports to the national NTDs/CDTI office. However CDTI reports were not integrated into the district information management system. Mectizan@: Mectizan@ supply was sufficient and controlled within the govemment system. Orders from the district levels are sent to the national level through regional coordinator. On arrival from Mectizan Donation Programme to the national drug store, Mectizan tablets are distributed to districts pharmacy, who later distributed them to front line health facilities. CDDs fetch Mectizan@ tablets from the FLHF and distribute them to their respective communities. The uality of census data were good enough in most communities. The supply system was timely, adequate and uncomplicated. Training and HSAM: Cascaded trainings are practiced. National NTDs/CDTI staff train regional as well as district coordinators. District coordinators trained FLHF and CDDs. Training was routine in Songea and Namtumbo while in Mbinga it was focused. There were inadequate training materials. There was evidence of the effectiveness of advocacy. Leaders at all levels were aware of CDTI and participate fully in advocacy, sensitization and mobilization. Some district councils had started to 7Ruvuma CDTI Sustainability Evaluation, 2012 Page contribute to CDTL The FLHF staff in collaboration with village leaders use general village meeting to convey health education and sensitize the community about mectizan uptake. Community/ religious leaders were also involved in HSAM activities for CDTI and other NTDs. There were integrated HSAM materials for NTDs but grossly inadequate. Transport and other Materia! Resources The regional office has two Toyota Hilux vehicles, one had broken down while the other was functional but old. Binga district has a new vehicle. At health facility and community levels were one motorcycle and two bicycles donated by APOC for CDTI activities. Transport was inadequate especially at FLHF. Where it was available, maintenance was provided from APOC, basket or councilfunds. At the FLHF level, staff members used their personalfunds for running cost. The community did not provide support for transport to CDDs to collect Mectizan@ tablets or for other CDTI activities. Adequate equipment was only available at the regional level. There were no specific plans to replace the CDTI vehicles and equipment though government has policy for replacement for this. Materials for training, advocacy and awareness creation was in short supply at all levels. Financing Funding was provided by APOC, basket and the councils. However not all activities were budgeted for by the councils. The NGDO partner (Sightsavers) did not contribute to CDTI activities since 2009. According to Sightsavers Finance manager, this NGDO now funds NTDs (Oncho, LF, Trachoma, Schisto and STH) in 10 districts of Tanzania lsland/Mainland, hence, no direct fund to any region for CDTI activities. Budget holders followed due process in disbursement of funds and 70% -11OO% of the budgets were paid at the district level. Funds disbursed were mostly expended and accounted for. Shortfalls in budgets were met with funding from APOC and basket funds. The FLHF levels were neither involved in budgeting nor management of funds. Communities exempted the CDDs from community activities and levies but did not provide them with transportation for CDTI activities. Human Resources The regional, FLHF and community levels had inadequate staff. At the district level there were adequate human resources who were involved in CDTI and other health care activities' Coverage: - The region had a geographic coverage rate of 100% in the past 3 years while therapeutic coverage rate was 76.2%.83% and79.6% in 2009, 2010 and 2011 respectively. Treatment coverage dropped in 2011 because Ludewa district (a CDTI district in the border of Ruvuma and another region but being supplied with drugs by Ruvuma project ) had a therapeutic coverage rate of 70.2% due to insufficient drug. Sufficient drug was provided in 2012s. Seven aspects of Sustainability Six of the seven aspects of sustainability viz: Integration, Efficiency, Simplicity, Health Staff Attitude, Community ownership and Effectiveness were very much helping sustainability at all levels but resources were not helping at regional and FLHF levels but helping at district and community levels Ruvuma CDTI Sustainability Evaluation, 2012 Page 8 Five key aspects of the project critical elements of sustainability 1, Money- Is there sufficient money available to undertake strictly necessary tasks which have been carefully thought through and planned? Region- no, sustainability totally depend on APOC. Districts - yeS, some money from basket fund FLHF does not handle money; had no control of the budget and expenditure. The money allocated was insufficient. Contributions from the community were in kind, through exemptions from community development activities and levies. 2,Transport- Has provision been made for the replacement and repair of vehicles? Is there a reasonable assurance that vehicles will continue to be available for minimum essential activities? There had been no provision for replacement of vehicles at all levels, however the available CDTI vehicles were used for other NTDs . Funds for maintenance was from the council and basket fund. At district level, they had access to hire a vehicle from the pool or hire. At FLHF personal funds were used to maintain personal motorbikes. (No/Yes 3, Supervision- Has provision been made for continued targeted supportive supervision? Supervision was cascaded and integrated into other health programmes at each level. (Yes) 4,Mectizan@ - Is the supply system dependable? The supply system was dependable as it was integrated within the health system. The supply of Mectizan@ was timely and adequate. (Yes) 5,Political commitment: Effectively demonstrated by awareness of the CDTI process among policy makers There was high awareness of CDTI activities among policy makers at all levels. Councils do budget for some CDTI activities and the coordinators had access to pool vehicles when in need. The level of awareness and community ownership was high, as shown in the exemption of CDDs to levies and development activities. There was iinvolvement in sensitization and monitoring of CDTI and NTDs activities through use of community crier. (Yes) WAY FORWARI) Some issues were yet to be resolved at various levels. The following recommendations were made to ensure that the project improves on its achievement for sustainability. o MOH should make provision for replacement of the CDTI vehicles o MOH should recruit addition staffs to the programme o The RegionalNTDs/CDTI should improve on its record system to enhance accessibility and easy retrieval when need be. Ruvuma CDTI Sustainability Evaluation, 2012 Page 9 . All partners should increase financial support and ensure full disbursement of funds to districts. o Partners should provide transport and other equipment ( computers)to the Districts o All district staffs should be trained to implement CDTI activities o All partiers should increase financial support and ensure full disbursement of funds to FLHFs o Community members should mobilize resources to support transport and provide writing materials to CDDs to implement CDTI activities o Community members and leaders should decrease CDD ratio to 125 OVERAL SCORE TABLE NB: cut off point: 2.5 points average LEVEL INDICATORS 1-10 Pla ning Lead ershi p Inte grat ion Monit & super vision Mec. delive ry Train &. HSAM Transp /equip ment Fina nce Hum an Reso urces Coverge Total aYerage Region(1) J J J 4 4 J.J 1.8 r.8 1.5 4 2.9 District(2) J.J 3.7 J.J 5.5 4 3.1 2.5 3.2 4 J.J FLHF(3) 2.2 3.5 2.5 3.1 3.8 2.8 1.3 0.9 3.2 5.5 2.6 Villaee(4) 3.8 3.5 N/A 2.5 3../. 2.8 N/A 2.0 2.8 3.8 3.1 AVERAGE FOR THE WHOLE PROJECT 2.97 Ruvuma CDTI Sustainability Evaluation, 2012 Page l0 l.INTRODUCTION The Ruvuma CDTI Project is situated in the southwest part of Tanzania, and lies between latitudes l0 degrees south and I 1.5 degrees south and longitudes 33 degrees east and 38 degrees east. It shares borders with The Republic of Malawi and Mozambique to the west and south respectively. It borders Mtwara and Lindi Regions to the east while Iringa and Morogoro Regions forms a border to the north and northeast The Project was launched in 1999 and started operating in four endemic districts, which are Songea, Mbinga and Namtumbo located in Ruvuma region while the forth district Ludewa is located in Iringa region. This project is in its l4e year of MDA and has a total of 1,396 communities which are Hyper and Meso endemic with the total population of 398,574.It covers approximately an area of 64,333 sq. km of which 1,006 sq. km are inland water bodies from Lake Nyasa. With the exception of a small area along Lake Nyasa (altitude approximately 100 m above sea level) most of the project area lies between 500 and 1,600 m above sea level. The project area has a tropical climate characterized by two distinct seasons, notably wet and dry seasons. The dry season lasts from June to November/December. 1.1 POPULATION ACTIVITIES, CULTURES AND LANGUAGE The tribes in Ruvuma region are Ngoni, Ndendenle, Matengo, Yao and Nyasa while the common vernacular is Swahili. Major food crops grown in this area are maize, rice and potatoes. Legumes such as beans and soya are also cultivated in large quantity. Cash crops cultivated include tobacco and coffee. Economically the area is quite well-of although the wealth so generated is not equally distributed among the people, giving a wide range between the poor, who forms the majority, and the few effluent group. 1.2 COMMUNICATION SYSTEM The road network in the project area varies considerably. Seasonal roads that are only passable during the dry season-an important factor during Ivermectin distribution, serve Ludewa and Mbinga districts. Feeder roads going to meso and hyper endemic communities in all districts are only passable during the dry season. Songea district is served by one tarmac road, which passes in the Onchocerciasis area and therefore offers easy transportation to those communities situated along this road. 1.3 ADMINISTRATION STRUCTURE The head of the region is the Region Commissioner (RC) who has a secretary referred to as Regional Administrative Secretary (RAS). The Administration at Region is divided into Departments e.g Health Department of Region headed by the RMO, Water & Sanitation, Agriculture, Land, Natural Resources & Forestry. These departmental heads are answerable to RAS & RC. The RMO controls the Districts Medical Officers (DMOs) who deal with health issues in the Districts. The RHMT works with RMO and are responsible for health issues in the whole region. Reports from each department are submitted to RHMT regarding number of Health issues. Health plans is done by RHMT members at region while it is done by DHMT at district level and given approval by the RHMT. There are Ward Executive Officers employed by The District Ruvuma CDTI Sustainability Evaluation, 2012 Page ll Council who head several villages in their catchments areas. The District Council employs the Village Executive Officer while the community members elect the village chairperson. 1.4 HEALTH SYSTEM STRUCTURE/HEALTH CARE DELIVERY. The lowest level of health care delivery in the country is the village health service, providing preventive services offered within homes through two health workers chosen within the the community. The second stage is a dispensary, which can cater for up to 10,000 people progressing to health center usually accommodating the population of one administrative division or ward (approximately 50,000 people) Each district has a Council Health Management Team (CHMT), which determines the priorities for health for its people. There is also a district hospital for referrals from Health centres. In addition, every region has a hospital which offers similar services to those agreed at district level, however regional hospital have specialists in various fields and can offer additional services. The highest level of hospital services in the country is the consultant hospital of which there are currently four serving the entire population of the country. The people in Ruvuma Region are served by 10 Hospitals, 24Health centers and227 Dispensaries owned by Government, NGO's and private. 2. MAIN OBJECTIVES OF THE EVALUATION The main objective of the 2012 evaluation exercise is to determine the sustainability potentials of Ruvuma CDTI project at its fourteenth year. 2.1 THE SPECIFIC OBJECTIVES The specific objectives are: . To assess the performance of the individual groups of indicators of sustainability in Ruvuma CDTI Project . To identify the factors that may block or help the sustainability of the project . To discuss the outcome of the evaluation exercise with the relevant stakeholders and partners in Ruvuma CDTI project . To analyze the data collected and present a report including recommendations to the project, NOTF and APOC management 3. METHODOLOGY 3.1 PROTOCOL . Evaluation question: How sustainable is the Ruvuma CDTI project in its l4th year of implementation? Des ign: Cross-sectional, descriptive. Population: The Ruvuma Region CDTI project staff, its district coordinators, the FLHF staff, the community members and their CDDs. Sompling: A random sampling was done. Ruvuma CDTI Sustainability Evaluation, 2012 Page t2 3.2 SAMPLING The three CDTI districts (Songea, Namtunbo and Mbinga) in Ruvuma region were automatically selected for the evaluation. Concerning the FLHFs, a random sampling approach of selecting from far and near areas was adopted in selecting the areas for the evaluation in order to allow for even geographic coverage of the region. A list of the FLHFs in each district was made after which selection of one FLHF was made from both far and near areas, giving 2 FLHF per district. The same process of random selection was followed for the selection of 2 villages from each FLHF catchment area. A total of 6 FLHFs and 12 villages were drawn for the evaluation (Table 1). 3.3 SOURCE OF INFORMATION lnformation was gathered from interviews, inspection of documents and observations which were recorded on the appropriate evaluation instruments for analysis. Various categories of people interviewed include the National NTDs/CDTI coordinator and staff, Sightsavers Finance manager, Region Medical Officer, Region NTDs/CDTI Coordinator and Accountant, District policy-makers, Pharmacy officers, Transport officers, District NTDs/CDTI Coordinators, Ward NTDs/CDTI Coordinators, the FLHF staff, traditional leaders, CDDs and community members. See table I for the names of the districts, FLHFs and communities selected for the evaluation. Table 1: The list of Districts, FLHFs and Villages evaluated 3.4 ANALYSIS The data for each level was assembled and analysed at a time. The team arrived at the average grading of the sustainability rating for individual indicators and a scale of 0-4 was used to score each group of indicators. The score of all the group of indicators at each level was then illustrated graphically. The recommendations were then made by indicators for the project to achieve sustainability. The evaluators made a documentation on NTDs and came up with suggestion on the adaptation of the existing CDTI evaluation tools for the evaluation of other NTDs. S/N District R* (Coverage Rate) 2011 FLHF Villages 1 Songea (81%) meso/hyper endemic Matimira Dispensary l. Matimira 2. Mpangula Ruhimba Dispensary 1 2 Ruhimba Likalangilo 2. Namtunbo (80%) meso/hyper endemic Ligera Dispensary l. Namaoka 2. Mtelawamwahi Likuyuseka Dispensary 1. Mandela 2. Likuyuseka J Mbinga (8s%) meso/hyper endemic Liparamba Health. C. l. Liparamba 2. Mipotopoto Mango Dispensary l. Mango 2. Songambele Ruvuma CDTI Sustainability Evaluation, 2012 Page l3 3.5 LEVELS OF INSTRUMENTS Four instrumentsl were used for field sampling. Below are the instruments and the levels at which they were used; Region level - instrument 1 District level - instrument 2 FLHF level - instrument 3 Village level - instrument 4 3.6 CONSTRAINTS The fund released for the debriefing meeting could not accommodate the overnighVtransport allowance of concerned CDTIAT{TD personnel at districts, health facility and community levels, hence, two districts, the FLHFs and the villages sampled were not debriefed 4. TEAM COMPOSITION The core team members are listed below. The team was divided into 3 sub teams. The sub teams were assisted by one district coordinator each. These were, Mrs. Gladness Komba, Dr. Sebastian Mhagama. and Mr. Rajabu Chnikuta. Mrs. Mary O. Adenigba (Team Leader / Scout) Federal Ministry of Health, Department of Public Health, National Onchocerciasis Control Programme, Abuja, Nigeria Phone: +23 4803215 348 8, Email : maryol uwarotim i @yahoo.com Dr. Elizabeth Elhassan Sightsavers Villa 15 Cite Air France, Quest Foire Dakar, Senegal phone : +2217 7 9199603, Emai I : ee I ha ssan /4 s i gh tsavers.org Dr. Michael Munga National Institute for Medical Research P.O. Box 9653 Dar-es-Salam Tanzania Phone: +255-7 5673 1605, Email rn ichaclnr trnga rt r ahOo.ct-itt't Mr Eric Mgina National Institute for Medical Research Tukuyu Centre P.O.Box 538 Tukuyu-Mbeya Tanzania Phone : +25 5 -7 8498820 l, Email : erimgina@yahoo.com Ruvuma CDTI Sustainability Evaluation, 2012 Page 14 Ms. Jubilate Bernard Ministry of Health and Social Welfare Epidemiology Section P.O.Box 9083 Dar-es-Salam Tanzania Phone: +255-7 54883485, Emai l: iubbybm oo.com Ms. Latifa Kalinga Muhimbili University of Health and Allied Sciences P.O.Box 6500 I Dar-es-Salam Tanzania Phone; +255-7 l99l 9 I 3 l, Email: latifakalinga@yahoo.com Ruvuma CDTI Sustainability Evaluation, 2012 Page l5 5. EVALUATION FINDING REGIONAL LEVEL After 1 3th year of CDTI implementation using 2.5 points of a 4 point scale as the pass mark, the Region level had a 2.9 point performance. The details are as follows: REGIONAL LEVET 44 4 A-- 3.5* 3 3 3 3 2.5 2 1.5 1 0.5 0 I Serresl .-":*.-:.$""":".c "$""."* Planning - (3) There was a detailed plan of activities for NTDs which included essential CDTI activities like HSAM, training, monitoring and supervision, MDA, equipment and supplies, vehicle maintenance etc. CDTI was not in the overall written regional health plan but was mentioned in terms of human resources and logistic. Partners were involved in the overall planning and were clear about their roles. The NOTF/ National Planning meeting is once or twice ayear with WHO representative, regional / district coordinators and other partners in attendance. There was no record of any previous sustainability evaluation but each district developed NTDs/ CDTI sustainability plans to be funded by APOC. There were two internal monitoring teams from MoH in 2011 during which there was training on data entry for monthly financial and technical reports. The team recommended that pharmacists be actively involved in the delivery and collection of Mectizan. Monitoring recommendations could not be sighted. Integration - (3) CDTI activities were implemented in an integrated manner and were carried out with other NTDs, eye health, supervision of HIV/AIDS, TB and hospital management activities Leadership(3) Only the NTDs regional coordinator was involved in CDTI at this level. She was fully aware of the progress, successes and problems. The leadership was up to date with its targeted activities. NOTF meeting is once or twice ayear.lt is the forum where the regional and district coordinators meet, Ruvuma CDTI Sustainability Evaluation, 2012 Page l6 1.5 but the meeting was yet to hold in 2012. However, leadership at this level visits the districts and also communicate through telephone and e-mail mostly during MDA. The district medical coordinators have been delegated to supervise the district coordinators for the implementation of NTDs/CDTL Monitoring and Supervision - (4) Important CDTI records like treatment summary, equipment, vehicle, technical reports were available and sighted. Records were of good quality, the content was clear. However, budgets, disbursements and expenditure documents for 2009 &.2010 could not be accessed. This level spot checks the districts, checks materials for FLHF training and visits selected villages during supervision. There was an average of 2 supervisory visits to each district per year but Songea and Namtunbo were visited more frequently due to proximity. The project vehicle was utilized with fuel from APOC and basket funds. Number of days was determined by the distance. Supervisory checklists were used. This level effectively managed problems like drugs shortages, weak coordinators, inadequate CDDs etc while information on successes were communicated to the authorities/persons concerned with commendations Mectizan Procurement and Distribution - (4) Mectizan supply was controlled within the government system. This level receives order from the districts and send to National NTDs office where re-application of all projects are harmonized and sent to MDP. The drugs on arrival are delivered to the National drug store and then transported to the districts Pharmacy stores. There was sufficient Mectizan, the supply system was effective, uncompl icated and effi cient Training and HSAM - (3.3) No training is conducted at this level. The National NTDs/CDTI trains the regional and district coordinators. Training of the FLHF staff is planned and implemented by the district coordinators under the supervision of the regional coordinator. Training materials are supplied by the regional office. Training objectives is based on needs. There was advocacy during RHMC and PHC meetings where session was giving for presentation on NTDs/CDTI. There was advocacy visit to the RegionalAdministrative Secretary prior MDA in 2011 with advocacy message targeting MDA. Region also planned to carry out advocacy to the RHMT, RHS, CHMT. The project produced TV & Radio j ingles in 201 I . The coordinator seizes the opportunity of press people to talk on CDTI whenever she talks on blindness. HSAM activities has resulted in some districts contributing to NTDs/CDTI Recommendation: HSAM and Training materials Implementation materials to FLHF enough trainingensure Priority: HIGH Indicotors ofsuccess: o sufficient training materials available Ruvuma CDTI Sustainability Evaluation, 2012 Page t7 Wo to take Action o RegionalNTDs/CDTI o Ministry of health De adli ne for C omple tion ; July- Sept 2013 Financial - (1.8) The breakdown of 201O &2011 statement of cash flow from APOC funds is in the table below: N.B The figures in this table are for Ruvuma Region as a whole including the districts. There was no record of the amount received and expended by the regional office 2010 (Tsh) 2011 (Tsh) Budget 167,402,690 195,497,654.76 Balance carried forward 0 4,036,467.50 Amount received l3 I ,989,899 135,588,345.90 TotalAvailable 131,989,899 139,624,813.40 Expenditure 109,953,432 185,574,867.00 Balance 4,036,467.50 0 Over Expenditure -45,950,053.60 SOURCE: Accountant - National NTDs - Dar-es Salaam From the above table, budget from APOC funding increased, amount released by APOC increased and total expended by the region as a whole increased in20l I compared with 2010. There was no record of budget and disbursement from the regional office though through financial records were sighted at the districts. The disbursement from APOC should be decreasing while that of government should be increasing for sustainability. Control system was in place whereby request for expenditure of APOC funds was made to the RMO for approval. Allocation of expenditure was against specific budget headings and there was monthly which allowed for regular insight into budget. There was no record of cost of fueling through basket funding during CDTI supervision while the cost of vehicle repairs during joint supervision by the RHMT could not be quantified. Transport and other Material Resources - (1.8) The project had two Toyota Hilux vehicles, each donated by APOC and Sightsavers in 2005. The one donated by Sightsavers had broken down while the functional one can not travel far, logistic was therefore inadequate. Equipment like photocopier, desktop computer, LCD projector and printer were adequate while posters, CDDs brochure and household treatment register were inadequate but there was request for more copies. The functional vehicle was used to support activities at regional and district levels. Other programmes made use of the project vehicle but the coordinator did not have access to other projects' vehicles. There was routine maintenance after 1,000 kilometers with APOC and basket funds. Project vehicle was adequately controlled with the use of log book. Other equipment were repaired when they break down, provided there was fund. The government was not aware that replacement was needed for the vehicle but depended on the programme to provide and there was no evidence that there was request for vehicle from any NGO Ruvuma CDTI Sustainability Evaluation, 2012 Page l8 Recom mendation :_Tran sportation Implementation CDTI vehicles Priority: HIGH Indicators of success: o Transportation available for implementation of CDTI activities. Who to tqke Action o Ministry of Health Deadline for C ompletion July -Sept 2013 Human Resources - (1.5) The Regional NTDs/CDTI/eye care coordinator had being the only officer at this level since May 2009 and was trained in 2010. The previous coordinator was on the project since inception and retired in 2009. Two new members were co-opted in 2012 ( I cataract surgeon who is temporary and I ophthalmic nurse). The coordinator was the only one trained to perform CDTI activities like planning, report writing, training and HSAM, monitoring and supervision, data management and mectizan ordering and distribution. Human resources at this level was grossly inadequate Recommendation: Human Resources Implementation programme Priority: HIGH Indicators ofsuccess: o Adequate human resources available for the implementation of CDTI activities Who to take Action o Ministry of Health Deadline for C ompletion : July - Sept 2013 Coverage - (4) A geographic coverage rate of 100% has been maintained for the past 3 years while therapeutic coverage rate was 76.2%.83o/o and79.6%in2009,2010 and 20l l respectively. Treatment coverage dropped in 201 I because Ludewa district (a CDTI district in the border of Ruvuma and another region but being supplied with drugs by Ruvuma project ) had a therapeutic coverage rate of 70.2%o due to insufficient drug. Sufficient drug was providedin2012 Ruvuma CDTI Sustainability Evaluation, 2012 Page l9 DISTRICT LEVEL After l3th year of CDTI implementation using 2.5 points of a 4 point scale as the pass mark, the District level had a 3.3 point performance. The details are as follows: District level 4.5 4 3.5 3 2.5 2 1.5 1 0.5 0 3.7 4 4 3-3 3.3 33 3.2 23 3.1 2.5 r lndrcators Planning - (3.3) The CDTIA.,ITDs was integrated into all three districts' written health year plans. All districts made provision for all activities except Namtumbo district where provision was limited to supply of Mectizan@ tablets to FLHFs, training of the CDDs and logistics. The plans were developed in a participatory manner and took into account the communities preferred time of distribution. Integration - 3.3) There were integrated written work plans in all districts. District level staff members implemented activities in an integrated manner particularly with other NTDs/eye health and in most cases with other health programmes e.g malaria, EPI and HIV/AIDS. Leadership - (3.7) There were focal persons in each district responsible for CDTIAtTDs/eye health. The council health management teams under the chairmanship of the district medical officers discuss the plans of the districts following which the focal persons initiates the CDTIA{TDs activities. Monitoring/Supervision - (3.3) The reporting process is within the health system. Data from the zonal coordinators are collated by the district focal persons and submitted to the district medical officers who send them to the *"$o-!..-$..-""i".d o".$:'"-o* Ruvuma CDTI Sustainability Evaluation, 2012 Page 20 regional medical officers and to the national coordinator. The reports included all aspects of CDTI activities. However, treatment data are not integrated into the district information management system. The focal persons supervises zonal levels and FLHFs during distribution and other PHC activities with spot checks as required. Problems identified such as shortage of tablets, misconception on benefits, low coverage and late distribution of tablets were addressed by reallocation of excess drugs to areas where they were needed and HSAM. Mectizan@ - (4) Requests for tablets are based on community needs. Ordering and stock control is within the health system. Mectizan@ tablets were ordered and received by the district pharmacists through the regional store from the medical store department using the requisition forms. The supply was available timely and was adequate though shortages were reported in a district in 2009. Training/[ISAM - (3.1) Staff of Songea and Mbinga districts trained only the FLHF level. They had empowered other health staff atthe district level and FLHF staff to conducttraining. Training materials were used for training. Training was mostly routine in Songea and Namtumbo districts and the objectives were not necessarily restricted to focus on deficiencies. Advocacy was carried out to the council health management teams, PHC staff members and at times at FLHF level when required. There was evidence of the effectiveness of advocacy. Recommendation:_HSAM and Training materials lmplementation to FLHF Priority: HIGH Indicators of success: o sufficient training materials available at FLHF Wo to tqke Action o District CDTI coordinator Deadline for Completion Jan-march 2013 Financing - (2.5) Focal persons were aware of the funds budgeted for in two districts. The funds were within estimated incomes and clearly spelt out. There was evidence of increased budgets by the partners mainly APOC and basket funds in Songea district and only from APOC in Mbinga and Namtumbo districts. Councils only budgeted for some CDTI activities. The NGDO partner did not provide funds for CDTI. Mbinga district disbursed 100% of funds budgeted for while Songea and Namtumbo districts disbursed 70o/o each. Funds disbursed were mostly expended. Shortfalls in budgets were met with funding from APOC and basket funds. The budget holders used the health system control system; they sought and received approval in writing from their district executive directors through the medical officers and accounted for funds received. Allocation of expenditure was against budget headings and focal persons were aware of the balances. District coordinators are advocating for increased allocation of funds. Ruvuma CDTI Sustainability Evaluation, 2012 Page 2l Recommendation :-Financing Implementation and ensure full disbursement of funds to districts Priority: HIGH Indicators of success: o Adequate funds available and disbursed for implementation of CDTI activities Who to take Action o District CDTI coordinator Deadline for Completion : Jan-march 2013 Transport and other resources - (2.3) Only Mbinga district had a motor vehicle donated by APOC and it is used for CDTI and other PHC activities. Songea and Namtumbo made requests for vehicles to implement CDTI activities from the district pool of vehicles. When vehicles were unavailable or additional vehicles were needed, approval to hire was sought and received. None of the district focal persons had equipment. The district focal officers made and received approval to travel from their district medical officers. Running costs were mostly met from APOC and basket funds but when transport was from the pool, government provided funds for maintenance. The NGDO partner made no contributions to transport to any district. There were no specific plans to replace the CDTI vehicle; although government has regulations and guidelines on replacement of vehicles, there was no evidence that this would be honoured. Material resources used comprised of various posters and CDD brochures for NTDs. These were provided by the MOH, APOC and other partners but were inadequate although staff had made requests for additional materials from the national level. Recom mendation :_Transport Implementation equipment ( computers)to the Districts Priority: HIGH Indicators of success: o Transportation and equipment available to suPport implementation of CDTI activities Wo to take Action o District, NGDO and APOC Deadline for Completion July -September 2013 Human resources - (3.2\ All districts had adequate human resources who were involved in other health care activities. A number of the staff members were skilled. However, Namtumbo district had fewer skilled staff. The personnel received training in various PHC activities and were committed. Some staff were commended verbally and/or at social gatherings to mark performance Ruvuma CDTI Sustainability Evaluation, 2012 Page 22 Recommendation : Human resources Implementation CDTI activities Priority: MEDIUM Indicators ofsuccess: o All staff empowered in implementation of CDTI activities Wo to take Action . Regional CDTI coordinator Deadline for Completion : July - September 2013 Coverage - (4) The geographic coverage over the last three years was mostly 100% for all districts except in 2009 in Namtumbo district. The therapeutic coverage was increasing and in the range of 70%o - 90% except in2009 when Namtumbo district attained a coverage of 65%o. FRONT LINE HEALTH FACILITY LEVEL After l3th year of CDTI implementation using 2.5 points of a 4 point scale as the pass mark, the Front Line Health Facility level had a 2.6 point performance. The details are as follows: FLHF level 3,8 ill 2.8 2.5 4 3,5 3 25 - 2.2 t.z 33 il[21.5 i10.50 0.9I *"!*"t!"{""..."|""s*f"*'^1.""""}""i.."e t'$s r lndlcators Ruvuma CDTI Sustainability Evaluation, 2012 Page 23 Planning - (2.2) A written plan for implementation of CDTI activities was available in one FLHF (Mango dispensary in Mbinga district). Arrangement for receiving and distributions of mectizan to the community seemed to be properly organized at this level. There is proper mobilization of village leaders and CDDs for Mectizan distribution across all FLHFs. However, FLHFs are not involved in the entire planning of all CDTI activities with district authorities. The FLHF in-charge collect information on the population size of the communities and send them to the district for Mectizan@ tablets estimation as well as ordering. Written plan for CDTI activities was not sighted in most FLHFs. Recommendation :-Planning Implementation and use it to guide implementation of activities. Priority: MEDIUM Indicators ofsuccess: o Detailed plan of action available and used to guide implementationof CDTI activities. Who to take Action o Regional, District and zonal coordinators. Deadline for Completion July-Sep 201 3 Integration - (2.5) Some CDTI activities are integrated within the health facility activities, and some CDTI tasks are combined with other HF tasks. Sensitization and community mobilization is done in village meetings before distribution. Since sensitization is a continuous process, it is also done during distribution of Mectizan@ tablets. In Matimira dispensary, some CDTI activities are combined with vaccination. CDTI data follow the government system of reporting, from HF level to national level, though the data are not integrated in HMIS (filled in separate forms)' Recom mendation :-lntegration Implementation other health activities are combined Priority'. HIGH Indicators ofsuccess: o CDTI activities combined with those of other health programmes Wo to take Action o Regional, District and zonal coordinators. De adline for Completion Sep-Dec 2013 Ruvuma CDTI Sustainability Evaluation, 2012 Page 24 Leadership - (3.5) FLHF receives Mectizan@ tablets from the District and send them to CDDs, Staff at this level plan for distribution with the CDDs. Health facility management team takes full responsibility for CDTI activities. Political Leaders and village administration at this level are aware of CDTI activities and are normally involved in mobilizing people to take mectizan. Monitoring/Supervision - (3. 1) At FLHF level, reporting process follow the same government system. Data from CDDs are compiled by FLHF in charge and sent to district coordinator. Supervision is done during distribution every year, and in routine H/F supervision, CDTI is combined with other programmes. There were no supervisory checklists but time table found. Inadequate transport was the major common problem which hindered close monitoring. Mectizan supply and management - (3.8) In general, sufficient Mectizan @ tablets were supplied to this level and arrived on time. There was no report of shortages. Mectizan are collected, stored and effectively delivered within the government system of drugs management. CDDs fetch mectizanfrom FLHF. HSAM and training - (2.8) All FLHF staff in collaboration with village leaders use general village meeting to convey health education and sensitize the community about Mectizan@ uptake. Sub-village/hamlet leaders mobilize people in their respective areas. Training for CDDs is conducted based on the needs in one district (Mbinga), particularly when there are newly recruited CDDS. In the remaining two districts, CDDs' training is done annually for both old and new CDDs (not targeted). Training is done after arrival of Mectizan@ to the FLHF, and the staff use the same venue to distribute mectizan to CDDs. The common problem on this indicator was lack of training materials in most FLHFs. Also trainings are not properly conducted (only some instructions for Mectizan@ distribution are provided in l-2 hours, and few photocopies of leaflets in some areas) due to lack of resources and support from the district level. Recommendation :_Trainin g Implementation are available Priority: HIGH Indicators ofsuccess: o Sufficient training materials available for implementation of CDTI activities. Wo to take Action o Regional, District and zonal coordinators. Deodline for Completion July - Sep 2013 Financing - (0.9) There is no budgeting at this level, funds are controlled at district level.They just receive Mectizan@ tablets and training material from the district. Insufficient funds are disbursed for CDTI activities. Ruvuma CDTI Sustainability Evaluation, 2012 Page 25 FLHF are not aware of the amount of money or proportional allocated for them. They didn't even know the source of funds. Recommendation :_Financing Implementation CDTI activities. for implementation of CDTI activities and ensure full disbursement of funds to FLHFs Priority: HIGH Indicators of success: o FLHF staff are involved in budgeting for CDTI activities o Funds are disbursed to FLHF staff for CDTI activities o MOH, Districts and NGDO partners allocation and disbursement of funds is increased Wo to take Action o MOH, NGDO partner, Regional, District and zonal coordinators. De adline for Completion April - June 2013 Transport and other materials - (1.3) Generally, transport at this level was inadequate. One FLHF had a motorbike and one had a bicycle provided by APOC. The bicycle was not in good condition and needed to be replaced. The motorbike is serviced by the government. Liparamba health centre uses a vehicle provided by Ministry of Health and Social Welfare for all activities in the health centre, so the vehicle is fuelled and serviced by the government and its used always. One FLHF staff uses his personal motorbike which is fuelled by the government and serviced with his money. The remaining FLHF didn't have any means of transport. There was no evidence of a plan for replacement of any means of transport. Recom men dation :_Transport Implementation Priority: HIGH Indicators ofsuccess: o Transport available for implementation of CDTI activities. combined with those of other health programmer Who to take Action o APOC, NGDO partner and, District and zonal coordinators. Deadline for Completion Sep-Dec 2013 Ruvuma CDTI Sustainability Evaluation, 2012 Page 26 Human Resource - (3.2) Generally, there was inadequate staff in most FLHFs. The CDTI focal person was the in charge in most health facility and is loaded with other activities. Among available staffs, only 75Yo were competent to do CDTI activities. In most cases there was staff stability, mostly, staff have been in the same health facility for more than five years. On the job training was conducted for newly recruited staffs. Coverage - (3.3) ln most FLHF the Geographic coverage was good, about 100% in 2011. For previous years (2009 and 2010) the geographical coverage ranged from 57- 100%. Overall therapeutic coverage was good, for 2009-2011 period, the therapeutic coverage was above 65oh on average. The coverage trend was increasing in all FLHFs. COMMUNITY LEVEL After l3th year of CDTI implementation using 2.5 points of a4 point scale as the pass mark, the Village level had a 3.1 point performance. The details are as follows: Community level 3.8 3.84.0 3.5 3.0 2.5 2.O 1..5 1.0 0.5 00 - 3.5 3.2 2.8 2.8 2.5 I I 2.0 l *$*o""'"-.r"J """ -""' r lndrcators Planning - (3.8) For most of the surveyed communities, overall written plans for CDTI activities were not available at this level .However, community members were indirectly involved to support planning activities for CDTI, particularly by submitting information regarding population sizes of each community. Informants confirmed that CDTI issues were discussed during community meetings, although the evaluation team could not access the minutes of the meetings. Community members were also involved in CDTI. Ruvuma CDTI Sustainability Evaluation, 20L2 Page 27 Leadership and Ownership - (3.5) Community leadership supports the CDDs to implement all CDTI activities such as drug distribution, sensitization, and census. The leadership also help to solve problems related to distribution of drugs whenever they arise. Community members were responsible for selecting and changing CDDs if need be, they decide on the timing and mode of Mectizan distribution and monitor CDTI. Community leaders support the work of CDDs to mobilise communities and solve problems related to implementation of the programme. Community members were aware of the advantages of taking Mectizan@ tablets viz: smooth skin, reduction of anaemia, improved vision etc. They however were not aware of the reasons for long term treatment. In this aspect, team members took the liberty to explain the reasons for long-term basis. Monitoring - (2.5) Reports from CDDs covering villages and sub-villages under each facility's catchment area are submitted to the in-charge of that particular facility who compiles a comprehensive report to be sent to the district CDTI focal person. The reports normally comprise of coverage statistics, drug distribution data, and information about drugs received, distributed and balances. Members of the community do not arrange transport to support CDDs operations. Most CDDs travel long distances (and more often, on foot) to bring their reports to the health facilities. Recom mendation :-Monitoring Implementation transportation for implementation of CDTI activities. Priority: HIGH Indicators of success: o Transport is available to CDDs for implementation of CDTI activities. Wo to tqke Action o Community members Deadline for Completion Sep-Dec 2013 Mectizan@ - (3.2) In all surveyed communities the evaluation respondents confirmed that they receive the right amount of drugs and at the right time. Generally the quality of the census data was good which made it possible for the evaluation team to compute the TCRs for all communities. The CDDs indicated that, Mectizan@ tablets were fetched from the FLHF; and that there was no arrangement by community members to support CDDs with transport. However, in cases where communities are too remote from the front line health facility, the in-charge of these facilities or other health workers (within that facility) take the drugs to the communities. The team found no record that Mectizan were left for those that were ineligible during treatment . Ruvuma CDTI Sustainability Evaluation, 2012 Page 28 Recom mendation :Mectizan@ Implementation Mectizan@ tablets in the communities for one month for treatment of temporarily ineligibles. Priority: MEDIUM Indicators of success: o Mectizan@ tablets available in the community for treatment of temporary ineligibles. Wo to take Action o Community members,CDDs, zonal coordinator and FLHF staff. Deadline for C omplet ion Sep-Dec 2013 Training&HSAM-(2.8) The CDDs were properly trained by the FLHF staff. CDDs in all surveyed communities confirmed that they normally use village meetings to convey different messages relevant to the implementation of CDTI and NTD activities. Community religious leaders were also involved in HSAM activities. Recommendation: HSAM Implementation should intensify health education Priority: MEDIUM Indicators of success: o Community members are fully sensitized and mobilized on the CDTI process and importance of long term treatment with Mectizan@ tablets. Wo to take Action o Community leaders, FLHF staff and coordinators CDDs, zonal Deadline for Completion Sep-Dec 2013 Financing(2.0) In general, there were no financial commitments from the community members to support CDTI activities. There was no provision for record books, pencils, transport and other expenses incurred during CDTI activities. However, informants confirmed that CDDs receive quite substantial (moral) and 'in-kind' support from community members. For example, they are exempted from other community development activities and levies Ruvuma CDTI Sustainability Evaluation, 201.2 Page 29 Recom m endation :-F inancing Implementation resources to support transport and provide writing materials to CDDs to implement CDTI activities Priority: HIGH Indicators of success: o Transportation and writing materials are provided to CDDs for implementation of CDTI activities. Wo to take Action o Community community FLHF staffs. leaders, members and Deadline for C ompletion Sep-Dec 2013 Human Resources - (2.8) Generally, CDDs workload was observed to be high in almost all surveyed communities. The ratio of CDDs to population ranged from I : 125 to l:450. This ratio exceeded the recommended figures. Although from a face value this workload ratio seemed huge, the team did not make note of any complaints from interviewed CDDs. On average each CDDs walks between I kilometre to 8 kilometres to reach each targeted household for drug distribution. In all surveyed communities, all CDDs indicated that they received appropriate training prior implementation of CDTI activities. They funher clarified that the training received did focus on how to conduct census, determine eligibility and ultimately give the right doses to the eligible persons, managing mild side effects and identify severe cases for referrals. There were plans at the community level to select and train more CDDs to replace the dropped-outs. CDDs in all communities expressed high willingness to continue their work, albeit emphasising the need for additional incentives. Generally in all communities sampled, very few CDDs were reported to have dropped out of CDTI activities. Recommendation :-Human Resource Implementation decrease CDD ratio to 125. Priority: HIGH Indicqtors of success: o The CDDs population ratio of l:125 is attained in all communities. Wo to toke Action o Community community FLHF staff. Ieaders, members and Deadline for Completion : Sep-Dec 2013 Ruvuma CDTI Sustainability Evaluation, 2012 Page 30 Coverage - 3.8) For the past three year period of implementing CDTI activities of which this evaluation focused, treatment coverage among the eligible persons for almost all surveyed communities was high. Majority of communities surveyed registered a Therapeutic Coverage Rate (TCR) of 650/o of more. However there were few communities which had a TCR way beyond the prescribed threshold (more than 90%o). This is an indication that probably census updates were not properly carried out. 61. Overall sustainability grading for Ruvuma Region OVERAL SCORE, TABLE NB: cut off point:2.5 points average LEVEL INDICATORS 1 -10 Pla ning Lead ershi p Inte grat ion Monit & super vision Mec. delive ry Train &. HSAM Transp /equip ment Fina nce Hum an Reso urces Coverge Total average Region(1) J J J 4 4 J.J 1.8 1.8 1.5 4 2.9 District(2) J.J 3.7 J.J 5.5 4 3.1 2.3 2.5 4 3.3 FLHF(3) 2.2 3.5 2.5 3.1 3.8 2.8 1.3 0.9 ).2 3.3 2.6 Villaee(4) 3.8 3.5 N/A 2.5 3.2 2.8 N/A 2.0 2.8 3.8 3.1 AVERAGE FOR THE WHOLE PROJECT 2.97 Ruvuma CDTI Sustainability Evaluation, 2012 Page 3l 7 7.1 ASPECTS OF SUSTAINABILITY Aspect Judgment: to what extent is this aspect helping or blocking sustaina in this , Integration Resources Not helping at regional level, helping at district level, blocking at FLHF level and hel at communi level Efficiency Very much helping sustainability Simplicity Health staff acceptance (Attitude of the health staff; Com ownersh Effectiveness Below is the situation with reference to the indicators of sustainability; The findings regarding the aspects of sustainability are broadly as follows: SEVEN ASPECTS O SUSTAINABILITY 1. Integration: Very much helping Integration of CDTI activities into other health programmes at all levels in the region allows for optimal use of resources and promotes sustainability. 2. Resources: Not helping at regional and FLHF levels and helping at district and communitv levels Only one person is responsible for all CDTI activities. The region does not contribute much to CDTI activities. At district level, there is adequate human resources and financial contributions from the APOC, Council and Basket funding. At FLHF level, there was insufficient human resource, they were not involved in budgeting or management of funds. The communities had reasonable numbers of CDDs although this was betow the acceptable CDD:popukation ratio. The CDDs were exempted from other voluntary community activities and levies which motivated them and ensured that they had more time to work on CDTI activities. Political leaders at all levels were also committed to the implementation of CDTI. 3. Efficiency: Very much helping Both geographicaland therapeutic coverages were high and all stakeholder of CTDI were involved in planning and supporting implementation of CDTI activities. lntegration of CDTI activities into other health programmes has helped to improve efficiency examples of these Very much helping sustainability Very much helping sustainability Very much helping sustainability Very much helping sustainability Very much helping sustainability Ruvuma CDTI Sustainability Evaluation, 2012 Page 32 include human resource, supply of Mectizan@ tablets, transport and monitoring and supervision. 4. Simplicity: Very much helping The procedure for implementing CDTI activities at all levels is simple and not complicated such that the health workers, CDDs and community members easily understand and implement with resources available. 5. Health staff acceptance(attitude of health staff): Very much helping The high acceptance of CDTI has enabled a positive attitude among health workers towards . successfulimplementation 6. Community ownership: Very much helping Community leaders, CDDs and community members were committed to support implementation of CDTI activities. They were involved in selection of CDDs, sensitization, replacing drop outs, exempting CDDs from development activities and levies. They complied with annual treatment. 7. Effectiveness: Very much helping The evidence of the effectiveness of the CDTI is in the high geographic and therapeutic coverages attained and compliance with annual treatment. These were made possible by the timely procurement and distribution of Mectizan@ tablets by the committed health workers and CDDs. JUDGEMENT OF THE PROJECT ACCORDING TO ASPECTS OF SUSTAINABILITY Five key aspects of the project critical elements of sustainability l. Money- Is there sufficient money available to undertake strictly necessary tasks which have been carefully thought through and planned? Region- no, sustainability totally depend on APOC. Districts - y€S, some money from basket fund Between 70-100%of budget were disbursed for CDTI activities and most of these funds were expended. Shonfalls in funding were met by APOC and basket funds. District coordinators are advocating for increasing council contribution to CDTI activities. In one council (Songea district) government funding is increasing. FLHF does not handle money; have no control of the budget and expenditure. The money allocated is insuffi cient. Contributions from the community are in kind, through exemptions from community development activities and levies. Ruvuma CDTI Sustainability Evaluation, 2012 Page JJ 2. Transport- Has provision been made for the replacement and repair of vehicles? Is there a reasonable assurance that vehicles will continue to be available for minimum essential activities? There has been no provision for replacement of vehicles at all levels. The government has a Policy for replacement of vehicles, but there is no evidence of a plan for replacement of any means of transport. Repair : Funds for maintenance come from the council and basket fund. At district level, they have access to hire a vehicle from the pool or hire. At FLHF personal funds are used to maintain personal motorbikes. (No/Yes) 3. Supervision- Has provision been made for continued targeted supportive supervision? Supervision is cascades and integrated into other health programmes at each level. (Yes) 4. Mectizan@ tablets- The supply system is dependable as it is integrated within the health system. The supply of Mectizan@ tablets was timely and adequate. (Yes) 5. Political commitment: Effectively demonstrated by awareness of the CDTI process among policy makers (resulting in tangible support); and a sense of community ownership of the programme? There is high awareness of CDTI activities among policy makers at all levels. Councils do budget for some CDTI activities and the coordinators have access to pool vehicles when in need. The level of awareness and community ownership was high, as shown in the exemption of CDDs to levies and development activities, involvement in sensitization and monitoring of CDTI activities through use of community crier. (Yes) Five key aspects of the project critical elements of sustainability 1 Money- Region- no sustainability totally depend on APOC. Districts - y€S, some money from basket fund Between 70-100o/oof budget were disbursed for CDTI activities and most of these funds were expended. Shortfalls in funding were met by APOC and basket funds. District coordinators are advocating for increasing council contribution to CDTI activities. In one council (Songea district) government funding is increasing. FLHF does not handle money, have no control of the budget and expenditure. The money allocated is insufficient. Contributions from the community are in kind, through exemptions from community development activities and levies. No/Yes 2 Transport There has been no provision for replacement of vehicles at all levels. The No/Yes Ruvuma CDTI Sustainability Evaluation, 2012 Page 34 government has a policy for replacing vehicles, but there is no evidence of a plan for replacement of any means of transport. Repair: Funds for maintenance come from the council and basket fund. At district level, they have access to hire a vehicle fro the pool or hire. At FLHF personal funds are used to maintain personal motorbikes. J Supervision is cascaded and integrated into other health programmes each level Yes 4 Mectizan@ - The supply system is dependable as it is integrated within the health system. The supply of Mectizan@ tablets was timely and adequate. Yes 5 Political commitment: There is high awareness of CDTI activities among policy makers at all levels. Councils do budget for some CDTI activities and the coordinators have access to poolvehicles when in need. The level of awareness and community ownership was high, as shown in the exemption of CDDs to levies and developmental activities, involvement in sensitization and monitoring of CDTI activities through use of community criers. Yes 8. CONCLUSION: Having scored 2.97 which is above the 2.5 points cut off mark, the RUVUMA CDTI project is adjudged to be MAKING PROGRESS TOWARDS SUSTAINABILITY. 9. ADVOCACY VISITS TO THE POLICY MAKERS As part of the mandate of the evaluation team, the team paid advocacy visits to the Regional Medical Officer (RMO). The evaluation team briefed the RMO on the team's mission to the region. The RMO pledged his support for the programme. 10. FEEDBACK MEETING The Participants at the regional debriefing meeting included the Regional Medical Officer, the Regional NTDs/CDTI Coordinator, District Medical Officer of Songea, Songea NTDs/CDTI Coordinator and the six evaluators. They were debriefed on the findings at the Region, District, FLHF and the village levels and some of the recommendations were highlighted. Judgement on the seven aspects of sustainability and the five key aspects of the project critical elements of sustainability were also highlighted. The overall score of 2.97 was mentioned. The response of the RMO, DMO and the regional NTD/CDTI coordinator include the following: Ruvuma CDTI Sustainability Evaluation, 2012 Page 35 o Communities will be sensitized for them to provide transportation to CDDs during MDA. o The district officers control funds at FLHF level due to unpleasant experiences ( lack of good results ) they had when FLHF staff were allowed to handle money for CDTI activities. However, the zonal managers in Songea district oversee the FLHF staff and control money o RMO promised to assign more staff to CDTI in Namtunbo district o Other districts will be made to emulate Songea district in the are of transportation whereby vehicles are hired from the pool of district vehicles and motorcycles hired for CDTI activities o At regional level more emphasis is on capacity building at the district level to enhance effective implementation of activities while the region is to supervise, hence little resources is kept at regional level o Inadequate human resources is a cross cutting issue in the nation. The nation is just approachin g 40% - 50% of its need, while human resources for health sector is 45%o of the need. However, two officers have been sent on training for more hands on eye health, though, the regional NTD/CDTI coordinator needs administrative support. o The Regional NTD/CDTI coordinator pledged for improvement on CDTI project having learnt many things during the evaluation. She stated that she was planning to have people at district level to join her in supervision of CDTI activities o The RMO pledged for improvement on the identified challenges At the National level, the WHO iountry Representative (WR) was debriefed on 18th October ,2012. The WR promised to discuss the issues identified in Ruvuma region with the top officials (Minister, CMO etc) of Ministry of Health. The Sightsavers Country Director was on leave while other officials were out on official assignment but the Finance Manager was available. The National NTD coordinator was also away for training but the acting coordinator was debriefed. (The Director of Preventive Service went to Mozambique while the acting director had number of meetings) Ruvuma CDTI Sustainability Evaluation, 2012 Page 36 11. DOCUMENTATION OF THE NTDs PROGRAMME INTRODUCTION: Tanzania is prevalent with eight Neglected Tropical Diseases (NTDs) viz: Onchocerciasis, Lymphatic Filariasis, Trachoma, Plague, Schistosomiasis, Human African Trypanosomiasis, Soil Transmitted Helminthiasis (STH) and Leprosy. Mapping for NTD PCT has been completed for LF, Oncho, STH and Schistosomiasis but mapping of Trachoma was yet to complete. Five PCT in Tanzaniatargeted NTD are co-endemic in various districts. Implementation of NTDs started in Ruvuma Region in 2009. The three CDTI districts treat for Onchocerciasis, LF, Schisto, STH and Trachoma, except Mbinga district that does not treat for Trachoma. This is summarised in the table below: Co - endemic of NTDs in CDTI Districts of Ruvuma Re ion Mectizano and Albendazole@ tablers are distributed to treat both Onchocerciasis and LF in the communities sampled. The country uses Albendazole for the treatment of STH, hence this disease is automatically treated during LF treatment. The under 5 years are de-wormed with Mebendazole during NID Programme. Concerning Schisto, the School Health Teachers treat the school children with Praziquantel. The un -enrolled children are also invited to the school for treatment. School Teachers are provided with treatment registers which are submitted to the FLHFs after each treatment. The CDDs are trained to administer Zithromax@ syrup for under 5 years and the tablets for 5 years and above. The Community treatment registers captured Mectizan@, Albendazoleo Zithromaxo tablets distributed, hence treatment data can be extracted Planning Planning meeting is held at national level annually with other Regional NTDs ( RNTDs) and District NTDs (DNTDs) Coordinators. The RNTDs Coordinator meet with the Coordinators of the 5 NTDs district in Ruvuma at regional level before attending the annual planning meeting. The FLHF staff plan on how to geographically allocate their areas to CDDs and allocate CDD teams. This is done prior to the MDA during CDDs training. The communities select CDDs and when the MDA is to be conducted and the mode of distribution Activities for NTDs including Oncho are planned, budgeted for and implemented at the district by the District Health Management Team (DHMT) NTDs plans are approved by the Council Health Services Board (CHSB), and checked by RHMT and final review and approval is done by PMO- RALG and MoHSW before funds are disbursed to the council for implementation. The health plans are developed nationally following identified local and national priorities. NTDs including CDTI have been included in the Health Plan of each district though there was still inadequate funding Schisto STH TrachomaDistrict Oncho LF Songea Namtunbo Mbinga Ruvuma CDTI Sustainability Evaluation, 2012 Page JI Leadership The NTDs Programme is managed by a coordinator and other leadership at all levels. Leadership at Regional level comprises the RNTD Coordinator, RMO and Regional Pharmacist. At the district level are DNTD Coordinator , DMO and District SHT officer while at the FLHF are Zonal FLHW, FLHW at each Health Facility, Ward Executive Officer and Village Executive Officer. Leadership at the Community level include the village leaders, CDDs, VHW and CORPS Integration The NTDs including CDTI activities are carried out by same personnel except treatment for Schistosomiasis that involves the service of the school health teachers. Logistics are shared as much as possible while training, monitoring and supervision on NTDs are carried out in an integrated manner. The reporting forms for the NTDs were also integrated. Integration of CDTI and other NTDs has increased the work load of CDDs therefore they ask for more incentives by being involved in incentive giving prorammes like malaria and immunization.. Finance The NTDs programme are funded by APOC and the Health Basket Fund (HBF) which is a central basket that is comprised of funds from MoHSW, PMO-RALG, MOF and basket-donors including that of the NTD interventions Mectizan@ tablet and other NTDs drugs Application for the NTD drugs are made by the National level after having the data (population, drug inventory) from the district and lower levels. All donated PCT drugs are handled, stored and distributed by the Medical Stores Department (MSD) to districts' Pharmacy stores. The CDDs and School Health Teachers collect drugs from HF at the end of training to do the MDA in communities. Mectizan@ + Albendazole@ &Zithromax@ tablets are distributed by the CDDS, Praziquantel@ are distributed by School health Teachers Monitoring and Supervision At regional level, the RNTD, RMO, RHMT are involved in monitoring and supervision of NTDs while at the district levelthe RNTD Coordinator, RHMT, DNTD, DMO, CHMT are involved. At the Health facility level, the DNTD Coordinator, District Pharmacist, District.SHT and CHMT carry out monitoring and evaluation while the DNTD Coordinator, Zonal FLHW Managers and District. SHT are involved at the community level. The School Health Teachers are involved during supervision of NTDs. The list of indicators include the community population census, training data, number of people treated, therapeutic coverage, SAE, MDA medicines received/utilizedlremaining, NTD morbidity and financial reports. The NTDCP developed data collection mechanisms and established the national HMIS. The IDSR have incorporated a number of indicators for NTDs. For instance, trachoma,LF, Onchocerciasis, STH, Schistosomiasis, TBRF, Trypanosomiasis, and Leprosy are reported in the IDSR. The HMIS collects health facility data on PCT NTDs. Training and HSAM Cascaded training is conducted for Regional and district coordinators, Regional Pharmacists and Project Accountant by NationalNTD secretariat during annual review meeting, whereby the school health teachers and health facility staff are trained.. CDDs' training is facilitated by District / FLHF coordinators and District School Health Teachers. Ruvuma CDTI Sustainability Evaluation, 2012 Page 38 The National NTDs Programme produced IEC materials for integrated NTDs control (e.g Posters, CDDs brochures) for training and sensitization on NTDs. Community meetings, radio and TV were also used for sensitization. The IEC materials were in short supply, hence photocopies were used for sensitization/mobi lization. Human Resources Health workers were employed by the Government - Ophthalmologist, Accountant, Ophthalmic Nursing Officer, Pharmacist, Teachers, Nurses and other HWs. At community level there were also CDDs and VHWs. The CDDs distribute Mectizan@, Albendazole@ and Zithromax@ House to House while the School Health Teachers distribute Praziquantel@ tablets in schools. Transportation and other material Resources There were project vehicles in the NTDs Regional office and Mbinga district. Namtumbo and Songea Districts share vehicle with the Regional office, At the FLHF level there were few CDTI motorcycles and those of other Health projects e.g TB & Leprosy while few distributors have CDTI or personal bicycles otherwise they walk on foot. The Community Treatment Registers were inadequate most especially in Namtumbo district. Coverage - Treatment Registers which captured the NTDs were sighted. Only treatment coverage for CDTI was determined, though coverage of other NTDs appeared good EVALUATION TOOLS Below is the suggestions on the evaluation tools l. Partnerships: Inclusion of new partners based on the NTDs that are a priority to the countries: To take this forward, the following need to be done: Determine the NTDs supported by the country. Examples of some new partnerships are as follows: SCH and STH: Ministry of Education, School authorities at regional, districts and community levels; UN Agencies- Unicef and NGDOs involved in education - Plan, Save the Children, Water Aid, World Visionwhich Trachoma: Ministry of Water Resources, Ministry of Environment, LIN Agencies- Unicef and NGDOs involved in education Plan, Save the Children, Water Aid, World Vision Other NTDs : As applicable APOC will need to decide which NTDs it wants to be involved in as this will defer by country. It is important to state that for elimination of trachoma the strategy of the SAFE. A decision on which components of the strategy it wants to be involved in. If it decided on just the A, elimination of the disease will not happen with emphasis on one component- all four will need to be supported. All the a a a Ruvuma CDTI Sustainability Evaluation, 2012 Page 39 components of the SAFE strategy are included in the suggestions below. APOC will need to pick one. This may apply to other NTDs that are a priority to the countries. Suggestions for the review of Instruments to include the NTDs in each indicators of the instruments is as follows: Inclusion of these new partners in the tools as target group to be interviewed e/g. rather than just MOH, other ministries will be included, Selection of samples size should include schools for SCH and STH, provision should be made to interview school teachers At national level, interviews should include Ministry of Education, LIN Agencies and NGDO partners as applicable to the country At regional level, as for regional levels At district level as per region All the instruments will require more details as follows: - Planning :will need to be changed to include partners of other NTDs - Integration: will need to be changed to include other interventions in the NTDs - Leadership: will need to be changed to include other leaders of other NTDs - Monitoring and supervision: will need to be changed to include monitoring and supervision for other NTDs - Mectizan@: will need to be changed to Medicines, consumables and supplies to include other tablets e.g Albendaozole, Zithromax, Praziquantel; consumables for components of the SAFE strategy for Trachoma etc - Training and HSAM: will need to be changed to include other interventions making up the NTDs - Transport and other materials resources: will need to be changed to include other NTDs - Financing: will need to be changed to include other NTDs - Human resource: will need to be changed to include other NTDs for SCH,STH- schools; Trachoma to include the SAFE strategy rather than just Antibiotic distribution; water, environment - Coverage: the geographic and therapeutic coverages will have to include other tablets distributed, schools for SCH/STH; water points and laterines for F and E of SAFEtrachoma etc a a a a Ruvuma CDTI Sustainability Evaluation, 2012 Page 40 Seven aspects of sustainability:, and other components of the SAFE strategy for Trachoma Need to be changed to seven aspects of success programme implementation: . Integration: crucial and should apply to integration of all aspects e.g. planning, implementation of interventions . Efficiency: crucial and should apply to interventions . Simplicity: crucial and should apply to interventions . Health staff attitude: need to be changed to staff attitude since we now have other service staff members e.g. health, education, water, environment etc . Community ownership: crucialand community to include schools . Effectiveness: crucial and should apply to interventions Five key aspects of project critical elements to sustainability: need to be changed to Five key aspects of project critical elements Money: retain Transport: retain Supervision: retain Mectizan@: to change to Medicines, consumables and supplies ( because of trachoma etc) Political commitment: retain Ruvuma CDTI Sustainability Evaluation, 2012 Page 4t APPENDIX 1: ITENERARY OF THE EVALUATI ON OF RUVUMA CDTI PROJECT ActivityDate Responsible officer Monday 24tn Sep 2012 Extemal evaluator Planning meeting with the NTDs Coordinator and WHO team o External evaluator Interviews with NTDs national Coordination team Interview with WHO team (NTDS FP and administrative officer) WHO Operations manager o a Tuesday 25th Sep 2012 Wednesday 26tn Sep 2012 External evaluator Travel to Ruvumaa o Meeting regional staff o Selection of sites (FLHF & Communities) o Planning for meeting of briefing o Courtesy visits to authorities of the three districts Thursday 27tb - Fri 28th Sep 2012 External evaluator Internal evaluators Arrival of internal evaluators at Ruvuma aSunday 3Oth September. 2012 Dr. El Hassan arrives Dar Es Salam a External evaluator Meeting of all evaluators - study of the guide and instruments Grouping of evaluators into sub- teams a o Mondayl't October 2012 External evaluator Dr. El -Hassan arrives RuvumaoExternal evaluator o Courtesy call to the Policy makers at Ruvuma Region o Data collection at Regional level o Collection of data from districts, FLHF and communities. Tuesday 2nd October 2012 Evaluators Evaluators Collection of data from districts, FLHF and communities. oWed.3'd - Sat 6th October 2012 Study of documents collected from districts aSun 7th Oct2012 Evaluators Evaluators o Analysis of the data o Formulation of recommendations o Report writing o Briefing on Health System Mon 8th - Thur. 11'n Oct2012 Place o Dar Es Salaam Dar Es Salaara o Ruvuma a Ruvuma o Ruvuma o Ruvuma Rural o Ruvuma o Ruvuma Ruvuma CDTI Sustainability Evaluation, 2012 Page 42 o Structure inTanzan\a Development of Recommendations for adapting the currently available tools for evaluation of sustainability of CDTI project to accommodate co-implementation of control of other NTDs alongside Onchocerciasis control Fri 12th Oct2012 Evaluators Debriefing meetinga Sat. l3'n Oct.2012 Evaluators Travel back to Dar Es Salaama Debriefing -NOTF -NGDO partners (WHO & Sightsavers) -Director of Preventive sector -Director of planning -Chief accountant oMon 15* - Tue l6'n Oct2012 Evaluators Updating / fine-tuning of reportaWed. l7'n - Thur 18th Ocl2012 External Evaluators Fri. lgth Actober External evaluators o Departure a Ruvuma o Dar Es Salaam a Dar Es Salaam o Dar Es Salaam APPENDIX 2: PARTICIPANTS LIST OF FEEDBACK MEETING SA.{o NAME DESIGNATION ADDRESS I Dr. D.A Malekela RMO MoH, Ruvuma 2 Dr.ldda Ngowi NTDs/CDTI Coodinator MoH, Ruvuma J Dr. Daniel Rausen DMO Songea district 4 Gladness komba NTDs/ CDTI coordinator Songea district 5 Dr. Elizabeth Elhassan External Evaluator 6 Mrs. Mary Adenigba External Evaluator 7 Ms. Jubilate Bernard Internal Evaluator 8 Dr. Michael Munga Internal Evaluator 9 Mr.Eric Mgina Internal Evaluator 10. Ms. Latifa Kalinga Internal Evaluator Ruvuma CDTI Sustainability Evaluation, 2012 Page 43 o APPENDIX 3 DAY: Thu 11th october 2012 REGION/DISTRICT LEVEL FEEDBACK MEETING AGENDA 08.00 - 08.30am Ms. KalingaI Registration Opening prayer 08.30 - 08.35am2 08.35 - 08.50am Dr.ldda NgowiJ Introduction of participants RMO08.50 - 09.00am4 Welcome Address Mrs. Adenigba Dr.Idda Ngowi 09.00 - 09.15am5 Presentation: o The workshop programme o Administrativematters Dr. Elhassan09.15 - 09.30am6 Presentation: o The objectives of the evaluation o What is sustainability o The evaluation methodology 09.30 - I 1.00am Dr. Micheal. \ Dr..El-hassan Mrs. Adenigba Mr.Eric 7 Presentation of the main findings: . Community level Local Government level State Project level a a o FLHF level 11.00-ll.30am8 Open Discussions I 1.30 - l2.00pm Dr. Mungal Ms. Bernard Mr. Eric Ms. Kalinga & Mrs. Adenigba 9 SWOT analysis What is the situation on sustainability of our project and What could be the solutions to these problems? Dr. Mungal12.00 - l2.30pml0 Presentation 12.30- 12.-45pm Dr.Idda Ngowi1l REFRESHMENT l'i nre- Fac ilitatorItern ,\ctir in Ruvuma CDTI Sustainability Evaluation, 2012 Page 44 APPENDIX 4 LIST OF PERSONS MET/INTERVIEWED DURING SUSTAINABILITY EVALUATION a COMMUNITY LEVEL FLHF LEVEL DISTRICT LEVEL REGIONAL LEVEL LUHIMBA DISPENSARY SONGEA RURALLUHIMBA VILLAGE CDDs George pallangyo-CDTl manager Ruvuma zone Gladness komba- CDTI coordinator Dr. Daniel Rausen Songea DMO Dr. D.A Malekela RMO Zainabu rahi -076608s3r6 Juliet matifali-CO MBINGA Dr.ldda Ngowi NTDs/CDTI Coodinator Amimu ngwenya -0757710876 Orafu pilli-CDTI manager Gumbivo ward Faustine Mhagama- CDTI coordinator Damagi kayela-DMOShabani mapongela -0765000689 Shorastika tawete MANGO DISPENSARY Shaibu mwina-DED Felista mkuwa -0762349889 Fan komba-CDTI coordinator 07 58460924 Oresta mbawala NAMTUMBO Vitalis fusi Rajabu chiukuta- CDTI coordinator MANDELA VILLAGE MATIMIRA DISPENSARY Community leader- Juma mwindi Robison Mhagama-CDTI focal person CDDs Frolina Ngombaniza- nurse National and NGOs Dr. Upendo Joh Mwingira Nat.NTD Coorc Dr.Edward Kirr Ag NTD Coord Nat. NTDs Mr.Bernard KiL Be.- Finance m1 Nat. NTDs WR- Dr. Chator Dr. Masako Nar WHO focal Ms. Doris Oden Operations nanz wHo Mr.Mwakisole Finance/managr wHo Mr.Oscar Kaital Oncho focal per Nat. NTDs Mr. Andrew Kil ela- Finance/ma Si Ruvuma CDTI Sustainability Evaluation, 2012 Page 45 C leophas nyon i -chairman CDD Maneno mashaka Waiti isumaili LIPARAMBA HC.Adamu Malunda Zuberi bakari Leonatas Komba-CDTI focal person Amina likuata LIKUYUSEKA DISPENSARY MAPANGULA VTLLAGE Village leaders Joseph lwendo-C.O 0716393153 Frances Mhuwa-VCP LIGERA DISPENSARYAbdalah Mapunda- VEO Theiphil Mapunda-C.OKassimu masengo- agriculture field Tatu gingo-nurse CDDs Wilhem luoga Ritha mhagama Norasko komba Luciana kifaru MATIMILA VILLAGE Isaya Nchimbi-VCP CDDs Cleophas Nyoni Magret fuko Amoni komba Teodosia kapinga Asumini mbano Henrick mwingira Eliza komba Merania ntila Beatrice haule Vestina Timbwa Oliva kapinga Joyce mhoro Helena nditi LIKUYUSEKA VILLAGE a 46 Ruvuma CDTI Sustainability Evaluation, 2012 Page aSalehe mabukusela- VED CDDs Rehema Ngonyani Kaporo Ngumbe MIPOTOPOTO VILLAGE CDDs Michael mapunda Maurus ngonyani Alexia nyoni MANGO VILLAGE LEADERS Teresphod ndunguru- chairperson Yakobo hyera-secretary Job challe- Father(religion) CDDs Gabriel ndunguru Maria komba Eda milinga Regina ndimbo Tadei mhagama Community member Simon hyera SONGAMBELE VILLAGE leaders Ibrahim njowoka- chairperson CDDs Abeli lukwiwi Filo hiniu Balbina Nchimbi Keneth kayombo Adelevina haule Agatha komba a Ruvuma CDTI Sustainability Evaluation, 2012 Page 47 Sala ndunguru Salmon komba LIRARAMBA VILLAGE CDDs Egno komba Hilda lukas LIGERA VILLAGE VEO-Akwea kajao- 0687294551 VCP-kanis kangindo- 0683302404 CDDs Rehema soko- 0783364835 Kelvin soni- 0688985628 NAMAHOKA VILLAGE VEO-otilia mpomba- 0685905489 Vcp-mahmu nyon- 0683302129 LIKARANGILO VILLAGE VCP-Steven mbunda CDDs Mwanaharusi mwenda Marium mustafa Paulo mbunda Amiringonyani a 48 Ruvuma CDTI Sustainability Evaluation, 2012 Page It a Ia