Assessment of the sustainability of the Ruvuma CDTI project, Tanzania (fifth year) : October-November, 2003

World Health Organisation African Programme for Onchocerciasis Control Assessment of the Sustainability of the Ruvuma CDTI Project, Tanzania (Fifth Year) October-NoYember, 2003 Mariam AIly Abdul Daffa Oscar Kaitaba Oladele Kale - (Team Leader) Edna Massawe Joseph Okeibunor Frank Richards APOC RECU 0 4 trJ0y. 2003 APOC /DIR y ' I r t rr : o n i o/ll u t, r lnrr l' r.tt' rr s (' I )'l' I l,,v'tr I tt ul r on lfu pt t r! Page I of49 TABLE OF CONTENTS TABLE OF CONTENTS Abbrevi ations/ acron yms Acknowledgements Executive summary I.O TNTRODUCTION 2.0 METHODOLOGY 2. 1 SAMPLING........... 2.2 SOURCES OF INFORMATION 2.3 ANALYSrS............ 3.0 EVALUATION FINDINGS ........I I 3.1 SUSTAINABILITY AT REGIONAL LEVEL............... ........... ...1 1 3.2 SUSTAINABILITY AT THE DISTRICT LEVEL..... ...................I8 3.3 FIRST LINE HEALTH FACILITY .....,.....24 3.4 SUSTAINABILITY AT THE VILLAGE LEVEL ......28 3.5 COMPARATIVE ANALYSIS OF THE SUSTAINABILITY OF THE FOUR LEVELS 32 1 4.0 CONCLUSION...... 4.1 GRADING TTIE OVERALL SUSTAINABILITY OF RUVUMA FOCUS CDTI PROJECT 4.2 TWO FEEDBACI?PLANNING MEETINGS : 4.3 THE WAY FORWARD APPENDIX I. REGIONAL AND DISTRICT LEVEL WORKSHOP PROGRAMME II. The SWOT analysis lll. Persons lnterview at the Ruvuma Focus Evaluation IV. ADDRESSES FOR EVALUATION TEAM 35 35 -1 I 38 .40 .40 .42 .45 .47 I rrtt:trnto/liut ntttt l't)( rr, ('l)'l I l:\'(tluott()n ll(,pr)tt Page 2 of 49 Abbreviations/ acronYms African Programme for Onchocercrasis Control Annual Treatment Objective Community-Based Treatment with Ivermectin Community Based Management Informatron System Community-Directed Distributor (of I vermecti n) Community-Directed Treatment with Ivermectrn Council Health Management Team District Eye Coordinator District Administrative Secretary District Eye Coordinator Di strict Executi ve Director District Health Management Team District Health Officer Distrrct Medical Of[icer Distnct Onchocerciasis Coordrnator First Line Health Facility Health Education Sensrtisatron Advocacy and Mobilization Inter-Church Medical Association Ministry of Health Memorandum of Understanding Medical Stores Department National Eye Care Programme Non-Governmental Development Organlsation National Onchocerciasis Task Force Primary Health Care Planned Preventive Maintenance Regional Administrative Secretary Rrver Blindness Foundation Regional Health Management Team Regional Medical Officer Regional Medical Unit Regronal Onchocerciasis Coordinator Sr ght Savers International Tanzanian Revenue Authorities Tanzanian Shillin-es World Health Organisation World Health Organisatron Country Representatrve APOC ATO CBIT CBMIS CDD CDTI CHMT DEC DAS DEC DED DHMT DHO DMO DOC FLHF HSAM IMA MOH MoU MSD NECP NGDO NOTF PHC PPM RAS RBF RHMT RMO RMU ROC SSI TRA Tsh wHo WR I tr tt : tt tr r rr / ll u t, r t r n o l' r t t' t r ; (' I )' I I l,.t' tr I r r o ! t o ti ll (., I t' t I Page 3 of 49 Acknowledgements We are grateful to the following persons and organrsations for their contributions and assistance towards the successful execution of this assignment: . The Director, Dr. A. Seketeli. and staff at APOC Headquarters in Ouagadougou fbr making available the necessary financial and logistic requirements for the success of this assrgnment. ' The WR, Dar es Salaam and his staff provided support, which contributed to the smooth functioning of the evaluation team. ' The Country Representative of Sight Savers' International, Mr Pius Mabuba and his staff assisted with transport and other logrstics. ' Dr Grace Saguti, National Onchocerciasis Project Coordinator, and her team facilitated the smooth take off of the exercise in Tanzania. ' The Regional Administrative Secretaries for Iringa and Ruvuma for facilitating the conduct of the evaluation and providing relevant information. ' The Regional Medical Officers and Regronal Health Management Teams who provided useful information and prompt support. ' The District Executive Directors. District Medical Officers and District Health Management Teams for their cooperation. ' Health workers and community members in the Mbinga, Songea and Ludewa Districts who provided important information and contributed to the success of the mission. ' Last but not least immense gratitude to the team of accommodating drivers who drove the evaluation team over several kilometres of very demanding roads and terrain under tough conditions and oftentimes late into the evening. I ttrt:ttnro/llut runtt l'tst tt\ ('l)'l I l:,y'trlttLtttott ll( l)ot t Page 4 of 49 Executive summary Introduction The Ruvuma focus CDTI project. whrch has been supported by APOC since 1998 is rn its last year of agreed funding from APOC. An evaluation of the post-APOC sustainability of the project was carried out between the 20m of October and 3'd of November 2003, by a tearn of external evaluators from Nrgeria, Tanzania and the Unrted States of America (USA). The evaluators were charged wrth the tasks of evaluating the sustainability of the project. and supporting the personnel of the Regrons of Ruvuma and Iringa, in developing post-APOC sustainability plans. The evaluation on the field was carried out over a period of one week, followed by sessions of feedback and workshop for the development of post-APOC sustainability plans by the constltuent parts of the project. Information was gathered from review of relevant documents and reports, interviews and field observation of sampled sites at the Regional, District, First Line Health Facility and village levels. Findings Every village that had been identified as needing Mectizan@ treatment rs receiving it. There is however strong circumstantial evidence that a number of CDTI-eligible communities, which fall outside the original REMO boundanes are not included in the project. Therapeutic coverage of each of the three Distncts. which are under treatment in the Ruvuma focus is over 65Vo. The trend, using data for the two last treatment rounds however show a slight decrease. The range ln the previous year was 66 per cent to 7l per cent while the range for the last distribution was 6-5 per cent to 69.6 per cent. All the same. there is convincing evidence that Mectizan@ treatment is becoming part of the culture of people of the clifferent villages who expressed willingness to continue with treatment for as long as it is offered. Communities have been empowered to play a leading role in CDTI at the local level. The current satisfaction of communities with CDTI has the potential for creatrng demand for continuation of the progTamme and thus enhancing sustainability. At community level, various measures to enhance sustainability of the CDD programme are being implemented. For instance. though the ratio of CDD to household vaned considerably, giving about 1 CDD to 7 households in some cases and tn others I CDD to as many as 85 households, the communitres in each case gave sound rationale for the number of CDDs engaged. CDDs were rvrlling to contrnue because of job satisfaction and community apprecration and because the tablet rs helping thetn and their people. The evaluation Team concludes that CDTI at the community/village level is sustainable, provided appropriate and adequate support continues to be provided by the higher levels. Fundrng for CDTI by governntent (at the Regional and Distnct levels) [ras been very mintmal and -eoes mainll'for payment of salaries, provrsions of stationerres and transport a reflection of the intesrated use of these resources in the health departments. All operirtlons at the Regional level are furtded by' APOC. ln most of the Drstrrcts. CDTI actrvitres were not implemented rn I u n :o tt t tt/ ll u t t tr tl o l' ( )(, t t s (' I )' I I l,.v'tt I r t o I r rt ti l(t: ltr t r t Page 5 of49 2002, because of late anrval of APOC funds and this was not cushioned from any other sources. The evaluation team considers thq,t over dependence on external sources of funding does not enhanc e proj e ct s ustainability. The accounting officers and DMOs in some of the Districts lack knowledge of the details of APOC funding activities. The process of fund management in some District excludes the DMOs. The evaluators found that though there is a high-level of political commitment the leadership role of the government at this Ievel is rather weak and unclear. Following advocacy by the evaluation team, decisions to correct these deficiencies were reached by partners. Respondents during interviews, at all levels, highlighted the strong supportive role of project NGDO, SSI. The roles of the other partners were also made very clear. The evaluation team was satisfied with the strong leadership provided at the Distncts and in the communities. The attitude of staff and level of monitoring and supervision are satisfactory. There are enough financial and logistical resources to carry out activities but these are marnly derived from APOC and SSI funds. The dependence on these sources is consrdered to be seriously blocking sustainability. Regarding transport and Mectizan@ supply, there are no plans to meet the need for the replacement of vehicles and motorcycles in the future. The current Mectizan@ supply system, at the Regional level, is very efficient and fully inte$ated into the government system and this enhances sustainability of the project at that level. The same cannot be said of the lower levels. Generally, CDTI is adequately integrated into the government system. Most of the activities, such as Mectizan@ procurement and supply, monitoring and supervision as well as management and use of logistics are within the government system and the evaluation team considers this to be helping sustainability of the CDTI project In evaluating the project on the basis of the seven aspects and six critical elements of sustainability, the evaluation team concludes that the Ruvuma Focus CDTI is MAKING SAT I S F ACT O RY P RO G RE S S T OW ARDS SUSTA/NA B I LIT Y. With regard to the srx critical elements the evaluation team found that five help sustainability because they were present in the project. The only critical element that is apparently lacking in the Ruvuma CDTI project is in relation to 'Mectizan@'. Though the Mectizan@ supply system is well integrated into the government system, and its operations is both simple and efficient at the Regional level. The supply and distribution of the drug at the lower levels has not always been in consonance with the convenience of the communities. This has a potential for blocking sustainability. With respect to the seven aspects of sustarnability. the evaluation team found that frve. namely integration, efficiency, simplicity, attrtude of staff, community ownership and effectrveness were very much helping sustarnability of the project. However, resources were found to be blocking sustainability because governmertt fitnding for the programme is very mtnimal. ' l tt rt :tr tt t tr/ R u t t il n o l- ()(' n r (' l)' l' l l, t'rt l t r rt t t ()il llt.. f t) t ! Page 6 of 49 Way Forward As the Ruvuma Focus CDTI project in Tanzania reaches the end of the 5-year APOC-guranteed support the team of evaluators and the 'programme managers' made a critical appraisal of the issues that need to be addressed in the short- and medium-terms to ensure the sustainability of the project post-APOC. The following is a summary of the highlights of the five critical components of the "way forward" outlined at the joint final session between the external evaluators and the Ruvuma project operatlves. REMO The rdentification of all foci of hyper- and meso-endemic onchocerciasis throughout Tanzania, and specifically in the two Regions (Iringa and Ruvuma) incorporating the Ruvuma CDTI focus, that are at present outside CDTI operations is of the topmost priority. APOC support would be rnvaluable for this. Devolution The Ruvuma CDTI project whrch hitherto has operated successfully as ajoint endeavour between two regions. Iringa and Ruvuma. will now operate as integral parts of the National Eye Care Programmes (NECP) of the health services of the respective regions. This would necessitate the provision of special supplementary support from APOC and adjustment of the CDTI operations at the regional level. Mectizan Changes that would make the procurement and distrrbution of Mectizan an rntegral part of the health system of Tanzania have already been introduced. However it is obvrous that the intricate procedure for accounting for. reqursitioning and procuring Mectizan is beyond the capacity of virtually everybody in the Ruvuma project except the project coordinator, Dr. Kabuka. It would appear that the same limitations apply in all other Tanzanian GDTI projects. Therefore the national body is expected to mount a spectal trarnin-e and orientation programme for relevant cadres of staff at the regronal, district and FLHF levels to achieve this capacity building objectrve. Documentation An important area of deficiency that needs to be tackled expeditiously in order to enhance the sustainability of CDTI is the relative lack of expertise rn report writing and record keeping, at all levels. by the various operators rn the project. A series of natronal/regional workshops that address thrs critical shortcomtng is hi_qhly desrrable. Financing By mutual agreement the contribution of the vanous stakeholclers to the sustenance of the Ruvuma proJect post-APoc rs a major challenge. The commitment of all to this element of the programme was emphasised and would be gil'en approprlate prominence in the post-APOC plan of operations. I rttr.rrn ro/llut runn l, ttttt.t (' l )'l I l,.vtrl rrut rrtrt llcltot I Pagel of 49 Other stakeholders, namely the SSI. Regional and District representatives as well as the Natronal Coordinator of the programme in their respective comments on the way forward. noted these points and pledged to ensure the sustainability of the programmme. { trti;tttttrr/llut rutrrt l'rtt't{\ ('l)'l I l:.v'rtlrrttltrtn l(cpor I Page 8 of 49 1.0 INTRODUCTION The Ruvuma focus CDTI Project rs composed of three adjoinrng districts (Songea and Mbinga in Ruvuma Region and Ludewa in Iringa Region), all wrthrn the Tanzanian Southern Highlands Zone. ln the Tanzania National Plan for the Control of Onchocerciasis, Ludewa district had been scheduled to start implementing a CDTI hoject rn Phase III as the 4th project thus separating it from the Ruvuma focus. Following a series of drscussions between the National Onchocerciasis Office and Srght Savers International (SSI), a decision was taken to maintain the existing ivermectin treatment structure established in 1992 in the two Regions where all the three adjoining districts have been treated in one consolidated block - the Ruvuma focus. The two Regions - Ruvuma and Iringa - have rvorked very well together on thrs CDTI project, using previously established primary leadership in administrative structures in Ruvuma. The River Blindness Foundation (RBD supported distribution of Mectizan@ in the Ruvuma focus using the CBIT strategy between 7992 and rrud- 1995. Usrng the bridge funding from Inter-Church Medical Assistance (IMA) and Sight Savers Internatronal (SSD, solid plans were put in place to shift from a CBIT approach to a community-directed treatment with ivermectin (CDTI) strategy. A proposal to do this was presented to APOC for support. and. in 1998. it received approval and commitment to a five year funding support in 1998. The pro;ect has undergone two independent monitonng exercises to ascertain its compliance with thee principles of CDTI in its operations. One of the key findings of the last independenr monttoring exercise in year 2002 was the high rate of absenteeism during treatment, whrch was attributed to poor timing of treatment. Following this the proglamme prepared itself to treat when the communities wanted. The communities selected the dry season. unfortunately because of the delay in the release of the drug from the port in Dar Es Salaam distribution was subsequently made at an unfavourable period. The project, which is now in the fifth year of funding from APOC, is being evaluated for the post-APOC sustainability of CDTI implementation in the project area. as APOC winds down its five-year support. The evaluation team drawn from Nigeria. Tanzania and USA was therefore charged with the tasks of: o Evaluating the sustarnability potentials of Ruvuma focus CDTI project o Discussrng the findings and conclusions of the evaluatron with the Regional. projects and supporting NGDO partners o Supportin_q the proJect to develop post-APOC sustarnability plans I r t tt : tt tu t t/ll u r, t t n o l;( )(' t t, (' l )' l-l l,.v.o l r t o t t rln 1111 1,,1 t 1.1 Page 9 of 49 a 2.0 METHODOLOGY Evaluation questioni How sustainable is the Ruvuma Focus CDTI project? D e sigru Cross-sectional. descriptive. Population: The Ruvuma Focus CDTI project, including: Regional Medical Teams in Ruvuma and Iringa; its NGDO partner (SSI)I rts Disrricrs with their Council Health Management Teams (CHMT); the Health Areas Health Management Teams: the project villages and sub-villages, their cDDs and the project's finance officer. Sampling: Since there were only three Districts, all were included in the study. Details of the sampling of FLHFs and sub-villages are contained in Table l. I 2.1 SAMPLING The three Districts of the project were included in the evaluation exercrse. A multi-stage sampling approach was adopted in selecting the FLHF and communities for the evaluation. First, the therapeutic treatment coverage rates for the FLHFs during the last treatment rounds were computed and stratified into high and low. From each stratum. and in each District one FLHF was randomly selected. The treatment coverage rates for each FLHF was also computed and stratified into high and low for the villages and sub-villages. The simple random sampling approach was adopted in selecting villages and sub-vrllages from the different strata of villages and sub-villages in the sampled FLHF areas. Table 1: Distribution of Samples in Health Districts/Division, Health Areas and Communities: S/N District (Division) R* (Coverage Rate) Village/FLIIF Area Sub-Villages (R* Coverage Rate) I Songea (Mkongo & Muhukuru) Low (66.27o) Mtelawamwahi Mpingi l. Mtelawamwahi (68.3Vo) 2. Mpingi (75.07o) Chipole Muhukuru 1. Chipole (100.07o) 2. Magagura (57.6Vo) 2. Ludewa (Mlangali & Mawengi) Medium (67.2Va) Madindo 1. Madindo (59.l7o) 2. Mulanje (66.77o) Luana l. Majengo "A" (6l.7Vo) 2. Majengo "B" (61.7%') 3 Mbinga (Mpepo & Ruhuhu) High (68.57o) Lundo l. Kawawa (65.07o) 2. Lundo (65.jEo) Trngr l. Tingi "A" (7l.6Vo) 2.Tingi "B" (71.67o) 2.2 SOURCES OF INFORMATION I a n :tt n r a/ ll u t r l n o l' t.tc r r 3 t' I )' I I l'.v'a I tt o ! t ort l(1. 1'1 1 1 1 Pase i0 of 49 Information was collected from interviews, verbal reports and documents. Various categories of people were lnterviewed in the two Regions (Regional Administrative Secretaries (RAS) Regional Medical Officers (RMO), members of the Regional Health Management Teams (RHMT) and the Project Coordinator) as well as the Country Representatrve of the NGDO, SSI, partner. the project finance officer (accountant) and Ruvuma regional pharmacist. At the District level, the District Executive Director (DED), Council Chairrnen, District Treasurer, District Pharmacist and the Distrrct Health Management Teams (DHMT). were interviewed. Other persons interviewed were at the Frontline Health Facility (FLHF - Dispenser in charge) and the villages (village executives. sub-village leaders, CDDs. and community members). Information were recorded on the evaluation instruments and discussed extensively before the Evaluation Team undertook the grading of the level of performance on the indicator. 2.3 ANALYSIS Based on the information collected. each indicator was graded on a scale of 0-4 (worst to best), in terms of its contribution to sustainability. The average 'sustainabrlity score'for each group of indicators was calculated, for each level, and a graph was plotted. Summary statistics for the scores were calculated for each level, and for each group of indicators, and tables and graphics of these results were also presented. Recommendafions were generated in the format recommended by APOC. The six critical elements and the seven aspects of sustainability in the project were qualrtatively discussed and agreed to by the team in open debate. The project was graded using these aspects and elements in accord with APOC recommendations. The evaluators discussed qualitative description of problems. and dehberated on likely suggestions for solving the problems identified. ' I ?r n:n n rrr/ll u rr ttno lir)t' t t s (' ! )'l I l,.t tr I ttat r rtri l(t:pr t r I Page I I of49 3.0 EVALUATION FINDINGS 3.1 SUSTAINABILITY AT REGIONAL LEVEL Fig. 1: Ruvuma CDTI: Sustainability at Regional Level 4 3.5 3 1.5 1 0.5 0 2.5 2 t\ cn o =q, Groups of lndicators Planning: (Slightly; 1.3) There was a plan, which listed diseases of national priority. Onchocerciasis was however not listed in the official Regional document as one of the ten pnority diseases. It was affirmed that regrons merely provided support for project plans developed at the district level where the responsibility for such planning has been devolved in Tanzania. Although the processes of implementation of CDTI were usually discussed extensively and well understood by partners, every year. The regional plans were not documented. In short, there was no written annual plan with details on CDTI implementation. This lapse does not help the cause of sustainability. Further more, there was no evidence, wrrtten or otherwise, of any planning for the sustainability of onchocerciasis control activities post-APOC. Monitoring and Supervision: (Fully; 4.0) Staff members at the regional level monrtor and supervise only the level irnmediately below lt except for occasional spot checks. They have empowered staff members elt the next level to monitor and supervise the next lower level. Itrtt-ttntu/llut tun(t l-()L{t\ (.-1.)'l I l,.t'ulrtof tott l(cltrttt Page 13 of49 Training and HSAM: (Highly; 3.0) Staff members at thts level train only staff at the level immedrately below it. that is, the Council Health Management Team (CHMT). and have empowered the level rmmediately below to train lower levels. Such tratning episodes rvere always targeted to specific and justifiable needs. For instance. the newly recruited District Coordinators rn Ludew'a are promptly trained. The CHMT for the other Districts were retrained because of their proven competence at the implementation of CDTI in their various areas of operation. The training exercises were also very efficiently rnanaged as very few staff members of the RHMT were used and the training period was short and effective. The training of new Coordinators lasted about two days on the average depending on the ability of trainee to assimilate to the contents of the training programme. Since these trainrngs were specifically designed to address to needs of only the new Coordinators in Ludewa. the trainings werl undertaken in the District. Initial training and earlier retraining exercises for the various CHMT were more elaborate and staged in a place central enough for all the CHMTs. However, it was observed that training for CDTI was not integrated into any other known training programmes in the health management systems of the regions. The argument was that the content of the training on CDTI differed remarkably from the contents of the training on other health programmes. Moreover. There rs inconsistent evidence on the implementation ofHSAM. Some policy makers demonstrated knowledge of and show commitment to the tmplementation of CDTI in the regons. while others lacked knowledge of essential (basic) elements of CDTI, and referred evaluators to the Regional Onchocerciasis Coordinator (ROC) or the Districts for information on these. Integration: (Fully; 4.0) There was a remarkable amount of integration of CDTI into the health systems of the regions. Staff combined diverse programme tasks on each single trip to the District. Mectizan@ supply and storage systems were not only within the government system but were the same as the systems used for the supply and storage of other programme drugs in the regions. except that Merctizan was specially routed through the project office. There ire howevei plans to remove this routing so that the drug is handled in all respects like other government procured drugs. TheRHMT resources for programme implementation are pooled and used i, .o*1non for allprogrammes lncluding CDTI. The RHMT matntain common supervisory checklrsts and schedules for all disease control programmes rn the regions. All these enhance the prospects of sustainability. Financial Resources: (Moderately; 2.3) The costs for each onchocerctasis coutrol activitl, il,ere clearly spelt out rn a buclget. The project manager. at this lel'el. had clear estimate of the funcls that will be avarlable foionchocerciasrs control rn the comtng year and made budgets for CDTI rmplementatron to fall within this expected and estrmated rncome.

I ttrtatrttru/llut,urtrt I ttr rrt ('l)'l'l l,.t'ttlrtttltr.ttt ll,:1t1,1 1 Page 13 of49 Training and HSAM: (Highly; 3.0) Staff members at thrs level train only staff at the level immediately below rt. that ls, the Council Health Management Team (CHMT). and have empowered the level immediately below to train lower levels. Such traintng episodes were always targetecl to specific and justrfiable needs. For lnstance. the newly recruited District Coordrnators in Ludewa are promptly trained. The CHMT for the other Districts were retrained because of their proven competence at the implementation of CDTI in their various areas of operation. The training exercrses were also very efficiently rnanagecl as l,ery feu, staff members of the RHMT were used and the training period was short ancl effective. The training of new Coordinators lasted about two days on the average dependin-e on the ability of trainee to assimilate to the contents of the training programme. Since these trainings \.vere specifically designed to address to needs of only the new Coordinators in Ludewa. the trainings were undertaken in the Dtstrrct. Initial training and earlier retrainin-e exercises for the various CHMT were more elaborate and staged in a place central enough for all the CHMTs. However, it was observed that training for CDTI was not integratecl into any other known training programmes in the health management systems of the regions. The argument was that the content of the training on CDTI differed remarkably from the contents of the training on other health programmes. Moreover. There is inconsistent evidence on the implementation of HSAM. Some policy makers demonstrated knowledge of and show commitment to the implementation of CDTI in the reglons. while others lacked knowledge of essential (basic) elements of CDTI, and referred evaluators to the Regional Onchocerciasis Coordinator (ROC) or the Districts for information on these. Integration: (Fully; 4.0) There was a remarkable amount of integratlon of CDTI into the health systems of the regions. Staff combined diverse programme tasks on each single trip to the Distnct. Mectizan@ supply and storage systems were not only within the governlnent system but were the same as the systems used for the supply and storage of other programme drugs in the regions, except that Merctizan was specially routed through the project office. There are howevei plans to remove thrs routrng so that the drug is handled in all respects like other government procured drugs. The RHMT resources for programme implementation are pooled and used in common for all programmes including CDTI. The RHMT maintain common supervisory checklists ancl schedules for all disease control programmes rn the re-eions. All these enhance the prospects of sustainability. Financial Resources: (Moderately ; 2.3) The costs for each onchocerciasts control activrty were clearly spelt out in a budget. The project manager' at this ler"el. had clear estitnate of the funds that will be available for onchocerciasis control in the comrnq year and made budgets fbr CDTI rmplementation to fall within this expected and esttmated rncome.

I rtri:rtnrrr/llttr trrrtrt I rtr rr: ('l)'l l l,,y'rrlrrulrtttt lil,l'ttt i Page 13 of49 Training and HSAM: (Highly; 3.0) Staff members at this level train only staff at the level immediately below it, that rs. the Council Health Management Team (CHMT). and have empowered the level immediately below to trarn lower levels. Such trarning episodes were always targeted to specific and justifiable needs. For instance, the newly recruited Drstnct Coordinators in Ludewa are promptly trained. The CHMT for the other Districts were retrained because of therr proven competence at the implementation of CDTI in their various areas of operation. The training exercises were also very efficrently managed as very few staff members of the RHMT were used and the training perrod was short and effective. The training of new Coordinators lasted about two days on the average depending on the ability of trainee to assimilate to the contents of the training programme. Since these trainings were specifically designed to address to needs of only the new Coordinators rn Ludewa. the trainings were undertaken in the District. Initial training and earlier retraining exercises for the various CHMT were more elaborate and staged in a place central enough for all the CHMTs. However. it rvas observed that trarning for CDTI was not integrated into any other known training programmes in the health management systems of the regions. The argument was that the content of the training on CDTI differed remarkably from the contents of the training on other health programmes. Moreover. There rs mconsistent evidence on the implementation of HSAM. Some policy makers demonstrated knowledge of and show commitment to the implementation of CDTI in the regrons. while others lacked knowledge of essential (basic) elements of CDTI, and referred evaluators to the Regional Onchocerciasis Coordinator (ROC) or the Districts for information on these. Integration: (Fully; 4.0) There was a remarkable amount of integration of CDTI into the health systems of the regions. Staff combined diverse programme tasks on each single trip to the District. Mectizan@ supply and storage systems were not only within the government system but were the same as the systems used for the supply and storage of other programme drugs in the regions, except that Mercttzan was specially routed through the project office. There are however plans to remove this routing so that the drug is handled rn all respects like other government procured drugs. The RHMT resources for programme irnplementation are pooled and used in common for all prolrammes including CDTI. The RHMT maintain common supervisory checklists and schedules for all drsease control progralnmes rn the regrons. All these enhance the prospects of sustainability. Financial Resources: (Moderately ; 2.3) The costs for each onchocercrasis control actrvity were clearly spelt out in a budget. The project manager. at thts level. had clear estimate of the funds that r.rill be available for onchocerciasis control rn the comrng year and made budgets for CDTI rrnplementatton to fall within this expected and estimated rncome.

Iurr;rrttttr/llui tun(! l'o(,u\ ('l)'l I l,.y'olttolrott ll1p1111 Page 12 of 49 A multi-disciplinary and multi-sectoral management team does supervrsion as a group, because the programme was seen as the responsibility of the entire regional health management team. To cut cost and rationahze the use of resource the actrvities of programmes within the regional medical areas were rntegrated. Thus there \\'as an integrated process of monitoring and supervision. where resources were shared for supervision and few staff members are used for each episode of monitoring and supervisron. The Regtonal Health Management Team (RHMT) deals wrth problems as and when they arise at the District level with support from the Regional level when and where such supports were sohcited. Good performances were recognized wrth letters of commendation and awards. For instance the District Eye Coordinator (DEC). who is also responsible for onchocerciasis control activitles in Mbinga District, was recognized and presented with a letter of commendatron and a Radro Cassette player. at a formal ceremony. for his good work rn combating onchocerciasis and implementing CDTI in the District. Evidence of action taken to improve CDTI rmplementation. based on the recommendation of previous monitonng exerclse. was noted. For instance. followin,e the identificatron of distribution of Mectizan@ during the farming season as one of the maJor causes of low treatment coverage in the last independent particrpatory monitorrng exerclse. the RHMT. through the different CHMTs and FLHFs tried to ascertain the periods of distribution that would be most convenient for the people and planned to conform with the choice of the people. Mectizan@ Ordering, Procurement and Supply: (Fully; 4.0) There was an efficient ordering and storage systern that rs lvrthrn the government system. The Medrcal Stores Department (MSD). an outfrt of the Government of Tanzania delivers Mectizan@. along with other drugs. to the Regional Medical store. This system was considered simple' uncomplicated and efficient for the Government. It makes for rntegration of the Mectizan@ delivery system into the main stream of drug delrvery in the country. It also promotes ownership and sustainability of the programme even when the present external facilitating organizations withdraw. Sufficient amounts of Mectizan@ were supplied annually to the Regions and timely enough to meet the dernands of the Districts. except for the last treatment round where the demands for import duties on Mectizan@ by Tanzania Revenue Authories (TRA) stalled the drug distribution for a period of ntne months. This was not envisaged but the Tanzania National Government later stepped in to waive the payment of any taxes on Mectizan@ tablets in line with the Memorandum of Understanding (Motl) between the WHO and the Government of Tanzania. Sufficient amounts of Mectizan@ tablets were supplred to the Dlstncts and there were no reports of shorta-ees at any points. Mectizan@ tablets w'ere stored ln a common drug store w,rth other drugs rn the Regional Meclcal Lrnit (RMLI;. Thts r','as also considered as an eftrcrent and ratronal use of the resources of the region as u'ell as a verttable measure of rntegratron of CDTI pro,sramme into the health activitles of the reslons. I rt tt ^ o n t tr/ ll u r r lnu l"r t(' r t ! (' l )'l l l,,v'o l r r rt l r r-t ti l(t: pl t l Page 13 of49 Training and HSAM: (Highly; 3.0) Staff members at this level train only staff at the level immediately below it. that is. the Council Health Management Team (CHMT), and have empowered the level immediately below to train lower levels. Such training episodes were always targeted to specific and justifiable needs. For instance, the newly recruited District Coordinators in Ludewa are promptly trained. The CHMT for the other Districts were retrarned because of their proven competence at the implementation of CDTI in their various areas of operation. The training exercises were also very efficiently managed as very few staff members of the RHMT were used and the training period was short and effective. The training of new Coordinators lasted about two days on the average depending on the ability of trainee to assimilate to the contents of the training programme. Srnce these trainings were specifically designed to address to needs of only the new Coordinators in Ludewa, the trainings were undertaken in the District. Initial training and earlier retraining exercises for the various CHMT were more elaborate and staged in a place central enough for all the CHMTs. However, it was observed that trarning for CDTI was not integrated into any other known training programmes in the health management systems of the regions. The argument was that the content of the training on CDTI differed remarkably from the contents of the training on other health programmes. Moreover, There is inconsistent evidence on the implementation of HSAM. Some policy makers demonstrated knowledge of and show commitment to the implementation of CDTI in the regions. while others lacked knowledge of essential (basic) elements of CDTI, and referred evaluators to the Regional Onchocerciasis Coordinator (ROC) or the Districts for information on these. Integration: (Fully; 4.0) There was a remarkable amount of rntegration of CDTI into the health systems of the regions. Staff combined diverse programme tasks on each single trip to the District. Mectizan@ supply and storage systems were not only within the government system but were the same as the systems used for the supply and storage of other programme drugs in the regtons. except that Merctizan was specially routed through the project office. There are however plans to remove this routing so that the drug is handled in all respects like other government procured drugs. The RHMT resources for programme implementation are pooled and used in common for all programmes including CDTI. The RHMT maintain corrunon supervisory checklists and schedules for all disease control programmes tn the regions. All these enhance the prospects of sustainability. Financial Resources: (Moderately; 2.3) The costs for each onchocerciasrs control actrvity were clearly spelt out in a budget. The project manager. at this level, had clear estimate of the funds that will be available for onchocerciasis control in the coming year and rnade budgets for CDTI implementatton to fall wrthin this expected and estrmated income. I rttt:ontt/llut tuntr l,t,L rt t ('l) l I l:.\,il1|o!t()il ll(l(tt I Page 14 of 49 There was evidence of approval of expenditure. and funds for expenchtures were allocated according to the approved plan of action. The RMO approved both the proposed expenditure and funds for the implementation of CDTI in line with the work plan drawn by the CHMT and other partners for the control of onchocerciasis in the region. The project accountant maintained regular insight into each budget line and advise on the propositions for expenditures on the different activities. However, all the operations for the control of onchocerciasrs at thrs level were funded by APOC but there was not sufficient evidence of a cost reduction strategy. except for the targeting of training and the integration of activities. These did not reduce the level of dependence on APOC funding from what was planned from the initial sta-qes of the project. It was noted that no consideration has been apparently given to how activrties will be funded post-APOC Transport and other Material Resources: (Slightly; 1.8) The project has two APOC-supplied vehicles. thou-eh only one vehicle was functional at the time of the evaluation. The other. whrch needed major reparrs. has been grounded. Notwithstanding. transport has always been available for CDTI activitres because of the integratecl use of transport by the Regional Health Team. Here, all transport provisrons in the RHMT were in a pool to be drawn and used with authorization from the RMO. Transport. at thrs level was used for implementation of CDTI at the District level only. Logbook entries are reconciled with trip authorizations. Some of the equipment supplied by APOC. like thb laptop computer, were functional, while others. like the fax machtne were not. Transport and other matenal equipment were maintained regularly. The costs of maintenance of transport and other material equiplnent were met from ApOC funds. The current transport and equipment are not adequate considenng the work still to be done in the coming 5-10 years. There is yet no plan for replacernent of transport by Government post-Apoc. Human Resources: (Futly; 4.0) Staff members at this level are very stable and cornmitted to therr CDTI rmplementatron work. The RHMT members have remained in one place for an average of frve y"r.i. According to the RMO the ROC rs \/ery dependable and cornmitted to hrs CDTI vvork. Officials at the District level corroborated thl s rnformation. Coverage: (Fully; 4.0) All the Dlstricts in the Region had therapeutlc covera,se rates of 6-5 per cent and above hence the project at the Re-qlonal level was graded "fully". However the trend shows a very sltght decrease ' I tt tt ^rt n r o/ ll u r' t rrn d lot' r t.' (' I ) I I l..vo I r t tt t t r tt i l(r: ltr t t I Page 15 of49 between the last two distribution rounds. The range in the penultimate round of distribution was 667o to 7l7o whlle the range for the Iast distribution rvas 65Vo to 69.67o. The seeming decline in therapeutrc coverage rates for the penods reviewed rvas blamed on the intensification of mining and farming activities that took place during the last distribution. It was noted that because of the late clearance Mectizan@ for distribution, which has been discussed earlier, treatment was commenced nine months later than originally planned for. and during the unfavourable rainy season, which was peak of farming activities for the people resulting in a higher than usual rate of absenteeism. '{'trtt:onrrr/llrrt rtrn(t I'rtt rts ('D'I I l,.roIttolrrtrt llrltlrt Page 16 of 49 Recommendations for the Regional Level Recommendation Lnplementation Planning l. There is need to have a written plan rn regard to both Regions that should indicate clearly the role and the activitles of the various partners post APOC. Cost and sources of funds should be clearly indicated 2. Efforts should be made to have onchocerciasis control Iisted as a priorrty program in the Regional Health Supportive Program Under the Joint Health Basket Grant for both Regions. !!94ry': rllGrl Indicators of success: o One Plan recognrzed by both Regions or two Plans, one for each Region o Mention of CDTI activities in the Regional Health Basket Plans Who to take action: National, Regional Health Management Team for each Region Deadline for completion; End of J anuary 2004 Training and HSAM: l. Training in CDTI should be integrated into the RHMT training plans and activities 2. The RHMT should ensure regular and adequate sensitization of policy makers on CDTI Priori .\.ll.i )ll )! Indicators of success: o Documented evidence of RHMT training plan incorporating CDTI . Policy makers are able to discuss all relevant aspects of CDTI Wln to take action: RHMT D e adline for c omple ti ort B the end of March 2004. FinancingiFunding: Government should take action to make available adequate funds for the implementation of CDTI Priority: IIIGH lndicators of success: o Funds budgeted and released by government to meet the running costs of CDTI implementation Who to take action: RAS/RMO De adline for c ompletion B end of December 2004 Transport and other material resources 1. Government should plan for and ensure timely replacement of transport and other matenal resources provrded and needed for CDTI implementation. 2. Government should provrde resources for the maintenance of the capital equipment used for CDTI implementation 3. To ensure sustainabrlity of CDTI, APOC should ensure replacement of transport before the frnal wrthdrarval of ApOC sLlpport. P HIGH Indicotors of success: o Funds budgeted and released for the maintenance of capital equipment o All capital equlpment used for CDTI implementation are in functronal states o Replacement of capital equipment that have outlived their life an Wlrc to tuke action'. RMO and APOC Deocll utc .for contplettort Decernber. 2004 I rttt:trntrt/llut rtrno l.,tt'tL' ('l)'l I l,.v'ttlttturott |(apt,t t Page 17 of 49 Coverage: The current level of coverage should be raised and maintained to ensure maximum benefit to the eligible population by making Mectizan@ available at periods preferred by the communities. Priority: HIGH Ind ic ator s of suc c e s s'. o The geographic coverage rates sustained o Therapeutic coverage rates increased and sustained. Who to take action RHMT De adl ine for c ompleti on December, 2004. I tt tt -tt tt ttt/llu t t utt( t I t )( n\ (' I )'l I l, t tt I tt ttt t ot r lir ltr t t I Page 18 of49 3.2 SUSTAINABILITY AT TIM DISTRICT LEVEL Fig.2: Ruvuma CDTI: Sustainability at District Levet 4 3.5 3.3 0.5 0 3 6 2 2. 1.5 st .9 o =qj -*'$r.r'{SNi,"d${,..'*-oo.C...no:"""-"n" Groups of lndicators Planning: (Highly; 3.0) There is a general plan of action for all health actrvitres and CDTI activities were included. in all the three Districts visited. The written work plans had all the elements of CDTI. The plans were drawn in a partrcipatory manner involving all partners. However the plans did not appear to always take account of communrty preferences for timing of treatment. The trmrng of distribution rvas invanably dependent on the availability of drug as was apparent in the re-arrangement in respect of the last round of drstribution because of the delay in release of Mectizan form the port at the national level. Leadership: (Fully; 4.0) The Councrl Health Management Team (CHMT) takes full responsibiliries and initiatives for CDTI activlties in all the Drstricts. There is a focal person fbr CDTI in all the Drstricts a I r r n : o tt r rt/ ll tr' ut n o l' ()L' u, (' l )' l' l l,.v'o I r r a t r r,tu llt p r r t l Page 19 of49 Monitoring and Supervision: (Highly; 3.3) The reporting process is within the government system and the government's resources were used for transmitting reports to the higher levels. The District Eye Coordinator (DEC) rs the desk officer for CDTI in the District and reports to the District Medical Officer (DMO). The DMO sends the reports to the Regional Medical Officer (RMO), for the attention of the Regional Onchocerciasis Control officer. Supervision rs integrated. Officers in charge of different programmes team up and use common Council Health Management Team transport in shared manner for supervision. The Districts have common supervisory plans for the CHMT, with CDTI as a component part. A checklist for superviston is shared and reports based on the checklist are submitted to the District Health Officer (DHO). However, in Ludewa District. although supervision is integrative, it is done without a checklist. Problems identified during supervision (such as refusals to take drug or low morale of CDD due to lack of support by community) were left for the rural health worker to resolve together with the village leaderships. In other words, the CHMT members encourage rural health workers to resolve problems identified with village leaders. Successes were often recognized verbally. However. one of the rural health workers in Mbinga District who demonstrated good CDTI skills was taken round to other health facrlities to teach other rural health workers. This boosted the morale of that health worker and acted as an incentive to others. This approach might be used elsewhere in the programme. Mectizan@ Ordering, Procurement and Supply: (Highty, 3.0) The CHMT used Mectizan@ forms for ordering Mectizan@ from the higher levels of CDTI implementation in the Regions and requests for drugs were based on the FLHF and community data. Mectizan@ was available for the last distribution, although unfortunately not at the time convenient for the people. This was a major problem in the last distribution that coincided with the peak of farming activities in the different communities, thus leading to absenteeism during treatment. This was noted rn the last independent monitoring exercise and the different CHMTs worked towards remedying the situation. The circumstances were as follows. Last year, Government imposed import duties on donated drugs which action led to a nine-month delay in release of the drug before the levy rvas eventually lifted. The drug finally got to the people very late. Thus there were two distributions in 2003 and none in 2000. This affected efforls to remedy the wrong timing of distribution noted by the rndependent monrtors last year. There were no reports of shortages. Mectizan@ is being collected and stored wrthin the government system. rvhich is effective, uncomplicated and efficient. The C'HMT f-etches drugs from the regional Ievel. However. if anyone from the regional office ts vrsiting the Drstnct before the CHMT goes tor their drug, that person may take the drugs alon-e to the CHMT. The drugs are stored ln the District pharmacy before distribution to the FLHFs. { o rt ^ rt rt ta/ li tt t r il n (t l' / ){ u s (' l -)' l I l,,t'tt l r r at t() n l(L: p ( t t i Page 20 of 49 Training and HSAM: (Highly; 3.3) Staff members at this level only train FLHF staff. although when there are critical problems the FLHF staff has been assisted with trarning at the next lower level. However, in one of the Districts one of the FLHF staff apparently rvas trainecl, while the District staff went directly to the community level to train CDDs. Other FLHF staff members interviewed had been empowered to train CDDs. Training is mostly based on need. Mbinga 30 new rural health workers were trained. The previous year only 16 new and 6 old but unskilled rural health workers were trained. Training is integrated in some of the Districts. Resources for training are efficiently used as very few CHMT staff are involved in the training of FLHF staff. There is also in-service training for staff at this level. Staff members identify situations where HSAM is necessary and undertake it health educatron was undertaken during mobile clinrcs activities. In many cases Financial Resources: (Moderate; 2.0) Cost for each CDTI activity is clearly spelt out and there is ample evidence of cost containment strategies as reflected in the targeted training of FLHF staff. The managers have a clear estimate of the expected lncome and the budget falls within the estimated income although rn Ludewa the managers had no idea of the expected income. The amounts budgeted by the government for CDTI rs on the lncrease. For instance rn Mbrnga, a total of Tsh 9.400,000 was budgeted by the Council for CDTI activities. The previor. y"ur, th" District budgeted Tsh 7,663,200 CDTI implementation whereas Tsh 6.000,000 was budgeted for CDTI implementation the penultimate year. Such funding support from the Councils will no doubt enhance the sustainability of CDTI post-ApOC. Furthermore the evaluators noted u'ith satisfactron that the amounts released by government for CDTI activities are on the increase. For instance. in one of the Districts, Council Released Tsh 1.435,000; Block Grant gave Tsh 2.119.000 for the last round of distribution. This compares favourably with Block Grant gave Tsh 646.000 in the same Distncr, and Tsh 375,000 in another District in the year before. The policy makers. rn one of the Distncts visited noted that the managers of CDTI implementation activitres have not askecl for funds. hence there has been no release of funds. The Chairman of the Local Government Council noted that, "we never kne.n, that v,'e are expected to fiud the activities. Alier the recent x,ttrksltop helcl in Songea, y)e no\e krtor, ctncl the council lrcts app,o,ed the relt,ct.st, of' 2,000,000 Tinzanian shillings for tlrc urtplementrrtion o_l'CDTI uctn'ities in ortr Di.stnct". It rvas tndlcated to the evaluators that the Councrl ancl block -erant from DMOs office could make up for short falls. u'hen and where there rs an;,short fall. All the same. the evaluators loted that I un:onrtr/llur'rlnt l"ot'tts ('l)'I I l,.y'trI rratroti llcprtr'l Page 2l of 49 in most of the Districts, CDTI actrvities \\'ere not implemented in 2002 because of late arrival of APOC funds, which could not be cushioned from other sources. A measure of financral control was noticed. For instance, the District Executive Director (DED), through the DMO, gives approval for expenditure. Expenditure is allocated according to an approved work plan and the Councrl Treasurer maintains regular insight into residual funds for the different CDTI activities. In some cases however. evaluators noted that the accounting officers and DMOs lacked knowledge of details of APOC funding for activities in therr Districts. Transport and other Material Resources: (Moderately; 2.8) Vehicles are available for all health programmes in most Districts and transport is used in an integrated manner. Those vehicles from APOC are used for all district level activities including CDTI, in consonance with the level of integration in the CHMT. The vehicles are routinely maintarned in a programme of planned preventive maintenance (PPM), but in some of the Districts this is done for only the motor vehicles and not for motorcycles. Spare parts are supplied by donor agencies, in the case of Mbinga DANIDA. while the council pays for repairs and running costs for vehicles. Strict controls are employed in managing the available vehicles. For instance Log sheets were used even for motorcycles in some of the Districts. However, the condition of all motor transport is poor, and they will be need for replacement in the coming 5-10 years. Management is aware of the need to replace vehrcles but some of the Districts hoped that such replacement would come from non-government or APOC sources. The Mbinga DMO however noted that, "the central transport unit (CTU) in Dar Salaam makes provision for the replacement o.f vehicles for CHMT. In the past, one of the Hilux vans y'as retunted to the CTU and replaced with a new, vehicle in Mbinga". The replacement of APOC vehicle by the government may be feasible. Stationeries are provided through the Block grant Human Resources: (Highly; 3.0) Staff members at District level have been in post for not less than srx years except in Ludewa, where there is rapid turnover of staff leading to CDTI instability. This is attributed to the relatively undeveloped infrastructure of the area. The CHMTs have in-service training. The staff members are committed to their CDTI work because it combats a drsease. which hinders farmers from doing their;ob. The DOCs are enthusiastic about therr work even though there is no evidence that they receive any financial or non-financial compensation, other than their statutory remunel'ati ons. I rttt:tt nttt/llut tnti(t I t)( tt t (' I) I I 1' t til trttl rrtn l(t.' ltt,t { Page22 of 49 Coverage: (Moderately; 2.5) Geographical coverage has remained at 100 per cent for the last three treatment rounds. The range for the last round was 657o-67.57o and the year before. 667o - 70.7Vo showing that average therapeutic coverage is consistently above 65 per cent. However, a slight decrease was noticed in the treatment figures for the last distribution, compared to the former. This decrease was apparently due to irregular timing in the distribution of Mectizan@ occasioned by the nine months delay rn clearance of the drug from the port. Only 75.2Vo (115 out of 153) of the communities had therapeutic coverage of 657o and above in the last distribution. I r ttt:rr rt ro/ll u t r uno l, r )t t t s (' l) l' l l,,y'tt l tr tt l t ( )t! !l(|rtr r t Page 23 of 49 Recommendation for the District Level: District Recom mendations Implementation Financing: District Officers should know more about how the programme is funded, and be knowledgeable about the patterns of disbursement District Executive Director should be able to mobilize and allocate adequate financial resources to enable operations at District level to run smoothly. Priorih,: HIGI{ Indicators of Success: Demonstration of knowledge of funding processes Who to take action: Regional to inform District authorities D e adline fo r c om ple tio n : March 2004 Transport and other material costs: Routine maintenance and when necessary replacement of motorcycles and vehicles should be carried out PrioriQ: MEDIUN'I lndicators of Success: Maintenance Logs appropriate, functional motorcycles and vehicles Who to tctke action: District authorities De adline for completion: March 2004 Coverage: All communities should attain a therapeutic coverage of 65Vo or more. Priority: IIEDIITN{ Indicators of Success: 1007o of communities with 657o therapeutic coverage Who to take action: District authorities D e adline fo r comple tion : End of next distribution l tr n :tu r t tt/ll u t t unt t L t t ! t s (.' l )' l' l l,,t tt l tt ct l t ( ) n ll(, p (' t l Page 24 of 49 3.3 FIRST LINE TMALTH FACILITY Fig. 3: Ruvuma CDTI: Sustainability at the FLHF Level 4 3.5 3 2 1.5 1 0.5 0 2.5 t E, .9 o =d ,*"i]".u*"[".**t*""d -t-* *'"{-*'o* o.trd Groups of lndicators Planning: (Slightly; 1.0) No written r.vork plan was found in most of the facilities. The rnembers of staff at this level said that they discussed the CDTI actrvrties they undertake every year. but these were not documented rn any form. Documentation was thus the malor problem at thls level of operation. Leadership: (Highly; 3.0) Most of the FLHF staff members take full responsibility for CDTI activrties at this level as they do for other health programmes and activities. However. a few FLHF staff members lack knowledge on the basic elements of CDTI. The village heads partrcipate rn CDTI activrtres through mobilization of the people ancl identification and resolutton of problems. In one instance. it rvas observed that the drstances covered by CDDs was a maJor source of concern, which the village leaders addressed by mobilizrng the people to come to locatrons closer to the CDDs during dtstributton. I u tt. rr tt r n/ ll u r' t il n il l()L' ! t s (' l,)' l' I l,.t' o L tr ot r on lla p L t r I Page 25 of 49 Monitoring and Supervision: (Highly; 3.0) Reports are submitted through the government systern. CDDs submit reports to the dispenser in charge and he submits to the District Medical Officer. The FLHF staff members supervise CDDs routinely during and after drug distribution, and in an integrated manner with other health programmes. Unfortunately, checklists are not often used for these supervisory activities. Some FLHF staff members had copies of the checklist issued to them by the Regional/Districr Coordinator but have never used them Problems identified during the supervisory visits were taken to the head of the sub-villages for resolution, e.g. there were problems related to poor treatment coverage. Village leadership resolved these problems promptly resulting iri improved coverage subsequently in those villages. In one of the villages people were penalized for not taking the drug Incorrect calculations of treatment coverage rates were noticed in some FLHF. Similarly, summary sheets were not seen in some FLHFs, so determination of village treatment coverage rate was often not possible at this level. No system of management of successes or giving feed back existed. However, good practices among the sub-villages were commended verbally. Mectizan@ Procurement and Distribution: (Moderately; 2.5) Some FLHF staff members used order forms for the ordering and procurement of drugs. In this case, Mectizan@ tablets were recelved as requested. This is usually based on a formula using total population multiplied by a factor of 2.2. The quantity received during the last distribution was sufficient but did not arrive early enough for the time requested by the communities. In 2000, the year before the last distnbution. no treatment was given because of delay in clearing the drug from the port. Mectizan@ is stored with other drugs in the health facility. In most cases while the system of Mectizan@ ordering is driven from above. the procuring and storage is effective, uncomplicated and efficient. Staff of the FLHFs collect drugs from the DMO's office. Sometimes the drug is brought to the health facility from where the CDDs collect them. Staff ar the FLHF level feel considerable pressure to distnbute the drug as quickly as possible when it arrives and to send therr reports to the District. Training and HSAM: (Highly; 3.0) Training routines varied. For example, the FLHF staff trained the CDDs last in 2001 in Songea. In Ludewa CDDs were trained every year. because of the perceived need for refreshers. In one of the FLHFs the staff had not been trained and could therefore not train CDDs, so trarning was conducted by the CHMT. I ttnattrtttt/llutttnl(i l-()Ltt' ('l)'l I l'vttltrttltrttt ]lt ltttl Page 26 of 49 FLHF staff members do the health education and sensitization of community members only when there is need. ln some FLHFs. however. health education was poor as evidenced rn some people's lack of knowledge of why they are given the drug. Training materials were often scarce. Financial Resources: (Not at all; 0.0) There is no budget at this level and few resources. Only in one FLHF in Mbinga, were staff members allocated funds from the District for supervision. In other FLHFs the staff members use their personal funds for execution of key CIDTI activities, such as supervision. Transport and other Material Resources: (Slightly; 1.0) Of the six FLHFs vrsited. only one bicycle, whrch was non functronal. was seen. in Tingi. A missionary provided the bicycle (not APOC). The bicycle had been used for every activity, including CDTI. with the permissron of the officer rn-charge. There was no written authorization or logbook for recording authorization or use. There is no plan for the replacement or repair of the bicycle or provision of others in other FLHFs. Human Resources: (Moderately ; 2.0) As observed in the Districts. there is stabilrty of staff in the FLHF except in Ludewa where there is instability of staff. The region has provision for in-service training, which rotates among the health staff though not all eligible for consideration have had the benefit of the scheme. The evaluatron team noted that in some places the staff members had enough skill and knowledge to undertake CDTI activities Coverage: (Fully;4.0) The geographical coverage was 100 per cent. All the villages were under treatment. In the APOC instrument informatron was only collected on the geographical coverage at thts level; in most instances therapeutrc coverage could not be determined because of absence of summary sheets at the FLHF, or when present. incorrect calculation of treatment coverage rates. I tr rt a tr n t o/ R u yr rttt n l, r tr-' t t s (' l)'l l l.,r, t t I t t o t r o r t il t: pt t t I PageLl of 49 Recommendation for the FLHF Level: FLHF Recommendations Planning: All FLHF should have a written work plan which includes the CDTI activities. Prioriry: MEDILIM Indicators of Success Available work plans at all FLHF Who takes action District, FLIIF Deadline for completion 2004 Managing Mectizan: Drugs are provided for distribution at a time desired by the communities. Priorih,: MEDIUNI Indicators of Success; Communities confirm that times are what they want drug distribution Who takes action: National, Regional. District, FLftr Deadline for completion ; End of next distriburion Financial Resources: FLI{F should have a written budget that is approved to provide resources to them for CDTI activities. This budget should reflect all sources of income. including those from local council. Priority: IIIGII Indicators of Success: Written budget, evidence of release of mone1, different contributions Who to take action: National, Regional, District, FLHF De adline for compl etion January 2094 Transport and other Resources: There should be a realistic plan for the purchase and maintenance of transport at the FLHF. where such resources are needed. Priority: HI(;lI Indicators of Success Functional transport, where appropnate Who to take action: District. Councils. FLHF Deadline for completion J 2003 Human resources: There should be stability of staff involved in CDTI activities at the FLFtr whenever possible. Where changes occur, there should be prompt in-service training and orientation of new staff to the programme. Indicators of Success: FLHF staff involved in CDTI in their positions for 5 who know basic CDTI skills Who to take action Drstrrct De odline fot' t'orupletion End of next distribution Priority: HIGII I utt.trnto/llut runo l'rtt{tt (' l)'l I l' r'ttl tralrott llt'ltot t 4 3.5 3 2 1.5 1 0.5 0 Page 28 of 49 3.4 SUSTAINABILITY AT THE VILLAGE LEVEL Fig. 4: Ruvuma CDTI: Sustainability at the Community Level "l i 2.5 <f .9 o =a, n*t::0"$1.*0t""*"""tt+\.nun""*ruoaluu*uq" Groups of lndicators Planning: (Fully;4.0) A census update is carrred out dunng drstribution in some vrllages while in others the people preferred to conduct census update before drstributron. Reasons adduced for the preference by some CDDs included the fear that the work would get too cumbersome if they had to conduct census update and treat the people simultaneously. Moreover. others argued that it is better to know the correct census figures to calculate the quantity of drugs needed for the year. rather than having to make estimates based on figures collected in the previous year. The distances covered by CDDs are often great. due to the scattered residence pattern of the people. The village leadershrp, in some instances. trles to solve the problem of distances by assembling the people for central point treatment. In general, however, the communities elected house-to-house treatment. Leadership: (Highly; 3.0) Together with village members the leadershrp in the villages rdentify and try to solve problems related to the dru-e distnbution. Most of the major decisions on the implementatron of CDTI at the village ler,'el are rnade in this manner. For instances. r,rlla-9es selectecl CDDs from sub- vlllages during a vrllage meetin-el. and the l'rlla-ee Ieaders decrded on the rnode of distributron. Horvever. the tune fbr dtstnbutron has been tnfluenced by the avarlabihty of the drug. for at least I tt tt :tr n i o/ll u v r trnrr l' rt L' t t s (' l)' l'l l,,v'o I r t tt l i o ri ll L: lto t I Page 29 of 49 the last two treatment cycles. A village leader stressed "even if we decide to take the drug in October it is when the drug comes we ere git'en". On why the drug that arrives in April (for instance) cannot be kept till October when the people want it, he said that, "u'hen the drutg gets to the FLHF there is a pressure for report front the Regional level". In most cases the villagers were able to mention at least one of the benefits in ol takrng Mectizan@. They most often mention that Mectizan@ prevents itching, although blindness was mentioned as well. According to one of the village executives. "before this clrug, sorne people hrtd skin infection. Others abandoned their wirtes but noy,'thet,are okay".In Madindo, the people lack knowledge of why they are given the drug. The people are willing to take the drug for fifteen years or as long as it is offered. According to one of the villagers interviewed, "everybody loves the drug". In many cases, there is an understanding of the need to take Mectizan@ every year and for a prolonged period. Monitoring and Supervision: (Fully; 4.0) Reports are carried by the CDD promptly to the FLHF, even though the communities do not provide transport. They argued that this is because they are too poor to purchase bicycles and there are no commerciai transport facilities in the area. In all cases CDDs went on foot. Obtaining and Managing Mectizan@ (Moderately; 2.5) CDDs reported that the health facility staff allocated enough tablets for them to treat all those eligible in their villages. There was however no known basis for the allocation of Mectizan@ tablets to the communities. In some cases, the CDDs were given a single bottle ration, and were expected to return for more if there is need for more. This system increases the burden of CDTI work for the CDDs as they have to walk long distances to the FLHF for additional Mectizan@ for their respective communities. No tablets were kept for the treatment of those who were absent or temporarily ineligible. Pressure put on the CDDs to make reports and return surplus drugs to the FLHF staff members, who want to respond to the pressure for reports from the CHMT members within 2-3 weeks. HSAM: (Highly; 3.0) The community leaders educate the people on the benefits of the drug. In one of the cases, the village executive satd, "I norntally take the drug firsr in the start of distribution as a dentonstration and encouragement for the people to take the drtLg" . No deliberate step has ever been taken to encourage community members to provide resources for CDTI implementation. The CDDs purchase their own writing pens while the programme provided the community registets. I tut. t t n t rt/ llu : ! u n rt l ( ) ( t t s (.' l )' l l l',\'(t l rt til t t,)tt llL' l tt t t l Page 30 of 49 Financing: (Highly; 3.0) None of the communities visited gave any support to their CDDs. and made no provision for the implementation of CDTI in their domain. However, CDDs are often exempted from some communal assignrnents. One CDD said. hovt' can thet' gire me something when they lruve nothing". Human Resources (Highly; 3.7) The ratio of CDD to households or population vanes considerably. The ratio ranged from 1 CDD treating 7 households to 1 CDD treating 85 households. The explanation for this was found in the distances covered by CDDs. which varied widely. The communities gave sound rationale for the number of CDDs engaged. In Mpingi it was feared that too many CDDs could "spoil the work", while rn Madindo. the leaders complained that having more CDDs would imply exempting more people from communal labour. which means a great loss in the labour force. The FLHF staff mernbers have trained CDDs rn the various communities and the communities are prepared to pick another person to be trained as CDD rf any CDD drops out or performs poorly. As a proof to this. a village leader in Mpingi noted that. "tw'o CDD; were replaced because they traveled outside the village and w'ere awa,- for a long rime". CDDs interviewed are willing to continue as CDDs because of job satisfaction, community appreciation for their work. and because the tablet is helping them and their people. The CDDs obtain a degree of status from the task Coverage (Moderately ; 2.7) Geographical coverage was 100% (All the households in all the villages visited were under treatment). Therapeutic coverage rates. when available. showed some decline. They ranged from 60Vo to 73.9Vo and 70.6Vo to 77.17o for the last distribution and rmmediate earlier distribution respectively. I ttn:otttrt/llut rrtnl l,'ot'rts ('l.l'l 1 1..t',,1,,,rtrr>rr l(rltttr ! Page 3l of49 Recommendation for the Village Level Recommendations Implementation Managing Mectizan: Mectizan should be left at the village level for a period of at least 3 months, and plans have to be made for mop up treatments to take care of temporarily ineligibles and absentees. The capacity of CDDs needs ro be built in the correct determination of accurate quantities of Mectizan@ that will be required. Priorit_t: XlBPlflN{ Indicators of Success: Proportion of absentees that were treated 2 months after distribution Number of CDDs able to determine accurately quantity of Mectizan@ needed by their villages Who takes action: FLHF, Village leader, CDD D e adline for completion: End of next Distribution round Coverage: To maintain good therapeutic coverage. treatment should be offered at a trme convenient to the communities. Priority: MEDIUM Indicators of Success: Therapeutic coverage >657o Communities confirm that drug distribution times are what they want Who to take action: National, Regional, District, FLI{F, Communities Deadline .for completion: End of the next distribution period I u tt; o n r t/ ll u t t t nl ( t l' ( ) ( ! t \ (' l)' l' I l:v'tt I t t trt r o n lil l, t t t'i Page 32 of 49 3.5 COMPARATIVE ANALYSIS OF THE SUSTAINABILITY OF THE FOUR LEVELS All scores awarded during the evaluation to the Ruvurna Focus CDTI project for the various sustarnability indicators groups in are shown in Table l, as well as average scores for the admrnistrative levels. and the indicator groups. The overall score was 2.88. The FLHF clearly has the lowest average score for CDTI implementanon (Figure 5). The FLHF scored in the 'Moderate' sustainability potential range (average 2.17) compared other levels which clustered around the "High' sustainability potential rating (2.99-3.24). The weakest groups of indicators for the FLHF level rncluded plannin-e (1.0). transport (1.0) and human resources (2.0). A full score (4.0) was awarded for coverage to the FLHF level. however. this was due to the exclusion of community therapeutic coverage rates in the cornputation. Table 1: Average Sustainability Score of the Different Groups of Indicators by Levels of CDTI Implementation in Ruvuma Focus CDTI Project Fig. 1: Average Performance of the Different Levels of Ruvuma Focus CDTI Project on the Pooled Groups of Indicator. ERegion lDistrict EFLHF ECommunitv 3 2 1 Levels Groups of Indicators Average Planning Leadership Monitoring & Supervision Mectizan supply Training & HSAM Integration of support activities Finances Transport Human Resources Coverage Region 1.3 4 4 3 4 2.3 1.8 4 4 3.r6 District J 4 J.J J J.J 2 2.8 J 2.5 2.99 FLHF I 3 3 2.5 J 0 1 2 4 2.17 Community 4 3 4 2.5 -) 3 5./ 2.7 3.24 Average 2.33 3.33 3.58 3.00 3.08 4.00 1.83 1.87 3.18 3.30 2.88 'l'uri:tr n rtt/llur,ruttfi l' ttL'tr s (' l) l I l,.t'o IrroI rort Jlsp11 1 1 Page 33 of 49 Values from Table I are show graphlcally in Figure 6. The Regional level was weak rn planning, transport, and finance. The District was weakest in finance. transport and coverage. The community level's weakest areas were Mectrzan supply and coverage. In regard to coverage. there was considerable confusion arnong partners at the sustainability workshop in understanding how coverage assessments could vary so much between the different levels. r.vhere values of '4'(Fully) were assigned to the Region and FLHF level, but were under'3'for the District and Community level. The evaluation team recommends that APOC management reviews the scoring system for coverage, and suggests that indicators of leadership and integration. be evaluated at all levels. Fig. 6z Sustainability Score of the Groups of Indicators and Levels of CDTI Implementation in Ruvuma Focus CDTI project 4 3 2 I 0 \'u'\\tr\"s+ \1 u\\, o'oLaAa I Region I District E FLHF n Community =u=*l =l ={ =t.I =ilJ=.c =g =B{ a- 11 :u = (i{ =u =t =HEffi =H =FI =td =w =iI =H I I I tt ti - tt n to/ll tr l ilnd l, t )t:,'t t s (' l) I I l, \'il I ilu I t()ti ll, p, 1 1'1 Page 34 of 49 Mean sustainabrlrty scores for the groups of rndicators are shown graphically in Figure 7, below. The weakest groups of rndicators. overall. were the provision of Finance (1.83), followed by Transport/Material resources (1.87). Planning (2.33), and Mectizan (3). These findings are a good reflection of the weaknesses of the project, as APOC winds down, and the Evaluation Team made important recommendations in all of these areas. These concerns should be addressed in the post-APOC sustainability plans being preparecl. Fig. 7: Average Performance of Each Group of Indicator in the Entire Project 4 1 \.ur\\1, ae4% o.\\. 4oQ^ oz?c i. tt ,+ I ' I tt tt a rt n r rr/ ll u : t tm tt I' ot' t r s (' I )' I I l,.v'r t I t t it I t 1 tli ll1 I p1 t t I Page 35 of 49 4.0 CONCLUSION 4.1 GRADING THE OVERALL SUSTAINABILITY OF RUVUMA FOCUS CDTI PROJECT. Makrng a judgment of the project in terms of the seven aspects of sustainability (a1 N'Iakc a.iudgnrent of the pro.ject. in ternrs of each of thc seven 'aspects' <tt suslairrability: Aspect Judgment: to what extent is this aspect helping or blocking sustainability in this Integration Ilelping Resources Blocking Efhcicncy Simplicity ' Attitude of staff - !-oqryglitllly:r":lup _ - Bfl'cctivcness Helping Helping flelping II_cJp-rlg_ Ilelping l l a a Integration: There was an adequate amount of integration CDTI into the health systems at levels of the project implementation. Staff at the regional level combined diverse programme tasks on each single trip to the District. The resources of the health management teams at the different levels were pooled and used in common for all programmes including CDTI. Common supervisory checklists and schedules for all disease control programmes were used in the regions for CDTI and other drsease control programmes. However. the team was concerned about integration in post APOC era in Iringa Region. Resources (Human, financial and material): The government contribution has so far been mrnimal and limited to the provision of manpower. Government does not rneet the lunnrng costs for transport. Over reliance of APOC support at the Regional level could block sustainability when APOC funding terminates. Lack of trained human. financial and HSAM materials and transport at the FLHF Ievel block sustainability. I u tt :o n r u/ ll u t r r rrt tr l' rtt. rt t (' l)' I l l:.t' a I rt at t, t n llr: 7r11 1.1 Page 36 of 49 a Efficiency: There ls a rational use of resources. Programme support activities are being planned and shared. which results in lower cost and efficient management of resources. Eiamples are sharing of logistics and targeted implementation of essential CDTI activrties. o Simplicity: The project uses simple and uncomplicated procedures for the implementation of CDTI activities. The fact that there are only three districts in the CDTI project and the Regional headquarters office makes it relatrvely simple to admrnister. However one of those districts is in a separate Regton. When APOC funds stop each Region may have to develop structures for continuing CDTI implementation. a Attitude of Staff: At all levels. there is ample evidence that the staff members are positively disposed to continue CDTI implementation. The evaluation team rated the attitude of staff at all levels towards CDTI to be very positive. r Community Ownership: Communities make most of the decisions in the implementation of CDTI and gave sound rationale for their decisions on CDTI activrtres within their respective domains. In some communities, punishments were meted out for refusing to take Mectizan@. In many communtties there rs an established process of showing appreciation to CDDs for their CDTI work by deliberately exempting the CDDs from other communal assigpments. However in most comtnunltles the timing of distribution is dependant on the time when upper levels made Mectrzan@ available. Effectiveness:o Geographical coverage rate is 100 per cent. AII the Distncts rn the Region had therapeutic coverage rates of 65 per cent and above. and thrs has remained consistent. However. further refinement of REMO might be needed to determine if all communities in need have rn fact been targetted l'u r t : o n r o/ ll u t, t il n a l:r tt' r r :t (' I )' I I l,.r'tr I r r it t r o n ll t: pt, t'l Page31 of 49 (h) Next, the evaluation teaur cxanrined the six kev aspects of the pro,iect - 'critical elenrcnts ' of sustainabilitl,'. If these are not present it is unlikelv that the pro.iect rvill be sustainablc: Money: Is there sufflcient ut(ntey available to undcrtakc strictly ncccssar)' tasks. rvhich havc been carefully thought through and planned? (Absolute minimum residual activities). Transport: LIas provision been made for the replacement :rnd repair of vehicles? Is lherc a reasonable assurance that vehicles rvill continue to bc availablc for minimunt csscntial activities? (Note that 'vehicle' does not necessarily imply '4x.1' or even 'car'). Supenision: Has provision brccn madc lbr continued targeted supportive supervision? (The pro.iect lvill not be sus[ained without it). Mectizan@ supply'. ls the supply systcm dependahle') (The hottorn Iine is that enough drugs must arrive in villages at lhe time selected by the villagers). Political commitment'. Elfectively tlemonstrated by awareness of the CDTI proccss among policy makers (rcsulting in tangihle suppolt); and a sensc of cornmunity ownership of the programne. Hunrun resources? YES YES I YBS t- YES NO YES In line with the guideline for grading the whole project using the seven aspects and six critical elements of sustainability the evaluation team concludes that the Ruvuma focus CDTI project is MAKING SATISFACTORY PROGRESS TOWARDS SUSTAINABILITY. One of the elements, Mectizan@ supply system is not dependable at the lower levels. One of the aspects, resources, is blocking sustainability at the Regional and FLHF levels. 4,2 TW O FEEDBACK/PLANNING MEETINGS : One joint feedback/planning meeting, for Regions and District level teams was successfully organized. The programme is attached. The meeting was extended beyond the original duration to finalize and sign work plans and budget .lustification. These will be forwarded. with the necessary accompanyrng documents to APOC by the proSect through the NOCP at a later date. Below are a number issues that emelged after the briefing sessron. The present srtuation whereby the CDTI implementation in the trvo regions is berng rnanaged as one umbrella Ruvuma focus l'utt:unrtt/llns ttrntt l'rtt tt\ (-l)'l I l'.ytrlttalrott llt'ltrtt t Pase 38 of49 CDTI does not seem to be conducive for the sustalnabllity of the project post-APOC. Currently. the project belon-es to no one in particular. This rs workable rn the APOC era but the same cannot be said rn the post APOC era. Understandably, therefore. the regronal and District officrals from the two regions opted for the separation of the two regions. The Regional Medical Officer for Iringa region, which has one District in the programme, spoke extensively on this. According to him, "the management of CDTI post APOC has to change at the regional let'el. Iringa has one district, while rttvunta has tw,o. These have to be divided for administrative convenience. In Iringa, we ltave an advantage. There ls 55L We have comprehensive eye care. CDTI can be integrated into the contprehensive eye cure. We also have more Districts to expand the intentention. This justifies the Regional managentent of tlrc programnte for administrative convenience". The SSI Country Representative supported the RMO and argued that Iringa as an administration can take responsibility. But he was also quick to ask the nature of restructuring that may be required. The RMO noted that there has been a structure. There is a Coordinator for eye care, who can handle CDTI as well. Equally, at the Drstnct level. there is an Eye Coordinator. There rs thus a need to integrate the ordering of Mectizan. for instance, into the normal drug delivery system of the different regions. That is from MSD to the District rather than to Ruvuma. These positions were adopted as necessary step towards ensunng ow'nership sustainability of the programme. It was also recomrnended that those areas where onchocercrasis is suspected to be endemic should be mapped (REMO/REA) to confirm therr rnclusion into the CDTI system. The participants also SWOT analysrs of the findin-qs of the evaluators. This ensured clear understandin-q of the evaluation findings and the realization of the strengths, weaknesses, opportunities and threat to the prog1amme. The participants also went further to identify the solutions to thee identified weaknesses and threats to the implernentation of CDTI. Details of the SWOT analysis are attached. 4.3 THE WAY FORWARI) As the Ruvuma Focus CDTI project in Tanzania reaches the end of the 5-year APOC-guranteed support the team of evaluators and the 'programme managers' made a critical appraisal of the issues that need to be addressed in the short- and medium-terms to ensure the sustainability of the project post-APOC. The follou,ing is a surnmary of the hrghlights of the five critical components of the "u'ay forward" outlined at the joint final session between the external evaluators and the Ruvuma project operatlves. REMO: The identrfrcation of all focr of hyper- and meso-endemic onchocerciasis throughout Tanzanra. and spectfically ln the two Regrons (lringa and Rur uma) rncorporatin_e the Ruvurna CDTI focus. that are at present ' l'n tr : rut i tt/ ll u t,ut n t l' r tt' r r s (' l )' l' l l,.v'o l r r o t i o n llc U,,', Page 39 of 49 outside CDTI operations is of the topmost priority. APOC support would be invaluable in this resard. Devolution The Ruvuma CDTI project which hitherto has operated successfully as ajoint endeavour between two regions, Iringa and Ruvuma, will now operate as integral parts of the eye care programmes of the health services of the respective regions. This would necessitate the provision of special supplementary support from APOC and the ad.justment of the CDTI operations at the regional level. Mectizan changes that would make the procurement and distribution of Mectizan an integral part of the health system of Tanzania have already been introduced. However it is obvious that the intricate procedure for accounting for, requisitioning and procuring Mectizan is beyond the capacity of virtually everybody in the Ruvuma project except the project coordinator. Dr. Kabuka. It would appear that the same limitations apply in all other Tanzanian GDTI projects. Therefore the national body is expected to mount a special training and orientation programme for relevant cadres of staff at the regional, district and FLHF levels to achieve this capacity building objecrive. Documentation An important area of deficiency that needs to be tackled in order to enhance the sustainability of cDTI is the relative lack of experrise in report writing by the various operators in the project. A series of national workshops that address this shortcoming is highly desirable. Financing By mutual agreement the contribution of the various stakeholders to the sustenance of the Ruvuma project post-APOC is a major challenge. The commitment of all to this element of the programme was emphasised and would be given appropriate prominence in the post-APOC plan of operations. Other stakeholders, namely the SSI. Regional and District representatives as well as the National Coordinator of the programme in their respective comments on the way forward. noted these points and pledged to ensure the sustainability of the programnte. I tt ti -tt,t trt,/ll u t t ln( t l' ( )t ir : (' l) I I l, yti I ttrtl i oti lir ltt,t i Page 40 of 49 APPENDIX I. REGIONAL AND DISTRICT LEVEL WORKSHOP PROGRAMME Sustainability of Ruvuma Focus CDTI in Tanzania "Feedback"/Planning Meeting AGENDA DAY ONE I Regi stration of Participant 9.00 - 10.00 Regional Coordinator I Welcome and Open Remarks 10:00 - 10:10 Iringa RAS J Introductions 10:10 - l0:15 ROC (Dr. Kabuka) 4 Introduction to the workshop What are the objectives What is sustainabi 10:1-5 - l0:30 Prof Kale 5 Tea Break 10.30 - 10.45 Coordinators 5 "Feedback" on achievements. issues and lessons from the evaluation on sustainability of CDTI of Ruvuma Focus CDTI 10:45-11:15 Prof Kale 6 SWOT Anal s ll.15-11.30 Mariam 7 Discussrons on problems identified and the solutions to these problems using SWOT analysis in groups: I . Planning/monitoring/supervision 2. Finances/trainrng/HSAM 3 r 1.30 - 12.15 8 Report from Groups 12.15 - 13.00 Mariam/Kaitaba 9 LUNCH r3.00 - 14.00 Coordinator 10 Roles of the different levels and ers 14.00 - 14.30 Rrchards l1 Steps in Planning for sustainability in this ect and 14.30 - l6:00 Dr. Okeibunor t2 Tea Break 16.00 - 16.15 Coordinator l3 work 16:15 - l6:45 Facilitators t4 Closin Remarks 16.45 - 11.00 Ruvuma RAS l5 General Matters/Announcements 17.00- 17.15 Coordinator Item Activit Time Facilitator I rt tr :rur t u / ll u t r r tti rt l' r tr' u s (' l -)' l I l'.t;o l tr rt t t r,t tt lla po t'l Page 4l of 49 DAY TWO 1 Regi strati on of Participant 9.30 - 10.00 Regional Coordinator 2 Review of previous day's activities 10:00 - 10:10 Iringa RMO J Introduction to the day's activities 10: 10 - l0: l5 Prof Kale 4 Group Work l0:15 - 1 1.00 Coordinator 5 Tea Break 11.00- 11.15 Coordinator 6 Resumption of Group work 1 r.15 - 12.30 Coordinator 7 LUNCH 12.30 - t3.30 Coordinator 8 Presentation of Group Work 13.30 - 14.30 Kaitaba 9 Tea Break 14.30 - t4.45 Coordinator 10 Group work to incorporate corrections 14.45 - 15.15 Facilitators 1l Way Forward: APOC SSI MoH Regional Administration & Local Govt r-s.15 - 16.15 Prof Kale Mabuba Dr. Saguti RAS/RMOs Ruvuma & Iringa I2 Closing Remarks 16.15 - 16.30 Ruvuma RMO 13 General matters 16.30 - 17.00 Coordinator Iteur Activi Time Facilitator (a c =OEr = o M;- - =91-.a, O A, =de v) o F. a-za bo -=I t= o=>=9.'J F-O-O -: bo ,aa C ,-a' oLbo !;l do= .nq) a = E E', F ii *a = -i ".= u,<i (J:Y) UY oE F. {.= Z: o:'>=oooobOEooE=v-.u" --Ccl'Ju-'J-!u E A*:€ r ? r,=E€il-,-fr;F e O O o. o- i E-U O,S d E d = q - \dr.UOj;-z ^,= U Ar,e O = = ='3 ! = C = = E -2=i^=-YX:icn2v,i\FiiE;^a L= ! -:^'J- J-oqizoo a''-- =-?'==ra=P6t .. e E-E= P -a a ii X ", i !! d, o uEAZ4,ohiHui-G2 a tt- = r ') < 2 r:;i'r3F'tt{.ae?e a .n U)() e) 7 ? 7 .=?_96 d a i:-o!-i7 I u' =e - t = i iZ . z9 3'E:f = qET 1:- rii ,Pz=ili:r= ,=!g9a=x=d')9 E=:.;-: EE aiYEE"*4='ri ZEtEzl a UU-e -tu-- -- j :1, = oui - 'J t) j Y ! -:) a': >,u c -a ? c= u I u;oY9!r-.63 =EdyyzLz_ aI oo e)fr al E ? u ,= t !C aE !): - O c--o-U5 ?. = =Ys-o-o-*-=JAu L U u. ==-YuE--=ye;1y, ;5" 2 - tu-- - == L -'^.-, Z= :rr1= =a=;=ti=42=-=-Z g E;o 1 . o- -<J= -IV, ICU o ". !- e!:UGtP U= .J EAU-J!V'Ua a-a 4 u a; i \ >d;a?z> trr, 1! = X 9 Or . u)=2;adL d) - o- "d =- z.a o\$(! 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(t) q) L 3 o =aa ! u.=o t*C --cAo of so J -.t -o ra U) c) tr q tr aCr^t q-O .- C- >X= c >,c IU :-z2l|:Z=d a=;.:;.i=>\9HV\VA- Ch ?ts-=qa 95 =Y-o.r/rC= a U t, - !J <.1.- 9 'j(: Y tr o .t) U) o - o o c t -v)ra='J'Y v o_ ;! x .-ei:--u2u!-.- ; E r € t [,< E -uv- = x co-, a* a <5.E<EEE!E bo C)t-i al ->.:>.->71:Y= t)>li -tr 4^ / tg w. r.t) - o u; ^.2^,">YA-L- ->,iari,i"= --=ro!!E4 ,".'t 1':x Y- i';Vd61.r=.)a- I aq tr- $ -+$ q) oo o. F -k : i- I n l-rttt:onttr/llut runil l'ttr;tr.s ('l)'I I l'.vrrIitutrori l(cplrI Page 45 of 49 lll. Persons lnterviewed at the Ruvuma Focus Evaluation Natioman amd Regionan Lcvens 1. Dr.Grace Saguti - National Co-ordinator 2. Mr.Pius Mabuba - SSI Representative 3. Mr. J. B. Kitambi - Regional Administrative Secretary 4. Dr. Ida Ngowi - Ag. Regional Medical Officer 5. Dr. Wade A. Kabuka - Project Coordinator 6. Mr. January Haule - APOC Project Accountant 7. Mr. Sixtus Ponela - Regional Phamacist 8. Dr. Oscar Gabone - Ag. Regional Medical Officer 9. Mr. Robert Chiteji - Regional Nursing Officer 10. Mr. Maxander B. Khihatura - Regronal Health Officer (Vector Control) District Lcven 1. Mr. Rachide Tindwa - Council Chairman 2. Mr. H.Nkwera. - Council Chairman 3. Mr. Katanga - DED 4. Mr. Ezekra B. Mlimbila - Ag. DED -5. Mr. A.Kilonzo - DED6. Dr. A.S. Mashimba - DMO 7. Dr. John Budotela - DMO 8. Dr.Stanley Magessa - Ag. DMO 9. Mr. V.G. Lunyungu - Ag.Council Treasurer 10. Mr.B. Malogi - District Pharmacist 1 1. Dr...Mkamba Kasanga - DOC 12. Mathew Benson Nyirenda - DOC 13. Mr. Sebastian Mhagama - DOC 14. Mr.Cyprian Mhagama - DOT lFirst Line Heanth Fa,ciliry n-even 1. Jonas Mbele - Nurse 2. Mrs. Beatrice Rugrna - Nurse 3. Sister Maria Kosma - Nurse 4. Mr. J.Ndele - Clinical Officer 5. Mr. Jonasi Turuka - Trarned Nurse f I tt tt :u n t Lt/ ll tt t r t t n tt l' t t t' { t' (' I )'l I l'.y'rt I t, ttl r r trt ll 1 1t 1, 1 1 Page 46 of 49 Cormrnunity Level a L Mr. William Nyoni - Village Leader 2. Mr. John Kapinga - Village Leader 3. Mr.Musa Ibadi - Village Chairperson 4. Mr. Komba - Village Leader 5. Mr. Stephen Yohanna Fwolo - Village Leader 6. Mr. Adamu Gabriel Chowo - Village Executive Officer 7. Mr. Sandali Masudr - Village Leader 8. Mr. Renatus Mlewa - Village Leader 9. Mr. Abel Mhagama - CDD 10. Mr. Amanzi Saidi - CDD I 1. Mr. Cladeus Mhagama - CDD 72.}dr. Eubins Komba - CDD 13. Mr. Louisiana Nyoni - CDD 14. Mr. Theresa Frank Fwolo - CDD 15. Ivfu. Frank Thomas Luoga - CDD 16. Ms. Monica Komba- CDD 17. Mr. Mohamed Mpwata - CDD 18. Ms. Jemina WindaWinda - CDD 19. Mr. Jacob Mbele - CDD 20. Mr. John Mapunda - CDD 21. \/k. Steven Mapunda - CDD 22. Mr. Seleman Yasin - CDD 23. Ms.Asha Bilali _ CDD 24.|\h. Labia Chiponda - CDD 25. Mr. Kassim Abdallah - CDD 26.ldr.Ibrahim Mwinuka - CDD 27 .I:{k. Ben Audi Haule - CDD 28. Ms. Anna Nyoni - CDD 29.1\/k. Gabriel Sowo - CDD 30. Mr. Rafael Millinga - CDD 31. Mr. Faustin Tembo - CDD I un:onra/Rut tlno l, ttc'rts (' l)'l l l,.r'ttI trtt!tr,tn lirltitt i Page 47 of 49 IV. ADDRESSES FOR EVALUATION TEAM RUVUMA FOCUS a NAME ADDRESS Ms. Mariam Ally Ministry of Health P.O Box 9083 Dar Es Salaam Tanzania. Tel: 255 222120261-7 Cell: 255 744 436472 or 255 744 272571 e-mail : mariam_mwakobe @ yahoo.com Mr.Abdul Daffa District Onchocerciasis Co-ordinator Lushoto District Hospital P.O Box 66 Lushoto, Tanga Tanzania. Tel: 255 26 40098 Cell: 255 748 427449 Mr. Oscar Christian Kaitaba Deputy Coordinator National Onchocerciasis Control Programme Ministry of Health P.O Box 9083 Dar Es Salaam Tanzania. Tel: 255 222130009 Cell: 255 744 889390 e-mail: necp_nocp @raha.com Prof. Oladele. O. Kale - Team Leader College of Medicine University College Hospital Ibadan Nigeria. Tel: 234 2 8100397 Cell:234 0 8022912224 Fax 234 2 8100397 e-mail : ookale @ skannet.cont ookale @ yahoo.com Mrs. Edna Massawe District Onchocerciasis Co-ordinator Kyela Drstrrct Hospital Box 4 Kyela. Mbeya. I ttn:rttt tu/ll:tt tttntt l' t tt rr s (' l) l'I l rttl tt(tl t()tt ll( l'! )t i Page 48 of 49 Tanzanra. Tel: 25525 40419 255 25 40547 (Home) Dr. Joseph C. Okeibunor Departiment of S ociology/Anthropol ogy Unrversity of Nigeria, Nsukka Enugu State Nigeria. Tel 234 42 771169 (H) e-mail : jokeibunor@ yahoo.com Dr. Frank Richards Division of Parasitic Diseases Mailstop F -22 Center for Disease Control and Prevention 4770 Buford Highway ATLANTA.6A 3034I USA Tel: 770 488 451 I Fax: 170 488 4521 e-mail : irichards @cdc. gov a at