Community Directed Treatment with Ivermectin (CDTI) 4th and 5th year sustainability plan for Bitta Woreda (district) Kaffa-Sheka CDTI project: project period 2004-2005

Ethiopian Program for Onchocerciasis Control Community Directed Treatment with Ivermectin (cDrr) 4th and 5th Year Sustainability Plan For Bitta Woreda (District) Kaffa-Sheka CDTI Proj ect Project Period: 2004-2005 I. :i - "t, tr illEl, ?il03 Table of Contents Part I 1. Introduction...... 2. Background I"fo;;;i;" Part [l 1. Rapid Epidemiological Mapping of Onchocerciasis Part III l. CDTI implementation and Results 2. CDTI training achievements ......... 3. Treatment coveraoe Part IV 1. Financial Management of APOC Trust Funds 2. REMO Maps of Bitta woreda Part V Sustainability of Issues of Bitta rvoreda CDTI 1. Planning 2. Leadership 3. Monitoring and Supervision ......... 4. Mectizan supply and distribution........... 5. Training/FIESAM....... 6. Project Budget Financing/Funding 7. Transport and other Material Resource... 8. Human Resources 9. Coverage 10. Sustainability plan frame framework for Bitta woreda.......... I 1. List of Available Resources for program support 12. List of Materials, Supphes and Equiprnent Required for CDTI Activities Part V l. Budget justification (Explanation ......., 2. Budget Summary Year IV 3.Budget Summary of Sustainability plan for year V I 1 2 2 2 3 J 4 5 5 5 5 6 6 7 8 8 9 11 t2 13 15 16 Introduction Bita is one of the ten wordas (districts) of Kaffa zone, located about 521 kms away Southwest of Addis Ababa. Bita has a population of around 59,241. The woreda comprises of 24 kebeles (smallest admin r-rnits), whose inhabitants mainly depend on subsistence agriculture. The climatic zones of tlte woreda, in most places, are that of highland with longer annual rainfall period (6-8 nrorrths). In this woreda, there are three health stations. The infrastructlrre in the woreda is underdeveloped; no continuous electric power supply, poor teleplione service, inadequate roads connecting tl-re kebeles (rural communities) to the capital town, etc. The u,oreda is rvell known for its diversified cultural and ethnic composition. althoLrgh Kaffecho is tire most dominant one amongst others. Backgrou nd Information Onchocerciasis control program \\/as launched through cornmunity directed treatmeut with Ivermectin strategy in the year 2002. The project was ini{iated with a strong partnership between APOC, affected conrrnunities, regional, zonal, woreda admin councils and health departments, Federal Ministrl, of Health and an NGDO partner (The Carler Center). The program was initially designcd and inrplenrentcd as i(affa-Sheka CDTI project u,ith the overall coordination role assunred by the zonal health departmeirt. Horvever, i(al'ln- Sheka was later on split as tr,vo distirrct zones and the leadershrp role was then shifted to each zonal health office. Aearr.r, ver,r, recentll', in accordance to the decentralization policy of the goverrlment of Ettriopra, there \\/as A paradigm shift of power and authoritv, from zonal to woreda levels. It u'as at this junctLrre that the nridterm CDTI sustainability, evaluation of Kaffa-Sheka pro3ec[ *,as urrder-taken, In line rvith this developmerrt, it ri'rs recourrnended that the CDTI plan be *,orl<ed out at *,oreda level. After the midterm evaluation olCDTI sLrstainabilrty', tirere rvas SWOT analysis done [or' each level of health delivery'strLrctLrrc. As a rcsrrlt, coveragc, N4ectizan order antJ sLrltplv., motlitoring and supervision. as uell as lrarnins unri HI]S.,\NI ri,ere considerccl lclatrrclv 1 2as strong points at woreda and front line health facility levels. On the other hand, Financial Resources, Planning, Leadership, Transport and other materials and Human Resources were considered as weak points at this level. Efforts have been made to address these weak points in this action plan. Rapid Epidemiological Mapping of Onchocerciasis (R-EMO) The rapid epidemiological assessment canied out in selected communities in 1997 indicated that Bitta woreda is hyper and meso-endemic for Oncl.rocerciasis. CDTI Implementation and Results Although the woreda was known for its endemicity of Onchocerciasis, there rvas no mass treatntent activity conducted before tl.re laurtching of CDTI. Horvever, clinic-based treatments have been going on with diethylcarbanrazine (DEC) in sonte of the health institutions of Bitta Woreda. As mentioned earlier, CDTI was implernented for the first time in the woreda dr"rring the year 2002. The major partners were APOC, FMOH, respective health authorities, Iocal governments, affected communities, and the parlner NGDO (Carter Center). The nrass treatment had 100 percent geographrc coverage of the conrnrunities ir-r the rvoreda right from the beginning. CDTI Training in Bitta Woreda, Kaffa zone Year Health Personnel Others CDDs 2001 2002 11 34 210 2003 18 0 290 3Treatment Coverage, Bitta Woreda, Kaffa zone Financial Management of APOC Trust Funds The fir'rancial management ol CDTI projects used to be carried out by zonal healtli departments in the past two years. It rvas, therefore, not possible to come across conect figures for each woreda by year. Moreover, due to the restructuring process in tlie country (which is still underwal,) and lrequent change of staff (CDTI coordinators), it was not easy get access to the frnancial docur-nents. However, efforts were made to extract some data from the existing financial documents at zonal levels. Year Funds Received Other Sources Conrrlents APOC NGDO* 200r 2002 4t6t * None All approved budget from APOC was received! 2003 132t 837 None Only the 1't advance was received from APOC Total 5482 837 * NGDO support was mainly through nraterial and technical suppor1., New Leadership Role and Integration of CDTI In view of the recent decentralizatron polrcy, devolution of power and authority has been made to the woreda level structure. As a result of tlls change, CDTI has been consrdered as integral part of the overall three-year strategic health plar-r for Bitta',voreda. During the CDTI sustainability-planning rvorl<shop, ail stalteholders have participated and hav,e expressed their commitment to assunring the leaclership role in the irnplementation of CDTI in their respective areas. CDTI has bcen include<i in the malaria and other vecror bome diseases prevention and control Lrnit in the strategic rvoreda healtl-r plan. Year Total Nbr. of villages ATO Nbr. of Villages Treated Geogra phic Coverag e (%) ATO Covelage (%) Total Popn. ATO Nbr. of persons treated Therapeutrc Coverage (%) ATO Coverage 2001 2002 229 229 229 100 r00 5 5,65 3 44,522 35,607 63.98 79.93 2003 229 229 229 r00 100 57 ,57 t 46,057 42,684 t4 93 4REMO Map, Bitta woreda, Kaffa zone .I , ",i ,+ :i. 0echa j', i- Yeki t, ,l , .,;." ., 5Sustainability Issues in Bitta Woreda CDTI Planning This is an area identif,red as weakness during the midterm evaluation that requires immediate corrective action. The CDTI is incorporated in the overall three-year strategic health plan of the woreda. However, in the past, the woreda health office and FLHFs were not actively involved in drawing up the CDTI proposal and annual plans of action. It was mainly the zonal health deparlment that was responsible for planning CDTI activities in particular. Following the midtemr CDTI sustainability evaluatioll, however, it has been decided that all stakeholders at woreda and FLHF levels will assume the responsibility of working out their respective periodic plans of action from this time on. Short training course will be necessary to be organized to deveiop the planning skills of the health personnel working ir.r these institutions. Efforls u,ill be nrade to impiement the bottorn-up planning approach r,r'rtli the assistance of the NOTF in the remaining trvo project years. Leadership As introduced earlier, currently tl-rere is a paradigm shift in the admin structure and organizational set up of the oi,erall nranagentent of liealth and other developntent programs in the country. The general trend is to enlpo\\,er tlre t,oreda level stnrctrrres antl build capacities in all aspects of progranr management. The CDTI, being one of the recognized and integrated health progranrs of the rvoreda, ri'ill receive leaciership antl close guidance front the woreda admin council and the taskforce organized at this level. Monitoring and Supervision Monitoring atrd supervision is verv critrcal to the sLrccess oICDTI iiit is do.e i, a ti,tely, and effecti\/e manner. Horvet'er, rt u,'as Lrnderstood dunng the ev.aluation that thc frequency and coverage \\/as inadeqLrate. Supervisory checklrsts vu,ere not used regLrlarly and feedbacks rvere ltot conlnrLtnrcatecl iu rvritirrg. In most cases, sLrpervisory visrts rv,er.c not problenl oriented and targeted to inrproving poor perfoutrance of FLHFs and CDDs. During the sr.rstainability-planninq rvorltshop, it was agreed tirat the u,eal< polrrs identified uoLtld bc addressed verv cr-itrcallv althoLrgh sholtusc of health pcrsonncl rLnLl 6other competing health priorities at both woreda and FLHF levels could be possible threats in the implementation process. Mectizan Supply and Distribution This activity is considered as a strong point during the evaluation process. Mectizan procurement and distribution is fully integrated into the govemment health care delivery system. Every effort will be made to maintain the good achievement obtained thus far. Ordering Mectizan in good time and in sufficient quantity is indeed a commendable job favoring sustainability. However, there are areas that need fine tuning at FLHF and CDD levels, Minimizing wastage, proper record keeping and timely and complete reporting are some of the areas requiring attention in tlre reuiaining project period. Training/HESAM Organization and management of CDTI trairring progranrs were the responsibilities of the zonal program coordinator in the past three yeals. The woreda health office is not fully empowered to handle this responsibility. The future direction is however to build the capacities of the woreda health staff so that they can be in a position to plan and implement training sessions after carrying olrt needs assessment at FLHF levels. Efforts will be made to make CDTI training sessious focused on identified weaknesses of the health personnel and other partners including CDDs. Similarly, the woreda health office will be making proper use of its nreager resolrrccs bv integratirrg training programs to tlre best of its capacity. Health education, sensitization and conrnrLrnity nrobilization has been very effective in enhancing CDTI awareness to the general public. The perceived benefits of Mectizan are foundational grounds for the sustainability ol CDTI in the rvoreda. There will be a need to produce more powerful health edr-rcation and ser-rsitization materials in order to enhance further the active involvement ol conunLrnities in decision-nraking process. Moreover, the beneficiary commLrrrities rvill necd to be rnobilrzed to provide effective sLrpport for the CDDs serving their respective vil)agcs. This is believed to be one of the conrerstones for the effective slrstenzurce of thc I)logrllur in tlie r.voreda. 7Financing/Funding During the first three CDTI years, there has been no specific budgeting for onchocerciasis control activities in this woreda. Very recently, however, the woreda admin council has started allocating funds in block for all health programs in an integrated manner. Obviously, the amount of money is much smaller cornpared to the diverse needs of the woreda health office. Whatever the amount may be it is indeed a commendable start and it is hoped that it could be increasing over the remaining project period. Since the woreda health system functions in ar-r integrated manner, it is hoped that CDTI could also benefit from funds corning fi'om other sources like Globai Fund, EPI, etc. At this rudimentary stage of the woreda, however, more slrpport will be required from APOC. Transport and other Material Resources In this woreda, at it is the policy of the Ethiopian govenl.nent in general; available transport facilities are used in an integrated manner. In the midtemr evaluation, means of transport is one of the most importar-rt limitations identified at both rvoreda and FLHF levels. Ideally, it u'ould be appropriate if a pick up could be provided for the woreda health service and at least one motorcycle for each FLHF. Tire evaluation team has recommended replacernent of the motorcycles that are found to be lvom out and non functional in the evaluated woredas. It is strongly recommended that each FLHF rvould need one motorcycle for effective monitoring and supervision olCDTI activiries. At this junctLtre it is very important to underscore tlte need to consider building the capacities of the woreda and FLHFs inorder to be able ensure the sustainability of CDTI in this rvoreda. This rvoreda health office lacks important office ecluipnrent like computer, printer, photocopy machine, etc. These deficiencies need to be tacl<led as soon as possible. Other CDTI ntaterial resources like treatrrent registels. reporting booklets, training manuals, posters, flip cirarts, T-Sliirts, stationery, etc. shoLrld be supplied ir-r sufficient quantities for the effective contmlrance of CDTI in the rvoreda. 8Human Resources It is known beyond any grain of doubt that the availability of skilled and motivated human resource is very critical to the success of CDTI. The midtenn evaluators noted that there was a very high turnover of health personnel at both woreda and FLHF levels. It was also noted that most of the FLHFs are understaffed. In the coming couple of years, however, these shortcomings need to be addressed as much as possible. During the planning workshop, the woreda adrnin council and other authorities at higher levels promised to do their best in this respect. Plans have also been made to motivate health personnel and CDDs by means of rewarding best performing individuals and institutions. As stated above, training workshops rvill also be organized to fill the gap of knowledge, skills and competence of the available health personnel in plarming and management of CDTI activities. Coverage This woreda has already achieved 100 percent geographic coverage and therapeutic coverage of well over 65 percent during the past three years. Participants of this planning workshop believe the fact that if all other aspects and indicators of sustainability are rvell taken care of there won't be a probler-n to rnaintain the current geographic coverage and improve further the therapeutic coverage levels. 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'';. ^aO A '-'.-:vEv ;\^-k-i * (9.9', : -- ,?:'- 6rovr& : o >\ "jEq OE€ : >F.] --a ^3otJ- x c)v :- .^a(qC.t ;., q) x ll -E" :gE$EsgL/rYag^-+Eo,Koi ltI :E : ; t o E oE<:f'l:=*=F $\Cd oe t'? ==Bil[ ? ! -lla4co> ^6 G $ (3rU'U-i"r (\ ;ll ::! x x - 5 i'" lN C\ t--=-OC.l :R v] $ i_=tro5c. o It I xorR :Gi Gr ,n5nrFil cJ v' -.l - vui.g I ".i 9l r"€2E=E : eG)be € E_b E- ',.v-;.2?,E.rc.-t@&/^>ri:;EESEET.,; E.E E.E TE? 7E ; = & = i s; x = F € il c.l G) t) l-.1 t-.](-) oo t. .o lr()a @ O -o o\ gr JEfJ. o c!o LX() E-Eo 6 dr, (!O(J! g0> aE c-> Eq* -)y .YL- 'o7,9 o.; rf *c.o vrO etro)(E() YOaj-U'(i- - -od ^6J*a OE l aE!0J335 allt6Y.ru =o* -),, o >r< -'ltJ- c'.1 'o 0) L ,9n .= >Hb(J oD (.l Pui "a I(J eA5co Z,- (!o -u^ U:'L l-lO rr >v r' -( u,j'N hor tEotr )a !o ! .469a -o_ f (.) .:-:> Jw :F .-oL- = +rr.O o-/r-9,^ -iLY'ZAcTA > a.- O?-@'-oala,;:; U JL- *aui, a { tca =,=,_ -\-J>>'^ = (nE (E a(.) qJ o o 0 o! o- \c r- @ 16 Bu et Summ for Year MDTI in Bitta Wor Kaffa zone u.-) 1.0 MOH Carter Center Total Allocation S.No Budget Line Item APOC 127900 12,500 290I Personnel 4,000 96002 Capital Equipment 5 600, 0 10s 825 9303 Supplies 0 t843.67 83.78 42.3 1969.7 s4 Training 5 Monitoring and Supervision 1695.6 22t.42 0 1917.02 0 44.746 Resource Mobilization 0 44.74 1997.r77 HESAM ) ,714.44 t28.44 154.29 0 809.46 809.468 AnnualReview Meeting 0 9 Provision of Awards 0,l 180 180 10 Total Budget 10,853.71 13,083.38 6,301.05 30,238.14 0.00 814.031l NGDO overhead (7.s%) 814.03 0.00 t2 Grand total 11,667 .7 4 13,083.38 6,301.05 37,052.77 13 47,393 47,393 47,393Estimated Treatments 47,393 l4 Cost per treatment 0.25 0.28 0.13 0.66 15 % Input of Partners 0.42 0.20 17 Budget Summary of sustainability plan for Year V CDTI in Bitta Woreda, Kaffa zone S.No Budget Line Item APOC MOH Carter Center lfotat Allocation I 0 13,500 2eol 13790 2 Capital Equipment 0 U ol 0 J Supplies 0 110 8ool 910 4 Training l 000 88 I 001 r 188 5 Monitoring and Supervision r 000 225 ,l t225 6 Resource Mobilizatron 0 50 ol 50 7 HESAM 1,500.00 r30 I ool 1730 8 Annual Review Meeting 0 0 8oo.ool 800 9 Provision of Awards 0 0 r 8ol r80 t0 Total Budget 3,5oo.oo 14,103.00 2,270.00i 19,873.00 11 NGDO overhead (7.5%) 262.50 0.00 o ool 262.50 t2 Grand total 3,762.50 14,103.00 2,27o.ool 20,135.50 13 Estimated Treatments 48,767 48,767 $,7671 48,767 14 Cost per treatment 0.08 0.29 0.05 0.4r 0.1 1 115 % Input of Partners 0.19 0.70 lPersonnel