Assessment of sustainability: SWII CDTI project, Cameroon (8th Year) April 13-28, 2008

It I t World Health Organization Assessment of Sustainability: SWII CDTI Project, Cameroon (8th Year) April 13-28,2008 Joseph C. OKEIBUN0R D Daniel EBRH GermaiNE EKOYOL EII,RNE Chingere MflDUKfl Bambo Emmanuel NGHLfl Daniel Y0TR * flfrican Programme for 0nchocerciasis Control 2 6 MAt 2008 Re-evaluotion of SWII CDTI Project in Catneroon (April 14-28, 2008) Page i ( )I ) t {Acknowledgements I We are grateful to the following persons and organisations for their cooperation, contributions and assistance towards the successful execution of this assignment . The Director, Dr. U. Amazigo, and staff at APOC Headquarters in Ouagadougou for making available the necessary financial and logistic requirements for the success of this assignment . The WR, Cameroon and WHO staff provided support, which contributed to the smooth functioning of the Evaluation Team . Dr Ntep, National Onchocerciasis Project Coordinator, and her team facilitated the smooth take off of the exercise in Cameroon . The Delegate and staff of the Southwest Provincial Delegation for Public Health for facilititing the conduct of the evaluation and providing relevant information . The District Medical Officers and the teams who provided useful information . Health workers and community members in the health areas who provided important information and contributed to the success of the mission . Last but not least is our 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 $ # Re-evaluation of SWil CDTI Proiect in Cameroott (April 14-28,2008) Page ii h t ry t .t Abbreviations/Acronyms t 4WD Four Wheel Drive APOC African Programme for Onchocerciasis Control CBAF Chief of Bureau of Administration and Finance CBH Chief of Bureau Health CDD Community Directed Distributor of Mectizan@ CDTI Community Directed Treatment with Ivermectin CR Country Representative DHS District Health Service DMO District Medical officer DO District Officer HA Health Area HIPC Highly Indebted Poor Countries HSAM Health Education, Sensitization, Advocacy and Mobilization MDP Mectizan@ Donation Programme MEDP Manager, Essential Drug Programme A t a Re-evaluotion of SWll CDTI Proiect in Cameroon (April 14-28, 2008) Page iii MOH Ministry of Health NGDO Non-Governmental Development Organization NOTF National Onchocerciasis Task Force oPc Onchocerciasis Programme Coordinator PCGS Provincial Chief of General Service PCSAFA Provincial Chief of Seruice for Administration and Financial Affairs PCSME Provincial Chief of Unit - Superuision, Monitoring and Evaluation PCSP Provincial Chief of Seruice for Pharmacy PDPH Provincial Delegation of Public Health SAE Severe Adverse Effect sDo Senior District Officer ssr Sight Savers International SQI Systemic Quality Im provement SWII Southwest II SWAP Sector Wide Approach SWPDP South West Province Drug Programme , A I a Re-evaluation of SWU CDTI Projectin Cameroon (April 14-28,2008) Page iv SWPSFH South West Province Special Fund for Health TB Tuberculosis wHo World Health Organization WR World Health Organization Country Representative A a t Re-evaluation of SWU CDTI Projectin Cameroon (April 14-28,2008) Page v Executive summary Introduction The Southwest II CDTI project is the second CDTI p@ect in Southwest Province of Cameroon, with administrative headquafters in Buea. It covers eight health Districts, not covered under the SWI CDTI project in the same Provincial Area of Cameroon. The SWII CDTI project has been supported by APOC since 2000 and is on its eighth year of community mass treatment with Mectizan@ with APOC funding support. The mid-term evaluation of the project was carried out between April 21* and May 7h 2003. The results of the mid term evaluation identified lapses in the implementation of the programme and concluded that the project was not making satisfactory progress towards sustainability. Remedial steps were recommended. Summary of the 2003 evaluation findings are contained in the box 1 below. : I a Box 1: Pr6cis of 2003 Evaluation Results In 2003 the SWII CDTI project progress towards sustainability was adjudged unsatisfactory given the various short comings in its operation. Quantitatively, the project earned 2.17 points which was far below the 2.5 points benchmark for satisfactory performance. It was scored low on almost every group of indicators, with the exception of planning, Training/HSAM and human resources 2.88, 2.73 and 2.58 points respectively. The project scored <2.00 points on finance, transpoft, integration and coverage respectively. The Provincial/project level was the weakest with 1.92 points. Leadership, an indication of ownership of the project, was non existent here. The NGDO was overbearing and the project was seen as SSI project. SSI directed the implementation of the project generally. Leadership and political commitments were weak. The FLHF level was tops with 2.64 points. The other levels, community and District scored 2.00 and 2.11 points respectively. The evaluation team found serious barriers to sustainability and concluded that the project would require rethinking of the roles of partners as well as appropriate and carefully targeted HSAM to inject the right sense of ownership of the programme at the appropriate levels (Project and communities) as well as mobilize sufficient support for the sustainability of CDTI post-APOC. Community ownership, uncomplicated and reliable Mectizan@ supply system and leadership role of government paftners at all levels and community were lacking in the project. These deficiencies were identified to be seriously block sustainability in the project. Re-evaluation of SWII CDTI Projectin Comeroon (April 14-25,2008) Page vi Constitution and Task of 2008 Evaluation Team Five years later ApOC constituted another team of evaluators from Nigeria and Cameroon with the mandates of re-evaluating the sustainability performance of the project and supporting the implementers of the SWII aDTI project in developing sustainability plans. The tasks were undertaken between the 13 and 28 April 2008. The evaluation in the field was carried out over a period of one week. During this period, information were gathered from desk review of relevant documents and repofts, interviews with implementers anJ key stakeholders as well as field obseruation of CDTI implementation u.tiriti., in sampled sites at the provincial, District, First Line Health Facility and village levels' Focus group discussions were also held with community members. This was followed by a one day fe6dback session ind a two-day workshop for the development of a five-year sustainability plan by those responsible for the project implementation at the Provincial and District Levels. The collation and analysis of informati-on garnered from the field evaluation of CDTI activities in the SWII project arei anO planning of the feedback and sustainability planning workshops took three days of intense work by the evaluators. At the end of the feedback and sustainability planning workshop, the teams Grme up with draft plans which the District and Provincial level staff were asked to home, edit and make necessary corrections and forward copies duly signed by the appropriate authorities to APOC management in Ouagadougou. Mean*hile the evaluation team took the remaining days to revisit its evaluat'ron findings employing the new facts from the feedback session to fine tune its conclusions. It must ne noteO at his point that the feed back session provided a valuable opportunity to meet a wider spectrum of participants in the implementation of the CDTI project' Foi instance, only three of the eight health distiicts were visited during the field evaluation' The remaining five health district stiff members were met during the feedback meeting. They reflected on the findings and drew lines from the findings with happenings in their respective health districts. These-new pieces of information, consider vital in getting broader pictures of issues in the project was duly recognized and integrated into the conclusions on issues within the SWII project area. i a t Findings from 2008 Evaluation Every village that was identified as qualified for mass treatment with Mectizan@ is receiving it, except fZ of tne 15-villages in Ogurah health area, where treatment is currently not being carried out because of the co-endemicity of onchocerciasis and loa loa. Therapeutic coverage for the project for the last three treatment periods (2005-2007) is >65 percent.-Therapeutic coverage ior 2005, 2006 and 2007 was 72.9 percent, 75.1 percent and 76'2 percent respeciively. It showed that coverage has been on a steady increase' There is convincing evidence that Mectizan@ treatment is becoming part of the culture of people of the different villages and they expressed willingness to continue with treatment for as iong u, it is offered. fhe p6ople are beginning to dgmant Mectizan@. Even where CDDs refuse to distribute Mectizan@ in protest against 6ck of motivation, the people walk-to the health centers to demand and swallow Mectizan@' In one of the communities in Mamfe Health District, a woman gave Mectizan@ to a two year old baby, believing that the wonder drug Re-evaluation of SWll CDTI Project in Carneroott (April 14-28,2008) Page vii (Mectizan@) cures every illness. Unfortunately the baby died. The DMO is planning HSAM activities to address this wrong use of Mectizan@ as well as the negative campaign that may follow the death of the baby. Beyond that however, community members associated Mectizan@ with a number of other correct health and social benefits. One striking benefit mentioned by a community leader is that "Mqtizan@ makes you so strong that when you are beaten by rain durtng farm work your skin does not get soaked ". However, communities have not been empowered to play a leading role in CDTI implementation at the local level. They are not empowered to take decisions on the timing of distribution and in some cases selection of CDDs. More importantly they are not empowered to take decisions on ways of supporting or caring for the CDDs. Instead Government decided to, and pays CDDs for distributing Mectizan@ in the communities. The current community satisfaction with CDTI has the potential for creating demand for continuation of the programme, community ownership and support for distribution of Mectizan@ and thus enhancing sustainability. This has not been exploited. At ommunity level, measunes to enhane sustainability of the CDTI pfiogramme arc yet not implemented. CDDs were willing to continue because the tablet is helping them and their people. However, some CDDs complained of the non-payment of government's promised compensation for the last two distributions (2006 and 2007). Some threaten to discontinue distribution of Mectizan@ or pafticipating in any health activities, such as Polio eradication programme, if not paid. Others, however, request external bodies to sensitize the communities on the fact that this is a voluntary assignment where no one is paid so that the CDDs could be recognized as rendering altruistic services to their communities. Structures exist in the communities to support the CDTI process in the communities. For instance the village health committee is the highest dialogue structure on health matters in the communities. Some district health services are beginning to explore ways of integrating the CDTI programme into the mandate of the village health committees and by so doing resolve the dilemma of CDD compensation. A few communities are beginning to make arrangements to pay CDDs and prevent disruption in distribution of Mectizan@. The Evaluation Team concludes that CDTI at the village level is making atisfadory pnogress bwards sustainability and will beame sustainable, provided apptopriate and adequate support continues to be provided by the higher levels and ammunities arc sensitized to play their roles in CDTL There is high-level political commitment as evidenced in the involvement of some key members of the Southwest Provincial Delegation of Public Health in the campaign for Mectizan@ distribution. Contrary to the practice in 2003, the leaders here have assumed full leadership roles in the implementation of the programme. They no longer wait for the NGDO to push and direct them on what to do. The team now plans, initiates and undertakes CDTI activities. The leadership at the Provincial level is very much aware of the problems and progress in the project and plans are made to address the problems such as CDD compensation, relatively low coverage in some health areas and communities and the fear of severe side effects in areas with loa loa.The District teams however still wait to be pushed. The staff attitude, commitment and level of supervision are satisfactory though training is a routine activity with no objective need to be addressed at the Health Area level. The SWII /lt. a a- Re-evaluation of SWll CDTI Projectin Catneroon (April 14-28,2008) Page viii 1CDTI implementation team conducts HSAM when it is deemed necessary. All the same some key stake holders demonstrated poor knowledge of CDTI implementation at the Provincial level. It was noted that no HSAM activities were undertaken at the Provincial level. The team considered it unnecessary because the information media in Buea do not get to the target communities covered under the SWII CDTI project. However, the critical and key stakeholders, such as the Provincial Governor knows nothing about the SWII CDTI project. Worse still, HSAM at the community level has not been effective because many community leaders interuiewed pleaded ignorance on the roles of the communities in CDTI. In some, the community leaders are neither targeted with information nor involved in resolving problems facing the implementation of CDTI in their domain. Government funding for CDTI at Provincial and District levels has improved from what it was prior to the 2003 evaluation. Before 2003, Government did not make disbursements for CDTI field activities. Between 2003 and 2008 Government spent various amounts in suppott of CDTI implementation in the project area. These government funding supports was categorized into direct and indirect. As a direct funding, the MoH spent $2&268.00 on the SWII CDTI project. However this money went mainly for-payment of compensation to CDDs for the distribution of Mectizan@. In addition to this, Government paid salaries of the health staff and made provision for stationeries, transport and other logistics requirements for the implementation of CDTI within the SWII CDTI project area. Part of the indirect funding is the provision of running credit, for the health centeis, which are sometimes used for CDTI field activities like submission of reports. This comes as a reflection of the integrated use of resources in the health seruice. It has also made other indirect funding of the SWII project through NOTF supports for supervision. Between 2004 and 2OOB NOTF disbursed $1,683.00 to help the p0ect coordinator with supervision. The Southwest Provincial Delegation of Public Health maintains the capital equipment and vehicles and had spent $61047 on the maintenance of CDTI 4WD Hilux double cabin pickup van between 2005 and 2008. All the same the major funding for CDTI is from external sources, specifically APOC and SSI' Between 2001 and ZbOg, SSt provided technical and financial support of about $372,938.00 and still plans to give another g197,115.39 for the coming four years (2009-20L2). APOC, on the other hand, has committed $5341035.00 along with other technical assistance to the project since inception. The evaluators were of the view that although government is now disbursing funds for CDTI activities, the funds are wrongly channeled to CDD compensation which should be the responsibility of the communitiei. Worse still the amounts is not increasing propoftionately to the decline in external funding. Nothing is done to bridge shortfalls in funding for CDTI implementation. Again, the project finance officer was not a government staff. He was paid and suppofted by Sfi tnough in response to the recommendations of the evaluation team in 2003 he was relocated to the Provincial Delegation of Public Health in Buea. All the same he was not answerable to the authorities in the Delegation and the Political head here could not explain his where about during the evaluation. The Delegate however blamed this on the entire set up. According to him, this is not peculiar to CDTI. Vertical implementation of project activities and of course fund management is a fundamental problem in health care delivery system in A a t Re-evaluotion of SWil CDTI Proiectin Cameroon (April 14-28,2008) Page ix Gmeroon, which the government is now trying to address with the sector wide approach (SWAP) in planning, budgeting and programme execution. Still in response to the recommendation of the 2003 evaluation, the process of accessing APOC funds has been greatly simplified. Now the CDTI implementation team at the provincial level simply initiates demand for funds which is authorized by the Delegate. This order goes to SSI in Yaound6. It returns ready to be cashed in Buea. All the same there are sufficient funds to carry out target activities and the funds are efficiently managed. Albeit, these funds were from APOC and SSI and relatively very little was from Government. However, it is important to note that the Government is planning on pooling resources in a common basket, which is hoped to make funds available for implementation of CDTI support activities at this level and the levels immediately below (District and Health Areas). The current financial position of the project, with respect to government contribution is considered to be blocking sustainability. If the resources used in paying CDDs are channeled to support activities of the health service while communities are sufficiently sensitized to assume their roles in CDTI, which includes supporting CDDs, there will be enough funds for CDTI activities at all levels. This will be further strengthened with the planned sector wide approach in budgeting, integrating funds and activities of programmes in each sector. The evaluation team noted the availability of transport for the implementation of CDTI activities. The Delegation also maintains transport, although maintenance of vehicles is only when they break down or when they are needed for a pafticular activity such as polio campaign. There is no planned preventive maintenance of vehicles in the Delegation, except for the new Hilux Pickup the Government gave the Delegate recently. Worse still, there is no plan for replacement of these vehicles when they become dysfunctional. At the lower levels, transport facilities are non existent in some health districts. Where vehicles exist, they are poody controlled though used for the implementation of all health activities. The health system does not meet the maintenance cost for the vehicles. The officers maintain and use the vehicles for non health issues. With respect to Mectizan@, there is sufficient Mectizan@ every year. However, in 2008 Mectizan@ arrived late due to late ordering. The Project and NOTF are thinking seriously on ways of averting a reoccurrence of such lateness in future. It is important to note however, that in response to the recommendations of the 2003 evaluation, the procurement and management of Mectizan@ are integrated into the government system used by the provincial drug programme. This system is simple and effective. In evaluating the project on the basis of the seven aspects and five critical elements of sustainability, the Evaluation Team concludes that the SWII CDn is MAICING SATISFACTORY PROG R ESS TO WA R DS S USTAINA BI LITY, With regard to the five critical elements the Evaluation Team found that three (superuision, Mectizan@ and political commitment) were present in the project. The elemenB of money and transpott were not satisfadory in the prcject The resources were mainly from ouBide though there are opportunities for increased govemment funding. a- Re-evaluation of SWll CDTI Projectin Cameroon (April 14-28,2008) Page x With respect to the seven aspects of sustainability, the Evaluation Team found that five, namely integration, efficienry, simplicity, attitude of staff, and effectiveness were very much helping sustiinability of the project. However, fiesounaes and commun@ ownerchip were found to be Otoi*ng "rttinrOnny beause government funding and prcvision of both capitat and finsumable maierials for the pnogramme afre very minimal. The pruiect is) inaeA, over dependent on non-Government soutces for resources. Furthermore, ownerchip of the prugramme at the ommunity level is lacking, Att the same, the guantitative score of 2,85 shows that the proiect is MAKING sATrsFAcroRy pRbGREss rowARDs susrArNABrLrrY and would continue to pnogness if the remedial actions recommended by the Evaluation Team are taken. There were also clear indications of the implementation of the recommendations of the 2003 evaluation team. One of such indications was the relocation of the project finance officer from yaound6 to Buea. Others include the simplification of the process of accessing funds for supporting CDTI activities as well as the separation of APOC and SSI accounts. Fufthermore, the accounts are now operated in Buea. These went a long way to improving the leadership and ownership of the project among the policy makers in the Delegation. During the feed back meeting, the Delegate and other members of the SWII CDTI project laudei the findings as apt ariO eye opener. It was noted that some of these facts in the evaluation findingi were taken for granted but however acknowledged the legdlry role of APOC CDTI programme in pointing out errors and positing realistic remedies. *APOC leads the way always. ft does not ont/bring us closer to the ammunities but shows us how to do things betteri From this point and mindset the team proceeded to develop a five year sustainability plan with the evaluation finding and recommendations in mind and to address the weaknesses observed in the project. the-team also discussed ways of moving the project forward. Some of the ideas on the way forward are listed hereunder. Way Forward As the SWII CDn project in Cameroon moves over the period for APOC-guaranteed support the team of evaluators anO tne'programme managers' made a critical appraisal of the_ issues that need to be addressed in the ino,t- and medium-terms to ensure the sustainability of the project post-ApOC. The following is a summary of the highlights of the seven critical components of ih. "*.y forward" outtinid at the joint final session between the external evaluators and the operators of the SWII CDTI project. 1. Documentation: An impoftant area of deficienry that needs to be tackled in order to enhance the sustainability of CDTI is the relative lack of expertise in report writing by the various operators at tne lower levels in the project. This is with special reference to documentation of government contribution to the project implementation. A series of workshops at the level of the Districts and Health Areas that address this shortcoming is highly desirable. A a Re-evaluotion of SWU CDT\ Proiect in Cameroott (April 14-28, 2008) Page xi 2. Resource Mobilization: By mutual agreement the contribution of the various stakeholders to the sustenance of the SWII project post-APOC is a major challenge. It was agreed that the Provincial and District Teams should take advantage of the SWAP to plan and provide resources, both financial and material for the sustainable implementation of the project. 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. Fufther to this, the SSI has undertaken to train the implementers on strategies for resource mobilization to reduce dependence on donor funds 3. HSAM: In recognition of the poor sense of ownership of the project at the community level, it was resolved that high powered HSAM activities supported by staff from the District and Provincial levels should be undertaken to sensitize the community members on their roles in CDTI. The need for intensification of HSAM is further strengthened by the surrounding Mectizan@ in the Ogurah Health Area of Eyumujock. The area is endemic of loa loa and onchocerciasis. The strong fear of side effect makes it difficult for the people to receive treatment. The result is that only 3 of the 15 communities that should be receiving treatment in the Ogurah health area do that now. 4. CDD Compensation: There was a mutual agreement on the dangers of the current practice where Government pays CDDs for distributing Mectizan@ in their communities, This was seen as a threat to sustainability of the project. To address this imminent threat, it was agreed that steps should be taken to sensitize government on its roles in CDTI and re-channel such funds to supporting the activities at the Provincial and Distrid:/Health Area levels, while the communities are sensitized to take on their responsibility of supporting the CDDs. 5. Re-orientation of Health Staff: Following the obseruation of the evaluation team on the dissatisfaction of some health staff at the District and Health Area levels following the withdrawal of APOC allowances, it was thought fit to undertake a re-orientation of the health staff on the APOC philosophy as well as train new health workers in the new created Health Districts on APOC philosophy and CDTI strategy. The complaints against the withdrawal of APOC allowances are a clear indication of poor understanding of the APOC philosophy among some health staff. This needs to be addressed in the short term to ensure the proper implementation of the plans for sustainability of the SWII CDTI project. 5. Recruitment of a Government Staff and Project Finance Officer: It was also agreed that the Delegation should assign one of its staff as the project finance officer. The old practice where SSI recruited and paid the salaries of the project finance officer mere sustains the rejected principle and practice of veftical programming within the public health system. Such a finance officer naturally would not be answerable to the leadership of the Delegation. This also negates the principle of ownership of the project within the Delegation which it is meant to serue. 7. Operations Research: The evaluation team also found the new enthusiasm to take Mectizan@ very interesting in many respects and the sarne time awesome. The low CDD dropout rate, contradicts to what is seen elsewhere. Many CDDs expressed willingness to continue to distribute Mectizan@, irrespective of Government's failure to a' Re-evoluation of SWII CDTI Projectin Cameroan (April 14-28,2008) Page xii pay the CDDs every year as promised, because they consider their service to their communities more valuable than any pay. These need to be systematically documented and to serve as reference materials for promoting community ownership. It is reasoned that if these are real there are lessons to be learn from them. Thus both the evaluation and SWII CDTI implementation teams discussed and agreed that it will be rewarding to conduct one or two operation researches to ascertain the factors driving the zeal in the CDDs to continue to distribute Mectizan and the willingness of the people to continue to take Mectizan@. The questions for the CDD study will include a. To what extent is their willingness to distribute Mectizan@ driven by altruistic motives? b. What is the link between CDD willingness to distribute Mectizan@ and the current practice where government pays them for their roles every year? c. What is influence of their involvement in other programmes with incentive packages and their willingness to peform their CDD roles? For the community members the questions may include a. What are their perceived social and health benefits of taking Mectizan@? b. To what extent is their new interest in Mectizan@ driven by the perceived social and health benefits of taking Mectizan@? c. To what extent is the interest in taking Mectizan@ driven by external socio- economic factors like government paying the CDDs and the current low or no social or economic demands on the people? d. Will the people continue to want Mectizan@ if they are made to play their roles fully and support the CDDs? e. If government withdraws from paying CDDs will the people take full ownership of the programme to an extent that matches their high level of demand for Mectizan@ now? Re-evaluation of SWll CDTI Prajectin Cameroon fApril 14-28,2008) Page xiii TABLE OF CONTENTS Contents Acknowledgements ,r.....,....r. ..,........... ii Summary of Findings of 2003 Evaluation Findings of 2008 Evaluation. vi LIST OF FIGURES... ..xlflr vI 2 1.0 1.1 t.2 1.3 2,L 2.2 2.3 2.4 2.s 2.6 3.0 3.1 3.2 3.3 3.4 3.5 TNTRODUCTTON r.,rr......r... .....r....r...,...r..r..r.rr..r.i..ir..r.r.,.........,. 1 Background to the SWII Project Evaluation in 2008 ...... 1 Re-evaluation Questions.......... Evaluation Objectives First Line Health Facility (Health Area) Level Sustainability at the Community Level ........ Comparative Analysis of the Sustainability of the Four Levels .....3 4 4 4 4 5 5 6 2.O Design Population Sampling Sources of Information.......... ANALYSIS Summary of Findings of 2003 Evaluation .... Sustainability at Projed/Provincial Level Sustainability at the District 1eve|........ 8 8 2t 28 36 43 a' 4.O CONCLUSTON ........ ....47 4.L Grading the Overall Sustainability of SWII CDTI Project. .............47 4.2 Comparison of the Project Peformance during 2003 and 2008 Evaluations following Implementation of the Recommendation of 2003 Evaluation Team 55 Re-evaluotion of SWll CDTI Projectin Cameroon (April 14-28,2008) Page xiv APPENDIX..........t....r..r......t.........r.r...t....r....r.......r..............r.rttt""r""' """""" 67 Programme of Activities in the three day FeedbacVsustainability Plan Development............. SWOT Analysis South West II CDTI project in the South West Province of Cameroon ilI ry V VI VII viii x Solutions to the Weakness and Threats in SWII CDTI Persons Interuiewed at the SWII Evaluation ADDRESSES FOR EVALUATION TEAM MEMBERS Minutes of the Feed bacVsustainability Planning Workshop ' 4.3 4.4 II I FeedbacVPlanning Meetings: Way Forward List of Documents Observed.. Speech Delivered by the Provincial Delegate Attendance List at the Feedbac(Planning Workshop 59 62 t07 ....67 ....69 .... 88 ..., 9s ....97 ....98 .... 99 ...105 ' Re-evaluation of SWII CDTI Proiect in Cameroon (April 14-28' 2008) Page xv LIST OF TABLES Table 1 Table 2 Distribution of Samples in Health Districts/Division, Health Areas and Communities Average Sustainability Score of the Different Groups of Indicators by Levels of CDTI Implementation in SWII CDTI Project Table 3 Actual Contribution of Paftnerc to SWII CDTI Implementation .a Re-evaluotion of SWll CDTI Project in Carneroon (April 14-28, 2008) Page xvi LIST OF FIGURES Figure 1: Figure 2: Figure 3: Figure 4: Figure 5: Figure 6: Figure 7: Figure 8: Figure 9: Figure 10: Figure 11: SWII CDTI: Sustainability at Project Level SWII CDTI: Sustainability at District Level SWII CDTI: Sustainability at FLIIF Level SWII CDTI: Sustainability at Community Level Average Performance of the Different Levels of SWII CDTI Pooled Groups of Indicators sustainability score of the Groups of Indicators and Level of GDTI Implementation in SWII CDTI Project Average Performance of Each Group of Indicators in the Entire Project SWII CDTI Project: Performance of Group of Indicators Trend in Treatment Coverage for the 2005'2007 by Level of lmplementation Comparative Performance on All Groups of Indicators in the Entire Project 2003 & 2008 comparative Average Performance of All Levels of Implementation in the 2003 & 2008 Evaluation Periods I Re-evqluotion of SWll CDTI Proiectin Cameroott (April 14-28,2008) Page xuii LIST OF CHARTS Flow Chaft 1: Mectizan@ Flow in SWII CDTI Project Flow Chart 2: The Process of Accessing Funds for CDTI Activities in 2003 Flow Chaft 3: The Process of Accessing Funds for CDTI Activities in 2008 4 a Re-evaluation of SWll CDTI Project in Cameroon (April 14-28, 2008) Page xviii 1.0 INTRODUCTION 1.1 Background to the SWil Project Evaluation in 2O08 The Southwest II CDTI project is one of the two CDTI projects within the Southwest Province, with administrative headquarters in Buea, Cameroon. It was approved for APOC funding suppott in 2000, SWI having been approved earlier in 1997 to cover only nine out of the then 14 health districts endemic with onchocerciasis. At the beginning, SWII had a population of 405,320 in five health districts. By 2007, the population-of SWII was estimated at 7L7,gOg persons with 237,874 at risk of onchocerciasis. Thiee new health districts have since been carued out of the earlier five to give eight health districts now. Thus, today, the SWII CDTI project @vers eight health districts, namely Akwaya, Eyumojock and Mamfe in Manyu Division, Fontem in Lebialem Division and Ekondo Titi, Wabane, Bakassiand Mundemba in Ndian Division. Most of the SWII pqect area is characterized by dense and luxuriant equatorial forest in Ndian, Lebiatem and most oh Manyr. However, savannah vegetation characterizes the Akwaya region that borders the Nofthwest province and Nigeria. The area has a very tough topography with many steep hills and valleys. This renders the terrain very rough and difficult to access. Fast flowing streams, which provide breeding site for the black fly, Simulium, run in most of the valleys. prolonged rainy season, (mid-February to mid December), is a feature of the area. The area is overed with hills and' valleys and in some areas thick tropical rain forest. Rocky riverbed, interrupted by falls, is a distinguishing feature of the area. These contribute to the aerated waters, which creates conducivL habitat for Simulium, the vector for Onchocerciasis, and also make the communities inaccessible. The traditional council, chaired by a Chief, heads each village. It is this traditional council that makes decisions for the day to day activities of the village. The main occupations of the people include farming, trading and hunting. The SWII CDTI project has an Onchocerciasis Programme Officer (OPC) as the focal person for CDTI implementation at the Provincial level. The DMOs are the coordinators of CDTI implementation at the District level while the Chief of Post oversees implementation at the Health Areas level. At the end of the third year of implementation in 2003 the project underwent the mid term evaluation for sustainability between April and May 2003, in line with the recommendations of the representatives of NOTFs and APOC management in the Abuja meeting of June 2002. The mid term evaluation revealed that the project was not making satisfactory progress towards sustainability. This was informed by the absence of more than five aspects and critical elements of the sustainability respectively in the project. It lacked community ownership, had very complicated and unreliable Mectizan supply system. Leadership roles of Government partners at ali levels as well as in the community were absent. Government did not initiate planning and implemenbtion and made no financial contribution to the implementation of the bOn pioje6. Specifically, the project had serious barriers to sustainability and was required to -D Re-evaluotion of SWll CDTI Project in Cameroon (April 14-28, 2008) Page 1 D rethink the roles of the paftners as well as appropriate and carefully targeted HSAM activities to inject the right sense of ownership of the programme at the appropriate levels (Government and communities) as well as mobilize sufficient support for the sustainability of CDTI post-APOC. In the feedbac(planning meeting that followed it was agreed that the situation where the Provincial Delegation of Health is not in'driving seaf for planning and implementation of the CDTI project should be rejected and action put in place to correct the anomaly. In specific terms, all partners should recognized and respect the leading role of the government on the lines of the project proposal and the annual project agreements between WHO/APOC and Government. Now in its 8s year of implementation, and five years after the mid term evaluation, the project is being re-evaluated for sustainability. The Evaluation Team drawn from Nigeria and Cameroon was charged with the tasks of: Re-valuating the sustainability potentials of SWII CDTI project to specifically identify efforts at implementing the recommendations of the mid term evaluators Discussing the findings and conclusions of the evaluation with the Provincial, District and supporting NGDO paftners as wellas the NOCP Facilitating the development of five year post-APOC sustainability plans to be prepared by the project leadership The evaluation team visited three health districts, six health areas and twelve communities in three administrative divisions in the SWII project area to collect information from all the partners including the community members on the different sustainability indicators. The team also interacted with key actors at the Provincial and National levels as well as the NGDO. Feedback and sustainability planning meetings were health for the Provincial and District level implementers to develop five-year post APOC sustainability plans for the different levels of CDTI implementation. 1,.2 Re-evaluationQuestions 1. What steps have been taken to implement the recommendations of the mid term evaluation for sustainability in SWII CDTI project? 2. How sustainable is the SWII CDTI project now? 3. What are the structures now in place to sustain SWII CDTI programme as APOC pulls out it support for the implementation? 4. To what extent is the CDTI process part of the routine processes of health delivery in the District? 5. How integrated are the support activities of CDTI into the health systems? 6. How are the Mectizan@ procurement and delivery mechanisms performing? 7. What is the financing mechanism put in place to ensure the availability of local and dependable source of funding of SWII CDTI project when APOC pulls out? 8. What is the state of preparedness of the Government patners at all levels to maintain, replace and ensure the availability of transport and capital equipment for the continued delivery of Mectizan@ to the people for long term treatment? 9. How committed are the human resources for CDTI implementation in SWII CDn project focus? a a a t a' Re-evaluation of SWII CDTI Project in Cameroon (April 14-28, 2008) Page 2 10. What are the coverage results of the CDTI project in the last three years of implementation of the project? a, Are all communities identified by REMO for treatment receiving treatment? b. Is treatment coverage > 65 per cent? c. What are the trends in both geographical and therapeutic coverage rates? 1.3 Evaluation Objectives The general objectives for the re-evaluation exercise are to determine the sustainability potentials of the SWII CDTI project by its 8s year of operation and assist in developing plans for sustaining the project post-APOC The specific objectives therefore are: a) To assess the peformance of the different groups of indicators of sustainability of CDTI projects in the SWII CDTI Project b) To identify the factors that may block or help the sustainability of the project c) Discuss the outcomes of the evaluation exercise with the relevant stakeholders in the SWII CDTI project d) Develop plans for sustaining the SWII CDTI project post APOC -t Re-evaluotion of SWil CDTI Proiect in Cameroon (April 1a-28,2008) Page 3 2,O METHODOLOGY 2.L Design The design for the study is functionally evaluative however the cross-sectional descriptive design was employed as the process for data collection. This design ensured the one-time collection of data that permitted the description of the sustainability potentials of the SWII CDTI project, having been in operation for the past 8s years with APOC funding support. In line with this and with respect to the evaluation objectives and questions that need to be answered, data were collected in order to provide the analysis required in providing answers to the research questions. 2.2 Population The SWII CDTI project covers a total of eight health Districts with an estimated population of 7L7,969. The REA that supported the establishment of the SWII CDTI project put the population at risk of onchocerciasis at 237,874 in 506 hyper- and meso-endemic communities. This implies that at least one in every three persons in the project focus is at risk of onchocerciasis. The population for the evaluation in the SWII CDTI project area, however, includes the key players in the process of ensuring long term annual treatment with Mectizan@ of the people living in the onchocerciasis endemic areas. These were the members of the PDPH Team in Buea and the NOTF in Yaound6; the eight district health seruice (DHS) teams; the Health Areas/ Health Centres staff, the project communities and their CDDs. The others were the project's finance officer and the NGDO partners (SSI). 2.3 Sampling A multi stage sampling techniques was adopted. This entailed the selection of health districts and health areas within the SWII CDTI project focus as well as communities for the evaluation. First three health districts were randomly selected out of the existing eight health districts in the SWII focus CDTI project and were included in the evaluation exercise. Two Health Area health centres (FLHFs) were selected by balloting from the list of health centres in each sampled health district, giving a total of six health areas (FLHFs). The simple random sampling approach was also adopted in selecting two communities from each Health Area prior to the evaluation visits. See details of the sampling in Table 1 below. ( |, a t- Re-evaluation of SWll CDTI Project in Cqmeroon (April 14-28, 2008) Page 4 _t Table 1: Distribution of Samples in Health Districts/Division, Health Areas and Communities: 2.4 Sources of Information Information were collected from interviews, verbal reports and documents. Various categories of people were interviewed in the Province. These included the Provincial Delegate of Public Health (PDPH), Chief of Unit for Superuision, Monitoring and Evaluation, Onchocerciasis Programme Coordinator (OPC), Chief of Seruice (General Affairs including Transpoft and Human Resources) and Essential Drug Manager as well as the Country Representative of the supporting NGDOs (SSI) and her team. At the District level, the District Medical Officers (DMO), District Administrative and Finance Officer and Chief of Bureau (Health) as well as the Senior District fficer (SDO/DO) were interviewed. Other persons interuiewed were at the Health Area levels (Chief of Post - FLHF) and the communities (community leaders, CDDs and community members). Information was recorded on the evaluation instruments and discussed extensively before the Evaluation Team undertook the grading of the level of performance on the indicator by level of CDTI implementation. 2.5 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 'sustainability score' for each group of l 1 SAI Health District (Division) R* (Coverage Rate) Health Area Community/Villages (R, Coverage Rate) I Fontem (Lebialem Division) High(82.9%) Fotabong (80%) 1. Eselewonl (87.3%) 2. Belap (68.9%) Takwai (84%) 1. Takwai (81.7%) 2. Ebensuck (88.4%) 2. Ekondo Titi (Ndiam Division) Medium (7e.6%) lllor (72o/o) 1. Dibonda (49.1%) 2. Illor (81.6%) Ekondo Titi (87%) 1. Lobe Town (77.0%) 2. Ekondo Nene (82.9%) 3 Eyumojock (Manyu Division) Low (65.5%) Afap (se.S%) 1. Mbakang (65.7%)2. Afap (52.3%) Kembong (65.4%) 1. Ntuni (70.4%) 2. Ossins (69.6%) or Mamfe (Manyu Division) Bachuo Akagbe (82.2%) 1. Bachuo Ntai (81.5%) 2. Mbinjang (89.9%) Tali(79.0%) 1. Tnto (72.2%) 2. Ebeaswa (78.5%) Re-evaluation of SWfi CDTI Project in Cameroon (April 14-28, 2008) Page 5 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 as well as illustrative quotes from the field were presented at feedback workshop. The quality of the overall project was also assessed in using the different aspects and critical elements of sustainability present in the project. The five critical elements and the seven aspects of sustainability in the project were qualitatively discussed and resulb agreed to by the team in open discussion. The project was graded using these aspects and elements in accord with APOC guidelines. The evaluators discussed qualitative description of problems, and deliberated on likely suggestions for solving the problems identified. Thus judgment about the sustainability potentials of the project was based on the quantitative assessment of the average sustainability scores of the groups of indicators as well as the qualitative assessment of the critical elements and aspects of sustainability of the project. Recommendations were generated in the format recommended by APOC. 2.6 Summary of Findings of 2003 Evaluation The 2003 evaluation concluded that the SWII CDTI project was not making satisfactory progress towards sustainability. Quantitatively, the project earned 2.17 points, which was far below the 2.5 points benchmark for satisfactory peformance. It was scored low on almost every group of indicators, with the exception of planning, Training/HSAM and human resources 2.88, 2.73 and 2.68 points respectively. On finance, transpoft, integration and worst of all coverage, the project was scored 1.03, 1.97, 1.00 and 1.70 points respectively. In terms of the levels of implementation the project had the worst performance at the Provincial/project level (1.92 points). Leadership, an indication of ownership of the project, was non existent here. There was an over bearing attitude in the NGDO and the project was seen as SSI project. SSI directed the implementation of the project generally from Yaound6, the administrative seat of SSI in C:meroon. Leadership and political commitments were weak. The best level was the health area or FLHF with 2.64 points. The other levels, community and District scored 2.00 and 2.11 points respectively. The communities were not empowered to decide on the mode, period and number of CDDs to select. SSI and the health staff selected CDDs in many cases. The project was also evaluated on its performance on the aspects and critical elements of CDTI implementation respectively. The evaluation team concluded that the project had serious barriers to sustainability and would require rethinking of the roles of partners as well as appropriate and carefully targeted HSAM to inject the right sense of ownership of the programme at the Project and community levels as well as mobilize sufficient suppott for the sustainability of CDTI post-APOC. The evaluation team found three deficiencies that would seriously block sustainability because their virtual absence in the project. These included community ownership, uncomplicated and reliable Mectizan@ supply system and leadership role of government paftners at all levels and i I t- Re-evaluation of SWll CDTI Projectin Cameroon (April 14-28,2008) Page 6 community. The communities were the least involved in the implementation of CDTI. This was considered very critical for sustainability of the project. , -, Re-evaluation of SWil CDTI Projectin Cameroon (April 14-28, 2008) PageT -t 3.0 EVALUATIONFINDINGS 3.1 Sustainabilityat Project/Provincial Level Planning (Highly; 3.0) There is an overall written year plan of the health seruice at the project level, including the provincial level. This plan contained onchocerciasis, which is also listed as a priority problem in the area of focus, There is also a more detailed plan, which contains all key elements of CDTI. The different paftners, government and NGDO (SSI), participated in the development of the plans. The participation of the partners was documented in minutes of the meetings where the plans were developed. Attesting to this, the SSI country representative said, ...after appraisal meetings the DtrtricB plan with their health areas based on the timing requested by the communities. This may alter because of late funding or late arriual of Mectizan@, ds we experienced this year. Mectizan@ could be late because of the requisition process. Some National activities could also affect distribution. We (S$) are actively involvd developing the action plans. I t- Re-evaluation of SWll CDTI Projectin Cameroon (April 14-28,2008) Page 8 a In the office of the provincial Delegate of Public Health, there is a Provincial Comprehensive Heatth plan, The plan made adequatl provisions for the control of onchocerciasis. Fufthermore, the oPC has developed a three year (2007-2009) sustainability plan. According to the oPC, ...our Minister directed that we develop a three year sustainability plan, after the meeting A4OC hetd in Douala for the future of APOC. I personally developed it and showed it ti my superiors, here in the delegation before it was forwarded to the Ministry. We are still waiting for his response' There was however no evidence that the sustainability plans were shown to other paftners for their input. Obviously the NGDO paftner was not aware of the new sustainability plan' According to the SSI country representative, "...beyond the 2003 sustainability plan, which was develofid after the evaluation, we have not done any other'i Furthermore, the detailed plan did not differ for the three years (2005-2007) because according to the Onchocerciasis Programme Coordinator (OPC), there has ben an introduction of Eye case programme whic! is now implemented along with CDTT. There is also the problem of the low skills among the workerc at thZ lower levels and the recruitment of new nurses. All of these make it necessary to train every Yean The delegation did not also seem to be clear on its roles and responsibilities.as they expgcted the NGDO to support the project finance officer. The NGDO partner actually. supported the project finance offi'ce, throughout the period he served the project int hat capacity' Integration (FullY; 4.0) There is ample evidence of integration of activities in the project. There is a written work plan, which shows how u.tiriti", ar-e implemented in an integrated manner' For instance, staff combined tasks during routine freatn monitoring/supervision. Staff combines CDTI activities with those of other programmes, where this it is possible' The integration of activities and programmes is also recognized by the operators at this level as a major ingredient for the succesl of health services in the area' The supervision and monitoring of activities are coordinated in the office of the Provincial Chief of Unit for Supervision, ruonitorinl anJ evatuation (PCSME) and she organizes regular evaluation of the project performance along with other programmes in the Delegation. Leadership (HighlY; 3'0) The leaders (the Delegate, OPC, chief of unit for supervision, monitoring and evaluation, etc) are well aware of the progress, successes and problems of the project' The Delegate' for instance, identified COO motivation as the major problem in the project' He went on to nighfign[ the problems associated with payment of CDDs,. as volunteered by the Minister in r.ipo-nt" to the low coverage reported years earlier. According to him, t ? Re-evaluation of SWll CDTI Project in Cameroon (April 14-28' 2008) Page 9 ...if you do not pay the CDDs everything will go down. But we are trying now to push them into the dialogue structure (village health committees), where there is money. We want the communities to set up the committees and the CDDs will be catered for in the process. The OPC noted that the problem as CDD motivation and low coverage reported in some communities. According to him, ...one big problem is the payment of the CDDs, which the Minister promised during the stakeholders'meeting in Kribi. This has been iregular since 2006, Another concem is the low teatment coverage in some health areas. Generally, coverage has ben on the increase. Two yearc ago when we realized that coverage at the provincial level is incrasing we decided to focus on the communities. In 2005 we had 137, in 2006 we had 112 and in 2007 we had 84 communities with coverage <650/o. Our concern is to get all the 506 a mm u nitig score 65 o/o* . The Chief of Unit (Supervision, Monitoring and Evaluation) however argued that the seemingly low coverage figures are due to computational problems. In her words, ...we have areas where there are ppulation ftgures but when you get there you do not find people. We have denominator problem. This is not only for CDTI. It affecb other prognmme as well. One such place is in the Mundemba area. To solve the problem of CDD incentive she also corroborated the Delegate. According to her, "we planned to tain the dialogue structures with the special health fund. This way we hope to in qease o m m u n ity o wnersh ip'i In a nutshell, the leaders have assumed leadership roles for the implementation of the project following the reports and recommendations of the 2003 evaluation. According to the Provincial Chief of Unit for Supervision, Monitoring and Evaluation, ...when the proj*t startd we thought it was SSI projed. But thank God after the mid term eualuation the team ame up with a lot of findings and recommendations which we had to implement. There were issues of leaderchip and APOC finance officer. When we reah2ed that it was ours we had to sit up. Since then we are tryrng to take up the leaderchip. We no longer wait for SSL We have the budget and we plan our activitis.... The leadership is up to date with its reports and targeted activities. The leadership delegates responsibilities appropriately to colleagues at this and lower levels. The leadership has a sound and collegial working relationship with junior colleagues, and keeps them fully informed. NOTF meets regularly and its members are fully aware of current issues in the CDTI programme. However the Provincial Chief of Service for General Affairs lacked sufficient knowledge of the workings of the programme at this level. In his words, t r- Re-evoluation of SWil CDTI Projectin Cameroon (April 14-28,2008) Page 10 ...1 am not involvd in the budgeting and financial management of CDTT probably because the project has a finincebfficer. I know only of government input for payment of cDDs. I have no clear idea of the cost of the project. The Delegate blamed this on the entire set up. According to him, this is not peculiar to CDTI' .... If we take another prolect tike EPI, Rolt Back Malaria, TB, the question concerning account mighl Oi, n" same. The problem of iob description might be the same. The probteh of implication of the Detegation and appropriation of all these vertical projects might be the same. He thanked the evaluators for the revealing finding and argued further that, ...vertical implementation of project activities and of course fund management is a fundamental problem in ieaim are delivery system in Gmeroon, which the government is now trying to address with the sector wide approach (SWAP)' The SSI partner of the project summarized all of these facts pointing to the fact that the Detegation has assumed leadlrship of the project. According to the SSI representative, ...the projrt has reached a mature stage where the Province and Districb carry out project activities. Before we usd to push but now we get request from the proiinie, I have the feeting that DistricB need some pushing from the Province. They have not reached the stage where District r's pushing.... They are still strongty dependent on external funding. That may explain why they are not pushing enough.... Repofting has improved, On the working relationship in the project, the SSI representative said, "rh this proiect there is a good working relationshiP'i Monitoring and Superuision (Fully; 4.0) Relevant records were readily available to show treatment summaries and inventory of equipment, among others. The records are of good quality, the contents clear, detail and convincing. Supervision is based on objective needs. The OPC supervises the DMOs. Staff members at this level go beyond the level'immediately below, even to the community to resolve problem but that ijong when the DMOs request support from the Delegation. According to the OPC, ...we only superuise the District level. unless when there is a serious need then we can even get to the communities. Monitoring/superuision is being planned to make for efficient use of resources. Generally, available information revealed that resources for superuision are efficiently managed as there exists a supervisory plan for the health system, which makes for shared use of resources. I ? Re-evaluation of SWII CDTI Project in Cameroon (April 14-28, 2008) Page 11 t Supervisory visits are thorough. Checklist, which also provides the basis for approval of planned field visits by the authorities, exists at this level. Staff members plan for one or two routine supervisory visits for onchocerciasis per year, depending however on availability of funds and other conditions. According to the OpC, ...superuision depends on availability of funds and where there are problems, Resources are efficiently used for superuision. In 2007 there were two visits; 2006 one visit. Problems and successes identified in the process of monitoring and supervision are addressed in a very deliberate and systematic manner. As soon as problems are identified the appropriate officer deals with them. Such problems are passed to the DMOs but on request of the DMOs the Delegation assists in handling the problems. According to the OPC, ...when we noticed low coverage due to the attitude of the peoplq we may join the DMOs on request to health educate the community leaderc showing them their performance in comparison with the performance of other communities close by. Successes are recognized and feed back given in a systematic way. Furthermore it was obserued that the reporting of CDTI activities is within the Government system. Mectizan@ Procurement and Distribution (Highly; 3.O) Mectizan@ supply is controlled within the government system. The Provincial Manager of Drug Programme handled the collection and distribution of Mectizan@, along with other drugs for the Delegation of Public Health. According to the Manager of Southwest Province Special Fund for Health, who is in charge of the drugs in the Delegation, ...1 order the drug annually based on the previous yea/s consumptrbn, store in the central store with other drugs and distribute to the DMOs.... This has been the case following the results and recommendations of the 2003 evaluation. The system is effective, uncomplicated and efficient. More importantly, it is dependable and sustainable. There was sufficient Mectizan@ for the needs of the project area, though this year (2008) Mectizan@ came late due to the logistic problems associated with drug ordering at the National level. Explaining the late supply of Mectizan@, the OPC said, ...previously projects made their requisition straight to MDP. Then Medizan@ for any year ame early. But since the 200Q it was decidd that MectDan@ should be done centrally. Unfortunately, it was obserued that some people did not know how to make the requisition for what they needd. The NOTF decided to hold a training, where we all sat together to make the requisition for the country. Thtg was in October 2007 and it meant that the rquest was sent late and the drug arived late. J a Re-evaluation of SWll CDTI Projectin Cameroon (April 14-25,2008) Page 12 tOn the problems associated with Mectizan@ ordering and procurement, the SSI programme officer said the problem they had last year that led to the late arrival of Mectizan@ in 2008 was due to the new process in ordering Mectizan@. According to him, ...in the past each pro4ect ordered the Mectinn@ it neded straight from MDP' Since 2006 it chaiged to one order for att the projrcb in the country' Now, some projeffi do iot complete distribution until late October, Worse still, the change ii UOp and the exit of Mary Alleman affected the supply of Mectizan@ to the country. The District Health Service collect the Mectizan@ requirement for their various Health Districts from the provincial pharmacy using definite Mectizan@ order forms. The requisitions of the different Health Districts were located with the Provincial Drug manager. It is on these requisitions that the number of tablets needed by the Health Districts is compiled and forwarded to the appropriate quarters. Training & HSAM (HighlY; 3.3) Training is planned and undertaken in an efficient manner. No training has held_for this year' Accordi-ng to the OpC, "we only superuise the training of the Health Areas staff. The DMOs have been sufficiently trained' Health education, Sensitization, Advocacy and Mobilization (HSAM) was properly planned and carried out based on perceived need. Every opportunity for addressing any audience perceived important for the imfbmentation of CDTI'was seized and used. For instance, the Provincial oelegate for public iealth said he uses the opportunity of the SW special fund for health to ,.nri[ir" people about all health programmes including onchocerciasis control. According to him,..ffis is'the highest dialogue stricture. The Governor chairs the annual meeting while I, the Delqate, cnai the quaierty meetingl'. He also indicated that he uses the SW chiefs conference to advocate for eye care and CDTI. All the same, there was no evidence of increased government financial support for CDTI implementation in response to these HSAM activities. No HSAM activities are undeftaken at the provincial level. The OpC noted that the Governor is not aware. According to him, ...you murt have noticed from our meeting with the Governor, today, that he does not know much about CDTI. We do not do HSAM at this level because the Radio here does not get to our area of coverage. So it is at the Distrid level we dO HSAM, The evaluation team had to remind the OPC that HSAM is not only for those benefiting directly from the distribution of Mectizan@ but also for the stakeholders in the health of the people. The Governor needs to be sensitized on the disease and CDTI. More importantly, advocacy should be conducted on the Governor's office to get the political and administrative backing of the Governor's office and if possible financial support for the programme. C Re-evqluation of SWil CDTI Project in Cameroon (April 14-28, 2008) Page 13 Finance Resources (Slightly; 1.3) The costs for each onchocerciasis control activity were clearly spelt out in a budget and there is evidence of cost reduction. The OPC had clear estimates of the funds that will be available for onchocerciasis control in the coming year as well as the expected sources and made budgets for CDTI implementation to fall within this expected and estimated income. However, the Delegate, the chief accounting officer for the Delegation, is not clear about what is available for the implementation of the CDTI programme. According to him, ...1 do not know whether the APOC funds are still there. I know that sometimes papers come and they say APOC is paying or SSI is paying. I simply sign. The pro1&t accountant has gone without telling me. I decidd I will not go into the office of the APOC finance officer until SSI has come to bke inventory. SSI was paying him. The finance officer (PCSGA) of the delegation does not know the budget for the programme and the contribution of APOC and SSI. According to him, ...1am not told anything. Allthese projecB come with their project accountanB and they do not tell me anyffiing. I an only tell you what Government pub into the projecB but not what the donors contribute. There was evidence of approval of expendifure, and funds for expenditures were allocated according to the approved plan of action. The Delegate approved both the proposed expenditure and funds for the implementation of CDTI in line with the work plan drawn by the Onchocerciasis control team. However, all the operations for the control of onchocerciasis at this level were funded largely by APOC and SSI. The OPC noted that, "Govemment provides nothing except in the maintenance of vehicles and other apital quipment. Mort of the money from @vernment is spent on paying the CDD{'. The financial officer of NOTF however noted that the Government funds the project in many respects. According to him, There are two types of funding - direct and indirect. Dirxt funding oncerns the motiuation of CDDs. Indirect funding which is the money sent to the PDPH, that is in the budget for the Delegation you will not find a line on CDTI. But all the money sent here can be used for CDTI. In additbn, usually at the NOTF we send some money to the OPC for superuision. He went on to indicate that in 20M and 2006 the MoH disbursed US$28,268.00 for the payment of CDDs. Fufthermore, the NOTF supported superuision of CDTI in the project with US$541, US$601, US$361 and US$180 in 2004, 2005, 2006 and 2007 respective. "We also sent some HSAM materials, which we produced with the HIPC fund'i When asked why the funding support from the NOTF is decreasing, the NOTF finance officer said, "to meet HIPC conditions for further support we needed to show evidence of ost containment and reduction in expenditure'1 He proceeded to justify the decreasing funding on the state of the nation's finance. According to him, a a Re-evaluation of SWll CDTI Project in Cameroon (April 14-28, 2008) Page 14 II a ...the decreasing funding is due to the frnancial situation of the country. The MoH makes the budget but the Ministry of Finance decides what to pay. They even wanted to reduce the budget further but the Minister of Public Health will always plead that the CDTI activity is crucial and fufther reduction could jeopardize the program me. Project management is aware of shortfall but has no specific and realistic plan to bridge the shortfall. It relies on SSI to make up the shortfall. Unfoftunately, there is also a shortfall between what is expected from SSI and what SSI is ready to give. According to the Delegate, "SSI has not been able to completely fillthe space created by the fall in APOC funding. The only other way is to integrate activitis". He argued that this is because of the poor funding situation of the delegation. However, the Chief of Unit for Supervision, Monitoring and Evaluation noted that, 'APOC and SSI funds are made available and arangemenB are made to ensure that CDTI work is not blocked anytime because of unavailability of funds'i SSI finance officer said, ...the project team has managed to cope with shortfall by cutting cost. For instance, they have now learnt to train without per diem. We also hope to build their capacity to mobilize resources locally. The SSI country representative reaffirmed this fact and assured that 'i99/ will fund the training on resource mobilization.... With the integration of Eye @re, there are also funds coming from Eye Care". In thinking of the future, the Delegate emphasized that, ...it is hopd that with the planned sector wide approach (SWAP) funds in the delegation will be usd in an integrated manner and this way it will be possible for the Delegation to source funds from the @mmon health basket and support all programmes within the delegation. Funds disbursed for onchocerciasis control from the budget at this level are efficiently managed. There is also a well established control system used in disbursement of funds. The chief accounting officer in the Delegation is however unaware of residual amounts under different budget headings. ,4s the financial officer of the NOTF I used to ontrol their financial repoft. I have also been here to train the former projed finance officer [NOTF Finane OfficerJ. Re-evaluotion of SWll CDTI Project in Cqmeroon (April 14-28, 2008) Page 15 Transpoft and other Material Resources (Moderately; 2.3) Transport and materials are available and functional for CDTI activities. The project has one 4WD Hilux double cabin vehicle supplied by APOC. The project has 21 motorcycles, (20 from APOC and one from SSI). APOC also supplied a Desk Top Computer and accessories, which broke down long ago. SSI replaced this to make sure work is not stopped. Other capital equipment supplied by APOC include photocopier and fax machine. Other supplies include posters and leaflets as well as a training manual from APOC. fu can be noticed, all the supplies necessary for the implementation of CDTI in the area are from non-government sources. All the same, there are transport and other material resources in the Provincial Delegation for Public Health at the disposal of the Onchocerciasis control programme. The Delegation maintains the vehicle and other equipment. All the same, according to the Delegate, the Province has two problems namely vehicles and personnel. The personnel problem is really acute. The PCSGA indicated that they carry out routine maintenance of vehicles and other equipment. In his words, ...we have recruited an engineer for preventive maintenance of computerc, photocopierc and the internet system. Capital equipment and supplies may need replacement considering the work still to be done in the coming 5-10 years. This then requires the government to rethink its place in the supply of capital equipment and office requirement for the successful implementation of CDTI. The Delegate demonstrated his helplessness when he said, ...there is no plan for replacement. Replacement from Government standpoint? ...no hope.... Government just sends vehicls when they feel like doing so. You cannot predid Government This year they approved some vehicles for my Distt:cts but now there is a directive withdrawing all the vehicles due to problems they have with the budget at the Nationallevel.... We only rely on WHO. The Country Representative of SSI however assured that, "55/ will continue to support the maintenance of vehicle and other capital equipment'i Transpoft at this level is used to undeftake suppoft activities at the next level. Transport is properly controlled with trip authorization, and log books as is the general practice in the delegation. According to the PCSGA, "we issue travelling authorization to each beneficiary but no opy is kept at the delegation'i The team however observed that the travelling authorization is for the security clearance of the personnel and not so much a permission to use the vehicle. o: I t Re-evaluation of SWll CDTI Projectin Cameroon (April 14-28,2008) Page 15 aHuman Resources (HighlY; 3.5) Staff members at this tevel are very stable and committed to their CDTI implementation work. The Onchocerciasis control team members have remained in one place for an average of five years. The Project Coordinator (OPC) has been in the project area for eight years. There is also a high level of commitment among the staff. According to the Delegate, ...the OpC is very dependable and highly committed to his CDTI work. I can even give him 100o/o. Even the general demoralization that came with the withdrawal bf lpOC financiat support to perconneldid not stop him from doing his work. He carried on untitthe Eye Care programme was introduced. Other officials at this level corroborated this information. According to the Provincial Chief of Unit for Supervision, Monitoring and Evaluation,"...they are doing their work. It is one of the priority projects of the whole Cameroon'i The SSI country representative, SSI programme manager and SSI finance officer were all agreed on the level of commitment to the CDTI work by the Southwest II CDTI implementers. In the words of the country representative, ...the provincial staff is committed. We do not evpect all of them to be knowtdgeable at the same level. But I will say they are making good effofts to ensure the work succeds, The bottom line is that if these guys are not committd this will not be happening.... The work load and pressure from the DMOs and communities are enormous. You will ftnd they are very committed, However, there are indications that the OPC will soon proceed on retirement. The leaders at this level however argued that this is not a threat to the implementation of CDTI in the project area. According to the Provincial Chief of Unit, Supervision, Monitoring and Evaluation, ...thank God we have two OPC*. We shall either get smebody to underctudy him before he leaves finatly or the other OPC will oversee the project while we train another to take over. Recentty Government rqruitd new staff, I have many who have reportd to me I am stilt considering where to post them.'.. So that is not a problem at all. Beyond the OPC, the team has been the same except for the Delegate, the Pharmacist and Chief of Seruice General Affaire who joined later. All the same, the project accountant was not from within the government system. Following the recommendations of the 2003 evaluation, the project accountant hired and paid by SSI was merely relocated to Buea. He was however not answerable to the leadership of the Delegation since the Delegation was not paying his salaries. Explaining this anomaly, the SSI country representative said, t Re-evaluqtion of SWU CDTI Proiect in Cameroon (April 14-28, 2008) Page17 ...the reason why we could not use a govemment percon as project finance officer is beause of the nature of the requiremenb.... Govemment employees will not respond as fast as would be desired Coverage (Fully; 4.0) Geographical coverage has been 100o/o in the last three years (2005-2007). All the areas identified by REMO for mass treatment are under treatment. Treatment coverage ranged from 72.9o/o in year 2005 to 75.Lo/o and 76.20/o in 2006 and 2007 respectively. This shows a steady increase in treatment. People are beginning to show more interest in the drug and communities are beginning to demand for the drug. In response to the obseruation made by the evaluators on the poor coverage situation in Eyumujock due to the problem of loa loa in Ogurah, the SSI country faulted the DMO. According to her, ...it means the Eyumujock man is not doing his work. What happened in Ogurah is that laboratory technicians screend everybody in that area for loa loa. The list of people who could take Mstizan@ was given to the DMO. The DMO is not pushing. He needs to have someone who is pushing. In short we cannot do CDTI there else the projxt will break down again. Differing slightly, the SSI finance officer said, ...we may have to look at ways of intensifling HSAM in that area. We cannot blame them because they are scard of side effed..- I am from that area and I know of a woman who sid she would rather die than take a drug that will put her through so much pin and misery. a_ a Re-evaluation ol SWII CDTI Project in Cameroon (April 14-28, 2008) Page 18 Recommendations for the Project Level a -o Recommendation Implementation Planning CDTI based on need developing plans for sustainability showing reliability of funding sources PrioriU: HIGH fndiatorc of success: a) Existence of action plan with targeted activities endorsed by all partners b) Minutes of planning meeting c) Existence of sustainability plans with relia ble fundinaspqggq_ Who to take action: PDPH Dea dl in e for co m pletrbn : December 2008 Leadership their roles and responsibility in CDTI Priorittr, HIGH fndicafurc of success a) Minutes of sensitization workhop b) All members of the leadershiP demonstrating good understanding of the programme and their roles Who tu take action PDPH Deadline for com pletion End of next distribution Mectizan@ Prioritn HIGH fndicatorc of saccess a) Report of requisition of Mectizan@ Who to take acttbn Manaqer, Provincial Druq Programme Dea d I in e for com p letio n Before of next distribution Training & HSAM to the Governor and other Political Leaders in the Province fndicatorc ofsuccess b) Minutes of sensitization workshop c) All members of the leadership demonstrating good understanding of the Programme and their roles Who to take action PDPH Deadline for completion End of next distributio Financial Resources Prioritr VERY HIGH Re-evaluation of SWll CDTI Projectin Carneroon (April 14-28,2008) Page 19 funding CDTI activities by increasing its budgetary allocations and releases for CDTI implementation channel the funds used for payment of CDDs into supporting the CDTI implementation process at this level fndiatorc of sueess: a) Increased amount budgeted and released for CDTI activities b) Evidence of sensitization of the government on need to channel funds to supporting CDTI at this level c) Evidence of Government suppoft (increased funding) for the implementation process at this level Who to take acttbn PDPH and NOTF Dea dl in e fo r com pletio n End of next distribution period Transport and Material Resources replacing transport and other capital equipment for the implementation of CDTI at the lower levels PriOritn VERY HIGH fndiatorc of sucess: a) Evidence of planning for replacement of vehicle and equipment b) Signed MoU from the highest authorities of organizations promising to replace vehicles and capital equipment c) Transport made available for CDTI at lower levels Who to take acttbn PDPH and NOTF Deadline for com pletion End of the next distribution period , t Re-evaluation of SWll CDTI Project in Cameroon (April 1a-28, 2008) Page 20 3.2 Sustainability at the District Level Planning (Highly;3.0) There is a general plan of action for all health activities at this level and CDTI activities were included in the District Health plans of two of the three health districts covered in this evaluation. The written work plans had all the elements of CDTI, and were drawn in a pafticipatory manner involving all stakeholders. However the plans were routine. Activities were not targeted and unjustified. No reason was given for the routine planning of activities. The officer in charge simply said that, "what we do is to produce plan for one year and then replicate it for other yearl'. Further more, the plan was not integrated in one of the health districts visited. In this district each programme planned its activities vertically. Integration of Suppoft Activities (Highty; 3,0) The various support activities are planned and carried out in an integrated manner in two of the health districts visited. Staff members combine activities of CDTI and sometimes, different programme activities in one trip. CDTI is also integrated with the Eye care programme. CDTI support activities were however not integrated in one of the districts. Every programme carried out its own activities. The newness of the team was given as reason for this parallel -o Re-evqluation of SWII CDTI Project in Cameroon (Aprit 14-25, Z00B) Page27 o implementation of activities. According to the DMO, "ffe team has not mastered their responsibilities because it has jud been formed'i The district was only recently carved out of the Mamfe Health District. The team which was subsequently put together for the implementation of health activities is not yet acquainted with the details and activities in CDTI programme. Leadership (Fully; 4.0) The District Health Teams takes full responsibilities for CDTI activities in all the health districts visited. The management team at this level initiates activities. The DMOs are aware of the problems of the project. According to one of the DMOs interviewed, ...the project is trying in spite of some difficulties. The maior difficulty is the CDD problem. They have not been paid for 2006/07. That is the only probtem.... This year we had the training of the dialogue stuctures and we told them about CDTI. They assured me that the programme will not diq even where the government fails to pay the CDDs. Even for CSM, we give them ocample with their farms. If you spray your farm you ned to come back to see if you avered all the plants, else the pest will destroy the planB in areas not sprayd. So we encourage them to do community self monitoring of the distribution. The chief of Bureau for Health in Fontem noted that, ...initialty there were refusals. But the refusals have rduced. Many people refused because of hearsay. But with sensithation they have started demanding for it themselves. Now, Mutizan@ tablets are in the HAs but not yet distributd beause of tack of money for training.... Initially, some CDDs accepted the iob bmuse they thought it is an opportunity to make money. When they realized that it is voluntary they dropped.... The problem now is the payment of CDDs. We are tryrng to make the communities underctand that the programme is theirc.... We eualuate the programme to Hentify problems. At the beginning there were refusals. Now, if there is delay the people come to ask for the drug, Monitoring and Superuision (Highly; 3.0) There is routine superuision at this level, using a checklist. Sometimes there is spot check in communities. There is also regular supervision of all health programmes in the District, which covers the onchocerciasis control programme, However superuision is not targeted. Repofting is within the government system and resources of the District Health Service are used for transmitting reports. According to the DMO in one of the health districts, "we have an agency that takes repofts to the Delegation. The District Health fieruice pays'i As soon as problems are identified the staff at this level tries to solve it. For instance, when the CDDs refused to distribute Mectizan@ because of non payment of their allowances in 2006107 a Re-evaluotion of SWll CDTI Projectin Cameroon (April 14-28,2008) Page22 a, -a the team went out to the dialogue structure to suggest ways the communities could motivate CDDs. Unfortunately, this got io the attention of tlre Permanent Secretary who was obviously displeased. According to the DMO, ...the problems we can solve we solve. Those beyond our capability we invite the provinciat office to help. In one year the community decided to contribute money irrespective of the MinisterS directive. This was not acceptable to the Permanent Secretary. However the District team does not empower the FLHF staff to handle the problem in some of the Health Areas. They moved into the communities to resolve problems without any clear justification for doing so. Mectizan@ Supply and Distribution (Highly; 3.0) The District Health Seruice used Mectizan@ forms for ordering Mectizan@ from the Provincial Drug programme. Requests for drugs were based on the FLHF and community data. Mectizan@ wai avaiiable for the last distribution and sufficient for two of the District. In one of the Districts, the team complained of shortage. The District did not receive all that was requested from the provincial level. The system for the collection of Mectizan@ is different from the system used for other drugs. The E-ssential Drug Programme supplied other drugs quafterly to the Health Districts but the DMOs arrange foitfre iollection of Mectizan@ from the Delegation. According to one of the DMOs, ...it usually does not arive at the same time as other drugs do. Now we are distributing in March/Aprit but the drug programme ame in February and will come again in May. When asked why the drug programme could not supply Mectizan@ in February, the DMO said, "I am not sure Mectizan@ was in the country them'i Training and HSAM (ModeratelY; 2,3) District Health Teams only train FLHF staff, and is done routinely for 2-3 days every year with no objective or targeted need for the training. Training is not integrated' According to the DMO of Fontem Health -District, "we do it every year to refresh old nurses and put the new nurses through. This is necessary especiatty now that we are integrating eye care with CDTI". Resources for training are efficiently used. There is also in-seruice training for staff at this level. I Staff is planning and carrying out HSAM in an efficient manner. According to the DMO in one of the Health Districts visited, 1'we do advocaqt at the tevel of the Senior District Officer (SDO)'1 The result of the advocacy is that the SDO's office is aware of the programme. According to the l't Assistant to the SDO in Fontem, Re-evaluation of SWtl CDTI Project in Cameroon (April 14-28, 2008) Page23 ...1 am aware of the programme. Just that for the past two yearc the government has not paid the CDDs as it promisd. And the Minister has stopped the collection of money from the community members.... We are however working to make the CDDs continue with the distribution.... In one of the Health Districts visited, however, it was observed that HSAM activities are planned but inadequately executed. Insufficient advocacy is done towards traditional leaders, as they reported ignorance of the workings of CDTI programmed in their domain. Financial Resources (Slightly; 1.3) Costs for each CDTI activity are clearly spelt out in a budget. There is evidence of cost reduction as the years go by with increased integration of activities in the health system. Funds released are however mainly from APOC and SSI. Funds from government sources are mainly for the payment of CDDs. In one of the Districts visited it was reported that funds are usually inadequate and late in coming. According to the DMO in Ekondo Titi, ...nothing is done about shortfalls. The Health Seruice is not able to mobilize the resources it neds as wellas iB commitment to ownerchip Funds are efficiently managed. All the same the question of efficiency and accountability does not arise as the funds are forever insufficient. According to the DMO for Eyumojuck Health District, ...the money rseived is not in conformity with the money required by theprojxt So we just manage it to produce the result. The essential thing is to produce the result. Transpoft and Other Material Resources (Slightly; 1.5) Government provided two motor vehicles and two bicycles. APOC provided eleven motorcycles, most of which are not functional now. SSI provided seven other motor cycles. One of the Districts visited has no transport at all. Where it is available, transport is used in an integrated manner. These motorcycles are however ran and maintained by the individual officers using them. There are also computer and training manuals in the District Health Services visited. The District Health Seruice maintains the vehicles, though only when the vehicles break down. There is no plan for preventive maintenance or replacement. In Ekondo Titi the DMO said, ...the Government has the least ability to maintain the vehicle or pay for maintenancg repairs or replacement of tyres. When vehicles break down, memberc of sbft at this level, work by trekking long distances. Those using the motor cycles maintain them. L ). Re-evaluation of SWll CDTI Projectin Cameroon (April 1a-28,2008) Page24 .a Human Resources (Highly; 3.5) Some members of the staff of the Health Districts visited have been in one post since 1995. There is in-seruice training. Staff members express satisfaction with their present responsibilities. According to the DMO in Fontem, ...we are happy doing the job in spite of the difficult terrain, When people are happy taking Mectizan@ you are happy that you are helping them to get the drug and then you are happy too. The Chief of Bureau Health in Fontem said, ...1 am happy. First of all I must talk about the achievement. Before the introduction of Mectizan@, people were taking Notuin. Now people report of improvement in their eye sight and deworming. It is also free. When you go for tnining your expenses are paid. More impoftantly, it is integrated with other programmes, So you cannot separate them. The programme has assisted us in doing other things. For example they provided motor bikes which we use for other adivities. In Eyumojuck the staff is commifted but not satisfied. According to the DMO, "ffe programme started with much money and the money is gradually going out. The work load is too much" In Ekondo Titi the staff complained of the work load. According to him, "the work load is much because all programmes need so much detail". Coverage (Ful[, a.0) Geographical coverage has remained at 100 per cent since 2005 in the SWII CDTI project. However, only 3 of the 15 villages that should be taking Mectizan@ in one health areas (Ogura) in Eyumojuck Health District is currently receiving Mectizan@ because of the high prevalence of loa loa in Ogura. They do not have any health facility to take care of the severe side effect in Ogura. Therapeutic coverage is also high >650lo in the Health Districts visited. The range for the 2005 round was 7L.0o/o - 76.40/o with an average of 73.7o/o (73.7t3.81 SD). The range for the following year, 2006 was 68.00lo - 8L.4o/o, with an average of 75.8o/o (75.8+ 7.0 SD). ln 2007 this rose further to 65.00lo-82.90lo with an average of 76.00/o (76*9.6 SD). There is a general desire among the people to take Mectizan@. According to the DMO in Fontem, ...anytime we delay in giving them the drug they start coming to ask what is happening. Gone are the days when the pmple refused the drug out of fear. All that fear is gone now and the people are increasingly demanding the drug. Refusals are very few and isolated. Re-evoluation of SWll CDTI Projectin Cameroon (April 14-25,2008) Page25 Recommendation for the District Level: District Recommendations Implementation Planning integrated in all the District Health systems Prton'ty: HIGH fndicatorc ofSuccess: a. Minutes of meeting of Planning b. Plan documents Who to take action: DMO Deadline for completion : End of next distribution Period Integration activities should be integrated. DHS in all the Health Districts Prioriil: HIGH fndicatorc of Sucess: a. Minutes of meeting of Planning b. Evidence of integrated im plementation of activities c. Existence and evidence of use of superuisory checklist for all health programmes within a Health District Who to take action: DMO Dadline for ompletion: End of next distribution period Monitoring & Supervision target on weak areas Prton'ty: HIGH fndicatorc ofSuccess: a. Reports of monitoring exercise Who to take acttbn: DMO Dea dline for am pletion : End of next distribution Period Mectizan@ Supply and Distribution Mectizan@ every year integrated delivery of Mectizan@ by the drug programme along with other drugs in the Health system to avoid DMOs vertically collecting Mectizan@ Priority: MEDIUM fndicatorc of Sucess: a) Report on supply of Mectizan@ Who to take action: DMO Deadline for completion : End of next distribution in 2008 Training & HSAM Priortty: MEDIUM t_ Re-evaluation of SWll CDTI Proiect in Cameroon (April 14-28, 2008) Page26 -a opinion leaders and the elite of the communities to mobilize resources for CDTI implementation fndicatorc ofSuccess: a) Ust of training needs of FLHF staff b) Repoft of training c) Report of HSAM d) Evidence of effectiveness of HSAM or support from community leaders e) Who to take action: DMO Da dl in e for com plettb n : End of next distribution period in 2008 Financial Resources essentials for CDTI implementation be increased Priortty: HIGH fndiatorc of Success: a) Repoft on activities for 2008 b) Vouchers of government fund releases for CDTI implementation Who to take adion: DMO Deadline for amplettbn : End of next distribution period in 2008 Transport & Other Material Resources and running of all vehicles and equipment within the District Health System the control of motorcycles, especially motor cycles poolfor more control PrioriU: HIGH fndicatorc of Sucess: a) Existence of logbook b) Vouchers of DHS fund releases for running transport and maintaining equipment Who to take acttbn: DMO Deadline for completion : End of next distribution period in 2008 Coverage low compliance with Mectizan@ treatment communities for Loa loa in Ogura Health Area managing severe side effects where there is co-endemicity of onchocerciasis and loa loa PrioriU: HIGH fndicatorc of Sucess: a) Evidence of HSAM in low coverage areas b) Existence of plan for addressing the problem in Ogura HA c) Repofts on the development of skills in management of side effects d) Repoft of management of side effects e) C.overaqe increased in Eyumoiuck Who to take action: DMO and OPC Deadline for completion: End of next distribution period in 2005 Re-evoluation of SWII CDTI Projectin Cameroon (April 14-28,2008) Page27 3.3 Firct Line Health Facility (Health Area) Level Planning (Moderately; 2.{l) There were written work plans for implementation of CDTI activities in most of the health facilities visited. The plans made adequate provisions for onchocerciasis control activities. In one of the health facilities visited, the plans did not show integration of onchocerciasis activities with the other health programmes at this level. In another health facility visited, the officer was not aware of the existence of a plan he drew himself. This implies that the plans were merely drawn to satisfy higher authorities but were not used for the implementation of CDTI activities. The plan is only drawn in fulfillment of the demands of the District and Provincial officers. According to the officer, "really we do not have work plan in the health area. But activities are going on as normal. We plan verbally'i In another health centre, the officer said,"when we go up there the coordinator will ask us to plan. We are finding it difficult because we are not used to i(. o_' Re-evqluation of SWU CDTI Project in Cameroon (April 14-28, 2008) Page 28 aIntegration (Moderately, 2.0) Staff at this level claim to combine activities in implementation. The evaluators however observed an opportunity for demonstrating such integration which was allowed to fritter away because of the inherent attitudinal problem that borders on vertical implementation of activities and resource allocation. There was an opportunity to train for CDTI along with Polio since the same CDDs are used for Polio vaccination and start distribution but staff at this level is waiting for training funds specific for CDTI before they could train for CDTI. This has held up the commencement of Mectizan@ distribution. Leadership (Highly; 3.0) Some members of the staff at this level take full responsibility for the implementation of CDTI activities while others depend on a push from above to act. A third group awaits a framework from above but now makes decisions within the framework to fit their realities. For instance, a Chief of Post in Fontem Health District said, ...the Provincial Coordinator and DMO give us a time frame within which to distribute. We now decide on our own the particular time that suits us within that time frame Staff members in some Health Areas await instructions from the District to initiate some activities because of the availability of funds. According to a Chief of Post, ...for some adivities, the programme comes from the District, e.g. training because this is influenced by availability of funds. For superuision I draw my action myself, Generally, staff members here know about CDTI. According to a Chief of Post in Fontem Health District, ...with CDTI here ... we do not have any problems. Since the last 2 yearc the result is increasing, Even the one I brought now pmple are coming to my house to ask for it But I sid nq until I train the CDDs. There is no severe case. Now people do not come for consultation for blindness. In Ekondo Titi, the Chief of Post indicated that all nurses know about Onchocerciasis. Leadership here is good. The HA management team is taking full responsibility of CDTI at this level in an integrated manner. The Chairman of Ekondo Tlti health management committee demonstrated good commitment. The Chief of Post in Illor noted that, "the HA staff and management team consider the programme as theirc'i Re-evaluation of SWII CDTI Project in Catneroon (April 1a-28, 2008) Page29 Monitoring and Superuision (Moderatelyi 2.7) CDDs submit repofts of the distribution of Mectizan@ to the chief of Post of health centre. The officer in turn submits to the District Health Seruice. The transmission of reports is within the government system in most health areas. In some health areas, reports are submitted separately and cost paid by the affected programme. So CDTI reports are submitted with funds allocated for training and supervision of CDTI implementation. According to a Chief of Post, ...they give us some money for superuision. From there we fuel our motor qcle if we are going to submit reporE. I do the same when I am going to submit for other programmes..., You know that the programmes do not run at the same time. If I have repor6 for two programmes one will pay going while the other pays for my return..., The FLHF staff members supervise all CDDs routinely. One visit per community is planned in most of the health areas. According to one of the Chiefs of Post, "except there is problem, we w'sit each community only once in a year'i In some of the HAs CDDs are superuised 2-3 times during one distribution. Superuision is not targeted. tn Ekondo Titi, the Chief of Post noted that integrated supervision is carried out generally except during the distribution of Mectizan@ because the CDDs could make mistakes. Problems identified during the supervisory visits were discussed with the CDDs. According to the Chief of Fotabong, ...there is no problem. But if I obserue any mistakes I discuss it immediately with the CDD. Another Chief of Post said, ...when there is refusal I do counsel them on the benefrts of Mectizan@ and effst on the population if they default.... When the community is doing well I congratulate them on their contribution towards the control of diseases in our communities. The CDDs inform Chief of Post when there is problem, e,g. severe side effect. Some are resolved, others referred to the Health Centre. The traditional authorities are not involved in problem solving in some of the HAs Mectizan@ Ordering, Procurement and Supply (Highly; 3,0) In most cases, the DMOs decide on the quantity of Mectizan@ to supply to the FLHF. Staff at this level is not allowed or empowered to make requisition for the Mectizan@ required. According to a chief of Post, ...1 was given 3,000 tablets thr's year. This is less than the requirement. I would have asked for 4000 if I had done the estimate myself, In some cases there Re-evaluation of SWII CDTI Projectin Carneroon (April 14-28,2008) Page 30 -a were shoftages.... Last year (2006) I was given 3325 tablets in instalmenb. ...in 20051 was given 2000 tablets. Estimate is not usually from the HAs. Another Chief of Post said, ...1 was given 17,850 though I reguested 19,000. They said those of us close to the District should take small quantities because it will be easier for us to return for more than our counterparB who stay far away. Even where the Chief of Post is given a free hand to make estimates of what is required for the health area the estimates are based on wrong formula (10o/o of the last number of people treated added to the number of people treated in the last distribution period). This points to poor skills in Mectizan@ ordering among the staff at this level, which may explain paft of the reasons for the usurpation of this role by the DMOs. Mectizan@ is collected with a system that is effective and uncomplicated. However, it is not stored in the system as other drugs used within the health facility. The Chiefs of Post interviewed explained that the system of storage is dictated by the campaign nature of the CDTI programme. They feared that the community pharmacist may not be there when they need the drugs hence the Chief of Post needed to take custody of the Mectizan@ while other drugs are kept in the pharmacy. According to a Chief of Post, ...the Pharmacist is a community worker (that is employed by the community). She may not be there when I need Mectizan@. Another reason is that Mectizan@ is sent to the District while the Drug Programme brings other drugs rtraight to the Health Areas. Another Chief of Post simply rationalized it as a system he inherited. According to him, It is something that exirted before I came to this place. It is that way so that I can get the drug whenever I ned it. The percon in the pharmacy may not be there when I ned the drug. Training and HSAM (Moderately; 2.3) There is retraining before every distribution, but this is not targeted at any specific deficiency in the skills of the CDDs. According to one of the Chiefs of Post visited, "we do so in line with i n stru ctio n s from a bo ve " Only the In-charge of the FLHF does the training, which takes place in the health centre. The trainee-trainer ratio is satisfactory. In most cases not more than 20 CDDs were trained in one session by one FLHF staff. In some cases training was used as an incentive to CDDs. Some members of the FLHFs visited, argue that, .,there is need to train new CDDs and even retrain others because of the long time between the distributions. The CDDs may forget and it is the only way of compensating the CDDs. Re-evqluation of SWll CDTI Projectin Cameroon (April 14-28,2008) Page 3 1 Few dropouts were recorded and these were mostly due to non payment of the motivation rnoney promised by the Minister of Health for the past two years. Some community leaders interuiewed were not aware of CDTI while others know and help in sensitization and mobilization. The poor level of awareness is blamed on uncooperative Health Committee members. According to the Chief of Post for Talaruai Health Centre, "I sensitDe the ammittes but they dont carry the news to the people because every body is declaring ignorance of the topia...'i Another Chief of Post for Fotabong noted however, that he does sensitization of the people. According to him, ...everybody is aware of the programme. HSAM is done during distribution. Letterc are given to churchs for announcemenE. I did HSAM last year and the ommunities agreed to support the CDDs but they have not lived up to it. Finance (Slightly; 1.0) Budgets are not normally drawn, but estimates of the cost of some CDTI activities such as the training of CDDs, are made and forwarded to the DMOs. These trainings are financed from the APOC Trust funds. The NGDO partners also contribute to the financing of field activities, and no funds are provided from the government purse for the implementation of CDfi activities at this level in some health areas. The officers at this level blame this on poor financial position of the Health Centres. According to one of the Chiefs of Posts interuiewed, ...we are only given running credib for the routtne activitr?s in the hospital. Nothing is given for CDTI. But during distribution the DMO gives us some money for training and superuision which we justifr after, wlth the repott In spite of this the staff at this level could not tell the relative contributions of the different paftners for the fleld operations at this level. This is blamed on the absence of budgeting and poor documentation of funding. According to the Chief of Post for Takwa, "there is nothing like budget here. We do not budget in the health areas. They just dside on what we should do and give us funds for i(i Transport and other Material Resources (Slightly; 1.8) Some staff members make use of personal transport for the implementation of CDTI activities. The government did not provide transport for staff. Those without any private transport pay their way to the communities, irrespective of the distance, to superuise distribution of Mectizan@. The situation of transpoftation here is very despicable. The terrain is rough and tough and villages are far apart. In the few cases where there are motor cycles which APOC provided, such motor cycles are poorly managed. The control and use of transport facilities are poor because the officers using a- Re-evaluation of SWU CDTI Projectin Cameroon (April 14-28,2008) Page 32 such motor cycles are made to bear to cost of maintenance. The motor cycles are not parked in a pool and are used for personal reasons as well as for the implementation of all health activities in the Health Area. The Chief of Post for Takwai Health Centre blamed the failure of Government to meet the maintenance cost for the motor cycle on the enlightened choice of the staff at this level to enjoy the motor cycles fully. According to him, ...we are responsible beause we do not use log book and park it at the DMO'I office as directed. We want to enjoy it more without knowing that the enjoyment has compliations There is no realistic plan for replacement of the motor cycles. Some hope that APOC will provide them with new motor cycles. According to the Chief of Post in Takwai, " we have no plan for replacement APOC promisd to give us new motor cycles. We have been waiting'i Human Resources (Ful[; 4.0) As is the case with the District staffing, there is stability of staff in the FLHF. Most of the staff had spent a minimum of five years in their position. However, they lacked skill in the implementation of some CDTI activities such as Mectizan@ ordering. However, they demonstrated commitment to CDTI. Coverage (Fully, 4.0) Geographical coverage has remained stable at 100o/o since the 2005 in the health areas visited. In 2005, therapeutic coverage rates ranged from 60.40/o to 85.1% with an average of 76.60/o (76.6+8.84SD) for those FLHF areas sampled. In 2006, therapeutic coverage rates ranged trom 6L.6o/o to 96.6% with an average of 79.Lo/o (79.1*L2.67SD) for those sampled. This shows an increase in the therapeutic coverage between 2005 and 2006 distribution periods. However, there was a slight decrease in 2007. The therapeutic coverage in 2007 ranged from 62.0 to 86.4 with a mean coverage of 75.2o/o (75.2+10.3lSD). This decrease is blamed in part on the refusal of CDDs to distribute Mectizan@ if they are not paid to do so. All the same therapeutic coverage was consistently >650/o for the last three years. Re-evaluation of SWII CDTI Project in Cameroon (April 14-28, 2008) Page 33 3 Recommendation for the FLHF Level: FLHF Recommendations Imolementation Planning integrate all health programmes at this level should be documented Priority: MEDIUM fndiatorc of Success: a) Minutes of planning meeting b) Existence of inteqrated plan Who takes action: FLHF staff/DMO Deadline for completion : End of next distribution in 2008 Integration keeping integration PrioriU: MEDIUM fndiatorc of Surcs: a) Minutes of training Who takes acttbn: DMO Dea dl i n e for ompletio n : January 2008 Monitoring and Superuision areas the FLHF Priority: MEDIUI.I fndiatorc of Succss: a) Reoort of monitorinq exercise Who to take action: Chief of Post Dea dl i n e fo r ann plettb n : End of next distribution in 2008 Training & HSAM assessment ordering Priority: HIGH fndiatorc of Sgcrcs: a) List of training needs b) Report of training who a akeiffion: DMO Deadline for ompletion: End of next distribution in 2008 Financia! Resources implementation activities at this level of government funds (Health Centre Running Credit) used for CDTI activities, as government contributions documentation PrioriU: HIGH fndicatorc of Suress: a) Payment vouchers for CDTI activities at this level b) Records of government contribution c) Traininq report Who to take artion'DMO Deadline for ampletion : End of next distribution in 2008 a Re-evaluation of SWil CDTI Projectin Cameroon (April 14-28,2008) Page 34 aFLHF Recommendations Implementation Transport & other Material Resources transport and training materials for CDTI implementation of maintaining motor cycles control of the use of motor cycles PrioriU: HIGH fndiatorc of Success: a) Payment vouchers for CDTI activities at this level b) Existence of teaching aids provided by government c) Existence of motor cycles d) Existence oflog book to control ugq Who to take acttbnDMo Deadline for ampletion: End of next distribution in 2008 Coverage coverage CDDs Prioriil: HIGH fndicatorc of Success: a) Increased coverage Who to bke action FLHF staff Dea dl in e for com pletio n : End of next distribution in 2008 Re-evaluationof SWII CDTI Projectin Cameroon (April 14-28,2008) Page 35 3.4 Sustainability at the Community Level Planning (Highly;3.O) CDDs are planning and managing their CDTI work efficiently. They make announcements through town criers. They first distribute at a central place and later go to the homes of those who did not turn up for treatment at the central place. Community leaders decided on central place distribution to make the work easier since the CDDs are not paid. CDDs in some communities plan work to make it easier. For instance in Belap and Eselewon communities CDDs said, ...we diuide the community into quafters and treat one quarter a day. We go house to housq very arly in the morning because the people will not come out to take it if we ask them to come to a central place. We also update our register as we go from house to house for treatment. However, some CDDs update the registers differently from distribution. No reason was given for this planning. According to a CDD interviewed, "that is how we were trained to do i(. Leadership and Ownership (Highly; 3.0) In some communities the leaders take responsibility for distribution within their communities, though there are no community meetings to review happenings related to treatment. In most Re-evaluqtion of SWll CDTI Projectin Cameroon (April 14'28,2008) Page 36 I Ia of the communities, the leadership educated those who refuse to take Mectizan@. They give announcement in the market places and churches. According to the Chairman of the Dialogue Structure (Health @mmittee) in Fotabong Health Area, ...we go out to sensftize the paple on the ned for Mutizan@. formally, when it just sbrted they were not responding well out of fear. But with the sensitization they respond well. Some even come before the time to ask for Mectizan@. In others, the community leadership is not involved. Again, communities were not involved in decision making. In the views of the community membets,"the health workers and providers of the drug duide when to bring the drug...'i On the other hand, however, communities select the CDDs and decide on the mode of distribution. All the same, in some communities the health workers appointed the CDDs. For instance in Fotabong Health Area, the Chairman, Health Committee said, "the Chief of Post and some members of the health committee select CDDs because they know who can do the work". The CDDs interviewed demonstrated high degree of enthusiasm for their assignment for different reasons. According to a CDD, "the ommunity values the drug. The community members are very happy. Now they complain why have we not started distribution?" A community leader in Ebensuck said, ...if you bke the drug your body will be strong. You will work very well on your farm. It gives full power for work. If it rains your skin will not be soaked The wife of the late village leader in Takwai gave her personal experience. According to her, ...1 had filarial in my body and I was using Notuin. Because of the effed of Nobaltin I auld not complete the dose. My feet were black. Then I visited my auntie in Yaoundi. She advised me to bke Mectizan@. I went to the Pharmacy, and bought it for 800da. When I returned to the village I saw the drug being distributd fre. Since then I have ben taking it and my skin is clear now. The representative of the community leader wondered why the drug cannot be given twice a year. The people are now demanding for the Tablet. "It kills worm and hair lice'i Another community leader challenged, ...9o oubide there and ask any woman, irespedive of age she will tell you how good the drug is in this community. The people love it. Monitoring (Moderately; 2.O) Reports get to the FLHF promptly. In some of the communities, the CDDs collate the reports and submit to the leader of CDDs who then submits to the Chief of Post. The communities do not provide transpott in some cases. In some cases however, the council provides funds for transpoftation to the training venue. The community members in Ebensuck argued that the reason why the community does not assist the CDDs with transpoftation, Re-evaluatton of SWU CDTI Project in Cameroon (April 14-25,2008) Page37 ...is that the community contributes to the health facility.... So the Chief of Post pays the transport cost of the CDDs from the ammuni{s contributions. Obtaining and Managing Mectizan@ (Highly; 3.0) Treatment records, and interviews, indicate that all eligible persons who wanted treatment got treatment at the time of distribution. Treatment occurs during the period dedicated for it and drug is not held over for those that are not treated during this period due to absenteeism or temporary non-eligibility. Appropriate amounts of Mectizan@ are given each year, though in installments. CDDs collect the medication from the health facility and take the responsibility to arrange their transpoftation for the collection of medication, be this walking, bicycle, etc. The community does not arrange for transportation, but this does not seem to be a problem for these communities. The Chief of Post gives them money to offset the transportation cost to the training. However, in some cases the CDDs collect drug outside training and no transport is arranged, when they run out of initial supply of drugs (e.g. Afap) HSAM (Highly; 3.0) Both CDDs and some community authorities are sensitive to situations that require more information and provide it as much as possible. According to a CDD in Takwai, "the few pople who refuse out of fear of side effect are encoungd to bke it'i The HSAM has however been unsuccessful in getting the people to support CDDs. CDDs sensitize community members on the need to own the programme but request outside influence to get the community members realize that the programme has changed. According to one of the CDDs interviewed, ...we sensitize the community memberc but rqu& that people fiom oubide our community should come and tell the puple that there is nothing from government for us in this job. There should be ducation to let them know that the system has changed. Another said, "...there is need for a different body like the Chief of Post or the DMO to sensitize the people on the ned to motivate the CDDs'i Financing (Moderately; 2.0) The CDDs are not supported in cash. A few communities are making plans to begin to suppoft CDDs in doing their farm work. Some community leaders argued that CDDs are not compensated because they are doing community work. According to the community leader in Takwai, a Re-evaluation of SWil CDTI Project in Cameroon fApril 14-28, 2008) Page 38 ,...there is no support because it is community work. Some times we say we will support the CDDs by going to their farm. It is like being a catechist you do the work with no pay A community leader in Ebensuck, however said, "...we did not know that we should suppott the CDDs" The Chairman of one of the Dialogue Structures interviewed said, ...they do perform well but sometimes they grumble because of lack of motivation. It is now about two years since they have not been paid. The government was paying them but now we have decided that the community should help the distributors at least once in their own farms. In some of communities CDDs are exempted from community work. An example of such exemption from community labour was noticed in Ekondo Etiti. In Mbakam a fee of 100cfa was paid by each adult as arranged by the Village Chief. In Ossing it was arranged by CDDs and head of quafter to collect l0Ocfafrom each adult treated. In others nothing is done to support the CDDs. The Village Chief in Afap said, "...the CDDs are workers and we thought they are paid by government so they are doing their work. We were not well informed". In Nfuni, the Chief said, '7 thought the CDDs were paid by government Now that I know I am promising to give them a token if the means are available". Human Resources (Highly; 3.0) The CDDs are skilled and good at the job. One of the CDDs in Eselewon said, "... we have been rxeiving training since 2000'i There are two CDDs for every village. The ratio of CDDs to the population treated is good. Generally, there were two CDDs for an average of 250 persons. All the same in some villages there were as many as 1000 people to be treated by one CDD. A typical example of this was found in Ossing, where the village leader was not aware of anything about the programme. Frequenry of CDD dropout was low. In Ebensuck one CDD dropped and has not been replaced. 1 dropout in Dibonda but was replaced immediately. According to a community leader who is also a CDD, "the CDDs have been trained. There has been no dropout beause they are all farmers and live within the community'i Most of the CDDs professed their love for the job they are doing either because they derive joy seeing the people happy taking Mectizan@ or because they are serving their communities. Some of the typical expressions of willingness to continue with the programme are represented in the select illustrative quote below: ...1love my community. I do not want to disturb them. The way they take the drug is encouraging. It gives me joy ICDD in Takwail a Re-evaluation of SWll CDTI Project in Cameroon (April M-28, 2008) Page 39 ...if government refuses to pay we will continue because we are the community. The only problem will fu if government fails to bring the drug. Volunteering four days to serue our community is not too much. ... That is why they selected pople from the same community to serue in their communities, so that CDDs will have human feeling for their people [A CDD, speaking on behalf of other CDDs in Fotabong Health Areal. In Mbakam and Ossing the CDDs said they are willing to continue for the good of their people. In Ekondo Nene the CDD said, "I am established in the village and I do not want to move out. I prefer to remain here and help my people'i In illor, the CDD said, '7 am willing to continue even if they do not pay me anything. I have done it for four yeas and will not stop so that I an get my people's righ( All the same, there were few cases of CDDs who would not do the job unless they are remunerated. Examples were found in Ebensuck and Nfuni. According to the one CDD that dropped out in Ebensuck, " f have done it for four yeas. I will not stop even if I have to do it for more than ten yearc". He argued that, ...the new chief of post is too rude and does not care for our welfare. The former chief of post will talk to us gently and even give us things when we work or go for training. This new man tall<s rudely to us and give us nothing, hence I stoppd. In Nfuni, the old CDD said "I will not continue if there is no motivation'! Coverage (Fully; 4.O) In 2005 therapeutic coverage ranged from 54.90lo to 90% with an average of 75.9o/o (75.9+10.32SD) for communities sampled. In 2006 therapeutic coverage ranged from 50.0olo to 90.10o/o with an average of 74.620/o (74.62LL2.80SD) while in 2007 the average therapeutic coverage rose again to75.360/o (75.36+10.12SD) with a range of 52.3o/o to 87.30o/o. Though the coverage did not show a clear pattern for the three years under review, one finds that some communities made coverage of less than 65% in the three years. This is a pointer for the areas of concern. The reason for the low coverage in some communities was attributed to the fear of side effect in areas where there is co-endemicity of onchocerciasis and /oa loa in Eyumujock. The evaluation team recommended that steps should be taken to establish the situation with /oa /oa in the area. Steps should also be taken to allay fears of severe side effects among those that are free of loa loa. a Re-evaluation of SWlt CDTI Project in Cameroon (April 14-28, 2008) Page 40 T- Recommendation for the Village Level Jt Recommendations Implementation Planning undertake census update at the same time with distribution of Mectizan@ to reduce work burden PrtoTiU: MEDIUM fndicatorc of Suess: a) Distribution report Who taks action: FLHF staff Deadline for ampletion: End of next distribution in 2008 Leadership and Ownership involve communities in problem solving by holding SHM in communities CDDs Priority: HIGH fndiatorc of Success: Report on institution of CSM and SHM Who to take action: FLHF staff Deadline for completion : End of next distribution period in 2008 Monitoring arrange transpoft for CDDs to submit reports PrioriU: MEDIUM fndiatorc of Suress: Transport provided for CDDs where necessary Who to take action: Villaqe leader and FLHF staff Dea d I ine fo r am pletlon : End of next distribution in 2008 Obtaining and Managing Mectizan@ FLHF for treatment of absentees and temporary ineligibles transport for CDDs in distant location to collect Mectizan@ for their communities Priority: HIGH fndiatorc of Success: 1. Report showing that Mectizan@ was kept for the treatment of absentees and temporary ineligible 2. Transport provided for CDDs in distant locationa Who to take action: C.ommunity leaders and FLHF staff Deadline for completion : End of next distribution in 2008 Financing in CDTI implementation, especially on financial support for the programme PrioriU: HIGH fndicatorc ofSuccess: Evidence of community financial support for CDTI implementation Who to take adion: FLHF staff Deadline for completion : End of next distribution in 2008 Human Resources Encourage communities to select more CDDs and reduce work load for the Priority: HIGH fndiatorc of Success: More CDDs selected a Re-evaluation of SWll CDTI Project in Cameroon (April 14-28, 2008) Page 4L Recommendations Implementation existing CDDs Who to take action: FLHF staff Deadline for completion : End of next distribution in 2008 Coverage coverage to educate the people on the benefit of taking Mectizan@ to have co-endemicity of onchocerciasis and loa loa managing severe side effects severe side effect PnbriU: HIGH fndicatorc of Surcss: Increased coverage in communities currently experiencinq low coveraqe Who to take actlon: DMO/FLHF staff Deadline for ampletion : End of next distribution in 2008 t a Re-evaluation of SWII CDTI Projectin Cameroon (April 14-28,2008) Page 42 3.5 Comparative Analysis of the Sustainability of the Four Levels All scores awarded during the evaluation to the SWII CDTI project for the various sustainability indicators groups are shown in Table 2. The overall score was 2.85 points. The FLHF has the lowest average score for CDTI implementation (Figure 5). The FLHF scored 'Moderate' (average 2.50) compared with other levels which clustered around the "High' sustainability potential rating (2.86-3.14). Table 2: Average Sustainability Score of the Different Groups of Indicators by Levels of CDTI in SWil CDTI The weakest groups of indicators for the FLHF level included finance (1.0), transport (1.8) and monitoring and supervision (2.7); and highest score (4.0) was awarded for coverage in the FLHF Ieve!. a Groups of Indicators () OD 6t 6) { oa 'E= Edtr tE o 6 fr oa 6l F o -9al=Eo =3tre o BO6 9 oQ Levels EO c nr .Er -c o.= Ef:EEq oio6 a oEco Fl b! o o 2 € o a v) @ cl .Hh EB >a 3.00 2.00 3.30 4.00 2.91Community 3.00 3.00 2.00 3.00 1.00 1.80 4.00 4.00 2.s0FLHF (HA) 2.00 2.00 3.00 2.70 3.00 1.50 1.50 3.s0 4.00 2.86District 3.00 3.00 4.00 3.00 3.00 2.30 1.30 3.143.00 3.30 1.30 2.30 3.50 4.00Project 3.00 4.00 3.00 4.00 2.53 1.40 1.87 3.60 4.00 2.85Average 2.75 3.00 3.2s 2.93 3.00 Re-evaluation of SWII CDTI Project in Cameroon (April 14-28, 2008) Page 43 t Values from Table 2 are fufther shown graphically in Figure 6. The Health Area (FLHF) level was weak in planning. The weakest point for the District was in finance. The community level's weakest areas were finance and monitoring. Generally, finance was the weakest of all the groups of indicators. Transport and other material resources, then of course monitoring and superuision follow this. Fig.6: Sustainability Score of the Groups of lndicators aild Levelsof CDMmplementatlon ln 5\Alll COTI prolect +' r Community r FLHF r District r National r All Mean sustainability scores for the groups of indicators are shown graphically in Figure 7 below. The weakest groups of indicators, overall, were the provision of Finance (1.40), followed by Transport/Material resources (1.87), Training and HSAM (2.53). These findings are good reflections of the pefformance of the groups of indicators in the eight year. All the same it is a remarkable improvement on the 2003 situation. The Evaluation Team made important recommendations in all of these areas. These concerns are addressed in the post-APOC sustainability plans prepared in order to move the project towards being fully sustainable as APOC support ceases finally. a 5 4 3 2 L 0 "-'i"f"-r-S--f $"os-**"$-*-^"--*-.d""-"-s a IJ Re-evaluation of SWll CDTI Project in Cameroon (April 14-28, 2008) Page 44 tThe box plot below .shoyt_ the actual performance range of the different groups of indicators across the four levels of SWII project administration. It gives the actual ierformance range,which cannot be discerned from thL bar charts. Mectizan6 supply and Human resources were constant and lacked va_riability in the peformance of these groups of indicators across levels.l:l lE other groups of indicators, there were wide ranges oi performance, hence the need tohighlight this in the box ptot. The- box plot shows that finance and transport did not only performs poorly, but theperformance across the four levels for these groups of indicators range from a low 1.0 and peak at approximately 3.0 score. The median score for these groups of indicators is <2.5 for finance and transpoft across levels. simitarly, the median r.o16 r*'planning group of indicators and lq&s it >2'5 points. Fiflry per cent oi tre different levets of the project implementation scoredless than 3.0 on planning. On the other hand, coverage and human resources were the strongest points of the projectarea. The community members expressed satisfaction with Mectizai@. 'In many cases theydemonstrated the strength they gained from taking Mectizan@. In some cases, the people wondered w-hy they woutd not be allowed to take the oiug twice in a year for greater and sustained effects ofthe drug in the body. Re-evoluation of SWII CDTI Projectin Cameroon (April 14-28, Z009) Page 45 Similarly, the personnel involved in the handling of Mectizan@ at all levels are happy with the programme. For most of them, satisfaction with the programme derives from the fact that it i.raiprovided them with the tool to do more work. At the community level, the satisfaction derives from the joy they obserue on the faces of those who take the drug. They are happy to be associated with that which brings joy to their people. Fig. 8: SWll CDTI Project: Performance of Groups of lndicators Peformance on integration and Training and HSAM varied greatly among the different levels of implementation of CDTI. For instane, sustainabilitY peformance on integration ranged from as low as 2.00 points in the Health Area (FLHF) level and 4.00 points at the project level with a median score of 2.7 points. This shows that while CDTI is tullY integrated at the project level, it is not so integrated at the Health Area (FLHF) level. Similarly, the sustainability performance on Training and HSAM varied from as low as 1'50 poins jd tn" Health erea (fUf) bvelto as high as 3.3 at the-project level with a median score Lf Z.+O points in the entire project areas. fne fLHf bvel staff still need to intensify HSAM and target training for greater results in the implementation of CDTI in the project area. I j I Ii Re-evaluation of SWil CDTI Projectin Cameroort (April 14-28' 2008) Page 46 4.O CONCLUSTON 4.1 Grading the Overall Sustainability of SWII CDTI project. Making a judgment of the project in terms of the seven aspects of sustainability (a) il{ake a judgment of the project, in terms of each of the seven ,aspects' of sustainability: Judgment: to what extent is this aspect helping or blocking sustainability in this HELPING HELPING BLOCKING . Integration There was an adequate amount of integration of CDTI into the health systems at all levels of the project implementation. Every body in the District and FLHF levels know about CDTI. Staff at the project level combined diverse programme tasks on each single trip to the health district. CDTI activities are paft of the minimum package of health -care activities. The resources of the health management teams at the different levels were pooled and used in common for all programmes including CDTI. . Resources (Human, Financial and Material) The staff is skilled and committed though inadequate in terms of number at all levels. Government financial contribution has sb far been minimal and limited to payment of salaries and CDD compensation. Transpoft at the lower levels is grossly inadequate and poorly managed or maintained. Government does not meet the running costs for transport. There is over reliance on support from APOC and SSI for field activities. Over reliance on external sources could block sustainability. r Aspect ,I UIEU lntegration HELPING Resourccs BLOCKING Efficiency IIELPING Simplicity Health StaffAcceptance (Attitude of staff) Effectiveness HELPING Re-evaluation of SWil CDTI Project in Catneroon (April 14-28, Z00g) Page 47 It ownership a Efficiency Though activities like training and monitoring and supervision are not fully justified at the District and FLHF levels, there is a rational use of available resources. Programme support activities are planned and resources shared, which results in lower cost and efficient management of resources. An example is the sharing of logistics. For instance, at the Provincial level planning for supervision and trainings are based on needs. . Simplicity The project uses simple and uncomplicated procedures for the implementation of CDTI activities. For instance, the ordering, procurement and supply of Mectizan@ is very simplified. Similarly, the process of accessing funds for CDTI activities is very simple. a Attitude of Staff At all levels, there is ample evidence that the staff members are positively disposed to continue CDTI implementation. Generally there is high level of commitment demonstrated among the health staff. The Evaluation Team rated the attitude of staff at all levels towards CDTI to be very positive. . Community Ownership Communities welcome the drug and are willing to take Mectizan@. They are quick to mention the social and health benefits of taking Mectizan@. The people are increasingly demanding for Mectizan@ and in some they want to take it twice in a year. However, communities are not empowered to make the decisions on the implementation of CDTI. The health workers select the CDDs. In many communities visited community members demonstrated ignorance on their roles to support the CDTI process by supporting the CDDs. The programme is seen as government programme and Government is expected to pay the CDDs, where this fails CDDs threaten to stop distributing Mectizan@. Worse still, community leaders and traditional authorities are not sufficienUy sensitized and involved in problem solving. The evaluation team considers this, a serious block to sustainability and recommends HSAM activities targeting the communities and their members to sensitize them on their roles in CDTI. a a Re-evaluation of SWll CDTI Project in Cameroon (April 14-28, 2008) Page 48 ao Effectiveness Geographical coverage rate has remained 100 per cent since 2005 at all levels of implementation. The therapeutic coverage rate is >65 percent, and on a steady increase at the Provincial and District levels while the drop witnessed at the community level in 2006 79t has been cancelled by a fufther rise in 2007 (see Figure 9). All the same one is not ceftain what will happen at the end of 2008 distribution period with threats to stop distribution if Government fails to pay the CDDs for the 2006 and 2007 distribution periods, 80 79 Fig.9: Trendin Treatment Coverate for the 2005-2007 by Level of lmplementatlon 76.2 ,75.2 tze .!ltt oC ito oFE7s E n o873u 5tzc! Er.F 70 69 - _ _ -Communtty_FLHF -Distnct-Pfovin rAl All the same, the evaluation team considers the current coverage rates to be helping sustainability because it has remained >650/o and the people are increasingly demanding Mectizan@ having realized the benefits. In Mamfe Health District people are already taking steps to pay CDDs in some of the rural communities while in Mamfe community the people are trooping to the health facility to be given Mectizan@. (b) Nex! the Evaluation Team examined the five key aspects of the project - 'critical elemenls'of sustainability. If these are not present it is unlikely that the project will be sustainable: 'a 2005 2006 2007 Monqt: Is there sufficient money available to undertake stricfly necessary tasks, which have bcen carcfully thought through and planned? (Absolute minimum residual activities). Transporl: Has provision been made for the replacement and repair of vehicles? Is there a reasonable assurance that vehicles will continue to be available for minimum essential activitics? (Note that 'vehicle' docs not necessarily imply '4x4' or even 'car'). Sapervhion: Has provision been made for continued targeted supportive supervision? (The project will not be sustained without it). NO NO YES 765 75.8 75.9 73.7 Re-evaluation of SWll CDTI Project in Cameroon (April 14-28, 2008) Page 49 YES I Mectizsn@ supply: Is the supply system dependable? (The boftom line is that enough drugs must arrivc in villages at the timc selected by the villagers). Political commitment: Effectively demonskated by awareness of the CDTI proccss among policy makcrs (rcsulting in tangible support); and a sense of community owncrship of thc programme. YES a FE. 9a: Contrlbutlons ln (uSSl of Partners to cDn lmplementatlon ln SWll CDTI ProlectAr.r (2OOO/2oO1 to 2OOE) 250,OOO " 200,ooo . l50,ooo - IOO,OOO i I I I50.ooo 1 i I Ol 2001 2o,02 2003 2004 2005 2006 2o07 2008 I Year -APOC -SSt -NOTF r1O -MoH.1O -PDPH| IO Money The project lacks sufficient money to undertake necessary CDTI activities, hence it scored 1,4 points. As APOC funding is decreasing the Government funding is not increasing to cover the shortfalls. Unfortunately, the NGDO has not been able to fill the gap created by the decrease in APOC funding supports. Worse still, the implementers of the project at all levels are not able to mobilize funds outside APOC and the NGDO to finance implementation of CDTI activities. Much of the funds from government is for the payment of CDDs at the community level. It is thus recommended that government be sensitized to re-channel its funds to the implementation of CDTI activities at the health service levels while the communities are sensitized to take on their responsibility of suppofting the CDDs. To appreciate government contributions to the project the amounts were multiplied by a factor of ten so that the line curve could rise above the base. The actual amounts of the different paftners are contained in Table 3 below. d' Re-evaluation of SWil CDTI Project in Cameroon (April 14-28, 2008) Page 50 aTable 3: Actual Contribution of Paftnerc to SWII CDTI Project Implementation in US$ since Inception (2000/2001to 2008) Year AMOUNT RECEIVED TOTAL APOC rus$)1 ssr rus$)2 NOTF (US$) MOH (US$) PDPH (us$) YEAR 1 235,857 45,857 na' 281,7t4 YEAR 2 lt7,lg2 32,350 na 149,532 YEAR 3 92,499 4l,2gg 9,156 na 142,943 YEAR 4 27,208 52,057 541 9,215 na 89,021 YEAR 5 26,291 83,375 601 9,899 1,308 121,473 YEAR 6 17,142 45,796 361 E*po 2,400 65,699 YEAR 7 1,048 43,277 180 Exp 1,709 46,214 YEAR 8 16,808 28,931 Exp 630 46,365 TOTAL 534,035 372,931 1,683 28,268 6,047 942,964 Government funding for CDTI at Provincial and District levels has improved from what is was in 2003. Before 2003, Government did not make disbursements for CDTI field activities. Between 2003 and 2008 the MoH spent $28,268.00 on the SWII CDTI project. However this money went mainly for payment of compensation for CDDs. In addition to this, Government also paid salaries of the health staff as well as made provision for stationeries and transport as well as running credit for the health centers which are sometimes used for CDTI field activities like submission of reporG. This comes as a reflection of the integrated use of these resources in the health departments. Government funding suppoft was categorized into direct and indirect. The amount stated above is the direct funding government provided for CDTI implementation. It has also made some indirect funding of the SWII project through suppofts for supervision passed through the NOTF to the project. Between 2004 and 2008 government disbursed g11683.00 to the project coordinator to help with supervision in the project. The Provincial Delegation for Public Health maintains the capital equipment and vehicles and spent between 2005 and 200g. All the same the major funding for CDTI is from external sources, specifically APOC and SSI. Between 2001 and 2008, SSI provided technical and financial support of about g372,938.00 and still plans to give another $197,115.39 for the coming four years (2009-ZOLZ). APOC, on the other hand has committed $5341035.00 and other technical assistance to the project since inception. I ApOC also supplied other capital equipment and non financial support ' Exchange rate used was US$l .00 to 4l6cfa 'na:not available due to poor documentation o E*p = still being expected. Budget approved yet to be released a Re-evaluation of SWil CDTI Project in Cameroon (April 14-ZS, 2005) Page 51 Transport Provision has not been made for the replacement of vehicles. Every person interuiewed declared the inability of government to replace the vehicles used for implementation of CDTI at all levels. Routine presumptive maintenance of the vehicles are lacking in the project. Vehicles are only repaired when they break down or when the health service needs them for any major activity or campaigns. The Delegation repairs and maintains vehicle at the Provincial level. However, individuals using the vehicles repair them, when they break down at the lower levels. The project was thus scored 1.87 on transport for the foregoing reasons. Superuision Adequate provision has been made for supportive targeted supervision in the project at all levels. With the integration of CDTI and Eye Care programme the project is well positioned to conduct suppoftive supervision of CDTI in areas of weakness as the Eye programme is undertaken. Moreover, the health service has also a unit of superuision and monitoring which provides support for CDTI superuision. The project was scored 2.93 points on supervision. Mectizan@ There is always sufficient amount of Mectizan@ in the project, which also arrives the communities early. The process of ordering, procuring and supplying Mectizan@ is uncomplicated and very efficient. The Provincial Drug Programme procures and manages Mectizan@ along with other drugs in the Province. It was thus scored 3.0 points. a Re-evaluotion of SWll CDTI Project in Cameroon (April 14'28, 2008) Page 52 Flow Chart 1: Mectizan@ Flow in SWII CDTI Project t r{{ tI t" I Itm \dtJl.m *mLFr, of-dbgeth*ra md ul;rF .lalliw l:trrrlaE *aGfff*(* rcahrt*Eaffi lic lG(rirnrrt*orrrrnr !*s try {mflrffiJqrln*uw cf txll| rffr4.rr.lDh*ihrficf, cl'f,{r$rl'lrlslrtrrrrrf; fer- atr.<fr. ri& cl&crrHitSiEl .{r*rrae rJ* oafrsrrf..di.Gt*srqfifi *df *-*+ [k*:* "'''':"-', -.] Political Commitment The policy makers in the health service are committed to CDTI implementation. CDTI is considered paft of the minimum package for health in the country. The Ministry of Health has consistently lived up to its promise of paying the CDDs to increase compliance in the communities. It is however recognized that this does not promote community ownership of the programme and threatens sustainability. All the same, this is a demonstration of the commitment of policy makers to the eradication of onchocerciasis as a disease of public health impoftance in the communities. The communities have not assumed ownership of the CDTI. They fail to suppoft the CDDs. When asked why they do not suppoft the CDDs, since they recognize the benefits of taking Mectizan@ and demand to be treated every year they plead their ignorance on the need for 4 L-.AST-rHEf- h*ritrd pcftljrrxn 'af l{arl* drq: p*nfrm €gta:rllcr Re-evaluotion of SWil CDTI Project in Cameroon (April 14-25, Z00S) Page 53 :) community to support CDDs. They are always quick to note that government pays the CDDs for their work. The policy makers in the health seruice recognize this weakness at the community level and are planning sensitization activities to exploit the present high demand for Mectizan@ and shift the responsibility of supporting CDDs to the communities and make the communities own the programme. The project was scored 3.25 points on leadership, which approximates to political commitment among the groups of indicators. In line with the guideline for grading the whole project using the seven aspects and five critical elements of sustainability the Evaluation Team concludes that the SWII CDTI project is MAKING SATISFAAORY PROGRESS TOWARDS SUSTAINABILITT Two of thc elements, transport and supervision were not dependable. Two of the aspects, resources ad community ownership are blocking sustai nability. The quantitative score of 2.85 also supports the qualitative decision which holds that the project is making satisfactory progress towards sustainability. Re-evaluation of SWil CDTI Project in Cameroon (April 14-28, 2008) Page 54 T rl 4.2 Comparison of the Project Peilormance during 2003 and 2OO8 Evaluations following Implementation of the Recommendation of 2003 Evaluation Team Having graded the project for its sustainability potentials in the 2008 evaluation exercise, the evaluation team proceeded to assess the level of improvement that has occurred in the project since the 2003 evaluation and following the implementation of recommendations of the 2003 evaluation team. The results of this assessment are contained in Figure 10 below. tr 4.5 tig.10:Comparatiye Performance on AllGroups of lndicators in the Entire Proiect 2003 & 2008 Figure 10 revealed a general improvement in the sustainability performance of the project on all the groups of indicators, with the exception of planning, training/HSAM and transpoft. The project was found to have declined from 2.88 points in 2003 lo 2.75 points in 2008 on planning. It also dropped from L.97 points in 2003 to 1.4 points in 2008 on transport and from 2.73 points in 2003 to 2.53 points in 2008 on T/HSAM. ft \, 4 J.5 3 2.5 2 1.5 I 0.5 0 F\ 12003 r200E On the other hand, thep@ect recorded appreciable improvements on the other groups of indicators between 2003 and 2008. In 2003 the project scored 1.0 point on integration but improved to 2.25 points in 2008. Leadership was another group of indicators on which the project recorded improvement between 2003 and 2008. In 2003 the coverage score for the project was 1.7 whereas the score in 2008 was 4.00 points. The case was the same on Mectizan@, rising from 2.13 in 2003 to 3.00 points in 2008 and finance rose from 1.03 points in 2003 to 1.40 points in 2008. On the whole the project sustainability score rose from 2.L7 points in 2003 to 2.85 points in 2008. It bears reiteration to note that the project recorded some improvements on finance from the situation in 2003, irrespective of the poor financial contributions of government towards the implementation of suppoft CDTI activities. A remarkable change in the financial position of the project, in response to the recommendations of the 2003 evaluation is in the simplification of the process of accessing funds available for CDTI implementation. The evaluation team in 2003 found that the process of accessing funds for CDTI implementation was very complicated as the implernenters had to go through a circuitous and toftuous process to access funds to support activities. Prior to the 2003 evaluation exercise, the team had to make seven excruciating contacts outside the project area before accessing funds (see Chart 2). This was reduced to one simple contact with the NGDO in Younde before the 2008 evaluation exercise (see Chart 3). o*-lo",--"""rr"O S-"" ^rC *t-"""^-.ot* -C"/ Re-evqluotion of SWII CDTI Project in Cameroon (April 14-ZS, 2008) Page 55 a tn Flow Chart 2: Process of Access Funds for CDTI Activities renrreqf tn OPC in Buea makes PDPH sends endorses SSI CR in Yaoundd studies and approves APOC finance officer in Younde conductsOPC raises cheque to PDPH PDPH signs SSI CR approves in Yaoundd APOC finance officer in Younde pays to joint APOC/SSI Account Funds get to joint APOC/SSI proiect account OPC raises cheque to be drawn on the annnrrnf in PDPH in BUea signs cheque SSI Rep. inlil'OPC withdrawsfunds from joint a Re-evaluation of SWll CDTI Projectin Cameroon (April 14-28,2008) Page 56 By 2003 the APOC finance officer was resident in the SSI country office in yaoundd and operated the financial transactions of the project in Buea from that point. The evaluation teamin 2003 obserued that this does not help sustainability as it strengthens the threat to sustainability of the project. It also made the implementation process to be complex and inefficient. Worse still it did not promote ownership of theproject by theDelegation. The leadership of the Delegation did not have knowledge of what is available for CDTI implementation. The APOC finance officer was seen as a staff ofS$ and this strengthened the perception of the project as SSI project. In 2008 the evaluation team observed that the APOC finance officer had the APOC finance officer the Delegation for public been transferred to Buea as recommended. The Delegation provided with an office space from where he operated the ApoCaccount within health in Buea. However, SSI paid the salaries of the finance officer. Thus, he was not answerable to the leadership of the Delegation. This was identified as a weakness in the project implementation even in 2008. All the same, leadership, which was lacking in the pqect-in 2003 received aboost. The policy makers in the Delegation have now realiied that [he project belonged to the Delegation and took steps to assume ownership. They now plan and undertake activities independently. Both the SSI staff and the leadership of the belegation, interuiewed were agreed on the fact that the Delegation no longer waited for a push to initiate activities in theproject. a Figure 11 below revealed movements in performance levets of the different levels of implementation of CDTI in the SWII project area. It showed, for in stance, that with the exception of the front line health facility (FLHF) level, there is a geneial increase in sustainability performance on the levels of implementation. The FLHF experienced a decline inperformance from 2.64 points in 2003 to 2.50 points in 200g. Flow Chart 3: Process of Accessins Funds for OPC raise request for funds for SSI issues a signed Delegate receives the signed cheque &^- sqr ^-J APOC finance officer cashes the cheques from APOC or SSI Re-evaluation of SWll CDTI Project in Cameroon (April 14-25, Z00B) Page57 L i ?,i it- t' tr t t. p. ? r; '' f.a t On the other hand, the Provincial or project level rose from a very low 1.92 points in 2003 to a very high 3.14 points in 2008. Similarly, the District rose from 2.11 points to 2.86 points in 2003 and 2008 respectively while the community level appreciated from 2.00 points in 2003 to 2.91 points in 2008. The Paradox here is that the FLHF which was the strongest point of the project in 2003 turned out to be the only level that Flg.11: Comparatfue Average Performance of All levehof lmplementation ln the 2003 and 2008 Evaluation Periods 2.91 2,86 2:6U-50 Community ttHF Dlstrict National All 12003 I 2008 3.50 3.00 2.s0 2.00 1.50 1.00 0.s0 0.00 2,8s t suffered a decline in 2008. This was attributed to the routine nature of implementation with proper justification of suppoft activities. For most of the FLHFs visited, integration was weak and the involvement of community leadership was very low. Opportunities that existed for integrated implementation of support activities were not used. Instead, some FLHF staff insisted on vertical implementation of activities. The improved leadership roles of the policy makers at the Delegation, the level of integration, targeted monitoring and superuision and the improved coverage recorded in 2008 over the 2003 scores, among others pushed the provincial or project level up on the sustainability ladder. Similarly, the interest in Mectizan@ due to the successful HSAM activities of the health seruice to improve coverage helped the sustainability potentials of the p@ect at the community level. a Re-evqluation of SWll CDTI Project in Cameroon (April 14-28' 2008) Page 58 ,, r.t I rt 4.3 Feedback/Planning Meetings One joint feedbac(planning meeting, for Provincial and District level teams was successfully organized. The objectives of the workshop were as follows: 1. To give feedback on the evaluation findings by the Team of Evaluators 2. Discuss the findings among the implementers, the policy makers and the Team of Evaluators 3. Discuss the concept of sustainability in relation to the SWII CDTI project 4. Develop plans for the sustainable implementation of SWII CDTI for the coming five years The workshop lasted for three days. The programme is attached. The sustainability plans, developed from the feedbac(planning meetings will be forwarded together with the necessary justification when they are duly signed by the appropriate authorities. These will be forwarded, with the necessary accompanying documents to APOC by the project through the NOCP at a later date. Below are some key issues and comment that emerged after the briefing session. These concentrated primarily on the provision and use of resources. Others were managerial and documentation issues. Planning was also weak. The evaluators also highlighted the problem with declining coverage in one health area in Eyumujock Health District as well as low integration in some Health Districts. Training was not targeted and in most cases. Record keeping was also identified as a weakness. The running and maintenance of vehicle and other capital equipment were dependent on non- government sources. This is not sustainable. Community ownership of the programme was largely absent in the project. Communities failed to support CDDs and Government paid CDDs for distribution of Mectizan@ in the communities. For the last two years (2006 and 2007) Government has been unable to pay and CDDs are beginning to complain. Some CDDs have actually refused to distribute Mectizan@ for the 2008 distribution period. Opening the floor for comments the Provincial Chief of Unit (Supervision, monitoring and evaluation) said, CDT| has not only brought us closer to the communities but has helped us to do a lot of things betten.,. The team (evaluators) has done well. We have been able to get what adually happened. She proceeded to call on participants at the workshop to react to the observation of the evaluators, Reacting to the obseruation that the low coverage in Afap health area was due to shortage in the supply of Mectian@, the DMO Eyumujock noted that the real problem in Eyumujock was not the shoftage of Mectizan@. According to him, i Re-evaluation of SWll CDTI Projectin Cameroon (April 14-25,2008) Page 59 ...the problem of Afap area is that two villages faild to carry out distribution of Medinn@. They had no CDD. We had to go to Ogomoko and Mbatum to request them to give us CDDs to distribute the Mecthan@. On the issue of government funding of CDTI field activities, the pafticipants blamed the seeming poor government funding of CDTI activities on improper documentation of government contributions. There was a consensus that the government allocates running credits to the health centers and the sometimes, due to the level of integration the health staff spend paft of their running credit on CDTI, but are unable to document this. According to the SSI country representative, ...finance scord low beause we do not know how to alloate our rgources, There is running credit. fume of the funds you (refering to the Distrid Health Seruice staff in the workshop) use for training are not from APOC and SSL We do not adequately rxognize government contribution. We need to be able to carue out money from what government gives that we use for prqramme implementation. Putting it succinctly, the OPC blamed the situation on documentation. According to him, "everybody has been putting in something but it is problem of documenfution'i The Provincial Chief of Unit (Supervision, monitoring and evaluation) agreeing with the others who spoke earlier said, ...Government is giving running credit. CDTI t's a programme that has ld the way for us to do thing better. It is left for the Chiefs of Post to allocate the running credit for CDTI. Govemment has already given money for running the seruice. It will not give any credit sp*ifically for CDTI The DMO for Eyumujock however lamented that, "those who are using the money are not apable of eualuating what government contributes. The difficulty we have is to put it in propo rtions o r pe ren b ges'l On CDD compensation, the Provincial Chief of Unit (Supervision, monitoring and evaluation) noted that, ...what government is doing now is a source of concern, We are also looking at ways of doing it better but it will take a lot of HSAM. The government funds for now are used for motivation of CDDs. We are thinking of how to get the communities to think. We are looking at how we can get the communities to take ownerchip. We plan to have health center workhops where the community members will work together with the health seruice to see how we an sensitize the community to take ownership of the programme.... With the CDTI plan for sustainability we should be able to boost what we have started,.,. Still on community ownership and following from the speech of the Provincial Chief of Unit (supervision, monitoring and evaluation) the SSI country representative emphasized that, a Re-evaluotion of SWll CDTI Projectin Cameroon (April 14-28,2008) Page 60 a I.... The big problem we have at the community level is that we have put too much responsibility on the CDDs. Sensitization and community meetings should be facilitated by the Health Center staff, This is not done in most communities. Some of the DMOs gave their experiences with the communities they work in. The first to speak was the DMO Akwaya Health District. According to him, .,some community leaderc are sensitized severally but they do very little for the CDDs. The reason is that they command very little respect among their subjects. While most of the other DMOs present agreed with him, stressing the weak authority of the community leaders over the people in contrast to what obtains in other parts of Cameroon, the Northwest province for example, it was reported that the community leaders in Mamfe have been able to get their people to support the CDDs. According to the DMO Mamfe, ...the situation of Mamfe is revolving. The CDDs refused to distibute M&tizan@. It has even affectd the Polio programme because the CDDs said they did not trust government anymore and will not participate in any health programme unless they are paid. But in one of the communities the people gave each CDD 1q000 da and dtrtribution is going on now. In Mamfe town it is different. Since the CDDs refusd to distribute Medizan@ the pmple are coming to my office to take Mectizan@. Finally, it was resolved that there should be sensitization of the communities to take ownership of the programme and support the CDDs to distribute Mectizan@. At the same time, steps will be taken to re-channel government funding to supporting field activities rather than motivating CDDs, which is seen as a threat to community ownership and sustainability. Closing this section and introducing pafticipants to the section on articulation of solutions to the problems discussed earlier and other issues raised during the feed back on the evaluation, the provincial Chief of Unit (superuision, monitoring and evaluation) said, ... I am happy with what we are doing because we are going into the qualities of what we are doing. Now we know who should do what... We are going now for guality not for generality. We know who is doing what and who should do what... CDTT is always opening our eyes to many things, The group proceeded to do the SWOT analysis of their project area. They identified the strength, weaknesses which were mostly those highlighted by the evaluators. They also proceeded to identify the threats to CDTI sustainability. They further identified the oppoftunities for countering the threats and taking CDTI implementation to a level of full sustainability in the next five years (see appendix II). Next they proceeded to identify solutions to the weaknesses identified on the implementation of CDTI. This was done for all the levels of CDTI implementation (see appendix III). Finally they developed a five year sustainability plan for the Provincial and Health District levels. Re-evaluotion of SWII CDTI Projectin Cameroon (April 14-28,2008) Page 61 4.4 Way Forward On the way forward, the Provincial Delegate thanked the evaluation team. He gave a speech which focused largely on what the Southwest Delegation of Public Health has been doing, what it plans to do given the opportunities that are coming its way and of course the constraints. According to him, ...the province is happy that the eualuation has come; the evaluatorc have seen and made recommendations. Certain indicators, which have appeared as hircups need to be addr*sed immediately in the entire health are delivery system.... The problems might be the same for all other vertical programmes. The government of @meroon has recognized it and is proposing to addrss them in the Sector Wide Approach (SWAP), The French, German and World Bank as well as WHQ UNICEF are working towards this SWAP to integrate resources etc. for health are delivery. We are still very indebted to ANC and SSI with respect to apibl equipment and funding. I believe you have worked hard in developing sustainability plans to addr*s the problems identified. After the Delegate, the participants were allowed to express themselves on any issues bordering on the evaluation as well as the implementation of CDTI within the SWII project area, past and future. The SSI country representative was the first to speak. In her speech she said, ...for SSI, even if APOC rtops funding the programme SSI will be there beause river blindness is within the Eye Care programme.... Sg will no support everything but will do anything to ensure MedEan@ geb to the stomach of the community memberc. SSI will organize resource mobilization training for the SWII CDn project implementerc to enable them mobilize other resources for CDTI implemenbtion. The representative of the National Coordinator, NOCP, pledged to ensure timely arrival of funds if funds received are adequately and promptly justified. Next, was the turn of the DMOs to express their feelings on the programme. The DMO Mundemba was the first to speak. In his speech, he said, ...this forum has been very illuminating and rewarding for us especially as this planning is concerned. There were many things we were doing, e.g. planning for the sake of planning and routinely. This forum has sharpend our focus. We pledge that with support from paftnerc we shall be there to do the work in spite of the shortage of staff. DMO Eyumujock said, ... I feel that the three days we spent is enriching. The firct thing is that we shall download the information we gained here to the Health Areas.... In the next five years we shall mobilize the communities to bke over the programme. We shall play only the role of assisting them to carry out the programme. Eyumujrck has problem with Ogurah HA so we solicit support of partnerc to daign programme to address these problems.... a Re-evaluation of SWll CDTI Projectin Cameroon (April M-28,2008) Page 52 !DMO, Wabane .... I am glad to have participated in this programme. Wabane is very new even though CDTI is not new to the pmple there. We have ceftain problems. Most of the actorc in CDTI implementattbn lack knowledge of the CDTI philosophy. Secondly, it is a Distict with only new personnel. They lack skills. So we need support to build capacity in these areas. I am very glad being here because I had no experience in planning before now. I have gained from this.... DMO Ekondo Titi ..., We are foftunate to have received one of the evaluation teams in our District. During the eualuatron we were made to appreciate the need to plan for specific activitis. When I go back we shall train the HA sbff on how to draw reah'stic plans duing the next coordination meeting. Although the communities are showing grater intered, we still have problems in Kumbe village where about 25o/o is still refusing teatment with MectEan@. This exercise has helped me to think out effective HSAM to address the issues. DMO Akwaya ...we want to appreciate those who alled to get firct hand informatbn and discuss the findings with us. We have come up with a 5 year sustainability plan. Our main challenge is to get the communities to own the programme. There is high demand for Mstizan@ but ammunities still think it rts government programme. We shall work to get more communities to support CDDs.... The attifude of the local leaders is a hindrance. But now we have a new breed of proactive leaderc in the council. We shall exploit the oppoftunity to push CDTI implementation forward. One of the things we got from here is to involve everybody n the DHS in the implementation of CDTL We shall do that. Wtth resped to capital quipment, Akwaya is a difficult terain so we shall be needing support in the form to transportation.... DMO Fontem ...after the evaluatron and fedback...I will be able to orientate my team on what the programme ought to be not what the staff want We sfrrted the campaign for community ownerchip. This meeting has proved that we were on the rightpart So we shall go back to reinforce it We are s:oliciting support from our partners to prosecute thb task effedively. DMO Mamfe ...1 will start by thanking those who conceived this programme. Having worked with CDTI for a long time f have seen the overflow of the benefits being bonowed by other prcgrammes. CDTI has been leading with otherc following. ArcC and SSI have greatly empowered us. CDTI in Mamfe is not a problem. We have had a very dynamic SDO who has taken his Mectizan@ in the open field for the past four yeas. This has made the comriunity members to see CDT| as a gift from God. However, there was an incident of a woman giving M*tizan@ to her two year old baby believing that Mecthan@ cures all illnesses. The baby died. I am yet to address that There is also the problem of CDDs refusing to distribute Mectizan@. However, the I Re-evaluation of SWil CDTI Project in Cameroon (April 14-25, 2008) Page 63 community membes are now coming to the halth cente to take Medinn@. Some are however compensating their CDDs, DMO Bakassi This is our firct experience. As I have noticed, we used to put the chart before the horce. But with this meeting we are getting refocused. This meeting has helped us to draw some plans which we shall take as a challenge to implement conscientiously. Closing the meeting, the Provincial Chief of Unit (supervision, monitoring and evaluation) remarked that the meeting has been wonderful. She thanked APOC and appreciated the opportunity given the DMOs to express their feelings about the programme, as the way forward for CDTI in SWII project is afticulated. She went further to say that she finds ...the comments of the DMOs very interesting. This forum has helped us to know that we have been joking. Planning is taken seriously now.... I want to ey here that in the appraisal meting we did here we also carried out SWOT analysis. Each percon has been given responsibilities depending on our levels. We were blking of health development plans. This meeting has helped us to know what we are doing. fuforq we were planning for another pe6on. This meeting has helped us to acknowledge our shortfalls. As the SWII CDTI project in Cameroon moves over the period for APOC-guaranteed 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 are highlights of the seven critical components of the "way forward" outlined at the joint final session between the external evaluators and the operators of the SWII CDTI project. 1. Documentation: An important area of deficiency that needs to be tackled in order to enhance the sustainability of CDTI is the relative lack of expertise in repoft writing by the implementers at the lower levels in the project. This is with special reference to documentation of government contribution to the project implementation. A series of workshops at the level of the Districb and Health Areas that address this shoftcoming is highly desirable. 2. Resource Mobilization: By mutual agreement the contribution of the various stakeholders to the sustenance of the SWII project post-APOC is a major challenge, It was agreed that the Provincial and District Teams should take advantage of the SWAP to plan and provide resources, both financial and material for the sustainable implementation of the project. 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. Further to this, the SSI has undeftaken to train the implementers on strategies for resource mobilization to reduce dependence on donor funds 3. HSAM: In recognition of the poor sense of ownership of the project at the community level, it was resolved that high powered HSAM activities supported by staff from the District and Provincial levels should be undertaken to sensitize the community members t Re-evaluation of SWll CDTI Project in Cameroon (April 14-28, 2008) Page 64 a aon their roles in CDTI. The need for intensification of HSAM is further strengthened by the surrounding Mectizan@ in the Ogurah Health Area of Eyumujock. The area is endemic of loa loa and onchocerciasis. The strong fear of side effect makes it difficult for the people to receive treatment. The result is that only 3 of the 15 communities that should be receiving treatment in the Ogurah health area do that now. 4. CDD Compensation: There was a mutual agreement on the dangers of the current practice where Government pays CDDs for distributing Mectizan@ in their communities. This was seen as a threat to sustainability of the project. To address this imminent threat, it was agreed that steps should be taken to sensitize government on its roles in CDTI and re-channel such funds to supporting the activities at the Provincial and DistricVHealth Area levels, while the communities are sensitized to take on their responsibility of supporting the CDDs. 5. Re-orientation of Health Staff: Following the observation of the evaluation team on the dissatisfaction of some health staff at the District and Health Area levels following the withdrawal of APOC allowances, it was thought fit to undertake a re-orientation of the health staff on the APOC philosophy as well as train new health workers in the new created Health Districts on APOC philosophy and CDTI strategy. The complaints against the withdrawal of APOC allowances are a clear indication of poor understanding of the APOC philosophy among some health staff. This needs to be addressed in the shoft term to ensure the proper implementation of the plans for sustainability of the SWII CDTI project. 6. Recruitment of a Government Staff and Project Finance Officer: It was also agreed that the Delegation should assign one of its staff as the project finance officer. The old practice where SSI recruited and paid the salaries of the project finance officer mere sustains the rejected principle and practice of veftical programming within the public health system. Such a finance officer naturally would not be answerable to the leadership of the Delegation. This also negates the principle of ownership of the project within the Delegation which it is meant to serue. 7. Operations Research: The evaluation team also found the new enthusiasm to take Mectizan@ very interesting in many respects and the same time awesome. The low CDD dropout rate, contradicts to what is seen elsewhere. Many CDDs expressed willingness to continue to distribute Mectizan@, irrespective of Government's failure to pay the CDDs every year as promised, because they consider their seruice to their communities more valuable than any pay. These need to be systematically documented and to serue as reference materials for promoting community ownership. It is reasoned that if these are real there are lessons to be learn from them. Thus both the evaluation and SWII CDTI implementation teams discussed and agreed that it will be rewarding to conduct one or two operation researches to ascertain the factors driving the zeal in the CDDs to continue to distribute Mectizan and the willingness of the people to continue to take Mectizan@. The questions for the CDD study will include a. To what extent is their willingness to distribute Mectizan@ driven by altruistic motives? a Re-evaluation of SWII CDTI Project in Cameroon (April I4-25, Z00B) Page 65 b. What is the link between CDD willingness to distribute Mectizan@ and the current practice where government pays them for their roles every year? c. What is influence of their involvement in other programmes with incentive packages and their willingness to perform their CDD roles? For the community members the questions may include a. What are their perceived social and health benefits of taking Mectizan@? b. To what extent is their new interest in Mectizan@ driven by the perceived social and health benefits of taking Mectizan@? c. To what extent is the interest in taking Mectizan@ driven by external socio- economic factors like government paying the CDDs and the current low or no social or economic demands on the people? d. Will the people continue to want Mectizan@ if they are made to play their roles fully and support the CDDs? e. If government withdraws from paying CDDs will the people take full ownership of the programme to an extent that matches their high level of demand for Mectizan@ now? a Re-evaluation of SWil CDTI Proiect in Cameroon (April 14-28, 2008) Page 66 a APPENDIX I: Programme of Activities in the three day Feedback/sustainability Plan Development PROVINCIAL AND DISTRICT LEVEL WORKSHOP PROGRAMME Sustainability of SWII CDTI project in Cameroon "Feedback"/Planning Meeting AGENDA DAY ONE ! t a I Registration of Participants 8.30-9.00 SecretariaUOPC 2 lntroduction of 9:00 - 9:05 All J Welcome and Opening Remarks 9:50 - 9:15 PDPH 4 Inhoduction to the workshop; What are the objectives What is sustainability for Evaluation 9:15 - 10:00 Dr. J.C. Okeibunor 5 Tea Break l0:00 - l0:30 Alt 6 "Feedback" on achievements, issues and lessons from the evaluation on sustainability of CDTI of SWII CDTI Provincial Level District Level Health Area (FLHF) Level Community Level l0:30- 1l:15 Dr. Ekoyol Ewane Ebah Daniel 7 SWOT Analysis 11.15 - 11.30 Dr. Bambo Ngala 8 Group Work Discussions on problems identified and the solutions to these problems using SWOT analysis in groups: 1. PlanningAntegration 2. Leadership/IMonitoring & Supervision 3. Mectizan/Finances 4. Training & HSAM l. Transport/Human/Coverage 1 1.30 - 12.30 9 R.eport from Groups & Discussions 12.30 - 13.00 Dr. Bambo Ngala (assisted by other evaluators) 10 Lt.INCH 13.00 - 14.00 Allll Roles of the different levels and 14.00 - 14.30 Dr. Maduka t2 Steps in Planning for sustainability in this ect and 14.30 - l6:00 Dr. Yota Daniel 13 Group work (Development of 16:00 - l6:45 All Activit Tirne FacilitatorItcnr Re-evaluation of SWil CDTI Project in Cameroon (April 14-29, 200g) Page 67 plans for Provincial and District Levels) T4 General Matters/Announcements 16.45 - 17.00 OPC DAY TWO DAY THREE a 8:30 - 9:00 SecretariatI Regishation of Participant 9:00 - 9:05 Rapporteur2 Review of previous day's activities 9:05 - 9:10 Chair to be elected from among the DMOs 3 lntroduction to the day's activities All9:10 - 10:004 Resumption of Group Work Alll0:00 - 10:305 Tea Break AI10:30 - 13:006 Resumption of Group work AllLUNCH 13:00 - 14:007 14:00 - 15:00 Dr Yota DanielPresentation of Group Work8 15:00 - 16:45 All9 Group work to incorporate corrections 16:45 - l7:00 OPC10 General matters Itcnr Activit Time Facilitator 8:30 - 9:00 SecretariatRegishation of ParticipantI Rapporteur9:00 - 9:052 Review of previous day's activities 9:05 - 9:10 Chair (to be elected from among the DMOs) 3 lntroduction to the day's activities 9:10 - 10:00 All4 Resumption of Group Work 10:00 - 10:30 AllTea Break5 10:30 - 12:30 Evaluation Team NGDO Rep National Coord. 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HA AEEs R e:e,:lEEos u:E ,u *sE i5E;;flgi;= ESEgEi aaaa G)lQ €r; f- o:f6 or- ' e^'E .eb,0:Y=- EEEg < E 3'5 a lr o CB o tr t) G) eP(B=HO46 =6)fr& C) oo cO Fr G) o C) o o "l tr@ o)bo6 o. 6s5N qi N$. l-tr a- o Pq) Eb i.)q) O' -r L) s(/: o o ll q) q,) (d c)k F B. trj ts o 9,e o u)U' o tr& CB 0) B -q b0 troL a -TEEeo-= .-oau)0)G e.3 rB€ F n.B.EiES egi A E.E Ei HS li (d o '(, o 0) r.l a III Solutions to the Weakness and Threats in SWII CDTI Level Indicator Weakness Suggestion ProjecV Provincial Planning The plan did not vary for the last three years Draw plans with showing needs of activities each year Some partners do not seem to be clear of their role Sensitize the parbrers on their respective roles The book keeping is not by govemment staff Assign a government staff for book keeping There is no evidence of showing the sustainability plan to other parfirers All partners should participate development of sustainability plans tn Leadership Some high ranking officials lack knowledge of the workings of the proiect Sensitize all officials on the working of the project Mectizan Mectizan arrived late The NOTF should endevour to order Mectizan twice a year to allow for early supply of Mectizan to projects that distribute between January and June T&HSAM No evidence of increased government financial support for CDTI implementation in response to HSAM Intensiff sensitization and advocacy Awareness of CDTI is low among the political leaders at this level Finance Some members of the leadership are not clear about what is available for CDTI lncrease involvement of key stakeholders in the planning and execution of activities Some members of the leadership at this level do not know the budget for the programme and the contribution of Govt., APOC and SSI The APOC finance officer was not responsive to the leadership at this level Assign a goverrment financial officer for APOC tunds The delegation provides nothing except in maintenance of vehicle and other capital Effectively plan and allocate resources for CDTI rt Re-evaluotion of SWII CDTI Projectin Carneroon (April 1a-28,2008) Page 88 aLevel Indicator Weakness Suggestion equipment Most of the Govt. funds are spent on paying CDDs No specific and realistic plan to bridge the shortfall Train on resource mobilization for meeting short falls The accounting officer is not aware of residual amounts under budget headings Increase involvement of key stakeholders in the planning and execution of activities as well as management of funds available for CDTI activities Transport & other Material Resources No copy of previous travelling authorization for use of vehicle was seen Copies of travel authorizations should be kept in relevant offices at this level There is no plan for replacement of vehicle and other equipment Make realistic plan and advocate for replacement of vehicle and other equipment Human Resources Project accountant is not from the govemment service and was not even seen during the evaluation Assign a government staff for book keeping District Planning Plans are routine and not targeted Draw plans with showing needs of activities each year ln one of the Districts the plan is not integrated Integrate CDTI activities into the overall health plan Integration Activities are not integrated in one of the Districts. Every prografllme carries out its own activities The reason is that the team has not mastered their responsibilities This means training has not been effective in that health district Plan activities and implementation activities in an integrated manner Ensure the training of members of DHS Monitoring & Supervision The District team does not empower the FLHF staff to handle the problems at their level in some Health Areas Train FLHF staff and delegate responsibilities to them Supervision is not targeted Focus supervision on areas with identified weakness Re-evaluation of SWII CDTI Projectin Cameroon (April 1a-28,2008) Page 89 Level Indicator Weakness Suggestion T&HSAM Training is conducted routinely every year There is no objective need for training in most cases Identiff the needs during supervision and yearly appraisals and nain accordingly In one of the Districts, it was observed that HSAM activities are planned but inadequately executed Insufficient advocacy is done towards traditional leaders Make sure all the objectives of HSAM are met by effectively implementing planned HSAM activities Finance The funds for field activities are mainly from APOC and SSI. Funds from Govt are mainly for the payment of CDDs and staff salaries Plan and allocate funding responsibilities to government and improve on the documentation of govemment contribution for field activities In one of the Districts it was reported that the funds are usually inadequate and late Train staff to mobilize local resources for implementation of field activities Budgetary disbursements are on the decline Advocate for increase budgetary disbursements for govemment sources Nothing is done about shortfalls Train staff to mobilize local resources for implementation of field activities District is unable to mobilize resources for CDTI Train staff to mobilize local resources for implementation of field activities Proper accounting is not considered essential in one of the Districts Re-orientate DHS staff on the need for accountability Transport & Other Material Resources The vehicles are not adequate Advocate for more vehicles There is no transport facility in most Districts Advocate for more vehicles When vehicles break down staff work by trekkinq long distances Advocate for more vehicles Vehicles are used for personal reasons There should be a system of control of use of vehicles There should be a fee for using vehicle for personal reason No plans for replacement of vehicles and equipment Plan and advocate for replacement of vehicles by govemment Vehicles are maintained The DHS should ensure the maintenance a Re-evaluation of SWII CDTI Projectin Carneroon (April 14-28,2008) Page 90 aLevel Indicator Weakness Sugqestion with the personal resources of staff in most cases of vehicles Human Resources Staff is dissatisfied in one of the Districts Re-orientate staff on the philosophy of programme Plan and implement programme to motivate staff Coverage Declining treatment coverage rate in Eyumojock Health District due to withdrawal of CDDs Conduct community meetings to sensitize communities on the need to support CDDs Improve supervision of distribution FLHF Planning The Plans do not show integrated implementation of activities in some FLHFs Train FLHF staff on planning and implementation of integrated activities In some FLHFs the staff did not know of the existence of a work plan they drew themselves Re-orientate staff on the importance of using the plans Plans are routinely drawn Plans of activities should be based on needs There was an opportunity to hain for CDTI along with on-going Polio since the same CDDs are used in both but the staff at this level did not in one health Area Staff is waiting for funds to train for CDTI hence commencement of treatment is held up There should be integrated implementation of activities at this level Leadership DMOs initiate training Staff at this level should be empowered to plan and implement activities Some of the opinion leaders at this level are unaware of CDTI Where the opinion leaders know they are ignorant of their roles in CDTI Conduct community meetings and sensitize community leaders on CDTI Monitoring &. Supervision In some FLHFs reports are submitted in a parallel manner using funds from specific prograrnmes Re-orientate staff on the principles of integration Re-evaluation of SWil CDTI Project in Cameroon (April 14-25, 2008) Page 91 Level Indicator Weakness Suqgestion Staff in some FLHFs supervise CDDs routinely Supervision should focus on area ofneed Traditional authorities are not involved in problem solving in some Health Areas Give feedback and involve traditional authorities in problem solve Mectizan Staff at this level are not allowed to make requisition for drugs in some health areas Empower staff at this level to make requisition for Mectizan tablets they need Some staff at this level do not know the right formula for ordering drugs Train staff on the formula for ordering Mectizan Mectizan is rationed and staff at this level is asked to retum to the District for more Supply Mectizan based on needs Training of CDDs is planned and conducted routinely Training should be based on needs No objective need for training Staff at this level insist on routine training before implementins activities Traditional leaders are not involved in some Health Areas Involve community leaders through community meeting and feed backs Finance No budget in most Health Areas visited Staff should budget for activities at this level The relative contribution of all sources of funding is unknown The relative contribution of all sources of funding should be adequately documented Transport & Other Material Resources Transport is not suitable for running CDTI activities at this level Plan and advocate for suitable vehicles Cost of maintaining vehicles and equipment is not met with health centre funds Maintenance of vehicles and other equipment should be met with FLHF resources Vehicle is used for personal reasons without due control There should be a system of control of use of vehicles There should be a fee for using vehicle for personal reason No plan for replacement Plan and advocate for maintenance of t Re-evaluation of SWII CDTI Project in Cameroon (April 14-28, 2008) Page92 ILevel Indicator Weakness Suggestion vehicle and other equipment Coverage There was a decline in 2006 Conduct community meetings to sensitize communities on the need to support CDDs Improve supervision of distribution In 2007 coverage was also <650 in one of the Health Areas visited because of shortase of Mectizan Planning Some update the registers differently from distribution Train CDDs to update census during distribution Leadership & Ownership In some communities the leaders are not involved Involve all community leaders in CDTI activities Health workers decide time for distribution Empower communities to take decision on implementation of CDTI In some communities health worker select CDDs Monitoring The commrrnities do not provide transport in many cases Communities should be sensitized to support CDDs and to carry out CSM Obtaining & Managing Mectizan In some cases the CDDs collect Mectizan outside training and no transport is arranged, when they run out of initial supply HSAM Sensitization has not successfully gotten the people to support the CDDs Engage high powered advocacy team from the District and Provincial levels to advocate support for CDDs Some community members demonstrated ignorance about the social and health benefits of Mectizan Engage high powered advocacy team from the District and Provincial levels to advocate support for CDDs Financing Nothing is done to support CDDs now Engage high powered advocacy team from the District and Provincial levels to advocate supDort for CDDs Some community leaders are not awate of their responsibilities Engage high powered advocacy team from the District and Provincial levels to advocate support for CDDs They think government pays the CDDs so they do not need to motivate the CDDs Engage high powered advocacy team from the District and Provincial levels to advocate support for CDDs Human In some communities Communities should be sensitized to Re-evaluation of SWII CDTI Projectin Cameroon (April 14-28,2008) Page 93 Level Indicator Weakness Suqgestion Resources there is a ratio of 1 CDD tol000 population increase the number of CDDS Some CDDs threaten to drop out if they are not paid CDDs should be sensitized on the need to help their communities Engage high powered advocacy team from the District and Provincial levels to advocate support for CDDs Coverage The trend in coverage is not steady increase in some communities Conduct community meetings to sensitize communities on the need to support CDDs Improve supervision of distribution , Re-evaluotion of SWll CDTI Projectin Cameroon (April 14-28,2008) Page 94 iIV Percons Interviewed at the SWII Evaluation NATIONAL LEVEL/ PARTNERS PROVINCIAL LEVEL DISTRICT LEVEL HEALTH AREA (FLIIF) Staff Interviewed S/l{o FULL NAME TITLE 1 Hendji Michael NOCP (Finance Officer) 2 Dr. Rosa Befidi SSI (Country Representative) J Cyril Evini SSI (Program Manager) 4 Ngole Roland SSVEye Care (Project Fin. Officer) 5 Wilson Arrey Etta SSI (Fin Offrcer) SNo FULL NAME TITLE 1 Eyeya Zanqa Louis Governor 2 Dr. Mafany Niie PDPH 3 Dr. M. Ako-Arrey Provincial Chief of Unit (Su peruision/Mon itori nq/Eval uation) 4 Mr. Oponde Peter oPc 5 Mr. ilambo Pius Mokeyo Provincial Chief of Service (General Affairs) 6 Mrs Ula Abunaw Manager, SW Provincial Special Fund for HeaIth (SWPSFH) SNo FULL NAME TITLE I Dr. Wamba Gaston DMO, Fontem 2 Njilem Joseph CBH, Fontem 3 Fongam Zachaia CBAF, Fontem 4. Ekoume Juines-Eric l't Asst to SDO, Fontem 5. Dr. Emalieu Toko Joseph DMO, Eyumuiock 6. Laluh William Aebor District Chairman 7 Dr Atembeh DMO, Ekondo Titi 8. Pa Luc CBH, Ekondo Titi 9 Madam Kule CBH, Ekondo Titi 10. Rose Wihe CBAF, Ekondo Titi 11. Niocha Romanus Admin. Personnel, Ekondo Titi 12. Ekie Ernestin Leprosy Supervisor, Ekondo Titi S/Ilo FULL NAME TITLE PLACE 1) Achuo Jonas Chief of Post Takwai Health Centre 2) Aiiawune Athanasius Chief of Post Fotabong Health Centre 3) Asaniiiames Noubila Chief of Post Afap Health Centre 4) Tebetah Harry Arrey Chief of Post Kembonq s) Ilambo Comlius Chief of Post Ekondo Titi Re-evaluation of SWII CDTI Project in Cameroon (April 14-25, 2008) Page 95 6) Mejame Ruth Nurse Ekondo Titi 7\ Ndive Clara Midwife Ekondo Titi 8) Enow Pauline Nurse Ekondo Titi e) Eta Justice Lab. Tech Ekondo Titi t0) Bau Patience Pharmacy Attendant Ekondo Titi 11) Emilia Oben Ward Maid Ekondo Titi t2) Okolle Peter Iloemeie Chief of Post Illor Health Centre 13) Airo Mispa Pharmacy Attendant Illor health Cenhe t S/no FULL NAME TITLE I Fongang Thomas Ashu Rep. Villaee Leader, Takwai 2 Enow Nyoh Comm Leader, Mamboh 3 Bisam Max Comm leader, Ebensuck 4. Chief Joseph Fotembe Comm. Leader, Eselewon 1 5 Achenq Niang Anthony Akawung Chair, FIA Health Committee 6. Arrey Arrey Peter Chiel Afap Community 7 Etah Obi Takar Raphael Mbakang 8. Niu Tabot Thomas Ossing 9 Agbor Takang Harry Nfuni 10. Chief Moki Augustine Chief, Dibonda COMMUNITY LEADERS COMMUNITY DIRECTED DISTRIBUTORS I S/no FULL NAME TITLE I Enow Wilson Ashu CDD, Takwai 2 Enoch Simon CDD, Ebensuck 3 James Nkengasong CDD, Belap Athanacious Achankeng CDD, Eselewon I 5 Philip Amiokens CDD, Eselewon 2 6 Takang CDD, Afap 7 Obi Emest Asau CDD, Mbakang 8 Besong Eric CDD, Ossing 9 Agbor Maka CDD, Ossing 10. Takang Andrew CDD, Nfuni 11 Akama Nangiya CDD, Dibonda Re-evaluation of SWII CDTI Projectin Cameroon (April 14-28,2008) Page 96 4. V LIST OF DOCUMENTS OBSERVED 1. Provincial Level - Provincial Comprehensive Health Plan2007 and 2008 - Provincial Budget Document 2006-2008 - SWII Three Year Sustainability Work Plan for CDTI 2007-2009 - Minutes of Planning Meetings - SWII Mectizan Treatment Coverage 2005-2007 - Log book for the project Vehicle 2. District Level - Comprehensive health plan2007 and 2008 - Payment Voucher (ustification) 2005, 2006,2007 - Three Year Action Plan for CDTI 2007-2009 - Workplan for CDTI - Budget 2005,2006,2007 - CDTI supervisory check list - Mectizan requisition form - Expenditure authorization form. - Training manual 3. FLHF Level - Three year CDTI work plan 2007-2009 - Mectizan distribution summary sheet 2005-2007 - CDDs training attendance list 2003 - CDTI supervision checklist - Mectizan Register - CDTI training manual (practical guide for hainers) 4. Community Level. - Community Register - Community Treatment Summary - Measuring Stick a Re-evaluation of SWII CDTI Projectin Cameroon (April 14-25,2005) Page97 vI ADDRESSESFOREVALUATIONTEAMMEMBERS SOUTHWEST II CDTI PROJECT NAME ADDRESS Dr Bambo Ngala Emmanuel Nkambe Ilealth District BP 1842 Nkambe North West Province Republic of Cameroon Cell Phone +237 77660654 E-mail: drbambo2OO5@vahoo.com Dr. Chinyere Maduka Ministry of Health Public Health Department Anambra State Nigeria chymadukaokpala@yahoo. com Tel+234 8073451 166 Dr. Yota Daniel Tubah Health District Po Box 6 Bambili Republic of Cameroon Tel+237 75 29 25 40 E-mail : yotadaniel@vahoo. fr Dr. Ekoyol Ewane Germaine Ministry of public Health Department of disease control Yaoundd Republic of Cameroon E mail : gracia2003 2003 (@.yahoo. fr Tel:+ 237 77 67 27 42 Mr. Ebah Daniel Ministry of Public Health CDAA{SP/SG Yaoundd Tel +237 77 66 52 8l E-mail : ebahzcmp@)rahoo. fr Dr. Joseph C. Okeibunor Departrnent of Sociology/Anthropology University of Nigeria, Nsukka Enugu State Nigeria. Cell: +2348043180351 e-mail : i okeibunor(D,yahoo. com t Re-evaluqtion of SWll CDTI Projectin Cameroon (April 14-28,2008) Page 98 IVU Minutes of the Feed back/Sustainability Planning Workshop (Minutes taken by Programme staff) SUSTAINABILITY OF SWII CDTI PROJECT IN CAMEROON: FEEDBACK / PLANNING MEETING. DAY ONE REPORT: 23-04-08 The meeting started at 9:30am with the registration of participants. An opening prayer was given by one of the participants. This was immediately followed by a welcome address made by the delegate's representative and introduction of participants. Dr. Joseph Okeibunor, the leader of the evaluation team made a presentation on the methodology used for the evaluation. He started by noting that this project was first evaluated in 2003 and this is a re-evaluation which has the aim of assessing the extent to which improvements have been achieved in the project following the findings and recommendations of 2003 evaluation. He specifically listed the objectives of this workshop to include A) giving feedback on the evaluation B) discussing the results C) developing a five year sustainability plan For the evaluation, the team, made up of two external and four internal members who went to three Health Districts, six Health Areas and Twelve communities. He presented an overview of the results showing that generally the project has made significant improvement over the 2003 results. This was followed by a coffee break. The presentation continued with Dr. Ewane on the feedback, on achievement issues and lessons from the evaluation of sustainability of CDTI SWII which was drawn from four levels. - The provincial level - The district level - The health area (FLHF) level - The community level Aspects of sustainability identified. A comparative performance on all the indicators in the entire project was done with finance, transport and other material resources for CDTI since some patners are withdrawing their funds. The presentation was followed by some reactions from the participants on the shortages of mectizan in some Health areas and communities, calculation of the next year's need of mectizan in the health areas and communities and the issue of sustainability by the community since the partners are gradually withdrawing their funds. Health area committee members do not pass health information to their communities and some CDD'S trained collect mectizan and keep due to lack of payment for the previous years. These reactions were addressed by the evaluators and programmed to be included in the plan, Meanwhile the formula for calculating the need for mectizan for the next distribution was given as follows 1. 1/n = total population Yn-1=total population 2. ATO=UTC=84o/o of total population 3. Need = UTC X 3 - left over of the previous year. Re-evaluation of SWll CDTI Projectin Cameroon (April 14-28,2008) Page 99 Despite the shortcoming Dr. Ikeibunor expressed the willingness of the CDDs to continue distribution and the community to take mectizan as discovered during their evaluation in the field. The next facilitator Dr. Bambo presented SWOT Analysis with group discussions on problems identified and solutions to indicators of sustainability which included leadership monitoring and supervision - Planning / integration - mectizan / finance - Training and HSAM - Transport, Human and Coverage Lunch break was at 4:00pm After the lunch the role of the different levels and partners were analyzed and steps involved in planning for sustainability in the project enumerated by Dr. Maduka and Dr. Yota respectively. This was concluded with the criteria for further APOC support after five years. Day's one activities ended at 5:30 pm. Reporters: Ayamba Helen Njilem Joseph t Re-evaluation of SWll CDTI Praject in Cameroan (April 14-25, 2008) Page 100 aMINUTES ON DAY II (24th Aprit, 2008) SUSTAINABILIW PTANNING MEETING ON cDTr ACTTVTTTES FOR YEAR 9 (CDTr SWrr) Moderator: Dr. Yota Daniel Agenda: Presentation of Group work of produced planned activities at different levels of the Health System. The presentation started at about 15:15 with the Provincial team taking the lead. Mr. YINOU Ernest who is also the chief of planning of programs in the Provincial Delegation of Public Health for the South west presented the plan of activities for the provincial level. This was followed by presentations from some districts which were as follows: - Dr. Bamulu for the Mamfe Health District Dr. Dogmo from Bakassi Health District Dr. Ndoko from Eyumojock Health District and Dr. Eric Wanneh from Wabane Health District respectively. Ten minutes were given for the presentation for each group and ten minutes for questions, opinions and suggestions and criticisms to the audience to react. During the periods for reactions, it was realized that there was a mix up between means of verification and expected out comes. To this, one of the evaluators explained the difference between the two points and advised that for a full plan to be made, the expected outcome should tie up with the activities carried out, in order to meet up with the objectives. Also it was said that ceftain points should be spelt out or put into sub points, rather than doing general costing of these items. It was also pointed out during the presentations that no financial presentations were made by any of the presenting groups. But later, it was attributed to time constraint and that by the next day all groups must have finished with their finance presentation. Also amongst the presenters, Dr. Ako Arrey from the provincial delegation of public health for the South West Praised the newly created Health Districts like Bakassi, Wabane and Eyumojock for their good presentations and Eyumojock especially for bringing out the problem of Oguram which is very peculiar in that district. The presentations ended at 5; 20pm while Mr. Oponde gave the closing statement, which is talking about the workload, insisting on an early start of work the next day and encouraging the other districts who were behind the scheduled work to speed up and finish up their work so that presentations can be finalized on the 3'd and last day of the program. He then wished everybody a goodnight and to burn their midnight candles. Reporter: IKOE Cyriel Okolie DAY III (25th April 28, 2008) At 8am the pafticipants reconvened and continued with the elaboration of their Sustainability plans. This exercise was briefly stopped at 10 am for coffee break of 30 minutes. On ! Re-evaluation of SWII CDTI Project in Cameroon (April 14-28, 2008) Page 101 resumption from coffee break, the group work of day one which was not completed had to be completed by al! the participants. Solutions to weaknesses identified during the evaluation were addressed by all in a pafticipatory manner. At 1.30pm, the Provincial Delegate of Public Health called in to officially close the workshop. After his closing statement, he advised the participants to continue and complete their plans. He apologized he had to do the closing a bit earlier because of other pressing official issues. (Copy of closing remarks by the delegate is attached). The participanb continued with drawing of their plans. After completion of this exercise, the following concluded the days' activities. WAY FORWARD The next item on the agenda was the way forward. At this level, the different bodies were required to give possible ways and means for which they think will help in the continuation of the project. The APOC representative was asked to speak first. He first of all appreciated the commitment and total involvement of all participants during the meeting. He then advanced the points: - 1. That he was going to make the necessary recommendations he finds fit for further support from APOC. 2. Also new capitalequipment and capacity building from APOC. SIGHTSAVERS INTERNATIONAL The country representative promised that 1. Sights savers will continue too fund the program even if APOC withdraws. 2. That sight savers will support mainly indispensable activities. 3. Organize a training session to advocate for funding (resource mobilization workshop) due to gap in funding. 4. Provide funds for activities for the next 3 years, and that the funds will increase as activities increases. NOTF The representative for NOTF was very better on the fact that financial issues were not properly handled. He made the following points clear: 1. That more efforts are put in financial reports and it should be of quality. 2. Justifications on all activities should be done 3. Money will be sent on time provided justifications are sent on time. At this point Mr. Oponde, the Provincial Coordinator for CDTI SWII added that Districts will have money for eye care (ten thousands francs per health area (10,000 FRS per health area, 5,000 FRS per health area for carrying out activities for eye care) At this stage the Team leader Dr Joseph asked each of the district medical officers to give their own way forward. a a Re-evaluation of SWll CDTI Project in Cameroon (April 14-25, 2008) Page 102 I -{ t DISTRICT OFFTCER FOR MUNDEMBA (DMO) The district medical officer for Mundemba started by saying that, he is going to improve on his planning strategy. He then pleaded that, the partners should continue to help so too the Ministry of Public Health for he has a committed staff to do the work. DMO EYUMOJOCK The DMO for Eyumojock said he was going to transmit all the information from the meeting to the health areas and the community, and he hope to mobilize and sensitize the community on CDTI. He then pleaded that all support be given him. DMO Wabane The DMO for Wabane said most of the actors do not know the philosophy of the program. So partners especially provincial Delegation of Public Health should help suppoft on sensitization program. He further explained that he has newly recruited personnel but they do not experience and he lacked material resources. He also acknowledged the fact that he has learned a lot on planification DMO Ekondo Titi The DMO for Ekondo Titi affirmed that he has understood the necessity of planning from Evaluato/s visit so well. He has also been trained on drawing realistic plans of action and to execute them. He made mentioned that the Community is aware of the prograrn and taking ownership except Kombe Baluwe. He promised that he is going to carrying out intensive HSAM in this area. He promised to improve in the next year's program. DMO Fontem The DMO for Fontem promised that he was going to Orientate his staff on what programs is supposed to be, reinforce CDD motivation, and improve on HSAM to have good coverage. He then pleaded to the Province to help orientate old staff because it is difficult to control them. DMO Akwaya The DMO for Akwaya said, his main challenge is to mobilize and get the community leaders to own the program and to explore the political leaders. He said ten communities gave support to CDDs. He went further to explain that he had coverage of 72-75o/o within the last two years and he will make efforts to maintain and improve on the results. By doing this he is going to involve all the staff in the activities. He also said; improve in the roads will help a lot. DMO Mamfe The DMO of mamfe said the provision of means of movement has helped in an improvement of results thanks to EPI. He also congratulated the OPC SWII for always being present in the field to solve problems and giving guides. He made mention of the fact that the Divisional Officer of Mamfe always take Mectizan in the field on National days and this has boost people to take t Re-evaluation of SWll CDTI Project in Cameroon (April 14-28, 2008) Page 103 Mectizan. He said one of the communities (Kadifou) has a very difficult settlement hence poor coverage. He promised to improve on his results and also pleaded that means of transport be provided. DMO Bakassi The DMO for Bakassi acknowledged the fact that the meeting has helped to improve on his skills especially as he has just been newly recruited and posted to the new Health District. He said he is now able to draw plans hence ease evaluation. He pledged that Bakassi be visited he the next Evaluation exercise. The Provincial Chief of Unit for Supervision Monitoring and Evaluation appreciated the fact that every DMO was given the opportunity this time to say something. She said, acknowledgements are very important. He acknowledged that the forum has made people to know that they have been joking when it comes to planning. She added that Provincial Delegation of Public Health (PDPH) will always assist but will not exceed the previous amounts. She reminded the participant that in the previous meeting of CDTI the SWOT analysis was there so as for them to know where they were going. The forum has also helped people to understand what they did for planning. She emphasized that people should stop thinking that they are working for other people and that work should be taken as an individuals own work, and that plans must be implemented. She went further saying that the DMOs should make their request clear to the Delegation and their needs will be provided. She conctuded by advising that targeted activities should be done and not routine activities and individuals should evaluate themselves first and not only wait to be evaluated. a- I a Re-evaluation of SWII CDTI Projectin Cameroon (April 1a-28,2008) Page 104 vur SPEECH DELIVERED BY THE PROVINCIAL DELEGATE OF PUBTIC HEALTH DR. MAFANY NJIE MARTIN, ON THE OCCASION OF THE EVALUATION OF SUSTAINABILITY OF SW II CDTI PROJECT IN CAMEROON. Date:25lO4l2OOe Place: Conference Hall, Delegation of Public Health Buea. I stand here to thank the External Evaluators here present, from APOC, Ministry of Public Health, official of NGo, sSI team, and other evaluators for a job well done. The Province is happy that evaluators came, have seen and have recommended. All we have to say is that ceftain indicators which have appeared again as hiccups need to be addressed to as fundamental problems of our health care delivery system. If we take another pCIect like EPI, Roll Back Malaria, TB, the question concerning the account might be the same. The problem of job description might be the same. The problem of implication of the Delegation, and appropriation of all these vertical projects might be the same. The government of Cameroon seeing all these, decided on SWAP, (Sector Wide Approach) in having a common basket for planning, execution, eualuation adapttbn of all projects. District Development plans draft (0) have just been realized, for all projects. They are being studied and in two weeks form now, the provincial conference to harmonize these plans willtake place. Hopefully as we are seeing the French Agency for Development, the German Agency for Development (KFW), World Bank mission, and other partners, WHO, UNICEF etc who signed these convention 2005, in Kribi, for the Sector Wide Approach, willing to reinforced its take off in 2009, and hoping that parliament will have the bill go through. For now, we think, we are still indebted to APOC, SSI, Ministry of Public Health etc, for vehicles, motorcycles, heavy exploitation, materials like computers to name a few and the problem of payment of CDDs addressed to. a Re-evaluotion of SWil CDTI Project in Cameroon (April 14-ZS, Z00B) Page 105 All of you have worked so hard to come up with plans which I believe reflect this vision. While wishing those who are leaving today safe return, those who have some days to enjoy our country site, you are welcomed. May God bless all of you. I declare this evaluation of SW II closed. Long live SWII CDTI pruject Long live international co-operation Long live the Ministry of Public Health Long tive the Republic of Cameruon with it illustrious President: President Paul Biya a l Re-evqluation of SWll CDTI Projectin Cameroon (April 14-28,2008) Page 105 IX Attendance List at the Feedback/Planning Workshop ilrrt r\. 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