Report of the second evaluation of sustainability of Morogoro CDTI Project, Morogoro region united Republic of Tanzania

World Health Organization African Programme for Onchocerciasis Control Report of the Second Evaluation of Sustainability of Morogoro CDTI Project, Morogoro Region United Republic of Tanzania October 2012 External Evaluators: Prof Kenneth AGWU Dr Matilda AKOH-ARREY (Team leader) lnterna! Evaluators : Ms Christina Sifeal MBISE Mr Prince MUTALEMWA Dr Deniss MASSUE Mr Clement MWEYA TABLE OF CONTENT: ABBREVTATTONS/ACRONYM NS IV EXECUTIVE SUMMARY v 2. BACKGROUNDINFORMATION: ..2 2.1 2.2 2.3 HEALTH AND SocIAL WELFARE SERVICES ORGANIZATION AND INSTITUTIONAL FRAMEWORK............... .......................2 MoRoGoRo REGToN: .........................2 MoRoGoRo CDTI Pno:rcr. ................3 SavpIINc AND SELECTION OF SITES: ORIENTATION OF EVALUATORS:...... DATA coLLEcroN: ...................... DEBRIEFING MEETINGS I 3.1. 3.2. 3.3. 3.4. 4. 5. DATA ANATYSIS AND GRADING OF INDICATORS: 7 FINDINGS ON SUSTAINABIIITY OF MOROGORO CDTI PROJECT: .................."...9 SUSTAINABILITY AT TH E REGIONAL 1EVE1......... REcoMMENDATIONS AT TH E REGIONAL LEVEL .......,..... SusrnrnaerLrry AT DrsrRrcr LEVEL ............. RECOMMENDATIONS AT DISTRICT 1EVE1............. SusrArNABILrry AT FRoNTLTNE HenLru FActLtrY LEVEL (FLHF)... 5.1. 5.2. 5.3. 5.4. 5.5. 5.6. 5.7. 5.8. 5.9. .....9 ...74 REcoMMENDATIONS AT FLH F............. Sustnt nn gt ltw at Co tvt vt u trt tw 1EVEI............. REcoMMENDATIONS AT COMMUNITY LEVEL...... Gnaolrve oF THE OVERALL MOROGORO CDTI PNO:TCT: ..t7 ..23 ..27 ..33 ..35 ..40 ..43 ..45 ..46 ..46 ..48 5.10. GRaoIruC THE PROJECT BY LEVEL OF OPERATION ... 5.11. QuaLtrartvrruDGMENToF THE PRoJEcr: .......... 5.11.1. Aspects of Sustoinability:.................. 5.11.2. Criticol Elements of Sustoinability..... 50 6. 7. ANNEXES 7.I. LIST OF EVALUATORS: NAME AND ADDRESSES OF THE EVALUATORS... 7.2 7.3 7.4 ..50 ..51 ..52 ..53 CALENDAR OF ACTIVITIES DEBRIEFING AT REGIONAL LEVEL . PHOTO GALLERY Report of the Second Evaluafion of Sustainability of Morogoro CDTI Prolect .5 -i- LIST OF TABLES Table 1 showing FLHF & communities selected and distonces............... ..'.'......5 Table 3 : Therapeutic coverage.. Table 4 showing budgets for 2070, 2071- ond 2072 LIST Of FIGURES Figure t Sustoinobility indicotors of the Regional level ........... Figure 2 Sustainobility indicators of the District \eve|............ Figure 3 Sustainability indicators of the FLHF level Figure 4 Sustainobility indicators ot the Community 1eve1........... Figure 5 Grophicol presentotion of the overoge grodes of indicotors of sustainobility of the whole Morogoro CDTI project Figure 6 showing the overage groding of sustoinobility ot the different levels of operotion of the ,......,....12 Table 5 showing summory of the grodes of the vorious groups of indicotors by level of operotion.....43 35 ...9 77 27 43 45 Report of the Second Evaluation of Sustainability of Morogoro CDTI Prolect -ii- ....................... 8 ACKNOWLEDGEMENTS 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. Paul-Samson Lusamba-Dikassa, and staff at APOC Headquarters in Ouagadougou for making available the necessary financial and logistic requirements for the success of this assignment. . The WR/Tanzania, Dr Rufaro Chatora and staff contributed to the smooth running of the mrssron The National Coordinator of the control of NTDs, Dr Upendo and herteam forfacilitating the smooth take off of the exercise in Tanzania. The Morogoro CDTI Project staff at all the operational levels for their cooperation. They provided relevant information to the evaluation team. The community leaders and members in the study communities, who provided important information and were very lively and enthusiastic in their interactions with the evaluation team. Report of the Second Evaluatnn of Sustainabilit.v of Morogoro CDTI Proiect -ilt - ABBREVTATTO NS/ACRO NYM N S APOC........ African Program for Onchocerciasis Control CDD.......... Community Directed Distributors CDTI ......... Community Directed Treatment with lvermactin CCHP........ ComprehensiveCouncilHealthPlan CHMT....... Council Health Management Team DMO......... District Medical Officer DOC DDH FBO District Onchocerciasis Coord inator Designated District Hospitals Faith Based Organization First Line Health Facility Geographical Coverage Rate Health Education, Sensitisation, Advocacy, Mobilization, lnformation, Education and Communication Joint Action Forum FLHF .. GCR... HSAM tEc..... JAF MDA......... Mass Drug Administration MoHSW..... Ministry of Health and Social Welfare MSD.......... Medical Store Department NGDO........ Non-Governmental Development Organization NTDs......... Neglected Tropical Diseases NOCP . National Onchocerciasis Control Programme NOTF .. National Onchocerciasis Task Force RAS............ Regional Administrative Secretary RHMT....... Regional Health ManagementTeam RMO.......... Regional MedicalOfficer SS............. Sight Savers TB/HlV Tuberculosis/Human lmmune deficiency Virus T2S........... Tanzania Shillings TCR........... Therapeutic Coverage Rate WHO .. World Health Organisation WR........... WorldHealthOrganisationRepresentative Report of the Second Evaluation of Sustainability of Morogoro CDTI Prolect -tv- EXECUTIVE SUMMARY The Morogoro CDTI project was launched in 2003. The project had the first round of mectizan distribution in 2004. The project has successively undergone the monitoring and evaluation processes as stipulated by APOC to ensure project sustainability when external funding stops. The project had lndependent Participatory Monitoring in 2OO7 and External Evaluation of Sustainability of the project in 2008. During this evaluation the project was 5 years old but had undertaken 4 rounds of treatment because distribution was not done in 2005. Thetotal population of the entire project area is 613,077 inhabitants of which 361,040 are found in the meso/ hyper endemic oncho zones distributed in 1,059 communities (sub villages). APOC is concerned about the sustainability of projects it supports after its funding ends. The big questio n is, "Whot would become of the proiect when externol funding stops?" APOC and the Tanzanian MoHSW, organized a second evaluation of the sustainability of the project, 8 years after its onset (7 rounds of treatment) The evaluation was conducted by a team of 6 evaluators (2 external and 4 internal) from the 24th September to l0th October 20L2. The evaluation team was charged with the following tasks: ,/ To evaluate the sustainability of the project; ./ To present and discuss the results with the relevant stakeholders and partners in the project. ,/ To discuss the way forward i.e assist beneficiaries plan to mobilise resources and put in place routine processesthat will ensure continuity of key activities of the project. ,/ To remind actors on issues of elimination of onchocerciasis in the project area. Morogoro CDTI project has only two districts hence the sites visited (FLHF and communities) were selected from these districts. lnformation was gathered through interviews, study of relevant documents and reports of activities from all the operational levels (National/project, District, FLHF and communities) using the 4 APOC instruments L, 2,3 & 4. Using the ten groups of indicators, the seven aspects and the five critical elements; the evaluation team analysed the data collected and came out with the following findings: Planning: CDTI activities are planned at all the operational levels and form part of the minimum package of each level. They are integrated in the yearly work plan at the district Report of the Second Evaluation of Sustainabilfiy of Morogoro CDTI Prolect and FLHF. Planning is done in a participatory manner with management teams and stakeholders of each level. Planning of activities is done at all levels but the aspects of sustainability are not clear for a project that has been evaluated for sustainability and had elaborated plans. At the regional level CDTI was not a priority for the year and therefore was not integrated in the plan. Management at the regional level explained that its function is monitoring and supervision of activities in the health districts and not implementation. The monitoring and supervision is done in an integrated manner. lt includes programmes in its yearly plan when it is necessary. But it makes sure the districts have CDTI activities in their yearly plans. The indicator falls between 2.5 and 3 with an average of 2.8/a and therefore favou rs sustainability. lntegration: CDTI is integrated into the health system. Key activities of CDTI are integrated as mectizan is supplied to the lower levels during training. As concerns integration with other health programmes, there is insufficient documentation to show how activities are carried out in an integrated manner. The indicator falls between 3 and 3.5/4 with an average of 3.2 which highly favours sustainability. Leadership: The initiation of CDTI activities starts with the planning of all health activities and this is usually done before the start of the next fiscal year. This planning is a routine activity of all the operational levels. After this, the other key activities start only when funds are available and are usually APOC and NGDO funds. The districts wait to get funds from the regional office and the FLHF also wait for the district to inform them when the funds are available. There are focal persons at the region and district levels. At FLHF the focal person is usually the in charge of the HF. The communities do select their CDDs, time and mode of distributing drugs. The CDDs in most communities carry out census before distribution. The community leaders and CDDs manage any problems that arise but most communities do not actively get involved in problem solving. The communities with leaders are not informed of or do not yet understand their ownership role. The community leadership and ownership indicator is 2.L514 (moderately) favouring sustainability while the indicator falls between 2 and 3 for the FLHF, district and region. The leadership initiates implementation but is limited due to lack of funds. Monitoring/ supervision: Data collected for CDTI activities is transmitted within the government system. Census and treatment data from the CDDs is submitted to the FLHF, Report of the Second Evaluation of Sustainability of Morogoro CDTI Project -vt - usually on time, and from thence to the district coordinators and subsequently to the regional coordinator. But at the level of the district data is not properly managed as the district coordinators submit data of the communities from FLHF directly to the regional coordinator. One of the district coordinators has been trained by APOC on data management. He collects the treatment data and records them directly into the computer of the region. Districts do not have individual reports. There are no hard copies and no annual reports. Supervision of activities is present but not adequate. This is revealed by the fact that 56 communities in Morogoro Rural disctrict had not been treated for two years (2010 and 1OLI) and the district and region were not aware. This was discovered by the evaluation team. Communities visited are not doing CSM and do not support the CDDs with transport to submit reports or collect mectizan where needed. There is need to document the processes of management of problems and successes. The average grade for this indicator is 2.91a. Mectizan@ Procurement and Distribution: Mectizan is procured and distributed through the government system. The calculation of the quantity needed does not use census data. lt uses a formula (total population x 2.21. However there has been neither shortage nor late supply of Mectizan since 2009 though no system of managing stock is in place. The indicator is3.2/4 Training and HSAM: The regional level trains district staff; district staff train FLHF staff who in turn train CDDs. At the district level and FLHF training is routinely done as refresher every year for all the actors both new and old (FLHF and CDDs). HSAM activities are planned at all levels. Advocacy meetings to RHMT, CHMT and PHC teams have been regularly conducted yearly since 2009. The execution of sensitization and health education activities at lower levels are inadequate. The communities and leaders are not informed of their ownership role. The impact of advocacy on mobilization of resources is yet to be felt as the mobilization of resources locally is still problematic. There are not enough training and HSAM materials at all the levels. This indicator with an average score of 2.4l4in this assessment is moderately favou ring sustai nabil ity Finances: The performance of the project in this indicator is still problematic. Activities start only on arrival of APOC and NGDO funds. Budgeted yearly plans are elaborated at regional and district levels but do not show strategies of cost reduction or containment. Also government contribution is usually released late. The country fiscal year runs from July to Report of the Second Evaluation of Sustainability of Morogoro CDTI Project -vii- June. During the time CDTI activities start, government funds are not yet ready for disbursement to the RHMT and the CHMT. The government contribution budgeted does not make up to half of the contribution of external partners. There are no local partners. Apart from the NGDO, SS, that is still to sign an agreement for financing the project after APOC funds stop, there is no other source. All the FLHF do not cost activities of CDTI. Funds disbursed are properly managed. Communities and their leaders believe CDDs are paid by the government so they do not discuss ways of supporting them. The performance in this indicator Qla) is moderately helping sustainability. Transport and other material resources: The project has one vehicle donated by APOC from the beginning of the project. The vehicle is used by both the region and the two districts. However districts have vehicles provided by the councils. Management of vehicles at both regional and district levels is done in a pool. Vehicles are maintained but there are no schedules for preventive maintenance. Request for replacements are regularly made to the authorities concerned but the response has not been positive. There is inventory of equipment at the regional coordination office. Laptop, computer, photocopying machine, fax machine and printers supplied by APOC are old and continuous maintenance is not cost effective. The performance of the indicator is 2.4/4, moderately helping sustainability. Human Resources: The staffs are adequate quantitatively and qualitatively. They consider CDTI as part of their job. They are stable in office. At the community level, the ratio of CDDs to household is inadequate. There is no problem of CDD attrition. Since the inception of the project very few replacements of CDDS have occurred due to deaths, marriage and relocation out of the community. This indicator is highly helping sustainabilitV P.2/a) Coverage: The geographical coverage for }OLO and Z.OLL as recorded at regional coordination office is 700o/o. But this is not realistic following reports from the field. The non treatment of 56 communities has been due to poor monitoring and supervision of activities. The project had attained 700% GCR before 2010. The TCR in some communities where treatment has been going on regularly, has been increasing (Mvuleni 68% in 2009, 7Lo/o in 2010 and 84o/o in ZOIL; Miembeni 7Lo/o in 2OO9,7L% in 2010 and 82% in 20LLl; and in others it has been fluctuating within the last three years showing good coverage in 2009, drop in Report of the Second Evaluation of Sustainability of Morogoro CDTI Project -vilt- 2010 and then increase in 2011. However, the average TCR for the past two years has been 77% in 20L0 and 8L% in }OLL. The average for the two years stands at79o/o. The average sustainability score of the whole project stands at 2.8. This is lower than the overall score of 3.6 in the first evaluation at year 5 (4tn treatment cycle). The APOC sustainability evaluation guide expects that for a Year 3 evaluation, a project should score at least 2.5 overall - that is equivalent to a judgment of 'Making satisfactory progress towards sustainability'. At Year 5 the score should be considerably higher than that. Also the guidelines indicate that where "one or two aspects are not fulfilled and one or two critical elements are not satisfied, the project is making satisfactory progress towards sustainability". Considering the aspects, "resources" are potentially blocking and "efficiency" is partially blocking sustainability while the critical element of "money" is blocking sustainability. The evaluation team found that the Morogoro CDTI project has potentials of being sustainable. Some critical steps have to be taken urgently to follow up and improve on some indicators of sustainability as CDTI is the driving force in the control of NTDs. Recommendations: The regional and district coordinators should ensure treatment of the communities that have not been treated since 2010. The project managers at regional and district levels should educate FLHF and communities on all the aspects of CDTI including community ownership. There should be improved documentation of activities to show evidence of the real integration, apart from the inclusion in the work plans. There is need to improve on the quality of monitoring and supervision at all operational levels. Census taking and distribution of mectizan by CDDs (recording of information in the registers) should be properly supervised. Districts should produce their individual reports (treatment reports, annual reports using the APOC annual report format) and submit hard copies duly endorsed by the DMO. They should have their copies in the district files. Report of the Second Evaluation of Sustainabrlity of Morogoro CDTI Proiect -tx- The regional coordination should put in place a system of stock management of mectizan/drugs. Elaborate drugs order forms. Districts and FLHF should have drug stock management registers (Refer to Mkindo dispensary). The Government should commit more funds to CDTI activities because donor fund is decreasing. Review sustainability plans and budgets to reflect cost reduction/ containment strategies. Activities of CDTI are carried out in the 2nd semester of the year and only on arrival of APOC andNGDOfunds.Thisfallsinthel-'tsemesterofthecountryfiscal year. Becauseofthisthe government's contributions usually come late after activities have been concluded. Government funds should be budgeted such that they can be used to start the activities. This will make the project less dependent on external funding. Communities should increase the TCR as the goal of CDTI is to eliminate onchocerciasis. xReport of the Second Evaluation of Sustamabiltty of Morogoro CDTI Project 1. INTRODUCTION: Onchocerciasis is a major public health problem in some parts of the United Republic of Tanzania as in other African countries. ln 2003, APOC and the government of Tanzania signed a protocol agreement of financing to control this scourge in the Morogoro Region of the country. Onchocerciasis is a disease that effectively gets eliminated after several years (at least L5 years) of treatment of everybody in the endemic areas with lvermectin to interrupt transmission cycle. The partnership agreement is made for a number of years but not covering all the years. APOC is concerned about the sustainability of projects it supports after its funding ends. The big questio n is,"Whot would become of the proiect when externol funding stops?" Hence APOC designated a team of 6 evaluators [2 external and 4 internal (nationals)] to conduct a second evaluation of the sustainability of the Morogoro CDTI project. The first sustainability evaluation was conducted in 2008. This second assessment took place from the 24th September to 10th October 2072. The main objective of the evaluation was to determine the SUSIAINABILITY of the Morogoro CDTI focus after 8 years of operation. The specific objectives were: 1. To assess the performance of the Morogoro CDTI project in the various indicators of sustainability. 2. To identify factors that are favoring or not favoring sustainability of the project. 3. To assess the level of implementation of recommendations of previous evaluations 4. To discuss the findings of the evaluation exercise with the relevant stakeholders and partners in the project. 5. To discuss the way forward i.e assist beneficiaries plan to mobilise resources and put in place routine mechanisms which will ensure continuity of key activities of the project. 6. To remind actors on issues of elimination of onchocerciasis in the project area. -1-Report of the Second Evaluation of Sustatnability of Morogoro CDTI Project 2. BACKGROUND INFORMATION: 2.1. Health and SocialWelfare Services Organization and lnstitutional Framework The MoHSW is charged with the responsibility of ensuring the provision of quality health services in the country. To accomplish this responsibility, the Ministry's functions are divided into six directorates which include: Hospital Services, Preventive Services, Human Resource Development, Policy and Planning, Social Welfare, Administration and Personnel. These departments are further divided into sections for a more effective implementation as reflected in the organogram. The Government operates a decentralized health system which broadly falls into three functional levels: district (Level l), regional (Level ll) and referral hospitals (Level lll). Under this system, the districts have full mandate for planning, implementation, monitoring and evaluation of health services. The district level provides primary health care services through health centers located at the ward level catering for 3-5 villages with an average population of 10,000 people. The current move is to have a dispensary catering for each village. The health centre is the referral level for the dispensary and it provides a slightly broader range of services than dispensaries, including in-patient care and it used to cover an average population of 50,000 people. District hospitals provide services to an average of 250,000 people. Almost all the districts have district hospitals, except for the 2L districts where there are no government hospitals. ln these districts, Faith Based Organization (FBO) hospitals are delegated as Designated District Hospitals (DDHs). There are 37 private hospitals and 66 Faith Based hospitals providing health services in the country. The Regional hospitals at Level ll serve as referral points for Level I i.e. District Hospitals with more specialized services and cater for a population of about 1,000,000 people. Level lll comprises of Referral and Specialized Hospitals. There are four referral hospitals in the country and four special hospitals providing psychiatry, tuberculosis, orthopedics/trauma and cancer care. Some of the private and FBO hospitals offer specialized services. 2.2. Morogoro Region: Morogoro Region, one of the 2L administrative regions of Tanzania Mainland is located in the Eastern part of the country. According to the 2002 population and human settlement 2Report of the Second Evaluation of Sustainability of Morogoro CDTI Project census, the region has an estimated population of about 1,759,805 inhabitants with an annual of growth rate of 2.6%. The region comprises six districts namely; Morogoro Rural, Kilosa, Ulanga, Morogoro urban, Kilombero and Mvomero. The region is inhabited by Luguru, Kaguru, Kwere and Masai tribes. These communities consist of indigenous and nomadic population; the mountainous areas being much more densely populated than the low land. The main occupation of the people is farming of food and cash crops, cattle herding, small scale fishing and timbering. Morogoro CDTI Focus covers two districts the Mvomero and Morogoro Rural. The two districts lie between latitude 8oand LOo south of Equator and between longitude 37o and 38o East of Greenwich. Several rivers and tributaries originating from the mountains cut across Morogoro region. Major rivers include Kilombero, Ruaha, Luwengu, Ruvu, Wami, Ngerengere, Mkondoa and Mkindo. There are about L43 rivers, which form very large plains in the lowlands consisting of fertile alluvial soils. Due to the climatic influence of the lndian Ocean, the Eastern Arch Mountains have unique plant and animal life. Although environmental degradation has affected the area for many years, there are still different species of fauna and flora. This is particularly true in the case of the Udzungwa and Uluguru Mountains. 2.3. Morogoro CDTI Project Morogoro CDTI project called Morogoro CDTI Focus is one of the 3 CDTI projects in Morogoro Region. The project was launched in 2003, and the first round of distribution of mectizan took place in 2004. ln 2OO7 (4th year after launching but 3'dround of mectizan distribution) lndependent Participatory Monitoring of the project was conducted. External Evaluation of Sustainability of the project was carried in 2008. The project was 5 years old but had undergone 4 rounds of treatment because distribution was not done in 2005. This was due to late funding from APOC. ln 2009, the project incorporated the distribution of drugs for the control of other NTDs Lymphatic Filariasis; Soil Heminthiasis and Schistosomiasis through school health programme. The total population of the entire project area is 6L3,077 inhabitants of which 351,040 are found in the meso/ hyper endemic oncho zones. The 361,040 inhabitants are distributed in 3Report ofthe Second Evaluatron ofSuslainabiltlt ofMorogoro CDTI Project 1,059 communities (sub villages). The sub-village is the lowest and smallest administrative structure. lt has a population ranging from 80 to 350 inhabitants. Partners in the Morogoro CDT! Project o Ministry of Health and Social Welfare o African Programme for Onchocerciasis Control o Sightsavers o District councils o Communities 3. METHODOLOGY: The methods used at each stage of the exercise were very participatory with the nationals and external evaluators taking active part. 3.1. Sampling and selection of sites: This exercise took place in the regional coordination office. lt was done with the participation of the regional coordinator, the district coordinators, the escort from the national NTDs coordination office and facilitated by the two external evaluators. There was no selection of districts as the project has only two districts. For each of the districts, a list of all FLHF with their therapeutic coverage rates was elaborated; the FLHF with the highest and lowest coverage rates were selected taking into consideration the geographical accessibility. Therapeutic coverage rates for 201L and 2010 were considered. Selection of the communities was done by first listing out the communities catered for by the FLHF selected. Two communities were randomly selected from each group. Geographical accessibility of the communities was an important factor in the selection. It is worth noting that the pre-evaluation visit coincided with the period of the evaluation. After the selection of sites letters were made by the RMO to inform the districts and FLHF. Because of the time limit much of the communication was made by telephones. Report of the Second Evaluatrcn of Sustainability of Morogoro CDTI Project -4- District Distance from RHO FLHF Distance from DHO Communities (Sub villages) Morogoro DC (Rural) 500m Matuli 75km Lamba Lulongwe Mkambarani 20km Mfine Mngusi Mvomero 38km Hembeti* 32Km Miembeni Mvuleni Mkindo* 35km Minazini Bohelo Table 1 showing FLHF & communities selected ond distances *Hembeti ond Mkindo ore in opposite directions from the district Table 2 showing the geogrophical ond therapeutic coveroge rotes per selected site for 2010 and 2011 3.2. Orientation of evaluators: This session took place in the coordination office with all the evaluators in attendance. The following topics were discussed: ./ Presentation of NOCP/Tanzania National Health System ,/ Presentation of Morogoro CDTI Project ,/ APoc Philosophy and cDTl concept ,/ Objectives and expected results of the mission ,/ Sustainability; District 20LO 20LL cc (%) rc (%) cc (%l rc (%l Morogoro DC (Rural) 100 80% 100 80% Mvomero 100 80.3% 100 8Oo/o r '.t. District FLHF Communities 2010 20Lt Morogoro DC (Rural) Matuli 84% 84% Lamba 84% 84% Lulongwe 77% 77% Mkambarani 82% 67% Mfine 80% 87% Mngusi 78% 75% Mvomero Hembeti 85% 68% Miembeni 80% 8Lo/o Mvuleni 89% 84% Mkinda 86% 80% Minazini 8L% 86% Bohelo 87o/o 77% Report of the Second Evaluatrcn of Sustarnability of Morogoro CDTI Project -5- o Definition o lndicators and grading of the indicators o The Aspects and Critical Elements of CDTI ,/ Study of instruments - the instruments were read out and discussed to obtain a common understanding. The team members were encouraged to read and study at their individual level the guidelines on Evaluation of sustainability of CDTI projects as they received them only in the morning of the orientation session. 3.3. Data collection: Using the 4 instruments for APOC evaluation of CDTI projects, information was collected from the National, Regional, District, Frontline Health Facilities and communities. o lnstrument l for National/Regional level o lnstrument 2 for District level o lnstrument 3 for FLHF level o lnstrument 4 for communities lnterviews with actors and study of relevant documents were conducted at allthe levels. At the national level interviews were conducted with WHO NTDs Focal person, APOC Administrative and Financial Assistant, staffs of the National NTDs coordination office. As concerns the NGDO partner, SS, one of the evaluators is the programme officer for SS and thus provided the necessary information Some members of the RHMT who were available (Acting Regional Medical Officer, Regional transport Officer, Project Coordinator) at the regional level were interviewed. At the district level, the District Medical Officers; District Pharmacists; District Transport Officers, District planning officers and District NTDs coordinators were interviewed. Other individuals interviewed included the Frontline Health Facility staff and in the sub- villages/communities, community leaders, CDDs, and community members from selected communities. The evaluators had discussions with the community members in group of L5 to 20. The team of evaluators worked in two sub teams of 3 evaluators and the district coordinator each. Each sub team had an external evaluator. Report of the Second Evaluation of Sustainability of Morogoro C DTI Project -6- Meeting with WR Tanzania representative, MoH, NGDO and Regional Administrative officials: While the APOC guidelines for conducting assessment of sustainability of CDTI projects solicit for meetings with WR country representatives, key officials of Ministry of Health and NGDO partner on arrival in the country and be briefed on the mission, this was not possible as they were reportedly out of office. At the WR/Tanzania office the officer in charge of Operations was met and briefed on the mission. However, the WR/Tanzania representative was later met and de-briefed about the key findings of the exercise. At the region the acting Regional Medical Officer and the acting Regional Administrative Secretary in Morogoro Region were met and briefed on the mission. Limitations Some of the key actors could not be interviewed as they were reported to be on annual leave. At the National NTDs control coordination office most staffs are new so their knowledge on CDTI activities was limited. The focal person for onchocerciasis control at this level was not available. 3.4. Debriefing meetings After the collection and analysis of the information, actors and officials were met and debriefed on the key findings. A session of debriefing was held in the office of RMO. The following officials were in attendance at the debriefing meeting; the NTDs regional coordinator, the district NTDs coordinators and representatives of the DMOs of the two districts. At the WR, the representative and the NTDs focal person were debriefed. At the MoH, the acting national NTDs coordinator was de briefed. The SS partner could not be met for the debriefing. However the notes for debriefing made for the national level were sent through the email address of the programme officer. 4. DATA ANALYSIS AND GRADING OF INDICATORS: Data analysis was done in two stages. Each sub team first assembled and analysed the data it had collected from each district, its FLHFs and communities. Then the two sub teams assembled the data from their work by level: district, FLHF and communities. The analysis was made by carefully making reference to the characteristics of each indicator or sub indicator. During the sessions of data analysis, the regional and district coordinators were Report ofthe Second Evaluatton ofSustainabiltty ofMorogoro CDTI Prolect -7 - call upon to clarify information for the evaluators. The grading of indicators was done by consensus of all the evaluators. The maximum grade is 4 as stipulated in the APOC guidelines of assessing sustainability of CDTI projects. Therapeutic coverage: ln this study we apply APOC recommendations of the 2008 JAF held in Kampala on grading of indicators within the framework of elimination of onchocerciasis. On the instruments the values for grading are 265% for fully, 60-640/o for highly, 55-59o/o for moderately, 50-54% for slightly and <50% for Not at all. Referring to APOC instructions the therapeutic coverage rates are: >8O% for fully, 70 -79% for highly, 60 - 69% for moderately, 50 - 59o/o for Slightly, and <50% for Not at all. Table 3 : Therapeutic coverage Grade Fully Highly Moderately Slightly Not at all APOC JAF >80% 70 - 79% 60 - 69% 50 - 59% <50% lnstrument >65% 60-64% 55-59% 50-54% <50% Report of the Second Evaluatrcn of Sustamability of Morogoro CDTI Project -8- 5. FINDINGS ON SUSTAINABILITY OF MOROGORO CDTI PROJECT: 5.1. Sustainability at the Regional Level Figure 1 Sustoinobility indicators of the Regional level The figure above presents the performance of the project in the key indicators of sustainability at the regional level Planning (3) There is an overall year plan for the service but onchocerciasis/NTDs control is not included though other disease control strategies as for TB/HlV, Reproductive health are included. The integration of the programmes in the regional overall plan depends on yearly priorities. This is also because the region considers that it has mainly a supervisory role and not execution. However the RHMT reported that it ensures during supervision that the districts conduct the activities of CDTI/NTDs and integrate them in the District Council Comprehensive Health Plan (DccHP). There is a more detailed plan for CDTI/NTD which contains the key elements for 2OIL/2O721. 1lt is worth mentioning here that the fiscal year in Tanzania runs from July to June while the APOC year runs from January to December Fig 1: Sustainability at Regional level 4+ 44 t lJ.) 6.i $ =roE c'l' .9N(u 3 rrr. o ED(E tuu? $ o 333 3 2.75 2.5 *"--"CC".u "t no-*C "C^.-t J "/ ^.s Group of lndicators Report of the Second Evaluahon of Sustainabil4t of Morogoro CDTI Project -9- There is no evidence of integration as the activities of CDTI/NTDS were not reflected in the overall year plan. The reason given for this was that, CDTI may not be top priority for the year, because the coordinators are invited to planning meetings only when they are needed as co-opted members. The partners (SS, lMA, WHO/APOC at the national level) participate in the planning meetings and make their contribute clear to other stakeholders as seen on the minutes of a meeting. NOTF has been dissolved and plans are on the way to create the NTDs Task Force. Meanwhile at the national level the coordination office is for NTDs with onchocerciasis included. At the project level, the partners for control of NTDs/Oncho like SS were at the meeting but the overall plan did not reflect their input. The project was evaluated for sustainability in 2008 and a three year sustainability plan (2009, 2OLO, and 2011)was elaborated. lntegration of support activities (3) Activities are reported to be integrated with staffs carrying out activities in an integrated manner. There was a work plan for CDTI activities that runs from May to December every year. Staffs combine training of FLHF staff with supply of mectizan and albendazole. They supervise MDA for onchocerciasis and LF as co-implementation of the two is taking place in the project area. There is no evidence of implementation of CDTI activities with other programmes.in an integrated manner. Log books are used for trips. Transportation is managed in a pool and authorisation forms are available but they do not specify the activities or programmes supervised. Leadership (3) Leadership is aware of the progress and challenges of the project. lt is aware that there is improved awareness of the programme in the community and also lack of proper documentation at all levels of implementation. The leadership delegates responsibilities to colleagues at this level (e.g supervision of activities) and district coordinators but there is inadequate feedback for prompt intervention. For example when reports of supervision do not reflect issues of the programme there are no queries. There is a good working relationship with colleagues. Report of the Second Evalualion of Sustainability of Morogoro CDTI Project -10- Monitoring/ supervision (2.75) lmportant records (treatment summary records, inventories of equipment, financial records, periodic reports and annual technical reports) are readily available. Treatment records are only found in the computer, there are no hard copies. There are no hard copies for individual district reports. The districts do not compile individual annual reports. The treatment coverage reports are not very reliable as they do not agree with field reports Recording of treatment data is not systematic, making it difficult to evaluate the performance of the FLHF within its catchment area. The staffs at this level supervise only the district while an equivalent team at the district level supervises the FLHF. Supervision of NTDs/CDTI is done by a team of 5 which comprises the RMO, the coordinator of school health, the coordinator of eye care, the NTDs/oncho coordinator and pharmacist. The supervisors may go below this level where there are problems. Supervision reports and minutes of planning meetings were available. There are 2 checklists for supervision one for oncho and the other for NTDs. However, only the checklist of NTDs is being used. The checklist in use does not allow details of operations to be captured succinctly. There are supervision reports for CDTI/NTDs. When problems are identified the coordinator gives instructions to district coordinators to follow up. Annual review meetings are conducted. Sometimes the follow up is not done for due to lack of funds. Successes are not documented. Mectizan@ procurement and distribution (4) The regional coordinator of the programme receives request from the district coordinators, compiles them and submits them to the national coordinator. The needs are calculated using the formula: total population x2.2. This formula is said to be used to take care of mectizan needs for the non oncho districts for the treatment of LF. The procurement of mectizan is done through the Medical Stores Department (MSD) based on the existing government arrangement and Public Procurement Act. The national MSD supplies mectizan directly to the district pharmacies using government logistics. Mectizan is supplied in time and in sufficient quantities to the districts. Report of the Second Evaluation of Sustamability of Morogoro CDTI Prolect -t7- Training and HSAM (4) Training is usually based on reported lapses identified in the previous year's report and therefore based on needs. There has been no training for this year (20L2) because there was no need. ln 2011 training was organised by the national level for both regional and district staffs. The training was sponsored by APOC. Advocacy meetings have been organized for the RHMT every year for the past three years. The reason advanced for organizing advocacy meetings to the same audience every year was in response to changes in leadership at this level. The region has produced a VCD on CDTI, produced spots for the media. Considering the outcome, the therapeutic coverage rate has been stable for the last two years. The national level produced posters and flyers. The region also organised a Mectizan Day sponsored by SS. During this day political, administrative authorities and community leaders took (swallowed) mectizan to encourage the population to participate. Finance (2.5) The yearly plans for CDTI activities are budgeted. Each activity has its cost. This is spelt out in the yearly plans for 2009,?OLO,2011 and even 2012 presented. There is no evidence of cost reduction/containment strategy, as the percentages allocated to each key activity are almost the same over the years. Table 4 below shows budgets for 2070, 2077 and 2072 Though the amount budgeted bygovernment is increasing annually; it is not up to half of the amount needed for a project in the seven year and has been evaluated for sustainability with elaboration of sustainability plans. The project coordinator usually has a clear estimate of what the NDGO partner (SS) will make available for the year, and makes estimates on what the government and APOC would give. Except for the NGDO contribution, not all the funds budgeted are received. The Year Total Budget Contribution of partners in TZ shillings ando/o APOC % MoH o/o NGDO % 2070 360,829,550 220,767,785 61.18 L07,949,415 29.92 32,Lr2,350 8.90 207L 432,62L,350 256,030,885 59.19 L37,6tL,Lt5 37.82 38,879,350 8.99 20L2 476,426,850 262,734,385 55.02 L72,687,2L5 36.25 4L,605,250 8.73 Report of the Second Evalualion of Sustainability of Morogoro CDTI Project -72- shortfalls are however met by redistribution of the funds (re-costing but maintaining the activities planned). There are no reliable sources of funding yet after APOC funding ends. However, there is an ongoing discussion to sign an agreement with NDGO partner to sponsor some aspects of CDTI. As concerns the management of the funds, the project coordinator makes a request based on activity planned and budgeted to the RMO. The RMO endorses it and a cheque is established by three signatories. The funds are released under the government financial control process. The request and approvals are available The coordinator has insights into residual amounts under the budget which presently stands at29, 474,804 STZ. Transport and other material resources (3.25) There is a pool of vehicles at the regional level. One of the vehicles provided by APOC is also used by two districts. There is no routine schedule for preventive maintenance though maintenance, servicing is reported to be normally done. The driver submits a request for maintenance or servicing of the vehicle to the transport officer who then follows up and ensures the maintenance is done. Transport at this level is used to undertake support activities at the next level and to lower levels only when there are problems that need solutions from the region. Since vehicles are in a pool and due also to integration of activities, authorisation forms and log books are not specific for CDTI activities. Plans and budgets for replacing vehicles available. Management knows that replacement will be needed and usually have made plans and forwarded them to the Regional Administrative Secretary. However response from the relevant authority is uncertain. Vehicles and the available photocopier need replacement within two years, they would have served for 9 years and repairs will not be cost effective. The region lacks funds to replace equipment. So far equipment is maintained only when APOC funds are available. However proposals are being made to the RHMT to take up repairs of equipment. Report of the Second Evaluation of Sustamability of Morogoro CDTI Project -13- Human resources (4) The regional coordination has a team of 5 very committed staff (RMO, NTDs coordinator, Eye care coordinator, School health coordinator and the pharmacist). They have been trained on the APOC philosophy and CDTI strategy. ln 201.1, APOC organised training in the region. There has been no training this year 2012, because there is no new staff. Ln 2010 a staffwas trained to replace the retired regional eye care coordinator and the others were refreshed. Staffs were trained when APOC funding began and many are still in post and new ones are reportedly trained. The staffs are stable. Coverage: According to the data at the regional coordination office the geographical coverage rate is LOO%. Following reports from actual communities surveyed, 56 communities in Ngerengere zone were not treated in 2010 and 2011. This gives GCR of 94o/o. From the records the TCR stands atSOo/o for 2010 and 20L1 but calculation from the field reveals that the TCRatT3o/o, 74%in 2011and 2010 respectively. 5.2. Recommendations at the regional level Recommendation lmplementation Planning: L. Considering that treatment of the at risk population for onchocerciasis is done every year, it is important to plan the follow up and supervision of the activities in the districts. The activities should be inserted in the overall plan of the region as this will remind the actors to seek for funding for them. 2. The region should review the sustainability plans and make them more realistic. Priority: High lndicotors of successl. ,/ CDTI activities are integrated in the overall plan of the region. ,/ Evidence that the RHMT is taking responsibility to sustain CDTI activities when APOC and NGDO funding stops. ./ Activities at regional level are more targeted than routine. Who to toke oction : RMO and Regional Coordinator of the Project Deo dl i ne for com pl eti on : At the review meeting of the present distribution cycle. lntegration lmplementation Write up work plans, supervision schedules, supervision checklist and reports of activities to show how activities are implemented in an integrated manner. Priority; High lndicotors of success: Documents showing evidence of how activities are implemented in an integrated manner. Report of the Second Evaluatrcn of Sustamabilfiy of Morogoro CDTI Project -1,4- (This recommendotion wos mode in the first evo I uatio n of sustoi no bil ity) Who to toke oction : Regional Coordinator of the Project Dea dli ne fo r com pleti on January 2013 Monitoring and supervision lmplementation L. Organise data quality audit in the two districts and ensure that 2. Put in place a system whereby districts produce their individual reports - treatment reports, activity reports and APOC annual reports. 3. Ensure that the staff trained by APOC on data management records data in the computer systematically. 4. Supervise the activities of the district coordinators and the cascade supervisors Priority: Very High Indicotors of success; ,/ Same data is found at all operational levels. ,/ Hard copies of district reports duly signed by the DMO are found in the project coordination office, making sure they have copies in the district coordination office. '/ Reports on the supervision of activities of district coordinators and cascade supervisors Who to toke oction : Regional Coordinator of the Project/ Data manager Dead I i ne fo r com pl etion: During the present distribution cycle. For data quality audit at the end of the present distribution Mectizan@ procurement and distribution !mplementation Put in place a system to ensure proper management of mectizan to avoid wastage of excesses. 1. Elaborate order forms for drugs and ensure that CDDs/community leaders are capacitated to requisite for the quantities of drugs needed using the census data. 2. FLHF should make their request from the needs of the communities (synthesis of community needs). 3. Ensure that FLHF supply to each community its real needs 4. Ensure that the FLHF have drugs stock management registers as seen in the Mkindo Dispensary. 5. Ensure that the district coordinators have good documentation on mectizan procurement and supply even when the pharmacists dispense the drugs to the FLHF through the cascade supervisors. Priority: High lndicators of success ,/ Drugs order forms are available and are used at all levels / Drug stock management register are in place and are being used in allthe FLHF. / The district coordinators have good information on the management of mectizan. Who to take oction Regional and District coordinators/DMOs De o d I i ne for co m pl etion : March 2013 For stock management start at the end of this distribution Report of the Second Evaluation of Sustainabiliy of Morogoro CDTI Project -15- Training and HSAM !mplementation 1. Enhance the capacity of district teams, FLHF and communities on the APOC philosophy and CDTI strategy. 2. Provide more training/HSAM materials to districts 3. Target advocacy meetings at regional and district levels on mobilization of resources 4. Make provision for HSAM activities to be carried out at the Ward and Sub village levels 5. HSAM activities should been properly documented to show their effectiveness. (This 5th recommendotion wos made in the first evo I uotion of susta i na bi I ity) Priority: High lndicators of success : ,/ The actors at all levels understand the APOC philosophy and CDTI/CDl strategy. ,/ Evidence of funds provided and used for HSAM activities at the Ward and sub village levels ./ HSAM activities and outcome are documented Who to toke oction: RMO/National and Regional project coordinators/OlvtOs Deadli ne for com pletion April 2013 Finances lmplementation L. Review sustainability plans and budgets to reflect cost reduction/ containment strategies. Activities of CDTI are carried out in the 2nd semester of the year and only on arrival of APOC and NGDO funds. This falls in the 1't semester of the country fiscal year. Because of this the government contributions usually come late when activities are ongoing. 2. The government funds should be budgeted such that they can be used to start the activities. This will make the project less dependent on external funding. 3. Document clearly how shortfalls are met. Priority: High lndicators of success: ,/ Budgets of sustainability plans are realistic ,/ Funds from the government are used to start activities ,/ Management of shortfalls are documented. Who to take oction : RMO/RHMT/ Project coordinator Deadline of completion : March 2013 For the shortfalls start at the end of this distribution cycle if any and whenever they occur Transport and Other Material Resources lmplementation !. Continue with advocacy to external partners and government to obtain transport means for this level and also for the FLHF. 2. lntegrate the equipment of project coordination in the pool of servicing of other equipment of the region. Priority: Medium lndicotor of success : ,/ The region acquires at least an appropriated vehicle each year ,/ The FLHF responsible for a catchment area has a means of transport (motor cycle) Who to take action: RM O/RH MT/Project coord inator Deadline of completion Continuous Report of the Second Evaluation of Sustainability of Morogoro CDTI Project -16- Coverage !mplementation Ensure that the communities that have not been treated for two years are treated this year Supervise data recording Priority: High lndicotors of success All documentations on the treatment of the com m u nities are available (com m u nity registers showing census and treatment of households, activity reports etc) Who to toke oction : Regional coordinator, DMO and DOC of Morogoro rural/ data management Deo dl i n e of com pl etion : During the present distribution cycle. Fig 2: Sustainability at Distract level s o- o (Y) rl). C! c{ ,l). lo o o 3.5 3.3 3.53.2 3 3 3 o2.8 2.8 sl .9p o, B o uo(E L o, (g "*ue---"--C s# ."t"-C "-C ^.-- .--" ,'".- ^c Group of lndicators 5.3. Sustainability at District Level Figure 2 Sustainability indicotors of the District level The figure above presents the performance of the project in the key indicators of sustainability at the district level Planning (3.0): Both districts (Mvomero and Morogoro Rural) have CDTI activities integrated in their Council Comprehensive Health Plan for 2010 and 2O11.CDT| intervention is integrated in the overall Report of the Second Evaluatton of Sustainability of Morogoro CDTI Prolect -L7- plan but only as a component of NTD with appropriate budgetary allocation. ln the plan CDTI is part of the yearly programme and it is considered as part of the district yearly routine. . There are separate plans for CDTI/NTDs in 20L0, 2011 and 20L2. Among the activities that are included in the plans are HSAM (advocacy meetings to CHMT and PHC members on MDA, sensitization meetings to community members), training for the CDTI implementers, plan and budget for drugs distribution and supervision. Plans are reported to be made in a participatory manner through meetings involving heads of various health departments putting together their district plans. Only written plans were available but there were no minutes for the planning meetings. lntegration (3.5): There is a written work plan and the plan of implementation of activities at the district level in an integrated manner. The CHMT members conduct one supervisory visit per month and it is during these trips that CDTI activities are combined with other tasks. Trip plans and/or authorization were seen at the districts health departments and indicated how CDTI activities are implemented in the field (HSAM and training for CDTI). The CHMT members are involved in monitoring and supervision and also in the training CDTI staff at the cascade and sometimes at FLHF levels in an integrated approach. Leadership (3.0): At the two districts, focal persons for NTDs are also in charge of CDTI and initiate key CDTI activities under the coordination of the DMOs. These essential activities (planning, targeted monitoring/ supervision, targeted training and HSAM, Mectizan ordering/ distribution) all depend on the arrival of Mectizan. Additionally, there are two levels of CDTI activities planning (1) planning at the zonal level that involves FHLF staff at those cascade areas and (2) planning at the district level that involve the CHMT and other people to directly supervise and monitor the distribution. The DMOs initiate the planning of CDTI activities every year basing on the deadline as to when their plans are to be submitted to the districts planning officers. The health plans from the DMOs are then submitted to the district council for endorsement and transmission to the Regional Secretariat. Both districts have focal persons for CDTI, now called NTDs coordinator (since 2009). Report of the Second Evaluation of Sustainability of Morogoro CDTI Project -18- The leadership takes initiative to start but have problems of implementation due to lack of funds. The funds for implementation of the district health activities are provided by the District Council Health Service Basket Fund. These funds usually come late with respect to timing of CDTI activities. This is because of the difference in the fiscal year of the country and that of APOC (country financial year (July to June) and APOC financial year (January to December), the funds that are usually available on time to carry out CDTI activities are APOC funds. Monitoring and Supervision (2.8): The data transmitted from the district to the project level included coverage reports, Mectizan statistics, training reports and all other financial reports. Treatment data from FLHF is recorded directly in the computer in the regional coordination office. Districts do not have individual treatment reports at the district level. District coordinators submit reports directly to the regional coordinator. The DMO does not endorse the reports. The districts do not have annual reports. This process does not encourage ownership at the district and may adversely affect sustainability. District level supervision of CDTI activities is reported to be integrated basing on identified needs. The district has supervision checklists for NTDs and CDTI but the one in use is that of NTDs which does not contain important details on the CDTI program (content of advocacy/sensitization meetings, management of supplies, record keeping, CSM). Supervision schedules were not available. Supervision is routinely done and upon the availability of funds it is expected that quarterly visits were carried out per year. Cascade supervisors at zonal level normally supervise FLHF staff on the CDTI activities in order to amend problems such as poor record keeping and/or where data from the FLHF had some issues to rectify. Some activity reports (reports on advocacy meetings, training, supervision and financial) for 2011 were available. A number of FLHF were supervised between August and December 2011 but only one general summarized report on supervision was written. The report does not indicate issues from individual health facilities, thus it does not allow for particular issues of these health facilities to be addressed Report of the Second Evaluation of Sustarnability of Morogoro CDTI Project -19- There is a defined plan in place, though not documented, for managing the problems and successes. Management of problems sometimes is not prompt due to funds shortages. Mectizan Procurement and Distribution (3.0): The FLHF submit their requisition for Mectizan to the district coordinator who compiles them and then submits to the regional coordination office. The needs are calculated using the formula: total population x2.2. The regional coordinator compiles district requests and submitted to the national coordination office. When Mectizan is available at the national level, the Medical Stores Department is responsible to discharge it the districts. "Ihe notional NTDs coordinotion office does the poperwork for the procurement ond distribution of Mectizan and the MSD does the distribution to the districts". This is integrated with the distribution of other essential drugs and supplies are made directly to district pharmacy. The FLHF cascade persons (zonal supervisor) collect Mectizan and Albendazole from the district pharmacy and supply to the facilities under them. There is evidence of integration of Mectizan and Albendazole collection, storage and delivery in the government system. Mectizan collection, storage and delivery are within the government system. Supply of Mectizan has always been timely and in adequate quantities. There has been no report of shortages although occasional delays to FLHF for few days occur due to transport challenges. However, there is no proper documentation on stock management at the district. Only vouchers of reception and supply of Mectizan are available in the district pharmacy. Vouchers at the district pharmacy showed that Mectizan was collected for all communities in the Morogoro Rural district for 2010 and IOLL, but some communities were not treated for two years. Training and HSAM (3.2): At the district level, the DOC assisted by CHMT members train the cascade supervisors who in turn train the FLHF staff that are to train the CDDs. Training materials, timetable for training were available and were seen. Training conducted in 2011 was reported to be based on needs due to identified skills deficiencies (refresher courses) and need to train newly recruited staff. However, training is conducted yearly and routinely as refresher courses at the health centre where staffs in charge of FLHF are grouped in order to reduce Report of the Second Evaluation of Sustainability of Morogoro CDTI Prolect -20- cost. From the 2011 training report, the training topics were more on the causes, symptoms and treatment of NTDs. Community appropriation and ownership were not included. HSAM activities are planned and implemented by the district oncho/NTD coordinators on the NTDs that include CDTI. Advocacy meetings were planned and conducted for CHMT and PHC members for the last two years. lmportant to note is the fact that there have been improved coverage in the communities thus showing the impact of successful HSAM activities. Training materials were inadequate as also confirmed by staff at FLHFs. Finance (2.8): Both districts (Mvomero and Morogoro Rural) have CCHP which estimates for the funds intended for CDTI activities. The local source of funding is the District Council Health Service Basket Fund which funds the running costs for District and Municipal Council health services based on the CCHPs2. But CDTI activities start only when APOC funds are available. This basket receives funds from Government MoHSW and all the donors except APOC and NGDO (Sight Savers). The Health Service Basket Funds are usually released to the districts late with respect to the timing of CDTI activities. Budget lines concerning CDTI are already inserted in the council budget Health Service Basket Fund for 2011 to 2014.The budgets show the APOC funds for the CDTI activities and also contribution of the district council but other CDTI activities are not sufficiently budgeted for. For 2OtL/L2 year budget allocation of 26.5 million for NTDs but only 1.5 million was disbursed (Morogoro rural). From the Health Service Basket Fund (Mvomero DC) the amounts budgeted for CDTI are 2Ot2 = TZS 13,340,000, 2OL3 = 18,450,000, 2OL4 = 23,600,000. ln 2OLL, TZS 27,9L9,094 were budgeted and T2525,499,008 were released in Mvomero district. These funds were used to motivate the CDDs (payment vouchers for training of CDDs were available) and also to pay for the production of measuring sticks. However, there are no immediate plans to take over the funding of CDTI activities as reported by the district finance officer. They expect APOC to continue fulfilling the obligation until counter-part funding becomes sufficient. 2Strategic Master Plan for the NTD control Program2O!2-20\T,Ianzania Mainland Report of the Second Evaluation of Sustainabhty of Morogoro CDTI Prolect -27- Approvals for expenditure are obtained from the RMO/regional NTD coordinator and district finance officer for specific activities. Disbursements made by the district NTD coordinator are properly made. Fund disbursed to CDTI activities are managed properly through management procedures as laid down in the government financial regulations and procedures. Transport and Other Materials (2.9) The Toyota Pick-up denoted by APOC is well maintained and used for both the Regional and the two District CDTI activities. One of the DMOs (Mvomero) reported the CHMT saved funds and purchased a vehicle and a lorry for the district. This shows their concern to have its means of transportation and consequently encourages sustainability. However, there is inadequate transport service in terms of numbers and ability to function as all are more than 8 years old. No replacement might affect CDTI activities. The motor cycles supplied by APOC, Sight Savers and some procured by the district are well maintained and are functional. The maintenance follows the schedules (seen).The motor cycle is used by one of FLHF staff for both NTDs and CDTI activities but also not adequate as they sometimes are un-serviceable so are not cost-effective to repair A system of usage of the vehicle exists as evidenced by a log book currently used. These transport vehicles are also used for NTDs and other health related activities if they do not clash with CDTI activities. Training materials and posters are highly inadequate considering the amount of work ahead for 5-10yrs. Human Resources (3.3): The number of staff available at this level is stable. They do in service refresher training courses prior to Mectizan distribution for both CDDs and FLHF workers. CDTI staffs are committed to their work though co-implementation with NTDs increased their workload. Occasionally they are given certificates of commendation for outstanding performance. lt is however very crucial to train more than required at all levels when necessary in order to contain the challenges especially at the facilities as available staffs are insufficient to cope with the level of services required within the project area. Report of the Second Evaluatron of Sustainability of Morogoro CDTI Prolect -22- Coverage: (4) Reports indicate GCR and TCR of LOO% and 80% respectively for both districts. But in Morogoro Rural, from the field visit, these proportions quoted are not realistic for CDTI based on identified number of FLHFs and communities that had discontinued drug distribution since 2010. Hence the GCR for 20L0 and 2011 isgL% in Morogoro Rural.The GCR for Mvomero district has been LOO% for the past two years, and the TCR recorded is stable atSO%. The GCR and TCR rates though high, they may not be reliable. 5.4. Recommendations at district level Recommendations lmplementation Planning Priority: High Planning in both districts is carried out efficiently and effectively but under the umbrella of NTDs. L. CDTI being the driving force for NTDs control, the activities should be clearly spelt out in the NTD planning. A greater focus on specific disease is required in order to ensure goal achievement and hence ensure the program sustainability. 2. Develop minutes of planning meetings from which resolutions, especially those concerning resource mobilisation would be followed up lndicotors of success: ,/ Comprehensive work plan with key activities of CDTI ,/ Minutes of meetings are available and resolutions are being followed up Who to take oction: DMO/CHMT Deod I i ne of com pleti on : Yearly starting from planning for next distribution lntegration lmplementation Produce reports of activities to show how they are implemented in an integrated manner Priority: High lndicators of success: Reports that reflected all activities integrated Who to take oction: DMO/CHMT Deodline of completion: Start from 1't quarter of 2013 and continue Leadership lmplementation The DMOs take initiative to start but have problems of implementation due to lack of funds. The districts do not generate funds. CDTI activities start only when external Priority: High lndicotors of success: ,/ Council Funds are available to start activities ,/ The CHMT is involved in CDTI activities Report of the Second Evaluation of Sustainabilrty of Morogoro CDTI Project -23 - funding (APOC and SS) is available. The councilfunds always come late. L. The CHMT should budget activities such that the Council funds could be used to start CDTI activities. 2. There should be disease specific focal persons to ensure specific program achievement. thus inspiring sustainability Who to toke oction DMO/CHMT Dea dl i ne of co m pletion : Start from planning of the next cycle of distribution and continue Monitoring and supervision lmplementation Districts should be responsible for reporting of CDTI activities in the districts: 1. They should produce their individual reports - treatment reports, annual reports using the APOC format and submit them to the regional office duly endorsed by the DMO. 2. They should have hard copies of the reports properly filed 3. Data from FLHF should be systematically recorded according to FLHF catchment area. 4. The two districts should use the CDTI checklist alongside the NTD checklist to complement gaps on important aspects of CDTI that are not in the NTD checklist 5. lmprove supervision of FLHF a. Monitor activities of the cascade supervisors 6. Supervisors should submit individual supervision reports stating issues found in individual FLHF Priority: Very High lndicators of success: ,/ Hard copies of reports of district activities are available both in the district and regional office ,/ Districts annual reports in the format of APOC annual report are available. ,/ Data from FLHF are systematically recorded and performance of FLHF catchment is easily assessed{ Both checklists are effectively used ,/ There is evidence of effective supervision in the individual FLHF supervised. Who to toke action: DMO/CHMT/DOC Dea dl i ne of com pl etion : From the present distribution and continuous Mectizan Procurement and Distribution Implementation Put in place a system to ensure proper management of Mectizan to avoid wastage of excesses. 1. Use order forms for drugs requisition 2. Ensure that CDDs/community leaders are capacitated to requisite for the quantities of drugs needed using the census data. 3. FLHF should make their request from the needs of the communities (synthesis of community needs). 4. Ensure that FLHF supply to each community its real needs Priority: High lndicotors of success: / Mectizan is ordered using census data{ Drugs order forms are available and are used at community and FLHF levels ,/ Drug stock management register are in place and are being used in allthe FLHF. ,/ Stock management registers for the drugs are available and are being used ,/ Timely delivery of drugs Who to toke action: DM o/cH MT I Doc/ FLHF/CDDs MoHSW/District council (for transport) Report of the Second Evaluation of Sustainability of Morogoro CDTI Project -24- 5. Ensure that the FLHF have drugs stock management registers as seen in the Mkindo Dispensary. 6. District coordinators should have stock management registers for the drugs. 7. There should be stable and reliable transport in order to meet unexpected transport challenges within the district during distribution. Deo dl i n e of com pl etion : ,/ April 2013 and continuous ,/ For stock management start at the end of this distribution Training & HSAM Implementation More thorough training is required for improving efficiency and achieving sustainability L. Enhance the capacity of cascade supervisors, FLHF and communities on the APOC philosophy and CDTI strategy. 2. Plan adequately and supervise training of CDDs 3. Provide more training/HSAM materials tp FLHF 4. Target advocacy meetings at district levels on mobilization of resources 5. Ensure that HSAM activities planned and budgeted for the Ward and Sub village levels are effectively carried out 6. HSAM activities should been properly documented to show their effectiveness. Priority: High lndicators of success: ./ Training reports / Reports of advocacy meetings ,/ Effects of advocacy meetings are well documented '/ Availability of training materials, ,/ Availability of timetable for training Who to take oction DMO/ National and Regional project coordinators/DMOs Deodline of completion Moy 2013 Finances lmplementation L. As the situation is, there is a need to more clearly reflect all components of CDTI in terms of budget in order to fully achieve sustainability 2. There should be regular calculation of residual amounts under budget headings. 3. The Government should commit more funds to CDTI activities because donor fund is decreasing Priority: High lndicotor of success: ,/ There is a clear estimate of funds for CDTI activities in council budget each year. r' Proper management of funds through proper financial record Who to take oction District Council DMO/DOC Dead li ne of co m pleti on : From planning for next round and continuous Transport and Other Material Resources lmplementation 1. There should be stable and reliable transport in order to meet unexpected transport challenges. 2. Training materials and posters should be Priority: High lndicotors of success: The available transport facilities are well maintained by the district council. Report ofthe Second Evaluation ofSustainability ofMorogoro CDTI Project -25 - made available in sufficiency The maintenance follows the schedule of routines (seen). Who to take action: District Council De odl i ne for com pl etion June 2013 Human Resources lmplementation The district should inspire the staff who are committed to CDTI activities Priority: High lndicotors of success: Availability of committed CDTI staffs Who to take action Deadline of completion June 2013 Coverage lmplementation 1. Ensure that the communities in Morogoro Rural District that have not been treated for two years are treated this year 2. Supervise data recording 3. There should be monitoring on need in order to rectify where TCR and GCR are below the recommended rates Priority: High lndicators of success: { All documentations on the treatment of the communities are available (community registers showing census and treatment of households, activity reports etc) ,/ GCR and TCR are as recommended Who to toke action DMO/DOC /FLHF Deadline of completion: December 2072 and continuous Report of the Second Evaluation of Sustatnabiltty of Morogoro CDTI Project -26- Fig 3: Sustainability at FLHF level { rJ)_(o (a lr) c.i 6l rr}- r,)- o o 3 33 33 <l s, .g(ui o oo(! o (g 2,7 )4 2 1.7 1.2 oS*dc".u "t.""-t"-C"-g^.-- J "*"d ^-s Group of lndicators 5.5. Sustainability at Frontline Health Facility Level (FLHF) Figure 3 Sustdinability indicators of the FLHF level The figure above presents the performance of the project in the key indicators of sustainability at the FLHF level Planning: 12.751 All the FLHF surveyed had written plans of health activities in the catchment area. CDTI activities were integrated into the overall year plan in 2 out of the 4 FLHF surveyed. The key activities comprise the training of CDDs, monitoring and supervision of distribution in the sub villages, and reporting. The reason advanced for not integrating CDTI activities in the overall plan in one of the FLHF was because the staffconsidered there were no problems to address in 2009, 2O!O, zOLt. But there were yearly plans on sensitization for CDTI with clear objectives for these years. ln one facility, the worker was newly recruited in 2010 and had not been oriented or involved in CDTI activities and there was no documentation from her predecessor. However 3 out of 4 facilities have the calendar of all CDTI activities that runs from May to December each year. CDTI forms part of the minimum package of the FLHF. Report of the Second Evaluation of Suslainabilitlt of Morogoro CDTI Project -27 - lntegration of support activities: (3) Some facilities fairly develop plans for CDTI activities and combine tasks during the implementation. The facility staff reported they combine activities in such a way that, when they conduct lmmunization it is combined with other activities like family planning, environmental sanitation and health education. During supervision also staff combines different aspects. ln some facilities, supervision reports and logbooks (which indicate location only) were available. There are no timetables/schedules of field trips showing integration Leadership: (2) The initiation of activities is resource driven. When funds and drugs are available at the district, the FLHF receive instructions from the district to start activities. They start with ordering of the drugs, then conduct training of CDDs, health education campaigns in sub-villages where necessary, and follow up with monitoring/supervision of the distribution of the drugs, taking care of side effects when they occur and reporting (compilation of CDD reports and forwarding them to the districts). Though the staffs consider CDTI activities as part of their activities at the health facility level they cannot initiate activities because they do not have the resources, financial in particular. Some sub village leaders at this level do and others do not participate in CDTI activities. Monitoring and Supervision: (3) Reporting of activities is done within the government system. The availability of census figures, distribution and coverage reports from facilities to zone centre and from zone to district confirmed transmission of information within the existing government system. Monitoring and supervision of CDTI activities are integrated with other routine/supervisory activities. Staffs of the FLHF visited, reported they supervise activities in the communities and during these visits they address other health related issues e.g educate households on environmental hygiene and sanitation. The FLHF are carrying out co-implementation of treatment for onchocerciasis and Lymphatic Filariasis. The staffs do not supervise census taking. This was evidenced by the observations made by the evaluators on the filling of registers. Exercise books used for registers were Report of the Second Evaluation of Sustainability of Morogoro CDTI Project -28- inappropriately ruled and used over the years without correction. Registers of some CDDs were incompletely and poorly filled. Some FLHF presented supervision timetable for 2OL2 and reports on supervision for 2010 and 2011 while others had neither timetable nor report of visits to the community. There are no checklists at this level. The processes of managing problems and successes exist and vary at this level. lssues related to misconception in taking drugs and many others were addressed through health education and sensitization meetings in the community. People who have recovered are invited to the sensitization meetings as speakers and hence it has improved trust. ln some FLHF, the health workers work with community leaders and/ or CDDs in solving problems. Most communities are however, not informed of their successes and CDDs who do wellare congratulated at the levelof the HF during review meetings. However in one facility, available staff had no experience in dealing with CDTI issues hence nothing has been done for the past two years. Mectizan ordering and Supply: (3) There were no order forms for Mectizan in the visited health facilities, what is normally done is the written request raised by the FLHF in-charge to the cascade (HC) supervisor. The quantity of mectizan requested is based on the CDD census data (census population x 2.21. Drugs are supplied on time and communities have never experienced any Mectizan shortage. Mectizan procurement and supply at this level follows the government pharmaceutical procurement and supply system. The system is effective, uncomplicated and efficient. The system is simple since government provides the transportation for movement of Mectizan with other drugs to various health facilities. Mectizan from the MSD reaches the district pharmacy with other drugs through a transport system supplied and paid for by the government. The FLHF either collect their needs from the district pharmacy or are supplied their needs by the cascade supervisors. This is done most often during training of the FLHW. From the FLHF the CDDs collect mectizan for the communities. Report of the Second Evaluation of Sustamability of Morogoro CDTI Proiect -29 - Drugs are kept in the facility store and later distributed to CDDs. One of the FLHF (Mkindo) presented a good stock management register for mectizan. The register contained information on source of supply, quantity received, batch number, expiry dates, quantity issued out; and name and signature of issuer and receiver. All movements were dated. However one facility reported to have neither requested nor received Mectizan since 2010. Training and HSAM: (2.5) The district level staffs train the FLHF staffs who then train the CDDs and community leaders. Since 2009, trainings are organized generally for NTDs including elements of CDTI at a nearest health facility or grouped at a convenient place within the community when CDDs collect drugs for cost effectiveness. Generally CDDs are routinely trained or refreshed every year. The training duration varies from 2 hours to 6 hours. Sometimes the training session were supervised by the district coordinator (minutes of training available). Sensitization and health education were reportedly carried out among communities/leaders, which appearto have lowcoverage and misconceptions amongthe reasons. One of the FLHF had identified problems and planned HSAM activities for 3 consecutive years (2009 to 2011), targeting various communities and coverage rates (plans pasted on the wall). This year 20L2, HSAM activities were not planned because there were no problems. Another FLHF reported that health education sessions are carried out in the dispensary, at sub village and public meetings. However, there was neither plan nor report of HSAM activities. Still, one facility had not developed any plans for HSAM related to CDTI since 2010. HSAM activities related to CDTI mostly comprise of health education, advocacy and community sensitization. The messages seemed to be mainly on disease, treatment and prevention as the community leaders and community members expressed ignorance on the aspect of community ownership and appropriation during discussions with the evaluators. Generally documentation like training reports, training timetable and training manuals were lacking in the facilities. Financial: (1.75) Two FLHF had budgets for CDTI activities as seen on the annual plans for one (lump sum of TZS 380,000) and minutes of the planning meeting for the other. Additionally, in the facility Report of the Second Evaluation of Sustainability of Morogoro CDTI Project -30- there was no definite budgetary provision by the government for CDTI activities except payment for salaries, partial equipment maintenance and occasional transport. However in one facility, which had not distributed drugs since 2010, there was neither trace of CDTI plans nor budget. The fourth FLHF had plans of action for HSAM activities only and they were not budgeted. Generally, the FLHF visited did not have good budgeted plans indicating cost of CDTI activities. The facilities wait for funding from the project to start with training of CDDs. The funds are not managed at this level. Funds allocated for training are brought to the HF and disbursed on the day of training by the district coordinator or cascade supervisor. The FLHF staffs received funds for supervision. Transport and other Material Resources: (1.25) Majority of FLHF had no basic equipment used for CDTI activities and training materials are inadequate in number. Only one facility had government owned transport-motorcycle, which is used to facilitate all operations at the facilities including CDTI, and receives appropriate maintenance from district council. The facility only initiated proposal for acquisition/replacement of transport and submits to the distric| and its outcome is uncertain. Human Resources: (3) The FLHF have good staff strength of 5 to 7 very qualified nurses and midwives (clinical officers, enrolled nurses, health officers, public health nurses etc). ln the 4 FLHF visited, staffs have been in the same facility for at least two years. The staffs are stable, transfers are not so frequent. However, in Matuli dispensary (Morogoro Rural District), the staff in charge who was transferred to replace the one who died since 201.0 had not received any training on CDTI. This resulted in the communities of the catchment area not been treated for 2 years. Until the visit of the evaluators the staff did not know CDTI was part of the package of activities of the dispensary. Though the FLHF have good staff strength, only (L or 2) the in charge or the in charge and another staff, carry out CDTI activities. The others are reported to be trained on CDTI but are not implicated in the execution of the activities. Report of the Second Evaluation of Sustainabihty of Morogoro CDTI Project - 31- Coverage: (3! The Geographical Coverage Rate (GCR) for 2009,2010 and ZOLLfor 3 ofthe 4 FLHF has been LOO%. The TCR in these facilities have been in 2010 NkambaraniS2%, Hembeti85% and Mkindo 860/o; and in 2011 the TCR has dropped Nkambarani 67%o, Hembeti 68% and Mkindo 8O%). The drop was due to some other activities that occupied the community members - political campaigns - as explained by the staff. For Matuli dispensary, records at the project level show that the TCR was 84%for both 2010 and 2011. But field visit reports present no treatment in the communities under the health facility for the same period. However, the evaluators used data from the health facilities to calculate the TCR and found that there were some discrepancies in the coverage rates: Therapeutic Coverage Rate for Hembeti 77o/o 2OLO and 83% }OLL, Mkindo 79% 2OLO and 89.5% 20LL, Mkambarani 67% 2010 and 82o/o2OLL.Though good coverage rates, the inconsistency in the data between this level and project coordination office is risky for the sustainability of the project. Report of the Second Evaluation of Sustainability of Morogoro CDTI Project -32 - 5.5. Recommendations at FLHF Recommendations lmplementation Planning Priority: High All FLHF should elaborate yearly action plans for CDTI with clear costing of the activities lndicotors of success: ,/ Budgeted plans available every year for every FLHF Who to toke action FLHF/VHC Deo dl i ne of com pl eti on : Yearly starting from planning for next distribution lntegration lmplementation Elaborate schedu les/ti metables of activities and produce reports to show how the activities are implemented in an integrated manner Priority: High lndicotors of success: Schedules/timetables and reports that reflect all activities integrated Who to toke action: Officer in charge of FLHF Deodl i n e of com pl eti on : January 2013 and continuous Monitoring and supervision lmplementation All activities of CDDs, including census taking should be supervised. Present the report of treatment to the communities during quarterly community meetings Priority: Very High lndicators of success:{ Community registers are correctly filted '/ Community leaders/members are informed of their performance Who to toke oction: Officer in charge of FLHF/ community leaders Deodline of completion: From the present distribution and continuous Mectizan Procurement and Distribution lmplementation Capacitate CDDs to calculate the Mectizan needs for their communities. Compile Mectizan needs of communities in the catchment area using order forms; Open stock management registers Priority: High I ndicators of success'. ,/ CDDs/community leaders calculate the community needs and make orders from census data ./ Mectizan order is made from community needs using order forms. / Stock management registers are available and are used Who to toke oction DMO/DOCIFLHq Deod li ne of com pl eti on : Report of the Second Evaluation of Sustainabilit.v of Morogoro CDTI Proiect -33- End of this distribution and continuous Training & HSAM lmplementation Organise training of CDDs properly even when they are refresher courses 1. Elaborate an agenda of the training 2. Produce a report of the training 3. Conduct the training in the community. Organise and carry out advocacy meetings with the community leaders Use the quarterly community meetings to educate community leaders and community members on their roles Priority: High lndicotors of success: ,/ Training reports ,/ Reports of advocacy/sensitization meetings ,/ Effects of HSAM meetings are well documented Who to take oction ln charge of FLHF/Community leaders Deadline of completion Before next distribution Finances lmplementation lnvolve community members of the management of FLHF in the elaboration of action plans. lndicate clearly the cost of each key CDTI activity and the sources of funding Priority: High lndicotor of success: Cost of activities and sources of funding are known Who to take oction: ln charge of FLHF/VHC chairperson/community leaders Dea d I i ne of com pl etion : From planning for next round and continuous Transport and Other Material Resources lmplementation Provide means of transport (motorcycle to the FLHF)to facilitate their movements in the catchment area Priority:High lndicotors of success: Availability of means of transport in the FLHF Who to take oction: District Cou ncil/MoH/NG DO/APOC De ad li ne for com pleti on June 2OL3/20L4 Human Resources lmplementation lnvolve other staffs of the HF in the activities of CDTI Priority: High lndicotors of success: lmproved performance of the staff Who to take oction: ln charge of HF/DOC/DMO Deadline of completion: From the next distribution cycle Coverage Implementation Ensure that the communities in Morogoro Rural District that have not been treated for two years are treated this year Supervise data recording by CDDs Priority: High lndicators of success: ,/ All documentations on the treatment of the communities are available (community registers showing census Report of the Second Evaluatron of Sustamabtlity of Morogoro CDTI Prolect 34 and treatment of households, activity reports etc) / lncreased GCR and TCR Who to take action: DMo/Doc/FLHF/CDDs Deodli ne of completion : During this distribution and continuous Fig4: Sustainability at Community level t .99(u =obo(! o, IE <t rL rrt rl d H rl o o 3 3 3 2 5 2 2 15 1 1 a -*u-* -r""t """-- """t s* "-C "-" od Grotrp of lndicators 5.7. Sustainability at Community Level Figure 4 Sustoinqbility indicators ot the Community Level The figure obove presents the performance of the project in the key indicotors of sustoinability ot the Community level Planning and Management (2.5) CDDs in consultation with the communities decide the time and mode of drug distribution. The distribution is usually done in the dry season when roads are accessible and most of the community members are not involved with farming activities. The period of distribution falls between August and October. The duration of distribution varies from one week to two months in the communities. Some communities have had to make adjustments on time and Report of the Second Evaluation of Sustainability of Morogoro CDTI Project -35- mode of distribution. This has been due to some religious and traditional engagements. Some have changed the mode due to the response of the people during distribution. CDDs normally report any problem they encounter during distribution (e.g cases of refusals) to the sub-village leaders and also to the FLHF in-charge. ln most communities the leaders help them to find solutions but in others they have no help. However they continue to educate the people on the treatment. ln most communities CDDs conduct census and submit the information to the FLHF prior to drug distribution Generally CDDs work with their leaders and community members in planning and managing CDTI except in the communities under Matuli dispensary where treatment was interrupted for two years and nothing was done. After the death of the FLHF staff, the CDDs and the new community leader did not know how to continue with the activities. Leadership and Ownership (2.15) Community leaders are aware of the CDTI activities especially those who were trained at the start of the programme. lt is worth mentioning here that leadership in the communities is elected every five years. So they are either reelected or replaced. Where leadership has not changed most of them are enthusiastic and work with CDDs to ensure everyone in the community receives the drug. But where leadership has changed the new leaders have little or no knowledge in the organization of CDTI activities. Nevertheless some new leaders interviewed, though have little knowledge are actively involved in the activities while others do nothing. ln the case of the community which stopped drug distribution since 2010, the communities and their leadership made no attempt to solve the problem though they had knowledge that the treatment would last for 15 years. lt was informed that the new leadership had no information about the continuation of CDTI activities after the death of the FLHF worker. Two communities have had replacement of CDDs because of death, refusal to continue and relocation from the village. The replacements were done by interested members of the community, and where they was no one accepting to work as CDD the leader took up the responsibility. ln Minazini sub village, the leader is a CDD. Report of the Second Evaluation of Sustainability of Morogoro CDTI Project -36- Community members are responsible for selection of CDDs through community meetings. CDDs selection is based on individual commitment, being able to read and write and gender balance. The communities also decide timing of drug distribution. However problem identification and solving has not been involving the community at large Some of the communities support CDDs by exempting them from other community development activities during drug distribution exercise whereas other communities refused any support. Most CDDs reported that their people do not give them any support except moral support and the moral support is expressed by the people accepting to take the drug. "The community cooperotes with us because they know us" declored the CDDs in one of the communities. "Becouse of lock of communication between CDDs ond the sub villoge leoder, we connot decide the kind of support to give to the CDDS", declored o community member. Some community members were able to identify advantages of taking drugs. Most people acknowledge that they take mectizan to prevent the disease. The community where drug distribution was stopped did not express the need for it when discontinuation occurred, thus not showing understanding of its benefits and the long term treatment. Generally, community leaders work hard to encourage their community members swallow the drug. ln case of refusals, they were able to educate the people and caused them to take the drug. Some leaders were able to explain reasons for change in coverage rates for the past three years (2009, 2010 and }OLL), e.g in areas where the coverage was not adequate it was because some community members were absent throughout the distribution period while others shifted to other areas. Others could not explain why they were changes' The involvement of community leadership is inadequate because they lack knowledge on their role as owners of the programme as expressed during interviews. Except where the leader is a CDD, the other leaders feel the CDD job is a government paid job i.e. CDDs are highly paid by the government. Those interviewed promised to include CDTI on the agenda of their quarterly community meetings and invite the FLHF staff to educate them more on CDTI. Report of the Second Evaluation of Sustainability of Morogoro CDTI Project -37 - MONTTORTNG (3) CDDs usually return their summary report forms to the FLHF timely after completion of the drug distribution. Some registers (exercise books ruled by the CDDs after their training) from where data is collected to fill the summary are not properly filled. The columns on age and height are fixed for all the years. They do not vary with the years to give room for data for growing children. Though the CDDs compile the data and report to the FLHF on time, in most cases the data recording in the registers is not complete. This jeopardizes the quality of the results at the end. They are not supervised during census taking. Except for some leaders who follow up their work to ensure that people take the drug, there are no lay supervisors. Obtaining and managing Mectizan (3) The eligible community members received mectizan and some was left for absentees and the temporarily non-eligible. There were no shortages reported. CDDs in most communities surveyed conduct census prior to drug distribution exercises. But they do not use the data to calculate the mectizan needed for the next distribution. The FLHF staffs reported they calculate the mectizan needs for the communities using census population. Order forms were not available at the FLHF.From registers the quality of the data would not be good enough for an accurate calculation of mectizan needs. The CDDs fetch their mectizan from the FLHF. They are supplied amounts by the health facility who reported calculations are made from census data. The FLHF workers only provide sealed bottles (500 tablets) to each community despite census data. Except for communities where the health facility is located and at distances less than 20 minutes walk that may not need transport arrangements, the communities at long distances (1akm) from the HF donot arrange transport for CDDs for collection of mectizan. The CDDs therefore collect the mectizan during training. HSAM (1.s) Community meetings were organised at the start of the programme. Continuing sensitisation and education of the community members has been going using person to person communication strategy, house to house, public address system, and public schools. CDDs, community leaders and other community members continue to educate the people in Report of the Second Evaluation of Sustainability of Morogoro CDTI Prolect -38- areas of need (the importance of taking the drug where there are refusals and the fears of side effects; and misinformation on the use of the drugto dispel rumours. Most communities are routinely informed about the importance of taking the drug but not on the ownership aspect of the program. There are, however, communities where members declared they have neither seen someone with the disease, nor the poster. The leaders are not informed of their ownership role of the program hence do not sensitise the community members on providing resources. Financing (1) For some communities, CDDs are compensated by being exempted from community development activities during drug distribution period. However, in the communities where distribution stopped, communities had no tangible plans to support distribution and refused any encouragement to the CDDs even prior to the disruption of distribution. Generally, communities have not been providing stationery to CDDs. This has basically been due to lack of awareness of roles of CDDs in the community Human resources (2.45) Generally the number of CDDs in a community varies between 2 and 3 and in most the ratio of CDD to households of one CDD to 20 households or 2 CDDs per 250 population is not respected. This is as a result of misunderstanding of instructions the community leaders received from the districts to select at least two per community. ln communities with concentration of population the distance is not a problem but the population density. Whereas in communities with dispersed population the average distance for most CDDs ranges from 10 to 15 Km. The available CDDs were trained in disease symptom identification, transmission of disease, community sensitization, recognition and management of mild side effects and how to conduct census. This was clearly evidenced from their responses. The communities do not have a problem of co-endemicity. ln some communities the trainers of CDDs lacked thorough and comprehensive and targeted knowledge about CDTI activities. This definitely would affect the quality of training of CDDs. Report of the Second Evaluation of Sustainabilit.v of Morogoro C DTI Proiect -39- The CDDs are willing to continue with drug distribution despite challenges. Some replacements have been made in some communities due to marriage, relocation or assumption of other responsibilities outside the community and deaths. Only one drop-out was reported in one community. Coverage (3) The TCR reported at the project coordination office ranged fromTL%oto 84% in 2010 and from 670/oto 86% in 2011. The quoted TCR for Lulongwe of 7L% could not be substantiated at the field; it was actually 0% since treatment had stopped since 2010. This would be the same for the other communities in Matuli dispensary catchment area. TCR in some communities where treatment has been going on regularly, has been increasing (Mvuleni 68% in 2009, 7L% in 2010 and 84% in 20LL; Miembeni 7t% in 2009, 7L% in 2010and 82% in 2011);and in others it has been fluctuating within the last three years showing good coverage in 2OO9, drop in 2010 and then increase in 207L. However, the average TCR for the past two years has been 77% in 2010 and 8L% in }OLL. The average for the two years stands at79%. 5.8. Recommendations at community level Recommendations lmplementation Planning Priority: High Reinforce planning of mectizan distribution in the communities to include support to CDDs. lndicotors of success: Communities participate actively aspects of mectizan distribution community in all in the Who to toke action: Community leaders/VHC De odli n e of co m pl etion : Before next distribution and continuous Leadership !mplementation Newly elected community leaders should be informed and educated on CDTI activities; All community leaders ship should be educated on their role in CDTI Priority: High lndicotors of success: All community leaders are playing their role in CDTI Who to take action: Officer in charge of FLHF Deadline of completion : January 2013 and continuous Report of the Second Evaluatrcn of Sustamability of Morogoro CDTI Prolect -40- Monitoring and supervision lmplementation CDDs should be supervised durinB census taking and drug distribution. The registers should be supervised to ensure good quality of the data lnform treatment results to the communities members during quarterly community meetings ldentify community members to supervise the work of CDDs Priority: Very High lndicotors of success: ,/ Community registers are correctly filled '/ Community leaders/members are informed of their performance Who to toke oction: Officer in charge of FLHF/ community leaders Deo dl i ne of com pl eti on : From the present distribution and continuous Mectizan Procurement and Distribution lmplementation CDDs should use census data to calculate the Mectizan needs for their communities. Communities which have drug distribution for one week and do catch up for one week should increase the distribution period to at least two weeks and also keep the mectizan for two weeks to treat absentees and other temporary illegibles. Priority: High Indicotors of success; ,/ CDDs/community leaders calculate the community needs and make orders from census data ./ All eligible members receive treatment '/ CDDs are supported to collect mecizan Who to take action: FLH F/Com m u n ity leaders/CDDs De od li ne of co m pleti on : End of this distribution and continuous for mectizan order From the next distribution round HSAM lmplementation Continue to sensitise community members on the long term treatment with Mectizan lnclude CDTI on the agenda of quarterly community meetings Priority: High lndicators of success: Number of patients treated every year Who to toke oction ln charge of FLHF/Community leaders Deodline of completion Before next distribution Finances lmplementation lnvolve community members of the management of FLHF in the elaboration of action plans. lndicate clearly the cost of each key CDTI activity and the sources of funding Mobilise funds to support CDTI activities Priority: High lndicotor of success: Cost of activities and sources of funding are known Funds are available to support CDTI activites Who to toke action: ln charge of FLHF/VHC chairperson/community leaders Deodline of completion:From planning for next round and continuous Report of the Second Evaluation of Sustamability of Morogoro CDTI Prolect -47- Transport and Other Material Resources !mplementation Organise transport for CDDs to collect mectizan where necessary Priority:High lndicators of success: CDDs are supported in transport to collect Mectizan and submit treatment reports Who to toke oction: Community leaders and members Deo d li ne for com pleti on : From the next distribution round Human Resources lmplementation lncrease the number of CDDs to reduce the workload. Priority: High lndicotors of success: The ration CDD to household is increased. lmproved performance of the staff Who to take oction: ln charge of HF/Community leaders Deodli n e of co m pleti on : From the next distribution cycle Coverage lmplementation Ensure that the communities in Morogoro Rural District that have not been treated for two years are treated this year Communities which have drug distribution for one week and do catch up for one week should increase the distribution period to at least two weeks and also keep the mectizan for two weeks to treat absentees and other temporary illegibles Priority: High lndicotors of success: / All documentations on the treatment of the communities are available (community registers showing census and treatment of households, activity reports etc) ,/ lncreased GCR and TCR Who to toke action: FLHF/CDDs/Community leaders Deodline of completion: During this distribution and continuous Report of the Second Evaluation of Sustainability of Morogoro CDTI Prolect -42- 5.9. Grading of the overall MOROGORO CDTI proiect: Table Sshows summory of the grades of the vorious groups of indicotors by level of operotion Level Group of indicators Average Planning !ntegration [eadership M&S Mectizan Training & HSAM Financial Transport Human resources Coverage Community 2,s 2,75 3 3 1,5 1 2,45 3 213 FLHF 2,7 3 2 3 3 2.5 1.7 1.2 3 3 2.5 District 3 3,s 3 2,8 3 3.2 2,8 2,9 3 3 3.05 Region 3 3 3 2.75 4 4 2.5 3 4 4 3.3 Average 2.8 3.2 2.5 2.9 3.3 2.8 2.0 2.4 3.2 3.3 Average grade for the whole project 2.8 Fig 5: Sustainability of the whole proiect = 2,8 t lr)(., (t ro. N c! rq u? o o ,,, ) '\. ) 3.2 3.3 8 )o I <t .gP o 3(u uol! (l) (! 2.5 2,4 2 "*ue c*-u _rC s# ."d ",.a" ^.s .C ^.c ".-" J Group of lndicators Figure 5 Grophical presentation of the average grades of indicotors ol sustainobility of the whole Morogoro CDTI project The average grade of sustainability of the whole project stands at 2.8. This is lower than the overall score of 3.6 in the first evaluation at year 5 (4th treatment cycle). The APOC Report of the Second Evaluation of Sustainability of Morogoro CDTI Proiect 43 sustainability evaluation guide expects that for a Year 3 evaluation, a project should score at least 2.5 overall - that is equivalent to a judgement of 'Making satisfactory progress towards sustainability'. At Year 5 the score should be considerably higher than that. The evaluation team found that the Morogoro CDTI project has potentials of being sustainable. Some serious steps have to be taken urgently to follow up and improve on some indicators of sustainability as CDTI is the driving force in the control of NTDs. Planning of activities is done at all levels but the aspects of sustainability are not clear for a project that has been evaluated for sustainability and elaborated plans. Activities of CDTI are planned and costed at regional, district and some FLHF but they do not show evidence of a cost reduction/ containment strategy. The leaders of the various levels of operation of the project consider the onchocerciasis /NTD control as part of their activities. They include CDTI in their planning process. But they are limited in initiating the activities because they lack the funds. lnitiation and execution of activities depend on the availability of funds and the drug. Mectizan is always available on time. The activities start only when APOC and NGDO funds are available. The finance indicator has the lowest grade and it is at all the levels. The health services at the region, district and FLHF do not generate funds directly. They depend on the administrative and financial structures of the region/districts and the external funding. There are no local associations or NGOs that support CDTI activities. There is need to carefully study the situation such that Council funds which usually are released late could be kept and used to start the activities. So far activities start only when external funding is available. This does not favour sustainability at all The government contribution though indicated on the plans/budget is not always available on time. The country fiscal year runs from July to iune. During the time CDTI activities start, government funds are not yet ready for disbursement to the RHMT and the CHMT. Key activities like advocacy meetings and trainings are routinely carried out. There is inadequate documentation on activity reports to evaluate how activities are targeted and integrated. Advocacy meetings are organized every year to RHMT, CHMT and PHC teams even after the evaluation of the sustainability of the project in 2008. The region and districts should carry out advocacy for the mobilization of funds. Report of the Second Evaluation of Sustainability of Morogoro CDTI Project -44- The communities which are expected to own the programme are not well informed or do not yet understand their role. This could be explained by the average grade of the indicators of sustainability at this level (see figure 6). However, the communityleaders have the potentials of mobilizing their community members in favour of CDTI as they do mobilize for other development projects using their quarterly community meetings to discuss issues. The absence of plans of action in some FLHF, the non treatment of communities for two years and also the inconsistency of the data indicates a weakness in the quality of monitoring and supervision of the FLHF by the higher levels. The indicator of Mectizan procurement and distribution is good but there is a weakness in that there is no proper stock management. Communities are supplied mectizan in sealed bottles of 500 tables. There are no reports on shortage of drugs during distribution but there is need to ensure proper management of excesses to avoid wastage. 5.10. Grading the proiect by level of operation t lr,- (f) a4) ,r)- $t nl 1t). a/)- o o 3.05 3.3 sf -c .goo B oqo(E o lr' 2.3 .E "t"" "-'$ "f ""-" Group of lndicators Figure 6 shows the average grading of sustainability ot the different levels of operation of the proiect A comparative analysis of the sustainability of the project at individual levels of operation shows that the community capacity to ensure sustainability is still weak. This is followed by the FLHF. This would explain the level of decentralization of the activities. The project Report of the Second Evaluation of Sustamability of Morogoro CDTI Proiect -45- managers at regional and district levels should capacitate these levels to carry out CDTI activities as expected. 5.11. Qualitative judgment of the project: The qualitative judgment of the sustainability of the Morogoro CDTI is made according to the "aspects" and "critical elements" of sustainability. 5.11.1. Aspects of Sustainability: Aspect Judgment: to what extent is this aspect helping or blocking sustainability of this project? lntegration Helping Resources Blocking Efficiency Partially Blocking Simplicity Helping Attitude of Staff Helping Community Ownership Moderotely helping Effectiveness Partiolly Helping lntegration: Helping Sustainability CDTI activities can be said to be integrated with other health programmes in Morogoro region as a matter of necessity because of staff shortage. However, transport and other materials are used in an integrated manner. This aspect has great contribution to the sustainability of Morogoro CDTI Project. Resources: Potentially blocking sustainobility This aspect has potentially negative impact on the sustainability of the CDTI project. There had been no direct allocation of funds by government. There was no plan for the government to fund the bulk of CDTI expenses by the end of Year 5 of APOC funding. Unless the government or any other partner takes prompt actions, it will negatively affect the sustainability of the Morogoro CDTI project. Efficiency: Partially Blocking Sustainobility Regarding efficiency, training, monitoring and supervision and HSAM (advocacy meetings to RHMT and DHMT and PHC) were not efficiently carried out. Excessive periods were used for training, monitoring and HSAM. Cascade and FLHF staffs were involved at the same time Report of the Second Evaluatron of Sustatnabilrt.v of Morogoro CDTI Prolect -46- and activities were extended right down to the communities. Transport and equipment breakdowns were noted, there were no maintenance schedules, there were lack of budgetary allocations and could cause breakdown for CDTI activities. These require some action for improvement. Simplicity: Helping sustoinobility CDTI activities have been fairly simplified. Reporting and data collection systems are simple. Mectizan is transported entirely within the Government system. The way Mectizan@ is distributed to zonal level should be simplified. Attitude of Staff: Very much helping sustainability Personnel at the different levels of the project have recognised CDTI activities as an integral part of their activities in the health development of the population. This is a driving force towards the sustainability of the CDTI project. However, some staffs need some re- orientation towards CDTI as they feel their funds have been diverted and addition of NTDs is cumbersome. Community Ownership: Moderately helping sustainability The evaluation team found out that community members were playing active role in CDTI programme but lack knowledge on their ownership role. They participated in selecting CDDs, changing CDDs when necessary. CDDs were highly committed despite not being supported. The communities are not informed on or have not yet understood the most important aspect of the programme which is community ownership. So far, the leaders and the community members consider CDDs to be employees of the government/districts. They have no plans on how to mobilize resources for the activities. However, the community leaders have the potentials of mobilizing their community members in favour of CDTI as they do mobilize for other development projects. They made very important promises to include CDTI on the agenda of their quarterly community meetings. They had never used this forum to discuss CDTI. Effectiveness : Partial ly hel pi ng sustai nability Records at project coordination show that all the communities are receiving treatment since the start of the programme. But the evaluators discovered on the field that some communities have not been treated since 2010. This was quite surprising to the project managers at regional and district levels. The coverage rates reported may not be reliable. There is need to improve on monitoring and supervision of the activities of FLHF. Report of lhe Second Evaluatton of Sustamability of Morogoro CDTI Project -47- 5.L1.2. Critical Elements of Sustainability Critical Element Yes /No Money: ls there sufficient money available to undertake strictly necessary tasks which have been carefully thought through and planned? (Absolute minimum residual activities). No Transport: Has provision been made for the replacement and repair of vehicles? ls there a reasonable assurance that vehicles will continue to be available for minimum essential activities? (Note that 'vehicle' does not necessarily imply '4x4' or even 'car'). Yes Supervision: Has provision been made for continued targeted supportive supervision? (The project will not be sustained without it). Yes Mectizan@ supply: ls the supply system dependable? (The bottom line is that enough drugs must arrive in villages at the time selected by the villagers). Yes Politica! commitment: Effectively demonstrated by awareness of the CDTI process among policy makers (resulting in tangible support); and a sense of community ownership of the program. Yes Money: No There have been critical problems with regard to release of budgets and flow of funds that has a blocking impact unless some measures are taken soon. Transport: Yes Although transportation facilities have not been sufficiently availed for CDTI activities at some levels, the traditions of using pooled transport and providing transportation assistance across different sectors of the government helps the sustainability of the project. ln regards to replacement and maintenance of transport, vehicles are not readily repaired and there is no documentary evidence of assurance that this will be carried out in the future. Supervision: Yes Supervisory visits though not targeted at most levels, support shall always be there from a pooled source of funding for the zone. The evaluation team feels strongly that much improvement is required in the quality of the supervision. Supervisors at all levels need to make such visits both targeted and integrated as in many cases as possible. Mectizan@ Supply: Yes The supply system for Mectizan@ distribution to the communities has been simple and reliable. ln most cases, Mectizan@ was available in villages in good time for planned Report of the Second Evaluation of Sustatnabiltty of Morogoro CDTI Project -48- distribution, though not at the time required by the community. There is need to put in place a proper system of stock management. Politica! Commitment: Yes The government is fully aware of its roles and supports CDTI just like administrative and political leaders at cascade and FLFH levels have shown their supports for the project. The integration of the CDTI in the national strategic plan of NTDs control is also evidence of political commitment. However, community ownership of the programme is still weak. 5. CONCLUSION: The evaluation team has found that five of the seven "aspects of sustainability" were helping or not blocking the project moving towards sustainability; "Resources" at all levels was blocking, while "Efficiency" was seen as potentially blocking. ln relation to "Critical elements", it was found that "Money" was not sufficient at all levels and conseq uently not su pporti n g sustainability. The Evaluation Guidelines indicate that where "one or two aspects are not fulfilled and one or two critical elements are not satisfied, the project is making satisfactory progress towards sustainability". Therefore, the lndependent Evoluotion Team concludes thot the Morogoro CDTI Proiect hos potentiots of making progress towards sustainability (with on overoll grode ol 2.8). The project management should capitolise on the recommendotions of the two evaluotions especially those thot hove been repeoted. Report of the Second Evaluation of Sustainabilttlt of Morogoro C DTI Project 49 7. ANNEXES 7.1. List of Evaluators: Name and Addresses of the Evaluators a NAME ADDRESS Prof Kenneth K. AGWU Faculty of Health Sciences and Technology, College of Medicine, University of Nigeria Enugu Campus, Enugu State, NIGERIA Dr Matilda AKOH-ARREY MD, Public Health Expert c/o Regional Delegation of Public Health, Buea CAMEROON Tel 00 237 77 7483 tZl 00237 98 00 66 49 echi54@hotmail.com Mr Prince MUTALEMWA National lnstitute for Medical Research P.O.BOX 9653, Dar-es-Salaam pmutalemwa@nimr.or.tz +255 754005020 Ms Christina Sifael MBISE Programme Officer Sightsavers, Tanzania Country Programme Office P.O.Box 25t3, Dar es Salaam Office : +255 222780!54 c m b i se @ s i ghtsa ve rs. o relch m b i se (a va h oo. co m Mobile : +255 779 2OO 407/+255 784 885 959 Dr Dennis MASSUE National lnstitute for Medical Research P.O.Box 81, Muheza-Tanga dmassue@nimr.or.tz +255 754 542698 Mr Clement MWEYA Senior Research Scientist National lnstitute for Medical Research Tukuyu Medical Research Centre P.O.Box 538, Tuyuku TANZANIA cmweva@nimr.or.tz Report of the Second Evaluation of Sustainabilfiy of Morogoro CDTI Project -50- 7.2. Calendar of activities Date Activity Place Responsible officer 2410e Meeting with WHO team Meeting with NOCP/NTDs Dar es Salaam External evaluators Elaboration of a draft calendar of activities Dar es Salaam External evaluators/NTD coordinator 2s109 lnterviews with NTDs national Coordination team lnterview with WHO team (NTDS FP and ad m inistrative officer) WHO Operations manager Dar es Salaam External evaluators 26lOs lnterview with WHO NTDs Focal person/APOC Adm& finance assistant Dar es Salaam External evaluators Travelto Morogoro Lodging for evaluators Morogoro External evaluators 27lle Meeting with regional coordinator Briefing of regional team Morogoro regional health office Evaluators Selection of evaluation sites Regional coordination office Evaluators/ Regional/District coordinators Review of calendar of activities Planning for orientation meeting Arrival of other internal evaluators Morogoro 28109 Courtesy call to Regional Medical Director Morogoro Regional coordinator Orientation meeting of all evaluators - study of the guide and instruments Regional coordination office Eva luators/Regiona I coordinator lnterviews regional teams 07170 Data collection District Health Office Morogoro DC Mvomero Sub team of EvaluatorsFrontline Health Facility Matuli&Hembeti 02lto Data collection communities Lamba&Lulongwe Miembeni&Mvuleni 03170 Frontline Health Facility Mkambarani&Mkindo 04/70 Data collection communities Mfine&Mngusi Minazini&Bohelo s- T lro Analysis of the data Formulation of recommendations Report writing Morogoro Both teams o8/10 Preparation for Debriefing meeting Morogoro Evaluators oello Debriefing meeting Morogoro Evaluators/Regiona I coordinator tol1.o Departure of internal evaluators 7t/to Departure of external evaluators from Morogoro Debriefing of WR/TZING DO Dar es Salaam L2llO Debriefing of MoH authorities Dar es Salaam Evaluators 73/tO Departure of External Evaluators a Report of the Second Evaluation of Sustainability of Morogoro CDTI Proiect -51- 7.3. Debriefing at Regional Level DEBRIEFING MEETING: AGENDA - EVALUATION OF SUSTAINABILIw OF MOROGORO CDTI PROJECT Morogoro, 09lO9l201.2 a I Time Item Responsible 10.00am RMO - Dr Mrema 10.05 - 10.10 Objectives and methodology of evaluation 10.L0 - 10.40 Findings: Community Prof Agwu Findings: Facility Dr Massue Findings: District Prince/clement Findings: Region Dr Matilda 10;40 - 10.50 Aspects of Elimination of Onchocerciasis Dr Matilda 10.50 - 11.30 Discussions Alt 11.30 - 11.40 Way forward Dr Matilda 11.40-L1.45 Closure RMO 12.00 Departure of internal evaluators Report of the Second Evaluation of Sustainability of Morogoro CDTI Project 52- I lntroductory Remarks Dr Matilda 7.4. Photo gallery Photo 1: Dr Akoh-Arrey & Mr lugatta (Data manager of project): Study of TCR for selection of sites Photo 3: L to R Ms Christina Mbise; Mr Mweya Clement, Dr Amina Said (NTDCo Mvomero), Mr Prince Mutalemwa, Dr Deniss Massue, Dr Debora Kabudi (project coordinator), Prof Agwu Kenneth, Mr Lugatta Elias Photo 5: Meeting with Acting Regional Administrative Secretary: Mrs EF Lauwo Photo 2: Mr Prince & Mr ligatta (Data manager and NTDs coordinator Morogoro Rural District): Photo 4: R to L Prof Agwu; Dr Akoh-Arrey, Dr Debora Kabudi Dr Deniss Massue, Mr Prince Mutalemwa, Mr Mwayi Clement, Dr Amina and Mr Lugatta Elias Photo 6: Meeting with the community of Mvuleni I I i t I J=3tiltrnil r*t{}E - il! tf EIIII Report of the Second Evaluation of Sustainability of Morogoro C DTI Project -53- o -- I ,._{ \fr- u h -,ltn\ dq ,1". . , I- i rI J rF t-J a6 t h )t tl I I n 7)' .,l! L I !t ilIA r - n D ^t .a a -\ I 1 F 2 4t L : i II aPhoto 7: Meeting with the community of Mvuleni Photo 9: CDDs of Mvuleni [ (Mr Mlegu Lukas to R (Mrs Mwamvua Ramdhani) of Dr Akoh-Arrey Photo 8; Meeting with the community of Mvuleni (Dr Deniss explains discussions in Swahili) Photo 10r Meeting with the community of Miembeni: L to R: CDD (Levina Sabini) and chief of sub village (Mrs Stella Luranda) I a Photo 11: Meeting with the community of Miembeni Photo 12: Visit of the Mkindo Dispensary: lnterview with nurse in charge (Mrs BahatiFanuel) Report of the Second Evaluation of Sustainability of Morogoro C DTI Project -54- \_ I 5t_ .& /- \ i, { L- l!l +'l 1 a .:' Lil ur , t, ):i- ffi . *i ::i* ?,F E* * ltFt ,' iil- \ { x rd.$ ra Il i a Photo 13: Meeting with the community of Minazini Photo 15: Sub-team 2 at work on Data analysis L to R Mr Prince, Dr Deniss and Dr Akoh-Arrey Photo 14: Sub-team 1 at work on Data analysis : L to R Mr Clement Mweya, Prof Agwu, Ms Christina Mbise Photo 15: Debriefing of Acting National NTDs coordinator: Dr Edward KIRUMBI a Report of the Second Evaluation of Sustainability of Morogoro CDTI Proiect -55- I II , Er ln'q L L.- .I E .l 7- I 5{ E h tL.r T5 I