Assessment of the self-sustainability of the Malawi CDTI project

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World Health Organisation

African Programme for Onchocerciasis Control

Assessment of the self-sustainability of the Malawi CDTI project

May 2002

Chipeta, Lucy

Fayomi, Yemi

Munthali, Spy

Nwaorgu, Obioma

Onwujekwe, Obinna

Sitima, Laston

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Abbreviations and acronyms

APOC:

African Programme for Onchocerciasis Control

CBO:

Community based organisation

CDD:

Community-directed distributors

CDTI:

Community-directed treatment with ivermectin

CHAM:

Christian Health Association of Malawi

DHO:

District Health Officer

DHMT:

District Health Management Team

DOC:

District Onchocerciasis Co-ordinator

DC:

District Commissioner

EHO:

Environmental Health Officer

HA:

Health Assistant

HAC:

Health Advisory Committee

HCAC:

Health Centre Area Committee

HSA:

Health Surveillance Assistant

IEC:

Information Education and Communication

IEF:

International Eye Foundation

MP:

Member of Parliament

MOHP:

Ministry of Health and Population

NGDO:

Non-Governmental Development Organisation

NOCP:

National Onchocerciasis Control Programme

NOTF:

National Onchocerciasis Task Force

OC:

Onchocerciasis Co-ordinator

ORT:

Other Recurrent Transaction

SHSA:

Senior Health Surveillance Assistant

SWOT:

Strengths Weaknesses Opportunities and Threats

TA:

Traditional Authority

TOT:

Trainers of Trainers

MA:

Medical Assistant

WHO:

World Health Organisation

Acknowledgements

We would like to thank the following persons and organisations for their help:

• The staff at APOC headquarters in Ouagadougou, especially Dr Seketeli, Dr Amazigo, Dr Noma, Mr Agbonton, Mr Aholou and Mrs Matovu.

• Staff of the WHO office in Lilongwe, Malawi.

• Staff of NOTF and IEF in Blantyre, especially Mr Tambala, Mr Sitima, Ms Jere, Mr Nkhoma and the two drivers.

• Onchocerciasis control teams and community members in Mwanza and Thyolo districts.

• Our research assistants

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Executive Summary

Background:

Onchocerciasis is endemic in seven districts of Malawi and six districts are now implementing community-directed treatment with ivermectin (CDTI) with funding support from the African Programme for Onchocerciasis Control (APOC). However, Mwanza and Thyolo districts started implementing CDTI with APOC support before the others, and both are actually in the fifth year of operation. The support for CDTI in both districts will tentatively end in March 2003 and it is hoped that the CDTI project will be self-sustainable post-APOC funding.

Objectives:

The major aim of the evaluation was to determine the level of sustainability of the Malawi CDTI programme, in order to know whether it can function optimally with little or no external resources.

The other objectives were to determine the strengths, weaknesses, opportunities and threats of the project and proffer recommendations, and develop action plans that can put the project on the sure path of self-sustainability.

Methods:

A cross-sectional study design was undertaken and the study tools comprised a questionnaire survey, in-depth interviews and review of documents. These study tools were used to generate information on nine indicators (developed by an expert panel that was convened by APOC) that can be used to assess the sustainability of the project. The indicators were geographical and therapeutic coverage, planning, providing leadership, monitoring and supervision, Mectizan procurement and distribution, training and sensitisation/mobilisation, financial resources, transport/other material resources and human resources. Each indicator was graded between 0 (not sustainable) to 4 (fully sustainable).

The evaluation was conducted at four levels of the project organisational framework; namely the national (headquarters) level, district level, traditional authority (sub-district) level and at the village level. The two districts where CDTI has been in existence since 1997 were the main study areas. In each district, three traditional authorities (TA), together with two villages from each traditional authority were purposively selected based on coverage levels. Hence, TAs and villages with high, moderate and low therapeutic coverage levels were included in the study.

Major Findings:

The key finding at the national level that will work against the sustainability of CDTI was that CDTI is not in the national health plan and hence there are no budgetary allocations for the programme.

Similarly, the key directors in the Ministry of Health are unaware of CDTI, APOC and APOC- supported project in Malawi and there are no plans for financial/ other resources sustainability of CDTI and no plan on how to sustain CDTI when APOC pulls out exists. Also, there the NOTF has not made explicit plans for sustainability of CDTI after APOC funding ends. However, a positive finding for sustainability is the fact that government waives custom duty on all donated items and actually pays handling charges arising from the clearing of such items.

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The key findings at the district level that will work against sustainability of CDTI are that the policy makers and political leaders at this level were not sensitised and mobilized towards providing funds to support CDTI and that health education and IEC materials were not readily available at the districts. In addition, there were no explicit plans to cover the recurrent costs of running existing transport and to replace them. However, a high level of integration of services was found at this level.

The key findings at the health centre/TA level were the fact that the Insufficient knowledge of CDTI activities by chairmen of HCAC and Medical Assistants (that run the health centres). There were also inadequate transport facilities deterring effective supervision, non-inclusion of CDTI budget and financial support at TA Level and inadequate training of HSAs especially in Mwanza which affect coverage.

The key findings at the village level were that geographical and therapeutic coverage was good in most communities. However, it was found that both political and traditional leadership were not part of the mainstream CDTI programme. Also, it was found that CDDs did not know how to calculate required doses and order for Mectizan because the H.S.As bring the drug to them. Furthermore, the maintenance of registers and other CDTI records was generally poor due to weak training and supervision mechanisms. Finally, the villagers are not organised in any way to take financial responsibility for CDDs to operate smoothly as they believe government should do everything as is the case with the rest of medical services at that level.

Integrating the key findings of the entire project showed that the level of overall sustainability was 40%. The results achieved (coverage) scored 50%, activities that support CDTI (planning, leadership, Mectizan procurement and distribution, training and sensitisation/mobilisation) scored 48%, and resources provided (financing, transport and other material resources and human resources) scored 34%.

Key Recommendations:

The key recommendations at the national level are that there should be immediate sensitisation of all directors in the MOH, the permanent secretary, the Minister, deputy Minister and MPs from all the onchocerciasis endemic districts before August 31^st 2002. There should also be a participatory development of CDTI sustainability plans at the district and national level before November 30 2002 and there should be the development of a simple manual for undertaking field visits and strengthening the CDTI sustainability capability of the districts before November 30, 2002. The co- ordinator of NOTF and NGDO should drive the achievement of these recommendations.

The key recommendations at the district level are that the procurement and storage of Mectizan should be integrated in the district drug procurement and storage system. However, there should be immediate and intensive advocacy, mobilisation and sensitisation of district leadership towards funding CDTI activities. Furthermore, health education materials should be given to all essential programme officers at the district and planning of CDTI activities in the district should be integrated with other health programmes plans through participation in a District Health Management workshop.

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The key recommendations at the health centre/TA level were that there is urgent need for capacity building of HSAs and CDD to improve coverage. There should also be an urgent sensitisation and briefing meeting to chairpersons HCAC Medical Assistant. There should also be a complete integration of health activities to share transport by 2004 and the development of effective strategies for raising funds, workshop on financial sustainability.

The key recommendations at the village level were that thorough sensitisation of the political and village leaders on their role in the success of CDTI activities are needed to be undertaken as soon as possible (ASAP) by HSAs and DHO and the DC, by August 2002. Also, CDDs need to be properly trained on how to keep accurate records by HAsA/HSAs, NOTF co-ordinator/DOCs to be completed by September, 2002. Furthermore, the villagers need to be sensitised about the need for them to source for finances and establishing village incentive system to reduce the attrition rate of CDDs towards ensuring that CDTI is sustained. A systematic and regular supervision/IEC schedule in communities that is needed to deal with mistakes and spreading of wrong information or misconceptions should be established ASAP.

Conclusion:

The project is potentially sustainable, but will require re-thinking and mobilisation of high-level support to get it on the road of sustainability. The project staff will need external help to develop and implement some sustainability strategies if CDTI is to be sustained. The members of staff in NOTF/NOCP have to be quickly oriented to thinking, worrying and planning on how to sustain the CDTI programme in Malawi without APOC funding. All in all, the high level of integration of CDTI in the Malawian health-care system at the district and TA levels are opportunities that should be fully exploited to sustain CDTI in the country.

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1. INTRODUCTION

Onchocerciasis Control activities in Malawi started in 1984 after the launching of the Onchocerciasis Control Programme in the Ministry of Health and Population. The main stakeholders at that time were the Ministry of Health, the Tea Association of Malawi and the Malamulo Seventh Day Adventist Hospital in Thyolo district. There was only one and confirmed focus of the disease in Thyolo district, with over 100,000 people estimated to be infected. In 1991 the Neno Area of Mwanza district, about 160km north west of the Thyolo focus, also in the Southern Region was also found to be endemic with Onchocerciasis with an estimated 20,000 people infected.

Thyolo is one of the most densely populated districts in the country with more than 550,000 people. It lies to the South east of Malawi and forms part of the International boarders with Mozambique. It is a very hilly area with numerous riverine systems, which make it favourable for the breeding of the onchocerciasis vectors. Mwanza district with a population of about 332,000 is on the western boarder with Mozambique. It is endemic for onchocerciasis in Neno area, to the north of the district. Neno has similar topography and climate as that of Thyolo. The villages in Thyolo are denser and closer that in Mwanza where they are more scattered.

After successful trials with the new micro filarial drug ivermectin in 1987, mass distribution was commenced in November 1991 in Thyolo District. Distribution was extended to Mwanza district in 1993 with the assistance of the International Eye Foundation (IEF). Mass treatment with ivermectin has been going on in Thyolo and Mwanza districts with the full involvement of the Ministry of Health, Tea Association of Malawi, the IEF, WHO and Village Communities.

Malawi was incorporated into the APOC-funded CDTI projects in 1995. The African Programme for Onchocerciasis Control (APOC) advocates the philosophy of community ownership of community- directed treatment with ivermectin (CDTI) where the communities are involved in decision making by undertaking certain responsibilities. These include planning for and self-distribution of Mectizan.

Mectizan distribution is conducted by volunteer drug distributors called the community-directed distributors (CDDs), who are selected by their communities. Health Surveillance Assistants (HSAs), who are government employees based in the communities supervise the CDDs. There is 1 HSA per 1 or 2 villages. The HSAs are supervised by Health Assistants (HA)/Environmental Health Officers (EHO) who are based in the health centres within the jurisdiction of a TA. The HA/EHO is based at the Health centre, and each is responsible for at least 10 HSAs. CDDs collect drugs from HSAs. The HSAs collect the drug (Mectizan) from the Health centres. The Health centres collect the drug from the District Hospital, while the district hospital collects the drug from the NOTF Secretariat Office in Blantyre. The HSAs compile coverage data from CDDs’ registers and thereafter send the data to their supervisors.

This information is transmitted from the Health centre to the District Onchocerciasis co-ordinator (DOC), who is based in the District Hospital. The DOC sends the data to the NOTF Secretariat.

The National Onchocerciasis Task Force (NOTF) facilitates the implementation of CDTI by working closely with the district teams. The NOTF is a coalition of 5 partners, MOH &P, International Eye Foundation (IEF), Thandizani Moyo, Christian Health Association of Malawi (CHAM), and Tea Association of Malawi. CDTI implementation started in 1997 with funding from the IEF until APOC made the first disbursement of funds. With assistance from APOC, a countrywide survey using a methodology called Rapid Epidemiology Mapping of Onchocerciasis (REMO) was conducted in 1997.

Results from this survey showed that besides Thyolo and Mwanza, the disease is endemic in parts of Mulanje, Phalombe, Blantyre, Chiradzulu and Chikwawa District. Currently CDTI is being implemented in 6 districts, and they are Thyolo, Mwanza, Blantyre, Chikwawa, Phalombe and Mulanje.

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The APOC financial support to CDTI in Thyolo and Mwanza districts will tentatively end in March 2003 and it is hoped that the CDTI project will be self-sustainable post-APOC funding. Hence, the major aim of the evaluation was to determine the level of sustainability of the Malawi CDTI programme, in order to know whether it can function optimally with little or no external resources. The other objectives were to determine the strengths, weaknesses, opportunities and threats of the project and proffer recommendations, and develop action plans that can put the project on the sure path of self- sustainability.

The next section of this report (Section 2) discusses the methodology of the evaluation. It will describe how the sub-districts (TA) and villages were selected, and how the data collection instruments were administered. In section 3, the key findings and high priority recommendations for the four level evaluated (National, District, TA and Village) are presented in different sub-sections respectively.

Section 2 concludes with an overall assessment of the sustainability of the Malawian CDTI programme.

A Strengths, Weaknesses, Opportunities and Threats (SWOT) analysis is used to aid this assessment.

Hence, the key strengths and weaknesses (internal to CDTI)) and opportunities and threats (external to CDTI)) are itemised, together with a summary way forward to increase sustainability. The general principle behind the SWOT analysis is to improve the strengths, take advantage of opportunities, limit weaknesses and avoid the threats to sustainability of the programme.

The detailed findings are presented using samples of the instruments that were administered inn the field, in the 3^rd section of the report. Each completed form is followed by a brief exploration of issues related to the indicators that may not be clear in the summary results that are presented in the forms. The detailed high and medium priority recommendations for each level are itemised in Tables after the exploration of key issues. The key findings that formed the basis of the recommendations are presented in the first column of the tables. The appendices are presented in the last part of the report. Appendix 1 presents the timetable for all activities that were undertaken by the evaluation team. Appendix 2 provides the result of feedback workshops at the National level, in Mwanza district and in Thyolo district.

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2. METHODOLOGY

2.1 Study areas:

The two study districts: Mwanza and Thyolo were selected based on the fact that they are the only two districts as at the time of this evaluation that were implementing CDTI strategy in the fifth year of APOC funding. Other districts that are onchocerciasis endemic in their 1^st, 2^nd and 3^rd year are Mulanje, Phalombe, Blantyre, Chikwawa and Chiradzulu.

The community or village set up in Malawi mostly follows a common clan ancestry and or a similar cultural grouping and is headed by a Chief who may be assisted by several elders of a clan. In some districts several households belonging to one village headman can be scattered over several kilometres.

Several villages form a group of "super" village that is headed by a Senior Chief called Group Village Headman (GVH). Above the GVH is a traditional chief called Traditional Authority who looks after several GVH in a district. The district is an administrative unit in a geographical regional setting where there are 3 regions namely the North, Centre and the South. There are 26 districts in Malawi with an estimated at 11 million people.

The primary criterion used for selecting sub-districts (Traditional authorities) was therapeutic coverage and the secondary criteria were convenience and accessibility. Hence, 3 Sub-districts (TAs) were selected from each of the 2 ONCHO districts by applying the above criteria. Hence, TA s with the highest, medium and lowest treatment coverage were respectively selected from the study districts. Out of the 8 TAs in Thyolo district, the following TAs were selected:- Thomasi (67.7%: High coverage), Nchilamwera (54.9% Medium coverage) and Bvumbwe (46.1%: Low coverage). Similarly, out of 6 TAs in Mwanza district, Ngozi (60.5%: High coverage), Nthache (54.9%: Medium coverage) and Kanduku (49.7%: Low coverage).

Applying the same criteria, two villages were selected from each of the six TAs that were selected in the two districts, thus totalling 12 villages (Table 2.1). One village with the highest and one with the lowest coverage were chosen. This gave a total of 12 villages for the two districts. The villages selected from each TA are the following:

Table 2.1: Shows the villages selected and their coverage levels.

Traditional authority (number of villages) Villages selected and therapeutic coverage

Ngozi (14 villages) Chirombo: 84.7%; William: 26.3%

Kanduku (35 villages) Chikudzu: 80.7%; Ziyaya: 6.2%

Nthache (25 villages) Silota: 77.9%; Kagulo: 12.4%

Thomasi (16 villages) Jeremia: 88.0%; Chinthebe: 46.4%

Nchilamwera (32 villages) Magombo: 29.56%; Tembenu: 80.0%

Bvumbwe (40 villages) Maggie: 88.4%; Tayali: 0.9%

The selection of respondents to be interviewed at the district level was undertaken on the basis of the instrument that indicated the list of those that were to interviewed. These people were either directly or indirectly involved with health services at the district level and they were the District Health Officer (DHO) in-charge of the District Hospital, the District Onchocerciasis Coordinator (DOC) at least one of the District Onchocerciasis team members (the T.O.Ts), the District Commissioner (the policy maker at the district level) the pharmacist in-charge of the district hospital, the district hospital's accountant, the district hospital's transport Officer and NGDOs supporting the distribution of Ivermectin at the district level.

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Purposive sampling was used to select people that are directly involved with health activities at TA/

health centre level. These included the Clinical officer /Medical Assistance heading the Health Centre, the ONCHO Coordinator at Health Centre level, TA/Chairperson of Health Centre Advisory Committee and the H SA. Within a village interviews were conducted to the following respondents; Village head, 3 CDDs, 2 male and 2 female Community Based Organization members (CBOs) and 3 male and 3 female community members.

2.2 Sequence of visit

Following the selection of 6 Traditional Authorities (TAs) and 12 villages an agreed time table for their visit was prepared by the teams (Appendix 1). Data collection by the team started on Wednesday 15^th of May and ended on Saturday 19^th of May. Then, visit to the MOH&P in Lilongwe and feedback workshops were held in following week. The team started with the Mwanza and Thyolo district headquarters. In Thyolo HQ, the team was introduced to the hospital officials namely DHO, DC, Finance and Transport officials and Pharmacist by the DOC.(District Onchocerciasis Co-ordinator). The following individuals at the District level were all interviewed after the team had explained the objective of the visit to them namely: DHO, DC, Finance and Transport officers, Hospital pharmacist, DOC and SHSA. Thereafter the team paid courtesy visits to the residence of the Traditional Authority for Nchilamwera in Thyolo district and Kanduku in Mwanza district, during which the TAs were also interviewed.

2.3 Study tools:

The selected respondents were interviewed using survey instruments designed by APOC. The interview was based on the nine indicators of sustainability developed by APOC these included the following:

coverage, planning, monitoring, management of mectizan, transport and human resources. In general sustainability was graded on the basis of the nine key indicators drawn from the APOC instrument. At the national level, coverage was excluded, while leadership was excluded at the TA level and both training and transport excluded at the village level. The exclusions were because those indicators were considered not to be sustainability factors at those levels.

2.4 Data analysis:

After the field work each indicator was graded according to the response given by the respondent. The grading was based on the scale ranging from 0-4. The results were then tabulated and analysed using simple descriptive statistics giving mean and totals for the TAs. This was based on the nine indicators that were used during the fieldwork.

2.5 Study limitations:

During the field work it was not possible to interview all the selected respondents and villages because there were funerals in two villages; one in Mwanza (Ziyaya) and another one in Thyolo (Tayali) and due to limited time it was not possible to make a call back. In case of Thyolo there was a call back failure where the communities were not willing to be interviewed a day after the funeral. This reduced the original sampled number of respondents. The second limitation is that data was analysed based on the response of the respondent therefore the weighting of the response was subjective in certain circumstances but a general consensus was reached among the evaluators was reached. Also, grading was subject to the response of different respondents. For example the response from the District

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2.6 Team composition: The core members of the evaluation team were:

Mrs Lucy Chipeta: Chancellor College, Geography and Earth Sciences Dept, Box 280, Zomba, Malawi.

lkchipeta@chirunga.sdnp.org.mw/lkchipeta@yahoo.com

Dr Yemi Fayomi: North-central zonal co-ordinator, National Onchocerciasis Control Programme, Nigeria. remi@programmer.net

Mr Spy Munthali: Economics Department, University of Malawi, Box 280, Zomba, Malawi, smbiriyawaka@yahoo.com/spym@chanco.unima.mw

Prof Obioma Nwaorgu: Department of Applied Biology, Enugu State University of Science and Technology, Enugu, PBM 01660, Enugu, Nigeria, obinwaorgu@yahoo.com onwaorgu@infoweb.abs.net

Dr Obinna Onwujekwe (Team leader): Department of Pharmacology and Therapeutics, University of Nigeria Teaching Hospital, PMB 01129, Enugu, Nigeria.

Onwujekwe@yahoo.co.uk; obinna.onwujekwe@lshtm.ac.uk

Mr Laston Sitima, deputy national co-ordinator of NOTF and Mr Fedson Nkhoma of IEF assisted in the field-work in Mwanza and Thyolo districts respectively. In addition, three field workers were employed and trained in both districts respectively to assist in data collection at the village level. Ms Esther Jere of the NOTF office in Blantyre co-ordinated the typing of many aspects of this report.

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3. Findings and recommendations

3.1 National level

3.1.1 Overall grading (on a scale of 0-4)

Table 3.1: Sustainability of CDTI at the Headquarters

Cover Plan Lead Monitor Manage Train Finance Transport Human Resources

Total Sustain

NOTF chair NA 2 2.5 2 2 NA 1 1.3 1.3 12.1 33.6%

National Co-ordinator NA 2.8 3 3.2 3.7 2.3 1.4 2 2 21.4 59.4%

Directors of finance, planning & transport in MOH

NA 0 0 0 0 NA 0 0 4 4 11.1%

Mean NA 1.6 1.8 1.8 1.9 2.3 0.8 1.1 2.4 13.7 42.8%

3.1.2 Key findings

• CDTI is not in the national plan and hence there are no budgetary allocations to the programme.

• Onchocerciasis is not a high national priority in Malawi, but is only a high priority in the affected districts.

• The key directors in the MOH are unaware of CDTI, APOC and APOC-supported project in Malawi.

• Government waives custom duty on all donated items and actually pays handling charges arising from the clearing of such items.

• There are no plans for financial/ other resources sustainability of CDTI and no plan on how to sustain CDTI when APOC pulls out.

3.1.3 High priority recommendations

• There should be immediate sensitisation of all directors in the MOH, the Permanent Secretary, the Minister, deputy Minister and MPs from all the onchocerciasis endemic districts before August 31, 2002. This task should be driven by the National Co-ordinator of NOTF, together with the Chairman of NOTF.

• There should be a participatory development of CDTI sustainability plans at the district and national level before November 30, 2002. The Co-ordinator of NOTF and DOCs should drive the achievement of this recommendation.

• The chairman of NOTF, co-ordinator of NOTF and NGDOs should motivate the development of district CDTI policy plans that will specify the cost implications and budgetary requirements of CDTI, which will be incorporated into the national budget for 2003 - 2004. The co-ordinator of NOTF and DOCs should drive the achievement of this recommendation.

• There should be the development of a simple manual for undertaking supervisory field visits and strengthening the CDTI sustainability capability of the districts before November 30, 2002. The co-ordinator of NOTF and NGDO should drive the achievement of this recommendation.

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3.2 District level

3.2.1 Overall grading (on a scale of 0-4)

Table 3.2: Sustainability of CDTI at the ^Districts

Total Sustain

Thyolo 1.7 3 2.6 2.6 3.1 1.9 0.5 2.9 2.3 20.6 57.2%

Mwanza 2.5 1 0.9 2.6 3.5 1.5 0.4 1.6 2.7 16.7 46.4%

Mean 2.1 2 1.8 2.6 3.3 1.7 0.5 2.3 2.5 18.8 52.2%

3.2.1 Key findings

• Mectizan is stored in the DOC's office in Thyolo district.

• Leadership at District level are not sensitised and mobilized towards providing funds to support CDTI.

• Training and retraining are not consistent and integrated with those of other health service programmes.

• Health Education and IEC materials were not readily available at the districts.

• There are no explicit plans to cover the recurrent costs of running existing transport and to replace them.

3.2.2 High priority recommendations

• Drugs procurement and storage should be integrated in the District drug procurement and storage system.

• Advocacy, mobilization and sensitisation of district leadership towards funding CDTI activities should be undertaken.

• Training and retraining should be targeted at the weak links in CDTI and should also be provided for other health workers in the district.

• Health Education materials should be given to all essential programme officers at the district level.

• Planning of CDTI activities in the district should be integrated with other health programmes through participation in a District Health Management workshop.

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3.3 Traditional Authority/Health Centre level 3.3.1 Overall grading (on a scale of 0-4)

Table 3.3: Sustainability of CDTI at the Health centres; Mwanza

Total Sustain

Ngozi 1 0.2 NA 1 2.6 0.3 0.3 1 1.5 7.9 24.7%

Kanduku 3 1.4 NA 2.4 2.3 0.9 0 2.3 2 14.6 45.6%

Nthache 3 0.7 NA 2.7 2.8 2.7 1.5 3.8 1.5 18.7 58.4%

Mean 2.3 0.8 NA 2 2.6 1.3 0.6 2.4 1.7 13.7 42.8%

Table 3.4: Sustainability of CDTI at the Health centres; Thyolo

Total Sustain

Thomas 0 0.7 NA 2 1.1 2.9 0 0 1.5 8.2 25.6%

Bvumbwe 2.5 3.2 NA 1.5 2.4 1.9 0 0 2 13.5 42.2%

Mean 1.3 2 NA 1.8 1.8 2.4 0 0 1.8 11.1 34.7%

Table 3.5: Sustainability of CDTI at the Health centres; Combined

Total Sustain

Mwanza 2.3 0.8 NA 2 2.6 1.3 0.6 2.4 1.7 13.7 42.8%

Thyolo 1.3 2 NA 1.8 1.8 2.4 0 0 1.8 11.1 34.7%

Mean 1.8 1.4 NA 1.9 2.2 1.9 0.3 1.2 1.8 12.5 39.1%

3.3.1 Key findings

• There was medium treatment coverage at TA level with a score of 1.8 this is as a result of inadequate supervision of CDDs by HSAs.

• Insufficient knowledge of CDTI activities by Health Advisory Committee (HAC) Chairman and Medical Assistants (MA).

• Inadequate transport facilities deterring effective supervision.

• Lack of inclusion of CDTI in budget and financial support at TA Level

• Inadequate training of HSAs especially in Mwanza.

3.3.2 High priority recommendations

• The need for capacity building of HSAs and CDDs to improve reporting of coverage levels. The DOC in collaboration with NOTF should undertake and complete this task by March 2003.

• Organise adequate sensitisation and briefing meeting for Chairpersons of HAC and the Medical Assistants before May 2003. The DHO, DOC and HSAs should undertake this task.

• Ensure complete integration of health activities for sharing of transport by end of 2002. Task to be undertaken by MAs.

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3.4 Community (Village) level

3.4.1 Overall grading (on a scale of 0-4)

Table 3.6: Sustainability of CDTI at communities in Mwanza district

Cover Plan Lead Monitor Manage Train Finance Human Resources Total Sustain

William 2.3 1.5 0.9 1.5 0.8 NA 0.5 2.5 10.0 35.7%

Chirombo 3.5 2 1.8 3.3 2.2 NA 0.9 2.8 16.5 58.9%

Chikudzu 1.5 2.2 0.6 1.1 1.9 NA 0.9 2.6 10.8 38.6%

Silota 3.7 3.2 1.1 2 2.1 NA 0.5 2.7 15.3 54.6%

Kagulo 1 2.1 0.5 1.8 2.3 NA 0.9 2.7 11.3 40.4%

Mean 2.4 2.2 1 1.9 1.9 NA 0.7 2.7 12.8 45.7%

Table 3.7: Sustainability of CDTI at communities in Thyolo district

Cover Plan Lead Monitor Manage Train Finance Human Resources Total Sustain

Maggie 3.5 3.9 3.4 3.4 2.8 NA 1.3 3.1 21.4 76.4%

Tayali 1 2 2.5 2 1.6 NA 0.9 2.3 12.3 43.9%

Magombo 2.8 3.3 2.1 2 2.9 NA 0.8 2.3 16.2 57.8%

Tembenu 2.5 2.4 2.4 2.4 1 NA 0.4 2.8 13.9 49.6%

Jeremia 2.2 1 1.1 1.3 1.5 NA 0.8 2.5 10.4 37.1%

Chinthebe 1.6 1.3 2.2 2 2.1 NA 0.8 2.7 12.7 45.4%

Mean 2 2.1 1.9 1.9 1.6 NA 0.7 2.2 12.4 44.3%

Table 3.8: Sustainability of CDTI in combination of communities in Mwanza and Thyolo districts Cover Plan Lead Monitor Manage Train Finance Human Resources Total Sustain

Mwanza 2.4 2.2 1 1.9 1.9 NA 0.7 2.7 12.8 45.7%

Thyolo 2 2.1 1.9 1.9 1.6 NA 0.7 2.2 12.4 44.3%

Mean 2.2 2.2 1.5 1.9 1.8 NA 0.7 2.5 12.6 45.0%

3.4.2 Key findings

• Geographical and therapeutic coverage was very good in most villages.

• Political and traditional leadership were not to part of the mainstream CDTI programme.

• CDDs do not know how to calculate required doses of Mectizan.

• Maintenance of registers and other CDTI records was generally poor due to weak training and supervision mechanisms.

• There were no plans to ensure financial self-sustainability of CDTI.

3.4.3 High Priority Recommendations

• Thorough sensitisation of the political and village leaders on their role in the success of CDTI activities to be completed by DOC, HSAs and DC, by August 2002.

• CDDs to be properly trained on how to keep accurate records by HA/HSAs, to be completed by September, 2002.

• Sensitizing of villagers on sourcing for finances towards helping CDD work to be undertaken by DOC and HSAs and completed by end of December 2002.

• Setting up of a systematic and regular supervision and IEC schedule in communities to deal with mistakes and spreading of wrong information or misconceptions, to be undertaken by NOTF/DOCs/HSAs and completed by end of September, 2002.

• Establishment of a village incentive system to reduce the attrition rate of CDDs, to be undertaken by DC/village head/MP/H.S.A and completed by December 2002.

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3.5. Overall self-sustainability of the Malawi project

This is presented in Tables 3.9 to 3.12. The first two tables present the overall sustainability of CDTI in each of the two districts, while the third table focuses on the sustainability of the entire project. Finally, the last table combined information from the questionnaires, observations and other feedback to arrive at a SWOT analysis of the project.

3.5.1 Overall grading (on a scale of 0-4)

Table 3.9: Sustainability of CDTI in Mwanza District

Total Sustain

District 2.5 1 0.9 2.6 3.5 1.5 0.4 1.6 2.7 16.7 46.4%

Traditional authority

2.3 0.8 NA 2 2.6 1.3 0.6 2.4 1.7 13.7 42.8%

Community 2.4 2.2 1 1.9 1.9 NA 0.7 NA 2.7 12.8 45.7%

Mean 2.4 1.3 1 2.2 2.7 1.4 0.6 2 2.4 16 44.4%

Table 3.10: Sustainability of CDTI in Thyolo District

Total Sustain

District 1.7 3 2.6 2.6 3.1 1.9 0.5 2.9 2.3 20.6 57.2%

1.3 2 NA 1.8 1.8 2.4 0 0 1.8 12.5 34.7%

Community 2 2.1 1.9 1.9 1.6 NA 0.7 NA 2.2 13.4 44.3%

Mean 1.7 2.4 2.3 2.1 2.2 2.2 0.4 1.5 3.1 17.9 49.7%

Table 3.11: Sustainability of the entire CDTI project in Malawi

Total Sustain

Headquarters NA 1.6 1.8 1.8 1.9 2.3 0.8 1.1 2.4 13.7 42.8%

District 2.0 2.0 1.8 2.6 3.3 1.7 0.5 2.3 2.5 18.7 51.9%

1.8 1.4 NA 1.9 2.2 1.9 0.3 1.2 1.8 12.5 39.1%

Community 2.2 2.2 1.5 1.9 1.8 NA 0.7 NA 2.5 12.6 45.0%

Mean 2 1.8 1.6 2.1 2.3 1.8 0.6 1.2 2.3 14.4 40.0%

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Table 3.12: SWOT analysis and overall high priority recommendations

SWOT Findings Recommendations

Strengths 1.The level of integration of health-care services from the district level down to the villages in quite high.

1. The NOTF and DHO should ensure that CDTI is fully mainstreamed in the integration of service by end of 2002.

Weaknesses 1.Lack of commitment by many CDDs and their attrition rate is high in some areas due to lack of incentives.

2.Policy makers in MOH&P and political leaders lack knowledge about CDTI and APOC.

3. Monitoring not routinely done and information not shared on CDTI

4.Mobilisation and sensitisations materials are lacking at the TA and village level.

1.Use of village leaders and political leadership in villages to empower and motivate CDDs. The Coordinator NOTF, DOC, HA and HSAs to undertake his task by December 2002

2. NOTF/NGDOs to drive that all policy makers gain full knowledge of APOC and CDTI before November 2002.

3. There is need to strengthen the capacity of HSAs for effective supervision and monitoring of CDDs. The co-ordinator NOTF and DOCs complete this task by December, 2002.

4.Mobilisation and sensitisations materials to be made available all levels. By the Co-ordinator NOTF by December, 2002

Opportunities 1. Other Recurrent Transaction (ORT) is a possible means for meeting the CDTI financial resources.

2. There is a proposed Sector wide approach (SWAp) for funding health-care in Malawi and it is the major focus of a planned health reform package.

3. HSA programme is a plus for sustainability of CDTI.

1.This issue should be examined as possible source of funding for CDTI. Co-ordinator NOTF/DHO should

complete task by August 2002

2. NOTF should explore how CDTI can benefit from SWAp before the end of December, 2002.

3. The capacity of HSAs should be strengthened for effective supervision and monitoring of CDDs.

Threats 1.There are still misconceptions about Mectizan

2. Oncocerciasis is not regarded as a high priority disease in the country

3. Almost all health-care services delivered free in Malawi by the government and NGDOS, thus, people do not see any special thing in Mectizan being free.

1.Need for change in attitude through continuous sensitisation and mobilization of village members on CDTI and why they should take Mectizan annually.task should be driven by coordinator NOTF, DOCs, HAs and HSAs and should be started at not later than August 2002 and remain continuous.

2&3. The NOTF and NGDOs should develop better advocacy strategies to ensure that onchocerciasis is rightly recognised as a high priority disease that can be potentially eradicated with Mectizan.

Conclusion: The project is potentially sustainable, but will require re-thinking and mobilisation of high- level support to get it on the road of sustainability. The project staff will need external help to develop and implement some sustainability strategies if CDTI is to be sustained. The members of staff in NOTF/NOCP have to be quickly oriented to thinking, worrying and planning on how to sustain the CDTI programme in Malawi without APOC funding. There should be quarterly review meeting on CDTI involving all cadre at district, TA and village levels during which coverage data is presented, problems and successes discussed and solutions proffer for problems discussed.

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4. Detailed Findings 4.1 National level

1. Coverage

Not relevant at this level.

2. Planning

2.1 Check if the year plan for CDTI appears as part of an overall written plan for the health service at this level (it may appear under another name, e.g. 'onchocerciasis programme') (indicator of attitude, integration and effectiveness)

 CDTI should be integrated into the overall year plan at this level (showing that the management considers CDTI to be part of its yearly routine, like any other programme). It should not be separate.

 CDTI should be administered like other, similar disease control programmes.

 There should be written evidence of such integrated planning and management.

Findings:

CDTI is not yet integrated into the national plan.

However, the plan covers the control of all preventive diseases, of which onchocerciasis is one. All in all, onchocerciais control is still being run as a vertical programme driven by APOC funds.

Is this good for sustainability? Fully Highly Moderately Slightly Not at all Not applicable 2.2 Check if the plan contains all the elements needed for CDTI to work well (indicator of effectiveness)

 The plan should make provision for all key elements.

 Checklist of key activities: Mectizan supply;

targeted training; targeted mobilisation/

sensitisation; monitoring and supervision

Findings:

The vertical onchocerciasis-specific plan contains all vital CDTI elements.

Is this good for sustainability? Fully Highly Moderately Slightly Not at all Not applicable 2.3 Check if all partners (government, UN agencies, NGDOs) are meaningfully involved in the overall planning process

(indicator of integration and effectiveness)

 All partners should contribute to routine planning.

 The plan should give all partners specific tasks to perform.

 Partners should be clear about their own roles, and those of the other partners.

Findings:

The district onchoecrciasis co-ordinators, NGDOs, NOCP office and the national director of preventive health services (who doubles as the NOTF chairman) are all involved in the planning process. All partners clearly know their roles.

Is this good for sustainability? Fully Highly Moderately Slightly Not at all Not applicable 2.4 Check if specific planning for sustainability has taken place, for the period after APOC funding is withdrawn

(indicator of effectiveness)

 Staff should report that they have made plans for this period which will enhance programme sustainability.

 There should be written evidence that such planning has taken place.

Findings:

No specific planning for sustainability has taken place.

Is this good for sustainability? Fully Highly Moderately Slightly Not at all Not applicable

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3. Providing leadership

3.1 Check if there is an official, within the normal civil service organogram, charged with implementing onchocerciasis control (indicator of integration and effectiveness)

 There should be at least one official who has clearly been allocated the task of running the CDTI programme.

 There should be a document available which confirms this appointment.

 If this person/s has other responsibilities as well, s/he should have sufficient time for her/ his onchocerciasis control activities.

Findings:

The coordinator of the National Onchocerciasis Control Programme is a civil servant.

Is this good for sustainability? Fully Highly Moderately Slightly Not at all Not applicable 3.2 Check if there is evidence of political commitment to CDTI at this level (indicator of integration and attitude)

 The senior person (politician/ civil servant) in charge of health matters at this level should know about CDTI and appears committed to it.

 There should be evidence of specific past budgetary allocations and disbursements for CDTI, and the amounts should be increasing.

Findings:

There is minimal political commitment to CDTI since onchocerciasis is not seen as a high priority problem in the country. There have not been specific budgetary allocations to CDTI from the disease control vote. The government policy is not to fund activities that have funding from external sources. However, the

government covers the direct recurrent costs (salaries, some travel costs) of all government workers involved in CDTI.

4. Monitoring and supervision

4.1 Check if routine data concerning CDTI activities at this level are collected and transmitted entirely within the government system (indicator of integration)

The reporting process should take place within the government system, not using other resources.

Findings:

All routine data are transmitted entirely within the government system.

Is this good for sustainability? Fully Highly Moderately Slightly Not at all Not applicable 4.2 Check if only necessary information is being collected (i.e. necessary for making decisions) (indicator of efficiency

and simplicity)

All the information included in the reports should be potentially useful at this level, as a tool in planning and decision making

Findings:

The reports contain all elements that are useful for planning at NOCP office. However, the reports that are sent to the Chairman of NOTF, who is also the director of MOH preventive health services are summaries.

These summaries are not easy to understand and makes it difficult for the director of preventive health services to know what is happening in CDTI for optimal planning. However, the MOH planning office does not get reports of CDTI that can aid them in planning.

Is this good for sustainability? Fully Highly Moderately Slightly Not at all Not applicable 4.3 Check if the relevant person at the national/ State level is routinely supervising the CDTI activity of the LGA/ health

district on site (indicator of effectiveness)

 There should be evidence that each LGA/ district is visited at least once around the time of distribution.

 There should not be unnecessarily many visits - there should be clear justification for each one.

Findings:

The NOCP staff routinely visit districts at least once every two months to strengthen CDTI. They also visit a random sample of CDDs.

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4.4 Check if supervisory visits are being planned and executed as efficiently as possible (indicator of integration and efficiency)

 NOC/ SOC should routinely only supervises the next level, and empower the next level to supervise further down

 Supervision visits should be integrated where possible.

 Resources (human, transport etc.) should be efficiently used.

 Each visit should have a specific goal and / or checklist.

Findings:

The NOCP staff in addition to supervising districts also supervises CDDs once in a while. The visits are not integrated since CDTI is still being run as a vertical programme at the national level. In addition, not all visits have specific goals that need to be achieved.

Is this good for sustainability? Fully Highly Moderately Slightly Not at all Not applicable 4.5 Check whether there is a routine process of management of problems and successes, which are indicated by the

monitoring system (coverage data, visits and reports) (indicator of effectiveness and attitude)

 As soon as problems are identified in this way, the appropriate manager should deal with them.

 Planning should include activities which will improve coverage in areas where it is unsatisfactory.

 Successes should be noted and reported, and appropriate feedback given.

 The CDTI co-ordinator should be empowering the next level to cope with problems.

 Checklist of key activities: sensitisation/

mobilisation; training; improving Mectizan supply;

effective/ supportive supervision

Findings:

There is no routine process for dealing with problems and successes. However, district meetings are supposed to be held every 2 months to identify problems and the districts then send the report to NOTF.

The lower levels are not really empowered to tackle problems at the lower levels.

5. Mectizan procurement and distribution

5.1 Check if Mectizan is being stored and administered within the government system at this level (indicator of integration) The Mectizan:

 All costs of this activity should be met in the government budget.

 The Mectizan should be stored in a room made available by the government at this level - preferably in the same room as the other drugs.

 The Mectizan should be controlled within the government system, preferably using the same stock control system as for other drugs.

 No stage of the ordering / distribution should require input from APOC / NGDO.

Findings:

Mectizan is stored centrally at space provided by the International Eye Foundation (IEF) where the

NOTF/NOCP is based, because of the consensus taken at Enugu in 1997. However, the drug goes into the district stores from there when sent down to the districts.

The government contributes resources to take care of handling costs of importation. The districts collect the drug using transport that could either be provided by the government or NOCP/NOTF using APOC funds.

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5.2 Check if the alternatives fully dependable, in cases where parts of the system are not mainstreamed (indicator of effectiveness and integration)

 There should be a specific system for Mectizan distribution in such cases.

 This system should use self-sustainable resources.

Findings:

Integration of services can be used to transport ivermectin. However, there is no specific alternative dependable alternatives for Mectizan distribution is in place.

Is this good for sustainability? Fully Highly Moderately Slightly Not at all Not applicable 5.3 Check if the clearance of Mectizan is assured, when it is imported (indicator of effectiveness and integration).

 There should be a written agreement allowing free importation.

 The importation of Mectizan should not be delayed by bureaucracy.

Findings:

The clearance of Mectizan is assured, as the government waives custom duty and other charges for donated drugs.

6. Training and sensitisation/ mobilisation

NOTE:

 This refers to training and sensitisation activities performed by officers working at this level, for the next level.

 In Nigeria officers at the level of the State train the whole LOCT (the LGA oncho coordinator plus his/ her team of CHEWs); in other countries these higher level officers only train officers at the health district level.

6.1 Check if only necessary training is being done (indicator of efficiency and simplicity)

 There should be an objective need for each episode of training:

* There should be evidence that staff to be trained lack knowledge and skills to perform the job.

* Training to motivate staff is not a sufficient reason for training.

 The evaluator should be satisfied that the duration of training was justified.

Findings:

At the district level, the onchocerciasis co-ordinators, health inspectors, health assistants and people with higher forms of training in public health are given two- day training on CDTI. These people are trained once and then meet more than once a year in review meetings in their districts to refresh their knowledge. The NOCP also monitors the training of CDDs in the districts.

Is this good for sustainability? Fully Highly Moderately Slightly Not at all Not applicable 6.2 Check that training conducted at this level (i.e. training of district level staff) is being done by the appropriate staff

(indicator of efficiency and simplicity)

Staff of this level should only train the level immediately below it, and not further down.

Findings:

The training manager is at the national level and training of CDDs is co-ordinated by NOTF and implemented in the districts.

Is this good for sustainability? Fully Highly Moderately Slightly Not at all Not applicable 7. Financial resources

7.1 Check whether the cost implications of each CDTI related activity (monitoring/ supervision, training/ mobilisation, Mectizan distribution) are quantified in the yearly budget for the State/ province/ country (indicator of effectiveness)

 The costs for each CDTI related activity in the year plan should be clearly spelt out in the budget.

 Recurrent and capital costs (if any) should be separated in the budget.

 Checklist of key activities: Mectizan supply;

targeted training targeted mobilisation/

sensitisation; monitoring and supervision.

Findings:

The total costs of CDTI is provided but not broken down into costs of various activities. Hence, they are not broken down into recurrent and capital costs at the NOTF level.