CDTI project,

Health Organisation

African Programme for Onchocerciasis Control

Assessment of the

self-sustainability of the Mahenge CDTI ^project,

Tanzania

May -June2002

Dr. Runumi Mwesigye Francis Dr. Baine Sebastian

Dr. Kalinga A.R Dr. Gomile

Ms. Mariam Ally Dr. Katenga

Mr. Kaitaba

Index

Abbreviations/ acronyms aird acknowledgements Executive summary

Introduction and methodology Findings and recommendations

1.

^{National and Regional level}

2.

Ulanga

District

3.

^Kilombero

^District

10 16 20

Abbreviations/ acronyms

APOC African

Programme

for

Onchocerciasis Control

CDD

^Community Directed

Distributor

(of Ivermectin)

CDTI

^Community Directed Treatment

with

Ivermectin

CHO

Community Health

Officer

LG

^{local government}

LGA

Local Government

Authority

MOH Ministry

of Health

NGDO

Non-Govemmental Development Organisation

NGO

Non-Governmental Organisation

NOCP

^National Onchocerciasis Control Programme

NOTF

^National Onchocerciasis Task Force

PHC

^Primary Health Care

WHO World

Health Organisation

Acknowledgements

We would like to thank the

following

persons for their help:

.

_{The staff} at APOC Headquarters in Ouagadougou:

Dr

S6k6t6li,

Dr

Amazigo,

.

_Staff of NOCP/

MoH

in Dar es Salaam, for undertaking all the arrangements to make the evaluation successful.

.

Staff of the

MoH

_, for sparing time to talk to members of the team.

.

_The

_IMA

coordinator of the Onchocercaisis

.

Staff at the

WHO

offices in Dar es Salam for all the communication and logistical arrangements contributed to the evaluation team.

'

Health workers and community members in the Mahenge focus districts of Ulanga and Kilombero especial

ly

Dr. Kassi g a, Zeb eday o.and colleagues.

Executive summary

The Mahenge CDTI project has been supported by APOC for the past 4 years, and is in its last year

of

ageed funding from APOC.

An

evaluation of the self-sustainability of the project was carried out in May-June 2002, by a team

of

seven evaluators (Five from Tatuania

and}

from Uganda). The evaluators were charged

with

three tasks:

.

Evaluating the self-sustainability of the project.

.

Working

with

local stakeholders to plan

for

self-sustainability, based on the findings

of

the evaluation.

.

Advocacy

with

local political and

civil

service leaders, regarding their future role in the self-sustainability of the proj ect.

The evaluation was carried out over a period of eleven days. Information was collected

by

document study, interview and observation, at sampled sites at

five

levels of the health service: The National, regional, district, division/ward, and village/ community.

The

overall

judgement

_{of the team is}

that

the Mahenge

CDTI project

is

NOT NEAR

being self-sustainable. When one considers the six elements of self-sustainability given in the guidelines, the

following

is deduced:

fi

Efiecttveness: The project is effective-at national, district, division/ward, and community levels. The region is often by-passed ^.

dfr Efficiency/financing:

Areas of inefficient expenditure were detected especially at district level. The ward level and community are not yet

fully

empowered to carry out the possible tasks in mobilisation, sensitisation, and monitoring, and supervision.

8

Stmpliciry: Administration of the drug is appreciated to be simple, however, the disease concept and rationale for drug administration is not yet

well

understood by most CDDs. Training was done once to a few workers 2 years back.

fi Integration:Theprogramme

is not yet

fully

integrated

with

district programmes.

Inclusion of the project in the plan and budget has been attained at national level.

{

^Attttude: Stakeholders especially at the district and ward levels, know the project as

supposed to be part of the integrated routine

work.

More effort is required to bring them on board to plan and execute project activities in order to own the project. The project has been viewed for the past 4 years as a vertical program.

*

Resources: The project has been run almost entirely on APOC funding. The national level is contributing funds to run the project but levels

won't

be adequate since the ministry gives insu{ficient budget ceilings to budget

within

to

all

departments. The district is

just

going to plan how to include the project in their budget.

The question of self-sustainability is beginning to take root in the execution of the project.

There is, however, general pessimism as how the project

will

get basic resources, given the funding constraints experienced at

all

levels.

Recommendations based on the findings

of

the evaluation at the

five

levels have been made.

The most important recommendations concern:

.

Determining _the funding levels required for each level and getting commitments for the level

of

funding from stakeholders.

Mobilising

additional sources of funding is

imperative.

. Monitoring

and Supervision should

quickly

be integrated to

efficiently

utilise resources including though earmarked for other health programmes.

6

.

Empowering district level staff to take

full

charge of activities at their levels and tap the expertise now redundant at the regional level.

A

feedback/ planninil workshops was held for Morogoro region stakeholders where Ulanga and Kilombero districts are. The workshop drew participants from each level. The facilitators presented the findings for discussion and drawing future plans, as this is the planning and budgeting period for the coming fiscal year.

Workshop report to

follow

soon, after all pieces have been assembled.

Introduction

The

Ministry

of Health in collaboration

with

the

World

Health Organisation and the lnter- church Medical Assistance (trv1A), have been supporting projects in communities to prevent and control Onchocerciasis in Tarzania. The disease is

in

15

diskicts

found in the

Rift

valley.

The support has been in form of planning process at different levels of health care delivery, training of health workers working on the projects including Community Directed

Distributors (CDDs) and community leaders, mobilization and sensitisation of the masses, Mectizan delivery and distribution, providing logistical materials, and management services.

The support from WHO is envisaged to reduce

in

coming years as funding cannot be perpetual, given other disease program pressures on the Organisation. The government and communities are expected to run the project after external support has reduced.

An

evaluation team was set up to evaluate the Mahenge project

inTatuania

and gauge the level of self- sustainability

built

over the years.

Before this assumption, however,

African

Programme

for

Onchocerciasis Control (APOC) has found

it

imperative to assess the level of self

-sustainability

^of on-going projects before support is reduced. Can projects continue to deliver planned benefits and even perform better without support from APOC?

This report has been prepared from assess-"rrt

drn"

at National level - the

Ministry of

Health Headquarters, and Regional level

-

Morogoro region. The report aims to inform WHO

authorities and other stakeholders, on the picture

of

self-sustainability in order to come up

with

informed decisions regarding future project management.

2. Methodology

2.1 ^The'John

^the

Baptist'visit

Using the evaluation guidelines earlier sent, a 'John the

Baptist'

was sent to the Mahenge Project a few days to the commencement of the exercise to:

.

Liase

with

the field teams at the district and inform them on the impending exercise

.

Negotiate times and dates for all interviews

with

people purposefully sampled

for

evaluation at

District

and levels below.

.

Plan the planning and feedback meeting

with

stakeholders at those levels including civic leaders.

.

Sample sites for the evaluation

.

Ensure that all necessary documentation are made available to the team

.

_{Select local} team members

2.2 Sampling

Sample sites were chosen according to the guidelines using coverage rates and where ^needed accessibility ^as parameters. The sample, for comparative purposes considered ^areas

with

high and low coverage. Two health facilities were selected for each

division

in each district as

illustrated in the table below:

Ulansa

^(Maeenee)

District

Sample No.

Division Facilitv/Villase

Coverage

I

Mtimbila

Sofi

Maiiii

8s%

Madibila

_32%

2 Mwaya

Mzelezi tt9%

Lihela 34%

3

Vigoi

Mdindo _77%

Uponera

3t%

Kilombero District

4

Mlimba

Utengule 52%

Mpanga 26%

5 Mngeta

Mofu

Qdete\ 59%

Niaee L9%

6 Mang'ula

Mkula

59%

Kanyenia(Mwava\ _3%

During the visits, however, two health units in Kilombero could not be reached because

of

poor roads.

Mofu

and Kanyenja had to be substituted

with

Idete and Mwaya respectively.

2.3 ^Protocol

Research question: How self-sustainable is the Mahenge

CDTI

project?

D es ign: Cross-sectional, descriptive.

Population: The Mahenge project, included the

District

Health team members,

division

team members, Community leaders, health workers and CDDs.

Instrument:

from interviewees.

A

record sheet format was also developed for record purposes..

below.

analysis. Qualitative data was read to capture relevant information conceming indicators under assessment.

Source of

information:Yerbal

reports from persons interviewed, supplemented

by

documentary evidence and observations.

Analysis:

V Datafrom all

sources is aggregated, according to level and indicator.

I

Based on the

informationiott".t.a,

each indicator is graded on a scale of 0-4, in terms of its contribution to self-sustainability.

W ftte

summary findings for each group

oiindicators

were given at the end

of

each group.

(b _fne

_average 'self-sustainability score' for each group of indicators is calculated,

for

each level.

I l,qualitative

description of problem areas was done during the analysis..

2.4

Teams

Formed

Three teams were formed for easy and fast collection of data.

9

Team I

-

^for

^Ministry

Headquarters comprised

Dr. Runumi Francis Dr. Katenga

Team

II -

^Kilombero

^District

Comprised

Dr. Kalinga Ms

Miriam Ally

Mr.

Zebedeyo (Zonal Onchocercaisis Co-ordinator guided the team) One division of Kilombero was later done by Team

I

Team

III -

Ulanga-(Mahenge) District.

Comprised

Dr. Baine Sebastian Dr. Gomile

Mr.

Kaitaba

Dr. Kassiga (coordinator Mahenge focus project guided the team).

Before teams were despatched to the field, a meeting was held to develop ^a common

understanding of the guidelines and instruments, and how the information was to be analysed and presented. Field materials were also prepared

for

each team to carry along.

2.5

^Advocacy

^visits

and 'Feedback/

planning'

workshops

Advocacy visits were to be paid to relevant persons at each level of assessment. The

District

Chairmen and division councillors were contacted. Stakeholders were informed about the feedback meeting which was to take place after the visits to share results and suggest the way forward through making a realistic plan.

2.6 Limitations

S ^fne

documents required at health facilities were not readily available for review and scrutiny.

<F

_{tn spite}

of initial

briefings some project staff

with

the evaluation team took advantage to do some support supervision despite earlier warnings.

tb

Where roads became impassable, villages were substituted. Because of these physical barriers

it

became hard to know whether CDDs reach the people when other outsiders cannot access the villages.

l0

Findings and recommendations

1.5

{

3.5 3 2.5 2 1.5

1

0.5 0

HII{ISTRY OF HEALTH, REGI OH & BISTRICTS' CO ORDIIIATOR

ttru d,

o

()

(a

&,

o t-

€ g c E

ddo*d ^d*ooo

{.i* ^d"*,*c{"./

n{)rcAToRs

--"*-lrlOH/HQs

-.r-

^{Ragion Di€trict}

The

following

section presents key findings for the National and Regional levels.

Findings

at

National

and Regional Levels

All

respondents met at National and Regional levels knew the Onchocerciasis Project.

Ministry

offrcials indicated that project activities are put under consideration and a National coordinator

with staffto

support him had been put in place. Details of the project could not be given by individual

officials

and were known to be

with

the coordinator who was expected to be on the ground coordinating the projects. Head quarter results are basically views obtained from the NOCP coordinator and the General impression from the meeting

with Ministry

officials.

l.

Coverage

At

National level, Geographical coverage was known to be above 90o/o and Therapeutic coverage to be between 65 and 74Yo in most project areas. Failure to reach 100% was

attributed to many factors especially,

limited

knowledge on disease to health workers CDDs, and the community. Two out of four respondents at Morogoro region revealed coverage to be below 65%. This was attributed to lack of awareness of the disease due to management, community and resource limitations.

2. Planning

1l

At

National level, the

CDTI

is integrated in the Annual Health Plan and ^has its budget. The budget, however, is not driven by the need of the CDTI programme but the given budget ceiling from the Planning and Policy Directorate which guides the whole

Ministry

to budget

within

the available funding indicated by the Treasury. The CDTI programme therefore, cannot include all wanted needs but priorities.

After

the

Ministry

Annual Plan is approved,

CDTI

cannot plan when to do certain activities, as release of funds is always untimely.

Activity

schedule adjustments have to be done from time to time as per release of funds from the treasury.

A

detailed

CDTI

plan exists showing funding sources.

It

gives a layout of

all

activities and the expected funding source, which includes

IMA, African

Programme for Onchocerciasis Control, and the government. The plan details the level of

work

and assistance given to

all

CDTI projects in the 13 districts. Planning for sustainability is being considered given the warning of reduction

in

funds in the near future.

At

the region, occasionally hospital staff guide, district

official

to include

CDTI

activities in the Comprehensive

District

Health Plans.

Not

much

follow

up is known after this activity.

On the whole planning at National level scored 3.

3. Providing Leadership

The

Ministry

has included

in

its headquarters structure a position of National Onchocerciasis Control Programme Coordinator under the Epidemiology

Unit

to coordinate

CDTI

activities.

The Coordinator has another officer on the project. Plans to recruit 2 more technical officers are

in

advanced stages.

Strong support and commitment to advancing

CDTI

activities was shown by all top

officials

especially the Permanent Secretary and the Director of Policy and Planning. Lack

of

sufficient funds from the treasury and donors was sighted as the major

limitation

to undertaking desired activities on all prograrnmes under the

Ministry.

On the whole this indicator scored 3 4.

Monitoring

and Supervision

There is no routine data transmission although this is known and supposed to be done.

Annual project reports, however, exist and provide information crucial for the planning process.

After

decentralization, reporting mostly went to district level. lnformation from community activities goes to the

District

coordination level. Plans and information from the center is also directed to the District. This in principle seems to be

working

although

monitoring and supervision schedule were not available for review. The problem is compounded by irregular releases from Government.

Most supervision

work

is expected to be done by the

District

Onchocerciasis coordinator who informs the Center when need arises. Occasionally, problems at the district are attended from the Center.

On the whole this indicator scored I

t2

5. Mectizan Procurement and

Distribution

Mectizan is handled

like

any other drugs in the procurement system. Once the drug arrives at the

Airport,

the Medical Stores

pick it

and store

it.

The drug is kept separate waiting to be distributed specifically to places where

it

is required. Government pays all drug handling charges and in position to distribute

it

to beneficiary districts.

ln

practice, however,

District

^project coordinators drive to the Medical Stores to pick _the drug once they leam of its arrival.

It

is alleged that delay to pick the drug may lead to loss of the drug to other projects or delay the planned distribution. However,

it

was learnt that project coordinators delay

filing

returns so that Mectizan orders are delayed.

On the whole this indicator scores 3

6.

Training

and Sensitization/

Mobilization

Training

of

staff was done once at regional and district levels to equip staff additional

skills

to manage the program more effectively. The staff has a health/ medical background.

More training expected once funds become available.

On the whole this indicator scored 2

7. Financial

Resources

Financial resources required for project activities are included in the Annual health budget.

The figure budgeted is usually a

block

figure, broken down by the detailed

CDTI activity

budget.

The budget ceiling

limits

the inclusion of

all

identified activities under government.

However, there is hope to start increasing the budget once the phasing out starts.

The govemment system runs a cash budget i.e. amount of money available from taxes used to run govemment business. In most cases, adhoc activities are planned and done to absorb the money leaving planned activities to remain on paper.

On the whole this indicator scored 2 8. Transport and Other

Materials

Sufficient transport exists for

CDTI

activities. Three vehicles and 2 motorcycles have been used for project activities. The problem

with

transport is the aging of vehicles that demands high maintenance costs.

The vehicles are not managed

with

the log-book system. They are used as per need

for

all

CDTI

activities and others. No material constraints were identified since the programme has been

timely

availing funds. No plan to replace these vehicles by government has been made.

On the whole this indicator scored 3

l3

9.

Human

Resources

The team at national level has

well

trained staff capable of handling the planning, training and sensitisation, mectizan ordering and distribution, monitoring and supervising lower implementation levels.

On the whole this indicator scored 3.5

1.3

Recommendations

Recommendation lmplementation

Planning:

.

The planning and budget and budgeting can be improve

if

regular quarterly or bi-annual reporting is done in detail.

A

detailed and costed plan should be the outcome.

A

workplan should be made to guide implementation of the annual plan.

Priority: HIGH

Indicators of success:

r {

detailed plan and budget exists

for

200212003..

Who to take action;

.

National Onchocerciasis Proiect Coordinator Deadline

for

completion:

.

_September 2002

Financial resources:

.

The funds that

will

be available for the 2003 distribution must be accurately determined (from Government; from remaining APOC funding;

from

NGDOs, from the public

-

^{any realistic}

source).

Priority: HIGH

Indicators ofsuccess:

1.

Written breakdown of assured funds

for

2003.

2.

^Presence of commitment deeds

from

potential farmers.

3. Official

documents exist, which pledge the amount and duration

of

future financial support from outside.

Who to take action:

.

_NOCP coordinator,

.

_The Director Policv and olannins Deadline

for

completion:

l.

September 2002 Providing leadership:

r

_{{n order to secure}

_political

_commitment

to

CDTI

at the top level, there should be targeted and innovative leadership.

It

is advisable that the Chairman of NOTF gives regular briefings to the

Minister

and secure stronger support

for

mobisation.

Prioritv: HIGH

Indicators of success:

,

The level and innovations in advocacy

'

Adequate counterpart

funds

released.

Who to take action:

.

APOC management at

MOH

Headquarters

.

_{NOCP and}

NGDOs, MoH

Planning directorate

Deadline

for

completion:

.

September 2002 Transport and other material

resources:

I

Prioritv:

HIGH

t4

A

specific, realistic, dependable plan must be made for ensuring the continued

provision of adequate transport, once APOC funding comes to an end. This plan _should include a strict maintenance schedule, and funds for

it;

funds for fuel and repairs;

replacement of present project vehicles when these come to the end of their

life

(and considering cheaper alternatives); using alternative forms of transport (e.g. public transport).

APOC must be requested to consider meeting some pressing capital needs

(in

transport and equipment) which are expected to exist at the end of the funding period.

Indicators ofsuccess:

l.

Inclusion in the plan of capital expenditure towards vehicles.

2. ^A

^{document from APOC} or any other source committing itself towards the fundins

of

such caoital items.

Who to take action:

.

NOCP coordinator Dr. Katenga

'

^Chairman NOTF Dr. Mzige

.

NGDO oartners

Mr.

Charles Franzen Deadline

for

completion:

.

September 2002

o Monitoring

and supervision:

o

Monitoring notes should be made and kept for corrective actions and planning purposes.

o Motivation

and recognition of gobd performance should be started to encourage good service delivery.

tr

Guidelines and check-lists for key elements of monitoring and

supervision need to be availed to

all

stakeholders who

will

begoing out to undertake the activity.

Priorin; HIGH

Indicators ofsuccess:

which takes account of all the requirements on the left. This

timetable should be part of the overall detailed year plan.

recognise workers who perform well.

identifi cation and manaqement Who to take action:

Human resources:

tr

^{The remaining} staff planned

for

recruitment should be recruited and posted to make all project areas better served

Priority: MEDIUM

Indicators ofsuccess:

Trainine and sensitisation/ mobilisation:

Prioritv: MEDIUM

o A

refresher course required for the top management to keep abreast

with

developments in the management aspects.

o

Officers from the regional authority should attend the course

Indicators ofsuccess;

plan

Who to take action;

Deadline

for

completion:

September 2002 Mectizan procurement and distribution:

Priority; MEDIUM

tr

^The responsibility for ordering and storing Mectizan should be left to government and stop wastage of funds

Indicators ofsuccess:

at the headqurters in time.

15

going to fetch drugs ^at the stores ^LTho to take action;

Deadline

for

completion;

t6

. _{District Level}

2.1 ^{overall grading}

^(on a scale of 0-4) as per

District, ward,

CDDs,

Community

leaders and members.

ULANGA DISTRICT

4.5 4

tn 3.5

H? o E t.s

t

O6 F..3

$,'

1

0.s

0

.f, cd*o *,.** """..o"" ^.*** *""

HorcATORS

**f" _..o,$P

{f' c

--+-

Distrlct --.r-*W*rd

leryel

Communi} lEaders

*

CDOs

-{-

^{Community msrnb€rs}

Different respondent categories responded to parameter indicators almost

uniformly.

Responses partly reflected the extent to which they participated in the

activity

and the

perception of what was taking place. In general respondents expressed the short time they had known or worked on the project and the felt uneasy leaving the project _to run

without

external assistance.

f

Coverage: Both geographical and therapeutic coverage are high though not to project expectations. Factors of poor motivation on side of health workers and CDDs were sighted. The poor road infrastructure and lack of transport to reach all eligible households and population were sighted among factors of low therapeutic coverage. There were also mmours spread that mectizan drug was imported to render men impotent and have

family

planning indirectly.

A

number

of

communities where the disease is meso-endemic did not therefore take drug treatment as a serious issue and kept dodging CDDs at the time

of

distributing drugs.

3

Planning: There is no documented routine planning at the

Division

or lower levels.

Planning is reported to occur when the district coordinator asks

for it

or when drugs are about to come. Planning is mainly for drug distribution and does not involve a

lot of

other management and resource mobilisation aspects.

t7

f

Leadership: Leadership was generally luke warrn. Community members and CDDs appeal for more vigilance especially in fighting rumours against the disease. Community Ieaders feel they could play a greater role in mobilisation once they are sensitised more on the disease.

A

problem sighted was change in local leadership structure where most

of

those who were sensitised

left

office bringing in new ones who have not been sensitised.

I

Monitoring and Supervision:

Supervision and monitoring was said to be low and not covering the whole geographical area. Terrain, bad roads, old vehicles were among reasons given for this occurrence Supervision reports were mentioned in passing to be

in

existence. _{Some CDDs}

complained

of

lack

of

information because of not being reached in their working areas However, there was appreciation also where regular interaction especially

with

the project coordinator was common.

f

Mectizan supplY: Mectizan is usually collected and stored properly by the project coordinator. Drugs are never

in

shortage and CDDs are usually keen to take them to the people. Records

of

administering these drugs are kept and returns taken to the designated health

facility

in the area.

f

Trainine and

mobilisation:

Training on drug

distribution

had been conducted among CDDs. Some health workers did not know much about the drug and could not help in mobilisation of communities. There was demand

for

further training on the disease and drug distribution.

I

Finances/

funding: Lack of

sufficient and

timely

funds was singled out to be the most serious hampering factor for most activities. The local authorities do not generate adequate funds to use at the

district

and village level. They cannot therefore suitain any communal activity. No strategies have been thought about to supplement or replace funds currently supporting the project.

Il

Transport: In general this is inadequate. The double Cabin pick-up provided by the project is worn out, given the bad roads

it

has endured over the last 7 years.

Motor

cycles have broken down and repair costs are high. CDDs have been walking all villages and feel exhausted when they have to return several times to households when they bounce.

At Mlimba

where the terrain was rugged, CDDs mention purchase of boots asa possible solution to their

walking

problem.

I

Human resources: Health workers and CDDs are available and have basic health training.

Motivation

factors such as refresher courses, support supervision were mentioned to encourage health workers to do better.

l8

2.2

Recommendations

Coverage

*

Leadership should interact more

with

other

district

leaders to improve the advocacy and community mobilisation

*

Information over the project are needs to be collected regularly to ascertain levels ofcoverage.

.8.

_Need to improve funding from the centre and lay strategies

for

improvement

of

local revenue

PriOriN..

MEDIUM

Indicators of success;

o

^{Number of} meetings

with district

leaders

o

Number of relevant leaders brought on board

Who to take action:

o ^Dr

^Kassiga

o

Zonal Ocnho. Coordinators Deadline

for

completion:

o

^{September 2002}

Planning

*

Participatory planning should involve stakeholders at the

district

and lower divisions.

*

Many stakeholders should be given planning skills.

PrioriU: HIGH

Indicators of success;

o Availability of written

plan prepared by stakeholders

Who to take action:

o

^Dr. Kassisa and the Zonal coordinators Deadline

for

completion:

o

^Seotember 2002 Leadership

*

The

political

and

civic

leadership at

district

level needs to be informed more

fully

about

CDTI,

and motivated to take a more active interest.

.t

Project leadership should encourage participation

of

all potential key stakeholders and avoid characteristics of a vertical program.

Prioritv; HIGH

Indicators ofsuccess:

o ^Political

leadership ensures that

CDTI

is properly resourced and supported.

Who to take action:

o ^Dr.

Kassiga and colleagues.

o

^{Dr. Katenea}

Deadline

for

completion:

o

^{Seotember 2002}

Financine/ funding

i

The project must be helped to obtain the funds needed

for

the yearly distribution:

training and refresher courses, monitoring and supervision, and

all

other essential planned activities.

. MOH

should increase budget towards

CDTI

activities.

Prioriv: HIGH

Indicators ofsuccess:

o

Commitment

of

funds

from

donors and district.

LY'ho to take action;

o

The Permanent Secretary

o

The Chairman

NOTF

o

^{The NOCP} Coordinator

o

^The District Local

Authority

Chairman Deadl ine fo

r

contp I etion:

o

September 2002

t9

Training and mobilisation

*

Increase budget for training workers purposefully selected.

*

Train community leaders on

CDTI

activities.

Priority; MEDruM

Indicators ofsuccess:

l.

Budgetarylncrease.

Who to take action:

1.

NOCP coordinator

2. ^District LA

Chairman Deadline

for

completion:

.

September 2002 Supervision and monitoring

*

^{Make a} workplan for integrated support supervision

{. Avail

logistics for transport for key district

official

to move out and monitor

CDTI

activities.

Priority; MEDruM

Indicators of success:

o

^{Workplan present}

o

Presenceofsoundvehicles andbudget for monitorins and supervision.

Who to take action:

o

^{The district} coordinator Dr. Kassiga and his team

Deadline

for

completion:

o

September 2002 Mectizan procurement/ distribution

*

The project should arrange to collect their own batch of drugs from the Medical Stores using the same system for procurement of other drugs (such as the essential drugs.)

Priority: MEDIUM

Indicators ofsuccess:

o

Project obtains Mectizan from Dar es Salam Medical Stores along

with

the collection of other essential druss

Wo

to take action:

o ^District

co-ordinator Deadline

for

completion:

o

^Agreed time for distribution.

Transport

*

Vehicles should be replaced and integrated into the district transport system.

*

lnclude in the budget funds to buy boots and bicycles for _CDDs.

{.

^Strict adherance to the log-book to monitor vehicle use.

Prioritv: HIGH

Indicators of success:

o

^New vehicles present

o

Vehicles log-book present

o

^Funds boots and bicycle included and commitment to orovide funds existins Who to take action:

o

^{Chairman NOTF}

o

NOCP Coordinator

o District CDTI

Coordinator Deadline

for

compl etion:

o

December 2002 Human resources

*

New CDDs and Community leaders should be trained and orientated..

Priority: MEDIUM

Indicators of success:

o

New CDDs and community leaders trained.

Wo

to take action'.

o ^District

Coordinator

D eadline

for

^{comp I e t i o n :}

o

December 2002

20

3.

3.1

Kilombero District

Overall grading

(on a scale of 0-4)

KILOMBERO DISTRICT

o

UJ

E

o

oat,

E

o

F

I

o

=

4 3.5 3

2.5 2 1.5

1

0.5 0

e"ofs' o.utou -"""

".""t" """t" "."-""" ^.'"" -.C

^a"'". -/

".t.

^a.{9'

INDICATORS

*District *Ward

--#Community leaders JFCDDS --*-Community memb€rs

3.2 Main findings

Kilombero district had lots

of

similarities

with

Ulanga district and this is not surprising as the two district historically comprise the Mahenge focus. Management and administration are the same. Offices for coordination are the same, based at Ifakara.

It

is therefore not strange that when things go right or wrong the two districts are equally affected. The

following

is a picture of the assessment found by the team, as reflected in the graph.

*

Coverage: The geographical coverage was known to be high.

Almost

all villages have been reached over the last 4 years. However, the therapeutic coverage is perceived to be lower at about 50% because of people's refusal to take the drug after rumours that

it

interferes

with

reproduction.

ln

some areas CDDs, did not cover effectively the area expected.

I Plannine:

Planning is

still

weak basically

for

3 reasons.

i)

Players at different level do not have sufficient planning skills.

ii)

Data for basic planning is not readily available.

Only

one health unit could provide all records and returns from CDDs.

iii)

Lack of funds

for

planning sessions and budget for the plan.

There is need to involve a wider stakeholder consultation and

find

money from the

Ministry

and district to

try

and improve this process.

It will

be after this effort that one shall talk about self-sustainability of the project.

2t

I

Leadership: Although health centre staff is

willing

to play their part, there is

little

room for them to take the initiative

-

^{they have} to wait for instructions from above. There is however, appreciation of visits made around drug distribution time. CDDs contacted report having benefited and

felt

strengthened to carry out the

CDTI

work.

I

Supervision and monitoring: Some supervision took place and CDDs report to have benefited form the discussions held. The

activity

is reported to be hampered by a small irregular budget; old vehicles, some broken down; insufficient staff at

all

levels to supervise lower levels. The regional

office

has not yet been utilised to participate in the

F

Mectizan procurement and distribution: Generally this is working

well.

In most cases there is adequate storage space for the Mectizan at the distribution centres, and the CDDs themselves fetch the drug from there.

*

Training and sensitisation/ mobilisation: In most cases training of CDDS was undertaken by the

District

coordination team,

with

the local CHWs in attendance.

CDD

training takes place routinely, and is not targeted at all. Local

CtIWs

are routinely involved in community mobilisation however, and have sufficient IEC materials for this purpose.

I

Financing and

funding

The funding available enabled execution of planned activities.

The shortfall was reported to be big and causing inefficiencies in all control activities. No quick solution could be suggested to this problem but there was general consensus that efforts to

identify

new funding sources should be beefed up.

I

Transport: Accessibility to communities was generally good although some communities were cut

off

completely during the rainy seasons. Bridges were washed away. Matters were made worse when the ferry crossing Kilombero River sank

killing

35 people in

April 2002.

There is need to integrate transport

with

the

DMO's

so that

benefits from other program activities can help

CDTI

activities.

I

Human resources: Generally personnel at the health

facility

are

willing

to participate in

CDTI

and there is some stability at this level. Factors of retention and motivation need to be addressed.

22

3.3

Recommendations Coverage

. _{Copies of}

records

from the

health centre areas should be retained all be complete and retained health center.

.

Ward and village Health Workers /CDDs should enable district staff to calculate the coverage rates for their areas, as a

tool

for monitoring their own performance and planning their work.

Priority: HIGH

Indicators of success:

.

_Copies of community and district level

CDTI

data exist at the health centres.

. District

staff are able to interpret the data

from

their area. and to use

it

for olannins.

W'ho to take action:

*

Zonal coordinators

. District

level

staff

D eadline

for

completion:

.

_September 2002 Planning

. District

coordinators team should organise planning workshops to give skills to lower cadre staff.

. Ministry

should

identiff

immediate new source of funds to support the budget.

Prioritv: HIGH

Indicators ofsuccess:

.

The plan exists and has planning workshops

for

the lower level staff.

l{ho

to take action:

.

_Chairman NOTF

.

NPCP Coordinator.

Deadline

for

completion;

.

September?002

;

Drstnct coordrnator should

* Dlstnct

coordrnator should empower health centre staff to assume responsibility for managing the

CDTI

programme

in

their catchment areas.

lndicators oJ success:

o

Health centre staff take charge

otZlll

distribution in their areas

Wo

to take action:

o District

co-ordinator

with

his zonal coordinators.

o

In-charges of health centres Deadline

for

completion:

o

^{September 2002}

Supervision and monitoring

G Mentoring from the regional and

Ministry

headquarters on

CDTI

activities is required.

I

Community leaders opinion leaders be brought into sessions to equip them

with

skills of monitoring their own

communities.

Priority: MEDIUM

Indicators of success:

o

Headquarters

with

a workplan Who to take action:

o LG

PHC co-ordinator and LOCTs

o

^{CHEWs in} charse of health centres Deadline

for

completion:

o

December 2002 Mectizan procurement and distribution

I

Maintain the level of ordering and distribution strategy

Priority: HIGH

Indicators of success:

o

Drugs available on time and in required amounts

Wo

to take action:

o ^District

coodinator

o

Health centre In-Charses

D eadline

for

completion:

o

^September 2002

I

Training and sensitisation/

mobilisation:

!_Yearly

training of CDDs should be targeted - i.e. particularly focused on those who really need it.

I

Increase budget for this

activity in

all plans.

*

lntegrate training

with

other Health Education activities.

Priority: MEDIUM

Indicators of success:

o

^{CDDs who need haining} targeted

o

^More funds directed towards sensitisation and mobilisation.

o

Health Education integrating

CDTI

activities.

Who to take action:

o ^District

coordinator.

o

In-charges

ofhealth

centres.

Deadline

for

completion:

o

^September 2002 Transport and material resources

Priority: MEDIUM

*

Vehicles need to be replaced.

Activities

requiring transport should also be integrated.

Indicators ofsuccess:

o Availability of

means

of

transport during supervision

Wo

to take action:

o

^{The NOCP} coordinator.

Deadline

for

completion:

o

^September 2002

24

Conclusion

From the evaluation exercise, efforts have been put in implementation of

CDTI

activities.

The project is known in the 2 districts and at National level.

Officials

in the

Ministry,

the

District,

and community members appreciate the

work

so far done and have all indications and support for the project to continue, however, the

timing

of phasing out of APOC funding comes at ^a time when all implementation levels are not prepared.

From the district staff and community members,

it

is clear a lot is

still

required in terms

of

training, mobilisation, planning and most importantly

finding

substitute funding. Should the funding stop at this point the project

will

collapse. lntegration

effort

into other

district

activities is

still

in infancy and should be given time to take root.