CDTI project Northern

-l

World Health Organisation

African Programme for Onchocerciasis Control

Assessment of the sustainability of the Sudan Northern ^Sector CDTI project

Situation: end of Year 5 of APOC funding January ²⁰⁰³

Ilham Bashir

Khitma El Malek Elwasila Mohamed Chukwu Okoronkwo Detlef Prozesky

With

the assistance of

MPH

students:

. Mutaz Ibrahim Ahmed

.

_Sawsan

_Amin .

_Gomo

_{Atroun Attia} .

Enas

Gaafar

. Ahmed Ismail Julla

. _{Ali Ahmed}

_Osman

. Amel Salih

.

Hassan Hamza

Yasin

Index

Abbreviations/ acronyms and glossary Acknowledgements

Executive summary

Introduction and methodology

1.

Introduction

2.

Methodology

Findings and recommendations

l.

Federal level

2.

Zonallstate level

3.

'Province'

and'Locality'

level

4.

Community level and IDP camps

5.

Overall self-sustainability grading for the project

6.

^Issues presenting during the evaluation

Advocacy activities and feedback/ planning workshops

1.

Advocacy activities

2.

Feedback/planning workshops

Appendix

I

Feedback/ planning workshop for the Federal level Appendix

2

Results of group work at the Federal level workshop Appendix

3

Feedback/ planning workshop at Abu Hamad Appendix

4

Feedback/ planning workshop for Equatoria at Juba Appendix

5 ^Locality

sustainability plans: Juba workshop

Appendix

6

Feedback/ planning workshop at Wau

aJ 4

8 8 10

I4 t4 2t

30 38 44 46 51 51 54 56

6t

65 67 72 75

Abbreviations/ acronyms

AHST

^{Academy of} Health Science and Technology, Khartoum

APOC

^{African Programme}

^for

Onchocerciasis Control

CDD

^{community directed} distributor (of ivermectin)

CDTI

^community directed treatment

with

ivermectin

CSM

Community Self-Monitoring

r DG

Director-General

FLI# ^first

^{line health}

^facility FMoH

^Federal

^Ministry

^{of Health}

GoS

Government

of

Sudan

HAMT

Health Area Management Team

r

\ HC

health centre

.- HMIS

health management information system

HQ

headquarters

HSAM

healtheducation/sensitisation/advocacy/motivation

s IDP

internally displaced person

IEC

information, education, communication

MoH ^Ministry

^{of Health}

.-- MSF

^{M6decins Sans Frontidres}

NGDO

non-governmental development organisation

NOC

^national onchocerciasis coordinator

s NOCP

^National Onchocerciasis Control Programme

NOTF

^National Onchocerciasis Task Force

REMO

^rapid epidemiological mapping of onchocerciasis

!' SD

^{Sudanese dinar}

SHM

Stakeholders'Meeting

SMoH

^State

^Ministry

^{of Health}

TCR

therapeutic coverage rate

UNICEF

United Nations Children's Fund

WFP ^World

Food Programme

r WHO ^World

^Health Organisation

ZOC

zonal onchocerciasis coordinator

L ZOTF

Zonal Onchocerciasis Task Force

- ^Glossary

NOCP

team

the team of persons operating the onchocerciasis control programme at federal level: the NOC and his deputy, senior ^and

junior field

officers

ZOTF

team

^{the team of} person operating the onchocerciasis control programme at zonal

state first

unit of government administration below the federal level

zone

^a geographical area which the NOCP uses for convenience;

it

consists of parts of one or more states

province first

unit

of

government administration below the state level

locality

^{smallest unit}

^of

government administration

revised Aptil2003

Acknowledgements

We would

like

to thank the

following

persons

for

their help:

'

^{The staff at} the Headquarters of the

African

Programme

for

Onchocerciasis Control (APOC) in Ouagadougou:

Dr

S6k6t6li,

Dr

Amazigo,

Mr

Aholou.

.

Staff of NOCP/

MoH in

Khartoum,

for

undertaking all the arrangements: Prof Mamoun Homeida (NOC),

Dr

Magdi

Ali

and

Dr

Tong Chor Malek; the

field

officers and drivers.

Without

their dedicated assistance the evaluation team would never have managed to cover the ground that

it

did.

.

The ZOTF teams at Juba, Wau and Raja, and

Mr

Mahmoud Ahmed Elrashid at

Abu

Hamad, for undertaking all the local arrangements.

. Political

and traditional leaders, health workers and community members

in

the Abu Hamad, Juba, Raja and Wau zones, and the health workers in the IDP camps around Khartoum.

U

-)

Executive summary

The

African

Programme

for

Onchocerciasis Control (APOC) has been supporting the Sudan Northern Sector

CDTI

(community directed treatment

with

ivermectin) project

for

the past

five

^years.

In

accordance

with

instructions from APOC Headquarters an evaluation

of

the sustainability of this project was carried by a team of

five

evaluators

-

^three

^from

^{Sudan and}

one each from Nigeria and South Africa. This evaluation was carried out over a period of

two

weeks. Information was collected by document study, interview and observation, at sampled sites at all levels of the health service: federal, state/ zone, provincial,

locality, first

line health

facility (FLfm)

and community.

It

is important to note that the situation

in

Sudan is unique

in

two important respects: the size of the country, and the

widely

dispersed nature

of

the project zones; and the ongoing

civil

war and refugee situation. Both of these complicate the task of introducing sustainable

CDTI

considerably. There are at present two

CDTI

projects in the country: the Northern Sector project

(for

areas under Government

of

Sudan control) and the Southern Sector project

(for

areas under opposition forces). Another unique feature is the creation of the

'zone'

as a level of implementation of the

CDTI

programme. This has had the unfortunate effect

of

making the Programme vertical at almost every level.

The

following

are the principal findings of the evaluation:

.

Planning: There is a detailed plan for

CDTI

at federal level, integrated

with

other disease control prograrnmes. NOCP however has so far followed the year plans

in

the

original

APOC submission, and has not yet made a sustainable plan

for

Year 6. There are no plans at state and

locality

levels

-

^{only a few} health centres in Raja have written plans

for CDTI.

CDTI

is not included

in

'recommended packages' at any level.

.

Leadership: There is strong and dynamic leadership at NOCP level.

At

lower levels zonal coordinators take partial responsibility for the Programme - but state,

provincial

and

locality

leadership has only partial knowledge of

it

and takes no responsibility

for it.

Community leaders are usually involved, but often do not consult their communities

in

making decisions about the Programme.

.

Supervision and monitoring: Supervision is regular and thorough, but

highly

centralised

in

that NOCP staff do supervision right down to community level, in the company

of

zonal officers. This centralisation makes supervision almost entirely vertical, and more

expensive than

it

need be. Only in Raja are other levels involved, in that case

with

supervisors operating

from

health centres. Supervision checklists are not much used, nor is coverage data as a monitoring tool.

.

Training and

HSAM

(health education/ sensitisation/ advocacy/ motivation):

Training

and

HSAM

have been effective, in that zonal staff and CDDs are

in

general skilled and

knowledgeable. However

it

is also centralised

-

NOCP staff assists zonal staff

in

training CDDs and carrying out

HSAM.

The other

lower

levels are not involved. Once again Raja has integrated the Programme into the

life

of health centres, where the training of CDDs takes place.

.

Mectizan supply: Mectizan supply is

working well.

There have been no reported

shortages, although there are reports of over-ordering due to

faulty

census data. The state, province and

locality

levels are not involved (except

in

Raja); and in most cases the communities wait

for

the zonal level to deliver the drug to them

-

^{which is an expensive}

option.

revised Aptil2003

.

_Finances/ funding: The federal plan carries a handsome budget, but from the experience

of

the past

it

is

unlikely

that this

will

be released.

It

is known that the Carter Center

will

contribute a substantial amount

for

at least 3 years to come - but the NOCP has no clear idea yet of the funding that

will

be available to

it for

Year 6, and there is no prepared budget. NOCP team members have ideas about rationalisation but again there is no

written

'sustainability

plan'.

Zones prepare routine yearly budgets, but depend entirely on the NOCP for funds. There are no budgets

for CDTI

(or any other programme, often) at the other levels. Communities do not contribute

financially

to the Programme.

At

both federal and zonal level financial management is exemplary.

.

Transport and equipment: There is at present enough transport available, but running costs and repairs are paid for by APOC and the Carter Center.

At

NOCP level transport is very carefully controlled, but less so at zonal level. The vehicle maintenance routine is not spelt out. Some zonal offices lack basic space and equipment. There is no clear plan to replace transport when necessary.

.

Human resources: The number

of

staff

in

the NOCP team is very high,

in

comparison

with

other countries

-

^{again a sign of the vertical} and centralised nature of the project.

At

both federal and zonal levels staff members appear skilled (except

in

data management) and dedicated

-

but they receive substantial incentives the year round, which has grave implications

for

sustainability. Staff is not involved

within

the state,

provincial

and

locality

levels and the health centres, except in Raja. The ratio of CDDs to population is

low

in many communities, and there is a high drop-out rate especially in Juba.

.

Coverage: Geographical coverage is hampered by the

civil

war

-

^the shifting line

of

control and insecurity

in

many areas make

it

impossible to know who exactly is being reached, and to get to all communities in need. The therapeutic coverage rate

in

2001 was reported to be

just

_under 6O7o,btt calculation errors are common.

In

summary: after

five

years the project has succeeded

in

achieving good geographical and reasonable therapeutic coverage

in difficult

circumstances. In terms

of

sustainability however

it

is too centralised and too vertical (and therefore not integrated, and less efficient). The resources of existing levels

of

administration such as the state, province and

locality

are generally not used. GoS contributes salaries (which are

low),

and guarantees security

for prqect

personnel but hardly anything towards running costs, except the army transport made available occasional

for

movement of personnel and Mectizan from Khartoum to the South.

The only commitments are those of the Carter Center and possibly

WHO

(a small amount).

There is no clear 'sustainability

plan',

and those involved in the Programme at federal and zonal levels receive substantial incentives. The overall

judgement

of the

evaluation

team is

therefore that

Sudan

Northern

Sector

project

is

not making satisfactory

progress

towards sustainability.

Detailed recommendations were drawn up, based on the findings of the evaluation. The recommendations were prioritised, and indicators and deadlines were suggested for each. The most important recommendations concern ^:

. Clarifying

resources that

will

be available to the project

in

future; making a sustainable

plan

for

the coming yearl 3 years; securing funds

for

transport expenses; planning

for

^{. ,}

replacement of transport and equipment.

.

Decentralising Programme activities currently undertaken by NOCP and zonal level

staff

into recognised administrative structures: state, province (perhaps);

locality

and its heath centres; redeployingzonal staff and assets into these.

.

Integrating

CDTI

programme activities into the routine functioning of the above

mentioned levels;

identifying

focal persons for

CDTI

in each (depending on the situation);

empowering them to take on the key functions of planning and budgeting,

training/

HSAM,

supervision and monitoring, reporting and Mectizan supply. The way the Programme has developed in Raja can be used as a model.

r _d

_complete re-think of the present system of incentives and allowances

-

accommodating the amount

within

a realistic budget, harmonising

with

other programmes.

'

^{Training more} CDDs, to improve the CDD:population ratio.

.

Improving routine activities such as performing the census; supervision; data management; vehicle maintenance.

needed; to the federal level to solicit the release of budgeted funds; to communities to negotiate support

for

CDDs.

In

addition to the formal evaluation findings, several issues

of

significance/ interest presented themselves during the evaluation process. These concern the meaning of the terminology around 'sustainability plans'; whether the original

definition of 'sustainability'

_was a mistake;

process'; the suitability

ofthe

'therapeutic coverage rate' as an indicator

ofproject

performance; and the need to institutionalise training in

CDTI for

health workers.

Concerted advocacy activities were carried out at

all

levels

-

federal, state,

provincial, locality

and community. Five feedback/ planning workshops also held: one for

CDTI

programme stakeholders at the federal level, and one each

for

stakeholders at Abu Hamad, Juba, Raja and

!,

^{Wau. In each case} the evaluation team gave feedback on its findings, which were discussed

in

depth. Participants were then requested to draw up realistic plans to enhance the sustainability of the

CDTI

programme in their areas of operation.

:

..

a\

revised Aptil 2003

Introduction and methodology

1. Introduction

1.1

Onchocerciasis

in

Sudan

The disease exists in four well-defined areas, which are geographically distinct:

i.

The largest number of cases is in the ten Southernmost states

-

^the topography being

a

_

mixture of savannah and forest.

ii. A

substantial number

of

persons has moved from the Southern states to Khartoum during the past two decades. This migration is due both to the ongoing

civil

strife

in

the South, and to the fact that Khartoum is the economic hub of the country,

with

greater perceived employment opportunities. Many of these migrants

live in

camps for internally displaced persons (IDPs) around the

city -

^{and they have} brought their onchocercal

infection with

them.

It

is

unlikely

though that transmission is taking place in the Khartoum area.

iii. A

geographically separate focus of the disease exists

in

the far north of the country,

in Nahr-al-Nil

state, where

two

cataracts of the

Nile

provide breeding sites

for

the vector Simulium in this desert area.

iv. ^A

further small focus exists at Sunduz, on the border

with

Ethiopia.

1.2

Onchocerciasis

control in

Sudan

Onchocerciasis control

in

Sudan started

in

1990,

with

trials of ivermectin and mass

chemotherapy. The year 1992 saw the introduction

of

large-scale community based treatment

with

ivermectin, as

well

as passive treatment in health centres.

In

1995 a national

REMO

was carried out; widespread training began; and 100 000 persons were treated

-

^{all funded by the}

Carter Center.

ln

1997 APOC was launched,

with

its

CDTI

approach, and application was made to APOC to fund the development of two

CDTI

projects

in

Sudan.

As a result of the

civil

war

political

and

military

control of the Southern part of the country has in the past

five

years been divided between the GoS and ^a rebel coalition. This fact has made

it

necessary to have two

CDTI

projects to cover the country, as

follows:

The

following

should be noted:

'

Besides the two

CDTI

projects APOC has also approved a Headquarters support project

for

Sudan. This is rather unusual since the other countries where this has been done (Nigeria and Cameroon) contain large numbers of projects each. This HQ project has contributed to the Northern Sector one in terms

of

human resources and money.

Northern

Sector

nroiect Southern

Sector

proiect

Controlled by Government of Sudan Rebel coalition

Geographic

al

^area covered ^I

Nahr-al-Nil

state: Abu Hamad IDP camps in Khartoum Zones

in

10 Southern states under GoS control.

I

t

Zones

in

10 Southern states under rebel control

Population covered about 600 000 about 1 000 000

Imolementins asencv Federal

Ministry

of Health, GoS Ooeration

Lifeline

Sudan

There is now a single National Onchocerciasis Task Force (NOTF) which meets to plan

for

both projects. For operational reasons the Southern Sector project also has its own

'Southern Sector Onchocerciasis Task Force'.

.

Sudan is a very large country, and communications are problematical. The wide

geographical separation between

foci

in the Northern Sector project burdens the project

with

additional costs, and complicates supervision and support activities.

.

Due to the shifting line of control and the danger of movement outside a few well-defined areas, the national onchocerciasis coordinator (NOC) is convinced that there are large numbers of eligible communities that are not being treated by either project at present

(involving

perhaps as many persons as are being treated by either project on the South at present).

If

^peace comes to this part of the country

it

is very

likely

that an extension to the

two

existing Sudanese

CDTI

projects

will

be required, to cover these neglected areas and to harmonise the work of the existing two projects in the process. Even

if

^a peace

agreement were to be signed during 2003 there is bound to be a lag time

of

several years before the financial and organisational benefits

trickle

down to programmes

like CDTI.

.

Besides making

it

impossible to reach all affected communities, the

civil

war has greatly affected GoS's

ability

to fund disease control programmes

like

the Northern Sector project. Sudan is active

in

signing international documents and agreements, but their implementation is held back because

military

expenditure is the

priority in

the federal budget

-

^{and in the}

^limited

health budget salaries, and then emergencies

like

outbreaks

of

meningitis, take precedence. The fiscal situation is further complicated by the fact that international aid and grants have decreased sharply since 1991,

in

addition to a US economic blockade. There is however every reason to expect the retum

of

donors who previously withdrew, once a peace agreement is signed.

.

_Senior

_officials

_in

_MoH

_reported a commitment to programmes dealing

with

diseases

with

high endemicity in the South, as part

of

a 'hearts and

minds'

campaign. There is also ^a Higher Committee for Infectious Diseases (chaired by the President)

which

gives

additional support to programmes dealing

with

these diseases. Water, health and education are GoS priorities

-

^{but even so} the federal health budget is very small.

.

The Sunduz focus is as yet not covered by any project. There is talk

of

an application being made in the near future to APOC, to accept

it

as a third project

for

Sudan.

1.3

The present

evaluation

The Northern Sector project

in

Sudan is about to come to the end of its agreed

five

years

of

funding by APOC.

It

is therefore ready

for

a Year

5 'sustainability'

evaluation. The revised evaluation instruments (which were tested and fine-tuned in

Malawi

and

Kogi

state, Nigeria)

will

be used.

Note that the Sudan Headquarters project was not evaluated separately, although its effects (in terms of funding and human resources made available for the Northem Sector project) were noted. The fact that

it

too is due to cease being funded points to the urgent need to take the necessary steps to ensure the sustainability of the Northern Sector project.

revised Aptil2003

2. Methodology

2.1 Sampling

The Sudan Northern Sector project operates in the

following

areas:

Northern Sudan

.

Khartoum state: three IDP camps (Al-Baraka, Al-Salam, Al-Basheir)

-

16 communities.

. Nahr-al-Nil

state, Abu Hamad province, 3 localities (Al-Sheraik, Sheeri/

Al-Kab, Abu

Hamad) - 89 communities.

.

_Southern

_Darfur

state, Bura province, Radom council

-

20 communities.

Southern Sudan

.

Eastern Bahr-el-Ghazal state,

Aweil

province,

Aweil

council

-

9 communities.

.

_Western Bahr-el-Ghazal state, Raja province, Raja council

-

¹⁹ communities.

.

_Western Bahr-el-Ghazal state, Wau province, Wau council

-

50 communities.

'

Bahr-el-Jebel state; Eastern and Western Equatoria states, Imotog, Kaboita and Juba provinces

-

¹⁰³ communities.

It

was decided to sample

widely

from both Northern and Southern Sudan

- ^trying

^{to achieve}

representation

of

all the different situations concerned:

Area Sampled? Discussion

Khartoum Yes The displacement camps represent a unique situation.

Abu Hamad Yes

A

large. Northern proiect area.

Radoum No Small and access

difficult Aweil

No Small and access

difficult

Raia Yes Verv hish orevalence of infestation and blindness.

Wau Yes

A

large. Southern proiect _area.

Juba Yes The lareest proiect _area.

In

Southern Sudan the time available for

field

work was constrained by the available

flights

between Khartoum and Juba, Wau and Raja. This led to the

following

decisions about sampling:

The

final

sample selected is given below:

Area/

zone Sample

Abu Hamad Juba

Raja Wau

Locality

with

high TCR

Locality

with

low TCR

Dispensary/ HC

with

high TCR Dispensary/ HC

with

low TCR

Community

with

Community

with

Community

with

Community

with

high

TCR

low TCR high TCR low TCR

-+

->

-+

-)

Khartoum camps

Camp

with

high

TCR -+

^{1 commun}

Camp

with low TCR -)

^{1 commun}

ty

with

h ty

with

h

gh

TCR,

1

with low

TCR gh

TCR,

1

with low

TCR

State/

province

^Factors

taken into consideration Localities

samoled

Communities

sampled

ffCR)

Wau Only

2localities

are available, so both were chosen. From each

locality

a community

with

high and low TCR and

LTC

was chosen.

Northern FI/AI Daraiat

B

^(89%o) Zogolana (54.3Vo) Southern

Kosti A

33 (84.3Vo) Nazereth Khor

Mudir

40,41,42 (56.6Eo)

Abu

Hamad

From 3 localities

,2

were chosen

-

with

high and

unlikely

TCRs. From each

locality

a community

with

high and

low/ unlikely

TCR was chosen.

Abu Hamad

Al

Sinserab Shimai

067o\

Square

|

67Vo\

Al

Sheraik Abu Haitham ^(937o\

Altura

(glEo) Raja The 5 localities only contain ¹⁹

communities; so

I

community

with high,2 with

medium and

I with low

TCR were chosen (2001 data)

[see

left -

direct community samplel

Mangayat ^(87Vo) Tomsaha (407o) Hay Manga ^(65Vo) Hay Elmatar

657o)

Juba Only

2localities

in Bahr-el-Jebel

Kator Kator (Isreal) East (967o) state were accesslble and had clear

data, so both were sampled. From each

I

^community

with

high and

I with

low TCR was sampled.

Kator East

/

Center ^(40Vo) Juba

Hai Mayo ^(93%;o) Hai Jalaba (69.\Eo) Khartoum

IDP

camps

Out

of

3 camps 2 were chosen: 1

with

high, one

with low

TCR. From each camp

I

community

with

high and 1

with

low TCR was chosen.

Al

Salam Souare 3 (817o\

Souare 4 ^(707o\

Al

Baraka Mishekhia Center ⁽⁸⁷ Vo\

Farouq Center 07%o)

2.2

Levels and

instruments

The health service and administration in each country has a unique structure.

After

discussion

with

the NOCP team data collection instruments were matched to levels of the health service as

follows:

Level Instrument

Federal I

Zonel lstatel I

lProvince/

localitv/

council 2

Local supervisor/

FLfm

3

CDD/ community 4

[ ^]

^means: this level is probably not functioning/ not active in the project

2.3 ^Protocol

.

Research question'.

How

sustainable is the Sudan Northern Sector

CDTI

project?

.

Design: Cross-sectional, descriptive.

.

Population: The Sudan Northern Sector project, including:the federal team in Khartoum;

its NGDO partner (Carter Center); its

five

zones,

with all

staff involved

in

onchocerciasis control

in

them; the project communities,

with

their leaders and CDDs.

.

Instrument:

*' I

record sheet, structured as a series of indicators

of

sustainability. The indicators are grouped into nine categories/ groups. These groups represent

critical

areas

of

functioning of the Programme.

revised Aptil 2003

ll

x

_The instrument assesses sustainability at four levels of operation.

*

_The instrument guides the researcher to collect relevant information about each indicator,

from

a variety of relevant sources.

.

_Source of information:

*

Documentary evidence and observations.

*

Verbal reports from persons interviewed.

.

_Analysis:

*

_Data

_{from all}

_{sources is} aggregated, according to level and indicator.

i' I

qualitative summary of the situation regarding each indicator at each level is made.

This is aggregated and summarised for each category of indicator,

for

each level.

x

_{Based on the} information collected, each indicator is graded on a scale of 0-4,

in

terms

of

its contribution to sustainability.

x

The average 'sustainability _score'

for

each group of indicators is calculated,

for

each level.

x _Finally

_{an overall} assessment

of

sustainability is made, by considering the 7 aspects and 5

critical

areas

of

sustainability.

.

Recommendations:

*

These are strictly based on the findings

ofeach

area ofresearch.

2.4

^Team

composition

The core team members were the

following:

1.

Ilham Abdalla Bashir

*

clo Academy for Health Sciences and Technology, Khartoum, Sudan

* T ^(work):

^x 249

ll 224762;T

^(home)

*

_{249 11 480 710;}

_F: *

₂₄₉

l1

224799

x

ilhambasheir@hotmail.com

(or'bashier')

2.

^{Khitma Hassan}

^{El Malik}

*

Department of Preventive Medicine, Faculty of Veterinary Medicine, P. O.

Box

32, Khartoum North, Sudan

* T

^(home):

*

_{249 13 318}

272;T

^(mobile):

*

₂₄₉ 12 352 545

*

kelmalik@yahoo.co.uk or khitmaelmalik@yahoo.com

3.

Elwasila Elamin Mohamed

*

Department of Economics, Faculty of Economic and Social Studies,

University of

Khartoum, P. O.

Box

321, Khartoum, Sudan

* T: *

_{249 11775 427}

* wasila

moh@hotmail.com

4.

Chukwu Okoronkwo

*

National Onchocerciasis Control Programme, Federal

Ministry

of Health, Room 915, Federal Secretariat, Phase

II, Ikoyi -

^{Lagos, Nigeria}

* T: *

234

I

4821285

x chukoro

christ@yahoo.co.uk

5.

^Detlef Prozesky (team leader)

x

Faculty of Health Sciences, University of Pretoria, PO Box 667, Pretoria 0001, South

Africa

* T: * 27 123541147;F: * 27 123541758

x

prozesky@medic.up.ac.za or prozesky@icon.co.za

Team members were grouped into three sub-teams,

for

the purposes of

field

work. Each sub- team was accompanied by one or two NOCP team members, to act as guides and facilitators

(and translators). Each sub-team was further accompanied by one or more Masters students from the Academy for Health Sciences and Technology

(AHST),

who proved very

helpful in

data collection and contributed significantly towards arranging and running the feedback/

r

-

planning workshops. Each sub-team was also accompanied by a member

of

the NOCP team, to act as guide and facilitator. On the

first

day

of

the exercise the team members met to familiarise themselves

with

the evaluation process and instruments, and to complete planning

of

the evaluation process.

2.5

^Advocacy

visits and

'Feedback/

planning'

meetings

Advocacy visits were to be paid to relevant persons at each level, as many as possible, and

* officials

were to be debriefed at the end of the

field

visits

-

^again

^if

^possible.

Finally,

meetings were to be conducted for relevant

officials

at the federal and zonal levels.

During these meetings the evaluation team would give feedback on its findings, and the federal and zonal teams would be asked to develop sustainable plans, based on the findings.

- 2.6 Limitations

!

^{Only two members of} the team were from outside the country,

with

previous experience

of

sustainability evaluations. Since three zones had to be visited

in

the

first

week of the evaluation, this meant that the sub-team that visited Raja was composed

of

local,

first-time

u

evaluators (although especially Prof.

El

Malek had had many previous experiences

of

programme evaluation). In the event the sub-team coped very

well.

!-

The team leader had to leave unexpectedly before the

field work

in Abu Hamad had been completed. This meant that not all team members were present during the

final

analysis

of

data collected.

2.6

^The

data collection instruments

-

The instruments were found to work well. Three issues have however come to the fore:

.

The data and comments under the heading 'Coverage'

in

all the levels duplicate each other.

It

may therefore only be necessary to analyse and grade them once (say for the

L 'federal'

level). There are instances though (not

in

this case) where additional information

will

appear at the

'community'

_level.

.

The suggested ratio of CDDs to population

(l:125)

is too high for the situation

in

Sudan.

''J

This figure is based on studies conducted in Uganda, but where villages are compact and suitable candidates are

few

a ratio

of l:

250 is more realistic.

. At

Federal

level

'leadership' may have to be included as a group

of

indicators. There is ^a clear benefit to be had from capable/ inspirational leadership,

from

someone capable

of

forging alliances. There are also negative effects

of

leadership, e.g. an independence which leads to having the Programme isolated from the mainstream

MoH.

In the Sudanese

_

situation leadership at Federal level has been a crucial element of project successes.

revised Aptil2003 t3

L.

1.1

Findings and recommendations

Federal level

Overall grading

(on a scale of 0-4)

1.2 Main findings

and recommendations

1.2.1

Planning

There is a detailed, six page plan

(with

budget)

for

onchocerciasis control in the 2002 year plan

for

the Federal

Ministry

of Health (FMoH)

-

^{in the same format as} that used

for

other similar programmes. This plan was drawn up by NOCP and presented at a high level planning meeting in FMoH, where

all

similar prograrnmes were also presented and where

it

was approved.

There is a detailed work plan and budget for 2002, based on the one made

in

the original APOC submission. There is however

only

an incomplete skeleton plan

for

2003, which is

still

modelled on the previous ones.

The Carter Centre is actively involved in the planning. NOTF membership also includes a representative of the WR. The

FMoH

has good communication

with

NOTF, and has on occasion suggested changes to the plan.

Planning by NOCP

for

sustainability is in process, but has not yet been finalised.

NOTF

members and NOCP staff have ideas about ways to raise additional funds and to cut costs.

Sudan Northern Sector project: sustainability at

Federal leve!

4

3.5

3 .f

-

^2.5

E

.gl

g2

oED

$

^,.u

(E 1

0.5

0

planning monitoring Mectizan etc.

training/ integration funding HSAM

group of indicators

transport

human

^coverage

etc.

^resources

There are a few related documents, e.g. one

outlining

three future scenarios and a

draft

three year post-APOC plan. On the other hand Carter Centre has been very proactive

in

planning

for

the future, and has secured approval

for

a funded plan of

work from

2003 to 2008.

.

Reasons

for

^{not having completed the plan}

for

2003, and the 'sustainability

plan':

*

NOCP staff is waiting

for

the findings of the current evaluation,

in

order to include its findings

in

an overall plan

for

sustainability.

*

The whole question

of

'sustainability

planning'

is new.

1.2.2

Supervision and monitoring

I I

There is a team of eight

'field officers',

forming part of the NOCP team

in

Khartoum.

Some of these are allocated on ^a more or less

fixed

basis to a particular zone, and others move around between zones (some of them have responsibility

for

both onchocerciasis and trachoma control). These persons are present

in

the zones for extended periods

of

time, actively supervising the entire distribution process, right down to community level.

The size

of

such teams varies, but

it

is often more than one. The zonal teams depend on them to

fulfil

this function, rather than carrying

it

out by themselves.

It

should be noted that these supervisors are costly, each receiving a monthly allowance of _{$ 200} or more.

Supervision visits from NOCP level staff (e.g. deputy coordinator) take place more than once a year.

In

one or

two

areas this supervision is integrated

with

that

for

trachoma control. The

per

diem allowance paid

for

such visits is about $ 20 per day, but

it

^has been restricted recently to seven days per

visit/ trip.

Only

^a

few

supervisors use the supervision checklist developed by NOCP.

The NOCP level supervisors effectively pick up problems, and these are dealt

with

at a

variety

of

levels:

in

NOTF meetings, in the NOCP

office,

and on site in the zones. Here the NOCP level staff may take the lead in problem solving

in

some cases

-

^{again, the}

zonal staff is used to having them around to do this.

Coverage data are not being used as a tool for targeting supervision

-

^{the same}

supervision is done routinely

for

all zones.

Reasons why NOCP level is inappropriately involved in monitoring and supervision at the zonal level:

*

Since the

field

officers are available at the time of distribution they are seen as a resource, or partners, so are drawn into the zonal team.

*

The zonal teams have come to rely on the Federal level to initiate and manage the yearly

CDTI

process.

*

NOCP level staff expressed the opinion that the zonal level

won't

cope

without

regular visits and encouragement.

Recommendations:'Plannin ^g' Implementation

A

three year post-APOC plan and budget (2003

-2006)

should be developed:

* It

should be based on realistic needs and funds that

will

be available

for

project activities (in other words, a sustainable plan).

* It

should reflect the other recommendations made in this report.

* It

should be reflected in

FMoH

plan.

Priority: HIGH

Indicators of success:

Plan as described on the

left

exists;

report of workshop where plan was developed is available

Who to take

action:

NOC Deadline

for

completion'.

June 2003

revised Aptil 2003 t5

Recommendations:'S upervision/

monitorins'

Implementation

1.

2.

J.

4.

The 8

field

officers should only supervise the zonall state level. This should be set out in their terms of reference.

The

field

officers should empower zonal level staff members to supervise the levels below them, and to deal

with

the problems they

identify

themselves.

The time the

'field officers'

spend in the

field

should be minimized.

All

federal and zonal supervisors should make use of the checklist developed by NOCP.

CDTI

statistics should be used to

determine zones/ states

with low

coverage, so that these can receive targeted

supervision.

5.

Priority:

I. ^HIGH

Indicators of success:

1,2

ToR

for field

officers instruct them to supervise and empower zonal level

staff

only; zonal level staff supervise levels below them themselves.

3.

^Field supervisors spend less time

in

the field.

4.

Supervisors know and use the checklists.

5.

^NOCP staff routinely use the coverage data to plan their supervision.

Who to take action:

l-5

NOCP team, NOTF, ZOTF teams.

Deadline

for

completion:

l-5 Bv

the next round

of

distribution

1.2.3

Mectizan supply

The yearly Mectizan order is done by an NOTF member who is employed

within FMoH,

and who has been doing this

for

the NOCP since 1992. He bases this order on information provided by the zones. This system is simple,

efficient

and dependable, and is independent of outside resources.

It

is however singular, in that the function is allocated to a person rather than to a position

within

NOCP.

The federal level takes the responsibility

for

distributing the Mectizan to the zones and IDP camps, sometimes using transport provided by the Sudanese

Army.

The alternative has not yet been explored, which is letting states take the responsibility

of

ordering and moving the Mectizan from Khartoum, in the same way that they order and arrange transport

for

other supplies.

Reasons why NOCP takes

all

the responsibility

for

^arranging Mectizan supply:

*

The zonesl states are far from Khartoum.

*

The zonesl states are used to NOCP taking the responsibility for this function.

1.2.4

^Training and

HSAM

. _In

most zones NOCP

field

officers are involved

in

the yearly training

of

CDDs, and in community level mobilisation activities

-

zonal teams have the skills to do

it

themselves, but have become used to having this additional support.

Recommendations:'Mectizan supply' Implementation

1. NOTF

and

field

supervisors need to

find

out

from

state/ zonal level staff, whether they would be able to:

*

Take responsibility

for initiating

the yearly Mectizan order.

* Link

Mectizan supply to their present supply system

for

other drugs and supplies.

Priority:

1. MEDIUM

Indicators of success;

1.

Meetings between NOCP and state/ zonal level staff have been held.

Who to take action:

1.

^{NOCP team}

Deadline

for

completion;

l.

^{Julv 2003}

.

_{NOCP leaders routinely undertake yearly} advocacy at state level, even though the Programme has been running

for

5 years. They also play a leading role in the 'Oncho

Day'

celebrations in Wau and Juba.

.

Zonal level staff (coordinators and

field

supervisors) underwent training

in

Khartoum on one occasion, but no regular, formal

initial

or refresher training is available

for

them

in

the present system.

.

Field supervisors lack IEC materials for their work.

.

_Reasons wlty NOCP

field fficers

are inappropriately involved in HSAM and

training,

and why there is no system of regular in-service

training:

x

Since the

field

officers are available at the time of mobilisation and training they are seen as a resource, or partners, so are drawn into the zonal team.

*

The zonal teams lack confidence to

initiate

and manage yearly mobilisation and training by themselves.

*

Since zonal staff is stable there has been no need

for

new

initial

training

for

this level.

1.2.5

Integration of support activities

.

_When NOCP level staff

visit

the zones they supervise (and often participate

in)

the whole range of

CDTI

activities.

1.2.6

Finances and funding

.

Up to 2OO2 the detailed yearly budget required by APOC (and Carter Centre) was prepared. However the situation

for

2003 is very uncertain. Although there is a broad understanding that costs

will

have to be cut (and some very clear and realistic ideas about how this is going to be achieved) NOTF does not yet know the amount and source

of

funding that might be available. As a result the 2003 budget is yet to be put together.

. _In

_{2001 the} relative contribution of the major funders of the project was as

follows:

APOC

$

173 000 (667o); Carter Center $ 54 000 (2l%o); GoS $ 33 500 (only _{$ 9000}

in

salaries) (137o). The remainder of the GoS contribution represents a 'monetarisation'

of

contributions such as

office

space.

.

The planned GoS contribution to the NOCP budget for 2OO2

only

accounts

for

lOVo

of

overall costs, and consists of payment

of

salaries

of

some of the NOCP staff members.

Recommendations:'Trainins/

HSAM'

lmplementation

1.

NOCP staff should only

train

zonall state teams (coordinators and

supervisors). Such training should be targeted at zones where there are known to be problems.

2.

^{Zonall state} level staff should be empowered to train the next level entirely by themselves.

3.

NOCP staff should only conduct targeted high level

HSAM

activities where there is a proven need.

'Walis'

should especially be targeted.

4.

^{More IEC} materials, specifically posters and pamphlets, should be produced and distributed.

Priority:

1-3 HIGH

4 MEDIUM

Indicators of success;

1.

Reports of targeted training of zonall state staff, by NOCP staff.

2.

Reports of training carried out by zonall state staff, independently.

3.

Reports of targeted advocacy visits.

4. Availability

of IEC materials; numbers distributed.

Wo

to take action'.

l-4

NOCP team, NOTF, ZOTF teams.

Deadline

for

^{c ompletion:}

l-4 ^By

^{the next} distribution

revised Aptil 2003 t7

Although SD 3.5

million

was budgeted

for

running costs

for zllz,none

of this was released. Senior

FMoH officials

are quite open about their

inability

to get funds for this and similar programmes to be released, and of the need for the

civil

war to end before the budgetary situation

will

improve.

.

The Carter Center has obtained

fairly

substantial funding

for

2003 to 2008, but there

will still

be a large shortfall unless the budget is cut considerably. Though

WHO

Sudan has indicated its preparedness to assist the

CDTI

prograflrme

financially,

there is at present no other guaranteed source of funding for NOCP

for

2003 and beyond.

.

_Funds at the NOCP level are

efficiently

managed, using the

WHO

manual system and the Carter Centre systems as required. These

will

continue to be used even after APOC support comes to an end.

.

_{Reasons why NOCP has not yet}

_written

its 2003 'austerity budget', and there is

still

^so

much uncertainty about funding

for 2003;

why GoS is not contributing to NOCP running

CoStS:

*

There are sufficient funds in the

kitty

for to get the 2003 round of distribution started.

*

NOCP staff is waiting

for

the findings of the current evaluation, in order to include its findings

in

an overall plan and budget

for

sustainability.

*

GoS spending priorities are strongly directed towards the army and emergency

medical conditions such as epidemics. This situation is

likely

to continue

until

the war ends, which

will

lead to less expenditure on the

military

and much greater donor involvement in the country.

*

GoS knows that NOCP has had strong external funding, and has therefore used its

limited

funding for other purposes.

*

From his experience NOC believes that

it will

be possible to obtain additional funding when

it

is needed, from GoS or from relevant donors.

Recommendations:'Financing/ funding' Implementation NOTF must get immediate

clarity

on the funding

that is going to be available to

it

for the immediate and medium term future:

from

Carter Center,

WR's office,

and especially from

FMoH.

To this end high powered advocacy to the

FMoH

must be undertaken, to stress that APOC funding has come to an end and

FMoH

now needs to honour the commitment

it

made in the original Letter

of

Agreement.

A

budget must be prepared, tailored to

fit within

known resources,

for

2OO3l4 and the two years

following.

The budget must accommodate itself to the resources

which

are

likely

to be available.

Areas of integration

with UN

agencies and NGDOs should be clearly identified and utilized - e.g.

UNICEF

is investing resources in training

of

staff in PHC for Western Equatoria state.

Priority:

1-3 HIGH

4 ^MEDIUM

Indicators of succe ss'.

l. ^Written

commitments from these sources.

2.

^{Report of} the advocacy visits and their results.

3.

The budget document is available.

4.

Reports of meetings

with UN

agencies.

Who to take action:

1-4

NOC and

NOTF

Deadline

for

completion:

1-3 May

2003

4

^{Julv 2003}

1.2.7

Transport and material resources

.

There are adequate numbers

of

functional vehicles available

for

necessary activities at this level. In general the vehicles are appropriate. There is also sufficient

office

equipment

available, as

well

as materials

for

training and

HSAM.

The running costs

for

vehicles and equipment are however met by APOC and Carter Centre funding.

It

is not clear whether vehicle maintenance is being systematically carried out since the records are so incomplete. There is an

efficient

system operating for repair, but again this is funded by APOC and Carter Centre

-

^as is the overtime that drivers are paid when they

work

late.

The use of transport is strictly controlled using ^a model system of checks.

There are many ideas

for

replacing transport should this become necessary, but there is only one

firm

commitment

-

^{again from} the Carter Centre.

At

present the NOCP is housed at the Academy

for

Health Sciences and Technology

(AHST) in

Khartoum. This provides the project

with

sufficient and attractive

office

space at

minimal

cost, but may have the disadvantage

of

separating the

CDTI

programme

from

mainstream

FMoH

activities,

in

the minds of

FMoH

managers and planners.

From his experience NOC believes that

it will

be possible in future to obtain vehicles, from GoS or from relevant donors.

Reasons why running and maintenance costs are largely met by unsustainable sources:

*

Again this may be attributed to the NOCP waiting for the

'sustainability'

evaluation report before

it

puts together

its

'sustainability

plan',

and to the fact that funds have not yet run out.

*

The GoS spending priorities mentioned above.

1.2.8

Human resources

NOCP level staff members are knowledgeable and skilled, and are therefore able to carry out all activities pertaining to their level

of

operation. They also appear

highly

committed and

work

Iong hours uncomplainingly. However almost

all

are receiving substantial monthly financial incentives, costing the project $ 3000 per month.

A

few

field

supervisors are not employed by GoS, and the

monthly 'incentive'

is therefore their only income. Other federal HQ staff members receive their salaries

from

APOC funds, but also do work

for

other activities and programmes.

Compared to similar programmes in other countries the number of

full-time

staff at this level is very high (Nigeria

with

a large number of projects has three). In particular the number

of field

officers (8) appears excessive.

Admittedly

some

of

them also assist

with

I I

Recommendations:'Transport/ material

resources' lmplementation

1.

Every

effort

must be made to meet running costs

for

vehicles from dependable sources

Priority:

I-3 MEDITIM

which

will

include, in the medium term,

donor organisations; and in the long term, GoS funds. This

will

of necessity include rationalising vehicle use.

2.

^{The routine} maintenance system

for

vehicles needs to be clearly defined and implemented, to maximise their lifespan.

3. ^{A well}

planned arrangement has to be put in place

for

replacement of transport and other

office

equipment after the present ones reach the end of their lifespan.

Indicators of success:

1.

Budget shows that transport costs ^are increasingly being met by GoS funding.

2.

Maintenance system is defined

in

a document, and

in

operation.

3.

Replacement olan is available Who to take action:

1-3

NOC, senior supervisors,

NOTF

Deadline

for

^{c ompletion:}

l.

^May 2003 and yearly thereafter

2-3

June 2OO3

revised Aptil 2003 19

trachoma control, but

CDTI

only takes place

for

3 months per year, and zonal teams have now had

five

years' experience of running the

CDTI

programme.

NOCP level staff is generally stable (although the post of deputy coordinator has seen a

lot

of movement). New staff members are oriented and trained on the

job, which

seems to

work well -

^while there are enough experienced colleagues around to teach them.

Reasons why substantial monthly incentives are being

paid;

why the level of

stffing

appears high:

*

The NOCP

in

Sudan presents challenges which require more intense supervision (at least

initially)

than projects elsewhere: the worst disease burden is

in

a war zone; the endemic areas are

widely

scattered; the country is huge; communications are poor.

*

GoS salaries are very

low,

which obliges

civil

servants to seek ways

of

augmenting their income.

*

There has been a tendency in the Programme to over-centralise.

1.2.9

^Coverage

The total number of persons treated in 2001 was 350 000. The populations under census vary according to the

military

situation: 577 000 (1999); 498 000 (2000); 591 000 (2001).

Juba and Wau have the greatest populations, followed by Abu Hamad.

Geographical coverage

in

2001 was 9l7o (one of the Abu Hamad localities, Al-Sheraik, was not treated due to flooding).

Concerning geographical coverage there are two distinct scenarios:

*

In

Nahr-al-Nil

and Southern Darfur states all communities identified by

REMO

are being treated, as are the IDP camps around Khartoum.

*

In the Southern states there is however much uncertainty. Some Southern communities previously

in

the Northern Sector project are at present inaccessible, due to changes

in

the line of control.

It

is

likely

that many people at risk

find

themselves in places where Mectizan

in

not being distributed.

Therapeutic coverage

in

2001 was 59.5Vo (varying from 287o in

Aweil

to 9OVo

in

the

Al-

Salaam camp). Rates generally show an upward trend, but vary in latter years (according to the

military

situation):

*

The figures however are suspect in a number of cases. There are widespread examples

of

adding effors (e.g. 'no. treated' is greater than

'eligible population');

calculation errors (averages being smaller than any of their components); using

'eligible

population' as denominator and so on.

Recommendations:'Human resources' lmolementation

1.

The number

of

staff members at federal level should be rationalised, as the zonal and especially state levels take on more responsibilities.

Alternatively

the present number should be given _other responsibilities, funded

from

other sources, when they are not engaged in

CDTI

related activities.

2.

^{There is a need to} reduce the monthly financial incentives for NOCP staff

- ^for

example by cutting down the amount they receive, only paying

it

during the distribution period etc.

Priority:

I,2 HIGH

Indicators of success:

l.

The number of

full-time

project

staff

(managers and

field

supervisors) is reduced, or existing staff is redeployed.

2.

The total yearly

bill for

incentives and proiect funded salaries is substantiallv cut.

Who to take action:

I,2

NOC, NOTF

D eadline

for

^c ompletion'.

1,2

July 2003

* It

also became clear that,

in

^a number

of

instances, all breast-feeding women were excluded from treatment (not only those

within

7 days

of

delivery). This led to therapeutic coverage rates that were lower than they needed to have been.

*

Interestingly

it

was noted that high

fertility

rates lead to large numbers

of

ineligibles and therefore to relatively

low

therapeutic coverage rates - which do not do justice _to

- . n,*]n:';;;' r";;)z;r::;x2wxzn:";:"i;:,x' un,"no,n,

and

why,herapeu,ic

coverage is incorrectly calculated:

- ^. auililiiH,:il::il?::::l::ilT.1::il1ffii#1fiffiJ.:T:".fl:f"",*

dependable data about the number and nature of existing communities, nor is

it

possible

for field

staff to investigate such areas at present.

Presumably training of zonal level staff in data management is defective. Controls at federal level are also not being done

in

a systematic way.

Recommendations:'Coverage' Imolementation

1. A

detailed investigation should be conducted into the way

in

which coverage data are collected, analysed and checked, at every level of the project.

2.

^This should be followed by the necessary action to remedy problems that have been identified (training etc.).

3. ^At

the refresher training before the next distribution the

eligibility

of lactating women for treatment needs to be clarified.

4. ^A

^{new REMO}

^will

^{have to be}

conducted when the situation

in

the South normalises.

Priority:

1-3 HIGH

4, MEDIUM

Indicators of success:

1.

Report of investigation

is

available.

2-4

Reports on action taken are available (e.g.

training reports).

Who to take action:

l-3

NOCP team; ZOTF teams; SMoH focal persons

4.

NOCP team

Deadline fo

r

c ompletion:

1,2

December 2003

2.

Before the next distribution.

3.

Unsure

revised Aptil 2003 21

2. ZonaU state level

Sudan is a federal republic, consisting of 26 states

-

^each

^of

^{which has a} certain amount

of

autonomy, including for instance a State

Ministry

of Health (SMoH). The National

Onchocerciasis Control Programme (NOCP) however operates

within

^{'zones', as} the next level below the federal one. The zones are geographical entities which may

form

part

of

one state (e.g. Abu Hamad zone, which is part of

Nahr-al-Nil

state; Radom zone,

which

is part

of

Southern Darfur state); or which may contain parts of more than one state (e.g. Juba zone, which contains parts of Bahr-el-Jebel, Western Equatoria and Eastern Equatoria states; Wau zone, which contains parts of Eastern and Western Bahr-el-Ghazal states). This has led to the formation

of 'zonal'

structures (e.g. ZOTFs) and personnel (e.g. ZOCs) in the project, which are unique and vertical. Most of the

'zonal'

personnel are SMoH personnel but they do not function

within

the state environment.

-

^{rather as} an extension of the federal HQ.

One of the key determinants

of

sustainability is integration. The state structures exist (being functional to varying degrees) and

will

continue to do so, whereas the zonal structures ^are vertical and

likely

to be temporary. Throughout this section the assumption is therefore made that

it will

be better for Programme sustainability

if

zonal activities become integrated

into

state structures (which may be done rapidly or gradually).

2.1 Overall grading

^(on a scale of 0-4)

Sudan Northern Sector proiect: sustainability at zonall State level

3.5

3

a

^-."

E

.92

o

=

o,-

ED ^I.C

6o G1

0.5

0

planning monitoring Mectizan etc.

training/ integration funding HSAM

group of indicators

transport human

[coverage]

etc.

^resources