CDTI project Masindi

/u ^(.*'*.79

World Health Organisation

African Programme for Onchocerciasis Control

Assessment of the

sustainability _of the

Masindi CDTI project

June 2002

Richard _Gibson

Rose Korugyendo

James Mugisha

n

Index

Page Abbrevi ations/ acronyms and acknowled gements

Executive summary

Introduction and methodology Findings and recommendations

1. Distict level

2. ^Health centre level

3. Community level

4. Overall sustainability grading for the project Detailed findings

1. ^{Health district}

2. Sub-districil first line health facility level

3. Community level

4

Abbreviations/ acronyms

African Programme for Onchocerciasis Control Chief administrative officer (DCAO - ^{Deputy CAO)}

community directed distributor (of ivermectin) community directed treatment with ivermectin Deputy Director Health Services

District Onchocerciasis co-ordinator (ADOC - ^{Assistant DOC)}

District health team District management team

Local government level I (Incal council)

Local govemment level 3 (sub-county govemment) Local goverrrment level 5 @istrict government) non-governmental development organisation national onchocerciasis task force

Primary Health Care World Health Organisation APOC

CAO CDD CDTI DDHS DOC DHT DMT LGl

LG3 LG5 NGDO NOTF PHC

wHo

Acknowledgements

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

' ^{The staffat APOC} Headquarters in Ouagadougou: Dr S6k6t6li, Dr Amazigo, Mr Aholou

. _{Dr. Richard} Ndyomugyenyi, NOC, Kampala

. _{Staffof the} District Health Services in Masindi: Dr. Luwaga (DDHS), Byaruhanga

Cosmas

(DOC) and Mugayo William ^(ADOC)

' ^{Health workers and community} members attached to the Bulisa, Nyantonzi and Budongo

health

units.

Executive summary

The Masindi

CDTI

^project has been supported by APOC for the past 4 years, and is in its last year of agreed funding from APOC. An evaluation of the sustainability of the project was carried out in ApriV May 2002,by a team of evaluators. The evaluators were charged with three tasks:

.

Evaluating the sustainability of the project.

.

Working

with

local stakeholders to plan for sustainability, based on the f,rndings of the evaluation.

.

Advocacy

with

local political and

civil

service leaders, regarding their future role in the sustainability of the project.

The evaluation was carried out over a period of eleven days. Inforrnation was collected by document study, interview and observation, at sanpled sites at three levels of the health service: District, sub-district/ health cenfre, and village/ community.

The

overrll

judgement of the team is

that

the

Masindi CDTI project

is not

far from

being sustainable.

Regarding the six elements of sustainability, the situation is broadly as follows:

.

Efectiveness: The project is effective at all levels

.

Eficiency/

financing:

Many activities are not properly targeted, resulting in ineflicient use of scarce resources. I-ower levels (health _center / supervisors and community) are not yet

fully

empowered to carry out tasks at their level, even though the involvement of

stafffrom

higher levels is minimal.

.

Simplicity: Systems have been put in place for most processes, which may not be the most simple but function.

.

Integration: Due to the fact that funding has been parallel, most activities are still not integrated because

it

has never been necessary or desirable to integrate thern

.

_{Atlitude: Although} stakeholders have accepted the project as part of their routine work, some key players have not yet accepted the fact that they

will

have to cope without outside resources in the near future.

There is evidence of political commitrnent to the project but very

little

actual involvement.

.

Resources:

In

this key area the project

still

relies too heavily on APOC. There is a willingness to fund the program at

all

^levels ofgovernment, but thus far the desire has not seen material expression, largely because it has not been necessary.

Overall, it is apparent that because

CDTI

developed as a separate progranL with separate funding and separate requirements from role player, the need for involvement has been

minimal.

Consequently, the actual

involvement of

r"any

players, as required for sustainability, has been minimal

Regarding the position of the different levels of the project, at all levels there are problems requiring attention in the areas of leadership, training / mobilization and financing /

funding.

The communities are not significantly involved in plarming, while.at the district and health center levels supervision / monitoring remains a problern Detailed recomrendations were drawn up, based on the findings of the evaluation at the four levels. The recommendations were prioritised, and indicators and deadlines were suggested for each. The most important recommendations concern:

.

Determining the exact fi.rnding that

will

be available, and mobilising additional sources of frrnding

if

necessary.

'

^Tailoring activities (mainly training and supervision) to frt the budget.

'

Enpowering the supervisors and communities to take

full

charge of activities at their levels

Advocacy activr;:es were carried out at the level of the District (LG5 Chairman, Chlef Finance Officer, Deputy Chief Adminisrrative Officer, DDHS) and interim levels of government (Health Sub-distnct chref, LC3 chief, LC3 sub-accoun:ant).

One feedback / planning session was

held. It

was envisaged that the people rnvolved in annual planning for CDTI in this pro:ect, should attend to revisit the project plans for the

furure.

It was decided to include as rnany members of

oths

^{levels of} government, not included in CDTI activities to date, as possible. People were rnvrted from Hea.lth sub-district and LC3 levels, levels of government not involved in CDTI activities to date, but necessary

for

future sustainability.

The uorkshop process was not particularly successful due to a combinatron

of

lack of experrence of facilitators and relicence on ^'-he part of particlpants. Although participants _agreed wrth the findings of the evaluation tearq dunng the plann-rrg process they had

difficulty

changing mrndset and questioning activitres. This process was not helped by the fact that all members of the different levels of government kept grvrng assurances that they u'ould accept responsibility for all

CDTI

activitres, within their area of influence, creatinS, the impression that

6

the status quo would be maintained. Time for the process was limited, and so all of the goals of the meeting were not achieved

-

^{problem with} experience.

One positive outcome of the meeting was the cornmitment from all levels of government to support the CDTI process and determination to succeed. Government participans were made aware of the new requirements

of

CDTI and "guaranteed" the sustainability of the project.

Introduction and methodology

1. Introduction

The Masindi CDTI project _{was one} of the first group of projects to be approved by APOC, and to begin receiving funding in 1997 havng previously been engaged in other Mectizan distribution activities. Its 5 year period of funding is due to end in November 2002.

In 2001

a

decision was taken by APOC management that all projects should be

assessed,

to find out how sustainable they are. The Masindi project is one of 4 projects in Uganda which were evaluated for sustainability at this time

Accordingly the aim of this assessment was twofold:

. _To

_assess

_{the level of} sustainability of the Masindi project.

. _{To feed back the} findings of the team, and to undertake

a

workshop in which these findings are used in the planning process for next year.

The political arrangements in Uganda did not fall within the neat allocations of the instruments developed for this study.

Uganda is involved in

a

process of decentralisation of authority, whereby planning _and implementation of activities is carried out at the lowest possible level of govemment, while the higher levels are involved primarily in supervision and facilitation. This process is new, and it appqrs that the CDTI process

has

bypassed entire levels of government.

Govemment structure is

as

follows:

. _{National, district} (LG5),

. health sub-district,

. sub-county (LG3),

. health centre and

. _local (community) council (LGl).

The CDTI process has involved the following levels of health care

, _National, . _district,

' health centre and

. _local (community) council

2. Methodology

This is given in detail in the document: 'Using the instrument to determine the sustainability of APOC projects'.

Research question: How sustainable is the Masindi CDTI ^project?

Des ign :

Cross-sectional, descriptive.

Population: The Masindi project, including: the DOC and district Ievel staff, the zonal supervisors, the health centres, the CDDs

and

the communities in Onchocerciasis endemic areas.

Sampling:

I

8

* _{In the district} of Masindi, Onchocerciasis affects 2 sub-districts, therefore both sub- districts were sampled (Bulisa and Bujenje)

* _{Within the two} sub-districts, only 3 health centres are affected, therefore all three health centres were sampled (Biiso, Nyantonzi and Budongo). Zone supervisors, who may or may not be health centre staff, function in the role of the "front line health

unit"

as

described in the instrument. As far

as

possible these people were included in the sample, in addition to the health centre staffengaged in CDTI activities.

* _{Within each health} unit, two villages were sampled, one with low coverage, one with high coverage (Kihuuh4 _Bubwe, Nyantonzi TC, Bisaju II, Kyempunu and Maramu), these villages also fulfilled the criteria for endemicity (high and low rates included) and accessibility (accessible and inaccessible villages included).

Instrument:

* Questionnaire (see appendix: 'Detailed findings') structured

as a

series of indicators of

sustainability. The indicators are grouped into 9 categories.

* _The instrument

assesses

sustainability at levels of operation.

* _The instrument guides the researcher to collcct relevant information about each indicator.

Source of information:Yerbal reports from persons interviewed, supplemented by documentary evidence.

Analysis:

* _{Based on the} information collected, each indicator is graded on

a

scale of 0-4, in terms of its contribution to sustainability.

* The avemge 'sustainability score' for

each

group of indicators is calculated, for each level.

* A qualitative description of problem

areas

is given.

Limitations of the study were found to be the following:

* _{The people, at all} levels, required for interviews were generally not prepared for the visit, which coincided with trips out of the country / district, market days, workshops, etc. Much time was spent mobilising suitable people.

* _The dosumentation required was not ready and often not available - the respondents were not informed of this need in advance and it appears that record keeping at all levels, above that of the CDD, is not

a

priority issue.

I

9

Masindi Project: Self-sustainability at district level

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Group of indicators

Findings and recommendations

1. District level

1.1 Overall ^{grading (on} a scale of 0-4)

1.2 Main findings

Coverage:

Overall and geographic coverage are excellent Plannine:

Detailed year plans are apparently developed for CDTI, which are separate to the plans for the rest of the DMT and do not involve members of the DMT who are not directly

engaged

in CDTI activites.

Leadership:

The CDTI ^program is initiated largely by an annual planning workshop, hosted by the NGDO, in cornbination with Hoima district. Civil service decision makers (DDHS and DCAO) have been effectively included into the program.

Monitorine / Supervision:

District staff meet supervisors annually and at quarterly meeting (5 tinres per year)

as

s'ell

_as

during routine reporting meetings. Also involved in supervision of activities of

supervisors in ^form of spot checks. Planned visits to villages during'activities no evidence of

reasons

for specific visits - ^{involve only CDTI staff and few civil servants, not rest of}

D\{T.

Repor':'-ing

is via

a

parallel system, with monthly reporting and activity reporting.

Although problems are addressed at this level, there is little evidence of empowerment of

people

at lower levels.

t

n."".o.

l0

Mectizan:

The ordering and distribution of Mectizan is via

a

parallel system, yet appears to be sustainable and effrcient.

Trainine / Sensitisation / Mobilisation:

Training of supervisors and CDDs takes place annually, regardless of requirements.

District staffare mostly involved in supervisor training but also engage in CDD training -

spot checks and support. Stake holders meetings

are

held annually, involving people at all levels of government, but there is no evidence of

these

people becoming actively engaged in supporting CDTI.

Financine / Fundine:

Budgeting in the district is based on

a

bottom-up approach but availability of APOC funds

has

removed requirement of "lower" levels of government to become involved in financing. All CDTI activities are included under "PHC ou.treach", with no evidence of

careful planning for requirements of any individual element and separate CDTI planning according to APOC requirements.

Material Resources:

The

use

of transport is integrated at this level although vehicles are usually used for separate activities - ^due to the allocation of staff responsibilities. Control of vehicle use

at

this level is poor.

Human Resources:

Human resources at this level are knowledgeable and skilled, this is helped by regular salaries. There is no integration of activities between members of the DMT.

1.3 Recommendations

Recommendation Implementation

Plannine:

. _District staffshould include other DHT members into their planning activities

. They should consult with sub-district and sub- county staffduring the planning process

Priority: HIGH Indicators of

success:

. _{Evidence of other DHT staff}

including CDTI in their routine activities

. _Inclusion of CDTI in the planning and budgets at these levels

Wo to take action

. DDHS / DHT

. DOC

D eadl ine

for

^{comp I e t i o n}

. June 2002 The political and administrative leaders

at

the

sub-

district and sub-county levels should be included in the CDTI process

These leaders should be encouraged, thereby, to carry resf,onsibility for CDTI activities in their

areas.

Priority: HIGH

I nd i

cators of

suc ces s'.

. _{Targeted meetings with leaders}

having,speci

fi

c

obj

ectives

. _Reflected

_as

_above

Ll/ho

to take action

. DDHS / DHT

. DOC

Leadership.

Deadline for completton:

June 2002 Supervision and Monitorins.

. District staffshould try to further empower

supervisors to identify and manage problems with CDTI by systematically discussing reports and encouraging management activities

Priority: MEDIUM Indicators ofsuccess;

. Supervisors ability to identify and manage problems reflected in

reports

Who to take action:

. _DOC/ADOC

Deadline for completion:

. _{December 2002}

Trainine.

. Training programs should focus

less

on structured meetings and more on on-site kaining during normal activities of the DHT

Priority: Medium Indicators of success:

. _{Fewer training workshops}

arranged in ^year

. _Training activities carried out during routine health activities.

Deadline for completion : December 2002.

Fundine.

. _CDTI activities need to be revised within the available district budget.

. With increasing involvement of sub-district and sub-counf5r structures

as

above, they need to be strongly encouraged to contribute financially to CDTI activities

Priority: HIGH Indicators of success:

l. Consideration and reflection of

costs of all CDTI activities in

detailed plan

2. Reflection of CDTI activities in S/D and S/C budgets

1. DOC / ADOC

2. DHT

Deadline for completion:

December 2002 Who to take action:

' ^DOC

. _DHT

,,

t2

Sub-district Level (Health Unit)

Overall grading ^(on a scale of 04)

2.1

Masindi project: self-sustainability at health centre level

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Group of indicators

2.2 Main findings

Coveraqe:

Overall and geographic coverage

are

excellent Plannine:

CDTI is seen

as

being core activity of the health centres and detailed planning takes place

at

this level. However only staffidentified

as

supervisors are included in the planning and activities.

Leadership:

CDTI activities are initiated by

and

respond to the demands of the district staff.

Supervisors are expected to perform activities dictated by district and report to district, they then receive allowances from district. There

appears

to be political commitment to CDTI at this level, although active involvement

has

to

date

been limited.

Monitorinq / Strpervision:

There is excessive supervision

and

monitoring by supervisors. It is standard practice for supervisors to observe CDDs in action. All activities are carried out

as

routine -

regardless

of need - with little evidence of response to problems. Supervisors identify problems with CDTi activities in their

areas,

but no evidence of activities to deal with

these.

Reporting on CDTI activities follows

a

parallel procedure, excluding rtormal levels of

government.

I

-..c

*.@"

Mectizan:

The distribution of Mectizan is proceeding efficiently despite the fact that it follows

^a

unique path. Mectizan is

seen as

being an essential drug at this level. Ordering is directly to the DOC on the basis of census figures. Disitribution to health centres is by project staff.

Cotrol of Mectizan is separate, making use of CDDs reports, not stock control cards.

Trainine / Sensitisation / Mobilisation:

Training of CDDs is

^a

routine procedure lasting for 3 days regardless of needs of

CDDs. Sensitisation at this level is minimal, LC3 reports minimal sensitisation. Most sensitisation targeted to LCI - ^{and this mostly routine. Materials are mostly} unavailable -

many CDDs are not health centre staffwith no materials - ^{and where available}

^are

^{difficult to}

renew.

Financine / Fundine:

Health centre activities

are

included under PHC outreach. Despite detailed CDTI plans for APOC, no evidence that these plans used in determination of health centre budget.

Supervisors activities and allowances separately funded and have not been included in government budgets to date.

Material Resources:

ln some

areas

there are too many supervisors, not enough bicycles. Use of health centre transport is integrated although trips tend to be for specific activities.

Human Resources:

Supervisors

are

well trained and motivated. The system of supervisors developed

because

health centre staff were unable to cope with demands of CDTI activities. It is of

concern that should the system of supervisors fail, it is unlikely that the health centres will

cope with the current burden of activities.

2.3 Recommendations Plannine.

. Health centre staff should plan for reduced, targeted CDTI ^activities

Priority: MEDIUM Indicators of success:

. Targeted activities reflected in work plans Who to take action:

. Health centre staff

D

eadline for ^completion

. _December 2002 Leadership:

. _Health centre staff should continue to

raise

issues around CDTI ^{with LC3} politicians

' ^LC3 budgeting authorities should be encouraged to embrace the system of

supervisors from outside the health

system.

Priority: MEDruM Indicators ofsuccess:

. Increased awareness of LC3 pesonnel about CDTI

. _Budgetary allowances for supervisors

Wo ^to take action:

1. ^{Health centre staff} 2. DHT

D

eadline for comp'letion

' ^{December 2002}

Supen'ision Priority: MEDruM

t4 Supenrision needs to move from routine to superuision focused on identifying and managing problem

areas.

Supervisors should hold focus goup

discussions with LCl, CDDs and

communities to empower

these

people to identiff and manage problems.

Indicators of

success:

. Fewer supervisory contacts, justification for all contacts

' ^{Detail of} discussions to be included in activity reports

Who

to take action:

. Supervisors

Deadline for completion:

. December 2002 Training:

. Training needs to become

less

routine and more focused with fewer, shorter training

sessions

and more on-site training.

. Training should occur at the

same

time

as

other health activities

Priority: MEDIUM Indicators ofsuccess:

. _Cessation of routine training meetings

. Justification for training sessions

r Integration of health related visits.

Who

to take action:

. Supervisors

Deadline for completion:

December 2002 Fundine.

. LC3 politicians must be strongly

encouraged to include CDTI activities in their budgets

Priority: HIGH Indicators ofsuccess:

. Inclusion of CDTI activities in annual budget

Wo to take action:

. Health centre staff

. _DHT

Deadline for completion:

Jlune2002 Human resources.

. _The

use

of supervisors should be reviewed

and

number and activities should be determined by available resources.

Priority: HIGH Indicators ofsuccess:

. Detailed plan of supervisor activities against available resources

Who

to take action:

. Project staff(DOC, NGDO, Supervisors) Deadline for completion:

December 2002

I

a

3. Village level

3.1 Overall grading (on a scale of

G-4)

4.2 Main lindings

Coverage:

Overall and geographic coverage are excellent Plannine:

There is no evidence of planning at this level, CDTI personnel respond to requirement of higher levels. Census update and distribution separate.

Leadership:

The local council

as a

whole is minipally involved in CDTI.

Monitorins / Supervision:

Repor-ting is accurate and complete. Supervision of activities at this level remains the

responsibi

lity

o

f supervi sors.

Mectizan:

There have been no delays with distribution and sufficient Mectizan has been

received. Orcering based on census figures, when census has to be cancelled due to delayed

finances,

ordcring ^has been based on previous year's figures with no problems in distribution.

Trainine / Sensitisation / Mobilisation:

LOC members are poorly aware of CDTI activities. CDDs claim to be involved in sensitisation but no evidence, it appears that sensitisation remains

^a

routine activity carried out b)'superv'lsors.

Masindi project: self-sustainability at community level

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Group of indicators

l6 Financine / Fundine:

CDTI is seen

as

an externally funded, government run program. Half of communities provide incentives to CDDs from tax receipts.

Material Resources:

Transport is not

a

problem _at this level.

Human Resources:

CDDs are trained and knowledgeable. It is

seen as

being impossible for CDD training to take place at this level, it requires input from higher levels. CDDs and communities

appreciate the benefits of Mectzan and appreciate the need for long term treatment.

4.3 Recommendations Plaunins:

. The work of the CDD can be simplified by combining activities (e.g. census and distribution)

Priority: MEDIUM Indicators of success:

. Streamlined plan of activities

Wo to take action:

. Supervisors

. _CDDs

Deadline for ^completion

' ^{December 2002}

Leadershio.

. _{[ocal councils} should be encouraged to

accept

responsibility for

management of locally relevant problems including follow-up of non- compliant community members.

Priority: MEDIUM Indicators ofsuccess:

' ^CDTI becomes regular feature in local council discussions

Who

to take action

. Supervisors

. _CDDs

Deadline for ^completion

December 2002 Fundine.

. _{[ocal councils} should be encouraged to support CDDs from the

25Yo

of G- Tax,

as

medical expenditure

Priority: MEDIUM Indicators of success:

. _{Local councils offer} incentives to CDDs.

lVhq to take action:

. _LC3

. Supervisors

Deadltne for completion

^:

December 2002

4. Overall sustainability grading for the Masindi project

The overall irryression is ttrat the potential for sustainability is

high.

Although various problems have been identified with the prograrq most of these problems have arisen as a result of the system

of

funding the

prograrn

APOC money has been available, with its attendant requirements, making

it

diffrcult for systematic inclusion of the CDTI process into the mainstream of planning, budgeting and rnanagement. There is strong commitrnent to the program at all levels of political decision making, people see this as a Masindi prograrrt which the people of Masindi

will

manage. Additionally there is evidence that Mectizan was distributed before the advent of APOC, and there is a belief that there is no reason why distribution should not continue after APOC, as long as the supply of the Mectizan is assured.

There is a lot

of

pride in the achievements of CDTI, and enthusiasm that all role players are

finally

being brought on board.

Tick one correct assessment

Level

of

sustqinabiliv

Description

Excellent This proiect is completely sustainable

This project is not far from being sustainable. With feedback from the team before departure, the project staffshould be able to undertake the required remedial action.

Moderate This project is potentially sustainable, but

will

^require rethinking and mobilization of high level support to get it on the road again.

Low

This project is seriously unsustainable

-

there is some doubt as to whether

it

ever

will

be. It needs a lot of immediate expert zuidance from outside.

-

l8

FEEDBACK /

PLANNING

WORKSHOP,

MASINDI

4 JUNE 2OO2

Attendance list.

NAME

POSITION

Dr. Henry Luwaga DDHS

Byaruhanga Cosmas DOC

Mugayo

William

ADOC

Kasangaki Francis Sub-county chief, Budongo

Kiningi

John In Charge, Bulisa Health sub-district Bigabwa James In Qarge, ^Biiso health centre

Kyomye Rumbeiho Chairmaq Pakanyi

Byaruhanga Jack SACAO / Bulisa

Dr. G.Idayiko In Charge Bujenji Health Sub-district Mugenyi Malitubu Chairpersoq Biiso

Bategeka Joronim

Ql*!rr"u,

^{LC3, Budongo}

Antama Fred E / N, Budongo Health Centre Kirokimu John H / A, Biiso Health Centre

Mboineki

KCM

HMIS FP, DDHS office

Kazimura Alice N / A, Biiso Health Cenhe

Bukya Wilson S / Aide, Kinyara

Kyamanyira Dominic Rec Assistant, Nyantonzi Health Centre

Oyewa Denis Superviqor, Biiso

Kaahwa Bagonza Supervisor, Biiso

Kaija Ateenyi Ellison Supsryisor, Biiso

Asiimwe Jeska Supervisor, Biiso

Opomo Jane Supervisor, Nyatonzi

Byakagaba

Elly

Supervisor, Kasenene

Dramadri

Alfred

Supewisor, Kasenene

Nibihi Aniiku

Supervisor, Kibwona Katumba Charles Supervisor, Kinyang

Nsubuga Yosam Supervisor, Nyantonzi

Asiya John Supelyisor, Nyantonzi

Isuigoma David Supervisor, Hyabyeya

Avutia Emmanuel Supervisor, Nyantonzi

Problems identified.

Those in bold were identified by the evaluation team, and adopted by the participants.

Those

in italtcs were added by

the

participants Finance.

Parallel funding Separate planning No ^pressure to fund

Inaccessible / latefundingfrom sub-county / health sub-district Monitoring / Supervision

Too much routine supervision Not empowering

No action results from activities Lack of health stalffor these activities Planning.

Not bottom up lntegration

Plans are not implemented as scheduled Training.

Few are trained

Training takes long hence expensive Untargeted training

Mobilisation.

Low turn up

Lack of collaboration among some local leaders Some religious sects reject

the

program

Leadership.

At all

levels

few are involved

Inadequate political support at all levels Material Resources.

Lack of bicycles to supervisors and CDDs Lack of _fuel for motorcycles at health unit level Lack of bicycle maintenance allowance

Lack of protective gear (gum boots and rain

suits)

for supervisors during

ratny season.

20

Possible solutions.

Material Resources.

Increase the number of CDDs so

as

to

decrease

the number of households per CDD

lntegration of activities.

Leadership.

Advocacy for the program for all stakeholders lntegration of CDTI activities into health activities Have a focal person at Health Sub-district

Mobilisation / sensitisation of LC

1

- ^{5 on CDTI progrzrm}

Planning.

Planning should be bottom up. tn the

debate

which followed this statement, it

was decided that bottom up means consulting at all levels with leaders.

It should be integrated at all levels.

Stake holders to consider this program

as

priority

Training.

Implementors should be committed.

Implementors should adopt the idea of volunteerism Local leaders should also be trained to boost the CDDs Training should last for only one day

Training should be targeted, excluding those who are experienced.

Mobilisation.

All stake holders should get involved in mobilisation.

Leaders must be seriously sensitised More sensitisation to those religious

sects.

Finance.

Joint planning at all levels encouraging provision of Onchocerciasis activities Political will

Monitoring / Supervision.

Integration of supervision activities Focus goup discussions at all levels

Follow up of resolutions after workshops

Empower LCs and CDDs to restrict supervision to

a

minimum

AgTIVTTY

WHY DO ^WE NEED TO DO THIS?

WHO SHOULD DO THIS?

WHEN MUST

IT

BE DONE?

WHAT

RESULTS DO WE EXPECT?

Pakanyi Remaining part of 2002 Mobilisation

of

local communities and teachers

To create awareness to our communities

/

leaders

of

Onchocerciasis as a disease

Supervisors June 2002 Number of meetings

held

Training of CDDs Refresh CDDs on their roles

Supervisor June 2002 No of CDDs trained

Distribution

of

ivermectin

To eradicate oncho CDD July 2002 increased number

of

people taking Ivermectin Supervision Ensure effective

distribution

Supervisors

luly

^2OO2 Increased number

of

beneficiaries Data collection Assess level

of

performance / record keeping

Supervisor Aug

-

^{Sep 2002 High coverage}

Feedback Give feedback to the beneficiaries

Supervisor

Dec2002

Magrritude

of

attendance Plan for 2003

Update ofcensus registers

To plan for the next distribution of tablets

CDDs / supervisors Jan 2003 Number

of

registered beneficiaries Sensitisation

/

mobilisation of local communities

To create awareness to communities about the disease

Supervisor Feb 2003 Number of meetings

held Training of CDDs Refresh the CDDs on

their role

Supervisors Mar 2003 No of CDDs trained

22

ACTIVITY WHY

DO WE NEED TO DO THIS?

WHO SHOULD DO THIS?

WHEN MUST

IT

BE DONE?

WHATRESULTS DO WE EXPECT?

Budongo Sub-county CDTI plan Updating

of

registers

As to budget Community leaders, supervisors, CDDs

Dec2002

Update census figures Community and

local leaders sensitisation

Create awareness

of

Onchocerciasis activities

CDD, community leaders, supervisors

Jan 2003 Number of local leaders participating Select and

rain

more CDDs

To reduce on the area of distribution

Community and supervisors

Feb - March 2003 Number of selected and trained CDDs Supervision and

monitoring

of

ivermectin distribution and data collection

To check on corrpliance

Supervisors, local leaders

June 2003 Number of people treated

RESOI.IRCES WHERE CAN WE

OBTAIN THIS RESOURCE?

HOW CAN WE

OBTAIN

THIS

RESOURCE?

HOW SURE ARE WE TTIAT WE

WILL

GET THIS RESOURCE?

Human Community

Health services

Mobilisation / selection DDHS

Sub-county budget DDHS budget

Materials Sub-county

Health services

Sub-county budget DDHS budget

Incorporated in the sub- county and DDHS budgets

Financial

District

NGO Sub-county Community

Presentation of proposals Sub-county budget 25% contribution from

LCI

Fuel for distribution and support supervision incorporated in DDHS budget

Biiso Sub-county CDTI work plan

ACTIVITY WHY

DO WE

NEED TO DO THIS?

WHO SHOULD DO THIS?

WHEN MUST

IT

BE DONE?

WHAT

RESULTS DO WE EXPECT?

Updating register To know the population to serve

LCI,

CDDS, supervisors

Nov

-Dec

^{2002 To see}

if

the new people are there The increase and decrease

of

population Mobilisation and

sensitisation

of

community leaders and teachers

Create awareness Supervisors Jan 2003 To get more

involved and get necessary support Training of CDDs

newly identified

So that get the concept

ofCDTI

proiect

Supervisors Feb 2003 Functional CDDs

Support supervision of ivermectin distribution

To make sure that the community has swallowed the tablet

Supervisors Feb 2003 At95Yo coverage

should swallow the tablet

Data collection and reporting

To get the coverage and information

CDDs and supervisors

April2003

What has been done Feedback forum To make

community know

of

how tablet was swallowed

Supervisors June 2003 To get solution to

challenges

RESOURCES WHERE CAN WE

OBTAIN

THIS RESOURCE?

HOW CAN WE OBTATN THIS

RESOURCE?

HOW SURE ARE WE

THAT

WE

WILL

GET THIS RESOURCE?

Stationary Sub-county headquarters

LGDP

HSD and PHC tunds

Forwarding requisition and budget

Assurance from the sub- county

Allowances Sub-county, Health

Unit

and PHC funds and other sources

Forwarding requisition and budget

Assurance from Sub- county

24

Detailed findings

Instrument2: health districU LGA level

Important

notes

' By'district

rnanagement team'

(DMT)

is meant: the persons heading up sections or departrnents in the districU

LGA

health service, and who function as a team in running that service. Someone in this team

will

be responsible for communicable disease control programmes in the district/ LGA. The person actually running the

CDTI

progratnme in the district/ LGA is not necessarily a member of the DMT.

'

^{Some of the topics in the} instrument below refer to the functioning of the

DMT,

and others to the functioning of the onchocerciasis control prograrnme at this level.

I

To gather the information you you have to make use of the

following

sources:

Interviews

with:

*

_One or more knowledgeable members of the DMT, or district/

LGA

health

teanl

including:

-

The most senior person (e.g. the chairpersor; or district medical officer).

-

^The person responsible for CDTI at this level.

-

The pharmacist for the health district/ LGA.

-

The transport offrcer for the health district/ LGA.

-

The finance/ budget officer of the districU LGA.

*

_{The senior NGDO manager in the} project, for that district/ LGA.

+

_{The senior} politician in the district/ LGA, who is charged with supervising health matters.

These persons may need to be interviewed separately, since some may find it hard to disagree with others in their presence.

Documents:

*

_The coveftlge reports/ tables for the health district / LGA for the past three years (per sub-district; per village)

*

REMO reports, including lists of all endemic communities/ target populations

*

_The year plans for the health

distict

/ LGA for the past two years:

-

^Inctuding the plans for CDTI (integrated with the main plan, or separate)

- Also

quarterly or monthly plans

(if

these exist)

+

_The

_yeuly

_{budget for the last} three years for the health district/

LGA

(from all sources: the

LGA

itself, higher levels of the government, APOC, the NGDO partrrer)

*

_{Financial control} documents: expenditure authorisation slips, joumals, ledgers etc.

*

_Reports

_of

_{the last round of}

_CDTI

_in the health district/

LGA

*

_Reports

_(if

_these exist) of routine supervision visits by

DMT

members, to the sub-districts

* _All

_{the forms related} to ordering, issuing and control of Mectizan at the health district/

LGA

level

* _All

curricula, training materials, timetables, attendance lists and reports relating to training for CDTI and in-service training in the health district/ LGA over the last two years

* All repcts

of mobilisation/ sensitisation activities in the health district/

LGA

in the past two years.

+ _All

dotrmrentation related to control and use of oflicial transport at thislevel, over the last two years: trip authorisations, fuel allocations, log books etc.

NOTE:

'

^Whenever documentary information is requested, rt is not enough to receive verbal assurances that the documents ezist. They have to be inspected physically.

'

^{As far as} possible information gathered from these sources should be corroborated by information gathered from sources interviews and documents at other levels.

l.l

Check whether the geographical coverage in the health district/ LGA is satisfactory (indicator

of

I

.2

^Check

if all

sub-districts and villages have a satisfactory therapeutic coverage rale (indicator

of

Findinss:

No REMO lists are available but all reports quote 100%

geographical coverage.

All

sub-districts and villages identified by the latest REMO should be under treatment (i.e. the

geographical coverage rate is I 00o% and stable).

This should be confirmed by comparing coverage records with the REMO list of endemic villages

Slightly (many villages/ hamlets

not covered) Is this criterion for sustainability

being

tulfilled?

Highly

(problem

with

nomads

Moderately (a few villages/ hamlets not

covered)

Findines:

Coverage is 14.4"h The therapeutic coverage rate should be:

.

_{65ok or higher}

'

^{stable or} increasing.

Slightly (less than 65olo coverage) Is this criterion

for

sustainability

being

tulfilled?

Fully (>85%

coverage)

Moderately (65- 74%o coverage)

2.1 Check

rf

the year plan

for

^{CDTI appears as part of an overall} written plan

for

^the activities of the health

district/

LGA

(it

may appear under another name, e.g. 'onchocerciasis programme') (indicator

of

and

2.2 ftecktf

the contains

all

the elements needed CDTI to

workwell

2.3

Check

if

theyearly plans were drawn up in a participatory way (the overall district/ LGA

plarl

and the

CDTI of effectiveness

3. Providing

leadership. ^-

.

_.,,,

il-.:.,r*iti:-#'#ffiffi[

3.1

Check

if

the

district/

LGA health management team is

takingfull

responsibility

for

^{CDTI (the} composition

of

CDTI should be integrated into the overall plan (showing that the DMT members consider CDTI to be part of their

yearly

routine, like any other programme) It should not be separate.

Findines:

CDTI activities are planned in a different plan which is included in the year plan of the district

Fully

Highly

Slightly

Not at all Not applicable Is this criterion

for

sustainability

being

tulfilled?

The plan should make

provisionfor all

key elements.

Checklist

of

ksy activities: Mectizan supply;

urgeted training

;

^targeted mobilisation/

sensitisation ; monitoring ^and superttision t

I

Findines:

The plan was not seen but apparently makes provision for all activities

Fully

Moderately

Slightly

Not at

all

Not applicable Is this

srilsri.n for

sustainability

being

firlfilled?

ln both case*planning should involve

all

^relevant

staff

(e.g. sub-district, pharmaceutical stafr) preferably in a vvorl<shop situation.

Findinss:

Plan nrade in session

witlr

supervisors, DMO, DOC, DDOC. NOC ancl Sight Savers. No evidence

of

1tar1 ic ipal ion ol' othcl nrc nrbers o l'

Dl\'ll'

Is this criterion

for

sustainability being tulfilled?

Fully Highly Slightly Not at all Not applicable

Findinss:

I)r'olnrr)l irrrtiatcd

u'iilr

aid

ol'NOC

and

N(ilX).

l)roccss stiltls i.lt hcrirrrrinu

ol'vcar.

lirllou,s sct patte rn.

It should

te

^{the DMT which is} initiating the key CDTI _actit, ities: planning, monitoring/ supen,ision, training, Meclizan ordering/ distribution.

The DMT r hould no longer depend on lhe State/

regional/

iiCDO

leadershtl to carry out CDTL

a

I

Fully Highly Slightly Not at all Not applicable Is this criterion

for

sustainability

being tulfilled?

of this team from to indicator of i and attitude

I

Moderatelj

26

3.2

Check

if

there is evidence of

political

commitment to CDTI in the district/

LGI

(indicator

of

integration and attitude

The senior person (politician/ civil servant) in charge of health matters at district/ LGA level should

loow

about CDTI and appears committed to it.

There should be evidence ofspecific past budgetary allocations and disbursements

for

CDTI, and the

S and DCAO effectively included in

CDTI

activities.

amounts should be

is a budgetary allowance for CDTI, unable to

if

increasing.

Is this criterion for sustainability being tulfilled?

Fully

Moderately Slightly Not at all Not applicable

There should be evidence that each sub-district is visited at least once around the time of distribution.

There should not be unnecessarily many visits - here should be clear justification

for

^{each one.}

Only the sub-district should be routinely visited, not the villages.

rsits may be in response to needs or routine

health unit's visited routinely or for spot checks, all sors meet at the annual gathering and at quarterly

isits to villages for supervision of distribution and and community sensitisation involve DDHS

ADOC, NGDO Is this criterion

for

sustainability being

tulfilled?

Fully Highly Slightly Not at all Not applicable

4.1

Check

if

the relevant person at the LGA/ district level is routinely and

eficiently

supervising the CDTI

the sub-districts _on site ofeffectiveness and

4.2

Check

if

routine data concerning CDTI activities at this level are collected and transmitted entirely within

the

of

Check u/hether there is a routine process of management of problems and successes, which are indicated by the monitoring system (coverage data, visits and reports) (indicator of effectiveness and attitude

4.3

The reporting process should be within the government

ng is via a parallel sytem because requirenrents are activ not rout

not using other resources

in the Is this criterion

for

sustainability being

tulfilled?

Slightly Fully Highly

I

Not at all Not applicable

oppropriate manager should deal with them- Planning must include activities which

will

improve coverage in areas where

it

is unsatisfoctory.

Successes should be noted and reported, and appropri a t e fe ^{e db} ack giv en

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

Checklist of key activities : sensitisation/ mobtlisation ; training; improving ^Mectizan supply ; ^effective/

es.Have additional visits to areas with problems As soon as problems are in this way, the

with most problems

evidence of positive feedback.

evidence of emporverment at lower levels

Is this criterion

for

sustainability being tulfilled?

Fully Highly Not at all Not applicable

The order fc,-ms

for

^{the health district/ LGA exist,}

should be based on the sub-district orders.

The Mectizan should be available

for

the LGAs in time

for

distribution at o time which is convenient to villagers.

There shoulc be no reports ofshortages.

there have been there should be

in lolrn

ol'lttttr

to

N()('

hascrl on ccnsus llstrr e s

rrts ol'tlt'lavs or .rltorlage s.

\o

^rc;'rr

5.1

Check

if

'ient Mectizan is ordered and in Iime indicator of effectiveness fidud€raGly

M_o$!1ateJ51

ISlightly

5.2

Check if Mectizan is being stored and administered within the government system at this level (indicator

of

5.3

Check

if

Mectizan is being distributed appropriately and efectively to the sub-districts (indicator

of

plans to remedy them.

Is this criterion for sustainability being tulfilled?

Moderately Slightly Not at all Not applicable

The Mectban:

.

Should be orderedfrom the nu.t level usingforms supplied by the government.

.

Should be stored in a room made available by the governmerrt at this level - preferably in the same room as the other drugs.

.

_{Should be} controlled within the government system, preferably using the same stock control system as for other drugs.

Findinss:

Orders in fbrm of ^lette r to NOC based on census figures.

Delivered to DOC or pharmacy by project stafl, therefore may nol be stored in pharmacy.

Distributed by district stalf, no evidence of routine stock control being used.

Is this criterion for sustainability being tulfilled?

Fully

Moderately Slightly Not at all Not applicable

The sub-districts should obtain the Mectizan by means of transport supplied and

paidfor

by the government at the district/ LGA level

Preferably the sub-district shouldfetch the Mectizan from ^the district/ LGA level store.

Findines:

Distributed by district staff using vehicles in the district pool, maintained largely by district.

Slighay Not at all Not applicable Is this criterion for sustainability

being tulfilled?

Fully

Moderately

ili,il t1

6.1

Check

if

^{,s done}

of

and

6.2

Check that

taining

is being done at the appropniate level, by the appropriate

staf

(indicator of effrciency and

6.3

Check

if

in- service u'aining

for

CDTI is being integrated with other health programme training at this level Findinss:

Training is performed annually at training sessions for which allowances received.

Directiy involved in annual training of supervisors.

Supervisors other areas of training.

There should be an objective needfor each episode of training:

*

_{There must} be evidence that

staf

to be trained lack laowledge and skills to perform the

job.

a

_Trainbtg to motivate

staffis

not a

suficient

reason

for

^training.

The evaluator must be satisfied that the duration

of

train ing was i ustilied.

I

Fully Highly

Moderately Not at all Not applicable Is rh;s criterion

for

sustainability

being tulfilled?

Staffof thk level should only

tain

the level immediately below it, and nrtl

further

^down.

Findines:

Irocus ol'trainirtg is rlrt strpcrr isors hut irrr olvc<l in

CD[)

trairrinu as u'cll.

Is this criterion for sustainability being tulhlled?

Fully

Moderately Slightly Not at all Not applicable

Findines:

'l rarnirrg lakcs tltc tirrttt ol'solksltrrps altd tlucs lrot fi)rnr parl ol'tlre routinc tra\rring activrtie s irr thc tlistrrct.

Trainingfor CDTI ^{should be} integroted into the yearly

planfor

in-ser,'ice training in the health district/ LGA.

Fully

Highly Moderately

m

Not at all ^{Not applicable} Is this criterion for sustainability

being tulfilledt,

indicatr-rr

of

and effic

Highly

I

I

28

6.4

Check that

staf at

this level continue to be engaged in the sensitisation/ mobilisation ofrelevant

decision makers in there area

of

7.1

Check whether _{the cost} implications of each CDTI related activity (monitoring/ supervision, training/

rnobilisation, Mectizan distribution) are quantified in the yearly budgetfor the heatth district/ LGA

of

7.2

Checkwhether appropriate and adequate amounts are budgeted

for

^the planned CDTI related activities ofeffectiveness and

7

.3

Check whether funds ^{to cover these costs} are increasingly being supplied from district/ ^{LGA resources}

of

1.4

Cteck

if

^{r.z case of a deficit} between estimated costs and the amount provided by the government, ,s made to meet

it

of effectiveness and attitude

Staf

routinely identify situations where decision makers lack information obout/ commitment to CDTI, and undertake activities to inform and persuade these persons.

Staffhave promotional materials at their disposal

for

^{thb purpose}

^(liers,

^{posters etc.).}

Findines:

Hold annual stake holders workshops involve all political decision makers from LC V, LC

IV

and

LV lll

levels.

Apparently inform political staff at other times as we ll, but no evidence.

No appropriate rnaterial seen.

Is this critcrion

for

sustainability being tulfilled?

Fully Highly Slightly Not at all Not applicable

costs

for

^{each CDTI} related activity in the year plan should be clearly spelt out in the budget.

Recarrent and

capital

costs (if any) should be separated in the budget.

The Findines:

CDTI activities within the district budget are now incorporated under PHC outreach activities. Specific activities are not delineated.

A

separate budget

lbr

CDTI activities is used for outside funding.

Is this criterion

for

sustainability being tulfilled?

Fully Highly Slightly Not at all Not applicable

The amounts budgeted should be neither excessive nor too small - managers should be able to

justifi

the need

for

^{each amount,}

ⁱⁿ

^{relation to:}

.

The outcoma

resultingfrom

the previous year's CDTI

upenditure

'

^{The cost of}

^similar

activities

for

^otlter programmes.

Findines:

Amounts budgeted are hidden in the budget at each

level.

No specific plan seen for amount budgeted.

Is this criterion

for

sustainability being tulfilled?

Fully Moderately Slightly Not at all Not applicable

t

The relative contributions of the

distict/

LGA and other

prtnat

should be clearly spelt out.

'

^The

^proportbn

^{provided by the}

fficial

^health

service should be the major one by now.

'

^This proportion offunds should be increasing yeqrty.

Findines:

Because of the nature of the budgeting,

it

is impossible to determine how much money is allocated for CDTI activities. Allocations are made on the basis of good

will

and perceived need overall.

Is this criterion

for

sustainability being tulfiIled?

Fully Highly Moderately Not at all Not applicable

'

Manogement should be aware of the size of the shonfall, and have specific and realistic plans to bidge it.

'

^{If it is} planned that non-government sources

of

fundinz are zo be used after APOC funding ^ends, wrinet commitment

for

this should have been obtained at the highest level in these donor organisations (e.g. a new Memorandum o.f Undersnnding).

Findines:

Short

Iall

lras been taken u1t bv

Al,(X'arrtj N(il)().

I)oliticians speak ol'yrossibilitv to takc up sltortl'ull ar t'rrtl

ol'AI'}O('Iirnding.

hut lto cvi(lence thus lhr.

No Ilrrn conrrnilntcnl li'onr anv outsitle lirnrle r to car r v

c ()sl s.

Is this cn'<rion fr-'r ^s ustainabi li ty being _tulrilled?

Fully Highly Moderately Not at all Not applicable rModpratb.lY

iHiglily

7.5

Check whether CDTI funds in ^{the heqlth} district/ LGA budget are

eficiently

managed (indicator

of

effectiveness and

8.1

^Check

if

there is

suficient

transport

for

^{necessary visils to the} sub-district level

for

^{CDTI related}

activities

of

8.2

Check

rf

trips/ journeys undertaken

for

routine CDTI purposes are inlegrated with those made

for

other

or of

and

8.3

Check

if

the made available CDTI is

of

9. Human resources '

^r.

.',., :t,,,',*?i*l$S$ffi#

9.1

Check z'hether the health district/ LGA team is skilled and htov,ledgeable, regarding the CDTI

in

its area tion indicator of effectiveness

Findines:

Spending in the district is based on integrated funds. No specific budget itenrs

The budget holder should use a control system with the following ^elements:

:

Approval ofeach item ofetpenditure

.

Allocation of expenditure against specific budget headings

.

Regular calculation ofresidual amounts under budget headings.

Is this criterion for sustainability beins tulfiUed?

Fully

Highly Moderately Slightly Not at

all

There should be no reports

offailure

to undertake necessary CDTI qctivities at sub-district level, due to transport not being available or afordable.

Transport provided by the central level should no longer be

usedfor

routine CDTI activities at

LGA/

district level.

Checklis t of activities : monitoring/ supervisio n,

trainins/ mobilis ation, Mectizan distribution

I Findines:

No reports of laih.rles due to insufficient transport.

Transporl pool is integrated although there is a motor cycle provided by APOC, all are allocated to individuals not pro.jecls.

Is this criterion for sustainability being fulfilled?

Fully

Moderately Slightly Not at all Not applicable

Where

CDTI

is involved. trips should be authorised/

undertaken

for

more than one purpose.

Means of

rransport

provided by specific

programmes should be usedfor other programmes as well.

ChecHist

of

activities : monitoring/ supervision, trainins/ mobilisation, ^Mectizan

distibution

Findinss:

Most Onchocerciasis activities involve specific trips

All

vc'hicles poolcd.

Is this criterion

for

sustainability being

tulfilled?

Fully

Moderately Slightly Not at all Not applicable

uuLc,

a

I

Trips

madefor

CDTI purposes should be properly authorised

in writing bylhe

^relevant

fficial.

Each

trip undertakenfor

CDTI purposes should be recorded

in

^a log book.

Findines:

At this ^level there is no control of vehicle activity

Is this criterion for sustainability being tulfrlled?

Fully

Highly Moderately Slightly Not at

all

LGA/ health

dutrict

team members should have enough knowledge and

skill

to undertake

all

the key CDTI activities themt.elves, without help :

'

^Planning

'

^Training nnd sensilisation/ mobilisation

'

^Mectizan

r,rdering/

distribution

'

MonitorinT/super-vision.

Findinss:

-T'hc ()rrclrott'rcrrsi: slall'at

tlistrict lcrcl

appcar to bc u'cl I lrairtt'<l urttl ^k ntrrvlcrlccablc

Moderately Slightly Not at all Not applicable

I

Is this criterion

for

sustainability Highly tulfilled?

:I,Ii,Bhh

30

9.2

Check whether personnel at the heahh district/ LGA level is stable,and whetherprovision is made

'for

on

CDTI

skills when a trained moves ofeffectiveness

Staf

shoulel remain in one

postfor

at leastfive years.

There should be immediate training (in CDTI)

of

new, unskilled district/ LGA staffmembers who have CDTIrespory!ibilities.

Findines:

Stability of staff is not guaranteed although there is more than one person within the district able to manage CDTI activities.

NOC staff undertake training of staffat this level.

Is ttris criterion for sustainability beigg tulfilled?

Fully ^{;.. ..} Moderately Slightly Not at all Not applicable