World Health Organisation African Programme for Onchocerciasis Control Mid-term assessment of the sustainability of the Malawi 'Extension' CDTI project: Blantyr€, Chikwawa, Chiradzulu, Mulanje and Phalombe districts November 2002 Sebastian Baine ,--*--..F.*n'e*&qi ! Samuel Mugisha il Spy Munthali 2 [ l!lit i:iri;, ., Detlef Prozesky .t rI ., *....",""..'"=l Index Page Abbreviations/ acronyms and acknowledgements J Executive summary 4 Introduction and methodology 6 1. Introduction 6 2. Methodology 9 Findin gs and recommendations 13 1. National level 13 2. District level 20 3. Health centre catchment area level 26 4. Village level 30 5. Overall self-sustainability grading for the project JJ 6. A new insight 34 Advocacy activities and feedback/ planning workshops 35 l. Advocacy activities 35 2. Feedback/planning workshops 36 Appendix 1 Report on meeting with WR 37 Appendix 2 The district level feedback/ planning workshop 38 Appendix 3 District sustainability plans 40 Appendix 4 Suggested changes to the 'Sustainability' instrument 42 Appendix 5 Timetable of the evaluation visit 44 .) Abbreviations/ acronyms APOC African Programme for Onchocerciasis Control CDA community development assistant CDD community directed distributor (of ivermectin) CDTI community directed treatment with ivermectin CHAM Christian Hospital Association of Malawi CHSU Community Health Sciences Unit DC district commissioner DEHO distnct environmental health officer DHO district health officer DIP di strict implementation plan DOC district onchocerciasis coordinator EHT environmental health team FLHF first line health facility HC health centre HMIS health management information system HQ headquarters HSA health surveillance assistant HSAM health education/ sensitisation/ advocacy/ motivation IEF International Eye Foundation K Malawian kwacha MoHP Ministry of Health and Population NGDO non-governmental development organisation NOC national onchocerciasis ooordinator NOCP National Onchocerciasis Control Programme NOCT national onchocerciasis control team NOTF National Onchocerciasis Task Force REA rapid epidemiological assessment REMO rapid epidemiological mapping of onchocerciasis TA Traditional Authority wHo World Health Organisation 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/ MoHP in Blantyre, for undertaking all the affangements: Mr Tambala (NOC), Mr Sitima (Deputy NOC), Mr Mkhoma (training and monitoring supervisor), Mr Kwizombe (accountant), Ms Jere (secretary), Messrs Kamwana and Kaliati (drivers) ' Political and traditional leaders, health workers and community members in the Blantyre, Chikwawa, Chiradzulu, Mulanje and Phalombe districts. 3 Executive summary The African Programme for Onchocerciasis Control (APOC) has been supporting the Malawi 'Extension' CDTI (community directed treatment with ivermectin) project for the past three years. At a meeting of national onchocerciasis task forces (NOTFs) in Abuja in June 2002,it was decided that the sustainability of the projects which APOC supports should henceforth also be assessed midway through the funding period; the present evaluation is the first such evaluation. It was carried by a team of four evaluators - two from Uganda and one each from Malawi and South Africa. The evaluation followed on an evaluation in May 2OO2 of the first phase of the Malawi project (covenng the Thyolo and Mwanza districts), which found that there were considerable problems with sustainability after five years of funding. This second evaluation was carried out over a period of twelve days. Information was collected by document study, interview and observation, at sampled sites at four levels of the health service: national, district, first line health facility (FLHF) and village. The newly revised set of 'sustainability' instruments was used and found to be suitable for the Year 3 evaluation (although a few refinements are suggested). The following are the principal findings of the evaluation: . Coverage: The rate of implementation of the project has been slower than was originally planned. Mectizan has not yet been distributed in Chikwawa district and part of Blantyre district: a few CDDs (community directed distnbutors) remain to be trained, and many others await the Mectizan which finally arrived during the evaluation. Training has yet to commence in Chiradzulu district (the NOTF first wishes to clarify the endemicity situation there). Therapeutic coverage is lower than expected: several possible reasons for this state of affairs were uncovered, but more detailed research is needed to clarify them. Planning: Planning at national level is thorough, but the National Onchocerciasis Control Programme (NOCP) is not yet included in the yearly cycle of planning, with equivalent programmes, at the level of the Community Health Sciences Unit (CHSU) in Lilongwe. Similarly CDTI was only included in the district implementation plan (DIP) in one of the five districts. There is a strong and successful tradition of integrated yearly and monthly planning at the FLHF level, in which CDTI is present to varying degrees. The national onchocercasis co-ordinator (NOC) has clear ideas about obtaining resources for CDTI after APOC support is withdrawn, but these have not yet been written down in a systematic plan. Supervision and monitoring: Data from the village level move effectively to the national level, but in some cases the district health management team (DHMT) does not get to see it. There is an excellent system of review meetings after each distribution. Supervision as it is being conducted at present is not as efficient as it could be (it is being done routinely rather than being targeted, and a team of two is not always needed), nor as effective (NOCP team members are not really aware of the reasons for the low coverage rates, and although there are checklists available supervising staff repon not using them). There is almost certainly a problem with the way in which rates are being calculated at present, which needs to be rectified. There are at present no indicators for CDTI in the national health management information system (HMIS), but the relevant manager at Headquarters (HQ) level at the Ministry of Health and Population (Mo[IP) in Lilongwe would welcome suggestions. I and HSAM rh motivati Training targets are being exceeded in terms of numbers - this ts due to an under-estimation of the numbers of separate villages (and therefore CDDs) in the original project submission. In -1 general training is conducted efficiently, but there are no specific courses available for staff at the national level. Excellent HSAM materials are available but are in short supply, largely due to their expense. Much advocacy work has been done. but some traditional authorities (TAs) and district commissioners (DCs) have not yet been approached. Mectizan supply: This is working well, and takes place entirely within the government system. Integration of support activities: These are highly integrated at the district and FLHF levels - this is one of the great strengths of the Malawi programme. Available transport and other resources are routinely shared between programmes, and workers perceive themselves to be a team of multi-skilled professionals. Finances/ fundingl transport and equipment: The government's contribution is at present limited almost entirely to salaries - everything else is funded by APOC (transport, equipment, stationery, allowances, HSAM matenal). There is a small budget for onchocerciasis control in the WHO country representative's (WR's) biennial budget, but the methods and extent of government funding post-APOC remain to be spelt out. There is no doubt though that some funding will be available - MoHP has created posts for the programme, and in the local system this implies a commitment to providing the wherewithal for the programme to function. The use of transport is in general well controlled. Human resources: One of the great strengths of the Malawi programme is the fact that there are MoFIP employees at village level - the health surveillance assistants (HSAs) - charged with implementing approved preventive and promotive programmes. These persons were found to be knowledgeable, reasonably committed and stable. They are supported by specific staff at FLHF and district level. In some instances however too few CDDs are being trained. The overall judgement of the team is that the Malawi 'Extension' CDTI project is not far from being sustainable. The health system in Malawi is functioning at a level which is strong enough to carry CDTI; it is highly integrated; and it reaches effectively right to village level. There is still time to achieve maximal integration of the project into the MoHP system at all levels, and there is a reasonable assurance that MoHP will be able to supply the resources the programme needs to function when APOC withdraws. 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 : . Entering the Government planning and HMIS systems more fully, and drawing up a detailed 'Sustainability plan' based on current ideas. Bringing Chiradzulu district into the project immediately, and completing the necessary training in Blantyre district. Researching the reasons for low