World Health Organisation African Programme for Onchocerciasis Control Mid-term assessment of the sustainability of the TUKUYU FOCUS CDTI project. 15th –28th September 2003 Dr. Sebastian Olikira Baine (Team leader) Dr. Emanuel Emukah Mr. Geoffrey Tukahebwa Dr. Wade Kabuka Dr. Rehma Maggid Mr. Karoli Malley 1 Index Page Abbreviations/ acronyms and acknowledgements 3 Executive summary 4 Introduction and methodology 7 1. Introduction 7 2. Methodology 7 Findings and recommendations 12 1. Regional level 12 2. District level 20 3. First Line Health Facility Level 26 4. Village level 31 5. Overall self-sustainability grading for the project 36 Appendix I: Time table for feedback/planning workshop activities 38 Appendix II: List of attendance at advocacy and feedback/planning workshop 40 Appendix III: Report on the advocacy and feedback/planning workshop 41 Appendix IV: TFC Sustainability plans 43 Appendix V: CDTI Sustainability plans – Kyela district 49 Appendix VI: CDTI Sustainability plans – Rungwe district 56 Appendix VII: List of people interviewed 61 Appendix IX: Instruments used in the evaluation of TFC project 64 2 Abbreviations/ acronyms APOC African Programme for Onchocerciasis Control CDA Community Development Assistant CDD Community Directed Distributor (of ivermectin) CDTI Community Directed Treatment with Ivermectin DC District commissioner DOC District Onchocerciasis Coordinator DOTs District Onchocerciasis Teams MSD Medical Stores Department of Ministry of Health TFC Tukuyu Focus CDTI FLHF First Line Health Facility HMIS health management information system HQ headquarters HSAM health education/ sensitisation/ advocacy/ motivation NGDO Non-Governmental Development Organisation NOC National Onchocerciasis Coordinator NOCP National Onchocerciasis Control Programme NOCT National Onchocerciasis Control Team NOTF National Onchocerciasis Task Force PC Project Coordinator PHC Primary Health Care RPC Regional/Project coordinator. REA Rapid Epidemiological Assessment REMO Rapid Epidemiological Mapping of Onchocerciasis SSI Sight Savers International 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 A. Sékétéli, Dr Uche Amazigo, Mr Aholou, Victoria Matovu, and all the support staff. Staff of NOCP/ MOH in Dar Es Salaam, for undertaking all the arrangements: Dr. Grace Saguti (NOC), Mr Oscar Kaitaba (Deputy NOC) and all the support staff.. Political and traditional leaders, health workers and community members in the Tuyuku focus CDTI project (i.e. Kyela and Rungwe districts) for their contributions. 3 Executive summary The Tukuyu Focus for CDTI (TFC) Project in Mbeya Region of Tanzania is made up of the districts of Kyela and Rungwe, and one FLHF located in Ilege district. APOC funding for the TFC project started from 2000 to date. All projects funded by APOC are evaluated in the third and fifth years for the sustainability and it is against this background that the TFC project has been evaluated. The evaluation of the TFC project used the instrument developed by APOC to measure the sustainability of a CDTI project (Appendix…..). This instrument has been pre-tested in the field and revised. The instrument was used to assess sustainability of CDTI activities at four levels of operation i.e. Region, District, FLHF and Village levels. Purposive sampling of the study population took into consideration two criteria that included therapeutic and geographical coverage as a measure of impact, performance, and sustainability of the CDTI activities; and, endemicity (hyper- and meso- endemic areas) to ensure a representative sample of TFC project area. The sources of information were verbal reports from persons interviewed, and from documentary evidence. Advocacy visits were paid to relevant persons at the regional and district levels (e.g. District Executive Secretary, District Administrative Officer, etc). Planning/feedback workshops were conducted for the relevant officials at the regional and district levels (as shown in the appendices….). During these planning workshops efforts were made to develop sustainability plans. Finally, MOH and WHO officials were debriefed at the end of the missions. The key findings of the evaluation exercise are presented in the following sections: Planning CDTI activities are integrated into the overall comprehensive health service plan for the period beginning 2002. The plans vary from year to year according to specific needs of each year as more activities were introduced. A participatory approach is applied in the routine planning for the TFC project. All partners are actively involved, clear about their own roles, and those of the others. The regional level is not involved in the planning process but is fully informed, as it is responsible for the approval of plans before they are funded. The project management had made plans for the period ranging from 2002 to 2004 indicating needs, funding required identified resource gaps but strategies to cut expenditure and strategies to find dependable sources of resources were not indicated. There is no evidence that this plan is being successfully implemented. The FLHF levels had no detailed plans but locally developed timetables which are developed in a participatory manner and integrated with other health activities. There are functional committees at the community levels which make CDTI plans. Every sub-village decides on the mode, time and place of distribution. Leadership and ownership In each District, there are DOT members, who are responsible for implementation of CDTI. They are under the DMO who is the prime initiator of all integrated health activities. DOT members initiate CDTI activities based on the plan but occasionally depended on the Project Coordinator before action especially when APOC funds are not available. The level of political commitment of district leadership appeared satisfactory, although they have presently contributed little. The in-charges of FLHFs are the focal persons who initiate CDTI activities. These in-charges plan together with other FLHF staffs, village leaders, PHC committee, and the ward leaders all health activities including CDTI activities. 4 In all communities, local leadership through committees support CDTI activities especially distribution and solving associated problems. The community appreciates the importance of CDTI, and the community is in the advanced stages of owning CDTI activities. Monitoring/supervision Monitoring/supervision are done according to the recommended approach by APOC. Each level is empowered to supervise CDTI activities at their own level, as well as levels further down. Monitoring/supervision of CDTI activities are integrated with that of other health programmes. Attempts are made to solve the identified problems and failure to do so; they are referred upwards through the established chain of command. Successes are also noted, reported and appropriate feedback given in various forms. These provide incentives to improve performance. Training and HSAM The Project Coordinator trains the DOTs who are then empowered to train the FLHF in-charges who also train CDDs. Training for 2-3 days is usually done to update those involved n CDTI activities and this is perceived to be adequate. They are trained at one of the district headquarters, which reduces the costs of training significantly. HSAM activities are properly planned and carried out where there is an objective need for them. Decision makers have been approached and persuaded them to support CDTI activities in various aspects. HSAM activities have been effective e.g. support for CDTI activities has obtained from the district councils. Mectizan procurement and distribution The process of Mectizan procurement and distribution is properly done. A formula of total population x 2.2 was used and reported to facilitate acquiring adequate drugs. Distribution of mectizan at the community level is done at focal points (usually FLFT) that are close to the communities. There are by-laws that encourage swallowing of mectizan. Those who refuse to swallow mectizan are made to pay a fine of Tshs. 500 and then +swallow it in the presence of community members. Financial resources The costs for each CDTI activity were not segregated in the annual budget. There was no evidence of cost reduction/ containment strategies. The relative budgetary contributions of the government, APOC and SSI are clearly spelt out. APOC has been contributing most followed by the SSI (NGDO partner) and least contribution is from the government. However, central government contribution has increased as compared to the previous year. Government funding for CDTI activities is not half of the expenses; yet, the project is its fourth year. There is a budget control system. There are no contributions made by the FLHF and community. Transport and other material resources The project has one three years old Toyota hilux double cabin provided by APOC and two motorcycles (provided by APOC and SSI). They are in good working conditions. The project coordination office has: desktop computer photocopier and fax machine (non-functional) provided by APOC, and a laptop computer and printer provided by SSI. The project also has training/ HSAM material; a booklet, leaflets and videocassettes provided by APOC and SSI provided T-shirts used in mass mobilisation. The use of the vehicle was properly controlled by the District Executive