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Evaluation of the Sustainability of the Metekel Zone CDTI Project, Ethiopia May/June, 2009

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Evaluation of the Sustainability of the Metekel Zone CDTI Project, Ethiopia May/June, 2009 World Health Organization African Programme for Onchocerciasis Control Evaluation of the Sustainability of the Metekel Zone CDTI Project, Ethiopia May/June, 2009 Dr. Johnson Ngorok, Team Leader Dr. Margaret K. Akogun Dr. Tekola Endeshaw Mr. Abraraw Tesfaye Mr. Birhanu Melak Mr. Tamrat Belete Table of Contents Page List of Abbreviations………………………………………………………………….......3 Acknowledgements…………….……………………………….……………………..….4 Executive Summary…………..……………………….……………………………...…..5 1.0 Introduction…………………………………………………………………………….7 2.0 Methodology…………………………………….……………………………………..8 2.1 Sampling……………..…………………………………………………… 8 2.2 Protocol………………….......................................……………………..9 2.3 Performance of the Instrument………………………………………….10 2.4 Limitations…………………………………………………………………11 2.5 Team Composition………..………………………………………………12 3.0 Findings and Recommendations………………………………………………………………………...14 3.1 Zonal Level………………………………………….……………………………..14 3.2 District Level………………………………………………………….…….23 3.3 Front Line Health Facility Level………………………………………………………………………....31 3.4 Community Level……………………………………………………………….………...38 4. Conclusions………………………………………………………………………….…..44 4.1 Grading the Overall Sustainability of the Project……………………………………………………………………….44 5.0 Feedback/sustainability plan development workshop………………………….49 6.0 Advocacy visits and debriefing……………………………………………………...51 Appendices: Appendix 1: Evaluation Time Table Appendix 2: Programme for Feedback/Sustainability Planning Workshop Appendix 3: SWOT Analysis Appendix 4: List of Respondents Appendix 5: List of Documents Reviewed Appendix 6: Sustainability Plans. 2 List of Abbreviations APOC African Programme for Onchocerciasis Control CDD Community Directed Distributor (of ivermectin) CDTI Community Directed Treatment with ivermectin EPI Expanded Program on Immunization FLHF Front Line Health Facility HSAM Health Education/Sensitisation/Advocacy/Mobilization IEC Information, Education, Communication MOH Ministry of Health NGDO Non-Governmental Development Organization NOCP National Onchocerciasis Control Program NOTF National Onchocerciasis Task Force REMO Rapid Epidemiological Mapping of Onchocerciasis SWOT Strengths, Weaknesses, Opportunities, and Threats TCR Therapeutic Coverage Rate ToT Training of Trainers WHO World Health Organization ZOTF Zonal Onchocerciasis Task Force ZHDH Zonal Health Desk Head 3 Acknowledgements The Evaluation Team for Metekel Zone CDTI would like to thank APOC Management for the opportunity to be of service to the people of Ethiopia. The team appreciates the logistical support and administrative arrangements that enabled the evaluation be conducted without much difficulty. In particular, the team would like to acknowledge the following persons and institutions for their help: . The Director and the staff of the African Programme for Onchocerciasis Control (APOC) in Ouagadougou. WHO Country Office, Ethiopia, in particular Mr Tamrat Belete for in-country logistical arrangements. The Carter Centre Country Representative for stepping in to take up the role of the MoH which was in the midst of a restructuring exercise. The Metekel Zone officials (Zonal Administrator, Zonal Oncho Coordinator and the Head of the Health Desk) for the valuable support provided. The District Health Teams of Pawi and Dangur districts for the arrangements and making available the documents required for review. The representatives of Mandura and Guba districts for participating in the feedback and sustainability planning workshop. The Heads of the six FLHF visited for participation and mobilising the communities for the evaluation. The community leaders, community directed distributors and community members of the twelve communities visited. The scout, Mr. Abraraw Tesfaye, for planning the evaluation. 4 partner to continue providing financial support reinforces the sustainability of the project project the of sustainability the reinforces support financial providing to partner continue programmes were conducted in an integrated manner. The commitment of the NGDO sources were made available for commitment for oncho oncho was control not clearly when spelt activities good out, basis funds for for from sustainability of government the the and programme. other different Although government Resources; direct funding manner. integrated an in supervision support out carried staff health and programmes the five year strategic plans; transport programmes. Oncho control and activities were included in both the annual operational and materials were shared across different Integration; following the found out team evaluation the evaluation”, of “Aspects the assessing “lens” for a as instruments the Using below. Overall, the project performance was rated for each indicator per level as in the The table evaluation was carried out at four levels; zonal, district, FLHF and community. districts. endemic four the in implemented being is 2004 and in Metekel in initiated was districts, four i.e. Dangur, Guba, Mandura and Pawi are oncho endemic. CDTI project seven woredas (districts) and 125 kebeles (village/group Benshangul Gumuz of People’s Regional State. villages). The zone isOf administratively divided into the seven Metekel EXECUTIVE SUMMARY Overall average Comm FLHF District Zone zone, zone, located in the north-western part of Ethiopia, is one of the three zones in 3.3 2.8 2.7 3.3 3.3 3.2 3.5 3.3 3.2 3.0 Planning The The integrated use of vehicles, equipment and other materials provide a There was strong integration of CDTI activities into the overall health 3.0 Leadership 2.8 Monitoring & Supervision 3.5 3.5 2.3 3.5 3.8 3.2 3.3 Mectizan® 3.2 Training HSAM 5 - 3.7 3.8 3.7 Integrated Activities - 2.3 2.7 2.5 3.8 3.0 2.8 2.3 4.0 4.0 3.38 3.21 Transport 3.7 3.5 2.0 3.0 2.97 HR 2.2 Finance 4.0 Coverage 3.20 3.1 Average Efficiency; Efficiency of the use of resources was achieved by integration, conducting training sessions in cost free venues and limiting the duration of trainings. However, supervision, trainings and HSAM activities were not targeted; they were carried out routinely every year. These potentially waste limited resources. Simplicity: Simplicity was demonstrated in several ways, for example; delivery of mectizan from FMOH to the community level using existing structures and procedures, delivery of reports by CDDs to the FLHF and onwards as part of routine activities and without using extra resources; trainings being carried out in premises owned either by the government or the community. Attitude of staff: The health staff and the CDD expressed great interest and willingness to continue carrying out CDTI activities after APOC project phases out. The health staff considered CDTI as part of their routine duties. For the CDDs, this was despite the fact that they were not receiving financial or material support from their communities. Community Ownership: Although the involvement of CDDs and community supervisors was commendable and promoted sustainability, the community leadership and the rest of the community members did not show active involvement and ownership of the programme. Effectiveness: Full geographical coverage and therapeutic coverage rate of over 65% were achieved during the past three years. Therefore on the basis of the following: Aspects; five of the aspects were helping while two were partially helping the sustainability of the project. Critical elements, All the five critical elements for sustainability were present. Quantitative; The average score is far greater than 2.5 the evaluation team concluded that Metekel Zone CDTI project, in spite of some imperfections, meets the description of being “FULLY SUSTAINABLE” 6 1.0 INTRODUCTION Project location Metekel zone, located in the north-western part of Ethiopia, is one of the three zones in Benshangul Gumuz People’s Regional State. The zone is administratively divided into seven woredas (districts) and 125 kebeles (village/group of villages) and has a total surface area of 259,932 km land mass. The climate of the zone is typically tropical with two distinct seasons i.e. the rainy and cool season from June to October and the hot and dry season from November to May with temperatures ranging from 25 to 42 Degrees Celsius. The topography of land consists of low land (82%), semi highland (10%) and highland (10%). The economic mainstay of the inhabitants is agriculture involving both crop farming and the herding of animals. Gilgel-Beles is the zonal capital and the seat of the zonal administration. Onchocerciasis Control in Metekel Before the initiation of the CDTI project, oncho treatment in Metekel was clinic based. REMO survey conducted prior to initiating the CDTI project revealed that onchocerciasis was endemic in four woredas of Benshangul Gumuz People’s Regional State; Dangur, Guba, Mandura and Pawi. Apart from Pawi district which was found to be oncho hyperendemic, all the other three districts were oncho mesoendemic. CDTI project was consequently initiated in Metekel by APOC in 2004 in the four districts. Of the four, three of them (Dangur, Guba and Mandura) are located in Metekel zone while Pawi is a special woreda which also has the status of a zone. The four districts have a total of 145 villages The health infrastructure in Metekel CDTI project area consists of 1 zonal hospital, 4 health centres, 19 health stations (18 government and one NGO) and 11 government health posts. The Carter Centre is the NGDO partner. 7 2.0 METHODOLOGY 2.1 Sampling Sampling was carried out by the scout using primary and secondary criteria in line with APOC
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