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Ethiopia Janu Aryleebru Ùry, 2006 \ilorld Health Organisation African Programme for Onchocerciasis Control () Evaluation of the Sustainability of the North Gondar CDTI Project, Ethiopia Janu arylEebru ùry, 2006 Mary Alleman, Team Leader Uwem Ekpo Ben Male David Sang Abraraw Tesfaye ht, - i t ü i I Ita Ii: \-^ {)rr-t I I ;* o.. f* ç* I I 7 lrÂRS 2006 Contents Page Table of Contents .............,,...2 Abbreviations/Acronyms.............. ...........3 Acknowledgements.... .............4 Executive Summary.. ..............s 1. Introduction........... ...........10 2. Methodology.......... ...........12 2.1 Particular Circumstances. ..... .....12 2.2 Levels and Instruments....... .......12 2.3 Sampling... .........12 2.4 Protocol..... ......13 2.5 Team Composition. .....14 2.6 Advocacy Visits and Feedback/Planning Workshop... ........15 3. Evaluation Findings and Recommendations ......16 3.1 Regional Level.... ........16 3.2 ZonalLevel ............24 3.3 Woreda Level. .........31 3.4 Front Line Health Facility Level.... .........3g 3.5 Community Level.... ......43 4. Conclusions............ ..........50 4.1 Gradingthe Overall Sustainability of theNorthGondarCDTI Project....... ...........50 Annex 1: Persons Interviewed/Courtesy Visits........ ..................54 Annex 2: Tentative Timetable for Evaluation Activities.............. ................56 Annex 3: Feedback and S-Year Sustainability Planning Workshop Agenda..... ................59 Annex 4: Summary of Feedback and S-Year Sustainability Planning Workshop. ..............62 Annex 5: Participants at Feedback and S-Year Sustainability Planning \ilorkshop. ...........69 Abbreviations/Acronyms APOC African hogramme for Onchocerciasis Control ' CDD Community Directed Distributor (of Ivermectin) CDTI Community Directed Treatment with Ivermectin . EPI Expanded Progtam on Immunization FLHF Front Line Health Facility HIV/AIDS Humanlmmunodeficiency Virus/Acquired Immunodeficiency Syndrome HQ Headquarters HSAM Health Education/Sensitisation/AdvocacyÀ,Iobilization IEC Information, Education, Communication KOTF Kebele Onchocerciasis Task Force MOH Ministry of Health NGDO Non-Governmental Development Organisation r- NOCP National Onchocerciasis Control Program NOTF National Onchocerciasis Task Force PHC Primary Health Care REMO Rapid Epidemiological Mapping of Onchocerciasis SV/OT Strengths, Weaknesses, Opportunities, and Threats TB Tuberculosis TCR Therapeutic Coverage Rate ToT Training of Trainers WHO World Health Organization WOTF Woreda Onchocerciasis Task Force ZHDH ZonalHealth Desk Head Acknowledgements The evaluation team would like to thank the following persons for their help in carrying out this evaluation: ' The staffat the headquarters of APOC in Ouagadougou for their role in organizing the team and logistics for the mission and for providing the necessary budget. ' The staff at WHO-HQ (Geneva) and the WHO offices in Kenya, Nigeriq and Uganda for facilitating logistics for the team members. ' The staffat the WHO offrce in Addis Ababa, Ethiopia, particularly Mr. Tatek Mekonnen, for the role played in organizing the local logistics for the evaluation, for facilitating the logistics for local team members, and for participating in the feedback and planning workshop. The NOTFÀt[inistry of Health in Addis Ababq particularly Drs. Daddi Jima and Alemayehu Seifu, for the role played in briefing the team on the organization ofthe Ethiopian health services prior to departure for the evaluation, for attending the debriefing after the evaluation (via representation), and for providing the team with the services of Mr. Taddese Kebede, a Ministry driver for the duration of the evaluation. ' The Carter Center-Ethiopia, particularly Mr. Teshome Gebre, for his participation in the evaluation and the post-evaluation debriefing and for providing the team with the services of Mr. Melaku Zewde, a Carter Center driver for the duration of the evaluation. ' Mr. Abraraw Tesfaye, the evaluation team scout, for all of the work prior to the team's arrival to "pave the way" for the evaluation and for serving as a translator. Staff at the Regional Health Bureau, particularly Dr. Endale Engid4 Deputy Bureau Head, Mr. Kassa Tiruneh, Head Disease Prevention and Control, Mr. Tadesse Alamir, Team Leader Malaria and Other Vector-borne Diseases Prevention and Control, and Mr. Melesew Chanyalew, CDTI focal person, for welcoming us to the Amhara National Regional State and for their participation in the evaluation and in the feedback and planning workshop. Staff at the Zonal Health Desk, particularly Mr. Gashaw Tesfahun, Head Zonal Health Desk, Mr. Birhanu Melak, CDTI focal person, Mr. Yeshu Tilahun, Offrcer, Zonal Finance and Planning Department, and Mr. Tsegaye Alebel, former CDTI focal person and former Head of Zonal Health Desk, for their role in advising the team with regard to the local situation, their assistance in choosing the woredas and health centers/posts to include in the evaluation, their participation in the evaluation and the feedback and planning workshop, and for use of their offices and equipment during the evaluation. Staff at the Metema and Tacharmacheho Woreda Health Desks, particularly Mr. Nega Norahun, Head of Metema Vy'oreda Health Desk, Mr. Sitotaw Begashaw, Metema CDTI focal person, Mr. Melkamu Wale, Head of Tacharmacheho Woreda Health Desk, and Mr. Tewodros Asmamaw, Tacharmacheho Woreda CDTI focal person, for warmly welcoming the sub-teams to the woredas, their role as translators and field guides, their efforts in finding additional field guides and translators, and their participation in the evaluation and the feedback and planning workshop Mr. Belete Getnet and Mr. Yohannes who volunteered as field guides/translators in Tacharmacheho woreda. Health facility staff, administrative and traditional leaders, and community members visited in association with Asherie, Masero, Sanja, Meka, Metema Yohannes, and Shinfa Health Posts/Centers. The management/staff at the Nile Hotel for providing the venue for the feedback and planning workshop. Executive Summary The North Gondar CDTI project is one of nine in Ethiopia. It is located in the northwest of the country in the Amhara National Regional State and consists of three woredas Metem4 Quara, and Tacharmacheho. There are 963 communities in the current project area with a combined total population of 234,054 people, based on CDTI census data from 2005. The North Gondar CDTI project was approved by APOC in 2002. The supporting NGDO for the project is The Carter Center. The first round of CDTI occurred in 2003 in the woredas of Metema and Quara. 1n2004, and since, implementation of CDTI has occurred in all three project woredas. The sustainability evaluation described in this report was conducted in JanuaryÆebruary 2006 shortly after the completion of the project's third year of CDTI. Using the latest version (September 2004) of the evaluation instruments, data were collected from the national (NGDO partner), regional, zonal, woreda, FLHF, and community levels. Only two of the three project woredas (Metema and Tacharmacheho) could be included in the evaluation due to problems of inaccessibility and some rumors of insecurity in Quara woreda. Upon completion of the evaluation, a Feedback and S-Year Sustainability Planning workshop was held at the zonal level and was attended by project staff from the region (representing itself and the NOTF), zone, and all three project woredas, in addition to the APOC administrator based at the WHO office in Addis Ababa. During this workshop, the evaluation results were presented and discussed, and draft S-Year sustainability plans were prepared. EVALUATION FINDINGS: Sustrinsbilitÿ of thc Norlù Gonder CDTI ProjccÈOvcrall Grading 3.0 ÿ r.' .:! I z.o u b 1.5 a t.0 .§ -td ".'"t "/ """§ ""-C ""'i."",C ."§ -§ a"t" group ofindicators PLANNING: At the regional and zonal levels, there are annual work plans which integrate CDTI into overall communicable disease control activities; these work plans contain an overview of CDTI activities but not specific details since planning for and implementation of key CDTI activities occurs at the woreda level. Planning at the woredas occurs with some input from FLHF staff and communities. CDTI timetables/work plans containing key CDTI activities are finalized at the woredas and then sent to the FLHFs to "kick start" activities each year. FLHFs do not initiate planning on their own. Prior to this evaluation, there had been no formal planning for the sustainability of CDTI in the post-APOC period. CDDs and community members, in collaboration with FLHF stafl decide on the distribution strategy (house to house, central point, etc.) and times of day for distribution; however it appeared that the time of year during which treatment occurs (dry season), while agreeable to the communities interviewed, may have been influenced by project management. In many communities, CDDs carry out census well before Mectizan@ distribution, and because of high population mobility in portions of the project area, original census figures do not always reflect the population present during treatment, potentially leading to inaccurate therapeutic coverage figures. INTEGRATION OF SUPPORT ACTTVITIES: At each level included in the evaluation, there were examples of two or more CDTI tasks being combined during trips to levels below them (e.g. monitoring with supervision, fetching of financial records with supervision, monitoring with advocacy, etc.); planning for such integration of CDTI activities was suggested in the written timetables found
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