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Evaluation of the Sustainability of the Jimma CDTI Project, Ethiopia May

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Evaluation of the Sustainability of the Jimma CDTI Project, Ethiopia May World Health Organization African Programme for Onchocerciasis Control Evaluation of the Sustainability of the Jimma CDTI Project, Ethiopia May/June, 2009 Elizabeth Elhassan (Team Leader) Zerihun Tadesse Nigussie Birhane Contents Page Table of Contents………………………………………………………………………………………………2 Abbreviations/Acronyms…………………………………………………………………….…………….…..3 Acknowledgements……………………………………………………………….……………………..……..4 Executive Summary……………………………………………………….……………………………...……5 1. Introduction………………………………………………………………………………………………....8 2. Methodology……………………………………………………….………………………………………..10 2.1 Particular Circumstances………………..………………………………………….…………10 2.2 Levels and Instruments………………………………………………………….….…………10 2.3 Sampling………………………………………………………………………………………11 2.4 Protocol………………………………….........................................………………………… 12 2.5 Team Composition…………………………………………………………………………….12 2.6 Advocacy Visits and Feedback/Planning Workshop…………………………………..…...…12 2.7 Debriefing meeting on the outcome of the evaluation of the Sustainability of five CDTI Projects to Ministry of Health and NGDO partners………………………….………………..13 2.8 Limitations……………………………………………………………………………………..14 3. Evaluation Findings and Recommendations……………………………………………………………...15 3.1 Regional Level……………………………………….………………………………………..15 3.2 Zonal Level………………………………………….………………………………………...20 3.3 Woreda Level………………………………………………………………………………….25 3.4 Front Line Health Facility Level……………………………………………………………... 31 3.5 Community Level…………………………………………………………………………….. 36 4. Conclusions………………………………………………………………………………………………….40 4.1 Grading the Overall Sustainability of the Jimma CDTI Project…………………….………...40 5. Annexes Annex 1: Tentative Timetable for Evaluation Activities .……………………………..……………………44 Annex 2: Persons Interviewed/Courtesy Visits …………………………………………………………..….46 Annex 3: Sources of Data ……………………………………………………………………………………..49 Annex 4: Feedback and 3-Year Sustainability Planning Workshop Agenda……………………………...54 Annex 5: Summary of Feedback and 3-Year Sustainability Planning Workshop………………………...55 Annex 6: Participants at Feedback and 3-Year Sustainability Planning Workshop……………………...60 Annex 7: Health System Extension Programme, Ethiopia…………………………………………………..61 Annex 8: Report of Debriefing Meeting……………………………………………………………………… 62 2 Abbreviations/Acronyms APOC African Programme for Onchocerciasis Control BPR Business Programme Re-engineering CDD Community Directed Distributor (of Ivermectin) CDTI Community Directed Treatment with Ivermectin CNHDE Center for National Development and Health in Ethiopia CVBD Communicable and Vector Borne Diseases EOS Enhanced Outreach Strategy EPI Expanded Program on Immunization FLHF Front Line Health Facility MDG Millennium Development Goals HEWS Health Extension Workers HWs Health workers HIV/AIDS Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome HQ Headquarters HSAM Health Education/Sensitisation/Advocacy/Mobilization IEC Information, Education, Communication KOTF Kebele Onchocerciasis Task Force LLITNs Long lasting Insecticide treated Nets MCH Maternal and Child Health M&E Monitoring and Evaluation MOH Ministry of Health NGDO Non-Governmental Development Organization NOCP National Onchocerciasis Control Programme NOTF National Onchocerciasis Task Force PFSA Pharmaceutical Fund and Supply Agency PHC Primary Health Care PMTCT Prevention of Mother to Child Transmission (PMTCT) REMO Rapid Epidemiological Mapping of Onchocerciasis SWOT Strengths, Weaknesses, Opportunities and Threats TB Tuberculosis TCR Therapeutic Coverage Rate ToT Training of Trainers VBD Vector Borne Diseases WHO World Health Organization WoHO Woreda Health Office WOTF Woreda Onchocerciasis Task Force ZHDH Zonal Health Desk Head 3 Acknowledgements The evaluation team would like to thank the following persons for their help in carrying out this evaluation: . The staff at 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 the WHO office in Addis Ababa, Ethiopia, particularly Mr. Tatek Mekonnen, for his role in organizing the local logistics for the evaluation, facilitating the logistics for local team members, and for facilitating the payment of allowances, collection of data on funding from APOC and participating in the debriefing meeting. The NOTF/Ministry of Health, particularly Dr. Kesetebirhan Admasu, Diector General for Health Promotion and Diseases Prevention for finding time for the debriefing session despite his tight schedule. The Carter Center-Ethiopia, particularly Mr. Teshome Gebre, for his immense contribution to the successful planning and ensuring all logistic arrangements for the evaluation team members, post- evaluation debriefing and for providing the team with the services of Mr. Asfaw Benti, a Carter Center driver for the duration of the evaluation. Mr Dubiwak Gemada, the evaluation team scout, for all his work to ease the evaluation process prior to our arrival and Dr Zerihun Tadesse of the Carter Centre a team member for his support during the evaluation and serving as a translator. Staff at the Regional Health Bureau, particularly Mr. Asfaw Bekele, Head Plan preparation, Budget and M&E process owner, Mr. Shiferaw Degefu, Purchase, Finance and Property Management Process owner, Mr. Gemechu Asfaw, Finance Section Coordinator and Sr. Mulunesh Desta, Communicable Diseases Control and Surveillance Officer. Staff at the Zonal Health Office, particularly Mr. Abera Asefa, Deputy Head Zonal Health Office, Mr. Jihad Kemal, CDTI focal person, Mr. Faruke A/Dura, Zonal Finance and Economic Development Office, for receiving us and meeting with us, and to the health team for participation in the evaluation and the feedback and planning workshop. We also acknowledge Mr Asefa for allowing the team to use his office the entire day on the fourth day of the workshop for the finalization of the sustainability plans. Staff at the Mana and Shebe Sombo Woreda Health Office, particularly Mr. Awal A/Gidde, Head of Mana Woreda Health Office, Mr. Daniel Natae, Head Finance and Economic Development Office, Mr Temesga Woruku, CDTI focal person, Mr. Mohammed Abdurrahman, Head of Shebe Sombo Woreda Health Office, and Mr. Dawit Admassu CDTI focal person, for receiving us, facilitating the evaluation and participating in the evaluation and the feedback and planning workshop. We also thank the Woreda Head for his hospitality to Dr Zirhun Tadesse and Mr Mohammed Abdurrahman Head Health Office when the evaluation vehicle broke down in Shebe Sombo Woreda. Staff of Keangenam Limited (a road construction company) for their immense concern, support and providing transport from Shebe Sombo to Jimma for other members of the team. The Health posts and clinic staff of Kela Guda, Doyo Toli, Sebaha Wala and Cherkosa, Kebele leadership and all community members visited and interviewed during the evaluation. The management and staff at the Wolde Argaw Hotel for providing a meeting area daily for data analysis and report writing and Jimma Central Hotel for allowing us use the venue beyond the official hours for the feedback and planning workshop. 4 Executive Summary Jimma zone is one of 23 zones in Oromia Regional State in southwestern Ethiopia. It is divided administratively into 18 districts (Woredas). The Jimma CDTI project started in 2004 in three meso to hyper- endemic districts. With the creation of Shebe Sombo district in 2006, the number of districts increased to four. The project area is divided into 137 Kebeles and 4,123 “Geree” or villages and covers a population of 884,169. Each “Geree” consists of 25 to 35 households and is responsible for its health and development activities. The four major perennial fast flowing rivers are Gojeb, Ghibe, Gilgel Ghibe, Dedesa and Kawa. Eighty five percent of the zone has access to health facility and a third of these are in the CDTI project area. This is the first evaluation of the project. The APOC sustainability evaluation instruments were used to collect data at the national (region and NGDO partners) and project (zone, Woreda, FLHF and community) levels. The limitations of the evaluation were inaccessibility of some FLHFs and communities and absence of several Kebele leaders. Discussions with cross sections of members of all communities visited more than made up for the latter. The results of the evaluation were presented at a feedback and 3-Year Sustainability Planning workshop attended by staff from the zone and all four Woredas. EVALUATION FINDINGS: 5 PLANNING: (Highly, 3.8) The zone, both Woredas and all four health facilities visited had written annual overall plans of activities for control of communicable diseases with a section on Onchocerciasis control from inception to 2007/9. The CDTI section showed plans for training of health workers, community supervisors, training/retraining of CDDs and distribution of Mectizan® tablets. Detailed plans specifically developed for CDTI were only available in Woredas and FLHFs and these had the key activities listed. There was evidence that plans were mostly targeted to the needs of each year and were developed in a participatory manner at all levels from bottom up. There was no mid-term sustainability evaluation and therefore no sustainability plan. The CDDs agreed on the timing and mode of distribution of Mectizan® tablets with communities. Census update by CDDs was mostly for eligible population in all communities and figures were used by HEWs to determine the number of tablets required. The CDDs managed challenges
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