ORLD HEALTH ORGANIZATION ORGANISATION MONDIALE DE LA SANTE AFRICAN REGION REGION DE L'AFRIQUE AFRICAN PROGRAMME FOR ONCHOCERCIASIS CONTROL (APOC) PROGRAMME AFRICAIN DE LUTTE CONTRE L'ONCH(rcERCOSE B.P. 549 OUAGADOUGOU, Burkina Faso Tdl6gr.: ONCHO OUAGADOUGOU Tel.:(226')342953-342959-34 2960Telex: ONCHO524l BFFU<:Q26)343647-342875 t I I MISSION TO TANZANIA 10- 17 November 2002 Dr A. Seketeli, Director, APOC I Dr U. Amazigo, Chief, Sustainable Drug Distribution Unit, APOC I I I We are grateful to the Government of the United Republic of Tanzaniafor allowing this mission to be undertaken. Sincere thanla to the Honourable Minister of Health, Mrs A. Abdallah, the Country Representative of IVHO, Dr Simon Katenga, Mr Charles Franzen and (9v the NOTF of Tanzania. Our special thanlcs to Mn Paul Chikira, Regional Administrative Secretary, Regional Medical Ofiicer, District leaders of Ulanga and Kilombero and all other APOC partners for their assistance in making this mission possible and successful. WHo/APOCll0'|clo2-r BACKGROTII\ID Tanzania is one of the Africa's hotbeds of onchocerciasis (river blindness). It has a population of 35 million people and is among the 19 countries of the African Programme for Onchocerciasis Control (APOC) that signed the first and recently second Memorandum to eliminate onchocerciasis as a disease of public health and socio-economic problem. The ultimate goal of the National Onchocerciasis Control Programme (NOCP) in Tanzania is to eliminate onchocerciasis as public health problem within a period of l5 -20 years in the 14 onchocerciasis endemic districts. Funding from APOC has been approved for 6 ivermectin distribution projects (in Ruvuma, Mahenge, T*gq Kilosq Morogoro, Tukuyu districts), vector elimination in Tukuyu district and national headquarter (HQ) support projects. The objective of APOC is to establish a sustainable ivermectin delivery system in each member country with the goal of eliminating onchocerciasis from Africa. In 1997, APOC partners including Tanzania adopted the community-directed treatment with ivermectin (CDTI) approach as the principal skatery for the control ofonchocerciasis. Progress in establishing sustainable community-directed treatment with ivermectin (CDTI) in APOC counffies including Tanzania depends on the systemic critical revieVevaluation of current implementation practices of the national onchocerciasis Task Forces (NOTFs) with a view to doing things better in the future. This is the essence of the recent assessments of the sustainability of seven (7) CDTI projects in 9 geographically distinct areas in four countries undertaken in May/June 2002. The CDTI project in Mahenge Focus in Tanzania was among the nine projects that were evaluated. ' PIIRPOSE OF THE MISSION At the invitation of national onchocerciasis Task Force (NOTF) of Tanzania, an APOC management visit (Annex l) was undertaken to Tanzania with the purpose of: (i) Attending district leaders meeting to develop a three-year sustainability plan of the community-directed treatment with ivermectin (CDTI) project in Ulanga and Kilombero districts (Mahenge Focus CDTI project). The sustainability of projects has been the crucial ingredient in APOC CDTI programme and the Management has invested huge amount of resources into putting down the process of *APOC realising it. According to APOC Phase II document will monitor progress towards the establishment of sustainable CDTI and determine ... if and when a project has been successful. The success criteria would cover issues of treatment coverage, community directorship and ownership, health system support and integration of CDTI into the existing health care structures." Between May and June 2002, participatory evaluation of seven CDTI projects in nine geographically distinct areas in Uganda, Nigeriq Malawi and Tanzania were undertaken. Teams of national and outside experts, using guidelines and instruments developed by the core group on sustainability and field-tested, carried out these assessments. The main findings were discussed at the second meeting of the representatives of the national onchocerciasis Task Forces (NOTFs) in Abuja, Nigeria and the meeting made recommendations on criteria by which projects are to receive further support from APOC Trust Funds after five years. The progress .meeting concluded that" the Mahenge CDTI project is not making satisfactory towards sustainabllily' and for sustainability to be achieved, ownership of the programme by target communities, integration into healthcare system, support of the primary health care establishment (commitment of government) and performance of treatment activities need immediate attention. ' The result of the evaluation is available in two APOC documents - " The assessment of self-sustainability of the Mahenge CDTI projecf'and "Report of the Second meeting of the National Onchocerciasis Task Forces (NOTFs) Representatives: sustainability indicators, assessment of projects and lessons learned" In the light of the results of the evaluation on the Mahenge project and recommendations of the Abuja meeting, and following series of consultations, the NOTF Tanzania invited the Management of APOC to a meeting with district and council leaders of Ulanga and Kilombero districts. The mission is to assist the leaders to develop a sustainability plan with a view to revitalization of the project and putting it on the track to sustainability. (ii) Meeting with the Honourable Minister of Health of Tanzania ln 2001, the government of Tanzania represented by the Hon. Minister of Health. Mrs Anna Abdullah co-chaired the seventh session of the Joint Action Forum (JAF), the meeting of the . governing body of APOC. As is the practice, the Government of Tanzania will chair the eighth session of JAF that will be held in Ouagadougou in Burkina Faso. An aim of the mission was to debrief the Honourable Minister on the responsibilities of position that will be held by the Government of Tanzania for one year (December 2002 - November 2003). (iii) Participating in an NOTF Meeting The National Onchocerciasis Task Force (NOTF) Tanzania working towards enhancing sustainability indicators in all projects convened a meeting to review the programme. Following the meeting in Abuja, Nigeria in June 2002, APOC Management had written NOTF/Tanzania in October suspending further disbursement of funds to NOTF/HQ secretariat that oversees the implementation of APOC projects in Tanzania. The management noted that it would resume funding when there is discernible evidence of technical support to country projects by HQ office as foreseen in the Letter of Agreement. The APOC mission was therefore to dialogue and agree with the NOTF/Tanzania the way forward and find solutions. DISTRICT LEADERS MEETING ON SUSTAINABILITY OF THE MAIMNGE CDTI PROJECT Objective of the meeting The objectives of the meeting as presented were: o To assist the leaders of Ulanga and Kilombero (Mahenge focus) districts to formulate a three-year CDTI sustainability plan. o To address critical indicators highlighted in the evaluation report of Mahenge project that stand in the way of sustainability. o To discuss and agree on the conditions for further support by APOC, district financing commitments and dialogue on sustainable approaches to secure community and district ownership of the project in foreseeable future. o To sensitise the leaders of the districts of Ulanga and Kilombero in Mahenge focus on the benefits of the Community -Directed Treatment approach. Partners present at the meeting The partrrers represented at the meeting included: - Morogoro Regional Administration - Regional Medical Offrce, Morogoro region - District Health Management Teams of Ulanga and Kilombero - District Planning Office - Ulanga - Ulanga and Kilombero District Onchocerciasis Coordination teams - National Onchocerciasis Task Force (NOTF) of Tanzania - National Institute of Medical Research (NIMR) - WHO /Tanzania - NGDO Coalition, Tanzania represented by Inter-Church Medical Association (IMA) - WHo/APOC The list of participants at this meeting is attached as annex 2 Key issues CDTI sustainability plan for Ulanga and Kilombero districts Onchocerciasis is endemic in two districts (Ulanga, Kilombero) of the Mahenge Focus. In 1995, the control of onchocerciasis through community-based ivermectin treatment (CBIT) strategy began in the two districts supported by MoH in partnership with lnter-Church Medical Association (tMA). ln 1997, the control strategy was converted to community-directed treatment with ivermectin (CDTI) with funding support from the African Programme for Onchocerciasis Control (APOC), and the project is in its fifth year of operation. The support for CDTI in both districts will tentatively end in December 2002.1n May/June 2002, an assessment of the project was undertaken. The major aim of the evaluation was to determine the level of sustainability of the Mahenge CDTI project, in order to know whether it can function optimally with little or no external resources, post-APOC funding. The other objectives were to determine the strengths, weaknesses, emerging issues, opportunities and threats of the project and propose recommendations, and develop action plans that can put the project on the sure path to sustainability. The evaluation report concluded, " The project is not making satisfactory progress towards sustainability." As consequence, the Abuja meeting of NOTFs recommended among others that a detailed post-APOC implementation plan that is dependent on local resources be developed