World Health Organization African Programme for Onchocerciasis Control .l Evaluation of the Sustainability of Phase IV CDTI Project August-September 2006 Coordinator of Phase IV Uganda CDTI: Prof. Oladele Akogun District Team members Page ADJUMANI O. Akosun. O. Ochiene. E. Masawe l5 APAC L. Matagi" D. Abdul, T. Mu.qa'yo 31 GULU A. Turinde, T. Abraraw, F. Byenume 46 KIBALE J. Musisha. S. Aeunvo. G. Pallansvo 61 MOYO N. Ene-Obon g. A.Begumisha,A. Byamungu,T. Lakwo 78 Secretariat: NOCP/Iv{oH : Andrew Byamungu, Peace Komukama, Zakia Mugaba, V/HO/APOC: Joseph Kajubi, DRAF'T REPORT 2 0 SEP. 7006 TABLE OF CONTENTS ABBREVIATIONS/ACRONYMS ACKNOWLEDGEMENT EXECUTIVE SUMMARY t THE \ryAY FORWARI) l.O INTRODUCTION 2.0 METHODOLOGY 13 2.1 Sampling 13 2.2 Sources of Information l5 2.3 Analysis 15 3.0 EVALUATION FINDINGS IN EACH DISTRICT t6 3.1 ADJUMAI\I t6 3.1.1 Sustainabiliÿ at the District Level 16 3.1.2 Sustainabiliÿ at the FLHF Level 2T 3.1.3 Sustainability at the Community Level 25 3.1.4 Conclusion and Grading the Overall Sustainability 29 3.2 APAC 32 3.2.1 Sustainability at the District Level 32 3.2.2 Sustainability at the FLHF Level 36 3.2.3 Sustainability at the Community Level 40 3.2.4 Conclusion and Grading the Overall Sustainability 44 3.3 GULU 47 3.3.1 Sustainability at the District Level 47 3.3.2 Sustainability at the FLHF Level 51 3.3.3 Sustainability at the Community Level 54 3.3.4 Conclusion and Grading the Overall Sustainability 59 3.4 KIBALE 63 3.4.1 Sustainability at the District Level 63 3.4.2 Sustainability at the FLHF Level 68 3.4.3 Sustainability at the Community Level 7l 3.4.4 Conclusion and Grading the Overall Sustainability 75 3.5 MOYO 78 3.5.1 Sustainability at the District Level 78 3.5.2 Sustainabiliÿ at the FLHF Level 83 3.5.3 Sustainabiliÿ at the Community Level 89 3.5.4 Conclusion and Grading the Overall Sustainability 93 4. PHASE IV APPENDICES ABBREVIATIONS/ ACROIIYMS APoCAfricanProgrammeforonchocerciasisControl CDD CommuniÿDirected Distributor (of Ivermectin) CDTI community Directed Treatment with Ivermectin DDHS District Director of Health Services .: DOC District onchocerciasis control coordinator ' DOCT District Onchocerciasis Control Team -. FLHF First Line Health FacilitY - HSAM Health Education Sensitisation Advocacy and Mobilization MOH Ministry of Health NGDoNon-GovernmentalDevelopmentorganisation NOCP National Onchocerciasis Control Programme NOTF National Onchocerciasis Task Force ONCHO Onchocerciasis REMO Rapid epidemiological Mapping of onchocerciasis V/HO World Health Organisation ACKNO\ilLEDGEMENT We wish to express our sincere appreciation to all those who made contributions to the successful accomplishment of the evaluation task, especially: ' The Director, APOC, Dr. U. Amazigo and staff in Ouagadougou for their confidence in the team and for providing the necessary support for the success of this assignment. The V/HO Representative , Uganda, Dr Meville George and his staff. National Onchocerciasis Control Programme Coordinator for Uganda Dr Richard Ndyomugenÿ and his Deputy Dr Andrew Byamungu . District and Central Ministry of Health personnel at all levels provided information and an assured environment for the assignment. Chairmen, CAO, DDHS, DOC and subcounty i/c health facilities and their Assistants twere especially helpful. Health workers and community members in Adjumani, Apac, Gulu, Kibale and Moyo districts provided information and contributed to the success of the mission. EXECUTTVE SUMMARY Overvîew The uganda Phase rv communiÿ directed treatment wilh five districts Ivermectin (CDTD projects in of Adjumani, Àt;, Guru, rrurr, *à'tutoyo ,o*.ràrJthe APoc support since in 1998' receipt of î;;am of externa u/as bv Apoc to evalyf^t"- "uJoltors therefore commissioned ,!ru, of the èoii to make sustainabilirv wlïâPoc fundinistops. eü*J, progress towards After inô#ation was levels' the findings were gathered at rhe various shareJ *itt, trr"-ù-ori,-Ëirrri", ofîicials workshops conducied for the and FLHFS and deveropment of sustainab,ity plans. Procedures In each of the five districts, two FLHFs were randomly lots (where this selected from the subcounties by was possible and security situation aitoweo; communities and from each FLHF two were selected' Interviews were conducted and subcounty with community leaders, district chiefs, and communitv directed airt 4 respectively' iluàr, (cDDs) using instruments Information was ut.o gatt 2 to er"d from ih. ."rir* of available documents at each level as well relevant as p.luià,r. oist icimoniiorirg report. Findings All but one of the five district projects are ugand4 located in a in an area uoraerine s,fiJi-*r,"r t border share rhe insecuriry;hi;hl* "nr*i.rio*ffi;l:i::'illi;:iiff;: been on f";;;;; a decade. The restful with a great deal communities are âr ,,ou.-"nts and redefinition situation' Despite the "9p*urriiv depending on the stress *a .tr"i" on the district ,érou.""r, able to sustain the projects have been CDTI as best trrey coura to iï.i ir"rrr"",in participatory' They delivery is community have also u.tn to instiiute"nr*" ai"inàgrution deworming, rymplatic "ut. of the .DTI psect to riluriai. Jilination, .;;; -wiû,airoiurrior, in the home and a host of mararia management otnà. .imil* p."J;;t" the visibility Assistant cadre with responsibiliÇ of rhe Hearth âr outreacÀ visits to communities poised for an the districts are effective tutt"nun." or corr. rto*"r"r, tî" .uin insecurity and the fluidity trr. à'r-unities challenges aside from whom ur, *àuirity of the hearth lies the supervision or.oÀ*urityp.ograrim","i -.Àipiing jirliuairg assistant on notification. other surve,lance and disease chalrenges *" ËpiaÀi., .r,"Ër, retugees. Nevertheless tÀ'. "i ;J;rh;.' coping wi*r fi; ;tr-t i"1r" making progress ^11" ffiË"a towards liJiÏiil'9,#ïo"cific situation in-"u"t orthe ai.iriri, i. indicatei ilüî:" The findings indicate-that Adjumani District Implementation CDTI is making unit of uganda phase rv salisra!!.ouiiriutt'rrwards sistainabilitybased the necessarv crireria. on thà ablity to meet Tho;gh ,hi;;;qrr-e is implemented in an has made a grear dear of pro;; dd;iu"irg.r,",#ü;" area oiinsecurity it of service to and effecriv" i, irr" delivery the tom-unityït.uÀ. The lJvel the orrl.Ërà"teeping and documentation district level is very good but very at poor at the FLHF level. The District Management Team.pl'.r.u1t y Health i*nortllrole in the iÀpL-"rtation of coverage rates are Àig[ aespitl CDTI activities. ,r-J i"", that it i, i, u îu. zone. FLHFs incorporated into ttre are now being Ôort activities and adavantag;;il to of Health Assistants-wh9 be taken or ttr" availability cary oriout r".h activitiJs catchment à ,1 .".*unities within the FLHF area and the integration ofmany preventable diseases into the responsibility of the FLIIF' The.major hindrance to the sustainab,itv ir ffi .i:f; :i,*ï'#:;t,'§dff j,#;:[î:'#î,Ë:',:ï,*i Apac District ]3;l;;ri,îïTj"..,: imnllT,:t *iîüiiÏ"f3,b*" ihe unit of uganda prrase rv cDrr. underor*,;§ff ',*i:i.ttrittt*nrrï3h##;y*r,::.,mxrhe disrrict is sustainabiliÿ based on the tuirii, workers jo-*".t ,r.-ir.r..u.y_.rit.ria. have been ttevptayÀir'ôou irpr"-"î,"riil TËe DHT and FLHF finks hearth linedhigha;;;,n"insecuriryintry services wirh IeverF-iiË::îüHffJ,:'îï'#r:î#""ffif orrecora keelinü;;;*"",u,i"r-",îï;""flr':ffiï;r,ïrj;l:::iaî;i:,ir,Ji: desired' rransnort u""i'ià.rin"àî, ,ir*î,i* 'dum " bi;;iffi;ïsustainability. I,1:"'J:ffiïîîi,iff"i""' *iri""..îu,r,e new 'iiii.vrr., diskict a great dear in the Gulu District This report prese-nts the findings activiries of the evaluation on selÊsustainability in Guru atut ict, ug;iili::lr^:y.;,:il;: of GDTI The findings reveal.tha' â"tiîJtrr"'on-goirg \20o6by a three_man ream.. the rasr conflict tf,at has rwo dec3d9rl tr,r'à1roi" i;"-rËü;;"'rosirivedisrupted the activities for sustainabiliÿ' A t'-i .t id., io**., .DTI Ëiiffi -"î,r"1îilîï:,:ï#*',:i"?,:r,*,,ii,i":,ff#::ï;:J.:T:r^"g ir,"r*t and commitment u/as as poritici'ansl-'Ë,ifi "ï noted tnterventions such as: steeping guinea which is a positive ;o;, srep towaràs 'i"kn"r., _schistosomi*r.,- mararia, etc still hampered rir^?,:ei*; ôïi..However, bv.excrusion è;Ti activities are funding pâo.^r"îrj among otrrg^ "iâ.-i*rrr, t."ping ;;ir"r"r, and o"rpir. tîî uini., tr"ut poor "on.t i.i, .ourrrge were high in *iiri'g;",, on part or the a, the .or*,ni,i",',à .ilt,,ue taking Kibale:lffii*Ti"î:§flJi1rnà District The evaruarion findings of Kibare making ,01._" gD3 p§ect indicates saisfactotT progress _furl thatthe project is rhough uiarly sustainabitityi:r* the pioject t on evaruation indicators. to overwhelming i*pj"*LËJi, ,r,.ï;;,,ïffi#.,rh.i.rt ,rrour." o:r1î a;r*r, u'i"irab,ity due reasonable ; tlere r,* u-"* ïn"Lbl amount of resources for tire.impr"-"r,",iï, the districi ro arrocate district level à!c9r1 displaye!.more fr".rt"""r activities. whereas the evaluation r*,ir-"rîï.àîîr"rn" indicators there is critical'*;'*rrove àLrrilpro by the grosstv imporrant the p..roàun.e of the FLHF rhat the ;"n,*irirv r"*,rr'i. tevet. lt is arso ownership and the related r*..r.^r,ip i"r"* ôî"",#ffi"-plîered-_t9 ,rk; ;;.;omrnunity but there is critical need to i-pt"i" at a, rever; *;;; satisfactory management community i"ri ur.".rment at all levels' The màjor and quality of data been iind.ro".