evaluation of the sustainability of the jimma cdti project

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

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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

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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

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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.

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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:

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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 they faced effectively.

INTEGRATION OF SUPPORT ACTIVITIES: (Highly, 3.7)

There is an integrated plan of action for Onchocerciasis and Malaria known as Maloncho and other vector borne

diseases within the 17 diseases minimum health package. Staff members combine two or more tasks i.e.

collection of tablets, monitoring and supervision, training, health education, fetching of records and delivery of

tablets and HSAM during trips to FLHFs as well as various health interventions. There are focal persons at the

zone and Woredas who have been in post for two to six years. At the FLHFs, staff members are responsible for

the 17 minimum health packages. During advocacy, sensitization and mobilization for other health programmes

Zonal health offices take the opportunity to carry out HSAM for Onchocerciasis and Malaria.

LEADERSHIP: (Highly, 3.8)

The leadership has taken ownership of CDTI. It is effective, fully aware of the progress, successes and challenges

and makes efforts to address the challenges. Responsibilities are delegated to the CDTI team members at each

level and the relationship among all team members and NGDO partner is cordial. Annual review and quarterly

meetings on all health programmes (including CDTI) are held at the zone and Woredas with the participation of

other relevant sectors. There is a health and Oncho committee in a Kebele and a FLHF with opinion leaders as

members. The HEWs initiate CDTI activities in an integrated manner. Community members and CDDs affirmed

the leadership role played by Kebele leaders in promoting participation and ownership of CDTI. Community

members selected CDDs either from persons nominated to coordinate community development activities, or

based on willingness, equity, community mobilization skills and literacy. Members of the community were

knowledgeable in all aspects of CDTI; they recalled the community treatment round, duration of treatment and

expressed commitment to long term treatment.

MONITORING AND SUPERVISION: (Highly, 3.8)

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The CDTI activities are monitored by cascaded supervisory visits made by staff. Evaluators found that

supervision was not necessarily targeted to geographic areas with problems or specific needs. Woreda staff

members reported supervision of FLHFs and only supervise communities when there is a need. There is an

integrated checklist for Malaria and Onchocerciasis which incorporates all key aspects such as census, collection

of records, Mectizan® tablets inventory, identification of problems, challenges and actions taken. Issues

identified were discussed with superiors. Checklists were sometimes used as trip reports by the zone and Woreda.

In some health facilities trip reports were available in which problems such as poor recording and inadequate

number of CDDs were identified.

MECTIZAN SUPPLY: (Highly, 3.8)

The requests for Mectizan® tablets are generated at the FLHFs from community census and sent through the

Woreda, zone, MoH and to Mectizan® Donation Programme. The WHO receives, clears and delivers Mectizan®

tablets to the Pharmaceuticals Fund and Supply Agency (PSFA). The NGDO partner has devolved collection of

tablets from PFSA to the zone. The Woreda pharmacist and FLHF staff procure Mectizan® tablets along with

other drugs and supplies from their respective medical stores based on census population. Sufficient tablets were

received annually except in 2006 when shortages were reported in two health facilities. Additional drugs are

requested and supplied as needed. Store receipt and issue vouchers were available at each level and tallied with

what was provided at every level. The CDDs are informed of when to return for Mectizan® tablets when they

submit census data to FLHF staff. They do not require transportation because all communities are within a

walking distance to health facilities. All eligible members of the communities visited received treatment annually

except a few households in a community in 2006. In some communities, absentees are followed up for treatment

for one month after which the remaining tablets are returned to the health posts. Treatment registers were of high

quality and well handled although updating of census was only for eligible population.

TRAINING AND HSAM: (Highly, 3.5)

Training is cascaded from the national down to the FLHFs level and training objectives are developed from

issues identified during monitoring and supervision. Two to four staff members facilitate training using training

manuals and IEC materials in local languages. Health and community facilities are used without compromising

quality. Training was integrated with LLINs, Enhanced Outreach Strategy (EOS), EPI and hygiene. Training of

CDDs was generally based on need. Copies of training summary reports of four years were available for review

at all levels. In one district there was a new CDTI team member who had not been trained. Staff members avail

themselves of opportunities provided by other programmes and quarterly meetings for HSAM to promote

ownership of CDTI. The HSAM is a cross cutting component of the other 16 components of the minimum health

package and is planned as such in the timetables. Various opportunities at the community level are utilized to

pass on messages. There is evidence that HSAM activities have been effective and resulted in improved

ownership

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FINANCES: (Highly, 3.3)

There is a sum allocated for CDTI as MalOncho under CVBDs at each level except the FLHF. The health

budgets are prepared by the Kebele leadership and HEWs and compiled by the Woreda staff for approval and

allocation of funds by the Woreda cabinet. There are usually no shortfalls in government funding; integration and

contingency funds in the case of the new Woreda, have been used to meet challenges and constraints without

compromising performance. As a policy, HEWs should not handle funds, must live within their catchment areas

and integrate all 17 programmes in the minimum health package. The Woredas supply all drugs and reimburse

and any costs incurred in collection of drugs. The CDDs interviewed were all aware of their status as volunteers

and expressed willingness to continue distributing Mectizan® tablets for as long as required despite the

challenges of poor motivation.

There was evidence of utilization of government systems and procedures for request and accounting for funds for

CDTI activities by staff members and awareness of budget balances. The budgetary contribution of each partner

was clearly spelt out in the MoUs and Technical Service Agreements (TSA). At some levels government has

increased its annual budget, honored all its commitment annually and spent as budgeted at all levels. There has

been a recurring under utilization of APOC’s funds due to delays in accounting. As a result, only the first

installments of APOC funds were ever released and no funds were transferred in 2006. The zone utilized only

47.8% and 70% of its first allocation in 2007 and 2008 while the Woredas utilized 88% and 100% of their first

allocations in the same period.

TRANSPORT AND OTHER MATERIAL RESOURCES: (Highly, 3.7)

There is a pool of appropriate motor vehicles available for CDTI activities at the zone and Woredas and this is

illustrated in Shebe Sombo district where lack of transportation did not affect CDTI activities. Government

provides funds for running costs and vehicle and equipment maintenance. Some of the equipment donated by

APOC was functional. There were no inventories and log books were not used. Transport is used appropriately to

support CDTI implementation in an integrated manner and there are policies and procedures in the transport unit

for control. There are no plans for replacement of vehicles at any level. Replacement of vehicles is the

responsibility of the Regional Health Bureau (RHB) and requests have been made for these. There are sufficient

materials for training and HSAM materials donated by partners were visible in all facilities. Stationery is

provided by the Woreda Health Office either quarterly or bi-annually and there are plans for continuous supply.

HUMAN RESOURCES: (Highly, 3.4)

Five staff members are involved in CDTI activities in the zone and Woredas and only two of these have been

with the programme for five years. One of the remaining three has been in post for 2 years while two others are

just two months in post. The health clinic staff has been in post for over five years while six HEWs at the three

health posts have been in post for two to three years. All staff members except one are sufficiently skilled and

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knowledgeable; all are very committed and pleased salaries and allowances are paid timely. Some staff had

received certificates and commendation letters from government for services rendered. In most of the

communities visited CDD to household ratio was one CDD: 10-12 households. All but one community had

selected additional CDDs to reduce workload or replace drop outs. All CDDs interviewed were very

knowledgeable and several had been serving since the commencement of CDTI in 2004/2005 and are willing to

continue for as long as required despite little motivation. The CDDs were treating people in their neighborhood

and stated that the trust and community compliance motivated them.

COVERAGE (Fully 4):

All 137 Kebeles were consistently treated from 2006, 2007 and 2008 thus attaining a geographic coverage of

100%. In several communities the 2009 distribution of Mectizan® tablets was either ongoing or had been

completed. The treatment registers were well kept and treatment was verified in discussions with cross sections

of adults and youths of both gender in communities. The trend of the average therapeutic coverage was 82.4% to

86.7% from 2006 – 2008 and stable.

OVERALL GRADING:

The evaluation team found that all seven aspects of sustainability were helping the project move towards

sustainability. Six of these were classified as ‘very helping for sustainability’. Human resource (seventh aspect)

was judged as ‘helping’. On the critical elements, we found four and half of the five elements fully satisfactory.

The element not fully addressed is transport. The zone and Woreda do not purchase vehicles. However, both

offices have made requests to the region for vehicle replacement and purchase respectively. There is a budget

allocation and release for vehicle maintenance at both levels. Both levels have budgetary allocation for vehicle

maintenance. Also with integration of activities vehicles donated for other programmes have been and will be

made available for implementation of CDTI activities. The evaluation team therefore concludes that the Jimma

CDTI Project is close to becoming fully sustainable. This is in agreement with the quantitative analysis of the

project, which gave an average numerical score of 3.72.

1. Introduction

The Jimma CDTI project is in one of 23 zones in Oromia Regional State in the southwestern part of Ethiopia.

The zone is divided administratively into 18 Woredas. The project shares borders with Kafa Sheka CDTI project

to the south, Illubabor Zone to the west and Southern Nations Peoples Republic to the north east. The major

perennial fast flowing rivers in the zone are Rivers Gojeb, Ghibe, Gilgel Ghibe Dedesa and Kawa. The health

system is fairly well established and covers 85% of the zone. There is one referral hospital, a district hospital and

16 health centres, 46 health stations and 113 health posts and the CDTI project area has thirty four percent of the

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194 health facilities in the zone. The health service extension programme (HSEP) an innovative approach for

accelerated expansion of primary health care service in all 15,000 Kebeles of the country (MOH, 2005 and

CNHDE, 2006) started by government in 2003 has made this possible. Training and deployment of 33,200

HEWs to all Kebeles in the country and establishment or upgrading of 3,153 health centers to strengthen referral

linkages and supportive supervision to HEWs with a view to attainment of equitable essential health care service

and achieving the health sector MDGs (CNHDE, 2006). The HSEP is the bedrock of health care delivery to the

rural population.

Rapid Epidemiological Mapping of Onchocerciasis was carried out between 1998 and 2003. The results showed

that the Seka Cherkorsa, Mana and Dedo districts of Jimma zone are meso to hyper endemic. The four Woredas

of the project have a population of 884,169 and are further divided into 137 Kebeles and 4,123 “Geree” or

villages. Each “Geree” consists of 25 to 35 households and is responsible for its health and development

activities. After the approval of the project in 2003, CDTI was launched in 2004 in the three meso and hyper-

endemic districts with support from APOC and The Carter Center. After the creation of Shebe Sombo district

from Seka Cherkosa, in 2006, the number of endemic districts was increased to four. From inception, the project

has attained a geographic coverage of 100% treating all 3,607 communities and the 516 additional Kebeles

created in 2007hav. The therapeutic coverage has generally increased from 78.2% to 83.2% in 2008 except for

the dip to 71% in 2006 due to treatment in the rainy season.

2. METHODOLOGY

2.1 Particular circumstances

The 5th-Year sustainability evaluation described in this report was made possible through the coordinated

Teshome Gebre and the WHO Country office as the Ministry of Health was developing a new strategic plan

and business line. The onus then fell on The Carter Center and WHO.

2.2 Levels and Instruments

In order to carry out the evaluation exercise properly, it was essential to relate the instruments provided by

APOC to the different levels (administrative structures) that exist in Ethiopia. In this regard, the four

instruments were used as follows:

Instrument 1 was used for the national/regional/zonal level – equivalent to State level in the instrument.

Instrument 2 was used for the Woreda level – equivalent to LGA level in the instrument.

Instrument 3 was used for the FLHF (Health Centre/Clinic/Health Post) level.

Instrument 4 was used for the community/village (Kebele, Gott, and Gere) level.

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2.3 Sampling

Sampling of Districts (Woredas)

The four (4) endemic Woredas in the Jimma CDTI Project are Seka Chekorsa, Shebe Sambo Mana and

Dedo. The team took another sample from that of the scout to allow for even coverage and selected two

Woredas Mana and Shebe Sambo.

Sampling of FLHFs

From the randomly selected districts two FLHFs were randomly chosen from each district. Some FLHFs

were excluded from the sampling due to inaccessibility.

Mana district:

o Kela Guda Health Post

o Doyo Toli Health Post

Shebe Sambo district:

o Seka Chekorsa Clinic

o Sebaha Wala Health Post

Sampling of Communities/Villages

Communities in the chosen FLHFs that were considered inaccessible were excluded from the list and three

accessible communities (villages) were randomly selected for the evaluation as follows:

Kela guda Health Post

o Afeta 3 community

o Koye 5 community

o Kujo community

Doyo Toli Health Post

o Doyo Toli community

o Lalo community

o Geso community

Chekorsa Clinic

o Banto community

o Warso community

o Sephera community

Sebera Wala Health Post

o Bomba community

o Kochi community

o Bosa community

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2.4 Protocol

Research Question: How sustainable is the Jimma CDTI Project?

Design: Cross-sectional and descriptive.

Population: The Jimma CDTI project, its NGDO partner (The Carter Center), the staff involved in CDTI,

zonal, Woreda, and FLHF levels, the project communities with their leaders and Community-Directed

Distributors (CDDs). At the Oromiya Regional Health Bureau, the interview included staff of Communicable

Disease, Health Plan Preparation, Budget, M&E, Purchase, Finance, Vehicles and Transport, Procurement,

and Pharmaceuticals units and Light for the World the NGDO partner for West and East Wollega. At the

national level the director PSFA was interviewed.

Instruments:

* A record sheet, structured as a series of indicators of sustainability. The indicators were grouped into ten

categories/groups. These groups represent critical areas of functioning of the programme.

* The four instruments assess sustainability at five levels of operation – national/regional/zone, district.

FLHF and community.

* The instruments guide the researcher to collect relevant information about each indicator from a variety

of sources.

Sources of information:

Documentary evidence and observations.

Verbal reports from persons interviewed.

Analysis:

* Data from all sources were aggregated according to level and indicator.

* A qualitative summary of the situation regarding each indicator at each level was made. This was

aggregated and summarized for each category of indicator for each level.

* Based on the information collected, each indicator was graded on a scale of zero to four in terms of its

contribution to sustainability. In cases where the indicator was not relevant it was judged as non

applicable.

* The average ‘sustainability score' for each group of indicators was calculated for each level.

* Finally an overall assessment of sustainability was made by considering the seven aspects and five

critical areas of sustainability.

Recommendations:

These were based on the findings of the evaluation. The recommendations were prioritized; indicators of

success identified and deadlines for implementation were indicated.

2.5 Team Composition

Dr. Elizabeth Elhassan (Team Leader)

Regional Director

Sightsavers International

West Africa Regional Office – West

13

15 Villa Ouest Foire, Cite Air France

Dakar, Senegal

TEL: +221- 338205295

FAX: +221- 338201863

Mobile phone: +221 77 818 9603

e-mail: [email protected]

Dr. Zerihun Tadesse

Director of Programs, The Carter Center - Ethiopia

Addis Ababa, Ethiopia

Mobile phone: +251-191401498

e-mail: [email protected]

Mr Nigussie Birhane

CDTI Focal Person

Kafa Sheka CDTI Project

2.6 Advocacy visits and Feedback/Planning Workshop

The first visit was to the zone. Personnel in the Finance Department were debriefed on the evaluation and the

outcome. We informed them of the need for continuous budgetary allocation and release of funds for CDTI

activities for as long as required. In his response, the head of the Finance Department explained factors taken into

account in budget allocation to the Woredas. These include population, distance from the zone and development

status of the Woredas. The personnel further elaborated that Communicable Diseases are given due emphasis in

the budgetary allocation given the burden in the zone. We were reassured of the commitment of the zone to

control of Vector-borne diseases.

The team also paid an advocacy visit to Mana Woreda Finance Bureau to debrief the Head of Mana Woreda

Finance Bureau and a Budget Expert in the Bureau on the results of the five years evaluation and ask for

continuity of support to CDTI for as long as required. The officers approached explained that huge amount of

funds is allocated to expedite construction of health posts, bring services close to the community and increase

coverage and quality of services in order to achieve the MDGs. The Woreda also allocates adequate funding for


2.7. Debriefing meeting on the outcome of the Evaluation of the Sustainability of five CDTI Projects to

Ministry of Health and NGDO partners, Ethiopia

The objective of the meeting was to debrief partners of the outcome of the evaluation of the Sustainability of

CDTI projects. The meeting was attended by Dr. Kesetebirhan Admasu, Director General, Health Promotion and

Disease Prevention Directorate General, Ministry of Health, Mr Teshome Gebre Country Director, The Carter

Center, Mr Derebe Mekennon, Country Representative Light for the World. Two representatives each from the

three teams of Jimma and Illubabor CDTI, East and West Wollega CDTI and Gambella CDTI evaluation teams

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were in attendance. The Jimma /Illubabor and West/East Wollega were represented by their team and sub team

leaders. The Metekel team was still in the field and hence could not participate in the meeting.

Each of the teams made graphical presentations on the overall performance of the respective projects after which

were discussions. Issues discussed and clarifications provided (in bold) were as follows:

1. What plans does government have to deal with the difficulty in demonstrating government’s financial

contribution which has been an issue with evaluation exercises in the past and these? Ethiopia has

limited resources and therefore promotes integrated approach like Health Extension Programme and

MalOncho programme

2. The evaluation teams gave the least score to transport. Do the evaluation teams expect government to

assign vehicles specifically for CDTI activities? How should the vehicles be used? APOC strongly

supports integration of programmes including use of resources for multiple programmes. The projects

scored least on transport not due to integration but due to lack of documentation that demonstrates the

use for the intended purpose, use of log books, approval by supervisors and specific plans for

replacement

3. The evaluation teams found health workers skill gap a major bottleneck in future programmatic activities.

What is the ministry planning to do? The issue raised by the evaluation teams is valid. The Ministry of

Health of Ethiopia is cognizant of the skill gaps and is making the necessary preparations to conduct

series of trainings at all levels. The trainings will be integrated.

4. The Ministry is undergoing major reform. Is it not difficult to do this without involving partners? The

Ministry carried out the Business Process Re-engineering first and foremost to respond to the needs of

the people of Ethiopia. The most important priority is therefore the best interest of the country and its

people. However, the ministry involved major partners throughout the reform.

5. There is a dearth of human resource at the Woreda level. What is government’s plan to alleviate the

problem? There is a high turnover of staff at all levels. That is the major reason why we switched our

focus from “specialists” to “generalists” who can be deployed to many areas. A Human Resource

Strategy (HR 2020) which will solve many of the human resource problems will be launched soon.

The debriefing session was concluded in an hour with a brief remark by Dr. Kesetebirhan who thanked

the APOC evaluation teams for a job well done and reassured them that the country will take major leaps

in the near future and similar evaluation exercises in the future will come up with entirely different

outcomes.

2.7 Limitations

Limitations include inaccessibility of some FLHFs and communities which were excluded from the sampling

procedure.

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3. Evaluation Findings and Recommendations

3.1 SUMMARY OF FINDINGS AND RECOMMENDATIONS AT THE REGIONAL LEVEL

PLANNING (Highly, 3):

There is an overall written annual plan for the Regional Health Bureau and plans from 2006-2009 were available

for review. Onchocerciasis control is integrated with Malaria and other Vector-borne Diseases under

Communicable diseases. The strategy for control is annual mass distribution of Mectizan® tablets and activities

listed in the plan are training, supply of drugs, monitoring and supervision, quarterly reporting and bi-annual

review of work plans. There is no Regional Onchocerciasis Task Force (ROTF). Planning starts at the Woreda

level based on baseline data after which the RHB aggregates the plans into a regional plan with technical

partners. Regional review meetings are organized and attended by partners; the recent meeting of February 2009

was followed by planning meeting.

The projects in the region have not been evaluated for sustainability before now and no formal sustainability plan

has been developed. The Regional Health Bureau has a financial plan and is allocating funds for project. We

were reassured that post APOC funding will not pose difficulties and officials cited an example where

government replaced a project vehicle after a major partner withdrew funding.

16

INTEGRATION OF SUPPORT ACTIVITIES (Moderately, 2)

After 2006, the RHB reported devolving detailed planning to the zones and such plans are available at there.

Despite the abundance of plans with policy makers, programme managers could hardly present a plan. Staff and

partners reported integration of Oncho control activities with malaria and polio with zonal staff members.

Training, monitoring and supervision of MalOncho was said to be carried out but supporting documentation was

not provided. The trip report available for review was for a non CDTI endemic zone. MalOncho checklists were

presented as evidence of integration of activities.

LEADERSHIP (Highly; 3):

The Oromiya Regional Health Bureau does not have an ROTF. Earlier attempts to establish a taskforce were

unsuccessful due to staff turnover rate. However, discussions with heads of various sections of the RHB indicated

that the leadership was fully aware of CDTI, delegates responsibilities to lower levels and provides the required

support. The RHB is a member of the National Onchocerciasis Task Force (NOTF) along with Ethiopian Health

and Nutrition Research Institute, WHO, NGDOs and Addis Ababa University. Despite the current Business

Process Re-engineering (BPR) in the Ministry and its resultant high turnover rate of focal persons, there is

evidence that the region provided the required leadership, was up to date with its technical reporting but wanting

in financial reporting on APOC funds.

MONITORING AND SUPERVISION (Moderately, 2.75):

A range of documents though partial were available to enable staff members to keep abreast of each CDTI

Project. The TSAs with APOC were available for 2007 and 2008 for all projects. Routine project reports from

2005-2007 for Jimma project, from 2004 – 2007 for Illubabor project, West Wollega from 2004-2008 and East

Wollega for 2008 only were available. Only Jimma CDTI project submitted financial reports on government

funding for the last three years. The reports were of good quality and contained treatment summary records,

inventory of equipment, financial records and trainings.

Supervision is integrated and a MalOncho checklist is used. RHB staff members reported supervising 2-3 times a

year starting at the zone to Woredas and FLHFs in company of the zone focal persons and empowering the lower

level. Feed back on supervision is given to the zone and supervisors and problems identified such as inadequate

training and transportation as a result of creation of new zone from West Wollega were discussed with zones and

partners. In addition, review meetings on VBDs are held to discuss the progress and issues of concern. There was

paucity of documentation on activities carried out by staff members. No inventories were available. Trip

authorizations were available for review by the evaluation team.

MECTIZAN SUPPLY (Not applicable):

17

The RHB is not involved in supply of Mectizan® tablets. This is handled by the Federal Ministry of Health. The

requests for Mectizan® tablets commence with the zones where a Mectizan® Donation Programme (MDP)

request form is completed. The forms are complied by the Carter Center Project Officer and National

Coordinator, after which an electronic copy is sent to MDP by the former while the endorsed copy, is sent by

MoH. World Health Organization clears and sends the tablets to Pharmaceuticals Supplies and Logistics

Department and from 2009 tablets to PFSA. Documentation available showed that sufficient tablets were ordered

for the projects and that Zonal Health Departments collected their supplies from PFSA. All the 18,245 tins of

Mectizan® tablets received for 2009 were collected by each of the nine CDTI projects timely. A partner reported

that audit of tablets showed a negative balance because tablets were not returned after treatment. Inventory forms

in the local language were developed to address this.

TRAINING AND HSAM (Moderately, 2):

The zonal and Woreda staff members are trained using the integrated MalOncho training guide. Zonal focal

persons cascade the training to the levels below them. Seven to eight facilitators from the RHB and the NOTF

trained 70 – 80 new staff members in a government facility which saved cost. Refresher trainings are not held

due to budgetary constraints. The HSAM is mainly done by zones and Woredas using role plays and IEC

materials collected from MOH and distributed by the RHB. The RHB translates brochures and flip charts into the

local language. Feedback after supervisory visits has been used to facilitate support from policy makers.

FINANCES (Moderately, 1.75):

There is a budgetary allocation for Onchocerciasis under the MalOncho budget line. Funds allocated to the zones

and Woredas are disbursed directly. According to finance staff members, programme managers have a clear idea

of the funds available and submit requests for funding based on that. Requests for field trips and expenses are

approved by the immediate superior of the programme staff. The finance section checks out the budget balance to

ensure funding is available and spent as budgeted. Programme staff however, did not appear to be familiar with

their budget allocation and expenditure.

No shortfalls were said to have been reported. Government funding was not increasing annually. It disbursed

ETB 1,440 for stationery, ETB 20,000 for fuel and oil, for 2008 and 2009; ETB 35, 000 for per diem in 2008 and

ETB 33,950 in 2009. Funds from Light for the World are disbursed through the RHB to West and East Wollega

while The Carter Center pays out funds directly to Jimma and Illubabor zones. No project has ever received more

than the first installment of funds due to perennial delays in accounting for APOC funds. This has resulted in

perpetual under utilization of approved funds by all projects in the region and with holding of funds by APOC for

a year.

TRANSPORT AND OTHER MATERIAL RESOURCES (Highly; 3.25):

18

The region has twenty seven 4x4 Wheel drive vehicles and 8 trucks; some of which were donated by UN

Agencies, NGOs and Bilateral organizations for specific programmes and others purchased by government. Six

of the vehicles are currently non- functional. The vehicles are in a pool and usually released on written requests.

There is a schedule and budget line for vehicle maintenance. Minor maintenance is handled by the transport unit

while major servicing is done by supplier companies. Travel authorization forms which made provision for

destination, duration of trip, number of passengers and fuel and oil consumption were the norm up until the

introduction of log books three months ago.

Light for the World that expressed its readiness to provide transport was not granted duty except status. It

therefore has no commitment to replace vehicles. The RHB planning unit was unaware that APOC vehicles and

equipment will have to be replaced probably due to the BPR and the high turnover rate. The team was informed

that a phased replacement plan could be prepared but funding is available for maintenance and with the pool

system and integration, transportation would not be a problem. There are several computers, photocopiers and

printers in each unit with maintenance agreements with suppliers of equipment to ensure functionality.

Materials less than 3,000 ETB are purchased directly by departments. Purchases of 3,000 -5,000ETB require

proforma invoices while those above 5,000ETB require a bidding process.

HUMAN RESOURCES (Moderately, 2.5):

There are four staff members in the MalOncho team. Of these four, the one who was in post for five years is

currently on graduate studies. One other member was transferred from a zonal CDTI project two years ago and

another has only recently been deployed to the unit. Two of three current team members are knowledgeable in

CDTI, have acquired computer, planning, monitoring and supervision skills. Perseverance and swiftness will be

required to deal with persistent delays in accounting and optimal utilization of APOC funds.

COVERAGE (Fully; 4):

Summary treatment records were only available for 2008 treatment round. Of the total 16,638 communities

eligible for treatment 16,625 were treated giving a geographic coverage of 99.9%. The therapeutic coverage for

the year was 78.7%.

19

Recommendations for the Regional level

Recommendations Implementation

Planning:

1. Develop an integrated work plan.

2. Facilitate approval of duty except

status for Light for the World.

Priority: HIGH

Indicators of success:

1. Detailed integrated work plan developed and used

2. Duty except status for Light for the World

approved

Who to take action:

RHB, NOTF and NGDO partner

Deadline for completion:

July- August 2009

Integration:

Document integration of support

activities.

Priority: HIGH


Availability of documentation for support activities

Who to take action:

RHB and NOTF.


July- August 2009

Monitoring and Supervision:

1. Limit supervision to immediate

lower level with spot checks to

Woreda.

2. Document Technical Service

Agreements, MoUs with NGDOs,

annual technical and financial

reports for each project.

Priority: MEDIUM


1. Supervision limited to zone with occasional spot

checks at Woreda

2. TSAs, annual technical and financial reports

documented

Who to take action:

RHB


July 2009

Training and HSAM:

Reduce the number of participants in

trainings workshops ensure quality.

Priority: MEDIUM


Manageable number of trainees invited to training workshops

Who to take action:

RHB


July 2009

Finances:

1. Budget holders should be aware

of budgetary allocation and

undertake regular calculation of

balances.

2. Government to improve

budgetary allocation to

MalOncho programme post

APOC.

3. Facilitate financial reporting to

APOC and monitor balance of

funds transferred.

Priority: HIGH


1. Budget holders aware of budget allocation and

managing funds

2. Increased funding to MalOncho programme post

APOC

3. Improved financial reporting and optimal utilization of

APOC funds

Who to take action:

RHB


July 2009

20

3.2 SUMMARY OF FINDINGS AND RECOMMENDATIONS AT THE ZONAL LEVEL

PLANNING (Highly, 3.5):

The zonal office has an overall written annual plan for communicable disease control namely Tuberculosis,

HIV/AIDS and EPI activities with a section on Onchocerciasis control. The Onchocerciasis control section

showed plans for mass treatment, training/retraining of CDDs, health workers and community supervisors. The

plan varied in the last three years indicating that it was targeted to the needs of each year. No detailed plan

specifically developed for Onchocerciasis control was available. The coordinator is also the malaria supervisor.

All partners namely the Zonal and Woreda administrations, NGDO partner and Regional Health Bureau were

involved in annual planning. The meetings had clear objectives, identified gaps in the implementation and

recommendations to improve performance.

There was no mid-term sustainability evaluation and therefore no sustainability plan was developed. The

sustainability plan developed after this evaluation will be used for the period after APOC funding is withdrawn.

However, the zone has a budget and funds are released for integrated implementation of programme activities.

21

INTEGRATION OF SUPPORT ACTIVITIES (Highly, 3):

There were detailed plans for the previous two years but not for the current year. Onchocerciasis and Malaria

have an integrated plan of action which covers all activities. Other programmes namely TB, EPI and HIV/AIDS

are also integrated into this. During advocacy, sensitization and mobilization for other health programmes the

Zonal health offices seizes the opportunity to carry out HSAM for Onchocerciasis and Malaria. Supervisory

checklists were used during supervision which allowed for supervision of all aspects Malaria and Onchocerciasis

including census, collection of records, Mectizan® tablets inventory and identification of problems, challenges

and taking appropriate actions.

LEADERSHIP (Fully, 4):

The leadership is effective and has taken ownership of the programme. It is aware of the progress and challenges

of the programme and makes efforts to address the challenges (e.g. having treatment and inventory data in hand,

being aware of accessibility problems etc.) and delegates responsibilities to the CDTI team members. There is

cordial relationship among the management, Onchocerciasis team and NGDO partner. All information regarding

the programme was readily available to the evaluation team.

There is an annual review meeting on CDTI and other health programmes and quarterly review meeting on

Vector-borne diseases prevention and control programmes. There is a zonal Oncho committee chaired by the

zonal administrator and the zonal health department head acts as secretary. Members consist of Capacity

building, Agriculture, Education, Water resources, Finance and Women affairs. This committee meets twice a

year to review programme activities.

MONITORING AND SUPERVISION (Highly 3.75):

Treatment summary records of the zone sent to the NOTF, financial records and annual technical reports from

2004 to 2008 were available. Reports from the Woredas to the zone were also available for the same period. The

records were of good quality. There were no records of APOC equipment at this level since such equipment goes

directly to the Woreda from the region.

Supervisory visits were made by all members of Onchocerciasis team each to different Woredas using vehicles

made available from the pool. The duration of the supervision is on average two days per Woreda. All Kebeles

now have two HEWs who are supported and supervised by Health Extension Programme Supervisors (HPSs)

which improves routine management of problems and the overall CDTI performance.

There was evidence that staff members supervised the Woreda level and carried out spot checks. Problems

identified during supervision were addressed by the appropriate level i.e. CDDs unwilling to perform roles were

22

discussed with FLHF/Kebele leaders. Other problems identified such as delays in the release of APOC funds,

shortage of vehicles, inadequate funding from government were discussed with district administrators. However

treatment registers at the community level revealed the need for improved supervision to ensure updating of

census not only for eligible but also for ineligibles.

MECTIZAN SUPPLY (Fully, 4):

Once the drugs are in Addis Ababa, the tablets are either transported from the store to the project area by the

NGDO partner or picked up by zonal staff when they are in Addis Ababa. The zonal medical store collected

drugs from Oromiya Regional Health Bureau in 2007, from FMOH in 2008 and by NGDO partner from

FMOH/Pharmaceuticals Fund and Supply Agency. The Mectizan® tablets requests are generated at the FLHFs

based on community census through the Woredas and the zone. The requests are forwarded to the Regional

Health Bureau which forwards these to the MOH who sends the request to the Mectizan® Donation Programme.

The supply of Mectizan® tablets is controlled within the zonal medical store by a pharmacist.

Sufficient tablets were received annually. In 2007 it received 3,960 tins of Mectizan® tablets, allocated to all

Woredas and had a balance of 144 tins while in 2008 all 3,952 tins of Mectizan® tablets received were allocated

to the Woredas. Of the 4,337 tins of Mectizan® tablets received in 2009, 4003 tins were allocated to the

Woredas. There is a balance of 334 tins of Mectizan® tablets. When additional drugs were required, requests

were made to the zone who supplied the requested tablets. The drug inventory at this level tallied with the drugs

allocated to the Woredas.

TRAINING AND HSAM (Highly 3.6):

The staff members were trained by the national level. They in turn train the Woreda level staff using flipcharts,

various Onchocerciasis posters and CDTI activity summary sheet. Some reports of trainings were available along

with the list of participants for the previous four years. There was evidence of need based training. Issues

identified during monitoring and supervision such as HSAM, poor reporting, non use of checklist, were used to

develop training objectives. Training was integrated and allowed for efficient use of few staff members, little

time without compromising quality and showed cost effectiveness. In Shebe Sombo district there was a newly

appointed member of the CDTI team who was not trained though this was the time his skills were need to support

CDTI activities.

To promote ownership of CDTI, staff members avail themselves of opportunities provided by other programmes

i.e. polio campaigns, Vitamin A, de-worming and Tetanus Toxoid (TT) vaccines for HSAM activities. Other

opportunities that have been utilized have been quarterly review meetings. There is evidence that HSAM

activities have been effective and resulted in improved ownership.

23

FINANCES (Highly 3):

There is a sum allocated to communicable diseases for the zonal office. These funds are utilized in an integrated

manner for all diseases. The managers are aware of government funds available to them. The budgetary

contributions of government, NGDO and APOC are clearly spelt out. Government has made an increasing annual

allocation for both current and capital expenditure. These have both been honored annually.

However, there has been a consistent under utilization of APOC funds by the project due to delays in liquidation

of funds. In 2007 only 47.8% of APOC’s funds were utilized by the project while in 2008, 70% of the allocation

was utilized. Even at this, data from WHO – Country Office and APOC revealed that only the first installments

of APOC funds were ever released which project staff did not seem to be aware of. Funds from The Carter

Center were administered by its staff in accordance with the MoU to facilitate optimum utilization and

accounting.

There were no shortfalls from the government funding, although the project could make do with additional funds.

The challenges and constraints were managed without compromising performance. Also the zonal budget has

been progressively increasing in the last 3 years. Request for release of funds are discussed with the zonal head,

a budget line identified and the request approved. The approval is sent to the finance unit for release of funds. All

funds released were spent as budgeted except APOC’s fund. Documentation was available for the requests and

expenditure.

TRANSPORT AND OTHER MATERIAL RESOURCES (Highly 3.25):

There is a pool of appropriate motor vehicles available for CDTI activities. There are sufficient quantities of

training and HSAM materials provided by APOC and partners. The transport and material resources have been

effectively used. Government provides funding for vehicle and equipment maintenance, covers cost of vehicles;

maintenance is carried done after every 5000 Kms and tyres replacement are done bi-annually. All equipment

except the photocopier was functional. The photocopier was not functional because of inadequate maintenance

skills at the zone. No inventory was available. Transport is used appropriately and to support CDTI

implementation. It is controlled by the transport unit through its policies and procedures. We did not see any log

books. The transport unit has documentation of all approved trips.

Replacement of vehicles for this level is the responsibility of Regional Health Bureau and requests have been

made to the RHB. The government at this level has no plans to replace vehicles and is dependent on donations.

To forestall a gap in transportation, vehicles and equipment are pooled; activities integrated maintenance is

ensured through budgetary provision and release of funds.

HUMAN RESOURCES (Highly 3.5):

24

Three staff members are involved in CDTI activities. Only one staff member has been with the programme for

five years. Of the other two, one has been in post for two years while the current CDTI focal person is just two

months in post. The new coordinator who now manages the Maloncho programme was previously a malaria

coordinator in another Woreda for ten years. He has been trained in CDTI and is assisted by the former

coordinator. All staff members are sufficiently skilled and very committed to the programme.

COVERAGE (Fully 4):

All endemic communities were consistently treated in the last three years of 2006, 2007 and 2008 thus attaining a

geographic coverage of 100%.

The therapeutic coverage has been also been progressively increasing from 71% in 2006 to 83% in 2007 and

2008.

Recommendations at the Zonal level


Planning:

Zonal staff should develop detailed plan of

action and use it to guide the day-to-day

activities

Priority: HIGH


Detailed plan of action is available and used to

guide implementation of programme activities.

Who to take action:

Zonal CDTI Focal Person, Head of Zonal

Heath Department


June 2009


Zonal staff to spot check district population

figures to ensure updating of census includes

ineligibles.

Priority : HIGH


Ineligibles included in district population

ineligibles

Who to take action:

Zonal CDTI Focal Person


February – March 2010

Training and HSAM:

1. Train newly assigned member of CDTI

team in Shebe Sombo and other health

workers in all the four CDTI districts.

2. Train district staff on inclusion of

ineligibles in census update.

Priority: MEDIUM


1. New district staff is trained by zonal

staff.

2. Census includes ineligibles

Who to take action:

ZHDH, Zonal CDTI Focal Person, partner

NGDO


January 2010

Finances:

Facilitate financial reporting to APOC and

monitor balance of funds transferred.

Priority: HIGH


Improved financial reporting and optimal

utilization of APOC funds

25

Who to take action:

ZHDH, Zonal CDTI Focal Person,

NOTF/APOC


July 2009

Resources:

Follow-up on request for vehicles for the

region.

Priority: MEDIUM


Vehicle for the Zonal is replaced by the region.

Who to take action:

ZHDH, Zonal CDTI Focal Person,

NOTF/APOC


June 2010

Coverage:

Update census to include ineligibles

Priority: HIGH

Indicators of Success:

Realistic therapeutic coverage in the range of

80-85%

Who takes action: FLHF staff, Woreda and

zone CDTI teams

Deadline: January - February 2010

26

3.3 SUMMARY OF FINDINGS AND RECOMMENDATIONS AT THE WOREDA LEVEL

PLANNING (Fully, 4):

Both Woredas visited had detailed integrated plans of activities. In Mana Woreda, plans were available for 2004,

2006, 2007 and 2008 whereas in Shebe Sombo Woreda which was created in 2007 plans for 2007-2009 only

were available. The integrated plans are developed in a participatory manner with the Kebele management. At the

Kebele level the Health Extension Workers and Kebele leaders develop a draft plan which is refined and

approved by the Woreda health management team. Kebeles are grouped by the health facilities that serve them.

Activities listed in the plans included training of health workers, Mectizan® tablets supply based on community

requests and integrated HSAM and monitoring and supervision. The Woreda has demonstrated ownership of the

programme.

INTEGRATION OF SUPPORT ACTIVITIES (Fully, 4):

The focal person at Mana district has been in post for six years. He is also responsible for the Health Extension

Programme supervisors (17 minimum health packages). Through this; he initiates CDTI and Malaria control

referred to as MalOncho programme which staff members combine. In Shebe Sombo Maloncho activities are

27

combined with Integrated Diseases Surveillance and Response, family planning, Tuberculosis (TB) and

HIV/AIDS. Besides these several tasks such as monitoring and supervision, HSAM and collection of reports are

combined during trips to FLHFs and campaigns for various health interventions.

There is an integrated checklist for MalOncho which is used for supervision and submitted as trip reports. In

Mana Woreda trip reports are written and discussed with Woreda Health Office Head.

LEADERSHIP (Highly 3.5):

In both Woredas visited there are Woreda health committees comprising of the Woreda administrators, heads of

Woreda Health Offices, disease control focal persons, representatives of education, agriculture and women affairs

for inter sectoral linkages. The committees meet quarterly and the Woreda administrators and heads of Woreda

Health Offices serve as chairs and secretaries respectively. The CDTI focal persons create awareness; present

their plan and budget proposal for the year, report on CDTI activities and challenges. This promotes ownership of

CDTI by the various sectors in the Woreda.

MONITORING AND SUPERVISION (Highly, 3.65):

The reporting process is within the government health system and is well documented. In most places visited the

CDDs submit treatment registers to the HEWs who generate treatment data from the registers. In others, CDDs

collate their data. The health posts submit data to the Woreda Oncho focal persons who collate and submit to

zone health department. The reports of 2004- 2008 for Mana district and 2006-2008 for Shebe Sombo were

available and provided information on health facilities, census, coverage, trainings, ITNs and Mectizan® tablets

inventory. The training summary of community supervisors, health workers and CDDs were available for the

years stated above. Funding was allocated for communicable diseases control programmes which allowed for

integrated monitoring and supervision of activities. Financial reports of integrated activities were available for

2007 and 2008. Reports to APOC and NGDO partners were available for 2007.

The staff members utilize the plan for integrated supervision to the FLHF with spot checks to communities

during implementation of other programmes. The checklist used is for MalOncho; it is submitted as reports and

problems identified during supervision and polio campaigns were noted. Low coverage during the early years of

treatment, delays in supply, shortages, inadequate awareness and replacement of CDDs were addressed through

advocacy seminars for Woreda Administration, Kebele leaders and HEWs and discussions with community

members using IEC materials. Malaria funds were utilized for payment of allowances during delays in receipt of

APOC funding. However, treatment registers at the community level revealed the need for improved supervision

to ensure updating of census not only for eligible but also for ineligibles. There was evidence of staff motivation

through award of certificates and letters of commendation.

28

MECTIZAN SUPPLY (Fully, 4):

The drug supply is within the MoH drug supply system. The Woreda pharmacist procures Mectizan® tablets

along with other drugs and supplies from the zonal medical store based on census population from the FLHF and

communities. All drugs and supplies are stored in the Woreda medical store. Supply of Mectizan® tablets to

FLHF is controlled by the Woreda pharmacist who manages all drugs and supplies. Store receipts and issue

vouchers for 2004 -2009 in Mana district and for 2008 and 2009 in Shebe Sombo district were available for

review. In both Woredas visited sufficient tablets were collected from the zone and distributed to the respective

health facilities and were available timely for community use. Where additional tablets were required by Kebeles

a request is made to the zonal office for additional tablets.

TRAINING AND HSAM (Highly, 3.84):

The Woreda team trains the FLHF staff (HEWs and other HWs) training manuals, flipcharts, posters and

measuring sticks produced in local languages. In Shebe Sombo there was a training plan with objectives, need

based training for new health workers and community supervisors while previously trained health workers

received refresher trainings. The training is carried out by three to four staff members who share the topics

among themselves. It is efficiently carried out using the Woreda Health Office/health center hall and integrating

with Malaria as MalOncho and Enhanced Outreach Strategy (EOS). Summary reports of trainings carried out are

sent to the zonal office and copies of previous years were available for review.

There is a new team member in Shebe Sombo district health office who is not trained on CDTI. The district

health office will request the zone to train him before the next distribution of Mectizan® tablets.

HSAM is a component of the minimum health package identified as cross cutting for the other 16 packages.

There is a health education plan developed at the health center and posts. In Mana, the Woreda is divided into six

zones and zonal leaders are orientated on integrated HSAM of the programmes based on the schedule. In Shebe

Sombo social gatherings and Kebele meetings are used to disseminate health education messages. When there is

a need to sensitize decision makers, the Woreda teams take advantage of other health programmes meetings

organized i.e. polio campaigns to sensitize decision makers. During supervisory visits the leadership of the health

centers is visited first for advocacy. The focal persons support and monitor performance of HSAM.

FINANCES (Highly, 3.5):

The Woreda budgets are compiled by the coordinator Kebele based on budgets of communicable diseases

prepared by the Kebele leadership and HEWs and presented to the Woreda cabinet for approval and allocation of

funds. Funding for health programmes is through an integrated fund framework for communicable diseases in

which the budget line for Maloncho under vector-borne diseases. The managers have clear estimates of the funds

29

available for communicable diseases. In Mana Woreda, funding of vector-borne diseases increased over the last 3

years. It budgeted and released ETB 74,228 in 2009, ETB 43,163 in 2008 and ETB 33,582 in 2007. Only the first

installments of the annual APOC allocations were ever received and projects were unaware of these. From the

2008 ETB 22,136.76 received, ETB 19,386 was utilized (87.6%). In 2007 of the ETB 29,405 received ETB

29,273.68 was utilized representing 99.6%.

For vector-borne diseases and consumables, Shebe Sombo district budgeted and disbursed ETB 60,622 in 2008

and ETB 51,520 in 2007. The APOC funds received for 2007 and 2008 were ETB 22,957 and ETB16,440.

Despite full utilization, these were only first installments. The NGDO funds received through the zone were fully

expenditure and accounted for.

Requests for funds for CDTI activities are made using travel request forms, which are approved by the head of

Woreda Health Office and submitted to the finance office for disbursement. The documentation retained by the

finance unit was available for review. The budget holders keep an up to date account of their expenditure and are

therefore aware of the budget balances.

There were usually no shortfalls in the budget provision. When this occurred in Shebe Sambo, district

contingency funding was utilized. Funds from APOC and The Carter Center compliment government. If donor

funds were to cease a request would be made to the Woreda cabinet to increase its budgetary allocation. The

integrated budgeting and implementation of also allows for effective management of deficits should there be any.

TRANSPORT AND OTHER MATERIAL RESOURCES (Highly, 3.75):

There is a pool of vehicles for use by the Mana district Health Office staff. In Shebe Sombo the three motorbikes

available were donated by Unicef and are utilized for integrated implementation of health programmes. The

motor bike donated by APOC was retained by Seka district after the creation of Shebe Sombo. In both districts

there are budget lines for running costs and vehicle maintenance. There are no plans for replacement of vehicles

by the Woredas as they do not have the authority to purchase vehicles. However both districts have made

requests to the zone and the region for vehicle replacement.

The head of the Woreda Health Office approves and authorizes the use of vehicles, allocation of fuel and oil by

the transport unit and Woreda finance office. Maintenance and replacement of tyres are carried out once or twice

a year. The pool of vehicles and integration of activities has ensured adequacy and efficient use.

The CDD training guides, flip charts, posters, measuring sticks and CDD brochures for training and HSAM are

provided by partners. There were available and in adequate quantities.

HUMAN RESOURCES (Moderate, 2.75):

30

There are four staff members implementing the activities. Three have been in post for two to six years and

knowledgeable and sufficiently skilled to undertake planning, training, HSAM, supplies, monitoring and

supervision of CDTI activities. They have also received various trainings in malaria and HIV/AIDS control. The

new staff member in Shebe Sombo district who is two months old has not been trained on CDTI even at this

crucial time of CDTI activities. Plans were said to have been made to train him.

Staff members in both districts are committed to CDTI. They expressed satisfaction with their roles and

responsibilities, in the words of one health worker, “I am pleased of my involvement in an exemplary public

health intervention which should be adapted by other public health programmes”. The HWs were also

motivated by the training they received and service they rendered which they saw as their reward. All the staff

members were pleased that salaries and allowances were paid timely. Some had received certificates and

commendation letters from the Woreda administration, zonal health department and health centers.

COVERAGE (Fully, 4):

All 1,519 villages in the both Woredas were treated annually over the last six years which indicates the

effectiveness of CDTI implementation. The trend in therapeutic coverage was 82.4% to 86.7% from 2006 – 2008.

It has been stable and increasing.

31

Recommendations for the Woreda level



Woreda staff to ensure district population

includes ineligibles.

Priority : HIGH


Registers updated to include ineligibles

Who to take action:

Woreda CDTI Team, HEP supervisor



Training and HSAM:

1. Train newly assigned member of CDTI

team in Shebe Sombo district.

2. Train FLHF staff to supervise census

update effectively.

Priority: HIGH


1. New CDTI team member in Shebe Sombo

trained by Zonal staff.

2. Census data updated to include ineligibles

Who to take action:

Woreda CDTI Focal Person, HEP supervisors,

partner NGDO


January 2010

Finances:

Facilitate financial reporting to APOC and

monitor balance of funds transferred.

Priority: HIGH


Improved financial reporting and optimal

utilization of APOC funds

Who to take action:

WoHO, Woreda CDTI Focal Person,

NOTF/APOC and NGDO


July 2009

Resources:

1. Follow-up on requests for allocation of

vehicles to Shebe Sombo Woreda.

2. Follow up on vehicle replacement

request made to the region for Mana

Woreda.

Priority: MEDIUM


1. Shebe Sombo Woreda allocated a

vehicle.

2. Mana Woreda vehicle is replaced.

Who to take action:

WoHO, Woreda CDTI Focal Person,

NOTF/APOC and NGDO


June 2010

Coverage:

Include ineligibles in census update.

Priority: HIGH



80-85%

Who takes action: FLHF staff, Woreda and

zone


32

3.4 SUMMARY OF FINDINGS AND RECOMMENDATIONS AT THE FLHF LEVEL

PLANNING (Fully, 4):

All the four health facilities visited had integrated written plans for the minimum health package programmes for

their respective areas and CDTI was a component of these plans. The plans were developed with the Kebele

leadership consisting of Kebele leaders, cabinet members including health extension workers, clinic heads where

applicable, school directors and community representatives. The plans are sent to the Woreda for review and

collation of the Woreda plan.

INTERGRATION OF SUPPORT ACTIVITIES (Fully, 4):

Staff members combine two or more tasks i.e. collection of tablets, monitoring and supervision, training, health

education, fetching of records and delivery of tablets. The CDTI activities are combined with EPI, family

planning, environmental hygiene, malaria control and TB. In some health facilities trip reports are available and

indicated problems identified such as poor recording and inadequate number of CDDs.

33

LEADERSHIP (Fully, 4):

The HEWs are part of the Kebele management team and develop plans together with the management.

Comments received on the plans sent to the Woreda are discussed and itemized into monthly timetables. There

are different committees in the Kebele. The health committee is chaired by the Kebele leader and members

consist of teachers, HEWs, opinion leaders and in some cases NGDO staff (Packard Foundation). There was also

an Oncho committee in one health facility. It is chaired by the Kebele leader and membership includes teachers,

opinion leaders and an agriculture extension worker. The HEWs have been trained on initiating CDTI activities

in an integrated manner. Kebele leaders agree mode and time of distribution with communities. Travel requests

by HEWs for collection of drugs are approved by the Kebele leaders. Problems identified are reported to the

Kebele leaders and management teams for discussion and solutions. A Kebele received a radio from the Woreda

for its support to Health Extension Workers and their activities. Feedback was given to the CDDs at public

gathering.

MONITORING AND SUPERVISION (Fully, 4):

The health workers collect the treatment data from the treatment registers. There is an integrated reporting system

for MalOncho. In some health facilities reports for 2004 - 2008 were available. Data in the reports included total

population, treatment coverage, Mectizan® inventory, number of LLITNs distributed, training of CDDs,

community supervisors and health workers. Original copies of the reports are sent to the Woreda Health Office

and duplicate copies kept in the Health Post files.

Supervision is integrated and an integrated checklist for the minimum package is used. Supervisory visits are

scheduled for two to three times a year but reviewed when there is a need. Programmes implemented include

environmental hygiene, TB and MalOncho. Activities carried out during supervision include assessment of

awareness, capacity of CDDs, epidemics investigation and intervention and management of health programmes.

Problems identified are addressed either by health education, discussions with Kebele leaders and training.

The Kebele leaders and the communities manage problems that arise i.e. the need to change the mode of

distribution from central point to house-to-house, nomination of new/additional CDDs to reduce workload of

CDDs and communal support to CDDs during harvesting to compensate for time lost. However, treatment

registers at the community level revealed the need for improved supervision to ensure updating of census not

only for eligible but also for ineligibles.

MECTIZAN SUPPLY (Highly, 3.6):

Orders for Mectizan® tablets are based on community census. Mectizan® tablets were made available at the

agreed distribution time. Shortages were reported in two health facilities in 2006 only. Mectizan® tablets are

collected from the Woreda medical store along with other medical supplies (Co-artem, contraceptive pills and

Depo provera®) on notification of availability by public transport. The drug inventory was available for 2004 –

34

2008 except for a new health facility where records were available from 2007 to date. It is well documented and

managed. The staff members who come to collect the drugs are reimbursed their transport cost by the Woreda.

When CDDs submit census data to FLHF staff, they are informed of when to return to collect Mectizan® tablets.

In most communities tablets were not kept for absentees after distribution.

TRAINING AND HSAM (Highly, 3.9):

Training of CDDs was generally based on need. New CDDs are trained for two days on implementation of CDTI.

Old CDDs receive refresher training based on observations during supervision. In some health facilities training

was routine and both old and new CDDs received the same training. The training materials used were CDD

brochures, posters and flipcharts. Training was either at the FLHF, primary school, Farmers Training Center

(FTC), village by village or cluster of three villages. Training was integrated with other programmes i.e. LLITNs,

EPI and hygiene.

HSAM is a cross cutting component of the minimum health package and is planned as such in the timetables.

Kebele leaders are oriented on CDTI to enable them to mobilize their communities. HSAM is carried out during

Kebele and religious gatherings and house-to-house visits. It is also integrated into environmental health,

Maternal and Child health (MCH) and communicable diseases control (malaria, HIV/AIDS and Tuberculosis).

Flip charts are available and used during health education. The HEWs carry out health education on all 16

components of the HEP. The CDDs also give health education as a result of which people are more aware and

demanding Mectizan® tablets.

FINANCES (Not Applicable):

There is no budget at this level. The HEWs live within their catchment area and are not expected to incur any

expenditure. All activities are integrated and any cost incurred during collection of drugs is reimbursed by the

Woreda.

TRANSPORT AND OTHER MATERIAL RESOURCES (Fully, 4):

There are sufficient materials for training and HSAM. Posters, flipcharts, brochures provided by APOC and The

Carter Center were seen in all facilities. Stationery is provided by the Woreda Health Office either quarterly or

bi-annually and plans to provide stationery as required.

HUMAN RESOURCES (Highly, 3.75):

Each of the three health posts is manned by two female health extension workers and they had been in post for

two to three years. In the only clinic visited the head had been in post for six years. The HEWs have received

training on CDTI and implementation of other programmes namely safe delivery, Prevention of Mother to Child

35

Transmission (PMTCT), TB and Malaria control. Some had also received training on planning and report

compilation. All were knowledgeable and sufficiently skilled to undertake CDTI activities.


All communities eligible for treatment under the catchment area of the health facilities visited were treated

annually from inception of the programme to date. In several communities Mectizan® tablets have either been

distributed or were on going for the year. Therapeutic coverage was stable and between 80% and 82% in Kela

Gude Health Post. In Doyo Toli health post which was created in 2007 records were available only for the last

two years. There was a decrease in treatment coverage from 81% in 2007 to 77% in 2008. In Chekorsa and

Sebaka Wala health posts coverage was stable between 82% and 86%.

Recommendations for the FHLF level



HEWs should review treatment registers to

ensure census update includes ineligibles.

Priority : HIGH


Ineligibles included in census update

Who to take action:

HEWs



Mectizan procurement:

CDDs to store Mectizan® tablets for

temporarily ineligibles and absentees after

distribution for a month.

Priority: HIGH


Temporarily ineligibles and absentees treated

Who to take action:

HEWs, Kebele leaders, CDDs


May-June 2010

Training and HSAM:

Train CDDs to include ineligibles in census

update.

Priority: HIGH


CDDs include ineligibles in census update

Who to take action:

HEWs, Kebele leaders, CDDs


January 2010

Coverage:

Include ineligibles in census update

Priority: HIGH



80-85%

Who takes action: CDDs, Community leaders,

FLHF staff, HEP supervisors, Woreda CDTI

focal person


36

3.5 SUMMARY OF FINDINGS AND RECOMMENDATIONS AT THE COMMUNITY LEVEL

PLANNING (Highly, 3.7):

The CDDs either agree on the timing and mode of Mectizan® tablets distribution with communities or choose

convenient time. In all communities census is updated by CDDs and figures used by health extension workers to

determine the amount of Mectizan® tablets needed for distribution. However, in most of these communities the

update of census was only for eligible members of the community. When there are problems such as refusals the

CDDs provide health education on the benefits of Mectizan® tablets and if it persist, they report to the HEWs

and Kebele leaders. In cases of reactions, analgesics are provided and sick persons are referred to health centers.

LEADERSHIP (Highly, 3.92):

We were informed during interviews with community members and CDDs that Kebele leaders promote

community participation, educate and mobilize community members; ensure registration of new arrivals, provide

information on emigrants, availability of drugs and announce the drug distribution. The leadership also ensures

right timing for distribution, encourages community members where the mode of distribution is central to come

to the central point with water, unwilling members of the community to receive treatment to increase coverage,

reporting of side effects and monitor distribution. The communities reported that members are more than willing

to come to the central point but where turnout was poor, the CDDs are requested to go house-to-house.

37

At community meetings, selection of additional CDDs to reduce the work load of existing CDDs was facilitated

by the leaders. In some communities the CDDs are selected from persons nominated to coordinate community

development activities, in others, they are selected on the basis of willingness, fairness, community mobilization

skills and literacy. Community members recalled the benefits of treatment, ineligibles, the treatment round and

that they had 6 more years to go. They also mentioned that the benefits of Mectizan® tablets are not only for this

generation but also for the next.

Community members reported that when there are delays in supply of Mectizan® tablets, people request for the

drug”. All the communities are committed to long time distribution.

MONITORING AND SUPERVISION (Highly, 3.92):

On completion of distribution CDDs submit treatment registers/reports to the health facilities along with drugs

balances timely. Transport is usually not required because the communities are all within a walking distance to

the health posts/clinics. In some communities the members are involved in monitoring.

MECTIZAN SUPPLY (Highly, 3.71):

All eligible members of the communities visited received treatment annually except in Geso community of Doyo

Toli health post where four house holds did not receive Mectizan® tablets in 2006. In some communities,

absentees are followed up for treatment for one month after which the remaining tablets are returned to the health

posts. Upon receiving information of availability of Mectizan® tablets from the HEWs the Kebele leader, the

CDDs collect their allocation of tablets from the health posts based on the updated census they submitted to the

health posts. However, census was only updated for eligible population and drugs were not reserved temporarily

ineligibles. Treatment registers were of high quality and well handled. All communities are within walking

distance to health posts/clinics. The CDDs therefore did not require transportation to collect Mectizan® tablets.

HSAM (Fully, 4):

Health education is provided either during census update or distribution by the CDDs and Kebele leadership. The

messages include transmission, eligibility, ineligibility and management of adverse effects. Health education is

given during social gatherings, Kebele meetings, schools and other community meetings and it is integrated and

includes malaria control and environmental sanitation. Information flows from Kebele leaders to village leaders

and subsequently to villages. In the first year of distribution, some CDDs reported many refusals in their

communities. This was addressed through intensive health education and as community members saw the

benefits of treatment, the refusals decreased in subsequent years.

38

FINANCES (Highly, 3.5):

During nomination of CDDs, Kebele leadership made it clear that the CDDs are to provide service for free and

advised the CDDs to use their spare time for distribution. All the communities visited do not provide support in

cash. Of the twelve communities visited only two communities (Bomba and Kochi) in Sabah Wala health post of

Shebe Sombo Woreda supported CDDs in kind by ploughing, weeding and harvesting. Community members

interviewed said they appreciate the CDDs, provide moral support, avail themselves at the time of distribution to

reduce the work load of the CDDs and thank the CDDs for services rendered. Also when central point

distribution is inconvenient the communities willingly changed the mode of distribution to house-to-house. All

CDDs interviewed expressed satisfaction with their roles and responsibilities except one. All expressed

willingness to continue providing service for as long as required. In a few communities CDDs reported that they

purchased pens and note books (not registers) on their own because they were supplied only during the

commencement of the programme.

HUMAN RESOURCES (Highly, 3.72)

In most of the communities visited house holds to CDD ratio was in the range of 10-12 households per CDD. The

CDDs were well trained and received refresher trainings. In most villages visited more CDDs have been selected,

trained and deployed for the current distribution and when there were drop outs they had been replaced except in

Afeta community in Kela Guda health post in Mana Woreda where the CDD has not been replaced for two years.

All the CDDs interviewed were very knowledgeable, informed communities of eligibility, dosing, side effects

and duration of treatment and that there were no complaints with distribution recently.

Several of the CDDs had been serving since the commencement of CDTI in 2004/2005 and were willing to

continue for as long as required. The CDDs said that the communities trusted and believed in their capacity,

participated activity without wasting their time, selected additional CDDs to reduce work load and were satisfied

with their performance. On their part, CDDs talked about the vast knowledge acquired, recognized that they are

providing good service and were determined to contribute to control and elimination of Onchocerciasis given its

severity. If they succeeded, government will use them for other programmes.

In all the communities visited the CDDs were treating people in their neighborhood. The communities’

willingness to take Mectizan® tablets also encouraged some of the CDDs to provide free service.


All communities visited had been treated annually since the inception of the programme. The treatment registers

were well kept and treatment verified through discussions with cross sections of the community which included

adult and youths (male and female).

39

Ineligible persons were not registered and this resulted in excessively high therapeutic coverage in the last three

years. In Mana district, for communities under Kela Guda health post, the therapeutic coverage was in the range

of 76.9% - 92.6% and in Doyo Toli health post, it was 72.5% - 93.4%.

For the same period in Shebe Sombo district, the therapeutic coverage for communities in Sebaha Wala health

post was in the range of 69% - 96% while for communities in Chekorsa clinic catchment area it was 80.6% -

90%.

Recommendations for the Community level


Planning and Management:

The Kebele leadership and the community

members in Afeta 3 to nominate additional

CDDs to replace the CDD who dropped out.

Priority: MEDIUM

Indicators of Success: Newly nominated CDDs in

Afeta 3 trained by FLHF

Who takes action: Community leaders, CDDs,

and FLHF staff

Deadline: January 2010

Mectizan Supply:

CDDs to retain Mectizan® tablets in

communities for temporarily ineligibles and

absentees.

Priority: HIGH

Indicators of Success: Temporarily ineligibles

and absentees treated within the treatment round

Who takes action: Community leaders, CDDs,

and FLHF staff

Deadline: March -April 2010

Finance:

Community members to provide writing

materials for CDDs

Priority: MEDIUM

Indicators of Success: Kebele leadership provides

CDDs with writing materials

Who takes action: Kebele leadership

Deadline: March -April 2010

Coverage:

CDDs to include ineligibles in census pdate

Priority: HIGH


Realistic therapeutic coverage in the range of 80 -

85%

Who takes action: CDDs, Community leaders,

FLHF staff and Woreda


40

4. Conclusions

4.1 Grading the Overall Sustainability of the Jimma CDTI project

A judgment of the sustainability of the Jimma CDTI Project was made according to the following “aspects of

sustainability” and “critical elements.”

Aspects of Sustainability:

Aspect Judgment: to what extent is this aspect helping or

blocking sustainability of this project?

Integration Very much helping

Resources Helping at zonal and Woreda levels. Very much helping at

the FLHF. Health Posts do not manage funds. They live and

work in their catchment area, Woredas provide drugs,

material and supplies and reimburse travel expenses.

Efficiency Very much helping

Simplicity Very much helping

Attitude of staff Very much helping

Community ownership Very much helping

Effectiveness Very much helping

Integration: Very much helping sustainability

The policy of integration of disease control activities in the Ethiopian health system allows for the pooling of

resources and the use of these resources for all health programmes at all levels. The Jimma CDTI Project has

achieved high geographic and therapeutic coverage since its commencement in 2004. The weakness of CDTI

being integrated with other disease control activities is that it may be seen as less of a priority in the health

system due to pooling with highly endemic or potentially fatal diseases such as malaria, Tuberculosis and

HIV/AIDS. However, the setting up of MalOncho programme will ensure this does not happen.

Resources: Helping sustainability at zonal, Woreda and vey helping at FLHF levels

Human resources are generally adequate except in the Shebe Sombo which was created two years ago. Most staff

members at all levels were in post since the inception of the programme. They are committed, stable, and skilled.

The training and deployment of HEWs (two females each per Kebele of 5,000 population) has greatly aided the

smooth implementation of CDTI at the FLHFs. Material resources were available in sufficient quantities at all

levels except in the community. There is a shortage of transport in Shebe Sombo. The integration of activities

helps to ensure effective utilization of available vehicles.

Efficiency: Vey much helping sustainability

During various campaigns and other programme activities the CDTI team avails itself of the opportunity for

HSAM to policy makers. Other activities such as health education and mobilization, training, Mectizan® tablets

procurement, monitoring and supervision and reporting are carried out in an integrated manner. Integration of

activities has therefore promoted efficiency of the project.

41

Simplicity: Vey much helping sustainability

All aspects of the project are being implemented using the existing structures at the health service and the

community level. Since no new structures are created for implementing CDTI the project operates with ease.

Even where transport is not provided for FLHF staff members, public transport system is being utilized

effortlessly to fill the gap expenses are reimbursement promptly.

Attitude of Staff: Very much helping sustainability

Health care personnel interviewed at all levels were organized, articulate and passionate about their roles and

responsibilities. They were committed to integrated service delivery and readily provided supporting

documentation for review.

Community Ownership: Very much helping sustainability

The communities have taken total ownership of CDTI programme. The level of awareness in all the communities

visited is very satisfactory. The community leadership is responsive and supportive of CDTI. When there is a

need for additional CDDs the leadership facilitates nomination of new CDDs. Most of the CDDs interviewed

have been with the programme since inception. Community members interviewed readily recalled the number of

treatments they had had and how many years they have to receive treatment. Treatment coverage has been very

high.

Effectiveness: Very much helping sustainability

The effectiveness of the project is demonstrated in its high geographic coverage of 100% and average therapeutic

coverage of 84.6% in 2008, 86% in 2007 and 84% in 2006 in the twelve communities visited by the evaluation

team.

Critical Elements of Sustainability:

Critical Element Yes/No

Money: Is there sufficient money available to undertake strictly necessary tasks which have

been carefully thought through and planned? (absolute minimum residual activities). Yes

Transport: Has provision been made for the replacement and repair of vehicles? Is there a

reasonable assurance that vehicles will continue to be available for minimum essential

activities? (note that ‘vehicle’ does not necessarily imply ‘4x4’ or even ‘car’).

No/Yes

Supervision: Has provision been made for continued targeted supportive supervision? (the

project will not be sustained without it). Yes

Mectizan supply: Is the supply system dependable? (the bottom line is that enough drugs must

arrive in villages at the time selected by the villagers). Yes

Political commitment: Effectively demonstrated by awareness of the CDTI process among

policy makers (resulting in tangible support); and a sense of community ownership of the

programme.

Yes

42

Money: Yes

The project was judged to have sufficient funds to implement CDTI activities. The integration of activities

ensures effective and efficient utilization of funds. Donor funds are available for all health programmes. If

donor funds failed to be available in the future, government funds, the establishment of the HEP and integration

particularly by the HEWs will facilitate implementation of essential CDTI activities.

Transport: No/Yes at all levels (Zone, Woreda and FLHF)

Request for replacement of vehicles and allocation for zone and Woredas have been made to the region.

However, there is no guarantee that this will be provided. The government’s policy is that HEWs assigned at the

FLHF should be living in and providing services within their catchment area and hence do not require transport.

When HEWs need to collect drugs they use public transport which is readily available. Expenditure incurred for

such activities is reimbursed by the district health office.

Supervision: Yes

It is likely that supervision for CDTI can be sustained due to government’s policy of integrating disease control

activities. Moreover, the Health Extension Programme established in 2003 created fertile ground for integrated

implementation and supervision of health programmes. The HEP supervisors who are stationed in the health

center provide supportive supervision to the nearby health posts to ensure proper implementation of programme

activities. The HEWs who live within their catchment area supervise CDTI activities along with other health

programmes.

Mectizan supply: Yes at zone, Woreda, FLHF, and communities

The supply of Mectizan® tablets is integrated within the government health system. It is simple, effective and

sustainable. Communities collected adequate quantities of Mectizan® tablets based on census.

Political Commitment: Yes

There is strong political commitment at all levels. There are health committees at all levels and Onchocerciasis

Task Forces in Jimma Zone and a FLHF. The Kebele structure promotes participation and committed leadership

along with the communities has taken total ownership of CDTI. Co-implementation of malaria and

Onchocerciasis under MalOncho programme will ensure that CDTI is not lost among the highly endemic and

potentially fatal diseases controlled by the same departments.

Grading of the project as a whole:

The evaluation team found that all seven aspects of sustainability were helping the project move towards

sustainability. Six of these were classified as ‘very helping for sustainability’. Human resource (seventh aspect)

was judged as ‘helping’. On the critical elements, we found four and half of the five elements fully satisfactory.

43

The element not fully addressed is transport. The zone and Woreda do not purchase vehicles. However, both

offices have made requests to the region for vehicle replacement and purchase respectively. Both levels have

budgetary allocation for vehicle maintenance. Also with integration of activities, vehicles donated for other

programmes have been and can be made available for implementation of CDTI activities. The evaluation team

therefore concludes that the Jimma CDTI Project is close to becoming fully sustainable. This is in agreement

with the quantitative analysis of the project, which gave an average numerical score of 3.72.

44

Annex 1

Tentative timetable for evaluation activities (Dr. Elizabeth Elhassan, Dr. Zerihun Tadesse, Mr Niguse

Birhane)

Day/Date Team Members Activity

Saturday 16th May 2009 External team members External team members arrive

Sunday 17th May 2009 All team members Review of Instruments

Monday 18th May 2009 All team members Visit to The Carter Center

Office, Commercial Bank of

Ethiopia

Travel to Jimma

Arrival in Jimma town.

Tuesday 19th May, 2009 All team members Visit to zonal Health

Department, interview Deputy

Head of zonal health

department and CDTI team

members

Visit to Mana district health

office, interview CDTI focal

person,

Visit to district medical store,

interview with district

pharmacist

Data compilation, analysis,

interpretation and report

writing of Jimma CDTI

project level

Wednesday 20th May, 2009 All team members Visit to Kela Guda Health

Post and three communities,

interview Kebele chairperson,

HEWs, CDDs and community

members

Visit to Doyo Toli Health Post

Interview HEW at Doyo Toli

Health Post



writing of Mana district level

Thursday 21st May, 2009 All Team Members Visit to three communities of

Doyo Toli health post,

Interview CDDs and

community members

Visit to Shebe Sombo district

health office, district medical

store

Interview head of district

health office, CDTI focal

45

person, district pharmacist



writing of Shebe Sombo

district level

Friday 22nd

May 2009 All team members Visit to Chekorsa clinic,

Sebah Wala Health Post,

Interview clinic head and two

HEWs

Visit to three communities of

Sebah Wala health post

Saturday 23rd

May 2009 All Team Members Visit to three communities of

Chekorsa clinic

Interview CDDs and

community members



writing of FLHFs and Shebe

Sombo district level

Sunday 24th 2009 All Team Members Data compilation, analysis,


writing of Shebe Sombo

district,

Review of zonal, districts,

FLHFs reports



writing of communities

Preparing agenda for

sustainability planning

workshop

Monday 25th 2009 All Team Members Data compilation, analysis,


writing of communities

Finalizing agenda for

sustainability planning

workshop

Visit to the zone medical store

to interview zonal pharmacist

Completion of zonal report

Preparing venue and purchase

of workshop materials

Preparing presentations for

the workshop

Tuesday 26th – Thursday 28

th,

2009

All Team Members plus

workshop participants

Presentation of evaluation

methodology, results and

recommendations

Discussions of outcomes

Development of sustainability

plan for each district and an

46

overall plan

Advocacy visits to Zonal and

Mana district policy makers

Friday 29th May, 2009 All Team members Report writing

Saturday 30th May, 2009 All Team members Return to Addis

Sunday 31st May, 2009 Report writing

Monday 1st June, 2009 All team members Visit to Oromiya Regional

Health Bureau

Interview Head of the

Regional Health Bureau and

CDTI focal person



writing

Tuesday 2nd

June, 2009 All team members Visit to Federal Ministry of

Health,

Debriefing on findings of

APOC’s evaluation of

sustainability of CDTI Project

Review of draft report

Wednesday 3rd

June, 2009 All team members Departure

Wednesday 10th June, 2009 Dr Zerihun Tadesse Interview Light for the World

Country Director

47

Annex 2

Persons Interviewed/Courtesy Visits:

NOTF and National Onchocerciasis Control Programme:

Mr. Teshome Gebre, Country Representative, The Carter Center

The World Health Organization:

Mr Tamirat Belete (email communication)

Oromiya Regional Health Bureau:

1. Sr. Mulunesh Desta, Communicable Disease Control and Surveillance Officer

2. Mr. Ajeme Wegie, Communicable Disease Control and Surveillance sub process owner

3. Mr. Asfaw Bekele, Health Plan Preparation, Budget, M & E process owner

4. Mr. Shiferaw Degefu, Purchase, Finance and Property management process manager

5. Mr. Wubishet Mekonnen, Vehicles maintenance and Transport officer

6. Mr. Dejene Akir, Record and Transport officer

7. Mrs. Yenenesh Engida, Procurement Plan and Market assessment Officer

8. Mr. Gemechu Asfaw, Finance Section Coordinator

9. Mr. Abdulmelik Ebro, Pharmaceuticals Administration sub process coordinator

10. Mr. Addisu Mekasha, Entomologist (currently studying in AAU)

Pharmaceuticals Fund and Supply Agency

1. Mr. Yetemgeta Demessie, Storage and Distribution Director

Zonal Health Desk:

Mr. Abera Assefa, Deputy Head, Zonal Health Department

Mr. Jehad Kemal, CDTI focal person, Zonal Health Department

Mr. Kunuz Jajjij Bederu, CDTI team member, Zonal Health Department

Mr. Birhanu Shewareged , Pharmacist, Zonal Medical Store

Zonal Bureau of Finance, Planning and Economic Development

Mr. Fekadu Aba Dura, Head, Finance, Planning and Economic Development

Mana Woreda Health Office:

Mr Awel A/Goddi, Health Woreda Health Office

Mr. Temesgen Worku, CDTI focal person

Ms. Banchi Yirga, Pharmacist Woreda Medical Store

Mana Woreda Bureau of Finance, Planning and Economic Development

Mr. Daniel Natae, Head, Finance, Planning and Economic Development

Mrs. Addis Alem Shawl, Budget Expert

Kela Guda Health Post:

Mrs. Foziya Haji, HEW

Kela Guda Kebele:

Mr. Ahmed Abajemal, Chairman, Kela Guda Kebele

Mr. Mulat Mitiku, CDD, Afeta 3 community

Mr. Abdu Ababosen, CDD, Koye 5 community

Mr. Kedir Abagisa, CDD Ugo community

48

Group discussions with cross section of community members (women, men and children): Afeta 3, Koye 5

and Ugo communities

Doyo Toli Health Post:

Ms. Indi Aba Raya, HEW

Ms. Jemila Awol, HEW

Doyo Toli Kebele:

Mr. Nezif Abamecha, CDD Doyo Toli community

Mr. Jihad Abagaro, CDD Doyo Toli community

Mr. Amin Abafita, CDD, Lalo community

Mr. Ahmed Abagid, CDD, Lalo community

Mr. Amin Abamick, CDD, Geso community

Mr. Nasir ShehHussein, CDD, Geso community

Group discussions with cross section of community members (women, men and children): Doyo Toli, Lalo

and Geso communities

Shebe Somboo Woreda:

Mr. Mohammed Abduhassen, Head, Woreda Health Office

Mr. Dawit Admasu, CDTI focal person, Woreda Health Office

Ms. Tsehaye Kassa, Phamacist, Woreda Medical Store

Chekorsa Clinic:

Mr. Tesfaye G/Meskel, Head, Chekorsa clinic

Chekorsa Kebele

Mrs. Fakiya Abanega, CDD, Banto community

Mr. Mohammed Yasin, CDD, Banto community

Mr. Amin Abateka, CDD, Warso, community

Mr. Alemayehu Ababora, CDD Sebera, community

Group discussions with cross section of community members (women, men and children): Banto, Warso and

Sebera communities

Sebah Wala Health Post:

Mrs. Zeineba Temam, HEW, Head of the Health Post

Ms. Amsalu Asrat, HEW

Sebah Wala Kebele:

Mr. Fekadu Getachew, CDD, Bomba community

Mr. Mustefa Abamecha, CDD, Kochi community

Ms.Munisa Abamecha. CDD, Bosa community

Group discussions with cross-section of community members (women, men and children): Bomba, Kochi

and Bosa communities

49

Annex 3

Source of Data for Evaluation at Region, Zone, District and FLHF

Region Zone District FLHF

Indicators of activities and processes: planning

Examination of:

* Written plans: yearly, quarterly, monthly etc. √ √ √ √

* Minutes of planning meetings. x x x x

Examination of

* Plans: yearly, quarterly, monthly etc. √ X √ √

* Minutes of NOTF meetings. √ X X NA

Examination of the written sustainable plans. NA NA NA NA

Interviews with various persons √ √ √ √

Indicators of activities and processes: Integration of

support activities

Examination of documents: trip authorisations, log books, trip reports etc. √ √ √ √


Indicators of activities and processes: leadership

Inspection of:

Year plans. √ √ √ √

Reports. √ √ √ √

NOTF minutes. √ NA NA NA


Indicators of activities and processes: monitoring/ supervision

Examination of the documents mentioned, and their source documents (e.g. district/ LGA reports). x √ √ √

Examination of:

* Supervisory checklists, plans and reports. √ √ √ √

50

Indicators of activities and processes: Mectizan® procurement and distribution

Examination of all Mectizan ordering and stock control documentation at this level. √ √ √ √


Indicators of activities and processes: training and HSAM

Examination of training materials, plans/ programmes, reports:

* At this level. x √ √ √

* At the levels below this one. √ √ √ √

Examination of HSAM plans/ programmes and reports. x √ √ √


Indicators of resources: financial

Examination of the budget documents. √ √ √ NA

Examination of:

* Budget documents (government, NGDO etc.) √ √ √ NA

* Records of disbursement and expenditure (ledgers, orders, approvals for expenditure etc.)

* The budget documents. (government, NGDO etc.). √ √ √ NA

* Records of expenditure (ledgers, orders, approvals for expenditure etc.). √ √ √ NA

* Letters of agreement √ √ NA

Inspection of:

* The budget documents (government, NGDO etc.). √ √ √ NA

* Financial control records (ledgers, orders, approvals for expenditure etc.). √ √ NA


Indicators of resources: transport and other material resources

Inspection of:

* Each vehicle in the pool, each piece of √ √ NA

51

equipment: its source; its functional status.

Training materials and stationery stocks √ √ √

Inspection of:

* Vehicle and equipment maintenance schedules. √ √

* Vehicle and equipment maintenance records √ √

Inspection of vehicle control documents:

* Copies of trip authorities (also noting destination and purpose). √ √

* Log books x X X NA

Inspection of letters of agreement. √ √


Indicators of resources: human resources

Inspection of:

* Staff files. x √ √

* Training reports and timetables x √ √ √

Inspection of staff files.

The table in 9.1. x √ √


Indicators of output: coverage

Inspection of:

Distribution reports and statistics at national/ project level, for the past 3 years. 1 of 3 √ √ √

National REMO records. x √ √ √

Inspection of:

Distribution reports and statistics at national/ project level, for the past 3 years. 1 of 3 √ √ √

National REMO records. x √ √ √


52

Source of Data for Evaluation at Community level

Indicators of activities and processes: planning

Inspection of community treatment registers √

Interviews with:

* CDDs. √ * Community members (the chief not being

present). √

* Community leaders. One of 12

FLHF staff √

Indicators of activities and processes: leadership and ownership

Inspection of minutes of community/ council meetings (where available).

Interviews with: √

* CDDs. √ * Community members (the chief not being

present). √

* Community leaders. 1 of 12

FLHF staff. √

Inspection of minutes of community/ council meetings (where available). X

Indicators of activities and processes: monitoring

Inspection of community distribution reports. √

Interviews with:

* CDDs. √

The persons supervising CDDs: FLHF staff, lay supervisors etc. √

Indicators of activities and processes: obtaining and managing Mectizan®

53

Inspection of treatment register for the community (held by CDDs; or at higher levels) √

Interview with:

* CDDs. √ * Communty members (the chief not being

present). √

* Community leaders. 1 of 12

The persons supervising CDDs: FLHF staff, lay supervisors √

Indicators of activities and processes: HSAM

Interviews with:

Community leaders. 1 of 12

Communty members (the chief not being present). √

CDDs. √

The persons supervising CDDs: FLHF staff, lay supervisors etc √

Indicators of resources: financing

Interviews with:



CDDs. √


Indicators of resources: human resources

Interviews with:



CDDs. √


Indicators of output: coverage

Inspection of:

* CDDs’ treatment registers. √

Yearly distribution reports for that community √

54

Annex 4

Feedback and 3-Year Sustainability Planning Workshop

3-Year Sustainability Evaluation Jimma CDTI Project

May 26-28 2009

Agenda

Day 1: Tuesday 26

May, 2009

Facilitator Reporter

9:00AM-9:15AM Opening remarks Head of Zone Health

Dept

Dr. Zerihun

Tadesse/Mr.

Nigussie Birhane 9:15 AM- 9:30AM Introduction of participants Dr. Zerihun Tadesse

9:30AM-9:45 AM Workshop program and administrative matters Dr. Zerihun Tadesse

9:45AM-10:00AM Review of the CDTI process Mr. Nigussie Birhane

10:00AM-10:15AM What is sustainability?

The objective of the evaluation

Dr. Elizabeth Elhassan

10:15AM-10:30AM Evaluation methodology Dr. Elizabeth Elhassan

10:30AM- 11:00AM Tea/coffee

11:00 AM-12:30 AM Presentation of main findings:

Community - discussion

Health Facility - discussion

Woreda - discussion

Zonal - discussion

Overall grading - discussion


Dr. Zerihun Tadesse

Dr. Zerihun

Tadesse/Mr.

Nigussie Birhane

12:30AM- 2:00PM Lunch break

2:00PM – 2:15 PM Introduction to SWOT analysis

(Division into 4 groups)


2:15PM – 3:00 PM SWOT Analysis:

Group 1: Community

Group 2: FLHF

Group 3: Woreda

Group 4: Zonal

Participants Each group

assigns a reporter

and presenter

3:00PM – 3:45 PM SWOT Analysis Presentation

(10 minutes for each group)


presents

3:45PM- 4:15PM Tea/coffee

4:15PM – 4:45PM Introduction to Group Work: What resources

are we likely to have at each level for the next

three years?

Group 1: money and human resources

Group 2: transport and material resources

Division into two groups

Dr. Zerihun Tadesse

All participants

Each group

assigns a reporter

and presenter

4:45 -5:30PM Presentation of Group Work

(10 minutes/group)


presents

5:30PM Closure of Day 1

55

Day 2: Wednesday 27 May,

2009

Reporter

8:30AM-8:45AM Guidelines for writing a 3-year

sustainability plan

Dr. Elizabeth

Elhassan

8:45 AM-9:00AM APOC financing years 6-8 Dr. Elizabeth

Elhassan

9:00AM-10:30AM Group Work: Writing the

three-years sustainability plan:

Division of groups along

administrative lines zone, each

Woreda

All groups/facilitators

Each group assigns

a reporter and

presenter

10:30AM-11:00AM BREAK BREAK

11:00AM-12:30PM Continued Group Work:

Writing the 3-years

sustainability plan

All groups/facilitators Each group assigns

a reporter and

presenter

12:30PM- 2:00PM Lunch Break

2:00PM-3:30PM Continued Group Work:

Writing the 3-years

sustainability plan


a reporter and

presenter

3:30PM- 4:00PM Tea/coffee

4:00 – 5:30 PM Continued Group Work:

Writing the 3-years

sustainability plan


a reporter and

presenter

5:30 PM Closure of Day 2

Day 3: Thursday 28

th May,2009 Facilitator Reporter

8:30AM-10:15AM Presentation of 3 years

sustainability plan

(20 minutes for each group)

All groups/facilitators Each group presents

10:15AM -10:30AM Discussions of two groups All groups/facilitators

10:30 AM-11:00AM BREAK

11:00 AM -11:30 AM Discussions of three groups All groups/facilitators

11:30 AM-12:30PM Group work

Finalization of work plan by

incorporating comments from

the discussion sessions


a reporter

12:30PM-2:00 PM Lunch break

2:00PM-4:30PM Group work cont’d

Finalization of work plan by

incorporating comments from

the discussion sessions


a reporter

4:30PM Closure of Workshop

56

Day 4: Friday 29th

May,2009 Facilitator Reporter

8:30AM-10:15AM Finalization of work plan with

Chekorsa District team,

printing and endorsement

All facilitators Each group presents

10:15AM -10:30AM Finalization of work plan with

Jimma Zone team, printing

and endorsement


11:00 AM -1:30 PM Finalization of work plan with

Dedo District team, printing

and endorsement


1:30 PM-3:30PM Finalization of work plan with

Mana District team, printing

and endorsement

All groups/facilitators Each group presents

4:30PM-6:30PM Finalization of work plan with

Shebe Sombo District team,

printing and endorsement


6:30PM Closure of Workshop

57

Annex 5

Summary of Feedback and 3-Year Sustainability Planning Workshop

Jimma CDTI 3 years Sustainability Evaluation

Feedback and Planning Workshop

26th

– 28th

May 2009

Day 1

Start time: 10:30 AM

The Zone Deputy Administrator gave the opening remarks. He appreciated the support given by the partners and

assured that the people are benefitting. He expressed the need to expand the service beyond the project Woredas.

Dr. Zerihun Tadesse explained the agenda for the three days workshop and the ground rules and administrative

issues.

Mr. Nigussie Birhane CDTI focal point for Keffa zone gave a talk on the CDTI process. He explained how CDTI

used the government health system and the community structures, the partners, their roles and responsibilities and

the strategy. The key activities in CDTI were explained. He highlighted the benefits of integration of Malaria and

Oncho and other health programmes. The role of HSAM in the successful implementation of CDTI activities was

emphasized. CDTI he said has contributed to the human resource development of health workers at various

levels, CDDs and the community members. This has enriched the knowledge base with regards to

Onchocerciasis.

Dr. Elizabeth presented the objectives of the evaluation and sustainability. She explained to the participants the

main purpose of the evaluation is to find out whether the CDTI project can continue on its own after cessation of

APOC’s support. She gave details of the four instruments used, applied at each level, analyzed and how the

evaluation team reaches its conclusion and recommendations.

The results of the sustainability evaluation for each of the four levels and the overall sustainability score were

presented. Participants asked for clarification on those indicators with lower score such as human resource and

finance. The evaluation team members explained the findings, analyses and how the scores were agreed. The

participants accepted the explanations in most of the cases.

Summarized Presentations – SWOT Analysis

I. Zone level

Strengths

- Committed leadership

- High coverage

- Effective monitoring

- Timely training

- Adequate human resource

- Timely procurement and delivery of Mectizan® tablets

Opportunity

- Availability of NDGO - The Carter Center

- Integrated programmes

Weaknesses

- Absence of detailed plan

- Delayed liquidation of APOC funds

Threats

- Insufficient vehicle and motorbikes

58

- Inadequate government budget

- Overlapping campaigns during distribution of Mectizan® tablets

II. Woreda level

Strengths

- Integration with other programmes

- Inter sectoral collaboration

- Commitment of health workers

- Timely supply of Mectizan® tablets

Weaknesses

- Incomplete census data

- Low political commitment – other activities at the Kebele level

- Inadequate supervision and lack of review of outcomes of supervision by the Woreda level

- Inadequate training

Opportunities

- Deployment of HEWs

- Integration with other campaigns – polio campaign used to pass integrated HSAM

- In-service training

Threats

- High turnover of health workers and CDDs

- Poor funding and logistics

- Inadequate transportation

- Migration of population

III. Community

Strengths

- Kebele level taskforces

- Willingness of the CDDs to provide service for as long as needed

- Committed HEWs

- Community participation

- Community encourages, thanks CDDs

Weaknesses

- Incomplete census

- Failure to replace drop out CDDs

- Inadequate supervision at the Kebele level

- Inadequate female CDDS

Opportunities

- No cost incurred for Mectizan® tablets

- Availability of HEWs

- Gov structure at the Kebele level

- Health is one of the assignment of Kebele leadership

59

Threats

- Any disruption to supply of Mectizan® tablets

IV. FLHF

Strengths

- Timely procurement of Mectizan® tablets

- Timely training

- House-to –house supervision

- High coverage

- Integration

- Committed leadership

Weaknesses

- Inadequate documentation of Mectizan® tablets inventories

- Inadequate advocacy

- Shortage of IEC materials

- Inadequate documentation of supervisory visits

Opportunities

- Integration with other programmes

- Availability of human resource

Threats

- High turnover of staff

- Unforeseen disruption of Mectizan® tablets supply

Summarized Presentations – Solutions to Weaknesses and Threats

I. FLHF

Solutions to weaknesses

- Improve inventory of Mectizan® tablets

- Improve advocacy

- Increase production of IEC materials

- Improve supervision using checklists

Solutions for threats

- Continuous accessibility of Mectizan® tablets

- Selection of HEWs from the community

II. Community

Solutions to weaknesses and threats

- Updating census both for eligible and ineligible population

- Monitoring by Kebele leaders

- Mobilization of Kebele taskforce members

- Nomination of female CDDs

60

- Training of CDDs on updating of census and timely submission of reports

III. Woreda


- Improve training

- Advocacy to political leaders

- Improve documentation and reporting system

- Conducting supportive supervision with checklist

- Deployment of health workers

- Capacity building of health workers through In service training

- Ensuring adequacy of Mectizan® tablets for new settlers

IV. Zone


- Prepare detailed implementation plan

- Timely liquidation of APOC funds

- Government to allocate adequate funds for CDTI

- Request vehicle replacement by APOC

- Adjust programmes for other activities to overcome overlap through discussions with stakeholders.

- Timely training of new Woreda CDTI staff

- Hold review meetings at Woreda and spot checking at Kebele levels after supervision

27 May, 2009

Future Resources

The participants were given guidelines to identify financial, material and human resources available for CDTI

implementation the sixth to eighth year (2009, 2010 and 2011) and group them in to two resources they are

certain to get and resources they are likely to get.

In the breakout session five groups were formed one for the zone and each of the four Woredas. They worked on

the resources and made presentations in plenary. Modifications to enrich the group work were made based on

feedback.

Advocacy Visits

The first visit was to the zone. Personnel in the Finance Departmetn were debriefed on the evaluation and the

outcome. We informed them of the need for continuous budgetary allocation and release of funds for CDTI

activities for as long as required. In his response, the head of the Finance Department explained factors taken into

account in budget allocation to the Woredas. These include population, distance from the zone and development

status of the Woredas. The personnel further elaborated that Communicable Diseases are given due emphasis in

the budgetary allocation given the burden in the zone. We were reassured of the commitment of the zone to


The team also paid an advocacy visit to Mana Woreda Finance Bureau to debrief the Head of Mana Woreda

Finance Bureau and a Budget Expert in the Bureau on the results of the five years evaluation and ask for

continuity of support to CDTI for as long as required. The officers approached explained that huge amount of

funds is allocated to expedite construction of health posts, bring services close to the community and increase

coverage and quality of services in order to achieve the MDGs. The Woreda also allocates adequate funding for


61

3- Year sustainability plan

The facilitators presented the format for developing the 3-Year sustainability plan to the group. Some of the

participants asked questions for clarification. The participants were divided into five groups again to develop

their 3 – year sustainability plans. Each of the five teams brought lap top computers to the workshop and used

these in developing their plans. This made development of the plans easier.

62

Annex 6

Participants at Feedback and 3-Year Sustainability Planning Workshop

S/N NAME Region /Zone/Woreda RESPONIBILITY

1 Fekadu Bekele Dedo CDTI Focal Person

2 Teyib Hassan Dedo Head, WoHO

3 Awol Aba Temam Dedo Administrator

4 Dereje Eshete Seka Chekorsa CDTI Focal Person

5 Girma Azaz Seka Chekorsa Head, WoHO

6 Mohammed Fatii Seka Chekorsa

Woreda Deputy

Administrator

7 Mohammed Abdurahman Shebe Head, WoHO

8 Dawit Admassu Shebe CDTI Focal Person

9 Temesgen Worku Manna CDTI Focal Person

10 Said Sherif Manna Administrator

11 Awol Abagidi Manna Head, WoHO

12 Abera Asefa Jimma zone D/Head,ZHD

13 Jihad Kemal Jimma zone CDTI Focal Person

14 Wakjira Terfase Jimma zone Deputy Administrator

15 Biya Aba Fogi Shebe Driver

16 Zakir Zinab Seka Chekorsa Driver

17 Mohammed Riad Dedo Driver

18 Wondimu Eshete Manna Driver

19 Jehad Kelifa Zone Admin Driver

20 Tadesse W/Senbet Zone Health De Driver

63

Appendix 7: The components of Health Service Extension Package:

1. Disease Prevention and Control (4 packages): major emphasis is given to Malaria, Tuberculosis, and

HIV/AIDS.

2. Family Health (5 packages): deals with maternal and child health, family planning, EPI, adolescent

reproductive health and nutrition.

3. Hygiene and environmental sanitation (7 packages): i.e. Safe excreta disposal, Solid and liquid waste

disposal, Water supply and safety measures, Food hygiene and safety measures, Healthy home

environment, Control of insects and rodents and Personal hygiene

4. Health education serves as a tool to implement all other package programs for effective awareness

creation and community mobilization. These package programs are being implemented at household and

health post level in each Kebele. On average a Kebele consists of 5,000 people and gets the service by

two trained female Health Extension Workers (MOH, 2005).

64

Appendix 8: Minutes of the Debriefing meeting on the outcome of the Evaluation of the

Sustainability of five CDTI Projects to Ministry of Health and NGDO partners, Ethiopia

Date: June 2, 2009

Time: 1:00 – 2:00 PM

Session chaired by: Dr. Kesetebirhan Admasu, Director General, Health Promotion and Disease

Prevention Directorate General, Ministry of Health

Minutes taken by: Dr. Zerihun Tadesse, Director of Programs, The Carter Center

Five of the six teams which were out in the field managed to make the necessary preparation and attend

the debriefing meeting of the evaluation of sustainability of CDTI projects to Ministry of Health and

NGDO partners. The teams which participated in the debriefing session are as follows:

1. Jimma CDTI evaluation team

2. Illubabor CDTI evaluation team

3. East Wollega CDTI evaluation team

4. West Wollega CDTI evaluation team

5. Gambella CDTI evaluation team

The teams were represented by their team and sub team leaders. The Metekel team was not yet in town

and thus could not participate in the meeting.

The five teams each made graphical presentations on the overall performance of the respective projects

after which discussions of the results followed. Issues raised and discussed are presented as follows:

1. In these evaluation exercises and the previous ones financial contribution of the government has

been difficult to demonstrate. What is the government planning to do to deal with this?

Dr. Kesetebirhan: The Government of Ethiopia has limited resources and therefore promotes

integrated approach like Health Extension Programme, MalOncho programme and so on. There

is no way for the government to promote vertical programmes. Under the Business Process Re-

engineering which the ministry is carrying out, staff members and resources will be pooled for

promotive and preventive interventions and referred to as ‘generalists’. There will no longer be

focal persons for diseases. It is therefore very difficult to allocate financial or human resources

specific for Onchocerciasis control and this responsibility will fall on experts who work on

communicable disease to run Onchocerciasis control. At the village level the HEWs in areas

where Oncho is endemic will be given the proper training to enable them to discharge their

responsibilities.

2. The evaluation teams gave the least score to transport. Do you (evaluation teams) expect the

government to assign vehicles specifically for CDTI activities? How should the vehicles be

used?

Team leader of CDTI evaluation team: APOC strongly supports integration of programmes including

use of resources for multiple programmes. The projects scored least on transport not due to integration

but due to lack of documentation that demonstrates use for the intended purpose, use of log books,

approval by supervisors and specific plans for replacement..

65

3. The evaluation teams found health workers skill gap as a major bottleneck in future

programmatic activities. What is the ministry planning to do?

Dr. Kesetebirhan: The issue raised by the evaluation teams is valid. The Ministry of Health of

Ethiopia cognizant of the skill gaps and is making the necessary preparations to conduct series

of trainings at all levels. The trainings will be integrated.

4. The Ministry is undergoing major reformation. Is it not difficult to do that without involving

partners?

Dr. Kesetebirhan: The Ministry carried out Business Process Re-engineering first and foremost

to respond to the needs of the people of Ethiopia. The most important priority is therefore the

best interest of the country and its people. However, the ministry involved major partners

throughout the reform.

5. There is a dearth of human resource situation at the Woreda level. What is your plan to alleviate

the problem?

Dr. Kesetebirhan: There is high turnover of staff at all levels. That is the major reason why we

switched our focus from “specialists” to “generalists” who can be deployed to many areas. In

addition to this, we are developing various mechanisms to build capacity of the staff such as

weekly continuous education and planning exercises carried out by groups to ensure skill

transfer among experts. A Human Resource Strategy (HR 2020) which will solve many of the

human resource problems will be launched soon.

The debriefing session was concluded by a brief remark by Dr. Kesetebirhan who thanked the

APOC evaluation teams for their good work and reassured them that the country will take major

leaps in the near future and similar evaluation exercises in the future will come up with entirely

different outcomes.

Debriefing session adjourned at 2:00 PM.

Annex 9: References

M. NOMA, B. E. B. NWOKE, I. NUTALL, P. A. TAMBALA, P. ENYONG, A. NAMSENMO, J.

REMME, U. V. AMAZIGO, O. O. KALE and A. SEKETELI - Rapid epidemiological mapping of

onchocerciasis (REMO): its application by the African Programme for Onchocerciasis Control

(APOC) - Annals of Tropical Medicine & Parasitology, Vol. 96, Supplement No. 1, S29–S39 (2002)

evaluation of the sustainability of the jimma cdti project

Documents