Report of TCC mission to Ethiopia, 16-19th July 2003

REPORT OF TCC MISSION TO ETHIOPIA l6-19'h July 2003 Professor Adenike Abiose Professor Eka Braide Dr Peter Bnyong Dr Stefanie Meredith Dr Johnson Ngorok For Acur- To: CD(D I ';". i. ar' 6 i ' ' -, - .ri. rti,i 2 8 itjtt. ?00.1 nP.-,.-;ililt For lnforrrotlon To'trlfu P\0 BF) CSD L,i.V Br4 L.DT 2Table of Content List of Appendices. Background. . . . . . Schedule of Activities...... Mission Report. Findings and recommendations. Acknowledgement. Appendix I- Team members. Appendix II-Terms of Reference from APOC Appendix III-List of Members of NOTF. Appendix IV-NOTF Ethiopia Response to TCC 16..,.. Appendix V-APOC Project Summary Statistics & Definitions. Appendix Vl-Endorsement letter from Oromia District ..3 ...3 ...3 ',.4 . ..5 ,.,9 ..10 .....11 .....t2 ...... I 5 .....16 3Background The Technical Consultative Committee (TCC) meeting that took place in Ouagadougou 17-22 March 2003 recommended that a TCC mission be undertaken to Ethiopia. The mission was to provide technical assistance to the NOTF Ethiopia to revise their proposals and plan for the implementation of the new projects. As a follow-up of this recommendation, APOC management constituted a team to carry out the mission to provide such technical advice to NOTF Ethiopia so as to address the issues highlighted by TCC 16. The team consisted of five members (Annex I): Professor Adenike Abiose (Team Leader) Professor Eka Ikpi Braide (TCC Chair) Dr Peter Enyong Dr Stephanie Meredith Dr Johnson Ngorok The terms of reference (TOR) were to assist the NOTF Ethiopia to effect the necessary revisions to the 6 proposals so as to enable the NOTF to submit the proposals to APOC. The mission was to ensure that the revisions addressed (i) the common issues that cut across the six project proposals and (ii) the specific amendments recommended for each of the six CDTI proposals.(Annex II) Schedule of Activities July 15, 2003 Arrival in Addis Ababa July 16, 2003 Courtesy call on WR Ethiopia Courtesy call on Chair NOTF Ethiopia Preliminary Meeting with NOTF Ethiopia July 17,2003 Proposal Review Meeting with NOTF Courtesy call on ORBIS Representative in Ethiopia Courtesy Call on CBM Representative in Ethiopia July 18, 2003 Team Meeting and Draft report writing Debriefing of the NOTF Chair Meeting with NOTF July 19, 2003 Group work by NOTF Ethiopia Final meeting of team with the NOTF July 20,2003 Departure from Addis Ababa (except Prof Braide) July 21,2003 Debriefing of WR (Prof Braide on behalf of team) 4Mission Report Courtesy calls Team members arrived in Addis Ababa on l5th July and commenced the mission on 16ft July with a courtesy call on the Acting WHO Representative for Ethiopia, Dr Angela Benson. The team also paid a courtesy call on the Chair of NOTF Ethiopia, Dr Alemayehu Seifu and briefed him on the objective of the mission. This was immidiately followed by a preliminary meeting with the NOTF Ethiopia, at which the team requested background documents. The following background documents were made available: o National Plan of Action for the Control of Onchocerciasis 2000-2004 o Revised CDTI project proposals for East Wellega, West Wellega, Illubabor and Jimma in Oromia Region, Metekel in Beshangul-Gumuz Region and Gambella in Gambella Region. o NOTF response to TCC 16 comments . Updated REMO Map . Map of Ethiopia showing existing and new project areas o List of NOTF Members Meetings with the NOTF The first meeting with the NOTF took place afternoon of 16m July 2003.The following members were present at this and subsequent meetings: Dr Gezahegn Tesfaye -Team Leader, Malaria and ovDpc-MoH Dr Ambachew Medhin Yohannes -National programme officer, Malaria -wHo. Dr Asnakew Kebede -National Officer, Malaria-WHO Dr Daddi Jima -Expert, Malaria and OVDpC, MOH Dr Teshome Gebre -Norn secretary, NGDO chair (carter centre) Dr Assefa Worku -Carter Centre (Appendix III Full Membership of NOTF) The NOTF was briefed on the TOR of the mission and TCC concerns on the new proposals. NOTF gave a detailed response to the TCC concerns (Appendix IV) and indicated that each of the proposals had been revised and the points-iaised had been addressed in the revised version. Team members systematically discussed each of the common issues identified with the NOTF, and indicated that the specific ones would be addressed in greater detail when individual proposals were reviewed. Working sessions took place on lTth and lSth July 2003, at which the revised proposals, which had been reviewed by team members, were discussed with NOTF and adviie was given for further revision and appropriate amendments. NOTF members independently worked further on the proposals and also had a session on REMO with Dr Enyong, at which effort was made to use available REMO data and map to ideniify-the villages/districts that qualify for CDTI. Final review of work done so far took place on l9s July. 5ISSUES ADDRESSED Common Issues 1. REMO The main purpose of the nation-wide REMO exercise 2001 was to deliniate the CDTI priority areas and to train the members of the NOTF on how to conduct a survey. The plotting of the data directly on a l:200,000 map revealed that the disease is very focal in nature. The foci are interspaced with large onchocerciasis-free zones. When this information was related to the different projects, it leads to a reduction in the number of woredas to be treated in four of them. The errors encountered during the TCC review have been corrected using the present REMO data and map, but for a clearer picture of the project areas, a REA is uigently needed. It has now been agreed that the projects start treatment in the following woiedai, confirmed as CDTI areas, in the first year: o In the Jimma project, 3 woredas (Dedo, Mana, Sakachokorsa). o In the Illubabor project, 6 woredas (Mettu, Darimu, yayu-Hurumu, Alge- Sache, Ale Dido, Bedele-Dabo). o In the West Wellega project, 6 woredas (Dile-Lalo, Dawo-Dale, Hawa-Wollel, Sayo, Amfilo, Gimbi). o In the East wellega project, 7 woredas (Jima-Arjo, Diga, Bako-Tibe, wama- Bonaya, Sibu-Sire, Guto-Wayu, Leka Dulecha) o In the Gambella project, the number of woredas remains the same (Gambella, Abobo, Godere, Dima). o In the Metekel project, the number of woredas also remains the same (pawe, Guba, Mandura Dangur). The population figures will also be adjusted accordingly. 2. Technical quality of proposals The team and the NorF discussed the following amendments necessary to improve the technical quality of the proposals: Inconsistency in population Jigures and missing information:It appears that there was some confusion regarding definitions, which resulted in inconsistency in the population figures and treatment goals. The team was shown a document, apparently provided by APOC, which contained inaccurate definitions of UTG, ATO, and therapeutic coverage (Appendix V). It was agreed that the proposals should clearly indicate accurate figures for total numbers of CDTI kebeles, total number of CDTI villages, and total populalion of CDTI villages. 6For each proposal, number of persons to be treated each year (ATO) and Ultimate treatment goal (UTG) should be provided. Consistency of population and treatment figures within the document is paramount and this can only be achieved when the REA has been completed. InsufJicient information: More information should be provided on training topics to be covered for CDDs, detailed procedures for supervisions (including use of check lists, feedback and follow up), Community Self Monitoring , stakeholders meetings, type and duration of trainings for subsequent years and clarification on financial and material input by the Government at all levels. A concise summary of each planned project should be given. This should contain information on number/population of CDTI villages to be covered in year l, treatment goals, and detailed procedures for key CDTI activities. Cross border considerations and special risk issues need to be elaborated on for each project, as REA and even completion of REMO could not be carried out in certain districts due to access and security issues (e.g, Gambella and Metekel). 3. Budgeting The budgetary issues were reviewed and the NOTF has downsized the budget for capital equipment and there is now government commitment for core CDTI activities. The NOTF will clearly indicate government input into CDTI activities at every level and also adjust the rest ofthe budget according to the revised population figures and ATOs resulting from the REMO data revisions. 4. GovernmentCommitment The Ministry of Health of the Federal Republic of Ethiopia recognizes onchocerciasis as a public health problem and is anxious that Ethiopia takes advantage of APOC support before the program closes. The Primary Health infrastructure is well established in most of the project areas, and disease control activities are carried out in an integrated fashion. Letters of commitment have been obtained from the relevant Regional Ministries of Health for funding of 25% of budget costs of projects in the absence of an NGDO partner. These will be attached as endorsements to the revised proposal. (Appendix VI) 5. Partnership There are now 4 project proposals from the NOTF in Ethiopia without an NGDO partner, namely; East Wellega, West Wellega, Metekel and Gambella. The TCC recommended that "the absence of a partner NGDO should not be an absolute contraindication to approval ofa new proposal provided: 7a) the proposal is technically sound b) There is evidence that efforts to attract an NGDO have occurred but have not been successful c) A searchfor an NGDO partner, local or international, will continue d) The national Government will commit itself to providing 25% of the non-APOC funding requirement e) The proiect environment and level of PHC development is adequate to support CDTI Following the TCC mission, it is expected that the technical issues in the project proposals will be addressed and thus the first criteria will be fulfilled. It was clear from our discussions with the NOTF and from the NOTF response to the TCC report (Annex IV) that efforts had been made to find NGDO partners for these projects. Africare had been approached, had originally agreed to be involved but has now withdrawn. The NOTF hopes to identify other partners through the Christian Relief Development Agency (CRDA), an umbrella organization for NGDOs working in Ethiopia, but this will take time. The TCC mission met with representatives from two NGDOs, Orbis and CBM on July l8m to explore the potential foipartnership. l) Dr Assefa Chernet, country director for ITI, but working under the auspices of Orbis until ITI has been officially registered in Ethiopia. Dr Chernet explained that the Orbis Country Director was away. The Orbis mandate is to work in prevention of blindness programmes, currently mainly trachoma and cataracts. Their project areas currently are in Southern Region of Ethiopia, same districts as the current Carter Center onchocerciasis treatment programs or are on non-onchocerciais endemic districts. Orbis may expand into Oromia region which includes east and west Wellega, Illubabor and Jimma .Dr Chernet would convey our discussions to the Orbis director and our hope that Orbis would remain open to participating in the APoc programmes, if they expand into oromia Region.2) DrAmir Bedri, CBM. The CBM office in Addis is the regional office for countries in the horn of Africa. CBM works on prevention of blindness and community based rehabilitation, and as limited survey data from West Ethiopia gave no indication of any blinding onchocerciasis, CBM is not likely to be involved as a partner. However, CBM is a funAing agency working with many different local partners, thus if the NOTF identified specific iechnical areas where one of CBM's partners could be involved, the MOH could approach CBM directly and they may be able to provide some sort of support. The team also discussed the logistics and procedures for registration of NGDOs in Ethiopia with the NGDO representatives. There are clear criteria and documentation required, but the registration process for an NGO takes at least one year. In the interim, an NGO can operate under the auspices of an already established organization (e.g. ITI 8and Orbis ), with some restrictions like not being able to open a bank account, office or import equipment. Orbis and CBM will be supporting a position for a Vision 2O2O coordinator at the WHO office in Addis Ababa. A close working relationship with this person will be important as onchocerciasis is part of vision2020 disease control activities. The TCC mission was satisfied that serious efforts to find NGDO partners had been made and will continue. The PHC infrastructure in the 4 project areas appears to be adequate to support CDTI and the MOH will be budgeting onchocerciasis activities into the Bi-annual budget, thus the government financing should be available. These projects without an NGDO partner have a very good chance of attaining sustainability. Specific comments on proposals The specific issues for each proposal were reviewed and discussed systematically. It was observed that, to a great extent, the NOTF had addressed a number of the comments and revised the proposals accordingly. Where the comments had not been addressed, the proposals were either amended directly during the discussions or when this could not be done immediately, NOTF was advised to take note of the issues for later further revision of the projects proposals. These included; o Adjustment of ATos to realistic goals and refinement of the UTGs o Redesigr and standardization in all projects of Table I o Inclusion of RAPLOA in west wellega and Gambeila CDTI projects. o Inclusion of the full list of sustainability indicators as provided for in the sustainability evaluation tool. o Further review of the list of woredas to ensure that only hyper and meso endemic communities were included. o The inclusion of CSM and stakeholders meetings o Deletion of NGDO overheads where no NGDo had been identified. The NOTF members agreed to further review and revise the proposals to address these issues. Recommendations 1. REMO refinement and REA to be carried out urgently as a basis for identifying the villages qualified for CDTI and determining the treatment population. APOC would need to update the REMO map of Ethiopia accordingly. It would be useful for the NorF to have current administrative maps of the project areas. 2. apoc to make available to NorF Ethiopia the folrowing documents: o Guidelines for implementation of community Self Monitoring 9o Guidelines for implementing Stakeholders' meeting, and o The new format for Annual Technical Reports 3. the team noted the manpower shortage and overloading of existing staff. This will become more pronounced when the new projects are approved. The Team therefore supports the NOTF request for technical assistance from APOC, in form of an experienced national expert, particularly as attempts to attract NGDO support for the new projects have so far proved unsuccessful. Consideration should also be given to having a full time national onchocerciasis coordinator. 4. NOff to finalise the project proposals as soon as possible and submit them to APOC for review and approval. In order to start treatment in January 2004, an urgent review of the proposals is needed, to ensure that an order for the needed Mectizan@ is submitted by September 2003 (ie. four months in advance of the treatment period). Conclusion The team reviewed the amended Illubabor proposal with the NOTF and noticed that all recommended amendments had been incorporated. We are therefore confident that the capacity to effect the necessary changes for the other proposals exists, and the other proposals will be finalized speedily, given the enthusiasm of the NorF. Acknowledgement We appreciate the travel ,urangements made by WHO offices in Cameroon, Kenya and Nigeria, the WHO HQ in Geneva, and the logistic and financial arrangement made by the WHO office in Ethiopia. The members of NOTF Ethiopia grnerously made themselves available for all the work that had to be done. We also appieciate thlir hospitality. The team would like to express its appreciation to the Director of APOC for the opportunity to participate in this mission. 10 Appendix I- Team Members Professor Adenike Abiose (Team Leader) Si ghtcare lnternational P O Box 10392 Kaduna, NIGEzuA E-mail : abiose@infoweb.abs.net; adenikeabioseo@yahoo.com Phone (234) 62 417373 Fax (234) 62 4),0873 Professor Eka I Braide (TCC Chair) Department of Zoology, University of Calabar, Calabar, NIGERLA Tel.(234) 803 3416842 E-mail : ekanem_b @hotmail. com Dr Peter Enyong Tropical Medicine research Station POBox55 Kumba, CAMEROON e-mail : penyon g@camnet.cm Phone/Fax (237) 33 5 423 I Cetl (237) 77s4101 Dr Stephanie Meredith 134 Chemin du Recredoz 01220 Divonne, FRANCE e-mail: smeredith@wanadoo.fr TeUFax ( 33) 450 20 21 40 Dr Johnson Ngorok Sight Savers International P O Box 34690 Nairobi, KENYA e-mail : jn gorok@si ghtsavers.or.ke Tel. (254) 722 567897 1) Mr. Alemayehu Seifu Z)Dr. Girma Azene 3) Mr.Asnakew Kebede 4) Dr. Afework FVMariam 5) Mr. Fekede Balcha 6) Dr. Assefa Worku 7) Mr. Yohannes Mesfin 8) Mr. Gezahegn Tesfaye 9) Dr. Daddi Jima l0) Mr. Ambachew Medhin l1) Dr. Ahmed Ali 12)Mr. Nessibu Adugna Institute 13) Mr. Esey Batisso l4) Mr. Teshome Gebre l1 - NOTF Chairperson and DPCD Head, MoH - Department Head, PPD, MoH - National Officer/RBM - WHO - Expert, Malaria and OVDPC National Coordinator - Researcher, Pathobiology Institute - Program Officer - GRBP (Carter Center) - Expert, Pharmacy Dept. - MoH - Team Leader, Malaria and OVDPC - MoH - Expert, Malaria and OVDPC - MoH - National Officer/RBM - WHO - Community Health Dept., Addis Ababa University - Researcher Health & Nutrition Research - Regional Coordinator (SNNPR) - NOTF Secretary, NGDO Chair (Carter Center) Appendix II Terms of Reference from APOC Appendix III LIST OF ETHIOPIAN PROGRAM FOR ONCHOCERCIASIS CONTROL (EPOC) MEMBERS t2 Appendix IV July 14,2003 Responses of NOTF-Ethiopia to TCC16 Report PREAMBLE As a result of the preliminary discussions made between APOC Director and representatives of the Ethiopian government at the JAF8 Meeting, NOTF-Ethiopia submitted six new project proposals to the TCC in January 2003. Reilizing the urgency and short duration remaining before the phasing out of APOC support and considlring the relatively larger arealpopulation requiring mass treatment in- ttris period, NOTF members worked very hard to meet the submission deadline for TCCl6. However, to our surprise, all the six proposals were completely rejected. Having reviewed all concerns expressed by the TCC16, the NOTF realized the fact that at leasi some of the proposals could have been approved with conditions so that we could have quickly addressed those issues requiring immediate attention. The NOTF was dismayed with tie final decisions and measures taken by TCC16. Nevertheless, the national secretariat has taken up most of the issues and has tried to incorporate the amendments in the respective project proposals accordingly. Part I: Cross Cutting Issues I. REMO There were some differences observed in the earlier REMO maps and village data we were referring to when working out the proposals. However, after receivin[ the latest version from APOC/Dr. Noma, we have tried to sort out the differences and lddress the concerns of TCC16 in the revised CDTI proposals. We have carefully studied the maps and excluded/included areas as appropriate; per the most recent REMO map and have made adjustments to the geographic scope and population data accordingly. 2. Technical Quality of Proposals The NOTF followed similar pattems/approaches in working through the technical aspects of the proposals. There were three CDTI projects submitted to th. TCC and approved earlier' It was believed that we should follow similar standards as we hoped that this would certainly qualify the technical requirements of TCC/APOC. However, after receiving those feedbacks the NOTF secretariat has tried to go through some of the issues outlined and have tried to elaborate on some of the iteml, particularly as regards to various aspects of CDTI activities like training, health education, supervision, etJin view of sustainability indicators. The plans of action and timetables were revised reflecting the changes suggested by theTCC' More details have been included in the project description section.-Sustainability indicators were also incorporated as outlined in the TCC recommendation. I Il3 3. Budgeting In preparing the budgets for each project again we used essentially similar approach in calculating the requirements for each item as we did before. As advised previously by Mr. F. Agoboton, APOC Finance Manager, we tried to clearly illustrate how expenses for each line item have been calculated. Budget justifications for each item (capital equipment, personnel, training, etc.) have been provided. Major revisions on capital equipment and personnel were made (scaled down). However, the NOTF realized the fact that the TCC misunderstood the acronym for woreda health office (!VHO) as world health organization in the budget details. This time we have tried to use a different acronym to denote the woreda health office as DHO, which we thought is a universal kind of abbreviation for similar level of health care delivery. The TCC resolved that the NGDO contribution line items be removed for projects where there are no supporting NGDOs. However, the NOTF felt that deleting the NGDO line completely would imply that the search for NGDO partner has come to an end and there is no room for success anymore. Therefore it was decided that the line item be retained as a reminder and the search for partner NGDOs be pursued further. Moreover, the policy statement outlined by the most recent TCC session for projects without partner NGDOs also qualifies our position (TCCl6 report, item # 28). 4, GovernmentCommitment The NOTF has carefully examined the statement made by the TCC in line with this critical issue. Most notably, the crucial statement underscored by the TCC reviewers 'allocation of budget to core CDTI activities especially in areas without NGDO partners' was greatly acknowledged. Thereforc, realizing the fact that contributing to core CDTI activities (without being limited to covering personnel cost only) is a major step towards ensuring sustainability, the NOTF decided to make significant revisions in the budgets for all the six proposals, of course, in consultation with and consent of the respective regional governments. Special attention was given to CDTI projects with no supporting NGDOs in this particular case. The government contributions in the budget were structured in such a way that it would show an increasing trend year after year, beginning from Year L 5. In Case of Lack of NGDO partners NOTF Ethiopia duly recognizes and concurs with the concerns expressed by the TCC regarding the need for NGDO partners. The NOTF, being dismayed for having four projects without NGDO partner (it was three previously but now Gambella is also included because Africare has withdrawn), agreed to pursue with its effort of identifying NGDO partners through CRDA and the respective regional state governments. I I , { t4 Meanwhile, the NOTF fully affirms that the five policy statements have been carefully looked into while revising the four project proposals. Most notably, efforts have been made to make sure that govemment contributions will not comprise, in any way, less than 25Yo of non-APOC funding requirements. The Carter Center Ethiopia, as the lead NGDO partner for NOTF Ethiopia, has reaffirmed its readiness to continue providing technical support for those projectJwithout NGDO partners. Similarly, WHO Ethiopia as a concemed UN agency and in its capacity as NOTF member has pledged its good intention to pursue with its effort in sustaining thl partnership throughout the project lifespan. On the other hand, the NOTF warmly welcomes the move by Sight Savers lnternational to fill the gap of NGDO partners in Ethiopia. Part II: Specific fssues All specific issues stated in the TCCI6 report have been critically considered while revising each one of the six CDTI projects (copies of the CDTI project proposals provided). The following points are worth noting under this section: ' The confusion regarding "definite CDTI" and "non-cDTI" areas was carefully sorted out . Care has been taken not to set 'ambitious targets' ' Suspected Loa loa endemic areas will be surveyed before launching CDTI . Budget on capital and personnel cost has been scaled down ' Armual Treatment Objectives (ATOs) and Ultimate Treatment Goals (UTGs) have been clearly set for Year LI Community Self Monitoring will be considered and stakeholders meeting has already been considered starting from the first year. ' Membership of taskforces below Federal level has been specified ' Work plans and timetables were revised to reflect changes incorporated in the respective proposals General Recommendations Reducing paperwork, simplifying technical and financial reporting systems wouldbe very instrumental to achieving compliance and - enhanclng program sustainability. Additional technical support required (hire a fulltime consultant with the required logistics) at NorF level as we launch six new projects at a time. ! a ,