Community Directed Treatment with Ivermectin (CDTI) sustainability plan for project supporting levels (national, regional & zonal: 2004-2005

WIt! tte Ethiopian Program for Onchocerciasis Control Community Directed Treatment with Ivermectin(cDrI) Sustainability Plan for PROJECT SUPPORTING LEVELS (National, Regional & Zonal) Project Period: 2004-2005 Ld G & ffi t*i fi t,, Table of Contents 1. lntroduction Background lnformation ............ Rapid Epidemiological Mapping of Onchocerciasis CDTI implementation and Results ...... Financial Management of APOC Trust Funds....... New Leadership Role and lntegration of CDTL, 7. Sustainability of CDTI projects 8. Sustainability Plan Framework Year 4 (2004) 9. Budget Justification Year 4 (2004) i0. Budget Summary Year 4 (2004) i 1. Sustainability Plan Framework Year 5 (2005) "1.2. Budget Justification Year 5 (2005) 13. Budget Summary Year 5 (2005) 14. List of Available Resources I 1 2 4 5 6 6 9 11 t2 2. 4. 5. 6. ...15 t6 ...18 II 1. Introduction Onchocerciasis is prevalent in the North, Northwest, West and Southu,est part of Ftitioll.r. Aborrt twenty years back, Omen estimated the Nunrber of people infccted to be arourrd 47),-U 50 ur rur i-u.ci.r of 132,000 square kilometer. Later on, in i988 the Onchocerciasis cases in the coLrntry u,crc estimated to be around 1,380,000 and the population at risl< to be close tol.3 millror \\ ll.!l/o sl the total population of the country based on the REMO census data. Rapid Epidenrio,ic,r,,'.rl Mapping of Onchocerciasis /REMO/ studies were carried out it't 1997,1998, 2000 .,i.,j 2001 :,r various parts of the country and it shorved conrplete picture about the distribLrtion of the ci,.,';rs, and level of endemrcity in different pads of the country. Based on these surveys a large .,r-ea ol' Southem, South'uvestern, and Northrvestent Etiriopia u,ere louud to be hylter and lreso-crrclcr.prc lrrr Onchocerciasrs (map 1). The regions that arc Iocated in tltese endemic areas inclucle: Arlltara, Benishar-rgul Gutnttz, Oromia, Gambella and Southenr, Natrons, Nationalrties a11d Peoples Regiorr (SNNPR). 2. Background Information CDTI implementation in Ethiopia was first introduced in the then I(affa-Sheka zone of [hs Southern Nationalities and Peoples Region, SNNPR in 1,ear 2001 as Kaffa-Shel<a CDTI pro.;ect. The fornler Kaffa-Shekazone (norv Kaffa and Sheka zones) is one of tl-re highly affe:recl iireas arci hence prioritized for interventioti through Conrmr:nity Directed Treatpept r,,.rtlr lr,cr:rccl.irr (CDTI). CDTI activities were started in orte u'oreda of I(aflh zopc apd all three uor-erlas oIshekir zone lll 200l Based on the success of year'-1, I(affa zone exl)anded to inclLrde fir,c'i:r;:-r 1,.o,-cclrrs dLrrirrg the second year and a.other lour *,orcdas dLrring the thrr-d 1,s2,- to,ral<e a total ol10. Furthermore, the CDTI implernentation rvas starled in Bench-Maji zone (Beirch-ir4aji (:'ll t, project) in SNNPR arld Norlh Gondar CDTI project in Anrhara region in 2003. The CDTI prrgr.anr is ltrrther expanded to include 6 neu,CDTI projects; IllLrbabor, Jin.rnra, \\zest \Volleg1. apcl tasr Wollega CDTI projects in Orornia region, Metekel CDTI project in Benshangul-Gunruz Rcgio6, arrd Gar.nbella GDTI project in Gambelra regior.r dLrring 2oo3l4. 2The project was initiated with a strong partnership between APOC, affected conrnrLrnities, regic'ral, zonal, woreda admin councils and health depaftments, Federal Mirristry of Health and a1 NGDC partner (The Carter Cenrer). Aft.:i'the midtemr evaluation of CDTI sustainability, SWOT analysis r.r,as done lor eaclr lcvcl ol- health delivery structure. As a result, coverage, Mectizan order and supply, Financial Resources, Planr',.ne, Leadership, Transporl and other nraterials, Human Resources as well as trainipg apcl HSAM were considered relatively as strong points at national and regior-ral levels. On the other- itand, nr<-rnitoring and supervision was considered as weak points at these levels. Efforts hayc bee rr n:ade to address these weak pornt in thrs trvo-year sustainability plan. 3. Rapid Epidemiological Mapping ol' Onchocerciasis (REMO) Rapid Epidemiological Mapping of Onchocerciasis /REMO/ studies rvere carried or-rt in I997. 1998,2000 and 200i in various parts of the country. REMO refinenrent was slrpl)o11ccl by APO(' in areas that both APOC and NOTF/Ethiopia had identified in the westeni and southern Regions ol- Ethiopia for the exercise, Nov. i9 - Dec. 23,2001. This was can-ied out to generate enoLrgh epidenliological data on Onchocerciasis in the area and to identify areas/zones rvirere Ivernrcctrp disrrihution to the communities should be implemented. The study covered parts of SoLrth 'inclutl.lg Bench-Maji), Gambella and Ororniya Regions as well as frorn Amirara (including Metenra..,'Quara area). and Benshangul-GLrnrr-rz regions. Witlt the present exercise, REMO has bcen cr''llu!'telY refined in the countty and tlrere are relatively eriough epiderliological data on tltc distributiolt and itttensity of Onchocerciasis irr the arca in order to prioritize areas nrass treatnrcnl witil ,'sllnectltl (rrtap 1). Horvever', still there ale ferv areas rvhere REMO needs to be rcfine-rl urrrl plan is underu,ay to conduct the survev in Decentber 2003. aa 'l a Cdq) t-{ CO (.) O C) C)a a co(.) L{ co F eO o z () J4 F RU U) Cd C) L<d F aU ca 6t t{ Fri z tEl F (, F< F ; 3 .3!oY Io EJ +4. CDTI Implementation and Results CDTI implementation in was first Iaunched i' tlie country, in Kaffa-Srreka GDTI project of trreSNNPR' in year 2001' There was no Mectizan mass distributio, prior to introduction of cDTlstrategy' The major partners were APoc, FMOH, NOTF menrbers, respective rrealth autrior.rrreslocal governnlents' affected communities and NGDO (The carter ce.ter). The for,rer Kaffa-Sheka zone (now split into Kaffa and Sheka zones) is one of trre highry affected areas and rrerceprioritized for GDTI' The mass treatment did not staft at once in ail erigibre communities becauseof lack of previous experience with Mectizan nrass treat,rent as well as Iarge popuiation a,cigeographic area of the disease distributio,. GDTI actjvities rvere stafted in one woreda c:rt of I0weredas of Kaffa zone and three (all) woredas of Sheka zone. Based on the succcss of year.-r,Kaffa zone expanded to include five more woredas duri,g the second year and anotrrer rorrrworedas during the third year to nrake totar of ten. During the same year, (2003) cort projcct *,15expanded to Bench_Maji and Norlh Gondar. The National oncho Taskforce/ NOTF has been invorved i, training of professiorrars c, ,-:, he,demic region since the Iaunching of the cDTlprogram in the country. Traini,g or rrarrrersi l.Llrat zonal levels was carried out by the region and NOTF. In sorne places, wrrere there rvas short.rgeof health workers' schoolteachers and Agriculturar Deveropment Agents were trained r,- bctrainers/supervisors of cDDs' cDDs who received traini,g on GDTI did weu in undertaking theirresponsibilities and roles: in health educating and mobirizing opf trre communities, condLrcti.gvillage censlls' takirlg correct height of patierts, giving rigrrt crosage of Mectizan tabrets, rra,agirrsnrild Mectizatl ad'erse effects and reportirg acrrie'e,ents to tire next le,els. Mass treattllent \\''as carried out in Kaffa-Sheka cDTI project ciurirg the first t\\,o years, i.c.200r ct2002 Berrch-Maji and North Gondar CDTI projecrs ri'ere ircruded during rhe year 2003. Iiafftr-Sheka .DTI project had high coverage bot. geographical a,d rherapeuticar througrr out the rrrr.ee)/ears' Be,ch-Maji also scored high t,erapeutic coverage <Jurirg trre first vear and sc did Nor.(irGondar CDTI project' Acceptance of Mectiza. b;, trrc communities has bee, \,er.), irighParricularly' the beneficial srde effects of Mectizan, such as \vor-, expursron has beerr r,acle. thcpeople love the drug a lot. 5Ye ar CDTI l,---J _-_ I No-ln ' ,',.rrdar Ta e2.T bt T nrn n Var olJs TI 200 _20 rea t Coverage. in Va rious CDTI r) ro i ects 200r - 2003 Ii__ I Kaffa- l S, eka 200 I 2002 2003 l, nt'O Covcrl gc 9t6 92.6 L- I ri"'rch- lNlal ?003 78.0 5. Financial Management of APOC Trust Funds Sirict: the Iaunch of the program MoH, APoc ard the NGDO (The carter center Ethiopia) rrave beert actively illvolved in allocation of finance to the projects. The co,tributio, fronr Apoc rs higlrdLlring the first year of each GDTI project because of pro'isio./procurenrent of capitar equip,rerrs.The firrancial lllput frollt the govem,crt is q.acl,ally ircreasi.g *,hilc t6e ApoC ir,rrt rsdecreasing. Ta le 3. tn an ct ISu ort A C & Pal'tne for DTI ro ec Du rin ?00r - 2003 CDl-I TOl'AL Kafta-Sheka 589 841 2003 s58.856[-s L--- t'ncl^,-Ma 3l(r.789 Kaffa-Sheka pro ect eB n C h ]\,I a I t'P o ec t oN Grth on ad Pr ecro tHealth ersonnel Others CDDs Health nel Others CDDs Health ersonnel Others DDs 2001 135 48 934 2002 167 269 2 424 2003 286 220 3408 146 185 1 371 40 5 732TOT 588 537 766 146 18s 7tI 40 5 732 Year 'I'otal # of villages ATO 500 s00 No. ol' Villagcs Treated Gcog. Covcragc ('7,) Poltrr. in nrcso/h.\, 306,088 i ATO 254 842 233,309 I No. or l)ersons frca tcd ("1') I167-l 'lh c ra 1t. Coveragc 32tl 2086 2086 64 656, I 0g 548,62s s07,807 ll .4 925277 3277 3271 100 955,443 t7 5,282 I18.241 I6.52003 794 610 610 16.8 271,349 221,190 203,316 t s.0 91.9 711 363 363 51 126,906 t11,536 86,428 68.0 APOCYear o'I' Btal u etdg (USD ) uB c t rc CI sadp cd (usD ) NGDO i\{oIl 200 1 207 709 194 169 137,363 50 0002002 196 094 196.094 t 12.425 54.243r38,lsl s3.23 8 192.21 95,400 50 000 80,000 3 1,8002003 90,996 90.986 21 451 31,800 I Norti, Gondar 2003 160 625 71S ??1 3277 15 66. New Leadership Role and Integration ol.CDTI The health policy of the government of Ethropia focuses on prevention, prornotion and treat,ert of comnlunicable diseases and for this the health sector development program (risr.;p) .a,lric;h has eight conrponents, is designed. The liealth systenr is decentralized and integr"..cd and hence, onchocerciasis contror is integrated into trre generar hearth services. A1 ali le'els Malaria and other Vector-bome Diseases prevention and control Urrit is prir:rarrly responsible for orlchocerciasis control. The natroral, r'egional a,d zonal coordinators,,u,n,ho arc members of this team, assume collective progranr r-nanagenrer-rt responsibilrties and share tasl<s arrcl specific duties among themselves and other concemed sections rvithin the health care st.rcture. Funding and other health care resources are also nranaged in an iritegrated a,d pooled nrarrer. oncltocerctasls as one of the major comrnunicable diseases has been duly recognizeci anci isincluded rn HSDP II and in regronal as rvell as zonal lhree years strategic pla.s rvSich plays a nrajor role for sustainability of the progrant. 7. Sustainabiliry of CDTI project The issue of sustainability has received co,siderable attention since the inception of .atio,al onchocerciasis control program in Ethiopia. The Ethiopian program for onchocerciasis co,trol(EPoc) ltas done a great deal on the issue of susr.airabrrity starting f.o,r t5e first yrar.ol t'eprogram' The nlost irnporlant aspects and conrPoncnts of CDTI sLrstainabilrty are br.iel.ly cliscr:ssctl belou,. Planning The GDTI is incorporated in the HSDP II docunrent of FMoH , year-lypla.rs of Malaria a,t-r othe r\/ector-bonle Diseases Pre,ention and cortrol rea,s ard the overall t'ree-1,s3r-strategic.ealtlr plarr of the Regional Health Bureaus and zo,al health offices. Ho\\,e'er, in rhe ,ast, trrcr.c- \\.irs,o separate sustainability pla, *'orked out since tlic p.og.a.r has ar.eady bee, f,1y i,tcgr-ated i,ro rrrchealth service at all levels' Zonal health offices u,cre par-ticuiarly responsible to plan at thc 1project level. Following the midterm CDTI sustainability evaluation, however, it 5as beel deciclccl that all stakeholders at Woreda and FLHF levels should assunte the responsibility of rvorking out their respective periodic plans of action lronr this time on. Efforts will be nrade to iprple,re,r a paiicipatory and the bottom-up planning approach with the assistance of the NOTF rn lhc remairiing two project years. \ r,cadership Cutrei^li.' there is a paradign-r shift in the adr-nin structure and organizational set up of the over-all :rairdBcll'r.nt of health and other developmeut programs in tl-ie country. The general trend rs to efflpowcr the Woreda level structures and build capacities in all aspects of progralr ntapageprcpt. The CDTI, being one of the recognized and integrated health progranls of the Worecla hcalrlr serviou,'will receive leadership and close guidance from the Woreda adntip coupcil ald rhe tasr<lorce organized at this level. The federal regional and zonal levels r.vill focus o1 giving ge,cr.al suppon and the overall organizatron and management of the progranls. Monitoring and Supervision Monitoring/supervision is very critical to the sLlccess of CDTI if it is dope ip a tintely apcl elfecri'c manner. However, it was understood during the rnidtem evaiuation that the fi-eqLrelcy arrci coverage was inadequate. Supervisory checklists were not used regularly ald feedbacks were ,or communicated in writing especially at federal and regiol-ral levels. ln most cases, supervisor-1, visits were not problem oriented and targeted to irnproving poor perfonuance. These weak porpts have heen addressed in this sustainability plan. \Iectizan Supply and Distribution '--t'i: activity is coltsidered as a strong point dLrling tl-re evaluatior-r process. Mectizap pl'ocLlr-cprupt and disii'';'ution is fully integrated into the govemrnent health care delivery,systen-t. Eflorrs ri,rll r-c -'.'nue'., maintain the current level of perfomance. Train ing/HESAi\,I Org:rrri'z;,',sn and training of trainers has been tlie responsibility of natiorral and regiopal levcls pa r.'Lilarly lor parricipants from regional healtlt bureaus and zone health offices. TIte zonal stufl'rn 1un'' gives training of trainers to the Woreda and health facility staff rvho giVe trainilrg to CDDs 8and supervisors. The future direction is to build tlie capacities of the Woreda 6ealth staff so that they can be in a position to plan and irnplement trainirrg sessions after carrying out need:- assessment. Advocacy, health education, sensitization and community rlobilization has been very effective i, enhancing CDTI awareness to the general public. There is a good acceptance by the political leaders at all Ievels. There will be a need to produce nlore powerful health educatron arrd sensitization materials in order to enhance further tlte active involvement of contnrr-rnities i, decision-making process. Moreover, the beneficiary comn-rr-rnities r.vill need to be nr.,5ilized to provide effective suppo( for the CDDs serving their respective villages. Financing/Funding During the first three CDTI years, there has been no specific bLrdgetir-rg for onchocercia-,s r-o,trol activities at all levels since onchocerciasis controi is rntegrated to ol.her health systenrs. Horvsvsl-, in this sustainability plan separate budget rvill be indicated for CDTI activities. Since tit,r.\/o,-e..,, health system functions in an integrated manner, it is hoped tlat CDTI could also be,efit.ror,l funds coming front other sources like Global Fund. Transport and other Material Resources As apolicyof the Ethiopian government, available transporl facilities are used in an inLegrated a.ci pooled manner, which is a good indication of sustainability. Human Resources It is knou'n beyond any grain of doubt tl'rat the availability of sl<illed and motivated Iiunrarr resource is very critrcal to the success of CDTI. Ilorvever there is a shortage of skilled persorrcl at all levels. The midtenn evaluators rioted that there was a very high tlrmo'er as rvell as understaffing of healtli personnel at all levels. This, u,e hope, rvill inrprove in the years Ir j,, co*c as civil sen'ice refonn ls underway in the eutire country. Plans 6ave also beep urade to nroti,ate health personnel and CDDs by means of recognizing and rervarding best perfonling ipdir,lduals and institutions. 9Or*'erage The Cu'ii has achieved 100 percent geographic coverage and a therapeutic coverage of rvell over 65 perce;;1 Participants of the sustainability planning workshop believe the lact that if all other aspects and ir-rdicators of sustainability are rvell taken care there won't be a problem to maintain the current geographic coverage and improve furlher the therapeutic coverage levels. Efforts will need to i;e intensified to reduce the current rates of absentees and refusals to the best nrinimunr leve's. aC)p q) o! Oo a :E rrOoco.1o zE\2 :C rr Oom e5Q EES?Z O o a. clN o o oo"1 5ooc.lo On^ x9 r, on \D (\ co o .'1" ^O nal _ct(6cO L) 'c0 O O t-- cn OO \ q O .1 q OO GI L a U) : 6Yi o .9 EE .=un)q =!>6,o.= ] o.;: E,- e i orto",H ts"EEE=0) E o uAlo oJ<i:lrgtrv d! 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