Project proposal for Community Directed Treatment with Ivermectin Jimma Project, Jimma zone, Oremia regional State, project period 2003- 2007

il!J )r' t i; r-l :i LJ r-tlr :l i.i rt U il ilt it '{ \3 ,i :-i I a I January 2003 WMH &HMWPffi E@E Jinrnra Zone Oromiya Regional State trTHIOPIA Project Period: Year 2003-2001 AFRICAN PROGRAM FOR ONCHOCERCIASTS CONTROL (APOC) RECU 2 s iAN. 2003 APOC/DIR ffiffiffiw IJ titttJ t'1:l j I TABLE OF CONTENTS LIST OF ACRONYMS iii SECTION I: BACKGROUND INFORMATION 1 INFORMATION ON THE PROJECT AREA FOR CDTI .............. Il.l. Geographical and administrative areas... I1.2 Topography, Climate, Access...... ..........,............ 61.3 Onchocerciasis Endemicity Levels 71.4 Community Structure .................... g 2. PAST AND CURRENT STATUS OF CDTI IN PROJECT AREA l0 SECTION 2: PROJECT EXECUTION OUTLINE 1i 3 DESCRIPTION OF PROPOSED CDTI3.1. Outline Plan and Timing3.2. Health Education and community lnteraction and participation ....3.3. l.ocal Operational Research. a l1 11 t2 l5 4. 5 SUPPLY, IMPORTATION, STORAGE, INVENTORY AND DELIVERY OF MECTIZAN TABLETS 16 S UPERVISION, MONITORING AND EVALUATION5.1. SupervisionduringEvaluation 5.2. Monitoring CDTI......... 5.3. Evaluation of CDTI ...:............... 6. SUSTAINABILITY OF THE CDTI AF'IER THE WITHDRAWAL O EXTERNAL FUNDING 17 I7 18 19 F ..,} j ) 6. t. 6.2. 6.3. lntegration of GDTI into other community Based pHC Systems ..... Cost Recovery System during CDTI........ Other Issues........ Organizational Structure for CDTI Financial Administration................ Timed Plan of Action..................... 20 20 23 24 7. 8. CROSS BORDER CONSIDERATIONS 25 SPECIAL RISK TSSUES SECTION 3: ADMINISTRATION/FINANCIAL ......... 27 9. ADMINISTRATION J .J 26 9.1 9.2 27 27 28 329.3 l-ltr IO. BUDGET 34 34 38 40 4t .) 10.1. Budget Estimate...........:.......... 10.2. Budget Justification................ 10.3. Current Resources available in CDTL.. APPENDIX 1: Estintated.Numbers of Contmunities and Persons to be Treated each Year by Endemicity level... Indicatois for Evaluation, Sustatnability and Integration of CDTI Budget Details Ii1 ,! rl :i f-l APPENDIX 2: APPENDIX 3: 43 44 LIST OF MAPS: MAP 1: SKETCH MAP OF JIMMA ZONE, OROMIYA REGIONAL STATE, ETHIOPIA. MAP 2: SKETCH MAP OF CURRENT CDTI WEREDAS IN JIMMA ZONE, OROMIYA REGIONAL STATE, ETHIOPIA 3 MAP 3: DISTNBUTION OF VILLEGES, ROAD NETWORK AND RIVERS IN JIMMA ZONE, OROMIYA REGIONAL STATE, ETHIOPIA 4 MAP 4: CURRENT CDTI AREAS IN ETHIOPIA LIST OF FIGURES: FIGURE l: Organizattonal Structure of National Onchocerciasis Control Program 27 2 5 FIGURE 2: FIGURE 3: FIGURE 4: Request and Disbursement of APOC Funds ... Percentage of Contribution of Each Partner for 5 years for Jimma CDTI Project...... ........:...... Annual Treatment Objective (by Endemicity Level). 29 37it;l I 42 ll 1 I 1j ! ti LIST OF ACRONYMS ? APOC- ATO- CDDs- CDTI- EARP- EPI. FDRE- GIS- IEC- KAP- MIS- MOH- MOVDCD- MOVDCU- NGO- NOTF- PHCU- REA- REMO- RHB- ROTF- SNNPR. TBA- TCC- TMEC- TOT- WOTF- ZAC- ZHO- ZOTF- African Program for Onchocerciasis Control Annual Treatment Objective Community Drug Distributors Community Directed Treatment with Ivermectin Eligible At Risk Population Expanded Progrant of Immunization Federal Democratic Republic of Ethiopia ' Geographic lnformation System lnformation Education Communication Knowledge, Aftifude, and Practice Management lnformation System Ministry of Health Malaria & Other Vector-borne Diseases Control Department Malaria & Other Vector-borne Diseases Control Unit Non Governmental Organization National Onchocerciasis Task Force Primary Health Care Unit Rapid Epidemiological Assessment Rapid Epidemiological Mapping of Onchocerciasis Regional Health Bureau Regional Onchocerciasis Task Force Southern Nation Nationalities & Peoples Region Traditional Birth Attendants Technical Consultative Committee The Mectizan Expert Committee Training of Trainers Woreda Onchocerciasis Task Force Zone Administrative Council ZoneHealth Office Zone Onchocerciasis Task Force ,i .: --J .I J I .J ,l it fr rl I .J I SECTION I: BACKGROUND INFORMATION 1. INFORMATION ON THE PROJECT AREA FOR CDTI 1.1 Geographical and administrative area(s) Jimma CDTI Project is located in the southwestem part of Oromia Regional State, in Jimma zone, extending from about 70 13" N to 80 56" N latitude uni 350 5ti' ta 370 37" E longitude. Th-e zone shares borders with West Shewa in the north, South Nations Nationalities and Peoples Regional States (SIVNPR) and Illubabor zone in the east and East Wollega and Illubabor zone in west. Jimma zone has a total surface area of 19,316.18 Sq. km. Out of this land area 26.8 % is covered with forest,29 oA is used for agricultural activities, 15.2 for grazing,animals and the remaining29.03 oZ is unused. According to the population and housing census conducted in 1994, the projected total population is 2J 18,865. About 9L o/o of thepopulations live in the rural area. 9 %o of the population live in the urban areas. Major occupation of the rural community is traditional farming. Jimma zone is one of the 12 zones in the region. The zone is further divided in l3 woredas and about 505 kebeles. Onchocerciasis disease is found to be present in almost all woredas of Jimma zone according REMO surveys carried out at various times. However, 3 woredas namely, Seka-bnokorsa, Mana and Limu-Seka have been prioritized for the first year CDTI and includes the others in the consecutiveyears. The total population of the three CDTI woredas in the first year is estimated to be 606,916. Table l: - Estimates of Number Population (Total & Risk), Kebeles and Status of REMO byWereda, Jimma Zone, Oromia Region, 2003 i .., r1 1t -t ;.J t-t .t i-i FI:( i: tt * WEREDA NO. OF Kebeles ESTIMATED POPULATION Estimated At Risk Population (EARP) REMO COMPLETED (Yes/No) Limusekar 42 l 53,320 122,656 Yes Manar 23 t46,332 I 17,065 Yes Sekachekorsat 58 307,t64 245,731 Yes Limu Kose 60 232,006 185,605 No Dedo 54 282,202 225,76t No Nada 39 232,265 I85,8r2 No Sokoru 36 143,071 lL4,456 No Gome 54 318,444 254,755 No Gera )a 94,789 75,83 I No Sigmo I6 9 r ,395 73,t t6 No Sentema l9 1 07,1 89 85,75 I NoTiro Afete 25 I t9,467 95,574 No Kersa 3I l 55,916 124 749 NoJimma lown 2t I 35,285 108,228 No TOTAL 505 2,s 18,865 CDTI ll/eredas for year one. I 2,01 5,090 ti(l I II] z r)l t? I o X FN Hoti *r 7 F> llY A ht \- lr(7F'?H N zI L+-j w :N ,-\ ?Itl-( : ^)IL^J o oz F O H Fl ILl "trJ F.l|* *( l+'( al t'iii t! l-r E fl FIil il t-J iJ l'' I tt-J ii iI i,J u cl:l c-! :j a:t N I t x :. 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Avl+{ flf,, il fl iJ IIIJ :, .i J J (..l rl tl i] rl ':-1 :l tl :.1 il it :l(-, i,lii 1.2 Topography, climate, access. 1.2.1. Please describe the type of country or bio-climatic zones that will be covered by the CDTI (e.g., rain forest, forest-savonna mosaic, Guinea sovanna, Sudan savanna, mountainous orflat), providing maps, if appropriate. Topographically, the zone lies between 880-3344 meters above sea level. Climatically the zone is classified into three geo-climatic zones: 16%hi$iand,62 % mid-land and 22 % lowland area. The mean annual Temperature rages from 10 oC to 16 0C in the high land, 160C -260C in the midland and 230C -330C 'in Iowland. The Annual Rainfall totals are highest in the highlands of th'e zone reaching 2000mm. There are two rainy seasons. The main rainy season is between June and October while small rainy season is from January to April. Some of the perennial fast flowing rivers that cross Jimma zone include: Gojeb, Ghibe, Gilgel Ghibe, Dedessa, and Kawa. There are also a number of small rivers and streams, which are tributaries of the large ones in many places in the zone. There is a main asphalted road about 239 Kms that connects the two ends of the zone extending from river Ghibe through Jimma town to Agaro town. tn addition each CDTI woreda capital is. connected to Jimma town with all weather roads. However, within the rural communities the roads are only for dry weather. 1.2.2. Give the approximate times of the rainy and dry seasons andthe months covered by thefarming season. There are two distinct seasons in the project area: Rainy season (June - October) and dry season (November - May). Agricultural activities (clearing, farming, and herding) occur all year round in the project area, but are most intensive during the rainy season. Harvesting occurs from October to December, leaving January - March as the optimum treatment period. 1.2.3. Provide information on the state of the roads, and the effect of this on the movements of CDTI personnel in the area at different times of the year. (A map may be useful) The Zonal capital city Jimma is located 335 kms southwest of Addis Ababa. The main asphalted road runs from Addis Ababa through Jimma town to Agaro town, which is located 45 kms west of Jimma. The rest two CDTI woredas are also connected to the capital with all weather roads. Nevertheless, during rainy season it is difficult to travel to the CDTI communities to carry out supervision and monitoring due to poor accessibility of the roads. Therefore, Mectizan distribution will have to be carried out during the dry seasons (January- March). Access to the health care service is about 43o/oin the zone, the effective coverage is estimated to be much lower than the above estimate due to difficult terrain, low j l 6 ,i :l .i _- t a'-lil I:r' t ,.} .t :: F'a 'vi ..: -a ..i road infrastructures and affordability, etc. [n the project zone, there are two hospitals, l3 Health Centers, 7l health stations and 10 health posts. 1.3. Onchocerciasis Endemicity Levels The levels of Onchocerciasis endemicity in communities in the CDTI areas ntust be assessed by simple ntethods before treatment starts. For the purpose of this proposal, the level of endemicity in a community or a group of similar communittes is defined on the basis of the prevalence of nodule carriers (See table l). TABLE 2: Classification criteria for endemicity levels in rural communities I .3.1 Based on the system in Table I and using the format in Appendix l, please indicate the estimated numbers of comnrunities at eoch endemic level and the numbers of persons in thent. The recent REMO data for the three districts, namely, Mana, Limu-seka and Seka-Chekorsa indicate the presence of meso to hyper endemic levels of onchocerciasis in most of the surveyed villages. See appendix l. complete Appendix I for each area covering the next 5 years of the project. 1.3.3 If methods of assessing endemicity thresholds other than nodule prevalence were used when your endemicity data were collected, please tndicate the method used. The levels of endemicity in communities of this zone were defined on the basis of nodule prevalence rate obtained by REMO Survey conducted in 1998,2001 and2002. 1.3-4- For oreas still to be covered, where endemicity levels are not yet known, please describe the method you wilt use to collect the necessary endemicity data. REMO will be refined for the remaining woredas so as to expand the CDTI project in the zone. t: i.i CJ i1 1.3.2. 7 Endemicity Level and Recommended Type of Treatment Percent of nodule carriers in REA sample (minimum sample 50 adult men) Estimated prevalence of O. Volvulus in the whole community Hyper-Endemic Community Treatment (Urgent) Greater than39%o Greater than 59o/o Meso-Endemic Communitv Treatment (Desirable) 20 -39% 40 - 59% Hypo-Endemic (Non-Urgent) Less than 20% Less than 40% lt +-t 1i L, 8.1rl :l)l ,I .i .. i :l : ., .i t:\: 1.4. CommunityStructure. Provide background inforntatiort on the social organizalions of communities in the CDTI areas. This may include infonnation on settlement pattern of the community (e.g. hamlets, seasonal farmsteads, dispersed population, etc.) The communities in CDTI areas are settled farmers, while population density in each village is very high. most of the villages are scattered apa( but a few settlement villages are so clustered. The ethnic groups in the community. I t ,. I a a A majority of community members belong to Oromo nationality. The remaining peoples belong to other ethnic goups such as: Kaffa, Dawro, Amhara, Yem, etc. . Please provide information about the area covered by CDTI indicating whether they are migrants, nomads, refugees or internally displaced populations. The community included in the proposed CDTI project area are settled farmer. Some are displaced settlers from other parts bf the country. The settlers came to the area more than two decades ago. Com muni ty I eaders hip s t ructur e. L.J Jimma zone is made up of 13 woredas. The community leadership structure in the zone is organized by the zonal administrative council (ZAC), which consists of elected members from each woreda. The ZAC is responsible for giving guidance and leadership to the community for all socio-economic activities. Each woreda is divided into large administrative communities called kebeles (4000-5000 people per kebele on average). Kebeles are further divided into smaller clusters of hbuseholds called menders (villages). Since the exact number of menders is unknown, the number of CDDs will be determined based on the size of the population (using 2-3 CDD per 250-300 as a standard). Informal social organizations in the communities include: edir, equb, etc. whereby the community members share and discuss their problem. The diagram below shows the community leadership structure. Zonal Admin Council ) Woreda Admin Council ) Kebele Admin ) Village Elders/Religious or Opinion Leaders ) Households Main occupation of comntunity and periods of major communal activities , a The main occupation of the community is farming, animal husbandry, and handcrafts. Farming activities, however, decrease from December to February after the completion of 8 fl Ft{rilit rl IJ 'i :. I t-l ;-l r-J t: ii .i ,-J L-!:{ ti n : crops harvesting. During these months, there are traditional religious celebrations such as Gena (Christmas), Timket (Epiphany), and Id-Al-Fatir. Preferred channels of communication in the contmunity. The preferred channel of communication in the community is passing messages through the community leadership structure and from'the local farmers or urban dwellers association chairpersons to the village chief and to the head of households. Besides, there are trained community health workers and traditional birth attendants that bridge the community with the health care services. Mass'media such as radio is available in certain rural communities as well. Existing active community association/groups in the area (e.g. social, religious, etc.) The existing and active community associations/groups include the farmers associations and traditional religious leaders in the rural areas and the urban dwellers associations in towns. [n addition the churches, mosques, and elders rlso have dominant roles to play in community mobilization. a a a a a a Established distribution systems in the community. There are some existing distribution systems, EPI activities such as polio campaigns, vitamin A, family planning and malaria control, which are organized through the social and religious associations mentioned above. It is also through these organizations that community mobilization and health education will begin for CDTI. The community could also recruit their distributors through these systems. Social communal activities and months during which the acttvities take place. There are various social and communal activities. Prominent among these are traditional religious celebrations such as, the foundation of the True Cross (Meskel) in September, Gena (Chrtstmas), Timket (Eptphany), and ld-Al-Ferir, in January, Eater in April. Any previous experience of the community with development/health projects. Most communities in the zone have been involved in EPI, Polio eradication campaigns, family planning, well construction, and spring protection activities. There are also community health posts managed by community health agents and traditional birth attendants in some communities. The communities therefore have well- established systems of mobilization to enhance participation in communal events. Description of other anthropological characteristics of the communities. The people of Jimma zone are predominantly muslins and Oromo by ethnicity. Sheiks and traditional religious leaders possess strong influence in decision-making and health-related behaviors. All Fridays are spared for religious activities in the Muslim 9 il1.t r! I!l trl communities. The female take responsibilities of fetching water, washing clothes at the rivers and collection of firewood from the forest. 2. PASTS AND CURRENT STATUS OF CDTI IN PROJECT AREA. 2.1 Please indicate if the CDTI is an expansion of an existing CDTI. There are two CDTI projects which have been going on for the last two-years in the neighboring region, SNNPR. However, Jimma project is a new CDTI project area. 2-2 State the number of yeors the programme has been operating, and if possible enclose previous statistical, financial and annual repQrts. Not applicable. 2.3 State the number of persons treated each year for the last 5 years: Not applicable. 2.4 List the organization(s) involved tn the programme, tlte sources and amount offunds used each yearfor the last 5 years. Not applicable I 'I I 'l I ri ..t ri :".t1t ;-i r0 TJ f!:t i., l I I E f. 'I i .t i-'1 ,!]J r-lrl ;''! '-J r! 1t}. Y--' rt T' ?'*. rlr2 r! t..5 an i1;l Ll SECTION 2: PROJECT EXECUTION OUTLINE 3. DESCRIPTION OF PROPOSED CDTI The main strateg) of the project will be to develop antl estoblish CDTI sysrems, which can be sustained by lhe endemic communities themselves withoul external support after the i-year proiect period. This section should describe how the N)TF plans to develop and implemeit CDTI ii att iigi-rtsii communiries in theproject area- The plan should take into account the need to develop approaches to CDTI, which are appropriate, for the different local situations, and the need to carefully eviiuate the implemenlation of the selected approaches and adjust them when required. 3.1 Outline Plan and Timing Activity/Justifi cation Length of Time 'sensitizaand attion theAdvocacy andzonal woredaregional, levels bewill acedemphasis pl on introduc the sEaAPOCiCDTImg and the theof leveltegy, enlisting withsupport regional the fo the NOTFAIOCPparticipation administra tive council oflicesreglona 5 weeks Agreement on the definition of roles and region based on APOC Guidelines, etc of all partners - through MoH withresponsibilities 4 weeks Procurement of essentia I proj ect Computers, Mectizan drugs, and equipment and supplies vehicles, and others. l6 rveeks trainers at regional zonal and levels, Training to those who will function as trainers and Training/ of project supervisors. 4 weeks AcalRapid EAssessments/R.Epidem iologi bey,ill outcarried to activiCDTI CSti, toexpand other woredas onbased the the levels 4 weeks ofregional,Mobilization zonal districtand uth esoriti, to the ectsupport proJ 4 weeks Pre-intervention KAP surveys and other studies will be conducted to have a baseline data to develop appropriate IEC activities and monitor behavioral changes and also assess re-infection rate. Conduct KAP Studies 12 weeks Mobilization tcendem contmunof ties, theof ect asstresslng community wellownership proJ heatheAS educationth MCSS 4 weeks andSelection Directedoftraining tributorsDisCommunity 'Ds)(CD selection of CDDs theIS of theresponsibility communiry 3 weeks registration villageHousehold and census umen trainederation DsCD Iwl I out censuscarry 2 weeks Mectizan @ Collection and Distribution tn endemic communities 8 weeks Monitoring and supervisors supervision of Mectizan@ disfibution activities by zonal and woreda 4 weeks ves CDDof distribution vitiesactiInspection andchecks)(spot by TFNOregional superv$ors I week- MIS (Management Information System fo andtreatmentsReporting wl be AS thelntralnmg on monthlareq uired, bas S andpast, v sentfeedbackappropriate theto iders ensureto theprov adherence correctl'of ve mea SUTCS recommended. Monthly NOTF/APOC eva luation team conduct internal and extema evalua tion fo the proJect 4 weeks Arutual reviews will be conducted and reports generated and used to ensure continuous improvement in designing the following yeari action plan. Review of Treatm ent A c t ivi t ies I week Preparation ofA foction Plan ther next year 2 weeks il I ,3 I l i! iT il EI ) ll il .t il 1 ,I :, I .l jl }J nrl L,, t,lrsit, n .:i, 3.2 Health education and Community Interaction and Participation 3.2.1 How will you approach and interact with the comntntity? There already exist systems of communication with the proposed project area through other health programs as described earlier. However, the following strategy will be implemented to maintain good relations with the communities: a) Discussions with zonal council chairman and head of social affairs and with woreda chairpersons, lbcal farmers and urban dwellers associations, religious leaders, community elders and'opinion leaders to better understand community values,'customs and beliefs. b) Focus group discussions will be held with social and religious groups to further mobilize the community with the support of the community leaders. c) Focus goup discussions will be held with the community members as appropriate (separating men and women, depending on the community traditions). The community members will also be encouraged at this point to take ownership of the program, defining their roles and distribution mechanisms. 3.2.2. Health education Health educotiort and comntunity mobilization will continue to be an integral part of all approaches to CDTI. Health educatiort activities should ensure continuous exchange with regards to knowledge, awareness, perception and observable attitudinal changes about Onchocerciasis and ils treatment. Appropriate health education messages in theform of posters, pamphlets and verbal presenlatiotts will need to be developed and tested. Heatth educatiott should address the following issues (Table 2); Table 2: Critical Issues in the Development of Health Education for cDTI II t i I t; a ISSUES Health Education Messages Knowledge of the disease a Local name of the disease Symptoms, Causation/transmission (simple)a Knowledge of treatment a Previous experiences with Diethylcarbamazine (DEC) Introduce Mectizan@ (ivermectin) Dosage Exclusions, Reactions, Beneficial side effects a a a Aftitude to treatrnent Advantages of Treatment: o Free, Yearly treatment . Possibiliry of Self-treatment at community level . Importance of maximal coverage Attitude to disease a The disease can be controlled Onchocerciasis blindness and skina can be Attitude to good record keeping . Minimum requirements for record keeping . Records are confidential and shictly for health use Records requrred are for subsequent drug supply t2 il n:t '. I I I r I a) Have uny KAP surveys been rlone in the project area and i,f so, whal were Ihe results/ No KAP studies had been carried out in the project area. b) Wat methods will be used to develop health education materiolfor tlte contmunities trncl for the agents who will be responsiblefor lvermectin treatment? Health education materials such as posters, leaflets and flipcharts will be developed in local languages by the project and submitted to NOTF for standardization. These materials will be field-tested and refined/adjusted in accordance with APOC accepted strategies prior to mass production. c) Wat methods will be used to provide health education to the endemic communities and to the agents responsiblefor treattnent? Jimma zone has in the past used various media for providing health education to endemic communities. Such methods include: face-to-face discussions with community members, traditional birth attendants, community health agents, the use of posters and flipcharts in local languages, and drama (role playing in local languages). Community leaders will first be informed about the disease and the necessity for regular treatment with ivermectin. These community leaders will serve as agents for the program, encouraging community members to comply with ivermectin treatment. All community members will be engaged in discussions about the health education messages, and given the opportunity to ask questions they may have regarding any aspect of the program. Community members will also provide valuable input into the development of health education messages and materials. 3.2.3. Community Participation In community-directed ivennectin delivery systen$, members of the ende'ntic communities do the execution of ivermectin treatment lhentselves. Trained personnel, lcnown as Community-Directed Distributors (CDDs) who should be fully supported by the community itself may provide treatment. The community should be responsible for the organization and execution of the CDTI with minimum but fficttve medical supervisiort, once it has received the necessary information and training. Various organizational structures at the community level, ranging from women's cooperative to traditional structures, are important for sustaintng and strengthening the support network of the CDDs. a) Explain the organization of the intended community-direcred ivermectin treatment in the project. The formation of an Onchocerciasis task force at all levels is essential in order to promote coordinated activities of Onchocerciasis control in all endemic areas. At Federal level the :d -l : r-.J l3 E' t!{t 1-.l LI 'l ,. I 'I I -t l _1 I:-. ,-1 :i n iiEJ rt l-: s, a f-\ t: NOTF is responsible for routine progranr management and acts as the liaison betwcen MOH, RHB, and NGO partners rvithin the country and outside. The NO'|F will be the governing body for Onchocerciasis control activities in Ethiopia. At regional level, MOVDC is represented by a depa(ment and will be responsible for program implementation at that level. The head of MOVDCD will act as a ROCP Coordinator. Similarly, at the Zonal and Woreda levels corresponding Onchocerciasis Control Task Forces (ZOTF and WOTF respectively) will be established. The WOTF will be responsible for program implementation at Woreda level (ensure selection of CDDs, supervision of treatment activities, record keeping, etc). Also, local health institutions under the WOTF will be responsible to coordinate, monitor, and supervise CDTI at each locality. Village (Mender) will be the smallest unit for ivermectin distribution to the communities. Several villages are clustered together to form administrative Kebeles Ied by a Kebele chairperson. CDDs selected by the comniunities will be trained on the CDTVAPOC strategy for ivermectin distribution. CDDs and other local primary health care workers will then provide health education to communities on Onchocerciasis, i.e. its cause, transmission, clinical manifestations and treatment including its prevention and control mechanisms. Communities will be mobilized to provide appropriate supporl to CDDs when they are engaged in CDTI activities to ensure sustainability of the programme. Census of households will be carried out to identify eligible and non-eligible individuals and keep the records before Mectizan distribution. The CDDs will follow up defaulters using their treatment registers. Census of households will be updated every year before Mectizan distribution. Both Woreda and Zonal health staff will carry out supporlive supervision and monitoring activities. b) How will ivennectin distributors be selected? The communities will be informed about the CDTI and APOC strategies and will be given the responsibility to select CDDs. The communities are fully empowered to replace those CDDs that show poor performance. There will not be any external influence in the process of selection of the CDDs. These CDDs are expected to be honest, dedicated, literate, and permanent residents of the community. c) How will non-eligibles be identified and defaulters followed-up? Non-eligible individuals will be identified using the complete household census registration book and this will be updated each year. Similarly, defaulters, absentees, refusals, etc will be identified using treatment record book after each treatment schedules. The identified defaulters and new eligible such as previously pregnant women but who have delivered will be treated through mopping activities. a ) t4 iait al; .-t fl 'ail .., .: i 3.3. Loca! Operational Research Are lltere any pktns to contluct locul operalional research'? ,/ YES NO If yes please give details The following operational research areas are suggested for consideration ' Establish a database on prevalence of Onchocerciasis and the associated blindness . Pre-and post intervention KAP surveys . Assessment of the therapeutic efficacy of Ivermectin in GDTI areas ' To evaluate the impact of CDTI programmes on reduction of the burden of Onchocerciasis and its beneficial effect on other internal and external parasites Q lVhat training will be provided to ensure the developntent and sustainability of the CDTI? Training of CDDs to operate CDTI is very vital to the program. To ensure sustainability of the CDTI program, TOT sessions will be conducted by the NOCP. Those trained here rvill represent both regional, zonal and Woreda levels. These individuals will in turn train representatives from health facilities who also train CDDs at community level. The training sessions will focus on the following topics: . Epidemiology of onchocerciasis, its signs and symptoms, including its treatment . APOC philosophy and CDTI strategy . Health Education and community mobilization o About Mectizan@ its advantages and the related adverse effects and management of its adverse reactions . lnclusion and exclusion criteria for ivermectin treatment . Dosage of Mectizan o Methods of dug distribution . Record keeping and reporting . Supervision and monitoring b) Indicate criteria for selecting trainees (supertisors and community-directed distributors). I) Criteria for selecting CDDs 1;) -i t:: i1 f+ (i) (i i) (iii) (iv) (") ("i) Literate if possible Resident in the community Willing to serve the community Must be honest Must be available Must be selected by community l5 il II ;lUJ 1.1!l .l -l i :J;l iJ i1li il al LJ gt :t ,:,iJ i--! 1,., II) Criteria for Selecting Supcrvisors Zonal Supervisor: Should be a PHC staff preferably zonal malaria expert Must be knowledgeable Must be interested in helping the community Must be honest (i) (ii) (i ii) (i") Woreda Supervisors: The same criteria as those for the zonal supervisor are applicable here. c) Indicate number, type and duration of training courses intended Type of Training (Workshops) Duration Number per year Orientation wor at re al level 5 days I ZonalTraining 5 days I Worgda Training 5 days J _!pD Training 3 days 200 Sessions SUPPLY, IMPORTATION, STORAGE, INVENTORY AND DELIVERY OF MECTIZAN TABLETS This secliort is only a reminder and concertts the supply, irnporlalion, slorage, inventotl, and delivery of ivennectin tablets, donated by lt[erck & Co, who yvill also pay hanclling charges for ivennectin Io their accredited ogents Mectizan@ consignments will be received through WHO and stored in the Federal MOH central stores in Addis Ababa. It rvill then be transporte.d by road to rhe Regional Health Bureau, and from there to the Jimma Zonal Health Office. The zonal health office will be responsible for delivering the drug to the Woreda Health office and health facilities (ln some areas the Woreda health office is located far from the communities. In this case, the nearby health facilities will serve as the final collection point). CDDs will then collect the drug from'the Woreda health office or health facilities. A report showing the use of the drug will be sent to MEC (Mectizan Expert Committee) at the end of every year, by the NOTF, with the subsequent application. Copies of the application and the report of its use will also be sent to APOC. An application for Mectizan@ tablets will be submitted every year by the end of August to the NorF, using the standardized form of Mectizan@ Expert Committee (MEC). This application will then forwarded to MEC in Atlanta for review and approval. 4. a r6 IJ -l .i r{ 5. SUPERVISION/MONITORING AND EVALUATION 5.1. Supervision during CDTI Projects are required to be supervised and monitored regularly. However, APOC funded projects will need to be designed to function with effective but minin-rum supervision compatible with its objectives. a) Please describe the supertisory arrangetnents you consider will be requiredfor the CDTI you propose. How will this continue at the cessotion of APOC support? There will be supportive supervision at all levels of program, during and after cessation of APOC suppoft. The supervisory teams at the national, regional and zonal levels will be responsible for supervising woreda health offices and randomly selected health institutions and CDTI targeted communities in all aspects of the programme activities. Trained supervisors from the woreda health office and the health facilities will be responsible to carry out supervision activities in their catchment CDTI areas on regular basis. Supervision activities will include performance of CDDs such as proper record keeping, complete census enumeration, Mectizan@ inventory and dosage, and monitoring during the actual distribution process. Moreover, representatives of the community will do direct supervision and monitoring activities on a regular basis in their own village following after they are given training. NGO partners will be involved during in supervision activities along with MOH supervisors The results of the supervision will be discussed with each supervised workers and thus corrective measures will be taken at the spot. This will be documented and reported to different partners at various levels. b) Describe how you would ensure that supervision would be carried out so as to . fall within the requirements of accourtting for ivermectin use . be sustained when the program ends in 5 years . ensure maximum involventent of the contmunilies in the process To ensure that the above requirements are met, the program will support regular monitoring during the actual distribution process to ascertain that correct dosage is being administered, exclusion criteria are being observed, and the collection and proper storage of unused drug is occurring. [n addition, the program will support advocacy visits to the woredas and villages by NOTF, regional, and zonal and woreda representatives of the onchocerciasis task forces at each level to encourage the active support of the community. Once training of CDDs has been completed. Zonal and Woreda supervisors will check that household enumeration has been completed according to APOC requirements. Standard supervision checklists will be used to ensure the above requirements. I :'it IJ iI iJ H t1 r.t n .a .., fl ,1 i :l I j ', 5.2 Monitoring of CDI'I It is imporlant to collect infornrution lo trtortilor the progress of the CDTI. indicalors will be used to monitor: . Ivermectindistribulion? . Health educcrtiort and contmttnity participation? o Managemenl systems? What The following items ntay be considered. Ivennect in D istrib u ti o tr . Nuntbers of contntunities and persons treated wilh ivermectin . Number of lvermectin tablets distributed/consumed o nuntber of communities reporting shortage of supplies . Regularity of treatment exercise . Contpliance o Reporting adverse reactiorts Itlt Education and Comnt unl tv Participatiorr a Numbers of comntunities participating in the project Changes in behavior towards the disease, its trealnrcnt, prevention and control Community support given to CDDs Man ent . Are activities being carried out accordmg to plan and on schedule? o Inventory control, o Are record foruns accurale and completed on time? . Numbers of persons trained o Balance of genders in staff of the program The project will consider the following indices for monitoring the program of CDTI Ivermectin 'ribution: Since Jimma zone will be starting Onchocerciasis control activities for the first time, there is currently no Management Information System (MIS) for Onchocerciasis control. The NOTF will use standardized monitoring system previously developed in other CDTI areas prior to the beginning of treatment. These include communities and persons treated with ivermectin, treatment coverage, regularity of treatment, treatment compliance, and drug reactions. In 1 I I I 'l :l tt :.- :E.' a a l8 / LI fi 7':l ;l 'l : ,i '-t .-t rl :r{ -i t, :-1i! LJ ,-rlr i"1 ,-Ja1 : addition' the project will monitor the following rates and percentages usingAnnual rreatment objectives established at the beginning of each year: . Annual treatment objectives (ATO): High-risk villages (number of high risk villages rargeted for rreatment) At risk villages (numberof at risk villages targeted for treatment) Estimated at risk population (totar popuration at risk in the region) a Treatment coverage (related to ATOs): - % of high risk villages/communities covered - % of at risk population treated Cost per person treated Tablets distributed Number of ivermectin tablets in store at He, in the field, on order, or to be ordered cat uild a a a 5.3 The degree of community participation in mobilization activities will be used asan indicator of community mobiiization. In addition, the support of the leadersand key opinion leaders in the communities will be indicative of successful mobilization as well. The impact of health education messages will be measuredthrough periodic focus group discussions and KAp studies. The project will develop through its integration with the regional, zonal, anddistrict health management and supervisioniystems to monitor, ' The planning and implementation of activities according to the timelineo Mectizan@ inventory levels o Monthly reporting of treatment indices . Numbers of personneltrained o Attempt to balance gender in staffing Evaluation of CDTI Annual external review incorporating fietd visits will be undertakert to ensure thatproiects are meeting target indtcations outlined in this proposal. Such reviewswill provide TCC with the assurance that each proiect is moving towards its longterm stated goal and if appropriate make ,"ro**"ndotions aboit any deficienciesor modifications to this project. Such reviews will draw on the indicatorsdeveloped by TCC o, o guidr.- I9 :) ;LJ ,-!rl 6. SUSTAINABILITY OF TIIE CDTI AFTER TIIE WITHDRAWAL OF EXTERNAL FUNDING Tlte cottcept of xtstairtability refers to the ability of countries and aflected comntunitrcs following inilial external investrnent to ntainlain lhe viability and continuity of the ivernteclin lreatment process wilhout exlernal support. For APOC funded projects, such support will norntally last 5 years, as the APOC donors dentand that there shall be a visible and achievable end point for the extenrctl donation aspect of the programme, and that the contntunity based distribution systents established shall thereafter be sustainable by the governments of the endemic countries concerned. Progress and plans towards sustainability, including the phasing out of external and NGDO support, ntust be reported annually and satisfactory progress in this direction will be a condition for each succeeding yeor's fimding installment. Please address the followirtg areas that relate to sustainability: integration into prinrury health care, cost- recovery, and other sustainability issues. 6.1. Integration of the CDTI into other Community-based or Primary Health Care (PHC) systems. The principal goal of the APOC is to establish cost-effective iverntectin-based control for Onchocerciasis, which can be sustained bv the endenic contmttnities and countries. One way to ensure suslainability is to integrate the CDTI into the PHC systent of the country, which nrcans ntore than just using the system for ive rntect i rt dis t r i but ion. 6.1.1 Is there an official PHC policy and struclure in the courtlty? ,/ YES NO If yes, please give a brief oulline of what it is; Primary Health Care (PHC) policy in Ethiopia is to develop and strengthen grassroots and community participation in health care. lncluding Onchocerciasis among priority health problems in the national health policy will do the integration of CDTI into the PHC system. At the regional, zonal, and woreda levels, the MOVDCU will be responsible for program implementation at'the respective levels. [n addition, combining training on CDTI with other on job training activities, including Onchocerciasis control activities in the planning process at all levels, and including Mectizan@ in the list of national essential drugs delivery system will further enhance this. The PHC system will be used to achieve full integration at peripheral level by further integrating CDTI into the activities of the PHC (training on CDTI into training of health workers). This way the PHC system will be used to achieve full integration of CDTI into general health service by obtaining support from Regional, Zonal and Woreda authorities, bilateral and multilateral organizations. rt 20 b) c) &t n II n6t n!Iil -t:l L..l i-lI ., it i, .J rl rj t-, n il 1t .-_t ln summary, the PHC structure is as lollows MOH ) REGIONAL HEALTH BUREAU) ZONAL HEALTH DEPT ) WOREDA HEALTH DEPT.^{EALTH FACILITIES (hospitals, health cenrers, health stations, health posts etc) ) COMMUNITY HEALTH poSTS (CHAs & TBAs) a) Howfunctional is lhe Printary Health Care systent? Fu I ly fu n c t i o na l, P a r t I y fu nc t io nal o r no n-fun c t i on a I (p I eas e s pe c ify) ? The system from the National level is fully functional up to the Woreda./health facrliry level. However, at the communiry level health coverage is limited. Does il cover the whole project area? ./ Yes No lf no, in what part(s) of the project area is there a fulty functional PHC structure? Wat percentage of contnruttities where Onchocerciasis is endentic, and which are eligible for commttnity-based treatment, have an existing and functionat PHC system? About 43 percent of the endemic communities have functional PHC coverage. what organizations are supporting the development of pHC in your project area? Govemment of Ethiopia (Ministry of Health), wHo, LINICEF, and some NGDos Is there any past experience in the country of a programme integrating wirh the PHC? If so, what programme was it and how successful was the intigratiin? d) e) J) s) EPI, Malaria control, and family planning drug distribution continues successfu lly. The integration Are there any plans to integrate other rural health programme, such as the Expanded Programme of Imntunization, Maternal and Chitd Health Programmes or programmes for the control of other parasitic diseases, with the PHC system? EPI, maternal and child health program malaria prevention are already integrated with the PHC system. Describe how the CDTI will be integrated into the pHC system; the way rhe PHC system will be used to achieve integration and the key persons in the PHC system that will be needed to achieve the integration. 2t t.t r, 6'.1 1i .., At the Federal level MOVDCU will be responsible for routirre program management and act as the liaison between MOH, RHB, as well as with NGO partners. Members of the Malaria unit share responsibilities among themselves and hence a separate entity of vertical program nature will not be established. The head of this unit will act as NOCP coordinator. At regional level, MOVDC is organized as a department and will be responsible for program implementation (contacting community leaders, explaining the program objectives, discuss issues related to Mectizan@ security, at regional level, including monitoring and supervision). The head of MOVDC will act as a Regional Onchocerciasis Control Coordinator. Similarly, at the zonal and woreda levels will establish corresponding Onchocerciasis Control Task Forces (ZOTF and WOTF). The WOTF will be responsible for program implementation at the woreda level (ensure selection of CDDs, supervision of treatment activities, record keeping etc). [n areas where access to the woreda health office is restricted, local health institutions will coordinate, monitor, and supervise CDTI activities The primary health care units normally provide both preventive and curative health care services with health education to populations in their catchment areas. These health care programmes are provided as a package not in isolate form and thus the CDTI activities will also be incorporated into the health extension packages in place. h) htdicate how early in the CDTI the process of integration will be introduced; how it will continue thereafter, and after how many yeors within the externally supported lifetime of the CDTI it will be contpleted. CDTI activities in Ethiopia will be integrated from the very beginning. The establishment of the program rvill rely on existing systems of health service delivery at all levels. 6.1 .2. If there is at presenl no PHC syslem in operation or in those areas where lhese slructures are non-functional, describe how the CDTI may be used to initiate and expand into such a system, giving a limeframefor intended progress. NOT APPLICABLE 6. 1.3. In which way(s) can community-directed ivermectin lreatment initiate or slrengthen PHC? CDTI is likely to encourage and facilitate the acceptance of new health initiatives in the community and at home level. Also, through the new CDTI strategy, the community will likely play a greater role in the support and ownership of the PHC system. The structures already put in place would be utilized by the PHC to enhance effective planning and implementation of the project. For example, the CDDs will develop t.a tr il 22 il ..'l ,l a, r'lil .t ,l I c:l :J i, iJ iJ €tii a-.! .: capacities and skills, which will strengthen other programs such as health education, increase IMCI coverage, initiate horne-based treatment. 6. 2. Cost-recovery Systems during Com m u nity-based It,ernt ectitt Treatnten t Cost recovery for Primary Health Care is mandatory in some countries and it may be one means of sustaining a CDTI after APOC funding ceases. However, please note well that since ivermectin is donated free, there con be no cost recovery in respect of the value of the drug itself; cost recovery can only relate to the costs of distribution. 6.2.1. Please state whether there will be any system of cost recovety (such as this recommended in Initiative) to help cover outlays on the distribution of iverntectin in the present CDTI. NO 6.2-2- State exactly how any such system will be organized, including answers rc rhe questions listed below. Wat charge will be ntade per person or per farnily? NOT APPLICABLE d) Which groups of persons witl be exempted from payment? NOT APPLICABLE e) I'ttill payments be in cash or in kind? If in kind hotv will this ensure sustainabilily? NOT APPLICABLE ) Wtat provision witl be made to ensure that all those eligible to take iverntectin, bttt who are unable to pay, will also receive treatment? How will it be deterntined who is unable to poy? NOT A??LICABLE g) Who will collect the payments? How will this person safely rransport funds to a place of safekeeping? NOT APPLICABLE h) Where and by whom will anyfunds collected be safely kept? NOT APPLICABLE i) Llthat systems will be put in place to ensure the proper use and management of collected funds? NOT APPLICABLE j) For what purpose(s), including defrayment of distribution costs, will the funds collected be used? NOT APPLICABLE k) l4/hat role will Village Health Contmittees play in the management and allocation of thefunds raised? NOT APPLICABLE 23 6.3. Other issues Please provide inforntatiott ort other issaes and constrainls relaling to sustoinabilitlt s1 CDTI 1,ou anticipate and identifu how they will be overconte. For example: The mobilizatiott of endemic contmunities Tlrc maintenance of adequate supervisiort and monitoring Inadequale huntan resources Logis tics and communicatiorts S oc ia l/cu I tur a I fac t ors Declining comntunity contpliance O Mobilization of endentic comrnttnities: Sometimes problems of mobilization of endemic community can be obstacle to sustainability of CDTI. This can be solved through sustained advocacy visits, by assigning individuals with good communication skills and expe(ise in conducting mass health education meetings to increase awareness of the community, KAP surveys to monitor belief systems. Obviously there will be a need to establish good relationships with the community leaders in order to have increased access to the communities at times like these. (ii) Maintenance of adequate supen,ision and monitoring Mectizan@ distribution should include community leaders to further increase acceptability and sustainability of the program. All records should be verified during supervisory visits, and informal discussions should be encouraged to determine community perceptions of the Mectizan@. (iii) Inadequate Human Resources lnadequacy of trained health staff and PHC units are expected to be constraints in implementing supervision and monitoring. These can be overcome by allocating adequate time for supervision, in addition to training additional supervisors from health facilities and community members. ln absence of roads in some remote areas, mules and horses can be used. (iv) Logistics and Communications During the rainy season in October to December travel to the endemic areas may be restricted. Proper planning (Mectizan@ drug orders etc) will focus on providing all high-risk villages with their drugs during the dry season (prior to the Jan-March distribution window), and encouraging completion of distribution before the rains if convenient for the communities. 24 ,alrJ I -l .-, I .-t 6.4 (v) Social/Culturalfuctors Careful attention will be paid to cultural and social factors such as: the appropriate gender for CDDs especially in Muslim communities, respecting tlie traditional beliefs, and selecting supervisors and distributors who speak the local languages. (v, DecliningCommtnityCompliance Declining community compliance will be avoided through conrinuous mobilization activities prior to each treatment period. Community members could be interviewed to determine the reasons for the non-compliance, and corrective measures taken where possible and appropriate How do you intend to monitor and nteasure the progress towards sustainability (See Appendix 3 for a ltst of possible indicators of sustainability)? Progress towards sustainability can be monitbred and measured by evaluating the project in terms of financial management/contribution, communications, training and capacity building. This will help enhance integration. Financial management should be incorporated into the usual government financial administration. Financial flow in the CDTI project should comply with government financial management procedures so that there will be safe resource management. Regional and zonal health department heads, and administration/finance managers at each level will be accountable for proper utilization of CDTI resources. The ability of managers at different levels to familiarize themselves with financial and human resources in the project can also be used to measure and monitor the progress of CDTI towards sustainability. ln addition, the ability of community members to about understand the cause and effects of Onchocerciasis, and the mechanisms for its control can be considered indicators of progress of CDTI to sustainability. The success of the program will depend on the attitudes and practices of the community towards the disease. 7. CROSS-BORDER CONSIDERATIONS ll/here an endemic area extends across the borders of two or more adjacent States, special problems of cooperation between the respecrive countries CDTI may arise. In the event that there are areas to be covered by your proposed CDTI where the endemic zone extends across the frontier into one or more neighboring countries, and where there are likely to be transitory or even large-scale migrations of onchocerca-infected persons either way across the border. r:! -:a 25 C' : ) I I HiI i] =l 'l t.,i!;i iIr! 7l tsJ - 1:)) 7.1 Plectse rlescribe the particttlur situtttiott us it is likell, to uflecl ivermectitt lrealnrcnt, ancl Ihe ntethocls yotr will use to deol with it. The Neighboring state, SNNPR, has already CDTI project in Kaffa Sheka zone since 2000-l and will not affect this CDTI project, as they are similar in all aspects. Rather the experience in the Kaffa-Sheka will of great value to the proposed CDTI project. The proposed CDTI districts do not share boundaries with other countries. 7.2 Include pertinent obserttations on current political and health relations witlt the neighboring State(s). There is good relationship between Oromia region and SNNPRs in ever aspects including political, economical, social, cultural aspects. 8. SPECIAL RISK ISSUIg.S In sonte areas of some countries there ntay be special risks, which could hinder the smootlt running of o CDTI. 8.1 Please describe the situation in any ereas covered by your proposed CDTI were lhis factor may interfere with the program, and assess future prospecls NOT APPLICABLE l::l !.1 LJ 26 il tt :i c:l ii SECTION 3: ADMINISTRATION/FINANCIAL 9. ADMINISTRATION 9.1. Organizational structure for CDTI 9.1.1 Please provide an organogram for tlrc CDTI showing the organizational structure responsible for implementing the proposal. Fig.1. Organizational Structure of National Onchocerciasis Control Program,l 1 .-J tr tt 3 i,iii,i.)il 27 9.2 Financial Adnrinistration Mechanisms of disbursements and transfer of funds from the World Ilank to countries Funds from the World Bank APOC Trust Fund rvill be translerred to the WHO country office account in Addis Ababa. On request through the proper channels by authorized officer of the MoH, wHo/Addis Ababa will transfer the fund directly to the bank account of the respective Regional Health Bureaux (RHBs) according to the approved CDTI project proposals. The signatories of the bank account into which APOC funds will be transferred at the regional level will be the head and the administration and finance officer of the regional health bureau. All the lmperest returns will be submitted monthly by RHB to WHO country office in Addis Ababa that will forward them to APOC headquarters in Ougadougou. Monthly reconciliation statements will be forwarded to the central Malaria and Other Vector-borne Diseases Control Unit (acting as the secretariat of NOTF) for follow up. APOC will issue cheques (advances) in accordance with WHO rules and tlie previously agreed project documents and./or plans of operations. When the total payment in cash required for the project exceeds $ 100,000, the paynnent must be made in installments. The first installmenVadvance could cover 3 months or 6 months of activity depending on the duration and magnitude of the project. Management of funds by projects and WHO/APOC mechanism for monitoring The size of the project will determine which of WHO's contractual systems is used, e.g. Technical Service Agreement, Letter of Agreement, Contractual Service Agreement or Agreement for the Perfomlance of work. A document on administrative and financial procedure will be made available to project being funded by APOC. Built into this document is an impress mechanism, whereby the project will report its expenditure on a quarterly basis - and receive further advances on that basis. Each project funded by APOC will require a periodic external audit at project expense. Each project must have one senior staff member who is accountable for the management and control of project funds. Standard internal financial checks and balances must be incorporated into each project's financial management plan. 28 il 7a .! ;lL.t r-:lit .t -l I 'I Fig. 2 Request and Disbursement of APOC Funds Disbursement --------| Financial Report H rl 'l -I,;a( L-i !'l llr! i^,rliI.-iI.= fJ.'r'e*ae,i: i:-it+tili i;r.rll.. 'lloa**t' isiEriill [tr.1;ria. i.r+giri.r,i iE raritii i ljirrr<rr. \,,ivB 1bJ;riu-oi-. 29 .i J il il [J I l iJ iJ H )arla! 'i :t ., 9.2.1 Input from the Ministry of Health a) Indicate resources that will be provided by the Ministry of health and other governmenl agencies. Personnel, logistics, office accommodation and counterpart [unding b) Please provide a list of personnel assigned by the MOH to this project, including their name and proposed time (State percentage of tinte allocated to the project) for the project and where appropriate their experience in Onchocerciasis control through ivermect in lreatment. At present, there are experienced personnel at national levels and in SNNPRs since they have started CDTI earlier years. However, none of the personnel in Orimia Regional Health Bureau and in Jimma zone have had experience since CDTI is new to them. Oromia Resio nal Health Bureau Jimma Zonal Health Office: woreda Health Office: --r I :j n :! rr l.: .: i-9 t: Name Post Region 7o Time Mr. Dereje Olana Dept. Head MOVDCU Cromia 25% Mr. Sheleme Chibsa Team leader, Vector Control Cromia 25% Mr. Tadesse Hundie Expert in Vector Control Jromia 25% Mr. Addisu Mekasha Expert in Vector Control Oromia 2s% Dr. Kebede Itana Team Leader, Diagnostics and Epidemiology Team Oromia 2s% Name Post Zone 7o Time Mr. Mohammed Hussen Head, Zonal Health Offi ce Jrmma 30% Mr. Wondimu Tesgera Expert, Disease Prevention and Conrrol team Jimma 2s% Name Post Woreda o/o Time lv{r. Daniel Kaba Flead, District Fiealth Office Seka Chekona 25o/o Iv{r. Mulugeta Mekonen Disease prevention and C-ontrol expert Seka Chekona 25o/o Iv{r. Awol Kedir FIead, District Fleahh Office Iv1ana 25o/o lvG. Vorknesh Idcha Disease prevention and Control expert lvlana 25o/o \zIr. Jihad Kedir Flead, District Flealth Office Limu-Seka 25o/o Mr. Nigatu Alana Disease prevention and Control experr Limu-Seka 25o/" 30 a rl -t iI It J ---l Ij 9.2.2 Input from the partner NGDO(s) o) Please prowde o letter fiom the Executtve Dtrector or the Diractor of Onchoccrcrusis progrommes of each parlicipattng NGDO sloting llteir tntentions to porticipttlc m and support tlte National Onchocerciosis Control Programme b) Give inforntation of the inputfrom each NGDO porticipating in this Project The Carter Center's input willbe:- Funds: Per the agreement made between APOC and the FMOH, The Carter Center will not have direct responsibiliry or roles relating to the management and reporting on APOC funds. Mectizan@: The Carter Center will not have direct responsibility or roles relating to the accountability of ivermectin in Ethiopia. The drug will be consigned directly to the WHO and sent to MOH central stores in Addis. a a a ':l .tr '-l !) .--t ',i :., l?! !: -. f--t ..: t: a Staff and consultants: The Carter Center has been involved in some areas of public health in Ethiopia since 1992. In 1993, The Carter Center began assisting the Ethiopia Guinea Worm Eradication Program through the FMOH. The Carter Center has provided excellent technical, logistical and financial support in the implementation of the first CDTI project in Kaffa-Shaka, Bench- Maji and North-Gondar projects. In light of this experience, The carter center is ready to continue providing technical, financial, and logistical support to the Onchocerciasis control program in this project. office space and facilities: The carter Center will support the national secretariat by providing technical and logistical support through a local office in Addis Ababa. Please provide also a nominal list grading and post description for the personnel to be provided by partner NGDO(s). Indicale clearly what will be theirfuncfions tn the program and thetr experience in onchocerciass control through i,u,erntectin distribution. Most of the staff of The Carter Center has been involved in the implementation of the Kaffa-Sheka, Bench-Maji & Norrh Gondar CDTI projects currently. It is understood that most of them have got some experience c) ltfi s-r NAME POSITION OATIIME Mr. Teshome Gebre Country Representative 250 Frew Demeke Driver/Logistican 25% Murida Kemal Admin/Finance Manager 25% Dr. Assefa Worku Program Officer/ GRBP 50% Asfaw Benti Driver so% Seble Aliye Accountant 25% lr U'l ,.1jl at it 9.2.3 Inputs front othcr agcncies. Please list any other agenctes or parlies that will be involved tn the running or Jinancing of the CDTI, and indicate clearly their roles, fttnctiorts and contributiotts. WHO: WHO Ethiopra wrll assist the pro.;ect in the procurement and clearance of Mectizan@ imported into the country by using its diplomatic status. 9.3 Timed plan of action Provide a titne chart(s) showing how the various activities of the CDTI will proceed over lhe course of the proposed progra,n. Numerical annual targets for atl planned aclivities sltould be providedfor each time point. The linte charls shottld also indicale how external support wtll be phased out over the 5 year period. -t I .i FI}I ll r't '1 *-a Et:( t-ii 32 7A f. la17F-i ENzFl Fl o z H 7Ft tn It trJ U i] it I :l r1 ,_l i.J t{ i"t U r--t ttEI r.-.t I i 5! U fl il ll -J J ;l il fl c) o t F) F(D s.(D o+) -l F CD D) (D o =. CD(t CD J pJ CDx o J p) o A) o oF <o2Eoo{J -5 oa A) o) oa(D 3 .D af5 A)3. o U' oo o o >+) o U U o- U) tst o A)o CDa V) o o (D ox'a 7 o oFl oa A) o- U) E o ? (/) o 7 (D o N A) @ U U) J.(, o :bo(b ao o* :(! 0a;': o a\ o(! Ca V1 c) o 3 7 od N F0 o CN CD o c) o F) o- >-t F) o+) o U Ut, o o o- o XLPrd a o- oa 7m 7'a1CDe8 -a- o a t-rj o- CDj o o oq op) C-l o) >1L' a) (DJ a) p, a9- a(D (Daj{5'o=' oi oc o- F) oo<+, I(Dl fc, H €(D c) NF.]On'5p) EEd>Ho H) fcl F €.(D C) Fl PJ o ,.1a pc cDt -lFtg. =5qt o+) E >1 e. (D c) F.t p) or-t U) A) (D o o o 'U>1 o c) CD o o+) o U) U'(D A) 'o - €.(D o D) o- (D U) 3>5-q7)o(D 3o o CD o-(D + o ot A>oa o- O,i =oPS -oo) (<, OD) nIOB5.- o:X a- e. 9st A)3. o CD .) h..)OO(,\ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ b.J oA\ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ b..) (,t\ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ b.J o o\\ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ b.Joo -I\ \ \ \ \ \ \ \ \ \ \ \ il I I , IO. I}UDGET l0.l Budget Estimates Budget ntust inclicate total ftmds to underlake the project. The atnount of funding requestecl front APOC, and the amount prot,ided b7, 11',n MOH, NGDO(s) antl other partners. All must be macle in US dollars. Each budget must include at least the following major categories (see appendix 2) indicating the contribution of the partners to reJlect sustainability of CDTI. . Personnel (services) . Capital equipment . Supplies Training . Healtheducation/mobilization o Travel r Communication o Consultant . Operating expense o External audit I r1 t tJ 34 YEAR ONE SUMMARY BUDGET FOR ONCHOCERCIASIS CONTROL IN JIMMA CDTI PROJECT YEAR 2OO3 7.5% NGO overhead cost il 5 .l 'l { ljl .l :i :i u!3T r.-l [-J i-) ti fl I g il J il it $t 2003 CATEGORY APOC MOH NGO TOTAL Persomel 0 26,489.00 2,500.00 28,989.00 Capital equipment 52,735.00 27,145.60 14,187.50 94,068.10 Supplies 42,032.00 0 8,200.00 50,232.00 70,820.00 0 9,000.00 79,820.00 Education/mobi lization 52,800.00 0 16,000.00 68,800.00 vel 16,984.00 0 3,800.00 20,784.00 n 2,910.00 0 450.00 3,360.00 nsultants 0 0 Audit 0 0 0 itulation 8,700.00 0 0 8,700.00 ex e 5,298.00 445.00 3,300.00 9,043.00 Total 252,279.00 54,079.60 57,437.50 363,796.10 NGO overhead cost 18,920.93 18920.92s Grand Total 271,199.93 54,079.60 57,437.50 382,717.03 Estimated No. Treatments 485,452 485,452 485,452 485,452 70.9 l4.l 15.0 100.0 Cost treatment 0.56 0.1 I 0.12 0.79 35 Iraining l* l< l>II Y E lqho lo li 13 ln r,t; lc 16lo E E t la I< E IrIFlo E !l ; a Ci o o I 2 I i x 2 l 9 f - I a! 5 i 4: 9 , 9 -_ a : a 1 o o t ; t 8 88 9 8 ? 8 8 8 8 8 3 ;; 't 7 t 8 x 8 8 8 8 8 8 8 e E 8 a a I Q 8 a c zoo 8 8 8 I 8 I 8 8 8 8 8 8 I 5 8 I oI - = L 8 6 = 8 8 9 : E 8 8 t u u 8 8 8 i I 8 I 8 a 8 8 ; E 8 a 8 8 8 2 o o E 8 I 8 8 8 a a ^l I r ; 8 g 8 3 8 5 8 8 6 8 9 8 o ;: 8 t t v 8 8 8 8 8 ; I I oE 8 L 8 8 8 8 8 ; e a 8 E 8 8 8 8 8 zo o ; :' 8 I F L 8 ; 8 I 8 5 8I o8 8 8 8 I oi r 3 : 8 8 ; L 8 8 : t 8 o 9 8I I8 88 ; 8 A I 8 o I !3 88 a 88 ; e a 8 a a I 88 88 z I 6 H u E 8 ? 8 8 8 8 5 e Ioi - B 8 8 o B 8 8 6 8 8 8 8 8 8 I 8 o 3 ts 8 8 8 ? I e ; e8 8 E 8 8 8 8 8 z o 8 8 t 8 9 8 {oi T E 8 : I o E :I 3 8 g 8 g 8 8 8 8 8 8 - 8 o ts =?5 8 a a 6 a a 8 ! g 8 . 8 8 a o o 8 8 B s ; 8 U 7-lit T.J ?-'1i-l -t ., .) r.--.} -l .t l; r-J .") ._ | t.1if :l (-1l.i L.J tj: ra L' ,i FI iI fl [l il rlit .t :J (I &t IT U H 8 3 I5 3 3 3 I ; E 3 3 3 8 8 L B Percent lnput :rN(r5(ro)-.Jcoooooooooo {l J.f i) ft ,-. I .., 1I r.' , '; ra 'l ,'i f? ;d .j t: !" J ET li ;rE3 i1 'r1 (o c.) ! o ao ol ot GI o o o o5 =.q cn o , o m 0) o !q, ;I3 o oa Ol oql o o g 3 3 o o oJ ! o oo Noo c.) N)oo5 $H Noo o, ri iI U $ il U :l :,1.\J (}){ "l IIg g E I() Noo\.1 trd ., .l'" . -j'.11-' ":t-i. .-- ''''i I '"t-,: I I r, --. .-. l -.:ft: - i.-' : _:a:,r.. ', :'...,: ""lr'a'' '.':il1*I. .id:i;:l :,#H:ajil.. ':l-:-rY.,+: 1-{t{#l$lr Jfffi6F;ffi1ffil i- :. i,i:?i ';, !,1-i'3Eq +-,:+iS ,r*l# '.ri:g{frAi! . . ri&.-'.E.._ F;'EB?'l -' .,$urj:. I ':,;ti, I -I i' i.:- i. \',. 'r:* l, ,"'5, i I .t- .i, tt [- -l I' i i il FI U fl(, ,rl il i1 iJ fl it t] iJ fa ,:!lrr-lt, 91 :l -._1 10.2. BudgetJustification Please provide a rtarrative descriplrcn of the reasons for each proposed ltne itents of lhe budget. (l) Personnel The personnel budget reflects the need for staff at all levels (MOH, RHB, ZHD, WHO, and NGOs) to support distribution activities at the community level (CDDs). The MOH and NGO staffwill provide support to the program in the form of: . Mobilization of authorities and community leaders . Health education and community sensitization on the need for the drug o Assisting in the organization of the distribution program . Training of supervisors and CDDs o Getting ivermectin to the pickup points . Transportation of other essential supplies . Ensuring proper supervision of drug distribution o Ensure proper record keeping and accountability . Accounting for funds spent (both APOC and other) . Participating in program evaluation and feedback to local communities MOH and NGO staff is already in place and will participate in progranr implementation on either a part time or full time basis. However, the degree of involvement in APOC activities will decrease from year to year as the communities take more and more responsibility and ownership of the program. Eventually the CDDs will take on the major local function of the program by the end of five years and with the strengthening of the PHC system, CDDs will become PHC staff and take on additional duties besides Onchocerciasis control. (2) Capital equipment ln order for the program to properly function, it must be well equipped. The equipment requested is meant to facilitate the work of the MOH (Regional, Zonal, and Woreda) and NGO staff includes: o Vehicles and motorcycles . Communication equipment (phones, faxes, radio operators, megaphone) . Computers, printer, photocopier . Training equipment (overhead projector) (3) Supplies: Office supplies are essential for the smooth running of daily program operations. Since this is the beginning of the program, APOC will be requested to provide all essential : 38 il 7,| rl office supplies (computer toner ca(ridges, diskettes, calculalors, paper, pencils, pens, fasteners, file folders etc). (4) Training Training demands relatively higher investment due to items such as transportation, per diems for trainees and trainers, production of training materials etc. It is also an activity that is carried out on a continuous basis, with re-training at all levels as new personneljoin the program, and as CDDs need to be refreshed prior to the distribution period. Being essential to the implementation and success of the program, the following is proposed: At the community level, CDD training is expected to be continuous throughout the duration of the program, with the community assuming more responsibility over time. The training activities will be supported by APOC. APOC, MOH and the NGDO will also support workshops for regional, zonal; woreda staff, as well as CDDs. The NGDO will provide funds for management review workshops at zonal levels. APOC is expected to provide support for the printing of training materials and sponsoring some training workshops. Funds are also requested to support computer training for staff, especially in GIS and MIS to facilitate better program management. - ii cl :1 (s) Health Ed u cation/lVlobilization : Community mobilization and advocacy activities are required to build the support needed [o ensure program sustainability. Communities will be mobilized through advocacy campaigns (to gain the supporl of community opinion leaders), information packets (to educate the media and other parties) visits to the community by MOH personnel from the National, Regional, Zonal, and Woreda levels. General public awareness can also be supported by such techniques as the distribution of posters, brochures, stickers, and T-shirts etc. MOH and the NGDO will provide funds for these activities. APOC is requested to provide funds for Regional and Zonal training orientations, information packets, health education aids such as posters, brochures, stickers, T-shirts and flipcharts. As the awareness for the need for onchocerciasis activity increase at the national, regional, zonal, woreda, and community levels, the amount of funds required will subsequently decrease. (6) Travel: Travel is required for advocacy visits, training, retraining, supervision and monitoring, and evaluation activities are all important for effective program implementation. 39 EI flst il fl ,l .l flil FI il n rJ r: iJ r-Jt.: t: APOC and the NGDO will be responsible lor supporting travel expenses necessary for the implementation of the program. APOC is also requested to provide funding for fuel and maintenance for vehicles and motorcycles, and domestic airfare. (7) Communication: At the National, Regional, Zonal, and Woreda levels, telephone, courier and other media means of communication (such as radio and e-mail) will be used among project operators. At the community level, communication will be mainly through the use of radios and megaphones. APOC and the NGDO are requested to support expenses associated with communications including courier services. (8) Consultants: Consultants would be required to conduct KAP studies (to help in the development and refinement of health education and other materials); program evaluations, computer maintenance and other aspects of computer work, to ensure total quality management of the program. APOC and the NGDO are expected to support the costs of these consultants. (9) External Audit External audit will ensure proper accountability. Since APOC will support the costs of external auditing specific budget is not indicated in the budget details. (10) OperatingExpenses: This will include costs such as utilities, costs of quarterly meeting (NOCP), development and maintenance of MIS. Also included in this line item is the cost of operational research, printing of essential reporting forms (treatment summary forms for community, Woreda, Zonal, and Regional staffl), household cards, and community registers. These expenses will be supported by APOC. The NGDO and MOH will share some costs such as office utilities. 10.3. Current Resources Available for CDTI Existing CDTI projects (for continuation or expansion) will have resources already available. Please provide a detailed list of all existing personnel, equipment and supplies (including vehicles, etc.) belonging to the program, indicating their ownership (MOH, NGDO, other Agency, etc.) and their level offunctionality. NOT APPLICABLE 40 Uil L' li! l, :l -l ./ c'l ri a1il :lat ra ti :.iE, at I .l APPENDIX I: ESTIMATED NUMBERS OF COMMUNITIES AND PEII.SONS TO BE TREATED EACH YEAR, BY ENDEMICITY LEVEL (PHASE ONE) AREA COVERED: COMMUNITY LEVEL ENDEMIC HYPER- ENDEMIC MESO- ENDEMIC HYPO- ENDEMIC+ TYPE OF TREATMENT Community- Directed Community- Directed YEAR t - (2003t4) No. of communities to be treated 814 l 068 Total population in above communities 218,454 261,000 YEAR 2** - (2004t5) No. of communities to be treated 1,311 1,610 Total population in above communities 329,239 402,513 YEAR 3** (200st6) No. of communities to be treated r,928 23s6 Total population in above communities 481,951 589,051 YEAR 4** - (2006t7) No. of communities to be treated 1,928 2356 Total population in above communities 495,921 606, I 33 YEAR 5** - (2007t8) No. of communities to be treated 1,928 2356 Total population in above communities 510,309 623,1ll tOnchocerciasis is not considered an important Public Health problem in hypo-endemrc communrties and APOC wrll nor normally fund community-based treatment in such communities. The inclusion of such communities rn rhe proposal will require a specialjustification for consideration by the TCC **lt is understood that the figures for years 2-5 are estrmates that may change depending upon the results of the REMO surveys conducted. 4t I : ! !) $ nr, il -t jl .1 f'l 't il il .t \,1 i:! IJ :t i-' 2l Ivermectin Treatments reflected in Appendix 1 were obtained as follows: Total population in Jimma zone targeted for first round treatment in the year 200314 is 485,454. Out of the Estimated At Risk Population (EARP) 218,454 are classified as hyper - endemic and267,000 as meso-endemic. YEAR 1: A treatment objective of l00vo EARP of all hyper and meso-endemic communities (485,454) in the selected woredas will be targeted to allow the program to get accustomed to CDTI, including monitoring adverse reactions, community attitudes towards the strategy and drug, and 3mg tablet management. YEAR 2 with some experience, the program will gradually increase one additional Wereda in year 2 after REMO refinement. YEAR 3 on the third year, depending up on the outcome of the REMO refinement, another one Wereda will be included. YEAR 4-5 The program rvill continue distribution of Ivermectin in all woredas targeted for the CDTI. Fig 4. Annual Treatment Objective by Endemicity Level o 700,000 600,000 500,000 400,000 300,000 200.000 1@,000 .r#Hyperendemrc --a-Moso-endemrc 2001 2006 20072003 2005 Yea, 42 tl t; r-t ..{(, fl $ il iJ 3 il il I i s^ &t il il -l :i .) r'-t:-l r'i -'l,,:r i.J ,-a .-I t2 $i it APPENDIX 2: INDICATORS FOR EVALUATION, SUSTATNABILITY AND INTEGIIATION OF CDTI Project Evaluation Management Financial Management Effectiveness of Communications Training and Capacity Building Institutional Commitment Fulfillment of other relevant factors Problem solving capacity lntegration of operational research Project Effectiveness Result of the KAP studies Treatment Coverage Follow up of non-eligible and absentees Management of adverse reactions Reliability of reporting S u stain ab ility/Integration Political will of Host government Political wtll as shown in policy statements and apparent commitment of hrgh-level Officials Official actions including assigning personnel, funds, vehicles to program Long-term planning Is there a long-term plan for sustaining the financing and the management of the program? Progress toward financial sustainability If program sponsors cannot continue their current level of commirment for at least another five year, what percentage of running costs is now paid for host governments or fees? Progress toward integration To what extent has ivermectin distribution been integrated with other health service programs? 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UI =- (D J. C) (D os q o =(D o o, (D o o l(D U'(D 3. c)(D lols o c, -- o f(D o (!, c = =-(D al mx 0, oJ =o - ovo =E I rn r- -t - trCv m C co o o, -n c l c o n -G' o3oo a nT c =.(D @ 7r @ nI @ -l (D = a-o n -@ m o o o o_ o @ o f. o oo N)ooo Nooo 5oo O colOIOI ol C =o oo o o 3 z 9 o Cf o o c o (D o x. a =. c f, c (D @ AoI o j., o)I o,f A' =.o f o x. a =-l o oo N)o s o g o J(D o o) c =.o U' 5o bo o)o P No s o a(D o o(D 3oo No s o o o o @9 o oo U t't il tiit L, r-1 il -t ,-I sii- I nir iJ 2: ,t3 :li, I i: .:U fl fl il EI 3 ,l ;1 .J il il H vg) o o 0) (D a o @ lt oT =o - (-. 7 = Noz m @ cg o o) I ltc J ='c (D o =C)o p 0) C)(D C =. (D- @ l{ l(D lrofolrloll l(D mxg :)(o o f 9.(D N -o NI o NI o NT o NI o at o C o o Ooo (o oo N)oo N)oo @ooo c =o oo o (D 3 z 9 o C f =o -5o)(,! Poo (,l o9oo A(Jt obo oPoo oobo 5 -o oobo { og o oo l<.yrlo lstollILlo(D o o (D o) o- (D x 6 f. :,(o c f, c oo (, o s o C Ut(D o o) o It) o- ox6'C f(o ol =lol(Dt -lol o)lC)Iol (Jl os o =o =(D o It c =- -.oo I <rrlols t3ll l@l(I lolllo l6- roIJo l o 6(D 2 C)(D I m xg o, :,q) C. o :, =o -r =C U, =z zo @ mx oI oxona € mv m(f - m r{I o -tl Io m(, (t cr{ og 'Tt c :l c (D lo o'o aloo o(D C =. (D a mxE(D =a o o 3 o,o =.s. o. o th o1 =.o :l €(D o o- 0) €o o o- o) €o o o- o) a oE1o o @Oo o)oo t\)oo C =o oo o (D 3 (, (, (, z 9 o C =o !.,5oIoo i\)oobo (o oobo (, o9oo -lo 0) o o t l(,lols lo IClo lotol+o (D o)oi< (D x 6' =f(O c l =c (D o l<.rrlols lo lE lo IJ la lo)lo-tslolx lq. t5' rolo a ool -l 'olsl ol ."l (, o s o g o f(D o o) c =. 6' a m xE' o, f o, =-o :l oI{ o{ r lslql lo)ot_ z o o +I m o v -t m v o mz -{ mv { o !r -o J9ooop (D f-l O) 3oo =j o lclalo l1 lo)lato llL 6 rot.)- o -o o --. =o a d o:lo1xl st :lot{lfl -lot -l lolo l3iolct-lo o3oo c l C (D 5 =a o J o(D lmlx l-ololfla le to l3 lq!lo l?' o(! o of.E =.o z o o z o o z o o z o o z o o z o o U' oc ao o () oo --l(, o o o ooo 5ooo 5 @ -o oo C =o oo o o 3 z 9 o =o -5 @f(, o (^) --I !r'oo @ --t Lno N(,obo (, -.I(,bo -o oobo N) -o oObo { o o, o oo I N) Ol s a C @o o- o o loJo o) c) =. 6'o N(,l s o' coo o- o o lo =o 0,o =-s. =.oo N(,I s o' cao o_ o o lo o o,o =.s. =.oo N(, s o' ca(D o. o o)oJ o 0)o =.s. =.(D @ N)(, s @ ca(D o- o ol C) =o ID o s: =(D o1 I r\) l<.rr ls t-.tf o o ca(D o_ o o) o o f,o =o o o <l ='lro'ial t,lxIElil =o, a- o =i II .l 'i :i -1 .i :l I r: :l .l ,i et 5(n .1 Bii il il ,^l ll J il [J r loljt\loto = o @o o _t.E =o f T lf !3 EElE4lrxlrelS rDlE5t;' (olti o 6I ,= o z o o{ - m o n -{ mv o mz{ mv IJ =trltl I-1 'J '-l I , I :.i i-l ,i, :.1 : .I 'i-lLJ F;t -I Fi{ .r-l .i '- l A o, ,,t U B a tl i] l il il fl o o -o o fo6 N. lo N Ch 3o ooo q) o oo l il(, @I l ! 0) 0) oo 0) 3 o ooo 3(o o v oD o ll(O o-' 3 v(D e. o -ol o oo og g o o a o o' l 1) =o ooo o 0) oc o o I o 0)f o- {o)(D @ q o (D @ mx ! o :, o o o 3 o o =s. o oo of.! =o -o o -o oo ll oo -U oo 1l ! o ! C) o o c oo (I o 5 (, o 5o (n o CDo {(, o =o 3 o o Noo O o N oO 5o N N) z 9 o AN -o o !.,oo (r oo N N -o o oo N o, -o oIO N:oo Ntu sroo o Poo oo oIoo o -log o oo Tl o d- 0) 3 o = o a o-(D o (D o o o ol o 3- o C) --l o o) o o- o 0) @oa -Tl o o o, o f o (, d(D o (D o o f(, os o (D 3 @ c) =.f o o) o o_ c) d)ooo c-n6o(D: o1 +(DOD -o(, =.<fo(o Pcro< oooI{(D o o-q) o o) f o- No f o :n o l o oo o F o o 3o O) o o) o = o o o) f o. oo o (D 6 o) o l ool aC ln o f(D !(D o l =(D(,{(D o o)o ol(D o C o(D o f(D o) (n =-o :lo c)x o N l(D o o (D o)(-) =(,{o o o_ o)o o 0) OJ :l 0) a' 0) o =o oC C -o 'Tl o C oiFa o o o No =o =(D @ o o) f o =o a mx {o o I n(D oof fo o 3 (n c o zo o z o o zoo a oc oo 5 () oO C J o o6 o o N)ooo No z 9 o c -@ooo bo -n o o o 4. l(o u o :n{(D (D o- o,o o) f, o. Nof(D ln ol(D q oox o o 3o o) (D(!) oJ (D (D o) l o_ obo o9oo o9oo -tog o o o tat-lq o l o a mxE o J o o o 3 Do o C) No o t-{o{ r la lmt>l.C ?o -U (D o_ (D' 3 o a -o) 5'(D -@ o oo oa lolo lela lo) l5'5'to o f oo --{ lmlxIElo =o(D o 3 A.l o !3. s. o oq of,.!f. o f ! oo ! oo n oo a oc I o o (^)(, oo o(, O)o @ @o OCl?.f-io5o o (, C^) z 9 o c =o { -o@Nobo -(^)(,oobo (^) -o, @obo (, -cnO)5Ioo -lo q, o o o '!o 6'I D =. o\ o\ o o x N) o x X @ O G x(,{o o o-p UC, & LP o\O o U :l) o (JJ o .! o- A) x UJ 'oo o-g) X ()J o-DYv mxEilf 0)a oJ lolo lo 0) -' 5'(O{o x @ J oE l-{lo lo' lf,tc)lo -{t:Nol e z a o z o o a oc I o o oOo @Ooo C f o o o o z 9 o c f o loE ooIoo 'Jo o- I x tJ o x NJo o- + l..Jo @ Ooobo o- o 3 p p oo oo o iao 3 -lo o oo m x il =n,3. o J il il a I ,i rt .1 t i.i r-li{ r-t s-.li; T-' ir' T 15' rc3 EEl(D=ll;l- <.) lE u,15cl=. o-tE3 eg P.6 z o o -{ - m o v -l m n o mz{ rn v it iti1 5 --J l.i fi a:r LJ EI $J g ilU il U il iJ FI cl g f, i P- o U U 2. o- o-p oa 6 =. o ! I I o =. o a (.) U U 't o l:tts l:! I:r toa ls tc IN I c-. l=lJIFl=IJIN tolf, lo lo7'D mo s o- p o oY 3 -o P. oa N o5 L o- o Y 3 6 lnx o5 o o o s. a ta o 6 .o =.o o o -(J o o IJ o 'J a) o r) o Ut oo UJ NJ Oo o O o O- 56Jo o o o o\ o c'7 -o J\., 00oIoo N) -o oIo 6 o 1 o o -o\o P o O : O o oo o Oo i o Ft-, o .) o o- N F) F) o- o o a G 0)o >. o o U o o -? o- ooc o rfl 5 o D) o U U ()) o N)ooo oDo og D 5'a E) =!) =.oi, 'Uo o F p ,o o p o ; o a-, o .)o D' .) =Y a 'oD 9. p :J ot Jl t rD r! o- DJ o o- 6' F ) 'o o D 3. ; o FN a oo D, o = o' D .l 'oo + 3 o oa ;o a A) o-{o .D a- ftx 'o D D 8 FEE;.Ie, R.i EERFREr; N z L) i Ir, o F -l t4 ort z -lIt U il it I a r- -l :ll .t ;l . -'t !I r_J .lti '-l o E- @ o J. C l-lt;lvt: t-l<.lall3o oqo o I x o =o o 3 p o3.l.q U o of. no =, z o o z o a) zo (n oo l..J O- o-56ro l-.Jo o o C\oOO _o\oo Poo Po b 6 o I o -o oobo i o P- o I o U U o-o DJT o- & 3D o o- oo G (.p o tJooo r!D r) o o & op o o U U D o- o .D .} o :1 3 :] .D 3 o-o rnx 't, D D o :l .i il il H r.1 .l J rl $I fl A @ acg o A' @C -o (D 3 @ o l q z o{ -n I o o 3(D 2o kolrt-lo lmtxIrl6lrlolo @ f o o s. o oo o =.:o o :, 1)oo -o oo @ o c o(D o) oo C f, o oo o o 3 N) N) z 9 o =o OTN obo (, N) bo AJoPoo -{o !r o oo I I N) x x o oc fo z 3o 3q o o o I J OJf. o T 15BoloE lt=i lE4l:': xl* I'ld rDlie(og 0o o =o 3 o + ovo t I m r -l - @Cv m C 3 o -(- = = Noz m - m r{ - o 'n -n o m l<loI =F a ; L C] 6ln x o a) X o q rn hn U J rn r -t o a o a a co og -Tt cq CU f,. C) l f o- o oEg o (D = o- o v(D(o of, o) @c !o 3 @o o No l o Ao{o o o-o @ mlxEo f, oo o 3 o, o o.(! oo 6' *- olJ] 1) o ! oo o otr o o N @o (o O)o C f, o oo o o 3 (, (D z 9 o C ='o -.1NIoo @5obo N)ooo x 3 i o Lno C @g (D x N) 3 o @ 0) A) bo(, (D ao l o) C @o x o o oo 0) o {o o- o) @ l+lo lo,; o 6 mx9 o,fq, =o5 a c(, o 0, l-nIC l(D L C ol o 3 o lo €l ot -lolEIol al 4l N o l 0) a c! o 3 @ o {o o o- 0) o o) f o- o-:- o lml.lolflolot-. lot= t\ lo,to z' o_ ooo =.E =.oJ -o oo ! oo a oc o o N C ='o o o o (D 3 (, (, z 9 o C =o O) @ obo (, c, bo @oo x 3(r x 3 = o x o i^,(rr C @0 o X N) 3 oo 0) N x o Coo x o ! E.oo o o{o o o. o og o o6 q, 6 C C o E I loloIU L.- cE 3 o - q 7 =T ;" 9. 6 a) ,l o ll l=lql: lot: t.lf x e 'o; fl 3 oI 6- oo ls IUt- lfl)t: lolalo l= o-D 3 :B oo tr N O @O !6@ (' o o o : L 9 o C 2. o o\A o !(! N bo 9 OO IJ uO bo o o O o , x C o x a a =, = d O o oO I p x 9 C a x Y x o o :. a I H IElit_ t;to lr ll s f D lh I ;<'E E) r- a @ o t t -7 L' o '_t J fn o *t rn o zi rr, F J o lL li t; r: l= li t? toll o E =.fF lr- E tEt;lft: t; 6 =c E =.)F I l=n t& E l: lot, > -l 1_ o 3 ls l3t: la li ls. t:ld E' 5) z o o z o o o o z 6) o c- o C IO !O !OO 6O : o o e' 3 p p z I o C f @o I o !IoO o I o a ! o oo ! o;' l ) 5O a { r -s OP OO ! o 6 3 6 O p NoO eg NP Oo o o J o ; o o2 It il ;,T - r--{ ,lI r-t :? ,^! )3f: c! :tii fl f, il I 3 il fl E a (, 5I olol a, cg o o I l-t ;-lo )q t o o C: lmlxIEtolf, o ='o f o o =-s. o oo o -1.! =o f =oo oo a o oo OO O C f o oo o o 3 p z 9 o C l o i, UIIoo NC bO Poo J o !r o oo o of, C 6' 5 =' z a) -ln N o o- o o- N 3 =' -l f ;- o C @ o- o C 3 o E(J t, 2 o -l a1 o- t o-p 3. 3 .E ,o =o , e13€j-lo olqa v lJ i'91",*;lsP rlto.gls" Ilsa u, 19 P.(- lti Av m C o - L = Noz m I m t-{r o 'nIo m a g og l-l blvlolrIn lr I lollt;lo l<. l< lolol6 o1E 6'5 oo (t, oc o o @ O c =o oo o o 3 N z 9 o c =o I6 I O tr 6 o f = z o --lt f a { p oo o 0, o oo o :E C3c a 3 z z o @ mx o -ox o no € mv m o r m r{I o .Tt I() ma a cg o o l{lo l<oDl= o l o txl!lolf,lol6l-. o 3 o o = o. ooo -4.E =.o :, -o oo o oc oo (, o C f o oo o o 3 N z 9 o CJ o lo,lolelo E -.1oq o o o{ t- 1)oo o o -{ - m o v{ mv o mzi m n <t, c6 o 9l t( )lolcl= l(D lmtxlElolf (D o 3 oo =.s. oooo =.! =.o f zo o z G) o @ oc o @ (, o o)o C f o oo o (D 3 N) (, zI o tr ='o s(,lIoo (, o)9oo (oobo -log o oo lolo 3 cf. o B.o l E. =z o{ 'Tl to o o-oa f =@ o-ooc 3(D l nf 0, o a- t_ t .--t 'l :i il tt ..a :-J l-i - il et ;it_, (, o \' .! .'ii:J n iiJ rlll I ,l ,.-J a rl J i iJ .l! .a ..t '-i il f, ti,l rl rl I t 1l! o l o_i' !a G' c o-(o o o o g. d lr tl l: o : ! oo Jo{ r 4 o o p o o D B o o{ oo ,q INIbt:t- t^l- 5 I ,0 o o 3 oo 'Q m xEo f o o o 3 o =.s. (f olh o =.E =o o o oo (t oc o o o *\ o C ='o oo (f) :lt o c =o o\oo t-Jo Ai^ o -{o 0, c) oIt (fJ o 'oo o 'o o x o o- x qJ o- D + l'.)oo D o +(^(x oo UJ o o o-p A "oo o ;i x o\ o l) x a- D + lJ)oo p 'o oI L6oiol o +o mx 0) =.o -l I i 'l I ,I L-i il tt LJ ttt! I, {. )' ,l rii-J q tl il rl {l:I :"1 itJ lt &t II H a ! T 15'oP 19E'lga k?xloe 19 u,ldct- o- EAItBId EL. 15fo(Df o6- i'lP ^G) LXo-?3 do =oth o):a -{o o, f a oE oo o Cf o o th o o 3 o z 9 o c =o F o A' o o an mxE o,f A' =o = a I Liti t t rt ) I fl;; :1 r! LJ n (!(rlr, ?-! i.a r1); I it , t al : '1 ^!k,i2 st .arq m *t -ft. b mx!(D J o(D o o oo l<o 6 6 Pg)F l<to o ta o 3 =' f o l<a le l^ lp l-5' f^s lf lIl!tf la t: la f l9 t! lalr- lgly le IRlofo !{6' lmlx IEl6lot_- lgI\lo lot-. l<_ l<lololn o E. o .i oo (J tl o oo r) o @ o c o o p o\ oo p N O ooo OCif F=ioJO o f.O oo -cnN(o 90oo ! 90Oo oO pI Oo p -o oI o oO o --l o ; oo o\o o2 o o C6 - a f a 3 o o o o 3 o o { o- Noo o o o C o = - a o Io o of 7 6' aL 3 o 3 F f 7 =' m xEF f 0, =.oJ T t3 t B 15BOIoDol=q 13*lo s* IEPla, o-l=. @15oh l$gIo=t:6l6lo o T ov o =F I m r -{I @C 7 m C =oIL = = N oz m I m r -{r o 'Tt .Tt o m @ c(, o !r ^ =o(D C oa lmt;lot;lo l='lolft\ lorlo = o. o an o f. E. o f 7r @ a oc o o N)(, o OC+J q3 5O o CZfo ='oO N(,Ioo N(,Ioo -{o OJ o o th { O) o o) o mxEd q, =.o a C ct o !r o(D c =o a m xE(D J o o \<l olotolot a.l zl ol ,l NI o o) oc o o N(Jl C =o ott z 9 o C ?. N lrroo N(Jlbo -{o 0) o oo m oo =.a. { 0) (D o o =o =o o) g, =.o f,o(D o 3 o) o r I a g o !r o =o C o) c oo -.Jo CJ o o @ 6 z 9 o C5 -.1obo € 0) 6. o) fo -{I -.to o, o oo 0) m x =o -r C @ m z. oo -{ - m c) v{ mv o mz{ mv =z ztf a m x PoI ox o n @ E mv m o I m r+ l o 'nIo m(t -{ o !r o a.o (D)'ac o))o(D o =o- (D o o_ l< lq IP la lo)Il lotl lo,lo(D C a(D o_ z o o z o o z oo @ o o(D (D o ooo N)ooo C = o oo zI o c =. l -(,l(,oo oo oIoo 5 @c o) foo oo -n c o 6 0) o l o- o) N o l o) {(D (D o- O) N) oo -to OJ o o @ it r I I ! t a --1 ,j f, :lif f, il:l .'- a -t f!tIr.l F-!): :: ra t-' c t II K LIu $ $til ilil :l .1 .T i.l r'l i.I st U $ a o oo @ f