West Wellega project: project proposal for community directed treatment with ivermectin, year 2003-2007

PBoP0J$ru f0]E uCIiMlutuilrHry ffiEffiffiffiPRffiffiF West Wellega Zone Oromia Regional State FEDERAL DEMOCRATIC REPUBLIC OF ETHIOPIA Project Period: Year 2003-2007 Submitted to African Program for onchocerciasis contror (APOC) uflilrfl l For Acdun To: TccTt hsdr,'.r19 ") coopb CSD CI-V Bttr LoP bh For lhrfior.mollon To' Dtf.., Ao trS,,f totiO3 :i i JiItL 2tiiiii! I t L 0 t It: l i a {1 ,..J Revised July 2003 I I A? 92r:tL1|. era0T. {lilfto,a.t hr\4t ooT"tt"+ THE GAMBELI/I. PEOPLES NATIONAL REGIONAL STATE +', DATE 04 /';aIEn.ft228 rn$ (LC HEALTH BUREAU IIEF. No. zfNq GAMBELI.A Disease Prevention and Control Department Minisbyof Health Addis Ababa. Dear Sir/ Madam Subject:- Annroval of the New CDTI Proiect Proposal . According to your letter Ref. No aorn | 1491451956 dated Llllllggs E.C. We learnt that you need our interest on the New CDTI project proposal. For your information our region has highly accepted the New CDTI project Proposal. Hence,wearegoingto implement this project inthe yearof 2003. Your cooperation is highly appreciated. ./, {,with regards1q4 h1 'l fir g-2 .:, ?o .a f KOANC JOCE C.C a L, t',1 sI of Planning & Programming Service Malaria & Other s Y tBlD tP I C/Department Tcl. 51 0138 51 0t 4r 51 01 42 51 05 36 I,'ax 51 02 14 5t 02 15 ,r4(t&f r t\.lhP? af,.{l,tG aAn rLArn sx{tctutFtt tr-c &.r{r} Please quotc our reference nr'-her in reply. c tcn / fta +.r'c.-...-. 6rn (,f..-l ni hq A 14'8Yll\1';t' 4"1 ftzoo.l f? ?+otrl-Cr\ r., a I C. * rh. l- r-A;c t.. y. (,- ^fl.,q-,f h t. h. ! 1, 4' r.n Nh fnul'r0,} "?.tn-bc Federal Democratic Republic of Ethiopia Ministry of Health jl. t "e Jur ias,r 42,r.r: H lzt I6[ /t:1 For Acti;^;. ,' To: T(+ Pl5aprwt:':t'ri - C.ooeo - cs-bcel Btn C^p BR, For lnformotlon To, b tQ- Ao Dr. Azadigo S6k6t6li Director, African Program for Onchocerciasis Control Ouagadougou 0l Burkina Faso Tele: (226) 34 29 60 /34 29 59 I 34 29 53 Dear Dr. S6k6t6li, Subject: Submission of Six Revised CDTI Project Proposals of Ethiopia It is to be recalled that NOTF of Ethiopia had developed and submitted six new CDTI project proposals to APOC for possible approval and funding in order to initiate Onchocerciasis Control Programme through Community Directed Treatment with Ivermectin (CDTD in three National Regional States, namely Oromia, Benshangul- Gumuz and Gambella. However, TCC in its sixteen session has rejected all the proposals and recommended the proposals to be revised. As a follow up of its recommendation, TCC mission visited Ethiopia to give a technical advice to NOTF from 16-19 July 2003. Based on the issues raised by TCC 16 and the technical advice extended by the mission, the NOTF has revised the proposals thoroughly. We hereby enclosed: l. Revised CDTI Project Proposals for: Illubabor, Jimma, East Wellega, West Wellega, Metekel and Gambella project areas 2. Signed endorsement letter from the Ministry of Health/ NOTF and NGDO commitment letter for the Revised CDTI Project Proposal for the years 2003- 2007. 3. Commitment letters of Regional Health Bureaus from areas where no partner NGDO is available, so that 25oh of the contribution is going to be met by the government for the first year and the goverrrment's financial support will increase from year to year to ensure sustainability of the programme after the withdrawal of external support. Please be informed that Illubabor and Jimma projects do have NGDO partneg the Center. The rest do not have NGDO partner for the time being Seifu Solornon Ref. No....... i:i:CiJ 3 I JU|L. 2$03 APOC/DIR. tffir, liltc+tz Diseases Preven6on E€eaf@t' and Control I{Ead Minister'sofficeFaxNo.25l-l-519366,MCH51 6677,PYD51269lDCPD527033,534867,Procurement535l66 E- mail moh@telecom.net.et a 1234Telex2|84MET I srzor t,st73og,st783t1t762t, 5t7923,5178t8 @An nLn.ftn.l.?.t! rhT', f..fl4tl +fc tl,t4,fi- In reply Refer to our Ref. No. This is, therefore, to kindly request the management of APOC to approve the project proposals. We would like to take this opportunity to thank APOC Management and TCC for extending their unreserved support towards the realization of Onchocerciasis Control Program in Ethiopia. We also appreciate the support and input given by the TCC mission of l6-19 July 2003 to NOTF. Sincerely yours, ,\ {r rs d E Se ifu Scll''1"'" ' PN mtion DcBortmcnt' and Control Head Cc . H.E. Minister's Private Office . H.E. Vice Minister's Office . Planning and Programming Department . Diseases Prevention and Control Department o Malaria and Other Vector-borne Diseases Prevention and Control Team Ministry of Health Dr. Angela Benson WHO Representative, a.i., Addis Ababa a a a a a Mr. Teshome Gebre, Country Representative The Carter Center Addis Ababa Oromia Regional Health Bureau Addis Ababa Benshangul- Gumuz National Regional State Health Bureau Assossa Gambella National Regional State Health Bureau Gambella 7 ? Letter of Endorsement from the Government of Ethiopia to The African Programme for Onchocerciasis Control (APOC) for Support of the Proposed Onchocerciasis Control Project In accordance with the memorandum of agreement for the APOC L The Ministry of Health, on behalf of the Government of Ethiopia, herby endorses the attached project proposal to be submitted to APOC for financial support. 2. This proposal reflects the collaboration between the members of NOTF and APOC with a view to conduct an onchocerciasis control project in Ethiopia. 3. The NOTF is a partnership of the government, NGDO's and other participating parties which will be responsible for the implementation of this project 4. The government shall assure free entry of lvermectin into the country for delivery to the applicant without imposing duty, tax or other costs. 5. The government of Ethiopia pledges its full collaboration with the APOC in the expectation of acceptance of the present proposal. January 30, 2003 place and date Solonrttt\Aleoaych $c{u Dtad rtor@ DnQartmcd' rnd Control Head Name and Title of signatory National Onchocerciasis Task Force of Ethiopia Application for Support from APOC In accordance with the memorandum of agreement of APOC: The NOTF on behalf of the Governnrent of The Federal Democratic Republic of Ethiopia, (a partnership of government, the NGDO's and other partners) hereby express its wish to enter into collaboration with the APOC and the MEC with a view of conducting Onchocerciasis control project in Ethiopia. 2. Onchocerciasis in Ethiopia is considered by the health authorities as a problem of sufficient importance to warrant the implementation of a control project in the endemic areas with the aim of eliminating as a public health and socio-economic problem throughout the country. 3. It is estimated that out of the total population of 65 million there are 2 million people infected with the parasite, Onchocerciasis volvulrzs, causing blindness, serious visual impairment and debilitating skin diseases. 4. The proposed control project will rely on community directed treatment with Ivermectin (CDTI) as its main intervention tool. 5. The NOTF has scrutinized the criteria and conditions for application to the APOC and is satisfied that the proposed projects meet all the criteria and fulfill the conditions established by the APOC. 6. Details of the project proposals for the control of Onchocerciasis in East Wellega, West Wellega, Metekel, Illubabor and Jimrna zones and Gambella region in Ethiopia, including the support requested from APOC to successfully implement the project are provided in the enclosed proposal. 7. The NOTF of Federal Democratic Republic of Ethiopia pledges its full collaboration ,.1 /ttt th APOC in the expectation of acceptance of the present proposal. *".),' '/ t. 1,.'^ -:i _.? ,! ,.i ;fi 'ic nr,.ie Tadesse '(Ih.) 30, 2003 t ir iit" uary 30, 2003 b a Place, Date, Rep. of Government C9' t.K ,. .- \,".r ii! ,.a l. l, i'1\ Name and Tile of the Signatory iil Eil;'-r: ;7 THE CARTER CENTER February 28,2003 Dr Azodoga Seketeli Director WHO African Program for Onchocerciasis Control 8.P.549 Ouagadougou 01 Burkina Faso Dear Dr. Seketeli, The Carter Center has been working in Ethiopia collaborating rvith the Ministry of Health in the Guinea Worm Eradication Program and the Ethiopian Public Health Training Initiative since 1993 and 1997 respectively. tn 1999, the Center expanded its health activities to assist the Ministry of Health in establishing a river blindness program. As stated in the proposal submitted by our representative in Ethiopia, Mr. Teshome Gebre, The Carter Center confirms its intention to be a partner with the Ministry of Health in implementing the CDTI projects in Illubabor andJimma. After reviewing the project proposal, I would like to confirm full technical assistance based on the activities listed in the proposal and financial support not to exceed the budget as stated in the proposal. I look forward to a successful collaboration. Sincerely, Donald R. Hopkins, M.D. Associate Executive Director cc Mr. Teshome Gebre, The Carter Center/Ethiopia Chair, National Onchocerciasis Task Force/Ethiopia * * * * oNE COPENHILL . 453 FREEDOM pARK'0rAy . ATLANTA, GEORGIA 30lO? . (404) 420.383?. FAX (404) 8?4.55t5 { :1.. I a- tllrr*. .vtt <lalt? lt1r" ,t u11, .S ll./ € 6a Date To: trrlrheulul ()u.ou.u Natinrl nGdod $ff, Ref. No 43P[^ak'h Brnwrr Disease Prevention and Control Departrnent Fax: (0 I )52 -7 0-331 5348-67 MOH Sub: Program for onchocerciasis program We have received your fax message of letter dated lllll95 with reference No. oofi11491451956. We appreciated the procedures undertaking to start with conhol program of onchcerciasis in our region. As the survey conducted indicates onchocerciasis is serious problem in Benishangul- Gumuz Regional State. Hence the regional health bureau would like to confirm that it is ready to implement the control progrcm with existing resources and would provide any necessa.ry support for the achievement of the control program throughout the project life as well as to sustain the program after the termination of the program. .D.P.C Team RTIB ) @ t{ q, r a (!.f,/a a, @ .,, o\ rof rL"- ca l.t tJZ lr .t i t GryIa' MOH CC ): -.. Ref. No Date ,. *,L5.:c E.fi-..-;.: -i :,.. ...r rl.; -,.,* To: Disease pretenrion and #$1t A+e6U^i.Ministry Of Health "*-..a j:-'--. - 1 onchocerciasis is one of the most prevalent communicable diseases in oromia regionalstate' Five out of fourteen zones of the region (35.7%) are endemic for onchocerciasis.The result of REMO conducted with, thelupport fromlo* office and Apoc clearlyindicated that significant proportion of the fiue zones, trrougr, there are differences amongthem' are meso and hyper endemic for the disease. L;g; ,r*bers of populations residingin these areas are continually exposed to infection. HJnce, onchocerciasis is consideredas one of the big health and socio-economic challenge in the region. w. *... thinkinghow to confront this challenge. But to start the prog.Imme on our own, on one hand welack experienced health professionals with onch,ocJ.ciasis control and on the other handthere is shortages of funds and logistics like drugs ,o u. ,r.a for the control prograrnme. It was at this juncture that we heard of good news from MoH. Apoc is ready to supportonchocerciasis contror program in Ethiopia. REMO ** aor. in oromia. Hyper andmeso-endemic areas, which are eligible to be included in the .or,.oi p.ogram, areidentified, though some areas still need to be refined. proposal were prepared andsubmitted to APoc based on the REMO result. we were Iooking forward to start theprogramme' Still we hope that the proposal will be approved with some amendments. Addis Ababa Subject: - so commi tment to control Onc If the project is approved the Oromia Health Bureau is committed to cover at least 25%oof the total CDTI cost starting from the initial proJ ect year. Increases the budget allocatedfor this programme with in consecutive years and is ready to over take the whole projectat the end of the fi fith year. We also try to do our best to create a budget line for CDTIrntegrated within malaria control programme. Now we are eagerly looking approval of the project for the benefit of theexposed communities. o With best resards.aSHALLO DABAC.C Head, Oromia Health Deputy Head, Oromia Malaria control service OHB NOTF- Ethiopia Addis Ababa - J..;' - I'Y HEAD, OROMIA HEALTII BUREAU --, */ I -.-:l), :'-'.) l ..-.J . '..^ ,i !,' TABLE OF CONTENTS LIST OF ACRONYMS SECTION 1: BACKGROUND INFORMATION 1. INFORMATION ON 'I'I{E PROJECT AREA FOR CDTIl.l. Geographical and administrative areas...... 1.2 Topography, Climate, Access 1.3 OnchocerciasisEndemicityLevels 1.4 CommunityStructure 2. PAST AND CUTTRENT STATUS OF CDTI IN PROJECT AREA SECTION 2: PROJECT EXECUTION OUTLINE .. 3. DESCRIPTION OF PROPOSED CDTI ......3.1. Outlrne plan and Trrnrns 3.2. Health Education and conrrnunity Inte'acrion and par.ticiparion3.3. Local Operational Research ......... 4. SUPPLY, IMPORTATION, STORAGE, INVENTORY AND DELIVERY OFMECTTZAN TABLETS SUPERVISION, MONITORING AND EVALUATION5.1. Supervision during Evaluation5.2. Monitoring CDTI 5.3. Evaluation of CDTI 6. SUSTAINABILITY OF THE CDTI AFTER THE WITHDRAWAL OF t\/ I I 2 8 9 ll ll lt li l.l l(r 5. I8 r8 l8 t9 2t 2T ,.) 25 26)l 7 8 CROSS BORDER CONSIDERATIONS 28 SPECIAL RISK ISSUES 28 EXTERNAL FUNDING ..............6.1. Integration of CDTI inro other Community Based of pHC Systems6.2. Cost Recoverv S ystem during CDTI ..6.3. Other Issues 6.4. Methods of Measuring the Progress Towards Sustainabi SECTION 3 ADM IN ISTRATION/FINAN CIAL 9. ADI\{INISTRATION...... 9.l. Organisational Structure for CDTI 9.2. Financial Administration................. 9.3. Timed Plan of Action IO. BUDGET 10.1. Budget Estimate 10.2. Budget Justification ................. 10.3. Current Resources available in CDTI .. le 29 3l .i.', .j7 31 40 4t 29 2L) lj 44 LIST of MAPS: ITAP I: MAP 2: MAP 3 II4AI'4: [4AP 5: LIST of ITIGURtrS FIGURE 2: FIGURE 3: I,-IGURE 4: LIST of 'tABLES Table l. Table 2 Table 3. Table 4. T'able 5 Table 6 Onchocerciasis CDTI Zotrcs itt Etliopia (APOC 2003) Oromia Regional Stctte, Etliopia ll'est Wellcga Zone, Orotnia Regiorr Districts Selected for C' DTI P roject Distributiott of Healtlt lnstituttotts & Population Density (1994 Census) lUest Wellega Zorte Recluest and Disbtu'setneti oJ'APOC Ftrnd Budget Input of Partners for tlrc Project Years Annual Treatmetu Objective b), Endemicity Level Estinruted Nuntber of Populariott, ATO artd Status of REMO b1t District, West Wellega Proiect Area Classification Criteria of Ertderuicity Levels in Rural Communities .............. Criteria Issues in the Developrnent of Health Education.for CDTI Intplenrc nt at i ot t Ti rne F rar rte Year one Suntnrury Budget for Onchocerciasis Control in luest ll/ellega Zone Five Year Budget Sununary for Onclrccerciasis Control -1 4 5 (t 1 FIGURE 1: Organisational Structrrre of Nutiortal Oncltocercictsis Contrctl Progrant 8 t-l .16 :18 39 LIST of APPENDICES APPENDIX 1: APPENDIX 2: APPENDIX 3.I: APPENDIX 3-2: APPENDIX 3-3: APPENDIX 3-4: APPENDIX 3.5: APPENDIX 3-6: APPENDIX 3.7: APPENDIX 3-8: APPENDIX 3.9: APPENDIX 3-10: ESTIMATED NUMBERS OF COMMUNITIES AND PERSONS TO BE TREATED EACH YEAR BY ENDEMICITY LEVEL ... IN DICATORS FOR EVALUATION, SUSTAINABILIY /INTEGRATION OF CDTI Budget Line ltent - Parsonttel Buclget Line ltent - Caltital Eclttipntenr Budget Line ltent - Supplies Budget Line ltem - Training Budget Line ltent - Health Educatiort & Social Mobiliz.cttiott Budget Line ltent -Travel Budget Line ltem - Comnrunicatiort Budget Line ltent - Consultants Budget Line Item - Recapitulatiort Budget Line ltem- Operating Expenses 42 4.5 46 11 +9 50 .st .s3 .5 jl 55 .56 ilt ) LIST OF ACRONYN{S APOC African program f or.Onclrocer.ciasis Control ATO Annual Trearnrent Ob.;ective CDC Communicable Diseases Control CDD Community Drug Distributor CDTI Community Directed Treatment rvith Ivermectin DHO District (Woreda) Healrh Office DOTF District Onchocerciasis Task Force EPI Expanded Progr.anr ol'lntnrunization GIS Geographic Information System KAP Knowledge, Artitude, practice MIS Management Information systent MOH Mrnistry of Health IvIoVDCD Mararia & other vecror-bor-ne Diseases contror Department MOVDPCT Malaria & other Vector-borne Diseases Pre'enrion & Control Team NGO Non Govelnmental Orglnisation NOCP National Onchocerciasis Control program NOTF National Onchocerciasis Task Force PHC Primary Health Care RAPLoa Rapid Assessmenr prorocol for Loasis REA Rapid Epidemrological Assessmenr REMO Rapid Epidemiorogicar ii4apping of onchocerciasis RHB Regional Health Bureau ROCP Regional Onchocerciasrs Control program ROTF Regional Onchocerciasis Tasl< Force TOT Training of Trainers ZHD Zonal Health Department tv SECTION I : BACKGROUND INFORI\,IATION 1. INFOITi\,IATION ON THE PROJECT AIIEA FOR CDI'I l.t Geogralllricalandadministrativearea(s) Pleose da.sc'ribe tlrc urea(s) of the coutur), itt t+,lticlt the prctposed CDTI will ba carriad ottt. (List tlrc admitistrative uttits or parts thereof e.9., Loc'al Got'ernrttettt Arcrts, Di.rlrict.r', Arrort dissentettls, Ilealth areas etc. tltot tt'ill ba coverctl urcl prot,icle u ntop sltowing tlteir lay-out) Oronria Regiorral State is one of the 9 National Regional States in tlre Federal Democratic Republic of Ethiopia (Map l). West Wellega zone. tocated at 80 l2t - lOu 03' N latitucle and 340 08r - 36u l0rE longitude, in the western part of Ethiopia, is one of the l2 zones in the Orornia llegional State (Map2). Based on the 1994 national census, the projected population o[ the zone in the year 2003 is estimated to be I ,941,430. The zone has a total surface area of 23,980 sq. krr-r and is further divided into 20 distlicts and 741 villages. One district narnely Gidame slrares a 76 knr border area with the Sudan and the zone is also bordered by the Benshangul-Gumuz and Gambella National Regional State and East Wellega and IllLrbabor zones of the Oromia region. About 90.3 Vo of the population lives in rural areas artd 9.lVo live in urban area. The zone has a population density of 80 persons pel square km. The zone is identified as Onchocerciasis endenric area and districts rvith h-r,pel and meso Ievels of endernicit; are proposed lol thc inrplementatiorr of CDTI activitres. The pro3ect objective for Year-One is to conduct CDTI in srx prior-rty clistrrcts. The Annual Treatment Oblective (ATO) for Yezrr'-One rs 563,909 and the UltirnaLe Treatment Goal (UTG) will be deterr.nrned l,r,hen REMO reftnement rs completed in November 2003, in the other srx clistricts ol'East Wellega proJect al'ea. Table l: - Estirnated Number of Populatiorr, ATO and Stattrs of REMO b1, District, \\/cst \\'ellcg:r P ect area 2003 S. No \\'orcda Estimatcd CDD \/illagcs Total Population Annual'freatnrent Objective (ATO) REITIO St:rttrs 1 Grmbi 521 130.327 104262 Ycar I CDTI Area 2 Gawo Dale 559 139,789 111831 Year I CDTI Area J Dale Lalo 476 1 19,064 95251 Yeal I CDTI Area 4 Anfilo 282 70,499 56399 Year ICDT[ Area 5 Hawa Welel 409 102,138 81710 Yeal ICDTI Area b Sayo 572 143,070 1 14456 Year I CDTI Area Subtotal 2819 704,887 s63,909 7 Yubdo 144 36,008 28806 To be retlned 8 Nole Kaba 538 134,529 107623 To be retined I Lalo Asabi 297 74,150 59320 To he rel'incd 10 Haru 268 66,937 53550 To be retlned 11 Aira Guliso 407 101,798 B1 438 To be retined 12 Jima Horo 197 49,224 39379 To be rclrned Sub Total 185'l 462,646 370,116 Crand'l'otal 4670 1,167,533 934,025 L.2 Topography,, climate, access. 1.2.1. Please clescribe the Dtpe of coutilrl,or bio-clinrutic zorrcs that will be covcrccl by tlte CDTI (c.g., roin foresr, forest-savanna ntosaic, Guinea savannct, Sudatt sovatuta, motuttoinous or Jlat), providing nrups, ,J appropricue. The topo-eraphy of the zone is donrinated by hills and gor_ees thar range in altittrde from 600 m in the extrenre Western end to 2100 m above sea level in the eastern part of the zorre. The zone has three big rivers namely Didesa. Birbir and Keto rivers that drain in to the Blue Nile. The area has many other small rivers and streams that drain in to the basin (Map 3). 1.2.2. Give tlrc approxintate tintes of tlrc rainy q17cl dry seasons ancl the ntonths coverecl by the farnting seasort. The clrmate of west wellega is characterized by distinct rainy ancl clry seasons. The major rainy season nronths are from June to Septenrber with short rainy season from February to March. The mean annual rainfall varies from area to area ranging trom 800 mm to 2000 mm. The mean annual temperature of the zone ranges from l0oc-30oc. Farming activities(clearing, farming, and herding) occur all year round, but are most intensive during the rainy season. Harvesting occurs from November to January, leaving February - May as the optimum treatment period. t.2.3 Provide inJorntatiort ott the state of tlrc roads ancr the effecr oJ'this ctn the rnot;ements of CDTI persorutel in the area at difJerent times oJ'the ),ear. (A nrup nruy be useful) The zone capital Gimbi is connected to 17 districts by all weather roacls whrle the three other districts are only accessed cluring the dr.y season. All the GDTI districts selected are accessrble by road all round the year. Two district, Dembidello and Begi are also linked by domestic air transporl service to Addis Ababa. All the districts have automatic and operator assisted telecommunication service and l0 of them have also postal Service stations. Road transportation is one of the widely used and most important mocle of transportation in the zone. The roads provide access to l7 district capitals, however most villages could be accessed only on foot or on pack animals while some villages could be reached by motorcycle. During the rainy season supervision and monitoring of CDTI may be difficult due to flooding of rivers and roads. Therefore, conducting Mectizan distribution during the dry season (February-May) is advisable. 2 cn o f(, o ED oF ca (\l U o tr] (t) q) oN )-<F U C') ch (J L() Io I t-{ G\-a ,; u, l:. t- = :! |,- 3 ,' :(,ii'i.t. I l, j ' j' I _1 : l.:i-- - t-- :/-.- ){' r :, a- Legend E Oromia Region I\{AP 2. OROMIA REGIONAL STATE, ETHIOPIA t-"5 tl.t' :'.'1l ? '.... " -- i __1 It' rrtt. "t' \- I\' /, I I I i {'-- I 4 ,rl..;'i' I I a I MAP 3. West \4/ellega Zone, Oromia Region Leoend West Wellega Zone tllubzbor 5 Map 4. Districts Selected for CDTI Project r I -t- i .-- I t i 't-- II .r.i Haru Nole K3ba L f L. t lgrra Guliso r Legend Jrmma Grdami lYear-One CDTI Districts IDistricts for REMO Refinernent in Year Trvo !None CDTI Sites 6 I i,-r t tt .'r .JI I I I'r,--i, \ MAP 5. West Wellega Tnne Population Density (1994 Census) and Health Facilitv Distribution lJ H0SP[aL + lr; HtA,lH CElrIERCrrnc + p; t{trtTHrlION + rrr ?oFU..TOYOEXCTY v.OC [€. tlrr a 6.O fl. ,0 tl. r0) tot .,50 iH a:r.roI vt.., ! ,o-.r.., Jrmma Grdam Anfrlo Gauo Oale H:ua Welele Aryra Guliso Orle [.alo + lvbna Srbu Jarso Haru Yubdo Nole Kaba Sayo Gimbi TABLE 2: 1.3. Onchocerciasisendemicity levels. The levels of ottchocerciasis entlenticitf in communities in the CDTI area tnust be assessed b7,siruple ruetlnds before treatment s.tarts. For tlrc ptffpose oJ'rhis proposal, the level of endenticin,in a conunnttity or e group oJ'sinilar commwities is defined on the basis of the pret'alence oJ' nodule c'arriers (see table I ). Classification criteria for endemicity levels in rural communities ENDEMICITY LEVEL and recommended type of treatment Percent of nodule carriers in REA sample (minimum sample -50 adult men) Estimated prevalence ol O. volvulus in the Whole communitl, HYPER-ENDEMIC Community Treatnrent (URGENT) greater than 39Vo greater than 59%, MESO-ENDEMIC Commun i ty Treatment (DESIRABLE) 20 - 39Vo 40 - 59%, HYPO-ENDEMIC (NON-URGENT) less than 207o less thin1oz ---l 1.3.1. Based ort the systeminTable I and usirtg thefornrut inAppendix l, please ittdicate tlte estimated numbers of conununities at each endernic let,el and tlrc nuntbet"s of persons in thent. 1.3.2. Contpleta Appendix I Jbr each area covering the ne.rt 5 years of tlrc projecr. (See Appendix l) L3.3 I.f nrctlnds of assessing endernici^, thresholds other than noduLe prevalettce were used wlrcn your endemicity data yvere collected, please irtdicate tlte ntetlnd used. 8 The levels of endemicity in communitres of the selected districts in this zone \\'ils done based on nodule prevalence obtained by REMo exercises conducted in 2001. The results indicated rhat out of 33 villages surveyed in the zone 5 hyper-endemic, 3meso-endemic rvere identified in 6 districts. For the other villages, refinemenr of REMO will be done. 1.3.4. For areas still to be covered, v,ltere endenticity levels are not yet known, please clescribe the method t,ou will use to collect tlrc necessar\, ettdenticiry datct. NOT APPLICABLE 1.4 Community Structure. Provide background infornmtion on the socictl organiTations of contmunities in the C.D.T.I. ctreas. This ma1, include infortnot.'ott on; Settlement patteru of tlrc conunuttit\,(e.g. hctntlets, seasonalfannsteads, dispersed population, etc.) The population in the CDTI project districts is settled farmers and the setrlement density differs from place to place as can be seen on Map 5. o The etltnic groLtps in lhe conuntutitl,. The population is composed of different ethnic groups. The majority of the community members belong to the Oromo (96.l%o) and the rest belong to Amhara(2.27o),Mao (0.97o) and others (O.4Vo). o Please provide infunnation about the arecr cot,ered by CDTI incliccttilg whethcr tlrcy are tnigrants, nomads, refugees or intenruil1, clisplacecl populations. The community included in the proposed CDTI project area is composed of settled subsistence farmers, government employees, and merchants engaged in small-scale businesses. . Community leadership structure. The zone is inhabited by an estimated of 1.9 million people in 20 districts and 741 kebeles (administrative villages). Out of this, 704,881 people living in 6 distri6s and 2819 villages (CDD villages) are included in this CDTI proposal for rhe first project year. The community leadership structure in the zone is organised around zonal administrative councils, District (Woreda) Administrative Council, which consist of elected members from each village. The District Administrative Council is responsible for giving guidance and leadership to the community for all socio- economic activities. Each District has kebeles (administrative villagei) *itt, their own village committee. The number of CDDs will be determinecl based on the size of the kebeles (using 250 peoples/2 CDD as a guideline). I The Administrative Structure belou,shorvs the community leadership systenr Zone Administrative Council )District Council Chairman ) Kebele Chairnran ) Elders/Religious/ Opinion Leaders ) Household Head . Main occupation of c'otttuttutity n,rO Orriotls oJ'nrujor comntunal activities. The main occupiltion of the comnrunity is farming and small scale business on cash ct'o1r such as coffee. The urban population is engaged in snrall scale business, civil service and manual labour. Farming activities is low during from January through April. During these months, there are traditional religious celebrations such as Gena (Christmas), Timket (Epiphany), Id Al-Adha and Id-Al-Fetir. PreJerred chcuutels of conunutticctliort in tlte conuntuit,v The preferred channel of communicatron by the conrmunity is from the local farmers ot' urban dwellers association chairmen to the village chief to the head and members of the households. No forms of mass media are easily accessible to these rural communities. Existing actir)e conunwtirl, associcttiort"/groups in the area (e.g. social, religious, etc.) The existrng and actlve community associations/groups include the farmers associations in the rural areas and the urban dwellers associations in towns. In addition the churches and mosques also have dominant roles to play in community mobilization. a a a a Estab|ished clistribution s)tstems irt tIte conttrttttti11'. There are some existing distribution systems, such as polio immunization, malaria control, vitamin A distribution, and family planning services that 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. Since the accessibility of existing health facilities in the project area is low, enrolling community health agents needs to be strengthened in the context of CDTI sustainability. Social comntunal activities cutd ntonths during which the activities take place. There are various social and communal activities. Prominent among these are traditional religious celebrations such as Gena (Chrisunas),Timket (Epiphany),ld-Al- Adha and ld-Al-Felir, which take place from January to March. Any previous experiettce of the conununity tvith development/health projectsa t0 Most communities in the zone have been involved in EpI, family planning, wellconstruction and spring protection activities. There are also communitl, health postsmanaged by community health agents and traditional birth attendants in somecommunities' The communities therefore have u,ell-established systems ofmobilization ro enhance participation in hearth projects. o Description of other anthropological characterisrics of the com1turtities. The people in the zone are followers of diff'erent religions. The most dominantreligions are protestant, orthodox and catholic christiins and Moslems. priests, shekies and traditional leaders possess strong influence in decision-making andhealth-related behaviours. Planning Ivermectin distribution cycles during religiousand public horidays can be important to access most community members. 2. PAST AND CURRENT STATUS OF CDTI IN PROJECT AREA. 2.1 Please indicare if trrc CDTI is an expansiort oJ'cut existi,g )DTI. No, this site is selected for the first time. 2'2 state the nuntber of 1'ears rhe programnte lru.s' beett opercttittg, curcl if possible ettcpt'.eprevious statistical, financial and annual reports. NOT APPLICABLE 2.3 State the nuntber of persons treated each year for tlrc lqst 5 ),ears; NOT APPLICABLE 2'4 List the organiTarion(s) involved in the progranznle, tlte sor.trces.arul artou,t oJ-furrcl.s.usccleach yectrfor the Last 5 years. OT APPLICABLE SECTION 2: PROJECT EXECUTION OUTLINE 3. DESCRIPTION OF PROPOSED CDTI The main strategy of the proiect will be to clevelop arul establish contmunir yn-buse; ivennectirttreatment s)tstenls, u,hich can be sustained by tie endenti.c ,rrr-rrrriirr"',llri,ur"trrs wirhrutexternal iupport afte r the 5-year project periid. This section slzould deScribe hoy, the NoTFplans b develop and intplentent'cDit in all high-risk comntunities in the project urea. Theplan should take into account the- neecl ,o" arr"i$ approaches to cDTl, wltich areappropriarc, for the different local situations, attd'the' 'need ,o ,orrfriy evaluate theimplementation of the serected approaches and idjust them when required. lt The project objective for Year-One is to conduct CDTI in six priority districts. The Annual Treatment Objective (ATO) for Year-One is 563,909 and the Ultimate Treatment Goal (UTG) rvill be determined when REMO refinement is completed in November 2003, in the other six districts of East Wellega project area. Outline of the activities that "vill be carried during the first year is described in the following table. 3.1 Outline Plan and Timing of Activities fbr the Period 2003 - 2004 3 weeks A ctivity/Justi[ication Length of Time Advocctcl'and sensitisation at the regional level - emphasis rvill be placed on introducing the APOC CDTI strategy, and enlisting the support of the regional level rvith the participation of the NOTF/NOCP, regional administrative council offices 4 weeks Agreenreril on the defittition of roles and responsibilities of all participrurls - through MOH with the regron based on APOC gurdelines, 4 weeks Prctcuretttent oJ essenttal project equipntent artd supplrcs'. Contputers, Mectrzarr drugs, and vehicles. I 6 rveeks Ttairtng/retraitting of prolect trainers at rhe regiottal let,el: Trarnrng to those who will function as trainers and supervisors 4 rveeks Ra p id Ep itle truo lo g ica I A s s e s s me nts : Epidenriologrcal surveys lor Onchocerciasis have been conrpleted in the Regron. REA surve;,s horvever rvill be carried out to identify all villages that qualify for CDTI. 4 rveeks Cotiluct RAP Loa in all CDTI Villages 4 Weeks Mobtli:rttiort of regrcnol and District authorities to support the pro.lect 2 rveeks Cortduct KAP Studtes Since this is the first time for treatment to be carried out in thls nerv project site, KAP surveys are essential to gurde the development of appropriate health education matenals rn the District l2 weeks MobiLiza'on of endentic cotnmurtities, stressing community orvnership of the project as well as the key health educatron messageJ 4 weeks Selectiort and tratning of Conununity Directed Dstributors (CDDs) Selection of CDDs is the responsibility of the community H ouselnld registration, and census enumcration 2 weeks Mectean @ Collection and Distribution in endemic communities 8 u,eeks Monitoritry & supervisiotr of Mectizan@ distribution activities by Distrrct supervisors 4 weeks Ittspectiott of CDD drstribution activities (spot checks) bv regional supervisors and NOTF rep resentatives I week M I S ( Management I nfo ntution System) Inclusion of CDTI activities in the routine monthly reporting system Monthly NOTF evaluation team will conduct evaluation of the project 4 weeks Review oJTreatnrcnt Activities: Annual reviews and reltorts rvill be generated and used to ensure continuous improvement in designing the following years action plan. I week Action Plan for the next year 2 weeks I2 3.2 Health education and Contmunity Inl.eraction and Participation 3.2-l How will you approach and interact vt,irrt rhe conttnuni4, There are already existing systems of communicariorr rvith the proposed project area throu_qh other health programs as described earlier'. Hou,ever, the following strategy will beimplemented to maintain good relations with the cornmunities: a) Discussions with District administrative council chairmen and social affairs heads and then with local farmers and urban dwellers associations, religious leaders, community elders and opinion leaders to better understand community protocol b) Focus group discussions rvith social and religious groups to further mobilise the community with the support of the community leaders c) Focus discttssions u'ith the community menrbers as appropriate (separating men and women' or not, depending on the community traditions). The commrnity -".bers willalso be encouraged at this point to take ownership of the program, defining their roles and di stri bution mechanisms -1.2.2. Health educarion Healtlt educrttiott and conunnnitv ntobilizariort tvill continue be cut itltegral part oJ all approctches to CDTI. Health eclttcaliort ac'tit'ities slrcukl ensure cortrinuous exc.lrcurya witlt regards to htowledge, covareness, perL'eption ancl observable attituclinal c.hang"es. ctboul Onchocerciasis and ils treatntent. Altpropriate health educcttion message.s in the form oJ'posters, pantphlets and verbal presentatiotts will need to be d,evelopirt a,rl tested. Health education should address tlrc Jbttowittg tssues (Table 2): l3 Table 3: Critical Issues in the Development of Health Education for CDTI a) Have ant' KAP sun,eys been done in tlte projec't area ancl d'so, w'hat were tlrc resuLts'/ No KAP studies have been carried; however. there is a need for KAP in sample villages This will be done in collaboration rvith other partners. b) What ntetltods w,ill be used to clevelop health education nruterial for the conutturtities attd for the agetils who will be resportsible for ivennectin treatntent? Health education materials such as posters, leaflets and flipcharts will be developed rn local languages b1, the project and submitted to NOTF for standardisation. These matenals r.vill be field-tested and refined/adjusted as necessary prior to mass production. Video films rvill be produced and utilised as a mobile video film show. c) Wlrut ntetltods will be used to provide health educatiott to the endemic conmrunities artd to the agents responsible for treatnrcnt ? The zone has used several media in the past for providing health education to endemic communities. Such methods have included face to face discussions with health workers, the use of village mobilizers, traditional birth attendants, community health agents and ISSUES Health Education l\{essages Knou,ledge of the disease . Local name of the disease . Symptoms . Causation/transmission (simple) Knowledge of treatment . Previous experiences with Diethylcarbanrazine (DEC) . lntroduceMectizan@ (ivermectin) o Dosage o Exclusions o Reactions . Beneficial side effects Attitude to treatment Advan tages of Treatment: . Free . Yearly treatment . Possibility of self treatment at community level . Importance of maximal coverage Attitude to disease . The disease can be controlled . Onchocerciasis blindness & skin changes can be pret'ented Attitude to good record keeprng . Minimr-rm requirements for record keeping . Records are confidential and strictll' for health use . Records required are for subsequent drug supply t4 other associations and faith-based institutions n'ill participate and the use of posters and flipcharts in local languages, and drama.(role playing in local plays). Community leaders rvill first be informed about the disease and the necessity for regular treatment with ivermectin. These communitl' 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 educattott 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 healtlt education messages and materials 3.2.3. Community ParticiPation In commtutity-directed it,erruectin delivery,.t-yJ'Ir',,?.r, members of the endemic communities do fhe execufion of ivennectin lrealntenl tltentsclves. Trahrcd persorutel, krtovt't7 os Communitl,-Directed Di"triburors (CDDs) tvlls slrctulcl be fttlly supported b)' tha co,ttrru,tiry itself nruy provicle treattnetl. Tlrc c'otrtttutttity 5l1eu1d be responsible for tlru organizcttion and exictuio, ofthe CDTI tvith rrtirtinrttnt but e.ffective ntedical supe rvisiott, once it has received tlrc necessar), infornrution and training. Various organiTational structures at the contntunity level, ranging ft'ortt t)ottrcrt's cooperative to trctditionctl structLtres, are intportant for sttstaining ancl slrengthening the support network of the CDDs. a) Explain rlrc organization of the inrenclecl comnutnity-directed ivernrcctin trecttment itt tlte 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 Malaria and Other Vector-borne Diseases Prevention and Control Team (MOVDPCT) is responsible for routine program management and acts as the liaison between MOH, RHB, as well as with NGO partners within the country and outside. The NOTF will be the governing body for Onchocerciasis conrrol acrivities in Ethiopia. A senior staff from this unit will act as NOCP coordinator. At regional level, Malaria and other Vector-borne Diseases Prevention and Control Department (MOVDCD) is responsible for program implementation at that levet. The head of MOVDCD will act as a ROCP Coordinator. Similarly, at District level District Onchocerciasis Control Task Forces (DOTF) will be established. The DOTF will be responsible for program implementation at this level' (ensure selection of CDDs, supervision of treatment activities, record keeping etc). Also, local health institutions uncler the DOTF witl be responsible to co-ordinate, monitor and supervise CDTI at each locality' r5 For ivermectin treatment purposes the number of CDDs rvill be cletermined basecl on a guideline of 50 households or 250 people per two CDD. Once communities select theirCDDs, they rvill be trained in the CDTI APOC srrategy for ivermecrrn distribution. CDDs and other local prirnary heulth care workers will then proviclc health education to communities on Onchocerciasis (its cause, transmissiop. control and preventive mechanisms). Prior to the distribution exercise, registration of all households will be can'ied out and non-eligible individuals identified. After registration, ivermectin clistribution will begin. The CDDs will follow up defaulters based on their treatment registers. Both District and Regional health staff will carry out supervision and monitoring activities. b) Ilotv yyill ivernrcctirt distributors be selected? c) The selection of CDDs will be the responsibility of the community. This rvill be done under the guidance of the village leaders. The CDDs will be expected to be honest, dedicated, literate and permanent residents in the village. Hou, trliII notrel i gible be identijied and deJaulters followed-up ? Non-eligible are mainlf identifred by having a complete household registration census and defaulters are identified by referring to distribution record or house hold cards. Defaulters, upon identification, will be treated by the CDDs. This is also done after previously non-eligible (such as pregnant women) have delivered, and therefore now eligible for treatment. 3.3. Local Operational Research Are there any plarts to conduct local operationctl research? / YES NO If yes please give details Operational research will be conducted on issues that will be identified in the course of the implementation of the project in the first year. These research activities will be carried in collaboration with research institutions and partners. a) What training will be provided to ensure tlrc development ancl sustainability oJ the CDTI? Training of CDDs to operate CDTI is very vital to the program. To ensure sustainability of the CDTI program, Training of Trainers (TOT) sessions will be conducted by the NOCP. Those trained here will represenr both regional and District levels. These individuals will in turn train representatives from District l6 and health facilities. These will in tum train CDDs. The training sessions willfocus on the following topics: o Basic CDTI principles . Village census : il::H,:"t':ff ",,Ti:;Iil,Il? t'::ii,,ll" "o""rse errecrs and management of its adver-se reactions o Inclusion and excltlsion criteria for ivermectin treatment . Dosing of Mectizan : r;T,TiJJ,fi:":;xJ3:li:[ b) Indicate criteria for selecting trainees (supervisors and community-directecldistributors). I) Criteria for selectirrg CDDs: Literate if possrble Resident in the community Willing to serve tlre conlnunity Must be honest Must be selected by conrmunity II) Criteria for selecting supen,isors: D istrict r: (i) (ii) (iii) (i v) (v) Must be a PHC staff selected by the state RHB Must be knorvledgeable and honest Must be interested in helping the community Must be stable rvith relatively low turn_over Indicate nuntber, type ancl cruratiort of trainirry courses intend.ed. Trainin-g_ in subsequent years rvill be focused, targeted and integrated with other PHC training. (i) (i i) (iii) (i v) * eof ksh Duration Number rRegional Trai ning 5 days I District Training 3 days I CDD Training 3 days I t7 4. SUPPLY, IN{PORTATION, STORAGE, INVENTORY AND DELIVERY OF N,ItrCTIZAN TABLETS Thi-r sactiort i.r orrl-t, a remiuder and couc('n$ llrc suppb,, intportation, storoqc, invetfiorv anrl delit,en, of iennectitt tublcts, rlonatccl by Merck & Co, who v'ill ulso pctv hatulling churge.s for ivenrrcctirt to their accredited ogents. Mectizan@ consignments will be rcceived through WHO and stored in the MOH central stores in Addis Ababa. It will then be transported by road to the regional health bureau, and from there to West Wellega health office. The District health office will be responsible for delivering the drug to the health facilities. (ln some areas the District health office is located far from the communities. In this case, health facilities rvill serve as the final collection point). CDDs will then collect the drug from the District health office or health facilities. A report showing the use of the drug will be sent toThe Mectizan@Expert Committee (TMEC) at the end of every year, b1, tlre NOTF, with the subsequent applicatron. Copres ol' the application and the report of its use rvrll also be sent to APOC. Drug delrvery, distribution and reporting rvill follorv the existing drug management systent and reporting on progress of activities will be done by the respective health unlts at each of level ol'the health service delivery system. An applicatron for Mectizan@ tablets rvill be submitted every year b1'the end of Septenrber to the NOTF, using the standardized form of TMEC. This applrcation rvill then be foru'arded to TMEC in Atlanta for review and approval. 5. SUPERVISION/N{ONITORING AND E\/ALUATION 5.1 Supervision during Evaluation Projects are required to be supervised and monitored. However, APOC funded projects rvrll need to be designed to function with effective but minimum supervision cornpatible with its objectives. a) Please describe tlrc sttpe n'isot),arrangenrcnts you consider will be requiredfor the CDTI l,ou propose how will this contirute et tlxe cessation of APOC support? There will be intensive supervision at all levels of program, especially during the early years. Since the program will be integrated into the Malaria and Other Vector Bome Diseases Control units, the supervisors and monitors will be staff of these units. The Distnct health workers trained to train CDDs will also be responsible for supervising their activities (proper record keeping, complete census enumeration, Mectizan@ inventory and dosage, and monitoring during the actual distribution process). The supervisory teams at the District level will be responsible for supervising health institutions (management of side effects, Mectizan@ accountability, and reporting on treatment coverage). Most important will be supervision at the community level where most treatment activities are carried out, and CDDs are responsible for proper distribution of ivermectin. Findings r8 from supervisory visits rvill be reported along u,ith monthly treatment data, and rePorting on adverse reactions. There will be a feedback on rhe findings of the supervi sion and' fol lou,-up of i mplementation of recommendari on s. As the program matures, the communitl, will assume more and more responsibilitl,, 1n.,rOing deciding on merhods of supervrsion, and those who u,ill cary thenl out. 1'his process may involve community, opinions, and religious Ieaders. b) Describe lton, r'ou rvoultl ensure that supervisiott will be carriecl out so as to a full witltitt tlrc requirement accou,tting for ivernrcctitt use 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 tlre collection and proper storage of unused drug is properly practiced. be sustctitted y'hen the progrant ends in 5 yearsa The got'enlment is implementing Onchocerciasis control activities integrated 'uvith in the Health Service delivery system and has indicated on the financial plan that government expenditure increases year by year. The Regional Health Bureaus tvhet'e the CDTI projects are Iocated has also committed to allocate budget for onchocerciasis control as a component of the Malaria & other Vector-Borne Diseases Prevention and Control Budget. . ensure ntaxintum int,olvenrcnt of the conuflLuttties in the process The program rvill support advocacy visits to the woreda and villages by MOH, regional, and MetekelZone representatives of the Onchocerciasis task forces at each level to encourage the active support of the community. 5.2 l\tlonitoring of CDTI It is irnportant to collect itdorntatiort to tttonitor lhe progress of tlrc CDTI. Wlrut indicators will be used to monitor: . Ivennectin distribution? . Healtlt educariott and contmuniry participation? c Mcun?en'tent $,stems? t9 Tlrc follox:ittg indicators will be considered: I v e n n e ctin Distributio rt . Nuntbers of conununities and persorts treated with iverruectirt o Treatment Coverage . Re?ularity of treatment exercise . Compliance . Reporting adverse reactiorts Healtlt Education and unitv Participatiott . Nuntbers of conunurities participating in tlrc project o Evidence of impact of health education . Are activities being carried out accorcling to plan and on schedule? . Inventory control, . Are record forn'ts accurate and contpletecl on time? o Numbet's of persons trained c Balance of genders ilt staff of tlrc progrant The project will consider the following indices for monitoring the program of CDTI I v e rmectirt Distributio n : Srnce Ethiopia has already been conducting Onchocerciasis control activities tbr tlre last three years, there is an established Health Management and Information System (MIS) including for Onchocerciasis control activities. The NOTF will ensure continuity of this system prior to the beginning of treatment in the new project areas. These rvill enable the NOTF to monitor the communities and persons treated with ivermectin, treatment coverage, and regularity of treatment, treatment compliance, and drug reactions. In addition, the project will monitor the following rates and percentages using Annual Treatment Objectives established at the beginning of each year: Annual treatment objecti ves (ATO): At risk villages (number at risk villages targeted for treatment) Estimated at risk population (total population at risk in the region) Treatment coverage (geographical and therapeutic coverage): Treatments (number of persons treated) At risk villages (number of at risk villages targeted for treated) 14atrugenrcnt a a 20 cost per person treated Tablets distributed Number of ivermectin tablets in store at MoH, in the field, on order, or to be ordered The degree of communitl'participation in mobilization activities u,ill be used as an indicator of community mobilization. In addition, the support of the leaders and key opinion leaders in the communities will be indicative of successful mobilization as well. The impact of health education messages will be measured through per.iodic focusgroup discussions and will be assessed in relation to the baseline kap findin-e,that wilr be can'iecr in coilaboration *,ith other partners. Managentenl The project will develop, through the integration of Onchocerciasis control to theMOVDPCT, a regional and District ,rnu!.r.nt/ supervisory system that monitors: ' The planning and implementation of activities according to a timelineo Mectizan@ inventor.y levels o Monthly reporting of treatment indices o Numbers of personnel trained o ' Attempt to balance gender in staffing 5.3 Evaluation of CDTI Arutual exrennl review inc'orporating fietct visits will be und.ertakett to ertsure thatprojects are nteeting target inclicatioits outlinetl in this proposal. Such reviex,,s tyillprovide TCC with the assurattce that each proiect is moving toward its lortg tert, statedgoal .and if appropriate ntake recomntendatiotis about any deficiencies or nndiJic.atiott.s.to this project' such reviews will clraw on tlrc indicators developed by TCC as a guide. 6. SUSTAINABILITY OF THE CDTI AFTER THE WITHDRAWAL OFEXTERNAL FUNDING The concept of- sustainabitity refers to the ability of countrtes and affectecl contmuntties following initial external investment to maintain the viability anclc-ontinuity of the iverntectirt treatnrcnt process witlnut external support. For ApOCfunded proiects, such support will iormatty last 5 years, as tlrc Apoc dorutrs,demand that there shall be a visible and achievable end point yo, tie externaldonation aspect of tlrc programme, and that the contmunity basecl clistributit.trt o a a 2t i,\rslenrs established shall thereafier be sustaitruble by tlte Soventnrcnts ol' tlrc e ntle m ic cotu t ri e s conce nted. Progress ond plans towards sustainability, i,rr,,,rrrng the plrusirtg rtul ctJ'extcnrul and NGO? suppofi, nrust be reported aruurullt' and satisfactor)' proBress itt tlis directiort tvitl be a condition for each succeeclirry ),€ar's funditry installntetu. Please address the following areas that relate to sustainabiliry: integratiott inlo p ri n ru rt' he alth care, cost - recove ry, and othe r su stainabiliq' issles. Efforts rvrll be rnlde ro ensure post-APOC sustainabilrty of tlre program according to the sustar nabilrty, rndicators shown belorv. Planning: CDTI rvill be integrated with the Primarl'Health Care (PHC) from the beginrring. At the National, regional, zonal, and woreda levels, the N'IOVDCU rvill be resllonsible tbr prograrn implementation. Onchocerciasis taskforces will be established at all levels. Planning would be carried our rhrough participatory methods, using bottom-up approach and integrated with the basic health service. Lcadershi;l: taskfbrces rvill be emporvered and community leader s rvould be encouraged to be actrvell,rnvolved rn CDTI implementation. Involving communlties rn decrdrng time and mode of N,lectrzan drstrrbutron, CDD selection, etc rvould ensure comnlLlnlt)'o\\,nersltrp of the program. [\lonitoring and evaluation: wtll be carried out regularlv rr,ith proper checklrst by the MOH slaft rn addrrron to the Community Self Monitoring, which s'rll be conducted bi' trained communltv mernbers. Training. Health Education, Social nrobilization, Advocacl' and Sensitization: would be underraken in such a way that sustainability of the CDTI project rvould be ensured after the termrnarion of external funding. In other words, all these efforts should Iead to empowering the communrtles so that they can assume ownership responsrbrlrty. Finance and Funding: Short, medium, long-term (post-APOC) frnancial sustainability plans rvill be prepared ar Woreda (districQ and regional levels Budget line rvill be created for CDTI actrvrties by the respective local government. Transportation: The respective health offices at each level will provrde transportation tacilitres for Onchocerciasis control activities according to the need. Human Resource: Existing health workers in the system rvill spend a portion of their rvorking time for Onchocerciasis control activities in their respective rvork areas. Treatment Covcrage: Effort to achieve al1)Vo treatment coverage in the targeted areas will be ensured through continuous health education and community mobilization during the implementation of communitydirected treatment activities. Mectizan Procurcment, Storage and Distribution: Mectizan availability will be ensured through timely procurement, storage and distribution system that will be further strengthened to meet the demand. 22 6.1. Integration of the CDTI into other community-basecl or primary Health Care (PHC) systems. The principal goal of the APOC is ro establish cost-ffictive ivermectin-bas.ecl c'ontroL for Onchoc'erciasis, which can be susrained Oy ln, endemic communittes. and cotuztries. One way to ensure sustctinabilirl, is to'integrate the CDTI into thePHC system o-f the country, which meat.ts ntore than just u.ring the sysrem foriverme cti rt di st ri b ut ion. 6' l ' l ' ls there an fficial pHC poricy anr) structrt'e in the count ry? ,/ YES NO If yes, please give a brief outline of what it is There is policy and structure for Primary Health Care (PHC) in Ethiopia. The pHC system is used to achieve full integration of health related activities it all levels. APrimary Health Care Unit (PHCU) in Ethiopia has one health centre and fi'e satellite health posts serving an estimated 25,000 population. Trained communityhealth workers and traditional birth attendanrs ui" atro serving the communit,v under the support and supervision of the health posts. Therefore, there is afunctional Primary Health Care delivery sysrem ihat implements preventiye, curative and promotion of good health practiCes. This system is currenily capable of implanting Onchocerciasis control activities. In summary, the PHC structure is as follows: FEDERAL MINISTRY OF IIEALTH ) REGIONAL TIEALTH BUREAU)ZONAL HEALTH DEPT.) WOREDA HEALTH DEPARTMENT/PHCU )COMMLINITY HEALTH POSTS (CFIWs & TBAs) a) Howfunctional is the primary Health Care systent? Fully functional Partlyfunctional The system from the National level is fully functional until the . Health/health facility revel. However, at the community Ievel health coverage is limited. Non functtonal (Please specifu ) b) Does it cover the whole project area? No,/ Yes If no, in what part(s) of the project area is there afuily functionar pHC structure? wat percentage of communities where onchocerctasis is endemic, and which are eligible for communiry-based. treatment, have an existing and functional PHC system. c) 23 f) All communities in the Onchocerciasis endemic area have an existing functional Primary Health Care System (PHC). But as the health service coverage in the country is accessible to 6LVo of the population some communities could still be very far fiom the PHC unit but accessed by trained CHWs and TBAs. d) Wat organizations are supporting the development of PHC in your projec.t area? Government of Ethiopia (Ministry of Health), WHO, LTNICEF, USAID, Ireland Aid, Italian Cooperation and other civil societies and research and academic institutions are active participants in the development of the PHC. e) Is there any past experience in the country) of a programnue integrating witlt the PHC? If so, what progrctmnte was it and how successJul wcts the integrtttion? Program such as the EPI, Malaria control, and family planning are integrated in the PHC and the planning, implementation and evaluation of activities and use of organizing and concerted resource utilization approach is being implemented. Are there any plans to integrate otlrcr rural health programmes, such as the Expanded Progranune of Inurumization, Maternal and Child Health Programtnes or programmes for the control of other parasitic diseases, with the PHC system? EP[, maternal and child health program are already integrated. IMCI that focuses on the integrated management of childhood illnesses, especially malaria and pneumonia is also being strengthened. Describe how the CDTI will be integrated into the PHC system; the wctv the PHC systern will be used to achieve integration and the key persons in the PHC system that will be needed to achieve the integration. At the Federal level MOVDPCT will be responsible for rourine program management and act as the liaison between MOH, RHB, as well as with NGO partners. Members of the team share responsibilities among themselves and hence a separate entity of vertical program nature will not be established. The head of this team will act as NOCP coordinator. At regional level, MOVDCD 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 MOVDCD will acr as 8) 24 6.1. Integration of the CDTI into other community-basecl or primary Health Care (pHC) systems. The principal goal of the APOC is to estabtish cost-ffictive ivermectin-bas.ecl c'ottr.ol for Onchoc'erciasis, which can be snyained Oy lne enclenttc communities ctrtd cotuttries. One way to ensure sustainabiliq' is to'integrate the CDTI into tltePHC system o.f the country, which means nrore than juit us.ing the system frtrive rme ct irt dist ri b uti on. 6.1 .1. ls there an fficial pHC policy ancl structut.e in the country? ,/ YES NO lf yes, please give a brief outline of wfutt it is: There is policy and structure for Primary Health Care (PHC) in Ethiopia. The pHC system is used to achieve full integration of health related activities at all levels. APrimary Health Care Unit (PHCU) in Ethiopia has one health cenrre and five satellite health posts serving an estimated 25,000 population. Trained communrryhealth workers and traditional birth attendants aie also serving the community under the support and supervision of the health posts. Therefore, there is afunctional Primary Health Care delivery system ihat implements preventiye, curative and promotion of good health practices. This system is currenily capable of implanting Onchocerciasis control activities. In summary, the PHC structure is as follows: FEDERAL MINISTRY OF HEALTH ) REGIONAL FIEALTH BI-IREAU)ZONAL FIEALTH DEPT.) WOREDA HEALTH DEPARTMENT/PHCU )COMMTINITY FIEALTH POSTS (CHWs & TBAs) a) How fimctional is the primary Health Care systent? - Fully functional - Partly functional The system from the National level is fully functional until the , Health/health facility revel. However, at the community level health coverage is limited. - Non functional (Please spectfy) b) Does it cover the whole project area? No,/ Yes If no, tn wltat part(s) of the project area is there afuily functionar pHC structure? Wat percentage of contmunities where Onchocerciasis is endemic, artcl whiclt are eligible for comrnunity-based treatment, have an existing and. functional PHC system. c) 23 f) All communities in the Onchocerciasis endemic area have an existing functional Primary Health Care System (PHC). But as the health service coverage in the country is accessible to 6lVo of the population some communities could still be very far from the PHC unit but accessed by trained CIIWs and TBAs. d) Wat orgardzations are supporting the development of PHC in your projec't area? Government of Ethiopia (Ministry of Health), WHO, LINICEF, USAID, Ireland Aid, Italian Cooperation and other civil societies and research and academic institutions are active participants in the development of the PHC. e) Is there any past experience in the country of a programnte integrating witlt the PHC? If so, what programn'te was it and how successJul was the integrcttion? Program such as the EPI, Malaria control, and family planning are irttegrated in the PHC and the planning, implementation and evaluation of activities and use of organizing and concerted resource utilization approach is being implemented. Are there any plans to integrate other rural health programmes, suclt as the Expanded Prograntme of Intmunization, Maternal and Child Healtlt Prograntmes or programmes for the control of other parasitic diseases, vtith the PHC systeru? EPI, maternal and child health program are already integrated. IMCI that focuses on the integrated management of childhood illnesses, especially malaria and pneumonia is also being strengthened. Describe how the CDTI wilL be integrated into the PHC system; the wav the PHC systetn will be used to achieve integration and the key persons in the PHC system that will be needed to achieve the integration. At the Federal level MOVDPCT rvill be responsible for routine program management and act as the liaison between MOH, RI{8, as well as with NGO partners. Members of the team share responsibilities among themselves and hence a separate entity of vertical program nature will not be established. The head of this team will act as NOCP coordinator. At regional level, MOVDCD 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 MOVDCD will act as 8) 24 a Regional Onchocerciasis Control Coordinator. Similarly, at the Distr-ict levels will establish corresponding Onchocerciasis Control Task Forces ( DOTF). The DOTF will be responsible for program implementarion ar the District Ievel (ensure selection of CDDs, supervision of treatmenr activities, record keeping etc). In areas where access to the District health' office is restricted, local health institutions will coordinate, monitor, and supervise CDTI activi ties h) Indicate how early in the CDTI the process of integration will be introduced; how it will continue thereafter, and after how many years within the externally supported lifetinte of the CDTI it witl be complered.. CDTI activities in Ethiopia will be integrated from the very beginning. The establishment of the program will rely on existing sysrems oi health service delivery at all levels. 6.1-2. lf there is at present no PHC systen't in operation or in those areas where these structltres are non-fut'ctional, describe how the CDTI may be used to initiate and expand into such a system, giving a time frame for intended progress. NOT APPLICABLE 6.1.3. In which way(s) can communiq,-clirected ivermectin treatnxent tnitiate or strengthen PHC? CDTI is likely to encourage and facilitate the acceptance of new health initiatives in the community. Also, through the new CDTI strategy, the community will likely play a greater role in the supporr and ownership of the PHC system. The structures aheady put in place would be utiliz"O Uy the PHC to enhance effective planning and implementarion of the project. For example, the CDDs will develop capacities and skills, wfritn -witt strengthen other programs such as health education, other drug distribution. 6.2. Cost-recovery Systems during Community-based lvermectin Treatment Cost recovery for Primary Health Care is mandatory in sorue countries and it may be one means of sustaining a CDTI afier APOC funding ceases. However, please note well that since ivermectin is donated free, ihere ca,t be no cost recovery in respect ofthe value ofthe drug itsei; cost recovery can only relate to the costs of distribution. 6-2-1. Please state whether there will be any system of cost recovery (such as is recommended in Initiative) to help cover outlays on the distribution oJ' ivermectin in the present CDTI. NO. 6.2.2 state exactly lrcw any such system wil be organized, includ,ing answers to the questions listed below. What charge will be made per person or perfamily? NOT APPLICABLE 25 Which groups of persons will be exentptedJ'rom paynxent? NOT APPLICABLE Will payments be in cash or in kind? If in kind how will this ensure sustainability? NOT APPLICABLE What provision will be made to ensure that all those eligible to take ivermecttn, but who are tmable to pay, will also receive treatment? How vvill ir be determined who is unable to pay? NOT APPLICABLE Who will collect the payntents? How will this person safeLy transport funds to a place of safekeeping? NOT APPLICABLE Where and by whom will any funds collected be safely kept? NOT APPLICABLE What systerus wili be put in place to ensure the proper use cutd management of collected funds? NOT APPLICABLE For what purpose(s), including defrayment of distribution costs, wiLl the funds collected be used? NOT APPLICABLE What role will Village Health Contmittees play in the management and allocation of the funds raised? NOT APPLICABLE 6.3. Other issues Please provtde information on otlrcr issues and constraints relating to sustainability of CDTI you anticipate and identify how they will be overcotne. For example: the mobilization of endemic communities the maintenance of adequate supervision and monitoring inadequate human re s ources lo gistics and communications s o c ial/c ult ur al fac t o r s . declining commutxity compliance I ) Mobilizcttion of endemic communities: Experience from the Bench-Maji and Keffa-Sheka CDTI projects indicate that sometimes minor problems of mobilization such as misconception and misinformation regarding the use of ivermectine in new CDTI area can be obstacle at the early phase of implementation of the CDTI. This can be solved through sustained advocacy visits, by assigning individuals with good communication skills and expertise in conducting mass health education meetings to increase awareness of the community, surveys to monitor belief systems. 26 (2) (3) Obviously there will be a need to establish good relationships with the commLrnity leaders in order to have increased access to the communities at times like these. Mctintenance of adequate supervision cuul monitoring Meciizan@ distribution should include community leaders to further increase acceptability and sustainability of the program. All records will be venfiedduring supervisory visits, and informal discussions will be encouraged to determine community perceptions regarding the importance of the Mectizan@. Inade q uat e H untan R e s o urc e s Inadequacy of trained health staff and PHC units are expected to be constraints inimplementing supervision and monitoring. These can be overcome by allocating adequate time for supervision, in addition to training additional supervisors fl-omhealth facilities and community members. [n absenle of roads in some remore areas, mules and horses can be used. (4) Ingistics and Communications (5) During the rainy season in June to September 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 ,"uron (prior to the Jan-March distribution window), and encouraging completion of distribution before the rains if convenient for the communities. S oc ial/C ultural factors : So far constraints related to social and gender differences in relation to the use ofIvermectin have never been observed. Aowever, careful attention will be paid to cultural and social factors such as: the appropriate gender for CDDs especially inMuslim communities, respecting the t.uaiiionut relilion, and selecting supervisors and distributors who speak the local languages. Declining Community Compliance : Declining community compriance will be avoided through continuous mobilization activities prior to each treatment period. Community members couldbe interviewed to determine the reasons for the non-compliancl, and corrective measures taken where possible and appropriate 6.4- Methods of Measuring the progress towards sustainability(See Appendix 3 for a list of possible indicators of sustainability)? Progress towards sustainability can be monitored and measured by evaluating theproject in terms of financial management/contribution, communications, training and capacity building. This will help enhance integration. Financial management (6) 27 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 District health office heads, and administration/finance managers at each level rvill 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. In addition, the ability of community members to 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 Where an endendc area extends across tlte borders of two or more adjacent States, special problerus of cooperation between the respective country CDTI may-artse. In the event that there are ureas to be c'overed bt,your proposetl CDTI wlrcre the endemic zone extends across the J'rontier irilo one or more neighbouring countries, and where there are likely to be transitory or even large-scale migrations of Onchocerca-infected persons either way across the border. 7.1 Please describe the particular situation, as it is likely to affect ivermectirz treatment, and the methods you will Ltse to deal with it. The Jima Horo districts of the West Wellega project selected for REMO refinement is bordered to the Sudan. Therefore, working with the neighbouring country during village visits for REMO activities on issues elated to security and other cross border collaboration requires attention. 7.2 Include pertinent observations on current political and health relations with the neighbouring State(s). There is a strong collaboration through an Intergovernmental commission established by both countries that assess and address cross-border issues. 8. SPECIAL RISK ISSUES In some areas of some countries there may be special risks, which could hinder the smooth running of a CDTI. Security and other issues related to landmines in border areas could be considered as special risk. However, the problem can be identified and tackled in collaboration with the bordering provinces of both countries. 28 a8.1 Please describe the situation in any areas covered by your proposed CDTI were this factor may interfere with the program, and assesifuture prospects. At the moment, there are no factors that are feared to interfere witltr aciivities in the CDTI areas and we believe that such issues are unlikely unless otherwise. SECTION 3: ADMINISTRATION/T.INANCIAL 9, ADMINISTRATION 9.1. Organizational structure for CDTI 9' 1' 1 Please prov_ide an organogram for ttte CDTI showing the organizational structure responsible for implementing the proposal. Fig.l. Organizational Structure of National Onchocerciasis Control program J 29 :1,-/-r ij I,-, -. '{ ..r.1pr,,pi, t )!.,.'l,i:,,. 9.1.2 Membership of Taskforces 1. Regional Level 2. Zonal level 3. Woreda level Regional admi nistrati ve counci I Malaria & Other Vector-Bome Diseases Control Head Regional capacity building department (education and health desks) Regional Planning and Economic Department Regional' Rural Development Office Regional Finance Office Zonal Administrati ve counci I Zonal Capacity Building coordination departmenr (education & heath desks) Planning and Economic Development Department Rural Development Office Finance Office Woreda Administrati ve council Woreda Capacity building coordination office (health &education offices) Planning and Economic Department Rural Development Office Finance Office Religious Leaders Famous personalities 4. Kebele (community) level Chief of Kebele administrative council Kebele capacity building office Religious leaders Infl uential personalities Representati ve of women's association Representative of youth association I 30 9.2 Financial Administration Mechanisms of disbursements and transfer of funds from the World Bank to countries Funds from the World Bank APOC Trust Fund will be transferred to the WHO country office account in Addis Ababa. On request through the proper channels by authorised officer of the MOH, WHO Addis Ababa will transfer the fund directiy 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 transfen-ed at the regional level will be the head and the administration and finance officer of the regional health bureau. AII the imperest returns will be submitted monthly by RHB to WHO country office in Addis Ababa that will forward them to APoc headquarters in ouagadougou. Monthly reconciliation statemcnts will be forwarded to the central MOVDPCT (acting as the secretariat of NOTF) for follow up. APOC will issue checks (advances) in accordance with wHo rules and the previously agreed project documents and./or plans of operations. When the total payment in cash required for the project exceeds $ 100,000, the payment must be made in instalments. The first instalment/advance 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 contracrual systems is used, e.g. Technical Service Agreement, Irtter of Agreement, Contractual Service Agreement or Agreement for the performance 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 imprest 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. 3t Fig. 2 Reguesf and Disbursement of APOC Funds Disbursement Financial Report '-l/-., ,-,:; -rt -.t: :,:i ,)...."i: .\ 'i't \, !-u/ 1..-,^--_ii ,i,'".'r,l 32 r - ,__:- ri,;,.1!'! l!:,Lr:'/ !_E_rl,:;-tlJr.d -'G.\(att- ., -1i).<,-,, :- !-Lr- ,'.:, ,'\\tt'r :,'..' r r',''ll .ij-',t ' r': -.-, 9.2.1 Input from the Ministry of Health ct) Indicate resources that will be provided b1, ylru Ministry of health and otlrcrgovernment agettcies. The Federal Ministry of Health o Personnel, o Logistics-and provision of additional vehicle, o Office accommodation o Running cost for Vehicles maintainace and office Utilitieso Training, Supervision and monitoring, . Clearing, storage and transportation of Mectizan Regional Health Bweau/Zonal Health Desk Personnel, Logistics and provision of additional vehicle, Office accommodation Running cosr for vehicles maintainace and office Utilities Training, Supervision and monitoring, Storage and transportation of Mectizan District (Woreda) Health Office Personnel, Logistics and provision of additional vehicle, Office accommodation Running cosr for vehicles mainrainace and office utilities Training, Supervision and monitoring, Storage and transportation of Mectizan a a o a a o o a a a a a b) Please provicle a list of personnel assigned by the MOH to this project, includingtheir name and proposed time (State percentage of time allocated'to ihe prctiectlfor the project and where appropriate thirr ixperience in onchocerciasis cortrol through ivermectin treatment. This project is new for the District so that none of the personnel has had any priorexperience in onchocerci asi s control through i vermecti n d^i stribution. 33 Name Position Region 7o Time Mr. Dereje Olana Head, MOVDCD Orormia Regional Health Bureau lOVo Mr. Shelleme Chibsa Head, MOVDCT Orormia Regional Health Bureau 10Vo Mr. Addisu Mekasha REMO (CDC report) Oromia Regional Health Bureau t0%, Mr. Tadese Hundie Vector Expert Control Oromia Regioonal Health Bureau t0v,; Regional Health Bureau: West Wellesa Zone Health Department: * 4 additional staff members from each CDTI district will also be participating in the CDTI activities for 25 - 30Vo of their working time. Vo Time 25Vo 20Vo Name Position ZonelDistrict Mr. Abraham Rumicho Department Head West Wellega Mr. Olana Ayana Zone CDC expert West Wellega 207o Mr. Kedir Gobena MOVDC Experr West Wellega 20Vo Mr. Teshome Kene Healtth Programs Coordinator West Wellega 20%, Mrs Eshete Ne_easso Head, District Office Health Seyo District 20Vo Mr. Denu Fite Head, Office District Health Hawa District Welel 20Vo Mr. Mihretu Tarekegn Head, District Office Health Gawo District Dale 20%, Mr. Negaso Kinfu Head, District Office Health Anfilo District 20Vo Mr. Bayisa Gemeda Head, District Office Health Dale District Lalo Mr. Sisay Ashena Head, District Office Health Jima District Horo 20Vo Mr. Tafese Terefe Head, District Office Health Gimbi District 207o Mr. Abose Waqwoya Expert, Distnct Health Office Gimbi District 20Vo Mr. Jemal Beshir Expert, District Health Office Gawo District Dale 207o 34 9.2.2 Input from the partner NGDO(s) a) Please provide a letter front rhe Executive Director or tlze Director of onchocerciasisprogr(lnxmes of each participating NGDO st(tttng their intentions to participate in an4 support the National Onchocerciasis Control prigrantme. b) Give information of the input front ecrch NGDO participcttitzg in thisproject. c) Please provide also a nominal list grading and post description for thepersonnel to be provided by partner NGDO(s). Indicate clearly what will be their functions itt the program and their experience in Onchocerciasis control thro u gh tv e rme c t in dist ri b ut ion. There are no partner NGOs in the area that can participate in the project Therefore, all the contributions will be met by the government and community. 9.2.3 Inputs from other agencies. Please list any other agenctes or parties tlrut will be involved in the running or financing of the CDTI, and indicate clearty their roles, functions artdcontributions. WHO: wHo Ethiopia will assist the project in the procuremenr and clearance of Mectizan@ imported into the couniry by using its diplomatic status. 9.3 Timed plan of action Provide rt time chart(s) showing how the varions activities of the CDTI willproceed over the course of the proposed program. Numeical a-nnual targets forall planned activities shourd be providedfor each time point. The time charts should also indicate how external support wilt be phasecl out over the 5 year period. 35 a t.- cil \ \ \ \ \ \ \ \ \ \ \ \ \ \ \o (\i \ \ \ \ \ \ \ \ \ \ \ \ \ rn al \ \ \ \ \ \ \ \ \ \ \ \ r+ ol \ \ \ \ \ \ \ \ \ \ \ \ \ ail \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ (, <1 = .9 boI() o q .E o=ay EO d! ro(JE dq(J .: o L.) iE q o o o E (.) 1C o o C) oo uo oo 'a o. 'Eo oo_ q=(-) J o-o .C cd o! b9 =Lu.5 o5d8l ol >tot -l6ltrl ot odolLl o io sd o C) ai o. o oo o b F q ! q) L o() '- o. oo cs) E_0 o: oo:Ca EA .JH L& oJ A o Eqq o q ca o 'a o ,= o o. rrl =o. & o N -oo 2 o(J o U) nr V (J o a oU o0 = ! I oO c. L o (J o 6.)(n oo ! o h a o0 o -O u(i C)o2E rrr O o -o n @ (d N oo 2 oq 0.) o. a bo o o z q() 't o(! o -o L 13 a oU - -v,cooo ool oulo. ol90) Hvl O E € o E o ood (! z o0 ooda(.) >\&v) o O <! Lo x 0) (! C) q (.) () a) E IF o =0) C) p. o o q) NL Er q) F q) q) !+ e) F 10. BUDGET 10.1 Budget Estimates Budget ryus1 tndicate total funcls to turlertctke the project. The antount of fundirtgrequested from APoc, and the amounr prot,ided. b,"- the MoH, NGDo(s) and. otlterpartners. All must be made in US dollars. Eaclt budget must inclitde at least the follorving nrujor categories (see appendix 2)indicating the contributtort of the partners to reJtei sttsiainability of CD:TI. ! o Personnel (services) o Capital equipment . Supplies Training o Health education/mobilization o Travel . Communication . Consultant . Operating expense o External audit 37 38 Tab|e 5. YEAR ONE SUMMARY BUDGET FOR ONCHOCERCIASIS coNTRoL, 2oO3 CATEGORY APOC MOH TOTAL Personnel 0 96,009.20 96,009.20 Capital equipment I14,170.00 18,778.10 t32,948.10 Supplies 59,267.00 0 59,267.O0 Training 20,299.50 6,380.00 26.679.s0 Health Education/mobil izatior 34,896.65 7,625.00 42,52t.65 Travel 8,800.00 1,964.00 ,10,764.00 Communication 2,520.00 2,520.00 Consultants 0 External Audit 0 0 Recapitulation 9,600.00 0 9,600.00 Operating expense 14,370.00 14,370.00 Total u7,033.15 147,646.30 394,679.45 Estimated No. Treatments 563,9r0 563,9r0 563,910 Vo input 62.6 37.4 100.0 Cost per treatment 0.44 0.26 0.70 g5 o o a. 8 g E o = s a 8 a t3! 8 g I g. 8 E o = ; J t,I a 8 8I S g F E a c.; E ooC 8 8o-! o RN. 3 8 8I ?; a a. o I a :. I 8 a g. I g a e a roE E E N a N. 8 T ! 3 a il c{I &g ooc a g. q 8 g I E E o o E I @- I a N- 8 9 3. 8- I 6 8 a o Eo = a @- ag aE : I a. a 8 g q a 6 a o- 8I I6 cr a a o a o J a J a :9 o a 3 8 8 t oi 3 a .1 ai 8 g a Zo = ; 8 E o; a: 8 I N 8 o- oi 8. ooq a E o 8 8 8 I u1 a rj a Fo F a s I a a T d o_ 8 a 8 G. 8I a\ 8g Eo = J o a 8 8 g. 8 g 8 ts aqo J o ooc 8 N. g N- E o a I a a o E Fo a E a I ;.g 8 a @- 8I 9 a g N. 8 E 8 .?: t o o- o 8 g Eo g. a tr G. a E. 8 ts. 8 T a a N. a 0- a. o o? o@o ooo a 8 q a aN. aq a 8 a 8 g E o o- @ a EooU F o E e 60 E E E o 8 E a E E 35I E ll6 € T E E EItt 5l a E e B 6 E E 'a] 8tGI e t. EI A] 5 o C 5 c E oz E E E] *l E, sl8t o- L c oo I ah .(! o o() o otr o o E E v, o Ef(D (E o o .=tt (og o(!F I o{ E o; .l J a s q o_ 10.2. Budget.lustilicttion Plt'tt-st' l)l'rtt tLlt (t tt(ll't'.t!tt t' t/t t, l't1t71,,,, 1tl lllt t ('(1\r)/1 t lttt' t'tttll 1t1 1t1tq :,q',f llll( It('ttt.\ ()l llrt'bttdgt't ( 1) ['ersonnel Thc bLrdrlct scL-n Llndcl lrrre rtcnr Pet'sonttcl rcl'lccts tlte necd fbr stul'l'iit the IcYc'ls ol' \1OH. RIIB :rnd Drstrrct hcllth ol'l'rcc ltr l'ucrlrtute tlic CDl'l lrctrvitrcs i.rt tltr- conrnr.lnltv Icrcl. l-hc I\lOIl rrtll pt'oi'trlc srll)p()r't rrt tlte lbtttt ol': o \ltltlt ltst ltg r.tuthrlt'ttlcs lttttl ('()lllllllllllt\ lclttlt't.: . Orgatttstt.tg und lcurlrnS tlrc drstrtbtltl()tl I)t'ogt'ittll o l'r'aining ol'sLtl)ervrsors rttlcl CDDs . Gctting and sLrltplr rns l\ cl'l'llL-ctlll o'l't'ansportatron ot'essettttltl sLrPllllcs . Regular supervisiott . Accountrng l-or f'urtcls sPcttt (both APOC rtttd otlrers) . Pt'ograltt er,;-tluitttott (2) Callital ecluipnrenl Fol thc plr)qrirnt to functirrrr I)r'(rl)crl_t. thc IlllB. Drstrrct hcaltlt ofI'rce rind sonre health l'acllrtlcs r-r-rust Lrc \\cll crlurllpecl tt rllt thc ncccsSitt'1i tr',,.-,' ',,t (3) Supplies Office supplies are essential l'trr the snrooth rlurnrnq of daily program operatrons. Srnce this ts the bcgrnnrnu o1'the progrlnr. APOC rvill be reqLrested to provide ali essentral ofl'ice supplres. (4) 1'raining: Training is essential to the implementation rnd success of the program, and it rs an activity that is carlied out on l contrnuous Llrsrs, u'rth training and re-training at all levels as new personnel join the program. Trainrng rs also very important for the supervisory activrties of the program Thcse actrvities rvill be supported by APOC. (5) Health Education/i\'Iobilization: Comnrunrtl,r.r-robrlrzirtron and rrdvocitcv uctrvrtres are requrred to burlc[ the support nceded to ensure progralr sustarnabl llty MOH pel'sonnel from the National, Re-qronal, and District levels rvill mobilize communities through advoczic.r' campargns, rnformation packet and visits to the communitl,. General public a\\areness can also be supported by such techniques as the distribution of posters, brocltures, strcl<ers, and T-shirts etc. 40 (6) Travel: Travc-l rS r-eQLlrrc-tl l()l ir(l \ ()jlc and L'\'i.tlL[rtton i.rctl\ ltlc\ trr.L. APOC rr rll Lrc. l.csl)()n\rtrlc- l'trr (7) Contrnunication: -\' \ rsrts. lli.unrns. rL-lriulllnq, supel-\ r.srOrt lrnd nr()nlt()r.ilrg all rrrrPtll'tlrnt l()l' t'l'l'e crrvc I)r'ogr :rnr nnplenr.-nr.;rtroi sLl[)l''rortrng tr.ir\ cl crltenscs nccL-ssl[ \ At the Nlttttlttltl- [lt'lttrttltl. urtrl Drstrrct lc\cls. telc.lthtlnc. c()lil-tL'l-lrnrl Otlrcr.ntL-i.lns ()l collllllLllll('i'ttl()ll rr rll Irc ttsctl lu]tr)n-g [)l'().lcct o[)L-nrtors. At thc cr)n)nrulrt\ lcr c]. conlnlunlcittloll \\lll bc ttllttttll'throtrgh the usc ol-rudros and nrc'9,lrpl.rsr.,rcs. ApOC rsl'equestccl to stll)lx)l't cx[)cnse s lssrlcrirtecl \\ tth contnturrications includirril co,l.lcl. servi ces. (8) Consultants: Consultants tvotrld bc t'cqrttrecl to concluct K.^\P studres (to hclp rn thc dL.\,elopprcrt and t'eftnetnent tl{'hcalth educittton and othcr nraterials); progranr c'uluatrr-rps, computer maintcnilllcc alld other asPects of conrpLrter u,ork, to .nrt',,. totll cluulrtl managemcnt of tlte p[ogrant. APOC is requested to support the costs of rhr:sc consultants. (9) External Aurlit: External audrt u,rll cnsurc pr.oper accolrnl.abrlrt\,. glngg APOC u,ill supPorl thc costs ol.extemal audit,g sPccrl'rc budeet rs not inclicated in the budget detarls. (10) Operating lirpcnscs: This w'ill rnclude costs such as utirrtres, costs of quarterry meeting (Nocp),development and rnalntcnance o1'Ir{lS. Also rnclucled in this line itern is the cost of'operitttonal t'eseat'ch, prlntlns of essential reporting fornrs (treatment sunlrnar.), fornrsfor communrry, Drsr'rcr, and Regronar srair), [ousetroto ;;;;;: ,;;';;;r,Lrnrr' registers. These expenses u,ill be Jrppo.tect br Apoc. NGos and MoH,,,i1 'r;,;;. some costs such as office utrlitres. I0.3. Current resources available in CDTIs Existittg CDTt't (for c'orrtitttrcttiort or expcutsiott)tvill have resourc.a,s ctlrecttll, available' Please pro,icla a dctailecl lisr of alt existing persorutel, eclttipttrcril atd srqplies (ittclucling t'ehic'les, etc.) belinging to tlte progrcutt, itt4ic.atirtgtlrcir on,rrcrsttip (MOH, NGDO, other Age niy,hr.) o,ril ttrii, level of funcrionaLirl'. NOT APPLICABLE 4t a APPENDIX I: ESTIMAI.ED NUMBERS oF.COMMUNITIES AND PERSONS ToBE TREATED EACH YEAR, BY ENDEMICITY LEVEL Total population rn above communrties YEAR 2xx (2004) No. of communlttcs to bc tr-c-ule-d fotal populatron rn irbovc comntunitres \'Orrcltoc'ert'irr.r'r.r r.r tt()t ('()ttri(larac! atr itttltortartt Prbltc l{eoltlt problcttt irt l^,ptt-ctrtlc,tic,t'otrttttttttitia.s tttut ,,\p( )C trrll nol ttor,tall.t, _fiuttl c.<lrttttuttitt,-bttsatl trt,tttntcttt itr .tttcltt<tilttttttttitit,.r 'l'ltr, rttt lttrtott ttl stt<lt tctntttttttttlit.: ttt tltt, lrrttlttlsttl rttll r<,t1tttt.L, (t .\/t.,(ttllj u s I iJi ( d t t ot t .l o t c ( ) t t.\ i ( I (, t-( t r t ( ) t t l)\. t t r c'fC C. AREA COVERED COMMUNITY ENDEN,IIC LEVEL HYPER- ENDEMIC MESO- ENDEN,IIC HYPO-ENDEMIC,i TYPE OF TREATMENT Communitl,- based ContmLrnitl.-based YEAR 1 - (2003) No. of communrties to bc tr-eatcd 160 105 451 475,370 267,r74 t,245,786 No. of communrtles to bc treated r60 105 451 Total populatron rn aboYc communltres { 71 I ,281 911YEAR 3x* (2005) No. of commLlnltles to be tr-eutecl r60 105 151 Total populatron rn abovc contmunrtres {68,905 37 l.-ll9 'EAR 4,j,{, _ (2006) No. of communittcs to bc lr-cLrted r60 105 +-57 Total population rn ulrovc conlmunltres l8 400 29 I,-157YEAR 5** - (2007) 160 l0-5 -1.5 7 .l 397 llr I,39(r,70(r **ll i's tttulc't''\tttoa! 111111 tltt' .lt.qtrrc's Jbr Icurs 2-5 ttt e lil,alt' trt l-tc, cstirttrtlcs tltttt tlt(t\ cltttttyc, tt.s tltt, 1 t t'ctj c, c t /)/'(,t ti'.r.r t,s lli- +t F3 -o % lnput Nobo NobO Oo OO @o o O)O oO AO oO Noo(, -Tt €' s, l, o C) o TD CL GI o E o 1' 0,f o o o o '(, o oo o o, @ NoO5 Noo O) (DO oJo i(, N)oo .\t A Iverntectitt Treatnrents reflected in Appendix I uere obtained as follou's: Total pr.rpulation in thc- 20 districts in the zone in the year 2003 is 2.012,741 6 of th.- 2t) i11511-i.1. arc- hrpcr or nresoendcr,ic c1ualif1,i.c rbr cDTI AII thc six districts rr ill be treated in y,ear onc and REN.{O rcllpcrrrcpt u'ill be done i. othcr 6 drstricts. Year-Onc Total populatrorr in the 6 districts targeted for Year-one,704,gg7 Total nunrber of persons to be treated in year one: 563,910 On the cottsc'cutivc)/ears tlie progrant u'ill still cover 100% EARp of tlie treatment objective u'itlt natural gronth at a rate of 2.9%per year ip t5e fryc districts selected for ),ear t\\'o intcn'cntion. Fig 4. Annual Treatment Objective by Endemicity Level 450000 4 00000 350000 300000 250000 1 50000 100000 50000 2004 2006 2007 F 200000 0 2003 2005 Year <- Hyperendemrc + Mesoendemrc 44 ..\PPI]\DIX 2 I\DICATORS FOIT E\-{LL-.\I-IO\. SLISTAI\.{BILIT\ /I\I-EGRATIO\ OF'CDTY .l Iu ttctgctttc ttt Fr rurnci ul lnr.lnitqentcnt It'l cet r vcr)L-ss ol' crrrI] ntrrn ILal.i ons -l nrrrtrr.tg l.rncl c:rl).tert\' [rLrrlc[rng I rtst r t trL r r-lrrtrI cclrrrlt.tr t nte.lrt F'Lrllllrlcnt ol'othcr rcle r unl. sectot's ProLrlcrl scllr rng cultacrtY Intcgl'i.rl.t on ol- operational research P roj c c t cJJ'e c I i v u t e s s ResLrlt of KAP Srudies Trcatntcnt covel'rrge Follori,-up o1- non-elrgible and absentees I\{urrlqcmcnt ol udvcrse reactions Rel rabr lit1, ol reporlr ng S tt strtirtnbiIity/I rtcgratio tr Prtlitital w'ill o./ lrost eoverntnent Polrtrcul ii'rll as shorin rn polrcY statenrents unclappalcnt conrmitment of hi gh-level Offi c rals offrcral uctron asslgnnr-q personnel. funds, r chrcles {.o progranr Lottg -tc rtt t pl utu tt rt g ls thcrc a long-term plan for sustaining the frnancrn-e and the mana_gement of the progranr? P r o g re s' s t o w o rd .fi rrcu tc i ctl s ust ct i r tab i I i r t, If program sponsors cannot continue their cunent lcvel of commitment for at least another five vear, rvhat percentage o[ running cost.s is no\\/ paid for host govenlments or fees? P ro g rt,s s t ott, a rd i nt e g rat i ott To u'hat cxl.ent lras iverrnectrn distribution been integrated u,ith other health sen,ice programs? evrdence of contmunlty empowerment and orvnership changc ilr KAP over time extent ot rnvolvement cif both gender.s and non-llteri.tte 45 l) ro i c ct I')rul rtot io tt o J. o I o 3 o o I €oI €o o :c I o, o -t' - o' -oo =J o 6- o o a o =ol T o aol :, o U) cu o lo o o ooi o o o + :, 0) oII oo = o) o. = o 8. 0) oo o 0l o ll o a, 6-J th a (t I o D oIg o o =. o N oi -n N ol q_ oo oq :f o olal 1' oa 6'3 o -o or o a o c1o o NIo a o c Io o J c o, a o f f L 0) o (n f\) @ N) 5 N) @ N)A O)(Jlo o)(,o N)(noo O) oo @ o o @ zI o o o \J55oo 6 O) N) o)! ! -.J O) oo (Jl O) @ oo -to 0, o o A @ o,Ioo G)Ioo o)9oo 5 oop oo ..1 oPoo { o D o lo o =o 0r t o o o 3 ooo s :o t 6o .'eq =: =3 o s @ o oo o = =- =3 o o -to6x TI o oo o 3g o loq :. o R s =o o N s o =o 3o o :, o No beq =Io =.3 o o o No "-Qg =I(D =.3o No s o J o. =f o o Nof,o + 0,o -TI o oo o 3q o It t,g o 3 o o 8 o- Jo o N(,r o\ of D d'l flacu I og ololf,(D 0) a o ? o' ooIq o =. o oo o c f 0)f, l> o_ 3 5' a: I o O)a a. I o, = d o 3 6' o- ; o o sl o. o (tI oo or 5' 0) o l, oq 6'l o aT TD II G] llr G] llr @ llr ul Ta G] llIgl a o c1 o o O)(,o O)(JIo @Oro (,o (,ro N)(,oo ,\)(ooo C,) 5 N) cg a tD z 9 o o !o ;.,(o !o No O) snoo O) snoo @ .(J,oo .(J,oo (, oo N)(JlIoo N)(oIoo (^) 5 N)o i o D o 0, 6- o C o, o-{o trlo oe o l- a =o o o of, o A) ao 3.oo(D Iq, o -oo\ o fq. =o 3 o o o o o\ =a =o l o tfo ;eq fIo =f o ooocf 0lf o- 3f tt a q, 0,)- o Es o r- a J o =l o -oo\q a. e.J o =3 o 6 o 8 s o,) o @I o\ o f '4J o o o 8 s A,l o o ;s lq. J oll lDl o, =.of oI -toJ r @ o) oo Jo No -rg\ t oo -t oo{ o{ r on -i ;q o o o o o l o I oj. I(D a a- n 0)q o o o 3 3c J oI o l oI.o o)1' =o f oo I t-oo T o oI o o (D o O) o. o o o c o I l-I]LJo oo o :9. o 3 0)oJ f(D 'Tt 0)x 3 o)o z. f o lrlalot.lot-rolr t1 l(D tl o o)lo x 0) l o.{ = o ooox oE oo 3D o :1 o)ooo6 @ o:(D a Ao o { o) (D l< t9.lo o o 6- ls l€lo l'o lotxl-l(] l(D f o o o oa 9_ -o oo -o o -o oo -o oo ll oo -o oo ! oo ll oo ! oo 1loo ll oo ! oo 1l oo o o o(D (n o (, oo -c,)oo -(, oo N)o _(,o o (, oo -o oo .. oo O)oo -(n oo _(,ooo -Cnooo C 2. o o o o o 3 O) O) N @ z 9 o C =.o P{o oo (,Ioo (n oIoo NooIoo r\) -o oIoo -.J N)9oo (,l o9oo -(,ooIoo Ju t\)oIoo O)oIoo -(rt oIoo (rl _5 ooIoo -(rlooIoo -log o oo o Nof or_ 6- q o Nof 0r_ o- q !o € o c! P- o oc o 3 o o{ o o. D o € o oo !, of o. Nof o l 6 0) =o f o € o o o. D' o q o !r_ o-- g 0) o o of !L 6- g l:rlo tatalclo lo la,l=-o l o No :, 0r_ ouo l o =lol olololcl3lol al 'l loll t:l=ll lq'l-loltlolf lor lolr =looo o or' 9. oo =o ooo o. 5 A, f@ c l ol o oo 3 !C 6', o Nof!r ofo =ooo o. o,q oof, 9_ oooq fg. l(o C f t-{lr lalolrlo lo toko 6-a o 0,oJ o o, o6' 6' ol ol al olq1 <l --l6l @l lo lalcfololz lolf lolfto 6' d o 3. =: oq I N of A, o G mx!il =o =.ol3 lmlxlEl(!lrtalot_- lo t3t\l0)lo ?' o ooo =.! =.o3 a o'o -n c f =c o Ao l lq to l(Dl^ fo l0)o o ls lg llf. lof o o lol<loll l(D lot lo-ro o oo s l-D l3t-tot6lolo lo l o)o f - l- o) @ o o o @x o €o o f, a- o lt oI .Tt T -n I -n (J I -n oT -n o :E -n :E 7l I o o o o oo (,) -.J(n o -o o (n oo -o o O)oo -(n oo -(nooo C 2. o o ah o o 3 z 9 o C =.tn -o(.) -J s, o CN9oo @ :.J(rr o (, o bo (n Ioo (^) oIoo O)Ioo (n Poo -o o9oo { og o oo (rl sq coo c J c o ao o 3(D f l(r lslot;lal6 lol; =o O) o- ox ?)(O o o'(D 6 rc o)o o l(, t-" tat;t@ l(D lot;l-lo o) o-Fo x. ? f(o 0) l o- 9_ o- (DJ o (D o o co o o o_ o x. o =. o o =o O) o- o o o\ o co o 0r_ o x.o =- 3 0)o a f, o t.- ls lo lcl6 lolol; =(D 0) o- o x. 6 fIo Er.lrl otrl I t-lo lsto l.lo LO o o) o 0, o_ ox c rl(o1 olol3lD o o ocI o 3 o (D o oa l o) 6ol EI Orlol -olo-l o =o o o_ !:.oo E oo ! D. o t<to l:t LO 1l oo o J o o-' oo 3o ol o rxEI 6 a o, =o :, -Yt m(, m l0 t- =oI o o = :1(, c o) o I o) x 0, =o. 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T oo G) A(Jl J (^) (l)bo 5(,l o at 0) Ca@ G) o o 0r_ C,J co T O) O)o o 0) 3q (rtoo 3(o g ooo O)o(, f, o l\){ =.ag, A) C :t o o 0) f ol o (D O) 3. o :fa -o oo o o E o =. = o loo\oo\ o o q) ,; o N{ N) -.JIoo o(rt =.3 A) o o. o o fo o U'd o o oo a 0)(o o ll(D(o 6 o o ooo @ o a o 9_ C' 0) o a o ; l.o o1fJoltlol6l 'l s @ _-. c) o-' o =o 0) J 3 o U'a 0)(o IO l)a196lo '=-lc, oloflooldal'.-^ l*ElOrl- -' uq)(DE -o)(Dro <o o_a o)! o(D ='D6'o 6) c) :, o) 'Tl(D:t; o)D5 =.7 xf ci o 6 $siH g(,cdi a.o31d9 BElo) 0) ao o 6 rl o'l !:.f, o o o)l =.o. ko lo d O) x A)l o-{J ='g ld Iq lslo-kolo lat- l-ol=lo o C) o FO 3 o) c) =lo o o C f o o o o (n 3 z o o f =o { o 0, o o o f 0, =.o f lh U, o G'x o o CI, -Tt o N ol 0) 6- (D o f(D -o oo (,l (Jl t\)Ioo > C (,l o,oir o CN oxo -o oo ! oo 1l oo 1' oo ll oo ! oo ! oo -o oo (n (,l o o iu(, O)o o (Jto oo 5oo (n O)(o tol\)(n O) (Jt -.J O) f\) 5@ N) Or N bo(n bo i\)oobo co -(,l C,) orbo N t\) -o O)obo 5sbo { N) Poo A coIoo G)oobO (,OIoo o o O)(o o o =Ld o so :t o 0) 0) 9. 6'tt ='o o- 6' a) al ol =o oo{ (,l o,(o =. =(rt q) Ca@ (,l E o =. = o o be o Jo O)(o o Eo]C oo =.3 A) o o- o o :lo o ad o o oo o oa o o o 0,o =oo -{ I N)(, E o E 6'o o l\)s E 6'o oo 0) 3 of o f o o 3 of =U' o o, o-6' =.o @ o o U' o a A) =. 0) C O)o o 3 ol J o o f, o 5 @ ! ooir o o 0) o o, o o o 5 @ J(D 0r_ = 0)g o'(, ='@ o- a' =-o a 0, Ca o 3 0)o =5' o + C oo (,l o Ca@ C,Io ,\) O) ]C1'fElo-oi' = (,)I i:r5 ..;PCO 'I3 (oE(D3p 0).6 (,(o i\) O) .{ bo 5(o l tn o ro ol-trfg(Dx 3' '' gl -{cE. .oolo t6C] o =a 1' ooo{o{ r alloc 3.o ==[o o,o:rO ^€U3J()J(D o oooa o_C =-f(ol -o oo i, (,)(,(,)(,) NII\) @ JD(, o (,o CNO =o -{o{ r o-O<ool u o'l o o o o D. l o a 4,. € o o_g) r-1ooo) --{3o <l6o+o ol A+ o)qi5Oltr(Doo, (DJ <o-e.g o 6 o. 0) l @(u o 3 o, o e' o oo mx 6'f oI oI a oc o o @ o C l =o o o o o 3/ (, o.)o (,o 1 9 o c J o @9O n\) (,o9O { o 9r o o(t, 0i 5 o a 5 O) o- o:o 6 f o 1 g f O) oo o @ (a0) o= a!616(of,o og) a E C @ @ oa E o 0) 5 o E o-i) 5 <$Oo -Joo- l< 3 -n o O)o c) o loo i=<r )I -r oJi o=qE3 ofo'loqo N) <o= B =Ss 9;o-o :1€;T;; ci o- tn =o) .ni@o I Fo5 -9 rD -nr -6 -= ru€Oo) o- nD =-o(D mx o, f o, =.o a a 'o oo t trBB ooIf :1 0 mio- c)Sl+9.@oclo- s.o o9: o =OTq o'af l, o o{o{ r i a =:1a E =ro :l o =oo o o Or' a. a 3 o cna 0)(.o o o d'irl o 0) f o o o q) l o_ o =o @ o o o ocd o 3 0) l (D ln o U, o o :l 9. ='o o 3 0) d =(o 0)(o o T o <h o(, -l o,lo 3 o' U' 6' PI q.(o f, ao a 3E o 3 oIt Ao of o =0)f N)ooo o 0)oJ 5' o o 3 q) o) :, T -4. =. o o(t o o of. =o 0) o o o o oo L a. 5 o ot o o) o O) ]i 90?a'ciio6'or-c)^ 3io-o 3E de =.ON(o)- =. 0) ol:li o o =.ol6 6'l o (,,N(DO Jf F'aA)= ^'(oJo, 3 3(D o =.ol 6t o'f, o o o. oo 0)o O) :l o. o. o 0, :, o. f o o f -o oo :o oo -I) oo ! o c) l) oo oI o:r a o o o N) I(rt I 9 cn (rl (, C3 o o o o (Dl 3l Cnooo f\)ooo (,r o)oo (,(,) co5o 5(,r N)o (,(n zI o cl o I I c.,A -co @ o) b, Ol -oooobo l\)boobo -(,(,)oIoo o, -(o N)obo o, ..I O) b,(rr -J (rl -o, oIoo Juolo lrtoo { o 0) o o an (rlooo{ o =ItI Ca@ to lC o p. oo o o o o ol 9'I =o o) = €o r(D t, 0)l o- o J o a oa o o 3 3 c f ltnlol= o o6 0,l o- o =o ! 0) ;1l o o o cdo(t o ox o C) o0 o q) l o. o o 3 3cl o-'g) o- o o (n D oo o o o,o = o 3 =o o E oo o D o(t (D U' o oq) oJ s. o q) I Oro ooL =o 0) o o 5(, 1l A' I(,r gcrl 6lhg =-5l9.ot: :p53(Doorl:hqeEe(D 4-:(/, Q.Y 3Ee ='- O i qe!( -ro - oo 9xE E +.3lii'Ede6. eo \ ==oYq= coJ ? oP d OO^ l.J D)o<6g =D TQ cYA (,q)i-<ag -:<lg =D o4 EeoE OEq)=-of(D -f 6'f 8E 3i=f(D.o odEs *, o-., eegB{glro .<o, Foi oPl o- o' algE E$lo-Sarg m o, :, 0, =.o f (n oI (, o !, -n c(D Co =.o 0, 6 o :, o. oo s @ o a Nof D- 6' oI oI o o l\) (, oo o oo o f, N N) C l zI o N)oo N) N) o,o Poo g o o O)oox 3 llt (rr x 3 (D 0) C U, m l9 l<;o ='o g o(D ol (.) 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PBoP0J$ru f0]E uCIiMlutuilrHry ffiEffiffiffiPRffiffiF West Wellega Zone Oromia Regional State FEDERAL DEMOCRATIC REPUBLIC OF ETHIOPIA Project Period: Year 2003-2007 Submitted to African Program for onchocerciasis contror (APOC) uflilrfl l For Acdun To: TccTt hsdr,'.r19 ") coopb CSD CI-V Bttr LoP bh For lhrfior.mollon To' Dtf.., Ao trS,,f totiO3 :i i JiItL 2tiiiii! I t L 0 t It: l i a {1 ,..J Revised July 2003 I I A? 92r:tL1|. era0T. {lilfto,a.t hr\4t ooT"tt"+ THE GAMBELI/I. PEOPLES NATIONAL REGIONAL STATE +', DATE 04 /';aIEn.ft228 rn$ (LC HEALTH BUREAU IIEF. No. zfNq GAMBELI.A Disease Prevention and Control Department Minisbyof Health Addis Ababa. Dear Sir/ Madam Subject:- Annroval of the New CDTI Proiect Proposal . According to your letter Ref. No aorn | 1491451956 dated Llllllggs E.C. We learnt that you need our interest on the New CDTI project proposal. For your information our region has highly accepted the New CDTI project Proposal. Hence,wearegoingto implement this project inthe yearof 2003. Your cooperation is highly appreciated. ./, {,with regards1q4 h1 'l fir g-2 .:, ?o .a f KOANC JOCE C.C a L, t',1 sI of Planning & Programming Service Malaria & Other s Y tBlD tP I C/Department Tcl. 51 0138 51 0t 4r 51 01 42 51 05 36 I,'ax 51 02 14 5t 02 15 ,r4(t&f r t\.lhP? af,.{l,tG aAn rLArn sx{tctutFtt tr-c &.r{r} Please quotc our reference nr'-her in reply. c tcn / fta +.r'c.-...-. 6rn (,f..-l ni hq A 14'8Yll\1';t' 4"1 ftzoo.l f? ?+otrl-Cr\ r., a I C. * rh. l- r-A;c t.. y. (,- ^fl.,q-,f h t. h. ! 1, 4' r.n Nh fnul'r0,} "?.tn-bc Federal Democratic Republic of Ethiopia Ministry of Health jl. t "e Jur ias,r 42,r.r: H lzt I6[ /t:1 For Acti;^;. ,' To: T(+ Pl5aprwt:':t'ri - C.ooeo - cs-bcel Btn C^p BR, For lnformotlon To, b tQ- Ao Dr. Azadigo S6k6t6li Director, African Program for Onchocerciasis Control Ouagadougou 0l Burkina Faso Tele: (226) 34 29 60 /34 29 59 I 34 29 53 Dear Dr. S6k6t6li, Subject: Submission of Six Revised CDTI Project Proposals of Ethiopia It is to be recalled that NOTF of Ethiopia had developed and submitted six new CDTI project proposals to APOC for possible approval and funding in order to initiate Onchocerciasis Control Programme through Community Directed Treatment with Ivermectin (CDTD in three National Regional States, namely Oromia, Benshangul- Gumuz and Gambella. However, TCC in its sixteen session has rejected all the proposals and recommended the proposals to be revised. As a follow up of its recommendation, TCC mission visited Ethiopia to give a technical advice to NOTF from 16-19 July 2003. Based on the issues raised by TCC 16 and the technical advice extended by the mission, the NOTF has revised the proposals thoroughly. We hereby enclosed: l. Revised CDTI Project Proposals for: Illubabor, Jimma, East Wellega, West Wellega, Metekel and Gambella project areas 2. Signed endorsement letter from the Ministry of Health/ NOTF and NGDO commitment letter for the Revised CDTI Project Proposal for the years 2003- 2007. 3. Commitment letters of Regional Health Bureaus from areas where no partner NGDO is available, so that 25oh of the contribution is going to be met by the government for the first year and the goverrrment's financial support will increase from year to year to ensure sustainability of the programme after the withdrawal of external support. Please be informed that Illubabor and Jimma projects do have NGDO partneg the Center. The rest do not have NGDO partner for the time being Seifu Solornon Ref. No....... i:i:CiJ 3 I JU|L. 2$03 APOC/DIR. tffir, liltc+tz Diseases Preven6on E€eaf@t' and Control I{Ead Minister'sofficeFaxNo.25l-l-519366,MCH51 6677,PYD51269lDCPD527033,534867,Procurement535l66 E- mail moh@telecom.net.et a 1234Telex2|84MET I srzor t,st73og,st783t1t762t, 5t7923,5178t8 @An nLn.ftn.l.?.t! rhT', f..fl4tl +fc tl,t4,fi- In reply Refer to our Ref. No. This is, therefore, to kindly request the management of APOC to approve the project proposals. We would like to take this opportunity to thank APOC Management and TCC for extending their unreserved support towards the realization of Onchocerciasis Control Program in Ethiopia. We also appreciate the support and input given by the TCC mission of l6-19 July 2003 to NOTF. Sincerely yours, ,\ {r rs d E Se ifu Scll''1"'" ' PN mtion DcBortmcnt' and Control Head Cc . H.E. Minister's Private Office . H.E. Vice Minister's Office . Planning and Programming Department . Diseases Prevention and Control Department o Malaria and Other Vector-borne Diseases Prevention and Control Team Ministry of Health Dr. Angela Benson WHO Representative, a.i., Addis Ababa a a a a a Mr. Teshome Gebre, Country Representative The Carter Center Addis Ababa Oromia Regional Health Bureau Addis Ababa Benshangul- Gumuz National Regional State Health Bureau Assossa Gambella National Regional State Health Bureau Gambella 7 ? Letter of Endorsement from the Government of Ethiopia to The African Programme for Onchocerciasis Control (APOC) for Support of the Proposed Onchocerciasis Control Project In accordance with the memorandum of agreement for the APOC L The Ministry of Health, on behalf of the Government of Ethiopia, herby endorses the attached project proposal to be submitted to APOC for financial support. 2. This proposal reflects the collaboration between the members of NOTF and APOC with a view to conduct an onchocerciasis control project in Ethiopia. 3. The NOTF is a partnership of the government, NGDO's and other participating parties which will be responsible for the implementation of this project 4. The government shall assure free entry of lvermectin into the country for delivery to the applicant without imposing duty, tax or other costs. 5. The government of Ethiopia pledges its full collaboration with the APOC in the expectation of acceptance of the present proposal. January 30, 2003 place and date Solonrttt\Aleoaych $c{u Dtad rtor@ DnQartmcd' rnd Control Head Name and Title of signatory National Onchocerciasis Task Force of Ethiopia Application for Support from APOC In accordance with the memorandum of agreement of APOC: The NOTF on behalf of the Governnrent of The Federal Democratic Republic of Ethiopia, (a partnership of government, the NGDO's and other partners) hereby express its wish to enter into collaboration with the APOC and the MEC with a view of conducting Onchocerciasis control project in Ethiopia. 2. Onchocerciasis in Ethiopia is considered by the health authorities as a problem of sufficient importance to warrant the implementation of a control project in the endemic areas with the aim of eliminating as a public health and socio-economic problem throughout the country. 3. It is estimated that out of the total population of 65 million there are 2 million people infected with the parasite, Onchocerciasis volvulrzs, causing blindness, serious visual impairment and debilitating skin diseases. 4. The proposed control project will rely on community directed treatment with Ivermectin (CDTI) as its main intervention tool. 5. The NOTF has scrutinized the criteria and conditions for application to the APOC and is satisfied that the proposed projects meet all the criteria and fulfill the conditions established by the APOC. 6. Details of the project proposals for the control of Onchocerciasis in East Wellega, West Wellega, Metekel, Illubabor and Jimrna zones and Gambella region in Ethiopia, including the support requested from APOC to successfully implement the project are provided in the enclosed proposal. 7. The NOTF of Federal Democratic Republic of Ethiopia pledges its full collaboration ,.1 /ttt th APOC in the expectation of acceptance of the present proposal. *".),' '/ t. 1,.'^ -:i _.? ,! ,.i ;fi 'ic nr,.ie Tadesse '(Ih.) 30, 2003 t ir iit" uary 30, 2003 b a Place, Date, Rep. of Government C9' t.K ,. .- \,".r ii! ,.a l. l, i'1\ Name and Tile of the Signatory iil Eil;'-r: ;7 THE CARTER CENTER February 28,2003 Dr Azodoga Seketeli Director WHO African Program for Onchocerciasis Control 8.P.549 Ouagadougou 01 Burkina Faso Dear Dr. Seketeli, The Carter Center has been working in Ethiopia collaborating rvith the Ministry of Health in the Guinea Worm Eradication Program and the Ethiopian Public Health Training Initiative since 1993 and 1997 respectively. tn 1999, the Center expanded its health activities to assist the Ministry of Health in establishing a river blindness program. As stated in the proposal submitted by our representative in Ethiopia, Mr. Teshome Gebre, The Carter Center confirms its intention to be a partner with the Ministry of Health in implementing the CDTI projects in Illubabor andJimma. After reviewing the project proposal, I would like to confirm full technical assistance based on the activities listed in the proposal and financial support not to exceed the budget as stated in the proposal. I look forward to a successful collaboration. Sincerely, Donald R. Hopkins, M.D. Associate Executive Director cc Mr. Teshome Gebre, The Carter Center/Ethiopia Chair, National Onchocerciasis Task Force/Ethiopia * * * * oNE COPENHILL . 453 FREEDOM pARK'0rAy . ATLANTA, GEORGIA 30lO? . (404) 420.383?. FAX (404) 8?4.55t5 { :1.. I a- tllrr*. .vtt <lalt? lt1r" ,t u11, .S ll./ € 6a Date To: trrlrheulul ()u.ou.u Natinrl nGdod $ff, Ref. No 43P[^ak'h Brnwrr Disease Prevention and Control Departrnent Fax: (0 I )52 -7 0-331 5348-67 MOH Sub: Program for onchocerciasis program We have received your fax message of letter dated lllll95 with reference No. oofi11491451956. We appreciated the procedures undertaking to start with conhol program of onchcerciasis in our region. As the survey conducted indicates onchocerciasis is serious problem in Benishangul- Gumuz Regional State. Hence the regional health bureau would like to confirm that it is ready to implement the control progrcm with existing resources and would provide any necessa.ry support for the achievement of the control program throughout the project life as well as to sustain the program after the termination of the program. .D.P.C Team RTIB ) @ t{ q, r a (!.f,/a a, @ .,, o\ rof rL"- ca l.t tJZ lr .t i t GryIa' MOH CC ): -.. Ref. No Date ,. *,L5.:c E.fi-..-;.: -i :,.. ...r rl.; -,.,* To: Disease pretenrion and #$1t A+e6U^i.Ministry Of Health "*-..a j:-'--. - 1 onchocerciasis is one of the most prevalent communicable diseases in oromia regionalstate' Five out of fourteen zones of the region (35.7%) are endemic for onchocerciasis.The result of REMO conducted with, thelupport fromlo* office and Apoc clearlyindicated that significant proportion of the fiue zones, trrougr, there are differences amongthem' are meso and hyper endemic for the disease. L;g; ,r*bers of populations residingin these areas are continually exposed to infection. HJnce, onchocerciasis is consideredas one of the big health and socio-economic challenge in the region. w. *... thinkinghow to confront this challenge. But to start the prog.Imme on our own, on one hand welack experienced health professionals with onch,ocJ.ciasis control and on the other handthere is shortages of funds and logistics like drugs ,o u. ,r.a for the control prograrnme. It was at this juncture that we heard of good news from MoH. Apoc is ready to supportonchocerciasis contror program in Ethiopia. REMO ** aor. in oromia. Hyper andmeso-endemic areas, which are eligible to be included in the .or,.oi p.ogram, areidentified, though some areas still need to be refined. proposal were prepared andsubmitted to APoc based on the REMO result. we were Iooking forward to start theprogramme' Still we hope that the proposal will be approved with some amendments. Addis Ababa Subject: - so commi tment to control Onc If the project is approved the Oromia Health Bureau is committed to cover at least 25%oof the total CDTI cost starting from the initial proJ ect year. Increases the budget allocatedfor this programme with in consecutive years and is ready to over take the whole projectat the end of the fi fith year. We also try to do our best to create a budget line for CDTIrntegrated within malaria control programme. Now we are eagerly looking approval of the project for the benefit of theexposed communities. o With best resards.aSHALLO DABAC.C Head, Oromia Health Deputy Head, Oromia Malaria control service OHB NOTF- Ethiopia Addis Ababa - J..;' - I'Y HEAD, OROMIA HEALTII BUREAU --, */ I -.-:l), :'-'.) l ..-.J . '..^ ,i !,' TABLE OF CONTENTS LIST OF ACRONYMS SECTION 1: BACKGROUND INFORMATION 1. INFORMATION ON 'I'I{E PROJECT AREA FOR CDTIl.l. Geographical and administrative areas...... 1.2 Topography, Climate, Access 1.3 OnchocerciasisEndemicityLevels 1.4 CommunityStructure 2. PAST AND CUTTRENT STATUS OF CDTI IN PROJECT AREA SECTION 2: PROJECT EXECUTION OUTLINE .. 3. DESCRIPTION OF PROPOSED CDTI ......3.1. Outlrne plan and Trrnrns 3.2. Health Education and conrrnunity Inte'acrion and par.ticiparion3.3. Local Operational Research ......... 4. SUPPLY, IMPORTATION, STORAGE, INVENTORY AND DELIVERY OFMECTTZAN TABLETS SUPERVISION, MONITORING AND EVALUATION5.1. Supervision during Evaluation5.2. Monitoring CDTI 5.3. Evaluation of CDTI 6. SUSTAINABILITY OF THE CDTI AFTER THE WITHDRAWAL OF t\/ I I 2 8 9 ll ll lt li l.l l(r 5. I8 r8 l8 t9 2t 2T ,.) 25 26)l 7 8 CROSS BORDER CONSIDERATIONS 28 SPECIAL RISK ISSUES 28 EXTERNAL FUNDING ..............6.1. Integration of CDTI inro other Community Based of pHC Systems6.2. Cost Recoverv S ystem during CDTI ..6.3. Other Issues 6.4. Methods of Measuring the Progress Towards Sustainabi SECTION 3 ADM IN ISTRATION/FINAN CIAL 9. ADI\{INISTRATION...... 9.l. Organisational Structure for CDTI 9.2. Financial Administration................. 9.3. Timed Plan of Action IO. BUDGET 10.1. Budget Estimate 10.2. Budget Justification ................. 10.3. Current Resources available in CDTI .. le 29 3l .i.', .j7 31 40 4t 29 2L) lj 44 LIST of MAPS: ITAP I: MAP 2: MAP 3 II4AI'4: [4AP 5: LIST of ITIGURtrS FIGURE 2: FIGURE 3: I,-IGURE 4: LIST of 'tABLES Table l. Table 2 Table 3. Table 4. T'able 5 Table 6 Onchocerciasis CDTI Zotrcs itt Etliopia (APOC 2003) Oromia Regional Stctte, Etliopia ll'est Wellcga Zone, Orotnia Regiorr Districts Selected for C' DTI P roject Distributiott of Healtlt lnstituttotts & Population Density (1994 Census) lUest Wellega Zorte Recluest and Disbtu'setneti oJ'APOC Ftrnd Budget Input of Partners for tlrc Project Years Annual Treatmetu Objective b), Endemicity Level Estinruted Nuntber of Populariott, ATO artd Status of REMO b1t District, West Wellega Proiect Area Classification Criteria of Ertderuicity Levels in Rural Communities .............. Criteria Issues in the Developrnent of Health Education.for CDTI Intplenrc nt at i ot t Ti rne F rar rte Year one Suntnrury Budget for Onchocerciasis Control in luest ll/ellega Zone Five Year Budget Sununary for Onclrccerciasis Control -1 4 5 (t 1 FIGURE 1: Organisational Structrrre of Nutiortal Oncltocercictsis Contrctl Progrant 8 t-l .16 :18 39 LIST of APPENDICES APPENDIX 1: APPENDIX 2: APPENDIX 3.I: APPENDIX 3-2: APPENDIX 3-3: APPENDIX 3-4: APPENDIX 3.5: APPENDIX 3-6: APPENDIX 3.7: APPENDIX 3-8: APPENDIX 3.9: APPENDIX 3-10: ESTIMATED NUMBERS OF COMMUNITIES AND PERSONS TO BE TREATED EACH YEAR BY ENDEMICITY LEVEL ... IN DICATORS FOR EVALUATION, SUSTAINABILIY /INTEGRATION OF CDTI Budget Line ltent - Parsonttel Buclget Line ltent - Caltital Eclttipntenr Budget Line ltent - Supplies Budget Line ltem - Training Budget Line ltent - Health Educatiort & Social Mobiliz.cttiott Budget Line ltent -Travel Budget Line ltem - Comnrunicatiort Budget Line ltent - Consultants Budget Line Item - Recapitulatiort Budget Line ltem- Operating Expenses 42 4.5 46 11 +9 50 .st .s3 .5 jl 55 .56 ilt ) LIST OF ACRONYN{S APOC African program f or.Onclrocer.ciasis Control ATO Annual Trearnrent Ob.;ective CDC Communicable Diseases Control CDD Community Drug Distributor CDTI Community Directed Treatment rvith Ivermectin DHO District (Woreda) Healrh Office DOTF District Onchocerciasis Task Force EPI Expanded Progr.anr ol'lntnrunization GIS Geographic Information System KAP Knowledge, Artitude, practice MIS Management Information systent MOH Mrnistry of Health IvIoVDCD Mararia & other vecror-bor-ne Diseases contror Department MOVDPCT Malaria & other Vector-borne Diseases Pre'enrion & Control Team NGO Non Govelnmental Orglnisation NOCP National Onchocerciasis Control program NOTF National Onchocerciasis Task Force PHC Primary Health Care RAPLoa Rapid Assessmenr prorocol for Loasis REA Rapid Epidemrological Assessmenr REMO Rapid Epidemiorogicar ii4apping of onchocerciasis RHB Regional Health Bureau ROCP Regional Onchocerciasrs Control program ROTF Regional Onchocerciasis Tasl< Force TOT Training of Trainers ZHD Zonal Health Department tv SECTION I : BACKGROUND INFORI\,IATION 1. INFOITi\,IATION ON THE PROJECT AIIEA FOR CDI'I l.t Geogralllricalandadministrativearea(s) Pleose da.sc'ribe tlrc urea(s) of the coutur), itt t+,lticlt the prctposed CDTI will ba carriad ottt. (List tlrc admitistrative uttits or parts thereof e.9., Loc'al Got'ernrttettt Arcrts, Di.rlrict.r', Arrort dissentettls, Ilealth areas etc. tltot tt'ill ba coverctl urcl prot,icle u ntop sltowing tlteir lay-out) Oronria Regiorral State is one of the 9 National Regional States in tlre Federal Democratic Republic of Ethiopia (Map l). West Wellega zone. tocated at 80 l2t - lOu 03' N latitucle and 340 08r - 36u l0rE longitude, in the western part of Ethiopia, is one of the l2 zones in the Orornia llegional State (Map2). Based on the 1994 national census, the projected population o[ the zone in the year 2003 is estimated to be I ,941,430. The zone has a total surface area of 23,980 sq. krr-r and is further divided into 20 distlicts and 741 villages. One district narnely Gidame slrares a 76 knr border area with the Sudan and the zone is also bordered by the Benshangul-Gumuz and Gambella National Regional State and East Wellega and IllLrbabor zones of the Oromia region. About 90.3 Vo of the population lives in rural areas artd 9.lVo live in urban area. The zone has a population density of 80 persons pel square km. The zone is identified as Onchocerciasis endenric area and districts rvith h-r,pel and meso Ievels of endernicit; are proposed lol thc inrplementatiorr of CDTI activitres. The pro3ect objective for Year-One is to conduct CDTI in srx prior-rty clistrrcts. The Annual Treatment Oblective (ATO) for Yezrr'-One rs 563,909 and the UltirnaLe Treatment Goal (UTG) will be deterr.nrned l,r,hen REMO reftnement rs completed in November 2003, in the other srx clistricts ol'East Wellega proJect al'ea. Table l: - Estirnated Number of Populatiorr, ATO and Stattrs of REMO b1, District, \\/cst \\'ellcg:r P ect area 2003 S. No \\'orcda Estimatcd CDD \/illagcs Total Population Annual'freatnrent Objective (ATO) REITIO St:rttrs 1 Grmbi 521 130.327 104262 Ycar I CDTI Area 2 Gawo Dale 559 139,789 111831 Year I CDTI Area J Dale Lalo 476 1 19,064 95251 Yeal I CDTI Area 4 Anfilo 282 70,499 56399 Year ICDT[ Area 5 Hawa Welel 409 102,138 81710 Yeal ICDTI Area b Sayo 572 143,070 1 14456 Year I CDTI Area Subtotal 2819 704,887 s63,909 7 Yubdo 144 36,008 28806 To be retlned 8 Nole Kaba 538 134,529 107623 To be retined I Lalo Asabi 297 74,150 59320 To he rel'incd 10 Haru 268 66,937 53550 To be retlned 11 Aira Guliso 407 101,798 B1 438 To be retined 12 Jima Horo 197 49,224 39379 To be rclrned Sub Total 185'l 462,646 370,116 Crand'l'otal 4670 1,167,533 934,025 L.2 Topography,, climate, access. 1.2.1. Please clescribe the Dtpe of coutilrl,or bio-clinrutic zorrcs that will be covcrccl by tlte CDTI (c.g., roin foresr, forest-savanna ntosaic, Guinea savannct, Sudatt sovatuta, motuttoinous or Jlat), providing nrups, ,J appropricue. The topo-eraphy of the zone is donrinated by hills and gor_ees thar range in altittrde from 600 m in the extrenre Western end to 2100 m above sea level in the eastern part of the zorre. The zone has three big rivers namely Didesa. Birbir and Keto rivers that drain in to the Blue Nile. The area has many other small rivers and streams that drain in to the basin (Map 3). 1.2.2. Give tlrc approxintate tintes of tlrc rainy q17cl dry seasons ancl the ntonths coverecl by the farnting seasort. The clrmate of west wellega is characterized by distinct rainy ancl clry seasons. The major rainy season nronths are from June to Septenrber with short rainy season from February to March. The mean annual rainfall varies from area to area ranging trom 800 mm to 2000 mm. The mean annual temperature of the zone ranges from l0oc-30oc. Farming activities(clearing, farming, and herding) occur all year round, but are most intensive during the rainy season. Harvesting occurs from November to January, leaving February - May as the optimum treatment period. t.2.3 Provide inJorntatiort ott the state of tlrc roads ancr the effecr oJ'this ctn the rnot;ements of CDTI persorutel in the area at difJerent times oJ'the ),ear. (A nrup nruy be useful) The zone capital Gimbi is connected to 17 districts by all weather roacls whrle the three other districts are only accessed cluring the dr.y season. All the GDTI districts selected are accessrble by road all round the year. Two district, Dembidello and Begi are also linked by domestic air transporl service to Addis Ababa. All the districts have automatic and operator assisted telecommunication service and l0 of them have also postal Service stations. Road transportation is one of the widely used and most important mocle of transportation in the zone. The roads provide access to l7 district capitals, however most villages could be accessed only on foot or on pack animals while some villages could be reached by motorcycle. During the rainy season supervision and monitoring of CDTI may be difficult due to flooding of rivers and roads. Therefore, conducting Mectizan distribution during the dry season (February-May) is advisable. 2 cn o f(, o ED oF ca (\l U o tr] (t) q) oN )-<F U C') ch (J L() Io I t-{ G\-a ,; u, l:. t- = :! |,- 3 ,' :(,ii'i.t. I l, j ' j' I _1 : l.:i-- - t-- :/-.- ){' r :, a- Legend E Oromia Region I\{AP 2. OROMIA REGIONAL STATE, ETHIOPIA t-"5 tl.t' :'.'1l ? '.... " -- i __1 It' rrtt. "t' \- I\' /, I I I i {'-- I 4 ,rl..;'i' I I a I MAP 3. West \4/ellega Zone, Oromia Region Leoend West Wellega Zone tllubzbor 5 Map 4. Districts Selected for CDTI Project r I -t- i .-- I t i 't-- II .r.i Haru Nole K3ba L f L. t lgrra Guliso r Legend Jrmma Grdami lYear-One CDTI Districts IDistricts for REMO Refinernent in Year Trvo !None CDTI Sites 6 I i,-r t tt .'r .JI I I I'r,--i, \ MAP 5. West Wellega Tnne Population Density (1994 Census) and Health Facilitv Distribution lJ H0SP[aL + lr; HtA,lH CElrIERCrrnc + p; t{trtTHrlION + rrr ?oFU..TOYOEXCTY v.OC [€. tlrr a 6.O fl. ,0 tl. r0) tot .,50 iH a:r.roI vt.., ! ,o-.r.., Jrmma Grdam Anfrlo Gauo Oale H:ua Welele Aryra Guliso Orle [.alo + lvbna Srbu Jarso Haru Yubdo Nole Kaba Sayo Gimbi TABLE 2: 1.3. Onchocerciasisendemicity levels. The levels of ottchocerciasis entlenticitf in communities in the CDTI area tnust be assessed b7,siruple ruetlnds before treatment s.tarts. For tlrc ptffpose oJ'rhis proposal, the level of endenticin,in a conunnttity or e group oJ'sinilar commwities is defined on the basis of the pret'alence oJ' nodule c'arriers (see table I ). Classification criteria for endemicity levels in rural communities ENDEMICITY LEVEL and recommended type of treatment Percent of nodule carriers in REA sample (minimum sample -50 adult men) Estimated prevalence ol O. volvulus in the Whole communitl, HYPER-ENDEMIC Community Treatnrent (URGENT) greater than 39Vo greater than 59%, MESO-ENDEMIC Commun i ty Treatment (DESIRABLE) 20 - 39Vo 40 - 59%, HYPO-ENDEMIC (NON-URGENT) less than 207o less thin1oz ---l 1.3.1. Based ort the systeminTable I and usirtg thefornrut inAppendix l, please ittdicate tlte estimated numbers of conununities at each endernic let,el and tlrc nuntbet"s of persons in thent. 1.3.2. Contpleta Appendix I Jbr each area covering the ne.rt 5 years of tlrc projecr. (See Appendix l) L3.3 I.f nrctlnds of assessing endernici^, thresholds other than noduLe prevalettce were used wlrcn your endemicity data yvere collected, please irtdicate tlte ntetlnd used. 8 The levels of endemicity in communitres of the selected districts in this zone \\'ils done based on nodule prevalence obtained by REMo exercises conducted in 2001. The results indicated rhat out of 33 villages surveyed in the zone 5 hyper-endemic, 3meso-endemic rvere identified in 6 districts. For the other villages, refinemenr of REMO will be done. 1.3.4. For areas still to be covered, v,ltere endenticity levels are not yet known, please clescribe the method t,ou will use to collect tlrc necessar\, ettdenticiry datct. NOT APPLICABLE 1.4 Community Structure. Provide background infornmtion on the socictl organiTations of contmunities in the C.D.T.I. ctreas. This ma1, include infortnot.'ott on; Settlement patteru of tlrc conunuttit\,(e.g. hctntlets, seasonalfannsteads, dispersed population, etc.) The population in the CDTI project districts is settled farmers and the setrlement density differs from place to place as can be seen on Map 5. o The etltnic groLtps in lhe conuntutitl,. The population is composed of different ethnic groups. The majority of the community members belong to the Oromo (96.l%o) and the rest belong to Amhara(2.27o),Mao (0.97o) and others (O.4Vo). o Please provide infunnation about the arecr cot,ered by CDTI incliccttilg whethcr tlrcy are tnigrants, nomads, refugees or intenruil1, clisplacecl populations. The community included in the proposed CDTI project area is composed of settled subsistence farmers, government employees, and merchants engaged in small-scale businesses. . Community leadership structure. The zone is inhabited by an estimated of 1.9 million people in 20 districts and 741 kebeles (administrative villages). Out of this, 704,881 people living in 6 distri6s and 2819 villages (CDD villages) are included in this CDTI proposal for rhe first project year. The community leadership structure in the zone is organised around zonal administrative councils, District (Woreda) Administrative Council, which consist of elected members from each village. The District Administrative Council is responsible for giving guidance and leadership to the community for all socio- economic activities. Each District has kebeles (administrative villagei) *itt, their own village committee. The number of CDDs will be determinecl based on the size of the kebeles (using 250 peoples/2 CDD as a guideline). I The Administrative Structure belou,shorvs the community leadership systenr Zone Administrative Council )District Council Chairman ) Kebele Chairnran ) Elders/Religious/ Opinion Leaders ) Household Head . Main occupation of c'otttuttutity n,rO Orriotls oJ'nrujor comntunal activities. The main occupiltion of the comnrunity is farming and small scale business on cash ct'o1r such as coffee. The urban population is engaged in snrall scale business, civil service and manual labour. Farming activities is low during from January through April. During these months, there are traditional religious celebrations such as Gena (Christmas), Timket (Epiphany), Id Al-Adha and Id-Al-Fetir. PreJerred chcuutels of conunutticctliort in tlte conuntuit,v The preferred channel of communicatron by the conrmunity is from the local farmers ot' urban dwellers association chairmen to the village chief to the head and members of the households. No forms of mass media are easily accessible to these rural communities. Existing actir)e conunwtirl, associcttiort"/groups in the area (e.g. social, religious, etc.) The existrng and actlve community associations/groups include the farmers associations in the rural areas and the urban dwellers associations in towns. In addition the churches and mosques also have dominant roles to play in community mobilization. a a a a Estab|ished clistribution s)tstems irt tIte conttrttttti11'. There are some existing distribution systems, such as polio immunization, malaria control, vitamin A distribution, and family planning services that 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. Since the accessibility of existing health facilities in the project area is low, enrolling community health agents needs to be strengthened in the context of CDTI sustainability. Social comntunal activities cutd ntonths during which the activities take place. There are various social and communal activities. Prominent among these are traditional religious celebrations such as Gena (Chrisunas),Timket (Epiphany),ld-Al- Adha and ld-Al-Felir, which take place from January to March. Any previous experiettce of the conununity tvith development/health projectsa t0 Most communities in the zone have been involved in EpI, family planning, wellconstruction and spring protection activities. There are also communitl, health postsmanaged by community health agents and traditional birth attendants in somecommunities' The communities therefore have u,ell-established systems ofmobilization ro enhance participation in hearth projects. o Description of other anthropological characterisrics of the com1turtities. The people in the zone are followers of diff'erent religions. The most dominantreligions are protestant, orthodox and catholic christiins and Moslems. priests, shekies and traditional leaders possess strong influence in decision-making andhealth-related behaviours. Planning Ivermectin distribution cycles during religiousand public horidays can be important to access most community members. 2. PAST AND CURRENT STATUS OF CDTI IN PROJECT AREA. 2.1 Please indicare if trrc CDTI is an expansiort oJ'cut existi,g )DTI. No, this site is selected for the first time. 2'2 state the nuntber of 1'ears rhe programnte lru.s' beett opercttittg, curcl if possible ettcpt'.eprevious statistical, financial and annual reports. NOT APPLICABLE 2.3 State the nuntber of persons treated each year for tlrc lqst 5 ),ears; NOT APPLICABLE 2'4 List the organiTarion(s) involved in the progranznle, tlte sor.trces.arul artou,t oJ-furrcl.s.usccleach yectrfor the Last 5 years. OT APPLICABLE SECTION 2: PROJECT EXECUTION OUTLINE 3. DESCRIPTION OF PROPOSED CDTI The main strategy of the proiect will be to clevelop arul establish contmunir yn-buse; ivennectirttreatment s)tstenls, u,hich can be sustained by tie endenti.c ,rrr-rrrriirr"',llri,ur"trrs wirhrutexternal iupport afte r the 5-year project periid. This section slzould deScribe hoy, the NoTFplans b develop and intplentent'cDit in all high-risk comntunities in the project urea. Theplan should take into account the- neecl ,o" arr"i$ approaches to cDTl, wltich areappropriarc, for the different local situations, attd'the' 'need ,o ,orrfriy evaluate theimplementation of the serected approaches and idjust them when required. lt The project objective for Year-One is to conduct CDTI in six priority districts. The Annual Treatment Objective (ATO) for Year-One is 563,909 and the Ultimate Treatment Goal (UTG) rvill be determined when REMO refinement is completed in November 2003, in the other six districts of East Wellega project area. Outline of the activities that "vill be carried during the first year is described in the following table. 3.1 Outline Plan and Timing of Activities fbr the Period 2003 - 2004 3 weeks A ctivity/Justi[ication Length of Time Advocctcl'and sensitisation at the regional level - emphasis rvill be placed on introducing the APOC CDTI strategy, and enlisting the support of the regional level rvith the participation of the NOTF/NOCP, regional administrative council offices 4 weeks Agreenreril on the defittition of roles and responsibilities of all participrurls - through MOH with the regron based on APOC gurdelines, 4 weeks Prctcuretttent oJ essenttal project equipntent artd supplrcs'. Contputers, Mectrzarr drugs, and vehicles. I 6 rveeks Ttairtng/retraitting of prolect trainers at rhe regiottal let,el: Trarnrng to those who will function as trainers and supervisors 4 rveeks Ra p id Ep itle truo lo g ica I A s s e s s me nts : Epidenriologrcal surveys lor Onchocerciasis have been conrpleted in the Regron. REA surve;,s horvever rvill be carried out to identify all villages that qualify for CDTI. 4 rveeks Cotiluct RAP Loa in all CDTI Villages 4 Weeks Mobtli:rttiort of regrcnol and District authorities to support the pro.lect 2 rveeks Cortduct KAP Studtes Since this is the first time for treatment to be carried out in thls nerv project site, KAP surveys are essential to gurde the development of appropriate health education matenals rn the District l2 weeks MobiLiza'on of endentic cotnmurtities, stressing community orvnership of the project as well as the key health educatron messageJ 4 weeks Selectiort and tratning of Conununity Directed Dstributors (CDDs) Selection of CDDs is the responsibility of the community H ouselnld registration, and census enumcration 2 weeks Mectean @ Collection and Distribution in endemic communities 8 u,eeks Monitoritry & supervisiotr of Mectizan@ distribution activities by Distrrct supervisors 4 weeks Ittspectiott of CDD drstribution activities (spot checks) bv regional supervisors and NOTF rep resentatives I week M I S ( Management I nfo ntution System) Inclusion of CDTI activities in the routine monthly reporting system Monthly NOTF evaluation team will conduct evaluation of the project 4 weeks Review oJTreatnrcnt Activities: Annual reviews and reltorts rvill be generated and used to ensure continuous improvement in designing the following years action plan. I week Action Plan for the next year 2 weeks I2 3.2 Health education and Contmunity Inl.eraction and Participation 3.2-l How will you approach and interact vt,irrt rhe conttnuni4, There are already existing systems of communicariorr rvith the proposed project area throu_qh other health programs as described earlier'. Hou,ever, the following strategy will beimplemented to maintain good relations with the cornmunities: a) Discussions with District administrative council chairmen and social affairs heads and then with local farmers and urban dwellers associations, religious leaders, community elders and opinion leaders to better understand community protocol b) Focus group discussions rvith social and religious groups to further mobilise the community with the support of the community leaders c) Focus discttssions u'ith the community menrbers as appropriate (separating men and women' or not, depending on the community traditions). The commrnity -".bers willalso be encouraged at this point to take ownership of the program, defining their roles and di stri bution mechanisms -1.2.2. Health educarion Healtlt educrttiott and conunnnitv ntobilizariort tvill continue be cut itltegral part oJ all approctches to CDTI. Health eclttcaliort ac'tit'ities slrcukl ensure cortrinuous exc.lrcurya witlt regards to htowledge, covareness, perL'eption ancl observable attituclinal c.hang"es. ctboul Onchocerciasis and ils treatntent. Altpropriate health educcttion message.s in the form oJ'posters, pantphlets and verbal presentatiotts will need to be d,evelopirt a,rl tested. Health education should address tlrc Jbttowittg tssues (Table 2): l3 Table 3: Critical Issues in the Development of Health Education for CDTI a) Have ant' KAP sun,eys been done in tlte projec't area ancl d'so, w'hat were tlrc resuLts'/ No KAP studies have been carried; however. there is a need for KAP in sample villages This will be done in collaboration rvith other partners. b) What ntetltods w,ill be used to clevelop health education nruterial for the conutturtities attd for the agetils who will be resportsible for ivennectin treatntent? Health education materials such as posters, leaflets and flipcharts will be developed rn local languages b1, the project and submitted to NOTF for standardisation. These matenals r.vill be field-tested and refined/adjusted as necessary prior to mass production. Video films rvill be produced and utilised as a mobile video film show. c) Wlrut ntetltods will be used to provide health educatiott to the endemic conmrunities artd to the agents responsible for treatnrcnt ? The zone has used several media in the past for providing health education to endemic communities. Such methods have included face to face discussions with health workers, the use of village mobilizers, traditional birth attendants, community health agents and ISSUES Health Education l\{essages Knou,ledge of the disease . Local name of the disease . Symptoms . Causation/transmission (simple) Knowledge of treatment . Previous experiences with Diethylcarbanrazine (DEC) . lntroduceMectizan@ (ivermectin) o Dosage o Exclusions o Reactions . Beneficial side effects Attitude to treatment Advan tages of Treatment: . Free . Yearly treatment . Possibility of self treatment at community level . Importance of maximal coverage Attitude to disease . The disease can be controlled . Onchocerciasis blindness & skin changes can be pret'ented Attitude to good record keeprng . Minimr-rm requirements for record keeping . Records are confidential and strictll' for health use . Records required are for subsequent drug supply t4 other associations and faith-based institutions n'ill participate and the use of posters and flipcharts in local languages, and drama.(role playing in local plays). Community leaders rvill first be informed about the disease and the necessity for regular treatment with ivermectin. These communitl' 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 educattott 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 healtlt education messages and materials 3.2.3. Community ParticiPation In commtutity-directed it,erruectin delivery,.t-yJ'Ir',,?.r, members of the endemic communities do fhe execufion of ivennectin lrealntenl tltentsclves. Trahrcd persorutel, krtovt't7 os Communitl,-Directed Di"triburors (CDDs) tvlls slrctulcl be fttlly supported b)' tha co,ttrru,tiry itself nruy provicle treattnetl. Tlrc c'otrtttutttity 5l1eu1d be responsible for tlru organizcttion and exictuio, ofthe CDTI tvith rrtirtinrttnt but e.ffective ntedical supe rvisiott, once it has received tlrc necessar), infornrution and training. Various organiTational structures at the contntunity level, ranging ft'ortt t)ottrcrt's cooperative to trctditionctl structLtres, are intportant for sttstaining ancl slrengthening the support network of the CDDs. a) Explain rlrc organization of the inrenclecl comnutnity-directed ivernrcctin trecttment itt tlte 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 Malaria and Other Vector-borne Diseases Prevention and Control Team (MOVDPCT) is responsible for routine program management and acts as the liaison between MOH, RHB, as well as with NGO partners within the country and outside. The NOTF will be the governing body for Onchocerciasis conrrol acrivities in Ethiopia. A senior staff from this unit will act as NOCP coordinator. At regional level, Malaria and other Vector-borne Diseases Prevention and Control Department (MOVDCD) is responsible for program implementation at that levet. The head of MOVDCD will act as a ROCP Coordinator. Similarly, at District level District Onchocerciasis Control Task Forces (DOTF) will be established. The DOTF will be responsible for program implementation at this level' (ensure selection of CDDs, supervision of treatment activities, record keeping etc). Also, local health institutions uncler the DOTF witl be responsible to co-ordinate, monitor and supervise CDTI at each locality' r5 For ivermectin treatment purposes the number of CDDs rvill be cletermined basecl on a guideline of 50 households or 250 people per two CDD. Once communities select theirCDDs, they rvill be trained in the CDTI APOC srrategy for ivermecrrn distribution. CDDs and other local prirnary heulth care workers will then proviclc health education to communities on Onchocerciasis (its cause, transmissiop. control and preventive mechanisms). Prior to the distribution exercise, registration of all households will be can'ied out and non-eligible individuals identified. After registration, ivermectin clistribution will begin. The CDDs will follow up defaulters based on their treatment registers. Both District and Regional health staff will carry out supervision and monitoring activities. b) Ilotv yyill ivernrcctirt distributors be selected? c) The selection of CDDs will be the responsibility of the community. This rvill be done under the guidance of the village leaders. The CDDs will be expected to be honest, dedicated, literate and permanent residents in the village. Hou, trliII notrel i gible be identijied and deJaulters followed-up ? Non-eligible are mainlf identifred by having a complete household registration census and defaulters are identified by referring to distribution record or house hold cards. Defaulters, upon identification, will be treated by the CDDs. This is also done after previously non-eligible (such as pregnant women) have delivered, and therefore now eligible for treatment. 3.3. Local Operational Research Are there any plarts to conduct local operationctl research? / YES NO If yes please give details Operational research will be conducted on issues that will be identified in the course of the implementation of the project in the first year. These research activities will be carried in collaboration with research institutions and partners. a) What training will be provided to ensure tlrc development ancl sustainability oJ the CDTI? Training of CDDs to operate CDTI is very vital to the program. To ensure sustainability of the CDTI program, Training of Trainers (TOT) sessions will be conducted by the NOCP. Those trained here will represenr both regional and District levels. These individuals will in turn train representatives from District l6 and health facilities. These will in tum train CDDs. The training sessions willfocus on the following topics: o Basic CDTI principles . Village census : il::H,:"t':ff ",,Ti:;Iil,Il? t'::ii,,ll" "o""rse errecrs and management of its adver-se reactions o Inclusion and excltlsion criteria for ivermectin treatment . Dosing of Mectizan : r;T,TiJJ,fi:":;xJ3:li:[ b) Indicate criteria for selecting trainees (supervisors and community-directecldistributors). I) Criteria for selectirrg CDDs: Literate if possrble Resident in the community Willing to serve tlre conlnunity Must be honest Must be selected by conrmunity II) Criteria for selecting supen,isors: D istrict r: (i) (ii) (iii) (i v) (v) Must be a PHC staff selected by the state RHB Must be knorvledgeable and honest Must be interested in helping the community Must be stable rvith relatively low turn_over Indicate nuntber, type ancl cruratiort of trainirry courses intend.ed. Trainin-g_ in subsequent years rvill be focused, targeted and integrated with other PHC training. (i) (i i) (iii) (i v) * eof ksh Duration Number rRegional Trai ning 5 days I District Training 3 days I CDD Training 3 days I t7 4. SUPPLY, IN{PORTATION, STORAGE, INVENTORY AND DELIVERY OF N,ItrCTIZAN TABLETS Thi-r sactiort i.r orrl-t, a remiuder and couc('n$ llrc suppb,, intportation, storoqc, invetfiorv anrl delit,en, of iennectitt tublcts, rlonatccl by Merck & Co, who v'ill ulso pctv hatulling churge.s for ivenrrcctirt to their accredited ogents. Mectizan@ consignments will be rcceived through WHO and stored in the MOH central stores in Addis Ababa. It will then be transported by road to the regional health bureau, and from there to West Wellega health office. The District health office will be responsible for delivering the drug to the health facilities. (ln some areas the District health office is located far from the communities. In this case, health facilities rvill serve as the final collection point). CDDs will then collect the drug from the District health office or health facilities. A report showing the use of the drug will be sent toThe Mectizan@Expert Committee (TMEC) at the end of every year, b1, tlre NOTF, with the subsequent applicatron. Copres ol' the application and the report of its use rvrll also be sent to APOC. Drug delrvery, distribution and reporting rvill follorv the existing drug management systent and reporting on progress of activities will be done by the respective health unlts at each of level ol'the health service delivery system. An applicatron for Mectizan@ tablets rvill be submitted every year b1'the end of Septenrber to the NOTF, using the standardized form of TMEC. This applrcation rvill then be foru'arded to TMEC in Atlanta for review and approval. 5. SUPERVISION/N{ONITORING AND E\/ALUATION 5.1 Supervision during Evaluation Projects are required to be supervised and monitored. However, APOC funded projects rvrll need to be designed to function with effective but minimum supervision cornpatible with its objectives. a) Please describe tlrc sttpe n'isot),arrangenrcnts you consider will be requiredfor the CDTI l,ou propose how will this contirute et tlxe cessation of APOC support? There will be intensive supervision at all levels of program, especially during the early years. Since the program will be integrated into the Malaria and Other Vector Bome Diseases Control units, the supervisors and monitors will be staff of these units. The Distnct health workers trained to train CDDs will also be responsible for supervising their activities (proper record keeping, complete census enumeration, Mectizan@ inventory and dosage, and monitoring during the actual distribution process). The supervisory teams at the District level will be responsible for supervising health institutions (management of side effects, Mectizan@ accountability, and reporting on treatment coverage). Most important will be supervision at the community level where most treatment activities are carried out, and CDDs are responsible for proper distribution of ivermectin. Findings r8 from supervisory visits rvill be reported along u,ith monthly treatment data, and rePorting on adverse reactions. There will be a feedback on rhe findings of the supervi sion and' fol lou,-up of i mplementation of recommendari on s. As the program matures, the communitl, will assume more and more responsibilitl,, 1n.,rOing deciding on merhods of supervrsion, and those who u,ill cary thenl out. 1'his process may involve community, opinions, and religious Ieaders. b) Describe lton, r'ou rvoultl ensure that supervisiott will be carriecl out so as to a full witltitt tlrc requirement accou,tting for ivernrcctitt use 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 tlre collection and proper storage of unused drug is properly practiced. be sustctitted y'hen the progrant ends in 5 yearsa The got'enlment is implementing Onchocerciasis control activities integrated 'uvith in the Health Service delivery system and has indicated on the financial plan that government expenditure increases year by year. The Regional Health Bureaus tvhet'e the CDTI projects are Iocated has also committed to allocate budget for onchocerciasis control as a component of the Malaria & other Vector-Borne Diseases Prevention and Control Budget. . ensure ntaxintum int,olvenrcnt of the conuflLuttties in the process The program rvill support advocacy visits to the woreda and villages by MOH, regional, and MetekelZone representatives of the Onchocerciasis task forces at each level to encourage the active support of the community. 5.2 l\tlonitoring of CDTI It is irnportant to collect itdorntatiort to tttonitor lhe progress of tlrc CDTI. Wlrut indicators will be used to monitor: . Ivennectin distribution? . Healtlt educariott and contmuniry participation? c Mcun?en'tent $,stems? t9 Tlrc follox:ittg indicators will be considered: I v e n n e ctin Distributio rt . Nuntbers of conununities and persorts treated with iverruectirt o Treatment Coverage . Re?ularity of treatment exercise . Compliance . Reporting adverse reactiorts Healtlt Education and unitv Participatiott . Nuntbers of conunurities participating in tlrc project o Evidence of impact of health education . Are activities being carried out accorcling to plan and on schedule? . Inventory control, . Are record forn'ts accurate and contpletecl on time? o Numbet's of persons trained c Balance of genders ilt staff of tlrc progrant The project will consider the following indices for monitoring the program of CDTI I v e rmectirt Distributio n : Srnce Ethiopia has already been conducting Onchocerciasis control activities tbr tlre last three years, there is an established Health Management and Information System (MIS) including for Onchocerciasis control activities. The NOTF will ensure continuity of this system prior to the beginning of treatment in the new project areas. These rvill enable the NOTF to monitor the communities and persons treated with ivermectin, treatment coverage, and regularity of treatment, treatment compliance, and drug reactions. In addition, the project will monitor the following rates and percentages using Annual Treatment Objectives established at the beginning of each year: Annual treatment objecti ves (ATO): At risk villages (number at risk villages targeted for treatment) Estimated at risk population (total population at risk in the region) Treatment coverage (geographical and therapeutic coverage): Treatments (number of persons treated) At risk villages (number of at risk villages targeted for treated) 14atrugenrcnt a a 20 cost per person treated Tablets distributed Number of ivermectin tablets in store at MoH, in the field, on order, or to be ordered The degree of communitl'participation in mobilization activities u,ill be used as an indicator of community mobilization. In addition, the support of the leaders and key opinion leaders in the communities will be indicative of successful mobilization as well. The impact of health education messages will be measured through per.iodic focusgroup discussions and will be assessed in relation to the baseline kap findin-e,that wilr be can'iecr in coilaboration *,ith other partners. Managentenl The project will develop, through the integration of Onchocerciasis control to theMOVDPCT, a regional and District ,rnu!.r.nt/ supervisory system that monitors: ' The planning and implementation of activities according to a timelineo Mectizan@ inventor.y levels o Monthly reporting of treatment indices o Numbers of personnel trained o ' Attempt to balance gender in staffing 5.3 Evaluation of CDTI Arutual exrennl review inc'orporating fietct visits will be und.ertakett to ertsure thatprojects are nteeting target inclicatioits outlinetl in this proposal. Such reviex,,s tyillprovide TCC with the assurattce that each proiect is moving toward its lortg tert, statedgoal .and if appropriate ntake recomntendatiotis about any deficiencies or nndiJic.atiott.s.to this project' such reviews will clraw on tlrc indicators developed by TCC as a guide. 6. SUSTAINABILITY OF THE CDTI AFTER THE WITHDRAWAL OFEXTERNAL FUNDING The concept of- sustainabitity refers to the ability of countrtes and affectecl contmuntties following initial external investment to maintain the viability anclc-ontinuity of the iverntectirt treatnrcnt process witlnut external support. For ApOCfunded proiects, such support will iormatty last 5 years, as tlrc Apoc dorutrs,demand that there shall be a visible and achievable end point yo, tie externaldonation aspect of tlrc programme, and that the contmunity basecl clistributit.trt o a a 2t i,\rslenrs established shall thereafier be sustaitruble by tlte Soventnrcnts ol' tlrc e ntle m ic cotu t ri e s conce nted. Progress ond plans towards sustainability, i,rr,,,rrrng the plrusirtg rtul ctJ'extcnrul and NGO? suppofi, nrust be reported aruurullt' and satisfactor)' proBress itt tlis directiort tvitl be a condition for each succeeclirry ),€ar's funditry installntetu. Please address the following areas that relate to sustainabiliry: integratiott inlo p ri n ru rt' he alth care, cost - recove ry, and othe r su stainabiliq' issles. Efforts rvrll be rnlde ro ensure post-APOC sustainabilrty of tlre program according to the sustar nabilrty, rndicators shown belorv. Planning: CDTI rvill be integrated with the Primarl'Health Care (PHC) from the beginrring. At the National, regional, zonal, and woreda levels, the N'IOVDCU rvill be resllonsible tbr prograrn implementation. Onchocerciasis taskforces will be established at all levels. Planning would be carried our rhrough participatory methods, using bottom-up approach and integrated with the basic health service. Lcadershi;l: taskfbrces rvill be emporvered and community leader s rvould be encouraged to be actrvell,rnvolved rn CDTI implementation. Involving communlties rn decrdrng time and mode of N,lectrzan drstrrbutron, CDD selection, etc rvould ensure comnlLlnlt)'o\\,nersltrp of the program. [\lonitoring and evaluation: wtll be carried out regularlv rr,ith proper checklrst by the MOH slaft rn addrrron to the Community Self Monitoring, which s'rll be conducted bi' trained communltv mernbers. Training. Health Education, Social nrobilization, Advocacl' and Sensitization: would be underraken in such a way that sustainability of the CDTI project rvould be ensured after the termrnarion of external funding. In other words, all these efforts should Iead to empowering the communrtles so that they can assume ownership responsrbrlrty. Finance and Funding: Short, medium, long-term (post-APOC) frnancial sustainability plans rvill be prepared ar Woreda (districQ and regional levels Budget line rvill be created for CDTI actrvrties by the respective local government. Transportation: The respective health offices at each level will provrde transportation tacilitres for Onchocerciasis control activities according to the need. Human Resource: Existing health workers in the system rvill spend a portion of their rvorking time for Onchocerciasis control activities in their respective rvork areas. Treatment Covcrage: Effort to achieve al1)Vo treatment coverage in the targeted areas will be ensured through continuous health education and community mobilization during the implementation of communitydirected treatment activities. Mectizan Procurcment, Storage and Distribution: Mectizan availability will be ensured through timely procurement, storage and distribution system that will be further strengthened to meet the demand. 22 6.1. Integration of the CDTI into other community-basecl or primary Health Care (PHC) systems. The principal goal of the APOC is ro establish cost-ffictive ivermectin-bas.ecl c'ontroL for Onchoc'erciasis, which can be susrained Oy ln, endemic communittes. and cotuztries. One way to ensure sustctinabilirl, is to'integrate the CDTI into thePHC system o-f the country, which meat.ts ntore than just u.ring the sysrem foriverme cti rt di st ri b ut ion. 6' l ' l ' ls there an fficial pHC poricy anr) structrt'e in the count ry? ,/ YES NO If yes, please give a brief outline of what it is There is policy and structure for Primary Health Care (PHC) in Ethiopia. The pHC system is used to achieve full integration of health related activities it all levels. APrimary Health Care Unit (PHCU) in Ethiopia has one health centre and fi'e satellite health posts serving an estimated 25,000 population. Trained communityhealth workers and traditional birth attendanrs ui" atro serving the communit,v under the support and supervision of the health posts. Therefore, there is afunctional Primary Health Care delivery sysrem ihat implements preventiye, curative and promotion of good health practiCes. This system is currenily capable of implanting Onchocerciasis control activities. In summary, the PHC structure is as follows: FEDERAL MINISTRY OF IIEALTH ) REGIONAL TIEALTH BUREAU)ZONAL HEALTH DEPT.) WOREDA HEALTH DEPARTMENT/PHCU )COMMLINITY HEALTH POSTS (CFIWs & TBAs) a) Howfunctional is the primary Health Care systent? Fully functional Partlyfunctional The system from the National level is fully functional until the . Health/health facility revel. However, at the community Ievel health coverage is limited. Non functtonal (Please specifu ) b) Does it cover the whole project area? No,/ Yes If no, in what part(s) of the project area is there afuily functionar pHC structure? wat percentage of communities where onchocerctasis is endemic, and which are eligible for communiry-based. treatment, have an existing and functional PHC system. c) 23 f) All communities in the Onchocerciasis endemic area have an existing functional Primary Health Care System (PHC). But as the health service coverage in the country is accessible to 6LVo of the population some communities could still be very far fiom the PHC unit but accessed by trained CHWs and TBAs. d) Wat organizations are supporting the development of PHC in your projec.t area? Government of Ethiopia (Ministry of Health), WHO, LTNICEF, USAID, Ireland Aid, Italian Cooperation and other civil societies and research and academic institutions are active participants in the development of the PHC. e) Is there any past experience in the country) of a programnue integrating witlt the PHC? If so, what progrctmnte was it and how successJul wcts the integrtttion? Program such as the EPI, Malaria control, and family planning are integrated in the PHC and the planning, implementation and evaluation of activities and use of organizing and concerted resource utilization approach is being implemented. Are there any plans to integrate otlrcr rural health programmes, such as the Expanded Progranune of Inurumization, Maternal and Child Health Programtnes or programmes for the control of other parasitic diseases, with the PHC system? EP[, maternal and child health program are already integrated. IMCI that focuses on the integrated management of childhood illnesses, especially malaria and pneumonia is also being strengthened. Describe how the CDTI will be integrated into the PHC system; the wctv the PHC systern will be used to achieve integration and the key persons in the PHC system that will be needed to achieve the integration. At the Federal level MOVDPCT will be responsible for rourine program management and act as the liaison between MOH, RHB, as well as with NGO partners. Members of the team share responsibilities among themselves and hence a separate entity of vertical program nature will not be established. The head of this team will act as NOCP coordinator. At regional level, MOVDCD 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 MOVDCD will acr as 8) 24 6.1. Integration of the CDTI into other community-basecl or primary Health Care (pHC) systems. The principal goal of the APOC is to estabtish cost-ffictive ivermectin-bas.ecl c'ottr.ol for Onchoc'erciasis, which can be snyained Oy lne enclenttc communities ctrtd cotuttries. One way to ensure sustainabiliq' is to'integrate the CDTI into tltePHC system o.f the country, which means nrore than juit us.ing the system frtrive rme ct irt dist ri b uti on. 6.1 .1. ls there an fficial pHC policy ancl structut.e in the country? ,/ YES NO lf yes, please give a brief outline of wfutt it is: There is policy and structure for Primary Health Care (PHC) in Ethiopia. The pHC system is used to achieve full integration of health related activities at all levels. APrimary Health Care Unit (PHCU) in Ethiopia has one health cenrre and five satellite health posts serving an estimated 25,000 population. Trained communrryhealth workers and traditional birth attendants aie also serving the community under the support and supervision of the health posts. Therefore, there is afunctional Primary Health Care delivery system ihat implements preventiye, curative and promotion of good health practices. This system is currenily capable of implanting Onchocerciasis control activities. In summary, the PHC structure is as follows: FEDERAL MINISTRY OF HEALTH ) REGIONAL FIEALTH BI-IREAU)ZONAL FIEALTH DEPT.) WOREDA HEALTH DEPARTMENT/PHCU )COMMTINITY FIEALTH POSTS (CHWs & TBAs) a) How fimctional is the primary Health Care systent? - Fully functional - Partly functional The system from the National level is fully functional until the , Health/health facility revel. However, at the community level health coverage is limited. - Non functional (Please spectfy) b) Does it cover the whole project area? No,/ Yes If no, tn wltat part(s) of the project area is there afuily functionar pHC structure? Wat percentage of contmunities where Onchocerciasis is endemic, artcl whiclt are eligible for comrnunity-based treatment, have an existing and. functional PHC system. c) 23 f) All communities in the Onchocerciasis endemic area have an existing functional Primary Health Care System (PHC). But as the health service coverage in the country is accessible to 6lVo of the population some communities could still be very far from the PHC unit but accessed by trained CIIWs and TBAs. d) Wat orgardzations are supporting the development of PHC in your projec't area? Government of Ethiopia (Ministry of Health), WHO, LINICEF, USAID, Ireland Aid, Italian Cooperation and other civil societies and research and academic institutions are active participants in the development of the PHC. e) Is there any past experience in the country of a programnte integrating witlt the PHC? If so, what programn'te was it and how successJul was the integrcttion? Program such as the EPI, Malaria control, and family planning are irttegrated in the PHC and the planning, implementation and evaluation of activities and use of organizing and concerted resource utilization approach is being implemented. Are there any plans to integrate other rural health programmes, suclt as the Expanded Prograntme of Intmunization, Maternal and Child Healtlt Prograntmes or programmes for the control of other parasitic diseases, vtith the PHC systeru? EPI, maternal and child health program are already integrated. IMCI that focuses on the integrated management of childhood illnesses, especially malaria and pneumonia is also being strengthened. Describe how the CDTI wilL be integrated into the PHC system; the wav the PHC systetn will be used to achieve integration and the key persons in the PHC system that will be needed to achieve the integration. At the Federal level MOVDPCT rvill be responsible for routine program management and act as the liaison between MOH, RI{8, as well as with NGO partners. Members of the team share responsibilities among themselves and hence a separate entity of vertical program nature will not be established. The head of this team will act as NOCP coordinator. At regional level, MOVDCD 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 MOVDCD will act as 8) 24 a Regional Onchocerciasis Control Coordinator. Similarly, at the Distr-ict levels will establish corresponding Onchocerciasis Control Task Forces ( DOTF). The DOTF will be responsible for program implementarion ar the District Ievel (ensure selection of CDDs, supervision of treatmenr activities, record keeping etc). In areas where access to the District health' office is restricted, local health institutions will coordinate, monitor, and supervise CDTI activi ties h) Indicate how early in the CDTI the process of integration will be introduced; how it will continue thereafter, and after how many years within the externally supported lifetinte of the CDTI it witl be complered.. CDTI activities in Ethiopia will be integrated from the very beginning. The establishment of the program will rely on existing sysrems oi health service delivery at all levels. 6.1-2. lf there is at present no PHC systen't in operation or in those areas where these structltres are non-fut'ctional, describe how the CDTI may be used to initiate and expand into such a system, giving a time frame for intended progress. NOT APPLICABLE 6.1.3. In which way(s) can communiq,-clirected ivermectin treatnxent tnitiate or strengthen PHC? CDTI is likely to encourage and facilitate the acceptance of new health initiatives in the community. Also, through the new CDTI strategy, the community will likely play a greater role in the supporr and ownership of the PHC system. The structures aheady put in place would be utiliz"O Uy the PHC to enhance effective planning and implementarion of the project. For example, the CDDs will develop capacities and skills, wfritn -witt strengthen other programs such as health education, other drug distribution. 6.2. Cost-recovery Systems during Community-based lvermectin Treatment Cost recovery for Primary Health Care is mandatory in sorue countries and it may be one means of sustaining a CDTI afier APOC funding ceases. However, please note well that since ivermectin is donated free, ihere ca,t be no cost recovery in respect ofthe value ofthe drug itsei; cost recovery can only relate to the costs of distribution. 6-2-1. Please state whether there will be any system of cost recovery (such as is recommended in Initiative) to help cover outlays on the distribution oJ' ivermectin in the present CDTI. NO. 6.2.2 state exactly lrcw any such system wil be organized, includ,ing answers to the questions listed below. What charge will be made per person or perfamily? NOT APPLICABLE 25 Which groups of persons will be exentptedJ'rom paynxent? NOT APPLICABLE Will payments be in cash or in kind? If in kind how will this ensure sustainability? NOT APPLICABLE What provision will be made to ensure that all those eligible to take ivermecttn, but who are tmable to pay, will also receive treatment? How vvill ir be determined who is unable to pay? NOT APPLICABLE Who will collect the payntents? How will this person safeLy transport funds to a place of safekeeping? NOT APPLICABLE Where and by whom will any funds collected be safely kept? NOT APPLICABLE What systerus wili be put in place to ensure the proper use cutd management of collected funds? NOT APPLICABLE For what purpose(s), including defrayment of distribution costs, wiLl the funds collected be used? NOT APPLICABLE What role will Village Health Contmittees play in the management and allocation of the funds raised? NOT APPLICABLE 6.3. Other issues Please provtde information on otlrcr issues and constraints relating to sustainability of CDTI you anticipate and identify how they will be overcotne. For example: the mobilization of endemic communities the maintenance of adequate supervision and monitoring inadequate human re s ources lo gistics and communications s o c ial/c ult ur al fac t o r s . declining commutxity compliance I ) Mobilizcttion of endemic communities: Experience from the Bench-Maji and Keffa-Sheka CDTI projects indicate that sometimes minor problems of mobilization such as misconception and misinformation regarding the use of ivermectine in new CDTI area can be obstacle at the early phase of implementation of the CDTI. This can be solved through sustained advocacy visits, by assigning individuals with good communication skills and expertise in conducting mass health education meetings to increase awareness of the community, surveys to monitor belief systems. 26 (2) (3) Obviously there will be a need to establish good relationships with the commLrnity leaders in order to have increased access to the communities at times like these. Mctintenance of adequate supervision cuul monitoring Meciizan@ distribution should include community leaders to further increase acceptability and sustainability of the program. All records will be venfiedduring supervisory visits, and informal discussions will be encouraged to determine community perceptions regarding the importance of the Mectizan@. Inade q uat e H untan R e s o urc e s Inadequacy of trained health staff and PHC units are expected to be constraints inimplementing supervision and monitoring. These can be overcome by allocating adequate time for supervision, in addition to training additional supervisors fl-omhealth facilities and community members. [n absenle of roads in some remore areas, mules and horses can be used. (4) Ingistics and Communications (5) During the rainy season in June to September 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 ,"uron (prior to the Jan-March distribution window), and encouraging completion of distribution before the rains if convenient for the communities. S oc ial/C ultural factors : So far constraints related to social and gender differences in relation to the use ofIvermectin have never been observed. Aowever, careful attention will be paid to cultural and social factors such as: the appropriate gender for CDDs especially inMuslim communities, respecting the t.uaiiionut relilion, and selecting supervisors and distributors who speak the local languages. Declining Community Compliance : Declining community compriance will be avoided through continuous mobilization activities prior to each treatment period. Community members couldbe interviewed to determine the reasons for the non-compliancl, and corrective measures taken where possible and appropriate 6.4- Methods of Measuring the progress towards sustainability(See Appendix 3 for a list of possible indicators of sustainability)? Progress towards sustainability can be monitored and measured by evaluating theproject in terms of financial management/contribution, communications, training and capacity building. This will help enhance integration. Financial management (6) 27 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 District health office heads, and administration/finance managers at each level rvill 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. In addition, the ability of community members to 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 Where an endendc area extends across tlte borders of two or more adjacent States, special problerus of cooperation between the respective country CDTI may-artse. In the event that there are ureas to be c'overed bt,your proposetl CDTI wlrcre the endemic zone extends across the J'rontier irilo one or more neighbouring countries, and where there are likely to be transitory or even large-scale migrations of Onchocerca-infected persons either way across the border. 7.1 Please describe the particular situation, as it is likely to affect ivermectirz treatment, and the methods you will Ltse to deal with it. The Jima Horo districts of the West Wellega project selected for REMO refinement is bordered to the Sudan. Therefore, working with the neighbouring country during village visits for REMO activities on issues elated to security and other cross border collaboration requires attention. 7.2 Include pertinent observations on current political and health relations with the neighbouring State(s). There is a strong collaboration through an Intergovernmental commission established by both countries that assess and address cross-border issues. 8. SPECIAL RISK ISSUES In some areas of some countries there may be special risks, which could hinder the smooth running of a CDTI. Security and other issues related to landmines in border areas could be considered as special risk. However, the problem can be identified and tackled in collaboration with the bordering provinces of both countries. 28 a8.1 Please describe the situation in any areas covered by your proposed CDTI were this factor may interfere with the program, and assesifuture prospects. At the moment, there are no factors that are feared to interfere witltr aciivities in the CDTI areas and we believe that such issues are unlikely unless otherwise. SECTION 3: ADMINISTRATION/T.INANCIAL 9, ADMINISTRATION 9.1. Organizational structure for CDTI 9' 1' 1 Please prov_ide an organogram for ttte CDTI showing the organizational structure responsible for implementing the proposal. Fig.l. Organizational Structure of National Onchocerciasis Control program J 29 :1,-/-r ij I,-, -. '{ ..r.1pr,,pi, t )!.,.'l,i:,,. 9.1.2 Membership of Taskforces 1. Regional Level 2. Zonal level 3. Woreda level Regional admi nistrati ve counci I Malaria & Other Vector-Bome Diseases Control Head Regional capacity building department (education and health desks) Regional Planning and Economic Department Regional' Rural Development Office Regional Finance Office Zonal Administrati ve counci I Zonal Capacity Building coordination departmenr (education & heath desks) Planning and Economic Development Department Rural Development Office Finance Office Woreda Administrati ve council Woreda Capacity building coordination office (health &education offices) Planning and Economic Department Rural Development Office Finance Office Religious Leaders Famous personalities 4. Kebele (community) level Chief of Kebele administrative council Kebele capacity building office Religious leaders Infl uential personalities Representati ve of women's association Representative of youth association I 30 9.2 Financial Administration Mechanisms of disbursements and transfer of funds from the World Bank to countries Funds from the World Bank APOC Trust Fund will be transferred to the WHO country office account in Addis Ababa. On request through the proper channels by authorised officer of the MOH, WHO Addis Ababa will transfer the fund directiy 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 transfen-ed at the regional level will be the head and the administration and finance officer of the regional health bureau. AII the imperest returns will be submitted monthly by RHB to WHO country office in Addis Ababa that will forward them to APoc headquarters in ouagadougou. Monthly reconciliation statemcnts will be forwarded to the central MOVDPCT (acting as the secretariat of NOTF) for follow up. APOC will issue checks (advances) in accordance with wHo rules and the previously agreed project documents and./or plans of operations. When the total payment in cash required for the project exceeds $ 100,000, the payment must be made in instalments. The first instalment/advance 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 contracrual systems is used, e.g. Technical Service Agreement, Irtter of Agreement, Contractual Service Agreement or Agreement for the performance 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 imprest 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. 3t Fig. 2 Reguesf and Disbursement of APOC Funds Disbursement Financial Report '-l/-., ,-,:; -rt -.t: :,:i ,)...."i: .\ 'i't \, !-u/ 1..-,^--_ii ,i,'".'r,l 32 r - ,__:- ri,;,.1!'! l!:,Lr:'/ !_E_rl,:;-tlJr.d -'G.\(att- ., -1i).<,-,, :- !-Lr- ,'.:, ,'\\tt'r :,'..' r r',''ll .ij-',t ' r': -.-, 9.2.1 Input from the Ministry of Health ct) Indicate resources that will be provided b1, ylru Ministry of health and otlrcrgovernment agettcies. The Federal Ministry of Health o Personnel, o Logistics-and provision of additional vehicle, o Office accommodation o Running cost for Vehicles maintainace and office Utilitieso Training, Supervision and monitoring, . Clearing, storage and transportation of Mectizan Regional Health Bweau/Zonal Health Desk Personnel, Logistics and provision of additional vehicle, Office accommodation Running cosr for vehicles maintainace and office Utilities Training, Supervision and monitoring, Storage and transportation of Mectizan District (Woreda) Health Office Personnel, Logistics and provision of additional vehicle, Office accommodation Running cosr for vehicles mainrainace and office utilities Training, Supervision and monitoring, Storage and transportation of Mectizan a a o a a o o a a a a a b) Please provicle a list of personnel assigned by the MOH to this project, includingtheir name and proposed time (State percentage of time allocated'to ihe prctiectlfor the project and where appropriate thirr ixperience in onchocerciasis cortrol through ivermectin treatment. This project is new for the District so that none of the personnel has had any priorexperience in onchocerci asi s control through i vermecti n d^i stribution. 33 Name Position Region 7o Time Mr. Dereje Olana Head, MOVDCD Orormia Regional Health Bureau lOVo Mr. Shelleme Chibsa Head, MOVDCT Orormia Regional Health Bureau 10Vo Mr. Addisu Mekasha REMO (CDC report) Oromia Regional Health Bureau t0%, Mr. Tadese Hundie Vector Expert Control Oromia Regioonal Health Bureau t0v,; Regional Health Bureau: West Wellesa Zone Health Department: * 4 additional staff members from each CDTI district will also be participating in the CDTI activities for 25 - 30Vo of their working time. Vo Time 25Vo 20Vo Name Position ZonelDistrict Mr. Abraham Rumicho Department Head West Wellega Mr. Olana Ayana Zone CDC expert West Wellega 207o Mr. Kedir Gobena MOVDC Experr West Wellega 20Vo Mr. Teshome Kene Healtth Programs Coordinator West Wellega 20%, Mrs Eshete Ne_easso Head, District Office Health Seyo District 20Vo Mr. Denu Fite Head, Office District Health Hawa District Welel 20Vo Mr. Mihretu Tarekegn Head, District Office Health Gawo District Dale 20%, Mr. Negaso Kinfu Head, District Office Health Anfilo District 20Vo Mr. Bayisa Gemeda Head, District Office Health Dale District Lalo Mr. Sisay Ashena Head, District Office Health Jima District Horo 20Vo Mr. Tafese Terefe Head, District Office Health Gimbi District 207o Mr. Abose Waqwoya Expert, Distnct Health Office Gimbi District 20Vo Mr. Jemal Beshir Expert, District Health Office Gawo District Dale 207o 34 9.2.2 Input from the partner NGDO(s) a) Please provide a letter front rhe Executive Director or tlze Director of onchocerciasisprogr(lnxmes of each participating NGDO st(tttng their intentions to participate in an4 support the National Onchocerciasis Control prigrantme. b) Give information of the input front ecrch NGDO participcttitzg in thisproject. c) Please provide also a nominal list grading and post description for thepersonnel to be provided by partner NGDO(s). Indicate clearly what will be their functions itt the program and their experience in Onchocerciasis control thro u gh tv e rme c t in dist ri b ut ion. There are no partner NGOs in the area that can participate in the project Therefore, all the contributions will be met by the government and community. 9.2.3 Inputs from other agencies. Please list any other agenctes or parties tlrut will be involved in the running or financing of the CDTI, and indicate clearty their roles, functions artdcontributions. WHO: wHo Ethiopia will assist the project in the procuremenr and clearance of Mectizan@ imported into the couniry by using its diplomatic status. 9.3 Timed plan of action Provide rt time chart(s) showing how the varions activities of the CDTI willproceed over the course of the proposed program. Numeical a-nnual targets forall planned activities shourd be providedfor each time point. The time charts should also indicate how external support wilt be phasecl out over the 5 year period. 35 a t.- cil \ \ \ \ \ \ \ \ \ \ \ \ \ \ \o (\i \ \ \ \ \ \ \ \ \ \ \ \ \ rn al \ \ \ \ \ \ \ \ \ \ \ \ r+ ol \ \ \ \ \ \ \ \ \ \ \ \ \ ail \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ (, <1 = .9 boI() o q .E o=ay EO d! ro(JE dq(J .: o L.) iE q o o o E (.) 1C o o C) oo uo oo 'a o. 'Eo oo_ q=(-) J o-o .C cd o! b9 =Lu.5 o5d8l ol >tot -l6ltrl ot odolLl o io sd o C) ai o. o oo o b F q ! q) L o() '- o. oo cs) E_0 o: oo:Ca EA .JH L& oJ A o Eqq o q ca o 'a o ,= o o. rrl =o. & o N -oo 2 o(J o U) nr V (J o a oU o0 = ! I oO c. L o (J o 6.)(n oo ! o h a o0 o -O u(i C)o2E rrr O o -o n @ (d N oo 2 oq 0.) o. a bo o o z q() 't o(! o -o L 13 a oU - -v,cooo ool oulo. ol90) Hvl O E € o E o ood (! z o0 ooda(.) >\&v) o O <! Lo x 0) (! C) q (.) () a) E IF o =0) C) p. o o q) NL Er q) F q) q) !+ e) F 10. BUDGET 10.1 Budget Estimates Budget ryus1 tndicate total funcls to turlertctke the project. The antount of fundirtgrequested from APoc, and the amounr prot,ided. b,"- the MoH, NGDo(s) and. otlterpartners. All must be made in US dollars. Eaclt budget must inclitde at least the follorving nrujor categories (see appendix 2)indicating the contributtort of the partners to reJtei sttsiainability of CD:TI. ! o Personnel (services) o Capital equipment . Supplies Training o Health education/mobilization o Travel . Communication . Consultant . Operating expense o External audit 37 38 Tab|e 5. YEAR ONE SUMMARY BUDGET FOR ONCHOCERCIASIS coNTRoL, 2oO3 CATEGORY APOC MOH TOTAL Personnel 0 96,009.20 96,009.20 Capital equipment I14,170.00 18,778.10 t32,948.10 Supplies 59,267.00 0 59,267.O0 Training 20,299.50 6,380.00 26.679.s0 Health Education/mobil izatior 34,896.65 7,625.00 42,52t.65 Travel 8,800.00 1,964.00 ,10,764.00 Communication 2,520.00 2,520.00 Consultants 0 External Audit 0 0 Recapitulation 9,600.00 0 9,600.00 Operating expense 14,370.00 14,370.00 Total u7,033.15 147,646.30 394,679.45 Estimated No. Treatments 563,9r0 563,9r0 563,910 Vo input 62.6 37.4 100.0 Cost per treatment 0.44 0.26 0.70 g5 o o a. 8 g E o = s a 8 a t3! 8 g I g. 8 E o = ; J t,I a 8 8I S g F E a c.; E ooC 8 8o-! o RN. 3 8 8I ?; a a. o I a :. I 8 a g. I g a e a roE E E N a N. 8 T ! 3 a il c{I &g ooc a g. q 8 g I E E o o E I @- I a N- 8 9 3. 8- I 6 8 a o Eo = a @- ag aE : I a. a 8 g q a 6 a o- 8I I6 cr a a o a o J a J a :9 o a 3 8 8 t oi 3 a .1 ai 8 g a Zo = ; 8 E o; a: 8 I N 8 o- oi 8. ooq a E o 8 8 8 I u1 a rj a Fo F a s I a a T d o_ 8 a 8 G. 8I a\ 8g Eo = J o a 8 8 g. 8 g 8 ts aqo J o ooc 8 N. g N- E o a I a a o E Fo a E a I ;.g 8 a @- 8I 9 a g N. 8 E 8 .?: t o o- o 8 g Eo g. a tr G. a E. 8 ts. 8 T a a N. a 0- a. o o? o@o ooo a 8 q a aN. aq a 8 a 8 g E o o- @ a EooU F o E e 60 E E E o 8 E a E E 35I E ll6 € T E E EItt 5l a E e B 6 E E 'a] 8tGI e t. EI A] 5 o C 5 c E oz E E E] *l E, sl8t o- L c oo I ah .(! o o() o otr o o E E v, o Ef(D (E o o .=tt (og o(!F I o{ E o; .l J a s q o_ 10.2. Budget.lustilicttion Plt'tt-st' l)l'rtt tLlt (t tt(ll't'.t!tt t' t/t t, l't1t71,,,, 1tl lllt t ('(1\r)/1 t lttt' t'tttll 1t1 1t1tq :,q',f llll( It('ttt.\ ()l llrt'bttdgt't ( 1) ['ersonnel Thc bLrdrlct scL-n Llndcl lrrre rtcnr Pet'sonttcl rcl'lccts tlte necd fbr stul'l'iit the IcYc'ls ol' \1OH. RIIB :rnd Drstrrct hcllth ol'l'rcc ltr l'ucrlrtute tlic CDl'l lrctrvitrcs i.rt tltr- conrnr.lnltv Icrcl. l-hc I\lOIl rrtll pt'oi'trlc srll)p()r't rrt tlte lbtttt ol': o \ltltlt ltst ltg r.tuthrlt'ttlcs lttttl ('()lllllllllllt\ lclttlt't.: . Orgatttstt.tg und lcurlrnS tlrc drstrtbtltl()tl I)t'ogt'ittll o l'r'aining ol'sLtl)ervrsors rttlcl CDDs . Gctting and sLrltplr rns l\ cl'l'llL-ctlll o'l't'ansportatron ot'essettttltl sLrPllllcs . Regular supervisiott . Accountrng l-or f'urtcls sPcttt (both APOC rtttd otlrers) . Pt'ograltt er,;-tluitttott (2) Callital ecluipnrenl Fol thc plr)qrirnt to functirrrr I)r'(rl)crl_t. thc IlllB. Drstrrct hcaltlt ofI'rce rind sonre health l'acllrtlcs r-r-rust Lrc \\cll crlurllpecl tt rllt thc ncccsSitt'1i tr',,.-,' ',,t (3) Supplies Office supplies are essential l'trr the snrooth rlurnrnq of daily program operatrons. Srnce this ts the bcgrnnrnu o1'the progrlnr. APOC rvill be reqLrested to provide ali essentral ofl'ice supplres. (4) 1'raining: Training is essential to the implementation rnd success of the program, and it rs an activity that is carlied out on l contrnuous Llrsrs, u'rth training and re-training at all levels as new personnel join the program. Trainrng rs also very important for the supervisory activrties of the program Thcse actrvities rvill be supported by APOC. (5) Health Education/i\'Iobilization: Comnrunrtl,r.r-robrlrzirtron and rrdvocitcv uctrvrtres are requrred to burlc[ the support nceded to ensure progralr sustarnabl llty MOH pel'sonnel from the National, Re-qronal, and District levels rvill mobilize communities through advoczic.r' campargns, rnformation packet and visits to the communitl,. General public a\\areness can also be supported by such techniques as the distribution of posters, brocltures, strcl<ers, and T-shirts etc. 40 (6) Travel: Travc-l rS r-eQLlrrc-tl l()l ir(l \ ()jlc and L'\'i.tlL[rtton i.rctl\ ltlc\ trr.L. APOC rr rll Lrc. l.csl)()n\rtrlc- l'trr (7) Contrnunication: -\' \ rsrts. lli.unrns. rL-lriulllnq, supel-\ r.srOrt lrnd nr()nlt()r.ilrg all rrrrPtll'tlrnt l()l' t'l'l'e crrvc I)r'ogr :rnr nnplenr.-nr.;rtroi sLl[)l''rortrng tr.ir\ cl crltenscs nccL-ssl[ \ At the Nlttttlttltl- [lt'lttrttltl. urtrl Drstrrct lc\cls. telc.lthtlnc. c()lil-tL'l-lrnrl Otlrcr.ntL-i.lns ()l collllllLllll('i'ttl()ll rr rll Irc ttsctl lu]tr)n-g [)l'().lcct o[)L-nrtors. At thc cr)n)nrulrt\ lcr c]. conlnlunlcittloll \\lll bc ttllttttll'throtrgh the usc ol-rudros and nrc'9,lrpl.rsr.,rcs. ApOC rsl'equestccl to stll)lx)l't cx[)cnse s lssrlcrirtecl \\ tth contnturrications includirril co,l.lcl. servi ces. (8) Consultants: Consultants tvotrld bc t'cqrttrecl to concluct K.^\P studres (to hclp rn thc dL.\,elopprcrt and t'eftnetnent tl{'hcalth educittton and othcr nraterials); progranr c'uluatrr-rps, computer maintcnilllcc alld other asPects of conrpLrter u,ork, to .nrt',,. totll cluulrtl managemcnt of tlte p[ogrant. APOC is requested to support the costs of rhr:sc consultants. (9) External Aurlit: External audrt u,rll cnsurc pr.oper accolrnl.abrlrt\,. glngg APOC u,ill supPorl thc costs ol.extemal audit,g sPccrl'rc budeet rs not inclicated in the budget detarls. (10) Operating lirpcnscs: This w'ill rnclude costs such as utirrtres, costs of quarterry meeting (Nocp),development and rnalntcnance o1'Ir{lS. Also rnclucled in this line itern is the cost of'operitttonal t'eseat'ch, prlntlns of essential reporting fornrs (treatment sunlrnar.), fornrsfor communrry, Drsr'rcr, and Regronar srair), [ousetroto ;;;;;: ,;;';;;r,Lrnrr' registers. These expenses u,ill be Jrppo.tect br Apoc. NGos and MoH,,,i1 'r;,;;. some costs such as office utrlitres. I0.3. Current resources available in CDTIs Existittg CDTt't (for c'orrtitttrcttiort or expcutsiott)tvill have resourc.a,s ctlrecttll, available' Please pro,icla a dctailecl lisr of alt existing persorutel, eclttipttrcril atd srqplies (ittclucling t'ehic'les, etc.) belinging to tlte progrcutt, itt4ic.atirtgtlrcir on,rrcrsttip (MOH, NGDO, other Age niy,hr.) o,ril ttrii, level of funcrionaLirl'. NOT APPLICABLE 4t a APPENDIX I: ESTIMAI.ED NUMBERS oF.COMMUNITIES AND PERSONS ToBE TREATED EACH YEAR, BY ENDEMICITY LEVEL Total population rn above communrties YEAR 2xx (2004) No. of communlttcs to bc tr-c-ule-d fotal populatron rn irbovc comntunitres \'Orrcltoc'ert'irr.r'r.r r.r tt()t ('()ttri(larac! atr itttltortartt Prbltc l{eoltlt problcttt irt l^,ptt-ctrtlc,tic,t'otrttttttttitia.s tttut ,,\p( )C trrll nol ttor,tall.t, _fiuttl c.<lrttttuttitt,-bttsatl trt,tttntcttt itr .tttcltt<tilttttttttitit,.r 'l'ltr, rttt lttrtott ttl stt<lt tctntttttttttlit.: ttt tltt, lrrttlttlsttl rttll r<,t1tttt.L, (t .\/t.,(ttllj u s I iJi ( d t t ot t .l o t c ( ) t t.\ i ( I (, t-( t r t ( ) t t l)\. t t r c'fC C. AREA COVERED COMMUNITY ENDEN,IIC LEVEL HYPER- ENDEMIC MESO- ENDEN,IIC HYPO-ENDEMIC,i TYPE OF TREATMENT Communitl,- based ContmLrnitl.-based YEAR 1 - (2003) No. of communrties to bc tr-eatcd 160 105 451 475,370 267,r74 t,245,786 No. of communrtles to bc treated r60 105 451 Total populatron rn aboYc communltres { 71 I ,281 911YEAR 3x* (2005) No. of commLlnltles to be tr-eutecl r60 105 151 Total populatron rn abovc contmunrtres {68,905 37 l.-ll9 'EAR 4,j,{, _ (2006) No. of communittcs to bc lr-cLrted r60 105 +-57 Total population rn ulrovc conlmunltres l8 400 29 I,-157YEAR 5** - (2007) 160 l0-5 -1.5 7 .l 397 llr I,39(r,70(r **ll i's tttulc't''\tttoa! 111111 tltt' .lt.qtrrc's Jbr Icurs 2-5 ttt e lil,alt' trt l-tc, cstirttrtlcs tltttt tlt(t\ cltttttyc, tt.s tltt, 1 t t'ctj c, c t /)/'(,t ti'.r.r t,s lli- +t F3 -o % lnput Nobo NobO Oo OO @o o O)O oO AO oO Noo(, -Tt €' s, l, o C) o TD CL GI o E o 1' 0,f o o o o '(, o oo o o, @ NoO5 Noo O) (DO oJo i(, N)oo .\t A Iverntectitt Treatnrents reflected in Appendix I uere obtained as follou's: Total pr.rpulation in thc- 20 districts in the zone in the year 2003 is 2.012,741 6 of th.- 2t) i11511-i.1. arc- hrpcr or nresoendcr,ic c1ualif1,i.c rbr cDTI AII thc six districts rr ill be treated in y,ear onc and REN.{O rcllpcrrrcpt u'ill be done i. othcr 6 drstricts. Year-Onc Total populatrorr in the 6 districts targeted for Year-one,704,gg7 Total nunrber of persons to be treated in year one: 563,910 On the cottsc'cutivc)/ears tlie progrant u'ill still cover 100% EARp of tlie treatment objective u'itlt natural gronth at a rate of 2.9%per year ip t5e fryc districts selected for ),ear t\\'o intcn'cntion. Fig 4. Annual Treatment Objective by Endemicity Level 450000 4 00000 350000 300000 250000 1 50000 100000 50000 2004 2006 2007 F 200000 0 2003 2005 Year <- Hyperendemrc + Mesoendemrc 44 ..\PPI]\DIX 2 I\DICATORS FOIT E\-{LL-.\I-IO\. SLISTAI\.{BILIT\ /I\I-EGRATIO\ OF'CDTY .l Iu ttctgctttc ttt Fr rurnci ul lnr.lnitqentcnt It'l cet r vcr)L-ss ol' crrrI] ntrrn ILal.i ons -l nrrrtrr.tg l.rncl c:rl).tert\' [rLrrlc[rng I rtst r t trL r r-lrrtrI cclrrrlt.tr t nte.lrt F'Lrllllrlcnt ol'othcr rcle r unl. sectot's ProLrlcrl scllr rng cultacrtY Intcgl'i.rl.t on ol- operational research P roj c c t cJJ'e c I i v u t e s s ResLrlt of KAP Srudies Trcatntcnt covel'rrge Follori,-up o1- non-elrgible and absentees I\{urrlqcmcnt ol udvcrse reactions Rel rabr lit1, ol reporlr ng S tt strtirtnbiIity/I rtcgratio tr Prtlitital w'ill o./ lrost eoverntnent Polrtrcul ii'rll as shorin rn polrcY statenrents unclappalcnt conrmitment of hi gh-level Offi c rals offrcral uctron asslgnnr-q personnel. funds, r chrcles {.o progranr Lottg -tc rtt t pl utu tt rt g ls thcrc a long-term plan for sustaining the frnancrn-e and the mana_gement of the progranr? P r o g re s' s t o w o rd .fi rrcu tc i ctl s ust ct i r tab i I i r t, If program sponsors cannot continue their cunent lcvel of commitment for at least another five vear, rvhat percentage o[ running cost.s is no\\/ paid for host govenlments or fees? P ro g rt,s s t ott, a rd i nt e g rat i ott To u'hat cxl.ent lras iverrnectrn distribution been integrated u,ith other health sen,ice programs? evrdence of contmunlty empowerment and orvnership changc ilr KAP over time extent ot rnvolvement cif both gender.s and non-llteri.tte 45 l) ro i c ct I')rul rtot io tt o J. o I o 3 o o I €oI €o o :c I o, o -t' - o' -oo =J o 6- o o a o =ol T o aol :, o U) cu o lo o o ooi o o o + :, 0) oII oo = o) o. = o 8. 0) oo o 0l o ll o a, 6-J th a (t I o D oIg o o =. o N oi -n N ol q_ oo oq :f o olal 1' oa 6'3 o -o or o a o c1o o NIo a o c Io o J c o, a o f f L 0) o (n f\) @ N) 5 N) @ N)A O)(Jlo o)(,o N)(noo O) oo @ o o @ zI o o o \J55oo 6 O) N) o)! ! -.J O) oo (Jl O) @ oo -to 0, o o A @ o,Ioo G)Ioo o)9oo 5 oop oo ..1 oPoo { o D o lo o =o 0r t o o o 3 ooo s :o t 6o .'eq =: =3 o s @ o oo o = =- =3 o o -to6x TI o oo o 3g o loq :. o R s =o o N s o =o 3o o :, o No beq =Io =.3 o o o No "-Qg =I(D =.3o No s o J o. =f o o Nof,o + 0,o -TI o oo o 3q o It t,g o 3 o o 8 o- Jo o N(,r o\ of D d'l flacu I og ololf,(D 0) a o ? o' ooIq o =. o oo o c f 0)f, l> o_ 3 5' a: I o O)a a. I o, = d o 3 6' o- ; o o sl o. o (tI oo or 5' 0) o l, oq 6'l o aT TD II G] llr G] llr @ llr ul Ta G] llIgl a o c1 o o O)(,o O)(JIo @Oro (,o (,ro N)(,oo ,\)(ooo C,) 5 N) cg a tD z 9 o o !o ;.,(o !o No O) snoo O) snoo @ .(J,oo .(J,oo (, oo N)(JlIoo N)(oIoo (^) 5 N)o i o D o 0, 6- o C o, o-{o trlo oe o l- a =o o o of, o A) ao 3.oo(D Iq, o -oo\ o fq. =o 3 o o o o o\ =a =o l o tfo ;eq fIo =f o ooocf 0lf o- 3f tt a q, 0,)- o Es o r- a J o =l o -oo\q a. e.J o =3 o 6 o 8 s o,) o @I o\ o f '4J o o o 8 s A,l o o ;s lq. J oll lDl o, =.of oI -toJ r @ o) oo Jo No -rg\ t oo -t oo{ o{ r on -i ;q o o o o o l o I oj. I(D a a- n 0)q o o o 3 3c J oI o l oI.o o)1' =o f oo I t-oo T o oI o o (D o O) o. o o o c o I l-I]LJo oo o :9. o 3 0)oJ f(D 'Tt 0)x 3 o)o z. f o lrlalot.lot-rolr t1 l(D tl o o)lo x 0) l o.{ = o ooox oE oo 3D o :1 o)ooo6 @ o:(D a Ao o { o) (D l< t9.lo o o 6- ls l€lo l'o lotxl-l(] l(D f o o o oa 9_ -o oo -o o -o oo -o oo ll oo -o oo ! oo ll oo ! oo 1loo ll oo ! oo 1l oo o o o(D (n o (, oo -c,)oo -(, oo N)o _(,o o (, oo -o oo .. oo O)oo -(n oo _(,ooo -Cnooo C 2. o o o o o 3 O) O) N @ z 9 o C =.o P{o oo (,Ioo (n oIoo NooIoo r\) -o oIoo -.J N)9oo (,l o9oo -(,ooIoo Ju t\)oIoo O)oIoo -(rt oIoo (rl _5 ooIoo -(rlooIoo -log o oo o Nof or_ 6- q o Nof 0r_ o- q !o € o c! P- o oc o 3 o o{ o o. D o € o oo !, of o. Nof o l 6 0) =o f o € o o o. D' o q o !r_ o-- g 0) o o of !L 6- g l:rlo tatalclo lo la,l=-o l o No :, 0r_ ouo l o =lol olololcl3lol al 'l loll t:l=ll lq'l-loltlolf lor lolr =looo o or' 9. oo =o ooo o. 5 A, f@ c l ol o oo 3 !C 6', o Nof!r ofo =ooo o. o,q oof, 9_ oooq fg. l(o C f t-{lr lalolrlo lo toko 6-a o 0,oJ o o, o6' 6' ol ol al olq1 <l --l6l @l lo lalcfololz lolf lolfto 6' d o 3. =: oq I N of A, o G mx!il =o =.ol3 lmlxlEl(!lrtalot_- lo t3t\l0)lo ?' o ooo =.! =.o3 a o'o -n c f =c o Ao l lq to l(Dl^ fo l0)o o ls lg llf. lof o o lol<loll l(D lot lo-ro o oo s l-D l3t-tot6lolo lo l o)o f - l- o) @ o o o @x o €o o f, a- o lt oI .Tt T -n I -n (J I -n oT -n o :E -n :E 7l I o o o o oo (,) -.J(n o -o o (n oo -o o O)oo -(n oo -(nooo C 2. o o ah o o 3 z 9 o C =.tn -o(.) -J s, o CN9oo @ :.J(rr o (, o bo (n Ioo (^) oIoo O)Ioo (n Poo -o o9oo { og o oo (rl sq coo c J c o ao o 3(D f l(r lslot;lal6 lol; =o O) o- ox ?)(O o o'(D 6 rc o)o o l(, t-" tat;t@ l(D lot;l-lo o) o-Fo x. ? f(o 0) l o- 9_ o- (DJ o (D o o co o o o_ o x. o =. o o =o O) o- o o o\ o co o 0r_ o x.o =- 3 0)o a f, o t.- ls lo lcl6 lolol; =(D 0) o- o x. 6 fIo Er.lrl otrl I t-lo lsto l.lo LO o o) o 0, o_ ox c rl(o1 olol3lD o o ocI o 3 o (D o oa l o) 6ol EI Orlol -olo-l o =o o o_ !:.oo E oo ! D. o t<to l:t LO 1l oo o J o o-' oo 3o ol o rxEI 6 a o, =o :, -Yt m(, m l0 t- =oI o o = :1(, c o) o I o) x 0, =o. 'rl 0, 3 3 or of, o =], rn o o - m r{ -ql C a) m c @ o og o =oo ll c f. c (D ao m c 3(D f o =oo oJ 9. o lmIxl!l(!lll6 l(Dt- lolf o o € o-l(!l6lolrl :DI @ a -q, II @ U' o c o o @oo N)ooo -oooo C =o oo o o 3 l\) z 9 o C =.o ,\) iuoPoo CoIoo NoIoo JoooIoo -{og o ott o -oo\ o c(t o o (D x.o =-a o o o C l. c o ao 3o = o ;e o coo o o =oo lo l;e lolcl6 lolo lo,i-(n !,o o x.o =-l(o (D1 rl ot ol Io ooog l o) 6 l t,txlold)l!, o :, I a o = 3 o 9Jp a)_ m -o sp 3 l o o le"INlo f o o- o oo 3 3 cf o o, ol 3 =f, o -{ -'Tt z oi 11 5{ G)boIoo NIo 3 o - €oo l=o 4 oo{ od 6' o -o0, J o =o oo r fo ol o 0)p. or_ m _oc =' 3 o3 o TI c f, c o Ao (,l oo o o Coooo o :, o oo o o 3 N lrt NN srtoo -lo 0, o o tn co o o x. o =. o =o o- coo o 6' o c f c @r o f N) Ol s o x. c c6 o I\)(,r s U' o 0) TI c = c ao 3 tn o = or (rl =o oo;l o 3 or c o o o) = o o @Ioo -to I l(dlo xq co o o 9. co(D o -r'l J ='c o ao ml r =o {{ 90 o 5 @ a oo t oo ! oo -{I o) I ac c' o I -n c oo ! o 3(D 0) !.l o N)(,r o ooo O)oo =.l o o =9_ o. T oo G) A(Jl J (^) (l)bo 5(,l o at 0) Ca@ G) o o 0r_ C,J co T O) O)o o 0) 3q (rtoo 3(o g ooo O)o(, f, o l\){ =.ag, A) C :t o o 0) f ol o (D O) 3. o :fa -o oo o o E o =. = o loo\oo\ o o q) ,; o N{ N) -.JIoo o(rt =.3 A) o o. o o fo o U'd o o oo a 0)(o o ll(D(o 6 o o ooo @ o a o 9_ C' 0) o a o ; l.o o1fJoltlol6l 'l s @ _-. c) o-' o =o 0) J 3 o U'a 0)(o IO l)a196lo '=-lc, oloflooldal'.-^ l*ElOrl- -' uq)(DE -o)(Dro <o o_a o)! o(D ='D6'o 6) c) :, o) 'Tl(D:t; o)D5 =.7 xf ci o 6 $siH g(,cdi a.o31d9 BElo) 0) ao o 6 rl o'l !:.f, o o o)l =.o. ko lo d O) x A)l o-{J ='g ld Iq lslo-kolo lat- l-ol=lo o C) o FO 3 o) c) =lo o o C f o o o o (n 3 z o o f =o { o 0, o o o f 0, =.o f lh U, o G'x o o CI, -Tt o N ol 0) 6- (D o f(D -o oo (,l (Jl t\)Ioo > C (,l o,oir o CN oxo -o oo ! oo 1l oo 1' oo ll oo ! oo ! oo -o oo (n (,l o o iu(, O)o o (Jto oo 5oo (n O)(o tol\)(n O) (Jt -.J O) f\) 5@ N) Or N bo(n bo i\)oobo co -(,l C,) orbo N t\) -o O)obo 5sbo { N) Poo A coIoo G)oobO (,OIoo o o O)(o o o =Ld o so :t o 0) 0) 9. 6'tt ='o o- 6' a) al ol =o oo{ (,l o,(o =. =(rt q) Ca@ (,l E o =. = o o be o Jo O)(o o Eo]C oo =.3 A) o o- o o :lo o ad o o oo o oa o o o 0,o =oo -{ I N)(, E o E 6'o o l\)s E 6'o oo 0) 3 of o f o o 3 of =U' o o, o-6' =.o @ o o U' o a A) =. 0) C O)o o 3 ol J o o f, o 5 @ ! ooir o o 0) o o, o o o 5 @ J(D 0r_ = 0)g o'(, ='@ o- a' =-o a 0, Ca o 3 0)o =5' o + C oo (,l o Ca@ C,Io ,\) O) ]C1'fElo-oi' = (,)I i:r5 ..;PCO 'I3 (oE(D3p 0).6 (,(o i\) O) .{ bo 5(o l tn o ro ol-trfg(Dx 3' '' gl -{cE. .oolo t6C] o =a 1' ooo{o{ r alloc 3.o ==[o o,o:rO ^€U3J()J(D o oooa o_C =-f(ol -o oo i, (,)(,(,)(,) NII\) @ JD(, o (,o CNO =o -{o{ r o-O<ool u o'l o o o o D. l o a 4,. € o o_g) r-1ooo) --{3o <l6o+o ol A+ o)qi5Oltr(Doo, (DJ <o-e.g o 6 o. 0) l @(u o 3 o, o e' o oo mx 6'f oI oI a oc o o @ o C l =o o o o o 3/ (, o.)o (,o 1 9 o c J o @9O n\) (,o9O { o 9r o o(t, 0i 5 o a 5 O) o- o:o 6 f o 1 g f O) oo o @ (a0) o= a!616(of,o og) a E C @ @ oa E o 0) 5 o E o-i) 5 <$Oo -Joo- l< 3 -n o O)o c) o loo i=<r )I -r oJi o=qE3 ofo'loqo N) <o= B =Ss 9;o-o :1€;T;; ci o- tn =o) .ni@o I Fo5 -9 rD -nr -6 -= ru€Oo) o- nD =-o(D mx o, f o, =.o a a 'o oo t trBB ooIf :1 0 mio- c)Sl+9.@oclo- s.o o9: o =OTq o'af l, o o{o{ r i a =:1a E =ro :l o =oo o o Or' a. a 3 o cna 0)(.o o o d'irl o 0) f o o o q) l o_ o =o @ o o o ocd o 3 0) l (D ln o U, o o :l 9. ='o o 3 0) d =(o 0)(o o T o <h o(, -l o,lo 3 o' U' 6' PI q.(o f, ao a 3E o 3 oIt Ao of o =0)f N)ooo o 0)oJ 5' o o 3 q) o) :, T -4. =. o o(t o o of. =o 0) o o o o oo L a. 5 o ot o o) o O) ]i 90?a'ciio6'or-c)^ 3io-o 3E de =.ON(o)- =. 0) ol:li o o =.ol6 6'l o (,,N(DO Jf F'aA)= ^'(oJo, 3 3(D o =.ol 6t o'f, o o o. oo 0)o O) :l o. o. o 0, :, o. f o o f -o oo :o oo -I) oo ! o c) l) oo oI o:r a o o o N) I(rt I 9 cn (rl (, C3 o o o o (Dl 3l Cnooo f\)ooo (,r o)oo (,(,) co5o 5(,r N)o (,(n zI o cl o I I c.,A -co @ o) b, Ol -oooobo l\)boobo -(,(,)oIoo o, -(o N)obo o, ..I O) b,(rr -J (rl -o, oIoo Juolo lrtoo { o 0) o o an (rlooo{ o =ItI Ca@ to lC o p. oo o o o o ol 9'I =o o) = €o r(D t, 0)l o- o J o a oa o o 3 3 c f ltnlol= o o6 0,l o- o =o ! 0) ;1l o o o cdo(t o ox o C) o0 o q) l o. o o 3 3cl o-'g) o- o o (n D oo o o o,o = o 3 =o o E oo o D o(t (D U' o oq) oJ s. o q) I Oro ooL =o 0) o o 5(, 1l A' I(,r gcrl 6lhg =-5l9.ot: :p53(Doorl:hqeEe(D 4-:(/, Q.Y 3Ee ='- O i qe!( -ro - oo 9xE E +.3lii'Ede6. eo \ ==oYq= coJ ? oP d OO^ l.J D)o<6g =D TQ cYA (,q)i-<ag -:<lg =D o4 EeoE OEq)=-of(D -f 6'f 8E 3i=f(D.o odEs *, o-., eegB{glro .<o, Foi oPl o- o' algE E$lo-Sarg m o, :, 0, =.o f (n oI (, o !, -n c(D Co =.o 0, 6 o :, o. oo s @ o a Nof D- 6' oI oI o o l\) (, oo o oo o f, N N) C l zI o N)oo N) N) o,o Poo g o o O)oox 3 llt (rr x 3 (D 0) C U, m l9 l<;o ='o g o(D ol (.) Eo @of, o Eo 0) {.o o CE o 3 @ o a o =o o o-6 :. r) 6 l -n cq -g =.o O)f a !, o o 3 A) o 5No (,ooo (, 0) ?o A' 0) f !, =o f oI ou o ! mo 6z r @cr m c o I{o6 €g NIo o I O) C)(fJ o ah -l! o -tI m J-{r oTI .7t o m U, a r m - -l 4 f-f(D (Dt -i 0) (D a 'Jl Nl I o -t r @ cg og -o 0) J .Tt 0, c. s @ o oooa U)c o o !, f o 0, f o- s @ o U, o o -o oo l,oo a oc o o C f o o6 o o 3i o) s o c f, oo 59oo -to o o o tc o a o l(, =(D 0, = A, o =.oo 0) o) Ca cEo ?a o a o o(, oi' =3 oo D) {o * o @ o o ol x 3 o A) C @ e, o = oo O, I o GJ 3o o uo @ of 5 ooof o.6 o q) o C (,) =@ o o. -@' o o o N cEo 3 @ o a loc 3'(D o D o f o =.ol a=or oT o l, m o oz r I m - -l 4 (D Cf, m C =oxt m U,{ € mrr m o NI0 l3lo - crt oo{ o a -{f, o{ I m r -lI o 'Tt .Tt o mo o --l r co]Uo3 3i o-J3o JO-c(of93o eq o b o, o tn oa U' u o oEJof, o ."t 0)x o o 3 cf o 0r_ of,t =' = 9) o c =.o o o) l a C 3of a o o f !I @ aI @ a oc oo @o (,o C3 o oo ol (!l 3l N) 5 z-I o C f o o 9r o oo I Ca @ ooo 0) c oo (o o,Ioo c O)lo o , a(D ? 6'o o N 3o l =a o o) c(, o !r --{ o o rc J of, o -n g) xo o 3 Cl oI of{ = 0) c(o o 2 o(o o :f O)l o-to o o. 9) NI @ Nr @ a o o o (,o C.)o C = o oo o (D 3 N) 5 z 9 o C f o O)o9oo 3of = o 0)x ooa Crro a(D 3oo o N 3ol {t\)Ioo =a N)Ioo -{o o oo o oo o a co o -l(D oDf oJ 0)xo o 3c f o'g f ={ = (O (D l Nof, o (D(o o' l ooc IE'l=tol= oI o oI o a o o o (rl o o)o C f o oq o -l ol3l N) z 9 o C f o t\)Ioo J o 0) o o6 oo(t 0) @ o 26'o o N 3of f6 O)oIoo (, o (D oo lo 0, C U' @(, o.6' f,.o o o) o- o' =.o o f 0, =o f r I o (, G) lmlx IE t: l(Dlloltot I c U)6(r s @ =.o o O) o- a' o(t rct3 :.(D(D6- =i9o: :CD au) =X9a* (Dg; =(D 0).(, 1' oo a oc Io o o o an =o 3 I 9r ol+l et = o { o o, o o lh mx o f a a a (n 5 o 1' o o o - a 5 ) { o{ t- I @ =.o o o o) = = o fl o o' € 3 o o =.l N o l o o o o.)f =c o :D o o' € 3 oI = mx! o3 o o o 3 o =. o oo o =.E' =,of -D o o -o oo a oc ao o o,5oo C,)l\)oO C) =o o o l* o c) U, Jo o,oo O) 5OO o) -N) OO -lo D' o o tn aE d3r ::l- aEcl'6Njgi d)_ u, =. =-qAE E OL-^ * rE tioo-S6' ai 0i !g64.<o3 0efu'o S og Ca ; rf c-nY.O O rnO s **Y;f1*oaJ o o- Xo Q.o.X i6 =q 6.x E -rO Y --3.3'5 -r-.u5-{8",o+l-(,o-;! SEE E a.--aa9 o iidi *t'<.< .i q a' - ieo rnxg !, =!, =.of + o 0) rnxE o :, o o o 3 o =.s. o oo o =.'o 3. o3 o J. a oc ao o o C J =o o o O It o trJ o o -lo n, o o o rnxg !, a D) =.o J 1- 1c dE (DXlp T@o@oco)o- -o (o ='o DO =.O3q6 ! a (rl(rr q o o o o D o ol ?'(D 3 0r. f. (Dl 0)l c)o eo 3. f, o o g a o o a.o o oo (DD o, -' o N ol(D o =o' o 1f, o (D f o(o c o) 3 P.2(D :,q, lo(D l(Dt Nol O) 3 o)o zl(D6 ut O)l O)x 6 o 3oo o o o o o o oo o f. of o :E o f, T E' N :E c] II @ NIo l, I(D N -o a o ool (, 5 ot lu(, (, o o o o =o 3 N cn J 6 O) AoIoo -@ (r)Ioo N <noIoo l\)oIoo o oo ca6(Jo oo @(D _?.oo Eo 3 of = o t\) 3 o =f@ A' o 0, o Co Dcl c) c o E(D 3ol = 3 f o (DEq C ct @(,oo E(D a o 3.oo(n =3oo E(D (Dq, o (D 7.o 6- =>OC@a) D('(,o Eo 3 0,o =fo o oo 3Ec o E f o t, f o, !, 3 A)oJ 5'o N o,f tt =of o c = o. o tn o fo o o 0r_ U' or l o.{0l (D o o c o o Cf, o o o o o 3 z 9 o cl :l oo bo o oo o or_ oo 3o(D ol l\) (Jr o 3o o ! oo a(, o 0, o + oI o F f, m o olzl>I m t-{r G'C f,, m C =o - € o]n € o, N I o t? or O) o(f J !! oC moI o6 -tI 6ia t Cl o o ,3 $ =f @ mx (D f @o a -o o ool Ui s tt o o a o, x r <t, u o o) 0)tr tI o o o'(D c =. =,(D a m o-o =.o =or oI o (/, o o o CJ 6 3 o o o f. o o oo Ju o)o O)9oo -lo o) o o6 Lx 3o ==o 4 C @ (n o 'o (D 3ol f o gr 6o 3ooo oll s @ =.o o 0,l 0, d'f x a a o- o oo a o 5'o c =6'o m o, f o-{ O) o llIg, a o o o o)oo cf o o o al 3 z .o o C :l O)oI oo o 3 olfo o (D(O o' :,Dl o 0) oo 3ooo N f(D o, J ctc o A'c E(D