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

I, ,) t) ffi ffiffi lllubabor Zone Oromiya Regional State ETHIOPIA PROJECT PERIOD: 2003 - 2OO7 For h:icimotion To: brp, Ao AFRICAN PROGRAM FOR ONCHOCERCIAS IS CONTROL (APOC) Ylou I l otep( ? f; JAru. 2[J03 *rL.''ii'r *-t v- 3t.32 leJrtrkrn 4"q€ 33Jan'uary 2003 v Ii I i i ; I I tlt! Fol Action To: /' '.CocD CF*v/ C5A ioP i,n, Bto lcctlL a U t. Ii -r,- TI [] ll tii , I I II trftiii il 1 tI TABLE OF CONTENTS LIST OF ACRONYMS SECTION 1: BACKGROUND INFORMATION 1. INFORMATION ON THE PROJECT AREA FOR CDTI ..............1.1. Geographical and administrative areas. lll , I 1 6 7 7 1.2 1.3 t.4 Topography, Climate, Access....... Onchocerciasis Endemicity Levels Community Structure Organizational Structure for CDTI. Financial Administration................ Timed Plan of Action............ 2. PAST AND CURRENT STATUS OF CDTI IN PROJECT AREA g SECTION 2: PROJECT EXECUTION OUTLINE t0 3. DESCRIPTION OF PROPOSED CDTI 3.1. 3.2. 3.3. Outline Plan and Timing Health Education and Community lnteraction and Participation Local Operational Research. SUPERVISION, MONITORING AND EVALUATION 5.1. Supervision duringEvaluation 5.2. MonitoringCDTI........ 5.3. Evaluation of CDTI SUSTAINABILITY OF THE CDTI AFTER THE WITHDRAWAL OF EXTERNAL FUNDING6.1. Integration of GDTI into other community Based pHC Systems ........6.2. Cost Recovery System during CDTI.........6.3. OtherIssues........ 10 10 l1 l4 4. 5 SUPPLY, IMPORTATION, STORAGE, INVENTORY AND DELIVERY OF MECTIZAN TABLETS ............ 15 16 t6 l7 t9 6. T9 t9 22 23 7, 8 CROSS BORDER CONSIDERATIONS SPECIAL RISK ISSUES 25 SECTION 3: ADMINISTRATION/FINANCIAL.......... 26 9. ADMINISTRATION 25 9.1. 9.2. 9.3. 26 26 27 3l 10. BUDGET 10.1. Budget Estimate. t0.2 Budget Justifi cation...... 10.3 Current Resources available in CDTI......... APPENDIX 1: Estimated Numbers of Communities and Persons to be Treated each Year by Endemicity level... 40 APPENDIX 2: Indicators for Evaluation, Sustainability and Integration of CDTI 42 APPENDIX 3: Budget Details 43 LIST OF MAPS: MAP 1: SKETCH MAP OF ILLUBABOR ZONE, OROMIYA REGIONAL STATE, ETHIOPIA. 2 MAP 2: SKETCH MAP OF CURRENT CDTI WEREDAS IN ILLUBABOR ZONE, OROMIYA REGIONAL STATE, ETHIOPIA MAP 3: DISTNBUTION OF VILLEGES, ROAD NETWORK AND NVERS IN ILLUBABOR ZONE, OROMIYA REGIONAL STATE, ETHIOPIA........ 4 MAP 4: CURRENT CDTI AREAS IN ETHIOPIA LIST OF FIGURES: FIGURE 1: Organizational Structure of National Onchocerciasis Control Program FIGURE 2: Request and Disbursement of APOC Funds 28 FIGURE 3: Percentage of Contribution of Each Partner for 5 years for Illubabor CDTI Project... ... FIGURE 4: Annual Treatment Objective (by Endemicity Level) 4t JJ JJ 37 39 aJ 5 26 36 ll LIST OF ACRONYMS ) APOC- ATO- CDDs- CDTI- EARP- EPI- FDRE- GIS- IEC- KAP- MIS- MOH- MOVDCD- MOVDCU- NGO- NOTF- PHCU- REA- REMO- RHB- ROTF- SNNPR- TBA- TCC- TMEC- TOT- WOTF- ZAC- ZHO- ZOTF- African Program for Onchocerciasis Control Annual Treatment Objective Community Drug Distributors Community Directed Treatment with Ivermectin Eligible At Risk Population Expanded Program of Immunization Federal Democratic Republic of Ethiopia Geographic Information System Information Education Communication Knowledge, Attitude, and Practice Management lnformation System Ministry of Health Malaria & Other Vector-borne Diseases Control Department Malaria & Other Vector-borne Diseases Control Unit Non Governmental Organ ization National Onchocerciasis Task Force Primary Health Care Unit Rapid Epidemiological Assessment Rapid Epidemiological Mapping of Onchocerciasis Regional Health Bureau Regional Onchocerciasis Task Force Southern Nation Nationalities & Peoples Region Traditional Birth Attendants Technical Consultative Committee The Mectizan Expert Committee Training of Trainers Woreda Onchocerciasis Task Force Zone Administrative Council ZoneHealth Office Zone Onchocerciasis Task Force lu SECTION 1: BACKGROUND INFORMATTON 1. INFORMATION ON THE PROJECT AREA FOR CDTI 1.1 Geographical and Administrative Area(s) Illubabor project is found in Illubabor zone, which is located in the southwestern part of Oromia Regional State, in Ethiopia. It shares borders with Gambella Region in thi west, West WollegaZone in the North West, and East Wollega Zone inthe North East, Jimma Zone rn the South and South East and Kaffa-Sheka Zone that found in Southem Nations, Nationalities and Peoples Region (SNNPR) in the South. The zone has a total surface area of 15,870.00 Sq. km. According to the 1994 population and housing census, the projected total population of the zone for the year 2003 is estimated at about 1,053,15 1. About 9l %o of the populations live in the rural area. 9 o/o of the population live in the urban areas. Major ociupation of the rural community is subsistence farming. Illubabor zone is one of the 12 administrative zones in Oromiya Region. It is divided in 13 woredas (districts) and further subdivided into 466 kebeles. Various REMO survey results conducted in the zone show the presence of Onchocerciasis in almost all woredas. Currently, eight woredas namely, Aligesache, Bure, Chora, Darimu, Getchi, Metu, yayu- Hurumu and Bedele Dabo are given priority for CDTI for the first round treatment while others will be considered following the completion of REMO. The total population of the eight CDTI woredas is estimated to be 783362. The table below -summarizes the estimates of at risk and total population by village, kebele and woreda. Table 1: - Estimates of Number Population (Total & Risk), Kebeles and Status of REMO by Woreda, Illubabor Zone, Oromia Region, 2003 Vereda No. of Kebeles Total Population Estimated At Risk Population REMOC-ompleted (Yes/No) Mettu* 60 13427 I 107417 Yes Darimu* 42 tt7959 94367 Yes Alge-Sache* 32 72745 58196 Yes Yayu-Hurumui 39 I 03809 83047 Yes Halu-Bure* 34 68476 54781 Yes Chora-Kumbabe* 38 104357 83486 Yes Gatchi* 23 59,990 47992 Yes Bedele Dabo* 53 121755 97404 Yes Alle Dido 45 91234 72987 No Dega Mako 29 s7730 46184 No Sale Nono 20 22808 18246 No Didessa 27 54949 43959 No Boracha 24 43068 34454 No Total 466 1,053,151 842,521 * COTI lYeredas for year one. I 7Ft fil t: a(t) XEFi o *r? -t hiY hl lrlF -C l+l I tr aY N zHL^l I^ ^r7tst I ^rE o:-( z F aH >t H L^-./tHH *r H cU g t\) t 7A FU !:, I a X Ed Hoh{lJ( ? -t hl r+r \J P; -(-5FP'N ,EI -\JdzXFrI.i rrCUz. >-i >1 1r< 3E '*) /Jtt!HI .FI E 'tA ii - =z*-/-i -\/ lirh(L .Y. t -L_>EU lli ! ^rN z -trJ oCFF fr, z -.1 oU -l riF FN o (, -ri_- i,.' .J ,i a? -.t ft 3 :\JF{(n HHst =thi C N= ^I!z \Jaz -t' A A f=lF<A-vtr?!FLFt-4 lL) >g , L^JFats"X'Utr h, 5Ezo2zL- raSair=EVr! ,0;X t-l Piz =\J\-/ hla /\/ .Y tlJ+<P; LAJI ^J(n z F tC H l+l t* oHa a-a 5 1l :;):i J. 7Ft rg 5 aa I o L<Ft FNzH otlvFl FI F taJ (t) FI z l!Hhll*(t-AvtiYF{ EEGGO +\l-Ho???.b5UJ r-.O\O\oO zoo.c 6- tt, s E6Z'vd:o5.!eo.)5.5(.oO-Ha=€3H I H oao(DuDJAO)Fs7,-l(u F0aq o H x o, o a J oxx A' ! o o o {o op o o oo ht NN b :-; [c] t) 6rl -Ie_' tD r:\i, '-.acr .Cl E9r "e] h'h c, -fj Ielrclral "' iG) r.?r -rc rd: lilr TC] .:cl Ic}] 'il -acl Irj lgr -.. " r*'?.: G) ,:cl .rclrtlrel rd r9rr:rr Llt/ Ic, .i ' ,'-l la taf zsr 1,+,Td.+ iE,-, TC;IC] fa\ -t _.:cl3 'ic: :fr' tgl ..cl IC] lcl lcl tc,t -- iar . [c] -i'cl'v |c l- 1.2 Topography, Climate, and Access. 1.2.1. Please describe the type of country or bio-climatic zones that will be covered by the CDTI (e.g., rain forest, forest-savanna mosaic, Guinea savanna, Sudan savanna, mountainous orflat), providing maps, if appropriate. The zone has very complex terrain with altitude ranges between 1000-2576 meters above sea level. Ecologically it is a tropical rain forest. Climate in the zone shows great seasonal and inter-annual variations which is traditionally classified into three broad geo- climatic zones, i.e., 160/o cold highland,62 o/o sub-humtd mid-land, and22 o/o hot lowland area. The mean annual temperature ranges from 10 0C to 16 oC i., the highlands, 160C - 260C in the midlands, and 230C -330C in the lowlands. The annual rainfall totals ranges from 1000 millimeters in the lowlands to 2200 millimeters in the highlands. Some of the perennial fast flowing rivers that cross the zone include: Sor, Geba, Birbir and Dedessa,Offa, Sesie, and Gumerrivers. There are also quite numerous small rivers and streams, which are tributaries of the main rivers in many places in the zone. 1.2.2. Give the approximate tintes of the rainy and dry seasons and the months covered by the farming season. There are two distinct seasons in the project area, i.e., the rainy season (April - October) and the dry season (November-March). There is a mono-modal rainfall pattem in the zone. Agricultural activities (clearing, farming, and herding) occur all year round in the project area, but are most intensive during the rainy season. Harvesting occurs from October to December, leaving January- March as the optimum treatment period. 1.2.3. Provide information on the state of the roads, and the effect of this on the movements of CDTI personnel in the area at dffirent times of the year.(l ntap ntuy be use.ful) The main road that runs 600 km from Addis Ababa to Mettu, the zonal capital town, passing through Jimma zone is Asphalt road and woredas alongside of the road are connected with Mettu town. There are about 576 kilometers dry weather roads that corurect woreda centers with Mettu town. Except Selenono woreda, all the other 12 woredas have all weather roads and are corurected with Metu town. However, access to rural communities appears very difficult during rainy seasons. Therefore, Mectizan distribution will have to be carried out during the dry seasons (January- March). The general health care service coverage in the zone at present is estimated at about 69oh, but the effective coverage is estimated to be much lower than the above estimate due to difficult terrain, low road infrastructures and affordability, low public awareness. Most settlement villages are also scattered and takes longer time to travel from one village to another. Currently, there are t hospital, 8 Health Centers, 64 health stations and 17 health posts in the zone. 5 1.3 OnchocerciasisEndemicityLevels The levels of Onchocerciasis endemicity in communities in the CDTI areas must be assessed by sintple methods before treatment starts. For the purpose of this proposal, the level of endemicity in a community or a group of similar communities is defined on the basis of the prevalence of nodule carriers. (See table 2). Table 2:-Classification Criteria for Endemicity Levels in Rural Communities Based on the system in Table 2 and using the format in Appendix l, please indicate the estimated numbers of comryunities at each endemic level and the numbers of persons in them. The recent REMO data for the eight districts, namely, Alige-Sache, Bure, Chora, Darimu, Getchi, Metu, Bedele-Dapo and Yayu-Hurumu show hyper endemic levels of onchocerciasis in most of the surveyed villages. See appendix l. Complete Appendix I for each qrea covering the next 5 years of the project. Done! If methods of assessing endemicity thresholds other than nodule prevalence were used when your endemicity dota were collected, please indicate the method used. The levels of endemicity in communities of this zone were dehned on the basis of nodule prevalence rate obtained by REMO Survey conducted in 1998, 2OOO, some of which were also validated in 2001 by APOC consultants. For areas still to be covered, where endemicity levels are not yet lorcwn, please describe the method you will use to collect the necessary endemicity data. REMO will be refined for the remaining 5 woredas so as to expand the CDTI project in the zone. 1.4 Community Structure Provide background information on the social organizations of communities in the CDTI areas. This may include information on settlement pattern of the community (e.g. hamlets, seasonal farms teads, dispersed population, etc.) The communities in CDTI areas are settled farmers with hamlets, while population is widely dispersed in most districts except those areas with resettled populations. 1.3.1 t.i.2. 1.3.3 1.3.4. 6 Endemicity Level and Recommended Type Of Treatment Percent of nodule carriers in REA sample (minimum sample 50 adult men) Estimated prevalence of O. Volvulus in the whole community Hyper-Endemic, Community Treatment (Urgent) Greater than39o/o Greater than 59o/o Meso-Endemic, Community Treatment (Desirable) 20 -39% 40 - s9% Hypo-Endemic (Non-Urgent) Less than 20o% Less than 407o aa a a The ethnic groups in the contmunity A majority of community members belong to Oromo nationality. The remaining peoples belong to other ethnic groups such as: Amhara, Gurage, Tigrie, Agnuaks and Nuers, Shekicho, Kaffa, and Kulo, etc. Please provide information about the area covered by CDTI indicating whether they are migrants, nomads, refugees or internally displaced populations. The community included in the proposed CDTI project area are settled farmers with a few displaced settlers from other parts of the country. The settlers came to the area more than two decades ago. C ommuni ty I ea d ers hip s t ructur e Illubabour zone is made up of 13 woredas. The community leadership structure in the zone is organized by the zonal administrative council (ZAC), which consists of elected members from each woreda. The ZAC is responsible for giving guidance and leadership to the community for all socio-economic activities. Each woreda is divided into large administrative communities called kebeles (4000-5000 people per kebele on average). Kebeles are further divided into smaller clusters of households called menders (villages) with 250-300 peoples. Elders and religious leaders play a major role at each level. lnformal social organizations in the communities include: Edir, Equb, etc. whereby the community members share and discuss their problem. The diagram below shows the community leadership structure. ZAC ) Wereda Admin Council )Kebele Admin ) Elders/Religious Leaders )Households Main occupation of community and periods of major communal activities. The main occupation of the community is farming, and animal husbandry. Farming activities, however, decrease from January to March after the completion of crops harvesting. a Preferred channels of communication in the community The preferred channel of communication in the community is passing messages through the community leadership structure and from the local farmers or urban dwellers such as community representatives, elders, and heads of the household. Besides, there are trained community health workers and traditional birth attendants that bridge the community with the health care services. School clubs from rural primary schools can be used in reaching CDTI communities. However, mass media such as radio is less available in most rural communities. 7 aa a Existing active contmunity association/groups in the area (e.g. social, religious, etc.) The existing and active community associations/groups include the farmers associations, urban dwellers associations and traditional religious gatherings. There are informal social organizations such as ldir, Ekub, etc. Established dtstribution systems in the community. There are some existing distribution systems for EPI activities such as polio campaigns, vitamin-A distribution, family planning and malaria control, which are organized through the social and religious associations mentioned above. It is also through these organizations that community mobilization and health education will begin for CDTI. The community could also recruit their distributors through these systems. Social communal activities and months during which the activities take place. There are various social and communal activities. Prominent among these are traditional religious celebrations such as, the foundation of the True Cross (Meskel) in September, Gena (Christmas), Timket (Epiphany), and ld-Al-Fetir, in January Eater in April. Any previous experience of the community with development/health projects. Most communities in the zone have been involved in various EPI, Family Planning, well construction, and spring protection activities. There are also community health posts managed by community health agents and traditional birth attendants in some communities. The communities therefore have well-established systems of mobilization to enhance participation in communal events. a a Description of other anthropological characteristics of the communities. The people of Illubabour zone are predominantly muslins and Oromo by ethnicity. Sheiks and traditional religious leaders possess strong influence in decision-making and health- related behaviors. All Fridays are spared for religious activities in the Muslim communities. 2. PASTS AND CURRENT STATUS OF CDTI IN PROJECT AREA. 2.1 Please indicate if the CDTI is an expansion of an existing CDTI. Illubabour zone is a new CDTI project area and has no past experiences on CDTI program 2.2 State the number of years the programme has been operating, and if possible enclose previous statistical, financial and annual reports. Not applicable. 2.3 State the number of persons treated each yearfor the last 5 years: Not applicable. 2.4 List the organization(s) involved in the programme, the sources and amount of funds used each yearfor the last 5 years. Not applicable. 8 SEGTION 2: PROJECT EXEGUTION OUTLTNE 3. DESCRIPTION OF PROPOSED CDTI The main strateg) of the project will be to develop and establish community-based ivermectin treatment systems, which can be sustained by the endemic communities themselves without external support after the S-year proiect period. This seclion should describe how the NOTF ptans to develop ani implement CDTI in all high-risk communities in the project area. The plan should take into account the need to develop approaches to CDTI, which are appropriate, for the different local situations, and the need to carefully evaluate the implementation of the selected approaches and adjust them when required. 3.1 Outline Plan and Timing Advocacy and sensitization at introducing the APOC/CDTI the regional, zonal and woreda levels - emphasis will be placed on strategy, and enlisting the support of the regional level with the participation of the NorFAIocP, regional administrative council offices Selection and training ofCommunity Directed Dis tributors (CDDs) Selection of CDDs is the responsibility of the community Household registration and census enumeration hained CDDs will carry out village census Justification Length 5 weeks Agreement on the definition of roles based on APOC Guidelines, etc and responsibililies of all partners - through MoH with region 4 weeks ofessential project equipment and supplies Computers, Mectizan drugs, and vehicles, and others Procurement l6 weela ofproject trainers at regional zonal and levels, Training to those who will function as hainers and Training/ supervlsors 4 weeks Rapid Epidemiological Assessments/REA wilt be carried out to expand CDTI activities to other woredas based on lhe levels'the 4 weeks Mobilization of'regional, zonal and district authorities to support the project 4 weeks Pre-intervention KAP surveys and other sflrdies will be conducted to have a baseline data to develop appropriate IEC activities and monitor behavioral changes and also assess re-infection rate. Conduct I(AP Studies l2 weeks Mobilization comtnunendemic theofof ities, AS aswell thestressing ownershipcommunity proJect k"y educationhealth 4 weeks 3 weeks 2 weeks Mectizan @ Collection and Distributlon in endemic communities 8 weeks supervision of Mectizan@ distribution activities by zonal and woreda supervisorsMonitoring and 4 weeks Inspection of CDD distribution activities (spot checl<s) by regional supervisors and NOTF I week Reporring of treahnents and training will be required, as in the past, on a monthly basis and appropriate feedback sent to the providers to ensure the adherence of corrective measures recommended. MIS (Management Information Sys tem) Monthly NOTF/APOC evaluation conductteam andinternal evaluationextemal theof ectproJ 4 weeks Annual reviews will be conducted and reports generated and used to ensure continuous improvement in designing the following years action plan. Review of Treatment Activities I week Preparation of Action Plan for the next year 2 weeks 9 3.2 Health education and Community Interaction and Participation 3.2.1 How will you approach and interactwith the community? There already exist systems of communication with the proposed project area through other health programs as described earlier. However, the following strategy will be implemented to maintain good relations with the communities: a) Discussions with zonal council chairman and head of social affairs and with woreda chairpersons, local farmers and urban dwellers associations, religious leaders, community elders and opinion leaders to better understand community values, customs and beliefs. b) Focus group discussions will be held with social and religious groups to further mobilize the community with the support of the community leaders. c) Focus group discussions will be held with the community members as appropriate (separating men and women, depending on the community traditions). The community members will also be encouraged at this point to take ownership of the program, defining their roles and distribution mechanisms. 3.2.2 Health education Health education and community mobilization will continue to be an integral part of all approaches to CDTI. Health education activities should ensure continuous exchange with regards to knowledge, awareness, perception and observable attitudinal changes about Onchocerciasis and its treatment. Appropriate health education messages in the form of posters, pamphlets and verbal presentations will need to be developed and tested. Health education should address thefollowing issues (See Table 2). Table 3: Critical Issues in the Development of Health Education for CDTI t ISSUES Health Education Messages Knowledge of the disease . Local name of the disease . symptoms , Causation/transmission (simple) Knowledge of heatment a Previous experiences with Diethylcarbamazine (DEC) Introduce Mectizan@ (ivermectin) Dosage Exclusions, Reactions, Beneficial side effects a a Attrtude to treatment Advantages of Treatnent: o Free, Yearly treatment o Possibility of Self-treatment at community level o Importance of maximal coverage Attitude to disease a The disease can be controlled Onchocerciasis blindness and skin changes can be prEvented Attihrde to good record keeping o Minimum requirements for record keeping o Records are confidential and strictly for health use Records required are for subsequent drug supply 10 a) Have any KAP surveys been done in the project area and if so, what were the results? No KAP studies have been carried out in the project area. b) What methods will be used to develop health education material for the communities and for the agents who will be responsiblefor lvermectin treatment? Health education materials such as posters, leaflets and flipcharts will be developed in local languages by the project and submitted to NOTF for standardization. These materials will be field{ested and refined/adjusted in accordance with APOC accepted strategies prior to mass production. c) What methods wtll be used to provide health education to the endemtc communities and to the agents responsiblefor treatment? Illubabour zone has in the past used various media for providing health education to endemic communities. Such methods include: - face-to-face discussions with community members, traditional birth attendants, community health agents, - use of posters and flipcharts prepared in local languages, and - drama (rble playing in local languages). Community leaders will first be informed about the disease and the importance of regular treatment with ivermectin. These community leaders and representatives will serve as agents for the program, encouraging community members to comply with ivermectin treatment. All members of the community will be directly engaged in discussions about the health education messages, and given the opportunity to ask questions they may have and make decisions regarding any aspect of the CDTl-program. Community members will also provide valuable input into the development of health education messages and materials for final distribution. 3.2.3. Community Participation In community-directed ivermectin delivery systems, members of the endemtc communities do the execution of ivermectin treatment themselves. Trained personnel, lcnown as Community-Directed Distributors (CDDs) who should be fully supported by the community itself may provide treatment. The community should be responsible for the organtzation and execution of the CDTI with minimum but ffictive medical supervision, once it has received the necessary information and training. Various organizational structures at the community level, ranging from women's cooperative to tradttional structures, are important for sustaintng and strengthening the support network of the CDDs. ll a) Explain the organization of the intended community-directed ivermectin treatment in the project. The formation of an Onchocerciasis task force at all levels is essential in order to promote coordinated activities of Onchocerciasis control in all endemic areas. At Federal level the NOTF is responsible for routine program management and acts as the liaison between MOH, RHB, and NGO partners within the country and outside. The NOTF will be the governing body for Onchocerciasis control activities in Ethiopia. At regional level, MOVDC is represented by a department and will be responsible for program implementation at that level. The head of MOVDCD will act as a ROCP Coordinator. Similarly, at the Zonal and Woreda levels corresponding Onchocerciasis Control Task Forces (ZOTF and WOTF respectively) will be established. The WOTF will be responsible for program implementation at Woreda level (ensure selection of CDDs, supervision of treatment activities, record keeping, etc).Also, local health institutions under the WOTF will be responsible to coordinate, monitor, and supervise CDTI at each locality. Village (Mender) will be the smallest unit for ivermectin distribution to the communities. Several villages are clustered together to form administrative Kebeles led by a Kebele chairperson. CDDs selected by the communities will be trained on the CDTVAPOC strategy for ivermectin distribution. CDDs and other local primary health care workers will then provide health education to communities on Onchocerciasis, i.e. its cause, transmission, clinical manifestations and treatment including its prevention and control mechanisms. Communities will be mobilized to provide appropriate support to CDDs when they are engaged in CDTI activities to ensure sustainability of the prograrnme. Census of households will be carried out to identify eligible and non-eligible individuals and keep the records before Mectizan distribution. The CDDs will follow up defaulters using their treatment registers. Census of households will be updated every year before Mectizan distribution. Both Woreda and Zonal health staff will carry out supportive supervision and monitoring activities b) How will ivermectin distributors be selected? The communities will be informed about the CDTI and APOC strategies and will be given the responsibility to select CDDs. The communities are fully empowered to replace those CDDs that show poor performance. There will not be any external influence in the process of selection of the CDDs. These CDDs are expected to be honest, dedicated, literate, and permanent residents of the community. t2 c) How will non-eligibles be identified and defoulters followed-up? Non-eligible individuals will be identified using the complete household census registration book and this will be updated each year. Similarly, defaulters, absentees, refusals, etc will be identified using treatment record book after each heatment schedules. The identified defaulters and new eligible such as previously pregnant women but who have delivered will be treated through mopping activities. 3.3 Local Operational Research Are there any plans to conduct local operational research? { YES NO If yes please give details The following operational research areas are suggested for consideration. o Establish a database on prevalence of Onchocerciasis and the associated blindness o Pre-and post intervention KAP surveys o Assessment of the therapeutic efficacy of Ivermectin in GDTI areas o To evaluate the impact of CDTI programmes on reduction of the burden of Onchocerciasis and its beneficial effect on other internal and external parasites a) What training will be provided to ensure the development and sustainability of the CDTI? Training of cDDs to operate CDTI is very vital to the program. To ensure sustainability of the CDTI program, TOT sessions will be conducted by the NOCP' Those trained here will represent both region al, zonal and Woreda levels. These individuals will in tum train representatives from health facilities who also train CDDs at community level. The training sessions will focus on the following topics: . Epidemiology of onchocerciasis, its signs and symptoms, including its treatment o APOC philosophy and CDTI strategy o Health Education and community mobilization o About Mectizan@ its advantages and the related adverse effects and management of its adverse reactions . [nclusion and exclusion criteria for ivermectin treatment o Dosage of Mectizan o Methods of dug distribution o Record keeping and reporting o Supervision and monitoring l3 b) Indicate criteria for selecting trainees (supervisors ond community-directed distributors). I) Criteria for selecting CDDs (i) (ii) (iiD (v) (v) (vi) Literate if possible Resident in the community Willing to serve the community Must be honest Must be available Must be selected by community II) Criteria for Selecting Supervisors Zonal Supervisor: (i) Should be a PHC staff preferably from zonal MOVDPU(ii) Must be knowledgeable(iii) Must be interested in helping the community(iv) Must be honest Woreda Supervisor: The same criteria as those for the zonal supervisor are applicable here c) Indicate number, type and duration of training courses intended 4. SUPPLIES, IMPORTATION, STORAGE, INVENTORY AND DELIVERY OF MECTIZAN TABLETS This section is only a reminder and concerns the supply, importation, storage, inventory and delivery of ivermectin tablets, donated by Merck & Co, who will also pay handling charges for ivermectin to their accredited agents. Mectizan@ consignments will be received through WHO and stored in the Federal MOH central stores in Addis Ababa. It will then be transported by road to the Regional Health Bureau, and from there to the Illubabour Zonal Health Office. The zonal health office Type of Training (Workshops) Duration Number per year Orientation workshop at regional level 5 days I Zonal Training 5 days 1 Woreda Training 5 days 8 CDD Training 3 days 300 Sessions t4 will be responsible for delivering the drug to the Woreda Health office and health facilities (In some areas the Woreda health office is located far from the communities. ln this case, the nearby health facilities will serve as the final collection point). CDDs will then collect the drug from the Woreda health office or health facilities. A report showing the use of the drug will be sent to MEC (Mectizan Expert Committee) at the end of every year, by the NOTF, with the subsequent application. Copies of the application and the report of its use will also be sent to APOC. An application for Mectizan@ tablets will be submitted every year by the end of August to the NOTF, using the standardized, form of Mectizan@ Expert Committee (MEC). This application will then forwarded to MEC in Atlanta for review and approval. 5. SUPERVISION/MONITORING AND EVALUATION 5.1. Supervision During CDTI Projects are required to be supervised and monitored regularly. However, ApOC funded projects will need to be designed to function with effective but minimum supervision compatible with its objectives. a) Please describe the supervisory arrangements you consider will be required for the CDTI yottpropose. How will this continue at the cessation of ApOC support? There will be supportive supervision at all levels of program, during and after cessation of APOC support. The supervisory teams at the national, regional and zonal levels will be responsible for supervising woreda health offices and randomly selected health institutions and CDTI targeted communities in all aspects of the programme activities. Trained supervisors from the woreda health office and the heilth-facilities will be responsible to carry out supervision activities in their catchment CDTI areas on regular basis. Supervision activities will include performance of CDDs such as proper record keeping, complete census enumeration, Mectizan@ inventory and dosage, and monitoring during the actual distribution process. Moreover, representatives of the community wiil do direct supervision and monitoring activities on a regular basis in their own ui1ug" following after they are given training. NGO partners will be involved during in supervision activities along with MOH supervisors The results of the supervision will be discussed with each supervised workers and thus corrective measures will be taken at the spot. This will be documented and reported to different partners at various levels. b) Describe how you would ensure that superttision would be carried out so as to: o fall within the requirements of accountingfor ivermectin use o be sustained when the program ends tn 5 years . ensure maximum tnvolvement of the communities in the process l5 To ensure that the above requirements are met, the program will support regular monitoring during the actual distribution process to ascertain that correct dosage is being administered, exclusion criteria are being observed, and the collection and proper storage of unused drug is occurring. [n addition, the program will support advocacy visits to the woredas and villages by NOTF, regional, and zonal and woreda representatives of the onchocerciasis task forces at each level to encourage the active support of the community. Once training of CDDs has been completed. Zonal and Woreda supervisors will check that household enumeration has been completed according to APOC requirements. Standard supervision checklists will be used to ensure the above requirements. 5.2 Monitoring of CDTI It is important to collect information to monitor the progress of the CDTI. indicators will be used to monitor: o lvermecttn distribution? o Health education and community participation? o Management systems? Wat The followtng items may be considered. Ivermectin D istrib utio rt o Numbers of communities and persons treated with ivermectin o Number of lvermectin tablets distributed/consumed o number of communities reporting shortage of supplies . Regularity of treatment exercise o Compliance o Reporting adverse reactions Health Education and Communitv Participation o Numbers of communities participating in the project o Changes in behaviour towards the disease, its treatment, prevention and control o Community support given to CDDs c Are activities being carried out according to plan and on schedule? o Inventory control, o Are recordforms accurate and completed on time? o Numbers of persons trained c Balance of genders in staff of the program Manageme4t The project will consider the following indices for monitoring the program of CDTI t6 Ivermectin D istributio rt : Since Jimma zone will be starting Onchocerciasis control activities for the first time, there is currently no Management lnformation System (MIS) for Onchocerciasis control. The NOTF will use standardized monitoring system previously developed in other CDTI areas prior to the beginning of treatment. These include communities and persons treated with ivermectin, treatment coverage, regularity of treatment, treatment compliance, and drug reactions. In addition, the project will monitor the following rates and percentages using Annual Treatment Objectives established at the beginning of each year: a Annual treatment objectives (ATO) High-risk villages (number of high risk villages targeted for treatment) At risk villages (number of at risk villages targeted for treatment) Estimated at risk population (total population at risk in the region) Treatment coverage (related to ATOs)a a % of high risk villages/communities covered o/o of at risk population treated o Cost per person treated o Tablets distributed o Number of ivermectin tablets in store at HQ, in the field, on order, or to be ordered Health Education and Communitv Mobilization: The degree of community participation in mobilization activities will 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 mobili zation as well. The impact of health education messages will be measured through periodic focus group discussions and KAP studies. Management The project will develop through its integration with the regional, zonal, and district health management and supervision systems to monitor, o The planning and implementation of activities according to the timeline o Mectizan@ inventory levels o Monthly reporting of treatment indices o Numbers of personnel trained o Attempt to balance gender in staffing t7 5.3 Evaluation of CDTI Annual external review incorporating field visits will be undertaken to ensure that projects are meeting target indications outlined in this proposal. Such reviews will provide TCC with the assurance that each project is moving towards its long term stated goal and if appropriate make recommendations about any defictencies or modifications to thts project. Such reviews will draw on the indicators developed by TCC as a guide. 6. SUSTAINABILITY OF THE CDTI AFTER THE WITHDRAWAL OF EXTERNAL FUNDING The concept of sustainability refers to the ability of countries and affected communities following initial external investment to maintain the viabiltty and continuity of the ivermectin treatment process without external support. For APOC funded projects, such support will normally last 5 years, as the APOC donors demand that there shall be a visible and achievable end point for the external donation aspect of the programme, and that the community based distribution systems established shall thereafter be sustainable by the governments of the endemic countries concerned. Progress and itlans towards sustainability, including the phasing out of external and NGDO support, must be reported annually and satisfactory progress in this direction will be a condition for each succeeding year's funding installment. Please address the following areas that relate to sustainabtlity: integration into primary health care, cost- recovery, and other sustainability issues. 6.1 Integration of the CDTI into other Community-based or Primary Health Care (PHC) systems. The principal goal of the APOC is to establish cost-effective ivermectin-based control for Onchocerciasis, which can be sustained by the endemic communities and countries. One way to ensure sustainability is to integrate the CDTI into the PHC system of the country, which means more than just using the systemfor ivermecttn distribution. 6.1.1. Is there an official PHC policy and structure in the country?{ YES NO If yes, please give a brief outline of what it is: Primary Health Care (PHC) policy in Ethiopia is to develop and strengthen grassroots and community participation in health care. lncluding Onchocerciasis among priority health problems in the national health policy will do the integration of CDTI into the PHC system. At the regional, zonal, and woreda levels, the MOVDCU will be responsible for program implementation at the respective levels. In addition, combining training on CDTI with other on job training activities, including Onchocerciasis control activities in the planning process at all levels, and including Mectizan@ in the list of national essential drugs delivery system will further enhance this. l8 b) c) The PUiC system will be used to achieve full integration at peripheral level by further integrating CDTI into the activities of the PHC (training on CDTI into training of health workers). This way the PHC system will be used to achieve full integration of CDTI into general health service by obtaining support from Regional, Zonal and Woreda authorities, bilateral and multilateral organizations. In sumrnary, the PHC structure is as follows: MOH ) REGIONAL HEALTH BUREAU) ZONAL HEALTH DEPT.) WOREDA HEALTH DEPT./HEALTH FACILIIES (hospitals, health centers, health stations, health posts etc) ) COMMUNITY I{EALTH POSTS (CHAs & TBAs) a) I{owfunctional is the Primary Heatth Care system? Ful ly functio nal, P artly funct ional or non-func ttonal (p I eas e specifu) ? The system from the National level is fully functional until the Woreda./health facility level. However, at the community level health coverage is limited. Does it cover the whole project area? ./ Yes No IJ'no, in what part(s) of the project area is there a futly functional pHC structure? What percentage of communities where Onchocerciasis is endemic, and which are eligible for community-based treatment, have an existing and functional PHC system? About 69 percent of the endemic communities have functional PHC coverage. Wat organizations are supporting the development of pHC in your project area? Government of Ethiopia (Ministryof Health), wHo, UNICEF, and some NGDos Is there any past experience in the country of a programme integrating with the PHC? If so, what programme was it and how successful was the integration? EPI, Malaria control, IMCI and family planning drug distribution. The integration continues successfully. Are there any plans to integrate other rural health programme, such as the Expanded Programme of Immunization, Maternal and Child Health Programmes or programmes for the control of other parasitic diseases, with the PHC system? EPI, maternal and child health program malaria prevention are already integrated with the PHC system. d) e) J) l9 Describe how the CDTI will be integrated into the PHC system; the way the PHC system 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 MOVDCU will be responsible for routine program management and act as the liaison between MOH, RHB, as well as with NGO partners. Members of the Malaria unit share responsibilities among themselves and hence a separate entity of vertical program nature will not be established. The head of this unit will act as NOCP coordinator. At regional level, MOVDC is organized as a department and will be responsible for program implementation (contacting community leaders, explaining the program objectives, discuss issues related to Mectizan@ security, at regional level, including monitoring and supervision). The head of MOVDC will act as a Regional Onchocerciasis Control Coordinator. Similarly, at the zonal and woreda levels will establish corresponding Onchocerciasis Control Task Forces (ZOTF and WOTF). The WOTF will be responsible for program implementation at the woreda level (ensure selection of CDDs, supervision of treatment activities, record keeping etc). [n areas where access to the woreda health office is restricted, local health institutions will coordinate, monitor, and supervise CDTI activities The primary health care units normally provide both preventive and curative health care services with health education to populations in their catchment areas. These health care programmes are provided as a package not in isolate form and thus the CDTI activities will also be incorporated into the health extension packages in place. h) 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 lifetime of the CDTI it will be completed. CDTI activities in Ethiopia will be integrated from the very beginning. The establishment of the program will rely on existing systems of health service delivery at all levels. If there is at present no PHC system in operation or in those areas where these structures are non-functional, describe how the CDTI may be used to initiate and expand into such a system, giving a timeframefor tntended progress. NOT APPLICABLE 6.1.3. In which way!) cqn community-directed ivermectin treatment initiate or strengthen PHC? CDTI is likely to encourage and facilitate the acceptance of new health initiatives in the community and at home level. Also, through the new CDTI strategy, the community will s) 6.1 .2 20 likely play a greater role in the support and ownership of the PHC system. The structures already put in place would be utilized by the PHC to enhance effective planning and implementation of the project. For example, the CDDs will develop capacities and skills, which udll strengthen other programs such as health education, increase IMCI coverage, initiate home-based treatment. 6.2. Cost-recovery Systems during Community-based Ivermectin Treatment Cost recoveryfor Primary Health Care is mandatory in some countries and it may be one means of sustaining a CDTI after APOC funding cedses. However, please note well that since ivermectin is donated free, there can be no cost recovery in respect of the value of the drug itself; cost recovery can only relate to the costs of distribution. 6.2.1. Please state whether there will be any system of cost recovery $uch as this recommended in Initiative) to help cover outlays on the distribution of ivermectin in the present CDTI. NO 6.2.2. State exttctly how any such system will be organized, including answers to the questions listed below. a) What charge will be made per person or perfamily? NOT APPLICABLE b) Wich groups of persons will be exemptedfrom payment? NOT APPLICABLE c) Will payments be in cash or in kind? If in kind how will this ensure sustainability? NOT APPLICABLE J) Wat provision will be made to ensure that all those eligible to take ivermectin, but who are unable to pay, will also receive treatment? How wtll it be determined who is unable to pay? NOT APPLICABLE Wo will collect the payments? How will this person safely transport funds to a place of safekeeping? NOT APPLICABLE h) Where and by whom will anyfunds collected be safely kept? NOT APPLICABLE s) 2t t) i) k) What systents will be put in place to ensure the proper use and 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 Committees play in the management and allocation of the funds raised? NOT APPLICABLE 6.3. Other Issues Please provide information on other issues and constraints relating to sustainability of CDTI you anticipate and identify how they will be overcome. For example: The mobilization of endemic communities The maintenance of adequate supervision and monitoring Inadequate human res ources Logistics and communications S o c tal/cul tur a I fa c t o r s Declining community compliance O Mobilization of endemic communities; Sometimes problems of mobilization of endemic community can be obstacle to sustainability of CDTI. This can be solved through sustained advocacy visits, by assigning individuals with good communication skills and expertise in conducting mass health education meetings to increase awareness of the community, KAP surveys to monitor belief systems. Obviously there will be a need to establish good relationships with the community leaders in order to have increased access to the communities at times like these.(i, Maintenance of adequate superttision and monitoring Mectizan@ distribution should include community leaders to further increase acceptability and sustainability of the program. All records should be verified during supervisory visits, and informal discussions should be encouraged to determine community perceptions of the Mectizan@. (ii, Inadequate Human Resources Inadequacy of trained health staff and PHC units are expected to be constraints in implementing supervision and monitoring. These can be overcome by allocating adequate time for supervision, in addition to training additional supervisors from health facilities and community members. In absence of roads in some remote areas, mules and horses can be used. 22 (iv) Logistic,sandCommunications During the rainy season in October to December travel to the endemic areas may be restricted. Proper planning (Mectizan@ drug orders etc) will focus on providing all high- risk villages with their drugs during the dry season (prior to the Jan-March distribution window), and encouraging completion of distribution before the rains if convenient for the communities. (v) Social/Clulturalfactors: Careful attention will be paid to cultural and social factors such as: the appropriate gender for CDDs especially in Muslim communities, respecting the traditional beliefi, and selecting supervisors and distributors who speak the local languages. (vl DecliningCommunityCompliance: Declining community compliance will be avoided through continuous sensitization and mobilization activities prior to each treatment period. Community members could be interviewed to determine the reasons for the non-compliance, and corrective measures taken where possible and appropriate 6.4, How do you intend to monitor and measure 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 the project in terms of financial management/contribution, communications, training and "uputitybuilding. This will help enhance integration. Financial management should be incorporated into the usual government financial administration. Financial flow in the CDTI project should comply with govemment financial management procedures so that there will be safe resource management. Regional and zonal health department heads, and administration/finance managers at each level will be accountable for proper utilization of CDTI resources. The ability of managers at different levels to familiariLe 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 about understand the cause and effects of Onchocerciasis, and the mechanisms for its control can be considered indicators of progress of CDTI to sustainability. The success of the program will depend on the attitudes and practices of the community towards the disease. 23 7. CROSS.BORDER CONSIDERATIONS Where an endemic area extends across the borders of two or more adjacent States, special problems of cooperation between the respective countries CDTI may arise. In the event that there are areas to be covered by your proposed CDTI where the endemic zone extends across the frontier into one or more neighboring countries, and where there are likely to be transitory or even large-scale migrations of Onchocerca- infected persons either way across the border. 7.1 Please describe the particular situation as it is likely to affect ivermectin treatment, and the methods you will use to deal with it. The Neighboring state, SNNPR, has already CDTI project in Kaffa Sheka zone since 2000-1 and will not affect this CDTI project, as they are similar in all aspects. Rather the experience in the Kaffa-Sheka will be of great value to the proposed CDTI project. The proposed CDTI districts do not share boundaries with other countries. 7.2 Include'pertinent observations on curuent political and health relations with the neighboring State(s). There is good relationship between Oromia region and SNNPRs in ever aspects including political, economical, social, cultural aspects. 8. SPEGIAL RISK ISSUES In some areas of some countries there may be special risks, which could hinder the smooth running of a CDTI. 8.1 Please describe the situation in any areas covered by your proposed CDTI were this factor may interfere with the program, and assess future prospects NOT APPLICABLE 24 SECTION 3: ADMINISTRATION/FINANCIAL 9. ADMINISTRATTON 9.1. Organizational Structure for CDTI 9.1.1 Please provide an organogram for the CDTI showing the organizational structure responsible for implementing the proposal. Fig.l. Organizational Structure of National Onchocerciasis Control program 25 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 authorized officer of the MOH, WHO/Addis Ababa will transfer the filnd directly to the bank account of the respective Regional Health Bureaux (RHBs) according to the approved CDTI project proposals. The signatories of the bank account into which APOC frrnds will be transferred at the regional level will be the head and the administration and finance officer of the regional health bureau. All the Imperest returns will be submitted monthly by RIIB to WHO country office in Addis Ababa that will forward them to APOC headquarters in Ougadougou. Monthly reconciliation statements will be forwarded to the central Malaria and Other Vector-borne Diseases Control Unit (acting as the secretariat of NOTF) for follow up. APOC will issue cheques (advances) in accordance with WHO rules and 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 installments. The first installment/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 contractual systems is used, e.g. Technical Service Agreement, Letter 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 impress mechanism, whereby the project will report its expenditure on a quarterly basis and receive further advances on that basis. Each project funded by APOC will require a periodic external audit at project expense. Each project must have one senior staff member who is accountable for the management and control of project funds. Standard intemal financial checks and balances must be incorporated into each project's financial management plan. 26 Fig. 2 Request and Disbursement of APOC Funds Disbursement -_--_-> Financial Report H 27 ; i.: ;-', - 9.2.1 Input from the Ministry of Health a) Indicate resources that will be provided by the Ministry of health and other government agencies. Personnel, logistics, office accommodation. Counterpart funding Security b) Please provide a list of personnel assigned by the MOH to this project, including their name and proposed time (State percentage of time allocated to the project) for the project and where appropriate their experience in Onchocerciasis control through ivermectin treatment. At present, there are experienced persormel at national levels and in SNNPRs since they have started CDTI earlier years. However, none of the personnel in Orimia Regional Health Bureau and in Jimma zone have had experience since CDTI is new to them. Resional Health Bureau: Illubabor Zonal Health Office Name Post Region 7o Time Mr. Dereje Olana Dept. Head of MOVDCU Oromia 25% Mr. Sheleme Chibsa Vector Control Team leader Oromia 2s% Mr. Tadesse Hundie Vector Control Expert Oromia 2s% Mr. Addisu Mekasha Vector Control Expert Oromia 25% Dr. Kebede Itana Diagnostics and Epidemiology Team Leader Oromia 25% Name Post 7.ane "/o "fime Mr. Haile Ayana Head, Zonal Health Office Illubabor 25% Mr. Tibebu Amentie Expert in Malaria & other Vector Borne Disease Prevention and Control 30% Mr. Kedir Ahmed Disease prevention and Control Expert ( 2s% 28 Woreda Ith Office: 9.2.2 Input from the partner NGDO(s) a) Please provide a letter from the Executive Director or the Director of Onchocerciasis programmes of each participating NGDO stating their intentions to participate in and supporr the National Onchocerciasis Control Programme. b) Give information of the inputfrom each NGDO participating in this project. The Carter Center's input will be:- Funds: Per the agreement made between APoc and the FMOH, The carter Center will not have direct responsibility or roles relating to the management and reporting on APOC funds. Mectizan@: The Carter Center will not have direct responsibility or roles relating to the accountability of ivermectin in Ethiopia. The drug will be consigned directly to the wHo and sent to MoH central stores in Addis. a a Staff and consultants: The Carter Center has been involved in some areas of public health in Ethiopia since 1992. In 1993, The Carter Center began assisting the Ethiopia Guinea Worm Eradication Program through the FMoH. The Carter Center has provided excellent technical, logistical and financial support in the implementation of the first CDTI project in Kaffa-Shak4 Bench-Maji and North-Gondar projects. In light of this experience, The Carter Center is ready to continue providing technical, financial, and logistical support to the Onchocerciasis control program in this project. Name Post Woreda 7o Time N{r. Tegegn }vtrekonen Flead, District Flealfi Office Memr 25o/o lvIr. Alebachew Flailu Disease Prevention and Control Expen 25o/" lvIr. Tolera Kabata Flead, District Fledth Office Darimu 257o IvIr. Dereje lvfamo Disease Prevention and Corurol Expen 30o/o Ivk EiiC" Kumsa Flead, District Flealth Office Alge Sache 25Vo lvfr. Tsegap Flka Ivlalaria 6r Orher VCB Control E4pert 31o.h l[r. Bepne Bushira Flead, Disrict Flealth Office YayrFfurumu 25Yo lvfr. Fetene Birhanu Disease Prevention and Control Expen 3jYo Flead, District Fleafth Office Flalu Bure 25o.h IvLlaria &OtherVCB Control Expen 30Yo Ivfr. Kelifa Ibrahim Flead, District FGdth Office Chora 25Yo lvfr. Kassa Aple Disease Prevention and Control Expert 30o/o }[r.Alemalahu Abeneazer Flead, District FIedtI Office Gatchi 25o/o It{r. Jembere Taddesse Disease Prevention and C-ontrol Expen 30o/o IvIr. Alemu Daddi Flead, District FIeaIth Office Bedelle Dabo 251o lvlr. Ordofa KejellJ Disease Prevention and Control Expert 30o/o 29 lvIr. Tarilor Jaleta a a Office space and facilities: The Carter Center will support the national secretariat by providing technical and logistical support through a local office in Addis Ababa. c) Please provide also a nominal list grading and post description for the personnel to be provided by partner NGDO(s). Indicate clearly what will be their functions in the program and their experience in onchocerciasis control through ivermectin distribution. Most of the staff of the Carter center have been involved in the implementation of the KSZ, BMZ, and North Gondar CDTI project in the current year. It is understood that most of them have got some experience. Name Post YoTime Mr. Teshome Gebre Country Representative 25% Mr. Frew Demeke Driver/Logistican 25% Mr. Murida Kemal Admin/Finance Manager 25% Dr. Assefa Worku Program Officer/ GRBP 50% Mr. Asfaw Benti Driver 50% Ms. Seble Aliye Accountant 25% 9.2.3 Inputs from other agencies. Please list any other agencies or parties that will be involved in the running or financing of the CDTI, and indicate clearly their roles,functions and contributions. WHO: WHO Ethiopia will assist the prqect in the procurement and clearance of Mectizan@ imported into the country by using its diplomatic status. 9.3 Timed Plan of Action Provide a time chart(s) showing how the various activities of the CDTI will proceed over the course of the proposed program. Numerical annual targets for all planned activities should be providedfor each time point. The time charts should also indicate how external support will be phased out over the 5 year 30 10. BUDGET 10.1 Budget Estimates Budget must indicate total funds to undertake the project. The amount of funding requested fromAPOC, and the amount provided by the MOH, NGDO(s) and other partners. All must be ma-de in US dollars. Each budget must include at least the fotlowing major categories (see appendix 2) indicating the contribution of the partners to re/lect sistainabiliry ;f CDff. o Personnel (services) o Capital equipment o Supplies Training o Healtheducation/mobilization o Travel o Communication o Consultant . Operating expense o Extemal audit 33 zIt f.U F ItJztrt FJ zH Fi o z r-l zIt It, EF 7 ttj o o FU F)5 o o{ o+) -Jt(D A' (D o+ o U) o5 Do (D x oI c) o F) tr o, o v)fr<h65 5C_ oa D'l, D)@o 5ol, a E D) ol5l U' r3 oo o o H) o U U A a) H o !Do (D v) lg (D C))f(A ?A o oI. oa A' o v,trd (Dt U' o Aoo N DD @ U a, s.d o (\\ sh(\G DOs.=oq -l(\0! u'\E o $ 6 q 14 lolo tpt9t5 lcti iod N Fo op la l(D l(Dla) lH.to lP lp0 a. +Ft o) ql ot o U U U) o o p- tro ,( ts CAg o- (Dq) *p3€8d o U' rn16 o.(D) o o oa o o) E.-lot tsii-. A) (DP i?i 5 p, a3- di *(D oaj{E' ai Oa o. o) oo <H)(D E €. oo N-J(J Ft5teN=' TE9o H) \J r_t €.(D o Ft po oH v) A)+l I 9lot I'r .--:lo -rH9. oj ls E:li! !Jl- oq ICD al< Y*lol- *dlEt &. (D o Bpc (D r_t U) co (D la rI-IJ HItroL5'C):ltri-)E5Ei,5+(D o:5 aQ E. *s(Do@3 F0 t €.(D o a>6-q7l (D(D i-l o o (D aoH o oFn a>oa o. o^ iioLB H<ODo 5e Ee'5 ='a ss s. o J 0l * o f) b,Jo(,\ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ t-JooA\ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ },JooUI\ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ }J o\\ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ N) o\t\ \ \ \ \ \ \ \ \ \ \ \ UJ(! YEAR ONE SUMMARY BUDGET FOR ONCHOCERCTASIS CONTROL IN ILLUBABOR CDTI PROJECT YEAR 2OO3 7.5% NGO overhead cost 2003 CATEGORY APOC MOH NGO TOTAL Personnel 0 73,487.00 2,500.00 75,987.00 Capital equipment 94,235.00 33,845.60 14,187.50 142,268.10 Supplies 57,0t7.00 0 14,200.00 71,217.00 Training 113,700.00 0 12,000.00 125,700.00 Health Education/mobi lizati on 148,800.00 0 19,000.00 167,800.00 Travel 33,762.00 0 7,160.00 40,922.00 Communication 2,960.00 0 480.00 3,440.00 Consultants 0 0 External Audit 0 0 0 Recapitulation 17,000.00 0 0 17,000.00 Operating expense 8,428.00 44s.00 3,300.00 t2,t73.00 Total 475,902.00 107,777.60 72,827.50 656,507.10 NGO overhead cost 35,692.65 35692.65 Grand Total 511,594.65 107,777.60 72,827.50 692,199.75 Estimated No. Treatments 626,690 626,690 626,690 626,690 % input 73.9 15.6 10.5 100.0 Cost per treatment 0.82 0.t7 0.12 r.10 34 ll H t>t, Eb Elr E 19 E b EbE t;tc EL Fts lEk tf, E El3 hhH o{ 6 tu|;lxItls lql- I 8 EI 5 aE 8EEI 6 5 8EE l* ls IEls :6 8 2 EI, E 8 rla iE t- al- slr 8 I li EI HIE H lb 8I }-l 6 i-t^:{ l= sla @l! L 8 8 8 8 8 l= L- t; :l= 88 :[, 6I; EI iEl lcEis FI a 8 ; 8.lrEl l=l Ll! ils sl: *l- a _t- xl: o 8 8 tlu elE 3E I kt:Slsl; iEl 8 3 3 h a 8 (, o\ o) -.t 6ooo(no Percent input tu@sooooo TT(o (/, ! o o o :, ol GI o o o o l cr c =.oJ o m ol o !!, J o o ol o o, lt o . cr o, cr o o o{ ! o o o N)oo o) N)oo5 <N)33 a(n N)oo O) l\)oo! =oI 1' oo \ 10.2. BudgetJustification Please provtde a narrative description of the reasons for each proposed line items of the budget. (1) Personnel Thepersonnel budget reflects the need for staff at all levels (MOH, RHB, ZIID,WHO, an{ -\!Os) to support distribution activities at the community level (CDDs). The MOH and NGO staff will provide support to the program in the form of: o Mobilization of authorities and community leaders o Health education and community sensitizationon the need for the drug o Assisting in the organization of the distribution program o Training of supervisors and CDDs o Getting ivermectin to the pickup points o Transportation of other essential supplies o Ensuring proper supervision of drug distribution o Ensure proper record keeping and accountability o Accounting for funds spent (both APOC and other) o Participating in program evaluation and feedback to local communities MOH and NGO staff is already in place and will participate in program implementation on either a part time or full time basis. Howevir, the degree of involvement in APOC activities will decrease from year to year as the communities take more and more responsibility and ownership of the program. Eventually the CDDs will take on the major local function of the program by the end of five years and with the strengthening of the PHC system, CDDs will become PHC staff and take on additional duties besides Onchocerciasis control. (2) Capital equipment In order for the program to properly function, it must be well equipped. The equipment requested is meant to facilitate the work of the MOH (Regional, Zonal, and Woreda) and NGO staff includes: o Vehicles and motorcycles o communication equipment (phones, faxes, radio operators, megaphone) o Computers, printer, photocopier o Training equipment (overhead projector) (3) Supplies: Office supplies are essential for the smooth running of daily program operations. Since this is the beginning of the program, APOC will be requested io prouiO" all essential office supplies (computer toner cartridges, diskettes, calculators, paper, pencils, pens, fasteners, file folders etc). (4) Training: Training demands relatively higher investment due to items such as transportation, per diems for trainees and trainers, production of training materials etc. It is also an activity that is carried out on a continuous basis, with re-training at all levels as new personneljoin the program, and as CDDs need to be refreshed prior to the distribution period. Being essential to the implementation and success of the program, the following is proposed: At the community level, CDD training is expected to be continuous throughout the duration of the program, with the community assuming more responsibility over time. The training activities will be supported by APOC. APOC, MOH and the NGDO will also support workshops for regional, zonal; woreda staff, as well as CDDs. The NGDO will provide funds for management review workshops at zonal levels. APOC is expected to provide support for the printing of training materials and sponsoring some training workshops. Funds are also requested to support computer training for staff, especially in GIS and MIS to facilitate better program management. (s) Health Education/lVlobilization : Community mobilization and advocacy activities are required to build the support needed to ensure program sustainability. Communities will be mobilized through advocacy campaigns (to gain the support of community opinion leaders), information packets (to educate the media and other parties) visits to the community by MOH personnel from the National, Regional, Zonal, and Woreda levels. General public awareness can also be supported by such techniques as the distribution of posters, brochures, stickers, and T-shirts etc. MOH and the NGDO will provide funds for these activities. APOC is requested to provide funds for Regional and Zonal training orientations, information packets, health education aids such as posters, brochures, stickers, T-shirts and flipcharts. As the awareness for the need for onchocerciasis activity increase at the national, regional, zonal, woreda, and community levels, the amount of funds required will subsequently decrease. (6) Travel: Travel is required for advocacy visits, training, retraining, supervision and monitoring, and evaluation activities are all important for effective program implementation. 38 APOC and the NGDO will be responsible for supporting travel expenses necessary for the implementation of the program. APOC is also requested to provide funding for fuel and maintenance for vehicles and motorcycles, and domestic airfare. (7) Gommunication: At the National, Regional, Zonal, and Woreda levels, telephone, courier and other media means of communication (such as radio and e-mail) will be used among project operators. At the community level, communication will be mainly through the use of radios and megaphones. APOC and the NGDO are requested to support expenses associated with communications including courier services. (8) Gonsultants: Consultants would be required to conduct KAP studies (to help in the development and refinement of health education and other materials); program evaluations, computer maintenance and other aspects of computer work, to ensure total quality management of the program. APOC and the NGDO are expected to support the costs of these consultants (9) External Audit: External audit will ensure proper accountability. Since APOC will support the costs of external auditing specific budget is not indicated in the budget details. (10) Operating Expenses: This will include costs such as utilities, costs of quarterly meeting (NOCP), development and maintenance of MIS. Also included in this line item is the cost of operational research, printing of essential reporting forms (treatment sunmary forms for community, Woreda, ZonaL and Regional staff), household cards, and community registers. These expenses will be supported by APOC. The NGDO and MOH will share some costs such as office utilities. 10.3. Current Resources Available for CDTI Existing CDTI projects (for continuation or expansion) will have resources already available. Please provide a detailed list of alt existing personnel, equipment and suppliis(including vehicles, etc.) belonging to the program, indicating their ownership fUOru,NGDO, other Agency, etc.) and their levet offunctionality. NOT APPLICABLE 39 APPENDIX I: ESTIMATED NUMBERS OF COMMUMTTES AND PERSONS To BE TREATED EACH YEAR, BY ENDEMICITY LEVEL (PIIASE ONE) AREA COVERED: COMMTINITY ENDEMIC LEVEL HYPER- ENDEMIC MESO- ENDEMIC HYPO- ENDEMIC* TYPE OF TREATMENT Community- Directed Community- Directed YEAR t - (2003t4) No. of communities to be treated 2180 326 Total population communities in above 545220 81470 YEAR 2** - (2004t5) No. of communities to be treated 301 8 450 Total population communities in above 754250 112704 YEAR 3** (200st6) N,o. of communities to be treated 301 8 450 Total population communities in above 776123 t15972 YEAR 4** - (2006t7) No. of communities to be treated 3018 450 Total population communities in above 798631 119336 YEARs** - (2007t8) No. of communities to be treated 301 8 450 Total population communities in above 821791 122,796 +Onchocerciasis is not consiaerea an important Public Health problem in hypo-endemic communities and APOC will not normally fund community-based treatment in such communities. The inclusion of such communities in the proposal will require a special justification for consideration by the TCC **lt is understood that the figures for years 2-5 are estimates that may change depending upon the results of the REMO surveys conducted. 40 Ivermectin Treatments reflected in Appendix I were obtained as follows: A total of 783,362 at risk population in the eight woredas are targeted for CDTI for the first year treatment rounds and during the second year an estimated total at risk population of 866 954 from the new five CDTI woredas, considering 37o population growth rate, are targeted for CDTI. YEAR 1: A treatment objective of lWvo EARP of all hyper and meso-endemic communities (626,690) in the selected eight woredas will be targered to allow the program to get accustomed to GDTI, including monitoring adverse reactions, community attitudes towards the strategy and drug, and 3mg tablet management. YEAR 2: with some experience, the program will gradually increase the treatment objective in year 2 to include r00vo of the EARP in the remaining five woredas and ljovo of the year 2003 eligible population of the first eight Woredas. YEAR 3.5 The program will continue distribution of Ivermectin in all woredas targeted for the CDTI. After the completion of REMo exercises the EARp may increase over the four years. Fig 4. Annual Treatment Objective by Endemicity Level ots 900,000 800,000 700,000 600,000 500.000 400,000 300,000 200,000 100,000 2003 2004 2005 Yea r 2006 2007 -Hyperendemic -Meso-endemic . 4t APPENDIX 2: INDICATORS FOR EVALUATION, SUSTAINABILITY AND INTEGRATION OF CDTI Project Evaluation Management Financial Management Effectiveness of Communications Training and Capacity Building Institutional Commitment Fulfillrnent of other relevant factors Problem solving capacity Integration of operational research Project Effectiveness Result of the KAp studies Treatment Coverage Follow up of non-eligible and absentees Management of adverse reactions Reliabi lity o f reporting S ustainability/In tegration Political will of Host government Political will as shown in policy statements and apparent commitment of high-level officials official actions including assigning personnel, funds, vehicles to program Long-term planning Is there a long-term plan for sustaining the financing and the management of the program? Progress toward financial sustainability lf program sponsors cannot continue their current level of commitment for at least another five year, what percentage of mnning costs is now paid for host governments or fees? Progress toward integration To what extent has ivermectin dish-ibution been integrated with other health service programs? Evidence of community empowerment and ownership Change in KAP over time Extent of involvement of both genders and non-literate 42 a cr I o q, lU)lotolcla K lst:t-.kla o) + o =. oI I oooc :, o, f o-l f, a d EA o 0) @ 9..o o)l lmlxlololalo lp.lo- l(D l3 lo lo kot-.(n U, @ ;o(o 6' =0r_ ooo a =(D oi l7(D ko o =o) ;oo ag f o) oI v -(D 7 -(I, v -(D v -@ T -(D v -(I, v -@ 7 -@ o oc o o 5No sNO (o @o Nooo Nooo N) Joa N Joo N oo t>l=l=lc 10, la o, lo, a\ ET(D =lol -l z 9 o o o, {(., ao 5Nbo s Noo (o @bo NoIoo NOobo N) JIoo sNIoo (rl N) srtoo { o 0, o!,ti a ! 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I, ,) t) ffi ffiffi lllubabor Zone Oromiya Regional State ETHIOPIA PROJECT PERIOD: 2003 - 2OO7 For h:icimotion To: brp, Ao AFRICAN PROGRAM FOR ONCHOCERCIAS IS CONTROL (APOC) Ylou I l otep( ? f; JAru. 2[J03 *rL.''ii'r *-t v- 3t.32 leJrtrkrn 4"q€ 33Jan'uary 2003 v Ii I i i ; I I tlt! Fol Action To: /' '.CocD CF*v/ C5A ioP i,n, Bto lcctlL a U t. Ii -r,- TI [] ll tii , I I II trftiii il 1 tI TABLE OF CONTENTS LIST OF ACRONYMS SECTION 1: BACKGROUND INFORMATION 1. INFORMATION ON THE PROJECT AREA FOR CDTI ..............1.1. Geographical and administrative areas. lll , I 1 6 7 7 1.2 1.3 t.4 Topography, Climate, Access....... Onchocerciasis Endemicity Levels Community Structure Organizational Structure for CDTI. Financial Administration................ Timed Plan of Action............ 2. PAST AND CURRENT STATUS OF CDTI IN PROJECT AREA g SECTION 2: PROJECT EXECUTION OUTLINE t0 3. DESCRIPTION OF PROPOSED CDTI 3.1. 3.2. 3.3. Outline Plan and Timing Health Education and Community lnteraction and Participation Local Operational Research. SUPERVISION, MONITORING AND EVALUATION 5.1. Supervision duringEvaluation 5.2. MonitoringCDTI........ 5.3. Evaluation of CDTI SUSTAINABILITY OF THE CDTI AFTER THE WITHDRAWAL OF EXTERNAL FUNDING6.1. Integration of GDTI into other community Based pHC Systems ........6.2. Cost Recovery System during CDTI.........6.3. OtherIssues........ 10 10 l1 l4 4. 5 SUPPLY, IMPORTATION, STORAGE, INVENTORY AND DELIVERY OF MECTIZAN TABLETS ............ 15 16 t6 l7 t9 6. T9 t9 22 23 7, 8 CROSS BORDER CONSIDERATIONS SPECIAL RISK ISSUES 25 SECTION 3: ADMINISTRATION/FINANCIAL.......... 26 9. ADMINISTRATION 25 9.1. 9.2. 9.3. 26 26 27 3l 10. BUDGET 10.1. Budget Estimate. t0.2 Budget Justifi cation...... 10.3 Current Resources available in CDTI......... APPENDIX 1: Estimated Numbers of Communities and Persons to be Treated each Year by Endemicity level... 40 APPENDIX 2: Indicators for Evaluation, Sustainability and Integration of CDTI 42 APPENDIX 3: Budget Details 43 LIST OF MAPS: MAP 1: SKETCH MAP OF ILLUBABOR ZONE, OROMIYA REGIONAL STATE, ETHIOPIA. 2 MAP 2: SKETCH MAP OF CURRENT CDTI WEREDAS IN ILLUBABOR ZONE, OROMIYA REGIONAL STATE, ETHIOPIA MAP 3: DISTNBUTION OF VILLEGES, ROAD NETWORK AND NVERS IN ILLUBABOR ZONE, OROMIYA REGIONAL STATE, ETHIOPIA........ 4 MAP 4: CURRENT CDTI AREAS IN ETHIOPIA LIST OF FIGURES: FIGURE 1: Organizational Structure of National Onchocerciasis Control Program FIGURE 2: Request and Disbursement of APOC Funds 28 FIGURE 3: Percentage of Contribution of Each Partner for 5 years for Illubabor CDTI Project... ... FIGURE 4: Annual Treatment Objective (by Endemicity Level) 4t JJ JJ 37 39 aJ 5 26 36 ll LIST OF ACRONYMS ) APOC- ATO- CDDs- CDTI- EARP- EPI- FDRE- GIS- IEC- KAP- MIS- MOH- MOVDCD- MOVDCU- NGO- NOTF- PHCU- REA- REMO- RHB- ROTF- SNNPR- TBA- TCC- TMEC- TOT- WOTF- ZAC- ZHO- ZOTF- African Program for Onchocerciasis Control Annual Treatment Objective Community Drug Distributors Community Directed Treatment with Ivermectin Eligible At Risk Population Expanded Program of Immunization Federal Democratic Republic of Ethiopia Geographic Information System Information Education Communication Knowledge, Attitude, and Practice Management lnformation System Ministry of Health Malaria & Other Vector-borne Diseases Control Department Malaria & Other Vector-borne Diseases Control Unit Non Governmental Organ ization National Onchocerciasis Task Force Primary Health Care Unit Rapid Epidemiological Assessment Rapid Epidemiological Mapping of Onchocerciasis Regional Health Bureau Regional Onchocerciasis Task Force Southern Nation Nationalities & Peoples Region Traditional Birth Attendants Technical Consultative Committee The Mectizan Expert Committee Training of Trainers Woreda Onchocerciasis Task Force Zone Administrative Council ZoneHealth Office Zone Onchocerciasis Task Force lu SECTION 1: BACKGROUND INFORMATTON 1. INFORMATION ON THE PROJECT AREA FOR CDTI 1.1 Geographical and Administrative Area(s) Illubabor project is found in Illubabor zone, which is located in the southwestern part of Oromia Regional State, in Ethiopia. It shares borders with Gambella Region in thi west, West WollegaZone in the North West, and East Wollega Zone inthe North East, Jimma Zone rn the South and South East and Kaffa-Sheka Zone that found in Southem Nations, Nationalities and Peoples Region (SNNPR) in the South. The zone has a total surface area of 15,870.00 Sq. km. According to the 1994 population and housing census, the projected total population of the zone for the year 2003 is estimated at about 1,053,15 1. About 9l %o of the populations live in the rural area. 9 o/o of the population live in the urban areas. Major ociupation of the rural community is subsistence farming. Illubabor zone is one of the 12 administrative zones in Oromiya Region. It is divided in 13 woredas (districts) and further subdivided into 466 kebeles. Various REMO survey results conducted in the zone show the presence of Onchocerciasis in almost all woredas. Currently, eight woredas namely, Aligesache, Bure, Chora, Darimu, Getchi, Metu, yayu- Hurumu and Bedele Dabo are given priority for CDTI for the first round treatment while others will be considered following the completion of REMO. The total population of the eight CDTI woredas is estimated to be 783362. The table below -summarizes the estimates of at risk and total population by village, kebele and woreda. Table 1: - Estimates of Number Population (Total & Risk), Kebeles and Status of REMO by Woreda, Illubabor Zone, Oromia Region, 2003 Vereda No. of Kebeles Total Population Estimated At Risk Population REMOC-ompleted (Yes/No) Mettu* 60 13427 I 107417 Yes Darimu* 42 tt7959 94367 Yes Alge-Sache* 32 72745 58196 Yes Yayu-Hurumui 39 I 03809 83047 Yes Halu-Bure* 34 68476 54781 Yes Chora-Kumbabe* 38 104357 83486 Yes Gatchi* 23 59,990 47992 Yes Bedele Dabo* 53 121755 97404 Yes Alle Dido 45 91234 72987 No Dega Mako 29 s7730 46184 No Sale Nono 20 22808 18246 No Didessa 27 54949 43959 No Boracha 24 43068 34454 No Total 466 1,053,151 842,521 * COTI lYeredas for year one. I 7Ft fil t: a(t) XEFi o *r? -t hiY hl lrlF -C l+l I tr aY N zHL^l I^ ^r7tst I ^rE o:-( z F aH >t H L^-./tHH *r H cU g t\) t 7A FU !:, I a X Ed Hoh{lJ( ? -t hl r+r \J P; -(-5FP'N ,EI -\JdzXFrI.i rrCUz. >-i >1 1r< 3E '*) /Jtt!HI .FI E 'tA ii - =z*-/-i -\/ lirh(L .Y. t -L_>EU lli ! ^rN z -trJ oCFF fr, z -.1 oU -l riF FN o (, -ri_- i,.' .J ,i a? -.t ft 3 :\JF{(n HHst =thi C N= ^I!z \Jaz -t' A A f=lF<A-vtr?!FLFt-4 lL) >g , L^JFats"X'Utr h, 5Ezo2zL- raSair=EVr! ,0;X t-l Piz =\J\-/ hla /\/ .Y tlJ+<P; LAJI ^J(n z F tC H l+l t* oHa a-a 5 1l :;):i J. 7Ft rg 5 aa I o L<Ft FNzH otlvFl FI F taJ (t) FI z l!Hhll*(t-AvtiYF{ EEGGO +\l-Ho???.b5UJ r-.O\O\oO zoo.c 6- tt, s E6Z'vd:o5.!eo.)5.5(.oO-Ha=€3H I H oao(DuDJAO)Fs7,-l(u F0aq o H x o, o a J oxx A' ! o o o {o op o o oo ht NN b :-; [c] t) 6rl -Ie_' tD r:\i, '-.acr .Cl E9r "e] h'h c, -fj Ielrclral "' iG) r.?r -rc rd: lilr TC] .:cl Ic}] 'il -acl Irj lgr -.. " r*'?.: G) ,:cl .rclrtlrel rd r9rr:rr Llt/ Ic, .i ' ,'-l la taf zsr 1,+,Td.+ iE,-, TC;IC] fa\ -t _.:cl3 'ic: :fr' tgl ..cl IC] lcl lcl tc,t -- iar . [c] -i'cl'v |c l- 1.2 Topography, Climate, and Access. 1.2.1. Please describe the type of country or bio-climatic zones that will be covered by the CDTI (e.g., rain forest, forest-savanna mosaic, Guinea savanna, Sudan savanna, mountainous orflat), providing maps, if appropriate. The zone has very complex terrain with altitude ranges between 1000-2576 meters above sea level. Ecologically it is a tropical rain forest. Climate in the zone shows great seasonal and inter-annual variations which is traditionally classified into three broad geo- climatic zones, i.e., 160/o cold highland,62 o/o sub-humtd mid-land, and22 o/o hot lowland area. The mean annual temperature ranges from 10 0C to 16 oC i., the highlands, 160C - 260C in the midlands, and 230C -330C in the lowlands. The annual rainfall totals ranges from 1000 millimeters in the lowlands to 2200 millimeters in the highlands. Some of the perennial fast flowing rivers that cross the zone include: Sor, Geba, Birbir and Dedessa,Offa, Sesie, and Gumerrivers. There are also quite numerous small rivers and streams, which are tributaries of the main rivers in many places in the zone. 1.2.2. Give the approximate tintes of the rainy and dry seasons and the months covered by the farming season. There are two distinct seasons in the project area, i.e., the rainy season (April - October) and the dry season (November-March). There is a mono-modal rainfall pattem in the zone. Agricultural activities (clearing, farming, and herding) occur all year round in the project area, but are most intensive during the rainy season. Harvesting occurs from October to December, leaving January- March as the optimum treatment period. 1.2.3. Provide information on the state of the roads, and the effect of this on the movements of CDTI personnel in the area at dffirent times of the year.(l ntap ntuy be use.ful) The main road that runs 600 km from Addis Ababa to Mettu, the zonal capital town, passing through Jimma zone is Asphalt road and woredas alongside of the road are connected with Mettu town. There are about 576 kilometers dry weather roads that corurect woreda centers with Mettu town. Except Selenono woreda, all the other 12 woredas have all weather roads and are corurected with Metu town. However, access to rural communities appears very difficult during rainy seasons. Therefore, Mectizan distribution will have to be carried out during the dry seasons (January- March). The general health care service coverage in the zone at present is estimated at about 69oh, but the effective coverage is estimated to be much lower than the above estimate due to difficult terrain, low road infrastructures and affordability, low public awareness. Most settlement villages are also scattered and takes longer time to travel from one village to another. Currently, there are t hospital, 8 Health Centers, 64 health stations and 17 health posts in the zone. 5 1.3 OnchocerciasisEndemicityLevels The levels of Onchocerciasis endemicity in communities in the CDTI areas must be assessed by sintple methods before treatment starts. For the purpose of this proposal, the level of endemicity in a community or a group of similar communities is defined on the basis of the prevalence of nodule carriers. (See table 2). Table 2:-Classification Criteria for Endemicity Levels in Rural Communities Based on the system in Table 2 and using the format in Appendix l, please indicate the estimated numbers of comryunities at each endemic level and the numbers of persons in them. The recent REMO data for the eight districts, namely, Alige-Sache, Bure, Chora, Darimu, Getchi, Metu, Bedele-Dapo and Yayu-Hurumu show hyper endemic levels of onchocerciasis in most of the surveyed villages. See appendix l. Complete Appendix I for each qrea covering the next 5 years of the project. Done! If methods of assessing endemicity thresholds other than nodule prevalence were used when your endemicity dota were collected, please indicate the method used. The levels of endemicity in communities of this zone were dehned on the basis of nodule prevalence rate obtained by REMO Survey conducted in 1998, 2OOO, some of which were also validated in 2001 by APOC consultants. For areas still to be covered, where endemicity levels are not yet lorcwn, please describe the method you will use to collect the necessary endemicity data. REMO will be refined for the remaining 5 woredas so as to expand the CDTI project in the zone. 1.4 Community Structure Provide background information on the social organizations of communities in the CDTI areas. This may include information on settlement pattern of the community (e.g. hamlets, seasonal farms teads, dispersed population, etc.) The communities in CDTI areas are settled farmers with hamlets, while population is widely dispersed in most districts except those areas with resettled populations. 1.3.1 t.i.2. 1.3.3 1.3.4. 6 Endemicity Level and Recommended Type Of Treatment Percent of nodule carriers in REA sample (minimum sample 50 adult men) Estimated prevalence of O. Volvulus in the whole community Hyper-Endemic, Community Treatment (Urgent) Greater than39o/o Greater than 59o/o Meso-Endemic, Community Treatment (Desirable) 20 -39% 40 - s9% Hypo-Endemic (Non-Urgent) Less than 20o% Less than 407o aa a a The ethnic groups in the contmunity A majority of community members belong to Oromo nationality. The remaining peoples belong to other ethnic groups such as: Amhara, Gurage, Tigrie, Agnuaks and Nuers, Shekicho, Kaffa, and Kulo, etc. Please provide information about the area covered by CDTI indicating whether they are migrants, nomads, refugees or internally displaced populations. The community included in the proposed CDTI project area are settled farmers with a few displaced settlers from other parts of the country. The settlers came to the area more than two decades ago. C ommuni ty I ea d ers hip s t ructur e Illubabour zone is made up of 13 woredas. The community leadership structure in the zone is organized by the zonal administrative council (ZAC), which consists of elected members from each woreda. The ZAC is responsible for giving guidance and leadership to the community for all socio-economic activities. Each woreda is divided into large administrative communities called kebeles (4000-5000 people per kebele on average). Kebeles are further divided into smaller clusters of households called menders (villages) with 250-300 peoples. Elders and religious leaders play a major role at each level. lnformal social organizations in the communities include: Edir, Equb, etc. whereby the community members share and discuss their problem. The diagram below shows the community leadership structure. ZAC ) Wereda Admin Council )Kebele Admin ) Elders/Religious Leaders )Households Main occupation of community and periods of major communal activities. The main occupation of the community is farming, and animal husbandry. Farming activities, however, decrease from January to March after the completion of crops harvesting. a Preferred channels of communication in the community The preferred channel of communication in the community is passing messages through the community leadership structure and from the local farmers or urban dwellers such as community representatives, elders, and heads of the household. Besides, there are trained community health workers and traditional birth attendants that bridge the community with the health care services. School clubs from rural primary schools can be used in reaching CDTI communities. However, mass media such as radio is less available in most rural communities. 7 aa a Existing active contmunity association/groups in the area (e.g. social, religious, etc.) The existing and active community associations/groups include the farmers associations, urban dwellers associations and traditional religious gatherings. There are informal social organizations such as ldir, Ekub, etc. Established dtstribution systems in the community. There are some existing distribution systems for EPI activities such as polio campaigns, vitamin-A distribution, family planning and malaria control, which are organized through the social and religious associations mentioned above. It is also through these organizations that community mobilization and health education will begin for CDTI. The community could also recruit their distributors through these systems. Social communal activities and months during which the activities take place. There are various social and communal activities. Prominent among these are traditional religious celebrations such as, the foundation of the True Cross (Meskel) in September, Gena (Christmas), Timket (Epiphany), and ld-Al-Fetir, in January Eater in April. Any previous experience of the community with development/health projects. Most communities in the zone have been involved in various EPI, Family Planning, well construction, and spring protection activities. There are also community health posts managed by community health agents and traditional birth attendants in some communities. The communities therefore have well-established systems of mobilization to enhance participation in communal events. a a Description of other anthropological characteristics of the communities. The people of Illubabour zone are predominantly muslins and Oromo by ethnicity. Sheiks and traditional religious leaders possess strong influence in decision-making and health- related behaviors. All Fridays are spared for religious activities in the Muslim communities. 2. PASTS AND CURRENT STATUS OF CDTI IN PROJECT AREA. 2.1 Please indicate if the CDTI is an expansion of an existing CDTI. Illubabour zone is a new CDTI project area and has no past experiences on CDTI program 2.2 State the number of years the programme has been operating, and if possible enclose previous statistical, financial and annual reports. Not applicable. 2.3 State the number of persons treated each yearfor the last 5 years: Not applicable. 2.4 List the organization(s) involved in the programme, the sources and amount of funds used each yearfor the last 5 years. Not applicable. 8 SEGTION 2: PROJECT EXEGUTION OUTLTNE 3. DESCRIPTION OF PROPOSED CDTI The main strateg) of the project will be to develop and establish community-based ivermectin treatment systems, which can be sustained by the endemic communities themselves without external support after the S-year proiect period. This seclion should describe how the NOTF ptans to develop ani implement CDTI in all high-risk communities in the project area. The plan should take into account the need to develop approaches to CDTI, which are appropriate, for the different local situations, and the need to carefully evaluate the implementation of the selected approaches and adjust them when required. 3.1 Outline Plan and Timing Advocacy and sensitization at introducing the APOC/CDTI the regional, zonal and woreda levels - emphasis will be placed on strategy, and enlisting the support of the regional level with the participation of the NorFAIocP, regional administrative council offices Selection and training ofCommunity Directed Dis tributors (CDDs) Selection of CDDs is the responsibility of the community Household registration and census enumeration hained CDDs will carry out village census Justification Length 5 weeks Agreement on the definition of roles based on APOC Guidelines, etc and responsibililies of all partners - through MoH with region 4 weeks ofessential project equipment and supplies Computers, Mectizan drugs, and vehicles, and others Procurement l6 weela ofproject trainers at regional zonal and levels, Training to those who will function as hainers and Training/ supervlsors 4 weeks Rapid Epidemiological Assessments/REA wilt be carried out to expand CDTI activities to other woredas based on lhe levels'the 4 weeks Mobilization of'regional, zonal and district authorities to support the project 4 weeks Pre-intervention KAP surveys and other sflrdies will be conducted to have a baseline data to develop appropriate IEC activities and monitor behavioral changes and also assess re-infection rate. Conduct I(AP Studies l2 weeks Mobilization comtnunendemic theofof ities, AS aswell thestressing ownershipcommunity proJect k"y educationhealth 4 weeks 3 weeks 2 weeks Mectizan @ Collection and Distributlon in endemic communities 8 weeks supervision of Mectizan@ distribution activities by zonal and woreda supervisorsMonitoring and 4 weeks Inspection of CDD distribution activities (spot checl<s) by regional supervisors and NOTF I week Reporring of treahnents and training will be required, as in the past, on a monthly basis and appropriate feedback sent to the providers to ensure the adherence of corrective measures recommended. MIS (Management Information Sys tem) Monthly NOTF/APOC evaluation conductteam andinternal evaluationextemal theof ectproJ 4 weeks Annual reviews will be conducted and reports generated and used to ensure continuous improvement in designing the following years action plan. Review of Treatment Activities I week Preparation of Action Plan for the next year 2 weeks 9 3.2 Health education and Community Interaction and Participation 3.2.1 How will you approach and interactwith the community? There already exist systems of communication with the proposed project area through other health programs as described earlier. However, the following strategy will be implemented to maintain good relations with the communities: a) Discussions with zonal council chairman and head of social affairs and with woreda chairpersons, local farmers and urban dwellers associations, religious leaders, community elders and opinion leaders to better understand community values, customs and beliefs. b) Focus group discussions will be held with social and religious groups to further mobilize the community with the support of the community leaders. c) Focus group discussions will be held with the community members as appropriate (separating men and women, depending on the community traditions). The community members will also be encouraged at this point to take ownership of the program, defining their roles and distribution mechanisms. 3.2.2 Health education Health education and community mobilization will continue to be an integral part of all approaches to CDTI. Health education activities should ensure continuous exchange with regards to knowledge, awareness, perception and observable attitudinal changes about Onchocerciasis and its treatment. Appropriate health education messages in the form of posters, pamphlets and verbal presentations will need to be developed and tested. Health education should address thefollowing issues (See Table 2). Table 3: Critical Issues in the Development of Health Education for CDTI t ISSUES Health Education Messages Knowledge of the disease . Local name of the disease . symptoms , Causation/transmission (simple) Knowledge of heatment a Previous experiences with Diethylcarbamazine (DEC) Introduce Mectizan@ (ivermectin) Dosage Exclusions, Reactions, Beneficial side effects a a Attrtude to treatment Advantages of Treatnent: o Free, Yearly treatment o Possibility of Self-treatment at community level o Importance of maximal coverage Attitude to disease a The disease can be controlled Onchocerciasis blindness and skin changes can be prEvented Attihrde to good record keeping o Minimum requirements for record keeping o Records are confidential and strictly for health use Records required are for subsequent drug supply 10 a) Have any KAP surveys been done in the project area and if so, what were the results? No KAP studies have been carried out in the project area. b) What methods will be used to develop health education material for the communities and for the agents who will be responsiblefor lvermectin treatment? Health education materials such as posters, leaflets and flipcharts will be developed in local languages by the project and submitted to NOTF for standardization. These materials will be field{ested and refined/adjusted in accordance with APOC accepted strategies prior to mass production. c) What methods wtll be used to provide health education to the endemtc communities and to the agents responsiblefor treatment? Illubabour zone has in the past used various media for providing health education to endemic communities. Such methods include: - face-to-face discussions with community members, traditional birth attendants, community health agents, - use of posters and flipcharts prepared in local languages, and - drama (rble playing in local languages). Community leaders will first be informed about the disease and the importance of regular treatment with ivermectin. These community leaders and representatives will serve as agents for the program, encouraging community members to comply with ivermectin treatment. All members of the community will be directly engaged in discussions about the health education messages, and given the opportunity to ask questions they may have and make decisions regarding any aspect of the CDTl-program. Community members will also provide valuable input into the development of health education messages and materials for final distribution. 3.2.3. Community Participation In community-directed ivermectin delivery systems, members of the endemtc communities do the execution of ivermectin treatment themselves. Trained personnel, lcnown as Community-Directed Distributors (CDDs) who should be fully supported by the community itself may provide treatment. The community should be responsible for the organtzation and execution of the CDTI with minimum but ffictive medical supervision, once it has received the necessary information and training. Various organizational structures at the community level, ranging from women's cooperative to tradttional structures, are important for sustaintng and strengthening the support network of the CDDs. ll a) Explain the organization of the intended community-directed ivermectin treatment in the project. The formation of an Onchocerciasis task force at all levels is essential in order to promote coordinated activities of Onchocerciasis control in all endemic areas. At Federal level the NOTF is responsible for routine program management and acts as the liaison between MOH, RHB, and NGO partners within the country and outside. The NOTF will be the governing body for Onchocerciasis control activities in Ethiopia. At regional level, MOVDC is represented by a department and will be responsible for program implementation at that level. The head of MOVDCD will act as a ROCP Coordinator. Similarly, at the Zonal and Woreda levels corresponding Onchocerciasis Control Task Forces (ZOTF and WOTF respectively) will be established. The WOTF will be responsible for program implementation at Woreda level (ensure selection of CDDs, supervision of treatment activities, record keeping, etc).Also, local health institutions under the WOTF will be responsible to coordinate, monitor, and supervise CDTI at each locality. Village (Mender) will be the smallest unit for ivermectin distribution to the communities. Several villages are clustered together to form administrative Kebeles led by a Kebele chairperson. CDDs selected by the communities will be trained on the CDTVAPOC strategy for ivermectin distribution. CDDs and other local primary health care workers will then provide health education to communities on Onchocerciasis, i.e. its cause, transmission, clinical manifestations and treatment including its prevention and control mechanisms. Communities will be mobilized to provide appropriate support to CDDs when they are engaged in CDTI activities to ensure sustainability of the prograrnme. Census of households will be carried out to identify eligible and non-eligible individuals and keep the records before Mectizan distribution. The CDDs will follow up defaulters using their treatment registers. Census of households will be updated every year before Mectizan distribution. Both Woreda and Zonal health staff will carry out supportive supervision and monitoring activities b) How will ivermectin distributors be selected? The communities will be informed about the CDTI and APOC strategies and will be given the responsibility to select CDDs. The communities are fully empowered to replace those CDDs that show poor performance. There will not be any external influence in the process of selection of the CDDs. These CDDs are expected to be honest, dedicated, literate, and permanent residents of the community. t2 c) How will non-eligibles be identified and defoulters followed-up? Non-eligible individuals will be identified using the complete household census registration book and this will be updated each year. Similarly, defaulters, absentees, refusals, etc will be identified using treatment record book after each heatment schedules. The identified defaulters and new eligible such as previously pregnant women but who have delivered will be treated through mopping activities. 3.3 Local Operational Research Are there any plans to conduct local operational research? { YES NO If yes please give details The following operational research areas are suggested for consideration. o Establish a database on prevalence of Onchocerciasis and the associated blindness o Pre-and post intervention KAP surveys o Assessment of the therapeutic efficacy of Ivermectin in GDTI areas o To evaluate the impact of CDTI programmes on reduction of the burden of Onchocerciasis and its beneficial effect on other internal and external parasites a) What training will be provided to ensure the development and sustainability of the CDTI? Training of cDDs to operate CDTI is very vital to the program. To ensure sustainability of the CDTI program, TOT sessions will be conducted by the NOCP' Those trained here will represent both region al, zonal and Woreda levels. These individuals will in tum train representatives from health facilities who also train CDDs at community level. The training sessions will focus on the following topics: . Epidemiology of onchocerciasis, its signs and symptoms, including its treatment o APOC philosophy and CDTI strategy o Health Education and community mobilization o About Mectizan@ its advantages and the related adverse effects and management of its adverse reactions . [nclusion and exclusion criteria for ivermectin treatment o Dosage of Mectizan o Methods of dug distribution o Record keeping and reporting o Supervision and monitoring l3 b) Indicate criteria for selecting trainees (supervisors ond community-directed distributors). I) Criteria for selecting CDDs (i) (ii) (iiD (v) (v) (vi) Literate if possible Resident in the community Willing to serve the community Must be honest Must be available Must be selected by community II) Criteria for Selecting Supervisors Zonal Supervisor: (i) Should be a PHC staff preferably from zonal MOVDPU(ii) Must be knowledgeable(iii) Must be interested in helping the community(iv) Must be honest Woreda Supervisor: The same criteria as those for the zonal supervisor are applicable here c) Indicate number, type and duration of training courses intended 4. SUPPLIES, IMPORTATION, STORAGE, INVENTORY AND DELIVERY OF MECTIZAN TABLETS This section is only a reminder and concerns the supply, importation, storage, inventory and delivery of ivermectin tablets, donated by Merck & Co, who will also pay handling charges for ivermectin to their accredited agents. Mectizan@ consignments will be received through WHO and stored in the Federal MOH central stores in Addis Ababa. It will then be transported by road to the Regional Health Bureau, and from there to the Illubabour Zonal Health Office. The zonal health office Type of Training (Workshops) Duration Number per year Orientation workshop at regional level 5 days I Zonal Training 5 days 1 Woreda Training 5 days 8 CDD Training 3 days 300 Sessions t4 will be responsible for delivering the drug to the Woreda Health office and health facilities (In some areas the Woreda health office is located far from the communities. ln this case, the nearby health facilities will serve as the final collection point). CDDs will then collect the drug from the Woreda health office or health facilities. A report showing the use of the drug will be sent to MEC (Mectizan Expert Committee) at the end of every year, by the NOTF, with the subsequent application. Copies of the application and the report of its use will also be sent to APOC. An application for Mectizan@ tablets will be submitted every year by the end of August to the NOTF, using the standardized, form of Mectizan@ Expert Committee (MEC). This application will then forwarded to MEC in Atlanta for review and approval. 5. SUPERVISION/MONITORING AND EVALUATION 5.1. Supervision During CDTI Projects are required to be supervised and monitored regularly. However, ApOC funded projects will need to be designed to function with effective but minimum supervision compatible with its objectives. a) Please describe the supervisory arrangements you consider will be required for the CDTI yottpropose. How will this continue at the cessation of ApOC support? There will be supportive supervision at all levels of program, during and after cessation of APOC support. The supervisory teams at the national, regional and zonal levels will be responsible for supervising woreda health offices and randomly selected health institutions and CDTI targeted communities in all aspects of the programme activities. Trained supervisors from the woreda health office and the heilth-facilities will be responsible to carry out supervision activities in their catchment CDTI areas on regular basis. Supervision activities will include performance of CDDs such as proper record keeping, complete census enumeration, Mectizan@ inventory and dosage, and monitoring during the actual distribution process. Moreover, representatives of the community wiil do direct supervision and monitoring activities on a regular basis in their own ui1ug" following after they are given training. NGO partners will be involved during in supervision activities along with MOH supervisors The results of the supervision will be discussed with each supervised workers and thus corrective measures will be taken at the spot. This will be documented and reported to different partners at various levels. b) Describe how you would ensure that superttision would be carried out so as to: o fall within the requirements of accountingfor ivermectin use o be sustained when the program ends tn 5 years . ensure maximum tnvolvement of the communities in the process l5 To ensure that the above requirements are met, the program will support regular monitoring during the actual distribution process to ascertain that correct dosage is being administered, exclusion criteria are being observed, and the collection and proper storage of unused drug is occurring. [n addition, the program will support advocacy visits to the woredas and villages by NOTF, regional, and zonal and woreda representatives of the onchocerciasis task forces at each level to encourage the active support of the community. Once training of CDDs has been completed. Zonal and Woreda supervisors will check that household enumeration has been completed according to APOC requirements. Standard supervision checklists will be used to ensure the above requirements. 5.2 Monitoring of CDTI It is important to collect information to monitor the progress of the CDTI. indicators will be used to monitor: o lvermecttn distribution? o Health education and community participation? o Management systems? Wat The followtng items may be considered. Ivermectin D istrib utio rt o Numbers of communities and persons treated with ivermectin o Number of lvermectin tablets distributed/consumed o number of communities reporting shortage of supplies . Regularity of treatment exercise o Compliance o Reporting adverse reactions Health Education and Communitv Participation o Numbers of communities participating in the project o Changes in behaviour towards the disease, its treatment, prevention and control o Community support given to CDDs c Are activities being carried out according to plan and on schedule? o Inventory control, o Are recordforms accurate and completed on time? o Numbers of persons trained c Balance of genders in staff of the program Manageme4t The project will consider the following indices for monitoring the program of CDTI t6 Ivermectin D istributio rt : Since Jimma zone will be starting Onchocerciasis control activities for the first time, there is currently no Management lnformation System (MIS) for Onchocerciasis control. The NOTF will use standardized monitoring system previously developed in other CDTI areas prior to the beginning of treatment. These include communities and persons treated with ivermectin, treatment coverage, regularity of treatment, treatment compliance, and drug reactions. In addition, the project will monitor the following rates and percentages using Annual Treatment Objectives established at the beginning of each year: a Annual treatment objectives (ATO) High-risk villages (number of high risk villages targeted for treatment) At risk villages (number of at risk villages targeted for treatment) Estimated at risk population (total population at risk in the region) Treatment coverage (related to ATOs)a a % of high risk villages/communities covered o/o of at risk population treated o Cost per person treated o Tablets distributed o Number of ivermectin tablets in store at HQ, in the field, on order, or to be ordered Health Education and Communitv Mobilization: The degree of community participation in mobilization activities will 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 mobili zation as well. The impact of health education messages will be measured through periodic focus group discussions and KAP studies. Management The project will develop through its integration with the regional, zonal, and district health management and supervision systems to monitor, o The planning and implementation of activities according to the timeline o Mectizan@ inventory levels o Monthly reporting of treatment indices o Numbers of personnel trained o Attempt to balance gender in staffing t7 5.3 Evaluation of CDTI Annual external review incorporating field visits will be undertaken to ensure that projects are meeting target indications outlined in this proposal. Such reviews will provide TCC with the assurance that each project is moving towards its long term stated goal and if appropriate make recommendations about any defictencies or modifications to thts project. Such reviews will draw on the indicators developed by TCC as a guide. 6. SUSTAINABILITY OF THE CDTI AFTER THE WITHDRAWAL OF EXTERNAL FUNDING The concept of sustainability refers to the ability of countries and affected communities following initial external investment to maintain the viabiltty and continuity of the ivermectin treatment process without external support. For APOC funded projects, such support will normally last 5 years, as the APOC donors demand that there shall be a visible and achievable end point for the external donation aspect of the programme, and that the community based distribution systems established shall thereafter be sustainable by the governments of the endemic countries concerned. Progress and itlans towards sustainability, including the phasing out of external and NGDO support, must be reported annually and satisfactory progress in this direction will be a condition for each succeeding year's funding installment. Please address the following areas that relate to sustainabtlity: integration into primary health care, cost- recovery, and other sustainability issues. 6.1 Integration of the CDTI into other Community-based or Primary Health Care (PHC) systems. The principal goal of the APOC is to establish cost-effective ivermectin-based control for Onchocerciasis, which can be sustained by the endemic communities and countries. One way to ensure sustainability is to integrate the CDTI into the PHC system of the country, which means more than just using the systemfor ivermecttn distribution. 6.1.1. Is there an official PHC policy and structure in the country?{ YES NO If yes, please give a brief outline of what it is: Primary Health Care (PHC) policy in Ethiopia is to develop and strengthen grassroots and community participation in health care. lncluding Onchocerciasis among priority health problems in the national health policy will do the integration of CDTI into the PHC system. At the regional, zonal, and woreda levels, the MOVDCU will be responsible for program implementation at the respective levels. In addition, combining training on CDTI with other on job training activities, including Onchocerciasis control activities in the planning process at all levels, and including Mectizan@ in the list of national essential drugs delivery system will further enhance this. l8 b) c) The PUiC system will be used to achieve full integration at peripheral level by further integrating CDTI into the activities of the PHC (training on CDTI into training of health workers). This way the PHC system will be used to achieve full integration of CDTI into general health service by obtaining support from Regional, Zonal and Woreda authorities, bilateral and multilateral organizations. In sumrnary, the PHC structure is as follows: MOH ) REGIONAL HEALTH BUREAU) ZONAL HEALTH DEPT.) WOREDA HEALTH DEPT./HEALTH FACILIIES (hospitals, health centers, health stations, health posts etc) ) COMMUNITY I{EALTH POSTS (CHAs & TBAs) a) I{owfunctional is the Primary Heatth Care system? Ful ly functio nal, P artly funct ional or non-func ttonal (p I eas e specifu) ? The system from the National level is fully functional until the Woreda./health facility level. However, at the community level health coverage is limited. Does it cover the whole project area? ./ Yes No IJ'no, in what part(s) of the project area is there a futly functional pHC structure? What percentage of communities where Onchocerciasis is endemic, and which are eligible for community-based treatment, have an existing and functional PHC system? About 69 percent of the endemic communities have functional PHC coverage. Wat organizations are supporting the development of pHC in your project area? Government of Ethiopia (Ministryof Health), wHo, UNICEF, and some NGDos Is there any past experience in the country of a programme integrating with the PHC? If so, what programme was it and how successful was the integration? EPI, Malaria control, IMCI and family planning drug distribution. The integration continues successfully. Are there any plans to integrate other rural health programme, such as the Expanded Programme of Immunization, Maternal and Child Health Programmes or programmes for the control of other parasitic diseases, with the PHC system? EPI, maternal and child health program malaria prevention are already integrated with the PHC system. d) e) J) l9 Describe how the CDTI will be integrated into the PHC system; the way the PHC system 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 MOVDCU will be responsible for routine program management and act as the liaison between MOH, RHB, as well as with NGO partners. Members of the Malaria unit share responsibilities among themselves and hence a separate entity of vertical program nature will not be established. The head of this unit will act as NOCP coordinator. At regional level, MOVDC is organized as a department and will be responsible for program implementation (contacting community leaders, explaining the program objectives, discuss issues related to Mectizan@ security, at regional level, including monitoring and supervision). The head of MOVDC will act as a Regional Onchocerciasis Control Coordinator. Similarly, at the zonal and woreda levels will establish corresponding Onchocerciasis Control Task Forces (ZOTF and WOTF). The WOTF will be responsible for program implementation at the woreda level (ensure selection of CDDs, supervision of treatment activities, record keeping etc). [n areas where access to the woreda health office is restricted, local health institutions will coordinate, monitor, and supervise CDTI activities The primary health care units normally provide both preventive and curative health care services with health education to populations in their catchment areas. These health care programmes are provided as a package not in isolate form and thus the CDTI activities will also be incorporated into the health extension packages in place. h) 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 lifetime of the CDTI it will be completed. CDTI activities in Ethiopia will be integrated from the very beginning. The establishment of the program will rely on existing systems of health service delivery at all levels. If there is at present no PHC system in operation or in those areas where these structures are non-functional, describe how the CDTI may be used to initiate and expand into such a system, giving a timeframefor tntended progress. NOT APPLICABLE 6.1.3. In which way!) cqn community-directed ivermectin treatment initiate or strengthen PHC? CDTI is likely to encourage and facilitate the acceptance of new health initiatives in the community and at home level. Also, through the new CDTI strategy, the community will s) 6.1 .2 20 likely play a greater role in the support and ownership of the PHC system. The structures already put in place would be utilized by the PHC to enhance effective planning and implementation of the project. For example, the CDDs will develop capacities and skills, which udll strengthen other programs such as health education, increase IMCI coverage, initiate home-based treatment. 6.2. Cost-recovery Systems during Community-based Ivermectin Treatment Cost recoveryfor Primary Health Care is mandatory in some countries and it may be one means of sustaining a CDTI after APOC funding cedses. However, please note well that since ivermectin is donated free, there can be no cost recovery in respect of the value of the drug itself; cost recovery can only relate to the costs of distribution. 6.2.1. Please state whether there will be any system of cost recovery $uch as this recommended in Initiative) to help cover outlays on the distribution of ivermectin in the present CDTI. NO 6.2.2. State exttctly how any such system will be organized, including answers to the questions listed below. a) What charge will be made per person or perfamily? NOT APPLICABLE b) Wich groups of persons will be exemptedfrom payment? NOT APPLICABLE c) Will payments be in cash or in kind? If in kind how will this ensure sustainability? NOT APPLICABLE J) Wat provision will be made to ensure that all those eligible to take ivermectin, but who are unable to pay, will also receive treatment? How wtll it be determined who is unable to pay? NOT APPLICABLE Wo will collect the payments? How will this person safely transport funds to a place of safekeeping? NOT APPLICABLE h) Where and by whom will anyfunds collected be safely kept? NOT APPLICABLE s) 2t t) i) k) What systents will be put in place to ensure the proper use and 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 Committees play in the management and allocation of the funds raised? NOT APPLICABLE 6.3. Other Issues Please provide information on other issues and constraints relating to sustainability of CDTI you anticipate and identify how they will be overcome. For example: The mobilization of endemic communities The maintenance of adequate supervision and monitoring Inadequate human res ources Logistics and communications S o c tal/cul tur a I fa c t o r s Declining community compliance O Mobilization of endemic communities; Sometimes problems of mobilization of endemic community can be obstacle to sustainability of CDTI. This can be solved through sustained advocacy visits, by assigning individuals with good communication skills and expertise in conducting mass health education meetings to increase awareness of the community, KAP surveys to monitor belief systems. Obviously there will be a need to establish good relationships with the community leaders in order to have increased access to the communities at times like these.(i, Maintenance of adequate superttision and monitoring Mectizan@ distribution should include community leaders to further increase acceptability and sustainability of the program. All records should be verified during supervisory visits, and informal discussions should be encouraged to determine community perceptions of the Mectizan@. (ii, Inadequate Human Resources Inadequacy of trained health staff and PHC units are expected to be constraints in implementing supervision and monitoring. These can be overcome by allocating adequate time for supervision, in addition to training additional supervisors from health facilities and community members. In absence of roads in some remote areas, mules and horses can be used. 22 (iv) Logistic,sandCommunications During the rainy season in October to December travel to the endemic areas may be restricted. Proper planning (Mectizan@ drug orders etc) will focus on providing all high- risk villages with their drugs during the dry season (prior to the Jan-March distribution window), and encouraging completion of distribution before the rains if convenient for the communities. (v) Social/Clulturalfactors: Careful attention will be paid to cultural and social factors such as: the appropriate gender for CDDs especially in Muslim communities, respecting the traditional beliefi, and selecting supervisors and distributors who speak the local languages. (vl DecliningCommunityCompliance: Declining community compliance will be avoided through continuous sensitization and mobilization activities prior to each treatment period. Community members could be interviewed to determine the reasons for the non-compliance, and corrective measures taken where possible and appropriate 6.4, How do you intend to monitor and measure 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 the project in terms of financial management/contribution, communications, training and "uputitybuilding. This will help enhance integration. Financial management should be incorporated into the usual government financial administration. Financial flow in the CDTI project should comply with govemment financial management procedures so that there will be safe resource management. Regional and zonal health department heads, and administration/finance managers at each level will be accountable for proper utilization of CDTI resources. The ability of managers at different levels to familiariLe 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 about understand the cause and effects of Onchocerciasis, and the mechanisms for its control can be considered indicators of progress of CDTI to sustainability. The success of the program will depend on the attitudes and practices of the community towards the disease. 23 7. CROSS.BORDER CONSIDERATIONS Where an endemic area extends across the borders of two or more adjacent States, special problems of cooperation between the respective countries CDTI may arise. In the event that there are areas to be covered by your proposed CDTI where the endemic zone extends across the frontier into one or more neighboring countries, and where there are likely to be transitory or even large-scale migrations of Onchocerca- infected persons either way across the border. 7.1 Please describe the particular situation as it is likely to affect ivermectin treatment, and the methods you will use to deal with it. The Neighboring state, SNNPR, has already CDTI project in Kaffa Sheka zone since 2000-1 and will not affect this CDTI project, as they are similar in all aspects. Rather the experience in the Kaffa-Sheka will be of great value to the proposed CDTI project. The proposed CDTI districts do not share boundaries with other countries. 7.2 Include'pertinent observations on curuent political and health relations with the neighboring State(s). There is good relationship between Oromia region and SNNPRs in ever aspects including political, economical, social, cultural aspects. 8. SPEGIAL RISK ISSUES In some areas of some countries there may be special risks, which could hinder the smooth running of a CDTI. 8.1 Please describe the situation in any areas covered by your proposed CDTI were this factor may interfere with the program, and assess future prospects NOT APPLICABLE 24 SECTION 3: ADMINISTRATION/FINANCIAL 9. ADMINISTRATTON 9.1. Organizational Structure for CDTI 9.1.1 Please provide an organogram for the CDTI showing the organizational structure responsible for implementing the proposal. Fig.l. Organizational Structure of National Onchocerciasis Control program 25 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 authorized officer of the MOH, WHO/Addis Ababa will transfer the filnd directly to the bank account of the respective Regional Health Bureaux (RHBs) according to the approved CDTI project proposals. The signatories of the bank account into which APOC frrnds will be transferred at the regional level will be the head and the administration and finance officer of the regional health bureau. All the Imperest returns will be submitted monthly by RIIB to WHO country office in Addis Ababa that will forward them to APOC headquarters in Ougadougou. Monthly reconciliation statements will be forwarded to the central Malaria and Other Vector-borne Diseases Control Unit (acting as the secretariat of NOTF) for follow up. APOC will issue cheques (advances) in accordance with WHO rules and 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 installments. The first installment/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 contractual systems is used, e.g. Technical Service Agreement, Letter 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 impress mechanism, whereby the project will report its expenditure on a quarterly basis and receive further advances on that basis. Each project funded by APOC will require a periodic external audit at project expense. Each project must have one senior staff member who is accountable for the management and control of project funds. Standard intemal financial checks and balances must be incorporated into each project's financial management plan. 26 Fig. 2 Request and Disbursement of APOC Funds Disbursement -_--_-> Financial Report H 27 ; i.: ;-', - 9.2.1 Input from the Ministry of Health a) Indicate resources that will be provided by the Ministry of health and other government agencies. Personnel, logistics, office accommodation. Counterpart funding Security b) Please provide a list of personnel assigned by the MOH to this project, including their name and proposed time (State percentage of time allocated to the project) for the project and where appropriate their experience in Onchocerciasis control through ivermectin treatment. At present, there are experienced persormel at national levels and in SNNPRs since they have started CDTI earlier years. However, none of the personnel in Orimia Regional Health Bureau and in Jimma zone have had experience since CDTI is new to them. Resional Health Bureau: Illubabor Zonal Health Office Name Post Region 7o Time Mr. Dereje Olana Dept. Head of MOVDCU Oromia 25% Mr. Sheleme Chibsa Vector Control Team leader Oromia 2s% Mr. Tadesse Hundie Vector Control Expert Oromia 2s% Mr. Addisu Mekasha Vector Control Expert Oromia 25% Dr. Kebede Itana Diagnostics and Epidemiology Team Leader Oromia 25% Name Post 7.ane "/o "fime Mr. Haile Ayana Head, Zonal Health Office Illubabor 25% Mr. Tibebu Amentie Expert in Malaria & other Vector Borne Disease Prevention and Control 30% Mr. Kedir Ahmed Disease prevention and Control Expert ( 2s% 28 Woreda Ith Office: 9.2.2 Input from the partner NGDO(s) a) Please provide a letter from the Executive Director or the Director of Onchocerciasis programmes of each participating NGDO stating their intentions to participate in and supporr the National Onchocerciasis Control Programme. b) Give information of the inputfrom each NGDO participating in this project. The Carter Center's input will be:- Funds: Per the agreement made between APoc and the FMOH, The carter Center will not have direct responsibility or roles relating to the management and reporting on APOC funds. Mectizan@: The Carter Center will not have direct responsibility or roles relating to the accountability of ivermectin in Ethiopia. The drug will be consigned directly to the wHo and sent to MoH central stores in Addis. a a Staff and consultants: The Carter Center has been involved in some areas of public health in Ethiopia since 1992. In 1993, The Carter Center began assisting the Ethiopia Guinea Worm Eradication Program through the FMoH. The Carter Center has provided excellent technical, logistical and financial support in the implementation of the first CDTI project in Kaffa-Shak4 Bench-Maji and North-Gondar projects. In light of this experience, The Carter Center is ready to continue providing technical, financial, and logistical support to the Onchocerciasis control program in this project. Name Post Woreda 7o Time N{r. Tegegn }vtrekonen Flead, District Flealfi Office Memr 25o/o lvIr. Alebachew Flailu Disease Prevention and Control Expen 25o/" lvIr. Tolera Kabata Flead, District Fledth Office Darimu 257o IvIr. Dereje lvfamo Disease Prevention and Corurol Expen 30o/o Ivk EiiC" Kumsa Flead, District Flealth Office Alge Sache 25Vo lvfr. Tsegap Flka Ivlalaria 6r Orher VCB Control E4pert 31o.h l[r. Bepne Bushira Flead, Disrict Flealth Office YayrFfurumu 25Yo lvfr. Fetene Birhanu Disease Prevention and Control Expen 3jYo Flead, District Fleafth Office Flalu Bure 25o.h IvLlaria &OtherVCB Control Expen 30Yo Ivfr. Kelifa Ibrahim Flead, District FGdth Office Chora 25Yo lvfr. Kassa Aple Disease Prevention and Control Expert 30o/o }[r.Alemalahu Abeneazer Flead, District FIedtI Office Gatchi 25o/o It{r. Jembere Taddesse Disease Prevention and C-ontrol Expen 30o/o IvIr. Alemu Daddi Flead, District FIeaIth Office Bedelle Dabo 251o lvlr. Ordofa KejellJ Disease Prevention and Control Expert 30o/o 29 lvIr. Tarilor Jaleta a a Office space and facilities: The Carter Center will support the national secretariat by providing technical and logistical support through a local office in Addis Ababa. c) Please provide also a nominal list grading and post description for the personnel to be provided by partner NGDO(s). Indicate clearly what will be their functions in the program and their experience in onchocerciasis control through ivermectin distribution. Most of the staff of the Carter center have been involved in the implementation of the KSZ, BMZ, and North Gondar CDTI project in the current year. It is understood that most of them have got some experience. Name Post YoTime Mr. Teshome Gebre Country Representative 25% Mr. Frew Demeke Driver/Logistican 25% Mr. Murida Kemal Admin/Finance Manager 25% Dr. Assefa Worku Program Officer/ GRBP 50% Mr. Asfaw Benti Driver 50% Ms. Seble Aliye Accountant 25% 9.2.3 Inputs from other agencies. Please list any other agencies or parties that will be involved in the running or financing of the CDTI, and indicate clearly their roles,functions and contributions. WHO: WHO Ethiopia will assist the prqect in the procurement and clearance of Mectizan@ imported into the country by using its diplomatic status. 9.3 Timed Plan of Action Provide a time chart(s) showing how the various activities of the CDTI will proceed over the course of the proposed program. Numerical annual targets for all planned activities should be providedfor each time point. The time charts should also indicate how external support will be phased out over the 5 year 30 10. BUDGET 10.1 Budget Estimates Budget must indicate total funds to undertake the project. The amount of funding requested fromAPOC, and the amount provided by the MOH, NGDO(s) and other partners. All must be ma-de in US dollars. Each budget must include at least the fotlowing major categories (see appendix 2) indicating the contribution of the partners to re/lect sistainabiliry ;f CDff. o Personnel (services) o Capital equipment o Supplies Training o Healtheducation/mobilization o Travel o Communication o Consultant . Operating expense o Extemal audit 33 zIt f.U F ItJztrt FJ zH Fi o z r-l zIt It, EF 7 ttj o o FU F)5 o o{ o+) -Jt(D A' (D o+ o U) o5 Do (D x oI c) o F) tr o, o v)fr<h65 5C_ oa D'l, D)@o 5ol, a E D) ol5l U' r3 oo o o H) o U U A a) H o !Do (D v) lg (D C))f(A ?A o oI. oa A' o v,trd (Dt U' o Aoo N DD @ U a, s.d o (\\ sh(\G DOs.=oq -l(\0! u'\E o $ 6 q 14 lolo tpt9t5 lcti iod N Fo op la l(D l(Dla) lH.to lP lp0 a. +Ft o) ql ot o U U U) o o p- tro ,( ts CAg o- (Dq) *p3€8d o U' rn16 o.(D) o o oa o o) E.-lot tsii-. A) (DP i?i 5 p, a3- di *(D oaj{E' ai Oa o. o) oo <H)(D E €. oo N-J(J Ft5teN=' TE9o H) \J r_t €.(D o Ft po oH v) A)+l I 9lot I'r .--:lo -rH9. oj ls E:li! !Jl- oq ICD al< Y*lol- *dlEt &. (D o Bpc (D r_t U) co (D la rI-IJ HItroL5'C):ltri-)E5Ei,5+(D o:5 aQ E. *s(Do@3 F0 t €.(D o a>6-q7l (D(D i-l o o (D aoH o oFn a>oa o. o^ iioLB H<ODo 5e Ee'5 ='a ss s. o J 0l * o f) b,Jo(,\ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ t-JooA\ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ },JooUI\ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ }J o\\ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ N) o\t\ \ \ \ \ \ \ \ \ \ \ \ UJ(! YEAR ONE SUMMARY BUDGET FOR ONCHOCERCTASIS CONTROL IN ILLUBABOR CDTI PROJECT YEAR 2OO3 7.5% NGO overhead cost 2003 CATEGORY APOC MOH NGO TOTAL Personnel 0 73,487.00 2,500.00 75,987.00 Capital equipment 94,235.00 33,845.60 14,187.50 142,268.10 Supplies 57,0t7.00 0 14,200.00 71,217.00 Training 113,700.00 0 12,000.00 125,700.00 Health Education/mobi lizati on 148,800.00 0 19,000.00 167,800.00 Travel 33,762.00 0 7,160.00 40,922.00 Communication 2,960.00 0 480.00 3,440.00 Consultants 0 0 External Audit 0 0 0 Recapitulation 17,000.00 0 0 17,000.00 Operating expense 8,428.00 44s.00 3,300.00 t2,t73.00 Total 475,902.00 107,777.60 72,827.50 656,507.10 NGO overhead cost 35,692.65 35692.65 Grand Total 511,594.65 107,777.60 72,827.50 692,199.75 Estimated No. Treatments 626,690 626,690 626,690 626,690 % input 73.9 15.6 10.5 100.0 Cost per treatment 0.82 0.t7 0.12 r.10 34 ll H t>t, Eb Elr E 19 E b EbE t;tc EL Fts lEk tf, E El3 hhH o{ 6 tu|;lxItls lql- I 8 EI 5 aE 8EEI 6 5 8EE l* ls IEls :6 8 2 EI, E 8 rla iE t- al- slr 8 I li EI HIE H lb 8I }-l 6 i-t^:{ l= sla @l! L 8 8 8 8 8 l= L- t; :l= 88 :[, 6I; EI iEl lcEis FI a 8 ; 8.lrEl l=l Ll! ils sl: *l- a _t- xl: o 8 8 tlu elE 3E I kt:Slsl; iEl 8 3 3 h a 8 (, o\ o) -.t 6ooo(no Percent input tu@sooooo TT(o (/, ! o o o :, ol GI o o o o l cr c =.oJ o m ol o !!, J o o ol o o, lt o . cr o, cr o o o{ ! o o o N)oo o) N)oo5 <N)33 a(n N)oo O) l\)oo! =oI 1' oo \ 10.2. BudgetJustification Please provtde a narrative description of the reasons for each proposed line items of the budget. (1) Personnel Thepersonnel budget reflects the need for staff at all levels (MOH, RHB, ZIID,WHO, an{ -\!Os) to support distribution activities at the community level (CDDs). The MOH and NGO staff will provide support to the program in the form of: o Mobilization of authorities and community leaders o Health education and community sensitizationon the need for the drug o Assisting in the organization of the distribution program o Training of supervisors and CDDs o Getting ivermectin to the pickup points o Transportation of other essential supplies o Ensuring proper supervision of drug distribution o Ensure proper record keeping and accountability o Accounting for funds spent (both APOC and other) o Participating in program evaluation and feedback to local communities MOH and NGO staff is already in place and will participate in program implementation on either a part time or full time basis. Howevir, the degree of involvement in APOC activities will decrease from year to year as the communities take more and more responsibility and ownership of the program. Eventually the CDDs will take on the major local function of the program by the end of five years and with the strengthening of the PHC system, CDDs will become PHC staff and take on additional duties besides Onchocerciasis control. (2) Capital equipment In order for the program to properly function, it must be well equipped. The equipment requested is meant to facilitate the work of the MOH (Regional, Zonal, and Woreda) and NGO staff includes: o Vehicles and motorcycles o communication equipment (phones, faxes, radio operators, megaphone) o Computers, printer, photocopier o Training equipment (overhead projector) (3) Supplies: Office supplies are essential for the smooth running of daily program operations. Since this is the beginning of the program, APOC will be requested io prouiO" all essential office supplies (computer toner cartridges, diskettes, calculators, paper, pencils, pens, fasteners, file folders etc). (4) Training: Training demands relatively higher investment due to items such as transportation, per diems for trainees and trainers, production of training materials etc. It is also an activity that is carried out on a continuous basis, with re-training at all levels as new personneljoin the program, and as CDDs need to be refreshed prior to the distribution period. Being essential to the implementation and success of the program, the following is proposed: At the community level, CDD training is expected to be continuous throughout the duration of the program, with the community assuming more responsibility over time. The training activities will be supported by APOC. APOC, MOH and the NGDO will also support workshops for regional, zonal; woreda staff, as well as CDDs. The NGDO will provide funds for management review workshops at zonal levels. APOC is expected to provide support for the printing of training materials and sponsoring some training workshops. Funds are also requested to support computer training for staff, especially in GIS and MIS to facilitate better program management. (s) Health Education/lVlobilization : Community mobilization and advocacy activities are required to build the support needed to ensure program sustainability. Communities will be mobilized through advocacy campaigns (to gain the support of community opinion leaders), information packets (to educate the media and other parties) visits to the community by MOH personnel from the National, Regional, Zonal, and Woreda levels. General public awareness can also be supported by such techniques as the distribution of posters, brochures, stickers, and T-shirts etc. MOH and the NGDO will provide funds for these activities. APOC is requested to provide funds for Regional and Zonal training orientations, information packets, health education aids such as posters, brochures, stickers, T-shirts and flipcharts. As the awareness for the need for onchocerciasis activity increase at the national, regional, zonal, woreda, and community levels, the amount of funds required will subsequently decrease. (6) Travel: Travel is required for advocacy visits, training, retraining, supervision and monitoring, and evaluation activities are all important for effective program implementation. 38 APOC and the NGDO will be responsible for supporting travel expenses necessary for the implementation of the program. APOC is also requested to provide funding for fuel and maintenance for vehicles and motorcycles, and domestic airfare. (7) Gommunication: At the National, Regional, Zonal, and Woreda levels, telephone, courier and other media means of communication (such as radio and e-mail) will be used among project operators. At the community level, communication will be mainly through the use of radios and megaphones. APOC and the NGDO are requested to support expenses associated with communications including courier services. (8) Gonsultants: Consultants would be required to conduct KAP studies (to help in the development and refinement of health education and other materials); program evaluations, computer maintenance and other aspects of computer work, to ensure total quality management of the program. APOC and the NGDO are expected to support the costs of these consultants (9) External Audit: External audit will ensure proper accountability. Since APOC will support the costs of external auditing specific budget is not indicated in the budget details. (10) Operating Expenses: This will include costs such as utilities, costs of quarterly meeting (NOCP), development and maintenance of MIS. Also included in this line item is the cost of operational research, printing of essential reporting forms (treatment sunmary forms for community, Woreda, ZonaL and Regional staff), household cards, and community registers. These expenses will be supported by APOC. The NGDO and MOH will share some costs such as office utilities. 10.3. Current Resources Available for CDTI Existing CDTI projects (for continuation or expansion) will have resources already available. Please provide a detailed list of alt existing personnel, equipment and suppliis(including vehicles, etc.) belonging to the program, indicating their ownership fUOru,NGDO, other Agency, etc.) and their levet offunctionality. NOT APPLICABLE 39 APPENDIX I: ESTIMATED NUMBERS OF COMMUMTTES AND PERSONS To BE TREATED EACH YEAR, BY ENDEMICITY LEVEL (PIIASE ONE) AREA COVERED: COMMTINITY ENDEMIC LEVEL HYPER- ENDEMIC MESO- ENDEMIC HYPO- ENDEMIC* TYPE OF TREATMENT Community- Directed Community- Directed YEAR t - (2003t4) No. of communities to be treated 2180 326 Total population communities in above 545220 81470 YEAR 2** - (2004t5) No. of communities to be treated 301 8 450 Total population communities in above 754250 112704 YEAR 3** (200st6) N,o. of communities to be treated 301 8 450 Total population communities in above 776123 t15972 YEAR 4** - (2006t7) No. of communities to be treated 3018 450 Total population communities in above 798631 119336 YEARs** - (2007t8) No. of communities to be treated 301 8 450 Total population communities in above 821791 122,796 +Onchocerciasis is not consiaerea an important Public Health problem in hypo-endemic communities and APOC will not normally fund community-based treatment in such communities. The inclusion of such communities in the proposal will require a special justification for consideration by the TCC **lt is understood that the figures for years 2-5 are estimates that may change depending upon the results of the REMO surveys conducted. 40 Ivermectin Treatments reflected in Appendix I were obtained as follows: A total of 783,362 at risk population in the eight woredas are targeted for CDTI for the first year treatment rounds and during the second year an estimated total at risk population of 866 954 from the new five CDTI woredas, considering 37o population growth rate, are targeted for CDTI. YEAR 1: A treatment objective of lWvo EARP of all hyper and meso-endemic communities (626,690) in the selected eight woredas will be targered to allow the program to get accustomed to GDTI, including monitoring adverse reactions, community attitudes towards the strategy and drug, and 3mg tablet management. YEAR 2: with some experience, the program will gradually increase the treatment objective in year 2 to include r00vo of the EARP in the remaining five woredas and ljovo of the year 2003 eligible population of the first eight Woredas. YEAR 3.5 The program will continue distribution of Ivermectin in all woredas targeted for the CDTI. After the completion of REMo exercises the EARp may increase over the four years. Fig 4. Annual Treatment Objective by Endemicity Level ots 900,000 800,000 700,000 600,000 500.000 400,000 300,000 200,000 100,000 2003 2004 2005 Yea r 2006 2007 -Hyperendemic -Meso-endemic . 4t APPENDIX 2: INDICATORS FOR EVALUATION, SUSTAINABILITY AND INTEGRATION OF CDTI Project Evaluation Management Financial Management Effectiveness of Communications Training and Capacity Building Institutional Commitment Fulfillrnent of other relevant factors Problem solving capacity Integration of operational research Project Effectiveness Result of the KAp studies Treatment Coverage Follow up of non-eligible and absentees Management of adverse reactions Reliabi lity o f reporting S ustainability/In tegration Political will of Host government Political will as shown in policy statements and apparent commitment of high-level officials official actions including assigning personnel, funds, vehicles to program Long-term planning Is there a long-term plan for sustaining the financing and the management of the program? Progress toward financial sustainability lf program sponsors cannot continue their current level of commitment for at least another five year, what percentage of mnning costs is now paid for host governments or fees? Progress toward integration To what extent has ivermectin dish-ibution been integrated with other health service programs? Evidence of community empowerment and ownership Change in KAP over time Extent of involvement of both genders and non-literate 42 a cr I o q, lU)lotolcla K lst:t-.kla o) + o =. oI I oooc :, o, f o-l f, a d EA o 0) @ 9..o o)l lmlxlololalo lp.lo- l(D l3 lo lo kot-.(n U, @ ;o(o 6' =0r_ ooo a =(D oi l7(D ko o =o) ;oo ag f o) oI v -(D 7 -(I, v -(D v -@ T -(D v -(I, v -@ 7 -@ o oc o o 5No sNO (o @o Nooo Nooo N) Joa N Joo N oo t>l=l=lc 10, la o, lo, a\ ET(D =lol -l z 9 o o o, {(., ao 5Nbo s Noo (o @bo NoIoo NOobo N) JIoo sNIoo (rl N) srtoo { o 0, o!,ti a ! 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(o o (D =oo o_ o oo o o s o c a, o o o, o o) o- o x. @f. :,(O ro0 o s o co(D o gr 6 o) o- (D x.(t * fo o =o oooo 3 0)o =5' o o s o c U'o o 0, o ID o- o x. an *.l(o 0)x 3 0)o =.Jo o s o @o o 9L a o) o. (D x.o *. =(o E :, o o s o coo o o, (D ID o- o x.o -. (O oo 3oC o C' oc at o 3(, o o o =o 1' oo o =o 6- o o o =' oo f(D o_ m x!,il3 0,f. of =o I aovo =F f m r{ I @cv m C U'cE * o 9t 'n c aa c o o oo qt o o,oo C =6'o -{ o (D 1' Jo =(D m x.(tt =J(O o J a. o m x!, of(o o o 3 o, of. s. o o o o =.!,c o = 7I @ nI @ v -@ n - TD v -(p o oc o o N)ooo Nooo 5oo 5oo oooo cJ o oo o o 3 z 9 o Cl o N Or CD Poo 5oobo 5oobo @Poo @Poo N)boobo -log o oo N)o s o C @o o 0, o o, o. o x. @ =.fo = :, c o U' No s o coo o gt 6 0)o o x. otf. f 3C o =oo ao 0,oo No s o g o =o o 0) c =6'o N)o s o c at(D o (D dE =o =o U'o 3oo mx9 o, =o,f. of A5 o oox oE oo 31fc (D 9.oiF c o 0 oo o 3 o f t-t-C(D (! o n Noz m oc cr og 'Tt c f, c o o 3 oo o o)oo C -. 6' at { o 6-to f o f o m x.o *.J(o o =o o m xt,o3 o o o 3 o, o4. s. CLoo oa!,t o N -o N -o N -o N -o N -o a otr eo f\)ooo (o oo N)oo Noo oooo C3 o oo o o J zI o cf o J,t olOlPoo 'o oIoo 5(rlIoo oIoo oIoo (Jl 'o oobo { o st o oo (,to s co(D c :f c o(t o coo oo olo s o g o J o o OJ c =6' U) coo o mx!,d Jq, d'f =o -I m o r{ =mv mo - m t- - o 'tIIo m @ CN E ET a{ og -n c ='c o o =o(D (r, ! o,oo C -. 6'(t m xEoJ an o o 3 o, o!3 s. CL oo oaE =o5 €(D o o-q) €o d o- 0, €o (D o- o) a oc o o ooo O)oo N)Oo C =o oo o o 3 o @ @ z 9 o C =o { irloobo 5boIoo N -5 oIoo ooIoo og o oo I (Jl o s o c at o o) a ID c f c o6 o c(, o o o =oo (Jt o s o o ; =(D o o) c4. 6'6 mx E.q, o,!i. o , 3 oI -{ o{ r G'(,) z o o{I m o v{ mv o mz mv { o 9l ! o o c)oE 6' -n 0)x 3 o)o = o IClo t(D lo- lolt6 l(Dt-IL l(D TOlr t5' to lo(D E' =(D I o) @ oitoF 0,l o-{ :t (D o o 3Ec o o =oo Ca = d s €o o =o o mx! o ::t, o o 3 ol o3. s o oo o - !,c o J z o o z o o z o o z o o z o o z o o an oc oo Ctroo -{ Oro ooo (, oo 5ooo A @ -o oo c l o oo o o 3 z 9 o cJ .A -5 @ l.l Olo (/) -.1 lrtoo @{ irto N)(,robo (,{ lrtoo -o oPoo Nbo9oo -{ og o oo I N(, o\ 6' c @o o- o o =o =o o,o =s. *o UI 6' c @o o. o c a(D o- o o f,o =o o)o!i 6'o N(,l s a co o o. o o :lo =o o)o3. =oo l\)(,l s ah c U'o o- o o :lo =o (!) c)* s. -.o(, N(,l s =.3 o o c U'(D o. o o) o o =o o)on 6'o I mxp. 0, =o, =lofl s(rl +15 E 813 E 13* l<a !+ lEq lF a' F n d z o o{ - m o n mv o mz{ m7 -lo !L T o 3o 0) N. o N)(I 3(o o ooo It)(, U' o IDf ]Jq) 0)oo o) 3 9_ (Jl oo 3(o o ooo 0)o anI f ticha no(o 6 d o':, ooo:r lo Ftc)lot:lo lo) t(D E U) 0) * oao a l, =o oooE o o) 13 o (D C) o, o-c It) o a ! =.f, o o o)f =.o-(o o o 0) -o) o.{ = o -{ ol(D o0, f =.o_(o o a, E =o ooop. o C] a'xo (D o o *oo aa E E. (D an lmtxIElolfltlot- to l3 Dlo oot, oat, :1 o) -U oo ! oo ! oo l,oo Too -o oo !oo llo c) 1'oo an otr o o (Jr o (, 95(, (,l o (,o -.1(n o C =o oo (,o (/) oo (,(ooo O)o oo @ o) <, o z o o Ot{ 'o Joo N) i$(,l9oo .CJoo9oo (rl -o --l oIoo -.J Nbo C,IoIoo @Ioo (o 9oo N)N sr'oo oIoo { og o o IA -Tt o o o) 3o f o @ o- o o oo o o o s o o 3oo* o 0) o o_ o o)a oa -n o (D rD f o l o(, a-(D lllolols lo l?'l(D l (D o =' o ID o o- o ID U)(D o I E-r(D6i <. o_:ooo(o<(D(D qd +(oilg €EXo =-3Rd6Oo96 1]r(D< 9E= (D o(D fo I o o o9. a d 6'l =lolololxl 'n o f(D @{o o o. o) CN o C o l<o lo tlloko lo)El=lol:l l(D a No Eo oF o Nol o o 6" o o)of @{o o- o. 0) o oo oE(D o) =ol lo l9r lo)lo)f o) l.<- @6' o) c)oocJ -. =(o o =o q.(o f{(D oo- o)o) l!l=.lr lfkolololfloIC lo l;C Foc ITI=lo l8lolofs.lr l(o lo-lololclflotl IU'l\ (Dlool o l-{lo E lr lolalo l-ololc) l(Dlilo lrulolf l(D l(D (D =6-Io ll)(o o I mxg o, Jq,e oJ { og voEo a. J(o o 3 at a o) n- o)(D o 6'o @Crog oo mx!,o oo oJ to4 0 oo o:.t4 o z o o z oo z o o o oc oo 5 (,r oo C a o oo (,(,oo No z 9 o tr .}NoIoo s -o oIoo oIoo oIoo { og o oo 0) 'TIfo Oi he 3E ofr@(, o- o^ova!l :n{o oo 0)o oJ o- Nofo :h o f o ooox o o l @ 0) ololotfl 6l<lol lN)lo l-olo)Iolxl6 loE lo)lolo t*toll lo)t: t<ofolo o) o f a lo lalx l(D I(Dla l'6lf, l(D La lo t0)lft:.lo ko l(D l9 lo to mx E.q, 5q, =.o a 5 O) {o{ t- I l7lmt>laIC t?to |t< 1'(D d o 3 o E.:(D o o ooo <n lololot* Its l=' lf ko lol= loto l-{ lmlxIElot:lo l1 to l3l\oo s. E, oao T' =of ll o C) 1) o C) -0 oo an ocioo (,(,oo (,ooo @ -.I -t(,l c , o oo @ @ z 9 o tr =. -(.,{oIoo -C.)(,o9oo 5 -oooIoo -.1 -oNo9oo -{o I o o ah d fo x N E. f x o €o o o- o) @ oa o o{o d o. 0, an X C,J o :, EIsB ElsE llP olli l-r !*lil'ol+c lE=Bo 6o q' =o zo o .:{ 4 m o 7{ mv o mz mv {o -{ loloo d J. f(o{o * o =oo ld li' lol(f EINlol=lot- l(Dt<lo v lmlxIEl(!lrI1'lot-. lo t3 tolo o ooo J-.!, =o5 zo o z oo U' oc oo Nooo oooo cJ o oo zI o c oo !o o- o o)4 ol f -o o 4 o o- x C' oao x + c o {o !L o o tn mx 5 -{ Noo9oo EEA Ei Fi s+Fs EE. EE BE F:dbEtb 15 oo 9.o o ooo { =.a =.J :lo @ooo a 5' o a =. =3o oooo oo +5I o o o0g !o o a ilT: S!l = o o\o la 5 a :lo o f oooxooo €o aoo oo oIo I 3oo @l No l o_ oo oIo I 3Eo @f mx!o:oo o 3 Do ooooft :1 oJ I,oo z o o 1' oo .I' oo l,oo \, oo ! o c) ll oo o oc oo o N oooo @oooo Nooo c J o oo o ot oooo oooo 5oo o oo oooo z 9 o cf Ab 'o oo 'o o -oooo oo o 'o oo oo @ Ioo oboo oo oboo o o -o o9oo @ .oo obo N -o Ioo -.1o o_ o o o f o o oog ooo o oo ,: oooc 3o f fo o oooJ ooo o fo o Jo a a 3 3cl? 3o 3q o 'n o oo 3 3c a 3og No -.o f olo oo ooo o ITlo lilo l<to IJb lololola lot-kElo lqtot-Et6 o a Nooo ooo = t<lotd tst--lr o o 3o o =Loo 1lo 4 o -3 Bf Eofo o -l oo) o o foo og € o Eo a o.Eo) o 3 {o ooo llo o 6'i df !oao =o .J ool @ o foo o 9. o !o + aEo f d 3 oq o -l Nolo o fo to aoo mx! ofg o: z o oIr m o v{ mv o mz{ mv -{og (D oo fc o llo o a mxto ,o o o = Io ? € o oooat, =o3 zo o z o o o oc oo c a o oo o G 3 ooo ooo z 9 o q J o o ooo oo boo oo o -o o9oo {o D- o oo lololot-lcld l@ lolrId t=. to t3lo lo lftd tolotf a lot-KElo l@lo trlo 6 Nooo oooJ mxEFf0 oa 5@ U'C ct og CG =.oo f a q) =o. o o-oq. o o =o o-' 1'oo ".9oio8 N o cf o oo o x:9s3o z 9 o c a s0 og = (o O)Ioo x x x N) Ioo x 3 (D x o:\ o x o) 'n c o ocf @ o) l o. ET o sr o =do {o a o. ll) o FO loIt ! oo '0 oo at otr oo N) @o (O O)o c = ooo o o 3 @ @ zI o c =o x 9(/)(rl x N e 3(D ln q, oo x 3 x o) x 6" g oo o -.1 o o oo '71 lr > E I{E 16', ali til* !4 lo, EEAGII c,o t =o =ot ovo =t 4 m t- -tI @cv m C =o T t-rC @ @ov Noz mr m I o '?lIo m l=loIl. m 6) -{ =m7 mo I m { 4 o .7,| Io m ut U' trr o er o aC o l, o c) 1' oo o oc oo N o) 5s @ cJ o o an o o 3 @ @ z 9 o Cf o -5ol(4,Nbo -o o 90oo -(,(, @sbo -t o I o o u, (ooo x 3 x 9(,(,r C o, -lxlEI olf,l orl @c E og lC) lC] lo l@IC ho l(D t? l6'l5' J ok f,o o) = o) o. o o) 6 l-ntc l(Dl-lcIU 6'o f, @ OJ f, o. o aE 9. o 3o6; o ol a {o oo o, U' o)+ mxT'(D =oo l, I olfl -u oo ! oo l, oo CI' o tr oo (,oo 5@o 5 @o cJ o oo o o 3 @ @ @ z 9 o C =.o x 5 o. o) o o)of Noo x 3 N x 3 o x oLo x 5 -.3o s x 3o o o x x o o x + @oo s ! oo -lo{ r l-IG, l{lo, | 1.,lo E -: r-- .-i,' z o o{I m o v{ mv o mz -{ mv o sr INloll lsr l-. lalolol-tsl=tilot-tol< (D{ ofl o-i ul ol ifJ 5(o l€lo lo-loloL toto 0 3 3 o o o € o)J o_ p. o,f l fltoi €(D o o-o(/, c I'o 3a 6'f lmlxtt,lol3lo lo of o o s. ooooat, =o z o zo o z o o oo (Jl N)o 5 @o 5oo c3 =o oo o o 3 N) z 9 o c = all -{ (no oo (, NIoo _(/) @5Ioo N) 'o oIoo {og o o an lrllo la. o 3 -ol !ofD =ol No N Eo of a !oo + oo co x + oo o o{o oos a 5(o x o"{ o co o Elsg 6EaEE' T =ls e illi a' IEg eH*v m c oc ET og -{ q_ oo =ofo 'Ttgl x ooc (D mxoo5ao o !t o ? oooo =t =o5 l,oo n oo llt oc oo oo (Io c a o oo A) A z 9 o c5 at LoIoo .N oIoo NoIoo { og o oo oo 3Ef o 6, =.of =. =zo --{ --n Nofoo OJfo{o o o- o)o =' f\) 3of f a o cdo f o ooc :lo = 6 1' oo l=lol-{ I r'r tollld l=l6 o looI l o loo t:o E mx!, 0 t2 oI a 3 o T rt-c ID @o n I m E - o -ttIo m o ET og -t @ oo =ofofI o,x m xto o o o 3 !,oc CLoo oaI,a o = !oo o oc oo @o c5 o oo N) z 9 o c = o (o o,obo (o o,Ioo i og o oo oo 3 cf. o 0) =of {. =zo --{ _Tl o(o o'f o)3 o-{(D o CL 0)o = N 3 of =a mxp. 0, a o, =o5 =oT m oI -{ € mv m tr, I m t-{ + o 'n .Tt o mo an cr og +o o lC =o =o mxt,o 6o o 3 alo 3 CLooo :1t =ot ! oo o oc oo (,l o c , o oo N z 9 o c =o oroobo oloIoo -{og o oo oo 3C :f o o)e o f, E. = o(o o -l Nol _o €o oo o,(, o) =o. =oq, =f o) a. (D tD =' N) 3o f J @ mxEF =!, q ! oo{ o{ r ! oo N io o)obo z o oII m o 7{ mv o mz{ m7 @c cr o t, {o oo =ofo ooc =.o mxt o o o o 3 t,o = ooln oat, =o zo o zo o o otr oo (, o OJo c a o oo t\) A z 9 o c = at 5 @Poo (, o,obo N)obo -{o s oo at oo 3Cf o' 0) o' = =. =z o -{ --n (D(o o -f No f oo o) =o_ to o o. o.}o l N) 3o) =6 l+ 6l @ (D o C to o =e ooC 3o =o mx E- A'5!,4 o (Jr o o{ r = o -(D o- o) o o 0) f fc o) ao s. o{ 3 oo =if,ioa INIolflot_lol<lot;lflllc lolt;o i5' € 3 og f(o lmlxIElolrlo l1 lo l3 o * s ooo o ?t otfl -u oo 1l oo a oc o o 5oo C'I@oo C =o o tn @ :tt o c = o J{ -o oo i\)oo -(rl@oo o gr o oo , (/)o ooop- o x @ o E(D - o- o) x(/) o- o) a + @ l\)oo -o) faEof + @(, oo -o o @ =3of o)g ='@ €(D -o o- o) U' o)o oo oo o x @ o) Eo1 o- o) x (Jr o- o) a + @soo -0) =aEo =+ @ o)oo (D (D a =3(D :J o) o. il5B 8IF E17xh* lHs lH*-l=olo'ollf d I ! a ()l ! l-i, E llEll i'los lEshi cLl=. lrrlloJo- EHl(D=ls vt Lnlo =or o7o =F f m t-{ I @cv m C a { {og oo o o o cg f,(o o o o o o- 3q) f (D :,q) =oo o =o(I) Cq. 5'to f,o{ o =o (D- 3q. f o f o) foo 5o € oo3uc o :r. 'n 0,( .I) Jo ooolJ o oo 3.oo mxt,ofo o o 3 !lof. s tr,o IDo t,c o3 !oo 1'oo l,o C) -t oo l,oo U' oc oo N O) ('roo 5No Nooo ooo c o oo o o = @ @ z 9 o c =o @LN 90oo -o o 90oo 5Nobo Jsooobo -o oobo og o o ,n lG) lo =ol =b o(,(, Ca0 o O) 3of =o o(, 3o o o o 6-o loola o;o ?6' l[o K 6I do(\). o Cr) 3o o c) o oo f o){(D o o_ o)6 lN)lolo 3 o2 = @oir(, Cao - o O) 3o =o @o 3.o ='ul 6a o)J o. oE ID o Nofo (D =do v(Dlo ID o, f, o_ oo ?. oo o oo 3 1C c (D F o)x 0) f o. tJo oo o E l s o =lolal mxEd o, =of (,r, c ct o I o 6'o c =- 6-o mxI,o =oo o 3 !,o =s CLo @o =t * o vI @ q oc oo N(,lo C3 o o tn o o 3 z 9 o C =an Nqtobo N(ttIoo -{og o oo m oo =0. 5{q) o o) o- q_ oE =o =o mxE 0t =olE o3 a =oI t-t-CE E o7 Noz m I m f- - o 'llIo m @c E o !r o =oo c = 6'o mx!o , aio o 3 t,oc s o. oo o :1tl4 o NI o U' o tr o o N)(,l c a o o ao o o = z 9 o c5 o N!,oo N(,lbo -{ o I o oo m oo =o. 5{ o) o ID :, o- o o 1C o:,o mxt, ot =!, * of =oI tr o I{ € m u mo - m { + o .ll lo m ah 3 o 4 -lo -{ - antrg o gL o 6'o c =- 6' @ 3 or €o (D o. o) o oc oo {o C) =o o @ o o 3 zI o c5 o t lrroo -to c,o -.I9oo -.{ o !l o oo m ooC.o :<{ OJ o 0) f o. o 6-o =o o mxg !, AI * o5 zo oII m o v{ m7 o mz -tmv {og ofo o ='oc o) f,oo (D lo o c E fo cg, o o. (D =o o- 3 o) f (D l o) foo c @o o. mxEo =a o o 3 0,o * s. o oooa!c ot z o o z o o z o o v) otr oo (,oo ooo Nooo c5 o o an o @ 3 z 9 o c =to _(l,G'oobo (/)o9oo -o oIoo NooIoo { o t, ooo 5oc 6 foo oo o 0) :o o -n c(D o oi of, o. o(o 6'f, -sr Nof, -sL{o o o_ o) o0I 0i =:f(o o (Jlos oo 3.o(D oo(t o o(D 3. a. fI o :n oE lD. mx E- 0) 0,t o = (,t N 5 -o oo o o tmllxllElloll5ll,J,ll.tl l=ltotl3l lollol t<t l.5l lo-l l8l