Second meeting of the National Onchocerciasis Task Forces (NOTFs) Representatives, Abuja, 17-22 June 2002: minutes of the meeting of the core group held in Ouagadougou in November 2001

African Programme for Onchocerciasis Control (APOC) Programme Africain de lutte contre l'Onchocercose National Onchocerciasis Task Force (NOTFs) of Nigeria Second meeting of the National Onchocerciasis Task Forces (NoTFs) Representatives, Abuja, 17-22 June 2002 MINUTES OF THE MEETING OF THE CORE GROUP HELD IN OUAGADOUGOU IN NOVEMBER 2OO1 DIR/APOC 04/06102 African Program for Onchocerciasis Control Sclf-su fficiency and Co un try P an Project - 2l Novenrber 2001Mcetin of tmplemcn tation u o dougou, I9 4 Minutes. j, l. Dr. Scketeli opencd the meeting by welcoming delegates. 2' Dr' Boatin welcomed delegates on behalf of of oCP emphasising that thc rcsults of the proccss will bcas impo(ant to OCp as they arc ApOC. v^ rrrv t"vr Dr Sckctcli's adddress. t 3.RemindedthedeIegatesthatAPoChasbeenfoundedonthebasisofthreedreams; ' By the year 2007,45 000 000 people, in high risk zones, will be receiving treatrnent yithlvermectin through a sustainable drug delivery system. ' By the year 20 I 0, the number of people receivini treatment will have increased to .5 I ooo ooothrough a reinforced, sustainable drug delivery syste*. ' After the term of mandate of APOC, after 2010, countries and communities will have in place mechanisms cnabling them to maintain the above achievements and to strengtt en una inc.eas" th"number of people under treatment to 59 000 000. The purpose of this meeting is three-fold; r Determine how best to assess whether CDTI programs are in line with the dream of sustainabledrug delivery and if not, what changes are nec€ssary. . Help other countries to develop sustainable drug delivery systems . To achievc this it is necessary to developI An indicator of sustainablity t A framework for project development r A system for feed-back to NOTF. 5' Fuhrre APOC philosophies will be based on the outcome of these deliberations. 6' Dr' Tarimo rcminded delegates that CDTI is about emporvering comn'runities to help themselves. Prescnlations by the APOC team (Background information) 7 ' Blinding onchocerciasis is an onviosly debilitating disease, but research has shown that the skindisease has economic impact on individuals and commuinities. 8. It is important to use a system like CDTI for the following reasons; . There is a need for annual mass treatment over a period of 15 years. . Delivery is not feasible tkough the health service . NGDOs are not able to continue funding for l5 years ' GDTI is useful as a vehicle for the dcrivery of othcr drugs / health services. 9. Thc situarion of ApOC today: . 49 000 communities arc involved in CDTI t 16Yo of communities havc selectcd CDDs + 70%, of communities collect their own drugs t 38% of communitics support their CDDs . 14 countrics arc actively involved . 22 donors . 12 NGDOs . 20 000 000 pcople are receiving trcatmcnt . 89 000 CDDs have rcceivcd training . l3 000 hcalth staffmembcrs have received training o Accountants trained in WHO procedures o l.arge quantitics of capital equipment have been distributed I0. Lcssons lcamcd (o datc: ; . There is a poor knowledge among communities about their rolc in CDTI . Pcrsistent demands for incentives from external partners for CDDs (thc projects may be secn as owncd by government or NGDOs) . Shortages of drugs exist in many communities ( often due to poor ccnsus taking) o Absenteeism (often due to poor empowerrnent) and refusals (often duc to side effects) have a negative effect on distribution figures i I l. The following contextual categories need to be taken into account when considering sustainability; . Category l: stable vs unstable political situation in the country . Category 2: among the stable countires; those with a long-standing history of tvermectin dishibution before the implementation of CDTI under APOC vs new CDTI projec'ts o Catgory 3: those countires with govemnment commitrnent vs those with little or none . Category 4: the NGDO philosophy including a hidden agenda of not empowering govcrnments and communities vs empowerment o Category 5: communities which support their CDDs vs those with no support. 12. Delegates were introduced to the REMO system, which is used to identify high risk zones, and to the Geographic Information System, which can be used to monitor the geographic coverage of CDTI on an ongoing basis. Terms of reference. 13. As amended by the delegates. I. To develop a simple framcwork, with realistic and measurable indicators of sclf- sustainability, taking into consideration options available to countries for filling resource gaps. This framework should help countries to: . Analyse cost implications for sustaining CDTI projects at the end of APOC support . Effectively monitor progress . Plan strategically and make decisions during phase II (2002 - 2007) II. To evaluate the current situation of l0 CDTI projects which rvill be completing their fifth year of APOC support by December 2002. The ten projects are in Nigeria (4), Uganda (4 districts), Tanzania (t) and Malawi (1). III. To assist the NOTFs and district management teams concerned to prepare realistic plans for the ten projects based on careful prioritising, more efficient use of funds and rcplacement of APOC funds with sustainable sources. IV. To assist APOC countries' NOTFs to prepare projects for sustainable post-APOC CDTI, using the framework mentioned above, introduced in good time and systematically in each project during its five year funding period. Discussion arising from the presentations: 14. The question rvas raised as to what APOC has done to encourage communities to really adopt the programs. It is difficult to generalise for programs. I5. When presenting information to communities, thcy do not necessarily understand concepts in the same way as the health worker. Communities tcnd to embrace concepts which touch on their social welfare, other issues may be sccn as rhetorical. This makes distribution in the 'post-honeymoon period', when symptoms havc abatcd, more complex. Materials uscd for cducation may need to be redesigned specifically for differcnt periods of thc program and for different sites. 16. It is ncccssary for thc program Lo bc intcgrated into the health system with the scnsitisation ofpoliticians and communal leaders. Unfortunately thcse people often dcmand incentirres- -ihe problem of inccntivcs is compoundcd by other programs which pay community mcmbers. fnis-issuc necds tobc addresscd and a uniform policy ofincentives derived. Integration Lfth" p.oc"ss n"caslo tat"placc at training institutions as well. i 17. I1 has bcen suggcsted that i[ is more important for the health system to transfer power to communitiesduring the CDTI process, than it is to transfer information. 18. Givcn the diffcrences which cxist bcfween projects and the extrcme situations prevailing in many areas, it is necessary for the instrument to be sufficiently flexible. Dcfi ning sustainability Presentations by Prof. prozesky 19. Summaritd*r. findings of a literature review into sustainability, emphasising the following point: . The different definitions of sustainability o Important facets of sustainability include output, financial, communiqr and systems sustainability 20. Summary of relevant findings in mid term, external evaluation report emphasising the following: . The definition of sustainability . Concerns arising include r the future of the NOTF partnership, r the continued delivery of ivermectin, + the integration of CDTI into health systems, r lack ofplanning for alternative resources,{ the NGDO effect (the belief that they will continue to support program) and r the need for increased flexibilify in phasing out the programs. Prcsentations by Dr. Tarimo 2 I . Summary of report on sustainability . Definition included three aspects; + evidence of communify empowerment, e evidence ofgood coverage and + evidence ofgood support for the district and from the district. o Points of priority included; r The need to ensure support I A lack of costing implications r Ensuring motivation of the CDDS a Procurement and distribution within the powers of government 22. Self-sufliciency and sustainability ' The GAVI report distinguished between self-sufficiency and sustainability o Sustainabiliry targes for EPI werc establishcd based on population size and resource base; giving variablc targets. Discussion arising from the prcscnta(ions. 23. The discussion following these prescntations focussed on thc relative merits of the terms SELF- SUFFICI ENCY, SUSTAINAB ILITY and SELF-SUSTAINABILITY. 24. Sclf-sufficiency: Govcrnmcnt acccpl.s full rcsponsibility for provision of resourccs for CDTI, excluding outsidc sources Has thc advantage of driving governmenb to accept responsibility for programmcs ip thc futurc without giving thcm 'carte blanchc' to raise funds from donor organisations , This is probably the ideal situation, cven if unattainable 25. Sustainability ' ' Ilaving thc capacity and taking thc rcsponsibiliry to mobilise resourccs at evcry levcl of servicc delivery. This starts with determining minimum levels of funding availablc at every level of the program. Implicit in the definition is the need sufficiently empowered people to function at each lcvcl. ' Problems with this model; it is difficult for workers at any level to take responsibility when thcy are dependent on higher levels, some of whom may be unreliable, some levels of health care delivery are absent or minimally functional in certain areas. 26. Self-sustainability . In the proposal documents to donors the term self-sustainability is used as the goal for COttprojects l o It is understood that the role players at different levels of CDTI take the initiative in securing resources Definition of self sustainability 27. The group adopted the term self-sustainability as the desired achievement of APOC rvith the following preliminary definition: t The central concern is that CDTI continuefor as long as necessary, after current externalfunding ceases. To thts end resources need lo be mobilised. The resources must be used as elficiently as posstble, within an integrated sStslem, af each level ' The responsibility for findtng the resources rests with lhe service provider* at each leyel, within lhe framewo rk of gover nnten t p ol icy Thts will require each sertice provider to supply lhe ntajor proportion of resources itseluf to ensure lhat the continuation of CDTI ts safeguarded. *This tncludes all levels of governement, including the village community Prescntations. Financial sustainabitity (Dr. Runumi) 28. It is important to understand the cost per unit of activity before trying to determine or to convince others of the necd for sustainability. To do this it is neceassary to defne activities at each level and then decide on the ability to cover costs and means for funding. Are people able to make these decisons at each level? Sources of funding, at each level, may include government, self collected revenues and inut from well-wishers. 29. It is necessary for government structures to identify their own prioritites for funding at each level. It is the responsibility of those involved in CDTI to ensure that their programmes are priorities. To do this people are going to need to be innovative. One needs to explore opportunities as in the SWOT model (strengths, wcaknesses, opportunities and threats) Systcms sustainability (Prof. I{omcida) 30. Systems are as important to sustainability as are financcs, evcn though they may differ betu,cen areas 3 I . The characteristics of a good systcm includcs the follou,ing: . It needs to answer the necds of the program r It must comply with the system within the country r [t must stem from local organisations, Iike the primary hcalth carc system a a a 32' I thc first few ycars of its life, a ncw system is vcry powerful, duc to Lhc abundancc of rcsourccs.This powcr may havc ccrtain spin-offs: . Thc local organisations, likc pHC, may bc revitalised . A forgoU.en discase may bc addresscd ' Thc systcm may bc secn as foreign, due to its lavishncss, and kill any local scnsc of owncrship 33. Local organisations Iikc PHC need the CDTI program bccause: , . It has bcen shown to rcvitalise the pHC system in areas . It may be the only health program in many areas ' Many othcr hcalth programs, with similar patterns, may bc ntcgrated into CDTI (e.g. trachoma,iodine supplcmenta and Vir A distribution) 34. CDTI needs effective health systems because: , o A strong organisation and system is needed to make distribution effectiveo CDTI benefits from having trained health workers in areas such as drug ordering and storage, outreach, etc. Community sustainability @r. Ekcjiuba) : 35' The role of women in the program needs to be enhanced because the perspectives of the two on health matters is different. Women need to be purposcly and effectively inciudei in th" p-;;;;. 36' The concept of commuities needs to be extended to include communities of role players. It is possibleto create intemational communities, inter-distoic communities and even inter-communit communitites. These bodies could function as alliances to discuss problems. Discussion arising from the presentations. 37' Again the importance of integration is emphasised, particularly with a polyvalcnt person at the frontline posisiton, responsible for all services, not having visiting:experts'. This allou,s the health workerto work in a tcam with the communiry. 38. The question of the definition of integration, its elements and the expected depths, needs to be addressed by this group. 39' In the absence of PHC facilites attempts have been made to create village health commiftees which can make demands for other health services. This is seen as being an important aspect of pHC, which in essence is what people can do for themselves. 40' The district level has been identified as the critical level in the process of CDTI, and attention needs tofocus on ensuring supervision and support from this level. These activities alsoneed to Ue integratea. 41. Parallel systems, for example drug importation, are identified as being poorly sustainable. Oneproblem is that if Mectizan becomes an essential drug, it is necessary for it to be stored in aitpharmacies, irrespective of the presence of disease. 42. Countires need to set specific targets for sustainability with time lines and including cost implications.New projects will need to plan for this 43. The issues of CDTI in conflict zones needs to be addressed clearly. [t was felt that tis is a separateissuc. 44. Conccrns regarding gendcr sensitivity were raiscd. It is important Io pay attention to the composition of the facilitatiott tcams. Expericnce has shown that ttrc gendcr composition of facilitators influen""s outcomcs. Gender influenccs sustainability in that women are lhe primary hcalth care givers within any family and (hcrcfor play a multi-facetcd rolc in compliance. At prcsent there is a 6ar that theprogram appcars to bc a male driven prograrn, excluding a largc portion of the population, bccause wonlcn arc not involvcd in dccision ntaking processcs. Is it possiblc to dictate gendcr scnsitivity, ignoring comunity and cultural scnsitivitics? It is fclt that it is imortant to looklor opp.tuniti", toincorporatc womcn in thc program, and by achicving good results to cncouragc growing involvemcnt. 45. A similar conccrn was expresscd for youth. Efforts ned to bc incrcased to includc the'r for the sustainability of the program. .46. A na{.ional day for Onchoccrciasis was mentioned as a possibiliry for mobilising resourccs and intercst.By having a national day,and thereby emphasising that this is a national issue, Interest is more wide sprcad and non affected communities may also be mobilised. Il'l:[frT[il."H"T"::'#i:J,:i]:',]:Bi'lll;,,o A,,ached , 48. From the discussions it became apparent that the following are the important predictors ofthe sustainability of items in the instrument. [t is necessary to ensure thaithese aieas of investigation are covered at each level of CDTI activiry, for all subject headings. o CDTI activities are affordable and uncomplicated o CDTI activities are carried out well . There is a good attitude present among CDTI workers 49. Delegates were asked to identify, for each level of CDTI activity, the sources of information needed under the following headings: . Source . Size of sample . Criteria for sampling o Method of recording data collected in the field . Method of analysing data. 50. From the discussion which follou,ed, it became claer that the following are criteria rvhich could be applied to sampling district, sub-districts and villages: e Coverage rates . Geographical spread . Population density . Population size r Ivermectin distribution before the advent of APOC . Incidence ofside effects . Ethnicity of population 5 l. Dccision was taken regarding the sample size: o No. of districts to be sampled per project: o Uganda- I t Tanzania-2 r Nigeria - 2 r lr,lalawi - 2 No. of sub-districts to be sampled pcr districl r Uganda - I r Tanzania - 2 r Nigeria - 3 r lr,lalarvi - 2 a a No. of villagcs to be sampled per project: I 6 for all countrics cxccpt l2 for Nigcria 52- Thc timc which is rcquircd for cach visit to a project will vary, but can be expected to bc about l0days. Work of the ficld (cams. 53. The composition of lhe tcams should include cxternal resource people and membcrs fronr within ihc countries / projccts. - It is suggested that 3 cxternal members include a NOC, a Health economist, a social scientist and someonc involved in pHC. ' Intemal members should include people involved in programs, both the program beilg assesscd and some not involvcd. Mcmbers of the health team should be taken on board as fullieam members at each stage of the visit i 54. The elements of a visit should include the following: -. ' The instrument should go to the county before the planned visit notifying peoplc as to which data is requircd at each level . Informing the health ministry . Planning with the NOTF allowing changes to the instrument r Data collection o Mecting with the NOTF to analyse the findings and to plan for self-sustainability . Meetings to inform I (he health ministry + The DHMTs in the projects being evaluated r DHMTs in other, newer projects o Feedback to communities should take place at the community during the visit or a firm commitment made for follow up. 55. Timing of the visits shuld be undertaken in consultation with the NOC and NOTF beforehand. Distribution time should be avoided. Uganda has requested visit during March and April at the earliest. Nigeria request no visits during January and February 56. Preparation for the visits should include: o Arrangements to be madc with Ouaga at least 4 months ahead of time r Arrangements to be made rvith the counkies . Identification of documentation required at the projects . Finalising documents we need to take with us i Instruments a Source documents 57. The report format should include: o Detailed findings (according to headings in instrument) and analysis thereof . A judgement of the degree of sustainability or time to sustainability . Report on sustainability plan made for project I Activities I Indicators ? Dates for implementing changcs . Raw data 58. The package rvill be pre tested after inputs from all delegates, probably in January. 59. It is necessary to develop standardiscd data points which can be entered and analysed, rvhich rvill allow thc projects to use the rcport as a baselinc for futurc assessmcnt. aa i i Plan for 22 Novcntbcr 200I Rcfinc thc documcnt on intcgration Dcvclop a grading systcm for sustainability Rolc play thc instrumcnt Operationalisc Lhose patu of the instrumcnt referring to finance Standardisc a rcport format ,AFRTCAN pRO6RA^4rr4E FoR ONCHOCER CT,AS.IS CONTROL (APOC) SELF-SUFFICIENCY AND COUNTRY PLAN PROJECT ,,TEETING oF IAAPLE,IAENTATI,N 6R,UPOUAGADOUGOU, !7-23 NOVEAABER ?OOI ,r^rNurEs FoR ?!-zz NOVEA4BER zool 2l't November' The Iate afternoon session dealt with the item on integration of GDTI withhealth services/PHC' In introd';id tiJsublect, o. r".i." prnted out thit integration is a series :i;'ffiil;iflSrfiH:t''s aimed ui*.ing that services u.i'rr."a as much as p;ssibre when trre Integrated services benefit from economies of scale and are more cost effective than verticalprograms' Another advantage is that integrated services ure popuru. with crients as they canobtain several types of '"'ii.", in one ,irit/"r.oun* p.our".s with integration of healthservices include concems of some staff with girirg ,p in;"rtirr.. urro power that go with verticarprograms' Another concern is that at timei irrEg.I,ion-.,uy u" counterproductive. Benefitsincrease with integrati,l but 3, 1"r.'poirt ben"f;ir't.gir'a decrease. thi, is because overrntegration leads to bureaucracies that -ut" a..irio;-;;i?;.ore and more difficurt. In the discussions that followed reference was made to ongoing studies in uganda and Nigeria.TCc is also reviewing a numbe.-orp.oporuls. Three ,""ru'.ior"orintegration were presented:Programs are organizid and imple-;ri;; separatery from the centre to the periphery; programsare separate at the centre, integiated at Regional/P.o"i".iui^r'"*rs and separate again at the +f:'[ffiT":""'#jff];::,'::ffi'"".T's#a''ffi;;,i.o,,ll,,ri,;";;;;;;fi'[*".,eve,s Below are some other comments and issues raised: iffffifl:xffiIi*i:'ftH,T:x',ment, cDrI is abour mass distribution of druss once a il,ff H :: J:[HLJ.'i,ft ";l;Xf Jiffi I []T ,;*:i c i rc u m s r a n c e s s e rv ed as en try { a There are several initiatives trying to integrate CDTI with Role-Back malaria. It was important to identify activities that can be integrated with CDTI. For example in the case of Onchocerciasis and lymphatic filariasis no diagnosis is required before treatment is given. But in the case of malaria diagnosis has to be made before treatment is provided. Can these programs be integrated? It was clear that the form integration of CDTI takes has to be worked out at different levels: the community; frontline health facility; district and central levels. Reference was made to countries X and Y. In country X, procurement and distribution of ivermecten is integrated to overall health services. Country X has persistent low coverage with ivermectin treatment. [n country Y the CDTI coordinator obtains ivercmectin and distributes it from his office. Country Y has persistent high coverage. Different views were expressed on which of the two countries has more potential for sustaining CDTI. The importance of carrying out SWOP and other studies on integration was emphasized. Communities, through local development committees and other mechanisms should be actively involved in these studies Finally it was agreed that Dr Tarimo would develop a briefing paper based on the discussions and relevant materials from APOC and other sources. 22"d-23'd, November. Grading system for sustainability Prof. Kale introduced the item. He grouped all the indicators in the instruments into 4 broad groups namely: planning, financing, monitoring and supervision and mobilization/coverage. The 4 broad groups were ranked differently at the National, District, Sub-district and Community level, depending on the perceived importance of the indicators at the different levels. Issues raised were discussed by a group, which later reported to a plenary session. As a follow up to discussions and suggestions made at the meeting, Professor Kale has modified the grading system on the lines indicated below. The matrix, in both tables I &2, below, is self-explanatory. The four levels of operation (national, district, sub-district & community) have equal rating-50 points. The meeting in Ouagadougou, listed'Leadership'as one of the ten activity indicators, as shown in table 1. However on further reflection it is clear that this is NOT really an activity, and that it is not readily amenable to objective quantification as an indicator of sustainability. Like 'capacity building', it should be dropped from the list. In its place it is recommended that an important sustainability activity indicator that was apparently overlooked as such at the meeting, viz. 'Record Keeping', (including report writing), should be included, as shown in Table 2. NB. Planning and the three coverage-related components of ivermectin management (procurement, delivery and distribution) the importance of which featured very prominently in the discussions at the Ouagadougou meeting have been given double the standard (20 points) weighting of other activities. NB' It was agreed that the various aspects of treatment coverage (Absenteeism, Refusals etc.) will be 'investigated' separately from the sustainability perspective. Thus it is not featured in this exercise. Comments and suggestionsfor modification and improvement are nrcst welconte, especially on l' How to accomntodate the Zonal and State level conjigurations of the Nigeriart progrant, and 2. the cut off pointsfor judgement on ptobable and unlikellt sustainability of assessedprojects. Table I of Indicators Table 2. of Acti' Indicators Activity National DistricULGA SubdistricUHlth. Dist. CommuniQr Total Comments Plonnin l5 t0 l0 5 40 Doubly weighted Financing 8 6 2 4 20 urceReso mobilise 5 5 5 5 20 I 9 8 2 20 l0 IO Plus some delivery l0 l0 20 Distribution t0 10 Plus some 'delivery'Su nitor 2 6 t0 2 20 l-eadcrshi p tt 2 2 8 t0 '.) Nor rcalll, an 'n ctl\ lty'!Com. Mobilisation I 2 3 t4 20 Total 50 50 50 50 200 lcjivity National DistricULGA SubdistricUHlth. Dist. Community Total Comments Plonning l5 l0 l0 5 40 Doubly weighted l0 4 2 4 20 Resource mobilise 1 5 3 5 20 I 9 8 2 20 Y lt Trainins Tverme ctin: Procurement Delivery Financins Training Ivermectin: Procurement l0 l0 Plus some 'delivery' Deliverv l0 10 20 Distribution l0 l0 Plus some 'delivery' Supervise/lVlonitor 2 6 l0 2 20 llccorrl kccllirrg 4 4 4 8 )tl Com. Mobilisation I 2 3 t4 20 Total 50 50 50 50 200 Role playing to assess self-sustainability of CDTI, using instruments developed by the meeting. National coordinators of Nigeria and Uganda were the respondents, while all the participants acted as the interviewers. Prof. Kale was the judge. The instruments for National and District levels were used sequentially. The role-play showed strengths and weaknesses of the tools. They also brought to the forefront, the need to pre-test the instruments so that useful and analysis information would be elicited. People to be interviewed at the National level to include the Minister, the Permanent Secretary, key Directors and National Onchocerciasis Control Program Coordinators. However, the NOCP Coordinators should be contacted to help decide on the people that would be interviewed. It was recognized by the group that advocacy is a big part of visits to Ministers and other senior staff at the National level. The procedure for applying the instruments was agreed on. Respondents should be informed in good time before the visit, so that they would have time to collect relevant information and documents. The group agreed that a triangulation of methods would be used to ensure the validating of the responses. For example, if the respondent claims to have reports of mobilization, the team could gently ask for documents that could shed more light on the claim. Another example is that of National level claims to feedback to Districts, the team would find out from the district whether it received the feedback. I operational format for the costing and financing at all levels. A team of economists worked on the abo-ve subject and reported back to the plenary. It was acknowledged that the framework might differ from country to "orrtry. Headquarters Headquarters ITEMS OF ACTIVI TY THEIR MEASUREMENT a) Are all the financial costs for CDTI included in the national budget? Capital costs for all activities included. Reassessment costs for all activities included. a b) Has the most viable economic plan been chosen on the national CDTI justifies the costs for differenia The Ministry outcome.activities their immediategovernment provide adequate funding?c) Does the a a The funds fromare Mithe annualnistry's budget Government moreprovides than o thef(70%) in estimated costs and amountd) Is there shortfall provided? on costs matched with available funds.Plans to raise extemal/more funds to bridge the shortfall. a a Data ITEMS OF ACTIVITY THEIR MEASUREMENT capital and adequate reassessment Has the best economic option been chosen on Are there costs? the national CDTI justifies the expcnditure for altemative plani Capital costs budgcted for recurrent costs budgct. a a Ministry Has the most viable economic plan been chosen at the national CDTI plan? Are all the financial costs included in the national budget? funds are from the Ministry annual budget. Government provides more than 7O%o of the budget. Ministry justifies the cost activities. Capital costs procurement/storage/distribution a a The in estimated costs and amountIs the shortfall provided? a a fundsThe are from Mthe S annuainistry budget Government moredes than of the shortfall in estimated costs andd) Is there amount provided? on costs matched with available funds. Plans to raise extemal/more funds to shortfall. a a bridge the Data District Sub-District As in district. Communit-v ITEMS OF ACTIVITY THEIR MEASUREMENT Are financial costs of different activities quantified in the budget? The capital and recurrent costs are clearly in the a Has the most viable cconomic plan been chosen? DHMT justifies costs of different activities by their outcomes. a Is there a gap between estimated costs and budget? Data on costs and funds available and gaps in funding known. Plans to bridge the gap and from what reliable sources. a ITEMS OF ACTIVITY THEIR MEASUREMENT Are the financial and non-financial costs of CDTI known or estimated? The community provides on estimated of the costs of the different activities: - Training - Mobilization - Community meetings - Distribution - Supervision - Transportation - Collection of drugs - Management of adverse events. Has the most viable economic plan been chosen? Community justifies the costs of different activities by their outcomes. a What funds are available at the community level to take care offinancial costs? Community bears lb0% of the financial costs of CDTI: - Transportation - Collection of drugs - Management of adverse events - Other financial costs. a How are shortfalls between financial costs and expenditures taken care of? a Presence of communal fund raising activities of CDTI: - Are people willing to paylcontribute - What other strengths are in place to raise money for CDTI. a a Dr Seketeli's Discussions with participants. ln welcoming Dr Seketeli, Dr. Tarimo explained that the group had almost fulfilled its TOR. He indicated that participants had given their best, productivity of the meeting was very high. Dr. Sek6t6li was impressed with the work done. He pointed out the work was being carried out ingood time for phase II of APOC which begins next year. He will be briefing the n"ext meeting ofJAF (December) and was expecting appreciation and support from the body-on the work donJUy the meeting. Instruments developed by participants would be useful for assessing sustainability and monitoring of ongoing projects. Finally he hoped that many participants in iire meeting *oula b" available for fieldwork to assess sustainability of projects and to pass their knowledge to CDTI staff. Format for reporting the findings from project instruments. Three suggestions were made: o Under section on Background, add "Endemecity of oncho", just before Oncho control activities. o Add a section on Conclusions just before "Report on sustainability plan made with project,,o Omit the peni-ultimate section, which begins with "Framework by irofessor Kale',. Minutes of the meeting Suggestions made: o Section 8. First bullet to read "There is need for annual mass treatment in each communit-v over a period of 15 years". Second bullet to read ". Adequate treatment cov;;;e cannot be achieved through health services.I Section 22 to read on the following lines, "The GAVI report on EPI distinguishes between self-sufficiency and sustainability as follows "Although self-sufficiency is the ultimate goal,in the near term sustainable financing. ... ability of a iountry to mobilLe and efficientli usedomestic and supplementary extemal resources on a reliable-basis to achieve target levels..ofperformance" should be the goal.