Surveillance and control of onchocerciasis and trypanosomiasis, and other blinding diseases: devolution plan

Onchoccrciasis Control Programme in West Africa Programme de Lutte contre I'Onchocercose en Afrique de I'Ouest. JOINT PROGRAMME COMMITTEE Office of the Chairman JPC .CCP COMITE CONJOINT DU PROGRATVIMEBureau du Pr6sident JPC10.7 (A) ORIGINAL: FRENCH November 1t8t Koulouba, August 1, 7989 JOINT PROGRAMME COMMITTEE Tenth session The 4-7 Becenber 1t8t Provisional aeenda item 9 MINISTRY OF PUBL]C HEALTH AND SOC]AL AFFAIRS NATIONAL DIRECTORATE OF PLANNING AND HEALTH AND SOCIAL TRAINING Telephonez 22 48 38 Koulouba NATIONAL D]RECTORATE OF PUBLIC HEALTH Telephone: 22 58 12 Koulouba SURVEILLANCE AND CONTROL OF ONCHOCERCIASIS, TRYPANOSOMIASIS, AND OTHER BLINDING DISEASES: DEVOLUTION PLAN l\",(^' I t }IAP OF YALI SHOIfING ONCHOCERCIASIS ZOIYES f. Hcn-onchocercal zone Onchocerciasis zone: Devolution PIen Orlginal IlB0/OCP Progreme lrGl coyered by the IffiI onchccerclasls zone: Ifestern ertenslon of IIBO/ocp erea, not coveredby the Devolution Plaa AIEEIIA I{ATIBITAilIA ts E N E B A L IIIGET !T'RKINA-FASO , B.ET W. Su.i:;,r GUINEI COTE D'IVOIRE a -3 TABLE OF CONTENTS SI]MMARY 1. INTRODUCTION 2. EPIDEMIOLOGICAL SITUATION Onchocerciasle Af rican human tr5rpanooomiasie Curable bllnding dl.seasee I'IAIN LINES OF SI,RVEILITNCE AT{D CONTROL OF ONCHOCERCIASIS, TRYPATISOMIASIS AI{D OTHER BLIITDING DISEASES The present 8tate of the health care sy8ten ln Hall The national epldeoiologlcal end entomological cunrel.llence eyBtem 4. OBJECTIVES OF THE DEVOLUTION PI.AII Onchocerlasis Trypanosomiaele Blinding diseases 5. DEVOLUTION PIM: II{PLEMENTATION STRATEGY Onchocerclaele Af rlcan hr:nan trypanosomlasis Blinding dleeaeee 6. MONITORING AND EVALUATION HonltorLng and coordl.natlon of the Plan Evaluatlon of the Devolutl.on Plan 7. RESOT'RCES A}ID COSTS OF THE PROGRAM Eunan resources Materlal resources Cost of the fLve-year Devolutl.on Plan TIMETABLE OF ACTIVITIES AT{NEXES 4 6 7 14 14 14 14 2.L 2.2 2.3 3.1 3.2 4.L 4.2 4.3 5.1 5.2 5.3 6.1 6.2 7.t 7.2 7.3 7 9 10 3 10 10 13 14 14 16 L7 18 18 19 19 19 19 19 8 9 2L 23 L 2 3 4 Areas included in the Devolution Plan and areas affectcd by trypanosoDiasLs Organization chart of llinietry of Publlc Health and Socia1 Affalrs Estimated cost of the Devolutlon PIan List of technical equipment 26 28 32 4- SI'MMARY The onchocerciasis control operatlons undertaken by the hchocercLasis Control Programe (OCP) in MaIi affect tro dlstlnct areags (1) The weetern ertenoion area, rtrere operatione began ln 1985-86 and are 8t111 in the actlve 8tage. (2) The orlginal progralule area, rhere operatione began tn 1975. The epider.iological data relating to onchocerciasis before that dete shorrs thEt the disease was highly endemic, with onchocercal bllndness rates of about 12 percent. In this zone, shlch l.ncludes about two flfthe of the area of the country (with a populatLon of 3,800,778, and poeeeBBes great nltural Potential for socioeconomic development, the auccees of OCP has beea euch that the consolidation and surveillance rctivltlee of the control progrtm vll1 ln future be directed by the t{lnletry of Publlc Eea1th and Social Affalre. These tcrivities will be lntegrsted Lnto the nrtr.onal publlc health EysteD, rhlch is based mainly on decentrallzed local egenclee. At thle level, r11 eocl.al end health services are provided through the DLetrl.ct health ceaters. At present, tranemieelon of the dLseEee hae been brought under control ln a large part of the eree. Bowever, vector relnfestatlon has occurred in the Kati, Bougouni, Kolondlebe rnd Yanfo1lla dLetricte, rtrere the epidemlologlcal data are leEs encouragl.ng and warrant the Latroductlon of lvetmectln treetment. Once begun, the treetEent w111 need to be rePeated eech year. The eucceee of OCP le thrertened by the fact that Africrn human trypanosomlasie and otber currble blindtng dl.aeaeee remel.n preieDt ln the oncho-controlled areae. The etrategy of eurvelllance end control of onchocercirsla vll1 include: passive detectl.on and treatment (slth ivenectl.n) through the petmanent eerrrices rt the dletrlct heelth centers; actl.ve detection and treatnent through eluple eptdeolologlcel skln enip surveye, follorred by nass Lvermectl.n trertment lf necessery; monLtoring of lndlcator vlllagea cvery three yeara. * * TrypanosomLaeis eurvel.llance and control w1.11 detectLon and treatment at the dietrlct health centera, medlcal Burveys uslng parasltologlcal and Lmunologlcal l,leasures to deal sith other blindlng dlseases decentralization of the follonlng eervlcee: * ophthalmological care ; bc conducted by passive md entomologl.cal and technlquee. w111 be bered on * -5- detection and treatnent of ei-nple eye aJ.lment8 rt tbc bcrlth centere; treatnent of compler eye Lnfectlons by the noblle aurglcal tear06. A11 these actlvities w111 be carrl.ed out by trelned generaliet etaff at the health centers, eupervieed and eupported by the coordinatlon unlt of the Divlslon of Epiderniology and Prevention (DEP) of the National Directorate of Public Health. Further traJ.nLng of the eristl.ng etaff , and lmprovemento both in resources (logistical eupport and technicel equlpment) end the mode of operation are essential for the effective lmplementation of the Devolution Plan. The estimated cost of the propoaed five-year proJect ie CFAF 811,365,395 or USS2,704,551.31 (US$1 - CPAF 300), wlth the follorrlng breakdosn: * * Capital cost Operating coste Evaluatlon Subtotal Contingencies (101) Tot8l cost Cost in US$ ($1 - CPAF 300) CFAP 479,794,903 CFAI 248,810,000 CFAF 9.000.000 CPAF 737,604,903 73,760,490.3 CFAF 811,355,393 us$ 2,704,551.31 t 1-6- INTRODUCTION In the past, the Republlc of Mall has benefited fron occrrional short-ter:sr, localized onchocerciasla control oPerations. This earlier e-perience eenred ae a baels for the preparation of a broader progran, lmplemented by IIHO. The OnchocerclasLs Control Programe (OCP) Iaunched by TJIIO in 1974 covered e Bore ertensLve area, lnclgdlng terrltory belonging to severel different countries. About 202,658 km- ln Mali cane under the progratrrne, including the whole of the Sikaeeo region and part of the Segou, Koulikoro and Moptl regions (for specific dlstrlcts, 6ee Anne: 1). It should be emphaslzed from the beginning that the origlnal Programte area covered only part of the total territory in Mali affected by the disease, with eI] its socioeconomlc consequences. The other regLone rere later Lncluded 1n the wegtern ertenolon arer. Thie ertenel.on vae approved Ln 1984' and operations started there aB recently as 1985-85. The proposed devolution of control and sunrelllance, EB deecribed in the present docunent, concerns only the oSlglnal OCP area tn l{a11. The 3,800,778 lnhabltants of these 2O2,658 km- are faced wlth other eerious public health problems. The National Onchocerciasls Comlttee (Conlt6 Natlonel de Lutte contre I'Onchocercose) will be responslble for operation of the devolution plan, and consequently lts ephere of actl.vitles w111 be conelderably enlarged. Follordng the vieit of a IIHO/OCP coneultatlve mlesion to the Government of Hall in 1986, the Natl.onal OnchocercLasis Comittee prepared and submitted a devolution plan to the Joint Progreme Comittee (JPC) ' vhich met in Geneva in 1985 and Accra ln 1986. Taking into account the evolutlon of the concept of devolution' Mali fully accepts the idea of progreesive Pertl.clPatlon ln the Progrrnrme. Accordlngly, the Government Lntende to erpand health servicee, Ptrtlcularly at the local level, Bo that they wlll be able to a88une responslbllity for eurveillance and coordinate all ectlvitl.ee aLned not only at mal.ntalning the gains achieved by OCP in the publlc health fleld but a18o et promotlng eocioeconomic progress in onchocerciasis-controlled treas. However, in those places where onchocerciasis has been brought under control, public health problems remal.n. Theee arl.oe ',. m other curable and preventable blinding diseasee, as ve11 ae African hurnan tryPanoEonLais. Such diseases threaten the development of the zones vhere onchocerclaels hee been controlled. The fundasrental objective of the Party and Governocnt of l{all ls ful! comrand of rrater and land resources, ln order to Pronote fOod eelf-sufficiency and securlty, and therefore thLs document aleo tekea lnto lccount trypanosomiasis and the curable and preventable bltndlag dl.reaees. In light of the encouraging results obtained by OCP, the National Onchocerciasis Cogmittee has set forth Ln this docurnent the proposed t -7- objectives, strategy, actl.vitl.ee and orgrnlzatlon for the .urvalllencc end cor,trol of onchoceitieeie, Afrlcrn huoan trypenoroml.aeir end othrr bltndtng diseases, as part of the nstlonal health care s]r8tem. tte docrunt elro identifies the local (operatlonal) and central resources needed ead provldes an estiglete of the cost of {qplementing the Devolution Plan. It should be noted that the actLvLtlee deecrlbed reltte oDl, to the devolution zone. 2 EPIDEMIOLOGICAL SITUATION Onchocerclasls Epidemioloclcal eltuatlon orlor to the etart of lawal control 2.L 2.L.L The OnchoceSciasie Control Programe la the Volte Rlver baein affects an area of 202,558 km' Ln Mali, wl.th a populatlon of nearly 4 rnllllon(3,800,778). Ir cover8 baelcally the South and Southeaet reglons of the country, west of the Niger River. Almoet the rrhole of the rLvcr beein sy8teE is affected, particularly ln the Slkasso region. Onchocercl.aels vee g,enerrlly regarded ee e publlc heelth problen Ln these rrea6, strlch are othemlee favored by Nature. The caee of the Prrako vaIley (in the Sikaeeo reglon) te elgnlfLcant beceuae of the epecLal attentl'on It was given. llell knorn ae a hyperendeml.c focue vl.th overell bltndnee8 rates as high as 12 percent, Lt received eporadlc lanrlcidtng treetaente wl-th DDT in 1966, before the advent of the OCP. The lnctdence ln 1971 ead 1976 renged between 3 percent and 10 percent. A11 of the focl vere locetcd Ln operatlonal zones 10.1 and 10.3. In these zone8, 56 percent of the crPture polnts bad an ATP (Annual Transmission Potentl.el) of over 800, reflecting e hyperendemic situation, while for 35 percent the ATP vas betveen 100 rnd 800. The follorlng teble ehowe data for the varioue rl.ver valleya froo the rePetted epidenlological Burveys, borh baslc and detal.led (ophthaLuologlcal), couducted rB pert of OCP in a nugrber of vlllages ln L976-77. Flndinqe of the OCP Survevs Zones Prevalence CMFL* Bllndnee s Uas soulou Banifing IV Konl-Fawara (Bani) Kank€laba Baou16 2s.502 23.L02 9.631 39. 312 85.99t .90t .702 .902 .602 .902 71.002 68.40t 45.702 68.702 89.602 1 1 2 L2 7 *CMFL = Cosmunity Mlcrofllarial Load -8- These figures, collected before Lasectlcl.de epraylng bcgen, reveal a hyperendemlc sltuatlon vlth uarked developnent of paraeitlc dircerc er rhcnr by the high CMFL, and an elevated bllndneee rate. The sLtuatLon ln the Bandlagara-Bankaoe zone, ln thc l{optt region, le less alarmlng. There, the rlek of onchocerclasl.e lnfectl.on le ereocl.rted rlth the artificlal breedJ.ng sltes created by the ensll deos coaatructed aB part of the socioeconomlc developoent of the area. 2.L.2 Epidenniolosical lmoact of vector control Of the varioue lanrlcldlng operatlone ln the orlglnal area of the Onchocerciasis Control Programe, only pbaeee l and 3lJeet applted to Mali. During phase 1, OCP began larvlcldlng on the eestern border of Malt ln 1975, covering the Lotlo, Farako and Banlflng IV. Ia 1976, durlng phaee 3 lfest, lanrlcldlng operatl.one covered eaetern MalI ae far eB the Nlger Biver, including the Bago6, Baou16, Ba16, etc. A detalled analyele of the date for the Farako zone Lndlcetee thlt the number of new clces of onchocerclaeie va8 very rnall efter thLr focuo rr8 brought into the OCP lanrlcldlng area. From the earll.er highly endeml.c eituation, prevalence felI to about 1 percent. Of the 554 eubJecte examl.ned in October 1983, only flve Ln the 3O-year age g,roup were found to be carrl.ere of nlcrofllariae, toplylng that oearly all thoee fomerly Lnfected vith theprraoite had been cured. Ocular paraeitlc lnfection had elco dl.eappeared. Slnce L976, only one case of mlcrofllarlae in the lnner chamber of the eye has bcen detected. Overall, the rcaulte of vector control have been cacouraging, from both the entomologl.cal end epldenlologl.cal .trndpoints. Prevaleace retes by 1989 had declined by at leaet 70-95 percent, vlth CHFL flgure8 approachl.ng zero and a bllndnese rate donn to alnoet zero end Lt muet therefore be concluded that larviclding has aucceeded io controlttng tranemleelon of the dlceaee. Onchocerclaeie is no longer a publlc health probleo ln the orlgLnrl OCP tree of Mali. 2.L.3 Reinvaeion of the onchocerclaeLe-controlled zonee and lvernectln treatment In eplte of the encouraging reeulta of the Slmull.um dasrnoeuur control operations, some problems bave arisen becauae fllee heve ml.grated fron untreeted ratercourses and reentered zones that had prevlouely been treated. OCP w111 therefore need to contLnue lanricldlag untll thl.s reLnvasl.on hae been overcone. The euccese of the Programe la serioualy threatened by the coDsequent reintroduction of the paraelte, leadLng to contl.nued transml.esloa tud the Persistence of focl of lnfectLon rhich ulght becoue Bources of cooteolnrtion. In fact, shlle the husun paraslte reeer:vol.r shms e urrLcd decllne in the onchocerciasis-controlled zonee, the trend Le lees evident (tad rmetlmes altogether absent) Ln the rel.nvaded zonea ln the BanJ.flng I, Paya, Brou16, Ksnk6laba, Bago6 and the Bal6 river besl.ne. -9- The situatlon Ls moet serl.oue ln the flrst-llne vlllegce. In Hadina Diassa, the ATP may be ae high as 1000. Moreover, three chlldren born after the start of control operatlons have teeted positlve ln the reluvaded zones. These findings Beem to indicate that transmiseion l-e contlnulng in these er,tensive areas of reinvaeion. The eucceBe Bo far achl.eved uay be seriously underoined unlese appropriate and etringently applled measuree are rapidly introduced. 2.L.4 Predlcted epidemiolof,,lcal trende and lnterruptl.on of larvlcldlng Encouraging trendo have been obeerved Ln certain zonea, €.8. Farako and Bandiagara, where larylcidlng operatlons have been suepended. The cltuation is less favorable in the reLnvaded zoneo, and therefore no date can be Buggeoted at present for ending larviclding ln those area8. Nevertheless, thls etep will have to be considered sooner or later. Routine and longLtudinal epldenlologlcal surveys, entomologlcal asse6sments, and evaluatione of lveroectln distrlbution ehould be contLnued, Bo that trends can be monltored and an Lnformed declsion can be taken regarding the termination of larviciding operations. The zones where onchocerclasl.s has been controlled (Koullkoro, Sikasso, S6gou and Moptl) have figured Dore prominently Ln the various economic development plansr partly because the beneficlal effects of vector control on the prevalence and tranemlesion of the disease have lncreaeed the productlve activity of the populatlon, and partly because ralnfall ie once more abundant. A consequence of the yeare of cevere drought vas coneiderable lnternal mlgratlon, partlcularly froo the desert reglons of the North to the South and Southeast, arees typically erposed to onchocerclaeie infection, but utrere ecological conditions were better. The present favorable cllnatl.c condl.tlons vlIl certalnly cncourege the new settlers to remain, and mlgration le llkely to Lncrease even Dore. The nusrbere of uigrants--l.n combination vlth the fevorable ecologlcal conditions and the termination of large-ecale vector control--prescnt eerious risks of a recrudescence of the dl.eeaee, unle88 a eunreillance etrategy and effectlve measures are Lurplemented. 2.2 2.2.L African Hunan Trvoanoeomiaale (AHTt Human trypanosomiasLs eunrel.llance before 1984 Before 1984, eurveillance of tr5rpenosonlaeis and e1l other neJor endemic diseases was conducted by 11 eubdlvielons of the Offlce of Grandes Endemies. Polyvalent mobile teane uere reBponsible for detection end treatnent. Because the Republic of Mall endorsed the goal of health for all by the year 2000 and adopted the strategy baeed on prlmary health clrer lt decided to integrete all activitLes et the district health center level. Accordlngly, the -10- activities of the foroer Grandee Endemlee aubdlvlsiong vere treneferred to the district centero. 2.2.2 The present poeition 16 Distrlcte in Uall, lncludlng 13 ln the devolutl.on 3oDe, rre affected by trypanosomlaeis. (see Anner 1 for a llst of affectcd dletrlcts, by region. ) Since L986, the Dlvisl.on of Epldemiology and Preventlon (DEP) has recorded a substantial lncreese in new casee of Lnfectlon detected by the local health services. 40 new caseg vere detected in 1986, and 109 ln 1987. In eddltl.on, a team from the Divielon of Epldernlology and Preventlon conducted fLve local Buryeys, in the couree of shlch 12 new caaee were detected. The vectors rere identified as Glossi,na palpa lts Ganbiensis and Glossina tachl.noidee. 2.2.3 Prospects AlI the doctors working ln the focl and the Epldemlology and Prevention officials reeponslble for coordinatlng trypanosomlasLe control are concerned that there tray be freeh outbreake of the dLseese tn H411. Every yeer, the nuslber of cases detected by health poote increaees. It ehould be emphasized that the resourceB avallable for eurvelllance end vector control ere lLnlted. 2.3 Curable Blindinq, Dlseases 2.3.L The present eD oloeical ooeitlon Of an estimated populatlon of 7,625,220 (L987), the ouober of bllnd people is 150,000, 1.e. about 1.9 percent of the total. A receat 3unrey carried out in an Brea where onchocerclasie ls hyperendemic gave the folloring causes of blindness: Onchocerciaeis: Cetaracts: Trachoma: Glaucoma ! Trauna: Other: 38.82 of all caoeo 31.42 L2.OZ 4.52 L.2Z L2.02 3 3.1 I{AIN LINES OF SI'RVEILITIICE AI{D CONTROL OF OIICHOCERCIASIS, TRYPA}TOSOMIASIS AITD OTHER BLII{DING DISEASES The present Btate of the alth care Bvstem ln Mali 3.1.1 The socioeconomic and demograohlc posltion The Republfc of Mall is a vast, landlocked country e-teadLug over an area of L,24L,138 km'. It ie bounded on the north by Algerta, oD the rtst by t -11 - Mauritania and Senegal, on the south by COte d'Ivoire and Gulaea, r,ad on the east by Burkina Faso and Niger. According to the provisional rcrultr of the April 1987 census, !/ Mall has a populatlon of 7,620,225, lhc raoe Bource estimated the annual rate of Lncrease eince the prevl.oue censuo rt 1.7 percent. However, projectione baeed oD the 1976 ceneue glve thc follovlng naln demographic lndicators for 1989: Maln Deuggrqphlc Indicatore (1989) Indicator 1976 Censue EetLroete for 1989 Birth rate Overall roorbidity rate Natural rate of Lncrease Average rate of lncrease Infant Bortelity rete Llfe expectancy et bl.rth3 Overall fertility rate Overall actlvity rate 43.202 18.602 2.302 2.50L 121.60 per thousrnd 45.9 yeare 49.7 yeare 181.6 per thousand 35.40: 41.30t 2.652 52 yeere 55 years 178.9 per thoueend Male FeoaIe Agriculture and stockrtislng ere Mali'g Bll.n economl.c tctl.vl.tl.ea. lhe DNSI's prelLminary analyala of the 1986 Economlc Accounts (Pebrutry 1988) shons that the estlmated per caplta annual lncoae le CFAF 76,667, or about US9255(US$L = CFAP 300). Mali is emong the least developed countriee, rnd haa been serlously affected by the world economic crLele. Thle hae had lneviteble repercuaeions on health care services. The health eltuation Ln MaIl reflects, on the one hand, the condltlons dictated by the natural envLronnent and Ean'8 relatl.ons vlth it, and, on the other, the country's eerious eoclal and economic problems. The Iow figures for the prlnclpal health indicators can be erplained by poor health care coverage (about 25 percent) and by the inadequacy of preventive and curative medlcal eenrl.cee. 3 .L.2 Oblectlvee of health care poll.cv Ln l{all The aim of Mali's social and health policies is to provlde heelth carefor the majority of the populatlon, wlth epecLal attentLon to the rc8t Ll General Population and Housing Census, Aprll 1987, DNSI. -L2- vulnerable groups. The nain lines of this policy, wtrich le baced nainly on Priurary Health Care, rre a6 follone: (a) control of the naJor endemic dieeaees (nalarla, echl.rtoloLaris, trypanosomiael.e , tuberculoel.e, leproey, trachona, onchocercl.asl.s ) ; (b) control of chlldhood dieeasee through vacclnatlon (meaeles, tuberculosie, whooping cough, tetanus, diphtheria, poll.onyelltls) ; (c) provlsion of adeguate rnd appropriate health care by lmprovl.ng eocial velfare and health eervices; (d) lmprovemente Ln llving condltlone (includl.ng: uater eupply, hygiene and sanitatl.on, vector control and a quantltatlvely and qualltatJ.vely balanced food supply). The Departnent of Publlc Eealth and Soclal Affalre, rtrl.ch ls responsible for puttLng theee pollcles Lnto effect, Ls organlzed Ln ll.ne with the adgrlnlstratlve Btructure of the country, es follws: * central eenrices; * regional eenrLces i * local gervl.cee.(See Organl.zatlon Chrrt, Anner 2) It ehould be noted that lt le the local eerrrlce ('dLrtrlct' level, according to I{llO termlnology) thet rre provided with the approprlate operational re8ources. A11 actlvlties ere integrated rt that level. 3.1.3 The existlng health eenrlce lnfrastructure Senices are provl.ded by the Minlstry of Public Health through the follordng health network : 3 natlonal hospltals; 5 regional hoepitale; 4 secondary hospitals; 5 per:manent ophthalnology centers, lncluding 4 vith ophthaLmologists Ln attendance; 6 ruobile ophthalnology teama (groupea ophthalnologlques mobilee - GOM); 45 district health centere i 6 comrune-level health centers (Banako dletrict); 237 local arrondlsaement health centersi 371 rural naternLty cllnlce end 451 rural dl.epenearl.ee 506 nedlcatlon dletrlbutlon poets; 27 prlvate dlspenearles 3.1.4 Personnel The natlonal health and social uelfare renrl.ces ere rtaffed ee follons: 13 371 doctors, includlng 4 oPhthslmologiete; 56 pharmacists; 25 surgeons; 727 cerLified nurses i 13 certifled nurses speclallzlng ln ophthal^nology; 344 nldwives; 1,453 health center aides; 96 sanltary technlcians; 10 eanitary engineere; 1.21 cosurunity develoPment workers ; 890 traditlonal birth attendantE; 2,456 hyglene assistante and flrst-aid workers; 1,414 tiiaittonal midwives who have received further trainlng. 3.2 The natlonal eoldemlologlcal and entomoloclcal survelllance svetem 3 .2.L Epi loclcal ourveLllance Survelllance is dLrected tonard both epldemlc dlseaees and the naJor endemic diseases: the el.r target dlseasee of the Expanded Progre'rme of Imrunization, melarla, cholera, cerebroeplual meningltle, yellm fever, Ieprosy, treponematosis, trypanoeomiasis, onchocerclasls, and bllnding dlseases. Under the Lntegratlon pollcy, the district and comune health centers are currently responslble for all health-reltted Ectivl.tl.ee ln their areas(education, prevention, treatnent and eanltttlon). In each of the Regional Health DLrectorate8, an epldemiology and prevention division has been eetabll.ehed, headed by a publlc health nedical Lffi""r, if no epideniologlst le avallable. At centrel level, the Division of Epiderniology and Preventlon (DEP) of the Natl.onal Directorate of Pub1ic Bealth ie responsible for nationrride surveillance. Since 1986, the Department of PublLc Health hae atarted to set up its owrr radio network with the aseistance of donor countrl.ee and ald egencles. Thirty-elght transceivers have been lnetalled through thle project, allocated as follows! one to the DEP, and one to each of the seven RegJ.onal Health Directorates and 29 Distrlct Bea1th Centers. Seventeen more are needed for the remaining Distrlct Health Centers. . Data 18 collected at ell the levels of the health 8y8teB pyranid. Every lrlonday, a weekly report of all caaes of epldemlc dLseaees, cuch as cholera, cerebrosplnal menlngl.tle and measlee, le eent over the 'Health-Radio" network by the medlcal offlcere 8t the health center8 to thelr rc3Pectl've Regional Directorates, vhlch ln turn send them on to the Natlonrl Dlrectorate of Pub1ic Health and the Divieion of Epldenlology and Preventlon. The ocdlcal officers at the health centerg are informed of the number of caees detected ln rural ereas through the cogmand radlo Bysten Ln those arrondieeeBents where it has been installed, or otherwise by whatever Deans ls avallable (blcycle or motorcycle). 14- IJhen an epJ.demic ia Judged eufficLently cerioue, tler cEtes end deathe may have to be reported dally. There le aleo a EyBteB of feedback from the Regional liealth Directorates and DEP to the dietrl.ct health ccnterr. ?he iinai coolponent of the system consiets of the nonthly rePorte frm the Natlonal Heelth Informatton System (SNIS), vhich are made available to DEP for rtudy before being fonrarded to the National Dl.rectorate of Plannlng end Eealth and Social Training (DNPFSS). 3.2.2 Entomoloc,lcaI eunreillance The National Dlrectorate of Publlc Hyglene and SanLtatlon (DIIBPA), ls responsible for vector control against Anophelee mosqul.toes, tLcLs' $!g mosquitoes, rodents and cockroaches. The echietoeomlasie coatrol program vith headquarters Ln the National Institute for Publlc Eea1th Becearch (II{R'SP) I's responsible for snail control. DEP ls reeponsible for control of teetse fly(Glossina) and Simulfu:m dasrroeum. Hwever, alI theee rctivl.tieB lre Lntegrated et 1oc81 level. 4 OBJECTIVES OF DEVOLUTION PI.AN The objectives of the Plan are: 4.1 Onchoce rciasLe 4.2 to prevent t recrudeecence of transmission of the disease; to help eafeguard the achleveuents of OCP. Trvpanosomlas Le to as6ess the prevalence of eleeplng slcknees; to identlfy and nep the erees of dletrlbutlon and determLne epparent densitl.es and the epecLes of @!na Lnvolved ln the transmissLon; to Bet up paraeite and vector coatrol ProgrEtn8. 4.3 Blindinc diseases to provide local health poete vlth the neceE8ary resources to combat blinding diseases and blindneee; to safeguard achievenents Ln the devolutlon zone; to provide effective eye care for 80 percent of patlents. DEVOLUTION PLAII: IUPLEMENTATION STRATEGY A11 actlvitles vlII be integ,rated at distrl.ct health center lcveI. The DEp team responslble for eurrreillance of comwrLcable dl.serree wlll be responsible for nationwide coordinatl'on. 5.1 Onchoce rcLasLs Once the objectl.ves of the OCP have been achLeved end thc rlek of reLnvasion by the infected sevanna speciee of fly has been eli.ml.aated' the 5 15- Simullum will be allorced to reproduce. The local lnhabltantc rlll hrvc to be prepared and informed in advance thet the return of tbe fller w111 aot cluse renewed outbreaks of the dieease. There is no doubt that the nuisance effect of the fller w111 reappeer. I{herever this problem reappears, vlllage comturitlee vould be glad to flnd the means of getting rid of it. Sunrelllance and control of oacbocerclaele v111 continue, through e Btrategy of both paselve and actlve detection end treetnent. 5.1.1 Eoidemioloclcal eurvelllance and lvermectln treatDent Responsibllity for epldemlological eunreLllance and onchocercLasie control will be assuned by the natlonEl dl.sease sunrel.llance tystem, !t both central and loca1 levels. The folloning activltLes vill be urdertaken: detectlon of cases of onchocerclaele !t pertranent facllltles (dlstrict and arrondiseement health centers, and rural dlepeaserlee). Only new ceseB wlll be regarded ae epldemlologlcally rlgntflcrnt ulth regard to the trensmission of the disease; routine epidemiological LnspectLone ; sImple eraninations, !B currently conducted under OCP ln lndlcator villages located ln the devolution zone Ln Hali, to nooitor the decline ln the varlous infectLon and transmlesion parBmeterei t Iver:oectln treetnent of onchocerciasie caoee detected by the pemanent health centers i mass Lvectermin treetnent caupalgne; evaluation of the effecta of treatoenti data collectl.on, conpllatlon aad proceeeJ.ng. Consequently, the main ectlvitles of devolutl.on vlll be lmplemented through the district health centers. Although the ertenslon of the erea of OCP lnterwentlon (reetern ertension) and the contlnuation of lanrl.ctdtng constltute effectlve mea8ures, t'e believe that, in the zones eubject to relnvaslon, these measures rhould be strengthened by mass ivermectin treatment caarpaigns ln all the flret-ll.ne villages, and any other Lnfected villagea, Bo aB to cleer up the buoan parasLte reservoi.rs and halt transmieelon as rapldly aB possible. The zoner ln questlon comprise the following distrlcts: Katl (Bantfing I and Paya), Dlolle (Baou16), Kolondi6ba, Bougouni (Bago6) and Yanfolila (Ba16). 5 .1.2 Organization of onchocercl.aele eurvel.llance and control 1. The encouraging results achieved over the ten yeara of the OCP campaign mean that nany health worker8, perticularly the younger one8, have * * * * * * -16- Iit'-l-e o: nu first-hand knorrledge of the eigne of onchocercierfu. Ia the absence of a suitable Lmunodiagnostlc teet that could be ueed by tbe public health services, clinlcal eraminations muet be ueed for detectlng polel'ble local recurrence of transmLsel.on, hosrever ltnlted. It lB therefore eseentlal that all health vorkerg Ln the devolution zone should have a good knowledge of the Byaptonatology of the dLaease rnd of paranedical neans of diagnosLs. Seminars uiII have to be arranged for Bealth Services personnel, Lncluding vlllage health workere, in order to lmProve surveillance. Z. Particular attentl.on will be pald to the dlagnoeie of locaIlzed onchocerciasis in any patient born after the start of ineectlclde apraying operations, and to any other new patlents. Such caeee wlll trlgger an active Gvestigation of infectl.on and transmiseion, ln the forn of a almple routine sunrey in the zone. 3. Slnple eraminations of the klnd carrled out under OCP ln the lndLcator vLllagee will be contlnued. OCP personnel rl11 deslgnate the villagee wtroee lnSabitante ehould contl.nue to be monltored in thle ray. Each villege rill be vlsited once every three years. These sfunple epldenlological evaluations sill be performed by the lnvestlgatlng teana from the dlstrlct health ceuters, at the eame time that they screen for leprosy and tryPenosonlasis ae before. The medical officer in charge of each health center rl11 be dlrectly reepousible for the work of these teaa8. Be wllI report thelr flndlngs to the Divleion of Epidemiology and Prevention, through the noImal health setx/Lce channele. 4. The nedlcal offlcer in charge of each health center will aleo be rceponel.ble for treatlng eny nwly dLagnoeed cl3e3 of onchocercl.aele, and for cerrying out utlse Lvermectl.n trertment lf necesEary. IvermectLn rLII be eupplled and dietributed from the health center to locel health fecilltlee acceaeible to the populatl.on groupe Lavolved. Logl.stical end technLcal support slll be provided by DEP. 5. The performlnce of theee dlfferent taeke vLll requlre the hande-on treLning of personnel concerned wlthr - epidemiologlcel surveye and examinatl'ons; - distributlon of lver:srectl.n, rnd the uonitorlng and treatment of lte possible side effecte. The valuable erperlence acquired ln theee dlfferent flelds by DEP's National Onchocerciasls Control Team will be put to use ln thle tralnLng progra$, whlch w111 be based on the etandard manuale eupplled by OCP. Rceources ior-logistic eupport, equipment and materiale, and for day-to-dry operrtlons(fuel and lubricentgr p€E diem and other items) vtll be provldcd. 5.2 African hunan rvDanoBomlasl.e -Trypanosomiasls control requlree the partlclpatlon of both nedl.cal and entomological teams. It involvee medical Lnepectl.ons (actl.ve ecreenl.ng and L7 treetment of patients), together with entonologicel asBesBoent. tbrt rhould be as thorough and complete as possible. 5.2.L Entomologlcal assessments updating of all entomologlcal data; on-the-job training for techniclans specializing ln tsetse fly control, together with lnstruction in laboratory technlques; training of village health workers in techniques for preparing traps and screens; talks for village resldente on the epldemiology of trypanosooLasis. 5.2.2 Medical inspections AIl vlllages where trypanoeomiasis J.s euspected wlI1 be vlolted and all subject6 at risk w111 be glven a medical and paramedlcal eramJ.nation, consisting of: palpation for ganglla; Card Agglutinatlon Test for Trypanosomiasie (CATT); blood serun tests. A11 {',qunologically Buepect caBeB (both eero-positive and inconclusive), and persons found to have ganglia (even lf testlng Bero-negetive) wl11 be given parasitologlcal eragrlnations (ganglion blopsy, blood testB, nAECf and Woo. Confimed caoes wlIl be treeted at dletrict health centers. A treatnent handbook ls being prepared and the staff of each center v111 recelve appropriate tralning. The headquarters teagl will provlde support for the health center teame. Supplies of the necessary medlcations will be available at all appropriate leveIs. 5.3 Blindinq diseases The strategy for the prevention and control of these diseases w111 be based on passive and active detectl.on and treatnent. The Ophthalmology Unit of the Publlc Hea1th Serrrice w111 be reeponslble for prevention, the al$ bel.ng todecentralize eye care and make lt accessible. The etrategy w111 conelst of thefollorring components : widespread educatlon of the publlc; enhanced resources (equipment) ;training of speclallzed pereonnel (doctors and, in partl.cular, health center nurses; Bee Anner 3 for details of training);guldelines for speclalized care. The Mobile Ophthalmology Teans (GOMs), working through local health centers, will have the folloving responsibllltles: 66 -18 * early detectl.on end treetnent of alnple lnfectLoaei * eelection of patients for epeclal eraol.natione, surgcrr to be performed by nobile medical terDs and postoPerative clre. After trainJ.ng, specialized personnel will be assigned to the district health centerB, and will replace the moblle ophthalnologlcal telas I'n carryLng out the ectivities lLsted above. MONITORING AT{D EVALUATION 1 Monitor and coordination o the Plan Because of lts functions, DEP hae the naJor reeponslbllity for lntegrating the activltiee of the health centers, and rl11 be the Ell'nsprlng of devoiution. The various operetLone relatlng to onchocerclael.e eunreLllance and control will be coordlnated by the Natloual Oncbocerclagle C@lttce, md ln partlculer by the Hinlstry of Publlc Health end Socl.al Affalrs, tbrough DEP(DNSP). ItB coordl.nating capabillty riIl be enhanced by: - the tralnlng of four epldenlologlcal erperts rnd three mdlcal entomologiste; - ehort tral.nlng coureee l.n laboratory technlquee, IFI, data proceeel'ng, and health Program Eanageueat; - logistical and material aupport (rlI-terral.n vehiclea, technl'cal end field equlpment, data proceaaLug equlpoent' etc.); - the etrengthenlng of the Badlo-Health ly8tem by provlding end installlng r transceLver ln orch dl.etrl.ct health center ln the devolutlon zone thtt does Bot alretdy poesess one. As regarde eupervl.elon, the Begional Publlc Bea1tb Dlrectoratcc v111 eupervise the hialth centere and report to the NatLoaal Dlrectorlte of Publlcgeatth through DEP, where the Central Coordlnatl.ng Teern ulll be rerpouel'ble for eupervision natlonwide. It lB at this level that decl.elonc on Dr88 I'vctoectin treatments must be taken. Once euch declelons are made, trettuent vlll be repeated every six or twelve monthe, untll the evaluatlon report8 on the trl"tr"r,ts indicate that tranemiseLon hae been checked. Close contact rl11 therefore need to be maintalned and strengthened betreen DEP and I|BO/OCP. A data base rrill be egtabllehed for all these rctlvitLcl, uring data, docr.mentation on the vlllageo Butrreyed and treated vlth lvcruactln, all other relevant data. Collectlon and analyale vlll be done by thc DEP processing unit. Advantage should be taken of erl.sting oCP steff ead Lrganization to help Lnsure the neceooary trainlng aad rupport. ttc dcta however, be processed Danually at all levele. In any c!oe' feedback v111 provided after cotnPuter proceesinE, baeed on etendardlzed data. fantly and data ctn, be -19- Perlodic reports rl11 be aubnitted to DEP by the nedicel offlcere ln charge of the dlstrict health ceaters. 6.2 Evaluatlon of the Devolutlon Plan A composite evaluation will be nede halftray through thc Plen, ln the course of the third year, folloned by a flnal evaluatl.on ln the ftfth year. Thefirst evaluation ls l-ntended to eosess the operational effectlveneee of the Plan's activj.ties and the e:tent to wtrich lt le lategrated lnto the*,natl.onal health care system. The final evaluatlon is intended to asBeBB the rchlevenents of the devolution plan and its furpact on the problerne as a rlrole. The National Dlrectorate of Plarurlng and Eealth and Social Tralning (DNPFSS) will be responsible for preparlng the evaluations, ln cooperatlon vith the National Dlrectorate of Public Heelth (Central Coordlnator for Plarurlng). DEP w111 eubmit eeml.annual and arurual rctlon reporto on the Devolutlon Plan, nhich will provlde updateB on the progrese of actLvl.tles. 7 7 RESOIIRCES AND COST OF THE PROGRAU Husran resources Logistic Bupport Data processing equipnent Technical equJ.pment Fie1d vl.sit equlpurent Trainlng and retaining Educational materlal Capital Cost: 1 7 .3.L Staff in both the district health centers and ln DEP w111 be ueed to carry out the devolutl.on plan. They rill loprove their skille through tral.nlng courses (see estisrated costs ln Anner 3). 7.2 Materlal re8ource3 Logistical aseietance to DEP and dlstrict health centera;provislon of technlcal equlpment and rupplles plus field vlslt equlpment, to DEP and distrlct health centere; data proceseing equipment for DEP.(See Anner 3 for detalle of eetlnlted costs.) 7.3 Cost of the Flve-vear Devolutlon Plan Capital costs CFAP 56,000,000 3,591,000 181, 037, 403 2, 896, 500 229,770,000 7, 500.000 CPAP 479,794,903 -20- 7 .3.2 Ooeratins, costs Vehicle mainteaance Per diem for mobl.le teamg Payments to coordinating tean Misc. medlcatl.one Mlsc. ltems for ABT camPalgn Office suppllee Operating coats 000,000 000,000 400, 000 500, 000 910, 000 000.000 CFAF 248,810,000 CFAF 9,000,000 CFAF 479,794,905 248,810,000 9, 000, 00Q CPAF 737.604,903 73,760,490 GPAF 811,355,393 s2,704,551.31 CFAF 53, 105, 5, 47, 24, 3. 7.3 .3 Evaluation Estimated cost of evaluatlone SI'M}IARY OP TOTAL COST Capital cost Operating cost Evaluatlon Subtotsl Contingenciee (102) Total coet of Devolutlon Plan - US dollars 2L- I I I I I I I I I I I I I IN I I I I I I IF I I I I I I Ir I I I I I I I 6!l IE CC cL 6r!6(l, eE -OO '! -- C'r L oO O6O tttL e6o o(UL + O 16 g Oeo o o L|!6 6 otr 9 , E E'O E6L C r^C O LOEC6c) -s O.-OOgLo $9qJeoLl-o (E '-.!OF 6uE 6 ,-Cl - at!OdvtLC.a .!A EeF (l, O O 6 '- Qrl!I,lS U C L c,aaD o ogc .F L-CN O-C O- ,'F O o vodo r!-.- ot- 6- @ E!, oo|!6L'iL '|!Ul o I L 5 O e O-ALE O O C! ul O ' = F=l L EE oc ,!geo gco a.F(UO'-Ue Ot! r! tr- t!.- 9 I o)L f L L O eO., c!Er9rE 6LrE.- o L O-O c o O c O.- O |! Clf .Fd I f ettd (l,GLCL/6 (U=L L'F I I CLv I -"; o16 o al,L>3O(')(J Lgto c9 CL .Fl! ,!oL> Q,L L(l} o. CLoo .F o, 16,\ o_v 9E .P roPOLL ro -od16 o<EDJq' EIc|! t!-EL ^^ 5 4eP O> CC:dr (t(u oo,u^'! O >.6 E E .-'OE- ce O6J60 (l,(u stg)|!,oaoE Y6 l!!f-- v, lC vo ,E \ 6(or,E o> cDE6-9P € El tr - 6E e O .- E6 o.- O. C-^ 6 ro .FJ CDO O O O r, LOro Ov E EJH O OlO.e- OTEL(,O - CDO o o)\O9 EH O L^ oro o E o c c rE\ L Ay)C,--- 6 .- I l4lllt C EL =.-EO6L c vl! -cvcoE.tra .-o I .-6! .-€OrC 6q O9r-6tO.-t.s L'- Cs.F l! 6.cL CLC: C!-E F O).6e CE qieF O (U O O O.F gE .c C\\\.- E- e O eF OELLLs LO.-EOlo9EL O O O.- qJ C C ' O.F cr9$r! , r=s ,--$ ,999L I E9 -OE-OtoooorEa,tqJSOlCfOO(-J LHts J=CLCO otJllll'J1lr lrl tltltltltltttl N6J ttllttlltrllllrltrllttrlllll(nlr}sl C\J ttttttllttllll ro tc tttr ltI llI llrttI trI trrolr)N I tt ItttltlllI ll Ittt II tt Itll IN6J(Y'S I I I I I I Is tttltttltttttl(\J- q E 16E(u6CrO o'!L (U(u 1CL -CL -O tro- os -o o,) .- O69 o +9 EL c o-cI -(l, ll ,P - E c-d rOEL Eqrr! o e.- o 0 o .-= (9 E o E ouJ +rd e O -cOO) e'!q,! cE.- rD E o ,F c c! o,!o.of o! c)6 46C q) 6- 9.-O C I C .6.- !,E oooLLcQt.-L-rtOL 4At=6L) r .O OJ.- L? > ro Luo<O Orq,L L6O- a LE O I I I 6 o F lrJ o o E ro U g U F lJ. d, lrl I F I d, U d C' E trJ N d KJ F F U F F(J r o U)(D F lrl = F 22- c|! G c o 5 o o trt o t_ o ,Ef '! o ,! r or tr6 o- c o 3 o o c) o o 6f .! o L u d EtrF616 rJFOd-(, o- e|! ooo cO^ >ro .-oE6>6 .-LO >,, o-cCL -efE-6c) 6ooE-!c Eu Ot t! .-coL O O.-9-E c.o E ooc =E,6 ^ ,! |! l, o 16 ro E r! o I o o(J 9 oo6 cr) ,! t6^ I F(U -g+ 'FCo^ > |! O- +O 3- C 6 4'F OO .F(,EO l> ,q L16.- c :, oE o 4L.F 9 (,l -- -_ tOi6 E.F L 9c E or.- ro c cLgloo o3 e o 4+ co ,6 '-,CF tr '-- - OE< oYt!- L x 90OJE C (uA O'-T' L OPoo -> LC: .-O O5 .s; tEO.- OJ OO! > e i! .;^so99E >C o cl! rOrqF O s.- c - c 6L 6 Oq, >f > P EA O 6 OJ rO9 LO L -qrc f > f !L .o 4.F 0 G ,- 4FU o.F .o r! ,u > q, 9v I q qL O)! ED6 OJ6) oo oo LGO -o Fg) t!cL 9 016q, .-q, CE > Ed e-C.F q, O O.F6 6 E'E' !) > 66 .F CEDl! O-u OL O^ cCL OO (l,O .FCD6 t 9CC 0J t! O (, 9.F0Jo Fs Fs elo. OJ O O_ O_.F O_ O_L 6 E f: E1' 6 € v6 .F0, .FC q= 6 A 6 C ./1'- =iin I(U E L o o CLo l ^ d, t! F(j.) d lrJ Fq d, lrJ o d, d U N d lrJ F F ,J eq, '3 c o 3 uJl =l>lxl 5l :olJJ rol FI LJt =lHlFI -23- AI{NEX 1 AREAS INCLUDED IN THE DEVOLUTION PLA}.I REGION DISTRICTS AREA(tot ') POPUI,ATION KOULIKORO Kangaba Dioila Kat i Total: Koulikoro SITGSSO Bougouni Kadiolo Ko lond i6ba Kout iala Sikasso Yanfo 1 i la Yorosso Total: Sikasso SEGOU B1a San S6gou Tominian Total: S6gou MOPTI Bandiagara Bankass Douentza Koro Mopt i Total: Mopti TOTAL: Devolution Zone 5,156 L2,794 22,500 40 ,450 20,60 6 ,640 7,980 L2.27O 20, 700 9,240 5 ,500 82,930 54,806 2O2,658 54,072 253,706 340 ,600 648,378 220,443 98,337 103,352 286,244 374,6LL LzL,378 104,463 1,308,828 150,382 202,096 418,621 L27,764 898 ,86 3 182,869 155,999 1 50 ,608 21 1 ,988 243,245 944,709 3,800,778 6,146 6,143 5,620 5,563 24,472 7 ,262 8,219 9 ,504 18,903 10,918 Source: DNSI - General Population and Housing Census, Provisional Report, April 1987 REGION - ?4- AI,INEX 1 (coltinued) AREAS OF MAI,I AFTLCTED BY AHT DISTRICTS AF}-ECTEI) Ki ta Bafoulab6 K6ni6ba Total: Kayes Kangaba Dioila Koulikoro Kati Total: Koulikoro Kadiolo Sikasso Kout ia 1a Kolondi6ba Yanfolila Bougouni Yorosso Total: Sikasso Bla San Total: Segou TOTAI, POPULATION IGYES KOULIKORO SIKASSO SEGOU 233,906 L43,939 101,788 479,633 54,O72 253,706 125,811 340,600 774,L89 98,337 374,6LL 286,244 103,352 121,378 22O,443 104,463 1,308,828 150,382 202,096 352,478 TOTAL: 2,915,128 a,ltlr'l -te LJ Cfo gl lrjr IL lLe UI ETa Flrl lr, c, JE r trJF -Co c -l lga lrJr ll,F 2 - E- a EI E E €4 c? C(9re x =o =L t! a,L oJ' E, oE l) ct- a1 aE E -25- tt 4r =o- ta, Lo{t Ecca) .Sq @(J =L C' ==+' !l T; E,E" -E :$. x _t u. \9 O. \ o-. lf,.r o =olZ s u F = lrlo tr)lrJu F z. l^l Lr r\ |a-rr\ lr.l F =lrj Ll 4 Ic(r-r {al C' G' ,L. 1r7; --L |.:: rltE + ilj'{' =o E, E- .C. L 6 ; C!E L i' a- iL. ,:.., C. . t'f{l(l+r.o 3 () I (D c, E'oL o- L l! O'- ) G(n a, C}LE.,8F L= €o{ ,a'91i;El-6 E ttttuc(J Cl '= .,[) 9 "d, c} f}.= c| o.o,)4 (.f (n a! c- lrl (-) I{ g E F l^J ,Jo =& t- g{ C) F LJtrllz g L, l!{f6 *? st'aE=2.; -L*= l)=>E '!P o(.i (-) @ ci =,c, o ea, !l=ET !>6 CLL cj-'- 7 (ra al @ C' a7 Lo Eo C)ot- !E cl E EBE62E g(/| Oa,EP P'A o< o .}g - .x. $6 o c, .o L F .D I- e e L(r io L tiL _t G .-J l-o c,o = iL, iE !_\ icF Ia orr lrjJI B t{q lrl a co G E !EotL L) U +:tr a! (t) {,!- o o'E co o-l,) oc.(ll 'F b@EE GIL -otI tL o' .' iE ta c C' ? Lr o) lE o A'- j L, tJ OF a, J) Ct o)(r) G -54 aafrJ L) (l l! Li l! IJ )zr (n L)IU E , S.' CI .- o L otft C' c tj L a)CL 4)cc Ll T U .4, E, oa O- 2 - aJ oc CT +'{J n or .]ct r (u L ..c' c. C} E L dc .ft fi o) 06E9Eg EE c-0 €H!so- l- L a) oL = tr) ET lrlo lrJo w fr, arl u lr, (rt lrl(t -)F(J Jg Ftn ad(:) J J =lr,o LIF = €g, anl^,C = {) E'TG E q t*J c +'E C' '.c, D- (L. E o- da L, a) ar,lrlu l^ILi \EI tft lal -t lrJ d 6o F L lr.l fJ ct lrl lrJJI rcJ lr,JI lr, r= F -lr.l L1 l, =a L {,,!- C) {rr tr-l cr (li E! (]co iD G L G t'!- cr = E & rG, vE -;-.- G' .L\ C,') U .D rE L .1, {..' ?C .L' L 4L' EL 'ct C .7r C, E o {L, '!-a (L' jt Grti a ib .{t} '5 (L'E' r;Ur I I 2 3 4 5 6 7 -26- MINISTRY OF PUBLIC HEALTH A}'ID SOCIAL AFFAIRS ORGAI,IIZATION CHART Minis ter 0ffice of the Minister Inspectorate of Public Health and Social Affairs DirectoraEe of Administrative and Financial Affairs (DAF) Coordinating Unit for IDA Health Development Project Infrastructure Strengthening: Tombouctou and Koulikoro (CEPRIS-TK) Na tional Directorate of Public Health Divisions: Epidemiology and Prevention; School and Sports Medicinei Pharmacology/Labs; Curative Medicine; Family Health' Services Regional PubIic Health Directorate 8. NaEional Di rectorate of Pub lic Hveiene and tation Ui"iSj-glg: Sanitary Engineering; Environmental Protection' Regional DirectoraEe of Public Hygiene. 9. National Directorate of Planning and Heal th Training Divisions: DERE; Training; Statistics/Documentation' Scnoots: ESS, EFDC, EFEP' EIPC PT G' EIPC Sikasso' CSI'IK' 10. Nationa I Directorate of Social Affairs Divisions: Community Development; Family Protection. Regional Directorate of Social Affairs. 11. National Ins titute of Public Health Research Divisions: Administration; conmunity Health; BioehemisEry; Production; Training. Rural Health Research Centers: Kolokani Gossi. Selinsue. 12. 52 district and corunune health centers (46 district centers and 6 conrmune centers ) . 13. ?.37 health cenEers in noncentral arrondissemenEs' 14. Development secEor heaLth units: Rural llaEernity clinics and dispensaries. I5. \.'illage health t.eams. 11 -27- ANNEX 3: ESTIIVIATED COST 0F THE DEVOLUTION PLAN . CAPITAL COST .1 Logistical support: (a) Central (Coordination team) 3 all-terrain vehicles G CFAF 8 million each (b) SupporL for operations 4 all-terrain vehicles G CFAF 8 million each Logistic Support: total .2 2 Dal'a processing equipment: total .3 Technical equipment (a ) Cent raI 2 sets of survey equipment (oncho.)(crar 2,l7l,t+04 x 2) Supplement for trypanosomiasis OpEhalmological teams_ Total (b) District leve1 1 set of survey equipment per district (x 18)(crar 2,17L,404 x 18) Supplement for trypanosomiasis(crar 2,2L7,900 x 11 districts) Supplement for blinding diseases(Cfaf 243,000 x 18 districts To ta1 (c) Noncentral arrondissements (91) 1 set of equipment per center(Crer 993,092 x 91) Technical equipment: total 1.4 Field Visit Equipment DEP central team(2 complete sets at 579,000 each Supplies for district surveys(3 complete seEs at 579,300 each) 1 1 CFAF 24,000,000 CFAF 32 000 000 CFAF 56,000,000 CFAF 3,591,000 AF 4,342,808 8 ,525 ,05 1 9,972,O00 CFAF 22,839,859 39,085,272 24,396 ,900 4 344 000 CFAF 67,826,L72 CFAF 90,371,372 CFAF 181,037,403 CFAF 1,158,600 1 , 737,900 CFAF 2,896,500 CF Field Visir Equipment: Lotal -28_ 1.4 1.4.1 (a) Training and retraining Long-term training Training 4 epidemiological specialists for 3 years $ZO,OOO x 3 years x CFAF 300 CFAF 72,000,000 Airfare: 2 RT x 4 persons (600,000 ea. ) CFAF 4,800,000 (b) - Training 3 entomologist/doctors in Bouak6 for two years 3 x 2 years x $19,900 x CFAF 300 CFAF 25.020,000 Airfare Bamako-Bouak6 RT CFAF 480'000 (c) Training 6 opthalmologists/doctors in Barnako 6 x 4 years x CFAF L,260'000 per year CFAF 30,000,000 (d) Ophthal. training for 12 State nurses in Bamako L2 x 2 years x CFAF 840,000 per year Long-term Training: total CFAF 20,160,000 CFAF 152,700,000 t.4.2 Short-term training (a) 3 inrnunologist/doctors (6 mths in Kenya?) 3 x 6 mths. x CFAF 305'000 per month CFAF 5,490,000 (b) 11 entomol. and glossino. technicians Four months in Bamako 1l x 4 mths. x CFAF 70,000 per month CFAF 3,080,000 (c) 5 lab. technicians for IFI 6 mths. training in Bamako 5 x 6 mths. x CFAF 70,000 per month CFAF 2,100,000 (d) 6 data processors & 7 health Program managers 4 months in the United States 13 x 9,000 x CFAF 300 Short-term Training: total CFAF 35r 100,o0o CFAF 45,770,000 1.4.3 Share of cost of retraining senior staff abroad 7 persons for 15-day courses once a year for first three years, i.e. 2t persons x 15 days(21 x $1,OOO x CFAF 300) Training Abroad: total CFAF 6,300,000 CFAF 204,770,000 Training in Mali 2 20-day training sessions in preventive medicine for docEors in charge of district village and commune centers & regional division chiefs CFAF 6'000'000 1.4.4 (a) 29- (b) Training nurses at arrondissement and district level and assistants Lo doctors resPonsible for districts(t arrondissement, 4 district, I asst. (18 courses at CFAF I miltion ea.) Training in Mali: total Training and Re-training: total 1.5 Inf ormaEion, education, conmunication Preparation of education and other material for raising public awareness Logistic Support Data Processing Technical equipment FieId visit equipment Training (a11 forms) IEC Investment: total 2.2 Per diem for mobile teams Oncho. surveys (estimated) AHT inspections Ophthalmology (GOM) 2.3 Central office coordinating Eeam 3 persons x CFAF 30,000 x 12 mths. x 5 years 2.4 Misc. pharmaceuticals for survey teams & GOM Support for epidemiological survey teams AHT control (survey teams & districts) Curable blinding diseases (districts & GOM) Pharnraceuticals: total oE Misc. items for AHT control Reagents and glassware Insecticides (vecEor control ) Traps and screens Misc. Products: Eotal 2 2 STJMI"IARY OF CAPITAL COST CFAF 56,000,000 3,591,000 181,037,405 2,896 ,500 228,770,0OO 7, 500.000 CFAF 479,794,905 OPERATING COSTS 1 Vehicle maintenance 7 vehicles traveling 81000 km per year ea., costing CFAF 225 per vehicle/km For5yearsz 7x8'000kmx225x5 CFAF63'000'000 CFAF 18, 600 ,000 CFAF 24,000,000 CFAF 228,770,000 CFAF 7,500,000 CFAF 105,000,000 5 ,400 ,000 2,500, 25 ,000 , 20 ,000 , CFAF 47,500,000 20 , 960 ,000 1 , 250 ,001-) a 700 , cOr) 400,000 000 ,000 000 ,000 95' 8, 2a 0 0 0 00 00 00 CFAF 24,910,000 -30- 2.6 Misc. office items Paper (crar 600,000/year x 5 years) Operating Costs: total 3. COST OF DEVOLUTION PLAN EVALUATION First evaluation Final evaluation Evaluation: total STJMI'I,ARY OF TOTAL COST Investment Operating cost Eva luat ion Subtotal ( I ) Contingencies (10? of 1 above) Total cost of Devolution Plan i.e., in US dollars CFAF 3,000,000 CFAF 248,810,000 4,000,000 5r 000 ,000 CFAF 9,000,000 CFAF 479,794,905 248 ,8 10 ,000 9) 000 .000 CFAF 737,604,905 73,760.490 CFAF 811,365,395 tzrTot+,551.31 31 LIST OF TICHNICAL EQUIPMENT ITEM Reference QuantitY No. CENTRAL DATA PRC]CESSING EQU] MENT IBM AT Computer + software Compatible portale IBM comPuEer Data Processing: total ONCHOCERCOS I S PROGRAMME TECHNICAL EQUIPMENT FOR DISTRICTS AND CENTAL OFFICE TEAI,I Holth clip Slides, with holder Eppendorff pipette S I ides Microtiter plate Straight scissors Kocher clip Rectangular trays (enameled) Personal scales Tens iome ter Thermome ter EDAK Binocular microscope Yamaha E.T. 500 generator Ivermectin monitoring kit Blood pressure kit + stethoiscope I One set of equipmenl District or Central Office: total Unit Price Total Price 1 3 1 ,56 3 ,000.0 6 76 ,000 .0 000.00 000.00 000.00 1,563 2,028 3,5 91 t t t A 1 4 L20 2 L20 20 2 2 4 I 1 1 1 I I 2 6 15 16 I 19 600 200 40 200 000 s00 530 400 000 000 000 .0 .0 .0 .0 .0 .0 .0 .0 .0 .0 .0 .0 .0 .0 .0 73,346 1 ,990 48,025 2,000 14,620 1 ,150 620 50,000 .0 20 , 350 .0 7,250.0 29 ,900.0 80 ,000.0 293,384.00 348 ,80o. oo 96 ,050.00 240,000 .00 292,400.00 2,300.00 I , 240.00 24 ,800 . 00 1 5 ,000 .00 16 ,500.00 1,530.00 1 9 ,400 .00 600 ,000 .00 200 ,000 .00 80,000.00 300 ,000 .00 81 ,400 .00 58 ,000 .00 5 9 ,800 .00 80 ,000 . 0! t t t t t t t t 2 EQUIPMENT FOR ARRONDISSEi'ENT CENTERS Binocular microscope I Holth clip 2 Slides, with holder 60 Slides, ordinary 60 Purified water 10 set of equipment for arrondissement center: 50,o0o.o 50.000.00 2,17L,404.00 600 ,000 .00 146,692.00 119,400.00 1 20 ,000 .00 7 ,000 .00 993,092.00 500, 73, 1, 2, 0 3 9 00 46 90 000 700 0 0 0 0 0 0ne 1tato 3. FIELD VISIT EQUIPMENT Camp beds and bedding Folding tables Cha i rs Adjustable stool Cooking equipment Cne set of f ield visit equiPment: 6 4 8 2 1 total 579,200.00 -32- LIST 0F TECHNICAL EQUIPMENT (cont'd) ITEM Reference Quantity No. Unit Price Total Price B. ADDITIONAL EQUIPMET{I FOR AHT CONTROL 1. CE}JTRAL OFFICE Zeiss KF binocular microscope IFI microscope Electric colunrn centrifuge (universal type sigma 4 x 250 m1.) Compact microtube centrifuge(sigma type 201 M) Kahn agitator, type 0-30 Electronic precision balance Bioblock portable pH-meter Binocular rnagnif ier Entolomological dissection'kit St i rrer Central 0ffice! total 2. DISTRICTS Electric agitator Colunrn centrifuge l.Jood cent.rifuge Wild magnifier, type 3 Stand for magnifier Gas refrigerator For 11 districts: total M 410,011* M 88 ' 203't M 88 ' 494't M 49,037,t M 17'197tt M 98,382* M 49,037* M 88,203* 1 1,013,950.0 208,600 .0 148,950.0 789,250.0 61,450.0 600 ,000 . o 16 ,66 7 .0 30,000 . o 1 2 513,200.0 L 1425,000.0 513,2 2,850 ,0 .00 0 1 ,01 3 , 950 .00 0.00 208 ,600.00 297,900.00 1,578,500.00 122,900.00 1 ,800,000.00 8,525,051.00 0.00 ,638,450.00 ,153,450.00 ,475 ,000.00 00 00 0 1 1 2 2 3 3 3 11 11 11 11 11 11 .0 .0 .0 950 950 000 000 000 000 148 1,013, 225, 50 ,001 .00 90,000.00 000.00 000.00 000.00 600 30 200 1 11 2 .0 6,600 .0 330 .0 2,200 24 1396,900.00 * See: Bioblock Scientific, 1989. , t t t - 33 _ LIST OF TECHNICAL EQUIPMENT (cont'd) ITEM Reference Quantity No. Uni t Price TotaI Pr ice C. ADDITIONAL EQUIPMENT FOR CURABLE BLII{DING DISEASES 1. EQUIPMENT FoR THREE MOBTLE OPHTHAL. TEA}IS OphEhalmological kits 3 Spare instruments (tits) 3 Enucleation kits 3 Testing kit (boite de d6cision ) 3 Electric ophthalmoscope 3 Battery ophthalmoscope 3 Sets of test glasses 3 Head photometer 3 Binocular magnifier 3 For three teams: total 2. EQUIPMENT FOR DISTRICTS Trichiasis kit Visual acuity scale for literates Visual acuity scale for illiterates For 18 districts: total 00 00 00 125,000.0 80 ,000.0 60,000.0 295 ,000 .0 1 , 250 ,000 .0 300,000.0 240 ,000.0 1 ,500.0 1 ,500.0 ,000.00 ,000.00 ,000 .00 614, 0.0 0.0 0.0 842 900 900 375 240 180 88s 750 900 1, 3, 300 300 t t 000 .00 000.00 000.00 000.00 000 .00 000.00 9,972,000.00 4,320,000.00 27 ,000.00 27 000.00 4 ,37 4,000 .00 t t t t t 18 18 I8