Project proposal for Community Directed Treatment with Ivermectin East Wellega Project, East Wellega Zone, Oromia Regional State, Federal Republic of Ethiopia: Project period year 2003-2007

IPftiolllE@u pBo]p0i$M $08 @0,tfllMlu,iltffiy ffiil[ilrffii l I :I East Wellega Zone, Oromia Regional State FEDERAL DEMOCRATIC REPUBLIC OF ETHIOPIA For ,4.c1r..^r To; 'l-r t l-rProject Period: year 20A3_2007 Su bmitted to [Clltlrrr,rlJ.,:i"i -Lt _,l. ,; C: l- r' i.'t__ t 51)' tt L )/t lo+lo t_ 1) T rJ African P.ogranr for onchocerciasis Control(APOc) F,)' 111fo1161r;...1 To, l.i.'. -()^", i .i: \ -*14;-J,.----.---x ,,s_4.i1 I Revised July 2003 ,j 'j 3 I l;tt itili; l ( I i I I I t. B I T t II TABLE OF CONTENTS LIST OF ACRONYMS SECTION 1: BACKGROUND INFORMATION IV I I 2 9 IO ,f 1. INFORMATION ON TI{E PROJECT AR,EA FOR CDTI ..............I. 1. Geographical and administrative areas..,....1.2 Topography, Climate, Access 1.4 CommunityStructure....... PAST AND CURRENT STATUS OF CDTI IN PROJECT AREA SECTION 2: pROJECT E)GCLIION OLILINE . . . CROSS BORDER CONSIDERATIONS 8. SPECIAL RISK ISSUES raction and Participation |SILY, rMPORrArroN,MECTIZAN TABLETS .....: SI'ORAGE, INVENI'ORY AND DELIVERY OF DESCRIPTION OF PROPOSED CDTI3.i. Outline plan and Timing .3.2. Health Educarion and Corimunity Inre3.3. Local Operational Research ..._... s-qPEryrsroN, I{ONTTORTNG AND E\/ALUA TrON : I Supervision during Evaluation SUSTAINABILITY OF THE CDTI AFTER THE WITHDRAH/AL OITF,XTERNAL FITNDTNG ................:...6'r' Integrarion orcDrr into other coT-;;il;u;ffiil6 ;;;ffi : . : : :6.2. Cost Recovery Sysrem auringCbTi....6.3. Other Issues .... . o -- ^6.4. Methods ;i M;;;r;rg'in. p."g..r, ro*r.a, srriuiru;il,;. . .. . . . ) 3. 2 2 12 I3 1,11+ t; 4 t9 t9 I9 20 22 6. tI t i 7 ,.) 24 )6 28 29 29 30 I S ECTI O N 3 AD M I N I STRATI ON/FI NAN CIAL 9. ADMINISTRATION 9.1. Organisational Structure for CDTI ..........9.2. FinancialAdministration........,.... 9.3. Timed Plan of Acrion 10. BUDGET 10.1. Budger Esrimare 10.2. Budger Justification .................. 10.3. Current Resources available in CDTI Onchocerciasis CDTI Zones in Etlttopia (ApOC 2003) Oromia Regional State, Ethiopia East Wellega Zone, Oromia Regiort Districts Selected fo r CDTI P roj ect Distribution of Health Institutions and. population Densirs,, East VleUega Zone, l994Censu.s (Central Statisrics Agency) LIST of FIGURtrS: FIGURE l: Organisational Structure of National Onclncerciasts Control Prograrn 3l 3t 3I 33 36 JO 38 4I 42 / LIST of MAPS: MAP I: MAP 2: MAP 3 MAP 4: MAP 5: Aa 5 6 1 15 FIGURE 2: FIGURE 3: FIGURE 4: Request and Disbursement of ApOC Fund Budget Input of Partners for the project years Annual Treatment Objective b1, Enderuicity LeveL Estimated Number of Populatiott, ATo and status of REM7 by. District, East Wellega Project Area, 2003 classification criteria of Endemicity Levels in Rural Communities.. criteria Issues in the Developntent of Health Educarion.for CDTI Implementation Tinrc F ranrc Year one summary Budget for onclncerciasis control in East Wellega Zone 3l 34 +-1 A<t-) l-5 LIST of TABLES Table 1. Table 2. Table 3 Table 4. Table 5. I 9 I i Y 39 Table 6. Five Year Budget sunmtary for onclrccerciasis conrrol II 40 LIST of APPENDICtrS APPENDIX 1: APPtrNDTX 2: APPENDIX 3.1: APPENDIX 3.2: APPENDIX 3.3: APPENDIX 3.4: APPENDIX 3.5: APPENDIX 3.6: APPENDIX 3.7: APPENDIX 3.8: APPENDIX 3.9: APPENDIX 3.10: ESTIMATED NUMBERS OF COMM(JNITIES AND PERSO,ryS TO BE TREATED EACH YEAR BY ENDEMICITY LEVEL... I N D I CATORS ^tr'OR EI.A LU AT I O N, S IJ STA I N A B I LI Y/INTEGRATION OF CDTI Budget Line ltem - personnel Budget Line ltern - Capttat Equipment Budget Line ltem - Supplies Budget Line ltern - Training Budget Line ltem - Contnunicatiott Budget Line ltent - Health Educatton & Social MobilizatiortBudget Line ltem - Travel Budget Ltne ltent - Consultants Budget Line ltem - Recapirularion Budget Ltne ltem - Operaring Expettses AAt+ 46 A1 48 50 5r 52 53 5.1 j,5 -56 51 a Y III APOC ATO CDC CDD CDTI DHO DOTF EPI GIS KAP MTS MOH MOVDCD MOVDPCT NGO NOCP NOTF PHC REA. REMO RHB ROCP ROTF TOT ZTID LIST OF ACRONYMS African Program for Onchocerciasrs Control Annual Treatment Objective Communicable Diseases Control .Community Drug Distri butor Community Directed Treatment with Ivermectin District (Woreda) Health Office District Onchocerciasrs Task Force Expanded Program of lmmunization Geographic Information System Knowledge, Attitude, practice Management Information sl,stem Ministry of Health Malaria & other Vector-borne Diseases control Department Malaria & other vector-borne Diseases prevention & contror ream Non Govemmental Organization National Onchocerciasis Control program National Onchocerciasis Task Force Primary Health Care Rapid Epidemiological Assessment Rapid Epidemiological Mapping of Onchocerciasis Regional Health Bureau Regional Onchocerciasis Control program Regional Onchocerciasis Task Force Training of Trainers Zonal Health Depa(ment\' IV ISECTION 1 : BACKGROUND INFORT\4ATrON INFORMATION ON THE PROJECT AREA FOR CDTI 1.1 Geographical and administrative area(s) Please describe the area(s) of tlrc country itt v,lticlt tlte proposed CDTI wilt becarried oul' (List the administrative units'or parts tltereof e.g., Local GoventrrcrttArcas, Districts, Arron dissements, Health areas etc. rint wilt be covered. ctrtclprovide a nrup showittg their lay_out) oromia Regional State is one of the 9 National Regional States in the FederalDemocratic Republic of Ethiopia (Map 2). East weiie Ea zone exrends from theGuder River to Didessa Rivei occupying wider ,."u oi vaned topography. Thezone is rocated at g0 z7t - r00 I:, N'ratitloe ano :06 oai _:zo 37, E-r-on;i,lo., ,nthe western part of Ethiopia, is one of the l2 zones in the oromra Regional state(Map3)' Based on the 19-94 national census, the projected population of the zonein the year2oo2 is estimated to be 1,488,001. Th; zone has a total surface area o[2L'980 sq' km with a total population of 1.56 million and is further divided into21 districrs and 453 kebeles (aiministrative vilrages). The zone is bounded b),theAmhara Regional state in the north, \\/est Shou,aln the east, Jimma administrarive zone in the southeast and Illubabor administrative zone in the southwest. About88'2vo of the population lives in rural areas and li .8vo live in urban area. Thezone is identifred as oncl.tocerciasis endemic area and in this proposal 162 kebeles(administrative'iuages) in seven districts n,ith typ". and meso level ofendemicity are proposed for the implementation of corr. Rapid Epidemiologrcallvlapping of onchocerciasis (REMO) rvill also be done in three other districrs rnthis project zone for refinement of level of endemicitf. As these drstricts areadjacent to onchocerciasis endemic area and have all the eco-climatic similarities,they are expected to rie in the hyper or meso rever of endemicity. The total population in the CDTI distncts is 7r2,49g. The Annuar rrearmenrobjective (ATo) for year one is 569,g9g and the Urtimate Trearmenr Goar (urG)will be determined when REMO refinement is completed in November 2003, inthe other three districts of the project area. Y S. No Woreda Estimated CDD Villages Total Population Annual Treatment Objective (ATO) REMO Status 1 Guta Wayu 835 20B,B58 1 67086 Year I CDTI Area 2 Diga 242 60,395 4831 6 Year I CDTI Area J Leka Dulecha 262 65,427 52342 Year I CDTI Area 4 Sibu Sire 349 87,312 69850 Year I CDTI Area q Jimma Ar.io 334 83,484 66787 Year I CDTI Area o Wama BuneYa 353 88,361 70689 Year I CDTI Area 7 Bako Tibe 475 1 1 8,661 94929 Subtotal 2850 712,498 569,ggg B Bila Seyo 345 86,202 68962 To be refined o Sassiga 345 86,251 69001 To be refined 10 Nunu Komba 227 56,772 45418 To be refined Sub Total 917 229,225 183,380 Grand Total 3,767 941,723 753,378 Table 1: - Estimated Nunrber of Population, ATO and Status of REMO by District, East Wellega Project area, 2003 L.2 Topography, climate, access 1.2.1 Please describe tlrc type of countrl, or bio-clinwtic zones that will bc covered by the cDTI (e.g., rain forest, forest-savatu'tas mosaic, Guinect savarutas, Sudan savannas, mowiaittous or flat), providing n.taps, t appropriate. The topography of rhe zone is classified in ro Iorvlands, mid altitude Iand and highland areas widely ranging in altitude from 900 - 3l7g m above- sea level.'fhe zone located in catchment drained by trvo perennial nvers namely Guder and Didessa. 1.2.2. Give the approxinute times of the rainy and dry seasons and the ntontls covered by the farming season. The climate of East wellega is charactenzed by distinct rarny and clry seasons. The major rainy season months are from June to September with short rainy season from February to March. The mean annual rainfall varies from area to area ranging from 1368 mm to 24OO mm. The mean monthly temperature of the zone differs widely from season to season ranging from 1l oc-38.8 oc. The area receives most of the rainfall (>B\vo) during the months of May through September. Animar herding is a major Y 2 1.2.3 larnr acrrvrty in addition to seasonal actrvitres of prepanng the land for cultivation and harvesting. The months from January to Apnl are generalll,months of low agncultural activity and the period is conducive for the rmplementation of mass treatment for onchocertiasis control. P rovide infonnatiott on the stare of the roads and the ffict of this on tlrc ntoventents of CDTI personnel in the area at dffirent tintes of the year. (A nrup may be useful) All iveather road access is available between the capital town of the zone, Nekemt, and the 2l distnct capitar towns. During months of heavy rains some access to some distncts could be difficult. All the CDTI distnct selected are accessible by road arr round the year. The capital town, Nekemt has also Air transport service to and from Addis Ababa. All the districts have automatic and operator assisted telecommunication service and Postal Service stations. Beyond the district capital towns, most villages are accessed only on loot or on pack animals while some villases could be reached by motorcycle. During the rainy season supervision and monitoring of iort .nry u.drfficult due to flooding of rivers and roads. Therefore, the best appropnate time to conduct Mectizan distribution and carrying other programme activities is during the months of January through aprit. Ttre Annual rreatment coverage (ATo) for year one is 569,999 and thc Ultrmate Treatment Goal (LJ-|G) ri,ill be determined rvhen REMO refinement is completed by November 2003, in the other three districts of the project area. Y 3 ?It t) t)(D (? (n (n o j,) N (!(a o b..) (JJ -t o GI o t 1) tronI In ! m @ E ,ma6 {o @ mI mf ro ooc 5 ,F4 tr8IeE8m<o-ritt tr o A) o € !r trtr l'.t "..i,. . .'l r:! i., ^.\ t" ;i i I' {; r) : ,f.- L' .,i I MAP 2. OROJVIIA REGIONAL STATE, ETHIOPIA _ /1 -, !- / k-- .._ ._I -. \ ./ r "'1 3t P) ( -r I I -y.i+- \d I t- i tl t:t '.' _, Jt ( r'-'' I I ffi Oromia Region v 5 I ) I( I \. i { L ) *,Jo^ r W Wellega lllub:bor N{AP 3. East \\/ellega Zone, Orornia Rcgion ffi East \\'ellega Zone Y 6 E. Har€rge 13 N'Iap 4. Districts Selected for CDTI project Kumbz Etr ),e a r-o n e . rrti 8,9,1 "1.,,LJ Districrs tor ItEl\IO RefirrenrenrI Non-CDTI Districrs t 1 Scyr It. .,,, , r'' i"t i: t,,. ,;.,t ,(.,-,,,, i rj,.i,r.,l rr.ilEr..,,. lDL,j; rtril , 't,i r,, ,., il '.,,., ,r,, iri-,.-, ,l;,1) ,1,' ,i;i: ii' ,,,--! ' ,J"r,, r;;,1 ,^ , ' ' ';U{qrr Map 5 Distribution of Health lnstitutions and population Density in East wellega Zone, 1gg4 census (central statistics Agency) Lmu + I I ibarYtu Jrmma Grda Kremu Arnuru J:dr Jrmma lt; hOsPrr^r + Ei HEALTH CEMER/CUN|C + pi HEALTH STAT|ON + [7i POPUTATTON OENSTTY TMAGE { Lcrr t[rn 6 6.,t0 I I I6e Oongorc + l it, l0t. 250 ".f-i est.soo $ ;:;:":1","+ Br(o I SrE \ Sayo o u,la Laka I I VIhm3 Eonayd + t 8 I.3. Onchocerciasisendenticitylevels Tlrc levels oJ Onchocerciasis endemiciry in cotrtnturtiries irt the CDTI ctrea ntust be assessed b1, sintple methods before treatntent starts. For the purpose of this proposar, the ret,er of encremiciq, in a contntuniry, or a groLtp oJsimtlar conuntt'ttities is definecl on the basis of the prrvolrrr" of nodule carriers (see tnbleI ). TABLE 2: Classification criteria for endemicity levels in rural communitics ENDEMI CITY 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 ({TRGENT) greater than 39Vo greater than 59Vo MESO-ENDEMIC Community Treatment - @ESIRABLE) 20 - 39Vo 40 - 59Vo HYPO-ENDEMIC (NON-LTRGENT) less than 207o less than 407o 1.3.1 t.3.2 L33 Based on the sysreru in Table 2 and using the format i, Appendix I, preaseirtdicate the esthnated nuntbers of contntuttities at eaclt endentic level artclthe rtuntbers of pcrsons in tlrcm. (See Appendix 1) Contplete Appendix I for each Areo covering the next 5 ),ears 9f tlrcproject. (See Appcndix 1) If ntethods of assessirtg endenticiry thresrrcrds other trtart rtodureprevalettce were used when your endenticity d.ata vtere collected., pleoseirtdicate tlrc ntethod used. t 9 The level of endemicity in conrmunrtres of the selected distncts in thiszone was done based on nodule prevalence obtained by REMg exercrsesconducted in 2000/2001. The risults rndicated that out of 2g villagessurveyed in the zone3 hyper-endemic, 6 meso-endemic were identified in9 districts. l'3'4' For areas still to be covered, wlrcre ettdemiciry levels.re tlot yet kttorr;rt,please 'describe the meiltocl y6v witt use to collect the trccessarl,endemicity data. NOT APPLICABLE 1.4 Community Structure. Provide background information ort .ttrc social organizatiorts of comrttunities ittthe c'D'T'l' areas' This may include infurmatiori ort; settlement pattern of thecomntunity (e.g. rrumrets, seasonarfarntsteads, dispersed popuratiott, ,r, I The population in the cDTldistricts is settled farmers and the sett.lement densrrl,differ from place to place as can be seen on Map 5. . The ethnic groups in the community. The population is composed of different ethnic groups. The majority of thecommunity members berong to the oromo ea.iqaand the..riu.tong,o'Arhrru(2.270), Tigre and Gurage fO.gEA and others (O 4Vo). ' Please provide infurmation about the area covered by cDTt ind,icating wlrctlterlley are migrants, nomads, refugees o, tnt"l'rrottyiirlirrra popurations. The community included in the proposed CDTI project area is composed of settledsubsistence farmers businesses. , government employees, and merchants "rgug"d in small_scale - . Comntunity leadership structure. Theproject area is inhabited by an estimated of 1.56 million people in 22 districts and453 villages' out of. this, 712,4gB people living in 7 diitricts and t62 villages(Kebeles) are included in this CDTI proposat. The community leadership strucrure rnthe zone is organised around zonal -administrative councils, woreda (district)Administrative council, which consist of elected members from each village. Theworcda Administrative council is responsible for giving guidance and leadJrship tothe community for all socio-economic activities. Eacrr fio.eda (district) has Kebeles(villages) with their own viltage commirtee. The number of cDDs will be determinedbasod on the size of the Keberes (using 250 peopres/2 CDD as a guideline). a r0 The Administrati'e Structure belor'slrorvs trre conrnrunity lcadership s5,stenr: 3,H:#L}Iffi; :: ffi: i"Xyfl ftil:il,,:jil.,, a n ) Ke be, e cha i rma n ) ' ll'[ain occupation of contmtutity and periods of ntajor cotnt?,ttlar activities. The main occupation oi the community is farming and sma, scare businessuch as coffee' The urban p"p;i;;;;" is engaged ,i ,rar--r.rre business, .,'i,il.il:I.#Imanuat labour- Farming a.tiriri"s.is low-diri;;;;;; lllro.r,through Aprir. Duringffi *lil lii;,iiilt m*n::*l:^j*:n"lt, ll",l,, "n s s uch,, 6., u (ch n s tm as ), . Preferred channels of corrtrttutticatiott in tlte cottmutniN. The preferred channel of communication by the community is from the locar farmers orurban dwellers association tr-,ui"".n to trre viilage .i,i.r ,o the head of househords. Noforms of mass media ,.. .;r;i;;;cJssrut. to these rurar communiries. ' Existittg aclive cotttrttuttity associutiott/group.s itt trrc are. (e.g. sociar, rerigious, etc.) The existing and active commu'ity associations/groups incrude the farmers assocratronsin the rural areas and the urban a*"tt"., associati-on, in ,or"nr. In addition the churchesand mosques arso have domin""i.or., to pra1, ,n .onr-unity mobirization. . Established clistribuliort systettts in tlrc corttnttutit\,. There are some existing distribution s),stems, such as porio immunization, maranaconrrol, viramin A distniutior, ;;' famiiyprrrr,rg r.i,,.", rhat are organized throughthe socrar and rerigious ,r;;;;;""s menrioneJ aboi,e. It is arso through rheseorganizations that community mobilizatio, ,rJ rr*1,r-, iar.ntion will begin for GDTI.The community could ol'o ,...uii'ir,.i. oist.uuto.s'irr.rgr., these systems. since the.ffiiil:?:,Il""|:H:If;J,?:Trii:iui" i'"ii.';;;J:,'j'.1, ,, ,ow, enr6,ring communi,y ' social conununal auivittes and ntonths duriltg which the activities take place. There are various social and communal activities. prominent among these aretraditionar rerigious cerebration, .r.r., as Gena lcir'ri',,,ror_), Tirnket (Epipiany), Id_At_Adrn and Id-At-Fetir, u'rictr tate frr.. from January ro March. c Any previous experiertce of ilte comttturtity tvitlt developmenr/health projects. Y il aMost communities in the zone have been inv,olved in Epl. iamrly plannrng, *,ellconstruction and spl'ing protection activitres. Tliere are also community health posts managed by community health agents and traditional birth attendants in somecommunities' The communities therefore have well-established systenrs ofmobilization to enhance participation in health proJecrs. Description of otlter anthropologtcal characteristics of tlte contnrunities.. The people in the zone are follorvers of different religions. The most dominantreligions are protestant, orthodox and catholic Chnstii-ns and Moslems. priests, shekies and traditional leaders possess strong influence in decision-making andhealth-related behaviours. Planning Ivermectin distribution cycles during religious and public holidays can be important to access most community members. 2. PAST AND CURRENT STATUS OF CDTI TN PROJECT AREA 2'l Please indicate if trrc GDTI is an expa,sion of art existirtg )DTI. No, this site is selected for the first time. 2'2 State the number of 1'ears the progranutte l,r,s been operating, atrcl if possible crtcloseprevious statistical, financial and. annual reports. NOT APPLICABLE 2'3 state the nuntber of persons treated each ye ar Jor trrc rast 5 years.- NOT APPLICABLE 2'4 Ltst the orgctntTation(s) involvecl in the prograttltne, tlte sources ancl arlout.Lr of futtcls use4eachyearfor the last 5 yeurs. NOT APPLICABLE SECTION 2: PROJECT EXECUTION OUTLINE 3. DESCRIPTION OF PROPOStrD CDTT The nruin strategy of tlrc proiect will be to develop antl establish community-based ivertttectirttreatment syslents, which can be sustained b), the enrlemic communities themselves witltout external support after the S-year projecr period. This section should describe lrcw tlte NOTFplal$ to develop and intplement CDTI in all high-risk comntunities in the projecr area. Tlrcplan should take into account the need to clevelop approaches to CDTI, which areappropriate, for the dffirent local situarions, and rhe neecl to carefully evaluate tl.taimplementation of the selecter) approaches and. acljust tlrcm whett requirecl. T2 The prc-;ect objectrve for Year-one rs to conduct CDTI in seven pnority drstricts. TheAnnual rreatment oblective (ATo) for Year-one is 569,999 and the Ultimate TreatmenrGoal (UTG) will be determined when REMO refrnement is completed in the otherdistncts of the project area. outline of the activities that will be carried during the firstyear is descnbed in rhe following table. 3'I Outline PIan and Timing of Activities for the period 2003 - 2004 Acti vity/Justi fi ca tion Length o[ TinrcA dvoc and SCNSQcy tizat tot at tlte onal evelreg has S wil beemp on n trod nuciplaced gAthe POC ICDT 'astr ate nd en lis6J he S oftrng he reupport velegional h thert nn ofpa the Npa o oTF/N CP re a miad n 'astr vegion cou NC offi CCS 4 u,eeks 4 weeks A re'enrcn heI on ton role .tdefi.rt and reof tbilitiJ .te, alspon rtof /.tpa icipan throughHMO rhrh re on,,gl PAPOC ,r s etcoposa Procurernent of ess vehicles. e nt ial p roj e c t e q uip ment and supplies: Comrputers, Mectizan drugs, and l6 weeks ining/retrai rcrojectTra 11 tn8 rQuTeofp at 'he re leional velITra n to hose ho iIng fu ctrn on as anIralners sud sors.perv 4 weeks proJec R dapt' ioloEpident Aical SE '.t,J enn1I emld ol aICEpi uS r e Sog rfo oNC lahocercv S ha been o n othe romlrnpleted Re ongrREA SU rve weho w,ilverys be meLd oud to c Ias SI nde eml rI efy vels n het' area 4 weeks obil lI/o redaA4 lollzat rc. otnl na dof I oullrcr e.t to ttS orI the e Cpp p roJ 2 w,eeksCottduct KAp Stuclies J n rh IS he fi me tnrenIrea betots edCATTI uto n Eth a, SKAP ur\/rop a reyses tren a de dhe8u evel n frr aopme health de ucapprorpnate o matena S ln the \\/oreda 12 weeks stressing community orvnershi p of the projecr asndenticof lt(,obil LUt 'lotl e t1cot etnltnltl s, ,CI a rh ke h healt Ledu at I1o (ame 4 rveeks ec lectio artdn tra LIConurt t1. Doft7g erect, D'diry t ri.buto rs ,DL .tD(lecSe tron ro DsCD resthe o SIn bi of hep COITUTTUNv rty 3 weeks 2 wecks 8 weeks \\,Mon .t& rvt .tIoring oolt MfLtpe ect @zan d butstn o actln tles b Soreda u,), lsorsperv 4 weeks . activities ( spot checks) b1, regionat ves Inspection of CDD distributiott superttisors and NOTF I rveek I,M .t M,( I, ranagement 'matiot7 "fo Sy,tem)ofReport ng Ireatmen antS d ra n n wl be u ired ASob rhtnreq on nmo hpast, basivnda il teap feed bacprop k nSC rho e ders to en reSU erhprov readhe tonce Ilcorrec veumeas res recom ndedme Monthly NOTFiAPOC e a u II leamon dcon uc rnallnte externaand e uval a oron thef ecproJ 4 weeks Tre at fo CR vte\ 'il cl A C l,lof nAn ua revle andWS \\'l bereports uand edSgenerated tone ureS tIcon n uou m enm desinprove n the owgn ob actlon anng years p I rveek CTA iott Pl,an tlte ne.xt r_fo, yea 2 weeks Houselrcld registrati on, and census enltnte rotiort 'Mectizan @ Coltectiott and Distribution in endemic communities l3 IC S a S tl n lt tes 3.2 l{ealth education and Communitl'Interaction and Participation 3.2.1 How u,tll you approach and interact with the cotnrnuniq, There are already existing systems of communication with the proposed project area through other health programs as described earlier. Horvever, the following strategy u,ill be implemented to maintain good relations with the communities: a) Discussions with Woreda administratrve council chairmen and social affairs heads and then with local farmers and urban dwellers associations, religious leaders, communrty elders and opinion leaders to better understand comntunity protocol b) Focus group discussions with social and religious groups to further mobilise the community with the support of the community leaders c) Focus discussions wlth the community members as appropriate (separating men and women, or not, depending on the community traditions). The community members rvill also be encouraged at this point to take ownership of the program, defining their roles and distribution mechanisms 3.2.2. Health education Health educatiort and conununitl' nro6'1'zatiotl will continue be an integral part of all approaches to CDTI. Health educatiort activtties should ensure cotttirtuoLts exchange wtth regards to knowledge, awareness, perceptiort and observable attitudinal changes about Onchocerciasis and its treatntetn. Appropriate health educatiort ntessct.ges itt the forut of posters, pamphlets and verbal presetilotiorts will need to be developed and tested. Health education should address the follotrittg issues (Table 2): t4 ISSUES Health Ed ucation l\tlessages Knowledge of the disease a a a Local name of the disease Symptoms Causation/transmission (simple)Knowled ge of treatment a a a a a a Previous experiences Introduce Mectizan@ Dosage Exclusions Reactions Beneficial side effects with Diethylc (ivermectin) arbamazine (DEC) Attitude to treatmeni Advantages of Treatment . Free . Yearly treatment a a Pos b SEof f Ireatmenty at com um NI evelvIm fo axlm ma veracotitude to diseaseAt a a disease can be controlled s can be ret,en [ed The Onchocerciasis blindness & skin cto good record kecpingAtrirude a a o Minimum requirements Records are confidential Records required are for fo for record keepi ng and strictl hr eal urhv SC SU uen USbseq drug pp v Table 3' criticar lssues in the Deveropment of Hearth Education for GDTI a) Have any KAP surveys been done in tlte project area artd i,f so, v,hat were trrc resttlts? No KAP studies have been carried out in the project area b) l[1nt methods witl be used to develop lrcaltlt educatiort ntateriar for trte contmu,ities a,lcrfor the agents who wilr be respotts;ibre for lvernrcctin treatment? Health education materials such as posters, leaflets and flipcharts will be developed inIocal langul.q:' by the project and submitted to NorF for srandardization. Thesematerials will be field-tested and refined/aolustJ in accordance with Apoc acceptedstrategies prior to mass production. video films u,ill be produced and utilized as amobile video film show. c) what methods wilt' be u,sed' to provide health educatiott to trte endemic cortrtturtities and.to the agents resportsible for treatment? l5 The zone has used several media In the past for proi,rdrng health educatron to endemrc communities' Such methods have included face to face discussions with health workers,the use of town criers, traditional birth attendants, community health agents the use ofposters and flipcharts in local Ianguages, and drama (role playing in localitaysy. Community leaders will first be informed about the disease and the necessity for regulartreatment with ivermectin. These community leaders ,,vill serve as agents for ihe program. encouraging community members to compll, with ivermectin treatment. All community members will be engaged in discussions about the health education messages, and given the opportunity to ask questions they may have regarding any aspectof the program. community members wiri arso provide vaiuabre inplut int6 the heartheducation messages and materials 3.2.3. Community participation In community-directed ivermectin delivery systen$, ntembers of tlrc ertdentic cotttmu,itiesdo the execulion of ivermectin treatrnenr lhemselt,es. Trained personnel, krtowrt a.sContruunity-Directed Distributors (CDDs) who sltould be fulty supported b1, rltecontnunity itself may provide lreatment. The contntunity shouid iu ,ripo,rribte for rheorganization and executiort of the CDTI with ninintutrt but effective medical supervisiott, once il has received the necessary informatiort and training. Various orgartizatiortal structures at tlrc conununitl'level, rangittg froru w'ottten's cooperative ti traditiotrul structures, ctre important for sustaining and strengtlrcning the iupport netyuork of rlrcCDDs. a) Explain the organilatiort of the intendetl cornntuniq,-directed iverntectin treatrtteril itrllrc project. The formation of an Onchocerciasis task force at all levels is essential in order topromote coordinated activities of Onchocerciasis control in all endemic areas. AtFederal Ievel the Malaria and other Vector-borne Diseases prevention and control ream (MovDpcr) is responsible for routine program management and acts as the liaison between MOH, RFIB, as well as with NCO partners-within the' country and outside. The NOTF will be the governing body ior Onchocerciasis control activities in Ethiopia. A senior staff of this unit will act as NOCp coordinator. At regional level, Malaria and other Vector-borne Diseases prevention andControl Department (MOVDCD) is responsible for program implementarion arthat level. The head of MovDCD will act as a RoCP Coordinator. Similarly, at woreda level woreda onchocerciasis contror rask Forces (worF) witi be established. The woTF will be responsible for program implementation at thisIevel (ensure selection of CDDs, supervision of lreatment activities, recordkeeping etc). t6 b) c) Also' Iocal health tnstttutions under the woTF rvill be responsible to co-ordinatc,monitor and supervise CDTI at each locality. For ivermectin treatment purposes the number of CDDs will be determined basedon a guideline of 50 households or 250 people per cDD. once communirres selecrtheir cDDs, they will be trained in the CDTI Apoc straregy for ivermecrrndistribution' cDDs and other local pnmary health care workers will then providehealth education to communities on onchocerciasis (its cause, transmrssron,control and preventive mechanisms). Prior to the drstribution.exercise, regrstration of all households will be carried outand non-eligible individuals identified. After registration, ivermectin distributionwill begin' The cDDs will follow up defaulters b-ased on their treatment registers. illi,,Y:*da and Regional health staff rvill carr), our supervision and monitonng How will iventtectin distributors be selecred? The selection of cDDs rvill be the responsibilrry of the community through thefarmers and urban dwellers associations. In some cases, leaders may make thisdecision on beharf of the communrt), The,\, rviil be expected to be honest,dedicated, literate, and permanent resrdents of the community. Hov, will non-eligible be id.enttfied artd clefattlre rs followed.-up / Non-eligible are mainly identified b1, havin-e a complete household registr.atrorrcensus and defaulters are.identified byrefemng to distribution record or house holclcards. Defaurters, upon identification, u,iil be trlated by the boor. This is arso doneafter previously non-erigibre (such as pregnant rvomen) have derivered, andtherefore nou, eligible for treatment. Local Operational Researclr Are there any plans to conduct local operatiornL researclt? ,/ YES NO If yes please git,e cletails Both regron and zone will conduct operational researches in GDTI areas ondifferent topics' Research will be carried out on the economic impacts of ,rr.disease in CDTI projecr areas. ', Y:"!;i:;ittg will be provided to ensure the deveropnrcrt at.td sustaitrubirirl, of 3.3. t7 Training of CDDs to operate CDTI rs very vital to the program. To ensur.e sustainability of the CDTI program, Trarnrng of Trainers (TOT) sesstons wrll be conducted by the NOCP. Those trained here rvill represent both regional and zone levels. These individuals will in tum train representatives from Woreda and health facilities. These will in turn train CDDs. The trarning sessions will focus on the following topics: . Basic CDTI principles . Village census . Health Education and community mobilization . Mectizan@ and its benefits and the related adverse effects and management of its adverse reactions o Inclusion and exclusion criteria for ivermecttn treatment o DosinB of Mectizan e Methods of drug distrrbution . Record keeping and reporting b) Irtdicate criteria for selecting trainecs dtstributors). (sttpen'isors artd comntunity-directed I) Criteria for selecting CDDs (r) (i i) (iii) (iv) (v) Literate if possrble Resident in the communitl, Willing to serve the community Must be honest Must be selected by community II) Criteria for selecting supen,isors: lVoreda Supervisor: Must be a PHC staff selected by the state RHB Must be knowledgeable and honest Must be interested in helprng the community Must be stable Irtdicate number, and duratiort courses intended (i) (ii )(iii) (iv) Type of Training (Workshops) Duration Number per year Regional Training 5 days I Zone Tlaining 3 days I Woreda Training 3 days I CDD Training 3 days I l8 .t 4. SUPPLY, IMPORTATION, STORAGE, INVENTORY AND DELIVERY OF MECTIZAN TABLETS Tltis sectiott is only a reminder ancl .cortcents the supply, importatiotl, storoge, i,ventoryand delivery of ivennectin tablers, rlonatea by Merck'& Co, who will also;;y";;;r:,;;;,:,; charges for iverntectin to their accredited agents. Mectizan@ consignments will be received through wHo and stored in the MoHcentral stores ih Addis Ababa. It will then be trlnsported by road ro rhe regionalhealth bureau, and from there to East Wellega health Depar-tmenrs rhen to CDTItargeted districtsAVoredas. The woreda treatttr office wltt u" ,.rfonrible fordelivering the drug to the health facilities. (In some areas the Woreda health officeis located far from the communities. In this case, health facilities will serve as thefinal collection point). cDDs will then collect rhe drug from the woreda healthoffice or health facilities. A report showing the use of ttie drug will bssent to TheMecrizan@ Expert committee (TMEC) ui th. end of every year, by rhe NoTF,with the subsequent application. Copies of the application and the'report of itsuse will also be senr ro APOC. An application for Mectizan@ tablets will be submitted every year by the end ofSeptember to the NorF, using the standardrzed form of TMEC. Thrs applrcationwill then be foru,arded to TIT4EC in Atranta forreview and approvar. 5. STJPERVISIONA{ONITORING AND EVALUATION 5.1 Supervision during CDTI Projects are.required to be supervised and monitored. However, APOC fundedprojects will need to be deiigned to function with effective but minimumsupervision compatible with its ob;ectives. a) Please describe the ,supen'isory arrangenrcnts you cotuider wilt be requiredfor the CDTI youpropose how will this continue at the cessation of Apoc support? There will be intensive supervision.at all levels of program, especially auring tieearly years' Since the p.og.u. will be integrared inti the Malaria and Other VecrorBorne Diseases control units, the supervisors and monitors will be staff of theseunits' The woreda health workers trained to train cDDs will also be responsiblefor supervising their activities (proper record keeping, comprete censusenumeration' Mectizan@ inventory and dosage, and monltoring during the actualdistribution process). The supervisory ,.ums ut the woreda level will beresponsible for supervising health insiitutions (management of side effects,Mectizan@ accountability, and reporting on treatment coverage). Most importantwill be supervision at the community level where most treatment activities arecarried out, and cDDs are responribl" fo, proper distribution of ivermectin.Findings from supervisory visits will be reported along with monthly treatmentdata, and repofting on adverse reactions. t9 As the program matures, the communlt),u,ill assume mor.: and nror.e responsibility, includrng decrding on methods ol supervision, and those ri,ho rvrll carry them out. This process may involve comntunity, opinions, and r-eligious leaders. b) Describe how' yott would ensure thal supen,isiort tvill be carriecl out so (ts to:o falt withitt rhe requirement accourtting for ivennectitt use . be sustained yvhen lhe program encls in -5 ),ears ' ensLtre tnaxirnunt irtvolvenrcnt of the conrnrunities in tlrc process To ensure that the above requirements are met, the program rvill support regular monitoring during the actual distribution process to ascertain that con-ect dosageis being administered, exclusion cdtena are being observed, and the collection and proper storage of unused drug is occumng. In addition, the progrant rvill support advocacy visits to the woreda and villages by MoH, regional, and zone representatives of the Onchocerciasis task forces at each level io encourage the active suppoft of the community. Once trarning of CDDs has been complcred, Woreda supervisors will check that household enumeration has been completed accordrng to APOC requirements. 1.2 Monitoring of CDTI It is irnportant to collect infonnation to ntonitor the progress of ttrc GDTI. ittdiccttors will be u.sed to rttortitor; . Ivennectindistribution? . Health education and contnttutitl, parriciparion? . Managen'Leti sl,stents ? Tlrc following items may be considerecl. Ivermecttn Distributiort t Nuntbers of conununities utd persons treatcd. witrt i,crttrcctirt o Treatrnent Coverage . Regularity of treatntent exercise . Corupliance . Reporting adverse reactiotts Ed,u n and llthar a a Matta etnettt Numbers of corunruntties participating in rhe project Evidence of intpact of health educcttiort a Are activities beitry carried our ctccording to plan and on scheclttLc'/ 20 o Inventory control, . Are recordforms accurate and contpleted on rime?o Numbers of persons lrained o Balance of genders in stafr of tlrc progranl The project will consider the following indices f,or monitoring the program of CDTI I v e rm e c tin D is,trib utio n : The NOTF will ensure continuity of the HMIS sysrem developed forOnchocerciasis control prior to the beginning of treatment. These will enable theNoTF to monitor the communities and p...on, treated with ivermectin, treatment coverage, and regularity of treatment, treatment compliance, and drug reactions.In addition' the project will monitor the following rates and percentages usingAnnual rrearment objectives established at the beglnning of "u.i y.r., ' Annual trearment objectives (ATO): High-risk villages (number of high risk villages targered for treatment) At risk villages (number at risk villages targeted foi treatment) Estimated at risk popuration (totar popurarion at risk in the region) Treatment coverage (related to ATOs): Treatments (number of persons treated) High-risk villages (numberof high risk villages rreared) At risk villages (number of at risk villages treated) Cost per person treated Tablets disrributed a a a a a Number of ivermectin tablets in store at MoH, in the field, on order, or to be ordered n and u The degree of community participation in mobilization activities will be used zrsan indicator of community mobilization. In addition, the support of the leadersand key opinion leaders in the communities will be indicative of ,u...rriul mobilization as well. The impact of health ed_ucation messages will be measured through periodic focusgroup discussions and KAp studies. Manaeement The project will develop, through the integration of Onchocerciasis control to theMOVDPCT, a regionar and woreda management/ supervisory system rharmonitors: o The planning and imprementation of activities according to a timeline . Mectizan@ inventory levels 2I o Monthly reporting of treatment rndices . Numbers of personnel trained o Attempt to balance gender in staffing 5.3 Evaluation of CDTI Annual external review incorporating fietd visits will be urtdertakcrt to crtsurc tlmtprojects are meeting target indicatiorts otillined in this proposal. Sttt.lt reviev.,s, wilL provide TCC with the assurance tltat each project is ntovittg townrcl irs lortgterrn stated goal and if appropriate nnke recontntendations aboLtt att1, cleficiertciesor modificatiot'ts to this project. Such reviews will d.raw ott tlte ittdicatorsdeveloped by TCC as a guide. 22 6. SUSTAINABILITY OF THE CDTI AFTER THE WITHDRAWAL OFEXTtrRNAL FUNDING The concepr of ,sustainability refers .to tlrc abitity of coutttries cutd affec.tedcornmunities following initiat extental investntent io nruintaitt tlte viabitirv andcotttinui| of the ivermectin treatme,t process without external support. ror'eto|lfunded projecys, such support will nonnalll, last 5 years, as tlte A1OC donorsdentand thctt there shatl ie a visible artd acltievabrl end poittt for the externaldonatiotz (lspect .of the proSran'tn'te, and tlut the community based distriburion 'l;;:;i,:::::;i:::,*:,:::,*aner be sustatnabte iv *, s\vernmen;ts of the Progress and prans towards sustainability, includ.ing the phasing out of extenrurand NGo? supporr, must be reported ainuaily o,ri ,oiiryoctory progress in trisdirection will be a conditionfor'each succeedittg year'sfunding instalmert. pleaseaddress the fotlowtng areas that relate to ,rrtoirobitity: integration into primaryhealth care, cost-recovery, and other sustaitrubility issues. i'iil:,Ji#rhH:::i#;ffi"Tst-APoC sustainabiritv or the program accordrng ro rhe Planning: cDTi wi, be integrated with. the pnmary Hearth care (pHC) from thebeginning. At the National, ,.glorri ,onol, and ,uoreia t"r"lr, the MOVDCU will beresponsible for program implementation. onchocerciasis ,urtio..". will be established at:l#; ;:iH,TfJ:J,j, r ;T;;3, ju*: ::1il;;ffi ; me, hod s u, i n g bo*o *, p Leadership: taskforces. will -be empowered and. community leaders would be encouragedto be actively involved .in CDTI impl"*entution. Invor'ving .o--unities in deciding :ffi:i1r:?ii."J,#*:an distribuiion, cDD selecrion, "iJ *oura ensure .on.,*rni,y Monitoring and evaluation: will be carried. out regularly with proper checklist by the X?#r':flil,1i1["J,';e::: comm;"i'v s"rru"ronlto,ing, *ii.n wiu be.ona,.iJa ry Training' Health Education, social nrobilization, Advocacy and se.sitizatio.: wouldbe undertaken in such a way,to, ,rr,uinubirity of tr,e coii prol"ct wourd be ensuredafter the terminarion of exteinar fr"did. ;; ;;t";'ffi;;iifJr" efforts shourd read roempowering the communities so that thJy can assume ownership responsibirity. Finance and Funding: short, medium, long-rerm (post-ApoC) financial sustainabilityplans will be prepareJ at woredalnJ''."gionor levels. Budget Iine will be creared forCDTI activities by the respective local gouErnrn.n,. Trattsportatio.: The respective lrealth offices at each level will provide transportationfacilities for onchocerciasis conrror u.iiri,ll, according to the need. 23 Human Rcsourcc: Existing hearth u,orkers irr the s),stem rviil spend a ponion of theirworking time for onchocerclri, .on,ror ,.livities in their respective work areas. Trcatment coverage: Effort to achie'e aIOOvo treatment coverage in the targeted areasilliff ,:HJ;;1,H:?'*ffi l;fffi i:il]1:**ffiI1,.,.J.i,,;,,,n.bi,i;;;;;0,,,., Mectizan Procurement, storage and Distribution: Mectizan availability will be ensured :',[ff["i:T:y,:::ilJ"#"* -o"*g""ona ai,t,iu",',' ,1,,.,, that u,,r be rurrher 6'1',i:fiilUfl?iifS,t?ilinto other communirv''based or primary The principal goal of the APoc is ro establish cost-effective ivennectin-basetrco,trol for onchocerciasis, whicrt cart b.e ,rrror,r"d-"by trrc ertdemic cornnunitiesand coutttries. One way to ensure sustainabttiry, is to itltegrate the CDTI tnfo rhe ilhy;::;,,i{,;::,":,oi,,ry, *it,i ,lea*s tttore trnn iust usins the sysrent for 6.1.1. Is there an offi.cial pHC policy and structure irt the country?,/ YES NO If yes, please give a brief outline of what it is; HH,.'ffIiS::.lt'91-ry,,.t in Ethiopia is to deverop and srrengrhen T o. s p ri on t v ffi ,T''Jdfi ';',"1;,".;: i:11 ffi? jffi' TIFf tf :f t:tntegration of CDTI into ihe PHc system. At the ."gionri and woreda levels, theMovDpcr wi' be responsib;#program impi-ementarion ar rhe respectrveIevels' In addition, combining rrainrng on GDTI with other on job tiainingactivities, incruding onchocercir'rir.on,.or actrvities,n tn. pranning process at a, 5::J: ilfl iffi.*:#J.ffiTt ;-;. Iist or n,,.n,i .,senriar drugs deriverl,- The PHC system wi, be used to achieve fu, integration at peripherar lever byfurther integrating CDTI lnto trre ,.tiuito or trr.'piC itraining on GDTI intotraining of health workers)' rnis waf ir,e PHc sysrem *itt'u" used to achieve fu,inregrarion of GDTI into g"n..ai'rreattn ...ui.. uy'outuining support fromRegional and woreda authori"tie., oirr"*r and murrirat Lrul-orgunirations. In summary, the pHC structure is as follows: MOH (MOVDPCT) ) REGIONAL MALTH BLIREAU) ZONAL FIEALTHDEpr.) woREDA F*ALTH Oerr)maLTH F,ACtr-rrms (hospitars, hearth :3?iil'Ji{'lstations' health posts etc) ) cotavflrNJiy FTEALTH bosrs 24 a) How functional is the primary Health Care system? - Fully functional - Panly functional The system from rhe National level is fully functional until the Health/hearth facirity level. However, at the community Ievel health . coverage is limited. - Nonfunctional (please spectfy) b) Does it cover the whole project area? No,/ Yes c) d) e) f) If no, in what parT(s) of the project area is there afuuyfunctionar pHC structure? wrut percentage of communities where onchocerciasrs ls endemic, and which are eligible for community-based treatment, have an existing and functional PHC system. wat orga,izatiotts are supporting the developme,t of pHC in your project area? Government of Ethiopia (Ministry of Hearth), wHo, LTNICEF,WB and some NGOs Is there any past experience in tlrc country of a programme integrating witltthe PHC? If so, wlnt programme was it and io* ,urrrssful was tlteintegratiott? EPI, Malaria control, and family planning drug distribution. The integration continues successfully. Are there any plans to integrate otlter rural health programmes, suclf asthe Expanded Prograntme of Immunization, Maternal Znd Child HealthPro.grammes or programmes for the contror of other parasitic diseases, with the PHC system? EPi, maternal and child health program are already integrated. Malaria control is under the process of integration. Describe how the 1DTI wiil be integrated into the pHC system; the way rhePHC systent will be used to achievi integration and the'key persons in thePHC systent that wiil be needed to achiei the integration. ' At the Federal lever MoVDpcr wiil be responsible for routine program management and act as the liaison between MoH, RHB, as well as withNGo parrners. Members of the team share ,"rponribirities among 8) 25 It) 6 1.2. themselves and hence a separate entrt),of ve(ical program nature will not be established. The head of thrs team ri,ill act as xocp coorclinator. At regional level, MovDCD ri,iil be responsible for progranl implementation (contacting communrty leaders, Lxplaining the prolrun, objectives, discuss issues rerated to Mectizan@ security, at regional livel. including monitoring and supervision). The head or udvocD wilt acr as a Regional onchocerciasis control coordinator. similarly, at the woredir levels will establish corresponding onchocerciasis conirol rask Forces(worF). The worF will be responsible for program implementarion arthe woreda level (ensure serection of cDDs, supervision of treatment activities, record keeping etc). In areas rvhere ,.."i, to the woreda health office is restricted, Iocal heatth institutions will coordinate, monitor, and supervise CDTI activities Indicate how early in the cDTI tlrc process of integratiort tvill beintroduced; how it w,ill continue thereafier, and, afie, iow n.tat"ty ycctr.t tvithin the exrentally supported tifetinte of tlrc GDTI it will be contpletecl. CDTI actrvities in Ethiopia u,irI be inregrated from the very begrnning. The establishment of the program wrll rely on existrng systems of health service delivery at all levels. lf there is at presertt no PHC syslent in operatiort or in those areas where tltcse strLtctures are rtort-functional, describe hov, Ihe cDTI nn1, be userl to irtittate atrd expartd itilo such a D'stent, git'ittg a tinrc fromc for itttenrled progress. NOT APPLICABLE 6.1.3. In u,hich way(s) can strengthen pHC? cotnnturtity-direcled ivermectitt treatment initiate or CDTI is Iikely to encourage and facilitate the acceptance of new health initiatives in the community. AIso, through the new CDTI strategy, rhe community will likely play a greater role in the support and owneritup of the PHC system. The structures arready put in place would be utitizej by the PHC to enhance effective planning and implemenrarion of the proleci. For example, the cDDs wilr deverop capacities and skills, whith -witt strengthen other programs such as health education, other drug distribution. 6-2. Cost'recovery Systems d u ring Co nrmunitS,- basecl Ivermectin Treatment Cost recovery for Priruary Heatth Care is mandatorl, in sonrc cottntries and it may be one n'teans of sustaining a CDTI after ApoC funding ceases. Howeve r, please note well tlnt since ivennectin is donctterl free, r7rcre crut be no cosr recovery in respect of tlrc value of the drug irself; cost recovcry can only relate to the costs of distributiott. 26 6.2.1 6.2.2 Please state whetlter there wiil be atD) systen-t of cost recovery (suclt as. isreconzntended in Initiative) to help cover outLays on rhe distributiott o1ivermectin in the present CDTI. - NO. State exactly how any such system will be organized, including answers tothe questiotts listed below. \hat charge wilt be mad.e per person or perfamily?NOT APPLICABLE y-li! groups of persons witl be exentptedfrom payntent? NOT APPLICABLE will payments be in cash or in kind? If in kind how wiil this ensure sustainability? NOT APPLICABLE what provision wiil be made to e,sure that ail those etigibre to rukeivermectin, but who are unabre to pay, will arso receive"treatment? Howwill it be determined who is unable to pay? NOT A\ILICABLEwo will collect the payments? Hiw u,ilt this person safery transport funds to a place of safekeeping? NOT AppLICABLE Wlere and by whom will any futtds collected be sa,fely kept?NOT APPLTCABLE what systems wilt be put itt prace to ensure the proper use artd.management of collectedfunds? NOT APPLICABLE For what purpose(s), includ,ing defrayment of distribution costs, wilt thefunds collected be used? NOT AppLICABLE wat role will vilrage Hearth comtnittees pray in the r,anagetllent andallocation of the funds raised? NOT APPLICABLE 27 6.3. Other issues Please provide infonnatiott ort other issues anrl constraints relating to sustainabtlity of CDTI you anticipate an(l identify how rhey will be or"rio,,rr. For example: the mobilization of endentic communities .tlrc maintenance of adequate supervisiort and rnontloring inade quat e human re s o u rc e s lo gistics and communications s o cial/c ult u ral fact o rs de c I inin g community c o mp I i anc e (1) Mobilization of endemic comntunities: Somettmes problems of mobilization of endemic community can be obstacle to sustainability of CDTL This can be solved through sustained advocacy visrrs, 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 behef systems. Obviously there will be a need to establish good relationships rvith the community leaders in order to have increased access to the communities at times like these. (2) Maintcnance of adequate sttpervision and monitoring Mectizan@ distribution should include community Ieaders to further increase acceptability and sustainability' of the program. All records should be venfied during supervisory visits, and informal discussions should be encouraged to determine community perceptions of the Mectizan@. (3) Inadequate Hrunan Resources Inadequacy of trained health staff and PHC units are expected to be consrrainrs iir 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. (4) LogisticsandConununicatiotts During the rainl'season in June to September travel to the endemic areas may be restricted. Proper planning (Mectizan@ drug orders etc) will focus on providing all high-risk villages rvith their drugs during rhe dry season (prior ro rhe Jan- March distribution window), and encouraging completion of distribution before the rains if convenient for the communities. 28 (s) (6) S o c ia[/ C utt u ral fac t o rs : careful attention will be paid to cultural and social factor.s such as: theappropriate gender for CDDs especrally in Muslim communities, respecting trretraditional religion, and selecting supervisors and distributors who speak the localIanguages. D eclini ng Corumunity Corupliance : Declining community compriance wiil be avoided through continuous mobilization activities prior toeach treatment penod. Community members couldbe interviewed to determine the reasons for the non-compliance, and corrective measures taken where possible and appropriate 6.4- Methods of measuring the progress torvards sustainability (See Appendix 3 for a list of possible indicators of sustainabirity)? Progress towards sustainability can be monitored and measured by evaluating theproject in terms of financial management/contribution, communications, trairingand capacity building This will help enhance integration. Financial ,nunug.r.n,should be- incolporated into the usual gou.rr.i"nt financial administration.Financial flow in the GDTI project should comply with government financialmanagement procedures so that there u,ill be safe resource management. Regionaland woreda health office heads, and administration/finance managers at eachlevel will be accountable for proper utilization of CDTI resources. The ability ofmanagers at different levels to familiarize themselves with financial and humanresources in the project can also be used to measure and monitor the progress orCDTI towards sustainability. In addition, the ability of community members to understand the cause and effectsof onchocerciasis, and the mechanisms for its contror can be consideredindicators of progress of GDTI to sustainability. The success of the program r.filldepend on the attitudes and practices of the community towards the disease. 7 CROSS.BORDER CONSIDERATIONS where an endemic area extends across _the borders of two or ntore adjctcertstates, special problents of cooperation between rrrc respter-rir, ,ou,rrries cDTInny arise. In tlrc event that there are areas to be covered by your proposed )DTI wherethe endemic zorte extends across the frontier inio o,te'or nxore neighbouringcountries, ctnd where there are rikery to be transitory or even large_scaremigrations of onchocerca-infecred peiso,ts eirher *oy orro* the border. 29 Please describe tlrc particrdar siturtton, d., it i.r likell, to ivermectirt trealment, and ilrc nrcthods you wiil use ro crear witrt itNOT APPLICABLE 7'2 Include pertinent observations ot'L currenr political ancl ltealrlt relatiorts with the neighbouring State(s). The zone is not bordered to a foreign country. However for activities that require collaboration with othei neighboring region and zones, ir can be managed by the Regional Health Bureaus. 8. SPECIAL RISK ISSTIES In some areas of sonte countries there may be special risks, wlticlt could hirtd.er tltesmootlt rurudng of a CDTI. 8.1 Please describe the situation tn any areas covered. by your proposed GDTI were this factor may interfere with the progrant, and assess'future prospects. There are no speciar nsks that may affect the GDTI activities. 7.1 affecr 30 SECTION 3: ADMINISTRATION/FINANCIAL 9. ADMINISTRATION 9.1. Organizational structure for CDTI 9'1'l Please prov.ide an organogram for the CDTI showing the organizational structure responsible for implementing the proposal. Fig'l' organizational Structure of National onchocerciasis Control program 3l i! .i d r i j i I I :1..-:E.,:,- i *]..: j :r itiri'i{r riicr riu;' , ': ' " ) '-; , iq,/ia).i,tjt !- 9.1.2 Membership of Taskforces 1. Regional Level 2. Zonal level 3. Woreda level Regional administrati ve council Malaria & Other Vector-Bome Diseases Control Head Regional capacity building deparrmenr (educarion and health desks) Regional Planning and Economic Department Regional Rural Development Office Regional Finance Office Zonal Administrati ve council zonal capacity Building coordination department (education & hearh desks) Planning and Economic Development Department Rural Development Office Finance Office Woreda Admi ni strati ve council _woreda Capacity building coordination office (health &education offices)Planning and Economic Department Rural Development Office Finance Office Religious Leaders Famous personalities 4. Kebele (community) Ievel Chief of Kebele administrative council Kebele capacity building office Religious leaders Infl uential personalities Representative of women's association Representati ve of youth association 32 9.2 Financial Administration Mechanisms of disbursements and transfer of funds from the World Bankto countries Funds from the World Bank APOC Trust Fund will be transferred to the wHOcountry office accounr in Addis A!u-bl_ on request through the proper channels by aurhorised officer of the MoH, wHo Addis Ababa will transferthe fund directry to the bank account of the respective Regional HearthBureaux (RFIBs) according to the approved CDTI p.oj".t proposars. The signatories of the bank account into which APoc funds will be transferred at the regional level will be the head and the administration and finance officerof the regional health bureau. AII the imprest returns will be submittedmonthly by RHB to wHo country office in Addis Ababa that will forwardthem to APoc headquarters in ouagadougou. Monthly reconciliation staremenrs will be forwarded ro the central MovDpcr (acting ur- irr.secretariat of NOTF) for follow up. APOC will issue checks (advances) in accordance with wHO rules and thepreviously agreed project documents and/or plans of operations. when thetotal payment in cash required for the project exceeds $ i00,000, tr,. pu1-.ntmust be made in installments. The first installment/advance could cover 3months or 6 months of activity depending on the duration and magnitude of theproject. l\{anagement of funds by projects and \\/Ho/Apoc mecrranism formonitoring T'he.size of the project wiil determine u,hich of wHo,s contractuar systems isused, e.g- Technical Service Agreement, Letter of Agreement, contractuarService Agreement or Agreemenifo, 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 impresrmechanism, whereby the project will report its expenditure on a quarterly basisand receive further advances on that basis. Each project funded by ApoC will require a periodic external audit at projectexpense. Each project must have one senior staff member who is accountable for themanagement and control of project funds. Standard internal financial checksand balances must be incorpo.ut"d into each project,s financiar managementplan. 33 Fig 2 Requesf and Disbursement of ApOC Funds Disbursement Financial Report 9.2.1 Input from the l\Iinistry of Healflr a) Indicate resources that will be prov'iclecl b1, the Ministry of health and othergovernmenl agutcies. I 34 .,:, t; '., '." ; ':' I ,,,t11, :.': - lr Personnel, Iogistics, office accommodation. Counterpart funding. Security b) Please provide a lisr of personnel assigned by tlte MoH to this project, includingtheir name and proposed time (state percentdge of time auocated'to ihe pr:ojiectlfor the project .and where appropriate their experience in Onchocerctasis c ont ro I thro u g h iv e rmect in t re atme nt. This project is new for the woreda so that. none of the personnel has had any priorexperience i n onchocerci asi s control through i vermecti n d'i stri bution. R urea Name Position Vo TimeMr. Dereje Olana Head, MOVDCD Oromia Regional Health Bureau Region L0Vo eme ChibsaMr. Shell Head, MOVDCT Health Bureau Oromia Regional L0Vo Addisu MekashaMr REMO (CDC report) Health Bureau Oromia Regional 10Va Dr Kebed Etana Epidemiologist Oromia Regional Health Bureau I0Vo Tadese HundeMr Vector Control Expert Health Bureau Oromia Regional l0Vo Sr. Mulu Desta Epidemiology Expert Health Bureau Oromia Regional L0Vo E t Well ne Irh t: Vo Tinte i .25Vo 20Vo 20Vo 20Vo * Four additional staff members from each district will also be participaring in the CDTIactivities for 25 -3OVo of their working time. Name Position ZonelDistrict Mr. Yohannes H/Ivlichael Department Head East WellegaZone Mr.Terfassa Tesema Zone CDC expert Eas t Wellega ZoneMr. Me laku Tesgera MOVDC Expert East WellegaZone Mr Deressa Keno Head Planning & Programme Team East WellegaZone 35 9.2.2 Input frorn ilrc partncr NGDO(s) a) Please providc a letter front llrc Exccutit,c Directot' or rhe Direclor of Ottchocerciasis prograttmte s of each participating NGDO staling their intentions to participare in anrl s Lt p p o r t t he N a t i o rnl O ttc lto c c rc ias i s C o nt ro I p ro g rantnrc. b) Give infonnation of ttrc inptu fronl each NGDO project. participctting in this c) Please provide also a nominal list grad.ing and post desciption for thepersormel to be provided by partner NGDO(s). Indicate clearly what will be their frnctiotls itt the prograrn and their experience in Onchocerciasis control th rough ive rnte ctin dist rib ution. There are no paftner NGOs in the area that can participate in the project Therefore, all the contributions u,ill be met by the government and community. 9.23 Inputs from other agencies. PLease list ctttl' other agencies or parties that will be involved irt the running or fi.natrcing of the CDTI, ancl inclicate clearll, their roles, fi.tnctions and cotiributtons. \\/Ho: wHo Ethiopia wiil assist the pr.oject in rhe procurement and clearance of Mectizan@ imported into the country by using rts diplomatic status. 9.3 Timed plan of action Provide a time chan(s) showittg lrcw the various activities of rhe CDTI wilt proceed over the course of tlrc proposed program. Nunrcricctl annttctl rargers for all planned activities shottld be prot,ided for each tinte poirtt. The time charts should also indicate how external support u,ill be phased out over the 5 year period. 36 r-- \ \ \ \ el r- ei \ \ \ \ \ \ \ \ \ \ \ \ \o N \ \ \ \ \ \ \ \ rr1 O c{ \ \ \ \ \ \ \ \ \ \ \ v N \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ ra c'l (J d E .9 oo OJ L ot( c .9 .9 .: E-(J(Jq> -()tr 66 -'If .E 9> U: <E qJ E o E .9 .= c tE(J ! o o Z() E ooL oo fi (! c o E o tuoq) dL o- '= ac() q C) o qJ E C)L o o o. (g q L o .E oo 'a o- o oo .E .E OJ b, c '= ',!- F () o o C) o -c q) o (g -OJ o L C)E a (J o 'a o- o o0 '= L (.) bD tr d F @ OJ tr q 0)q ?o 'to I o E 0) =o. rr.l =o- cg& c o 6 N =5 o A .E E E U lqloIE = u') A IZ o = tr oU l6 o OU o oO .= 'a CJ E, c .E 6 !C6 E o o() T V) lql)q C o o ! c o i o5 r ,2 oO o EE Oq =o o o E o o -o L t-..1 v) (! N (,) o z c 9 OJ o- = 6 oO o o z looU o c '5 oo o- c 0) u c5 c -o \, .9 Eq €E E() E(.) oO €c d 2 oo L o- qJ & E(-) q\ U) E .9) = a) o x(J dc L o lo 'a U E o E € 0) LF o .9 od E6 o. E .9 o q) q) F q) q,) !f,() F I.T 10. BIIDGET 10.1 Budget Estimates Budget nxust indicate total firnds to undertake tlrc project. The arnount of funding requested front APOC, and the amouttt provided b1, the MOH, NGDO(s) and. orher partners. All must be made in US dollars. Each budget nxust include at least tlte followirtg nrujor categories (see appendix 2) indicating the contribution of the partners to reJlect susrainability of CDTI. o Personnel (services) . Capital equipment . Supplies Training o Health education/mobilization o Travel o Communication . Consultant . Operating expense . External audit 38 TAbIe 5. YEAR ONE SUMMARY BUDGET FoR oNcHocERcIASIS coNTRoL, 20o3 CATEGORY APOC MOH TOTAL I 0 '72,527.20 72,527.20 Ca tal t 123,t70.00 28,669. 10 t5I,93g.l0 59,279.00 0 59,279.00 lnl 20,520.00 7,360.00 27,990.00 32,684.00 6,475.00 39,159.00 'ravel I1,160.00 1,440.00 12,600.00 Communication 2,540.00 2,540.00 Consultants 0 ExternalAudit 0 0 Reca tulation 0 era 18,5 10.00 19,5 10.00 Total 246,913.00 137,520.30 384,333.30 Estimated No. Trea tments 569,ggg s69,998 569,998 o//o 64.2 35.8 r 00.0 St treatment 0.43 0.24 0.67 rl Fo I 8 I Io = 8 a : 8C a o I a a Io - I a a ooc 6 8 o o- 8 a E -o o, N. a o- o c Fo -o - a 8c ots I .r. o. -o - a .: 8q a i 8 o e a g r; o. I to I C? @o o- o 8o a 8 q @ o- eo(3 F o c e Eg I 'E '6 a = E I E I 6 ts e c E E g E o E es d g o 9 E ol I E z E @ ! e z E s o o o oo .9 o(! '6 o(, oE o o o (\, E E U) o ! @ C,o o .= lJ- @g G,F 8 10.2. BudgetJustification Please provide a narrative description of tlrc reasons fot-each proposed line itents of the budget. (1) Personnel The budget seen under line item personnel reflects the need for staff at the 1evels ofMOH' RFIB and Woreda health office to facilrtate the CDTI activities ar rhe community level. The MoH will provide supporl in the form of:o Mobilising authorities and community Ieaders . Organising and leading the distriburion program o Training of supervisors and CDDs o Getting and supplying ivermectin o Transportation of essential supplies . Regular supervision r Accounting for funds spent (both APOC and others) o Program evaluation (2) Capital equipment For the program to function properly, the RFIB, Zonal Health Desks Woreda health office and some health facilities must be u,ell equipped rvith the necessary matenals. (3) Supplies: office supplies are essential for the smooth runnin-9 of daily program operations.Since this is the beginning of the program, APOC ,n,ill b" requested to provide all essential office supplies. (4) Training: Training is essential to the implementation and success of the program, and it is an activity that is carried out on a continuous basis, rvith training and re-training at alllevels as new personnel join the program. Training is also very important for the supervisory activities of the program. These activitieJwill be supported by ApOC. (5) I{ealth Education/l\rlobilization: Community mobilization and advocacy activities are required to build the support needed to ensure program sustainability. MOH personnel from the National, Regional, Zonal and Woreda levels will mobilize communities through advocacy campaigns, information packet and visits to thecommunity. General public awareness can also be supported by such techniques asthe distribution of posters, brochures, stickers, and r-shirts etc. 4t (6) Travel: Travel is required for advocacl,vrsits, trainrng, rctrarning, supervision and monitor-rng and evaluation activttres are all important for effectrve program implementation- APoc will be responsible for supporting travel expenses necessary. (7) Communication: At the National, Regional, Zonal and Woreda levels, telephone, courier and otrher means of communication will be used among project operators. At the communrity Ievel, communication will be mainly through the use of radios and megaphonres APOC is requested to support expenses associated u,ith communicatlons includ,ing couner services. (8) Consultants: Consultants would be required to conduct KAP studies (to help in the developm,enr and refinement of health education and other materials); program evaluatio,ns, computer maintenance and other aspects of computer work, to ensure total quallity management of the program. APOC is requested to support the costs of thresc consultants. (9) External Audit: External audit will ensure properaccountabilrtl,. Since APOC rvill support the costs of external auditing specifrc budget is not indicated in tlie budget details. (10) Operating Expenses: This rt'tll rnclude costs such as utilities, costs of quarterly meetrng (NOCp), development and nraintenance of MiS. Also rncluded rn this line item is the cost of operational research, pnntrng of essential reporting forms (treatment summary forms for community, Woreda, and Regional staffl), household cards, and communrity= registers. These expenses lvill be supported by APOC. NGOs and N{OH will share some costs such as office utilities. 10.3. Current resources available in CDTIs E-ristirtg CDTIs (for continuatton or expansiotz)tt,ill have resources 4lreacl1, available. Please providc a detatled list of oll existittg personnel, eclu.ipntenr and supplies (includirry vehicles, etc.) belonging to the progrant, ind.icating their owrrcrship (MOH, NGDO, other Agenq,, etc.) and tlrcir level oJ' functionality'. NOT APPLICABLE 42 +t e3 -c) s fEo)co oO NIoo o9OO @ I O IOO NJI o 'n (E' o 9^) ! o o o @ o.(a o o o !g) =o @ o o = o og) @ N O(]) N)ooA Noo O) N o ooO,O ACI A APPENDTX 1 TO BE TREATED ESTTMATED NL]MBER.S oF COI{I\ruNITIES AND PERSONS EACH YEAR, BY ENDE}IIC]TY LEVEL AREA COVERED: COMMLINITY ENDEN4IC LEVEL HYPER- ENDEMiC MESO- ENDEMIC HYPO.ENDEMIC,I. TYPE OF TREATMENT Community-based Communrty-based YEAR 1 - (2003) No. of communities to be treated 82 80 291 Total population in above communltles 334,680 377,B1B 851,519 YEAR 2*X (2004) No. of communities to be treated 82 80 29r Total population in above communlttes 344,386 388,775 876,213 No. of communities to be treated 82 80 'EAR 3** (2005) 291 Total population in above communities 354,373 400,049 901,623 'EAR 4** - (2006) No. of communities to be treated E2 80 29t Total population in above communrttes 364,650 411,651 927,770 No. of communities to be treated 82 80 29t YEAR 5*x - (2007) Total population in above communrtres 375,225 423,588 954,676 a *Onchocerciasis i.s ttot considered an in4tortattt Pubtic Health probLettt ttt ltypo-ertclentic corttrtturtities otd APOC witl not ttonnally fitnct cotnmunity-basec! rreotttrcrltt itt sttclr conununitics. Tlte irtclusiott of such conuttutti!ies in tlrc proposal t.u,ill rerlttire tt -specictLjustificoti<ttt Jbr consideration b1, the TCC- **lt is unrlerstoocl thcu tlw fLgures for years 2-5 ure likell' to be estinrdes tltat tttcty chuttga gs llte project progresses. 44 IIvernrectin Treatnrents reflected in Appendrr I n,ere obtained as follolvs: Total population in East welrega project area for the year 2003 is: 1,564,017 Total population targeted for treatment u,ith Ivermectin in year-one: 569,9g9 Thus, among the Estimated At Risk Population (EARp) of 334,6g0 are classified aspopulation living in hyperendemic and 377,glg in mesoendemic areas. In tlre first year, the program u'iil cover treatnrent objective of IOO% EARP of bothhyper- and mesoendemic comrnunities in the districts. On the consecutive)/ears the program r.l,ill still cover l0o% EARP of the treatment objective u'ith natural grolrth of the popuration by a rate of 2.9o/o. Fig. 4 Annual rreatment objective by Endemicity Lever 400000 350000 300000 I I l 250000 I l t ..1- i IT + 200000 1 50000 1 00000 50000 ATO 0 -Mesoendemic 2007 2003 2004 2005 Yoar 2006 45 APPENDIX 2: INDICATORS FOR EVALUATION, SUSTAINABILITY /INTEGRATION OF CDTV Proiect Eval,uatiott Management Financial management Effecti veness of communications Training and capacity building Institutional commitment Fulfilment of other relevant sectors Problem solving capacity Integration of operational research Project effectiveness Result of KAP Studies Treatment coverage Follow-up of non-eligible and absentees Management of adversc reactions Reliabi Iity of reporting S usta i nab tl ity / I nt e g ratio r t Polittcal will of host govenxment Political will as shown in policy statements and apparent commitment of high-level Officials Official action assigning personnet, funds, vehicles to program Long-term planning Is there a long-term plan for sustaining the financing and the management of the program? P ro g re s s to w ard fi nancial s us tainab ilitylf program sponsors cannot continue their current level of commitment for at least another five year, what percentage o[ running costs is now paid for host governments or fees? P ro gre s s toward inte gratio rt To what extent has ivermectin distribution been integrated with other heatth service programs? evidence of community empowerment and ownership change in KAP over time extent of involvement of both genders and non-literate 46 acE I og nr @ o c)C O)(Jl O)(, vI @ o o (D o) CN(D 3,ooa ID o)t (] _-. 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D o 0) :l(n(, oEo o0ao.0) =-ntsse(, o.80. a2. d-? 0' ao o)N) ai -o' "' o-<o6.< -O@ 9o) ooC _ CJ)d;ta oo =(Do-)o) 0:o 0)f, Do { o :r l f l(O 0) 6- € o)fo o ol oo -{ -o oo (, (, O) coo N -o oo NO(, Nobo -n o(, o) ;1 o: 9.l 3'(ooo o_ A) a o. o) o)o Ca6 5(, o)o o CNooI -lo =0) o-{ 0) foo tc o i I (n 2 oI ov o t v mo 6 rlrlm t- -J @ 7 m lz lo :E € ma -J € m ,-r mo NI o o -.1 o0 -{ o6 -tn o{ -lT o -n 11 o ma -J o r I m r . !r I' -E ocJ l Q;* i,o o:G Joc(3lo8; =c05c) @ z 9 0) f(D -n 0)x a f6 d) ol = S I I a o ;ol N coO lclf t;lolt, o ol 3l o o.)9OO 3 of, lf, of, o 0) oo o Ca @o o 6 o soo o N 3 o a- =a o) a o (D f b o 3 oo6 0) o o) o =o f 6 o a g og i o o If =of o -n 0) f o' 0) 6 l =)fl l @ o f o(D a or o o (,o o ?. o o ln o N c f, o {N o o) Ioo -J o, o 3 o o ll l(D oi ooa 0) C CN (Io lao 3oo o N 3of =6 oDoloI q) .)oa;l (,o o 3 oa a 0) o o I, t d)xoo 3 Cl6' dt -.o :l{ =) o f a (D = oo 3of, o oo of -.ol3t ? (J - (, O o o o f o 3 N z ; C -.1 N o O)Oo o o o o o o o 3 ol f, o 6iX ooI 0) Ca (, lao 3oo o N) f o l J6 0) o) o 6 o c0 3 N -<ll El a o N p1' o ooJ o otr 3 o6 a 0)(o oa o I o 0) o:r oo o o) f, o. o o a ttf, = t, E J l of oo o aoil'6l o o Io 5' o o l.t il :l(o A)(o o o) o) -l Nooo o o) o J l :l Ao o o L (, 3D 6' OJ 3 oa T:. oo(, o o o) o d oot, l3 0) o o) utl -l t' o -.1-{ o QO?6',dq8E Oa<5gE o-o 3g de =.ON(g.E o-{r5 o of,.(D il 6'tr s a of,6 N' 0) =.of E o(o 0) 3 3 o o =.o :f 0) of d' 0) o. oo 0) o 0) f o_ AI3 a o :, o :o oo -o oo 10 -o oo -u oo o - oI o o N Oin I(, (Jt (,l o oo o (,ooo (, oo (, o C,)ANoo 5 (o @o oor J o (, oo .ooo -o) oIoo -{ oobo bo I !r'ool o) (o oIoo -(rt -.I(, bo o o o o I =ro o) f l'tt = to -o(t 0)q) :f o- Ca N o =o o o -E o'o o o-'a o od 0)l o- o o D 0)ll o I 0) oo 3 3 f o o (,o 0) o = If, oa os. o 0) o f,0) C -o 3(/)@ o iJto J o If oo o ]f, o U, o(t o oo o) I C'I d' ID -r1 oC 0)o (/)g,(, !o o :lo o- o) lo o.oa 6 D o)f 0:Dq) :, o =.(DJ 0) 5'f 0, =o5 o) a Cho" @oo+(D o oa6 6' 0)f3 :)o 1' 0) =o. I] o) o of, f, o f, Cho 0){ o 3 oo 6', o. 0) o o) o = o 6 o) o' D o) f o) -n C O)a @ oo o_ o' -3 (Jl 0) E(D o :f o o. o) f, @ of oo 0) o' lDo oof, (D of o(D 6 o @6 f d' f o. s a. (,(rl ao ?oq) :1 o: 0) q. o. o) D 0, l o o oi 6' f 0) a o o E 0) a =o€' ooffii o- mt' o- (!5i^ o =@OCfo- S(Do-s'o =oN-$o) =O'@ (, C, a l o 0)f 9. a(, o o ll o ag f.I l 6 A)tr o. a o o o = I I (t c o o 5 o o N N 9 o @Ioo o o o @ (, 6 :f x o a C lNo 3 0) (Jl x 3 o ol -l C CN o =o -,f(D 0) 0) o 3 o I ov o?t n m o o-z r - m t- -tI =ox m o +{ mrr mo N -0 3 o r -.1 o oj o a .l n o{ I m r --{I o -n -n o ma o - -toi r o D -n o o l o_ o a o o o f, or oI a o oo ! O N o C =o o6 o o 3 N N z 9 cf a oo -l 0) o oo n| x o oo a C o C, a0 x g oo 0) Poo ooo Iot-lolxf =6' II(j(rr (D g oo OJ o ot Io I (D C n m C -l o of -l a a- o -l mx o' o a o I(D o = s 9 o oo o 0)f o. oD 0) s a. oo o @ c/) 3 ! o -o C) o C o o N o,o o)o N)o o o o f 3 ! A 5 o o Ioo Ioo o O)@Ioo o D o o a o N 5 3o 0) 0) 0) a 3(, 3 oo = o 3 oa I o, C @ = 0) Do 3.q o a o (J o.o {o xo 6 2.x =3 oa 0) : 0) @o @ N D o a o l oo o = 5 N(o oa D o of 5 os o = o N o. oc =3 oo o) q b o ol a o a Co o ? -b' o a o o C o 3 ! a m oo N @I o o)oI o -E o oo I @ f.o ! o o J o A' of.E o J o o o ol a o ao o tr It -lo 0.r o o a r\) 0, o I a oE :'(D od =i'Qc,Iboa; t! P ,o* df,O69 0) --a (,(, a l tr 3 o -t- 6' f -.t o 0) o o a of. o' tr mx o :l a o o 3 oa s. oI a o a o o O O o f o O -to o) o ot, A) A' o a a x lv 19 l oiJ <.: n<oo@OCOo9e do =.of,P. a I a I tJl O) m x fo o o o o o o o o o odso (Df,.o a o o 3 o) 5' (D l 0) fo(D Ao 3 l o o 6' o -c. oo oD 0) -'d Nol o o =6' o-' 3 ol 5' o f 0) foo f, o € N o f, 0) f oI o n Iq, Nr o nI @N -o nI @ Nr o o ao o o)(, o (, N(, ooo Noo o o o N N) (, N z 9 c o Ioo ! 'co(,Ioo or -o oobo AoIoo o ott C ag (Jo 1f(D 6o 3oo Eo 3of = N 3 f, :to o 0) o N 3I o a d D o o 1l o 3 l J ICtag(,oo oo It o 3.oo(, =3oo Eo o 0) o N) o =6' o CaVt0) (,o Eo 3 0)o 5' o o N 8 3E 6 -a E 3 o 0) Jo oX 3 0, o =fo N o f 1r R. .E ! oo a (, o A' l= o J o n o t v t? o -I m A' o €o 6- N J o =oI{ o oj ! n o C. lmo{ o aD{n o{a m o dz - - m t'{ -l u,C n m C c f- 5' o ol o!o O) =.l(O mxE(D f6(D th -5\t(oIool o o o) 6 o a tro o sr o)5 o. € 0)6 - (D a o ao o oo o o o o of 9 o o 0) o o o C CN @(,o 3 of = o 6o 3. (b6 d' N) 3of fo a vI @ 0, f o a, t- o o, lo) :l o-{ o) o - o =o o C = o ln l or o a o to o (,) o)o o oo -.J o o N) Ol N.)Ioo co9r(,,o Eo 3 of o 0, o(D 3.oo6 o N 3 of, :ro a a x sa o b lo. K lorf o.{ 0) o o 1o o N L f o oo 3 o)oo ;oo Ca (,to N 3o f :t o 0, a(D o - N 3o f, fol a) r ai t D (Jt{ OJ