Joint APOC/ SSI to Liberia: post-war assessment visit 25 - 29 March 2004

?***t JOINT APOC/SSI MISSION TO LIBERIA Post-war assessment visit 25 - 29 March 2004 La0cnd ! ^^.,"* CDII Uh.V ! n "**- .:' LJo, -kD o0 o l-9 o 10-19 o 20-39 o 40-100 0 50 100 Dr Uche Amazigo, Chief, Sustainable Drug Distribution Unit WHO/APOC Ms Verda Tarpeh, Project Officer, Sight Savers International West Africa Regional Office, Ghana Dr Joseph Okeibunor Department of Sociology/Anthropology University of Nigeria, Nsukka The team is grateful to the Government of Liberia for allowing this mission to be undertaken. Sincere thanks to the Honourable Minister of Health, Dr P. Coleman, Country Representative of IIHO, Dr Omar Khatib, CHAL and the NOTF for their assistance in making this mission possible and successful. 1 /.' :. !, \t, I] { .t 1: /' ' #"1 APOC CDD CDTI CHAL CHO CHT CMO COS DHO DPC Ex Dir MDP MoH NDS NGDO NOTF OIC NOCP PHC REMO SSI wHo ACRONYMS African Programme for Onchocerciasis Control Community Directed Distributor/Community Drug Distributor Community Diected Treatment with Ivermectin Christian Health Association of Liberia County Health Officer County Health Team Chief Medical Officer County Onchocerciasis Supervisor District Health Officer Disease Prevention & Control Executive Director Mectizan@ Donation Program Ministry of Health National Drug Service Non Governmental Development Organization National Onchocerciasis Task Force Officer In Charge National Onchocerciasis Control Programme Primary Health Care Rapid Epidemiological Mapping of Onchocerciasis Sight Savers' International World Health Organization 2 BACKGROLTND Liberia is one of the l9 countries of the African Programme for Onchocerciasis Control (APOC) with the goal of eliminating onchocerciasis as a public health problem through sustainable community-directed treatment with ivermectin (Mectizan@). Most rural areas have thick forest and are mountainous in nature, with many rivers and creeks, which provide rich breeding sites for the black fly vector, responsible for the transmission of the filarial worrns in the country. Onchocerciasis nodules, leopard skin, acute and chronic onchocercal dermatitis with unrelenting itching were easily identifiable in onchocerciasis endemic communities prior to the organizedtreatment with Mectizan@. In 1999, the rapid epidemiological mapping of onchocerciais (REMO) showed all counties have communities that are hyper or meso-endemic for onchocerciasis. In the same year, the first community-directed heatment with ivermectin (CDTI) project for mass distribution of ivermectin by communities, using ivermectin distributors selected from among their own ranks, was launched in four counties (LofalBonglMontserradoA{imba) in Liberia. These counties consist of 26 onchocerciasis endemic districts. Community-directed treatment with ivermectin was launched in all26 districts. In 2001, the Lofa/Bong/MontserradoA.,limba project treated 497,662 persons in one thousand nine hundred and eighty-eight (1988) communities and trained/retrained 5,738 community directed distributors (CDDs) and 104 Health workers. In2002, APOC approved two additional projects in the South Eastern and South Western regions. The South Eastern project has five counties namely, Grand Gedeh, Grand Kru, Maryland, Sinoe and River Gee. The South Western project consists of Grand Bassa, Bomi, Grand Cape Mount and Margibi counties. CDTI implementation was to start in these counties between 2002 and 2003 but delayed because of the withdrawal of UNICEF as a co-facilitating agency and the outbreak of the war. The implementation of these three projects would enable to protect more than 2,490,000 persons at risk. By December 2002, the country was plunged into one of the most gruesome internal conflict leading to massive loss of lives and property. Communities fled their homestead and hundreds of populations were displaced. As consequence, the CDTI projects in Lofa, Bong, Montserrado and Nimba counties and in the Southeast were halted while the project in Southwest could not take off. Unfortunately, during this period of conflict, in 2003, the national coordinator, Dr ZollD. Traub passed away. In October 2003, a new national coordinator, Dr Tudae Torbor was appointed. In March 2004, the Ministry of Health of Liberia invited the management of the African Programme for Onchocerciasis (APOC) to carry out a post-conflict assessment visit with the aim of resuming CDTI activities in Liberia. The team arrived in Monrovia on 24 March for a five-day mission. aJ PURPOSE OF THE MISSION A joint WHO/APOC and Sight Savers International (SS! visit was undertaken to Liberia with the purpose of undertaking a post-war assessment of the CDTI program; determine with the National Onchocerciasis Control Task Force (NOTF) where, when and how to resume CDTI activities and develop a work plan with timeline. The general objective of the mission is addressed in the report under five specific objectives/areas- Specific objectives To produce a good inventory of what is left of APOC CDTI financial and material resources post war and learn from CHAL and NOTF their experiences during the period of conflict. Identify and agree with NOTFlLibeia, counties to resume CDTI activities, when to resume and develop a work plan. Assess the level of commitment and plans of the Ministry of Health (MoH) to replace CDTI materials and equipment lost during the war in order to accelerate the resumption of CDTI implementation; discuss with MoH authorities strategies of integrating CDTI as routine activity of the health system at all levels. Review the philosophy of APOC, CDTI strategy and roles of the different partners at all levels of CDTI implementation with the NOTF; arrange training of NOTF members on WHO imprest/accounting system for the management of APOC Funds. Learn from WHO Representative the experiences of WHO/ Liberia on losses from the conflict. A POST-WAR ASSESSMENT OF THE CDTI PROGRAM INCLUDING RESOURCES FOR ACTIVITIES LOST DURING THE CONFLICT OBJECTIVE 1. INVENTORY OF WHAT IS LEFT OF APOC CDTI FINANCIAL AND MATERIAL RESOURCES POST WAR. With the return of peace following the cessation of hostility among the various rebel groups in Liberia, the NOTF/ Liberia decided to take stock of the CDTI program in the country with a view to resuming implementation of the control of onchocerciasis in the 1 2. 3 4 5 4 communities. The MoH invited APOC for a joint assessment of the status of CDTI implementation in the country and to review the security situation in the different counties implementing CDTL This also offered an opportunity to take stock of the cost of the war on the CDTI programme. (, Visit to CHAL and Assessment of APOC Equipment The mission visited the premises of the Christian Health Association of Liberia (CHAL), a local NGO in partnership with Sight Savers International (SSI) and MoH, and inspected the APOC vehicles provided to the government of Liberia and partners for CDTI activities. The mission found all four (4) Hilux double cabin vehicles secured in the compound of CHAL. However, the vehicles had been vandalized. It is commendable that SSI had repaired one of the vehicles. Three other vehicles need to be repaired. During the visit to CHAL, the mission also observed the extensive destruction and v andalizatro n o f prop erty. The visiting team from information provided by CHAL and the MoH prepared a summary list of capital equipment provided from APOC Trust Funds destroyed, vandalized and/or looted during the war. The list was discussed and endorsed by all partners at a meeting. These included 51 motorcycles, including 16 newly purchased ones, computers and their accessories, media and health education equipment and four Hilux double cabin vehicles supplied by APOC. CHAL made available to the mission a videocassette with documentation of damaged and lost items. A detailed list is attached in annex 3. The status of APOC equipment and materials was presented and discussed with the Representative of the World Health Organization (WHO) and the Hon Minister of Health. The mission highly commends CHAL for the extraordinary steps taken by the staff to safeguard the four project vehicles from looters. The mission recommends continued SSI strong support to CHAL as it continues to work closely with, and support the Ministry of Health in the control of onchocerciasis and other health interventions. (iil Visit to the office of the National Onchocerciasis Control Task Force @OfF) The mission visited the NOTF office and discussed with the NOTF secretariat items lost during the conflict. The NOTF secretariat had been completely vandalized and most office equipment and materials supplied by the government (Annex 2), APOC and SSI (Annex 1) were looted. Some financial records were however spared. At the request of the mission, the NOTF provided a list of items supplied by APOC and other partners that were looted and those that have been replaced by the Government of Liberia. As shown in the Annex 2, notwithstanding competing demands from other health programs and the complexity of the health situation caused by the war, the govemment 5 has made available some essential office furniture and continues to provide office supplies to the NOTF secretariat. The health authorities assured the mission of continued support to CDTI. The mission commends the NOTF for the level of commitment demonstrated by its members throughout the period of the mission. (tO Status of APOC Trust Funds releasedfor CDTI projects in Liberia Table I summarizes the findings regarding APOC Trust Funds disbursed to the projects Lofa/Bong/lVlontserrado/Nimba CDTI proj ect CDTI activities in Lofa/Bong/MontserradoA.{imba counties with 26 districts began in 2000 and received APOC Trust Funds amounting to US$186,787. The funds were used for CDTI activities before the onset of the last conflict. No funds were made available to this project in 2003. Southwest CDTI project The mission, NOTF and WHO/Liberia checked the financial records of the NOTF and WHO/Liberia office in order to determine whether the US$40,000 from APOC Trust Fund that was supposed to have been credited to the NOTF bank account for the South west project was lodged into the NOTF account or not. It was found that due to the sudden withdrawal of UNICEF as partner to Southwest CDTI project, the US40, 000 from APOC that should have been paid into the NOTF account was not transferred. However, in a letter reference # }I41COORD/APOC dated 6 February 2003 the management of APOC had advised the NOTF/Liberia to submit a work plan to WHO/Liberia with copy to APOC management. Following the submission of the work plan APOC would then advise WHO/Liberia to release the above-mentioned US$40,000 into the NOTF bank account. The records show that this US$40,000 for the Southwest project was not released to the NOTF because the plan of action requested from the NOTF by APOC management was not received. The mission concludes that WHO/Liberia did not release the tlS$40,000 since no plan was submitted by the NOTF. Southeast CDTI project For the Southeast CDTI project, the financial records from APOC showed that US$52,292 had been disbursed to the NOTF. However, the NOTF records reflected the lodgment of US$40,000 only. The mission could not reconcile the discrepancy of US$12,292 between the financial records of APOC and NOTFlLiberia and therefore recommends that the management of APOC and NOTFlLiberia take further action on this issue. It is important to note that in the APOC financial records US$ 12,292 was 6 specified for the local purchase of equipment that was neither reflected in the records of the WHO/Liberia nor in the NOTF financial records. Table 1: DISBURSEMENT OF APOC FUNDS FOR CDT! PROJECTS lN LIBERIA o *This amount was not lodged into the NOTF bank account as explained above. o ** US$12,292 still to be reconciled. OBJECTIVE 2. IDENTIFY AND AG WITH NOTF/LIBERIA. TO RESUME CDTI A TO RESUME AND DEVELOP A WORK PLAN. (t) Accessible counties to resume CDTI The mission was briefed by the NOTF on the accessible areas where CDTI operations can resume immediately. At present, the accessible counties are: a) Montserrado and some parts of Nimba Lo falB ongA,limba/Monts errado proj ect in the Northwest counties in the b) Margibi County. The other endemic counties- Bomi, Grand Cape Mount, Grand Bassa in the Southwest are not yet accessible. None of the endemic counties (Grand Gedeh/ Grand Kru/Maryland/ River Gee/ Sinoe) in the Southeast is accessible at present. The mission was informed that plans for disarmament by the UN are underway and would be accomplished by June or July 2004. Only then can CDTI activities resume in 7 APPROVED PROJECT 2000 2001 2002 2003 TOTAL US$ US$ US$ us$ us$ LOFA /BONG 45,630 ffr.1) 68,226 72,931 0 '186,787 SOUTH WEST Project not yet launched Project not yet launched 40,000* 0 40,000* SOUTH EAST Project not yet launched Project not yet launched 52,292 0 52,292n TOTAL 279,079** the counties in non-accessible areas. Consequently, the NOTF and the visiting team agreed that CDTI activities should resume in Montsewado and Margibi Counties. (t) Field visit to Margibi Counryt At the request of the NOTF, the visiting team, accompanied by Dr. Torbor, Onchocerciasis National Coordinator, Dr. Dukuly, consultant to the Ministry of Health, and Dr Bolay, DPC/ WHO Liberia visited the CW Rennie hospital in Kakata, Margibi County on Saturday, March 27. The team were warnly welcomed and met with the County Representative proxy, Mr. Joseph Korhene, Acting CHO/CMO of Margibi County. The mayor of the city and representatives of two Community Based Organizations, the Reproductive Health Forum and Radio Kakata, the County Health Team and staff of the hospital welcomed the mission. Although on a Saturday, the County Health team and hospital staff participated in a meeting with the visiting team. As had occurred with almost all hospitals and clinics in the country, this hospital too had been looted. The mission learnt that the County hospital lost nine motorbikes, two cars and generator during the last conflict and recently two microscopes. The acting CHO/CMO briefed the visiting team on the challenges faced by the hospital and the County Health Team. He then informed the mission that UNICEF carried out ivermectin treatment in Margibi County in 2001 only. According to the CHO the population have since been requesting for fuither treatment. After short introductory remarks on the purpose of the visit- assessing the possibility of resuming the CDTI- and discussions with the County health team, the CHT was able to draw up a work plan, incorporating CDTI into their Primary Health Care program. This plan was incorporated into the NOTF work plan for resumption of CDTI in Liberia. The group discussed also the CDTI strategy and issues related to the ownership of CDTI by the County health and communities. This visit allowed the mission to obtain firsthand information from the authorities of the county on the ability of the health team to resume ivermectin distribution and when. Although we were not able to visit the Montserrado County after being to Margibi, the mission agrees with the decision of the NOTF to resume CDTI in Margibi and Montserrado and recommends that resources be made available to implement the work plan of the NOTF. (iit) ll/ork plan for resumption of CDTI Activities In Liberia, three CDTI projects are being supported by APOC. Following the creation of awareness, sensitization, mobilization of the various stake holders the distribution of Mectizan@ started in LofalBong/MontserradoA.{imba counties in the Northwest in 2000. The Southwest and Southeast CDTI projects came on board and southeast had started the activities for the first ivermectin treatment before the resurgence of rebel activities in 8 December 2002, which disrupted the 200212003 treatment-round. With the gradual return of peace, the NOTF/ Liberia and APOC mission undertook a situation analysis of the security status of the counties within the CDTI project areas. The assessment revealed that security has improved considerably in two counties, namely Montserado and Margibi in the Northwest and Southwest CDTI projects respectively. There are also indications that the security status of some other CDTI counties is due to improve and become safe for CDTI implementation in a few months to come. Following this realization, the NOTF Liberia decided to commence CDTI implementation in the two counties that are considered safe enough, while plans are made to take on other counties both within the Northwest and Southeast project areas as well as those in the Southwest project area. On March 28,2004 the NOTF developed a work plan for the resumption of CDTI activities in Liberia. The work plan is presented in Annex 4. Due to the last conflict, the communities in Montserrado County lost one treatment round. It is therefore the wish of the NOTF that the project be considered as in its fourth rather than the fifth year. Similarly, the Southwest CDTI project has undergone it first treatment round under the facilitation of UNICEF before the resurgence of rebel activities in Liberia. Nevertheless, it was noted that LTNICEF was not guided by the APOC philosophy in the implementation of CDTI in the project area, which includes Margibi County. Since IINICEF has now pulled out of the program and Sight Savers has assumed the facilitating role, it is also the wish of the NOTF Liberia that southwest project be considered as being in its first year of CDTI. The mission recommends that:(i) The CDTI project in the Northwest (LofalBonglMontserradoA.,limba) be considered as in its 4th year as soon as activities can be resumed in the counties, in2004 (ii) The Southeast project (Grand Gedeh/ Grand Kru/Maryland/ River Gee/ Sinoe), as soon as activities resume, be considered as its second year. (iii) The Southwest project (Bomi, Grand Cape Mount, Grand Bassa, Margibi) be considered as its first year. This project as mentioned above has not yet received the APOC Trust allocated due to the outbreak of the war. 9 OBJECTIVE 3. COMMITMENT OF THE MINISTRY OF HEALTH AND INTEGRATION OF CDTI INTO THE HEALTH SYSTEM AT ALL LEVELS. (t) Meeting with the Honourable Minister of Health On 25 March the mission paid a courtesy call to the Honourable Minister of Health, Dr Peter Coleman. The visiting team presented the objectives of the mission with special reference to the development of a detailed work plan with the NOTF. Other key issues discussed with the Honourable Minister included (i) The role of the MoH in ensuring quick resumption of CDTI activities in accessible communities in the counties. (ii) Integration of CDTI into the routine activities of the Ministry of Health and long-term sustainability of ivermectin distribution, a prerequisite towards the elimination of onchocerciasis as a public health problem in Liberia. (iii) Community and frontline health care service participation in the planning and implementation of CDTI as well as the importance of the ownership of CDTI by communities and the health care service. (i") Absence of a separate budget in APOC Trust Fund for the replacement of equipment and materials lost during the conflict. The mission informed the Hon. Minister about the willingness of APOC management and SSI to assist as soon as there is evidence of the commitment of government to take a lead in the replacement of items. In his response the Honourable Minister - (i) Thanked APOC partners, in particular, the Director of the Programme for the immense support MoH Liberia continues to receive from APOC. (ii) He regretted the loss of equipment and materials for CDTI activities incurred during the conflict and assured the visiting team that the Government of Liberia would make efforts to replace some of the items for CDTI operations as the financial position of the MoH improves. He hinted on extemal financial support that would assist in rebuilding the PHC program of Liberia. Dr Coleman promised to write management of APOC on integration and issues related to the commitment of the Government of Liberia. 10 (iii) He also expressed concem that the CDTI in Liberia had thus far been implemented vertical to other MoH programs (as donor-driven). He strongly urged the integration of CDTI into the routine activities of the Ministry at all levels, and integration of CDTI with other programs for the prevention of blindness such as Vision 2020. (i") The Honourable Minister referred also to the decentralization process and revitalization of the PHC and its structures that are in the pipeline in the health sector of Liberia and hoped the changes would help to improve the performance of the CDTI. The Government of Liberia (GOL) immediately provided office space to the Onchocerciasis Control Programme/ MOH and Social Welfare after the third round of frghting in the country. In the list below, we present items replaced by the government of Liberia in the NOTF ffice tofacilitate the resumption of CDTI operations. * Wooden Chairs (2 Pcs) * Plastic Chairs (4 Pcs) * Wooden Desks (5 Pcs) * Executive chair (1 Pc) * Executive Desk (1 Pc) * Plastic chairs for the Conference room (25 Pcs) * Conference Table (l pc) (i, Special NOTF meeting with the Honourable Minister and the Visiting Team The NOTF oversees the implementation of CDTI in Liberia, and prior to the war met periodically (four times a year) to review activities in the counties. A meeting of the NOTF with the visiting team followed immediately after the courtesy call. The Hon. Minister attended this special NOTF meeting. Present at the meeting also were the Chief Medical Officer (CMO), Professor Benson Barh, chair of the NOTF, the executive director of CHAL, Mrs. Ellen George-Williams, researchers and consultants to the NOTF/Liberia. After the opening prayers, the CMO/MoH and representatives of SSI and CHAL made welcome remarks. The CMO in his remarks stressed on community participation as the bedrock of the PHC, and integration of CDTI. Dr Amazigo, chief of mission, presented the objectives of the mission. The Honourable Minister in his opening remarks welcomed the mission and expressed gratitude to APOC for the assistance given to Liberia to initiate the onchocerciasis control program on a large scale. He asked the NOTF and the mission to develop a new approach with a horizontal delivery system of ivermectin. He emphasized that the new 11 approach should maximize all the available resources by integrating, for example, the delivery of ivermectin with vitamin A and treated bed nets for the prevention of malaria. Further, the Hon. Minister reaffirmed that the Government of Liberia in spite of its present weaknesses posed by the war will do its utmost to resume onchocerciasis control activities. He urged that Vision 2020be integrated with the onchocerciasis control. As consequence, the mission recommends that as soon the letter from the Honourable Minister, on the position of the Government of Liberia with regards to resumption of CDTI in accessible counties and the plans of government on the replacement of other items for CDTI implementation, is received by the management of APOC, it would be absolutely necessary that APOC and SSI accelerate the implementation of the plan of action submitted by the NOTF in this report. OBJECTIVE 4. THE PHILOSOPHY OF APOC. CDTI STRATEGY. ROLES OF THE ARTNERS IN CDTI IMPLEMENTATI ON AND TRAINING ON WHO IMPREST/ACCO G SYSTEM. (t) NOTF workshop on APOC philosophy, CDTI strategy, partnership and integration To date, there is no macrofilaricide for the elimination of blinding and dermal onchocerciasis as public health and socio-economic problem. APOC and its partners whilst in pursuit of a search for a macrofilaricide have to rely for now on ivermectin, a microfilaricide which needs to be taken for more than 15 years to achieve the goal of eliminating onchocerciasis in the 19 APOC countries. Because ivermectin needs to be taken annually and for several years, sustainability of ivermectin distribution is a crucial ingredient in APOC CDTI. In order to establish sustainable CDTI projects in Liberia, it is imperative to include key onchocerciasis control activities (sensitization and mobilization, training of health personnel and CDDs, supervision and monitoring) as essential and routine activities of the Ministry of Health at all levels. Sequel to the changes in the leadership and composition of the NOTF/Liberia, the management of APOC directed the mission to re-examine with the NOTF, the APOC philosophy and partnership, CDTI strategy with emphasis on integration and sustainability. On26 March, the visiting team held a one-day workshop with the members of the NOTF. The participant included the staff of the planning, finance and IEC units of the MoH (Annex 5 list of participant). The Chief Medical Officer of the MoH/Liberia, who is also the chair of the NOTF, attended some sessions of the workshop. t2 iAPOC Philosophy, Partnership and CDTI strategy The presentations and discussions at the workshop covered the following key issues: KEY ISSUES:(i) The rationale for the creation of a regional program, APOC including the organizational structure, philosophy, objective and goal of the Programme; (ii) APOC partnership with particular emphasis on: a. The role and responsibilities of endemic communities, b. The role and contributions of Merck &Co Inc through its policy of free donation of ivermectin for as long as needed; c. The role and responsibilities of MoH of participating govemments, non- governmental development organizations (NGDOs)- international and national. d. The role of APOC, the umbrella organization; the committee of sponsoring agencies (WHO including TDR, World Bank, FAO, UNDP) e. The role of the donor countries. (iii) The CDTI strategl: A review of the CDTI approach was done with special emphasis on the relationship between CDTI and the philosophy of the PHC. The role of CDTI in revamping the PHC activities at all levels of health care services was emphasized by the mission. Some examples of achievements of APOC- sponsored CDTI projects in other countries were provided to encourage the replication of 'true' community-driven approach in the resumption of CDTI in Liberia. (i") The mission advised on turning the unfortunate situation created by the recent conflict into opportunity to reinstall CDTI projects with strong community and MoH ownership components. The mission referred to the important remark of the Hon. Minister that so far the CDTI projects have been implemented as vertical programs and emphasized the urgent need to integrate CDTI into other health programs of the Ministry of Health. (v) Independent participatory monitoring and technical reports show that the staff of the NGDO, CHAL initiate and oversee most of the activities and this is because the staff of the MoH had left a 'vacuum' by not taking full responsibility of CDTI. There had been little evidence of NOTF secretariat sharing the planning and implementation of field activities as well as the management of APOC Trust Funds with the County Health teams and the IOCs. The mission requested CHAL to facilitate capacity building of MoH staff in CDTI with special emphasis to the ordering and procurement of Mectizan@ from the Mectizan@ Donation Program (MDP), cascade training and supervision of health personnel at all levels. The mission urged CHAL in the spirit of the partnership to continue to provide strong support to the MoH l3 *.. without CHAL on the 'driving-seat.' This suggestion was accepted by CHAL. Based on the discussions of workshop participants the mission recommends that'. a. The NOTF/Liberia expands its membership to include Social Scientists/Anthropologists from the University of Liberia, MoH staff from the IEC, planning, PHC and Monitoring and Evaluation units; b. The NOTF organize a special workshop on CDTI for all county and frontline health facility staff (i.e. County Health Supervisors and Officers in-Charge of the frontline clinics) in areas where CDTI activities would resume. It is crucial that this workshop be held in this treatment cycle, prior to the commencement of community sensitization and mobilization so that staff at all implementation levels would imbibe/appreciate the spirit of ownership of the program. c. County and frontline health facility staff need to be trained/retrained and supported to re-launch community-driven CDTI ensuring that communities understand their role and assume their responsibilities. d. ALL partners - SSI, CHAL, MoH and APOC, particularly, the central office of the MoH should put in place the machinery that would enable the achievement of ownership of CDTI projects by the MoH and communities. The mission observed the absence of this important indicator of sustainability in the Liberian CDTI program. e. APOC management provides, if necessary, a 'one-time' financial support to CHAL to assist the NGO build the capacity of the new staff of the NOTF secretariat on key CDTI activities, in particular,Mectizan ordering and delivery. A staff of the MoH, member of the NOTF secretariat, preferably the national or deputy national coordinator, should be designated to manage the requisition of Mectizan@ from MDP. The staff should be attached to understudy the officer of CHAL who has been responsible for ordering Mectizan@. Further, the MoH through it's NOTF office should put in place the mechanism for procurement of Mectizan@, which is one of the responsibilities of the MoH in the APOC Memorandum signed by the government of Liberia. (i) Training of OICs. The MoH should consider a policy that allows OICs employed by NGOs in the districts to participate in CDTI training and supervision (ii) The stffing of the NOTF secretariat. The mission was of the view that the present composition of the NOTF secretariat would not promote integration. t4 To ensure integration and efficient management of CDTI after the withdrawal of APOC financial support the mission recommends (a) The appointment of staff of the Ministry of health, one each from IEC, Planning, Finance, Monitoring & Evaluation units to provide technical support to the NOTF secretariat in managing the national program. However, these staff so designated from other units should remain responsible to their parent units; (b) All staff of the NOTF secretariat, in particular, the national coordinators, accountant or finance and other key officers, should be staff of the MoH to oversee the CDTI program. While the MoH pay their salaries, such staff would receive technical assistance (top-ups) from APOC Trust Funds for a maximum of 5 years in support of their activities during the demanding 'start- up' period of the CDTI program. (iii) Training of project managers on IYHO Imprest system. The mission and members of the NOTF discussed the need to train NOTF members on the WHO Imprest (accounting) system. It was agreed the accountant, the new national coordinator and four other members of the NOTF should be trained as quickly as possible. The mission was in support of this recommendation and requested the Representative of the WHO, Dr Omar Khatib for assistance. The WR approved that the training be facilitated by the AOAilHO. He instructed the DPC, Dr Bolay to follow-up for which the mission was appreciative. The mission commends the WHO/Liberia strong support to the CDTI project and the NOTF. OBJECTIVE 5. LEARN FROM WHO REPRESENTATIVE THE EXPERIENCES OF WHO/ LIBERIA AND LOSSES FROM THE CONFLICT. (r) Meeting with the World Health Organization Country Representative for Liberia One of the objectives of the mission is to interact and hold discussions with a wide spectrum of stakeholders as well as people and organizations with similar experiences on losses due to the war in Liberia, to learn from them the magnitude of losses and their coping strategies. These issues were discussed during a meeting with the Representative of the World Health Organization for Liberia, Dr Omar Khatib on Wednesday March 25 2004. The DPC, Dr Bolay and the national coordinator participated in the meeting 15 d- The purpose of the meeting l. To brief the WR on the purpose of the mission. 2. To leam from him the experiences of WHO on their losses due to the war. 3. To discuss other issues that may affect the resumption and implementation of CDTI program in Liberia 4. To solicit the support of the WR for the integration of CDTI into the PHC system in Liberia KEY ISSUES t) Briejing on APOC equipment and materials lost during contlict. The APOC mission presented the WR with the list of capital equipment for CDTI implementation destroyed, vandalized and/or looted during the war in Liberia. The team then inquired on the experience of the WHO with regards to losses and possible recovery of such lost items belonging to World Health Organization. In his response, the WR noted that the greatest problem is that most of the looted items have been defaced and the owners may not even recognize them any more. At the request of the mission to support the NOTF with the repair of damaged and vandalized vehicles, the WR noted that WHO/Liberia special budget set aside to support the CDTI implementation in the country is relatively small. Nevertheless, he suggested the NOTF may wish to submit a proposal for the repair of one of the damaged four-wheel drive vehicle from the said funds if they considered that a priority. The mission recommends that APOC Trust Funds from the general budget in APOC HQ be used to repair two vehicles as soon as field activities are about to resume. However, it is not necessary to replace the HF radios and accessories looted from the vehicles in the meantime. (it) APOC Trust Funds for CDTI implementation in Liberia The team also briefed the WR on the forty thousand US Dollars, which APOC disbursed to the Southwest CDTI project but which the NOTF secretariat indicated it had not accessed. The mission with the support of Dr Bolay and the NOTF finance officer was able to confirm that WHO/Liberia had not disbursed the US$40,000 to NOTF. This is because the NOTF had not complied with the conditions for the release of the funds to NOTF as stated in the letter of the management of APOC (ref. 014/COORD/APOC) dated 6 February 2003. Regarding the southeast CDTI project, during the debriefing session, the mission informed the WR about the discrepancy of US$12p92 between the financial records of APOC and NOTF/Liberia and recommended further action on this issue. The WR thanked the mission for the efforts and hoped that further investigation would shed light on the outstanding USg 12,292 16 qii) Integration of CDTI into other Disease Control Programmes in Liberia The APOC team highlighted integration of onchocerciasis control using the CDTI strategy into other disease control efforts in the country. The team leader enumerated the various advantages this could bring to the PHC system as well as realization of the goals of the control programs. She also noted the disadvantages of vertical implementation of disease control program within the same health system. The WR agreed with the views of the mission and identified existing opportunities for integrating CDTI into the health system. According to him, the Ministry of Health should consider integrating CDTI with other helminth parasite control programs, which already has Schistosomiasis and Lymphatic Filariasis components. Furthermore, the WR expressed optimism on new opportunities that may be available to the Ministry of Health, which could be extended to support the integration of CDTI within the PHC. The mission and the WR during the debriefing session agreed that a PHC coordinating committee for all community-based programs could eventually replace structures like the NOTF to promote integration. The PHC coordinating committee would provide for efficient and cost-effective coordination of the strategies of the different programs at the community level. Furthernore, programs would not undermine or hamper the strategies of other programs. This would also promote mutual reinforcement among programs. DEBRIEFING THE CHIEF MEDICAL OFFICER (CMO) On 29 March, the mission debriefed the Chief Medical Officer (CMO) representing the Hon. Minister. Members of the NOTF attended the debriefing session. In debriefing the CMO, the visiting team summaized the achievements with regards to the objectives of the mission. It was agreed that the NOTF and team had achieved the eight specific objectives of the mission as in page 4. The CMO thanked the mission and reaffirmed the commitment of the MOH to CDTI and integration of CDTI activities into the general health services. He commended the NOTF and visiting team for the accomplished tasks and the visit to Margibi County. He also commended the management of the County hospital in Margibi for its unique leadership skills. t7 Annex 1. STATUS OF EQUIPMENT FROM SIGHT SAVERS INTERNATIONAL (SSI) TO PROJECTS Annex 2 Furniture, fittings and office equipment and supplies supplied to the National Onchocerciasis Control Programme office and lost during the war. Note: All of the above listed items were looted during the three rounds of fighting in the country. ITEMS Lofa/Bong/ South East TOTAL Supplied Status Supplied Status Video recorder 1 looted 1 TV 1 looted 1 Video camera I looted 1 Portable generator 1 looted 1 Motorcycles 5 Unknown 5 S/ N ITEMS Quantity SUPPLIERS APOC wHo LIBERIA MOH I 2 3 4 5 6 7 8 9 10 ll t2 l3 t4 l5 t6 t7 18 19 20 2l 22 Air conditioner Living room chairs Visitors chairs Book shelf Rug Floor mat Wooden Desk Executive Swivel chairs Wooden Chair Executive Desk Executive Chair Filling Cabinet Conference room Table Chairs Commode Bathroom Sink Desk Top Computer and accessories Honda Generator Canon Photo copier (16 cpm) Fax machine Telephone Tape recorder 1 Piece I Piece 6 Pieces I Piece 1 Piece 35 yards 1 Piece 2 Pieces 4 Pieces 1 Piece 1 Piece 1 Piece 1 Piece l5 Pieces I Piece I Piece 2 Pieces 1 Piece 1 Piece 1 Piece 1 Piece 6 Pieces l8 o6l O (.) Etr 9rF (d5Co: B €ooc tr)\o cOH e a d 0) o o $ o C\ e(! 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(! o t-r 9. z +i o o ac6(u iL) bo=tr(n '5 a) (s PA Ali c) tl Fr tr EEsE P s't E Y()o,Cl o) N d- d :EE3Eots oo >(6()()OHEeO li -- .;i Rl lra -trP>\O tr:l €-.9€E aB R? -E bo y !1 E i:E 3?H X ; B.E .:,eS!; c= v9-E: >,-c Z9 ,\ F c trt Q50()0tr PEEE5 B 99 " E.€gH!/) E H v i _vl r,aJi5 ooE E.F .rda.=iPnx!v3'E"EE 9.E P P H!, E O llr, .5O-tr.YV HL:H- HHg.iH o- -E F-r - -^ =;i.- IeE 3 !lrr:totrP .i q, x =chE=ESbEg EE!A a..= tr tAnnex 5 Lists of Participants at the NOTF Workshop L Professor S. Benson Barh 2. Dr. H. Tudae Torbor 3. Dr. Meimei Dukuly 4. Mrs. Ellen George-Williams 5. Mr James Goaneh 6. Dr. Fatorma Bolay 7. Mr. K. John Gaylah 8. Mr. Moses 9. Mrs. Annette Doe 10. Mr. Jacob Warloo 11. Mr. Nmah Bropleh 12. Mr. Julius B. Mchill 13. Mr. Joseph P. Nathan 14. Ms. Yah Dolo 15. Rev. Jenkins n. Jorgbor 16. Dr. Joseph Okeibunor 17. Dr. Uche Amazigo 18. Mrs. Verda Tarpeh 19. Mr. Augustine Parleh Chairman, NOTF National Oncho Coordinator Consultant, MoH Executive Director, CHAL Project Coordinator, CDTI S/E, CHAL DPC, WHO Asst Minister for Planning, MoH Accounts office, MoH Accountant, National Oncho Secretariat Dept of Planning, MoH Consultant, Dept of Planning, MoH Social worker, Dept of Social Welfare, MoH Social worker, Dept of Social Welfare, MoH Asst. Oncho Coordinator, NOS Project Coordinator, CDTI N/W, CHAL Univ. of Nigeia & member of APOC/SSI Mission CSD/APOC & Head, APOC/SSI Mission to Liberia Project Officer, SSI & member -APOC/SSlmission Secretary, National Oncho Secretariat 24