Joint visit to Tanzania July 14-22, 1996: summary report

WORI-O HEALTH ORGANIZATIONt, AFRICAN REGION 96/APOC/REP.006 July 31, 1996 ilt 2. July 14 July 15 ORGANISATION MONDIALE DE LA SANTE REGION DE L'AFRIQUE 1 i. ii AFRTCAN PROGRAMME FOR ONCHOCERCTASIS CONTROL (APOC) PROGRAMME AFRICAIN DE LUTTE CONTRE L'ONCHOCERCOSE B.P. 549 OUAGADOUGOU, Burkina Faso Tdl6gr.: ONCHO OUAGADOUGOU Tbl.: (2261 30 23 01 - 30 23 12 - 30 23 13 T6lex: ONCHO 5241 BF Fax'. (226) 30 21 47 JOINT VISIT TO TANZANIA JULY 14 - 22,1996 Summary Report by Dr A. S6k6t6lil Dr D. Etya'a162 Dr P. Ngoumou3 Dr U. Amazigoa OBJECTIVES to sensitize the nationalauthorities and the NGDOs on APOC objectives and strategy to gather useful information on the administrative structure of the Ministry of Health and of the National Onchocerciasis Control Programme (NOCP) and activities of NGDOs in Tanzania. to assist the National Onchocerciasis Task Force (NOTF) to further develop the National Plan, the proposal for sustainable community-based ivermectin treatments (CBlTs) and vector elimination using environmentally safe methods. to determine the current status of the Rapid Epidemiological Mapping of Onchocerciasis (REMO) project funded by the TDR Onchocerciasis Operational Research (OOR) Task Force and to identify and dealwith issues, to ensure speedy completion of the REMO exercise important for the development of the National Plan. CHRONOLOGICAL OUTLINE OF THE VISIT Arrival of members of the team in Dar-es-Salaam, Tanzania ln-house preparatory meeting; meeting with the NationalCoordinator, Ms. Mallya, Scientist (MOH) and the WR/Tanzania Coordinator, Office of OCP Director, Programme Manager/APOC, Ouagadougou NGDO Coordinator, WHO/PBD, Geneva STP, AFRo/Brazzaville Temporary Advisor, APOC/Ouagadougou iv 2 3 4 July 16 July 17 July 18 July 19 July 20 July 21 2 Meeting with the Director of the Christian Social Services Commission (CSSC) and the World Bank. Meeting with the Director General of the National lnstitute for Medical Research (NIMR). Working session with the National Coordinator and two members of the NOTF (office of the WR) Meeting with the NOTF. The Executive Director, lnterchurch Medical Association joins the visiting team. Discussions with NOTF on CBIT, Mectizan procurement and delivery Update on REMO/REA activities in Tanzania Working sessions on REMO. Selection of Project sites for CBtTs. NOTF meeting with Dr. Kilima, Director, Preventive Seryices, MOH. Dr. Kibatala, MD, lfakara District Hospital, joins the participants. Working session on National Plan; Reception by WR for the visiting team, NOTF members and participants of the current workshop on STDs. Working session with NOTF on National Plan, and CBIT project proposal; Mr George Kasiga, Coordinator ONCHO project in Mahenge focus, joins the participants. Working session with NOTF on National Plan, and CBIT pro.lect proposal. July 22 Meeting with the Principal Secretary of the MOH and the Director, Preventive Services, MOH; Meeting with the Hon. Minister of Health; Visit to the Medical Stores Department. 3. MAIN FINDINGS, CONCLUSIONS AND RECOMMENDATTONS Secretariat for National Onchocerciasis Control proqramme The structure of the National Onchocerciasis Control Programme (NOCp) is in line with the Health Sector reform philosophy. Accordingly, the NOCP structure is closely linked to the existing administrative and Primary Health Care Operational Structures. 3.1. 3The Committee and the team are of the view that the office of the National Coordinator be strengthened with the appointment of a Deputy Co-ordinator, a Secretary and an administrative assistant. The team recommends that qualified personnel in these positions in the Ministry of Health be seconded to the Secretariat of the National Onchocerciasis Control Programme to enable the Coordinator to effectively carry out his duties. 3.2. The National Task Force for Onchocerciasis Gontrol (NOTF) The activities/functions of the NOTF are curently undertaken by the National Onchocerciasis Coordinating Committee (NOCC) formed in 1995. The visiting team was informed that the membership of the NOTF will be constituted from the current list of NOCC. While not disagreeing with the composition of the NOCC, the team stressed the importance of establishing a functional NOTF, the role of NOTF in the day to day smooth running of the CBITs and in operational research. ln constituting the membership of the NOTF, the team recommends that: i) The spirit of partnership which is the underlying philosophy of APOC be reflected. ln this connection, the team is of the opinion that in the Task Force, the number of NGDOs be representative of all NGDOs contributing financially to CBlTs. ii) Effort be made to include experts and fleld officers capable of implementing CBITs and vector elimination, policy makers from national and district levels. These should be individuals who have substantial contributions to make, and actively participate in activities significant to the success of CBlTs. 3.3 Druo Procurement and Delivery ln the current system of ivermectin procurement, the NOTF is assisted by the Tanzanian Society for the Blind (TSB) with the clearing of ivermectin from the port of entry in Dar es Salaam. The drug is then collected from the TSB's store by the National Coordinator and delivered to the communities through the regional stores. But to put in place a more sustainable system for drug procurement and delivery within the Ministry of Health, the NOTF proposed that: in line with the Health Sector Reform activities of the MOH, ivermectin as other items should be delivered from the Medical Stores Department (MSD) in Dar es Salaam to Zonal Medical Stores (ZMS). ii) the district hospitals will collect their ivermectin consignment from the ZMS for delivery to the health centres or dispensaries. The village government shall be responsible for the collection of ivermectin from the dispensaries for distribution in the villages. The team visited the Medical Stores Department with a view to find out how the present structure and function of the MSD can be utilized in the clearance, transport and distribution of ivermectin to the districts, in a sustainable manner. The main findings and conclusions of that visit could be summarized as follow: i) 4i) The structure of the MSD comprises the offlces and central ware houses in Dar es Salaam and 5 zonal Medical stores located in lringa, Mtwara, Tabora, Mwanza and Tanga towns. ii) Areas affected by onchocerciasis allfall into the MSD zonal stores outreach Once the pharmaceutical products reach the zonal stores, they are delivered to the District Hospitals by MSD vehicles. From the district, the items are delivered to health centres and dispensaries by the district authorities. ln principle, the EPI kits are cleared and distributed straight to the districts, once a month by the MSD. Monthly vaccine kits delivery to the districts is assured for the next 3 years, thanks to the generous support of the Danish lnternational Development Agency (DANIDA) and the British Overseas Development Agency (ODA) Vaccine delivery chain stands a better chance for continued support in the long term. lt is therefore suggested to integrate ivermectin consignment delivery into the vaccine delivery chain. After the visit to the Medical Stores Department, the team is of the opinion that the mechanism proposed by the NOTF is adequate for timely and speedy delivery of ivermectin to the affected communities, provided there is a regular flow of related information between the National Coordinator, the MSD, the zonal stores, the district hospitals and the health centres or dispensaries. To this effect, the team recommends that the National Coordinator ensures that relevant information on ivermectin procurement, delivery and distribution is regularly and timely made available to all parties concerned. 3.4. Development of the National Plan and the GBIT Proposals 3.4.1 The National Plan A National Plan for the Control of Onchocerciasis in Tanzania did not exist before now. Also, there has been no concerted effort to control the disease by any method including vector control. Therefore, the draft National Plan submitted by the NOTF to the team is the first for a national control programme. Together, the team and the NOTF carefully reviewed all sections of the draft plan following the APOC guidelines for formulating a national plan for onchocerciasis control. ln addition, treatment of hypoendemic communities through clinic based approach was highlighted as an important responsibility of NOTF as these areas would not normally be covered by CBlTs. To address this issue in the national plan, it was agreed that the paragraph on the programme strategy will consists of three sections: principal strategy using CBIT, focal vector elimination and clinic-based(passive) distribution of ivermectin in hypoendemic areas. The visiting team was assured by the NOTF that the suggested amendments will be incorporated and the Plan revised to conform with Apoc guidelines. iii) iv) v) vi) 53.4.2 The CBIT Proiect Proposals For the selection of sites for CBIT projects, the NOTF with the assistance from the team first defined and agreed upon the criteria for selection, namely: i) level of endemicity (based on REMO/REA results) and severity of clinical disease (severe skin disease, epilepsy). ii) potential progress towards CBIT iii) potential to integrate the CBIT into the PHC system (degree of PHC development) Presence of or potential for NGDO's and other partners commitment and willingness to comply with APOC's principal strategy. On the basis of the above criteria, 8 projects sites were identified. The group agreed that these 8 projects will be covered in five phases. For phase 1, the Mahenge focus with a population of 271,300 persons at risk was selected (see Annex 1). 3.4.3 Date of Submission of National Plan and CBIT Proiect Proposals to APOC The NOTF and the team deliberated at length on the feasible dates for submission of projects to APOC for consideration. Given the non-availability of REA/REMO data in the whole of the southwest, the west and the northwest of the country, the presence of NGDO partner in only one region, and other additionalvital information required for the completion of the National Plan, the NOTF wishes to submit the first proposal rather by February 28, 1997 for consideration by the TCC in April 1997. 3.5 REMO Project funded bv TDR/OOR Task Force A proposal for Rapid Epidemiological Mapping of Onchocerciasis (REMO) to assess the levels of endemicity in the Western Regions (Kigoma, Kagera, Rukwa) of Tanzania was submitted to and approved by the TDR Onchocerciasis Operational Research (OOR) Task Force. Funds for this prolect were transferred to Dr. Siyame (Principal lnvestigator) in October 1995. the team on enquiry leamt that the REMO exercise is yet to begin and has been postponed several times. ln an attempt to have the researchers complete this very important exercise and provide the data necessary for further development of the National Plan for Onchocerciasis Control in Tanzania, the NOTF and the visiting team obtained: i) a written confirmation from Dr. Siyame that a substantial part ($31,430.00) of the TDR fund is still available (see Annex 3). ii) an undertaken by Dr. Maegga and the new National Coordinator to complete with Dr. siyame the REMo exercise by early october provided the funds are made available by Dr. Siyame (see Annex 4). A detailed workplan was developed by the researchers assisted by the visiting team(see Annex 2). The team is hopeful that the result of REMO will be available at the iv) 6agreed time. The new National Coordinator should closely follow-up this new development and act as team leader to oversee this activity. 3.6. Vector Elimination Proposal Tanzania is also one of the participating countries where vector elimination could be possible in selected foci. Feasibility studies show that the Tukuyu focus, at the north end of lake Nyasa, is the primary target for vector elimination in Tanzania. However, before the elimination operations can be put into practice (presumably in 1998), there is a need for a number of field and laboratory investigations to be undertaken in 1997. The team is pleased to report that the Plan of Action and Budget for these activities are ready for implementation as from 1997. The authorities were informed that APOC shall fund 1o0o/o of the vector elimination projects. 3.7 Other iss of concern 3.7.1 Administrative and Financial Manaqement of CBITs The national authorities through the Director of Preventive Services and other partners assured the team of their commitment to provide the minimum of 25o/o of the cost of CBITs as stated in the Memorandum of Agreement. During the working sessions, the team explained in details to NOTF members the various aspects of administrative and financial regulations for the management of APOC funds, in lines with the guidelines provided to the countries. Discussions focussed on the necessity of opening a special bank account for CBIT projects with two mandated signatories as stated in the guidelines: one signatory from the Ministry of Health and the other one representing the NGDO(s). The team was made to understand that the Ministry of Health plans to make maximum use of the existing systems and will find it difficult therefore to open a special account as requested. Moreover, the country regulations do not allow any NGDO to be signatory to an account opened within the Ministry of Health. The Director, Preventive Services (MOH) has therefore provided two other options for consideration, namely: i) Opening of an account under a special code within the Ministry of Health. Signatories to this account shall be: - the Chief Accountant of the MOH - the Assistant Chief Medical Officer for preventive Division - the National Coordinator ii) Opening of a separate account by the NGDO(s). The signatories to this account shall be the representatives of NGDOs and the MOH. The Director of Preventive Services further remarked that the disbursement and management of funds at the district and lower levels for CBIT projects will follow the existing pattem set up by the authorities. 7It is agreed that the issues mentioned above will be further discussed and followed up by the Ministry of Health's officials and the NGDOs. The visiting team highlighted that whatever option is choosed, it should guarantee efficiency, transparency, partnership spirit and make room for external auditing to take place regularly. 3.7.2 Sustainabilitu of CB lTs: Cost recovery and cost sharinq Tanzania hasa policyin cost-recovery and in cost-sharing introduced in 1994. This policy covers all hospitals but it excludes health centres, dispensaries and village health posts. lt also excludes those who are chronically ill (e.9. TB). This policy may change following the outcome of ongoing cost-recovery/cost-sharing impact evaluation study. Given the proposed structure of ivermectin delivery, the team is of the opinion that this policy will not affect the CBIT projects. Furthermore, since onchocerciasis is a chronic disease, it should be one of the disease exempted within the cost recovery/sharing policy guidelines. The team recommends that the NOTF closely follow-up this important issue. 3.7.3 Reinforcinq the WHO Office support in the lmplementation. Monitorinq and Evaluation of APOC proiects In our assessment, implementation, monitoring and evaluation of CBIT in Tanzania will be difficult because most endemic villages with the worst skin diseases are located on remote mountain slopes difficult to access even during the dry season, of limited human resources and the size of the country. For effective monitoring, the WR and the team agreed that the NOTF needs technical support from the WHO country team. ln this connection, the visiting team strongly recommends that the staff and facilities of the office of the WR in Tanzania be reinforced to provide NOTF with technical support and to play a visible role in the monitoring of CBlTs. 3.7.4 Sionino of APOC Memorandum of Aqreement The authorities were adequately briefed by the team on the importance of signing the APOC's Memorandum of Agreement. The team was assured that the Memorandum was already studied by the Ministries concerned and will be signed by the Hon. Minister of Health in Brazzaville, during the forthcoming AFRO Regional Committee meeting in September. 3.7.5 Minister of Health's attendance to the WHO/AFRO Reqional Committee Meetinq and the Action Forum The team stressed the importance of the Minister of Health's attendance to the above mentioned meetings. The National Coordinator, the Director of Preventive Services and the Principal Secretary will make sure that these meetings are included in the travel agenda of the Minister. I 3.7.6 Government's commitment to onchocerciasis control The Ministry of Health has in the 1996/97 budget allocated the sum of 7 million shillings (about fifteen thousand dollars) for onchocerciasis control activities. This sum will be used in priority for the payment of clearing and handling charges of ivermectin. The Hon. Minister of Health informed the team that this budget has been approved by the authorities. 3.7.7 NGDOs involvement in the ivermectin distribution campaiqn jn Tanzania Two NGDOs have been so far involved in the ivermectin distribution in Tanzania: The River Blindness Foundation (RBF) and the lnterchurch MedicalAssistance (lMA). The team was informed that the assistance of RBF will cease by the end of 1996. IMA will continue its support and the presence of the Executive Director, Mr Paul Derstine in Dar-es-Salaam to participate in our working sessions, is an obvious sign of the good willing of that organization to assist the country to develop sustainable CBIT projects. 4. AGKNOWLEDGEMENTS We wish to thank the Government of Tanzania for granting us the permission to undertake this mission. Our special thanks to the Honourable Minister of Health, the Principal secretary, MoH, the Director, Preventive Services, MoH, the world Bank Staff, the Director of the Christian Social Services Commission (CSSC) and his staff, the Director General of the Medical Stores Department (MSD) and his staff, the Director General of the National lnstitute for Medical Research (NIMR), for meeting with us, sometimes at very short notices. We are grateful for the logistic support received from the office of the WHO Representative (WR). ln this regard, special mention must be made of the assistance from the WR himself, Dr D. Waming and Dr M. Amri, Disease Prevention and Control, wHo, who devoted resources to ensure that the mission is successful. Our primary indebtedness is to the Executive Director of the lnterchurch Medical Assistance, lnc. (lMA), Mr Paul Derstine who travelled from USA to Dar-es-Salaam to attend our meetings and who devoted all his time for the mission. Finally, our special thanks to the National Coordinator, Dr Katenga and his collaborators of the NOTF who worked unrelentingly with us during the mission. 23 I ANNEX 1 CBIT PROJECTS BY PHASE Could be accelerated to phase I Hypoendemic but further investigation needed Planned after the completion of the REMO/REA exercise in the western limb of the Rift valley Phase Project No. Project site Population at risk Target date for submission of proposals 1st MAHENGE REGTON Ulanga district Kilombero district 271,300 Feb.28,1997 2nd 3rd RUVUMA REGION Songea district Mbinga district Tunduru district 675,000 218,000 Aug.31, 19971 Aug. 31 ,19972 ilt 4th 5th IRINGA REGTON Ludewa district MBEYA REGION Tukuyu district 120,000 467,000 Feb.28,1998 Feb.28,1998 IV 6th 7th MOROGORO REGION Uluguru district Kilosa district 160,000 420,000 Aug.31, 1998 Aug.31, 1998 V 8th TANGA REGION Eastern Usambara Muheza district Western Usambara 695,000 Feb.28, 1999 Vl3+? 9th3 + ? Western limb of Rift valley3 ? 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