il I ffiwffiw ffi WffiIffi t $ $ n* het f,:to: r # u:: r"r* ffi'r*pm $a F{'er; ils:rl-r + i S,f,mt* ffi *," i..lf .:*.t '11-r I il,f."* r l, t: ilrra*o{. l r*,u lpltroyo3 PROJECT PERICID: 2003 - 2007 For lnformotio. To, DtL ArU ffiL$ AFRICAN PROGRAM FOR ONCHOGERCIASIS CONTROL (APOc) -i 3 I JLilr" 3$03 t.[':., l.:R I. {: i For Action., To: 1cc17p"*i.*.i *20,LL J]- t' -, Ein' IrP 3,-t) July 2003 I l TABLE OF CONTENTS LIST OF ACRONY}{S lll l0 t1 II 15 I SECTION 1: BACKGROUND INFORMATION INFORMATION ON THE PROJECT AREA FOR CDTI ...l.l. Geographical and administrative areas.....1.2 Topography, Climate, Access.......1.3 OnchocerciasisEndemicityLevels 1.4 CommunityStructure.... 2. PAST AND CURRENT STATUS OF CDTI IN PROJECT AREA SECTION 2: PROJECT EXECUTION OUTLINE 3 DESCRIPTION OF PROPOSED CDTI3.1. Outline PIan and Timing3.2. Health Education and community lnteraction and participation3.3. Local Operational Research......... 4 SUPPLY, IMPORTATI I\{ECTIZAN TABLETS ON, STORAGE, INVENTORY AND DELIVERY OF SUPERVISION, MONITORING AND EVALUATION5.1. SupervisionduringEvaluation. 5.2. Monitoring CDTI.........5.3. Evaluation of CDTI 6. SUSTAINABILITY OF THE CDTI AFTER THE WITHDRAWAL OFEXTERNAL FUNDING I I 2 J 4 5 r0 5. t1 t7 17 l8 20 20 22 24 25 27 28 29 6.t Integration of GDTI into other community Based pHC Systems Cost Recovery System during CDTI..........6.2 6.3 Other Issues 7. CROSS BORDER CONSIDERATIONS ..... 8. SPECIAL RISK TSSUES SECTION 3: ADMINISTRATION/FINANCIAL ........... ADMINISTRATION 9.1. Organizational Struoure for CDTI9.2. Financial Administration................9.3. Timed PIan ofAction..................... 29 29 30 36 9 10. BUDGET...... 10. I 10.2 r 0.3 Budget Estimate.... Budget Justifi cation................ Current Resources available in CDTI 38 38 42 44 APPENDIX I: Estimated Numbers of communities and persons to be Treated each Year by Endemicity level... APPENDIX 2: Indicators for Evaluation, sustainability and Integration of GDTI APPENDIX 3: Budget Details . LIST OF MAPS: MAP I: SKETCH MAP OF ILLUBAB)R Z1NE, )R1MIYA REGIONAL STATE, ETHIOPIA MAP 2: 45 47 48 6 MAP 3: SKETCH MAP OF CURRENT CDTI I,YEREDAS IN ILLUBABOR ZONE, OROMIYA REGIONAL STATE, ETHIOPIA 7 DISTRIBUTION OF VILLEGES, ROAD NETWORK AND KIT/ERS IN ILLUBABOR ZONE, OROMIYA REGIONAL STATE, ETHIOPTA ........ 8 CURRENT CDTT AREAS IN ETHIOPIA. g LIST OF FIGURES: FIGURE I: Organizational Structure of National Onchocet-ciasis Control Program 29 MAP 4: FIGURE 2: Request and Disbursement of ApOC Funds FIGURE 3: 32 4t P_grgentage of Contributton of Each partner for 5 years forIllubabor CDTI Project... ... FIGURE 4: Annual Treatment objective (by Endemicity Level)......... 46 u LIST OF ACRONYMS APOC- ATO- CDDs- CDTI- EARP- EPI- FDRE- GIS- IEC- KAP- MIS- MOH- MOVDCD- MOVDCU- NGO- NOTF- PHCU- REA- REMO- RHB- ROTF- SNNPR- TBA- TCC- TMEC- TOT- WOTF- ZAC- ZHO- ZOTF- African Program for Onchocerciasis Control Annual Treatment Objective Community Drug Distributors Cornmunity Directed Treatment with Ivermectin Eligible At Risk Population Expanded Program of Immunization Federal Democratic Republic of Ethiopia Geographic Information System Information Education Communication Knowledge, Attitude, and practice Management Information System Ministry of Health Malaria & other vector-borne Diseases contror Department Malaria & Other Vector-borne Diseases Control Unit Non Governmental Organization National Onchocerciasis Task Force Primary Health Care Unit Rapid Epidemiological Assessment Rapid Epidemiological Mapping of Onchocerciasis Regional Health Bureau Regional Onchocerciasis Task Force Southern Nation Nationalities & peoples Region Traditional Birth Attendants Technical Consultative Comnrittee The Mectizan Expert Committee Training of Trainers Woreda Onchocerciasis Task Force Zone Administrative Counci I ZoneHealth Office Zone Onchocerciasis Task Force Ilt ISECTTON 1: BACKGROUND TNFORMATTON INFORMATION ON THE PROJECT AREA FOR CDTI Geographical and Administrative Area(s) Illubabor project is found in Illubabor zone, which is located in the southwestern part ofOromia Regional State, in Ethiopia. It shares borders with Gambella Region in the west, West WollegaZone in the North West, and East WollegaZone in the North East, Jimma Zone in the South and South East and Kaffa-Sheka Zoie that found in Southern Nations, Nationalities and Peoples Region (SNNPR) in the South. The zone has a total surface area of 15,870.00 Sq.k*.According to the 1994 population and housing census, theprojected total population of the zone for the year2O0l is estimated at abo"ut 1,053,151. About 91 o/, of the populations Iive in the rural area. 9 o/o of the population liye in the urban areas. Major occupation of the rural community is subsistence farming. Illubabor zone is one of the l2 administrative zones in Oromiya Region. It is sub-diiia.a i, t: u'oredas (districts) and further subdivided into 466 kebeles (Peasant Associations). illubabor CDTI project comprises of eleven rvoredas and about 3,800 r,illages. Out of these, six rvoredas are targeted for the first year CDTI. These are, Metu, Darimu, Alige- sache, Yayu-Hurumu, Alle-Dido, and Bedele-Dabo. The remaining five woredas rvill be included in the second year depending upon the result of REMO refinement. The totalpopulation of the six CDTI woredas is estimated to be 641,773. The Annual Trearment Objective (ATO) for the firsr year CDTI is 513,418. Table l: - Esttnlated Nunrber of Populatron, ATO and Status ol REIvIO by District, Illubabor project area, 2003 'Vereda Estimated Mllagcs Total Population Annual Treatment Objective (ATO) REMO Status Mettu 537 13427 I 107417 Year I CDTI Area Darimu 472 I t7959 94367 Year I CDTI Area Alge-Sache 29t 72745 58196 Year I CDTI Area Yayu-Hurumu 415 I 03809 83047 Year I CDTI Area Alle Dido 36s 91234 72987 Year I CDTI Area Bedele Dabo 487 12t755 97404 Year I CDTI Area Sub-Total 2567 641,773 513,418 Dega Mako 231 57730 46t84 To be refined Didessa 220 54949 439s9 To be refined Chora-Kumbabe 4t7 t04357 83486 To be refined Halu-Bure 274 68476 54781 To be refined Sale Nono 9t 22808 18246 To be refined Total 3800 950,093 760,074 t.t a D1.2 Topography, Climate, and Access. l'2'1' Please describe the type of country or bio-climatic zones that will be covered by theCDTI (e'g', rain forest, forest-savanna mosaic, Guinea sovanna, Sudan savanna, mountainous orflat), provtding maps, if appropriate. The zone has very complex terrain with altitude ranges between lo0o-z576meters abovesea level' Ecologically it is a tropical rain foresi. Climate in the zone shows great seasonal and inter-annual variations which is haditionally classified into three broad"geo-climatic zones, i.e., 16%o cotd highland, 62 %o sub-humtd midJand, and,22 %o hot lowland area. The mean annual temperature ranges from l0 0C to 16'C i, tfr" rrigti"rar,lircl260c in the midlands, and zloc -136c;;1h;i;*rlnds. The annuat rainfalt totals rangesfrom l00C millimeters in the lowlands to 22OO millimeters in the highlands. Some of the perennial fast flowing rivers that cross the zone include: Sor, Geba, Birbir and Dedessa, Offa, Sesie, and Gumer rivers. There are also quite numerous small rivers and streams, which are tributaries of the main rivers in many piu.", in the zone. l '2'2' Give the approximate times of the rainy antl dry seasons and the months covered by the farming season. There are two distinct seasons in the project area, i.e., the rainy season (April - October)and the dry season (November-March). There is a mono-modal rainfall pattern in the zone' Agricultural activities (clearing, farming, and herding) occur all year round in theproject area, but are most intensive during tile rainy season. Harvesling occurs fromOctober to December, leaving January - Mirch as the optimum treatment period. I'2'3' Provide informatton on the state of the roads, and the effect of thk on the movements of GDTI personner in the area at dffirent times of the year. The main road that runs 600 lcrn from Addis Ababa to Mettu, the zonal capital t6s,n,passing through Jimma zone is Asphalt road and woredas alongside of thl road are connected with Mettu town. There are about 576 kilometers d[, weather roads that connect woreda centers with Mettu town. Except Selenono woreda, all the other 12 woredas have all weather roads and are connected with Metu town. However, access torural communifies appears very difficult during rainy seasons. Therefo re, Mentizandistribution will have to be carried out during the Jry r"uion. (January_ Marchj. The general health care service coverage in the zone atpresent is estimated at about 69%o,but the effective coverage is estimateJ to be much lower than the above estimate due todifficult terrain, low road infraskuctures and affordability, Iow public awareness. Mostsettlement villages are also scattered and lakes longer time to travel from one village toanother' Currently, there are I hospital, 8 Health Celnters, 64 health stations and 17 healthposts in the zone. 2 1.3 1.3.1 1.3.2 1.3.3 I .3.4 1.4 Onchocerciasis Endemicitl, Levels The levels of Onchocerciasis endenticity in contmunities in the CDTI areas musl be assessed by simple methods before treatnxenl starts. For the purpose of this proposal, thelevel of endemicity in a commrtnily or a group of similar c)mmunities is defined o, tlrcbasis of the prevalence of nodule carriers. (See tible 21. Table 2:-Classification Criteria for Endemicitl,Levels in Rural Communities Endemicity Level Of Treatment and Recommended Type Hyper-Endemic , Community Treatment Meso- Endemic, Community Treatment le Percen t of nodule carriers in REA sample (minimum sample 50 adult men) Estimated prevalence of O. Volvulus in the whole community Greater than 39%o Greater than 59o/o 20 - 39% 40 - 59%H Endemic on- Less than 20% Less than 40% Bosed on the system in Table 2 and using rhe format in Appendtx I , please indicqte tlte estimated numbers of comruunities at each endemic level ancl the numbers of persons in them. A total of 2,561 villages (communities) in the six woredas are targeted for cDTI for thefirst year treatment. Out of these 2,233 are hlper-endemic villages and 334 are meso- endemic villages. The number of villages is estimated from the t;l population with the assumption that 250 residents live in a village (based on the CDTI'principle of 50households per two CDDs). See appendix l. Complete Appendix I for each area covering the next 5 years of the project. Done! If methods of assessing endenicity thresholds other than nodule pretalence u,ere usecl when your endemicitlt data were collected, please indicate the method used. The levels of endemicity in communities of this zone were defined on the basis of nqduleprevalence rate obtained by REMO Survey conducted in 1998, 2000, some of which were also validated in 2001 by ApOC consultants. For areas still to be covered, where endemiciry levels are not yet known, please describe the method you will use to collect the necessary endemicity data. Community Structure Provide background information on the social organizations of communities in the CDTI areas' This may include information on settlemeni pattern of tie community (e.g. lrumlets, seasonal farmsteads, dispersed population, etc.) The communities in CDTI areas are settled farmers with hamlets, while populatio, is widely dispersed in most districts except those areas with resettled populations.' 3 aa o The ethnic groups in the community. A majority of community members belong to oromo nationality. The remaining peoplesbelong to other ethnic groups such as: imhara, Gurage, Tigrie, Agnuaks and Nuers,Shekicho, Kaffa, and Kulo, etc. o Please provide information about th1-ar9a covered by GDTI indicattng whether they aremigrants, nomads, refugees or internally displaced popilotionr. The community in^cludedin the proposed CDTI project area aresettled farmers with a fewdisplaced settlers from other pu.t, of the country. the settlers came to the area more thantwo decades ago. o Community leadership structure. The community leadership structure in Illubabor zone is organized, by the zonaladministrative council (zAC), which consists of elected members from each woreda. TheZAC is responsible for giving guidance and leadership to the commuriav r". all socio-economic activities' Each woreda is divided into large administrative communities calledkebeles (4000-5000 people per kebele on uu..ug"l. Kebeles are further divided intosmaller clusters of households called menders(villages) with 250-300 p"opr"r. Elders andreligious leaders play a major role at each level.-Iniormal social offirutions in thecommunities include: Edir, Equb, etc. whereby the community members share and discusstheir problem. The diagram below shows the commurity l.ud..rhip structure. ZAC ) wereda Admin Council )Kebele Admin ) Elders/Religious Leaders )Households Main occupation of community and periods of maior communar activities. =The main occupation of the community is farming, and animal husbandry. Fariningactivities, however, decrease from January to Ma'rch after the completion of cropsharvesting. Preferred channels of communication in the communtty. The preferred channel of communication in the community is passing messages throughthe community leadership structure and from the local farmers or urban dwellers such ascommunity representatives, elders, and heads of the household. Besides, ih"." u." trainedcommunity health workers and traditional birth attendants that bridge the communitywith the health care services. school clubs from rural primary schoo"ls can ue used inreaching CDTI communities. However, mass media such as radio is less available in mostrural communities. 4 a Existing active contrnunity association/groups itt rlte arect (e.g. social, religious, etc.) The existing and active community-associations/groups include the farmers associations, urban dwellers associations and traditional religious gatherings. There are informal social organizations such as ldir, Ekub, etc. Established distribution systems in the contnrurtitl,. There are some existing distribution systems for EPI activities such as polio campaigns, vitamin-A distribution, family planning and malaria control, which are organized throughthe social and religious associations mentioned above. It is also through theseorganizations that community mobilization and health education will begin for CDTI.The community could also recruit their distributors through these systems. " Social contmunal actit'ities and months durirtg which the activities take place. There are various social and communal activities. Prominent among these are traditional religious celebrations such as, the foundation of the True cross (]t,i.eskel) in september,Gena (christmas), Tintket (Epiphany), and. kl-Al-Fetir, inJanuary, Eater in Rpril. Any previotts experience of tlrc communitlt tvith det,elopntent/health projects. Most communities in the zone have been involved in various EpI, Family planning, well construction, and spring protection activities. There are also "orn-unity health postsmanaged by community health agents and traditional birth attendants in some communities. The communities therefore have u,ell-established systems of mobilizationto enhance participation in communal events. Descriptiott of other anthropological characteristics of the contntuntties. The people of Illubabour zone are predominantll, muslins and Oromo by ethnicity. Sheiks and traditional religious leaders possess strong influence in decision-making and health- related behaviors. All Fridays are spared for religious activities in the Muslim communities. a a a a 2. PAST AND CURRENT STATUS OF CDTI IN PROJECT AREA. 2.1 Please indicate if the GDTI is an expansion of an extsting )DTI. Illubabour zone is a new CDTI project area and has no past experiences on CDTIprogram 2.2 state the number of ),ears the programme rtas been operating, and i,f possibte enclose previous statistical, financial and annual reports. Not appiicaUte. 2'3 State the nuntber of persons treated each yearfor the last 5 yeors: Not applicable. 2'4 List the organizatiott(s) involved in the programnte, the sources and amount offunds used each yearfor the last 5 years. Not applicable. 5 \o ? Fr F f-l HF Fa Fl z o f-l d, |-a o& o d ; o te ca Fl Fl .E o Fr ETa t \ a- -q); -l-\H oL q) H o +J U) 6nq)L a cg()fr l-l Fr ,^\ti U o l+l *r t-r 14 triF FO Fl z o - ri& tlra /, ikl FQri F U tl. EA Fq D Fl Fl t* o A tstz I t\ A< a E +tf,it5 E{}Emsil trt E =CD {}E II q.L E UI m nl ..*: ,r- - ':-' ,Ll , r'-' tl -t_^ 1t @a 'IJ(d o& aLr C) E 0il FEI tsriilp..oo2H V trl&.i ^- F!L' t-B< - F'(HaZJ =zACY l-{MU HE Flo FX ,rvOtri z1 -LJ =NF'( tvl-l - \JHM F{ FAaD -a'i . l-lI lr{ .dZ Fr l"{ > a c0 C) co E() O G)()(r) D a CB(.) L< co F RU o z o .V F O ad() L<d F oO ra 6t G U o 0"{ G F( ^'l-l \JFIl+l r{r F-r E1 zH a F]t l-l FrAlrl U i-l zri * fr) Q .+ g.r \-a c F r! !oY @ I E t' 'f";i'. ' -.i,- / 3. SECTTON 2: 'ROJECT EXECUTTON OUTLTNE DESCRIPTION OF PROPOSED CDTI The main strategy of the project wilt be to develop and e-rtablish commtutity_based ivermectin treatmentsystems' which can be sttstained by the end.emic contnturttties tltentselves without external support afterthe S-year proiect period. This siction should describe hotv tlte NorF ptans to develop and implementGDTI in all high-risk conununilies in the proiect area. Tlte plan should take into account the need todevelop approaches to CDTI, which are appropriate, for the dffirent local ,itrotionr, and the need tocarefully evaluate the implementatton of th-e'selecred approachei and adjusr thent when required. The Ethiopian program for onchocerciasis Control (EpoC) intends to implement CDTI in thecontext of the country's hearth sector derreropment plan (HSDp). In vie*r of the currentdecentralization scheme, the oromia region health br."uu will be directly responsible foroverseeing the project management next to the NorF. In particular experts f.om ttre departmentof malaria and other vector borne diseases control u,ithin the regional health bureau will beclosely monitoring the implementation process. All hyper and meso endemic areas will becovered with GDTI' Illubabor is sharing common bo.d..s with Sheka zone, which has beenimplementing GDTI over the past three yearsl and similar approaches will be used, as there is nomuch difference in the infrastructure and socio-cultural pattem of the two neighboringpopulations' The proposed project staff will have the offiunity to leam from the Kaffa-ShekaCDTI project by means of field visits as well as uy ni.rn, of participating in program reviewmeetings' The partner NGDO for this project, The carter center, hus u *ellth of experience inmanaging other GDTI projects in the country, which could be considered as a good source ofadditional inputs in providing technical, logistical and financial contributions. on top of allthese' other innovative progrim evaluation mechanisms such as community self-monitoring,spot-checks' program reviews and appraisals rvill be conducted as "pp."p.i"r.. There is ahospital and a nursin8 s1h.9.ol in this pill"ct area, rvhich could be a source of additional humanresource that can be mobilized to asiisi in training and srfe.uision of cDDs during the massdistribution program. t0 3.1 Outline Plan and Timing for the period 2003-2004 3.2 Health education and community Interaction and participation How will you approach and interact with the community? There already exist systems of communication with the proposed project area through other health programs as described earlier. However, the followinglstrategy will be implemented to maintain good relations with the communities: Activity/Justification Length of Time Advocacy and sensttization at the regional, zonal and woreda levels emphasi will be placed on introducing the APOC/CDTI strategy, and en Iisting the support of the regional level th thewtparticipation of the NOTF,AIOCP regional administrative council o ffices 5 weeks Agreement on the definition of roles and respons ibilitie$ of all partners through MoH wt th region based on APOC Guidelines, etc 4 weeks Procurement ofessen tialproject equipment and supplies Computers, Mectizan drugs, and vehicles, and others I6 weeks Training/ of project trainers at regional zonal and levels, Training to those w'ho will function ils trainers and supervisors 4 weeks Rapid Epidemiological Assessments/REA REA will be carried out to allvil that for CDTI 4 weeks Mobilization ofregional, zonal and district authorilies to pport the proJect Conduct KAP Studies Pre-intervention KAP surveys and other studies will be conducted to have a baseline data to develop appropriate IEC acrivities and monitor behavioral changes and also assess re-infection rate. 4 weeks l2 weeks Mobilization ofendemic communities, stressi ng comm unt ty ownership of the pro3ect a5 wel as the health education 4 weeks Selection and training ofCommun ity Directed Distributors (CDDs )Selection ofCDDs ls the responsibil ity of the communl ty 3 weeks 2 weeksHousehold regtstration and census enumeralion trained CDDs wr I I carry out vill age census Mectizan @ Coll,ection and Distribution IN endemic commun ties including mopptng J up 8 weeks Monitoring and supervtsion supervisors of Mectizan@ diskibuti on activities by zonal and woreda 4 weeks Inspection of CDD distribution activities (spot checl<s) by regional supervisors and NOTF I week Conduct Community Self Monitoring 4 weeks MIS (Managem enl Info rmation Sys tem) Reporting of treatments and the other CDTI activities will be done periodically. Monthly NOTF evaluation team conducts lntemal evaluati on of the proJ ect 4 weeks Review of Tr ea t m en I A c tiv i I i es Annual review will be conducted in July 2004 and reports generated and used to ensure continuous improvement in designing the following years iction plan. I week Preparation ofAction Planfor the next year 2 weeks 3.2.1 l1 a) Discussions with zonal council chairman and head of social affairs and with woreda chairpersons, local farmers and urban dwellers associations, religious i"ud..., "o.n,nrnnyelders and opinion leaders to better understand community values, customs and beliefs. b) Focus group discussions will be held with social and religious groups to further mobilizethe community with the support of the community leaders. c) Focus group discussions will be held with the community members as appropriate(separating men and women, depending on the community tiaditions). The community members will also be encouraged at this point to take ownership of the program, definingtheir roles and distribution mechanisms. 3.2.2 Health education Health educatiott and community mobilizatiutt wtll corttinue to be an integral part of all approacles toCDTI Health education activities should ensure conrinuous. exchange with regards to knov,letlge,au'areness, perceplrcn and observable attitudinal changes abour onihocerriari and its treatntent.Appropriale health education messoges in the fornt of piterr, pamphlets orrt uniiofpresentations tyillneed to be developed and tested. Heaith educotion shoitd addriss rhefollowing issues (see Tabte 2). Table 3: Critical Issues in the Development of Health Education for CDTI a) Have any KAP surveys been done in the project area and if so, what were the results? No KAP studies have been carried out in the project area. However, there is a need for a KApassessment to be done before launching the CDTI ISSUES Health Education Messages Knowledge of the disease Sl,rnptoms, Causation/transmissiona (simple) Local name of the disease Knowledge of treatment a a a a with Diethylcarbamazine (DEC) (ivermectin) Dosage Exclusions, Reactions, Beneficial side effects Previous experiences Introduce Mectizan@ Attitude to treatment Free, Yearly treatment Possibility of Self-treatment at community Ievel Advan tages of Treatment: a a of maximal Attitude to disease The disease can be controlled can be a tedOnchocerciasis blindness and skinto good record keepingAttitude Mina tm u u lrements forreq record keeping a Record are confidential and for healthstrictly SC Records red forare s uent t2 ut b) Wat methods will be used to develop health education material for the communities and for the agents who will be responsiblefor lvermectin treatment? Health education materials such as posters, leaflets and flipcharts will be developed in local languages by the project and submitted to NOTF for standardization. These materials will be field-tested and refined/adjusted as necessary prior to mass production. c) Wat methods will be used to provide health education to the endemic communtties and to the agents responsiblefor treatment? Illubabour zone has in the past used various media for providing health education to endemic communities. Such methods include: - face-to-face discussions with community members, haditional birth attendants, community health agents, associations and faith based institutions. - use ofposters and flipcharts prepared in local languages, and - drama (role playing in local languages). Community leaders will first be informed about the disease and the importance of regular treatment with ivermectin. These communify leaders and representatives will serve as agents for the program, encouraging community members to comply with ivermectin treatment. All members of the community will be directly engaged in discussions about the health education messages, and given the opportunity to ask questions they may have and make decisions regarding any aspect of the CDTl-program. Community members will also provide valuable input into the development of health education messages and materials for final distribution. 3.2.3. Community Participation In community-directed ivermectin delivery systems, members of the endemtc communities do the execution of ivermectin treatment themselves. Tratned personnel, knowrx as Community-Directed Distributors (CDDy) who should be fulty supported by.the community itself may provide treatment. The community should be responsible for the organization and execution of the CDTI with minimum but efective medical supervision, once it has received the necessary information and tratning. Various orginizational structures at the community level, ranging from women's cooperative to traditional structures, are tmportant for sustatning and strengthening the support network of the CDDs. g) Explain the organization of the intended community-directed ivermectin treatment in the project. The formation of an Onchocerciasis task force at all levels is essential in order to promote coordinated activities of Onchocerciasis control in all endemic areas. At Federal level the NOTF is responsible for routine program management and acts as the liaison between l3 b) MOH, RHB, and NGO partners within the country and outside. The NOTF will be the governing body for onchocerciasis control acti'ities in Ethiopia. At regional level, MOVDC is represented by a department and will be responsible forprogram implementation at that level. The head of MOVDCD will act is a ROCp Coordinator. Similarly, at the Zonal and Woreda levels corresponding Onchocerciasis Control Task Forces (ZOTF and WOTF respectively) will be established. The WOTF will be responsible for program implementation at Woreda level (ensure selection ofCDDs, supervision of treatment activities, record keeping, etc). Also, local health institutions under the WOTF will be responsible to coordinate, monitor, and supervise CDTI at each locality. Village (Mender) rvill be the smallest unit for ivermectin distribution to the communities. Several villages are clustered together to form administrative Kebeles led by a Kebele chairperson. CDDs selected by the communities will be trained on the CbfyapOC strategy for ivemrectin distribution. CDDs and other local primary health care workers will then provide health education to communities on Onchoceiciasis, i.e. its cause. transmission, clinical manifestations and treatment including its prevention and control mechanisms. Communities will be mobilized to provide appropriate support to CDDs when they are engaged in GDTI activities to ensure sustainabiliq,of the programme. Census of households will be carried out to identifu eligible and non-eligible individuals and keep the records before Mectizan distribution. The CDDs ri,ill follJrv up defaulters using their treatment registers. Census of households will be updated every year before Mectizan distribution. Both Woreda and Zonal health staff ivill carry out supportive supervision and monitoring activities. How will ivermectirt distributors be selecfecl, = The respective community leaders (Kebele administration) will be approached t-hrough the woreda council so that appointments are taken to meet with them and sensitize them about the program and later on ask them to arrange meetings with the communities atlarge. There will be.series of meetings with the respective communities targeted forCDTI. The communities will be informed about the CDTI and ApOC strategieJand will be given the responsibility to select CDDs. The communities will be fully eipowered to replace those CDDs that show poor performance. There will not be any external influencein the process of selection of the CDDs. These CDDs are expected to be honest, dedicated, literate, and permanent residents of the community. Moreover, the Kebele admin and the community at Iarge will be empowered to assume full responsibility of owning and managing the CDTI activities by themselves. t4 c) How wtll non-erigibres be identified and defaurtersfoilowed-up? Non-eligible (children under five.years, critically ill persons, pregnant women, lactatingmothers' etc') will be identified using the trousetota census regiit.ution book and they willbe followed up by the respective cPD-s similarly; ae[ulters, absentees, refusals, etc will beidentified using treatrnent record book after "u.r, o.ut.nent. The identified defaulters andnew eligible such as pregnant women but who have delivered will b. ;;;"d later on duringmopping up period or as each particular situation aictai".. 3.3 Local Operational Research Are there any plans to conduct local operational research? ,/ YES If yes please give details NO a) Both region and district will conduct operational researches in GDTI areas on varioustopics. Research will be carried out in the GDTI ur"u, o, issues that courd beidentified in the course of imprementation in rhe fi;;; ;;.. This can be done incollaboration with research instiiutions, universitie, und oth". partners. "Tr+if,r,ng will be provided to ensure the deveropmenr and sustainabirity of the Training of cDDs to operate CDTI is very vitar to the program. To ensuresustainability of the .DTI program, ToT slssions wi, be Jonau"t"J if",r,.NocP' Those trained here will include heath workers, teachers etc from regional,zonal and woreda levels. These individuals will in ** ,.ui, representatives fromhealth facilities who also train cDDs at community level. The sessions for Torwill focus on the following topics: ' Epidemiology of onchocerciasis, its signs and symptoms, incruding itstreatment o APOC philosophy and CDTI srrategy o Health Education and community mobilizationo About Mectizan@ its advantages and the related adverse effects andmanagement of its adverse reactions o Inclusion and excrusion criteria for ivermectin keatmento Dosage of Mectizan o Methods of dug distribution o Record keeping and reporting . Supervision and monitoring o Stakeholders meeting o Community self monitoring t5 The training session of the CDDs will rnainll, focus on . Basic CDTI principles o Village census . Health Education and community mobilization o Mectizan@ and its benefits and the related adverse effects and management of its adverse reactions o Inclusion and exclusion criteria for ivermectin treatment o Mectizan dosage determination o Methods of drug distribution o Record keeping and reporting b) lndicate criteria for selecting trainees (supervisors and community-1irectecl distributors). I) Criteria for selecting CDDs: (i) Literate if possible(ii) Resident in the communitl,(iii) Willing to serve the comnrunity(iv) Must be honest(") Musr be available(ui) Must be selected by comnrunity II) Criteria for Selecting Supervisors Zonal Supervisor: (i) Should be a PHC staff preferably from zonal MOVDpU(ii) Must be knowledgeable(iii) Must be interested in helping the community(i") Must be honest with relati'ely longer duration of stay in the area Woreda Supervisor: = = The same criteria as those for the zonal supervisor are applicable here. ,) Indicate number, type and duration of training courses intended integrated wth other PHC traintng. Type of Training (Workshops) Duration Number per year Zonal Traini 5 days I District 5 days 6 CDD Training 3 days 250 Sessions *In the subsequent years the trainings will befor a shorler duralion, focused and l6 4. SUPPLIES, TMPORTATION, STORAGE, INVENTORY AND DELIVERY OFMECTIZAN TABLETS This section is only a reminder and -concerns ,rhe supply, imporradon, storage, inventory and.delivery of ivermectin tablets, donated by Merck a c;: who ittt also pay handling charges forivermectin to their accredited agents. Mectizan@ consignments will be received through WHO and stored in the Federal MOH central stores in Addis Ababa. Thereafter, following the existing goverrrment health care management system for drugs and other medical equipmenl the Mectizan will betransported by road to the Oromia Regional Health Burlau, and from there to IllubabourZonal Health office. The zonal health office will be responsible for delivering the drugto the District Health Office and health facilities (In some areas the District health officeis located far from the communities. In this "ur", ih. nearby health facilities will serve asthe final collection point). CDDs will then collect the drug from the Disfrict HealthOffice or health facilities. A report showing the use of the drug will be sent to MEC (MectizanExpert Commitree) at the end of eYery yeat, by the NOTF, with the subsequent application. Copies of the application and the report of its use will also be sent to Apoc. An application for Mectizan@ tablets will be submitted every year by the end of August tothe NOTF, using the standardized form of MectizanO Expert Committee (MeC). fnis application will then forwarded to MEC in Atlanta for review and approval. 5. SUPERVISION/MONITORING AND EVALUATION 5.1. Supervision During CDTI Projects are required to be supervised and monitored regularly. However, ApOC fundedprojects will need to be designed to function with effective but minimum supervision compatible with its objectives. __ : a) Please describe the supervisory arrangements you consider wtlt be required for the CDII youpropose. How will this continue at the cessation of Apoc support? As indicated above, there will be supportive supervision at all levels of program management. The supervisory teams (NOCP taskforces) at the national, regional-and zonal levels will be responsible for supervising woreda health offices andrandomly selected health institutions and CDTI targeted communities in all aspects of theprogftImme activities. Trained supervisors from the woreda health office and the healthfacilities will be responsible to carry out supervision activities in their catchment CDTI areas on regular basis. Supervision activities will include performance of CDDs such asproper record keeping, complete census enumeration, Meitizan@ inventory and dosage, and monitoring during the actual distribution process. Moreover, representatives of the community will do direct supervision and monitoring activities on a regular basis in their l7 own village after receiving training on community self monitoring. NGO partners will be involved during in supervision activities along with MoH supervisors The results of the supervision will be discussed rvith each supervised workers and thus corrective measures will be taken at the spot. This will be documented and reported todifferent partners at various levels. b) Describe how 1'ou u,ould ensure that supen'isiott tt,ould. be caruied out so as to:o fall u,ithin the requirenrcnts of accounting for ivermectin use . be sustained when the program ends in 5 years . ensure maxintum involvement of the communities in the process To ensure that the above requirements are met, the program will support regular monitoringduring the actual distribution process to asceftain that correct dosage'is being administeredl exclusion criteria are being observed, and the collection and proper Ito.ug" of unused drug is well taken care. In addition, the program will support ad,rocacy visits to the woredas and villages by NOTF, regional, and zonal and woreda representatives of the onchocerciasis taskforces at each level to solicit the active involvement and support of communities. Once trainingof CDDs has been completed, Zonal and Woreda supervisors will check that household enumeration has been completed according to CDTI requirements. Standard supervision checklists will be used to ensure completeness and compare performances across CDTf villages.Most of all, rvoreda administrative councils and Kebele administrative councils will be encouraged to allocate budget for the continuation of CDTI activities after the withdrawal of external support. The CDTI will be incorporated with the other community development activities so that it will be part and parcel of the routine tasks of the woreda and kebele administrative at their respective management levels. The current decentrali zation scheme andthe health extension package initiative including the poverty reduction strategy paper rvill certainly empower the communities to effectively sustain the CDTI after the termination ofAPOC support in this particular project area. As most parts of the CDTI woredas in Illubabor zone are known for their cash crop (coffee growers), there are good reasons to believe that theproject could be reasonably sustained so Iong as community le;ders are effectively mobilized. Since political commitment has been evidently expressed for various CDTI projects in gnanyparts of the country, there won't be any doubt to solicit similar support in Iilubabor zone asperfectly demonstrated in other community health programs like Epiipolio, Malaria Control,HIV/AIDS, etc. 5.2 Monitoring of CDTI It is important to collect information to monitor the progress of the CDTI. indicators will be used to monitor: o lvermectindistribution? o Health education and communtty participation? o Management systems? Wat Thefollowing items may be considered. 18 Iverm ectin D istrib utio rt o Numbers of communities and persons treated. with ivermectin . Number of lvermectin tablets distributed/consumed . number of communities reporting shortage of supplies . Regularity of treatment exercise c Compliance o Reporting adverse reactions . Numbers of communities participating in the project : o Changes in behaviour towards the disease, its treatment, prevention and control . Community support given to CDDs Management o Are acrivities being carried out according to plan and on schedule?o Inventory control, o Are record forms accurqle and completed on time? . Numbers of persons trained o Balance of genders in staff of the progranl The project will consider the foilowing indices for monitoring the program : Iver m ectin D istributio n : Since Illubabor zone will be starting Onchocerciasis control activities for the first time, there is currently no Management Information System (MIS) for onchocerciasis control. The NOTF will use standardized monitoring ryri". previously developed in other CDTI areas prior to the beginning of treatment. These include communities and persons treated with ivermectin, treatment coverage, regularity of treatment, treatment complianqe, anddrug reactions. In addition, the project will monitor the following rates and percentages using Annual Treatment Objectives established at the beginning of each year. Theprogram will also establish Ultimate Treatment Goals (UTGs). o Annual treatment objectives (ATO): - Total number of villages (number of high risk villages targeted for treatment) - Estimated eligible popuration (g0% of total populattn in the area) o Treatment coverage (related to ATOs): - Percentage of high risk villages/communities covered (geographic coverage) - Percentage of persons treated out of the total population 1ttl..upeutic covlrage) l9 e Cost per person treated c Mectizan inventory control 'lt and Communitv Mobiliz.ation: The degree of community participation in mobilization activities will be used as an indicator of community mobilization. In addition, the support of the leaders and key opinion leaders in the communities will be indicative of successful mobilization as well. o The impact of health education messages u,ill be measured through periodic focus group discussions and KAP studies. Manaqement The project will develop through its integration u,ith the regional, zonal, and district health management and supervision systems to monitor, ' The planning and implementation of activities according to the timeline o Mectizan@ inventory levels o Monthly reporting of treatment indices . Numbers of personnel trained . Attempt to balance gender in staffing 5.3 Evaluation of CDTI Annual external revietu incorporating field vtsirs will be unclertaken to ensure tltatproiects are meeting torget indications outlined in this proposal. Such reviews tvill provide TCC with lhe assurartce that each project is ntoving towards its long ternt stateclgoal and if appropriate ntake recontmendations about any deficiencies or iodifications to this proiect. Such reviews v,ill draw on the indicators developecl by TCC as a guide. 6. SUSTAINABI FUNDING LITY OF THE CDTI AFTER THE WITHDRAWAL OF EXTERNAL Healt, Ihe concept of sustainability refers to the abitiq, of countries ancl a/fected communities following initial external investment to nruintairt the viabitity ani continuity of the iverntectin treatment process without extenrul support. For APOC funded projicts, such support will normally last 5 years, as the APOC donors demand that thire-shall be a visible and achievable end point for the external donation aspect of the programme, and that the community based distribution systents established shall thireaftir b"e sustainable by the governments of the endemic countries concerned. Progress and plans towards sustainability, inclucling the phasing out of external and NGDO support, must be reported annually and satisfactory progress in this direction willbe a condition for each succeeding year's funding tnitittment. please address the 20 following areas that relate to sustainability: integration into primary health care, cost- recovery, and other sustatnability issues. Efforts will be made to ensure post-APOC sustainability of the program according to the sustainability indicators shown below. Treatment coverage: Efforts will be made to ensure at least 65Yo therapeutic coverage as calculated out of the total population throughout the project lifespan. Attempts will be made to attain 100%o geographic coverage by Year III. Planning: CDTI will be integrated with the Primary Health Care @HC) from the beginning. At the National, regional, zonal, and woreda levels, the MOVDCU will be responsible for program implementation. Onchocerciasis taskforces will be established at all levels. Planning would be carried out through participatory methods, using bottom-up approach and integrated with the basic health service. Leadership: taskforces will be empowered and community leaders would be encouraged to be actively involved in CDTI implementation. Involving communities in deciding time and mode of Mectizan distribution, CDD selection, etc would ensure community ownership of the program. Monitoring and evaluation: will be carried out regularly with proper checklist by the MOH staff in addition to the Community Self Monitoring, which will be conducted by trained community members. Training, Health Education, Social mobilization, Advocacy and Sensitization: would be undertaken in such a way that sustainability of the CDTI project would be ensured after the termination of external funding. In other words, all these efforts should lead to empowering the communities so that they can assume ownership responsibility. Finance and Funding: Short, medium, long-term (post-APOC) financial sustainability plans will be prepared at woreda and regional levels. Budget line will be created {or CDTIactivitiesbytherespectivelocalgovernment. Transport & Logistics: Efficient use of APOC vehicles will be ensured and other vehicles from MoH and other partners will also be mobilized. Human resource: Health staff at all levels of the health care will be trained in CDTI and mobilized for mass heatnent activities. Development agents, teachers and other support staffand parbrers will also be involved in the CDTI project. Mectizan procurement, Storage and Distribution: Proper and timely request will be made to MDP using standard format. The MoH will ensure safe storage and distribution at all levels. Collection and delivery points will be determined and endemic communities will be responsible for the collection of Mectizan from the health units. 2t 6.1. Integration of the CDTI into other Community-based or Primary Health Care(PHC) systems. The principal gool of the APOC is to establish cost-effective ivermectin-based control forOnchocerciasis, which can be sustained b),t\rc endernic communities and counlries. One way to ensure sustainabilily is to integrate the CDTI into the PHC system of the country, which means more than just using the systemfor iverruectin distribution. 6.1 .l . Is there an fficial PHC policy and structure in the country? ,/ YES NO If yes, please give a brief outline of what it is: The principal objuctive of Primary Health Care (PHC) policy in Ethiopia is to develop and strengthen grassroots and community participation in health care. tncluding Onchocerciasis among priority health problems in the national health policy will do thi integration of CDTI into the PHC system. At the regional, zonal, and woreda levels, the MOVDCU will be responsible for program implementation at the respective levels. In addition, combining training on CDTI rvith other on job training u"tiriti"., including Onchocerciasis control activities in the planning process at all levels, and includin! Mectizan@ in the Iist of national essential drugs delivery system will further enhance this. The PHC system will be used to achieve full integration at peripheral level by further integrating CDTI into the activities of the PHC (rraining on Cbfi into training of health workers). This way the PHC system will be used to achieve full integration of CDTI into general health service by obtaining support from Regional,Zonal and Woreda authorities, bilateral and multilateral organizations. In summary, the PHC structure is as follou,s: MOH ) REGIONAL HEALTH BUREAU) ZONAL HEALTH DEPT.) WOREDA HEALTH DEPT./FIEALTH FACILITIES (hospitals, health centers, health stations, trealth posts etc) ) COMMUNITY HEALTH POSTS (CFIAs & TBAs) a) Howfunctional is the Primary Health Care system? Fu I I y fu n c t i o na l, P a r t I y fu n c t i o no I o r n o n -fu n c t i o nal (p I e as e sp e c ify) ? The system from the National level is fully functional until the Woreda/trealth facility level. However, at the community level health coverage is limited. Currently there is a very strong political commitment and strategi. plu, drafted to reach the unreached through health extension package. On top of this CDTI could be used as entry point for PHC in some underserved areas. Does it cover the whole project area? '/ Yes No b) 22 c) d) e) J) If no, in what part(s) of the project area is there afuily functional pHC structure? What percentage of communities where Onchocerciasls ls endemic, and which are eligible for community-based treatment, have an existing and functionat pHC system? About 69 percent of the endemic communities have functional pHC coverage. what organizations are supporting the development of pHC in your project area? Govemment of Ethiopia (Ministry of Health), wHo, UNICEF, and some NGDos Is there any past experience in the country of a programme tntegrating with the PHC? If so, what programme was it and how successful was the intigratiin? EPI, Malaria conhol, IMCI and family planning drug distribution. The integration continues successfully. Are there any plans to integrate other rural health programme, such as the Expanded Programme of Immunization, Maternal and Child Health programmes or progrdmmes for tlte control of other parasitic dtseases, wtth the pHC iystem? EPI, Maternal and Child Health, Malaria and other vector borne diseases control are already integrated with the PHC system particularly at the health care delivery levels. Describe how the CDII will be tntegrated into the pHC system; the way the pHC system will be used to achieve integratton and the key persons in the PHC system that will be needed to achieve the integration. At the Federal level MovDCU will be responsible for routine program management and act as the liaison between MOH, RHB, as well as with NeO partners. Members of the Malaria unit share responsibilities among themsplves and hence a separate entity of vertical progam nature will not be estallished. The head of this unit will act as NOCP coordinator. At regional level, MovDC is organized, as a department and will be responsible for program implementation (contacting community leaders, explaining the program objectives, discuss issues related to Mectizan@ security, at regional ievel, including monitoring and supervision). The head of MovDC will act as a Regional Onchocerciasis Control Coordinator. Similarly at the zonal and woreda levels will establish corresponding Onchocerciasis Control Task Forces (ZOTF and WOTF). The WOTF will be responsible for program implementation at the woreda level (ensure selection of CDDs, supervision of treatment activities, record keeping etc). [n areas where access to the woreda health office is restricted, local health institutions will coordinate, monitor, and supervise CDTI activities s) 23 6. t.2 6. t.3 The primary health care units normally provide both preventive and curative health care services with health education to populations in their catchment areas. These health care programmes are provided as a package not in isolate form and thus the CDTI activities will also be incorporated into the health extension packages in place. h) Indicate hott' early in the CDTI the process of integration wtll be introduced; how it will continue thereafter, and after how ntony, 1,ears within the externally supported lifetime of the CDTI it witl be completed. CDTI activities in Ethiopia will be integrated from the very beginning. The establishment of the program u,ill rely on existing systems of health service delivery at all levels. If tltere is al presettt no PHC system in operotion or irt tlrose areas where tltese structures are non-functiortal, describe how the CDTI ma.t' be used to ittitiate and expantl into such a systert,givirtg a tirue frame for intended progress. NOT APPLICABLE In w'lich wal'$) con conunutity-directet{ iverrtrectirt treotntenl initiate or slrengtlten PHC? CDTI is likely to encourage and facilitate the acceptance of new health initiatives in the community and at home level. AIso, through the ne*,CDTI strategy, the community rvillIikely play a greater role in the support and ownership of the pHCiystem. The structures already put in place would be utilized by the PHC to enhance effective planning andimplementation of the project. For exampie, the CDDs will develop capacities and skills, :'li.h will strengthen other programs such as health education, inireaie IMCI coverage,initiate home-based treatment. 6'2' Cost-recovery S1'stems during Community-based lvermectin Treatment o = Cost recovery-for Primary Health Care is ntanclatory in some countries and it may be one means of sustaintng a CDTI after APOC funrling ceoses. However, please note well that stnce ivermectirt is donated free, there can be no cost recovery in respect of the value ofthe drug itself; cost recovery can only relare b the costs of disiributioi. 6'2' 1 ' Pleose state whether there will be any system of cost recovery ftuch as this recommended in Initiative) to help cover outlays on the disiri'bution of ivermectin in the present CDTI. NO 6'2'2' State exactly how ogt 5v6fu system will be organized, including answers to the questionslisted below. 24 a) What charge will be made per person or perfamily? NOT APPLICABLE Which groups of persons will be exemptedfrom payment? NOT APPLICABLE b) J) s) c) will payments be in cash or in kind? If in kind how will this ensure sustainabtlity? NOT APPLICABLE What provision will be made to ensure that all those eligible to take ivermectin, but who are unable to pay, will also receive treotment? Hotv will it be determined who is unable to pay? NOT APPLICABLE Who wtll collect the payments? How will this person safety transport funds to a place of safekeeping? NOT APPLICABLE Where and by whom will any funds collected be safety kept? NOT APPLICABLE What systems will be put in place to ensure the proper use and management of collected funds? NOT APPLICABLE For what purpose(s), including defrayment of distribution costs, wttt the funds collected be used? NOT APPLICABLE Wat role will Village Health Committees play in the management and allocation of the fund" raised? NOT APPLICABLE Other Issues Please provide information on other issues and constraints relating to sustatnabittty of GDTI you anttcipdte and identify how they will be overcome. For eximple: The mobilization of endemtc communities The maintenance of adequate supervision and monitoring Inadequate human resources Lo gistics and communications S o c t a I / cu I t u r a I fa c t o r s D e clint n g communi ty co mp I ia nce h) i) i) k) 6.3 25 (, Mo b iliza tio n of endentic co mmu n i ties : Experience from the previous CDTI projects (Kaffa-Sheka, Bench-Maji and North Gondar) indicates that bad rumors, misconceptions and misinformation iegarding theprogram disseminated in the endemic communin, can be obstacle to sustainabiliiy ofCDTI. This can be solved through sustained advocacy visits, by assigning individuals with good communication skills and expertise in conducting *u.r -h"ulih education meetings to increase awareness of the community. Conducting stakeholders meetingsperiodically could also help solving such problems. Obviously there will be a need to establish good relationships with the community leaders in order to have increased access to the communities at times like these. Maintenance of adequate supervision and ntottiloring Mectizan@ distribution should include community leaders to further increase acceptability and sustainability of the progranl. All records should be verified during supervisory visits, and informal discussions should be encouraged to determine community perceptions of the Mectizan@,. Inadequate Human Res ources Inadequacy of trained health staff and PHC units are expected to be constraints in 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. Logistics and Communicatiotts ; During the rainy season in October to December travel to the endemic areas may be restricted. Proper planning (Mectizan@ drug orders etc) rvill focus on providing alt-nigh- risk villages with their drugs during the dry season (prior to the Jan-March distribution window), and encouraging completion of distribution before the rains if convenGnt for the communities. So c ia l/CuI tural factors : Careful attention will be paid to cultural and social factors such as the appropriate genderfor CDDs especially in Muslim communities, respecting the traditional beliefs, and selecting supervisors and distributors who speak the lbcal liguages. Declining Community Compliance; Declining community compliance will be avoided through continuous sensitization and mobilization activities prior to each treatment period. -ommunity members could be (i, (iiil (tr) (r) (vil 26 6.4, interviewed to determine the reasons for the non-compliance, and corrective measures taken where possible and appropriate How do you intend to monitor and measure the progress towards sustainability (See Appendix 3 for a list of possible tndicators of sustainability)? Progress towards sustainability can be monitored and measured by evaluating the project in terms of financial management/contribution, communications, training u"a "upu"itybuilding. This will help enhance integration. Financial rnunug"*it should be incorporated into the usual government financial administration. Financial flow in the CDTI project should comply with govemment financial management procedures so that there will be safe resource management. Regional and zonal health department heads, and administration/finance managers at each level will be accountable for proper utilization of CDTI resources. The ability of managers at different levels to fa'niliarize themselves with financial and human resources in the project can also be used to measure and monitor the progress of CDTI towards sustainability. In addition, the ability of community members to about understand the cause and effects of Onchocerciasis, and the mechanisms for its conhol can be considered indicators of progress of CDTI to sustainability. The success of the program will depend on the attitudes and practices of the community towards the disease. C ROSS.BORD ER CONS tD ERATION S Where an endemtc area extends across the borders of two or more adjacent States, special problems of cooperation between the respective countries CDTI may arise. In the event that there are areas to be covered by your proposed CDTI where the endemtc zone extends across the fr"ontier into one or more neighboring countries, and where there are likely to be transttory or even large-scale migrations of Onchocerca- infected persons either way across the border. 7 7.1 7.2 Please describe the particttlar sttuatton as it is ttkely to affect ivermecgn tredtment, and the methods you will use to deal with it. This project does not share common borders with any of the neighboring countries. Include perttnent observations on current political and health relattons with the neighboring State(s). NOT APPLICABLE 27 8. SPECIAL RISK ISSUES In sonte areas of some countries there ntalt be special risks, which could hinder the smooth running of a CDTL 8.1 Please describe the situatiort in any areos covered by your proposed CDTI v'ere this factor nxay interfere with the program, ond assess future prospects. No special risk is anticipated. 28 SECTION 3: ADMINISTRATION/FINANCIAL 9. ADMINISTRATION 9.1. Organizational Structure for CDTI 9.1.1 Please provide on organogram for the CDTI showing the organizational struclure responsible for implementing the proposal. Fig.1. Organizational Structure of National Onchocerciasis Control Program 9.1.2 Membership of Taskforces Regional Level - Regional administrative council - Head, Capacity Building Main Department - Malaria and other vector-borne diseases prevention and control service - Regional Plaruring and Economic Department - Regional Rural Development Office - Regional Finance Office 29 ,i."f l li F' .r71., :4.-' 2. Zonallevel - Zonal Administrative council - Capacity Building Main Deparrment - Zonal Health Desk - Planning and Economic Development Department - Rural Development Office - Finance Office 3. Woreda level - Woreda Administrative council - Capacity Building Department - Woreda Health Service - Planning and Economic Department - Rural Development Office - Finance Office - Religious Leaders - Famous personalities 4. Kebele (community) level - Chief of Kebele administrative council - Kebele capacity building office - Religious leaders - Influentialpersonalities - Representative of women's association - Representative of youth association 9.2 Financial Administration Mechanisms of disbursements and transfer of funds from the World Bank to countries Funds from the World Bank APOC Trust Fund will be transferred to the WHG country office account in Addis Ababa. On request through the proper channels 6y authorized officer of the MOH, WHO/Addis Ababa will transfer the fund directly to the bank account of the respective Regional Health Bureaux (RHBs) according to the approved CDTI project proposals. 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 officer of the regional health bureau. AII the Imperest returns will be submitted monthly by RHB toWHO country office in Addis Ababa that will forward them to APOC headquarters inOugadougou. Monthly reconciliation statements will be forwarded to the centralMalaria and Other Vector-borne Diseases Control Unit (acting as the secretariat ofNOTF) for follow up. 30 APOC will issue cheques (advances) in accordance u,ith WHO rules and thepreviously agreed project documents and./or plans of operations. When the total payment in cash required for the project exceeds $ 100,000, the payment must be made in installments. The first installnrent/advance could cover 3 months or 6 months of activity depending on the duration and magnitude of the project. Management of funds by projects and \\/Ho/Apoc mechanism for monitoring The size of the project will determine u'hich of WHO's contractual systems is used, e'9. Technical Service Agreement, Letter of Agreement, Contractual Service Agreement or Agreement for the Performance of u'ork. A document on administrative and financial procedure rvill be made available toproject being funded by APOC. Built into this document is an impress mechanism, whereby the project will report its expenditure on a quarterly basis and receive further advances on that basis. Each project funded by APOC will require a periodic external audit at project expense. Each project must have one senior staff member who is accountable for the management and control of project funds. Standard internal financial checks and balances must be incorporated into each project's financial management plan. 3l Fig. 2 Request and Disbursement of APOC Funds Disbursement -------+ Financial Report rH 7 32 9.2.1 Input from the Ministrl, of Health a) Indicate resolu'ces that will be provided b1'the Irtinistry of health and other government agencies. The Federal MOH willprovide: - Personnel - Logistics and transport, - Office space - Running costs for vehicles and office utilities - Pay taxes for capital equipment - Clearing of Mectizan, storage and transportation - Training and supervision The Regional Health Bureau/Zone Health Office u.illprovide: - Personnel - Logistics and transport, - Office space - Running costs for vehicles and office utilities - Pay taxes for capital equipment - Clearing of Mectizan, storage and transponation - Training and supervision The Weredas Health Office r.vill provide: - Personnel - Logistics and transport, - Office space - Running costs for vehicles and office utilities - Pay taxes for capital equipment - Clearingof Mectizan, storage and transportation - Training and supervision b) Please provide a list of personnel assignecl bS, the MOH to this project, including tbiir name and proposed time (State percentage of tinte allocated to the project) for theproject and where appropriate their experience in Onchocerciasis control through ivermectin treatment. At present, there are experienced personnel at national levels and in SNNPRs since they have started CDTI earlier years. However, none of the personnel in Oromia Regional Health Bureau and in Illubabor zone have had experience since CDTI is new to them. 33 Name Post Region %"Time Mr. Dereje Olana Dept. Head of MOVDCU Oromia t0% Mr. Sheleme Chibsa Vector Control Team leader Oromia t0% Mr Tadesse Hundie Vector Conkol Expert Oromia t0% Mr. Addisu Mekasha Vector Conhol Expert Oromia t0% Dr. Kebede Itana Diagnostics and Epidemiology Team Leader Oromia t0% Resional Health Bureau: Illubabor Zonal Health Office Post Woreda Health Office: Belene Fetene 9.2.2 Input from the partner NGDO(s) a) Plense provide- a letter fi'om the Executive Director or the Director of onchocerciasisprogrammes of each participating NGDO stating their intentions to participire in ard supportthe National Onchocerciasis Conirol programmi. b) Give inftrmatton of the inputfrom each NGD7 participating in thts project. The Carter Center,s input will be:_ r Name 7-one YoTime Mr. Haile Ayana Head, Zonal Health Office Illubabor 2s% Mr. Tibebu Amentie Expert in Mal ai.a & other Vector Borne Disease Prevention and Conhol ( 20% Mr. Kedir Ahmed Disease prevention and Control Expert 20% Name Post Woreda %o TimeI4r. Mekonen Memr 25o/o Flailu 30o/oFlead,Districtffi Darimu 25o/o lvlamo Disease Prevention E*p.n 3j%o Kumsa Flead, District Flealth Office Alge Sache 25o/o lvhlaria & Orher E*p.. 30o/o Yai,u Hurumu 25o/o Disease Prevention 3@/o Ivfr. AIe Dido 25Yo E{ VCB 3Wo Bedelle D;E- 25o/" IvIr. and Ery.rt 30o/o 34 Flead,DistrictFteaffi a Funds: Per the agreement made behveen APoc and the FMOH, The carler Center will not have direct responsibilitl, or roles relating to the management and reporting on APOC funds. Mectizan@: The Carter Center ri,ill not have direct responsibilify or roles relating to the accountability of ivermectin in Ethiopia. The drug will be consigned directly to the wHo and sent to MoH central stores in Addis. a Staff and consultants: The Carter Center has been involved in some areas of public health in Ethiopia since 1992. In 1993, The Carter Center began assisting the Ethiopia Guinea worm Eradication Program through the FMoH. The cartei Center has provided excellent technical, logistical and financial support in the implementation of the first CDTI project in Kaffa-Shaka, Bench-Maji and North-Gondar projects. In light of this experience, The Carter Center is ready to continue prol'iding technical, financial, and logistical support to the Onchocerciasis conhol prograni in this project. o Office space and facilities: The Cafier Center will support the national secretariat by providing technical and logistical support through a local office in Addis Ababa. c) Please provide also a noninal list gt'ocling and post description for the personttel to be provided by partner NGDO(s). htdicate clearll'v'hat will be theirfuictions in tlte progt'ant and their experience in ortchocerciosis control tltrough ivermectin distributiott. Most of the staff of the Carter center have been involved in the implementation of the KSZ,BMZ, and North Gondar CDTI project in the pasr rhree years. It is understood that most of them have got some experience. Name Post oh Time Mr. Teshome Gebre Country Representative t5% Mr. Frew Demeke Logistician ts% Mr. Murida Kemal Admin/Finance Manager t5% Dr. Assefa Worku Program Officer/ GRBP ts% Mr. Asfaw Benti Driver ts% Ms. Seble Aliye Accountant t5% 9.2.3 Inputs from other agencies. Please list any other agencies or parties that v,ill be involved in the running or financing of the CDTI, and indicate clearly their roles, functions and contributions. WHO: WHO Ethiopia will assist the project rn the procurement and clearance of Mectizan@ imported into the country by using its diplomatic status. a 35 9.3 Timed PIan of Action Provide a ttme chart(s) showing how the various activities of the CDTI will proceed over the course of the proposed program. Numerical annual targets for all planned ,itfrno should beprovidedfor each time point. The time charts should also indicate how external support will be phased out over the 5 year r 36 r-c- 6t \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \o (\t \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ rao 6l \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \f, =j I \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ a?) (\I \ \ \ \ \ \ >" o o (B .9 (! .N6r> '6 ar o=U'H *OENdE, -rdo_3s Eoo<g g< o o giO oc) o'= Pv) cOo* () Pt< E(g() C!) oFr 0) Cto -<P cn 0) ! (! oo 'a li a. 6 o ./)(n o qr o C) E 0)L (-) oti O. d oN o (0 U) t<o dk (H o oo '= s)i:>(-() (! () lr o O (n a ti() c0tr (H oo '=o :v>Eqr q C) oI) Far) OJ o o tr o - @ o tr @ @o o bo 0) o.t! o.(! & o tJ Uqi o 63 o oo 0) V) (h 0) a pr J O t oU o (! N -oo z q q q) U P q bo$\ *O ou -s\oa)bR {q) -o li V) o @ (! N o 0) z b0 fr o o ({< () o oo loo t'o o o o Eop. O € oo Lo o a C') JZo C) o cn 0) o(d tro p t< U) .g a a() q< o o o C) o. U) q f oAq) i() o o (€ o- o C) oo o(,) (nlr() rc o C)J(B t) o oO] an 0) o o) d 0) L<F(f o C) o& oo (.) C) Bo () r< (! t< oo o! a. (g o O(o (H o tdt3a dt* ri z F z o Fr Fz E] z frl rl FTa 10. BUDGET 10.1 Budget Estimates Budget must indicate totol ftutds to undet"take lhe project. The amount of funding requestedft-ont APOC, and the amount provided by the MOII, NGDO(s) and other partners. All must be ntade in US dollars. Each budget must include at least the following rnajor categories (see appendix 2) indicating the contribution of the partners to reflect sustainabilig. of CDTI. o Personnel (services) . Capital equipment . Supplies Training o Healtheducation/mobilization o Travel o Communication o Consultant . Operating expense o External audit 38 YEAR ONE SUMMARY BUDGET FOR ONCHOCERCIASIS CONTROL IN ILLUBABOR CDTI PROJECT YEAR 2OO3 f \ 2003 CATEGORY APOC MOH NGO TOTAL Personnel 0 33,795.00 10,800.00 44,595.00 Capital equipment 90,070.00 16,608.10 9,240.00 115,918.10 Supplies 55,321.00 0 12,200.00 67,521.00 Training 35,439.00 0 10,750.00 46,1 89.00 Health Education/mobilization 20,970.00 0 16,000.00 36,970.00 Travel 14,750.00 0 6,200.00 20,950.00 Communication 3,120.00 480.00 3,600.00 Consultants 0 0 External Audit 0 0 0 Recapitulation 19,021.00 0 0 19,021.00 Operating expense 4,200.00 935.00 2,300.00 7,435.00 Total 239,771.00 54,458.10 67,970.00 362,199.10' NGO overhead cost 17,982.83 t7982.825 Grand Total 257,753.83 54,458.10 67,970.00 380,181.93 Estimated No. Treatments 513,418 5 13,418 513,418 513,418 94 input 67.8 t4.3 17.9 r00.0 Cost per treatment 0.50 0.1 r 0.13 0.74 7.5% NGO overhead cost 39 Foq o c.c tro(, do @ @ J f z J ocFz o(, q o s o G,U(, oIozo c. oE FU(, of @ oE U U>lEI ii g[l1q3J3ltt1 qq111ffi 11 q tilfTT Iil{1 1tIIffiffi _i1q iqTTT flflqflqffit 1flqH -Sl EI-lll _tflitqflT _lljl{'1-17 l$L1rT- _Lffi{Iti _ulql'iT _t{lTtlr oo E c o !! I flqqI]ift I I 8l,/ sooz t o = NooN (oooN toLO.!oo o oa o. o o o -oG -a =o e, G o to o otr ts(u o- E o(! uJ o tr o = .o L c oo o o c,,G c o(, L o o- .'jg tt Eo C.,l (r)oo(\I oo o ooddJ oo c;(o oo c; F.- oq o@ oo CJ$l oo ci$ oo cilf) ndul luecrod \ 10.2. BudgetJustification Please provide a narrative descrilttiott of the reosons for each proposed line items of the budget. (1) Personnel The personnel budget reflects the need for staff at all Ievels (MoH, RHB, zHD, wHo, and NGOs) to support distribution activities at the community level (CDD;). The MOH and NGo staff willprovide support to the program in the form ofl . Mobilization of authorities and community leaders o Health education and community sensitization on the need for the drugo Assisting in the organization of the distribution program o Training of supervisors and CDDs o Getting ivermectin to the pickup points o Transportation of other essential supplies . Ensuring proper supervision of drug distribution o Ensure proper record keeping and accountability o Accounting for funds spent (both ApOC and other) o Participating in program evaluation and feedback to local communities MoH and NGo staff is already in place and will participate in program implementation on either a part-time or full-time basis. However, the degree of higher-level involvement in CDTI activities will decrease from year to year as the communities take more and more responsibilify and ownership of the program- Eventually the woredas will take on the major local function of the program by the *a of five years and with the shengthening of the PHC system, CDDs u,ill become PHC staff and take on additional duties besides Onchocerciasis control. (2) Capital equipment In order for the program to properly function, it must be well equipped. The equipnient requested is meant to facilitate the work of the MOH (Regional, Zonal, and Worlda; anaNGO staff. Federal MoH will be responsible for payrng the duty per the regulation imposed by the Government of Federal Democratic iepuUtic of etniopia. Th; list of capital equipment expected from ApOC includes: o Vehicles and motorcycles o communication equipment (fax machines, radio telephones, megaphones)o Computers, printer, photocopier o Training equipment (overhead projector) 42 (3) Supplies Office supplies are essential for the smooth running of daily program operations. Since this is the beginning of the program, APOC will be requested to provide all essential office supplies (computer toner cartridges, diskettes, calculators, paper, pencils, pens, fasteners, file folders etc). Also included in this category are side-bags for CDDs to carry necessary items, village registers one for each village (with hardcover for the entire project period (12 years), drugs for treating adverse effects of Mectizan. The partner NGDO will cover costs for printing of reporting formats to be used at all levels. (4) Training: Training demands relatively higher investment due to items such as transportation, per diems for trainees and trainers, production of training materials etc. It is also an activity that is carried out on a continuous basis, with re-training at all levels as new personneljoin the program, and as CDDs need to be refreshed prior to the distribution period. Being essential to the implementation and success of the program, the following is proposed: At the community level, CDD training is expected to be continuous throughout the duration of the program, with the community assuming more responsibility over time. The training activities will be supported by APOC. APOC, MOH and the NGDO will also support workshops for regional, zonal; woreda staff, as well as CDDs. The NGDO will provide funds for management review workshops at zonal levels. APOC is expected to provide support for the printing of training materials and sponsoring some training workshops. (5) Health EducationilVlobilization: Community mobilization and advocacy activities are required to build the support needed to ensure program sustainability. = o Communities will be mobilized through advocacy campaigns (to gain the support of community opinion leaders), information packets (to educate the media and other parties) visits to the community by MOH personnel from the National, Regional, Zonal, and Woreda levels. General public awareness can also be supported by such techniques as the distribution of posters, brochures, stickers, and T-shirts etc. MOH and the NGDO will provide technical support for these activities. APOC is requested to provide funds for Regional and Zonal training orientations, information packets, health education aids such as posters, brochures, stickers, T-shirts and flipcharts. As the awareness for the need for onchocerciasis activity increase at the national, regional, zonal, woreda, and community levels, the amount of funds required will subsequently decrease. r 43 (6) Travel: Travel is required for advocacy visits, training, retraining, supervision and monitoring, and evaluation activities are all important for effective program implementation. APOC and the NGDO will be responsible for supporting travel expenses necessary for the implementation of the program. APOC is also requested to provide funding for fuel and maintenance for vehicles and motorcycles, and domestic airfare. (7) Communication: At the National, Regional, Zonal, and Woreda levels, telephone, courier and other media means of communication (such as radio and e-mail) will be used among project operators. At the community level, communication will be mainly through the use of radios and megaphones. MoH and the NGDO are expected io rrppo.t expenses associated with communications including courier services. (8) Consultants: Consultants would be required to conduct KAP studies (to help in the development and refinement of health education and other materials); program evaluations, computer maintenance and other aspects of computer work, to ensure total quality management of the program. APOC and the NGDO are expected to support the cosls of'these consultants whenever requests are made separately as appropriate. (9) External Audit: External audit will ensure proper accountability. Since APOC will support the costs of external auditing specific budget is not indicated in the budget details. (10) Operating Expenses: This will include costs such as utilities, costs for vehicle maintenance, developmen't and maintenance of MIS. Also included in this line item is the cost for fueling of project vehicles. These expenses will be supported by APOC. The NGDO and MOH will share some costs such as office utilities. 10.3. Current Resources Available for CDTI Existing CDTI projects (for continuation or expansion) wilt have resources already available. Please provide a detailed tist of att existing personnel, equipment and supplies(including vehicles, etc.) belongtng to the program, indicating thbii ownershtp (MOH, NGDO, other Agency, etc.) and their level offunctionality. NOT APPLICABLE 44 AREA COVERED: Illubabor CDTI project COMMUNITY ENDEMIC LEVEL HYPER- ENDEMIC MESO. ENDEMIC HYPO- ENDEMIC* TYPE OF TREATMENT Community- Directed Community- Directed YEAR I - (2003) No. of communities to be treated 2,233 334 Total population in above communities 558,343 83,430 YEAR 2** - (2004) No. of communities to be treated 2,233 334 Total population in above communities 574,534 85,850 YEAR 3** - (2005) No. of communities to be treated 2,233 334 Total population in above communities 59 1,1 96 88 340 YEAR 4** - (2006) No . of communities to be treated 2,233 334 Total population in above communities 608,341 90,901 YEAR 5** - (2007) No. of communities to be treated 2,233 334 Total population in above communities 625,983 93,539 APPENDIX 1: ESTIMATED NUMBERS OF COMMUNITIES AN'D PERSONS TO BE TREATED EACH YEAR, BY ENDEMICITY LEVEL (PHASE ONE) *Onchocerciasis is not considered an important Public Health problern in hypo-endernic communities and APOC will not normally fund community-based treatrnent in such communities The inclusion of such communities in the proposal will require a special justification for consideration by the TCC. **It is understood that the figures for years 2-5 are estimates that may change depending upon the results of the REMO surveys conducted. 45 Ivermectin Treatments reflected in Appcndix I rvere obtained as follows: A total of 641,773 persons in the six woredas are targeted for CDTI for the first yeartreatment. Out of this population, 558,343\ive in hyper endemic villages and g3,430 livein meso-endemic villages. The number of villages is estimated from the total population with the assumption that 250 residents live in u uilag" (based on the CDTI principle of 50households per CDD). YEAR 1: AII hyper and meso-endemic communities (2,567) in the selected six woredas will be targeted for the fust cycle mass treatment. YEAR 2-5: A population growth of 2.9o/o has been considered during the following treatment cycles. However, this figure may change depending upon the outcome of the REMO refinement planned to be carriea out tateitoward the end of2003. Fig 4. Annual Treatment Objective by Endemicity Level 2003 2004 2005 Year 2006 2007 oF 600,000 500,060 400,000 300,000 200,000 100,000 -r Hyperenoem tc Meso-en0emtc 46 APPENDIX 2: INDICATORS FOR EVALUATION, SUSTHNABILITY AND INTEGRATTON OF CDTI Project Evaluation Management Financial Management Effectiveness of Communications Training and Capacity Building Institutional Commitnent Fulfillment of other relevant factors Problem solving capacity Integration of operational research Project Effectiveness Result of the KAp studies Treatment Coverage Follow up of non-eligible and absentees Management of adverse reactions Reliability of reporting S ustainabilityllntegration Political will of Host government Political will as shown in policy statements and apparent commitment of high-level officials official actions including assigring personnel, funds, vehicles to program Long-term planning Is there a long-term plan for sustaining the financing and the management of the program? Progress toward linancial sustainability If program sponsors cannot continue their current level of commitment for at least another five year, what percentage of running costs is now paid for host governments or fees? Progress toward integration To what extent has ivermectin distribution been integrated with other health service programs? 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Project proposal for Community Directed Treatment with Ivermectin Illubabor Project, Illubabor zone, Oremia regional State, project period 2003- 2007
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