t 'ilt l } {l' ffiffiffiffi WM{H \ For Actu 'Io r -fcc 1t + Gambella National Regional State , !q5r'.,-tg' "{.r- l) l. ( [',.(rt" *'r,r, 1r'rrn For irrfoimoiion Project Period: Year 2003-ZOO7 To, -r. lH , +{ ;J ETHIOPIA LB/ bilEA U I I .-*r a) ii SUBMITTED TO AFRICAN PROGRAM FOR ONCHOCERCTASIS CONTROL(APOc) Revised July 2003 ('*"* -""" r -;illll ; ,,', !, r-tl- I liJii. , 1TABLE OF CONTENTS LIST OF ACRONYMS SECTION I: BACKGROUND INFORMATION INFORMATION ON THE PROJECT AREA FOR CDTI 1.1. Geographical and administrative areas.... 1.2 Topography, Climate, Access....... 1.3 OnchocerciasisEndemicityLevels 1.4 Community Structure 2, PAST AND CURRENT STATUS OF CDTI IN PROJECT AREA SECTION 2: PROJECT EXECUTION OUTLINE 3 DESCRIPTION OF PROPOSED CDTI3.1. Outline Plan and Timing 3.2. Health Education and Community Interaction and Participation 3.3. Local Operational Research. 4. SUPPLY, IMPORTATION, STORAGE, INVENTORY AND DELIVERY OF MECTIZAN TABLETS .. SUPERVISION, MONITORING AND EVALUATION5.1. SupervisionduringEvaluation 5.2. Monitoring CDTI.......,. 5,3. Evaluation of CDTI 6. SUSTAINABILITY OF THE CDTI AFTER THE WITHDRAWAL OF EXTERNAL FUNDING 6.1. Integration of CDTI into other Community Based PHC Systems6.2. Cost Recovery System during CDTI.........6.3. OtherIssues........ CROSS BORDER CONSIDERATIONS SPECIAL RISK ISSUES SECTION 3: ADMINISTRATION/FINANCIAL ......... 9. ADMINISTRATION 9.1. Organizational Structure for CDTI 9.2. Financial Administration............... 9.3. TimedPlanofAction..................... 1 1 2 J 4 6 11 u1 t1 12 12 t6 t7 5 18 l8 19 21 7. 8. 21 22 25 26 28 28 29 29 29 30 35 v 10. BUDGET i0.1. Budget Estimate.... 10.2. Budget Justification...,............ 10.3. Current Resources available in CDTI APPENDIX 1: APPENDIX 2: APPENDIX 3: LIST OF MAPS: )/ 37 4I 43 Estimated Nuntbers of communities and Persons to be Treated each Year by Endemicity level... Indicators for Evaluation, Sustainability and Integratton of CDTI Budget Details ... Request and Disbursement of APOC Funds ... Percentage of Contribution of Each Partner for 5 years for Gambella CDTI Prolect ... Annual Treatment Objective (by Endemicity Level). 44 46 47 32 40 45 MAP 1: Sketch map of Gambella regional stote, Ethiopia MAP 2: sketch map of GDTI areas in Gambella regional state, Ethiopia .....,.... g MAP 3: Road network & rivers in Gantbella regional state, Ethiopia MAP 4: Current CDTI areas in Ethiopia (A?OC 2003) LIST OF FIGURES: FIGURE I: Organizational Stntcrure of National Onchocercictsis Control Program 29 7 9 5 FIGURE 2: FIGURE 3: FIGURE 4: Y lt 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 Obj ective Community Drug Distributors Community Directed Treatment with Ivermectin Eligible At Risk Population Expanded Program of Immunization Federal Democratic Republic of Ethiopia Geographic lnformation System Information Education Communication I(nowledge, Attitude, and Practice Management [nformation System Ministry of Health Malaria & Other Vector-borne Diseases Control Department Malaria & Other Vector-borne Diseases Control Unit Non Governmental Organ ization 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 Committee The Mectizan Expert Committee Training of Trainers Woreda Onchocerciasis Task Force Zone Administrative Council ZoneHealth Office Zone Onchocerciasis Task Force T rtr aSECTION 1: BACKGROUND INFORMATION I. INFORMATION ON THE PROJECT AREA FOR CDTI l.i Geographical and administrative area(s) Gambella National Regional State is one of the Nine Regional States of the Federal Democratic Republic of Ethiopia, and it is located in the western part of the country between 70 ).3" N to 80 17" N latitude and 330 52" to 350 02" E longitude. The Region shares borders with the Sudan in the West, Oromia Regional State in the East, SNNPR (Southern Nation Nationalities Peoples Regionat State) in the South and Beneshangul- Gumuz Regional State in the North. Gambella Region has a total surface area of 25, 274.88 square kilometers. Gambella has got 10.35% swampy areas and water bodies, 0.98% settlement areas and 37.22% is unused arable land. According to the population and housing census conducted in 1994, the projected total population of the region is 228,593, of which 82.4% are rural and 17.6oh are urban dwellers. The population is largely engaged in subsistence farming, animal husbandry, fishing and coffee and cotton plantations. Gambella Region is divided into trvo administrative zones and nine Woredas (districts). Gambella CDTI project comprises of nine Woredas and about 914 villages. Out of these, four Woredas are targeted for the first year CDTL These are Gambella, Godere, Dimma and Abobo (Dimma has been part of the previous Godere Woreda, which is now split into two). The remaining five Woredas will be included in the second/third years depending upon the result of REMO refinement. The total population of the four CDTI Woredas is estimated to be 100,821. The Annual Treatment Objective (ATO) for the first year CDTI is 80,656. Table l. - Estimated Populatron, Estinrated vrilages, ATO and REMO Status by Woreda, Garnbella Pro.;ect area, 2003 tWoreda Estimated Villages Estimated Population Annual Treatment Objective (ATO) REMO Stanrs Gambella 133 ) ),zJ J 26,s86 Year I CDTI area Godere t62 40,514 32,411 Year I CDTI area Dimma 38 9,5 l0 7,608 Year I CDTI area Abobo 70 17,564 14,051 Year I CDTI area Sub-Total 403 100,821 80,656 Itang 94 23,591 18,873 To be refined Gog 38 9,5 10 7,608 To be refined Jor 36 8,916 7,133 To be refined Jikawo 2t6 5 3,955 43,164 To be refined Akobo 127 31,800 25,440 To be refined TOTAL 914 228,593 182,874 t 1.2 Topography, climate, access. 1.2.1. Please describe the type of country or bio-climatic zones that will be covered by' the CDTI (e.g., rain forest, forest-sctvctnna ntosaic, Guinea sayanna, Sudan savanna, mountainous orJlat), providing maps, if appropriate. Gambella Region is an ecologically forest-savanna lowland area with altitudes ranges from 300-500 meters above sea level, with the exception of Godere Woreda, a highland fringe area with up to 2300 meters in altitude. The region has largely hot, humid and moist type of climate. The mean annual temperature ranges from 17.3 0C in the highlands to 280C in the lowlands (300- 1500 meters altitude). The mean annual rainfall totals vary from 900-1500 millimeters in the lowlands to 1900-2100 millimeters inthe highlands, 1200 mrn on average. The rainy season extends from May to October, July-August being the heaviest rainfall months. Majority of the population lives along the banks of rivers. These rivers are Baro, Gillo, Akobo and Aluero rivers. There are also a number of small rivers and streams. 1.2.2. Give the approxintate tintes of the roiny sv16l dry seasons and the months covered by the farming season. The rainy season extends from May to October with the heaviest rainfall taking place during July-August. The period from November to April is relatively dry, Agri-cultural activities (farming, rearing animals, fishing) occur all year round in the project area. Harvesting occurs from October to December, leaving January - March as the ideal period for mass treatment. 1.2.3. Provide inforntation on the state of the roads, and the effect of this on the moveruents of CDTI personnel in the areu ot difkrent times of the year. (A map may be useful) The status of infrastructure development in the region is very poor, apparently limited to the regional capital and the surrounding towns. There are about 585 km all weather roads and about 197 l<m dryweather roads. There is one airport in the Gambella town in the region. Water transport over Baro River is available from Gambella town to Sudan border. Access to rural communication is difficult particularly during rainfall seasons. Therefore, it appears appropriate to distribute Mectizan during the dry seasons (December- March). Access to health care service is close to about 45.5% in the region, the effective coverage is estimated to be much lower than the above figure due to poor road infrastructnres, scattered population settlement patterns, low awareness level of 2 athe community, and affordability etc. In the region, there is one hospital, 8 Health Centers, 49 health stations/health posts and l6 rural drug vendors. Essential communication services such as telephone, postal and electric power are mainly available in Gambella town. 1.3. Onchocerciasis Endemicity Levels The levels of Onchocerctasis endemicitT, in corrununities in the CDTI areas must be assessed by simple methods before treatntent starts. For the purpose of this proposal, the level of endemicity in a community or a group of similar communities is defined on the basis of the prevalence of nodule carriers (See table l). TABLE 2: Classification criteria for endemicity levels in rural communities Less than 40% 1.3.1. Based on the system in Table I antl using the format in Appendix l, please indicate the estimatecl numbers of communities at each endemic level ancl the numbers of persons in them. A total of 403 villages (communities) in the four woredas are targeted for CDTI for the first year treatment. Out of these 242 are hyper-endemic villages and 161 are meso-endemic villages. The number of villages is estimated from the total population with the assumption that 250 residents live in a village (based on the CDTI principle of 50 households per two CDDs) . See appendix l. 1.3.2. Complete Appendix I for each area covering the next 5 years of the project. 1.3.3 If methods of assessing endemicity thresholds other than nodule prevalence were used when your endemicity data were collected, please indicate the methocl used The levels of endemicity in communities of this region were defined on the basis of nodule prevalence rate obtained by REMO Survey conducted in 1998 and 200t. ! J Endemicity Level and Recommended Type of Treatment Percent of nodule carriers in REA sample (minimum sample 50 adult men) Estimated prevalence of O. Volvulus in the whole community Hyper-Endemic Community Treatment (Urgent) Greater than 39ok Greater tharl 59o/o Meso-Endemic Community Treatment (Desirable) 20 - 39% 40 - 59% Hypo-Endemic (Non-Urgent) Less than 20% 1.3.4 For areas still to be covered, where endemicity levels are not yet known, please clescribe the method you wtll use to collect the necessary endemicity data. REMO refinement will be further carried out for the remaining 5 Woredas in order to be able expand the CDTI project to other affected areas in the region. 1.4, Community Structure. Provide background information on the social organizations of communities in the CDTI areas. This may include information on settlement pattern of the communtty (e. g. hamlets, s eas onal farms teads, dispers ed population, etc, ) The communities in CDTI areas are settled subsistence farmers engaged in farming, animal husbandry, and hshing. There is dispersed population settlement pattern in almost all districts in the region except in resettlement areas. The ethnic groups in the community a a o A majority of community members belong to Nuers, Anuaks, and Mezengers while other minor ethnic groups such as Oromo, Amhara, Tigrie, etc also live in it. Please provicle informcttiort about the areu covered by CDTI indicating whether they are migrants, nomads, refugees or internally displaced populations. The community included in the proposed CDTI project area are settled farmer. Some are displaced settlers from other parts of the country. The settlers came to the area more than two decades ago. Community leaders hip structureo The community leadership structure in the region is organized by the Regional and zonal administrative council (RAC & ZAC), which consists of elected members from each woreda. The RAC and ZAC are responsible for giving guidance and leadership to the community for all socio-economic activities. Each Woreda is divided into large administrative communities called I(ebeles (4000-5000 people per Kebele on average). Kebeles are further divided into smaller clusters of households called menders (villages). Since the exact number of menders is unknown, the number of CDDs will be determined based on the size of the population. lnformal social organizations in the communities include: edir, equb, etc. whereby the community members share and discuss their problem. The diagram below shows the community leadership structure Regional Administrative Council ) Zonal Admin Council ) Woreda Admin Council ) Kebele Admin ) Village Elders/Religious or Opinion Leaders ) Households ! 4 aI o Main occupation of communitv and periods of ruajor comrnunal ctctivities. The main occupation of the community is farming, animal husbandry, and fishing including Coffee and cotton plantations. Farming activities, however, decrease from December to February after the completion of crops harvesting. . Preferred channels of comntunicatiort in the community. The preferred channel of communication in the community is passing messages through the community leadership structure and from the local farmers or urban dwellers association chairpersons to the village chief and to the head of households. Besides, there are trained community health workers and traditional birth attendants that bridge the community with the health care services. Existing active community association/groups in the area (e.g. social, religious, etc.) The existing and active community associations/groups include the fanners, Youth's Women's Associations in the rural and the urban dwellers associations. In addition traditional leaders, elders, religious leaders also have dominant roles to play in community mobilization. o o a Established distribution systems in the commrmity. There are some existing distribution systems, EPI activities such as polio campaigns, vitamin A, family planning and malaria control, which are organized through the social and religious associations mentioned above. It is also through these organizations that community mobilization and health education will begin for CDTI. The cornmunity could also recruit their distributors through these systems. Social communal activities and ntonths during 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 (Meskel) in September, Gena (christmas), Tintket (Epiphany), in January, Easter in April. Any previous experience of the contmunig, tvith development/health projects. Most communities in the zone have been involved in EPI, Polio eradication campaigns, family planning, well construction, and spring protection activities. There are also community health posts managed by community health agents and traditional birth attendants in some communities. The communities therefore have well- established systems of mobilization to enhance participation in communal events. a T a 5 Description of other anthropological characteristics of the comrnunities The people of Gambella are predominantly Christians and largely comprise Nuer and Agnuak ethnic grollps. Traditional (ethnic) and religious leaders possess strong influence in decision-making and health-related issues. The women take responsibilities of household tasks like childcare, fetching water, washing clothes at the rivers and collection of firewood from the forest. 2. PAST AND CURRENT STATUS OF CDTI IN PROJECT AREA. 2.1 Please indicate if the CDTI is an expansion of an existing CDTI. There are no previous CDTI projects in the region and thus there is no previous experience on CDTI programs. 2.2 State the number of t'ears the prograntme has been operating, ancl if possible enclose previous statistical, financial und annuol reports. Not applicable. 2.3 State the number of persons treated each yearfor the last 5 years Not applicable. 2.4 List the organization(s) involved in the progratnnte, the sources and amount offuncls usecl each yearfor the last 5 years. Not applicable. a 6 t-- Flil rdF F{a : 2 Id4 .l T x tsiIz lL !r E a- FI Qt- H va I x a coC) ,n o o U)(o o a C)li(c F U tl -*3 rd triF Er U) J z l- rl Hil HJ ri HFd4 rl\, zx a Fiil -F -tU ?ltstAv A - :a lrHUF td va I atN IH l-e o --t IJ n[ld l oE ( I ti o &FI tsH3 rc r.iF F U) l] z rh rd - rJ FI t* -:z f f,\ ztl at4 -tr-'l -t lrltlx tiz v&A\J ,-F -z Alii4 Ai\J & I aaff) A -t i!(a t_ t U) O t-r cd () O() C)a U) Cg O d F nU z C) '\4 F U a C) F U a N U ,-\vAFrl a l-(A -(^\\,lr(l+lt*r Fr E] z -la -N - -FrAtiU Fr z l+.!Ht&)(.) a!f, A - t-e F .E !i E: J a3.1 Outline Plan and Timing for the Period 2003-2004 3.2 Health education and Community Interaction and Participation 3.2.1 How will you approach ond interact with the community? There already exist systems of communication with the proposed project area through other health programs as described earlier. However, the following strategy will be implemented to maintain good relations with the communities: ! Activity/Justifi cation Length of Time Advocacy ancl sensitization at the regional, zonal ond woreda levels - emphasis will be placed on introducing the APOC/CDTI strategy, and enlisting the support of the regional level with the participation of the NOTFAIOCP, regional administrative council offices 5 weeks Agreemenl on the definition of roles and responsibilities of all partners - through MoH wrth region based on APOC Guidelines, etc 4 weeks Procurement of es'sential project equipment ancl supplies Computers, Mectizan drugs, and vehicles, and others. 16 weeks Training/ ofproject trainers' at regional zonal and levels; Training to those who will function as trainers and supervisors. 4 weeks Rapid Epidemiological Assessmenls/REA will be carried oltt to expand CDTI activities tct other woredas based on the class'ification of the endemicity levels 4 weeks Mobilization of regtonal, zonal and district authorities to support the project 4 weeks Conduct KAP Studies Pre-tntervention KAP surveys and other studies will be conducted to have a baseline data to develop appropriate IEC actrvities and monrtor behavioral changes and also assess re-infection rate. l2 weeks Mobilization of endemic cotnmunities, stressing community ownershrp of the project as well as the key health education messages 4 weeks Selection and training of Communi4, Directecl Distributors (CDDs) Selection of CDDs is the responsibility of the conununrty 3 weeks Household registratrcn and census enumeration trained CDDs will carry out village census 2 weeks Mectizan @ Collection and Distributton in endemic communitres 8 weeks Loa Loa assessment will also be done before launching CDTI using RAP Loa. 2 weeks Monitoring and s'upervision of Mectizan@ distributron activities by zonal and woreda supervisors 4 weeks Inspection of CDD dis'tribution activities (spot checks) b1, regional supervis,ors and NOTF repres entatives' 1 week Conduct Community Self Morutoring 4 weeks MIS (Management Information System) Reporting of treatments and the other CDTI activities will be done periodically Monthly NOTF will conduct internal evaluation of the project 4 weeks Revtety of Treotmenl Acttwties Annual reviews will be conducted and reports generated and used to ensure continuous lmprovement in designing the following years action plan. I week Preparation oJ'Action Plan for the next year 2 weeks 12 SECTION 2: PROJECT EXECUTION OUTLINE 3. DESCRIPTION OF PROPOSED CDTI The m(ttn strategy of the prolect will be to develop ancl estublislt CDTI systents, v'hrch can be sttstained bt, the endemrc communtties themselves without external support after the 5-year pt.olecl pertocl Thts sectton should descrtbe how the NOTF plans to develop and unplement CDTI ut all hrgh-ris\, ,o,,rurr,,rures m the proJect area. The plan should take into account the need to develop approaches to CDTI, y,htclt ore lpproprrute, for the dilferent locol situatrcns, ond the need to carefiilly evaluate the mtplententatrcn of the selecled approaches and adjust them when recluit.ecl The Ethiopian program for Onchocerciasis Control (EPOC) intends to implement CDTI in the context of the country's health sector development plan (HSDP). In view of the culrent decentralization scheme, the Gambella region health bureau rvill be directly responsible for overseeing the project management next to the NOTF. In particular experts from the department of malaria and other vector borne diseases control within the regional health bureau will be closely monitoring the implementation process. All hyper and meso endemic areas will be covered with CDTI. Gambella is sharing common borders with Sheka zone, which has been implementing CDTI over the past three years, and similar approaches will be used, as there is no much difference in the infrastructure and socio-cultural pattern of the two neighboring populations. The proposed project staff will have the opportunity to learn from the Kaffa-Sheka CDTI project by means of field visits as well as by means of participating in prograln review meetings. Other innovative program evaluation mechanisms such as commLrnity self- monitoring, spot-checks, program reviews and appraisals will be conducted as appropriate. There is a hospital and a nursing school in this project area, which could be a source of additional human resource that can be mobilized to assist in training and supervision of CDDs during the mass distribution program. At this moment, this CDTI project has no NGDO partner that will give support. However, the search for NGDO partner that will involve itself in this project is an ongoing process. There is a potential of involving local partners especially those which are actively involving in areas of refugee camps in the project area. a J 11 Ia) Discttssions with regional, zonal council chairperson and head of social affairs and with woreda chairpersons, local community representatives and authorities, religious and traditional or ethic leaders to better understand community values, customs and beliefs. Mass meetings will also be held with the entire community to discuss drug distribution mechanisms, selection of CDDs, collection of Mectizan, and other relevant CDTI issues. b) Focus group discussions will be held with social and religious groups, ethnic leaders to further mobilize the 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 traditions). The community members will also be encouraged at this point to take ownership of the program, defining their roles and distribution mechanisms. 3.2.2. Health education Health education and communitl, 77ro6'r'ration will continue to be an integral part of all approaches to CDTI. Health education actitities should ensure continuoui exchctnge with regards to knowledge, awareness, perception and observable attituclinal changei about Onchocerciasis and ils treqtment. Appropriate health eclucation messq.ges in thefornt-o1 portrrr, paruphlets and verbal presentatiotts' will neeel to be cleveloped ancl tested. Heatth eelucatiort should address thefollowing issues (Table 2). Table 2: Critical Issues in the Development of Health Education for CDTI ttitude to treatment a) Have any KAP surveys been done tn the project area and if so, what were the results? No KAP studies had been carried out in the project area. However, there is a need for a I(AP assessment to be done before launching the CDTI t, ISSUES Health Education Messages Knowledge of the disease o Local name of the drsease . Symptoms, Causatton/transmrssion(simple) Knowledge of treatment r Previous expenences with Diethylcarbamazine (DECt o InfroduceMectizan@ (ivermectin) o Dosage r Exclusions, Reactions, Beneficral side effects Advantages of Treatment: r Free, Yearly treatment o Possibility of Self-treahnent at community level a Imlrortance of maxrmal coverage Attitude to drsease o The disease can be controlled r Onchocercrasis blmdness and skin c s can be vented Attrtude to good record keeping a a a Mrnimum requirements for record keeping Records are confidential and strictlv for health use Records required ale lor drug supply 13 b) Wat methods will be used to develop health eclucation material for the communities ancl for the agents who will be responsible for lvennectin 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 in accordance with APOC accepted strategies prior to mass production. c) Wat methods will be used to provicle health education to the endemic communities ancl to the agents responsible for treatment? Gambella Region has in the past used various media for providing health education to endemic communities. Such methods include: face-to-face discussions with community members, traditional birth attendants, community health agents, associations, faith based institutions and through the use of posters, flipcharts in local languages, and drama (role playing in local languages). Community leaders will be informed about the disease and the necessity for regular treatment with ivermectin. These community leaders will serve as agents for the program, encouraging community members to comply with ivermectin treatment. All community members will be engaged in discussions about the health education messages, and given the opportunity to ask questions they may have regarding any aspect of the program. Community members will also provide valuable input into the development of health education messages and materials. 3.2.3. Community Participation In community-directed ivermectin delivery systems, members of the endemic communities do the execution of tvermectin treatment themselves. Trained personnel, known as Communitv'-Directed Distributors (CDDs) who should be fully supportecl by the community itself may provtde treatment. The conmtunity should be responsible for the organization and execution of the CDTI with minimunt but effective medical supervision, once it has received the necessary information and training. Vartous organizational structures at the community level, ranging from women's cooperative to traditional structures, are important for sustaining and strengthening the support network of the CDDs. a) Explain the organization of the intendecl comntunity-directed iyermectin 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 MOH, RHB, and NGO partners within the country and outside. The NOTF will be the governing body for Onchocerciasis control activities in Ethiopia. a J l4 At regional level, MOVDC is represented by a department and will be responsible for program implementation at that level. The head of MOVDCD will act as a ROCP Coordinator. Similarly, at the Zonal and Woreda levels corresponding Onchocerciasis Control Task Forces (ZOTF and WOTF respectively) will be established. The WOTF rvill be responsible for program implementation at Woreda level (ensure selection of CDDs, 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) will be the smallest unit for ivermectin distribution to the communities. Several villages are clustered together to form administrative I(ebeles led by a Kebele chairperson. CDDs selected by the communities will be trained on the CDT}APOC strategy for ivermectin distribution. CDDs and other local primary health care workers will then provide health education to communities on Onchocerciasis, 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 CDTI activities to ensure sustainability of the programme. Census of households will be canied out to identify eligible and non-eligible individuals and keep the records before Mectizan distribution. The CDDs will follow up defaulters using their treatment registers. Census of households will be updated every year before Mectizan distribution. Both Woreda and Zonal health staff will carry out supportive supervision and monitoring activities. b) How will ivermectin distributors be selected? The communities will be informed about the CDTI and APOC strategies and will be given the responsibility to select CDDs. The communities are fully empowered to replace those CDDs that show poor performance. There will not be any external influence in the process of selection of the CDDs. These CDDs are expected to be honest, dedicated, literate, and permanent residents of the community. c) How will non-eligibles be identified and defoulters followed-up'? Non-eligible individuals will be identified using the complete household census registration book and this will be updated each year. Similarly, defaulters, absentees, refusals, etc will be identified using treatment record book after each treatment schedules. The identified defaulters and new eligible such as previously pregnant women but who have delivered will be treated through mopping activities. t 15 a 3.3 Local Operational Research Are there any plans to conduct local operational research? ,/ YES NO If yes please give details Both region and district will conduct operational researches in CDTI areas on various topics. Research will be carried out in the CDTI areas on issues that could be identified in the course of implementation in the first year. This can be done in collaboration with research institutions, universities and other partners. a) Wat training will be provided to ensure the development cmd sustainability of the CDTI? Training of CDDs to operate CDTI is very vital to the program. To ensure sustainability of the CDTI program, TOT sessions will be conducted by the NOCP. Those trained here will represent both regional, zonal and Woreda levels. These individuals will in turn train representatives from health facilities who also train CDDs at community level. The training sessions will focus on the following topics: . Epidemiology of onchocerciasis, its signs and syrnptoms, including its treatment o APOC philosophy and CDTI strategy o Health Education and community mobilization . About Mectizan@ its advantages and the related adverse effects and management of its adverse reactions o Inclusion and exclusion criteria for ivermectin treatment o Dosage of Mectizan o Methods of dug distribution o Record keeping and reporting o Supervision and monitoring The training session of the CDDs will mainly focus on . Basic CDTI principles o Village census o Health Education and community mobilization o Mectizan@ and its benefits and the related adverse effects and management of rts adverse reactions . Inclusion and exclusion criteria for ivermectin treatment o Mectizan dosage determination o Methods of drug distribution o Record keeping and reporting a l6 b) Indicate criteria for selecting truinees (sr,ryervisors ancl community-clirectecl distributors). I) Criteria for selecting CDDs a (i) (ii) (iii) (iv) (v) (vi) Literate if possible Resident in the community Willing to serve the community Must be honest Must be available Must be selected by community II) Criteria for Selecting Supervisors Zonal Supervisor: Should be a PHC staff preferably zonal malaria expert Must be knowledgeable Must be interested in helping the community Must be honest (i) (ii )(iii) (iv) 4. Woreda Supervisors: The same criteria as those for the zonal supervisor are applicable here. c) Indicate number, type and duration of training courses intendecl *ln the subsequent years the other PHC training. tt'ainings will be lor a shorter duration, focused and integrated wnh SUPPLY' IMPORTATION, STORAGE, INVENTORY AND DELIVERY OF MECTIZAN TABLETS This seclion is only a reminder and concerns the xryply, importation, storage, inventorl, and delivery of ivermectin tablets, donated b1' Merck & Co, who w,ill also poy hanclling charges for ivermectin 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 government health care management system for drugs and other medical equipment, the Mectizan will then be transported by road to the Gambella Regional Health Bureau, and then to Zone health Offices. The zonal health Type of Training fl(orkshops) Duration Number per year Orientation at re onal level 5 days I Zonal 5 days 1 Woreda Training 5 days J CDD Training 3 days 200 Sessions t1 offices will be responsible for delivering the dmg to the Woreda Health Offices and health facilities. The nearby health facilities will serve as the final collection point in some Woredas where the health office is located far from the communities. CDDs will then collect the drug from the Woreda Health Office or health facilities. Drug consumption report will be sent to MDP (Mectizan Donation Program) at the end of every year 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 to the NOTF, using the standardized form of Mectizan@ Expert Committee (MEC). This application will then forwarded to MDP 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 funded projects rvill need to be designed to function with effective but minimum supervision compatible with its objectives. a) Please describe the supervisory arrangements you consider will be required for the CDTI you propose. Hoty'will this continue at the cessation of APOC support? There will be supportive supervision at all levels of program, during and after cessation of APOC support. The supervisory teams at the national, regional and zonal levels will be responsible for supervising Woreda health offices and randomly selected health institutions and CDTI targeted communities in all aspects of the program activities. Trained supervisors from the Woreda health office and the health facilities will be responsible to carry out supervision activities in their catchment CDTI areas on regular basis. Supervision activities will include performance of CDDs such as proper record keeping, complete census enumeration, Mectizan@ 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 own village following after they are given training. NGDO partners will be involved in supervision activities along with MOH supervisors The results of the supervision will be discussed with each supervised workers and thus corrective measures will be taken at the spot. This will be documented and reported to different partners at various levels. b) Describe how you would ensure that supervisiott would be carried out so cts to c fall within the requirements of accounting for ivermectin use o be sustained when the program ends in 5 years I r8 a. ensure maximum involvement of the conununities in the process To ensure that the above requirements are met, the program will support regular monitoring during the actual distribution process to ascertain that correct doiage is being administered, exclusion criteria are being observed, and the collection and proper storage of unused drug is well taken care. In addition, the program will support advocacy visits to the Woredas and villages by NOTF, regionalland zonal and Woreda representatives of the orrchocerciasis task forces at each level to solicit the active involvement and support of communities. Once training of 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 CDTI villages. Most of all, woreda administrative councils and I(ebele administrative councils will be encouraged to allocate budget for the continuation of CDTI activities after the withdrawal of extemal support. The CDTI will be incorporated with the other community development activities so that it will be parl and parcel of the routine tasks of the woreda and kebele administrative at their respective management levels. The current decentralization scheme and the health extension package initiative including the poverty reduction strategy paper rvill certainly .ripo*., the communities to effectively sustain the CDTI after the termination of ApOC support in this particular project area. Since political commitment has been evidently expressed for various CDTI projects in many parts of the country, there won't be any doubt to solicit similar support in Gambella region as perfectly demonstrated in other community health programs like EpVpolio, Malaria Control, HIV/AIDS, etc. Monitoring of CDTI It is importont to collect informatiort to monitor the progress of the CDTI. Wat indicators will be used to monitor; o lvermectin dntribution? . Health education and comntrmity pctttcipation? o Management systems? 5.2 The following items may be considered. Iv e r m e ctin D istrib utio n ! o Numbers of communities and persons treatecl with ivermectin o Number of Ivermectin tablets distributed/consumed o Number of communities reporting shortage of supplies o Regularity of treatment exercise l9 o Corupliance c Reporting aclverse reactions Particioation o Numbers of comntunities participating in the project o Chonges m behatior towarcls the disease, its treatment, prevention ancl control . Community support given to CDDs Mqnqgetngnl o Are activities being carriecl out according to plan and on schedule? o Inventory control, o Are recorcl forms accurate ancl completed on time? o Numbers of persons trained o Balance of genders in staff of the program The project will consider the following indices for monitoring the program of CDTI Ivermectin ution: Since Gambella Region 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 system previously developed in other CDTI areas prior to the beginning of treatment. These include communities and persons treated with ivermectin, treatment cove_rage, regularity of treatment, treatment compliance, and drug reactions. In addition, the project r,vill monitor the following rates and percentages using Annual Treatment Objectives established at the beginning of each year: Annual treatment obj ectives (ATO) : Total number of villages (number of high risk villages targeted for treatment) Estimated eligible population (80% of total population in the area) a Treatment coverage (related to ATOs) - Percentage of high risk villages/communities covered (geographic coverage) - Percentage of persons treated out of the total population (therapeutic coverage) . Cost per person treated . Mectizan inventory control Healtlt Education and a J 20 L] aHealtlt Education and Communitv Mobilization: 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. The impact of health education messages will be measured through periodic focus group discussions and KAp studies. The project will develop through its integration with the regional, zonal, and district health management and supervision systems to monitor, o The planning and implementation of activities according to the tirneline o Mectizan@ inventory levels o Monthly reporting of treatment indices o Numbers of personnel trained . Attempt to balance gender in staffing 5.3 Evaluation of CDTI Annual external review incorporating field visits will be undertaken ro ensure that proiects are nteeting target indicatiotts outlined in this proposal. Sttch reviews t'uill provide TCC with the assurance that each project is moving towctrcls its long term.stated goal and if appropriate make recommendations about any cleficiencies or modifications to this project. Such reviews will drart, ott the inclicators developed by TCC as a guide. 6. SUSTAINABILITY OF THE CDTI AFTER THE WITHDRAWAL OF EXTERNAL FUNDING The concept of sustainability refers to the ability, of countries ancl rfficted contnu,mities following initial external investment to nmintain tlte viabilitl, ancl continuitl, of tlrc iverntectin treatment process without externul support. For APOC fi,mclect projects, suclt support will normally' last 5 years, as the APOC donors demand that there shall be a visible and achievable end point for the external donation aspect of the progrcunme, and thut the community based distribution s1'stems establishecl shall thereafter be sustainable by the governments of the endemic countries concerned. Progress and plans towards sustatnabili\,, including the phasing out of external antl NGDO support, must be reported annually ancl satisfactory progress in this clirection will be a condition for each succeeding year's funcling installment. Please aclclress the following areas that relate to sustcinabilitl,; integration into primcuy healfh care, cost- recovery, and other sustainability issues. 21 Efforts will be made to ensure post-APOC sustainability of the program according to the sustainability indicators outlined by APOC. . Planning: CDTI will be integrated wrth the Primary Health Care (PHC) 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, bottom-up approach and integrated. 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. a a o o a 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 and Social Mobilization would be undertaken before every treatment season so that the CDTI communities and the local leadership will have preparedness to assume orvnership of the project. 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 for CDTI activities by the respective local government. 6.1. Integration of the CDTI into other Community-based or Primary Health Care (PHC) systems. The principal goal of the APOC is to estoblish cost-effective ivermectin-basecl control for Onchocerciasis, which can be sustained by the endemic communities and countries. One way to ensure sustainability is to integrate the CDTI into the PHC systent of the country, which nleans more than just using the system for iverm e ct in dis tribution. 6.1.1 . Is there an ofJicial PHC poliq, anel structure in the country'? ,/ YES NO I/'yes, plectse give a brief outline of what it is: The main objechve of Primary Health Care (PHC) policy in Ethiopia is to develop and strengthen grassroots and community participation in health care. lncluding Onchocerciasis among priority health problems in the national health policy will do the integration of CDTI into the PHC system. At the regional, zonal, and woreda levels, the MOVDCU will be responsible for program implementation at a 22 athe respective levels. ln addition, combining training on CDTI with other on job training activities, including Onchocerciasis control activities in the planning process at all levels, and including Mectizan@ in the list 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 eUC ltralning on CDTI 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 follows: MOH ) REGIONAL HEALTH BTIREAU) ZONAL HEALTH OFFICE )WOREDA HEALTH OFFICE) HEALTH FACILITIES (hospitals, health cenrers, health stations, health posts etc) ) coMMtrNITy HEATTH posrs (cHAs & TBAs) a) c) c) d) e) Howfunctional is the Primary Health Care System? F u I ly fu n c t ion al, P ar t ry fun c ti o n a r o r n o n -fttnc t i ona r (p r e as e s p e c ify) ? The systen-r from the national level ts fully functional up to the Woredaftrealth facrlrty level However, at the community level health coverage is limited. Does it cover the whole project area? ./ Yes No If no, in what part(s) of the project area is there afutlyfunctional pHC srructure? Wat percentage of communities where Onchocerciasis is enclemic, ctncl which are eligible for community-based treatment, have an existing ctncl functional pHC systent? About 45.5 percent of the endemic communities have functional pHC coverage. wat organizations are supporting the development of pHC in your project area? Govemment of Ethiopia (Ministry of Health), wHo, LINICEF, and some NGDos Is there any past expertence in the country of a programme integrating with the PHC? If so, what programme vvas it and how tur"itttul was the intigratiin? The integration of EPI, Malaria control, IMCI, tntegrated Disease Surveillance andResponse) IDSR and family planning drug distribution continues to be implemented successfully throughout much of the country. D 23 f) Are there ony, plctns to integrate other rural health programme, sttch us the Expctncled Programme of Inunurtizatiort, Maternal and Child Health Programmes or prograntrnes for the control of other parositic diseases, with the PHC system'? Programs such as EPI, maternal and child health program and malaria prevention are already integrated with the PHC system and they are further elaborated in the current health extension package policies and strategies of the country. Describe how the CDTI will be integrated into the PHC system; the way the PHC system will be used to achieve integration and the key persons in the PHC system that will be neecled to achieve the integration. At the Federal level, MOVDCT will be responsible for routine proglam management and act as the liaison between MOH, RHB, as well as with NGO partners. Members of the MOVDCT share responsibilities among themselves and hence a separate entity of vertical plogram nature is no longer in operation. At regional level, MOVDC is organized as a department and will be responsible for program implementation. 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. In areas where access to the woreda health office is restricted, local health institutions will coordinate, monitor, and supervise CDTI activities The primary health care units (PHCU) 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 isolated form and thus the CDTI activities will also be incorporated into the existing health extension packages. Incliccrte how ectrly in the CDTI the process of integration will be introduced; how it will continue thereafter, and after hov' man)' ))eors within the externally supported lifetime of the CDTI it will be completecl. CDTI activities in Ethiopia will be integrated from the very beginning. The establishment of the program will rely on existing systems of health service delivery at all levels. If there i.s at present no PHC system in operation or in those areas where these struclures are non-functional, describe hot+, the CDTI may be used to initiate and expand into such a system, giving a timeframefor intended progress. NOT APPLICABLE s) a h) 6 t.2 .t 6.1.3. In which w,ay(s) can comnu,tnity-directecl iverntectin treatment initiate or strengthen PHC? 24 aCDTI is likely to encourage and facilitate the acceptance of new health initiatives in the community and at home level. Also, through the new CDTI strategy, the community will likely play a greater role in the support and ownership of th;pHC system. The structures already put in place would be utilized by the pHC to enhance effective planning and irnplementation of the project. Foi example, the CDDs will develop capacities and skills, which will strengthen other programs such as health education, increase IMCI coverage, initiate home-based treatment. More over, CDTI empowers community and enables them to demand and exercise their rights for more health care services. 6. 2, Cost-recovery Systems during Community-based lverruectirt Treatment Cost recovery for Printary Health Cctre is tnanclatory in some countries ancl it may, be one means of sr.tstoining a CDTI after APOC firncling ceases. However, plectse note well that since ivernrcctin is donuted free, there ccm be no cost recovery in respect of the value of the drug itself; cost recover)'cat1 only relate to the costs of-clistribution. 6.2.1. Please state whether there vvill be anl,systerlt of cost recover)) (such as tltis recomntended in Initiative) to hetp cover outlays on the distribution of ivermectin in the present CDTI. NO 6.2.2. State exactly how an)) such system will be organized, inclucling answers to the questions listed below. wat charge will be made per person or perfcmtil/z Nor APPLICABLE d) wich groups of persons will be exempteclfr.om paymenl? NoT APPLICABLE e) Will payments be in cash or in kind? If in kincl how will this ensure sustainctbility? NOT APPLICABLE fl Wat provision will be macle to ensure that all those eligible to take ivermectin, but w'ho are unable to pay, will ctlso receive treatment? How will it be deternined who is utnable to pay'? NOT APPLICABLE d lVho will collect the payntents? How will this person safell, transport fttncls to u plctce of safekeeping? NOT APPLICABLE h) l44tere ancl b1' whom will any'funds collectecl be safety kept? NOT AppLICABLE i) Wat systems will be put in plctce to ensure the proper use ancl management of collectedfunds? NOT APPLICABLE , 25 j) For wltctt purpose(s), collectecl be usecl? inclucling defray,ruent of distribution costs, will the funcls NOT APPLICABLE k) Wat role will Village Health Contmittees play in the manogement ond ullocation of the funds raisecl? NOT APPLICABLE 6.3. Other issues Please provide information on other issues and constraints relating to sustainability of CDTI you anticipate und identify how they yvill be overcome. For example: The mobilization of enclemic communities The maintenance of adequate supervision and monitoring Inadequate human res ources Logistics and communicatio ns S o cia l/cu I tur al fa c t o rs Declining communitl, complian ce (t) Mobilization of endemic communities; Experience from the previous CDTI projects (I(affa-Sheka, Bench-Maji and North Gondar) indicates that bad rumors, misconceptions and misinformation regarding the program disseminated in the endemic community can be obstacle to sustainability of CDTI. This can be solved through sustained advocacy visits, by assigning individuals with good communication skills and expertise in conducting mass health education meetings to increase awareness of the community. Conducting stakeholders meetings periodically 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. (ii) Maintenance of adecluate supervision ond monitoring Mectizan@ distribution should include community leaders to further increase acceptability and sustainability of the program, All records should be verifled during supervisory visits, and informal discussions will be encouraged to determine community perceptions of the Mectizan@. (ii, Inaclecluate Human Resources Inadequacy of trained health staff and PHC units are expected to be constraints in implementing supervision and monitoring activities. These can be overcome by allocating adequate time for supervision, in addition to training additional supervisors from health facilities and community members. In some communities a 26 6.4, with no or lirnited access to transport, mnles and horses can be used for supervision and monitoring activity periods. (iv) LogtsticsandContmunications During the rainy season in October to December travel to the endemic areas may be restricted. Proper planning (Mectizan@ drug orders etc) will focus on providing all high-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 convenient for the communities. (v) Social/Cultural factors Careful attention will be paid to cultural and social factors such as: the appropriate gender for CDDs especially in certain communities, respecting the traditional beliefs, and selecting supervisors and distributors who speak the local languages. (vt) DecliningCommunityCompliance. Declining community compliance will be avoided through continuous rnobilization activities prior to each treatment period. Community members could be interviewed to determine the reasons for the non-compliance, and corrective measures taken where possible and appropriate How do yott intend to monitor and measure the progress towards sustainabiliry (See Appendix 3 for a list of possible inclicators of sustainability)? Progress towards sustainability can be monitored and measured by evaluating the project in terms of financial management/contribution, communications, training and capacity building. This will help enhance integration. Financial rnanagement should be incorporated into the usual govemment financial administration. Financial flow in the CDTI project should comply with government 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 familiarize 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 understand the cause and effects of Onchocerciasis, and the mechanisms for its control can be considered indicators of progress of CDTI to sustainability. The success of the program will depend on knowledge, attitudes or beliefs and practices of the community towards the disease. a I 2'7 a 7. CROSS-BORDERCONSIDERATIONS Where an endemic area extends ucross the borders of two or more acljacent Stcttes, special problems of cooperation between the respective countries CDTI may arise. In the event that there are areos to be covered by your proposed CDTI where the endemic zone extends across the frontier into one or more neighboring countries, and where there are likely to be transitory or even large-scale migrotions of Onchocerca-idected persons either way across the border. 7.1 Please describe the particular situation, as it is likely to affect ivermectin treatntent, and the methods you will use to deal with it. Gambella region shares border with the Sudan. However, the CDTI project Woredas for the first year do not border with the Sudan. 7.2 Include pertinent observations on current political ancl health relations with the neighboring State(s). There is good relationship between Gambella Region and the government of Sudan in political, economical and socio-cultural, health and many other aspects. 8. SPECIAL RISK ISSUES In some areos of some countries there nny be special risks, which could hinder the smooth running of a CDTI. 8.1 Please describe the situation in any oreos covered by your proposed CDTI were this factot' may interfere v.'ith tlte program, und assess future prospects. There are few refugee camps in some of the Woredas in Gambella CDTI projects areas. Hence the excessive influx or outflow of refugees may affect the overall process. C a 28 SECTION 3: ADMINISTRATIONIFINANCIAL 9. ADMINISTRATION Organizational structure for CDTI9.1. t 9.1.1 Please provide an organogram for the CDTI showing the organizational structure responsible for implementing the proposal. Fig.1. Organizational Structure of National Onchocerciasis Control Program 9.1.2 Membership of Taskforces l, Regional Level - Regional administrative council - Head, Capacity Building Main Department - Malaria and other vector-borne diseases prevention and control service - Regional Planning and Economic Department - Regional Rural Development Office - Regional Finance Office a at 29 2. Zonallevel - Zonal Administrative council - Capacity Building Main Department - 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) Ievel - Chief of I(ebele administrative council - Kebele capacity building office - Religious leaders - lnfluentialpersonalities - 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 WHO country office account in Addis Ababa. On request through the proper channels by 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 thb regional level will be the head and the administration and finance officer of the regional health bureau. All the Imperest returns will be submitted monthly by RHB to WHo country office in Addis Ababa that will forward them to APoC headquarters in ougadougou. Monthly reconciliation statements will be forwarded to the central Malaria and Other Vector-borne Diseases Control Unit (acting as the secretariat of NOTF) for follow up. APOC will issue cheques (advances) in accordance with WHO rules and the previbusly agreed project documents and/or plans of operations. When the t a oa 30 ntotal paynent in cash required for the project exceeds S 100,000, the paynent must be made in installments. The first installment/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 WHO/APOC mechanism for monitoring The size of the project will determine which of WHO's contractual systems is used, e.g. Technical Service Agreement, Letter of Agreement, Contractual Service Agreement or Agreement for the Performance of work. A document on administrative and financial procedure will be made available to project being funded by APOC. Built into this document is an 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 w'ill require a periodic externai audrt a[ 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. I ar 3l Fig. 2 Bequest and Disbursement of ApOC Funds Disbursement Financial Report H ,.| a 32 I 9.2.1 Input from the Ministry of Health a) Indicate resources that will be provitled by, the Ministry of health ctnd other government agencies. The Federal MOH will provide: - 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 will provide - Personnel - Logistics and transport, - Office space - Running costs for vehicles and office utilities - Pay taxes for capital equipment - Clearing of Mectizan, storage and transporlation - Training and supervision The Weredas Health Office will provide: - 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 b) Please provide a list of personnel assigned by the MOH to this project, including their name and proposed time (State percentage of time allocated to the project) for the project and where appropriate tl'teir experience in Onchocerciasis control through ivermectin treatment. At present, there are experienced personnel at national levels. Holvever, There are no experienced personnel on CDTI in Gambella Region although training in REMO has been given. This require therefore training on CDTI at regional, zonal and Woreda levels. ) a JJ Name Post Region YoTime Mr. Kuong Jock Head, Regional Health Bureau Gambella t0% Mr. Oman Ugud Head, Disease Prevention and Control Gambella r0% Mr. James Bof Head Malaria Prevention and Control Dept Gambella 10% Mr. Aberra Tessema Malaria Prevention and Control expert Ganrbella 10% Mr.Kurabachew Aberra Head, Plan and Programme Dept Gambella 10% Mr. Merga Waqira Malaria Preventron and Control expert Gambella 10% Gambella Resional Health Bureau: Zonal Health Office 9.2.2 trnput from the partner NGDO(s) a) Please prot'kle a letter from the Executivc Director or the Director of Onchocercias'is progrcunn'tes of each participuting NGDO stating their tntentions to participate in ctnd support the Natrcnal Onchocerciasis Control Programrne. At this moment there is no NGDO partner identified for this project. However, efforts are underway to attract NGDOs through the regional health bureau and the NOTF. The Federal ministry of health, the NOTF and the Gambella RHB will do their best to fill the gap of NGDO partnff in implementing the CDTI project. b) Give inforntation of the inputfront each NGDO participating in this Project. c) Please provide also a nominal list gradirtg and post description for the personnel to be protutled by partner NGDO(s). lnchcate clearly what will be their futnctrcns in the program and thetr experience in onchocerciasis control through ivennectin distt"ibution t { Name Post Zone 7o Time Gemechu Feyisa Head, Zonal Health Office Zone-7 25% Regassa Negeri Expert, Disease Prevention and Control team Zone-l 20% Regassa Gudisa Head, Zonal Health Office Zone-2 25% Gurmesa Kejela Expert, Disease Prevention and Control team Zone-2 20% Name Post Woreda o/o Time Melkamu Yimer Head,'Woreda Flealth Office Gambella 25o/o '!Tomdimagegn Head, lVoreda Health Office Godere 25o/o Flead, Woreda Flealth Office Diffrna 25o/o Getachew Batti F1ead, \Toreda Health Office Abobo 25o/o 34 Woreda Health Office: 9.2. .3. Inputs liom other agencies. Please list any' other agencies or parties thut yvill be invoh,ecl in the running or financing of the CDTI, und indicute clearly their roles, functiorts ancl contributions. WHO: WHO Ethiopia wrll assist the project in the procurement and clearance of Mectizan@ imported rnto the country by using its diplomatic status. 9.3 Timed plan of action Provide a time chart(s) showing hov, the various activities of the CDTI will proceed over the course of the proposed program. Numerical anrutal targets for all plaruted activilies shottlcl be providedfor each tinre poiut. The time charts should also indicote how externcrl support tvill be phosed out over the 5 year period. ) I 35 r* N \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \o (rl \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ ln .I \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ t+ (\l \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ ?a) N \ \ \ \ \ \ \ \ \ \ \ \ \ \ I q) d o 'da N() 6=a: :N C >' <ti9- (Jd 'o oo <9 qr o cn lJ- '= qr r.=:i o o= U)c U6 U) -0)t!()E' 0() t/) OD-<9 o() aL (n lcnoc) a./o= ,3 irn -(!Os IO$/c (-) .- O.d (.) U) ti C) H F ,-.,tU qio5 hn> d= La FN Oq) 'a li Oq<> oo o0 9) -> S o.r oe na l0) li 6l f- tr rr.l r'. oO Pi J C) (, Jq4) bo U) cn 0)t a J oJ (n L.l oU (H o oo cdtr (! o o(.) oa o d N -oo z E o(, q - qJ \J o L qJ rQ tru%s {! o -o tr (h l-.1 @ N o C) a U) C) (h o0 H o z o ! }r (n l-.1 vAEii 0) OQ<sooath OU) 'B ul Oe (r) * d() o o.o Iq) Cq o o (!g(! o. C)H oo 0)o th L{o oJi o o (, oo t o vo0 c)E ot* a(D aq dco< *o oo C)(.) B o) ol-r E(n Lr b0 oH (n ao o O (! 0) F(H () q) & or (-) (H ti (,) l- Il a a r-'lEt!rZ n -9 rc -2 -t-r Z l-lir F z ri =a ri ']t{ =Z a10. BUDGET l0.l Budget Estimates Budget must indicate totalftmds to undertake the project. The amount of firnding requestedfrottt APOC, and the antount provided by the MOH, NGDO(s) and otlter partners. All mttst be mctcle in US dollars. Each budget must include at least the following major ccfiegories (see uppendix 2) indicattng the contribution of the partners to reflect sustainability of CDTI. o Personnel (services) . Capital equipment . Supplies Training o Health educatiorVmobilization o Travel . Communication o Consultant o Operating expense o External audit a )/ YEAR ONE SUMMARY BUOGET FOR ONCHOCERCIASIS CONTROL IN GAMBELLA CDTI PROJECT YEAR 2OO3 t 2003 (Year l) CATEGORY APOC MOH TOTAL Personnel 0 30,503.00 30,503.00 Capital equipment 40,680.00 17,783.70 5 8,463. 10 Supplies t2,7 58.00 0 72,758.00 Training 5,727.00 0 5,727.00 Health Education/mobi1ization 14,350.00 0 14,350.00 Travel 8,966.00 o 8,966.00 Communication 1,440.00 1,440.00 Consultants 0 External Audit U 0 Recapitulation 7,020.00 0 7,020.00 Operating expense 3,024.00 27 5.00 3,299.00 Total 92,525.00 50,001.10 142,526.10 Estimated No. Treatments 80,657 80,657 80,657 '% input 64.9 35.1 100.0 Cost per treatment I .15 0.62 t.77 a 38 )o o R ;t $ $ o :" iE tsr : t ^j : .l ots ts tr H ln la la l1 6 5 s r o o o -t rn ! I l t-lI tl- t_- t_{ lslslslc 8 -+ 8 ie 6 6 E I llt-lll lal'l.l=l'l Itttt_ttl l,l=luiilElcl I I I_l:l,l,l I lalElslElrlsl I o I'i=l*i=i*lil llll.-1,-l.l l.lslIlSlEl:l lElslxl:;lsl3l Nooi"l,l*lnlnl=ll lElslcl:l8lsl l' l-i=l'l'lsl=ll I I l-l*l-l.l T l;l;lgl;lal;l I o o a l,l*i;l=l:i=l IIlt-!|lI l-l-l3l.l:l I lslglEl;lal;l I o oo i., o l|I"lll l;lxl;iEl'l,l I I'l=lslrl'lsTllttt_ttttllllal-l=l I l-lslFl'plElsl I lel;lul;lsl:l I o ! oo o o + i,l,l;iui=l=il lT t< tm t; l>tv lolclolo lm l,'toII lolzlolrlo lf;lrt6 l>la la lololzl{ Irl! lzlot> l< ltD IP t:lolrl;lztoIL lmloll G @ loll6l lEl c lsillll*lEl= -t I =lnl,ltl,l=l:l,clotot6tAtatot, =lelcl:lsl;lsl. l=l=l'i=l I l; lllll;lsl= =lglsl;lgl:l;lt =lalsl=lsl;l*liclelclelsl;lsl- l:lil=l'fI, Noeo I o l ll=l*l*l*i'l I I 1'oo I o - Percent input Ji\lalq'q){o(oo9-?9e"e-o-P-o-Fpaaaaaao0o-0ooooooO666 .T tO gl a ! ort o o !,(lt o o -h o o3 -t E ,+ o) o ,t nt 0, o J ! 0,T ort o ! ol oort o o oo Eo =o o0{ ! o oo N)oo o) N)oos ilHaol t\)oo o) looo\l 5 ei 10.2. BudgetJustification Please provide a naruative description of the reasons for" each proposed line items of the budget. (1) Personnel: The personnel budget reflects the salaries for staff at all levels (MOH, RHB, ZHD, and DHOs) that would provide support for mass distribution activities at the comrnunity level. It is assumed in this project that the government and the respective communities will be responsible for the entire personnel cost. The MOH staff ',vill provide support to the program in the form of: . Mobilization of authorities and community leaders o Health education and community sensitizatton on the need for the drug o 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 o Ensuring proper supervision of drug distribr"rtion o Ensure proper record keeping and accountability o Accounting for funds spent (both APOC and other) . Participating in program evaluation and feedback to local communities MOH staff is already in place and will participate in program implementation on either a part time or full time basis (as appropriate). There won't be project staff hired by APOC. This is meant to ensure the complete integration and sustenance of the CDTI project. Eventually the DHOs and the respective local community leaders will take on the rnajor local functions of the program by the end of five years. It is also assumed that CDDs will become PHC staff and take on additional duties and responsibilities as the new health extension package program is implemented at a wider scale. This will definitely ensure sustainability of the Gambella CDTI project. (2) Capital equipment: In order for the program to properly function, it must be well equipped. The equipmer-rt requested is meant to facilitate the work of the MOH (Regional, Zonal, and Woreda) staff and main items include: o Vehicles and motorcycles . Communication equipment (fax machines, radio telephones, megaphones) o Comp-uter, printer, photocopier o Training equipment (overhead projector) etc The government contribution in this aspect will be by means of covering the duty for the importation of vehicles and other capital equipment. On top of that office buildings, existing vehicles and other office equipment including stores/warehouses will be considered as counterpart contribution by the MOH at all levels. 4t (3) Supplies: Office supplies are essential for the srnooth 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). Field supplies such as CDD side bags, which are very essential for holding together all important items like Mectizan, village registers, promethazine, paracetamol, pens and notebooks, etc, are also included in this category. (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 persoruteljoin the program, and as CDDs need to be refreshed prior to the distribution period. Being essential to the implementation and sLlccess 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 at initial stages (mainly Year I and II) will be supported by APOC. APOC, MOH and the NGDO (when available) will also support workshops for regional, zonal; woreda staff, as well as CDDs. APOC is expected to provide support for the printing of training materials and sponsoring some training workshops. Funds are also requested to support computer training for staff, especially in GIS and MIS to facilitate better program management. (5) Health Education/Mobilization: Community mobilization and advocacy activities are required to build the support needed to ensure program sustainability. 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 persormel 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 APOC will provide funds 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 u,i11 subsequently decrease. 42 I (6) Travel: Travel is required for advocacy visits, training, retraining, supervision and monitoring, and evaluation activities are all important for effective program implementation. APOC 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 for the first few years. Gradually this will be overtaken by MOH. (7) Communication: At the National, Regional, Zonal, and Woreda levels, telephone, courier and other media means of communication (such as radio and e-rnail) will be used among project operators. At the community level, communication will be mainly through the use of radios and megaphones. The respective MOH offices will be responsible for covering the costs related to communication. (8) Consultants: Consultants would be required to conduct I(AP 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 partner (as appropriate) are expected to support the costs of these consultants. (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) OperatingExpenses: This will include costs such as utilities, costs of quarterly meeting (NOCP), development and maintenance of MIS. These expenses will be supporled by APOC. MOH will share some costs such as office utilities. 10.3. Current Resources Available for CDTI Existing CDTI projects (for continuation or expansion) will have resources already available. Please provide a detailed list of all existing personnel, ecluipment and supplies (including vehicles, etc.) belonging to the program, indicating their otvnership (MOH, NGDO, other Agency, etc.) and their level offunctionality. NOT APPLICABLE 43 APPENDIX I: ESTIMATED NUMBERS OF COMNIUNITIES AND PERSONS TO BE TREATED EACH YEAR, BY ENDEMICITY LE\'EL (PHASE ONE) AREA COVERED COMMLINITY ENDEMICITY LEVEL HYPER- ENDEMIC MESO- ENDEMIC HYPO- ENDEMIC* TYPE OF TREATMENT Communrty- Directed Community- Drrected YEAR I - (2003) No. of communltles to be treated 242 161 Total population in above communities 60,493 40,328 YEAR 2** - (2004) No. of communrtres to be treated 242 161 Total populatron in above communities 62,247 4t,497 YEAR 3** - (2005) No. of communitres to be treated 242 161 Total populatron in above communrties 64,052 42,101 YEAR 4** - (2006) No. of communrties to be treated 242 161 Total population in above communitres 6s,909 43,939 YEAR 5** - (2007) No. of communittes to be treated 242 161 Total populatron ln above communrtres 67,821 45,213 *Onchocercrasrs is not constdered an rmporlant Publrc Health problem rn hypo-endemrc communitres and APOC wrll not norrnally fund community-based treatment in such comnrunrtres. The rnclusion of such conrmunitres rn the proposal wrll requrre a spectal justificatron for consideratron by the TCC **lt is understood that the figures for years 2-5 are provisronal estrmates that nray change dependrng upon the results ofthe REMO surveys. t 44 I Ivermectin Treatments reflected in Appendix 1 were obtained as follows: A total of 100,821 population in the four woredas are targeted for CDTI for the first year treatment. Out of these population 60,493 live in hyperendemic villages and 40,328 live in meso-endemic villages. The number of villages is estimated from the total population with the assumption that 250 residents live in a village (based on the CDTI principle of 50 households per CDD). YEAR 1: A treatment objective of 1007a of all hyper and meso-endemic communities (403) in the selected four woredas will be targeted for the first cycle mass treatment. YEAR 2.5 A population growth of 2.97o has been considered during the following treatment cycles. However, this figure may change depending upon the outcome of the REMO refinement planned to be carried out later toward the end of 2003. Flg 4. Annual Treatment Objective by Endemicity Level ! ao,o00 120,000 1 00,000 00,000 i0,0 0 0 40,00 0 20,000 200c 2004 e o t 2005 2006 2007 q -Hyp€rendemtc -Meso-endemic 45 APPENDIX 2: INDICATORS FOR EVALUATION, SUSTAINABILITY AND INTEGRATION OF CDTI Project Evaluation Management Financial Management Effectiveness of Communications Training and Capacity Building lnstitutional Commitment Fulfillment of other relevant factors Problem solving cap acity lntegration 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 Su stain ability/In tegration Political will of Host government Polrtical will as shown in policy statements and apparent conmitment of high-level Officrals officral actions including assigning personnel, funds, vehrcles to program Long-term planning Is there a long-term plan for sustaining the financing and the management of the program? Progress toward financial sustainability If program sponsors cannot continue their current level of commitment for at least another five year, what percentage of running costs is norv paid for host govemments or fees? Progress toward integration To rvhat extent has ivermechn distribution been integrated wrth other health servlce programs? Evrdence of communify empowerment and ownershrp Change rn KAP over trme Extent of involvement of both genders and non-lrterate 46 t tNs -a oF o = o G g CL x uJ o E (, =o 3 o sO co q) E o) =Lo 3 o s roN o) E c =o 3 o s roN e s Go (! o Oq s@ co- CO o oO o Oq Oo @^ N oq\t @ e- rJ)(\ o o o ctz s oN o\f otr O) .cl s Go E :, oN @N ON @ O @N o o oo oI o oI o o -o oc o 'a o o- L o(! .EEL o oO oro q) L 0) = tIF o = o) q) .= 'o .E .c. =oq) - L o o .CaL oo C) Fo O E o Ilt)o o G' T CLx UJ q) E 'j, C,)C lz o =o s Lr)N c) E o)c ll L o 3 soN q) E o)c Yq o =o sON q) E o) .E .Y L o 3 soN a s G ?o G' o Oq r()oN o c.i o- cr) oq(o o oq @ o) oq o,o + o o o c,z (o =oc oo D Gto E)q oN @N O tr)N O @ O) @O) o o J oo o =N o -N oIN oIN o o o o o. 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I o c .9 (E a O) 0) 0) o u; fo 0)o 0) o) _a o I o -o a E oI E o o. o o -o =0) 0)c o O N g oo 0) q)p o o q) E (g 0) o LL E(o o- o o- 0.)pg 0) o c o s o o 0) 0) o) '6 o C 0) E(! o o tL a(I,o 0) o B v .E o o) : (o = O) -c o o) G -o c oF I ah o o E o oq ON oq tr) F- oq o cr) oq oN Oq rr)N o oN o c @ nN oq OO co- Oq O lJ) @- lr) Oq oo(o- oO o() f..- OcOO(o oq @ lJ) 1.- oi o .=) o c;z N N r ro O @ (oo @ otr)$ o rr)s o(o Oro OON E o = o o o() .= J o tr)N Ocr) o rr) |r)c! o co .t co O ro co oo J oo C) o o_ O o(L () o o- O o o. O o 0- O o(L O o- O o(I O o o_ O o 0- o o 0- q) ot o oq) q) tz .9, o C q) '6_ o C) o o E o_l a1ol cDl!l 'ctEI(oI ol -t(DI clolFI 6- = =EC o lz(I] .o q) o)1 =lil(Ul :lol CI LI o.l aL o o f oo oL o) oo oo(J o o -C o- >.1 aJlCIol ,-l$t at L o) Ni -ol 0)lOI blol ol(trt col olOI OI a E L o o)C =oo-q) x. fz o oo .o (E L .9 O) 0)tr ta U, a c(U O a -oo ooO o q) E OOlr) E E o 0)O N o(L C(U o oo o oO o O) E tr)N oc .N (tr 0) tr ol o_l I p = E o 1 I 'E oo o ?al8*la$ r; u)l x ;jl !blLvt8_;l 6o .=l o- () D Itrlo (u c o o- x IIJ o (! lr) X oE o o_ O @ @ q) o N o oD 0) o = o E o o o) .g o o(9 o cA x (o o) o. lr) @ @ a(g E Q) 3 E o oo (o @ -coc f) o(!E o) o 3 f o G rc 0) o- @@ x -)>tolot ol ,l el olCI (trl LI;l c.t I o o o G oF Oq OO lr)- Oq NN(o- CO oq oo(o oq t-C!t\ lr) @ .= tr o oz E o .= o th o o .= :) oO 1r) NN(o cr) oO @ oo =oo O o o- O o(L o oI tr .9 CL L a .a oo ,= .:() G Eo .= ooc o CL x IJJ 6 o (E c .o O)q)t tro O -co F oF tro O o O) .Ec 'o o o O ooo O o U)L o) .c oL o E .qo q) o- o I I E o ogs !t .=l ESIntl x ;.:l E' ;iI L€I8.e|5cL .=l o- N() o oc s CL x IU .o oE o-o c(o + FOEE!E o(.)(L: lr).= F=@9(8)ein CLop .:+ 0)o:Eb(!0 o_E oc cr)(o o -(o .98 6;E=9: ed =5 +a c>. .o iiI o.r OgL.O o> ,oi?.8 .!i qE .=oo= EOoooE lr)(5 u) o oo o- o o o o- a) oL o)! E o E .= :, E E oo o q) -c. o !C o oo O Eo o o) o q) C o U) 0)c oa c) o- E =G o) .c. a)E o Ec o o o O L o LL o o O .c.()$ o L o o)c o ao o o C,)c o o E L o LL IC 0) = o oE ,.]tl(o1 ol ol;lot OI -cl 3l 9lol olcl ol o o o E o oq o rO co- oq oO o- N Oq O O. $ ocOO @- Oq oo O) oq OO o) Oq Olr) @ oq O LO rJ)- N oq olr) cv)$ oo o'EZa s oOo$ OO o) OO o) oo o) o r() @ olr) @ oOc :E DO otr) cf) OO|r) N cr) o o) o U) O o o_ C) o(L O o(L O o(L O o(L O o(L O o(L O o o_ .9 CL L o o oo .= .z o G Eq) .= q) th tr o CLx IIJ c .9 oN ,6 c o) o C o o Cq) .C o E o o, L o- C .o o) o) x. c o o .N =a C oo C o o C 0) o E(E L o) L o_ oo o)L o q G o G E U, (!t oL o a o(L oo o)(! oa 0) E = (n .! -c. c) IF :(o fc(E o ro :f O) o o O ooo C) o o ooEE oo a o) o! p a o o(-) E o a {, o .c.o o -o o o EL o sl ot (!I NIr,sl ETItEl botE) '-ltGl;:l r; ullx ;-:lEblLft _t V eel I 1 ro I i r a tr o (E g o. x l.lJ o o E 0) = o .E o 0) (o o o) E N q) oE o X o U)f @ X u) tr oo 0) (r) oo E o- C o N @ + o o) E (o x @ (g ! x oal x oc o 2 0)o o o o o (E 0 o o e.l - oq o @ O) oq oo @- s oq o @ @- l'- o L J o c;z $ $ E o .= o o o o .E f @t $N oN o o oo o o0 o oL o o 0- o .E(, o ot, .= .2 ol! E o ,= q) o oo x UJ (u o (o! 0) o = -o c .o .a a o o_ =o o o C) -9 o o E o .= o o q) o c oo -o o f LL o o o =() =o c)E -o L .9o E 0) o- =o oo a) E o -o o o ul9]t o IF TU I F(J trFo o I o = .9 Gl c o CL x IU @(E ! 0) 0) =fo o o 0) o q) O E (0 D F- B x oal o X oq 0) N o 0) o o O) E N X oE o U) :) r.o o x o -- EY lr) EY oo O) o o o (I, ot- o @N q(o N oq(o osl of tr3 o dz N N tr 0) .= o o o o .= cf !t (o o o o .t) o (^L oL .9 CL o o oE :: o(E E o .= o oc a) CL x 0) ! ! c o oo o 0) 3 o o .9. a o o_ =o N 0) E -c C) ':C, o q) ! o o E(o ,C ! q) LL E o o @ o IJJ o lJ- lJ- o - uJr ulz oN I o = tr o (\, tr! CLx IJJ q(0 E 0) 3 f, o o o o) G o .o E al >.1olEI ol :l ol;l otalll ol -lXI CI ol al olol C.)l o C) o oq) E .E N X .= oaf tr) c? o X q: EY rr) F E ool N] o o o E oF q oo(o oq o coN oq o @ @ o .= f o c,z N N Eq) .= o o o o .= c J o CO o$ oo o U' o_ O 0- tr o CL L oo o! .ts .z o c, E o2 0)o o CL x IU o .o o) 0); od 0)C oN o o .9. e 0) o. oitc 6 o)tr -q .9 o o .: G o. 0) o ! (! o c(o .9 o f LL E o -of U) f lrJdf6rl-J lrJ I J uJ m = o I o = 3(, oo O) E') EEItr)GI#il .X Fl :gtg;l E .EI $ ro I l o = J F oF f o = tr o .U trg o. x uJ o c o E N .E a .0) =o o E =([ 0) c. od o oE 0) O) 3 0) N I 0) E =;tr o o o o E oF q o @s o co co$ o = f o oz N o .= o o o o = f o ri- o o o @ o =o tr .9 CL L oo o! 't Eo(t E o =o o 0) xlu q) oE o_ 0) 0)F G o of at) E o o uJ o lJ- tJ. o I.IJ - F9t Lo I o = tr o (! trg o. x IJJ ac c o E S .s o ! o) o) 3 E'C(u C .o U, olLI -t I-L IFI olzl -cl =lil 5l EIol cl :llEI btol 6 o o E oF oq o(o oq o(0(t o2 f o c;z N tr o .E o o o o J o cr) o o oq oIN o o. L o o oE' Eo(E E o .= oo o CL xt! xo LL 0)c o o- 0) 0)F t o ! o o uJ o IIII o FJ lrJ I uJz oN E o = I(EItrl(! lo-lx IJJ c o E (U a 0)c oN f E o O o o o (! o oq oo(o oq oo(o oE f o c,z c! tr o o o o o2 l o o o : oo d)I(. x(! LL ocot o- 0) 61F E o lt a @ a f IJJd J @9Pl E(!ol l:EHI TLJ (JI uJe':l -3,!l;!EI Jftrl Jdl :l r.il#:l E E.El oP;l i e-5I 8 I .9 CL oooE t o lI, Eo =oo c) CL x[J I () ro , f o otr s o.x IJJ oo c o EE a o oO + oo C a oO + oo o oo oo O -go o oo Oo o! o o] =c o EE o o o + E oo c6 ooN + oD N a! q @ o o oo o o oo f oF oo O)- o e{ co o ot o- t\ o = = oIt s o oo = l o O) @f.- o o oo o o 0- O o IL o o. oo oo :> o E o =(, 4t c oo x uJ E 0) o) E 3 0);o E o 6 o) Ec .9 o) c)E (t .E 0) 0) E 3 .q o) 6 :,C o E O) o a) 0) = FoF f t ct ol GI 5l ol(!I ololrl ..t EI ol =l oEl I 9-(! oo o o,! @ (,i .x!c 0, o-o i @ LO tr o G G CL x UJ =E L o o =j :8 O o) ni o o o G oF Oq o tr) oq o ro oq la, F- C! o =f o dz E o .= o o o o ,E trf o tr) o o J o oI o -o = o 'E o o ot, o o o o. x o o) ='a =oo o E o .o J U) F o :E o = o IJJI lt o T J IIJE o d, 9.o I I o = o o s a. x IJJ :b o G]j =O O 0) LU o o o .E o oo oq oo o .ts L = o C,z q) = o o o o ,= trf OO o o) o C, oIN ,9 o- L o o o! 't o G E o ,= o o tr o o- x uJ o .e = =oO o G o .cl (r, o I'J 9lrII o I FJ IJJ I tiJz oN o =Fj I o = L o (! tr G' q. x IU = -o o) o B; =o (_) 0) tu I o o o E o Oq l.r) N oq lo(\ o =tr = o c,z o .= o o o o .= f |r) N o o oo oI x. o o- L o o 0,E 't o G E o .: o oc o CL x IJJ o 0) : o(-) o G o ll a o ct s o- x IJJ o o .E E o E o. ooo o ! c o X o ui o f o. E o o .9 eq) o Ec o =oo 0) u 0) o E o) 6cI c') C) o .= ooo EC(o a 0) o,c '6 E o) U) c co E(o o i oa f r) d (rJ) c o E =lotolNI oE 0) 0) 3 s .g @ o o o o E$ o =Go o U;o cI, ,6 .E 0) o o o o o E s o oc E(o = o U)f(o c? o a) t c E =o@ o o o .E o OcOO co Oq Oo o- oq ON <f Oq oO @ Oq solr) oo +N o-(, o .= C) o o'z $ $ tr o = o o o o = oo co Ooo oNs oON @N o o J o U' C) o(L o o(L O o(L () o 0- O o(L c o q L o o oo .= o .E E o o U' C oo x uJ oo E oo L .q) o_ oO o o (L x o u- o =o- E oO =O)c o c o o '6 E o .()E o =0) O) =0) 0) .O o) 0) o o 'o E 0)E o o (r) : o 0) o o o E o T ! \ f uJu =o IF LrJI IJJ !0 =(, j I o = ot utlocl =ol E ,81 - crloclED CI!, Gl 68J ri ol x ;.il =tr|Esl ..-lvBg I t
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Project proposal for Community Directed Treatment with Ivermectin Gambella zone, Gambella National Regional State project period 2003- 2007
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