AFRICAN PROGRAMME FOR ONCHOCERCIASIS CONTROL PROGRAMME AFRICAIN DE LUTTE CONTRE L'ONCHOCERCOSE - APOC. REPORT OF A JOINT MISSION APOC MANAGEMENT- WHO/AFRO - WHO/HQ TO ETHIOPIA 5 - L3 June 1999 Dr A. SEKETELI, Programme Manager APOC, Head of Delegation Dr D. Etya'ale, NDGO Coordinator, WHO/IIQ Dr J.B. Roungou, Regional Advisor on Other Tropical Diseases, Rapporteur. By Il J I PM/APOC/DOC/ET.I 13t06t1999 Executive Summary Following the approval of the Honorable Vice-Minister of Health, a joint mission APOC Management/lVHO-AFRO/WHO-HQ visited Ethiopia from 5s to 13th June 1999. The delegation of the mission was composed of: Dr A. Seketeli, APOC Programme Manager and Head of the delegation; Dr D. Etya'ale, Coordinator of the Group of NGDOs actively involved the APOC activities and who is based in WHO/HQ in Geneva; Dr J.B. Roungou, Regional Advisor on Other Tropical Diseases, Rapporteur of the mission. The purpose of the visit was: (i) To provide further information to officials of the Ministry of Health, the World Bank, NGDOs and other interested partners on the objectives and strategies of APOC, as well as on the achievements of the Programmme since its inception in December t995. To sensitize the Ministry of Health Authorities on the need to have Ethiopia start APOC activities for the benefit of those who are suffering from onchocerciasis in the country. (iii) To obtain additional information on: The formation of a National Onchocerciasis Task Force (NOTF) in Ethiopia, after the workshop on APOC Philosophy and CDTI concept organized in Nairobi in April 1998 and in which five delegates from the Ministry of Health of Ethiopia participated; The partnership with the local and/or international Non-govemmental Development Organizations (NGDOs). (iv) To set up a time line for the development of the National Onchocerciasis Control Plan as well as a specific Community Directed Treatment with Ivermectin Project Proposal to be submitted to APOC for funding. The delegation of the mission had meetings and discussions with: the Acting WHO country Representative and the senior personnel of the WHO Office; the senior staff of the Department of Epidemiology and AIDS at the Ministry of health; (ii) the Head of the Department of Planning and Projects of the Ministry of Health; the Operations Officer for social sector of the Resident Mission of the World Bank; the Country Representative of The Carter Center. The Delegation had also a meeting with the Honorable Vice-Minister of Health. The outcomes of the mission can be summarized as follows: (i) The Ministry of Health has accepted to form a National Onchocerciasis Task Force (NOTF). The chairman of the NOTF will be the Head of the Department of Epidemiology and AIDS and the National Coordinator, Secretary of the NOTF will be the Team Irader of the Unit of Malaria and Other Vector-borne Diseases Control. The principle of the involvement of NGDOs in onchocerciasis control in Ethiopia has been accepted by the Ministry of Health. (iii) It was agreed by all the parties concerned that the WHO country Office will serve as a consignee and a clearance Agent for all shipments of Mectizan to Ethiopia. (ii) (iv) A consensus concerning the process to be followed, as well as the conditions to be fulfilled, for the launching and implementation of APOC activities in Ethiopia was reached (see Annex 1) A tentative outline for the development of a National Plan for onchocerciasis in Ethiopia was elaborated (see Annex 2) A schedule of CDTI projects development by phase in Ethiopia was elaborated (see Annex 3) (v) (vi) (vii) Agreement was reached on the amendments to be made to the format and content of the Irtter of Agreement, usually signed between WHO/APOC and the NOTFs, to suit the specific context of Ethiopia. According to the regulations of the country the signatories of the [rtter of Agreement will be two persons of the Ministry of Health: the Minister or the Vice-Minister of Health and a technical senior person yet to be identified. (viii) A national workshop will soon be organized by the MOH @epartment of Epidemiology and AIDS) on APOC philosophy and strategy as well as on the development of the National onchocerciasis Plan and CDTI Project proposals. This workshop will involve all the potential partners of the MOH willing to contribute to APOC activities in Ethiopia, especially the NGOs. The APOC Management and the WHO country office in Ethiopia have agreed to provide technical and financial assistance to that important and crucial workshop. Introduction Since the launching of the African Programme for Onchocerciasis Control (APOC) in December 1995,19 countries including Ethiopia, donor countries and the lnternational Organizations have signed the Memorandum of Agreement of APOC. Ethiopia signed the Memorandum on November 19,1997. Up till now, 11 out the 19 countries have, with their partner non-governmental development organizations (NGDOs), elaborated their National Plans and ivermectin delivery and/or vector eradication projects for onchocerciasis control. These projects,48 to date, are funded through APOC Trust Funds with contributions in kind or in cash from the African Governments and their NGDO partners. Ethiopia where onchocerciasis is highly endemic has yet to begin with control activities and has not as yet taken advantage of the unique partnership, which forms the basic philosophy of this new Prograrnme. Following the approval of the Honorable Vice-Minister of Health, a joint mission of APOC Management/WHO-AFROnVHO-HQ visited Ethiopia from 5th to 13e June 1999. The delegation of the mission was composed of: Dr A. Seketeli, APOC Programme Manager and Head of the delegation; Dr D. Etya'ale, Coordinator of the Group of NGDOs actively involved the APOC activities and who is based in WHO/HQ in Geneva; Dr J.B. Roungou, Regional Advisor on Other Tropical Diseases, rapporteur of the mission The purpose of the visit was: (i) To provide further information to officials of the Ministry of Health, the World Bank, NGDOs and other interested partners, on the objectives and strategies of APOC, as well as on the achievements of the Programme since its inception in December 1995. (ii) To sensitize the Ministry of Health Authorities on the need to have Ethiopia start APOC activities for the benefit of those who are suffering from onchocerciasis in the country. (iii) To obtain additional information on: The formation of a National Onchocerciasis Task Force (NOTF) in Ethiopia, after the workshop on APOC Philosophy and CDTI concept organized in Nairobi in April 1998 and in which five delegates from the Ministry of Health of Ethiopia participated; The partnership with the local and/or international Non-governmental Development Organizations (NGDOs). (iv) To set up a time line for the development of the National Onchocerciasis Control Plan as well as a specific Community Directed Treatment with Ivermectin (CDTI) Project Proposal to be submitted to APOC for funding. The chronology, activities and achievements of the mission are described below. DAY 1 1. Meeting with WHO Administrative Officer During the meeting the delegation was informed of the following points: o There is no Minister of Health appointed for the moment. However, the Vice-Minister is there and is acting for Minister. o For the last six months, there is no appointed WHO Representative in Ethiopia. Dr Babaniyi, the EPI officer has been acting as WHO Representative. o There are three WHO institutions in Ethiopia: - WHO Country office for Ethiopia - WHO office for OAU and ECA - WHO Emergency Health Training Programme for Africa o Funds were allocated for onchocerciasis control during this biennium in the regular budget of the WHO country Office (AFROPOC). Since APOC activities have not vet started, the Ministry of Health has reprogrammed this money and is using it for other activities. 2. Meeting with Dr Naphtali Agata, acting for the WR in the absence of Dr Babaniyi The delegation briefed the acting WR on the objectives of the mission. The acting WR assured the delegation that the Office will provide the necessary support for the mission to be strccessful. He also gave useful advice on how to proceed with the sensitive issues which are to be dealt with during the mission. 3. Meeting with the Head of the Department of Epidemiology and Aids and his staff In his introductory statement, Dr S6k6t6li, Head of the delegation of APOC indicated that the mission is concerned with the following key issues: (i) With respect to the spirit of partnership that characterizes APOC and according to the 5. (ii) Memorandum of the first phase of the Programme signed by all the participating countries including Ethiopia, a National Onchocerciasis Task Force (NOTF) should normally be established in each participating country. The mission would like to know if a NOTF has been created in Ethiopia and who are the members of this Task Force? If not, what are the steps to be taken in that regard? Non-governmental Organizations (be it national or international ) should in principle be involved in any APOC supported project in the participating countries. The mission would like to know where Ethiopia stands as far as NGDOs are concemed? Especially, is there any NGDO working now in Ethiopia which the Government intends to get involved in APOC activities? (iii) Mectizan is donated free of charge by Merck & Co for the treatment of onchocerciasis. So far, the donation, according to US regulations, is done through NGDOs, UMCEF and WHO as consignees. Hence, how does the MOH see the issue of importation of Mectizan in Ethiopia? (iv) Because of the complex partnership within APOC, the decision was taken by the Joint Forum Action (JAF), the governing body of the Programme that a separate bank account must be opened to receive the money coming from the APOC Trust Fund. In that regard two signatories are to be appointed: one representative of the MOH (usually the National Coordinator) and one representative of the NGDO partners. How does the MOH intend to address this financial issue? After a long and fruitful debate, the consensus was reached on the following points: . The formation of a NOTF is feasible. The backbone of this NOTF already exists. It was felt that the Team I-e,ader of the Unit of Malaria and Other Vector-borne diseases in the Department of Epidemiology and AIDS should act as the National Oncho Coordinator as he is already playing this role and that the Chairman of the NOTF should be the Head of the Department of Epidemiology and AIDS. The rest of the members of the NOTF will be identified in due course, especially representatives of NGDOs partners and experts from the regional and zonal levels. o The opening of a separate bank account at the central level of the MOH may not be feasible in the context of the current health system regulations. However, subject to confirmation by the officials of the Department of Planning and projects, the following arrangements were felt acceptable to the MOH and APOC: - On the basis of Irtters of Agreement signed between WHO and the NOTF of Ethiopia for the implementation of approved projects, Funds will be transferred by WHO to the WHO country Office imprest account in Addis Ababa. On request through the proper channels by the authorized officer of the MOH, member of the NOTF, WHO Addis Ababa will transfer directly to the bank accounts of the Regional Health Bureau(s) RfB) concerned, the amount (v) of money destined for field activities to be carried by the regions. The signatories of the bank account into which APOC funds will be transferred at the regional level will be the Head of the Regional Bureau and the Administrative and Finance officer of the Regional Health Bureau. All the imprest returns will be submitted monthly by the RFIB to WHO office in Addis Ababa which will forward them to APOC Headquarters in Ouagadougou. Monthly reconciliation statements will be forwarded to the Unit of Malaria and Other Vector-borne Diseases at the central level (acting as the secretariat of the NOTF) for follow-up - The share of funds to be utilized at the central level will be kept in the WHO imprest account in Addis Ababa and released on request by the authorized officer of the MOH. The justifications of the funds will be submitted by the Unit of Malaria and Other Vector-borne Diseases through the proper channels to WHO office in Addis Ababa for onward transmission to APOC Headquarters in Ouagadougou. DAY 2 4. Meeting with the WHO Administrative officer (AO) The objective of this second meeting with the AO was to find out if the office will be able to cope effectively with the financial iurangements agreed upon with the Department of Epidemiology and AIDS but yet to be confirmed by the Department of Planning and Projects. In that regard, the AO clearly indicated that the administrative and financial staff of the office is presently insufficient and will not be able to deal effectively with the additional workload that the proposed financial arrangements for the implementation of APOC activities will require unless a strengthening, through a financial assistant, is envisaged. He also mentioned that additional financial support for the activities of the Disease Prevention and Control Officer will be highly appreciated. Because there is only one imprest account at the WHO office in Addis Ababa, the AO indicated also that the original of all imprest returns of allocated funds (regular budget or extra budgetary funds) to programmes are sent to the Regional Office in Harare. However, in the case of APOC, copies of the returns will be made available to APOC management as requested by the delegation. This procedure is also currently used for the National Immunization Days (NIDs) and Guinea Worm Eradication funds. The Head of the delegation , the Programme manager of APOC, therefore, requested the AO to propose, before the departure of the mission, what the office would need (logistics, human and financial resources) to be able to cope properly with the additional workload that the proposed financial arrangements for the implementation of APOC activities in Ethiopia will require. 5 Meeting with the staff of the Department of Epidemiology and AIDS (i) Provided this will be acceptable to the Head of the Drug Administration and Control Department and The WHO Representative in Ethiopia, it was agreed after a long discussion that for the time being: . Importation of Mectizan tablets will be done through the WHO country Office in Addis Ababa which is exempted of duty taxes and will act as a consignee. o Clearance of Mectizan shipments will be managed by the WHO country Office in Addis Ababa and the consignments will be handed over to the NOTF (Chairperson and National Coordinator) for distribution to the recipient projects. (ii) The senior Staff of the Department of Epidemiology and AIDS finally accepted that NGOs (national or international) may be involved in oncho control activities in Ethiopia provided these NGOs are able to contribute financially and technically to the implementation of APOC supported projects. 6. Meeting with the Head of planning and Projects Department The main conclusions of this meeting can be summarized as follows: (i) There are three authorized channels to be used by the Partners when they lend assistance to the Government of Ethiopia: o Channel 1 :Budget support: funds brought into the country is put in the national Treasury either for direct support to public treasury (channel La) or earmarked for specific programme (channel Lb). . Channel 2 Sectoral Assistance: based on an agreed plan of action by both parties funds can be transferred directly to regions on request by the authorized official of the concerned sectoral ministry for the implementation of planned activities. This is usually the channel used by UN agencies (including WHO). . Channel 3: Geography based direct implementation of the agreed upon activities by an Agent of the Donor. The costs of these activities are paid directly by the Donor. But report of the work done and the money spent is requiered and must be submitted to the Ministry of Finance and the Sectoral Ministry concerned. (ii) In some instances more than one channel can be used. (iii) The Ministry of Economic Development and Cooperation (MEDAC) is the Government Institution mandated to negotiate and sign agreement with external partners. (iv) All funds coming from external sources into Ethiopia must be known, approved and registered by MEDAC. (v) MEDAC is also mandated to approve, on behalf of the Government of Ethiopia, the procedures of flow of funds that any given partner will use in application of a signed agreement. (vi) Ethiopia is willing to work with reliable and capable NGOs in implementing APOC supported projects. (vii) The Head of the Planning and Projects Department agreed to discuss the above issues with MEDAC and feedback to the group. (viii) As a background for this discussion , it was agreed that a clear and concise description of the process to be followed, as well as the conditions to be fulfilled, for the launching and implementation of APOC activities in Ethiopia will be made available to the Head of the Department of Planning and Projects as soon as possible (see Annex 1). DAY 3 Meeting with the Acting WHO Representative The WR a.i, Dr Babaniyi, (who was absent on the first day of the mission) received the delegation of APOC who expressed its appreciation for the efficient support given to it by the WHO country Office personnel, in particular the AO and the Disease Prevention and Control Officer (DPC). He was briefed on the activities of the mission since its arrival as well as the consensus reached in the negotiations with the Department of Epidemiology and AIDS. (ii) The WR a.i congratulated the delegation for the achievements so far. He indicated that a technical assistance may be needed to help the MOH in the development of the National Plan for onchocerciais control and project proposal(s) for ivermectin distribution. (iii) The WR a.i supported the proposal made by the AO with regard to the strengthening of the office in order to enable it to repond appropriately to the needs of the prograrnme given the financial arrangements and procedures so far retained by the delegation and the representatives of the MOH. (iv) With regard to the importation of Mectizan tablets into the country, the WR a.i totally agreed that the WHO country office should serve as consignee. He also agreed that the office will clear the shipments before handing them over to the Unit of Malaria and Other Vector-bome Diseases in its capacity as the NOTF secretariat. 7. (i) (v) To that effect a letter was immediately sent by the WR a.i to the Mectizan Donation Programme in Atlanta. (vi) As a result of the above undertaking, the Director of the Mectizan Donation Progrmamme responded promptly expressing her satisfaction to see the WHO Office serve as the consignee for Mectizan shipments for onchocerciasis control activities in Ethiopia. Meeting with the World Bank Operations Officer for social sectors As an introduction, Dr Seketeli mentioned the objectives of the mission and indicated the reasons why the delegation had wished to have a meeting with the Resident Mission of the World Bank. These were as follows: the World Bank (WB) is the fiscal agent and one of the biggest contributors to the Programme the delegation wanted to see how the Resident Mission can support the NOTF when it is formed. 8. (i) (ii) (iii) (iv) Dr Seketeli also gave a brief description of the philosophy and strategy of APOC as well as a concise account on the development and the achievements of the Programme. The World Bank Officer reaffirmed his institution's great interest in onchocerciasis control and also indicated that the Resident Mission of the World Bank would like to see the MOH implementing Onchocerciasis Control within the framework of the Health Sector Development Plan. The World Bank Officer informed the delegation that a Malaria Control Support Team (MCST) has been set up within the Unit of Malaria and Other Vector-borne Diseases Control. The MCST is composed of Representatives from the MOH, UNDP, UNICEF, USAID, WB and WHO. The MCST is led by the Head of the Unit of Malaria and Other Vector-borne Diseases Control. The roles of the MCST were described as follows: To support the development of Terms of Reference for the MCST To support Government develop a plan for malaria control and mobilize resources To help the regions develop regional plans for malaria control. The World Bank Officer gave useful information to the delegation on the viervs of the Government of Ethiopia conceming collaboration with NGDOs and advised on how to approach national authorities with regard to NGDOs involvement related issues. He also mentioned that The Carter Center is one of the well appreciated NGDOs by high rank Government Authorities. (v) (vi) 10 .t 9. Meeting with the Honorable Vice-Minister of Health (i) The meeting took place in the presence of the Acting WHO Representative and the senior staff of the Department of Epidemiology and AIDS. (ii) Dr Seketeli who spoke on behalf of the delegation thanked the Vice-Minister for the approval granted to the delegation to make the visit and all the arrangements made to facilitate the smooth proceeding of the mission. He especially mentioned how the letter of invitation the Honorable Vice-Minister sent to the Programme has greatly facilitated for the delegation the formalities of obtaining entry visas at the Addis Ababa airport. (iii) After a brief account on the development of the Programme since its launching in December 1995, the Head of the delegation of APOC highlighted the situation prevailing in Ethiopia and recalled the objectives of the mission. He then went on and emphasized the issues discussed with the Department of Epidemiology and AIDS, and the Department of Planning and Projects as well as the consensus reached so far concerning: - The formation of the NOTF of Ethiopia - The procurement of Mectizan tablets into Ethiopia with the WHO country Office to serve as the consignee and the clearance Agent for all the consignments before they are handed over to the MOH. - The process to be followed for the approval by the MEDAC and APOC of the National Plan for onchocerciasis control and specific ivermectin delivery project proposals. (iv) Dr Seketeli also explained to the Honorable Vice-Minister of Health the procedure proposed for the disbursement of APOC funds for the implementation of approved projects: - Transfer of funds by WHO to the WHO country Office imprest account in Addis Ababa; - On request by the authorized officer of the MOH, the main bulk of the money will be transferred into the bank account(s) of the Regional Health Bureau(s) of the concerned regions. The signatories for the withdrawal of APOC funds will be the Head of the Regional Health Bureau and the Administrative and Finance officer of the Regional Health Bureau; - The share of the funds destined for the central level activities will be kept in the imprest bank account of the WHO country office in Addis Ababa and released on request to the MOH. 11 (v) - All funds received must be justified according to WHO regulations. Dr Seketeli urged the Honorable Minister of Health to do all efforts to attend the next JAF meeting scheduled to take place in The Hague, The Netherlands from 8ft to 10ft December 1999. In his response, the Honorable Vice-Minister of Health thanked the delegation for coming to Ethiopia and stated the following points: (vi) - The structures of the Government of Ethiopia were changed since 1993 into a decentralized system. In the framework of the new system, the regions are responsible for the implementation of the health activities. The central level has the responsibility to define policies and to monitor and evaluate progress. A sectorwide programme has been developed by the Govemment and its partners including WHO - Three channels forthe flow ofdonors' assistance have been defined. WHO which is one the implementing agencies of the HSDP is allowed to use channel 2. According to the current regulations only the Minister, the Vice-Minister and Administrators are allowed to order money. - The consensus reached are acceptable and it is possible to transfer money to the regions as far as WHO is concemed. It is also possible for WHO to make funds available to the MOH through the authorized channels for the execution of the activities at the central level. - It will be posfrlE'to reach an agreement with MEDAC on the process for approving the National Plan and Project Proposals and the proposed financial arrangements. (vii) The Acting WHO Representative indicated that the WHO country Office is willing to provide any assistance the Ministry of Health may need in order to attend the forthcoming JAF meeting. He also mentioned that his office will make any arrangement to provide technical assistance for the development of the National Plan for onchocerciasis control and Project Proposals for ivermectin distribution if the MOH wish so. 10 Debriefing at the Department of Epidemiology and AIDS after the meeting with the l2 Honorable Vice-Minister of Health The Head of the Department of Epidemiology and AIDS informed the delegation of APOC that the Head of the Drug Administration and Control has no objection concerning the proposal that WHO country Office serves as a consignee and a clearance Agent for all shipments of Mectizan tablets sent to Ethiopia by the Mectizan Donation Programme. The delegation had the opportunity to meet The Carter Center country Representative who assured the delegation that once he receives appropriate instructions from his headquarters, his office will be in a position to join the NOTF and pitch in onchocerciasis control in Ethiopia. Sight Savers International was also mentioned by one of the staff of the Unit of Malaria and Other Vector-borne Diseases Control as another possible NGDO candidate to be involved in onchocerciasis control in Ethiopia. o The delegation and the staff of the Department of Epidemiology and AIDS agreed to start working on the outline of the National Plan for onchocerciasis control the next day. DAY 4 11 Follow-up on the letter sent to Director of MDP by the Acting WHO Representative o The Director of MDP responded promptly to the WR letter and expressed her satisfaction to learn that the WHO country office in Ethiopia will serve as a consignee for Mectizan shipments for treatment programmes in the country. . The Director of MDP sought clarification as to whether the WHO office will clear Mectizan for all treatment programmes , including the small, clinic-based ones proposed by some hospitals and NGOs? o The response of the WR to the question was also immediate and yes. Session on the elaboration of the outline of the National PIan for onchocerciasis control in Ethiopia o The delegation briefed the team of the Unit of Malaria and Other Vector-borne Diseases Control on the guideline for the development of a national plan for onchocerciasis control and project proposal for ivermectin distribution. The delegation gave directions to the team on how to develop a detailed tentative outline of the national plan. o The team then developed a tentative outline of the National Plan for onchocerciasis control, which was submitted to the delegation for comments and amendments. t2 t3 DAY 5 13 Session on the elaboration of the outline of the National Plan for onchocerciasis control in Ethiopia (Contd) . The delegation gave feedback to the team on the tentative outline of the National Plan which was then amended (see Annex 2). o With the assistance of the delegation the team elaborated a schedule of CDTI projects development by phase in Ethiopia (see Annex 3). o The modifications to be made on the format and content of the Irtter of Agreement, usually signed between WHO/APOC and the NOTFs, to reflect the specific context of Ethiopia was discussed with the Head of the Department of Epidemiology and AIDS. Agreement was reached on the amendments to be made to this document. One of the salient point of the agreement is that according to the regulations of the country, the signatories of the I-etter of Agreement will be two persons of the MOH: the Honorable Minister of Health or the Vice-Minister and a senior technical person yet to be identified. o A need for a planning workshop and assistance from APOC Management and WHO country office was expressed by the team and agreed upon by the delegation. To that effect, the MOH will soon submit a proposal on the planning workshop for assistance from APOC Management and the WHO country office. o APOC Management is still expecting a response to its letter sent earlier regarding the planned Impact Assessment baseline study in Ethiopia to finalize preparations in due time. DAY 6 14 Review and amendment of the mission report by Dr Desta Alamerew representing the Unit of Malaria and Other Vector-borne Diseases Control, Dr Eyob Tsegaye, DPC representing the WHO country office and APOC delegation. 15 Departure of Dr Etya'ale DAY 7 16 Departure of Dr Seketeli and Dr Roungou. T4 ACKNOWLEDGEMENTS We wish to express our deep gratitude to the Honorable Vice-Minister of Health Dr. Lamisso Hayesso for: - officially inviting us to conduct this mission in Ethiopia, - granting us an extensive audience despite his very busy work schedule, - pledging his personal support, as well as that of the Ethiopian Government to APOC activities in the country. A lot needed to be accomplished during the limited period of our visit to Ethiopia, and little would have been achieved without the hard work, competence and dedication of many Ethiopian colleagues. Our special thanks go to the following: Mr Tadesse Molla, Head Epidemiology and AIDS Control Department; Mr Tarekegn Abose, Head Malaria And Other Vector-borne Diseases control Unit; The Team of Experts in the Unit of Malaria and Other Vector-borne Diseases: o Dr Desta Alamerew, o Mr Gezahegn Tesfaye, o Mr Daniel Kebede, o Dr Dadhi Jima, o Mr Girma Aman, o Dr Afewort Haile Mariam, Dr Gebremaskal Habtemariam, Head of the Planning and Projects Department, MOH Dr Gebreselassie, Operations Officer for the social sectors of the Resident mission of the World Bank. We also wish to acknowledge the outstanding support received throughout the visit from the WR office with special reference to Dr Babaniyi , the WR a.i and Mr Tadesse, the Administrative Officer and Mr Belay Mekonen, driver for tlheir gitdun." and facilitatory roles. Finally, the delegation is particularly indebted to Dr Eyob Tsegaye, the Disease Prevention and Control officer of the WHO country office, for his most valuable assistance during all the very long working sessions experienced throughout this mission. 15 ANNEXES 16
ANNEX 1 PROCESS TO BE FOLLOWBD AND CONDITIONS TO BE FULFILLED FOR THB LAUNCHING AND IMPLBMENTATION OF APOC ACTIVITIES IN ETHIOPIA Background information o The objective of the APOC is to establish within 12 years a sustainable ivermectin distribution owned by the communities and well integrated in the national health system. o Like the other 18 participating countries, Ethiopia has signed on November 19, 1997 the Memorandum of APOC (see attached). This Memorandum clearly outlines the basic philosophy of APOC of which working through a global partnership is an important component. o At the national level this partnership is reflected through the National Onchocqrciasis Task Force (NOTF), composed of representatives of MOH, WHO, NGOs and other partners involved in the control of the disease. o As of today 11 countries out of the 19 have formed their NOTFs and have elaborated national plans for onchocerciasis control and 48 project proposals (see list attached). These countries are already benefitting from the APOC funds as stipulated in the Memorandum of Agreement. o With regard to Ethiopia, a NOTF has not been established yet and no national plan or project proposals have been developed. The following points are therefore suggested for approval by whom it may concem to initiate and accelerate the control of onchocerciasis in the country within the framework of APOC and in line with the Health Sector Development Programme of Ethiopia. (1) Formation of Ethiopia's NOTF. This should include: - current staff of the Epidemiology and AIDS Department: . Head of the Department: Chairman of the NOTF; o Team Lrader of the Unit of Malaria and Other Vector- borne Diseases: as National Coordinator and Secretary of the Task Force; o the six Experts of the Unit of Malaria and Other Vector-borne Diseases. the Head of the Planning and Projects Department or his representative T7 .l - the Head of the Drug Administration and Control Department or his representative - the Heads of Malaria and Other Vector-bome Diseases Control Department of the affected regions - the Disease Prevention and Control Officer of the WHO country Office - NGDO partner(s) yet to be identified (2) Development of a National Plan for onchocerciasis control by the Task Force members to be submitted to APOC for approval. (3) Development of one or several specific ivermectin distribution project proposal(s) to be submitted alongside with the National Plan to APOC for approval. (4) Signature of the finalized National Plan and project proposals by the Head of the Department of Epidemiology and AIDS, Chairman of the NOTF and the Representative of the NGDO partners and endorsement by the Honorable Minister of Health (see special forms attached). (5) Submission for MEDAC approval of the above signed and endorsed documents. (6) Transmission of the approved documents to APOC Headquarters in Ouagadougou through the WHO country Office in Addis Ababa. (7) Elaboration by WHO/APOC of lrtter of Agreement for each project proposal approved by the APOC Committee of Sponsoring Agencies (CSA). (8) Transmission of the above I-etter(s) of Agreement to the NOTF through the WHO country Office for signature by two authorized officers (to be identified). (9) Transmission of the signed I-etter(s) of Agreement to APOC Management in Ouagadougou through the WHO country Office in Addis Ababa. (10) Release of the first installment of funds as stipulated in the above signed Irtter(s) of Agreement to the WHO country Office bank account in Addis Ababa. (11) Transfer of the bulk of funds directly to the Regional Health Bureau (RFIB) bank account(s) by the WHO country Office in Addis Ababa as stipulated in the above l-etter(s) of Agreement. (12) Release on request of the remaining amount of money for central level activities. (13) Transmission by the Regional Health Bureau(s) concerned of monthly imprest returns to the WHO country Office in Addis Ababa as stipulated in the Letter(s) of Agreement. 18 (14) Transmission of all receipts of expenditures incurred by the central level to the WHO country Office in Addis Ababa. (15) Consolidation by the WHO country Office of all the above financial documents and transmission to APOC Headquarters in Ouagadougou. (16) Importation of Mectizan tablets into Ethiopia to be done through the WHO country Office in Addis Ababa which is exempted of any taxes and will act as a consignee. (17) Clearance of Mectizan shipments will be managed by the WHO country Office in Addis Ababa and the consignments will be handed over to the NOTF (Chairperson and National Coordinator) for distribution to the recipient projects. (18) Identification of appropriate NGDOs by the MOH for involvement in the onchocerciasis control activities in Ethiopia. l9
ANNEX 2 Tentative Outline for the Development of National Plan of Action for onchocerciasis Control in Ethiopia I. BACKGROLIND INFORMATION 1. Country profile 1.1 Geography & climate 1.2 Demography f .3 Economy L.4 Political and Administrative structure 2. Health profile 2.L National health policy and health care system 2.2 Health problems 2.3 Health infrastructure & organization 2.4 Onchocerciasis control in the context of Health Sector Development Prograrnme 3. Onchocerciasis in Ethiopia 3.1 Epidemiologr 3.1.1 Occurrence, Distribution, Magnitude and Disease burden 3.L.2 Vectors 3. I.3 Disease manifestation 3.1.4 Cross- border issues 3.1.5 Current status of Rapid Epidemiological Mapping of Onchocerciasis (REMO) 3.2 Socio-econornic impact of the disease3.3 Current onchocerciasis Control activities II. Rationale UI. General Objective: To eliminate onchocerciasis as a disease of public health and socio- econornic importance throughout the endemic areas of the country, by the 20 year 2O2O, and so contribute to the improvement of the welfare of the affected comrnunities. IV. Specific objectives f . By the year 2OO7, to establish within the framework of African Programrne for Onchocerciasis Control (APOC), effective and sustainable system for mass treatment with ivermectin in all meso and hyper-endemic areas in the country which will continue beyond the duration of APOC. 2. By the year 2OO4, to establish effective system for the clinic based treatment of onchocerciasis with ivermectin in all the h54po-endemic areas of the country. 3. Intermpt the transmission of onchocerciasis in selected foci through vector- control activities. V. Strategies 1. Community Directed Tteatment with lvermectin The main control measure that will be used is Community Directed Treatment with Ivermectin (CDTI) in all areas in the country where onchocerciasis is a disease of public health and socio-economic importance, i.e. meso and hyper-endemic areas. Applyrng this strategy means enabling the affected communities to have shared responsibility in the planning, execution, monitoring, evaluation and reportin$ process of the control activities. 2. Clinic-based Tleatment with ivermectin In all the hypo-endemic areas "passive" approach (clinic based treatment) will be undertaken. This will enable all those infected individuals in these areas, which are non-eligible for mass treatment, to have access to the drug. 3. Selective Vector Control The ministry of Health, with the assistance of any interested partner, will under[ake, where appropriate, local and selective vector control activities to intermpt the transmission of the disease, and so contribute to reinforcing the CDTI activities. 2t VI. Activities 1. Completion & Refinement of REMO I.I Training of survey teams i.:, ffiX,%:}il?or endemicity rever and cDrr priority areas 2. Sensitization & advocacy meeting at national, regional, zorral, district and community levels 3. Training of trainers on CDTI 4. CDTI training at regional level 5. CDTI training for Health facilities and Community Drug Distributors 6. Procurement & distribution of Mectizan@. 7. Development, printing & distribution of IEC materials 8. Identification of foci for selective vector control 9. Training on vector control 10. l,arwiciding 11. Operational research L2. Supervision, Monitoring & Evaluation L2.L Supervision L2.2 Monitoring 12.3 Evaluation 13. Recording and Reporting VU. Organisation & Management 1. Establishment of National Onchocerciasis Task Force. 2. Membership to NOTF 3. Responsibilities of NOTF 4. Management 4.2 Programmeexecution 4.3 Financialadministration 5. Sustainability of the prograrnme VUI. Budget 1. Introduction 2. Budgetjustification 3. Contribution of partners ' D(. Time plan 22 ANNEX 3 SCHEDULE OF CDTI PRO.IECTS DEVELOPMENT BY PHASE IN ETHIOPIA PHASE CDTI PROJECT Latest Date of Submission to APOC lst Year implementation NGO Partner Remark I MAJI 31 DEC 1999 2000 to be identified REMO to be refined PAWI 31 DEC 1999 2000 REMO to be refined METEMA 31DEC 1999 2000 REMO to be refined NORTH OMO 31 DEC 1999 2000 REMO to be refined tr HUMERA 31st DEC 2000 200r REMO to be conducted QUARA 31st DEC 2000 2001 REMO to be conducted ASSOSA 31st DEC 2000 2001 REMO to be conducted GIMBI 31st DEC 2000 2001 REMO to be conducted Itr GAMBELLA 31st MAY 2001 2002 REMO to be conducted ANGER GI]TEN 31st MAY 2001 2002 REMO to be conducted 23