Guidelines for development of national plan and project proposal for sustainable Community-Directed treatment with Ivermectin

AFRICAN PROGRAMME FOR ONCHOCERCIASIS CONTROL (APOC) GUIDELINES FOR DEVELOPMENT OF NATIONAL PLAN AND PROJECT PROPOSAL FOR SUSTAINABLE COMMUNITY-DIRECTED TREATMENT WITH IVERMECTIN June, 1999 APOC DOC.3/06/99 JAF (GUIDEA99.FIN) IMPORTANT INFORMATION In order to apply for funding to the African Programme for Onchocerciasis Control (APOC) you are required to: 1. Submit a national plan for onchocerciasis control from the national onchocerciasis task force. Information on this procedure is found on page 9. 2. Submit a proposal for funding for community-directed ivermectin treatment (CDTI). This should be submitted jointly by the Ministry of Health (MOH) of the country concerned and their partner (NGDOs) through the National Onchocerciasis Task Force (NOTF) to cover the whole or part of the National Plan. Proposal forms to be directly filled in: pages 11 to 36 If necessary and upon request, WHO/APOC may provide consultant advice to the National Onchocerciasis Task Force (NOFT) to assist in the preparation of their proposals. It must be noted that a proposal to APOC for financial support of a CDTI does not eliminate the requirement to apply for ivermectin to the Mectizan7 Expert Committee. Please note that request for ivermectin and report of its subsequent use must be made directly and separately to the Mectizan7 Expert Committee, using the forms provided by the Mectizan7 Donation Program and a copy sent to APOC. 3. Submit a signed request to APOC from the National Onchocerciasis Task Force (i.e. Ministry of Health and partner NGODs) (page 6) 4. Submit a signed letter of endorsement from the Ministry of Health (page 7) The national plan, the completed proposal form for funding, signed request from NOTF and letter of endorsement from Ministry of Health should be sent to: African Programme for Onchocerciasis Control B.P. 549 Ouagadougou Burkina Faso The forms should be received by: December 31st for review in February or 31st May for review in June-July. (i) CONTENTS Pages PART I: BACKGROUND INFORMATION ON THE AFRICAN PROGRAMME FOR ONCHOCERCIASIS CONTROL (APOC) ......................................................... 1 1. APOC: AN OVERVIEW ........................................................................................................... 2 1.1 Objective.................................................................................................................... 2 1.2 Strategy 2 1.3. Definitions 2 1.4 Partners 3 1.5 Funding 3 1.6. Organization 3 2. DEVELOPING COMMUNITY-DIRECTED IVERMECTIN TREATMENT (CDTI) 4 3. CRITERIA FOR PARTICIPATION IN APOC 4 3.1. The Disease 4 3.2. APOC Strategy 4 3.3. Partner Commitment 4 PART II: FUNDING REQUEST AND ENDORSEMENT FORMS 5 PART III: GUIDELINES FOR FORMULATING A NATIONAL PLAN FOR ONCHOCERCIASIS CONTROL THROUGH COMMUNITY-Directed IVERMECTIN TREATMENT...................................................................................... 8 1. BACKGROUND INFORMATION 9 2. OBJECTIVES 9 3. STRATEGY 9 4. ADMINISTRATION/MANAGEMENT 9 5. TIME - PLAN 9 6. BUDGET 9 PART IV: PROPOSAL FORM FOR COMMUNITY-Directed IVERMECTIN TREATMENT ..... 10 SECTION 1: COUNTRY PROFILE 11 1. INFORMATION ON THE PROJECT AREA FOR C.B.I.T. 11 1.1 Geographical and administrative area(s) 11 1.2 Topography, climate, access 11 1.3 Onchocerciasis endemicity levels 12 1.4 Community Structure 13 2. PAST AND CURRENT STATUS OF CDTI IN PROJECT AREA 14 (ii) SECTION 2: PROJECT EXECUTION OUTLINE 15 3. DESCRIPTION OF PROPOSED COMMUNITY-DIRECTED IVERMECTIN TREATMENT (CDTI) 15 3.1 Outline Plan and Timing 15 3.2 Health Education and Community Interaction and Participation 16 3.3 Local Operational Research 19 3.4 Training 19 4. SUPPLY, IMPORTATION, STORAGE, INVENTORY AND DELIVERY OF MECTIZAN TABLETS 20 5. SUPERVISION/MONITORING AND EVALUATION 20 5.1 Supervision during CDTI 20 5.2 Monitoring of CDTI 21 5.3 Evaluation of CDTI 21 6. SUSTAINMENT OF THE CDTI AFTER THE WITHDRAWAL OF EXTERNAL FUNDING 22 6.1 Integration of the CDTI into other Community-directed or Primary Health Care (PHC) Systems....................................................................... 22 6.2 Cost-recovery Systems during Community-directed Ivermectin Treatment 25 6.3 Other issues 26 7. CROSS-BORDER CONSIDERATIONS 28 8. SPECIAL RISK ISSUES 29 SECTION 3: ADMINISTRATION/FINANCIAL 30 9. ADMINISTRATION 30 9.1 Organogram of the CDTI Project 30 9.2 Financial Administration 31 9.3 Timed plan of action 33 10 BUDGET 34 10.1 Budget estimate 34 10.2 Budget Justification 35 10.3 Current resources available in CDTIs 36 PART V: APPENDICES 37 APPENDIX 1: ESTIMATED NUMBERS OF COMMUNITIES AND PERSONS TO BE TREATED EACH YEAR, BY ENDEMICITY LEVEL 38 APPENDIX 2: SAMPLE COPY OF BUDGET .................................................................................. 39 APPENDIX 3: INDICATORS FOR EVALUATION, SUSTAINABILITY/INTEGRATION OF CDTI .................................................................................................................. 40 PART I BACKGROUND INFORMATION ON THE AFRICAN PROGRAMME FOR ONCHOCERCIASIS CONTROL (APOC) 2 1. APOC: AN OVERVIEW 1.1 Objective The objective of the Programme (APOC) is to establish, within a period of 12 years (1996-2007), effective and self-sustainable community-directed ivermectin treatment throughout the endemic areas in the geographic scope of the Programme (i.e. those endemic countries of Africa outside OCP) and, if possible, to eliminate the vector and hence the disease, by using environmentally safe methods in selected foci. The attainment of this objective will ultimately realize the goal of elimination of onchocerciasis as a disease of public health and socio-economic importance throughout Africa and so contribute to improving the welfare of its people. 1.2 Strategy 1.2.1 Principal strategy The main control measure used by APOC will be mass treatment with the microfilaricidal drug Mectizan7 (of which the active ingredient is ivermectin MSD), provided free of charge for as long as needed to as many people as necessary by the manufacturers, Merck and Co., Inc., under the terms of the Mectizan7 Donation Program. Treatment will be through community-directed distribution, in all areas of the programme where onchocerciasis is a disease of public health and socioeconomic importance. The APOC will be a 12 year programme during which self-sustainable Community-Directed Ivermectin Treatment (CDTI) will be established in all participating African countries. The CDTIs must be designed to become self-sustaining, without APOC or other external support, within 5 years from their inception. 1.2.2 Local vector elimination Where appropriate CDTIs may be supplemented by local elimination of the blackflies (Simulium). Local vector elimination operations will be funded entirely by APOC except for any in-kind contribution from the Ministry of Health (MOH). APOC, through WHO, may provide external consultants to assist in the planning, training and execution of the vector elimination projects. 1.3. Definitions 1.3.1 Community-directed Treatment In community directed ivermectin treatment, the execution of delivery is undertaken by members of the endemic communities themselves. Treatment may be provided by trained personnel, known as Community-Directed Distributors (CDD's), selected from the various existing organizational structures at the community level, e.g. women cooperatives. Whatever the treatment approach used, it should be fully supported by the community itself and the community should be responsible for its execution under minimum but effective medical supervision, once it has received the necessary information and training. 3 1.3.2 Sustainability The concept of sustainability in this development process refers to the ability of communities following initial external investment to maintain the viability and continuity of the ivermectin treatment process without external support. 1.4 Partners The CDTIs with financial and technical support from APOC and through the National Onchocerciasis Task Force (NOTF) shall be joint, co-operative undertakings of the Ministries of Health (MOH) of the participating countries, working in partnership with Non-Governmental Development Organizations (NGDOs) and other participating partners which have experience in running CDTIs and which are prepared to continue to assist in implementing such projects and in achieving their full sustainability as stated above. 1.5 Funding Funding for CDTIs will be on the basis of up to 75% contribution from APOC, and a minimum of 25% budget contribution from the NGDOs and the host governments (working together as the NOTF), in cash or in kind (e.g. provision of personnel, office space, etc.). Contributions from the NGDOs shall not include overhead costs of these organizations outside the country whose CDTI they are assisting. Funds from the World Bank APOC Trust Fund will be channelled through WHO and APOC to the designated project bank account. Disbursement of funds will require 2 signatures from members of the NOTF, one representing the MOH and one representing the NGDO partners. Proposals for CDTIs will be reviewed by a Technical Consultative Committee (TCC) of APOC, which meets twice a year, in April and September, and which will make recommendations for funding to the Committee of Sponsoring Agencies (CSA) of APOC. 1.6. Organization The governing board of APOC is the Joint Action Forum (JAF), which is made up of representatives of: a) contributing parties b) participating countries c) four sponsoring agencies d) eleven representatives of NGDOs The Committee of Sponsoring Agencies (CSA), consisting of representatives of the FAO, UNDP, WHO and the World Bank, acts as an executive secretariat. APOC's funds are raised and held in trust by the World Bank. The Executing Agency for APOC is the WHO. The present Headquarters of APOC are located in Ouagadougou, Burkina Faso, and the interim Director of the Programme is also the Director of the OCP. The NGDO Coordination office for ivermectin distribution, a part of APOC's management, is directed in the Prevention of Blindness and Deafness Division of WHO in Geneva, and acts as a liaison office. 4 2. DEVELOPING COMMUNITY-DIRECTED IVERMECTIN TREATMENT (CDTI) The development of CDTI should pay appropriate attention to relevant socio-cultural factors at the community level and to the lessons learned from previous experiences. Continued development and improvement of CDTI will be important as was highlighted during a consultative meeting on APOC which concluded that ACDTI should form the main basis for the control strategy of the new programme. However, because of the diversity of endemic communities, the need for local solutions, the particular needs associated with gender differences, and the need to learn from experience, it will be necessary to continue the development and improvement of community- directed approaches during the new programme.@ The further development of CDTI will involve the reorientation of non-sustainable approaches to mass ivermectin treatment, the incorporation of operational research findings, careful evaluation of the implementation of new approaches, and adjustment of CDTI=s when required. It will be a learning process in which the regional structure of APOC is used to ensure that lessons learned are available to all participating countries. The development and implementation of CDTI will be undertaken by Ministries of Health and their partner NGDO=s through projects supported by APOC. It is anticipated that the development, implementation and fine-tuning of a CDTI project will take up to five years. The main criterion for supporting projects will be their proposal for progression towards development and implementation of sustainable CDTIs. It must be reiterated that the concept of sustainability shall be the underlying philosophy of the programme. 3. CRITERIA FOR PARTICIPATION IN APOC Criteria for participation in APOC relate to the disease, APOC's principal strategy and partners' commitment. 3.1. The Disease Onchocerciasis must be recognized at the national level as a public health problem warranting control. The epidemiology of onchocerciasis must be documented in terms of geographical distribution, population at risk, prevalence and severity of the disease. 3.2. APOC Strategy All involved partners (Ministry of Health, NGDOs other participating agencies and communities at risk) agree to the strategy of developing effective self-sustainable community-directed ivermectin treatment which will continue beyond the duration of APOC in order to eliminate onchocerciasis in all areas where it is a disease of public health and socio-economic importance. 3.3. Partner Commitment The Ministry of Health and NGDO partners agree to establish a National Onchocerciasis Task Force which will formulate and implement a National Plan for onchocerciasis control. The partners agree to meet at least 25% of the costs of CDTIs, and to provide annual operational and financial reports to APOC. The partners agree to internal and external evaluations, including audits, and to facilitate visits and activities of APOC staff members, or their representatives. PART II FUNDING REQUEST AND ENDORSEMENT FORMS 6 National Onchocerciasis Task Force (NOTF) of ........... Application for support to the African Programme for Onchocerciasis Control (APOC) In accordance with the memorandum of agreement for the African Programme for Onchocerciasis Control: 1. The NOTF on behalf of the Government of (..........), (a partnership of government, the NGDOs and other partners) hereby expresses its wish to enter into collaboration with the APOC and the MEC with a view to conducting an onchocerciasis control project in (..........). 2. Onchocerciasis in (..........) is considered by the health authorities as a problem of sufficient importance to warrant the implementation of a control project in the endemic areas with the aim of eliminating the disease as a public health and socioeconomic problem throughout the country. 3. It is estimated that out of a total population of .....000 in (..........), there are (number of infected people) people infected with the parasite, Onchocerca volvulus, causing blindness, serious visual impairment and debilitating skin disease. 4. The Proposed control project will rely on community-directed ivermectin treatment as its main intervention tool. 5. The NOTF has scrutinized the criteria and conditions for application to the APOC and is satisfied that the proposed project(s) meets all the criteria and fulfills the conditions established by the APOC. 6. Details of the project proposal for control of onchocerciasis in (..........) including the support requested from APOC to successfully implement the project are provided in the enclosed proposal. 7. The NOTF of (.........) pledges its full collaboration with APOC in the expectation of acceptance of the present proposal. _________________________ _________________________ Signature, place and date Signature, place and date NOTF Rep. of Gov. NOTF Rep. of NGDOs _________________________ _________________________ Name and title of signatory Name and title of signatory 7 Letter of endorsement from the Government of......... To the African Programme for Onchocerciasis Control (APOC) for support of the proposed onchocerciasis control project In accordance with the memorandum of agreement for the African Programme for Onchocerciasis Control: 1. The Ministry of Health on behalf of the Government of (.......) hereby endorses the attached project proposal to be submitted to APOC for financial support. 2. This proposal reflects the collaboration between the members of the National Onchocerciasis Task Force and APOC with a view to conducting an onchocerciasis control project in (............). 3. The National Onchocerciasis Task Force is a partnership of the Government, Non-Governmental Development Organisations and other participating parties which will be responsible for the implementation of this project. 4. The Government shall assure free entry of ivermectin into the country for delivery to the applicant without imposing duty, tax, or other costs. 5. The Government of (...) pledges its full collaboration with the APOC in the expectation of acceptance of the present proposal. _______________________________ Signature, place and date _______________________________ Name and title of signatory PART III GUIDELINES FOR FORMULATING A NATIONAL PLAN FOR ONCHOCERCIASIS CONTROL THROUGH COMMUNITY-DIRECTED IVERMECTIN TREATMENT 9 GUIDELINES FOR FORMULATING A NATIONAL PLAN FOR ONCHOCERCIASIS CONTROL The following questions should be considered in finalising a national plan 1. BACKGROUND INFORMATION What is the administrative and health structure? What is the primary health care system? What is the knowledge of the distribution and endemicity of onchocerciasis in the country? How far has Rapid Epidemiological Mapping of Onchocerciais (REMO) been carried out in the country? How far has Rapid Epidemiological Assessment (REA) been carried out in the country? What is the estimated population at risk? How many rural communities constitute the population at risk? What are the common clinical minifestations of the disease in affected communities? Is there a cross-border focus of onchocerciasis, if so which countries are involved? 2. OBJECTIVES What are the national programme objectives? 3. STRATEGY What is the overall strategy for the control of onchocerciasis? How are priority areas for onchocerciasis control identified? What are the criteria for including populations for CDTI (See paragraph 1.3 of the proposal form)? How will CDTI be developed, and how will communities be involved in this process? What are the plans for monitoring CDTI? How will ivermectin be procured? What mechanisms will be used to ensure delivery of ivermectin to CDTIs? Is there a national policy for cost recovery and how will this affect CDTIs? How are CDTIs to be made sustainable without external support at the cessation of APOC support? If there are cross-border foci of disease what particular action is being taken to deal with these areas? 4. ADMINISTRATION/MANAGEMENT Is there a National Onchocerciasis Task Force (NOTF)? If not what action is being taken to establish this body? Who are the members (organisations and positions) of the NOTF? Is there a National Co-ordinator? If not what action is being taken to establish this position? What is the formal link between the NOTF and Ministry of Health? How does the NOTF facilitate development and interact with CDTIs? 5. TIME - PLAN What are the major control activities to be undertaken year by year for the programme to achieve its objectives? 6. BUDGET What is the estimated budget year by year for the programme to achieve its objectives? PART IV PROPOSAL FORM FOR COMMUNITY-DIRECTED IVERMECTIN TREATMENT 11 SECTION 1: COUNTRY PROFILE 1. INFORMATION ON THE PROJECT AREA FOR C.B.I.T. * 1.1 Geographical and administrative area(s) Please describe the area(s) of the country in which the proposed CDTI will be carried out. (List the administrative units or parts thereof e.g., Local Government Areas, Districts, Arrondissements, Health areas etc. that will be covered and provide a map showing their lay-out) 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-savanna mosaic, Guinea savanna, Sudan savanna, mountainous or flat), providing maps, if appropriate. 1.2.2 Give the approximate times of the rainy and dry seasons and the months covered by the farming season. * Additional sheets may be used to provide information in this form where necessary 12 1.2.3 Provide information on the state of the roads and the effect of this on the movements of CDTI personnel in the area at different times of the year. (A map may be useful) 13 1.3 Onchocerciasis endemicity levels The levels of onchocerciasis endemicity in communities in the CDTI area must be assessed by simple methods before treatment starts. For the purposes 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 1) TABLE 1. Classification criteria for endemicity levels in rural communities 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 39% greater than 59% MESO-ENDEMIC Community Treatment (DESIRABLE) 20 - 39% 40 - 59% HYPO-ENDEMIC (NON-URGENT) less than 20% less than 40% 1.3.1 Directed on the system in Table 1 and using the format in Appendix 1, please indicate the estimated numbers of communities at each endemic level and the numbers of persons in them. 1.3.2 Complete Appendix 1 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 method used. 1.3.4 For areas still to be covered, where endemicity levels are not yet known, please describe the method you will use to collect the necessary endemicity data. 14 1.4 Community Structure Provide background information on the social organizations of communities in the C.B.I.T. areas. This may include information on: Settlement pattern of the community (e.g. hamlets, seasonal farmsteads, dispersed populations, etc.) The ethnic group(s) in the community Please provide information about the area covered by CDTI indicating whether they are migrants, nomads, refugees or internally displaced populations. Community leadership structure Main occupation of community and periods of major communal activities Preferred channels of communication in the community Existing active community associations/groups in the area (e.g. social, religious, etc.) Established distribution systems in the community Social communal activities and months during which the activities take place Any previous experience of the community with development/health projects Description of other anthropological characteristics of the communities. 15 2. PAST AND CURRENT STATUS OF CDTI IN PROJECT AREA 2.1 Please indicate if the CDTI is an expansion of an existing CDTI. 2.2 State the number of years the programme has been operating, and if possible enclose previous statistical, financial and annual reports. 2.3 State the number of persons treated each year for the last 5 years 2.4 List the organization(s) involved in the programme, the sources and amount of funds used each year for the last 5 years. 16 SECTION 2: PROJECT EXECUTION OUTLINE 3. DESCRIPTION OF PROPOSED COMMUNITY-DIRECTED IVERMECTIN TREATMENT (CDTI) The main strategy of the project will be to develop and establish community-directed ivermectin treatment systems which can be sustained by the endemic communities themselves without external support after the 5-year project period. This section should describe how the NOTF plans to develop and implement CDTI in all high-risk communities in the project area. The plan should take into account the need to develop approaches to CDTI which are appropriate for the different local situations, and the need to carefully evaluate the implementation of the selected approaches and adjust them when required. 3.1 Outline Plan and Timing 17 3.2 Health Education and Community Interaction and Participation 3.2.1 How will you approach and interact with the community 3.2.2 Health education Health education and community mobilization will be an integral part of all approaches to CDTI. Health education activities should ensure a two way feedback with regards to knowledge, awareness, perception and observable attitudinal changes about onchocerciasis and its treatment. Appropriate health education messages in the form of posters, pamphlets and verbal presentations will need to be developed and tested. Health education should address the following issues (Table 2): Table 2: Critical issues in the development of Health Education for CDTI ISSUES Health Education Messages Knowledge of the disease Local name of the disease Symptoms Causation/transmission (simple) Knowledge of treatment Previous experiences with Di-Ethyl Carbamazine (DEC) Introduce Mectizan7 (Ivermectin) Dosage Exclusions Reactions Beneficial side effects Attitude to treatment Advantages of treatment Free Yearly treatment Possibility of self treatment at community level. Importance of maximal coverage Attitude to disease The disease can be controlled Onchocerciasis blindness and skin changes can be prevented Attitude to good record keeping Minimum requirements for record keeping Records are confidential and strictly of health issues Records required are for subsequent drug supply 18 a) Have any KAP surveys been done in the project area and if so, what were the results? b) What methods will be used to develop health education material for the communities and for the agents who will be responsible for ivermectin treatment? c) What methods will be used to provide health education to the endemic communities and to the agents responsible for treatment? 19 3.2.3 Community Participation It must be reminded that in community-directed ivermectin delivery systems, the execution of ivermectin treatment is done by members of the endemic communities themselves. Treatment may be provided by trained personnel, known as Community-Directed Distributors (CDD's), selected from various organizational structures at the community level ranging from women cooperatives to traditional organizational structures. Whatever the treatment approach used, it should be fully supported by the community itself and the community should be responsible for its organization and execution with minimum but effective medical supervision once it has received the necessary information and training. a) Explain the organization of the intended community-directed ivermectin treatment in the project. b) How will ivermectin distributors be selected? c) How will non-eligibles be identified and defaulters be followed-up? 20 3.3 Local Operational Research Are there any plans to conduct local operational research? Yes G No G If yes please give details 3.4 Training Training and re-training of community-directed distributors to operate the CDTI is a vital first step in organizing the programme and remains a continuing commitment thereafter. a) What training will be provided to ensure the development and sustainment of the CDTI? b) Indicate criteria for selecting trainees (supervisors and community-directed distributors) c) Indicate number, type and duration of training courses intended 21 4. SUPPLY, IMPORTATION, STORAGE, INVENTORY AND DELIVERY OF MECTIZAN TABLETS This section is only a reminder and concerns the supply, importation, storage, inventory and delivery of ivermectin tablets, donated by Merck & Co, who will also pay handling charges for ivermectin to their accredited agents. PLEASE NOTE THAT REQUEST FOR IVERMECTIN AS WELL AS REPORTING OF ITS SUBSEQUENT USE MUST BE MADE DIRECTLY AND SEPARATELY TO THE MECTIZAN EXPERT COMMITTEE, USING THE FORMS PROVIDED BY THE MECTIZAN DONATION PROGRAM AND A COPY SENT TO APOC 5. SUPERVISION/MONITORING AND EVALUATION 5.1 Supervision during CDTI Projects require to be supervised and monitored. However, APOC funded projects will 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. How will this continue at the cessation of APOC support? b) Describe how you would ensure that supervision will: fall within the requirement accounting for ivermectin use be sustained when the programme ends in 5 years ensure maximum involvement of the communities in the process 22 5.2 Monitoring of CDTI It is important to collect information to monitor the progress of the CDTI. What indicators will be used to monitor: ivermectin distribution? health education and community participation? management systems? The following items may be considered Ivermectin Distribution numbers of communities and persons treated with ivermectin treatment coverage regularity of treatment exercise compliance reporting adverse reactions Health Education and Community Mobilization numbers of communities being mobilized by the project evidence of impact of health education Management are activities being carried out according to plan and on schedule? inventory control, are record forms accurate and completed on time? numbers of persons trained balance of genders in staff of the programme 5.3 Evaluation of CDTI Annual external review incorporating field visits will be undertaken to ensure that projects are meeting target indications outlined in this proposal. Such reviews will provide TCC with the assurance that each project is moving towards its long term stated goal and if appropriate make recommendations about any deficiencies or modifications to this project. Such reviews will draw on the indicators developed by TCC as a guide (see Appendix 3) for such evaluation. 23 6. SUSTAINMENT OF THE CDTI AFTER THE WITHDRAWAL OF EXTERNAL FUNDING The concept of sustainability refers to the ability of countries and affected communities following initial external investment to maintain the viability and continuity of the ivermectin treatment process without external support. For APOC funded projects, such 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 programme, and that the community directed distribution systems established shall thereafter be sustainable by the governments of the endemic countries concerned. Progress and plans towards sustainment, including the phasing out of external and NGDO's support, must be reported annually and satisfactory progress in this direction will be a condition for each succeeding year's funding instalment. Please address the following areas that relate to sustainability: "integration into primary health care", "cost-recovery", and "other sustainment issues". 6.1 Integration of the CDTI into other Community-directed or Primary Health Care (PHC) Systems The principal goal of the APOC is to establish cost-effective ivermectin-directed control for onchocerciasis which can be sustained by the endemic communities and countries. One way to ensure sustainment is to integrate the CDTI into the PHC system of the country, which means more than just using the system for ivermectin distribution. 6.1.1 Is there an official PHC policy and structure in the country? Yes G No G If yes, please give a brief outline of what it is. a) How functional is the primary health care system? - Fully functional G - Partly functional G (Please specify) - Non Functional G (Please specify) b) Does it cover the whole country? Yes G No G If no, in what part(s) of the country is there a fully functional PHC structure? 24 c) What percentage of communities where onchocerciasis is endemic, and which are eligible for community-directed treatment, have an existing and functional PHC structure? d) What organizations are supporting the development of PHC in your country? e) Is there any past experience in the country of a programme integrating with the PHC? If so, what programme was it and how successful was the integration? f) Are there any plans to integrate other rural health programmes, such as the Expanded Programme of Immunization, Maternal and Child Health Programmes or programmes for the control of other parasitic diseases, with the PHC system? 25 g) Describe how the CDTI will be integrated into the PHC system1; the way the PHC system will be used to achieve integration and the key persons in the PHC system who will be needed to achieve the integration h) Indicate how early in the CDTI the process of integration will be introduced; how it will continue thereafter, and after how many years within the externally-supported lifetime of the CDTI it will be completed. 6.1.2 If there is at present no PHC system in operation, or in those areas where these structures are non-functional, describe how the CDTI may be used to initiate and expand into such a system, giving a time-frame for intended progress. 6.1.3 In which way(s) can community-directed ivermectin treatment initiate or strengthen PHC? 1. Simply stating that the project will be integrated into PHC is not enough. 26 6.2 Cost-recovery Systems during Community-directed Ivermectin Treatment Cost recovery for Primary Health Care is mandatory in some countries and it may be one means of sustaining an CDTI after APOC funding ceases. However, please note well that since ivermectin is donated free, there can be no cost recovery in respect of the value of the drug itself; cost recovery can only relate to the costs of distribution. 6.2.1 Please state whether there will be any system of cost recovery (such as is recommended in the Bamako Initiative) to help cover outlays on the distribution of ivermectin in the present CDTI. 6.2.2 State exactly how any such system will be organized, including answers to the questions listed below. What charge will be made per person or per family? Which groups of persons will be exempted from payment? Will payments be in cash or in kind? If in kind how will this ensure sustainability? What provision will be made to ensure that all those eligible to take ivermectin, but who are unable to pay, will also receive treatment? How will it be determined who is unable to pay? Who will collect the payments? How will this person safely transport funds to a place of safe keeping? Where and by whom will any funds collected be safely kept? What systems will be put in place to ensure the proper use and management of collected funds? For what purpose(s), including defrayment of distribution costs, will the funds collected be used? What role will Village Health Committees play in the management and allocation of the funds raised? 27 6.3 Other issues Please provide information on other issues and constraints relating to sustainability of CDTI you anticipate and identify how they will be overcome. For example: the mobilization of endemic communities the maintenance of adequate supervision and monitoring inadequate human resources logistics and communications social/cultural factors declining community compliance 28 6.4 How do you intend to monitor and measure the progress towards sustainability (See Appendix 3 for a list of possible indicators of sustainability)? 29 7. CROSS-BORDER CONSIDERATIONS Where an endemic area extends across the borders of two or more adjacent states, special problems of cooperation between the respective country CDTI may arise. In the event that there are areas to be covered by your proposed CDTI where the endemic zone extends across the frontier into one or more neighbouring countries, and where there are likely to be transitory or even large-scale migrations of Onchocerca-infected persons either way across the border. 7.1 Please describe the particular situation as it is likely to affect ivermectin treatment , and the methods you will use to deal with it. 7.2 Include pertinent observations on current political and health relations with the neighbouring state(s). 30 8. SPECIAL RISK ISSUES In some areas of some countries there may be special risks which could hinder the smooth running of an CDTI. 8.1 Please describe the situation in any areas covered by your proposed CDTI where this factor may interfere with the programme, and assess future prospects. 31 SECTION 3: ADMINISTRATION/FINANCIAL 9. ADMINISTRATION 9.1 Organogram of the CDTI Project 9.1.1 Please provide an organogram for the CDTI showing the organizational structure responsible for implementing this proposal. 32 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 channelled through WHO and APOC to the Project bank account. Disbursements of funds will require 2 signatures from members of the NOTF, one representing the Ministry of Health (Government) and one representing the NDGO partners. APOC will issue cheques (advances) in accordance with WHO rules and the previously agreed project documents and/or plans of operations. When the total payment in cash required for the project exceeds $ 100,000, the payment must be made in installments. The first 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 projects being funded by APOC. Built into this document is an imprest mechanism, whereby the project will report its expenditure on a quarterly basis and receive further advances on that basis. Each project funded by APOC will require a periodic external audit at project expense. Each project must have one senior staff member who is accountable for the management and control of project funds. Standard internal financial checks and balances must be incorporated into each project's financial management plan. 9.2.1 Input from the Ministry of Health a) Indicate resources that will be provided by the Ministry of health and other government agencies. 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, their experience in onchocerciasis control through ivermectin treatment. 33 9.2.2 Input from the Partner NGDO(s) a) Please provide a letter from the Executive Director or the Director of Onchocerciasis Programmes of each participating NGDO stating their intentions to participate in and support the National Onchocerciasis Control Programme. b) Give information of the input from each NGDO participating in this project. c) Please provide also a nominal list, grading and post description for the personnel to be provided by partner NGDO(s). Indicate clearly what will be their functions in the programme and their experience in onchocerciasis control through ivermectin distribution. 9.2.3 Input from other Agencies. Please list any other agencies or parties that will be involved in the running or financing of the CDTI, and indicate clearly their roles, functions and contributions. 34 9.3 Timed plan of action Provide a time chart(s) showing how the various activities of the CDTI will proceed over the course of the proposed programme. Numerical annual targets for all planned activities should be provided for each time point. The time charts should also indicate how external support will be phased out over the 5 year period. 35 10 BUDGET 10.1 Budget estimate Budgets must indicate total funds to undertake the project. The amount of funding requested from APOC, and the amount provided by the MOH, NGDO(s), and other partners. All estimates must be made in US dollars. Each budget must include at least the following major categories (see Appendix 2) indicating the contribution of the partners to reflect sustainability of CDTI: personnel (services) capital equipment supplies training travel communications consultants operating expenses external audit 36 10.2 Budget Justification Please provide a narrative description of the reasons for each proposed line items of the budget. 37 10.3 Current resources available in CDTIs Existing CDTIs (for continuation or expansion) will have resources already available. Please provide a detailed list of all existing personnel, equipment and supplies (including vehicles, etc.) belonging to the programme, indicating their ownership (MOH, NGDO, other Agency, etc.) and their level of functionality. PART V: APPENDICES 39 APPENDIX 1: ESTIMATED NUMBERS OF COMMUNITIES AND PERSONS TO BE TREATED EACH YEAR, BY ENDEMICITY LEVEL AREA COVERED: COMMUNITY ENDEMIC LEVEL HYPER-ENDEMIC MESO-ENDEMIC HYPO- ENDEMIC* TYPE OF TREATMENT Community-directed Community-directed Community- directed YEAR 1 No. of communities to be treated Total population in above communities YEAR 2** No. of communities to be treated Total population in above communities YEAR 3** No. of communities to be treated Total population in above communities YEAR 4** No. of communities to be treated Total population in above communities YEAR 5 ** No. of communities to * Onchocerciasis is not considered an important Public Health problem in hypo-endemic communities and APOC will not normally fund community-directed treatment in such communities. The inclusion of such communities in the proposal will require a special justification for consideration by the TCC. ** It is understood that the figures for years 2-5 are likely to be estimates which may change as the project progresses. 40 be treated Total population in above communities 41 APPENDIX 2: SAMPLE COPY OF BUDGET (1997 - 2001) 1997 1998 1999 2000 2001 APOC MOH NGDO TOTAL APOC MOH NGDO TOTAL APOC MOH NGDO TOTAL APOC MOH NGDO TOTAL APOC MOH NGDO TOTAL Personnel Capital Equipment Supplies Training Travel Communication Consultants Operating expenses External audit Other Expenses (specify) Recapitulation for each year Total 42 APPENDIX 3: INDICATORS FOR EVALUATION, SUSTAINABILITY/INTEGRATION OF CDTI Project Evaluation Management Financial management Effectiveness of communications Training and capacity building Institutional commitment Fulfilment of other relevant sectors Problem solving capacity Integration of operational research Project effectiveness Result of KAP studies Treatment coverage Follow-up of non-eligible and absentees Management of adverse reactions Reliability of reporting Sustainability/Integration Politicial will of host government political will as shown in policy statements and apparent commitment of high-level officials official action assigning personnel, funds, vehicles to programme Long-term planning is there a long-term plan for sustaining the financing and the management of the programme? Progress toward financial sustainability if programme sponsors cannot continue their current level of commitment for at least another five year, what percentage of running costs is now paid for host governments or fees? Progress toward integration to what extent has ivermectin distribution been integrated with other health service programmes? evidence of community empowernment and ownership change in KAP over time extent of involvment of both genders and non-literates extent of involvment of local community-directed organizations This document was created with Win2PDF available at http://www.daneprairie.com. The unregistered version of Win2PDF is for evaluation or non-commercial use only.