Devolution plan: control of onchocerciasis, yaws, leprosy and Guinea worm in Ghana

Onchocerclasis Control Programme in Wcst Africa pnograrure de Lutte contle l'Onchocercose en Afrique de l'Ouest JOINT PROGRAI\{ME COMMITTEE Office of the Chairztan JPC .CCP COIVIIIE CONJOINT DU PROGRAIVIME Burcau du Pr6sident JPC11.8(c) ORIGINAL: ENGLISH Septenber 1990 JOINT PROGRAUT{E COHUITTEE Eleventh session Cona 3-6 December 1990 Provisonal agenda item 9 DEVOLTTTON PLAI{ - CONTROL OF ONCHOCERCTASTS, YAWS, LEPROSY AT{D GUIIIEA I|OR}I IN GHANA t,I i i t REPUBLIC OF GHANA MINISTRY OF HEALTH DEVOLUTION PLAN CONTROL OF ONCHOCERCIASIS, YA}VS, LEPROSY AND GUINEA }VORM Prepared by NATIONAL ONCHOCERCIASIS COMMITTEE NATIONAL ONCHOCERCIASIS SECRETARIAT MINTSTRY OF FINANCE & ECONOMIC PLANNInNG ACCRA JUNE I99O j 3SUMMARY The Onchocerciasis Control Programme (OCP) began its control operations in Ghana in 1974, in what is now called the Original Programme area in northern Ghana, covering the present-day Upper East, Upper West and Northern Regions. In 1988 the control activities were further extended southward to cover the southern Extension area. In the Devolution exercise about to take off, however, only the original Programme area is involved. Prior to OCP control operations, the epidemiological data showed that the original Programme area was highly endemic for the savanna blinding type of onchocerciasis. About a third of the population was afflicted by the disease, with a blinding rate reaching up to l09ir in certain communities. The area cqntained some of the worse affected localities, such as villages in the Sissili/Kutpawn area and along the Btack Volta, where prevalence rates reachecl 70% or more. Nakong, on the Sissili River, for instance, had a prevalence rate of 1000/u in adults. The disease created serious obstacles to the socio-economic advancement of much ol' the highly endemic area. Following intervention efforts by the OCP, significant control of onchocerciasis in the Programme area has been achieved. However, a number of 'black spot" areas have remained problematic. Those include the Sissili/Kulpawn area and the Bui area on the Black Volta where residual transmission still occurs, due to a combination of factors such as the high CMFL and high ATP in the past, occurrence of insecticide resistance and reinvasion by the flies. In the Devolution Plan of Ghana, the chief aims are to sustain the gain so far achieved, to prevent recrudescence of the disease and to overcome the problems posed by the "black spot" areas. The devolution activities will be closely integrated into the PHC programme, full1, involving community participation. Apart from surveillance and control of onchocerciasis, the Devolution Plan envisages the inclusion of the control of three other diseases of public health importance endemic in the proS,ramme area. These are leprosy, yaws (to be eradicated by 1995) and Guinea worm (to be eradicated by t993). Their inclusion in the Devolution programme is fully justified by the fact that, like onchocerciasis, they present distinct skin manifestations which lend themselves to easy differential disgnosis. They also constitute problems for the socio-econom ic development. In the Devolution Plan, three Potyvalent Teams, a Monitoring Team and an Evaluation Team are to be set up in order to ensure the effective execution of the plan. The PTs rvill provide technical resources and backings to all stages of the devolution activities, including the large-scale survey to be carried out once every three years. The Monitoring Team will assess and ensure the smooth implementation of all aspects of the institutional arrangements to be put in place. Finally, the Evaluation Team will carry out, in the third and fifth year of the programme, epidemiological and parasitological surveys to evaluate the progress and the achievement of the Devolution Plan. High priorities in the Devolution Plan are also accorded to the training of health personnel of all levels to cope with the integrated control programme and the strengthening of health facilities within the programme area. For the successful implementation of the Devolution Plan, the estimated cost for the l'irst five years amounts to 936,000,000 cedis or US $ 2.t40.000. 2TABLE OF CONTENTS EXECUTIVE SUMMARY 1. INTRODUCTION 2. EPIDEMIOLOGICAL SITUATION 2.1. Epidemiological situation of onchocerciasis 2.2. Epidemiological situation of other diseases: yaws, leprosy, Guinea worm 3. GENERAL SITUATION IN THE COUNTRY 3.1. General presentation 3.2. Demographic and Socio-Economic Indices 3.3. Organization Chart of Ministry of Health and Health Policl' 3.4. Personnel and facilities 3.5. Cost and Financing of Public Health Services 3.6. Function and Resources for Epidemiological Surveillance 4. SURVEILLANCE AND TREATMENT 4.1. Objectives for onchocerciasis, yaws, leprosy and Guinea worm 4.2. Activities for onchocerciasis, yaws, leprosy and Guinea worm 5. ORGANIZATION OF SURVEILLANCE AND TREATMENT 5.1. Human resources 5.2. Material resources 5.3. Cost of programme for five years 5.4. Ghana Government contribution to Devolution Plan implementation 6. PROVISIONAL TIMETABLE ANNEXES l. Phases of the implementation of the Programme in the original Programme area 2. Northern Ghana within the Volta Basin 3. Pre-control prevalence of onchocerciasis 4. Prevalence of onchocerciasis in 1989 5. List of diMstricts in the Devolution area 6. Estimated cost of the Devolution-Plan 7. Material allocations Pages 3 8 9 10 13 r3 14 14 4 5 5 7 8 15 15 16 L7 20 2t 22 23 25 26 27 28 29 30 38 52. EPIDEMIOLOGICAL SITUATION 2.1. Epidemiologicel Situetion of Onchocerciasis 2.1.1. Situatiort before the beginning of Vector Contol The objective of the Onchocerciasis Control Programme (OCP) is to eliminate onchocerciasis as a disease of public health and socio-economic importance throughout the Programme area and to ensure that there is no recrudescence of the disease thereafter (Anon, 1985). In pursuance of this the OCP is pre-occupied mainly with the savanna or blinding form of onchocerciasis which, in the Programme area, is endemic mainly in the savanna regions. The forest or non-blinding form of the disease is not covered by the Programme (Anon, 1986). Prior to the launching of the OCP in 1974 it was estimated that onchocerciasis affected berween 1.0 and 1.5 million inhabitants, with blind people numbering about 120,000 in the Votta River basin area. This area covered an estimated 764,000 sq. km in the seven originalll' selected endemic countries in West Africa (Anon, 1973). In Ghana the area involved covered all of Northern Ghana circumscribed by the Black Volta to the West and south-west, the Oti river to the east and with the Volta lake as the southern border. This covered an estimated 98,000 sq. km. with a population of 1.6 million (1970-71 Census) (See Annex 2). Duke-Elder (in Crisp, 1956) stated that about 30,000 of them were blind, i.e., about 25%of all blind persons in the original OCP area. In some villages, a tenth of the people were blind and in others, where the struggle had been won by the fly, the people had abandoned their homes carrying wirh them rhe menace of the disease to areas further south. Thus there were high population densities in the area between the valleys of the White and Red Voltas, the Sissili and the Kulpawn rivers, while the valleys themselves were sparsely populated or even uninhabited (Crisp, 1956). Relatively densely populated areas were encountered in the Bawku district in the extrenre north-east and around Tamale in the centre, and in the Wa and Lawra districts in the north-west. Generally, the northern portion of Ghana has low population density while the southern portion is rather densely populated. Annex 3, shows the prevalence of onchocerciasis in the Programme area. This area, particularly in the Upper Regions of Ghana, was among the worst onchocerciasis endemic areas in the Volta basin. The area drained by the Red and White Voltas, the Sissili and the Kulpawn rivers, and along the Black Volta supported prevalence rates of over 70%. And as stated above, the whole population was affected in some localities. Since the southern extension of the Programme. the high prevalence endemic areas of Asukawkaw in the Volta Region and Pru in the Brong-Ahafo Region have now also been covered. Crisp (1956) reported the following infection rates in the different age-groups in the Red Volta area: 30% (under l0 years); 9l% (10-20 years); 100% (31-40 years); 100% (41-50 years): 100% (50-60 years). In the village of Nakong on the Sissili river 100% prevalence rate u'as recorded. He also recorded 60J% at Widenaba, ?l% at Sapeliga. 77.E% at Zongoiri and 89(),r ar Tilli. It has been noted in the endemic areas in Ghana that blindness rates of over 590 were in villages of 200 inhabitants or fewer whereas they were exceptional in villages with 500 or nlore. Furthernrore there was no population growth in the communities where the blindness ratc' equalled or exceeded 5% (Rnon, l9E5). 2. 1.2. Tlrc prcscttt sinrutiotr a 4I. INTRODUCTION Ghana is situated in the middle of the coastline of West Africa. It extends some 850 knt between latitude 4o4'N and latitude llol2'N and stretches some 480 km between longitude tol2'E and 3ol5'W. It is bordered on the east by Togo, on the west by COte d'lvoire, on the north by Burkina Faso and on the south by the Atlantic Ocean, the Gulf of Guinea. Ghana lies squarely within the endemic onchocerciasis belt of West Africa. There is blinding onchocerciasis in the Volta basin which includes all of the Northern and Upper Regions and portions of the Brong Ahafo and Volta Regions. Forest onchocerciasis is also endemic in many parts of the forested southern areas of the country. In the past some efforts were made to study and control onchocerciasis by the Government of Ghana with assistance from various organisations such as the British Empire Society for the Blind and the UNDP. These efforts provided documentary information on the severity ol' the disease, its socio-economic importance, the vector blackfly and its ecology and distribution. They assisted in rhe use of various insecticides (including DDT) in larval Simulium (vector) control. Chemotherapy invotved the use of such existing drugs as Banocide (Diethylcarbamazine) in the treatmenr of all forms of onchocerciaisis, savanna and forest types. These efforts did not yietd the desired results. The Government of Ghana therefore associated itself with the decision thar the chances of obtaining successful and lasting effects would be greatest if the control were carried our in a sufficiently large ecological zone to protect against reinvasion b1' the fly after controt. It has consequently been associated with the Onchocerciasis Control Programme (OCP) since its inception. The OCP was launched in 1974 by the WHO, UNDP, the World Bank and FAO. It originalll" covered the Northern and Upper Regions of Ghana (See Annex l). In 1986 the southern extension was included in the controt area to cover existing endemic areas in the Brong Ahafo and the Volta Regions in order to prevent reinvasion of the fly from breeding sites south of the original area. The idea of "devotution" in the OCP has undergone much evolution in meaning and implication. lt is defined as progressive national participation in onchocerciasis control and a simultaneous effort to strengthen the preventive branch of the national public health systenr (JPC 9,9A, 1988). It is to be concerned with the maintenance of the gains made so far by the OCP in the original OCP area through surveillance and monitoring to provide earll' warnittg and prevent any recrudescence of onchocerciasis in the Onchocerciasis Freed Zone (OFZ)- Ghana has planned accordingly to incorporate and integrate the programme of devolution into her Primary Health Care programme which will include the treatment and control of yarvs (Framboesia), and leprosy which like onchocerciasis have skin manifestations and could be diagnosed simultaneously. In addition it woutd cover Guinea worm for which a national eradication programme is already in place and which is also endemic in the OFZ- This document has set out the operational strategy for devolution in the context of Ghana's health care delivery programme. It covers the methodology, required logistic support and estimates covering the cost of implementing the devolution plan. The original OCP area no\\' covers a population of 2,l3E,4OO in 24 districts in the Northern and Upper Regions. Emphasis is ptaced on strengthening the health care delivery system in those areas to enable thenr nraintain the gains of the OCP. It is hoped that this report would provide the necessary information to encourage bilateral and multilateral assistance and support ro enable Ghana execute the plan and thus help intprove and maintain the heatth of the people in the OFZ and thereby also support socio-economic development of the area. a 7The achievement of these objectives entails extensive travel by health services personnel to towns and villages in the country. Full advantage will be taken of these visits to carry out a number of disease control activities. These activities essentially involve simple procedures requiring no complicated technology and are not time-consuming. The decision to combine the eradication of yaws and Guinea worm, and the control of leprosy with the onchocerciasis devolution programme was thus based on considerations of compatibility and cost-effectiveness. Besides the health worker will be trained to carry out simple examination of the skin for signs of onchocerciasis, yaws, leprosy and Guinea worm all of which are endemic in the OCP area. The Ministry of Health in collaboration with Global 2000 - (Bank for Credit and Comnterce lnternational, BICC) plan to eradicate Guinea worm disease by the year 1993. ln addition. yaws is targeted for eradication by 1995. However, in the case of leprosy, the objective is to improve control of the disease by expanding the facilities for adnrinistering anti-leprosy drugs. 2.2. Situation of otlrer diseases yaws The logistic support for yaws eradication is very similar to that for onchocerciasis control using ivermectin. At present the disease is prevelent in all the regions of the country with more cases being reported in the forest areas of the south. ln 1974 51,432, cases were reported l9g4 9,160 i r 19889,628rii l9E9E,824i"i The disease has affected mainly the under l5 year old males and is confined to the rural areas. The control programme is currently being restructured. I enrosy This is mainly a rural disease widely endemic in Ghana. The logistic support requireci using anti-leprosy drugs is similar to that for onchocerciasis control, using ivermectin. The incidence of leprosy in Ghana for 1984-1988 is as follows: 1984 I per 100,000 people 1985 t.7 n i t986 0.8 0 n t9E7 0.9 i i 1988 2.3 r i This rise in incidence merits urgent attention. Guinea worm I 6Annex I shows the phasing of the prog,ramme in the original OCP.area and how Ghana was covered. Phase I commenced in 1974 and covered the Black Volta and the extreme western area. Phase 2 which started in 1975 covered the central area involving the Kulpawn, the Sissili, the White and Red Voltas and the Daka river. Phase 3 commenced in 1976 and covered the Oti river in.the east. The southern extension treatment started in February 1989 and covered the rivers Asukawkaw and Pru. Since the epidemiological and entomological evaluation of the programme began the general success achieved in the original OCP area also applied to Ghana. Thus in the different Progress Reports it was recorded that the large number of evaluations done in northern Ghana had indicated that the epidemiological situation was very satisfactory in most of the areas. However in the Kulpawn river basin and in the villages of Nakong in the Sissili and Goreba Somun in the Kulda river basin the regression of Community Microfilarial Load (CMFL) was not verv marked. lt was noted also that in the neighbouring Sissili river area onchocerciasis was generalll' no longer a problem of public health importance though one child born after the start of the control programme was found to be infected. But satisfactory control could not be clainred for the village of Goreba-Somun on an affluent of the White Volta south of the Kulpawn where three infected children were found. Since l98l no decrease in the CMFL was observed. Furthermore there were indications that significant transmission had taken place during the period. Relapsed transmission had also been demonstrated in the southern part of the Black Volta near Bui. This was not really surprising because vector control had always been difficult in that area which contained the largest breeding site in the OCP and where Annual Transmission Potentials (ATPs) have exceeded values of 500 for several years. However the ATP at Bui-Akanyakron in 1989 was only 128. Thus although there has been significant control of onchocerciasis in the general programme area in Ghana there are some "black spot" areas. These include the Kulpawn/Sissili area, the Bui area on the Black Volta, Asubende on the Pru and the Asukawkaw area due to high CMFL and ATP, insecticide resistance and re-invasion respectively. It is encouraging to note that the Programme has taken note of these problem areas in Ghana and is attending to them through chemotherapy using ivermectin, and vector control with larvicides. 2.1.3. Nsk ol rccrudescence ol trunnnission ond itemrcctin treal,ncnt. It is noted that control has not stopped as at now. But should it be stopped now then it must be stated that the possibility of recrudescence would be real. Reinvasion will recur and with the high CMFL and ATP, transmission will flare up.in most places. It has been accepted that ivermectin as a microfilaricide can at best only reduce ocular morbidity but ma1' nol effectively interrupt transmission. Measures should therefore be adopted lo sustain the control currently achieved as well as solving the problems posed by the "black spot" areas indicated above. The community must be involved in the imptementation of these measures as appropriate. 2.1.4. Predictiort of cpidcntiolo$cal tatds As stated above some controt work by OCP continues in the Programme area particularl)' in the 'btack spol" areas. If the problems in these areas are ultimately resolved then blinding onchocerciasis woutd have been effectively controlled in Ghana. lf the infection reservoir can be reduced to a level which does not support transmission. it is postulated that er'en on tht' return of the fly, transmission may nol recur. On the other hand if OCP should cease control activities in the area before the problents of the'btack spot" areas are resolved then the gains made would be reversed sooner than llter. IThe highest rainfall occurs in the south-west forest zone with over 200 cm per annum. It diminishes progressively towards the north with an average of 100-130 cm in the northern region. The Coastal belt has the lowest precipitation of about 76 cm annually. There is one rainy season in the north, lasting roughly from May to October with a peak in August ro September. In the southern part there are two rainy seasons with peaks in May/June and October respectively. Between December and February, during the major dry season, the north-east trade winds from the Sahara bring along the Harmattan, characterised by severely dry weather. 3.2. Demographic and socio-economic indices Demographic Ghana has a population of about l4 million with under l4 constituting approximately 459(r of the total (Census 1984). About 79% of the population live in rural areas. In recent years there has been a noticeable and steady drift of the rural population into the urban areas, thereby over-burdening the already fragile and inadequate facilities and infrastructures in the urban areas. The population of Ghana has a relatively high annual growth rate of 2.6% with crude birth and death rates of 50 and 20 per 1000 respectively. Life expectancy at birth is 52 years. Socio-economic Ghana is basically an agricultural country. 70% of its population are engaged in primarl, agricultural activities. Cocoa is the most important foreign exchange earner, accounting for 70% of the total value of exports. Gold comes second, accounting for l9%, followed by timber, mang,anese, diamond and bauxite. Apart from cocoa, other cash crops include coffee, kola, sheanus and pineapples. Salt is also produccd and exported. Petroleum and petroleum products account for 35% of the total value of imports followed by machineryt transportation equipment and other manufactured goods. Ghana produces also a wide variety of food crops and vegetables such as cassava, yanr, cocoyam, plantain, bananas, palm nuts, coconuts, tomatoes, pepper, onions and beans. These are mainly for domestic consumption. The per capita income in 1987 was 050,624.00 (Quarterly Digest, June 1989, VII No 2) Culture and education The people of Ghana have a rich and varied culture and historical heritage with diversified ethnic groupings. A number of languages and dialects are spoken in the countr),but Englislr has been adopted as the official language. Side by side with modern administration, traditional chiefs apart from being the custodians of the countryis culture and customs still exercise considerable power and influence in maintaining social order and stability within their areas of authority. The country's educational system is undergoing reform which aims at making it morc' relevant to the needs and reality of the society. Education is on a three-tier basis: prinrarl'. secondary and tertiary. Primary education is compulsory. IThis has been an endemic disease throughout the country; it is particularly prevalent in the dry savanna areas which include onchocerciasis endemic areas in the north. The disease tends to be seasonal with increase in the dry season when sources of water dry up. It affects all ages but is more prevalent in young and active adults. In l9E9 with intensive search a total of 170 353 cases have been recorded. The Guinea worm eradication programme would benefit from the logistic support of the onchocerciasis devolution prog,ramme. Forest onchocerciasis This is prevalent in the forest parts of the country but has not been covered by the OCP control activities. High prevalence rates have been reported from the Tano, Pra, Birim and Densu river basins. Ivermectin (Mectizan) has been recommended for use as a microfilaricide against forest onchocerciasis. Meanwhile there is no active control prog,ramme in Ghana. 3. GENERAL SITUATION OF THE COUNTRY 3.1. Generel presentation Political Once known as the Gold Coast, Ghana achieved independance in 1957, from British Colonial rule and became a Republic within the British Commonwealth in 1960. The country is governed by the Provisional National Defence Council (PNDC). Administratively, the country is divided into l0 Regions and I l0 Districts. The district is the basic unit of the decentralised administration with its own assembly through which people at the g,rass-root level are expected and encouraged to exercise their political power. Geographical As stated earlier, Ghana lies in the West African Sub-region within the onchocerciasis endemic area. It has an area of 23E,538 sq.km (92,100 sq miles) with a coast line of 537 knt. Topographically, the coastal belt and the Volta basin have elevations of 500 feet or less above sea level. The rest of the country consists of plateaus and plains of varying elevations, above 500 feet, with mountains above 2000 feet running north-south along Ghana's eastern border with Togo. There are many rivers in Ghana some of which are seasonal. In 1964, when the Volta River was dammed at Akosombo, the biggest man-made lake was formed behind the dant, occupying an area of 8,500 sq. km representing approximately 4% of the territory of the countr)'. Roughly the country can be divided into three vegetational zones. They are, from South to North, the coastal plain of shrubs and grassland, the high rain forest and semi-deciduous forest occupying the south-western part of the country and the Guinea Savanna covering the northern half of the country, characterised by grass and scattered trees. Ghana has a tropical climate with average annual temperatures ranging from 26oC to -iO"C with the northern part of the country being relatively hotter and drier than the south. I10 ln 1984, the population of school going age (6-t4 years) for the whole country was about 3.1 m. Out of this total 0.3 m. was recorded for the Northern Region,0.l m for the Upper West Region and 0.18 m for the Upper East Region. The above figures indicate that l99o ol' the total population of school going age in 1984 came from the 3 northern regions with a total population of 0.59 million. In l9E5/E6, enrolment in first-cycle schools reached 2 million, that of secondary schools 168,000 and that of tertiary institutes of higher learning about 9000 students. The country has three universities, offering a wide range of subjects for graduate and post-graduate study. Despite efforts made in education since independence illiteracy rate remains high at 65-70%. 3.3. Organization chart of Ministry of Health (MOH) and Heatth policy The Ministry of Health (MOH) is the official, as well as the major agency for the provision of Health Services. lt is organised hierarchicalty into national, regional and disrricr healrh services. The Ministry is headed by the PNDC Secretary (Minister) for Health. He is assisted by the Deputy Secretary. The technical operation is directed by rhe Director of Medical Services (DMS) and assisted by three Deputy Directors (DDMS) and two Heads of divisions. There are i. DDMS Medicat Care ii. DDMS Manpower and Training iii. DDMS pubtic Health iv. DNS Director of Nursing Services v. DPS Director of Pharmaceutical Services The PNDC Secretary is also assisted by a Chief Director of Rdminisrration and Finance. The Regional Director of Health manages the health activities in his Region. At rhe districr level, there is a District Medical Officer of Health, assisted b1' a Districr Heatth Management Team. (DHMT) In order to achieve the goal of health for all, Ghana has adopted the Primary Health Care(PHC) Strategy. This is organised into a 3-tier system with Level A at the communirl, level. level B at the Health Centre/Post (HC/P) level and level C ar the district level. In rhis srructure. the district is the basic operational unit responsible for planning and implemenring of the healrh policies and programmes within is catchment area with an average population of I00,000- 150,000. The goal of the National Health services is to maximise the toral heatthy life of the Ghanaian people. It has two objectives which are: i. To achieve basic and primary health care for atl the people of Ghana by the year 2000 ii. To effectively attack the healtlr prob'lems that contribute 80% of the unnecessary deatEs and disabilities affliciing Ghahaiani-by the year 2000. The principal means for achieving the twin objectives is the Primary Health Care Strategl'. The overall philosophy of this strateg,y is to reduce the rates of mortality and morbidity due to conditions for which prevention, easy treatment and control exist. I1 oI o z a { oz (n -.tnCo Ct rn o 'T'l za{u o 'T1 -m 1'(n <0o;- -y >!-1lnI m Epo0>; 6ln z \,CP9 -Pmz 7'v,{I 3pzom-n( >lnr o n m o{ o 3 ac!\,r m U' ! m a U, o z z mr 'Tl z. zo rn { n za ! o Di ma -l{ m o n mo{ o , o o 3<_EgoZU, 1 o z \,C tr n m !- o - m o0 -m =o{ oI o zVFmioa1 =oono 'r, 0 3q ffi8IO <.Tl n2OO!Oqo{rn UC 'o z0o a rnoD rn -.1 :D 3m09b o< \: mFp -3 =bJ- e# il31<- 9F m= ;flYm aOm{I'O oo m 'Tt U' = !<o;P r.31? u a 2utI fl{> aZ ia =c)I -tl ! !CPo H!,>3it, J- -m r{ - m oC s, zC{f, = oz m z *=to -z{3 -m { m3 .o I FACILITIES t') ORGANISATION OF HEALTH SERVICES IN THE REGIONS MANAGERSADMIN. LEVELS REGIONAL HOSPITAL DTSTRICT HOSPITAL HEALTH CENTRE & HEALTH POST COMMUNITY cLrNtc REGIONAL LEVEL c LEVEL LEVEL A LEVEL REGIONAL OIRECTOR & REGIONAL HEALTH MANAGEMENT TEAM DISTRICT MEDICAL OFFICER AND DISTRICT HEALTH MANAGEMENT TEAM MEDICAL ASSISTANT AND HEALTH POST STAFF COMMUNITY WORKERS EG. V.H.W. & T.B.A. ) tB 13 Health care delivery is an integral part of the total socio-economic development effort based on intersectoral co-operation and the active involvement of the people at the community level in the spirit of self-reliance. The fundamental resource for all health work is the community itself, and full community involvement is the basis for expansion of the health care system. Health care manag,ement is decentralised to the district which is the unit for health administration. Health districts are co-terminus with administrative districts. The district is managed by a Health Management Team, headed by a District Medical Officer of Health. The team is responsible for the total health care of the district. It has its own budget. Each district has a hospital usually located at the district headquarters. The district hospital is the highest referral facility in the d.istrict. In addition there are a number of level B centres situated in different parts of the district. The level B staff supervise and work closely with the communities at level A. Cost Recovery Policy It is the government's desire to extend health services to all Ghanaians. However in view of the rising cost of health care the government has instituted a cost recovery policy which calls upon Ghanaians to contribute toward their health care which is heavily subsidised by the government. Drrrg poliey i. The Ministry has an essential drugs list and National Formulary of Ghana which was launched in June, 1988. ii. Under the existing Pharmacy Act, drugs to be manufactured locally are listed, and those to be imported are brought in under specified procedures subject to qualily control. iii. Under thc cost recovery programme, drugs for the treatment of certain conditions of public health importance such as aids, cholera, pulmonarl' tuberculosis are free. 3.4. Personnel end facilities The MOH is the largest single provider of health services in the country. Its facilities include 2 teaching hospitals, 8 regional hospitals, I I special hospitals (Psychiatric, leprosaria and children's hospitals),36 district hospitals, l5 urban health centres, about 300 rural health centres posts and 175 community clinics. The Government's facilities are augmented by 35 Mission hospitals. 40 Mission clrnics and a number of private clinics run by industrial and institutional establishments and private practitioners. At rhe beginning of 1989, the MOH had on roll E55 Doctors and Dentists. 105 Pharmacists' ll,5OO Nurses and about l7,7OO supporting staff. In addition, there were about 300 Doctors in private practice throughout the country, and 487 Pharmacists in the private sector' The health services personnel are trained mainly in the two medical schools and 37 health training schools including 2E nurses training schools. 3.5. Cost rnd financing of Public Health Services The provision and maintenance of a country-wide cost-effective health delivery proS,ramme is one of the cardinat social objectives of the Government. t 14 Since the commencement of the Economic Recovery Programme (ERP I ) in 1984' a number of Regionat and district hospitals and health centres have had their most essential equipment and infrastructures rehabilitated. The health sector investment programme for the 1989-91 period is oriented towards improving tire effectiveness of health delivery services as well as increasing the coverage in both urban and rural areas. The total Government expenditure for the MOH recurrent and capital development are: (a) Recurrent 09.8 billion in 1988 and 015.8 billion in 1989 (b) Capital Development 01.6 billion for 1988 and 43.6 billion for 1989 From the Sectoral distribution of percentage share of investment, the health sector takes about 3%. See PIP 1989/91. 3.6. Function end resources for epidemiologicel surveillence The functions of the epidemiological surveillance in the country are: i. To study the behaviour of specific diseases with a view to their early detection and the institution of control measures. ii. To study the trcnd and pattern of the disease for proper planning for their prevention and control. The resources needed for effective surveillance are: i. Skilled and trained manpower ii. Quick and effective means of communication from one level to the other. Depending on the urgency of the information, weekly or monthly reports are made upwards from Level B through the Regional Director of Medical Services to the National Directorate in.Accra.--Appropriate-actions are taken at each level as necessary. Normally transmission of information from level A to Level C could be by foot, bicycle, motor cycle or nrotor car. Frotn Level C through regional level to Accra is by motor car or by means of radio or telegraphic communication. iii. Transport to investigate reported disease outbreaks iv. Data processing machines, and stationery. 4. SURVEILLANCE AND TREATT\TENT tn the devolution plan, the control of onchocerciasis tog,ether *'ith other diseases of public health importance will be integrated into the Primary Health Care Progranrnre. The other diseases are yawst leprosy and Guinea worm. A major component of the devolution process will be staff training. Under the devolution plan, health services personnel will be given training in the control of Onchocerciasis, leprosl' and in the eradication of yaws and Guinea worm. l5 ln addition, the Ministry of Health has plans to provide laboratory facilities for all Service Delivery Points (SDP) starting, with the Onchocerciasis-freed zone. Furthermore, the systenr of routine data collection and utilization for disease control will be streng,thened. 4.1. Objectives 4.1.L Ottcltoccrciasis i. To prevent a recrudescence of the disease in the OCP zone ii. To safeguard the achievement of the control programme. 4.1.2. Yows i. To update information on che prevalence of yaws in che countEr. ii. To eradicate the disease from the country by the end of 1995. 4.1.3. Leprosy i. To update informationon Ehe prevalence of leprosy in the country. ii. To reduce incidence of the disease. 4.1.4. Grtinea wonn i. To determine the extent of Guinea worm infestation in Ghana. ii. To eradicate Guinea worm from the country by the end of 1993. 4.2. Activities Devolution activities for onchocerciasis, yaws, leprosy and Guinea worm disease are as follows. Their common features are the training of health personnel and the provision of back-up laboratory services. There will be an independent evaluation of the programme in its third and fifth years. 4.21. Onchocerciasis i. Information, Education and Communication Campaigns will be carried out in the Oncho-freed zone to explain the expectations and achievements of the prog,ramme. ii. Yearly parasirological surveys of first-line villages along the importattt river stretches in order to monitor the level of infection and to enable early detection of recrudescence of infection. The village network for surveillance witt be selected jointly by the Onchocerciasis Control Programme and the Ministry of Health and the number of villages selected in each high risk area will be sufficient to allow yearll' screening of the area and the screening of a particular village at 3-yearly interval. iii. Epidemiolog,ical mapping of the surrounding villages for decision-making for possible intervention when the number of ne$ cases in the first-line villages is such as to constitute the start o[ recrudescence. Mass treatrnent of Communities with high prevalence rale. Passive screening and treatment of Patients attending SDPs. Appropriate training for health workers to enable thent carry out the devolution activities. tv vi I6 vii. Training of community members to identify the black fly and to report any increases in its biting activities to staff of the nearest SDPs. viii. Educating the community to be aware of the importance of reporting any new immigrant to the community to the SDPs for screening l'or onchocerciasis and possible management. 4.2.2. Yows il. lll. iv' 4.2.3. Leprosy 4.2.4. i. Active and passive case finding ii. Treatment of leprosy patients using anti-leprosy drugs iii. Health education of the population aimed at helping to identify leprosl' patients for treatment. iv. Rehabilitation and social integration of leprosy patients. v. Collection and processing of data on leprosy vi. Periodic review of leprosy patients. Guinea wonn i. Training of healrh personnet on the aetiology and control of Guine:t worm ii. Active case finding iii. Public education and information about the causes, prevention and control of Guinea worm iv. Distribution of water filter materials and education about their proper use. v. Social mobilization for sinking wells and boreholes. vi. Treatment of Guinea worm patients vii. Data collection and processing viii. ldentification and, in some cases, insecticidal treatment of unsal'e water sources. 5. ORGANIZATION OF SURVEILLANCE AND TREATIUENT ln line with the PHC straregy the district will be the unit for the implementation ol' thc Devolution Programme. Active case detection Mass treatment in high prevalence areas and treatment of individual cases and their close contacts in low prevalence areas. Data collection, compilation and processing Periodic reviews. t7 Within the district, health care delivery is based on a three-tier structure. (a) Level A (the community) (b) Level B (the health centre and health post) (c) Level C (the district) Each district is managed by a District Health Management Team (DHMT). lt is headed by a District Medical Officer who is responsible for the overall co-ordination of activities in the district. The DHMT is responsible for training and supervision of the field staff as well as planning and monitoring of their programmes. There are twenty-four districts in the devolution area (see annex 5). The Level B which is the most peripheral of the formal health care delivery structure operates within its "catchment areas'of l0 km radius or more. Health workers at level B do not only manage patients who come to them but will also be responsible for carrying out devolution activities in all communities which fall within their "catchment areas" 5.1. Humalr resources 5.1.1. Level A The community level workers are: i. Traditional Birth Attendants (TBAs) ii. Community Clinic Attendants (CCAs) These Community Health Workers are supported by Government and Non-Governnlental Organisations including revolutionary organs and women's organisations. In the Devolution Programme the community members will be trained to identify and report to Level B: (a) presence of biting flies and their breeding sites (b) presence of immigrants to the communities for examination (c) any person with clinicial changes associated with onchocerciasis, yaws, leprosy and Guinea worm for examination and .treatment. Reports will first be made to the village Health Worker who will then report to Level B for appropriate follow-up action. ii. The village Health Workers (VHWs) will mobilise the community members to carry out control programme activities such as sinking of wells for provision of good drinking water to reduce Guinea worm transmission. 5.1.2. I*wl B Level B personnel are: (minimum level) I Medical Assistant (Team Leader) 2 Community Health Nurses I Midwife I Assistant Environmental Health Officer I Laboratory Technician Their activities in the Devolution Programme will include: i. Appropriate training of the communities/VHW to enable them to identify devolution diseases, understand their CauSes, their prevention and control a I8 ii. The examination of patients attending clinics as well as organising survelrs to determine the presence of onchocerciasis, yaws, leprosy and Guinea worm iii. Appropriate treatment to be given after laboratory confirmation. iv. Data on all devolution diseases will be collected from the catchment areas, and regular reports submitted to Level C. v. Level B staff will pay regular visits to the communities to supervise the work of the VHW. vi. will assist the village health workers in sensitizing the communities at the time of yearly epidemiological surveys for new case detection. 5.1.3. Lcvcl C The District Level personnel are: I District Medical Officer (DMO) I District Public Health Nurse (DPHN) I District Communicable Diseases Control Officer (DCDCO) I District Environmental Health Officer (DEHO) I District Health Education Officer (DHEO) Their activities will include: i. receiving and analysing data on the devolution diseases collected within the district, and using the information to plan the control activities. ii. training of 'Level B staff in the operations of the devolution activities, particularly in the clinical recognition, laboratory identification and appropriate treatment of the devolution diseases. iii. Procuring and supplying of the requisite inputs to Level B stations iv. Paying regular visits to Level B stations to supervise their work and provide technical support, for example investigating and taking immediate action on increasing biting activities of the Simulium fly, and v. Organising mass health education campaigns, in particular sensitizing the villagers for yearly epidemiological surveys vi. Organising the onchocerciasis surveillance activities in the fornr ol' parasitological surveys in selected villages 5.1.4. Polyvsl.^t Teants (PT) (Regionol Lewl) In the devolution areas there will be three Polyvalent Teams set up at the regional level to provide technical support to the districts. These teams will be stationed at Tanrale, Bolgatangn and Wa in th Northern, Upper East and Upper West Regions respectively. The co-ordination of the PTs is the responsibility of the National Epidemiologist through the Regional Medical Officers of Health. Each Regional PT will be made up of the following: l9 I Epidemiologist I Entomologist I Parasitologist I Ophthalmologist I Statistician I Computer Specialist 2 Laboratory Technicians 2 Field Technicians Their activities will include i. Giving technical support to level C in epidemiologicalactivities, in particular carrying out parasitological surveys in selected communities in oncho high risk areas at yearly intervals and taking remediat action in conjunction witlr the DHMT ii. Investigation of any reported recrudescence iii. Giving general support for health care in the region, in particular conducting epidemiological investigation into other endemic and communicalbe diseases as appropriate. iv. Carrying out specific research activities as found appropriate v. Providing the necessary data base on all endemic diseases in the regions and servicing the national network. 5.1.5. Monitoing Teom (MT) A monitoring team would be set up jointly by the National Onchocerciasis Secretariat (NOS) and the Ministry of Health. The team will consist of four persons made up of two social scientists and two public health specialists. The team will visit the districts, monitoring the prog,ramme through the assessment of the plans and mechanisms at all levels of the programme activities to ensure that the institutional arrangements that have been put in place are satisfactorily implemented. Their report should be available by the end of April every year. 20 5.1.6. Evaluatiott An independent evaluation and review of the Devolution Programme would be carried out during the third and fifth years of the Programme activities. The main objective of the evaluation is to assess the progress and impact of the Devolution Programme. The evaluation ream formed by OCP/MOH would consist of 5 specialists in related fields and its work would be co-ordinated by the National Onchocerciasis Secretariat. The evaluation team may spend up to five weeks to complete its work. One week at the head office, three weeks in the field, and one week to finalise and write reports. 5.2. Material resources For the efficient management of the Devolution Programme, requisite logistics and technical resources will be needed for the various operations. As indicated in Annex 7, material resources would be procured for use by the following: i. Programme Co-ordinator (PC) ii. Polyvalent Teams (PT) iii. Level C Personnel (L-C) iv. Level B Personnel (L-B) v. National Onchocerciasis Secretariat/Monitoring Teams (NOS/MT) 2t 5.3. Cost of programme for five yeers 5.3.1. Investments and Training These Capital Costs are as follows: (i) Logistic Support(ii) Data Processing equipment(iii) Technical equipment(iv) Field equipment(v) Educational Materials(ui) Training and Retraining(vii) Evaluation of Programme Sub total 5.i.2. Reanmnt E4endirure These costs include the following: (i) Vehicle Maintenance(ii) Vehicle running cost(iii) Other equipments maintenance(iv) Per diem allowances(v) Stationery, drugs and insecticides Sub total SUMMARY OF COSTS (i) Capital Investment and training(ii) RecurrentExpenditure Total (iii) Contingencies (10%) Total cost of Devolution Plan rounded off to cedis 400,980,000 24,500,000 73,692,000 2,769,000 2,964,000 47,092,500 2,800,000 554,797,500 cedis 73,450,000 49,634,000 49,430,000 45,600,000 78,000,000 296,114,000 554,797,500 296. t 14,000 850,91 1,500 85,091,1 50 936,002,650 936,000,000 us$ 2,840,000 22 5.4. Ghena Governmctrt conlribution to Devolution Plen Implementalion The government of Ghana is committed to the total and integrated development of the arens of the country which have been freed from the scourge of onchocerciasis. Already, the government has voted money for feasibility studies and drawinBs for the construction of bridges and roads so as to improve accessibility to some agriculturally rich areas ol'the oncho-freed zone. Ghana's contribution to the devolution programme is in two main areas. The Governntent of Ghana will provide personnel whose totalemoluments over the five-year devolution period u'ill amount to approximately six hundred and eighty million cedis (C 680,000,000) tn addition, the construction and rehabilitation of health infrastructure -district hospitals. health posts, office accommodation- within the OCP area will cost about l'our hundred and l'il'teerr million cedis (C 415.000.000). Other contributions will come in the forrn of laboratorl'ec;uiprttent and reagents as well as other medical supplies. 2',] 6. PROVISIONAL TIME TABLE Table I I indicates schedule of activities under the five year Devolution Progranlnle. However mobilization towards the take-off of the Programme in Year One needs to be preceded by informal training and orientation courses by the OCP for the key progranrme personnel to ensure a smooth take-off. l. Establishment of PTs/MTs 2. Procurement of Logistic Supplies & Construction of Ofl'ices 3. Provision of technical, field and data processing equipment for operations: - PTs - District Health Management Teams - Health Centre/Post 4. Long-term Training: - PTs 5. Short-term Training: - Ophthalmic Nurses (48) - Lab. technicians (24) - Entomological Tech. (24) - Monitoring Team (4) 6. Retraining Seminars 7. Public Education (Campaigns) 8. Supply of ivermectin and other drugs 9. Screening and passive treatnrent of onchocerciasis 10. Simple epidemiological Survey of any new cases I l. Simple epidemiological Surveys in indicator villages 12. Inspection of Areas liable to high Annual Transm ission ( tvlapping) t3. Detailed examinltion and lrr'ltnlent ol cases discovered YEAR I YEAR II ilt YEAR IV YEAR YEAR ------i ------'1 E------ E------ :.1 14. Vector control (entomblogical surveillance) in co-operation with village communities 15. Collection and analysis of data 16. Monitoring & Supervision of local and Polyvalent teams (Monitoring Teams-NOS/MOH) 17. PT Monitoring of index areas 18. First evaluation of Devolution Programme 19. Final evaluation of Devolution Programme I YEAR ll YEAR lil YEAR IV YEAR YEA R I C) E z m t- z rq a a: '8. o \. 6) 2 a I ) a rYl \ ,g- - ) = ,m J\l\i z -1 )tI 'r r _r, :-r -li I) r @ m a lF:- - tt -. \- I t I I t-, I I I I I I f I -t- I , I I I I I I I I I I I L- ., I , ,'lC a @{ m T o. 0ac c) -D2 D I a t t I I I -'t I t t(_ I la -. 1/ ,,ot' ct -/.o z z m x c) E P m -6'o-- 6=azDMCM eo0D=azDrrlCD .l.-' ! . a -+o td OooDOo :caoao:-;:es3; :it:: l -, 3 9 o IPBi::;il:-"i:' -.-:Egi: -i? i :o ac-o c'3 :. :P :1 0e ;!:;?:e :e tI t-o ;- 6 , : : - 6 z0 - o6 z o m ai m z m 6)br ,t7 € {G I z o !n! D o z Dr D n D N o z o! a D{ 62 z re on e o'cnq o D a -z oi a a D o2 D - D! n D N c2 n c! f, o2 z e o oz D B , T a D o: oT m n _-t o z r TI tJl ma o -rl r I 6 I z 6) I i -i + 'n o o c o ,O -J(, I .D e. =f ='o o ; I =.o E ,o mo2 a r4r (It:-oIC oOi (D3 o=! .Do o ;(D9o BE: 6g .Dlro .D o I t'-\ I I \ % ,.t'* o= -a I a c) o Im 'a ,!0 a I I I I I I I I i I I I '..,| -t :l n! I oo 8 t, t I Tt c-o f 1' a rt| I --t- t I I -l I t: I I t I( I I I I oE I t +;-r . aI: o --- J(D z ; rI II t"l =.z .. -l a mI D l- 't) I I. -) I a, -- a 7 I I I l ANNEX 2 2.6 NORTHERN GHANA WTTHIN THE VOLTA BASIN t?o o;a?amuoou a Koudougou okoinsi t? = Yorgo 'BURKINA AS o .Nobe16 SC LE l: IOOOOOOilTL o 5 to ?o 30kml+J .Dobou '/2' o Ouosso rBo -. _v.r. Beuo , llo li Io ngo , ./Tumu ?on9o oylroo Lowro 9u wlno oGombogo -\. oWo N O RT H ERN GHAN A Tomole .Yendia Bole / a ndoro ) )(iI\ i t' 9o ! ! I I) r0P 9o Bui Yeli a { ! I o I z z mx ot \, e g oJ o o o 3 oe e o v sq d $$is ol .-!t "l o OG o o co tt7 rnooz -.1no T z, rrl r mzo m orl o zo -oo rn7o FL @ o c o e e c ll l, c) e9to=:i,o.i3'<fo6P crfoo.5eo.<q i-o [-st_lo -9 3 oo ooe o o o o O9 oc o co o O o Oj O3l 3 OO o 6) - z o e e o o t o o o e e e oeo o o o c ec o e o eo a oe eco G o o e Og oo G e o o oo G G o OO G OG o -. z G G e s G o G o ,^OG(, o o o G oo o co o G e oo bE- :zEzgmsx oo o+ 3 oe e o !sss o e o G G o G o o o G l,f, rn t- m zo m o -n ozoI oo mf,o a6 z (o @(o o ffi Is 5 ll -o c) ts3 EAg.? a =gd3 gq fr< o.o a t t ANNEX 5 29 LIST OF DISTRICTS IN THE DEVOLUTTON AREA > I UPPER EAST REGION CAPITAL POPULATION/No OF VILLAGES l. Bawku East 2. Bawku West 3. Frafra 4. Bongo 5. Kassena Nankani 6. Builsa Total UPPER WEST REGION l. Sisala 2- Lawra 3. Jirapa Lambussie 4. Nadawli 5. Wa Total NORTHERN REGION l. East Mamprusi 2. West Mamprusi 3. Chereponi Saboda 4. Gushiega/Karaga 5. Saveluga Nanton 6. Talon Kumbungu 7. East Dagomba 8. West Dagomba 9. West Gonja 10. East Gonja I l. Zabzugu 12. Nanumba 13. Bole Total Grand- total Bawku Zabilla Bolgatanga Bongo Navrongo Sandema Tumu Lawra Jirapa Nadawli Wa Gambaga Walewale Saboba Gushiega Savelugu Talon Yendi Tamale Damongo Salaga Sabzugu Bimbila Bole n9,tt0/342 62,000/80 t66,300/250 67,000/52 t35,400/ 136 79,000/9 I 62E,800/95 I 58,900/98 72.900/ t60 82,900/ r 85 E8,300/ I 28 I 35,300/ I 34 438,300/709 t27,800/377 73,t00/94 62,000/234 65,600/374 92,300/200 89,700/200 70,600/268 150,100/l4l 63,400/ 188 r 23,000/3 I 8 60,300/ I 74 9t,100/291 85,900/3 t0 I, 154,900/3 t 69 2.222,000/4825 ANNEX 6 I. INVESTMENTS AND TRAINING 30 ESTIMATED COST OF THE DEVOLUTION PLAN l.l. Logistics support 4 x 4 vehicles I vehicle each for 24 Districts I vehicle each for 3 PTs I vehicle for Programme co-ordinator 2 vehicles for NOS/Monitoring Team Motor cycles 2 x 13 districts- Northern Region I x 6 districts - Upper East Region I x 5 districts - Upper West Region iii. Mopeds I x 66 HC/P lv. Bicycles I x 66 HC/P \, Cinema Van lx3PTs vt Video and Television lx3PTs vil Electric Generators lx3PTs viii. Transceivers lx3PTs lxlPC I x I NOS/MT Sub total Quantity Unit Cost cedis Total cost cedis 30 37 66 66 3 5 3 5 r 0.000.000 900.000 200.000 30.000 12.000.000 600.000 2.400.000 1.500.000 300.000.000 33.300.000 t 3.200.000 1.980.000 36.000.000 t.800.000 7.200.000 7.500.000 400.980. ooo 31 1.2. Data Proccssing Equipment Quantity Unit cost cedis Total cost ced is t. Computer, printer & accessories lx3PTs I x I NOS/MT ii. Photocopiers x3 xl xl PTs PC NOS/MT iii. Electronic Typewriters lx3PTs lxlPC I x I NOS/MT Sub total I.3. Technical Equipment i. BinocularMicroscope lx3 ii. Field Binocular Microscopes I x 66 HP/P I x 24 Districts iii. Ophthalmocopes (Battery) lx3PTs iv. Head Photometers lx3PTs v. BinocularMagnifiers lx3PTs vi. Tensiometers lx3PTs vii. Eppendorff Pipettes lx3PTs viii.lvermectin Monitoring Kits lx24PTs lx3PTs ix. Bathroom scales I x 66 HC/P lx3PTs 4 5 5 J 90 3 3 3 3 3 27 69 4.000.000 r.200.000 500.000 900.000 500.000 64.000 r.400.000 400.000 t8.000 36.000 90.000 r6.000 t6.000.000 6.000.000 2.s00.000 24.500.000 2.700.000 45.000.000 192.000 4.200.000 1.200.000 5r.000 t08.000 2.130.000 l . r04.000 t 32 Quantity Unit cost cedis Total ced is cost x. Stethoscopes & Blood Pressure Apparatus I x 66 HC/P I x 24 districts lx3PTs xi. Enamel Trays I x 66 HC/P 2 x 24 Districts 2x3PTs xii. Clinical Thermometers 9 x 66 HC/P 2x3PTs xiii.Holths Clips I x 66 HC/P 2 x 24 districs 2 x 3PTs xiv. Kocher Clips I x 66 HC/P 2 x 24 districts 2x3PTs xv. Dissecting set 2x3PTs xvi. Knap Sack Sprayers 2 x 24 districts xvii.Visual Acuity scales a. for illiterates b. for literates 2 x 24 districts 2 x 66 HC/P 4x 3 PTs Sub total 93 r20 600 t20 t20 6 48 t92 45.000 5.000 2.000 56.000 6.000 t 8.000 75.000 t.t40 4. r 85.000 600.000 t.200.000 6.720.000 72.000 r08.000 3.600.000 2 r9.000 73.692.000 33 1.4. Field Equipment t. Umbrella Tents 4x3PTs 4 x I NOS/MT ii. Camp beds l0x3PTs 4 x I NOS/MT iii. Camp chairs 5x3PTs 5 x I NOS/MT tv Folding Tables 3x3PTs 3 x I NOS/MT Adjustable stools 2x3PTs 2 x I NOS/MT vi. Cmking Equipment lx3PTs I x I NOS/MT vii. Pressure lamps 2x3PTs I x I NOS/MT Sub total Quantity Unit cost cedis Total cost cedis l6 34 20 t2 8 4 7 5 r.000 38.000 6.000 t6.000 23.000 r 5.000 r 5.000 8 r6.000 r.292.000 120.000 192.000 r84.000 60.000 r05.000 2.769.000 34 1.5. Educetionel Materials i. Training booklets - 95 centres in devolution area - 8 booklets to a centre per year - 4 devolution diseases (onchocerciasis, yaws, leprosy and Cuinea worm) 120.00 cedis per booklet 95 x 8 x 4 x l20cedis x 5 years = ii. Posters - 95 centres - l0 posters per centre per year - 4 devolution diseases - 60 cedis per poster 95 x l0 x 4 x 60 cedis x 5 years = Sub total 1.6 Tnining end rctreining i. Long term Training for 48 ophthalmic Nurses for 2 years in Ghana 48 x 2 years x 182,000 cedis per year Sub total ii. Short term Training for 24 parasitological technicians in Ghana for 6 months 24 x 6 months x 15,000 cedis per month Tuition Sub total iii. Seminars/Workshops 1.824.000 cedis I .140.000 cedis 2.964.000 cedis 17.500.000 cedis 17.500.000 cedis 2,160,000 320,000 2,480,000 2,480,000 cedis Seminar on the management of the four devolution diseases for the DHMT 5 participants wilt attend 5 participants x 24 districts x 7 days x 5,000cedis perdiem x 5 years =21.000.000cedis - Resource persons for tuition: 8,000 cedis per day per resources person x 5 days x 3 regions x 5 years x 2 persons I .200.000 e'ed is - Course Director: I x 5 days x 8,000 cedis x 3 regions x 5 years 600,000 cedis 35 - Secretarial support - 3 I x 5 days x 2,500 cedis x 3 x 5 years - Stationery (Estimated) 250,000 cedis x 3 regions x 5 years - Conference facility (Estimated) 5,000 cedis per day x 5 days x 3 regions x 5 years Sub total 187,500 cedis 3,750,000 cedis 375,000 cedis 27 ,l12,500 ce d i s 2,800,000 cedis Cedis 400,980,000 24,500,000 73,692,000 2,769,000 2,964,000 47,092,500 2,800,000 554,797,500 1.7. Evaluetion of the Programme - 2 programme evaluations to be carried out - 5 specialists - 5 wecks (35 days) 8,000 cedis x 35 days x 5 specialists x 2 evaluations Sub total SUMMARY OF INVESTMENT AND TRAINING Logistics support Data processing equipment Technical equipment Field equipment Educational materials Training and retraining Evaluation of Programme Total a 36 2. RECURRENT EXPENDITURE 2.1. Vehicle Maintenance i. 4- WDVehicles 3l x 300.000 cedis x 5 years ii. Motor cycles 37 37x50.000x5years iii. Mopeds - 66 66x25.000x5years iv. Cinema Vans - 3 3x300.000x5years v. Bicycles - 66 66x 15.000x5years Sub total 2.2. Vehicle Running Cost: (a) i. 3 D 4 - WD Vehicles (Diesel) ii. 3 Cinema Vans l0 gallons per week per vehicle at 400 cedis 33 x 3,600.00 cedis x 52 weeks x 5 years = (b) i. 37 motors cycles ii. 66 mopeds 1.5 gallons per week per motor I03 x 700.00 cedis x 52 weeks x 5 years Sub total 2.3. Olhcr Equipmcnt Meintenance Cedis 46.500.000 9.250.000 8.250.000 4.500.000 4.950.000 73.450.000 cedis 30.888.000 r 8.746.000 49.634.000 cedis 2.300.000 9.000.000 7.500.000 20.000.000 7.500.000 3. r 30.000 i. Video and Television 3x0.6mcedisx25%x5 ii. Electric Generators - 3 3x2.4mcedisx25%x5 iii. Transceivers - 3 3x2.0mcedisx25%x5 iv. Computers - 4 4x4.0mcedisx25%x5 v. Photbcopiers - 5 5 x 1.2 m cedis x 25% x 5 vi. Electronic typewriters - 5 5x0.5mcedisx25%x5 years years years years years years Sub total 49.430.000 cedis 37 2,4. Per diem Allowence (a) PTs - 3 i. 5 specialists in Each Team ii. 8,000 cedis per night per specialist iii. 5 nighs in a month 15 specialists x 5 nights x 12 months x 5 years x 8,000.00 cedis (b) Nos/MT i. 4 specialists in NOS/MT ii. E,000 cedis per night per person iii. 5 nights in a month 4 specialists x 5 nights x 12 months x 5 years xB,ooo Sub total 2.5. Strtionery, Drugs rnd Insecticidcs (a) Insecticides and drugs Estimated 500.000 cedis x 24 districts in Devolution area x 5 years (b) Stationery Estimated 150.000 cedis x 24 districts in Devolution area x 5 years Sub total SUMMARY OF RECURRENT EXPENDITURE Vehiclc maintenance Vehicle running cost Other equipmcnts maintenance Per diem allowances Stationery drugs and insecticides SUMMARY OF TOTAL COST Investment and training Recurrent expenditure Sub total Contingencies (10%) Total Rounded off to = 36.000.000 cedis 9.600.000 cedis 45.600.000 cedis 60.000.000 cedis 18.000.000 cedis 78.000.000 cedis Cedis 73.450.000 49.634.000 49.430.000 45.600.000 7E.000.000 296.r r4.000 Cedis 554,797,500 296,1 14,000 850,9 t I ,500 85,091 , I 50 936,002,650 936,000,000 US$ 2,840,000 a Wc,tt. g Lc) 38 MATERIAL ALLOCATIONS ANNEX 7. Item Quantity Unit cost Cedis Million Total cost Cedis Million A. Programme Coordinetor l. Photocopier 2.Vehicle-4WD 3. Transceiver 4. Typewriter Sub total B. Polyvelcnt tcems (3) 1.4 - WD Vehicles 2. Cinema Vans 3. Video & Televisions 4. Electric Generators 5. Transceivers 6. Computer, Printer & Accessories 7. Photocopier 8. Typcwriters (Electric) 9. Binocular Microscopes 10. Ophthalmoscopes (battery) I l. Head Photometers 12. Binocular Magnifier 13. Tensiometer 14. Eppendorfy'Ripette 15. Ivermcctin Monitoring Kit 16. Bathroom Scales 17. Stethoscopes and Blood Pressure apparatus lE. Enamcl Trays 19. Holths Clips 20. Kolths Clips _ 21. Dissecting Set 22. Visual Acuity Scales (a) for illiterates (6) (b) for literates (6) 23. Umbrella Tens 24. Camping beds 25. Camping chairs 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 6 6 6 6 t2 t2 30 r5 t.2 r 0.0 r.5 0.5 r 0.0 r 2.0 0.6 2.4 r.5 4.0 t.2 0.5 0.9 0.064 1.4 0.4 0.0r E 0.036 0.09 0.0r6 0.045 0.005 0.056 0.0006 0.0r8 0.00t t4 0.05 r 0.038 0.006 t.2 r0.0 1.5 0.5 13.2 30.0 36.0 1.8 7.2 4.5 t2.0 3.6 t.5 2.7 0.t92 4.2 t.2 0.054 0.r08 0.27 0.048 0.1 35 0.03 .336 0.004 0. r08 0.014 0.6t2 I.t4 0.09 39 Item Quantity Unit cost Cedis Million Total cost Cedis Million 26. Folding tables 27. Adjustable Stools 28. Cooking equipment 29. Prcssure lamps 30. Office Accomodation Sub total C.Levcl-C(L-C) l. 4 - WD Vehicle x 24 districts 2. Motor cycles 3. Field Binocular Microscopes 4. Ivermectin Monitoring Kit 5. Stethoscopes & Blood Pressure Apparatus 6. Enamel trays 7. Holths clips E. Kocher clips 9. Knapsack sprayers 10. Visual Acuity Scales(l) for illiterates (24) (2) for literates (24) Sub total D. Level B (56) (L B) l. Mopeds (Mobylettes) 2. Bicycles 3. Bathroom scales 4. Stothoscopes & Blood Pressure Apparatus 5. Enamel Trays 6. Thermometers (5 x 66) 7. Holths Clips E. Kocher Clips 9. Visual Acuity Scale (2 x 66) (i) for illiterates (66) (i) for literates 10. Binocular Microscopes Sub total 9 6 3 6 3 24 37 24 24 24 48 48 48 48 48 66 66 66 66 66 600 66 66 t32 66 0.016 0.006 0.0r5 0.0r5 30.0 r 0.0 0.9 0.5 0.09 0.045 0.005 0.056 .0006 0.075 0.00r r4 0.20 0.03 0.0r6 0.045 0.005 0.002 0.056 .0006 0.001r4 0.5 0.t44 0.036 0.045 0.090 90.0 r98. r 56 240.0 33.3 r 2.0 2.t6 r.08 0.24 2.688 0.029 3.6 0.055 295.t52 t3.2 t.98 r.06 2.97 0.33 t.2 3.70 0.04 0.r5 33.0 57.63 I 40 Item Quantity Unit cost Cedis Million Total cost Cedis Million E. Nos/Monitoring Tcam (Nos/MT) l. 4-WD Vehicule 2. Computer, Printer & Accessories 3. Photocopier 4. Typewriter 5. Camping Beds 6. Umbrella Tents 7. Camping chairs 8. folding tables 9. Adjustable stools 10. Cooking equipment I l. Pressure lamps 12. Transceiver Sub total Grand total 2 I I I 4 4 5 3 2 2 2 I r0.0 4.0 t.2 0.5 0.38 0.05 r 0.006 0.0r6 0.023 0.06 0.0 r5 1.5 20.0 4.0 t.2 0.5 t.52 0.204 0.03 0.0s 0.046 0.12 0.03 r.50 29.20 593.338 I