Programme for devolution of onchocerciasis control activities in Côte d’Ivoire

Onchocertiasis Contrql Programme in West Africs Programme de Lutte @ntrc I'Onchocencose en Afrique de I'Ouest JOINT PROGRAMME COMMITTEE Off,cc of tbe Chairrun JPC.CCP COI,IITE CONJOINT DU PROGRAIVIME Burcau du Pr6sident JPC11.8(B) ORIGINAL: FRENCH Septenber 199O ( i rl : JOINT PROGRAUUE COI+{ITTEE Eleventh session Conakry. 3-6 Decenber 1 990 Provisional agenda iten 9 PROGRAU}IE FOR TIIE DEVOLUTION OF ONCH@ERCIASTS CONTROL ACTIVITIES IN COTE DIIVOIRE 'l Republic of C6te d'Ivoire Ministry of PubIic Health and Population Linity - DisciPline - lrork Programme for Devolution of Onchocerciasis Control Activities in C6te d'Ivoire Integration of these activities into mycobacterial control and sanitation progranmes June 1990 TABLE OF CONTENTS i i i SUMI{ART 1. INTRODUCTION 2, SITUATION OF ONCHOCERCIASIS Situation at the beginning of OCP's activities OCP's activities . . Present situation of onchocerciasis in C6te d'Ivoire Future prospects 3, SITUATIO}i OF DISEASE CONTROL PROGRAUMES INTO WHICH ONCHOCERCIASIS WILL BE INTEGRATED Selection of programnes The mycobacterioses 3,2.7. Leprosy 3,2.2. Tuberculosis 3.3. Environmental sanitation activities 1. GE}iER.AL SITUATION II{ THE COUNTRY General presentation Deurographic and socioeconomic indicators Organization chart and health policy Personnel and facilities Cost and financing of public health services Epidemiological surveillance Paqe 16 15 t? L? 18 18 18 19 1g 1g I I 1 2 2 3 2,7. ,, o.) on 4.1. 4.2. 4. 3. 4.4. 4.5. 4. 6. 4,7 . 3.1. 3.2. 6. 3. 6.4. 6. 5. ) ) 4 4 9 5 5 6 6 ? 11 13 15 15 15 Vector control 5. ONCHOCERCIASIS SURVEILLANCE AND TREATMENT 5.1. Surveillance strategy 5.1. 1. Objectives 5,7,2. Activities 5.2. Treatment 6. IDENTIFICATION OF RESOURCES AND EVALUATIO}i OF COST OF THE PROGRAI{}IE Training activities R'ecurrents costs C6te d' Ivoire Government's contribution Cost of programme for five years 6.1. 6.2. Capital costs 207, PROVISIONAL TIMET.ABLE ,qNNEXES 1. Larviciding operatiotral phases 2, Pre-control annua] transmission potentials 3. Annual transmission potentials in 1989 4. Pre-control prevalence of onchocerciasis 5. Prevalence of onchocerciasis in 1989 Page 2L 22 2) 24 25 26 2? 3I )2 6. Rura1 health sectors i, Estimated cost of the programme for five years SUMMARY BREAKDOWN OF COSTS PEB YEAR -LL1- sUilltABY As regards Onchocerciasis, C6te d'Ivoire presents three epidemiological patterns: - the savannah region of the northern and central parts of the countrl where the most serious form of onchocerciasis was to be found was included in the Onchocerciasis Control Programme (OCP) in 1974; - in certain central and southern regions, victims of deforestation, the same epidemiological aspect appeared, which starting in 1979, necessitated the extension of OCP's activities; - in the forest zone to the extreme south, forest onchocerciasis, which is not very blinding predominates and this zone is not covered by OCP's activities. After l5 years of uninterrupted vector control, transnission has been stopped in the northern zone. Larviciding wiII cease in 1991. it is up toC6te d'Ivoire to put in place the residual activities regarding epidemiological surveillance and treatment of new cases. The activities wiII be integrated into the already operational mycobacterial control programmes and the activities of the sanitation sections of the rural health sectors. Twenty rural health sectors out of a total of 26 in C6te d'Ivoire are concerned with these activities. In each sector, sone fornerly hyperendemic villages will be selected as indicators and prospections organized there annually by a national team. With regard to screening and treatnent of possible onchocerciasis patients, it is entrusted to personnel of the rural health sectors and they should be retrained and equipped for that purpose. In the extension zone, where OCP will continue with its activities for a few more years, and in the forest zone, the only activity that can be envisaged by the national health authorities is the treatment of onchocerciasis patients with ivermectin. The whole of the onchocerciasis surveillance and control activities is supervised by the National Coordinator, Assistant Director of the lrlajor Endemic Diseases, who is placed under the authority of the Director of PubIic Health and Population. To carry out these activities successfully, it is necessary to equip the National Coordinator's office for the collection of epidemiological data, provide the mobile teams of the rural health sectors with field-r,ist and sanple-taking equipnent, and train the medical, para-medical and community health workers for the duties they will carry out as part of the surveillance of onchocerciasis. External funding is necessary for the operating costs for five years excluding staff salaries. The costof the programne is estinated at 389,500,000 CFA francs (three hundred and eighty-nine nillion five hundred thousand CFA francs), i.e., US $1'370'000 (one million three hundred and seventy thousand US dollars). I 1. INTRODUCTION Since 1975, the Onchocerciasis Control carrying out onchocerciasis control operations auspices of UNDP, FAO, the World Bank and tr'HO. Programme (OCP) in C6te d'Ivoire has been under the After 14 years of uniterrupted activities in the savanna area (northern and central parts of the country), the results of epidemiological surve]'s show the complete success of the Programme. Large-scaIe vector controi wili therefore cease in 1991. In the initiaL area, C6te d'Ivoire wiII therefore have to take over from OCP and assume responsibility for residual activities' i.e. . epidemiological surveillance, entomological surveillance' and ivermectin treatment of new patients who have entered the territory as well as of the populations in the forest zone which is not covered by OCP's activities. These residual onchocerciasis control activities described above have to be integrated into the nornal activities of the rural health sectors in order to avoid making onchocerciasis control a vertical one. They can usefully be entrusted to the mycobacterioses (leprosy and tuberculosis) control teams and, particulary to the sanitation teams found in each of C6te d'Ivoirets rural health sectors. These teams, composed of a sanitary assistant, a labourer, a driver and a vehicle, have been given the responsibility of going to villages to promote the creation of village health committees by raising the awareness of the populations to hygiene and sanitation problems. It is therefore easy for those teams, retrained beforehand' to undertake onchocerciasis epidemiological surveillance activities during their visits to the villages. At present, these teams do not go out nuch because the economic crisis has led to the reduction of the operating credits for fuel and maintenance of the vehicles. The mycobacterioses (Ieprosy and tuberculosis) control teans can carrlr out the epidemiological surveillance of the populations served by the fixed health centres (with the help of the nurses of the said centres) and the sanitation teams the epidemiological surveillance of the villages not covered by a health centre, if necessary, with the help of the village health workers. 2. SITIiATION OF ONCHOCERCIASIS 2.1. Situation at the beginning of OCP's activities 2,L.7, Onchocerciasis foci The initial Iimits of OCP (Annex 1 ) were drawn to include the most serious foci of savanna onchocerciasis as known in 1975. They comprised: - north eastern C6te d'Ivoire with the ivoirian part of the Black Volta, including the regions of Bouna, Chache and Tagadi in the Bondoukou department; - the upper Comoe, from the border with Burkina Faso up to Groumania(Serbou) and reaching the Nassian, Dabakala and Prikro departments; -2- - the upper N'Zi basin in the Dabakala departnent up to Fetekro in the Bouake prefecture; - the basin of the lihite Bandama and the tributaries Bou, Solomougou, Lafigue upstream from the liossou lake including the Ferkessedougou, Korhogo, Tortiya, Niankaramadougou and Katiola departments; - the upper Bagoe in the Boundiali prefecture; - the upper Baoule in the Odienne prefecture. 2,1,2. Seruousness of the disease These foci were the most severely affected ones in C6te d'Ivoire. Surveys by different groups of researchers show that nost of the villages in the basins concerned were in a hyperendemic situation, i. e, , with - a prevalence of nore than 60%. The blindh-ess rates were very high - fcir example on the Black Volta, in the Bouna area, the average rate was 4.8% with a maxiuun of 15% in certain villages. The Tortiya focus on the Bou and Naramou tributaries had an average rate of about 3Z with a naxinum of 9%' while the rate ranged between 4 and 112 on the upper N'Zi and 3.7X in the Kong canton on the upper Conoe. In aII these foci, the seriousness of the disease was reflected in high Annual Transmission Potentials (ATPs) whose values ranged between 1000 and 2500, i.e., far above the tolerable threshold fixed at 100 (Annex 2). 2.2. OCP's activities Larviciding was started in February 1975 on the Black Volta, upper Conoe, upper N'Zi and l{hite Bandana basins. The upper Bagoe and the upper Baoule were brought under larviciding in 1977, ln 1978/7 9 it was decided to nake an extension of 110,000 km2 to include the more southerly foci where the clinical pattern of the disease is more or less serious depending on the sites and fron where savanna. vectors were leaving to reinvade the area delinited initially. The extension zone in C6te d'Ivoire comprised: (a) the upper Sassandra basin with the Boa, Bagbe, Bafing, Sien and Tiemba tributaries found in the Touba, Man and Odienne departments; (b) the Marahoue basin in the Seguela, Zuenoula and Bouafle departnents, the lower Bandama basin below the Kossou Lake in the Tiassale, Toumodi, Yamoussoukro and Bouake departments, as welI asthe savanna section of the Comoe basin, i.e., above the latitude roughly passing through Abengourou. 2.3. Present situation of onchocerciasis in C6te d'Ivoire AIl the catching points on the basins under larviciding since 1975/77, i.e., after 14 years of vector control, have an ATP of less than 100 and markedly below the threshold considered to be tolerable (Annex 3). The populations of the blackfly, the vector, have been reduced to such an extent that transnission of the disease is practically interrupted. The results of the analysis of the nedical evaluation data confirm the efficact' of the vector control: since the start of the operations only one child has been found infected at Tripongo on the upper Solomougou in 1984. -)- The prevalence of the infection and that of clinical manifestations' particularly ocular, have fallen everywhere (Annexes 4 and 5). In the light of these results, it c&n be affirned that onchocerciasis no longer constitutes a public health problem in the northern foci. Today, the entomological results on the basins under larviciding since 7979/80, are spectacular and reflected as follows in C6te d'Ivoire's extension area: - on the basin of the Sassandra and the I'laraltoue, the ttnsaiisfactot"v results obtained at the beginning started improving from 1985 onwards, i.e., the year in which lan'iciding was begun on the Guinea tributaries of the upper Sassandra basin in order to elininate the reinvasion phenomena. Thus. the ATPs in the different catching points were reduced below the tolerable threshold. An exception concerns the N'Zo at Logouale where the transmission indices appear to be high but are in fact attributable to forest-dwelling vectors that are responsible for a non-blinding form of onchocerciasis; - similarly, on the lower Bandama, Iower N'Zi and lower Comoe (within the lirnits of the control operations), the ATPs that are still high (between 400 and 800) on a few catching points are due mainly to forest blackflies. It should be noted that the "savannization" of the lower Bandana is leading to the colonization of this basin by increasingly greater proportions of savanna blackflies which are the vectors of serious onchocerciasisr but efforts are being made to maintain the ATPs of the savanna species at the Iowest possible level. The epideniological results are less satisfactorf in the whole of Cote d'Ivoire's extension area that has been under larviciding for some ten years now. Considering the mean duration of the fertility of the worms' which is of the order of ten to twelve years, the prevalence falls slowly even in the absence of new infections. 2.4. Future prospects To maintain the achievenents brought about by OCP's activities r+hich cover more than 662 of the C6te d'Ivoire, concrete actions should be taken: - in the northern zone freed from onchocerciasis, a surveillance network has to be naintained at the points exposed to reinvasion on the different basins and a nationa] ivermectin distribution network put in place to eliminate possible parasite reservoirs; - in the extension areas where OCP's vector control has to be continued for a ferr'nore years in its present form, all positive cases should be treated with ivermectin to relieve the patients and prevent risks of blindness. The objective of this joint action is to reduce the parasite reservoir to insignificant levels after some 14115 years of control so that the risk of recrudescence of the infection and of the disease would be negligible even if the vector succeeds in recolonizing the river basins. 3. SITUATION OF DISEASE CONTBOT PROGRAU}MS INTO IiHICH ONCHOCERCIASIS CONTROL I{IIL BE INTEGRATED 3.1. Selection of prograues The Rural HeaLth Sectors are responsible for control operations against the major endemic diseases and national health progranmes, such as EPI (Expanded Programme on Immunization), in the whole countr*v. -4- To this end, mobile teans have been used for ma,rry years. More and Eore' the fixed health centres in the rural areas also play a part. Thus, dispensaries and maternities carry out IIPI activities as weII as the treatment of leprosy and tuberculosis pa1:ients. The Ieprosy- tuberculosis mobile teans have thereby moved fron the status of drugdistributors to that of supervisors of activities of the peripheral health centres and it is therefore possible to entrust ttrem r+ith the work ofparasitological diagnosis of suspected onchocerciasis patients selected by the nurse of the health centre. Unfortunately' the density of the rural health centres is still too Iow, Ieaving a great part of the population isolated. In these villages, health activities are underbaken by mobile teams fron the sector base. One of these teans is particularly responsible for the promotion of hygiene in the villages and relies on the training of comnunity health workers. It is the sanitary team headed by a sanitary assistant. This tean, when trained beforehand, wiII be in a position to carry out a parasitological diagnosis of onchocerciasis patients screened by village health workers. Thusr as regards the reappearance of cases o:l onchocerciasis, the populations depending on the permanent health centres c'an be monitored by the nurse of the health centre and the diagnosis confirmecl by the mycobacterial team during the monthly supervisory visit. For the populations not likely to be covered by a permanent centre, the screening of onchocerciasis patients can be done by health workers and the parasitological confirnatic,n undertaken sanitary tean during its regulars visits. health v i Ilage by the 3,2, The rycobacterioses 3,2.7. Leprosy Leprosy control is under the authority of the Assistant Director of Major Endenic Diseases who is the National Coordinator of leprosy control. There were 31,684 patients as of 31 December t988 including 4 ' 189 nultibacillary and 27 r495 paucibacillary subjects, i.e., a prevalence of 2.8 per 1000 inhabitants. Out of the 31,684 patientsr 241291 were under treatment and 7,393 under post-treatnent surveillance. In 1988, the nunber of new annual cases was 2',0t34 (rate of detection: 19 per 100,000 inhabitants). In 1989, a great effort to check the files was made. Likewise, the staff concerned were given training for the introducl:ion of the new system for the collection of epideuiological data on leprosy (OMS.LEP). Fifteen of the 26 rural health sectors are using the new WHO standardized polychenotherapeutic treatments and four new sectors will be introduced to polychenotherapy every year. AII the peripheral health centres are involved in leprosy treatment which conprises a monthly taking of the drug under supervision at the dispensary followed by a self-treatnent for the rest of the nonth. Patients living very far fron the health centresi are given their drugs -5- nonthly by mobile teams which aLso undertake the nonthly treatment supervision given by the nurses of the dispensaries. The Raoul Follereau Foundation provides the greater part of the aid in terms of equipment and drugs for leprosy control in C6te d'Ivoire. 3.2,2, Tuberculosis A National Coordinator of tuberculosis control works under the authority of the Director of PubIic Health and Population. There is a nationaL tuberculosis control policy with standardization of treatments. The current treatment in C6te d'Ivoire is the short polychenotherapeutic treatment that Iasts six months. Drugs and reagents are bought by the State. There has never been stock shortage. Equipnent is provided by the National Tuberculosis Control Committee which operates thanks to the sale of stamps and gifts. Eight tuberculosis control centres and 18 centres integrated into the offices of rural health sectors are invoLved in the screening and treatnent of tuberculosis patients. The operations are highly decentralized and the ruraL dispensaries participate in the treatment of patients. Some of them even undertake the examination of sputa in the rural health sector bases. Supervision of the treatnents given in the dispensaries is nade monthly by the nobile leprosy-tuberculosis tean. In 1988, 6,589 new tuberculosis cases were screened in C6te d'Ivoire(annual rate of incidence: 6 per 10,000 inhabitants) and 4,595 treated patients were healed. A national tuberculinic survey was conducted in 1988. It made it possible to evaluate the rate of screening of patients, which is of the order of 752. 3. 3. Environrental sanitation Entrusted to sanitary assistants in the offices of the rural health sectors, these operations are manifold and conplex. They comprise the follor+ing stages: - raising the consciousness of the villagers so as to bring about the creation of village health comnittees; - identification and training of village health workers; - health education on the probleus of diseases related to water and excreta; . pronotion of latrine construction . fitting-out of edges of wells . advice on personal (washing of hands) and food (preservation, use of potable water, etc. ) hygiene. help to villagers in the setting up of village pharmacies. In 1989, I,L24 villagers out of the total of 8,000 in Cote d'Ivoire, hed c_omnunity hea-lth workers; 400 villagers had a village pharnaey. Duringthe first ha,If of the year,'602 new heilth workers ana tOS teacirers weregiven hygiene and sanitation training by the sanitary workers of the rural 6health sectors. The factors limiting these sanitary activities are the lack of fuel,' sometimes the bad state of some of the vehicles and fjnally the average age of the sanitary assistants some of whon are near to retirement and must be replaced. 4. GENEBAL SITUATION OF THE COUNTRY 4. 1. General presentation C6te d'Ivoire is a West African country bounded: - on the north by Burkina Faso and MaIi; - on the south-by the Atlantic Ocean; - on the east by Ghana; - on the west by Guinea and Liberia. It measures 600 km fron the north to the south arrd from the east to the west, and has an erea of 322'500 kn2. The relief of C6te d'Ivoire is monotonous and nade up of plateaux rising in steps: - to the north, a plateau region whose maximun altitude is 900 netres; - to the south, a Iow and flat coast; - to the west, a nassif in the Man area whose sunnit is Mount Nimba(1,752 n) found close to the border with Guinea. Four principal rivers run across C6te d'Ivoire, in a north-south direction, and flow into the GuIf of Guinea: - the Bandama - the Conoe - the Sassandra - the CavaIIy 950 km 900 km 650 km 600 kn In addition to these four big rivers, the hydrog:rapht'of C6te d'Ivoire also comprises part of the Black Volta basin as wr:II as three Sahelian watercourses: the Bagoe, the Baoule and two important tributaries of the Sankarani. C6te d'Ivoire has a cliuate that is both warm and wet and is characterized by four nain types of climate. The clinatic variation is determined by the quantity of the rains and their drstribution during the year and not by the temperatures which are always high and do not vary much. The following can be distinguished: - the major and the ninor rainy seasons (June-,liuly and October- November ) ; - the minor and the najor dry seasons (August-September and Decenber- March ) . C6te d'Ivoire is in a transitional zone with the savanna in the north and the forest in the south. 4.2. Derographic and socioecononic indicators As regards denography, the principal characteristics are the great -7- ethnic diversity, the high population growth {'3,2%), and a high percentage of youth (more than half of the population are less than 18 years old). The Iast census (1988) gave a population of 11.2 million. Based on Iiberalism and therefore free enterprise, the economic system ofC6te d'Ivoire is characterized by three main features: the important place occupied by agriculture, the great intervention of the State and a clear openness to the outside. The GNP per capita is tjS $710 (1983). Despite the great efforts nade in the field of public health, the results are not quite satisfactory. The principal causes of nortality are parasitic and infectious diseases related to ecological and climatic factors, health conditions, insufficient health facilities and their equipment, and difficulties in financing health expendi tures. A. General infornation on the country 1. Total area ( km2 ) 2. Total population (estimation mid-1985, million 3. GNP per capita, in dollars (1983) 4, Enrolnent in prinary schools (Z) (1982) 5. Enrolnent in secondary schools (Z) (1982) B. Demographic data 1. Density (population per kn2) (1985) 2. Urban population (Z) (1985) 3. Average population growth rate (%): - avera,ge 1965-?2 - average 1973-83 - average 1980-2000 Annual natural population growth rate Aggregate fertility index (1983) Crude birth rate per 1000 inhabitants Crude death rate per 1000 inhabitants ( 1e83 ) C. Data on health and nutrition Life expectancy at birth (1983) (years) Infant nortality rate per 1000 infants (1983) ChiId mortality rate per 1000 children (1983) Number of inhabitants per medical officer (1980) Number of inhabitants per nurse (1980) Number of calories consuned per day per inhabitant ( 1982 ) Number of calories consuned per dayr as a percentage of requirements ( 1982 ) 322 ,000 inhabitants ) : 10,2 710 76 17 32 44 4.6 4.6 3.3 4 5 6 7 ( 1983 ) ( 1983 ) 3.2 6.6 46 14 1 2 3 4 5 6 7 52 t21 20 21 ,040 1,590 2,652 115 Source: World Bank, Report on Development in the world' 1985. 4.3. 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Equlpm.nt E/D. !udg.t.nd aooounta !9oac, =[It<o Gi II(r< =5=FE(, .lrlAEzaO-(,F urJEfi - 3/D. tt.tl.tlc. .nd d.t. b.nk ulI ILlro 3? G, ttJF c2 = = G,FI = = S/D. Plrnnlng oa2.)<trs2zb =315J-CFqd or S/O. Horptt.l R.iulrllon ,y* H# fi =F vazzE=r: lr-rooEd= to E/D. Urben l{..lth Cantraa t/D. Ho.plt.l. = lrl 6tL99 -alr arlo- ci lrl eIi9ds JA<oc,2 z-TIFC'J lrt - E/D. llrlor Enrl.mlc D1...... rnd PHC Coc?dlnrtlon E/D. MCH.nd rchool modlclno 7zto <Fld< -JedJC,oa?e ci< E/D. Pr.Y.ntlv. il.dlcln. m.dlcln. -9- EOgE€Ertotro -rOC OiEO .-i 3E '6 e IJo =o.lro Yz<oEtro<FJo= uJ o.EO6o. rrCl ?7E-<t6tz-IF N z o c,o otrgE !UEbo6=OO d=;3 o o. =c o o = o oLo(r+ Eq6= o EO =oGGo@ IL oG|€L(, =oGO s53=aoo.EE3 oG EEoo E*6f o c oo E =IE o ooo! =oE}EEo=()6 o =b-o=:EcozOEotr =o EEts=oo E€e *,,i5 =a5EEE *E-,.XEE ELL(rc.= EHI\GV €Eo6 (U 6c o o.g o -10- attachment to the principles of Denocracy and Human Rights as defined by the Universal Declaration of 1948. The right to health is one of these Human Rir3hts: recognizing the individual or community's right to live. The authorities accord a priority place to rural health in a spirit of equity and social justice. Attached to the Minister's office are: - the general public health inspectorate and some intitutes; - Four commissions: National PubIic Health Conmittee National Public and Social Hygiene Committee Therapeutic HeaIth Commission Health Council - Eight central Directorates: Directorate Directorate Directorate Di rectorate Directorate Directorate Directorate Directorate of of of of of of of of Fublic Health and Population Hospital Medicine Planning and Health Statistics Equipment and Maintenance of HeaIth centres Financial Affairs Regional and International Relations Personnel Pharnaceutical Serv ices. - Eight Regional Directorates of PubIic Health. The Directorate of PubIic Health and Population is conposed of: - three Sub-Directorates at the central level Sub-Directorate of MCH and School Hea1th Sub-Directorate of Preventive Medicine in charge of EPI Sub-Directorate of lrlajor Endemic Diseases, National Coordinator of Oncho Programme in charge of the control of the nycobacterioses, nalaria, trypanosomiasis, etc. - eight regional health directorates, at the internediate level - 26 rural health sector bases, at the peripheral level. In general, there are two nedical officers per sector. The sector office has mobile teams: - EPI teans made up of nursesl - mycobacterioses teams composed of nurses having undergone a Ieprosy control course; - sanitary teans composed of one or two sanitarl assistants. The staff are not nurses but have a solid hygienist tra.ining permitting them to carry out health education activities in t.he villages. Ilith the sector's medical officers, they take part in the training of community health workers and the establishmer,t of village -11 - pharmacies. Recruitment having been stopped, they are now being replaced b.,- State registered nurses who undergo a hygiene and sanitation training in the sector bases. The rural health sectors are also responsible for rural dispensaries and maternities. The ruraldispensaries is run by a nurse. He treats patients' including those suffering from leprosy and tuberculosis. He undertakes EPI vacc inations. The rural maternity is managed by a midwife. Her activities include antenatal consultations, childbirths, weighing and nutritional consultations when there is no MCH centre. 0ften, the maternity and dispensary are combined to forn a health centre. Supervision of the activities of the peripheral clinics and maternities is done monthly by the nobile nycobacterioses tean and every two nonths by the sector's medical officer. The sanitary team goes to the villages and settlement located outside the scope of the pernanent health centres. 4.4. Personnel and facilities The health care system comprises two sectors: a public sector and a private sector. (1) PubIic sector - Directorate of Hospital Medicine General hospitals Teaching hospitals Regional hospitals 1st category hospitals 2nd category hospitals i.e., a total of 3i 20 54 84 with 9,083 beds Specialized hospital establishnents with 599 beds Raould FoIlereau Institute Cardiology Institute Erergency Medical Assistance Service (SAI{U) Bingerville Psychiatric Hospital Bouake Mental Protection and Psychiatry Centre National PubIic HeaIth Institute ( iNSP) - Directorate of PubIic Health and Population 26 rural health bases with 484 beds 649 dispensaries including 606 rural ones with 864 beds 301 maternities including 290 rural ones with 1,906 beds ?6 MCH centres 35 of which have been integrated into the 26 rural health sectors -12- 8 anti-tuberculosis centres. (2) Parapublic sector 37 military dispensaries 8 medico-social services of the National ilocial Securit.v Off ice ( CNPS ) (3) Private sector There are 23 hospitals, 27 surgeries and 11 denl:a1 surgeries with 600 beds; most of these facilities are in Abidjan. The public private sector. sector is by far the greatest enp.Loyer compared to the With the exception of the teaching hospitals, the health personnel(permanent and teporary staff) is distributed as follows: _t)_ Table of health personnel (permanent and temporary staff) per professional group as of 16 June (excluding teaching hospitals). Source: See list of health workers as of 14/6/89 by Mr Eponon Faustin, Service Infornatique, Direction de Ia Solde. Some Ministries have their own health services which are nainly MCH dispensaries and nedical analysis Iaboratories. This Defence. concerns the Ministry of Social Affairs and the Ministry of In alI, there are 354 workers including 101 nedical officers and surgeons in the health services of the Ministry of Defence and the Ministry of Social Affairs as well as 253 paranedical workers. There is a total of 919 health workers in the private sector including 308 nedical officers and 317 paramedical workers. A few non-governmental organizations (NGOs) work in the field in collaboration with the Directorate of Public Health and Population. More often than not they carry out prinary health care activities. It should be noted that nany religious congregations scattered over the country undertake MCH activities as weII as the training of traditional birth attendants in the villages. 4.5. Cost financing of public health services The financing of the operating and equipuent costs of the Ministry of Fublic Health is based nainly on the Budget of the State. There are two sorts of budget according to the nature of the expenditures: the general operating budget (GOB) and the special investnent and equipment budget (SIEB). years other. The trend in the general health operating budget over the past ten shows a progressive fall in the growth rates fron one year to the Group Number Percentage Medical officers Pharmacists Dental surgeons Senior Health workers PubIic health midwives Technical Health Off icers Midwives (Aid PubIic Health Dip. ) SociaI workers Nurses Specialist nurses Assist. social workers Assistant nurses Registered nurses Adn. Assistants and others 608 18 ooLL 195I 66 999 63 1 ,976 04 60 02 601 1,591 I 0 0 3 0 1 16 1 31 0 0 0 9 .78 .28 .35 .13 .14 .06 .07 .01 .79 .06 .96 .03 .67 26 TotaI 6,214 100.002 Year Amount in mil-Iions CFA f rancs Growth rate 1980 1981 -t oo, 1 983 1984 1 985 1 986 1 987 1 988 198I 23,870 28.853 31,574 32,853 31,439 29, 168 31,560 35. i43 36. 23i 38. 456 + + l + + + + 1 1 1 oq 0z 0z 9% 9% 0% t% 0% 07" 1 1 1 1 -14- Table of trend in general operating Budget fron 1980 to 1989. The share of the general.health operating Budget in the State's general operating Budget over the'past ten years represents an average proportion of 7/", This rate is low considerinB the growth of the overall health denand. Table of trend in operating Budget of Ministry of Health and Population conpared to that of the State fron 1984 to 1989 in million CFA francs Expenditure on personnel represent about 702 of the Health Budget. Year GOB State GOB Health GOB Health ------------z GOB State 1984 1985 1986 1987 1988 1989 428 ,850 418,130 458,850 480,980 493,500 499,478 30, 748. 4 29 , 168. 1 32 , 768. 6 35 , 743. 1 36,260 38,456 7 .t6?( 6. 97U 7.14 7 .432 7 .352 7 .40 _15_ Tab1e of Budget of Ministry of Public Health according to type of expenditure for 1988 ( in million CFA francs) * National Public establishments Table of Budget of tlinistry of PubIic Health and Population compared to the National Budget for 1989 (in million CFA francs) The budget for public health activities represents 9-112 of the Budget of the Ministry of PubIic Health and Population. 4.6. Epideriological surveillance The Directorate of PubIic Health and Population has structures (rural health sectors) that are scattered over the whole country. They are 26 in aIl. The rural health sectors fight against aII the endemic diseases, such as leprosy, trypanosoniasis, yaws, nalaria, trachona, onchocerciasis, bilharzia, tuberculosis, ye1low fever, etc. The rural health sectors carry out the epideniological surveillance of alI these diseases. Each rural health sector is a unit conposed of the sector base, centres, dispensaries and maternities. The officers in charge of these centres (nurses and nidwives) keep records of consultations and activities and prepare a nonthly norbidity report that is sent to the base, and after verification forwarded to the central level (National Health Institute, where the data entry is nade, and the Directorate of Health and Population by post). health health other sector Publ ic PubI ic Min. of HeaIth excluding NPEs NPEs* Total % Personnel Permanent Day labourers Tenportary workers 15,938. 771 3 , 593. 634 1 ,056. o0o 5 ,843. 910 621,384 1,144.000 2t ,7 82.681 4,215.018 2 , 2oo. 0oo 56. 69 10. 97 5.72 S/Total Personnel 20 , 588. 405 7 , 609. 294 28,197.699 73,37 Recurrent costs Operating Utilities 2,783,742 1 , 396. 100 4 ,892.7t2 7 62,400 7,676.454 2, 158. 500 19. 97 5,62 S/TotaI recurrents costs 4,779.842 5,655. 112 9,834 . 954 25. 59 Equipnent 168.513 230. 140 398. 653 t.02 Total 24 , 936. 760 1,394.546 38,431. 306 100 National Min. of Health % GOB 499,478 38,456.575 7.4 SIEB 149,448 5. 575 3.8 TotaI 648,926 38,462. 150 5.9 15 In case of epidemic, the nurse informs the Sr:ctor's Chief Medical 0fficer either by radio-message from the sub-prefecturr: or goes to the Sector Base by public transport or moped if he has one. As regards the nurse, he is informed by the community health workers or the villagers. The Chief Medical Officer, in turn, inforns the Regional Director by telephone, and the Director of Public HeaIth and Population by rarlio-message from the prefecture. In general, feedback is not done systematically 4.?, Vector control For trypanosomiasis, tsetse fly traps are distritruted to vj.liagers; the vector control is carried out jointll' by the Ministrl of Public Health and Population, the Bouake Pierre Richet Institute of the Organization for Coordination and Cooperation in the control of the Major Endemic Diseases (OCCGE) and the CIinica1 Research Programme on Trypanosomiasis at Daloa. With regard to malaria, there is no national pr()granme. The programme concerns only the towns of Abidjan, Bouake and Yanoussoukro. 5. ONCHOCERCIASIS SIJRVEIIIANCE AND TREATMENT 5. l. Surveillance strategy 5.1.1, Objectives They are two: - to prevent recrudescence of cases; - to maintain the achievements of the Progranme as regards interruption of transmission. An active screening therefore has to be done in the zones at risk. In the whole of the northern part of C6te d'Ivoirel they can be defined as all the first-Iine villages. In these villages, the teans of the rural sectors have to continue to take skin snips, on request, frcm suspects and treat screened patients with ivermectin. In case of grouped appearance of several patients, the national team will be called on. It is an itinerant tean that, on recuest, goes to the spot to undertake a na5s parasitological screening. In the Progranme's extension zone and in the non-treated forest zone, the populations in the onchocerciasis foci wilI be given iverglectin treatment once or twice per year according to the epidemiological pattern. Enphasis should be particularly laid on the fact that the planning of aII these onchocerciasis surveillance activities should be int.egrated into the planning of the general activities of the sanitary teams and the uycobacterioses control teams. These activities should under no circumstancr:s be conceived in a vertical wayr which would Iead to the setting up of an autonomous onchocerciasis control service to which aII the neans in terms of personnel and equipment would then have to be provided. Besidesr the means exist. B-y striving to train staff. repair equipment and provide the means for operation (fueI, sample-taking equipment and _L7_ druSs)r it will be possible to naximize the cost-effectiveness of the activities of the health service personnel already engaged in other duties but having sufficient tiure to integrate onchocerciasis surveillance into their activities. The same is true of the national surveillance team. it has already been established with nurses from the different rural health sector bases and is under the supervision of an Ivorian medical officer-entomologist. At present, it undertakes joint missions with the OCP teans and wiII take over when OCP ceases its activities. However, this team comes together only for missions of a duration of 120 days per year. The rest of the year each member of the team works in his rural health sector. 5,1,2. Actit'ities Onchocerciasis surveillance activities could be organized as follows. 5.1.2.1. In the zone initially covered by the Progranne: - In villages having connunity health workers, they would be given the responsibility of taking & census of migrants and encouraging them to go to the nearest health centre in case of suspicion of onchocerciasis (pruritus, skin lesions, nodules). - A special effort will be made to provide community health workers for the villages that do not yet have some. - At the health centre, the nurse will make a conplete clinical examination, takes the address of the presumed patient and requests him to come on the day of the monthly visit of the mobile team. This team will look for a parasitological confirnation of the affection and treat the patient with ivermectin. - At the rural health sector base: the Chief Medical Officer, helped by the officer in charge of the mobile team, wiII prepare a specific mapping of the appearance of new cases. In case of grouped appearance of several confirmed onchocerciasis cases the national team will be called on for a nass parasitological survey in the zone. - The national team will intervene at the request of the rural health sectors in the zones where the resumption of transnission is suspected. In addition to these requests, it wiII carry out parasitological surveys every year in first-Iine villages selected at random. carried out ivermectin. 5,1,2.2. In the OCP extension zone, the sane activities wiII be and, in addition, the populations will be treated with 5.1,2.3. fn the forest zone not covered by the Prograul,e surveys will be made by the national tean as and when necessary in order to better define the linits of the foci where ivermectin treatment is necessarl'. 5.2. Treatrent Be it individual treatment of newly detected cases or mass trea+-ment in the forest zone, the drug to be used will be ivermectin (Mectizan) according to the doses recommended by WHO. An initial nass ivermectin treatment trial took place in March 1988 in the Bettie area, under the supervision of OCP. 16,000 persons were treated without any serious post- -18- treatment incident. Treatment will be nade by the personnel of the health centres after they have been retrained and received kits containing the drugs that will enable them take care of the rare side-effects. Ivermectin wiIl be ordered b1 Cote d'Ivoire, using the right forms in order to obtain the product free of charge. Besides, a circular wiII be prepared forbidding the use of Notezine. As regards treatnents in the extension and forest zones, thel' will be made by the mobile teams of the rural health sectors which wilI, themseives, have to be in charge of the 36-hour post-treatnent sun'eillance in the villages not covered by a health centre. It is therefore necessar] to deiinrit the onchocerciasis hlperendemic zones with precision. 6. IDENTIFICATION OF RESOTIRCES AND EVAIUATION OF COST OF THE PBOGRA}TME 6.1. Capital costs Personnel: staff of the Directorate of Public Health and Population wiII be used, vizz - Sub-Director of the Major Endemic Diseases, National Coordinator - National Evaluation Team, conprising an entonological medical. officer, assistant to the National Coordinator, and six nurses including three nicroscopists - Medical 0fficers of the Rural Health Sectors Bases - Personnel of the mobile uycobacterioses control teams and of the sanitary teams of the Rural Health Sectors - Paramedical personnel of the peripheral health centres. All these workers are retrained. Furthermore, conmunity health workers will be trained in villages which do not have some. Equipnent A number of vehicles wiII have to be provided for the surveillance teans in order to inprove their srobility. Similarly, technical equipnent has to be given to the national team and each sector base for parasitological examinations, as welI as field equipment(details of these requirenents are appended to this docunent). 6.2. Training activities They include: - advanced training course for the central tean: 9 persons 75 Ieprosl'complete retraining of mobile teams of the sectors: controllers, 50 sanitary assistants - training courses for medical staff of the rural health sectors: 50 medical officers - 1q - - these trained nedical officers wiII be responsible for the organization of courses for personnel of the peripheral health centres (800 persons) and for the training of communitt' health workers within the framework of primary health care (2600 workers). These training activities would be incomplete without raising the consciousness of the populations, which is incunbent on sanitary assistants and necessitates the preparation of a teaching material. The details of the expenditures for the training activities are appended to this document. 6.3. Recurrent costs They have been calculated for five years of activities. They include, in the northern zone fornerly treated by OCP' activities concerning epidemiological surveillance and treatment of ner"-patients and in the southern extension and forest zones, not treated by OCP, ivermectin distribution to the peripheral health centres for the individual treatment of cases. 6.4. C6te dtlvoire Goverrrrentts contribution It consists of the assunption of financial responsibility for the National Coordinator and the nedical and paramedical staff of the rural health sectors as weII as the supply of equipnent (vehicles for the nycobacterioses control teams and the nedical officers of the sectors) and health facilities (cIinics, sector base laboratories, office for the national coordinator ) . 6.5. Cost of the prograne for five years Investnents and training Equipment for medical coordination Vehicles Technical equipnent Field equipment Training TotaI Recurren.t costs Vehicles Drugs Per dien Office supplies and others TotaI Investnents and training Recurrents costs Grand total Contingencies 102 14,600,000 73, 100,000 34, 190,000 15, 140,000 66,953,000 203,983,000 77,778r750 14,400,000 47 , 910,000 10,000,000 150,088,750 203,983,000 150,088,750 354 ,071 , 750 35,407,175 389,478,925 CFA francs Rounded up to 389,500,000 CFA francs Three hundred and eighty-nine nillion five hundred thousand CFA francs(us $1 ,370,000 ) . -20- 7 . PROVISIONAL TII.IETABLE Year Quarter 1 991 1 992 1 993 1 994 1 995 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 Trainins i T.aining of centrai rteam I Retraining of mobile teams of sectors Training of medical officers of sectors Training of personnel of peri- pheral centres Training of comnu- nity health workers Investments Equipment for central coordination Purchase of vehicles Purchase of techni- cal and field equipment Field activities Central team National Coordinator tlobi le tEams Permanent health centres Cormunity health workers AL C lr,(9 Z ltoFi t(, it - t_ I\s lllJ .C, lz-t- I t I I oo l! a - tr - f T II 1 If I t \ I t I t o t I .J I I a aa I I,aIa o I , I t IJ l1 I I I , + I I t I I)+ I I Cg o L aI a , , \ II I I I , t J ol, a ,I'to oE ! at; g o oe C Eoa6 5'NI Dr o ILoOlt !OC Ttitiiiir i: il:iii ii!;ii tr@r+aot E $ g 8 ar E o .E EgIo-ccL9tLCoo :E iaEc -o E! =+ eEt. tc,o:OJ + + It , - a l,ott aI o I U atl I,I + II|5lr< =8do a o2 o E E J IL o o tlJ tn -0. J zo F G lrl 0.o H xl! zz - , ;- I n ANNEX IT ... r . . o . Lltnllaof lnlllol orro .rr.-.- Linltr of loryidlngt lcch !/taOO OOO rxoloxclo /vcv/R. toE LU PRE - CONTROL ANNUAL TRANSMISSION POTENTIALS tN coTE O'tvolRe l! o o o o O q IOO roo - ttt too- lrt a@- 7tt > aoo hrDo. a a a a a a I a, a -ooao a aaa aaaa aa !ourto o a a Tloroh t t-rl Ioa \ a I a I a a L3 ANNEX Jtr ........ Llmilcof lnltlol orao ,-D.-.- Limlto of lorvidlngt Scol. |/S@OOOO ur{o/oxcto /vcu/e. foE ANNUAL TRANSMISSTON POTENTIALS 1989 IN COTE D, IVOIRE (ALL BLACK FLY SPECIES ) o o o o o < too roo - t99 200- t99 aoo - 799 > too bo a a a a a a a ( I a a a a aa aaao aa aa tosrlo a i a Tlorrch tt lb. -r i a t Io.r \ a a aO.' o LY o oo o o o oo c o C1 aot: ooo o o o o o o ot o o o o o o o o ooo o o coo OO o c o o o o o oo lrJ IE o : o UJF o o E ii a.o>DL-o5EOc-o 3q -oE >EFO =lEBg()(L il o o o o o o o o o o a6 o(r lrJ o oI(J z o tL o UJ C)z UJJ lrJtr(L Jo 0aFzo(J I trJ 0a o- o ooE 0 o(, co 0 e o. H x lrJ zz il H$i o coo o oo o o e oo o o o ooo C o o OO o OO o o o ooo oo o og o o o o o o o o oco OO o o o o o ooO9 lrJ E o o lr.l F o() ll E in I o!,>cL-f, E3 Bg -oEc .bE; 3e()0- ll o o @ 2 =aa () E td() o -() z o tr o trJ L) z UJJ UJ E o o o oo 9O o o o o $H$H o coo E .oHo C' xEUJE -q,Z.L a 1., L ANNEX E xoRHoqS DABATALA o SEOUELA a .BOUA(E DALOA a IOUAFLE a RO ,orxDrRo .tss!/l AOZOPE a eAexor a l!rDJrx orvo a RURAL HEALTH SECTSS OF COTE D',tVOtRE ) t( ,t A L ,-{ t I I 3-fI I\ \ r\ -lI\_ UPKII!A FASO \\q\;,'"L / rv \ I I \ I(t t\ \ J,tt -- vt \ . 1-^- FERXESSEOOUGOU / '.j\ oolErlIEa,l a t BOuilA . ) \ (r L \ \ Il--rt LljTOUBA\.a lo}roqrKou to f rll{o I I IIa I I \ / a/ I II L\ It tt \ (o\ e \ a { S \ \ eeosso\() o IIt a. (I) I XDRA lAx Pcoto U R ) 5 -)n- ANNEX 7: ESTIMATED COST OF PROGRAMME FOR FIVE YEARS CAPITAL COSTS a I telr Quant ity Unit price CfA francs TotaI price CFA Observat ions EQTIIPMENT, CENTRAL COORD I NAT ION Photocopier Preparation of office of Sub-Director of IlaJor Endenlc Diseases (door and reinforced air- condit ioning , electric circuit, etc. ) Installation of fax Purchase of office furniture 20 |IEGA conputer, soft vares + stabi I izer t Directorate of Public Health and Populat ion, Abidjan * Office of Sub- Director DPHP, Abidjan 2 , 100 ,000 6 ,0oo , ooo 1 ,000 ,000 I ,500 ,000 4 ,000 ,000 Sub-totel 14 ,600 ,000 VEHICLES 504 Peugeot pick-up Van, g-aeater * 20 sanitary teans of rural aectora r National evaluation teer 3 ,400 ,000 5 ,100 ,000 68 ,000 ,000 5 , 100 ,000 Sub-totaI 73,100,000 TECHNICAL EQUIPI'IENT Holth's punch Slides, with holder Eppendorf pipette Lancette Plate Gurved scissors Seraight scissors Kocher punch Enarel plate Haricot plate Binocular aicroscope Generator t2 4 0 2 2 20 2 2 z 4 1 set of petty itels necesaary for aalple takinS and exa^trination Total: 62 sets I pcr above aector 1 for national teaD i.e., 2l ricros- coPes 2L 250 ,000 600,000 290 ,000 t5 ,500,000 12 ,600 ,000 6 , 090 ,000 3 sets per RHS for the RHS of ODIENNE, BOUNDIALI , xoRHoGo, TEBKE, DABAIGL.A, BOUNA, BOXDOUKOU, BOUAKE, YAlloussouKno, SEGUEL/T, TOUBA, l.lAN, DTHBOKnO, TIASSALE, ABENGOU- ROU, DALOA, BOUAFLE, ISSIA, SASSANDRA, ADZOPE, 3x20=60sets and 2 sets for national teaD Sub-Total 3{ , 190 ,000 national 28 I tem Quantity Ass ignnent Unit Price TotaI Price Observations FIELD !'ISIT EQUIPMENT Canp beds and bedding Folding tables Folding chairs Adjustable stools Cooking equipment Field visit-equipment national tean 110 80 L20 40 20 o 50,000 40, 000 12,000 50, oo0 105 ,000 100,000 5 ,500,000 3,200,000 1 , 440, 000 2 ,000,000 2, 100,000 900,000 for 9 persons Sub-total 15 , 140,000 TRAINiNG ACTIvITIES Itetr Quant ity AssignDent Unit price Total prrce Observat ions fraining of ledical officers of sectors * Per dien 50 oedical officers trained for 5 days, i.e., 250 days I Per dien 5 teachers endsupervisors:8r5 days = 40 days * FueI for supervisors ( 2 ,000 Iitres ) * Hirlng of rooos 8x5=40days ?eaching lateriels 12 ,600 12 ,600 350 40 ,000 3,150,000 2 ,520 ,000 700,000 1 ,600 ,000 500,000 Training in each of the 8 Reg ional Heelth Directorates Sub-total 8 ,470 , 000 Training of nurses ofperipheral health centre6 * Per dieo 800 nurses for one day t Teachning raterials x fechnical note E00 notes 9 ,400 3 ,000 7 ,520 ,000 780,000 2 ,400 ,000 Trainin8 given b-v Chief Hedical officers in the 26 Rural Health sectors Sub-total l0 ,700 ,000 Treining of Leprosy- Tuberculosrs controllers and ssni- tary assistants of Rural Health sectors * Per diea - 75 Lepro5ycontrollersfor 5 days, i.e., 3?5 days - 50 sanitary assistantsfor 5 davs, i.e., 250 dalrs I ,400 9,{00 3,525,000 2 ,350 ,000 Training 6iven bv five supervisors ( central Ievel and external consultants ) 29 a Item Quant ity/AssignDent Unit price Total price Observat ions Trarning activ it ies ( cont 'd ) - 26 Sector nedical officers for 5 days, i.e., 130 days - Per dien 5 supervisors and teachers: 6 x 5 davs = 40 days * fuel supervisors ( 2,000 litres) * Hiring of roonsSr5days:40 days * Teaching uaterials t Technical note 150 notes t2 ,600 12 ,600 350 40,000 5 ,000 I ,636,000 2 ,520 ,000 700 ,000 I ,600,000 900 ,0oo ?50,000 in each Regional Directorate vith the help of nedical officers of the sectors Sub-toteI l3 .983 .000 Training of corDunity health workers feeching reteriels for courges (26 sets ) - Lodging, 2600 couunity health workerE2r2days per yeer for 2years, i.e., 2600r1x2= 20,E00 dayB 1,500 100,000 31,200,000 2 ,600 , 000 - I set per sector Sub-total 33 ,800,000 al 30- RECURBENT COSTS I teo Quant itv Unit price Total Drice/cFA observations VEHICLES llaintenance and repair of 21 vehicles for 5 years Maitenance electric generator FueI for 21 vehicles for 5 years Lubricants 21 vehicles for 5 years 21x5=105 21x5=105 21x5x1,500 = l5? ,500 I it res 21 x 5 x 15 I. : 1,575 litres 150,000 50 ,000 350 1 ,050 15 ,750,000 5 ,250 ,000 55 , 125 ,000 1 ,653 ,750 est inat ion : 10,000 km/vear at 15 I/100 km, i.e., 1,500 Iper vehicle, i.e., 7,500 I for 5 years per vehicle Sub-totaI 77 ,778,750 DRUCS Ivemectin for traatrent end supply to dispen- saries Consurable itels for 2l sector lab. r 5 yeers E.ergency kltB and resupply 21 x5x 100 ,000 260 + 520 = ?80 5 ,000 l0,500 , ooo 3,900 ,000 lree eupply Sub-totaI la,a00,000 PE8 DIET{ - Supervision, centrel level r 1 rcdicel officer r I drivcr - Netional t.a! * I aedicel officer r 6 nurses r I drivcr 20dr5=100 deys 20dr5=100 daya 120dx5=600 deys 120dx6x5= 3,600 days 120dx5=600 days 12,000 ?,500 12,600 9 "100 7,500 1,260,000 ?50 ,000 ? ,560,000 33,840 ,000 {,500 , ooo 20 days per year 90 deys of field visit per year Sub-total a7 .{10 .000 OIIICI EQUIPI{ET{T AND OTHEIS officc auppliea end others(contracts for reintenence of office cquip.ent for 5 yeers(central lcvcl) l0 ,000 , 000 2,000,000 peryear x 5 years sub-tot8l l0 ,000 , 000 t lr SUIvIIIARY * CAPITAL COSTS -3r- of Sector Medical officers of nurses of leprosy controllers and assistants of comnunity health workers - Equipment, Central Coordination - Vehicles - Technical equipment - Field visit equipnent Total capital costs TraininE activities 00,000 00 ,000 90,000 40,000 137,030,000 CFA francs 8,470,000 10, 700,000 13,983,000 33,800,000 66,953,000 CFA francs 14,6 73rl 34,1 15,1 , - Training - Training - Training san i tary - Training Total * Recurrent costs - Vehicles - Drugs - Per dien - Office supplies and others Total recurrent costs Grand total: 137,030,000 + 66,953,000 + 150,088,750 =Contingencies 102 150,088,750 CFA francs 354,071,750 35,407, 175 77,778, 14 , 400, 47,910, 10,000 , 750 000 000 000 389,478,925 Rounded up to 389,500,000 Three hundred and eighty-nine nillion five hundred thousand CFA francs i.e., US $1,370,000 (one nillion three hundred and seventy thousand US dollars). .( -)2- BREAKDOWN OF COSTS PER YEAR IN CFA FRANCS Year 1 Year 2 Year 3 Year 4 Year 5 CAPITAL COSTS Equiprent, centrel Coordinat ion vehicles Technical equipoent Field visit equipDent TRAINING Medical officers Nurses Mobile teals Comunity health worLers BECUBRENT COSIS ltaintcnance vehiches, generators, fuel and lubricants Consurable Iab. itcos lDergency kits Per dieo coordinator + control tear Offlce eupplies 14 ,600.000 73 ,000 ,000 34 ,000 ,000 15 , 140,000 \ 8,4?o,ooo 10 ,700,000 13,983 ,000 18,200,000 15 ,555 ,750 2 ,100 ,000 3 ,900 ,000 9 , 582 ,000 2 .000 .000 15 ,600 ,000 15,sss,?50 2 , 100 ,000 9,582 ,000 2 ,000,000 r5 ,555 ,750 2 , 100 ,000 9,592,000 2 ,000,000 15 ,555 , ?50 2 ,100 ,000 9,582 , ooo 2 ,000 ,000 15 ,555 , ?50 2 ,100 ,000 9,592 , o0o 2 ,000 ,000 Totsl 22t,520 ,750 44 ,83? ,750 29,237 ,750 29,237 ,750 29,237 ,750 a ,r