Report of the workshops on the decentralization of surveillance of onchocerciasis and the installation of community-based ivermectin distribution in the participating countries

WORI,I) I IEALI'I.I ORGANIZAI'ION ORGAMSATION MONDIALE DE LA SANTE ONCHOCERCIASIS CONTROL PROGRAMME IN WEST AFRICA PROGRAMME DE LUTTE CONTRE L'ONCHOCERCOSE EN AFzuQUE DE'L'OUEST I]XPEIIT ADVISORY COMMITTEE Scver)tecnLi) session Ouaqadouqou. l0-l4 June 1996 OCP/EAC17.4 ORIGINAL: ENGLISH RL.]I)ORT OF THE WORKSHOPS ON THE DECENTRALIZATION OF SURVEILLANCE OF ONCHOCERCIASIS AND THE INSTALLATION OF COMMUMTY-BASED IVERMECTTN DISTRIBUTION IN THE PARTICIPATING COUNTzuES Introduction A series of three{ay workshops on the decentraiisation of epidemiological surveillance of onchocerciasis and the installation of community-based ivermectin distribution leading to the preparation of a Plau of Action and Budget for thesc, were pla-uned and organised by Lch of the Participating Countrics of the Onchocerciasis Control Programme berweeu January and July 1996. Of the eleven Participating councries Burkina Faso, C6te d'Ivoire, Guinea, Mali,Senegal and Sierra Irone and Togo havc so far held their rvorkshops. The rest of rhe countries,Benin, Ghana, Guilea Bissau and Niger have planned to hold rleii workshops by rhc middle ofJuly 1996 'I'he specific dates for thc respective workshops are as shown i-u a-unex 1 . The National onchocerciasis Coordinators played a key role in the organisation of the u'orkshops Iiaising closely with Minisuy of Health Officials and the OCp. They were also responsiblc for the rvriting up of the workshop reports. Participants for each of the counties were drawn from the onchocerciasis affecteddistrict-s rvhich included Disuict Medical Officcrs (DMO) and some nurse/technicians from zuchdishicu' Regional mcdical Officers of health and. senior minisrry of health officials also took parr ':-Pt rvorkshops. Certain key rpcmbcrs of the Planning,, fraruatio" "na ii.*f"r, Units of theocP participated, and two extcrtral facititaton dJp.rd;il;t"dii,rr" *;it;;il. iil;;rk h"p wcre offici-ally opened by eirher by Orc directon oimedical scrviccs,,Tcchnicat Advisors to thcMinistcr of he-alth or as in Guinea and sierra Leonc by th. Mi"is;of n*tl or rhe co.ntries. St:ppoft for the workshops carte from the Governments of countries themselves withsome logistjc. rechnical and (rnancial input from OCp and rhe WHO Off,rces ;;;;;;;;;;countries. Objcrctive of the Worksbop G_Cngml C)biectivc - 'l'irc rvorkshops had a common general purposc. This was to draw up a plan of actionand budgct, follorving discussions based on clearly ser out guidclines (anoex Z), tor; a) a deccntralised onchoccrciasi$ surveillance and/or cvaluation system for the countries, andb) tlrc installation and implementation of a community-based ivermccrin disrributior) prograrrrmein thc rcspcctji,c countries. -2- The plan of action and budget coYered, in the shofl term, the 3 years of 1996-98' with forecasts for the medium and long rerrns from lggg tbrough the year 2W2. Workshop methodologr .lrr,omethodswereusedfortheworkshops'Thesev/ere' i) short plenary sessions which set the scene with national policy on decentralisation of epidemiological zurveillance activities and ivermectin distribution, backgrouud information on onchocerciasis control and surveillancc activities in the country, as well short presentations.on zurveillance acrivities of the endemic d.iseases that havc been retained in the country specific devolution plans. Plenaries were also held at appropriate period during the workshoP to rePort on the finclings of the grouP work. ii) main discussions leading to the preparation of the plan of action rcre carried out through group-work around the two-main objeciives. Thus SeParate grouPs worked on the themes of a) decenrraiisation of epidemiological surveillance and b) the installation of community-based ivermectin distribution- A rhird theme, the integration of devolution activities into the national health system was discussed in 8s a seParate subject onty in Burkina Faso, Togo and Cote d,Ivoire. This topic was i-ncorporated into ttre two main themes in Mali, Senegal, Sierta I-eone and Guinea. Outcome of the WorkshoP PIan g[ Action and Budqet for l9q6-98 Decentralisation of epidemiological surveillarrce of onchoccrciasis Decentralisation of rhe surveillancc of onchocerciasis was rcgarded to be irnporunt by all the countries givcn that such a process would facilitate iLs intcgration into the existing services. It was alsl necessary bccausi there was the need for it in conformity with thc Health Sector Reform process uow taking place in the countries, as part of national policy' The level to which the decenualisation was planned to be carried out' however, differed from c.unrry ro country. Thus Togo, Senegal and Mali optcd to decentralise down to the Regional level, whercai Sierra Ironel Guinea and Cote d'Ivoirc opted to <lecentralise up to the district level. Burkina Faso planued a decentralisation by zones rather than by district or region. Table (l) The choice of the level to which to decentralize the surveillancc of onchocerciasis by the countries was made, taking into consideration the numbcr of scntinel villages to be examined per year in thc onchocerciisis affected areas, and particularly the cost of equippirlg the teams needed to carry out this acrivitY. -3- Table I : Level for decentralization for epidemiologicd surveillance I nstal I ation o f community-based ivermectin ueatrnent The workshops identified two forms of community ivermectin distribution. These were defined as a) comrnunitv-based ivermecrin distribution in which the community selects its own distributor to bc trained by health instin:tion to U" .Ut. to administer ivermectin to the community but is not responsible of, the collection of rhe ivermectin to bc used in the communiry' The health instirution delivers the ivermectin to the distributor in the village when it is needed' b) Community-self treatmeRr. For this rype of distribution the villages/communities are entirely in.tr*g. tf," airtriU,rtio" i*fuding finding their own means to collect the ivermectin from the I{ealth i1-stitutions as well bringing infoiration on the ucatrnent undertaken to thc Health Agents. All thc counrries except Mali have opted for the community -based ivermrctin distribution in the first instance, Iater to be &nnged into community self-treatment' Mali' however. plans to convcrt the areas rvhere it already has community-based ivermectin distribution in pracrice to communiry-self treaunent and placc thc areas presently undcr mobile 7,oneDistrictRegion[,evel of decentralisation of epidemiolo gical surveillance CounFy tBurkina Faso ICote d'Ivoire IGuinea Mali rSenegal ISierra Leone ITogo -4- treatrnenl on communiry-based treatlDent' Decisions to adopt community-based ivermectin treatrnent were based on the conviction that this would be more affordablc for the Governmens and more likely to be sustainable' Ilorvever, community Self-treatrnent wa^s not acccPtable to the majority of the countries as an immediate option gir"n that this was still at the experimental stage' Specif-rc Obiectives Epidemiological zurveillance The following specific objectives were identified to be conunou to all the countries with respect to epidemiotigi."t .or""i[.r"e/evaluation for the P]an of Action and Budget: - to rrai' staff of all levels in the districs to be able to undertake epidemiological surveillance of onchocerciasis - to equip the districts , regions or Zones as the case may be with the material necessary for the surveillance activities - to undertalie epidemioiogical suryeillance /evaluation - to insrall a sysrem of supervision at the appropriate levels for the epidemiological surveillance/ evaluation activities -to unclertake an evaluation of the process of decentralized epidemiological surveillance/ . evaluation that is Put in Place Trainine of staff To effectively carry out thc epidcmiological zurvei!1arye/.ev{ua1io,1 of onchocerciasis in the deceutralizi ,",tiog^ the right ""t gory of staff at the -19vet at decentralization was esscntial. ln this regard d*r of tb "orrr,ttfo uUdenook a needS asscssment of numbers and skill of personnel in'tfr. respcct counuies. Thus the largest number of staff necded to be traired was at thc district level. This was common to all the countries' Tablc 2 shows the various categories of sraff that were identified for training' Table 2: proposed plan for training for epidemiological evaluation / surveillance' Countries Staff (number) Type of training Period for training Financial Source -5- Burkina Faso Medical officer (3) High level Epid. Course July - Nov. 96 OCP + WHO AFRO hb. Tech (a) Theory + Field work July - Dec 96 OCP + Govt BF + WHO AFRODistribution. Pers (to be deterrn.) C6te d'Ivoire Chief Med. Off. (42) Theory + Field work July 1996 Nov. 97,98 OCP + WHO/AFRO L:b.Tech. (63) Nov.96,97 July 1998 Comm.Health Workers. (117) Theory * passive diag Iuly 97 Guinea Dist. Med. Off (26) Theory + Field Work 48 in Dec.96 54 in Apr.97 54 in Apr.98 OCP and wHO AFRO I-ab. Tech (126) Mali DMo (40) Theory plus field work July thru Sept. 1996 OCP / WHO AFRO / Govt Lab.Tech. (35) Sierra Leone District Health Team (13) Theory plus field work Oct-Dec 96 OCP WHO AFRO Govt. Sierra lroneL:b. Tech. (78) Peripheral Health unit workers (500) lnstnrction in passive diagnosis June - Dec 96 Govt. of Sierra I-eone Traditional Bir& Attendans (2000) Dist. Med. Off. (4) High level Epid. Course. July 1996 OCP + WHO AFRO L:b tech.(7) Theory * field work April 1996 OCP Chief Med. Off plus Supervisors (1). Data analysis Novembcr 1996 OCP Dist. Med. Off (7+1 AFRO Module course Dec. 1996 AFRO Senegal -6- Togo l-ab. Tech (24 Theory+ Field work October 96 OCP Data Entry Staff (1) Data manage ment In all situations there was need to train the DMOs and the laboratory technicians at the peripheral level in the methods OCP Methodology for the active surveillance of ouchocerciasis. In some of the countries as for example Sierra I-eone the trained DMOs were expected latcr to be trairers of lower lcvcl staff. Trainiqg in higher level cpidemiology was identified to be a reguirement for medical staff in Senegal and Burkina Faso . In addition training in data handliqg was reguired by and planned for by Senegal and Togo. Tvpe of trainine The workshops ideuti.tied training to bc of two types; theoretical and practical tminiry. The practical training was'planned to bc undcrtaken when the periodic epidemiological surveillance is to be undertaken in a particular disrict. ffug trxining for the DMOs will be combined with instruction in the 4-module epidemiological surveiliance course designed by WHO AFRO. Period qf uainine The period of training was to stretch between the second quarter of 1996 through 1997 the training being given ia stages. In the counEics with part in the Original Progra-rrme area and the other in the extension, training will start in the districts in the Original area to be followed by those in the extension areas. The period of instruction has becn considercd to coincide with the field cpidcmiological zurveillance activities to cut down cosr, save time and at the same time have usable epidemiological results. Financins 9I &g traininq The cost for trainiqg was computed on the basis of pcrdiem for the staff co be rrained rhe uainirry materials rcquircd and transportation cost. The source of financing for the trainiug in all the countries was to be requested from OCP, ancl WIIO/ AFRO. Burkina Faso, Mali and Sierra hone. however, indicated finaucial input by their Governments as additional source of financing to that to be provided by WHO/AFRO and OCp. Equippine the uniLs A standard set of equipment needed to undertake an epidemiological surveillance was based on the material required for epidemiological surveillance using rhc OCP merhodology. -t- ln vierv of the high cost of equipping all the districs identified to undertake epidemiological surveillance, all the countries planned to equip the regions, rather than the disuics, with a set of material needed to undertake the aclive surveillance activities. These materials wili be available to the districts conccrned if and whcn available. In most of thc countries certain materials e.g. Microseopes, and other laboratory equipment were already available at the district level and no additional stuff was to be purchased at this stage. The cost of materials for active epidemiological surveys was computed for each counry and this is to be borne by the Governments directly or through funds solicited from externnl sources. Given that budgets for 1996 for all the countries had already been prepared and approved, the funds needed to equip the regions or zones is to be included in the 1997 budget. Fpidemioloeical surveillance. Suoervision and Evaluation of the decentralized epidemioloeical surveillance svstem Broad-li-ues for Country-specific schedule for epidemiological surveillance, the villages to be surveyed in each of the districs and the supervision of this activity were made. For the beneflt of fully integratiag this process inro rhe existing acrivities in the districts, the DMOs dccided to plan, particularly the supervisory visis, ro coincide with their routine schedule. ' Both internal and external evaluation of the system that had been put in place have been planned. The internal evaluation will be undertaken by independenr observers frr.rm other districts in the country whiles external evaluation will include country staff OCP staff or appointed individuals as well as ex(ernal obsenrers of the countries' choice. Thc internal evaluation wiU be carried out every three years, whereas the external evaluation will be carried out 3 years after the installation of the system i.e in 1998. Insullation of community-based ivermecrin distribution The specific objecdves werc ro: sensitize the comrnunities through Information, Education and Communication (lEC) i nterventions on onchocerciasis - train; i) all district health personnel to be able to zupenrise ivermectin distibution ii) community health workers to undertake community based-iverrnectin trea[ment iii) village distributors - generalise community-based ivermectin treatment in the areas presenrly under mobile ivermectin distribution - supervise the communiry-base tre:rrrnent - undertake internal and external evaluation - undertake operational rcsearch to assess the acceptability, sustainability record-keeping aud cost of communiry bascd ivcrmcctin <Iisuibutions -8- Sensitization f communities Careful sensitization through iEC interventions of the communities to receive iverrnectin and those presently receiving ivermectin treatment through the mobile system has been planned by all the countries. These will be preceded by Knowledge, Attitude, and Practices surveys in the communities where such information is not available. Materials needed for such activities are largely available. Where this is lacking OCP was to help in the provision of material that may have been received from an NGO, or new ones will be prepared by the countries, largely financed by the countries themselves. l-raining Tra-ining of the appropriate staff for community-based ivermectin treatment has been planned by each country as shown in table (3) Table 3. Proposed plan for training for communi ty-based ivermectin distribution Country Personnel Number to be trained Period for training Source of fund Ilurkina Faso Village distrib District Health team to be determined End 96 to 9l OCP + Govt. Burkina C0te d'Ivoire Comm.Health Worker (cHw) 351 From May 1996 OCP Guinea Village distrib. Health centers nurses District Health team Regional medical officer 2614 110 45 l End 96 to 97-98 End 96-97 End 96-97 End 96 OCP + NGOs Mali Med.officer Village distrib. Village distrib. Village distrib. 20 320 364 196 End 96 July - Dec 96 Jan.-Dec.97 Jan.-Dec.98 NGOs + OCP Senegal CHW 314 April 96-Nov 96 NGos (oPC) Sierra l.colre District Health team (trainers) District Health team Community Dist. 30 500 (to be determined) End June End June End September Govt'SL NGO + OCP Govt. SL -9- Countr,v Personuel Number to be trained Period for training Source of fund Togo Nurses District team Distributors 260 138 30y2 96-97 96-97 96-97 OCP This includes training at all levels for differenr purpose. Thus the training of medical off,tcers has been envisagcd by Mali to provide a pool of trainers to undertake the training of the village distributors. In C6te d'Ivoirc, Community health workers will be trained to undertake community-based treatment. These workcrs are already in place in the communities as multi- PurPosc workers. In Sierra lronc and Togo, District health teams will be traine<l to undertake the taining of rhe distributors. Dcpending on Oe counrry, the tralning phase will bc completed itr 1996 as in Senegal and by 1998 as in Cote d'Ivoire. All training is scheduled to bc completed and generalised community-based ivermecrin fully opcrational by the end of 1998. The cost for the training and the installation is to be borne by OCP, certaiu NGOs, and as in the case of Sierra Leone also by contribution from rhe government. Suoervision Although the ivermectin distribution will be undertaken by rhe communities rhemselves, all the countries have plauncd to use the peripheral health staff for zupervision. This will be undertaken as Part of their routine zupervisory duties and no added cosr is envisaged. In the case of Siena I-eone, it is planne<l to use the Village Development Committee who would have been part of the selection process for the distributors also as supervisors. Moni torlng The plan of action drarvn up by the countries envisage inrernal review at the end of each ye3r to ascertain the level of achicvcment in the generalisation of community-based ivermectin distribut-ion in the countries meazured against set pararneters. Additionally an externat independenr review is envisaged by the enct of 19gg in the plan. Operational Reseatch ln deciding and plaruling to install community-based ivermectin treatment it was realised that apart from very few areas in the OCP this mode of distribution was going be relatively new in a large area of the OCP. Furthermore it was the ultimate aim to install community ielf- utatment rvhich was iu the experimental stage. The countries planned ro undertake operational rescarch in the arcas of acceptability of the merhods of rreatmcnt, susrainability, record keepingbv the communities and tltc cost of treatment using these methods. The funds and tcchnical support for such research werc to be requested from OCp. AIS{EX 1 -10- PIan for workshops in OCP Participating Countries 1996 Rev.8/5/7996) Months Countries Dates January Burkina Faso 29-31 February Togo 19-21 March Senegal 18-20 Sierra lrone 23-25 Guinea 28-30 April Mali 11-13 C6te d'Ivoire 15-11 May Ghana 15-16 Guinea Bissau 27-23 July Niger Benin 10-12 18-20 a) AITW 2 -11 - WORI(SIIOP FOR TIIE, DESIGN OI? IN,IPLtrMENTATTON I'I.AN OF COMMUNITY-BASE,D TRE,ATMtrNT AND IIPIDE,MIOLOGICAL SUITVEILI-ANCtr O I? ONCIIOCE,RCIASIS GIiOUP I CUIDI]LINES ITOIT DISCUSSIONS Deccn tral i zation of Epidern iological Su rvei llance I. Irttrodrrction ir) Present state of epidemiological Surveillance of Onchocerciasis: activities (passive, vertical surveillance). Decen tra-l i zation of epidem iolog ical su rveillance of o nchocerci as i s mechanism of implementation. sl.rategy and structurc and 2. Needs identification Degrec of involvement of districts rvith onchocerciasis: existing situation Needs in terms of liuman, nraterial and financial resources for the implemenration of Onchocerciasis surveillance activities at all levels. 3. Reflexions on some priority activities a) Tra.ining: Who? How? Where? When? With what? Formulation and the establishment of decentralization of onchocerciasis surveillance activities The integration of onchocerciasis surveillance activities and surveillance of the other endemic diseases featuring in the devolution plans. Provision in the national budget for surveillance activities taking decentralisalion into account. Note tltat the national contribution in funding the activities should be clearly indicated with a yerly proportional growth. Monitoring or evaluation and follow-up of the system. b) c) e) Specific object-ives Strategies Act-ivities Irollorv-up indicators Period of Inrplementarion Persons to be responsible for activities I:inancial resources r.) b) d) 4. PIan of Action and budget for 1996-1998 For cach basin, the inrplementation rvill be based on the list of sentinel or indicator villages to be evaluated betrveen 1996-i998. Attention to be paid to a decentralized and integrated epi dem iological su rveillance/evaluation. a) b) c) d) e) f) s) 5. Addil,ional i(enu to be discussed at the cnd of groups, scssions. Refer to document dealing rvith "Relevant Issues for tlre draft Plan of Operations for thc OCP Phasing-out period" Arnex 2 (ccnt'd) -12- GITOUP II GUIDtrLINES ITOR DISCUSSIONS Iptcgr-a(ion of dcvolu(iorr activitics into (ltc national Ircaltlr carc systcrtr I Introduction a) Present situation of epidemiological surveillance and of other onchoccrciasis related endemic diseases within the national devolution plan: strategies and activities IntegraLion of multidisease and Onchocerciasis epidemiological surveillancc into the other health activities: opportunities, constraints and inadequacies. b) 2. Nceds identification a) The degree of involvement of districts in the surveillance of the endemic diseases associated with onchocerciasis: existing situation. Capability and staff requirement to implemdnt multidisease surveillance activities. Ivlaterial and financial requirements for the implementation of multidisease surveillance activities at all levels b) c) 3. Reflexions on some priority actions a) b) Training: Who? How? Where? With what? Definition and implementation of a decentralisation and integration policy of multidisease surveillance activities. Provision in' the national budget for multidisease surveillance activities taking decentralisation .into account. It should be noted that national contribution in the funding of activities must be clearly indicated with a yearly proportional growth. Monitoring or Evaiuation and follow-up of the system. Speciirc objectives Strategies Activities Follow-up indicators Persons to be responsible for ac[ivities Financial resources c) d) 4. PIan of Action and budget for 1996-1998 Plan of epidemiological surveillance of the endemic diseases included in the devolution pian for onchocerciasis, taking into account integrated activities in a decentralised system. a) b) c) d) D s) 5. Additional itenr to be disctrssed at the end of groups' sessions Refer to document dealing wiUr "Relevant Issues for the draft Plan of Operation for the OCP Ptrasing-out period" 13 Arrs 2 (ccrrt'd) GITOIJI' ITI GUIDI'LINES ITOR. DISCUSSIONS I rrSt e I let iop of :t cotrrltrtt rti{y b:rscd ivcrlttccti rt trcat tttcttt I. Ivcrntcctin distribtrtion b) Prescnt state of ivernrectin distribution: strategies and activities (mobile lreatrner]t, co rn muni ty-based treatment) Conrmunity-based treatment and comrnunity self-treatment with ivermectin: concept and rnet.hodology (in general) Selection of the rype of communify [eatment adapted to the different socio{ultura] contexts of the country. c) 2. Needs identification Degree of involvement of districs with onchocerciasis: existing situaiton. Needs in terms of human, material and financial resources for the implementation of community-based treatment I - Where? - Personnel and other partners? - Mechanism and organizational structure (at the district level, etc...) - Existing facilities, logistic and transport? a) a) b) s) h) 3. lleflexiors on sonre priority actions a) Preparation for the sefting up of community-based treatment with ivermectin in some basins in 1996 KAP studies Training: Who? How? Where? When? With what? IEC interventions Supervision I-ogistic, transport and budget - National contribution. Note that the national contribution in funding the activiries should be clearly indicated with a yarly proportional growth - OCP contributidns Evaluation and follow-up Operationai research b) c) d) e) f) 4. Plan of Action and budget for 1996-1998 Work out a plan of action and a budget for the basins in Sierra lrone under ivermectin treatment (basins to be implicated) a) b) c) d) c) r) s) Spccific objectives Strategies Activities Fol I orv-trp i nd ica-tors I rnplenrerrtation period Persons responsible for activities Financial resources 5. Additional itcms to be discussed at the end of groups' sessions. Rct'er to document dealing with "Retevant Issues for the draft plan of Operations fbr the OCP Phasing-out period"