Plan for devolution of the Onchocerciasis Control Programme in Niger

Qnstle6slsiasis Control Programme in West Africa Programnre de Lutte contre l'Onchocercose en Afrique de I'Ouest. JOINT PROGRAMME COMMITI'EE Office of the Chairman JPC .CCP COMITE CONJOINT DU PROGRA.\TME Bureau du Prdsident JPC7. 6 ( C) ORIGINAL : FRENCH September 1986 JOII\T PROGRA}IME COMMITTEE Seventh session Accra, 9-12 December 1986 Provisional nda iEen 13 PLAN FOR DEVOLUTION OF THE ONCHOCERCIASIS CONTROL PROGRAMME IN NIGER Budget for the devolution P lan in Niger Strengthening the health sysEem 1 Public health service (1986-1991) Great efforts are currently being rnade to strengthen the various treatment services and preventive nedical servlces. Thus, 12 690 7L7 500 CFA francs have been allocated for the period 1986-1991: 1 I Village health teams New building Third-1eve1 infrastructures Prevention of blindness other programmes Equipment for outlying units L63 2 400 2 257 450 6 083 1 335 650 000 204 380 989 494 000 000 000 000 000 500 Total 72 690 7L7 5OO CFA F L.2 Entomologlcal monitoring The State nade the following allocations for entomological nonitoring in 1985: Equiprnent 26 400 000 Insectici.des 175 000 000 Fuel 1 785 000 Personnel 12 660 000 2L5 845 000 CFA F 1.3 Epidemiological nooitoring In 1985 the State devoEed 27 4OO 000 CFA francs to epidemiological monitoring. a t JPC7. 6(C) p:lge 2 1.4 Drug distribu!lgq The NaEional Bureau of Pharrnaceutical and Chemical Products (01{PPC) has exclusive rights over imporEation. Distribution is carried out by: - the health units - 22 peoplets pharuacies - 36 private drug depots. 2. Estimated expenditure for devolution 2.L Blackfly monitoring Niger is taking over six catching points in the arrondissements of Say and T6ra, which are in Nianey Department; it is planned to have insect collectors and Eraps at these six points. Two monitoring teams are planned. 2.1.L Training 2 entoroological Eechnicians 18 firsE-aid workers 2.1.2 Equipment 18 bicycles 17 motor-cYcles 2 vehicles 2 transmitter-recelver sets 2 batches of sPraYing ProducEs 2 set.s of entomological equipment 12 traps Total 2 480 000 540 000 3 020 000 cFA F 1 800 8 500 16 000 8 695 4 000 840 96 000 000 000 650 000 000 000 Total 39 931 650 CFA F 2.L.3 Runni cos ts Fuel and maintenance Insecticides and lnsecticiding Tot.al for entomological moniEoring Epidemiological evaluation 5 000 000 cFA F ,? Niger is taki.ng over four epidemiological indicator vi1lages. Ttre evaluating tearu will be based ln Niamey. 47 95l- 650 CFA F JPC7. 6( C) Page 3 2.2.1 Equipment 2 standard sets of equiPment 1 vehicle Erection of two laborat,ories 2.2.2 Runni costs Fuel Reagents Total for epidemiological evaluation 2.3 Distribution of Ivermectin 0n1y transport cosEs are accounted: there are 75 000 potentlal recipients of 34 F x 75 000 = 2 55O 000 CFA F Total estimaEed expenditure Blackfly monitoring Epideuiological evaluation Distribution of Ivermectin 942 000 8 000 000 10 000 000 Total 18 942 000 CFA F 200 000 100 000 Total 300 000 cFA F 79 242 000 CFA F excluding contraindications it is estimated that Ivermectin in the arrondissements of Say and T6ra. 47 95L 650 L9 242 000 2 550 000 Total 69 743 650 CFA F A. INTRODUCTION 1. Niger has been in the maintenance phase of onchocerciasis control for some years Past Transmisslon has been halted and the prevalence of the disease is reducing to the point of disappearance. 2. Control of onchocerciasis in Niger has been discontinued in tbe adninistrative districts(arrondissements) of Say and T6ra, which have an area of 17 000 kro2 and whose poputation of 224 0O0 was heavily exposed to the disease at the start of operations. 3. There were initially 18 catching points in the counEryts entomological monitoring network. Today six of them remain. Sixteen of the 493 villages for epidemiological evaluation and control are in Niger. It should be noted that ErapPing on plates (Bellec plates) is being experimentally conducted in four localities in the OCP zone (Niger). The OCP Niamey subsector, which comes under the OuagadouSou sector, has an entomological techlicial, a laboratory assistant, a radio operator, three drivers, five insect collectors and two waE.chmen. 4. In the discussions on devolution at the recent neetings of the Joint Programme Coltrmlttee(JpC) of the onchocerciasis Control Programme (OCP) several participants suggested that OCP should collaborate with Participating Countries in examining their public health situation with a view to their services possibly being able to Cake on Ehe remaining onchocerci.asj.s monitoring in the post-OCP period. JPc7.6(C) Page 4 5. This reporE is a brief sumoary of the heatth situation in Niger, the facilities and programrnes of the countryts public health services, and development p1ans. ParEicular attention is paid Eo entomological and epidemiologicat monitoring in the context of devolution. 6. Even if some aspects of the devolution process stil1 have to be defined, it is clear thaE the activities to be undertaken by the Sovernments concerned will be of a limited nature and readily incorporable into the existing public health systems of the countries in questlon. In effect, what is involved is strengEhening the existing health services so that they can raise the alarn should there be any possible recrudescence of localized retransnission of the disease, and so that they can take the measures needed to contain and lnterrupt the transmj.ssion. 7. In addition to giving an operational definition of the activities that need to be undertaken to prepare and carry through devolution, this rePort could provide a basis for tdentifying the resources required and could thus strengthen lnternational and bllatera1 collaboration in the development of public health, the coordination of which is a task for the national services with the support, if required, of the tlorld Health 0rganization. B. CURRENT STATUS AND EXPECTATIONS PUBLIC HEALTH IN GENERAL 8. Social, health and economic situation in Niger 8.1 Socloeconornic and demographic situation 8.1.1 Niger has an area of 7 267 000 km2 (2000 km from east to west, 1300 km from north to south). The Sudanese zone in the south of the counEry is an agricultural region with shrub vegetation (about 600 mm of water annually) i the Sahelian zone farther north, which is the cattle raising reglon, is typifled by thorn-bush and acacia vegetation (200 mlo waEer Per year), while the Saharan zone, which covers the rest of the country (roughly two-thirds of the total area), is scarcely culrivable. 8.L.2 The toEal population of the country is esEimated at 6 149 102 inhabitants. Population denslty is very low (around 4.5 inhabitants/krnz). Some 757. of. the population occupy 12% of the national territory. The rural population is estimated to be 85%, as against L5"l in urban areas. The urban population is lncreasing considerably and permanent settlement is occurringquite rapidly. The country lras some 9000 villages and encampments. 8.1.3 The vital statistlcs are as follows: The population of Niger is Youngl 20 years old. 52 per thousand 25 Per thousand 27 per thousand 132 per thousand 7 per thousand 482 are less than 15 years old, nearly 58% less than 8.1.4 The proportion of children attending school (primary school) is now 22%, and the lit.eracy rate L2'/. (1982). The illiteracy rate is especially high among the female population; Ehe proportion of boys attending school is higher than the ProPortion of girls. 8.1.5 Transportation in Niger is by road in the main (19 000 km of roads and tracks in 1980). Although Niger lacks rail transport, the railway is one of the essential linlcs in the supply chaln of the country, especially through the Cotonou-Parakou 1ine, in which Niger is a co-shareholder. - Birth rate - Crude uortalitY rate - i'laEural Srowth rate - InfanE roortality rate (0-1 year) - Maternal mortality rate JPC7.6(C) page 5 8.1.6 The economy of Niger is nainly based on crop growing and cattle raising. Uraniun is the nain resource of the rnining industry, despite the fact that its contribution to the State budget and to exports fel1 fron 42% to 122 between 7979 and 1982. The gross per capita natior:al product was esEimaEed at US$ 330 in 1983. 8.L.7 Administratively, Niger is divided into seven departments, 35 administratLve districts, 24 administrative posts and seven communes. The health services are nodelled on t.hese structures. 8.1.8 The general State budget has undergone sone changes that reflect the economic situation experienced by the country since the end of 1982. That, however, has not prevented an increase in the budget of the }tinistry of Public Health and Welfare, which has been an ever-increasing proportion of the State budget (see the table below). 1981 L982 1983 1984 1985 National budget MPHW budget Increase of natlonal budget Increase of MPHW budget MPIM budget/ State budget 80 624 475 3 448 600 4.277" 93 8s3 819 3 809 205 L6.47" 70.45% 4.O58% 81 268 510 4 366 495 -L3.47" L4.657" 5.372 80 234 985 4 455 530 -t.27% 2.O3% 5.55% 85 969 08s 4 832 670 7 .L47" 8.461! 5.62% Budgets given in thousands of CFA francs. Source.' Ministry of Finance - Budgets. 8.2 Morbidity and mortality 8.2.7 A few figures w111 suffice to describe the health situation in Niger. According to the statistics on general medical consulEatiots,757" of all diagnoses in 1984 related to the following six states.' - assumed malarla 222 - diarrhoeal diseases L7Z - respiratory condltions 77"1 - conjunctivitis and Erachoma lOZ - cuts and wounds 9% - skin conditions 6"1 Source: Report on the activities of the Ministry of Public Health and Welfare for 1984. 8.2.2 A study (1979-1983) carried out in a maternity unit revealed that only 80% of newborn bables had a birth weight of 2.500 kg or over. Moreover, between L4.32 ar.lJ 242 of rhe children weighed and measured in MCH services had a marginal nutritional status. - 7.7% to 10.22 were suffering from serious malnutrltion; - 237" showed signs of vitamin A deficiencyl - O.4"1 to 2.4% suffered from scurvy. JPC7. 6(C) page 5 In addition sotre 60Z of children and pregnant wonen were suffering fron anaemia (surveys carried out in MCH centres in 1980 and 1982). 8.2.3 In October 1983, 34.2% of the rural population and, 481l of the urban population had a piped <Irinking-water supply. AdequaEe sanitary facilities were enjoyed by 36% ot the urban populaEion, as against 3Z of the rural population (canvassing data, 1983-1985). 8.3 The public health sys Eem and its operation 8.3.I The right of the citizen to health is formally recognized in all official texts and pronouncexnents. Niger fully subscribes to the social objective of tr{HO: health for all by the year 2000. Sj,nce 1965, well before the Alma-Ata Declaration, but especially since 1974, a health policy giving priority to primary health care has been developed in the country, especially in rural areas. 8.3.2 The public health strategy of Niger may be summarized as followsi the setting up of a structure providing extensive health coverage at village 1eve1 and strengthenlng of the staffing of health services from among the population, personnel traininS, improved operation of the lnfrastructures, and integration of the health system into the overall socioeconomic structure of the country so as to pronote the participation of all the people of Niger in health projects and the implementation of a population policy in line with the countryts resources. 8.3.3 The public health sysEem in Niger is based on the concept of "self-staffing of health facilities", the operaEional expression of which is Ehe acEivities of village health teams consisting of first-aid workers and birth attendants who have received 15 days of training and are convoked for retraining courses every three years. The individuals to receive this training to become first-aid workers and birth attendants are selected by the villagers themselves who, in large measure, assume responsibility for the operating costs of the teams. Ilowever, some drugs are supplied free of charge through the heads of medical districts or through rural dispensaries that receive them from the Ministry of Health. It should also be noEed that the Ministry of Public Health and Welfare I-s responsible for the initial equipping of the first-aid workers and birth attendants. 8.3.4 The village health teams are the first contact with the rural population in matters of health. The duties are simple but essential and much importance is attached to health education and functional literacy. The health teams are supervised by the nurses of the rural dispensaries (see be1ow, 8.3.5), by the nurses and midwives of the medical districts(see be1ow, 8.3.6), and by the Departmental Health Directorate (see below, 8.3.8). 8.3.5 The rural dispensaries, whlch are at vil lage 1evel, have preventiver treatment and educative functions, in addition to supe rvisory and administrative responsibilities. At the present time most rural dispensaries have a single cerEificated nurse. Medical stations have the same duties as the r,rr"1 dispensaries, but in addition they have 10 Eedsl-Tilof wtri.ch are for maternity cases, and more staff than the rural dispensaries (one regisEered nurse' two certificated nurses, and one nidwife and one driver). 8.3.6 The medical district hea uarters the maternit units and the maEernal and child protection centres are located in the administrative centres of the administraEive districts. In addition to t.heir preventive, treatuent and educaEive functions, these establishroents are responsible for the recepti,on of patients referred to them by the rural health services (see above, 8.3.3 and 8.3.5), for specialized laboraEory examinations, for personnel training and for supervision. In general, the medical district headquarters has two midwives, three or four registered nurses and four or five certificated nurses. 8.3.7 The hospital sector consists of tertiary health care establi-shnents, i.e. national hospitals and departmental hospital centres, and is the final 1eve1 of referral. All specialized treatnent facilities are concentraEed in this sector. 8.3.8 The Ministry of Publ.c Health and Welfarc is responsible for the irnplementation of health policy . At the central leve1 there are rhe Minister and his advisers (chief secretary and technical adviser), the general secretariat (general secretary, assistant gener a1 secretary), the inspectorates (public health, occupational medicine, pharmacies and laboratoiies), the central directorates (administration and finance, welfare and MCH, health JPC7.6(C) page 7 and nuEriEional instruction and education, treatment establishments, hygiene and mobile medicine). The division of healEh infrastructures and statisEics is dependent on the general secretariat, while the NaEional Bureau of Pharmaceutical and Chemical Products is managed by an administrative board. The Ministry of Health has a supervi.sory function over the National Bureau. 8.3.9 Special importance has recently been given to health service management problems in Niger, including planni.ng, prograrnming and evaluaEion. Field surveys have been conducted and operational research has-acqulred an ioportant supporting role in the managenent of health programmes. 8. 4 Public healch servLce resources g.4.1 Training for the greater part of the counEry's health workers is available in Niger, even if some special subjecgs are caught abroad, where pharmacists, dentists and sanitary englneers also receive t[eir training. There is aE the present time one doctor to 36 000 inhabitants in Niger (1989 projection: L/24 OOO), one nurse for 5500 inhabitanEs (1989: 1/3500), and one ii.arif" foi Z5OO wouen of child-bearing age (1989: L{43OO). In L985, 24 nedical students, 75 student-nurses (middle 1eve1), and 55 pupil-midwives (middle level) passed their final examinations. 8.4. 2 There are the following fac illties and health Personnel - Village health teans(roughly 45% of the countryrs villages) first-aid workers birth attendants - Permanent local treatment facilities rural dispensaries nedical statlons roedical dlstrict headquarters (1019 beds) naternity units (480 beds) MCH centres (number of inhabitants to one Permanent unit 22 2OO) doctors mi-dwives state-reglstered nurses certificated nurses - National hospitals (2) and department hospital centres (5) doctors /pharmac i s ts /dent lst s of whom - nationals of Niger - expatriates nurses, midwives laboratory technicians, radio oPerators, etc. - Total number of beds - Tuberculosis centres - People's pharmacies - Drug depots - Health service Sarages 3 900 (1e84) (1984) 6 7 600 100 275 24 38 50 28 150 183 34L 792 171 73 98 3s2 (s24) 108 3 600 ( 1e83 ) 6 18 27 5 - l,lainEenance services 3 JPC7.6(C) page 8 8.4.3 See Annex 1 for a list of the facilities provided by the public health services Public health services costs8.5 8.5.1 The publie health system in Niger is financed from three sources.' the State budget and popular participation (internal resources), and bilateral and mulEilateral cooPeration(external resources). Ihe budget of the }linistry of Public Health and Welfare receives an annual allocation from the general State budget (4 832 670 rnillion CFA fraucs in 1985). "staffing costs" represent more than half the total budget (5l- .57" in 1985). Although lt may be difficult to quantify popular participation in the operation of the health services, it is a far from negligible contribution. It consists of participation in staffing(flrst-aid workers and female birth attendants), who are unpaid volunteers drawn from the population (13 700 workers), and of participation over financial resources (the construction of one-thlrd of the dispensaries between L979 and 1983, to a value of 700 mill.ion CFA francs, the provision of equipmenE, the purchase of drugs and community works projects in public health etc. 8.5.2 InternaEional cooperaEion contributes roughly a quarter of the budget of the Ministry of public Health and Welfare. The main bilaEeral donors are the United States, France, the Netherlands, the USSR, Belgium, China, Japan and South Korea. The nultllateral donors are the United Nations system (US$ 1.5 million per year), Ehe EEC countries and the countries of the Arab Technical AssisEance Fund. The aid provided by international cooPeration is focused on health acEivities in rural areas. 9. The public health servi-ce estimates and the costs of the services 9.1 Examination of the 1985 budget of the llinistry of Public Health and Welfare shows that allocations for the hospital sector are sti1l as great as the resources allocated to Ioca1 health servlces, despite the fact Ehat the counEryts public health policy is to strengthen health services in the rural areas. Measures rrere adopted at the meeting of tlle Council of Ministers ot 26, 27 artd 28 June 1985. These Deasures involve.' - according special treatment to preventive medicinel - effecting a geographical readjustnent of infrastructures to reduce disparities and further rationalize evacuations on health grounds; - giving priority Eo retraining courses (in preference to long courses) and to the tralning of nurses, more especially at ENICAS in Zinder; - rigorously applying the existing legislation, in particular regarding the cost of consultation, exami.nation, hospitalization and evacuation on nedical grounds. g.Z Efforts to oake more rational use of existing financial resources will be increased. To that end, the methods of evaluation and operaE.ional research, which are already employed in the Ministry of Health, will be systematically applied. 9.3 The inevitable increase in health expendj-ture would make it oecessary for new national resources to be sought and for the people to take increasing responsibility for expenditure in this area, more especially by the application of an appropriate scale of charges for hospital services and for loca1 health care. It is also to be hoped that bilateral and multilateral collaboration are going to be strengthened, so that the contribution of external aid, which is already considerable, will be more manifested. 9.4 Village health teams The "coverage" does not at presenE exceed 457" (3900 teams for 9000 villages). Consequently, it is planned to train 3000 first-aid workers and 3000 female birth attendanEs durinj the next t5 years so as to be able to set uP new teams as follows: 200 in L986,2O0 :.n f987, 200 in 1988, 200 in 1989, 200 in 1990 and 200 in 1991. The "allocation of priorities" for Che health activiEies of the teams is under examination with the aim of avoiding the health workers being overloaded. It is therefore planned to intensify the training and retraining of staff in the management process through the creation of a National Health Developnent Ceotre (NHDC). JPc7. 6( C) Page 9 9.5 Total CFA francs 163 650 provision should be made for the establishment of 60 new rural dispensaries between 1986 1991 to ensure real supervision for 1200 new village health teams. - 40 000 x 60 CFA francs 2 4OO 000 000 9.6 Tertiary-leveI i.nfrastructure CFA francs ( 000s - Training (CFA francs 30 0OO/worker) - Retraining (CFA francs 27 OO0/worker) - Supervision (CFA francs 45 000/village/year) - First-aid chests (CFA francs 50 000/chest) - Birth aEtendants' kits (CFA francs 30 000/kit) - Reconstruction of che A'gadez District HosPital - Nephrology (Department) - Resuscitation, Niarney Hospital CFA francs (000s 1986-19 91 36 000 32 400 47 250 30 000 18 000 1 500 000 457 204 300 000 and 2 257 204 9.7 Natlonal Blindness Prevent ion Programme The Government has prepared a special blindness control Programme. A breakdown of the activltles by year and the cost estimates are given in the following table (it ls proposed that the programme begin in 1986). JPC7.6(c) page 10 1986 t987 1988 r989 1990 199 1 No. Cost No. Cost No. Cost No. Cost No. Cost No. Cost Study Mobile ophthalrnological teams Equipment Operation Permanent ophthalmological cent res Equipment 0perat ion National Blindness Prevention Centre Equipment 0perat ion Training Physicians SpecialisE nurses Department.al seminars 3 44 310 3 5400 1 20 000 60 000 24000 3 9000 900 14 000 2 16 000 2 4320 8 000 4320 3 1 2 2 3 4 3 6 480 4 32 000 3 6480 7 7sr20 2 44 3t0 9000 5 9000 7 L2600 2 600 29 540 s400 5 1 1800 1 1800 1 1800 I 1800 1 1800 2 5 8 3 48 9 000 000 r 3 000 600 Total CFA francs (000s) L79 zLO 20 520 106 660 20 280 94 L90 29 520 Grand total: 450 380 000 CFA francs. See Annex 2 for ful1er information. 9.8 Other lanned ammes Certain activities intended to strengEhen the Governmentts efforts in the field of public health have attracted the special aEtention of the national authorities. They are the programmes for the control of malaria, diarrhoeal di.seases and malnutrition, in addition to an expanded programme of lmmunization, family planning, strengthening the Welfare and MCH DiirecEorate, personnel training, health education and the promoEion of oral health. The total expenditure planned for these activities is put at: (thousands of CFA francs) Yearl Total Inves tment Recurring 2 827 402.0 L57 452.5 744 L22.3 L72 214.7 557 5L L67 65 427 434.r t66 904.9 5 255 006.5 828 982.9 !_J?Lq 3.0 3.0 1 8 698 L64 535 757 Total 2 984 854.5 863 292.9 9L6 337.0 725 L66.0 594 339.0 6 083 989.4 1 Girun that the year of commencement is stil1 not decided, the table refers to year 0(preparatory activities), year 1 (first year of implementation) and so on. JPCT . 6( C) page 11 In addition, Ehe esEimated expenditure to improve the equipment of the outlying health unit.s is 1 335 494 500 CFA francs. Details of these programmes are given 1n Annex 3. ENTOMOLOG] CAI, I,lON ITORING 10. CurrenE status of enEomological monitoring 10.1 lhe vectors monitored 10.1.1 Before the launching of the programme, the situation was dorninated by the following endemic diseases: trypanosomiasis, malaria, yellow fever, schistosomiasis and dracunculiasj.s. However, not all the vectors of these diseases were monitored. 10.1.2 Blackfly control has been undertaken by OCP for 10 years with the results that are known. Despite the lack of systematic monitoring of the vectors of such diseases as Erypanosomiasis, schistosomiasis, dracunculiasis and yel1ow fever, special efforts in this area are made if Ehese diseases appear. 10.1.3 Regarding malaria, activiEies are undertaken at conmune 1evel in the context of vector control. These activitles consist of: - larviciding; - household spraying with insecticides. L0.2 The facllit ies for vecEor monlEori.ng and control' and their operation 10.2.1 Monltoring and conErol are conducted by the Dlvision of Hygiene and Sanitation, which collaborates with the agricultural servlces, if necessary. 10.3 Ihe resources and the cost of monitoring 10.3.1 A seni.or entonological technician, currently worklng with OCP, has been trained in the context of devolution. The staff available for malaria vector control are: - 7 sanitary technlcians; - 14 labourers; - 7 dri-vers. 10.3.2 The equiproent available at the national level for malaria control consists of: - 1 vehicle with dusting equiPment; - 10 Fontanl - 10 Swing-Fog; - 20 Hudson sprayers. The annual fuel requirement is estimated at 7000 litres and malathion. 10.3.3 Financial resources in the year 1985 amount, to: Staff Equipnent Products Fue 1 The insecticides i.n use are Abate 72 660 000 CFA francs 26 4OO 000 CFA francs 175 000 000 CFA francs I 785 000 CFA francs 2L5 845 000 CFA francs JPC7.6(C) page 12 11. Entomolo ical monitoring prospec t s 11.1 Planned activities 11.1.1 It is envisaged that vector monitoring will be strengthened, especially tsetse fly and malaria vecror oonltoring (see section 1 of Annex 3). The possible establishrnent of a vector control team i-s being examined. It is envisaged that all d6partements and arrondissements will be provided with adequate resources in Eanpohrer, materials and finance to enable them to deal with their new task. Ll.z The means required and their cost lL.2.L The total cost for five years of malaria control is estimated at 343 342 7OO CFA francs (see section I of Annex 3). The total cost of vector control activities is 1 295 818 000 CFA francs for the first four years of devolution- LL.2.3 Cost of entomo 1og ical oonit.oring L987 1988 1989 1 990 O6 fitted out vehlcles Maintenance and fuel 238 Fontan 162 lludson Malathion Abate Baygon Training of 6 entomologists(6 nonths) 120 000 000 600 000 1 200 000 I 600 000 5 000 000 34 748 000 9 720 000 9 000 000 283 500 000 40 500 000 47 250 000 283 500 000 40 500 000 47 250 000 283 500 000 40 500 000 47 2sO OOO Laboratory equipuent (6)(see appended list) Subtotal TOTAL 178 468 000 371 850 000 L 295 818 000 372 450 000 373 050 000 L2. Present status of epideniol ogical monitoring L2.l The diseases subjecE to monitoring LZ.L.L The diseases subject to epidemiological moniEoring are malaria, diarrhoeal diseases, respiratory conditions, diphtheria, whooping-cough, influenza, jaundice, chickenpoxt tetanus, cerlbrospinal neningitis, ,easles, polioryeliti", onchocerciasis, syphilis, tryPanosomiasis, rabies, typhoid fever and tuberculosis. JPC7. 6( c) page 13 L2.2 Epideniological monlEoring facilities and their operaEion L2.2.1 The epidemiological daEa collected are sent at the end of every week from the rural dispensary to the medical centre, which collates Ehen and sends the weekly offlcial telegran(0T) wlth the data on the above diseases to the l"linistry of the Interior through the Sub-Prefect. These dafa are recorded daily on a report form in the rural dispensaries and sent weekly to the Ministry of Public Health and I,rlelfare. i.2.2.2 Shou1d there be a bulld-up of cases, the village communiEy advlses the nearest authorities or dispensary. L2.3 Means of monitoring 12.3.1 The nurse in charge of the rural dispensary dispatches the information to the raedical centre by any available means. At nedical cenlre 1eve1 there are four official means of dispatching inforrnation to the DHD or the MPHW: (a) the postal service, which is the neans nost frequently employed; (b) the telephone; (c) a coded radio message sent with the assistance of the Mlnistry of the Interiorl (d) supervlslon. 72.3.2 The duties of the staff concerned with epideruiological monitoring are an integral part of the ordlnary work of health personnel. 72.4 The cost of roonitoring L2.4.L MoniEoring cosEs are extremely difficult to estimate because of the multisectoral nature of the problem. An effort has, however, been nade, although it does not allow for staff salaries, telephone and supervision. L2.4.2 Approximate cost of monitorlng in 1985 0fficial telegrams (Ministry of the Interior) Stamps Paper Total Epidemiological monitortng prospects The cost of rnonitoring 20 000 000 1 200 000 6 200 000 27 400 000 cFA F 13 13.1 13.1.1 It is intended to strengthen the activities of the Expanded Programme on Immunization(EPI) to ensure the moniE.oring and control of the six diseases covered by that programme (see section 2 of Annex 3). 13.1.2 Studies are in progress to idenrify the means required, on the one hand, to improve the mobility of the staff of the rural dispensaries responsible for the surveillance of village health teams (supply of a moped) and, on the other haod, to improve telecommunications facilities (radio receiver/transmitter) exclusively in the ONCHO zone. L3.2 The means to be provided and their cost 13.2.1 Estimates have been made for EPI activities during the next five years, the total cost of which ls put at 2 692 486 100 CFA francs (see secti,on 2 af Annex 3). JPC7.6(C) page 14 t3.2.2 Ihe planned activiCies in the conEext of epiderniological surveillance are to strengthen the means of supervising Uhe rural dlspensary nurses and to lmprove health inforiatlon (feedback). The cost of the activities durlng the first four years will be 150 600 000 CFA francs. 1989t987 1988 1990 36 vehicles (MC supervision) Telegrams Stamps Paper 23 transmltEer- receiver sets Mai.ntenance and fuel 288 20 3 L2 100 000 000 000 000 000 525 000 000 000 000 000 000 20 000 000 3 000 000 12 000 000 525 000 20 000 000 3 000 000 12 000 000 525 000 20 000 000 3 000 000 12 000 000 525 000 Subtotal TOTAI, 423 525 000 35 025 000 528 600 000 35 025 000 35 025 000 14. Present status of drug d istribut ion 14.1 The National Bureau of Pharmaceuti-' exclusive rights over the importatlon of dressings and technlcal rnaterials. The natlonal pharmaceutical industry geared distribution of drugs is carried out by available by ONPPC through the peoplefs private drug depots (36) in the district without peoplers pharmacies. The villag' cooperative pharuacy, for the management responsible, is at an experimental stage DRUG DISTRIBUTION cal and Chemical ProducEs (ONPPC) has been given harnaceuticals and chemlcal ts , materials for developing asame Bureau has en given the tas o to the manufacture of essential drugs. The free the health units, whereas drugs for purchase are made pharnacies (of which there ate 22) and through administrative centres and important villages e pharmacies are run by the village health teams. A of which the Village Development Council will be (Tahoua) . 14.2 Every departmental healEh directorate has a truck to convey supplies of drugs froro ONppC to the departmental nedical districts. Distribution of the drugs to the health unlts is carried out by the vehicle of Ehe medical district. 15. Drug dlstribut ion prospects 15.1 Planned activit,ies 15.1.1 The experimental management of cooperaEive pharmacies by village development councils must be conEinued with a view to the completion of the system. L5.2 The means to be provided and their cost L5.Z.L No additional means are required for the planned activities because Ehe depots a;e in the private secEor and the drug distribution will be rnade through the existing distribution system. JPC7.6(C) PaSe 15 C. THE DEVOLUTION PROGRAMME 16. Blackfly moni toring 16.1 Proposed monitoring system for devolution 16.1.1 Although the definlEion of the process of devolution and its repercussions at the national leve1 still has to be thought out operationally, a tri.al Programme is already under examination in Niger. The general aim of this programme is to maintain t.he gains of Ehe OCP, and to continue its acEivities so as to ensure permanent control of the whole of the area and guarantee the wellbeing of the region. The strengthening of primary health care activities in the area is anoEher object of the programme. To achieve these ains it is proposed that the village health teams of the region be supplemented and that the first-aid workers be acquainted with entomological monitoring activities. It should thus be posslble to integrate the few remaining onchocerciasis monitoring activities at the time of devolution with the other cooponents of prinary health care. The intensity (rhythn) of these activj.ties remains to be deterruined. 16.2 0rganlzation, means and cost L6.2.L OCP will contj.nue its vector control actlvitles (entomological monitoring, larviciding if necessary) until the risk of transmission of the parasite is minimized or reuote. Should localized retransmission occur after discontinuation of the activities of OCPr l.e. during the devolution phase, the fact will become apParent from the appearance of new cases diagnosed by the health service and will be contained by mass distribution of Ivermectin in the conmunitles (viIlages) in which the cases occur. L6.2.2 The Government intends to set up a permanent blackfly monitoring systeo in close collaboration with oCP in order to be certain that the parasite is not being transmltted. When QCP ceases its activities in Niger the Governnent will have qualified staff trained by gCP in entomological nonitoring techniques. Should the flles return after larviciding has been halted, these staff will be responsible for keeping watch on the most exPosed points. L6.2.3 Should infective blackflies be detected the Government will call on OCP even if the Programme ls no longer operatlng in Niger. L6.2.4 It is not expected Ehat the staff trained in the identiflcation and dissection of blackflies (two or three teaus) wiLl be fu11y occupied on that. Consequently, these teams will be able to undertake other activities concerned with the monitoring of the vectors .of other diseases (malaria, schistosomiasis, etc.). Thus, these teans will ultimately constltute the nucleus of a vecEor monitoring service. L6.2.5 Regardlng the participation of village health teans (VHTs) in blackfly tronitorinS, 1t ls Eo be expected that the first-aid workers will assist the teams loca1ly, more especially for the recruitment and positioning of lnsect collectors and the Posltioning and monltorlng of traps. 16.2.6 Once the details of Ehe programme have been worked out, the cost esti.mates will be adopted. As a pointer, a preliminary estimate yields expenditure of the order of 106 915 000 CFA francs (for the four years) for the strengEhenlng of the public health system in the context of devoluEion. JPCT .6(C) Page 16 1987 1988 1989 1990 Trainlng of 60 village health workers Retrainlng Supervision First-ald boxes (30) Midwifery kits (30) Bellec traps 3 vehicles (equipped for vector control) 5 supervisory vehicles (MC-l'tP) 17 oachines (50 cc) for RD Awareness seminar (Personnel of the zone) Materlal for vector control team Malntenance and fuel Subtotal TOTAL 1 800 000 1 200 150 90 L20 24 000 40 000 8 500 500 2 000 5 000 000 000 000 000 000 000 000 000 000 000 675 000 120 000 7 250 000 1 620 000 675 000 675 000 120 000 120 000 500 000 7 250 000 7 250 000 82 280 000 8 045 000 108 535 000 10 165 000 8 045 000 L7. Ep ideniolog ical evaluation of onchocerciasis 17. 1 Evaluation system ProPo sed for devolution 17.1.1 I'he national measures on epidemiological evaluation will be on a very reduced scale, easily inEegrable into the routine acEivities of the Directorate of Hygiene and Mobile Medicine. In that context it seems appropriate to stress close collaboration between the teams and staff of OCP and their opposite numbers among the couotryts naEionals in the field so that the laEter may be introduced to Ehe duties of devolution. Frorn the point of view of admlnistration it is intended to set up a Vector Control Division. L7.L.2 The Government intends to take over exaoinations i.n four of the 16 cootrol villages for epidemiological evaluation in Niger. In that context, it should be enphasized that there is a need for ibsolute comparability betueen the results of the national teams and those of OCp. This comparabiliry will be made easier by the epideruiological evaluation manuals now being prepared bY OCP. 77.2 0rgani zatlon. means and cost L7.Z.l Examinations in the control villages for evaluation will be carried out by a Departmengal Hygiene and Mobile Medicine Teau. The members of these teams will be trained in ttre tieta by tire gCP teams. The examination is a simple one. Specialized ophthahnological examioations will continue to be carried out by the OCP teams. JPC7.6(c) Page 17 L7.2.2 Cost of epidemiolosical evaluation (see 13.2.2) 18. Distribution of IvermecEin (or of other drugs for the treatment of onchocerc iasi s ) 18.1 The distribution network and verification that the drug has been taken 18.1.1 As indicated above, should there be a localized resumption of transmission, there wtl1 be mass dlstributi.on of Ivermectin (or of oEirer drugs for the treatment of onchocerciasis) in the villages concerned. Niger has a health infrasLructure that ls adequate for that purpose. At the outlying level coverage by vlllage health teans (VHTs) is currently of the order of 45%. 18.1.2 Ivermectin will be routed frorn the centre to the village by the usual drug-distrlbution channels, i.e. fron the Minlstry of Health to Ehe DePartmental Directorate of Health (DDS), from the DDS to the nedical district, from the medical district to the rural dispensary, and from the rural dispensary to Ehe village. 18.1.3 To ensure that all individuals intended to receive Ivermectin have in fact been treated, a survey w111 be required if one has not recently been carried out. Therefore an lndividual record card will be completed for every lndividual liable to receive Ivermectin so as to check that the drug has been taken and to ensure that lt is not given at too frequent lntervals. 18.1.4 Ivermectin tablets will be taken in the presence of a public health worker who must ensure that the tablets have been swallowed. L8.2 Means and cost of distributlon 18.2.1 In view of the importance of this mass treatment and 1n order to avoid the resumption of transmission, it will be necessary to reinforce the village health teams with the staff of the rural dlspensary, and for the operation to be supervised by the dlstrict nedical officer. L8.2.2 No additlonal resources w111 be needed for the lntroduction of the producE except for lhe cost of the drug where it is not free. 19. Devolution tlme-tabIe 19.1 As pointed out above, national staff w111 have to be trained by the appropriate servlce of OCP before the Governoent can undertake the various actlvities planned for devolution. It is therefore proposed to constitute tI^Io entomological nonltoring teams during 1987 (date and place to be fixed in agreement with OCP), to hold awareness seminars for the nurses of the zone and to train firsc-aid workers. 19.2 In addition, it will be proposed that the entomological evaluation service of OCP should train the health tearns of Niger during 1987 to carry out epidemiological examinatLons ln control villages. 19.3 Consequently the health authorities in Niger would be in a positiou to begin the process of devolution froro 1988 onward. 20. Coordinatlon, follow-up and evaluation 20.7 The technical and administrative responsibility for the preparaEion and implenentation of devolution will be given to the appropriate services of the Ministry of Public Health and Welfare. These services will also be responsible for internal and external coordination and especially for collaboration rrrith OCP. 20.2 As the devolution process Sets under way, experience in the field could alter the operatiooal plan drawn up by the l,linistry of Public Health and Welfare, which will be responsible for the fo1low-up of day-to-day activities in this area. 20.3 Contlnuous evaluation will be instituted for assessment of the results and the cost-benefiE ratio of the operations under devolution. The National Onchocerciasis CommitEee will be responsible for this evaluation on the basis of reports supplied by the l4inistry of Public Health and Welfare. JPC7.6(C) Page 18 ANNTiX 1 Consultations given by fever diarrhoea headaches conditlons affecting wounds PUBLIC HEALTH SERVICE CARE first-aid workers the mouth " nose " ear " eye 4 954 L 232 L OLz 952 311 3L2 238 448 446 226 340 604 462 7]-7 630 250 136 687 74 63L 3 085 147 362 084 3 075 47 680 ( 1984 ) ( 1984) (le84) ( 1e84) ( 1e84) Assistance by female birth attendants (232 ot deliveries attended) Consultations (new cases) in rural dispensaries, rnedlcal posts and medical district premises Consultacions (al1 cases) i-n national and departtrental hospitals Hospital admissions in national and departmental hospitals and in nedical district premises beds admissions Cases JPc7. 6( C) page 19 Annex 1 DeathsNotifiable diseases diphtheria whooping cough tetaous meningitis pollooyelitis measles malaria serious diarrhoea pneumonia influenza jaundice chickenpox Expanded Prograrnme on ImmunizaEionl 6 10 170 427 L73 287 t7z 013 4t3 23L 227 s89 6s3 919 2 4 L7 75 7 487 70 t82 54 0 L2 1 2 40 I 338 10 1-2 3 immunization - yellow fever - measles - cholera - BCG - tetanus - whooping cough - neningitis 267 66L 25 236 31 250 652 752 333 804 5L7 904 560 770 1 According to surveys in 1981 it is estimated that one the age-group 0-12 nonths is immunized agalnst tuberculosis; against diphtheria,/whooping cough/ tetanus/potio. One o"t ot child out of four or five in one child out of 15 or 20 28 pregnant women is imnunized agalnst Eetanus. JPC7.6(C) Page 20 ANNEX 2 NATIONAL PROGRAM},IE FOR THE PREVENTION OF BLINDNESS 1. In Niger blindness is oainly due to Erachoma and conjuncEivitis associated with deficiency diseases (xerophthalmia and keratonalacia) and with degenerative conditions(cataract, glaucoma). Eye lnjurles also play a not unioportant role. Thanks to the efforts of the gnchocerciasis Control Programne this disease is no longer transmitted in Niger arrd' consequently, no longer gives rise to ner^I cases of blindness, alEhough there are stil1 a great-many o1d cases due to onchocerciasis. According to the statistics of public healfh establishments, trachoma and the various forms of conjunctivitis account fot 8% of the cases diagnosed by general pracEiEioners. Although there are no quantifled estimates for xerophthalraia and keratomalacia, the fact that a survey in Niamey revealed that 25.62 of children below five years o1d suffered from malnutrition suggests that vitamin A deficiency disease could be a serlous problem in Niger. As regards cataract and glaucoma, although there are no country-wide statistics, some indicaEion of the extent of the problem may be obtalned from surveys fron developing countries, which have shown that cataract is responsible for roughly 50% of cases of blindness, that the globa1 blindness rate is between 1 and 32 of the population, and that glaucoma is responstble for roughly 10% of all blindness. A survey of the prevalence of blindness carried out in August 1983 in two departments (Nianey and }laradi) revealed a prevalence of L.66% of the Earget population (4112 tndividuals) and 5.352 of the population effectively exanined (3009). According to another survey carried out in 1983, 120 000 partially sighted and blind people were recorded in an estimlted population of 6 000 000, which gives a prevalence of 2Z of the population. 2. Ophthaloology is practised in Niger ln two ophthalmological care centres, one in Nianey and the other in Tahoua. A Niger Association for the Advancement of the Blind (ANPA), which has been in exi.stence since 1974, Ls actively concerned with the education, rehabilitation' occupational training, reenployment and registering of the b1ind, and with public akrareness and lnformation campaigns. The consultaEions of departmental hospitals include ophthalmological examinations and operations. In 1984, for example, 16 000 patients were seen for ocular symptoms. Ihe most frequently performed oPeration was for caEaract, followed by trichiasis, foreign bodies and eye injuries. 3. It is proposed to instltute a National Blindness Prevention Programme to sErengthen blindness control in Niger. The general objective of the Programme will be to eliminate avoidable bllndness and promote ocular health so as to lower the prevalence of blLndness to less than O.5Z for the country as a whole and less than 12 for a given communiEy by 1985. In order go achieve Ehis objective it is planned to obtain country-wide epideroiological data on eye troubles and blindness; to pronote prevention, including ocular hyglene; to train staff at all levels for ophthalnological care, especially in the context of prlmary health care; gradually Eo set up national facilities to promote ocular health, and the Prevention, treatment and conErol of ocular conditions; to perforn surgical operations to reduce the exisEing number of persons disabled by sight disorders; and to apPly a social policy for the victlns of blindness. The above-mentioned taslcs will be facilitated by the establishment of a national committee for the prevention of blindness, which will arouse public awareness Eo the problem of blindness and stimulate conmunity projects concernlng it. The programme wl11 be concerned first and foremost with children (infectious diseases and nutritional deficiencies) and with adults (degenerative dlseases), above all in rural areas. 4. Village health teams will be the first 1evel of ophthalmological contact. It Soes wittro@ehea1E'hworkersarenottoexceedtheircompetenceandareaIdare that patients must be referred Eo a higher 1eve1. They will also concero themselves with ""y" "d.r""tion" and nuEritional education. These activities will be supplemented by itinerant health teams which are to concern themselves with eye problems at a higher 1eve1: administration of vit anln A for prevenEion and treatment, measurement of vlsual acuity to detect any loss of sight, especially cataract; removal of foreign bodies; conjunctivitisl surgical operations. 5. Euller ophthalnological care will be provided in the rural dispensaries and posEs and in the headquarEers of medical distric ts. to which vil lage healrh workers refer cases beyond their conpetence. These centres wilt thus provide further training in tl're area of eye conditions, immunization against measles, and health and nutrit.ional education. JPC7.6(C) Page 21 Annex 2 6. It is proposed to create sobile oPhthalnolo at departmental 1evel, which will spend two weeks of the Eontlt on tour in the department and the remainder of the month at a permanent ophtha lmological centre (see below). The mobile groups will provide systematic preventi.on; deLection; regisEration of Patients for surgical operation by the itineranE health tean; Post-oPerative care; data gatheringl and ongoing staff training. In addition, it is proposed to establish seven ermanent o thalmo ical centres in the seven depar tmenEs (one medically qualified ophthal st, two opht ,m og nurses, twoions, control ofoglabourers and Ewo drivers), which wlll be res ponsib-le for medical consultat the noblle ophthalnological groups, surgical operations and ongoing training. 7 Ihe prograuroing and central management of the National Progranrme for the Prevention of Blindness will be provided at the national level. Thus, it is proposed to institute a NaEional Ophthalmol ogical Centre with the task of providing scientific and technical support for the programrne (aPP 11ed research, educatlon, etc.); of providinS nanagement; of training specialized staffi and of contributing to the operation of the ophthalmological facilities at all levels. In addition, the Natlonal Co 'ni ttee for the Prevention of Bllndness, presided over by t5e Minister of Public Health and Welfare, will be responsible for app general programme and for each of the annual programmes put forward by the tec Eonnittel (see below) and for the evaluation and control of the activities of roval of the hnical the programne and lts financlal accounts. Ihe National CommitEee w111 deslgna te a technical committee to produce prograflDes of activities and annual budgets and to PrePare situat programme actLvltles for the National comnittee. reports on 8. The status of the programme will depend on its financing and on the extent to which nongovernmental bodies participate. Should the programme be enEirely state flnanced it will be I public body. Shouid there be participation by the state and by private bodies (National Associatlon for the Prevention of Blindness, etc.), the programme will be a semi-public body. In that context it is suggested that were the constitution of the l.Iiger Association for the Advancement of the Blind be modified it could become the "focal point" of the future NaEional CornmitEee for the Prevention of Blindness. g. The progranme wt11 be subject to continuous evaluation to measure its inpact on eye diseases and blindness. Ccnsequenlly, cost-effectiveness will be constantly verified. Surveys on eye conditions and diseases will be carried out as soon as possible throughout the country in vlew of the need to obtain valid data for more detailed programming and for posslble evaluation. 10. The priociple of step-by-sEep establishment of the Programme will be followed as much on grounds of seeklng the best conditions for lts irnplementatlon as on financial grounds. JPC7.6(C) page 22 ANNEX 3 OTHER PROGRA},I},IES FOR WHICH FINANCE HAS BEEN OBTAINEI) 1. Malaria control prograrDme Present situation/esEimates: malaria occurs Ehroughout Niger, even if transmission is limited in the desert areas. It is estimated EhaE the oorbidity rate is between 6 and 7Z of. the entire population, and thaE the fataliEy rate is around 0.32. Control of the disease is based on curative treatment, chemoprophylaxis and vecEor conErol activities. There is little information for assessment of the extent of all these measures. The nalaria control prograflune alms at early diagnosis and treatment of every suspecEed case through improvement in liligerrs laboratory services. Prlority will be accorded Eo children fron blrth t.o 10 years old. Chenoprophylaxis is reserved for pregnant \domen. The year for launching the programme not having yet been settled, the following (sumnary) tabte of estimaEed costs refers to year "0" (Preparatory activiEies), "1" (first year of programme implementation), etc. Year Investment Recurring expenditure 9 L9t 737.5 5 658.9 I 25 7 46.6 5 156.8 Z 52 928.4 7 447.6 t. 32 784.s 6 887.7 ! 18 017.8 6 976.9 Total 37t 2L4.8 32 L27.9 Total(thousands of CFA francs) L87 396.4 30 903.4 60 376.0 39 672.2 24 994.7 343 342.7 2. Expande d Programme on Immunization Present situation/estinates: The incidence of measles is 7% and the fatality rale L.227". The prevalence of paralytic sequelae of poliouyelitis in the age-groups between 5 and 14 years old is 6.4% it the rural "rrri.o.,r".rt ind 13.2% it the urban environment (Niamey department, 1981). Although there are no figures for neonatal tetanus and whooping cough, these two diseases would appear to be of imporlance, whereas diphtherta is the least important of the target diseases in the Expanded programme on Immunization. Tuberculosis remains endemic and yel1ow-fever, absent since 1939, is i cause for concern. Vaccine coverage is very inadequate at the present time owing to the scarcity of ghe existing resources and a relatively undeveloped cold chain. It is envisaged Ehat the Expanded Programne on Immunization will be integrated into all the coungryts permanelt health facilities and Ehat mobile teams will be tnstituted and then phased out. It is planned Eo improve vaccine coverage from 40% in year L to 9OZ in year 4. Year Investment Recurring expenditure 9 93L 229.2 100 748.7 I 334 989.0 LOO 748.7 Z 373 678.4 LOO 748.7 t. 305 897.6 98 018.6 I 248 408.6 98 018.6 Total 2 L94 202.8 498 283.3 ToLal L O3L 977.9 ( thousanils of CFA francs) 435 737.7 474 427.1 403 9L6.2 346 427.2 2 692 486.1 3JPC7.6(C) page 23 Annex 3 Control of diarrhoeal diseases PresenE situat ion,/estimates Mortality from dj.arrhoea is estimat.ed at L8% among children less than 5 years o1d. Diarrhoea is the nost important cause of death afEer malaria. Existing measures for the control of diarrhoeal diseases are in process of being coordinaEed through the institution of a national Programme. The progra.me for the control of diarrhoeal diseases w111 be based on improved environoental hygiene, health education, and the use of oral rehydration rtrith rehydration salts produced i" Nig".. It is hoped to arrive withj.n three years at a 597" coverage of chll<lren between btrth and 4 years old in the river region, 40% in rhe Sahelian region and 75% it the Saharan region. TotalYear Inves trnent Recurring exPenditure q 29 010.8 3 854.5 I 3 634.9 3 854.5 Z 3 634.9 3 8s4.5 l. 8 864.9 3 854.5 t_ 3 634.9 3 854.5 48 780.4 L9 272.5 Total (thousands of CFA francs) 32 865.3 7 489.4 7 489.4 t2 7L9.4 7 489.4 68 0s2.9 4. Programme for Ehe control of oalnutrition Present situation/estiEaEes Malnutritlon is a widespread problern in Niger. A survey conducted in one departnent (in 1979) showed rhat L8Z of babies had a birthweight of less than 2.5 kg. In another departnent, roughly one pregnant woman in five was anaemic (1982), and in Niamey department 37.57" of children between three months and five years o1d are underwelght. The programme for the control of nalnutrition will promote breast-feeding, steP uP nutrltlonal education, and promote the productlon, preservation, storage and dtstributlon of foods and the supply of drinking \rater. ESTI-T{ATED NEEDS Year InvestEent Recurring expenditure 9 43 7 55.7 L7 7t4.O T 33 576.7 2L 856.2 ? 53 189.1 23 739.O 1 32 949.1 20 329.2 t 27 LL8.7 t9 492.O Total t84 589.2 103 r30.4 Total.(thousands of CFA francs) 220 895.7 55 432.8 76 928.1 53 278.3 40 610.7 287 7L9.6 a JPC7. 6(C) Page 24 Annex 3 5. Streng thening of farnily planning activities Present assessment/estimates The populatlon of Niger is growing at a very rapid raEe (doubling r:oughly every 25 years) wlth all the known repercussions. A national seminar on farnily health and development (1985) recommended the adoption of populatlon pollcy and the setting up of a National Family Health Commission to put forward i"rffy planning strategies to Ehe Governoent. The National Family Health Centre (opened in November 1984) is already drafting legislation and Preparing draft recommendations for a national population policy. Ihe programme for the strengthening of farnily planning activities and the spacing of births will endeavour to suPport all actlvities for the adoptlon of a population policy, and Ehe activities of the National Family Healttt Centre' including staf f training. ESTIMATED NEEDS Total a Year Investment Recurring expenditure q L82 875.6 1 359.8 1. 128 283.8 1 359.8 Z L28 283.8 1 359.8 I 4t L52.O 1 359.8 t 41. L52.0 13598 521 747.2 6 799.O Total(thousands of CFA francs) L84 235.4 Lzg 643.6 L29 643.6 42 5L1.8 42 511.8 528 546.2 6. StrengEhen ing the act ivities of the Welfare and MCH Directorate Present situat ion/estimates In Niger, seven women in a thousand die in childbirth and one out of every two children dies below the age of five years. The Government has made considerable efforts to improve the situation by strengthening the system of health faciliCies and above all the MCH centres and materniEy units. The Welfare and MCH Directorate is also instituting travelling clinics(142 villages covered) and domiciliary visits. It is endeavouring to improve the health coverage for pregnant woEen and the provision of healthy baby clinic facilities. Ihe programme to strengthen the activittes of the Welfare Directorate will support the stepping up of itinerant activities, the integraEion of preventive and curative measures, the a.vliopn"ni of welfare activities in social centres and in the home, and staff supervision. ESIIMATED NEEDS Year Inves tment Rec urr ing expenditure q 39 69s.7 17 358.4 T 56 L07.4 21 023.6 Z 24 tLO.3 24 306.9 L 31 170.8 26 445.O I 8 368.6 26 '445.9 Total L59 452.2 115 578.8 Total(thousands of CFA francs) 57 054.1 77 t3t.O 48 4L7.2 57 6L5.8 34 813.0 275 03L.O at JPC7. 6( C) Page 25 Annex 3 7. Staff training Present situatlon/estimaEes The training of health personnel has been, and remains cne of the priorities of the l'linistry of Publlc Health and Welfare. Even so, the number of persons trained remains inadequate. Furthermore, refresher training has not been developed to the required leve1 and the coverage of the various categories of staff is unequal. It is planned to improve the situation by the following measures; intensification of basic trainlng at all 1eve1s; the trainlng of lnstructors; the further traiolng and refresher training of health personnelr' the planning and programming of staff speciallzation. The staff training programme aims to gear the training provided to the various health developnent programmes; to strengthen t.he documentation and teaching aids by relating thero to the programmes adopted; to retrain various categories of staff; and to inltiate a staff speclalization programme. ESTIMATED NEEDS Year Inves tment Recurring expenditure q L 243 L24.9 2 981.1 T 61 580.1 2 98L.r Z 62 388.7 2 98L.L !. 50 788.6 2. 981. 1 t 44 485.4 2 98L.t TotaI t 462 368.7 14 905.5 Total L 246 106.0 (thousands of CFA francs) 64 567.2 6s 369.8 53 769.7 47 467.5 t 477 274.0 8. Health education programne Present situation/estimates There is a health education office in the Directorate of Training, Health Education and Nutrltional Education of the Ministry of Rrblic Health and Welfare, but the resources allocated to it are scarcely sufficient for the proper conduct of its planned activitles. The health education progranme envisages Ehe est.ablishment of a national programme in this area; the reorganization and strengthenlng of the healttr education office; the training of key workers at all levels; and strengthened collaboration with the Ministry of Communicatlons and Culture. ESTI},IATED }IEEDS Year Investment Recurring expendi ture I t7 5 97 2.6 7 777.t t 54 6l-6.7 7 777.1 L 45 908.7 7 777.7 l. 53 905.5 7 777.L !_ 42 247.7 7 777.L Total 372 657.2 38 885.5 Total (thousands of CFA francs) L83 7 49.7 62 393.0 54 685.8 6L 682.6 50 024.8 4L7 536.7 aJPC7.6(C) pare 26 Annex 3 9. 0ral health activiEies A national seminar in December 1984 defined t.he target population and the elements of the programme as follows: - Oral health education. - Prevention of oral disease. - Symptomatic treatment of the xlost frequently occurring conditions. - Promotion of a good diet and a safe waEer supply. The cost of activitles under the programme has still not been estimaEed.