Sustainable Community-Directed Treatment with Ivermectin (CDTI) in Enugu, Anambra and Ebonyi States

,,I .f*--,h-- t i n_^, (,., I GRAMMtr (' {t- .tr AFRICAN PRO rOR ONCHOCtrRCIASIS CONTROL (APoc) Proposal for: Sustainable C ommunity-Directed Treatment with Ivermectin (C'DTI) IN: ENUGU, ANAMBRA & trBONyI STATtrS JanuaYyr lggS 3 0 lRf. 1998 ,t ILetter of endorsement from the Government of NIGERIA To the African Programme for onchocerciasis control (Apoc) for support of the proposed onchocerciasis control project In accordance with the memorandum of agreement for the African programme for Onchocerciasis Control : The Ministry of Heatth on behalf of the Government of NIGERIA hereby endorses the attached project proposal to be submitted to ApOC for finapcial support. This proposal reflects the collaboration between the members of the onchocerciasis Task Force and Apoc with a view to conducting an onchocerciasis control project in Enugu State. The National Onchocerciasis Task Force is a parfrrership of the Governmen! Non-Governmental Development Organisations and othtr participating panies which will be responsible for the implementation of this project. The Government shall assure free enfiy of ivennectin into the county fordelivery to the applicant without impoiing duty, tan, or other costs. The Government of MGERIA pledges its full collaboration with the ApOC in the expectation of acceptance of tlr. pr"rent proposal. REAR ADMIRAL JUBRILA AYINLA Name and title of signatory Hon. Minister of Health NIGERI,A DArE: tl f,-r fl 2. J 4 5 j date I Signature, L FR Ir'0ii-FEB-li8 14:46 14lI\j. 0F HEI]LTH OFF ICE. ZS4 g 52B4ES6 P. 02 I 2 J 4. Letter of endorsement from the Governnrcnt of MGERIA To the Afrieen Progremme for Onchocrcreiesis Control (APOC) for support of thc proposcd onchoccrcl*is control project In acc.ordance with the memorandunr of agree,ment for the African Plogramrne for Onchocerciasis Contol: The Ministry of Health on behalf of flreCrovernment of MGERIA hercby endorses the attached project proposal to be submitted to Apoc for financiar support This proposal rcflects the collaboration between the members of the Onchocerciasis Task Force and APOC wift a view to conducfing an Onchoceroiasis control project in Ebonyi & Ananbra States. The National Onchocerciasis Task Foroe is apartnership of th,e Crovernment, Non-Governmental Development Organisations and other partisheting parties which will be responsiblefordre i*plemcntationofthis p.j*r. r e The Gorcrnment shall sssure'Aee entry of ivrcrmectin into the conafiy for deliveryto the alplicant without imposing dury, tax, or o,thrrcosts. 5. The Government of MGERIA pledges its frrfl eoilaboration wirh.the APOC in the expectation of acce,ptaacsof the proposal,.present .4..*.,: \ and Date ftBuf+ REAR ADMIRAL JUBRTLA AY'IIILA Naus andtitle of sig4atory Hon. Minister of Health NIGBRIA "*f+ frfi 32 RE: National onchocerciasis Task Force (NorF) of Nigeria Application for Support to the African Programme for Onchocerciasis Control (APOC) ln accordarrce with the memorandum of agreement for the Afrlcan Programme for Onctrocerciasis Control: 1. The NOTF on behalf of the Govemment of NQeria, (a partnershlp of gwemment, the NGDOS and other partners) hereby expresses lts wish to enter lnto collaboratbn wlth the APOC and the MEC with a view of corrcluding an ochocerciasis controlprolect ln Nlgerh. 2. Ochocerciasis in Nigerh is conskJered by the health arihortties as a problem of sufficient importarrce to warrant the implementation of a control project in the endermlc areas with the aim of elimlnating the disease as a public health aM sockreconomh problem throughout the country. 3. !t ig estimated that ourt of a total populatinn of 10O millbn people, there are 4O million people at risk of infectbn of the parasite, octrccerca volvulns, which may result in btindness, serirus vlsul impairmeril or debilitating skin disease. 4. The Proposed controlproject will rely on cummunrty-based invermectin treatment as its main interventbn tool. 5. The NOTF has scrutinized the criteria and conditions for applicatbn to the APOC and ls satisJied that the proposed profects meets all criteria and fulfils the conditbns establlshed by the APOC. 6. Details of the projec't proposal for control of ochocerclasis in NQeria lrrluding th€ srlpport requested from APOC to surccessfully implement the prolect are provided ln the errcbsed proposai. 7. The NOTF of NQerin pledges its full collaboratbn wlth APOC In the expectatbn of acceptarrcc of the present proposal. t\ Representative of - Dr. J.Y. Jiya NOCP Coordinator/na> Date: i.(f I tm NOTF Representative of NGDOe Dr. E.S. llirl NGDO Co1!!!@Chairman Ve5 Date ADB APOC CBD CBIT CDD CDTI CHAN DHC FMOH GIS GLRA GRBP IDP tLo KAP LCI LCIF LGA LOGTs MEC MIS MOU NGDO NOCP NOTF PHC PHGDA PPFN RAS RBF REMO ACRONYMS African Development Bank African Program for Onchocerciasis Control Community Based Distributors Community Based lvermectin Treatment Community Directed Distributors Community Directed Treatment with lvermectin Christian Health Association of Nigeria District Health Committee Federal Ministry of Health Geographical lnformation System German Leprosy Relief Association Global 2000 River Blindness Programffhe Carter Center Ivermectin Distribution Programme lnternational Labour Organisation Knowledge, Aptitude and Practice Lions Clubs lnternational, District 404 Nigeria Lions Clubs lnternational Foundation Local Government Area Local (Government) Onchocerciasis Control Team Members Mectizan Expert Committee Management lnformation System Memorandum of Understanding Non-Governmental Development Organisation National Onchocerciasis Control Programme National Onchocerciasis Task Force Primary Health Care Primary Health Care Development Agency Planned Parenthood Federation of Nigeria Rapid Assessment River Blindness Foundation Rapid Epidemiological Mapping of Onchocerciasis SMOH SOCTs SPOs SVE UNFPA UNICEF USAID VBVs VHCs WHO State Ministry of Health State Onchocerciasis Control Team Members State Project Officers Sentinel Village Evaluation United Nations Fund for Population Activities United NationS Children's Fund United State Agency for lnternational Development Village Based-Health Volunteers Village Health Committees World Health Organisation zwF trlZ HC fr, E! 2 F{ -l- o c Bl s = oFC3(r, ev mv z.U, C, 7<x c 9 AG.l mzg v, zz& C0ltt 7 mzcC)c Ifi g &No E trC tp R Ex t, \ ri i ,.. ,. } ',\. l ) I I l, l, 1 J' t. l- -L I ,.i 1 !!' ,',-, a i- <rn PH E I 1) t;| =m N FNI.JCI.J STATE L7 LGAs IGBO-EZE T'DENU IsI-UZO IID[, i.IoErn EZDTGT' NKANU W. AWGTJ '.lr I iTTiT=i EAST trANrl nesr I s \ j \ I t. .:,, rT A1\,f\1VIDI(f\ DIAIts LGAs a ANAMBRA W. oYl AVKA N. AVKA S IDEMILI IHIALA EEtrE \/ 'I \ 6!1ilillllf!ttllnr pxoFE N. OGBARU +i a EBONYI STATE 13 LC.As ilil1 ISHELU Iillltlt I@ IZZIAI\I / zH o FJH,N H F rt o I o .- ) .u ?-- t- P I' I o -t H T o (D =o-o 6' A) -lo OJ6 a! =t60 (!D' -*+ go-G C0 o- 6'(Dr o()ol ')-AR P6 a tSECTION 1: COUNTRY PROFILE 1 INFORMATION ON THE P OJECT AREA FOR C.D.T.I 1.1 Geographical and administrative area(s) Please describe the area(s) of the country in which the proposed CDTI will be carried out. (List the administrative units or parts thereof e.9., Local Government Areas, Districts, Arrondissements, Health areas, etc., that will be covered and provide a map showing their layout). The proposed CDTI is to be carried out in 43 Local Government areas of Enugu, Anambra & Ebonyi States of Nigeria. The three States are part of the six South- Eastern States being co-sponsored by GRBP/Lions Clubs lnternational Foundation, for lvermectin delivery. The literal meaning of the names of the three States are: a) Enugu - "Hill-top" - derived from its position among the Udi hills on an altitude of 228.90 metres above sea level; b) Anambra - associated with "Anambra River"; c) Ebonyi - associated with the great Ebonyi River which traverses the state. Enugu & Ebonyi States are bounded on the North by Kogi/Benue States, on the East and South by Cross-river and Abia/lmo states, while Anambra is bounded on the North and North-west by Kogi and'Delta states, and by lmo State on the south. The three states combined have a total of 51 LGAs under the project unit. They all belong to Zone A of Nigeria's 4-Primary Health Care (PHC) Zones - Zones A,B,C and D. Tables 1.1,1.2 and 1.3 show the population status of the three States. (Table 1.1: LGAs and Estimated Population 2 ENUGU STATE LGA Estimated Population Aninri 106,485 Awgu 1 69,1 83 Enugu East 210,132 Enugu North 178,559 Enugu South 162,675 Ezeagu 133,836 lgbo-Etiti 164,278 lgbo-Eze North 165,333 lgbo-Eze South 89,784 lsi-Uzo 116,355 Nkanu East 133,899 114,706Nkanu West Nsukka 261,622 Oji River 102,251 Udenu 117,978 udi 190,509 Uzo Uwani 104,586 Sub Total 2,522,171 3 t Table 1.2 ANAMBR,A STATE LGA Estimated Population Aguata 202,697 Anambra East 78,325 Anaocha 171,076 Awka North 164,299 Awka South 146,524 ldemili North 373,946 lhiala 267,674 Njikoka 137,231 Nnewi North 86,753 Nnewi South 247,958 Ogbaru 49,443 Onitsha North 54,215 Onitsha South 39,649 Orumba North 243,313 Orumba South 162,271 ovi 117,349 Anambra West 61,672 Ayamelum 121,587 Dunukofia 105,705 Ekwusigo 56,560 ldemili South 232,734 Sub Total 3,119,990 4 a Table 1 3 EBONYI STATE Name of LGA Estimated Population Abakaliki 41,261 Ebonyi 24,404 lzzi 1gg,0g4 Afikpo North 26,363 Afikpo South 16,356 lkwo 133,574 Ezza North 143,115 Ezza South 180,107 Ohaozara 8,060 Onicha 29,996 lvo 5,632 Ohaukwu 65,974 lshielu 69,346 Sub Total 932,172 5The three states have a combined estimated population of 6,564,223 persons and cover an area of about 36,703 square kilometres. Out of the 3,335 villages assessed for onchocerciasis endemicity, 3,051 are qualified for Community Directed Treatment with lvermectin (CDTI) spanning 43 LGAs. The CDTI will therefore be carried out in 43 endemic LGAs. (See map of the States' endemicity on next page). The seat of government in the three States are located in Enugu for Enugu State, Awka for Anambra State, and Abakaliki for Ebonyi State. The next level of governance is the Local Government Council, where the Chairmen holds forth as the chief executive. The LGAs are divided into communities which themselves are made up of a number of villages. The villages each have their own administrative set-up, the structure of which varies from area to area. Health Care System Administratively, Health Care delivery stands tall on the priority list in Enugu, Anambra and Ebonyi States, and onchocerciasis is one of the diseases prevalent in these areas. (See Map of endemicity status). 1.2 Topography, climate, access 1 2 1 Please describe the type of country or bio-climatic zones that will be covered by the CDTI (e.9., rain-forest, forest-savannah mosaic, Guinea savannah, Sudan savannah, mountainous or flat), providing maps, if appropriate. Physical Features: Enugu, Anambra and Ebonyi states can generally be classified as tropical rain-forest areas, but they have other distinct geographical characteristics briefly summed up in the following: Enuqu State The bio-climatic zone is rain forest in nature, with annual rainfall between 152cm and 203 cm. The climate is moderate and the temperature ranges from 72.4'F (22.2"C) to 87.5"F (30.6"C), lt is the humidity rather than the temperature that causes discomfort to newcomers, and is between 78o/o and 95%. lt is generally cool during the rainy season, while the mean temperature in the hottest periods of February and April is about 87"F. The topography has two marked zones: hilly or mountainous and flat zones. The hilly zone stretches through Awgu, Udi, Ezeagu, Oji river, Uzo Uwani and part of lgbo-Etiti LGAs. The hilly nature gives rise to rapids and water-falls that exist ln most rivers especially Oji, Ogurugu, Anambra, Ajali and Duu . Anambra Anambra State is located between 5o.43' and 6o.48' N. The state derives its name from the placid Anambra River which is a tributary o'f the River Niger. The land has an undulating configuration. lt generally slopes from the north to the south and from east to west into the River Ntger which ls the major drainage channel The highest level is about 400 metres above sea level. The state falls within the south equatorial rain forest region which passes through the tropical forest and great oil palm belt of Nigeria, then thins out into the savannah area with clumps of trees. The rainfall is relatively high at J 6 L about 2,050 mm average. The highly fertile areas of Oji and the Manu rivers are also established breeding sites for Simulium damnosum. Ebonvi The topography of this area consist of undulating elevations of approximately 500 metres above sea level in the south and extends to the rugged terrain of'the central and northern parts, characterised with a uniform landscape of intermittent escarpments. The Cross-nver basin terrain is table land which favours most agricultural activities. The vegetation arrangement consists of the mangrove forest sparsely distributed along the Cross-river basin boundary of the state, with mainly the evergreen type of trees sparsely mtxed with the deciduous type. There is an average rainfall of between '150cm to 24Ocm per annum and average temperature of between TO 4'F to 86.1" F. 1.2.2 Give the approximate times of the rainy and dry seasons and the months covered by the farming season. The two different seasons in the CDTI project area are rainy and dry seasons. The rainy season is between May and October, while the dry season spans November through April. Farming activities take place throughout the year, but can be categorised as follows:- a b c Bush clearing Cultivation/planting Harvesting January to March April to July August to December 1.2.3 Provide information on the state of the roads and the effect of this on the movements of CDTI personnel in the area at different times of the year (A map may be useful) The three states are generally affected by gully erosion which, in many instances, separate communities and villages and thereby render the roads virtually impassable. ln the rainy season, apart from the few tarred-service roads, the untarred earth roads are muddy, slippery and full of pot-holes, while the roads are very dusty in the dry- season. Since over B0% of the villages exist in remote areas which have difficult terrain, this situation will have negative impact on the collection and retirement of drugs, except enough and rugged transport facilities are provided to overcome thrs problem, like 4-wheel drive vehicles, motorcycles and bicycles With these difficulties in mtnd, tt is crucial, therefore, that Mectizan distribution is planned for, and carried out during the dry-season of between November and April. ln the case of some villages sttuated tn the rrverine area of Anambra State, arrangement for ferry-boats or pontoons have to be made to ferry CDTI personnel rn and out of the villages. (See map of road network in the three States). 7 ) 1.3 Onchocerciasisendemicitylevels The levels of onchocercrasis endemicity in communities in the CDTI area must be assessed by simple methods before treatment sfarfs. For the purposes of this proposal, the level of endemicity in a community or a group of similar communities is defined on the basis of the prevalence of nodule carriers .(See table 2) Classification criteria for endemici levels in rural communities Table 2 ENDEMICITY LEVEL and recommended type of treatment Percent of nodule carriers in REA sample (minimum sample 50 adult men) Estimated prevalence of O. Volvulus in the whole community HYPER-ENDEMIC Community Treatment (URGENT) greater than 39% greater than 59% MESO-ENDEMIC Community Treatment (DESTRABLE) 20 - 39o/o 40 - 59o/o HYPO-ENDEMtC (NON- URGENT) less than 20% less than 40% Name of State Total No. Of LGAs No. Of LGAs Assessed No. Hyper/Meso endemic: LGAs Villages Enugu 17 17 17 1,331 Anambra 21 21 16 1 ,168 Ebonyi 13 13 10 552 Total 51 51 43 3,051 81.3.1 Based on the sysfem in Table 2 and using the format in Appendix 1, piease indicate the estimated numbers df communities at each tevet aind the numbers of persons in them. COMMUNITY ENDEMICITY LEVEL HYPER-ENDEMIC MESO.ENDEMIC HYPO- ENDENiIC Type of Treatment Community-based Community- Based Year 1: 1998 No. Of communities to be treated 2,OO1 1 t 050 Total population in above communities 925,752 792,531 1.3.2 Complete Appendix 1 for each area covering the next 5 years of the project See Appendix 1 completed. 1.3.3 lf methods of assesslng endemicity threshotds other than nodule prevalence were used when your endemicity data were collecled, please indicate the method used. The other methods used when endemicity data were coilected are:(a) Leopard skrn prevalence based on REMo and RAS standard format(b) Microfrlaria denstty prevalence based on 19Bg NOCP epidemrological prevalence survey and 1995 GRBP Sentinel Village Evaluation on skrn- snipping 1.3.4 For areas still to be covered, where endemicity levels are not yet known, please describe the methods you will use to collect fhe necessary endemicity data. The determination of endemicity levels have been completed in all selected villages in the proposed project area, using 1gg4 REMO and l ggs RAS methods. There is no intention to conduct any other survey in the remaining villages 1.4 Community structure Provide background information on the social organisations of communities in the C D.T l. areas. This may include information on: Setttement pattern of the community(e.9. hamlefs, seasonal farmsteads, dispersed populations, etc ) ln all the areas of the CDTI (Enugu/Anambra/Ebonyi States), the settlement pattern of the community is the cluster pattern with hamlets and seasonal farmsteads The Community is the next adminrstrative unrt to the Local Government Councils. The major ethnic group in the project area is 'lGBo,' a tribe with homogeneous cultural and lingurstic origin. 98% of the population practice Christianity as their major religion, while 2o/o belong to other religious sects. aa a a I The population is settled and indigenous, and the leadership structure is hierarchical. The communities are headed by a traditional leader or ruler (IGWE), assisted by a Council of Elders (lgwe's Cabinet). The community leader does not exercise absolute powers. He consults with his council members on matters of decisions. Each community has a number of villages attached to it with a Village head responsible to the traditional ruler. Farming, fishing, hunting, petty trading, palm-wine tapping, basket weaving, poultry and animal-rearing are the major occupation of the rural-communities in the project area. They also give prominence to festivals - like new yam festival, Easter, Christmas, etc. The ethnic group(s) in the community The project area is homogenous as they speak "IGBO' language, with a common custom and cultural lineage. Please provide information about the areas covered by CDTI indicating whether they are migrants, nomads, refugees or internally displaced populations. The area is characterised by predominantly nucleated, permanently-settled communities. Com mu nity leadership structure The leadership structure in all the communities is hierarchical, with the traditional ruler/leader at the head, assisted by the Council of Elders made up of Ndi-lchies, Nze and Ozors. At the community level, there are the Community Development Unions/Associations, established by the traditional ruler in Council to facilitate development activities. This is followed by the Village head and the village committee(s) for Works, Finance, Health, land, culture, women affairs, etc. There are also the Kindred/Family heads and, finally at the grassroots are the heads of individual households and their family members. On another angle is the leadership of the female group - called the Umuada. Usually, this is a strong female group led by an old woman (probably the oldest) which also influences a lot of activities within the community. (See diagram of Community leadership structure). A/lain occupation of community and periods of major communal activities Major occupations of the community inhabrtants are: Farming, fishing, palm-wine tapping, hunting and animal husbandry. Numerous men and women are also engaged in craft practice, marketing and petty trades. The major communal activities take place all year round. These range from communal bush-clearing from January to March, and cultivation, planting of crops and harvesting between April and December. The new yam festival and Masquerade dance is commonly fixed for between September and December along with the Christmas festival. a10 a Preferred channels of communication in the community The channels of communication preferred in the affected communities vary widely, and include: Meetings and discussion fora summoned by Community or Village leaders at village town-halls, churches, schools, market place's, as well as the popular'Town-crier'who is a well-known and unanimously chosen person in the community. a Existing active community associations/groups in the area (e.9. social, religious, etc.) The existing and active community associations/groups include social clubs, age grades, town development associations, women associations, youth associations, religious groups (Christian and others), farmers' associations, family & kindred meetings and associations. Established distribution sysfems in the communitya a a There are different existing distribution systems at the community level, and this varies between communities. However, it follows the hierarchical pattern of community leadership from the community leader (lgwe) to the village heads, down to the hamlets, the families, households and individuals. This method is applicable both in the distribution of food commodities, farm fertiliser, as well as for collection of levies. Social communal activities and months during which activities take place Every community has particular cultural festivals which are traditional in nature and relative to it, depending on its significance. There are however, social activities which are common to the entire lgbo ethnic group, like lchu Afo in March (first lgbo calendar month) - marking the beginning of bush clearing for planting; the Easter (April); New Yam festival - to mark the beginning of new yam harvesting season (August to October). Yam is regarded as the king of all crops and is held sacred in lgbo-land. The Offala festival (September- December), - for re-establishing the loyalty and support of the villagers to the Community head (lgwe); lndependence & Republic Day celebrations (October 1st); Christmas (December 25th); Masquerade festival (any time). Also tn the project area, the Muslim festivals are observed by the lslamic adherents, but uncelebrated by others. Any previous experience of the community with developmenUhealth projects Most communities have been involved in developmenUhealth projects, sponsored by either Government or by the communities themselves through levy. Examples include road construction projects, constructton of town halls, rural electrification projects, water supply and sanitation projects, construction of Health and maternity centres, Church buildrng and town halls, etc. Some of the projects are sponsored by either the government or international organisations and non-governmental organisations. 11 Description of other anthropological characfensfics of communities The people of the lgbo-speaking areas have strong democratic traditions in terms of leadership. Titled positions for both men and women, are given to those who have demonstrated achievements (material and othenr,rtise) in the community. The lgbos believe in hard work and self help, provided they can see their identifiable fruits. Wealthy lgbo men often practise polygamy, despite the influence of Christianity in the area. There is a strong attachment to one's village of origin, and most villages have some form of development association to which those from the area contribute financially and in other ways. Western education has been strongly embraced by the people of the region, and there is a high literacy rate for both males and females. ln recent years, however, most men have concentrated more on trade and other economic pursuits, and in many places, more girls attend school than boys. 2. PAST AND CURRENT STATUS OF CDTI IN PROJECT AREA 2 1 Please indicate if the CDTI is an expansion of an existing CDTI Yes and No. At rts inception by River Blindness Foundation in 1995 in joint partnership with Lions Clubs lnternational Foundation (LCIF), the programme was set-up as a project-driven programme for Enugu/Anambra states. ln 1995, a total of 253,2OO persons were treated from 12 Local Government Areas. ln 1996, 641,764 persons were treated in 23 Local Governments. Community Based Distributors (CBDs) were the major vehicle through which the distribution were carried out in the local communities/villages. However, after the GRBP (Global 2000 River Blindness Program) had come into existence in May 1996, the Federal Government of Nigeria created one new State by the excision of parts of Enugu and Abia States to form a new'Ebonyi State', with 13 LGAs, under the project unit. Further delineation and boundary adjustments of the old Enugu and Anambra States increased their LGAs to 17 and 21, respectively. The three states now have a combined total of 51 LGAs, while 1,625,006 persons have been treated so far in 1997. This proposal is an "expansion" and consolidation of the existrng arrangement, because, effort is already on the ground towards transforming the project to "client-driven" programme for rncreased community-participation. The communities are being mobilised and encouraged to demonstrate Acceptance, lnvolvement and Ownership of the programme by the creation of Village Health Committees (VHCs) which will take on responsibility for managing the programme at Community level. See appendices on sample of devolution reporting forms already in use and on Devolution Timeline. Similar effort is being made to elicit more involvement from the Local Government Area authorities as well as the State Government in the programme. Therefore: (i) CDTI strategy will be initiated and evaluated as a means to promote sustained treatment but with I a 2.2 decreasing costs, (ii) the expansion of this initiative will be explored to include other services Sfafe the number of years the programme has been operating, and if possib/e enclose previous sfafisfrca/, financial and annual reports. , The former Enugu/Anambra States' ivermectin distribution programme (now Enugu/ Anambra/ Ebonyi States) has been in operation for 3 years. ln 1995 & 1996, the programme was carried out by the Ministry of Health in partnership with the River Blindness Foundation (RBF) & Lions Clubs lnternational Foundation (LCIF). ln May 1996 when the GRBP was established, RBF's misston was subsumed in The Carter Center's Global 2000 program without alteration to the mode of operation. The accomplishments of RBF/GRBP are as shown rn Figure 1 (bar chart) and the adjoining table(s) Table 3 - Treat t and Trainino Summarv m 1995 - 1997 Year No. Of persons treated No. Of persons trained Number of villages treated 1 995 253,206 1,584 1,243 1 996 6.41,764 2,72 1 2,019 1997 1,625,006 2,484 2 549 2.3 sfafe the number of persons treated each year for the last s years The Table below shows treatment activities over the last 3 years in Enugu/Anambra/Ebonyi States' project, where 2,519,976 treatnnents have been administered. Table 4 - Distribution Summary for 1995 - 1997s Year Number of villages treated No. Of persons treated 1 995 1,243 2s3 , 206 1 996 2,O19 641,764 1997 2,549 1,625,006 Total 5,811 2,519,976 NUMBER (tN 0'000) _\ -@ oo -I -o oo --l -s oo _\ N)oo ..-\ -o oo @ C)o o)oo soo N)oo N(, _(,No o) o 1,584@(o(, , .T F i {7 rn +=6s =fi B=orU{{oi -.D(.C'=aa -l 2o @C = =v I -o, N _(Jloo O) o) .r J\ O)s 2,721 z o o f 0) ! oa @ o :la ;(oXI (oY*o) o o- 6 =:, oc @(Df o-a (o(o{ 1,243 2,O19 2,484 2,549 mEt683 i3cil.e- l8; tr <z:o 0)(oo o- @ -{X 24 13 List the organisation(s) involved in the programme, the sources and amount of funds used each year for the last 5 years. The River Blindness Foundation (RBF) initiated the project in joint partnership with Lions Clubs lnternational Foundation (LCIF) which provides funding. Table 5 - Source/Amount of F s Expended from 1995-1997 S/No Year State Govt. LGAs FMOH RBF/LCIF 1 1995 10,438 2,625 Not known 100,095 2 1 996 10,656 5 250 131,954 3 1997 11,996 7 650 104,488 Total 33,090 15,525 Not known 336,537 Note: Federal Government contribution is not known Exchange rate is 80 Naira to US $1 00 '14 SECTION 2: PROJECT EXECUTION OUTLINE 3 DESCRIPTION OF PROPOSED COMMUNITY-BASED IVERMECTIN TREATMENT (CDTI) The main strategy of the project will be to develop and establish community-based ivermectin treatment sysfems which can be sustained by the endemic communities themselves without external support after the S-year project period. Ihis secfion should describe how the NOTF plans to develop and implement CDTI in all high-risk communities in the project area. The plan should take into account the need to develop approaches to CDTI which are appropriate for the different local situations, and the need to carefully evaluate the implementation of the selected approaches and adiust them when required. 3 1 Outline plan and Timing. (Note: For detailed timeline of activities, see below. Many of the activities will be carried out simultaneously). Table 6 Activity/J ustification Length of Time Advocacy visifs to project Sfates Due to high turn-over of State and LGA chief executives, advocacy visits shall receive the priority attention of the project. This is necessary tn order to educate and mobilise the new policy makers after assumption of office, to support the devolution strategy. 4 weeks Procurement of essentra/ project equipment and supplies. All the existing project equrpment, particularly vehicles and computers would have become obsolete by 1998 when APOC funding will commence. B weeks ldentification of endemic communities through Rapid Assessment Surveys. Rapid Assessment surveys and cross-validation have been completed in all endemic communities in the proposed project area Refinery of RAS will be needed 4 weeks Mobilisation of Sfafes and Local government and communities. Followrng the enthusiasm demonstrated by States and Local government officials in the proposed project area, it is important to continue to maintain the mobilisation levels previously attained at both State and Local government levels. ln the same vein, mechanisms for sustenance of community interest are being put in place through the concept of community acceptance, involvement and ownership. 52 weeks Conduct of l(AP sfudies. No KAP survey has been conducted in the proposed project area. However, evaluation of the project was carried out in February 1997 by a senior consultant of the World Health Organisation (WHO). There is plan to conduct a KAP survey in the nearest future. 14 weeks M I S (M a nageme n t I nfo rm ati o n system) Monthly reports of treatments and training will be continued. Feedback must be sent to the funding agency to ensure the adherence to corrective measures recommended. 52 weeks 2 weeks Review/Annual ReporUNext year's Action Plan. GRBP holds quarterly program review meetings which rotates among the three project zonal offices in Enugu, Owerri, Benin City as well as in Jos - GRBP headquarters in Nigeria. The organisation also holds annual program review sessions in Atlanta, USA. 4 weeks 15 Sentinel Village Evaluation (SVE) At the beginning of the programme in the three states, 24 communities were selected for SVE. The prolect wrll continue wrth the evaluation and complete a careful analysis of available sentinel data with respect to the impact of treatment on CMFL (community microfilarial and eliminate infections in n children 3.2 Health Education and Community Interaction and Participation 3.2.1 How will you approach and interact with the community. For any approach and interaction with the community to be meaningful, it has to be through their leadership, but via the local government council. Advocacy visits will be made to the LGA by the State Onchocerciasis control team and the LGA chief executive will be requested to invite all the community leaders to a meeting on a scheduled date and at a centrally convenient place, with adequate notice. At the meeting, the community leaders will be asked to mobilrse their subjects for another meeting between them and the State, the LGA Oncho team, Village Health Committee and the CDDs. lssues under discussion at such meetings include: Orientation of CDTI and stress on community ownership of the programme and modalities for implementrng this, Health education messages and sensitisatron of community leaders on necessity for ivermectin treatment, a a '16 a Methods to be put in place to ensure proper distribution of lvermectin in the community. Appropriate and effective interaction will be established with the community using all available methods, both formal and informal. Mobilisation and health education messages will be conveyed by use of a variety of culturally-relevant media. These may include posters and handbills, video films, discussion groups, music and dance, radio jingles. Others are drama and story-telling sessions. It is proposed that VHCs (Village Health Committees) shall be established as a matter of course in all endemic villages where these do not already exist, and would be the main vehicle of communication, planning and implementation of CDTI 322 Health Education Health educatton and community mobilisation wilt be an integrat part of ail approaches to CDTI. Health education activities should ensure a two way feedback with regards to knowledge, awareness, perception and observable attitudinat changes about onchocerciasis and its treatment. Appropriate health education messages in the form of posfers, pamphlets and verbal presentations witl need to be developed and tested. Health education should address the following issues. Tabte 7 addresses criticalrssues in the development of Health Education for CDT\. Health education and community mobilisation are the bedrock of any disease control. These will form part of key activities in the present APOC CDTI plan. Through the health education, knowledge, awareness, perception and observable attitude about onchocerciasis and its treatment regimen will be created. Health education messages should be carried out in village meetings, schools, churches, radio and television and also through the community criers for effective impact. ln the present APOC arrangement, there is need to develop health education messages using pamphlets in local dialects, film/video/slide shows, posters/flip-charts/flannel boards and also demonstration objects such as blackfly samples. Health education should address the following issues. Table 7 Knowledge of treatment tt o Previous experiences with Diethylcarbamazine (DEC). * lt is called Banocide. * lt was the drug of choice for treating onchocerciasis before the advent of Mectizan. * Disadvantages are: " Many tablets have to be taken. A total of 150 tablets over 50 times a year for 2-3 years " It is expensive " Treatment may worsen damage to eyes. * Entire treatment course may not be completed. " Treatment is on individual basis. An individual can easily forget to repeat treatment every 2 to 3 years as required. . lntroduce Mectizan (ivermectin) * Drug of choice for treatment of onchocerciasis * Does not hurt the eyes " Does not have severe reactions " First used in Nigeria in 1989 . Dosage - adminrstered by height or weight Body weight (kg) Height (cm) Dose 15-25 90-119 1 26-40 120-140 2 45 -64 141 - 158 3 65 - 84 >158 4 . Exclusions * Pregnant and lactating mothers whose baby is not up to 3 weeks " Persons less than 5 years of age, 15kg (weight) or 90cm (height) * Very sick, including asthmatic, epileptic, cardiac, hypertensive and psychiatric patients. . Reactions - Has mild side effects such as * ltching, rash, headache, fever, nausea/vomitrng, diarrhoea, swelling of eyes, dizziness, insomnia. This is called the Mazzotti Reaction. Reassure the person that I ISSUES Health Education Messages Knowledge of the disease . Local name of the disease: * Oya lshi Ocha (lgbo name) , . Symptoms are. * Rash; itching; nodule; leopard skin; lizard skin; visual impairment and blindness. Hanging groin. . Causation/transmission (basic concepts) arasitic worm called Onchocerca volvulus. * Transmitted by the bite of female blackfly that breeds in fast flowing waters (rivers and streams) " Affects both male and female of all ages persons living mostly in rural and semi-rural areas " caused by p Affect '18 Reaction. * lndividuals with high level of parasite will equally have severe Mazzotti Reaction s * Mazzotti Reactions are usuaily ress severe during the second dosing and subsequent treatment. . Beneficial side effects: * Anti-helminths (intestinal) * Kills lice. Treatment for scabies * lncrease energy. . Advantages of treatment: * lt is free and only delivery costs may be involved where this cannot be avoided. * lt is easily administered. Treatment is free of charge. * Yearly treatment - it is a single treatment taken only on.e or twice a year for 10 - 1 5 years. " Can be administered by CBD . Possibility of self{reatment at community level. . lmportance of maximal coverage. these side effects are n " Any individual withou ormal and will soon go away. t parasite will have no Mazzotii Attitude to treatment rug regimen even after visible reduction of signs and symptoms of the disease Attitude towards adverse reactions associated with treatment Recognition of name of medicine, and persons who should not be treated Treatment of side effects with ORT, phernegan, pCM & chlorine, chloroquine. a a a o a Compliance to d Attitude to disease The drug will prevent the disease Onchocerciasis blindness and ski be prevented. Reduce the potentials for further spread and infection. when all in the village take the drug, children will not get infected. a a a a if taken once a year. n depigmentation will Attitude to good record keeping Ensure that your name is recorded Records are confidential and stricfly for health use Records required are for subsequent drug supply. a o o a Sustainabilty efforts State government involvement Local government support Community ownership, decision-making power, responsibilities and support for CDD lncentives for CDD. a a a a a t 19 They recognise the manifestation of the dlsease, and they see the nodules and leopard skin but they did not associate the disease with biting by black flies or an infectious agent such as helminthic parasite. They are totally ignorant of the causative agent of the disease. They associate LS with old age and nodules with groMh in the body. They also see it as the wrath of gods upon them or enchantment from an enemy. Their knowledge about the disease is poor. Their attitude towards the disease was lukewarm. They look at the individual manifestation as a disease entity, rather than the result of an underlying infectious process. They behave as if it does not concern the entire community, but between the individual and his god. Being ignorant of the disease causative agents and modern treatment for the disease, their treatment practices are always wrong and negative. They misdirect their treatment by consulting the oracles and appeasing their gods. (A) Have any KAP surveys been done in the project area and if so, what were the results? KAP surveys have not been carried out in the Project area, but a lot of awareness has been created within the few years of distribution. During the past years of distribution, a lot of questions have been asked informally'and many have replied that: l. ii. iii (A) (B) Those who were enlightened go for Banocide tablets. (c) Though they have no knowledge of the causative agent, they know that the pains associated with the nodules will go when the nodules are removed, so they go for nodulectomy. (b) What methods will be used to develop heatth education material for the communities and for the agents who will be responsibte for ivermectin treatment? Health education materials such as posters, handbills and flip-charts have been developed by the project and submitted to the sub-committee of NOTF for standardisation. Also, NOCP and Lions Clubs District 404 developed some Health Education materials which are currently in circulation, and specially designed to diffuse the already polarised local perceptions of the disease by the communities as well as encourage them to accept the new measures. These materials awaiting standardisation will be field{ested, refined and improved upon to reflect APOC accepted strategies before they are produced finally for use in the Communities and villages. The current materials in circulation are being criticised and communities are already providing inputs on the type and content of Health Education messages. '20 What methods will be used to provide health education to the endemic communities and to the agents responsible for treatment? Since the inception of the project in 1995, Health Education has received priority attention. Several Health Education methods have been used by both Oncho field team and the publicity Committee of the Lions Clubs lnternational. These include: focus on group discussion with health workers and communities; the use of posters, handbills, electronic media publicity provided by Lions Clubs lnternational; the use of town-crrers by the Community, video film shows and drama (role playing) in local languages. Face to face discussions and political lobbying of State and LGA functionaries will be the strategies to be put into use to ensure increased public awareness. Among the Health Education methods applied, the "modified Mara Film" appeared to be most successful initially. However, due to lack of electricity in B0% of the communities, this method can only be applied at LGA headquarters hence it is not very useful to the communities for which it was intended. Although Church & School announcements are very effective, the most useful method identified by the project is the use of posters and handbills, hence these items will be produced en-masse for distribution in all the project areas of the proposed CDTI. Production, review and dissemination of standardised and uniform high quality relevant health education materials, translated into local languages will aid in the mobilisation and education of target groups and individuals. The State and LGA Oncho control teams/units will have principal responsibility for education and will spend considerable time in travelling to field sites for intensive campaign. 3.2 3 Community participation ln Community-directed ivermectin delivery programme, the distribution of ivermectin is decided upon and carried out by members of the endemic communities themselves. Treatment is provided by trained personnel called Community-Directed Distributors (CDDs) who are fully supported by the community. The community is responsible for the organisation and implementation of the CDTI with minimal but effective supervision of qualified health-personnel. Various structures established at the Communityfuillage level like Village Health Committee, are important organs for strengthening and sustaining the CDTI programme (a) Explatn the organisation of the intended community- based ivermectin treatment in the project. The entire communities rn the proposed area have been identified and the CBDs already selected are to be integrated and reoriented to conform to the APOC- CDTI strategies. All endemic communities are to establish Village Health Committees (VHCs) to be chaired by a community leader. The VHC will be responsible for planning and decision-making regarding mobilisation and health (c) 21 education of community members, selection and remuneration of CDDs, collection and distribution of drugs and management of drug reactions. The Committee will also be responsible for storage of drugs and safe record keeping. The current supervrsory and monitoring roles by SOCTs and LOCTs will be devolved on VHC after working closely wrth the Committee for a determined length of time, but record-keeping and reporting will continue to be iointly done by CDDs, LOCTs and SOCTs. (b) How will ivermectin distributors be selected? Selection of ivermectin distributors is done by VHC or the traditional leader of the community, where there is no VHC. The criteria for the selection of the distributor are that the CDD should be literate (able to read and wrrte), resident in the community; willing to distribute the drug, be honest and acceptable to the community members. One CDD per village is ideal, but this can be increased to two for larger communities. (c) How will non eligible be identified and defautters be fottowed-up? Adequate mobilisation of communities, emphasising criteria for eligibility would discourage the ineligibles from presenting themselves for treatment. However, non-elrgibles are identified during: a) the household registration by CDDsb) distribution; by askrng questions about age, lactation, as well as abor.rt sickness due to asthma and eprlepsy Defaulters are identified and encouraged during distribution by CDDs to take the drug, and by LOCTs/SOCTs during supervision and screening of individual household cards. CDDs, VHC members, LOCTs and SOC-I-s would foilow-rrp such defaulters through intensification of health education anrl repeat mobilisation. '22 3.3 Local Operational Research Are there any plans to conduct local operational research? yes ttl No t l lf yes please give details. Enugu, Anambra and Ebonyi IDP has been programme-designed and directed.A new approach to ivermectin distribution has been adopted by the African Programme for Onchocerciasis Control (APOC), based on a strategy that stresses greater community stewardship of the local programme through devolution of most decision making functions to the community level. The theoiyis that this will empower communities, decentralise costs, and so promote sustainability. Recipients of APOC funding will need to adjust certain aspects of their programmes, and Enugu, Anambra, Ebonyi programme is no exception. lnthis case, the major areas affected include the need for community-based training (as opposed to training in the local government area), revised timetable and scheduling of treatment activities, community autonomy in the selection of CDDs, and relative community autonomy in the management of information, collection of Mectizan@ from central sites, reporting of drug utilisation, and provrsion of monetary or in-kind support. The challenge now for the Enugu, Anambra and Ebonyi is to transform this successful programme-designed and directed effort rnto the APOC community- dtrected treatment with rvermectrn (CDTI) scheme. As noted above, the structure until now has been largely programme-driven, wrth the Enugu, Anambra and Ebonyi management taking on the role of coordinator of activities, in consultation with the LOCTs, SOCTs, and the communities. Now the communities themselves must be empowered to assume a leadership position However, we anticipate certain problems likely to arise unless mechanisms areput in place to ensure some coordination, particularly within and between the communities themselves. We envision the need for a period of transition during which a combined decision-making mechanism and 'sustainability surveillance, will need to be established in order to win agreement with the communities about issues relating to CDD literacy, data collection, specified times for collection of the drug, distribution and submission of forms. ln particular, scheduling of the timetable of activities has to be generally agreed on and adhered to in order to facilitate the prompt distribution and efficient application for the next year,s allocation. Without careful management and coordination during the transitionperiod, the Mectizan@ for future treatment may not be procured in time (a process independent of any community-directed process), which could also have serious implications for the sustainability of the programme. Also required is intensified health education and mobilisation in the communities, so that the communities understand the nature of ttlectizan@ procurement activities managed outside of the communities. All of these are important issues of operattonal research which will be addressed through TQtVI directed operations research in the course of the project. 23 The operational research being proposed here is tiiled: "THE LEVEL oF PERCEPTION/COMPLIANCE/ACCEPTABILITY OF COMMUNIry-DIRECTED TREATMENT WITH IVERMECTIN". Statement of problem Since the inception of ivermectin treatment in the project area, no 5perational research has been conducted to determine the level of perception, compliance and acceptability of this treatment. Many misconceptions have been detected concerning the drug, including the notion that it is used for population control. These beliefs and misconceptions may have an adverse affect on the acceptability of the CDTI, and pose a threat to the implementation and sustarnability of the programme. Major objective The major objective of this proposed research is to determine the factors that will influence effective community participation and ownership for sustainability of CDTI in the project area Significance of the study To speed up community ownership to ensure active participation and involvement for the sustainability of the CDTI programme. Study Area Twelve communities will be selected from the project area. The choice of the study areas will depend on accessibrlrty and level of coverage. Methodology i. Method of Data Collection Data will be collected using closed and open ended questionnaires an4 in-depth interviews. ii Method of Data Treatm ent and Analvsis Data Clerk will code and feed the responses from the questionnaires irrto the computer. The analysis of the results will be carried out using Epi lnfo software. Research Team The research team will be made up of the Project Administrator, State Project Officer and SOCTs who are already experienced in ivermectin treatment, together with consultants from the National Office of GRBp. Estimated Bud et for the Studv PerDiem: For the Research Team Travel: For fuel and vehicle marntenance- Communication. For DHL postage, Fax and Telephone: For Stationery and computer consumable $2,250 00 $1,546 00 $ 750 00 $ s50 00 SuPPlres Total $5J96-00 ,24 3.4 Training Training and reiraining of community-based distributors to operate the CDTI is a vital firsf sfep in organising the programme and remains a continuing commitment thereafter We believe that the new challenges put foruvard by APOC, while welcomed in their focus on sustainability, have important implications for the management. The reorrentation of CBDs to CDDs will require innovative training that builds on what has been learned, while allowing flexibility to the communtties now being given increased responsibility. Managers must now pass proved designs on to the communities for inevitable changes, with the hope that the result wlll provide for the data needs and expectations of the new and old donors These new challenges require middle-level managers and implementors with effective, efficient, indeed state of the art management skills. lt also demands a transition period during which the training approaches used to effect the transition from CBIT to CDTI are frequently and critically evaluated' ln light of this, Training/Retraining of community based distributors (CBDs) to CDDs to operate the CDTI is a vital first step in organising the programme and remains a continuing commitment thereafter. (a) What training witl be provided to ensure the development and sustarnment of the CDTI? The trainrng needs assessment previously done rn the 3 states clearly show that the project needs to train and retrain CDDs at rntervals to maintain, uphold and improve standards. The measure of achieving an organisational goal is directly proportional to the quality of its staff (personnel). Such quality can only be assured if the staff are trained and retrained to update their knowledge, thereby motivating them. lt enhances their techntcal as well as managerial skills for programme effectiveness and geographical coverage. During the previous two y"air, training of field officers, the SOCTs, LOCTs and CBDs focused primarily on the importance of innovative training in the following areas: - EpidemiologY of onchocerciasis - Health Education - lVlobilisation (CommunitY) - Mectizan drstributton - Record keePing and rePorttng - Monrtoring and suPervlslon However, in view of the APOC strategy, the retraining of field officers (LOCTS and SOCTs) is very vital in the CDTI programme development. Emphasis will be on: Mobi lisation/health education Community acceptance of the programme Active tnvolvement of community and full partictpation Community ownership of the programme 25 - Community annual action plan - Monitorrng the sustainability of the programme - lntegration of CDTI into PHC system During the training needs assessment, evidence was adduced that field officers have the necessary technical skills but are deficient in vital manageffient skills. Hence they will need to be trained and retrained at the Sustainable Management Training Centre in Jos, in collaboration with NOCP, UNICEF and other NGDOs in Nigeria The following areas are to be covered: 1 Management concePts 2 Management principles and values 3 Advocacy 4 ' Need for continuous work improvement (Total Quality Management). 5 Programmeplanning,implementationandsustainability. (B) lndrcate criteria for selecting trainees (supervisors and community-based distnbutors) r) Criteria for selecting CDDs: - Must be unanimously done by the villagers - CDD must be resident in the community - Willrng to accept responsibility - Must be literate - Must be available to serve the community, especially during drstributron periods - Must be honest and loyal - Must not be a patent medic'ne dealer - Must accept to be accountable for any Mectizan@ allocated to him/her Crrteria for selecting supervisors (SOCTs & LOCTs) - Must be a staff of PHC/Disease Control department of MOH - [/ust be selected by the State MOH or LGA - Must be knowledgeable - [Vlust be interested and available to serve - Must be freld-oriented - N4ust be ready and wilting to learn "SOCTs and LOCTs are based at the State MOH and LGA, respectively TABLE 8 umber of Health Workers Trained in Anambra/E 19971996Category 1 995 1010 15SOCTs 12010s 1 4 1LOCTs 2,4841,467 2,559CBDs '26 (c) lndicate number, type and duration of training courses intended. Table 9: TYPES OF TRAINING AND DURATION OF COURSES No. Of Training Sessions per Year Type of Training Content Duration 3 for each State Training/Retrai ning/Reorientat ion (includes field practicum) of SOCTs and LOCTs (A) Technical . Epidemiology of Onchocerciasis o Communitymobilisation . Health education . MectizanDistribution . Record Keeping and Reporting o Monitoring, Supervision and Evaluation 3 days 3 for each State (same as above) (B) Manaqement o Program Planning and lmplementation o lnterpersonal Relationship (behavioural analysis, principles of communication, principle-centred leadership) o Advocacy o Need for continuous improvement - Total Quality Management (TQM) o Sustainability . Reorientation to CDTI 3 days 'l for each Endemic Community, LGA Training/Retrai ning/Reorientat ion of CDDstuillage Health Committee (VHC) leaders (Need basic knowledge and skills only) Same as'A Technical' above 2 days 27 1. The technical and management training should be run separately.2' The training need assessment survey conducted in March 1995 showedthat the majority of LOCTs, SoCTs and State Co-ordinators have the necessary technical skills, but are deficient in certain management skills AS: Team building Adequate leadership style Proper planning Monitoring and evaluation. These training will be provided by the Sustainable Management Training Centre, Jos,and careful records wiil be maintained on retraining and iresh training. 4. SUPPLY, IMPORTATION, STORAGE, INVENTORY AND DELIVERY OFMECTIZAN TABLETS rhis secfro n concerns fhe supp ty and delivery of ivermectin tablets, donated by Merck &Co' who will also pay handting charges for ivermectin to their accredited agents. 4.1 Supply and storage what provisions witt be made to ensure safe and proper storage in sufficient numbers, of ivermectin tabtets in the country, in time for the annual rounds oftreatment? Mectizan supplies are ordered in good time to ensure their arrival when required,supported by proper storage and accountability at all levels of Mectizan flow. Thiscould be a problem now with CDTI if communities select treatment times which are nottimes when supply of Mectizan@ is readily available. 5. SU PERVISION/MONITORING AN D EVALUATION 5.1 Supervision during CDTI Proiects require to be superuised and monitored. However, ApOC funded projects will ryed to be designed to function with effective but minimum supervision compatible withits objectives. (A) Please describe the supervisory arrangements you consider wilt be required for the CDTI you propose. How witt thii continue at the cessation ofAPOC support? The present supervisory structure in the project involves the State projectOfficers, the State Onchocerciasis Controi teams, (SOCTs) and the Local Note: a) b) c) d) t t 2B Government Onchocerciasis Control teams (LOCTs) who are primary HealthCare staff. Presently, functional village Health Committees (VHCs) already existin most communities, while more will be instituted in those comniunities wherethey don't exist. This structure will reinforce the current arrangement describedabove, and will gradually be empowered to take over ,"no continue thissupervisory role at the community level at the cessation of APOC support. Asub-committee to be headed by the Community and Village leaders as heads willbe constituted from members of the VHC to be solely r6sponsible for ensrringthat the drugs are given to the community as recommended by Apoc. Although the VHC will be made to assume greater responsibilities in thedistribution process, training, monitoring adverse reactions and data collation which are critical elements of the CDTI will continue to be the responsibility ofthe local government and community functionaries, who would, themselves, bythe end of APOC support, have gained enough technical, managerial knowledge and skills necessary for continuation of the programme. (b Describe how you wourd ensure that supervision wiil: ';!,i{'ii:!:{i#",#z',ff!in'irti:i!!ff!,#,,i;,,hepr.cess 1' The present GRBP supervisory standard for accounting for lvermectin use entails periodic checks on households registers anJ distribution cardsand face-to-face discussions with the clients (or consumers), in the communtty. This is to ensure that drugs recorded as taken agree with evidence obtained during visits and inteiview of household members. Thisprocess will be entrenched into the new Apoc guidelines. 2' Letter of Authorization of CDDs to collect drugs from the approved collection point must be signed by the Village Head as accepting the responsibility for accounting for the drugs so collected. 3' No CBD receives new consignment of drugs without accounting for earlier ones received. 4' For supervision, the structure described in 5.1(a) would have gained adequate knowredge for independent supervision. 5' The Communities would also be rnvolved in the initial planning andimplementation stages to enhance full community participation andintegration into the PHC system. Consequently, the existing supervisory arrangement in practice will be maintained, improved on, and sustained after ApOC's operation period. 5.2 Monitoring of CDTI It is important to collect information to monitor theprogress of the cDTl. what indicators will be used to monitor; f, Il I 29 ive r m ecti n d i stri b utio n ? health education and communtty participation? management systems? The following items may be considered lvermecti n Distrib ution numbers of communities and persons treated with ivermectin treatment coverage compliance regularity of treatment exercise reporting adverse reactron HeallhEducatLqj and Comm u nitv hlobilisation numbers of communities being mobilised by the project evidence of rmpact of health education Ir/lanaqement are activities being carried out according to plan and on schedule? inventory control are record forms accurate and completed in time? number of persons trained balance of genders in staff of the programme lvermecti n distri bution Standard MIS forms (Management lnformation System) forms from NOCP are already in use Returns of such documents to the project office enables the monitoring of communities and persons treated with lvermectin, the treatment round, coverage, complrance and drug reactions. The project also monitors rates and percentages of treatment on the following indicators: Annual Treatment Objectives (ATO) High risk villages At risk villages Estimated at risk population ,1 r' a a Treatment coverage (related to ATO) High risk villages At risk villages Estimated at risk villages . Cost per person treated . Number of tablets distrrbuted . Number of ivermectin tablets in store rn the office and on the field , 30 Health Edu ation and Communitv ilisation Part of the tools currently in use to monitor the number of mobilised communities include Quarterly Reports and Review Meetings as well as evaluation and supervrsory team visits by both GRBP and LCIF officials. The result of the proposed KAP study would be quite useful in this direction. Manaqement A standard monitoring system has been developed to monitor: a) Activities planned and implemented on scheduleb) Compliance with inventory control system c) Accurate completion and timely submission of recordsd) Number of persons trained e) Attempts to balance gender in staffing 0 Percentage cost covered by National sources (State and Government)g) Work-related problems solved by staff. Local ln addition, GRBP has developed indices of sustainability which will also be used to monitor this issue. These include: Community involvement: Measured by the number and percent of treated villages in which the community is involved in the design and implementation of the treatment programme and the selection of the CDDs. f-. o a a Government involvement: Measured by the number and percent of treated villages in which the CDD is a part of, or is supervised by, the pHC system. Also, by whether government at various levels have line items for onchocerciasis control, and whether these funds are actually released. Cost per treatment: Three different indices are utilised here: 1. Actual cosfs of treatment: Calculation includes all costs including proportion of HQ costs, overheads and salaries, local GRBp costs, overheads and salaries; delivery of drug from port of entry to the community, includrng cost of collection by cDD; training; MoH/pHC supervision and monitoring of the programme; and remuneration and incentives paid to CDDs by the community. 2. cosf provided by national government: Government cost' per treatment, and the percentage government is paying of actual costs. 3. cosf provided by APoc.' Amount Apoc provides for cost per treatment, and percentage APOC is paying. )3'r 5.3 Evaluation of CDTI Annual external review incorporating field visits will be undertaken to ensure that projects are meeting target indications outlined in this proposal. Such reviews will provide TCC wrth the assurance that each project is moving towards its tong term stated goal and if appropriate make recommendations about any deficiencies or modifications fo this project. Such reviews will draw on the indicators devetoped by TCC as a guide(see Appendix 3) for such evaluation. Noted SUSTAINABILITY OF THE CDTI AFTER THE WITHDR,AWAL OF EXTERNAL FUNDING The concept of sustainability refers to the ability of countries and affected communities following initial external investment to maintain the viabitity and continuity of the ivermectin treatment process without external support. For APOC donors demand that there shall be advisable and achievable end point for the external donation aspect of the programme, and that the community based distribution sysfems esfab/ished shall thereafter be susfarnable by the governments of the endemic countries concerned. Progress and plans towards sustainment, including the phasing out of external and A/GDO's suppori, must be reported annually and satisfactory progress in this direction will be a condition for each succeeding year's funding instalment. Please address the following areas that relate fo sustarnability: "integration into primary health care", and " oth e r su sta i n m enf issues". ln Anambra, Enugu and Ebonyi States, the monitoring of the sustainability of the programme is effected by following up indicators and recording findings: Community involvement: The percentage of all the endemic villages treated in which the community is actively involved by: a) acceptance and ownership of the programme;b) selecting their own CDDs; c) designing and implementing their own work-plan;d) directing all phases of ivermectin distribution at the local level; e) payingCDDs'transportationandcompensation. Government lnvolvement: The percentage of all villages treated in which the CDD is either part of or is supervised by the PHC system. Costs: The following will be considered in relation to cost per person treated with Mectizan: a) training of personnel (field); b) delivery of Mectizan from the port of entry to a central point for collection by CDDs; c) supervision and monitoring of the programme; b a '32 d) remuneration/incentives paid to cDDs by the community. The percentage share of these costs provided by the Federal Government (vs. external NGDos, APoc, etc.)will be calculated and reported. 6.1 lntegration of the CDTI into other Community-based or Primary Heatth Care(PHC) System The principal goal of the APOCis fo esfab/ish cosf-effective ivermectin-based control for onchocerciasis which can be sustained by the endemic communities and countries. One way to ensure sustainment is to integrate the cDTt into the cpHC sysfem of the country, which means more than iust using the system for ivermectin distribution. 6 1.1 ls there an official pHC poricy and structure in the country?Yes[/] No[ ] lf yes, please give a brief ouiline of what it is. Primary Health Care (PHC) policy in Nigeria is to develop and strengthen community (grassroots) active participation in health care, in accordance with the WHO PHC policy guideline. The National Primary Health Care Development Agency (PHCDA) develops national policy and supervises the state pHC headed by a Director. Each LGA has a PHC department that mobilises andtrains the community health workers for any pHC programme. pHC is community-based and the structure is as follows:- FMOH (PHCDA) I Zonal (PHCDA) I State (PHC) I LGA (PHC) Communities (VHC - J,,rn" Heatth Committee) (a) How functional is the primary heatth care system? - Fully functional ll ) - yes. lt is fully functional - Partly functional [ ] (p/ease specify) - Non functional [ ] (p/ease specify) .t (b) Does it cover the whole project area? yes y/ I No t l lf no, in what part(s) of the country is there a fulty functional PHC structure? (c) What percentage of communities where onchocerciasis r's endemic, and which are eligible for community-based treatment, have an existing and functional structure? 1OO%. All the communities where onchocerciasis is endemic have existing pHC system. (d) What organisations are supporting the development of PHC in your project area? GRBP, WHO, UNICEF, UNFPA, CHAN, ILO, LCIF, GLRA. @ ls there any past experience in the country of a programme integrating with thePHC? lf so, what programme was it and how successfu/ was the integration? Yes, EPI (Expanded Programme on lmmunisation) was integrated into pHC in1985- Before then, the coverage was 1 5-25% but coverage rose above B0% after 4 years of integration. Unfortunately, this peak was not sustained after withdrawal by UNICEF in 1991. The level of achievement remained below 25% until UNICEF returned to support the programme in 1gg4. The following aspects of programme activity which were not effectively transferred to the state and local governmenUcommunity levels could be said to have been responsible for the decline in the programme. - Advocacy/mobilisation - Training - Financial commitment in terms of:(a) Remuneration of field officers(b) Field perdiem to fietd officers at the state & LGA levels(c) Mobilisation cost(d) lmmunisation cost(e) Training cost(f) Supervision cost (F) The lack of commitment by policy makers also contributed to the decline. Are there any plans to integrate other rural heatth programmes, such as fhe Expanded Programme of lmmunisation, l/laternal anA Ciin Heatth programmes or programmes for the control of other parasitic diseases, with the PHC system? Other rural health programmes that have already been integrated 100% into PHC are: - Health education - Food and nutrition - Maternal and child health including family planning 34 Expanded Programme on lmmunisation Control of local endemic disease Water and sanitation Treatment of common ailments and injuries Provision of essential drugs Mental health Dental health The project plans to integrate lymphatic filariasis, schistosomiasis and guinea- worm programme with PHC, while integration of onchocerciasis to PHC is well under way. (g) Describe how the CDT\ witt be integrated into the PHC system, the way the pHC sysfem will be used to achieve integration and the key persons in the pHi system who will be needed to achieve the integration. CDTI is already partially integrated into the PHC system because it isCommunity-directed. Action plans for treatment are Orawn up by the VHC andthe previously trained CBDs. The CDDs in the villages also help in mobilisation of the villagers for treatment. cDTl will also use the ;xisting pHC health facilities as referral centres for side reactions. The following key persons will be utilised to achieve the integration:- PHC - PHC Co-ordinator or Supervisor of Health to assist LOCTs at LGA level(already functional). LOCTs - to train, mobilise, supervise and monitor the communities and CDDs(already functional) SOCTs - to train, mobilise and supervise LOCTs as well as state advocacy(already functional.) h) lndicate how early in the CDTI the process of integration witt be introduced; howit will continue thereafter, and after how many years within the exteinaly- supported lifetime of the CDTI it wiil be compteted. From the inception of our programme, LOCTs and SOCTs (who are primary health care staff) have been involved in the planning and implementation of lDp activities Therefore, integratigl with PHC system already exists to a large extent. However, under the APOC-CDTI strategy, it is expected that tne pfiCpersonnel will progressively advance towards empowering the VHCs and the communities together to continue to formulate strategies ior CDTI. As pointed out before, VHC members will be functional and availaote to oversee the CDTI intheir community. APOC's S-year funding period will be used to ensure that theintegration of CDTI process is consolidated and PHC's involvement sustained. 6'1'2 lf thereis af present no PHC system in operation or in those areas where fhese structures are non-functional, describe how the CDT: may be used to initiate and expand into such a system, given a time-frame for intended progress. 2E All the 495 Communittes in the 51 LGAs of the three states have operational PHC syr51sms, although some of them are weak and need to be strengthened and expanded. This will be achieved through giving further training to CDDs tobe involved in CDTI to enable them carry on other health activities such as essential drug revolving scheme (Bamako lnitiative) nutrition, education, anddistribution of Vitamin A supplement. During the stabilisation phase of ApOC strategy, the CDDs will expand their health activities in the communities whilethe VHCs will need more time to establish themselves before taking on otherhealth activities. This of course will last between 3-5 years. 6'1.3 ln which ways can community-directed ivermectin treatment initiate or strengthen PHC? The CDTI strategy, if properly established and continuously supported, is likelyto encourage and facilitate the acceptance of new health initiatives in the communities and the roles of these community directed programmes will be ableto be expanded. Moreover, since the structures are already-in place, they will be utiltsed by the PHC to enhance effective planning and implementation oi project activities. The establishment of VHCs will ensure-ownership and sustainability ofthe programme as they will assume the responsibility for advising the communities on general health issues. 6'2 Cost-recovery Systems during Community-based lvermectin Treatment Cost recovery for Primary Heatth Care is mandatory in some countries and it may be one means of susfarning an CDT\ after APOC funding ceases. However,p/ease note that since lvermectin is donated free, there can be no cost recoveryin respect of the value of the drug itself; cost recovery can only retate to the cosfs of distribution This is not Applicable 6'2 1 Please state whether there witl be any system of cost recovery (such as is recommended in the Bamako lnitiative) to help cover outlays on the distribution of ivermectin in the present CDTI. Not Applicable 6'2'2 Sfafe exactly how any such sysfe m witt be organised, including answers to thequesfions listed below. o What charge will be made per person or per family? Not Applicable . Which groups of persons will be exempted from payment? Not Applicable Jb a a a will payments be in cash or in kind? tf in kind how wiil this ensure sustainability? Not Applicable what provision will be made to ensure that all those eligibte to take ivermJctin, butwho are unable to pay, wilt also receive treatment? How wilt it be determined who isunable to pay? Not Applicable who will collect the payments? How wilt this person safely transport funds to aplace of safe keeping? Not Applicable Where and by whom wilt any funds cottected be safety kept? Not Applicabte what systems wilr be put in prace to ensure the proper use and management ofcollected funds? Not Applrcable For what purpose(s), including defrayment of distribufibn cosfs, witt the funds collected be used? Not Applicabte. 6.3 Other lssues a a a Please provide information on otherissues and constraints retating to sustainabitity ofcDTl you anticipate and identify how they wiil be overcome. For example: c the mobilisation of endemic communities ' the maintenance of adequate supervision and monitoring . inadeQuate human resources . logistics and communications o social/cultural factors . declinrng community comptiance (1) ilisat of c m ES Mobilisation actrvities have been recognised - Wrong commun 9o{d be hampered by some perceptions and beliefs thatin Enugu/ Anambra/ Ebonyi States. For example: ity approach Poor mobrlisation strategy Beliefs Non-utilisation of existing pHC structure 64 38 How do you intend to monitor and measure the progress towards sustainability (See Appendix 3 for a list of possib/e indicators of sustainability)? The following indicators will be used to monitor and measure the progress towards sustainability of CDTI. (Please see Section 5.2 for additional'discussion on sustainability monitoring to be implemented). Ma ent Already, the project has in place a management system that monitors the following: o Activities planned and implemented on schedule o Drug inventory control . Accurate completion and time submission of MIS forms . Numbers of personnel trained o Attempt to balance gender in staffing . Work-related problems solved by health-workers . Percentage cost covered by National sources (State/LGA) . Financial management, assessment of records of accounts, appropriate and timely retirement of cash advances o Meetings reporting deadlines . Number of health personnel trained and number of functional community structures. . Commitment of partners; by level of support and timely release of funds and provision of equipment and supplies as agreed . The use of operation research findings in reprogramming. Proiect Effectiveness Annual Treatment objective - High risk villages - At risk villages - Estimated at risk population a t o Treatment coverage - High risk villages - At risk villages - Estimated at risk villages . Cost per person treated o Tablets distributed . Number of ivermectin tablets in store . Number of KAP studies conducted o Number of successfully managed cases of adverse reactions . Comparison of number of persons treated, with number of [Vlectizan tablets used, and o Skilful management of adverse side reactions. Sustainabi I itv/l nteqration . ldentification of functional PHC systems . Determining Government percentage contribution ,37 These constraints can be overcome by an integrated mobilisation strategy. A realistic and successful approach to endemic communities can be achieved if community leaders/heads are used as initial entry point into various villages. ln addition, primitive beliefs can be overcome by identifying such beliefs in KAP studies. A strategy of effective education and mobilisation which accept and respect the norms and belrefs not harmful to the people's health will be adopted, while attempting to change those beliefs that are harmful. (21 Loqistics and Communications It is anticipated that endemic communities will plan their Mectizan distribution activities to fall during such periods that the communities are accessible to the project staff and other supervisors, and when the CDDs will be able to collect the drug from the collection point. Therefore, planning will focus on providing all high risk villages (prevalence of 60% or greater) with their drugs during the dry season, and encouraging completion of distribution before the rains. For the few areas that will have to be treated during the rainy season, the use of four-wheel drive vehicles stands as the only option. ln addition, the use of boats and canoes is highly advocated for communities situated within the riverine areas of Ogbaru and Anambra LGAs of Anambra State. (3) Social/Cultural factors Cultural, social and religious sensitivities will be duly observed and respected (4) Declininq Communitv ance/participation ln a situation of declining community compliance which is anticipated, a l(AP study would be conducted to identify the hindrances or the socio-cultural factors responsible, particularly after the "post honey-moon period" when the leopard skin and hanging groins are gone, but treatment not fully completed. The results will be used to develop mobilisation and information messages tailored to that individual community's "KAP diagnosis". This will reduce attrition to Mectizan@ usage and improve community participation. (5) lnadequate Human resources The project has sufficient human resources. Therefore no problem is envisaged in this drrection. (6) lnadequate Fundi q bv Government The commitment of the Federal Government to the control of onchocerciasis is crucial to the success and sustainability of the programme. All efforts will be explored to ensure that the State and Local Governments make substantial contributions to the overall onchocerciasis control efforts. This can be achieved by establishing a budget line item, and monitoring the amount released for onchocerciasis control by the two tiers of government. 39 . Number of other health programmes being carried out by the CDDs along with the onchocerciasis programme o Numbers of functional Village Health Committees (measured in terms of numbers of meeting held and contributions for CDDs) . lmproved compliance . Number of men and women involved in the programme and their literacy levels. The Management lnformation System (MlS) forms developed by NOCP in collaboration with the NGDO Coalition, will continue to be used in the proposed project area, to assess treatment coverage and other important monitoring indicators. . CDDs and VHCs will follow-up defaulters with a view to increasing treatment coverage . KAP studies will be conducted when required and the results used for programme planning . Timely release and judicious use of funds to the project . Uninterrupted use of programme vehicles o Mobilisation and retraining of community members . lnvolvement of community at every stage of the programme, from planning to implementation, and measured by community financial support to the project . Strengthening of existing institutions at the community levels to continue with the programme . Full integration of the programme into pHC . CDDs also involved in other pHC activities . Local and State Governments' political will as shown in policy and financial and personnel commitment. . Timely and adequate supply of Mectizan@ to the community. 7. Cross-borderConsiderations Where an endemic area extends across the borders of two or more adjacent Sfafes, special problems of co-operation between the respective country CDT1 may arise. 7.1 ln the event that there are areas to be covered by your proposed CDT: where the endemic zone extends across the frontier into one or more neighbouring countries, and where there are likely to be transitory or even large-scale migrations of Onchocerca-infected persons either way across fhe border. P/ease describe the particular situation as ff is likely to affect ivermectin treatment, and the methods you willuse fo deat with it. Not Applicable lnclude pertinent observations on current politicat and health relations with the neighbouring Sfafe(s) Not Applicable 7.2 8'40 Special Risk lssues ln some areas of some countries, there may be special risks which could hinder the smooth running of a CDTI. Please describe the situation in any areas covered by your proposed CDTlwhere this factor may interfere with the programme, and asses s future prospdcts. The political/security situation in all the States covered by this proposal is stable hence not likely to interfere with the programme. 81 41 SECTION 3: ADM I N ISTRATION/FI NAN CIAL 9. ADMINISTRATION 9.1.1 Please provide an organogram for the CDTI showing the organisational structure responsible for implementing the proposal. NOCP Steering Commiftee NOCP Non-Government ization Coalition Group/Nigeria NProcurement of MectizanPolicy formulation Formulation of National Plan of Action Monitoring, Supervision & Evaluation Collection of Drug from Lagos; Training of SOCTs; Operation Research; Supervision of SOCTs and LOCTs Monitoring & Evaluation na Onchocerc ntrol Team (State Coordinator, SOCT, Dir. pHC, pHC Coordinator) Collection of Mectizan from Zone Training of LOCTs Supervision of LOCTs Monitoring & Evaluation of lvermectin distribution Advocacy & Mobilization of policy makers, NGDOs & private sector nc c (Locr leader, Locr, PHC coord., Health Supervisor, District supervisor) Collection of Mectizan from State Advocacy & Mobilization of LGA policy makers Training of CDDs Mobilization of Endemic Communities Monitoring & Evaluation of ivermectin distribution nc Controe ce Community-based Self-treatment (c o m m u n it v L e a d e (sL vi ffl il';,"ff: : ,o.T#,.t;ff ,_toT,l5'' r' m e m b e rs, c D D s) lvermectin distribution Supervision of Community distribution activities Management of adverse reaction & referral Funds for transport of CDDs to collect drug lncentive for CDDs (See organogram next page) +mzC oC zl ={TD P,v= \,2 UPO-r =xro{z ilo u2 1' .s n o(- rno{ 'Tl z z o m o 'rI 'Tt o m7 a EIov m v E {F CTl- mfrx TnrflOzoc nG)>C =FEEg =Hfi=iuTIz,> s?mfot2d<T n la,:r 6) rn :' lT :m :<' :,JTI l- 'o r! o u)' i ,; i tr:,. t :: :' i i. .t r. !-:-:1-:' :. !::. : ,l :i ,, tii i.'tl Hm r}{ N z^ T!o .:. rj', < o o = =Cz z< m9z_i(- r-o6 s-+4nfrn =r[II a fls m3IDcoz 1-t<{ s?f, ifim'CDt 'ciE-nzo = oC 1- U' .,,,\r ,a,,,, , . ,.!::, :t oC 0a rn ,If" O.r m T oc U' rfll or [](/) xF& oC $J rn -orU U' ''| ,,',| 42 9.2 Financial Administration Mechanism of disbursements and transfer of funds from the World Bank to countries. Funds from the World Bank APOC Trust Fund will be channelled through WHO and APOC to the Proiect bank account. Disbursements of funds will require / signatures from members of the NOTF, one representing the fi/linistry of Health (Government) and one representing the NGDO partners. APOC will issue cheques (advances) in accordance with WHO rules and the previously agreed project documents and/or plans of operations. When the total payment in cash required for the project exceeds $100,000, the payment must be made in instalments. The first instalmenUadvance could cover 3 months or 6 months of activity depending on the duration and magnitude of the project. Management of funds by projects and WHO/APOC mechanism for monitoring The size of the project will determine which of WHO's contractual sysfems is used, e.g. Technical Service Agreement, Letter of Agreement, Contractual Service Agreement or Agreement for the Performance of work. A document on Administrative and Financial Procedure will be made available to projects being funded by APOC. Built into this document is an imprest mechanism, whereby the project will report its expenditure on a quarterly basis and receive further advances on that basis. Each proiect funded by APOC will require a periodic external audit at project expense Each project must have one senior staff member who is accountable for the management and control of project funds. Standard internal financial checks and balances must be incorporated into each project's financial management plan. 9.2.1. lnput from the Ministry of Health a) lndicate resources that will be provided by the Ministry of Health and other government agencies. . Personnel, Logistics, Office accommodation o Counterpart funding . Security. b) Please provide a list of personnelassigned by the MOH to this project, including their name and proposed time (Sfafe percentage of time allocated to the project) for the proiect and where appropriate, their experience in onchocercrasis control through ivermectin treatment. 43 ( Table 10(A) Enuou State lVlinrstrv of Health Personnel Table 10(B) Enuqu State LGAs Onch o Personnel D S/No Name Rank % Time Experience 1 Dr. L.U.M. Onoh DDC 20% B years 2 ET Alo SPO 1O0o/o 7 ( 3 L N Nweke SOCT 100o/o 7 ( 4 P A Udeh SOCT 100o/o 7 ( 5 R.N Arum (Mrs.) SOCT 100o/o 7 6 J.N. Ezika SOCT 100o/o 7 ( 7 M.C Nebo SOCT 100o/o 7 8 Ogwu R Driver 100% 5 It o Onu A. Driver 10Oo/o 5 t{ 10 Enekwe F Driver 100o/o 7 ( 11 Ezechukwu L Data Clerk 100o/o 7 ( 12 Egbu Simon Housekeeper 100% 7 13 lbezimakor E Messenger 100% 7 S/No Designation Number % Time Experience 1 PHC Coordinator 17 20o/o 2 years 2 Asst. Coordinator 17 25% 2 3 LOCTs 51 B0o/o 2 4 Supervisor for Health 17 1SYo 1 year il 44 Table 1 1(A) Anambra State Mint of Healthst Table 11(B) Anambra State LGAs Oncho Personnel nnel \ a S/No Name Rank % Time Experience 1 Dr. E. Chiegboka Ag. DPHC/DC 1B% 7 years 2 B.U. Ezumezu SPO lOOo/o 7 3 U L Efobi SOCT 10Oo/o 7 il 4 G U. Udorji SOCT 1O0o/o 5 5 T.U. Onyeagolu SOCT lOOo/o 5 ( 6 H.C. Ogboji SOCT lOOo/o 6 l( 7 M.C. Agu SOCT lOOo/o 7 B E.O. Obumneme Data Clerk lOOo/o 5 ( 9 E.A. Akudike Finance lOOo/o 4 g 10 D.O. Okafor Driver lOOo/o 5 il 11 A.O. lfediora Driver IOOYo 4 ( 12 A.A Udora Driver 1OO%o 4 tl 13 V.C. Akudike Messenger 1O0o/o 4 ( 14 E N. Ojukwu Housekeeper 1O0o/o 4 S/No Designation Number % Time Experience 1 PHC Coordinator 21 20% 3 years 2 Asst. Coordinator 21 25o/o 3 ( 3 LOCTs 63 80% 3 u 4 Supervisor for Health 21 21o/o 3 l( ( 45 Table 12(A) Ebonvi State Ministrv of HeaIth Personnel Table 12(B) Ebonvi State LGAs' Oncho Personnel: S/No Designation Number % Time Experience 1 PHC Coordinator I 20% 3 years 2 Asst. Coordinator o 25o/o 3 tt 3 LOCTs 27 80o/o 3 ( 4 District Supervisor 9 1SYo 3 ta NOTE: ln Enugu, Anambra & Ebonyi States project, the SOCTs are on full time assignment supervising IDP activities. They are also involved in Sentinel Village Evaluation (SVE) survey. S/No Name Rank % Time Experience 1 Dr. Enyang Oko DPHS 20o/o 8 years 2 Orogwu Stephen SPO lOOo/o 6 ( 3. Azi Raphael SOCT 100o/o 5 ( 4. Nwanga Nnamdi SOCT 10Oo/o 5 5 Nwachukwu Rosaline SOCT 10Oo/o 5 ta 6 Nwakpu Faith Data Clerk 100% 4 7 Agwunnamchi John Driver 100Yo 4 lt B Ogodo Godwin Driver 100o/o 4 (I Ndubisi Ewogu Driver 100o/o 4 at 10 Elem Nwuzor '[\4essenger 100o/o 4 ( 11 Itumo Rose Housekeeper 100% 4 al 12 Theresa Ogbonye Finance Clerk 100o/o 4 ! '46 9.2.2. lnput from the partner NGDO(s). a) Please provide a letter from the Executive Director or the Director of onchocerciasis programmes of each participating NGDo stating their intentions toparticipate in and support the National Onchocercr'asis Control programme b) Give information of the input from each NGDO participating in this projSct Global 2000 RBP's input will be:- . Funds - see budget o Mectizanprocurement: Application/Approval process, consignment delivery expenses $410.00per trip (4 trips per treatment year) . Staff and consultants - See section C below . Office space and facilities . Logistics and equipment Table 13: E GL S AND MENT S/No Item Total Number NGDO MOH LGAs Functionality 1 Vehicle (new) 4 4 Functional 2 Vehicle (old) 3 3 ( 3 M cle new 10 10 4 La o co uter 1 1 5 r old 1 1 Faulty 6 Deskto com uter 2 2 Functional 7 Photoco ier 1 1 8 TVruCR 1 1 ltI Overhead projector 1 1 It 10 Slide project 1 1 ( 11 Generator 1 1 12 Colour monitor 2 2 lt 13 Wall clock 2 2 14 Filing cabinet 3 3 I 15 Binatone voltage regulator b b 16 Air-conditioner 7 7 17 Chairs 36 36 It 18 Tables 17 17 19 6 6 20 Refr 1 1 ( 21 Gas burner 1 1 22 Gubai Safe 1 1 ( 23 o mrcros 1 1 ( 24 Dissecti mrcrosco A 1 1 25 Analytical balance 1 1 lt 26 Fan b 6 il 47 c) Please provide a/so a nominal list grading and post description for the personnel to be provided by partner NGDO(s) lndicate clearly what witt be their functions in theprogramme and their experience in onchocerciasis control through ivermectin distnbution. Table 14: NGDO's NOMINAL LIST 27 Laboratory fixtures 1 1 28 Fax machine 1 1 la 29 Computer printers 2 2 il 30 lBlVl electric typewriter 1 1 It I S/No Name Positions Experience % Time 1 Dr. Don Hopkins Director Health Section 9 years 2.5o/o 2 Dr. Frank Richards Technical Director I It 5o/o 3 Mr. Rick Robinson Asst. Director Accounts/Admin 6 ( 5% 4 Dr Emmanuel S. Miri National Director 6 ( 30o/o 5 Dr. Kenneth N. Korve Asst. National Director 3 ( 15o/o 6 Mr. Kehinde O Oyenekan Admin. Manager 6 ( 20o/o 7 Mrs Feyi Fadipe Finance Director 6 ( 20o/o B Mrs. Chinyere U. Maduka Project Administrator 3 ! 100o/oI Dr Abel Eigege Trarning Specialist 1 10o/o 10 Ms. lfeoma Umolu Training Specialist )J il 10% 11 Mr. Joseph Gotau National Administrative Secretary 4 10% 12 Mr. Chuwang Gwomkudu Laboratory Scientist 5 20% 13 Mr. Yohanna S. Chuwang Laboratory Assistant 3 fl 20% 14 Mrs Henrieta U. Egbuna Project Accountant 3 ! 100% 15 Mr. Paul Ugbadamu Project Secretary 4 1O0o/o 16 Mrs. Monique Umeh Data Clerk 3 1O0o/o 17 Ms Rita Okafor Finance Clerk 3 100o/o 18. Mr. Leonard Ofole Security 3 ( 1O0o/o 19 I\tlr. Christopher lowe Security 3 ( 100o/o 20 Mr. Boniface Agwonye Security 3 1O0o/o 21 Mr Godwin Chidobe Security 3 ta 1O0o/o 22 Mr. Emmanuel Okonkwo Driver 3 1O0o/o 23 Mr Hyginus Chinze Driver 3 ( 100o/o 24 Mr. Linus Ogene Driver 3 1O0o/o 25 Mr Patrick Okeke Driver 3 ( 100% 26 Mr. Dennis Nwankwo Driver 3 1O0o/o 27 Mr. Anthony Uwaezuoke Driver 3 II 1O0o/o 28 Mr. John Driver 1 year lOOo/o 29 I\4rs Chari Okafor Housekeeper 3 years 1O0o/o 30 Mr. Johnson Usim Gardener 3 100% ( (( ( il 12 3 4B 9.2.3 Input from other agencies. Please list any other agencies or parties that will be involved in the running or financing of the CDTI, and indicate cleaily their roles, functions and contributions. LCIF: The Lions Clubs lnternational Foundation of Oakbrook, USAIs currenfly providing funds to the project, through its District 4O4 Chapter of Lions Clubs lnternational in Nigeria. UNICEF UNICEF Nigeria assists the project in procurement and clearance of Mectizan imported into the country by using its diplomatic status. AFRICARE: The supply of Mectizan for NGDOs is stored in the AFRICARE warehouse in Lagos. 9.3. Timed Plan of Action Provide a time chart(s) showing how the varioul activities of the CDTI wilt proceed over the course of the proposed programme. Numerical annual targets for att planned activities should be provided for each time point. The time charts should also indicate how external support will be phased out over the 5 year period. (Timeline - See next page) s (,J N(,l A u) N) O @ -l o'\ o-A @o r5 crcC,e v;l(< D)@orD :.i (Doq3 o Oa 'ooI o z o N A) o (, CD (D rn PJ o (..) CD (D A) o. aa @o n:l d:J =c. 5\< cD oa =o o CD o o- A) o- -lt A) oq ,N o A) oq o .) o Ed (D o- o o o ts CDo ? o E CDI H t o FJo CD cD o o o t- -CDo CD U t C' o E(D (D H X ro tl F) ao E a 3 CD .D rra t |.ootl DJ o- H o U)o o z A) o Oq o a p) rD o c) oo C0to PD (.) o o o AJ D) (D :+z (, .'! Noa od NU O.D @a) o A) ! Oa ot2f o 'd ,U oo o tso o (D (D D) 'o € CDo .D .o (D A (D o c0 0) a- CD o rD o A) o ,(J t CD o-o (D A !J o- oo z o ,J rrl -)(.) o- oo q o oo a o ..l T9 aJ A {p(D € N t"I ts rr} rs rs rs -i 19 (., 5 I\) <DQo |.) (^t E Nt? r? .iI 19 f.' A rnz{ -{ mm -zJr fig #D xf .s -{6 =nrfl>!-m z@mo o1 l{ >ao -.t -{> =#1AUc; ^o .r -{(o-(o o I Noo]J a a N)o \c) oo -l o\ E A) o o't (D x ; 5)o o @ F(D id I q o o (D o (D o. o A) (D o- !D N(D a. FU oc (D CD aI qJE5r-o' Lq(Dc0 xc) orr frlF< FO DJ(DE i=O E5 A' -z oarr, 'ooo oH z o 'Jrl o o g -J CD 3 =. o I €. C) o H o a- o o ou) @J I ard c)(D5.o<7( o:lh7: ot Oq o. (D o .l5 to t$ F }a tr t, +L NooN Nc'o o A 49 10. BUDGET 101 Budget Estimate Budgets must indicate total funds to undertake the project. The amount of funding requested from APOC, and the amount provided by the MOH, NGDO(s) and othir partners. All estimafes musf be made /n US doltars. Each budget must include at least the foltowing major categories (see appendix 2) indicating the contribution of the partners to reflect sustainability of CDTI o Personnel (services) . capital equipment . supplies o training o travel . communications . consultants . operating expenses o external audit. (See Budget attached) I o, J(rl JA JG) JN) Jo (o @ '-l O) (,' .E G) N) J ! o -@off a- v m fl + o oa -lao 0) 3 of !o aa 2TCI -{x -lao 0) 3 ol o n zU -lo -l r s =llC -{ { o{ r o f o a mx! ofa oa mx o 'al fD r - C o_ o olac q) l a o o 3 3 Cf o ID =.of -{ -o) o m o_c o 0) -.ol og N 0) =.o = -t.-r N. f.l(o U)co E- o'a o(D o 0) m _o E. ro 3 of tI,C o o m{ s)(o(o I _.1s(, I \ J -@N) @(, I\o o) {(rl N@o (O@ Io (rl(rl @ --l(l) (,5 O){ No(rl Noo No ! oo (o(o @ @ (., (D @ o 5 A N) o o N(Jl -l o z ooo @ o o o N N o 5 @ =o - (, (oN J(,l o o N o Jo o o I(Jl No ro 9(Jls I (,^) @ @ J \ O) _O)(o J o (o O)o { o)@ Or N o) o @ \t(, (,o (,o (,N @o (o(o(o ! oo z o0 o 3 o + t- o N o) o N (o o @o o o o NN o N N) o, C'IOr @ o o o) @ @ o) o) N) o @ o o o) (,l (rl 5 G) {o J o @ @ 5gt or orq, 5 o) -.t @ @ { O)!s I -@ o -O)(o I .s P N)(rt o I G) --l o 5(, 5(tl G)o (,o Cr)(, 5@ o No !oo Nooo (, o o) 5 (rl G) (r) (,l o zo(f o o o Jo J o @ O) o) o o =o+ o o @ (rl (,t (rl (, o @ t-o I u)o I N)o o, J -@ O) -@(, C^) G) (n O)(o o) @ so(r)(,ooto(^,e5 N(, 5o G)o G)(Jl o (o !oo Noo (, O) (, N) o N N N o z oo o (o C'I(., o o o (, O) @ O) o) o N =o - No Or @ o o ! 5 @ @ o, o (Jl ro I N)o I Js N) -@ N) J i\)o --t (, -{ o -_tN N{(.t (,o N)oNo(,oN(,o No o N(, !oo NooN N { (rl N) o o o o o o o o zoq o 5 I(t, N o o (,) N) N o) N o N o - NN oG)o@N oo N) (, o o N ]-oD \)so J --l (,^) J aC = =7 (E C0mazMC{o ll (-OE7zr.> HE ,FNPO r"r!8 -Z- -@g>- EilY'z o ooao ,l Ca o o vc -\ r --\ -\ -r N) N) r$50r@-oN-Sbr-@-OiJoooooooc)ooogggg9_o-o9-o-o_o oooc)ooooooooooooooooooooooooooo()oo NUMBER OF PERSONS 641,764 253,206(o(o Ot >2o6 !C dD fiH:t cis H9{<v-[# ItrJ U'oo -z a(,(o{ or iurm tsI sg 0066251 (o(o o) (o(o(o 3Eo 7 TDIdgs trIt-ori3 6 1,718,283 1 ,766,910 1 ,816,914 1,868,333 Noo NooN 1,921,207 FTGURES (tN 0',000) rrrrN) N qt ::l -a -t! -(n \ -oq'o!Ia(,6oi6oooO0606 1,706 1,719,293 685 960 1 ,766,910 451 674 1,816,914 569 1,968,333 273 378 1,921,207 o 1,290 o A) oq, N o AI (., mo ET 3q) o CL ! o .t aorn3zAt- +eo1- E>- 8,= 1r=q6 -tvo'>i$m -tDPOkz(o* < Eilf+ E' to og q, a @ J(o(o @ I NooN 384 oq, 5 o 0) Or MIffiz-{>ooTilo =;ot*t,H+g ffiH'.--,- lo lmolool= THElr 8lo l{lalo ls, l(Dloililililil N)N)N)JIooo(o(oooo(o(oNro(o@ @@@@@99999N) CD G) (Jr (Ooo\s(o FTGURES (lN o',000) J -s oO J -(r) oO -N' oO J -J oO J -o oo (ooo @oO -{ o C) O)oO (Jloo soo (,oo N)oo J oO 'ie @oo) o) @ ol oq,\3 ooq) mz =@cz=o{= E h;= =c u,Fr't EqE 8B=r@-Ft BtsSESh o{ oq) (., o A) s N --t(,) -'.t o 0) (rr + + + rt++ -u)z> eSsE - o () @ C o_(oq ma =J 0) o o- lJ lo HEl+ l\lo lT,lo l(D la le ililililil N)N)N)AJooo(o(oooo(o(oN)rO(O@ @@@@@99999N)@G)(x(oOO--15(o '50 10.2 Budget Justification Please provide a narrative description of the reasons for each proposed line items of the budget. (1) Capital Equipment Since the Enugu/Anambra/Ebonyi Programme has been ongoing since 1gg5, most of the capital equipment initially purchased would be obsolete. The short life expectancy of computers (given rapid evaluation of memory and speed requirements of latest software), and vehicles (given the difficult terrain) means that there will be need to replace vehicles, motorcycles, computers, photocopiers and other equipment. Despite the initial costs for replacing capital equipment in the first year, it is also anticipated that in the fourth year of the APOC funding, there will be the need to replace some office equipment, such as Computers, photocopiers and printers. (21 Supplies Updated computer software, office and field supplies are required to enhance effective pro.lect administration. (3) Training Thoughtful training/retraining is an essential component of the CDTI orientation of the programme to ensure capacity-buildrng for sustainability. (41 Health Education The need for Health education and mobilisation, directed by KAP study is more pronounced now in Enugu/Anambra/Ebonyi project because of the high rate of default being observed. (5) Travel ln view of the size of the project area, and the need for reorientation to CDTI, there is need for supervision. This entails movement of officers from the respective States to the Local Government and down to the community. (6) Communication Telephone, courier and other media means of communication will be used among project operators at all levels. Thrs will ensure adequate management ofthe project, hence the need for communication budget. Electionic-Mail communication is being considered. (71 Consultants Consultants would be required to conduct KAP, lymphatic filariasis, schistosomiasis and other research studies to ensure total quality management of the programme. (8) Externa! Audit A budget for this will be required to engage external auditors to audit project account This will ensure proper accountability and probity. I 51 (9) Personnel The States Ministry of Health, LGAs, Communities and Global 2000 RBp will be responsible for the salaries, allowances and incentives of their respectiveprogramme personnel. These personnel are crucial and indispensdble in theimplementation of the programme. ,52 10.3 Current resources available in CDTIs Existing CDTIs (for continuation or expansion) wtll have resources already available Please provide a detailed list of all existing personnel, equipment and supplies (including vehicles, etc.) belonging to the programme, indicating their ownership (MOH, NGDO, other Agency, etc.) and their level of functionality. S/No Item Total Number NGDO MOH LGAs Functionality 1 Vehicle (new) 4 4 Functional 2 Vehicle (old) 3 3 ( 3 Motorcycle (new) 10 10 ( 4 Laptop computer 1 1 It 5 Laptop computer (old) 1 1 Faulty 6 Desktop computer 2 2 Functional 7 Photocopier 1 1 ta 8 TVruCR 1 1 9 Overhead proiector 1 1 10 Slide projector 1 1 aa 11 Generator I I 12 Colour monitor 2 2 13 Wall clock 2 2 14 Filinq cabinet 3 3 It 15 Binatone voltage regulator b 6 ( 16 Air-conditioner 7 7 ( 17 Chairs 36 36 al 1B Tables 17 17 ( 19 Carpet 6 6 20 Refrigerator 1 1 at 21 Gas burner 1 1 22 Gubai Safe 1 1 23 Olympus microscope 1 1 (( 24 Dissecting microscope 1 1 25 Analytical balance 1 1 ( 26 Fan b 6 27 Laboratory fixtures 1 1 28 Fax machine 1 1 l( 29 Computer printers 2 2 30 IBM electric typewriter 1 1 (( ta (t AREA COVERED: 39 Local Governments in En ugu/Anambra/Ebonyi States YEAR 1 . 1998 YEAR 2** - 1 999 YEAR 3** - 2000 YEAR 4** - 2001 YEAR 5** . 53 APPENDIX 1: ESTIMATED NUMBERS OF COMMUNITIES AND PERSoNS To BE TREATED EACH YEAR, BY ENDEMICITY LEVEL COMMUNITY ENDEMIC LEVEL HYPER-ENDEMIC MESO-ENDEMIC HYPO-ENDEMIC* TYPE OF TREATMENT No. of Communities to be treated Total population in above communities No. of communities to be treated Total population in above communities No. of communities to be treated Total population in above communitres No. of communities to be treated Total population in above communities No. of communities to be treated Total population in above communities Community based Community based 2,O01 1,050 925,752 792,531 2,001 1,050 951,951 814,959 2,O01 1,050 97g,gg1 839,023 2,001 1,050 1,006,594 861,739 2,001 1,050 1,035,081 886,1 26 "Onchocerciasis is not considered an important Public Health problem in hypo-endemic communities and APOC will not normally fund community-based treatment in such communities. The inclusion of such communities in the proposal will require a specialjustification for consideration by the TCC. "*lt is understood that the figures for years 2-5 are likely to be estimates which may change as the project progresses. NB: A growth rate of 2.83% per year by Zonal Office of Statistics, Enugu is used for the population projection. Project effectiveness Sustai nability/lntegration ,54 APPENDIX 3: !NDICATORS FOR EVALUATION, SUSTAINABILITY/INTEGRATION OF CDTI Project Evaluation Management . Financial management . Effectiveness of communications . Training and capacity building o lnstitutionalcommitment . Fulfillment of other relevant sectors o Problem solving capacity o lntegration of operational research . Resu/f of KAP sfudies . Treatment coverage . Follow-up of non-eligible and absentees . Management of adverse reactions . Reliability of reporting Political will of host government Political will as shown in policy statements and apparent commitment of high- level officials Official action assigning personnel, funds, vehicles to programme Long-term planning ls there a long-term plan for sustaining the financing and the management of the programme? Progress tow a rd fi n a n cia I s u stai n a bi I ity lf programme sponsors cannot continue their current level of commitment for at least another five year, what percentage of running costs is now paid for host governments or fees? Progress towa rd i nteg ration . To what extent has ivermectin distribution been integrated with other health service programmes? . Evidence of community empowerment and ownership . Change in KAP over time . Extent of involvement of both genders and non-literate a a a a Personnel 1 19,875 0 7,915 19,712 147,502 eqp4ul Equipment 200,222 256,923 3 842 15,162 476,149 Supplies 204,713 10,312 0 0 215,O25 Training 167,146 10,112 1 987 9,878 189,123 Education/Mobilization 134,023 11,831 987 9,992 156,833 Travel 173,387 13,964 999 1 0,1 01 198,451 Communication 118,210 4,214 1,872 12,212 136,509 Consultants 54,892 0 0 0 54 892 External Audit 10,000 789 0 0 10,789 Other Expenses 97,911 8,123 0 14,973 121,007 Totals 1,280,379 316,269 17,602 92,030 1,706,279 % Input 7 5o/o 19% 1% 5o/o 100% YEAR 1: BUDGET 1998 $1.00 US = 65 Naira ENUG U/ANAM BRA/EBONYI STATES ln U.S Dollars 3 0 JAN. 1998 YEAR 2: BUDGET 1999 $1.00 US = 65 Naira ENUG U/ANAMBRA/EBONYI STATES In U.S Dollars Personnel 125,766 0 1 1,810 19,242 156,819 Capital Equipment 0 79 B32 , 0 0 79,832 Supplies 80,214 1,212 5,967 12,813 100,206 Training 5 1 844 1,142 5,816 14,292 73,094 Education/Mobilization 50,131 1,923 8,318 14,824 75,1 96 Travel 149,892 1,047 I 1 52 14,891 174,992 Communication 72,924 1,896 5,939 16,157 96,816 Consultants 18,322 0 0 0 18,322 External/Int. Audit 10,000 998 0 0 10,998 Other Expenses 126,095 21,948 7,972 18,O72 174,O97 Total 685,188 109,ggg 54,974 110,291 960,351 %T 71o/o %11 60/o 12% 100% , YEAR 3: BUDGET 2000 $1.00 US = 65 Naira EN UG U/ANAM BRAJEBONYI STATES ln U.S Dollars Personnel 120,230 0 9,817 17,750 147,797 Capital Equipment 0 4,950 0 0 4 I 50 Supplies 47,914 2,860 5,894 14,910 71 ,578 Traini 34,832 2,915 6,122 15,260 59,129 Education/Mobilization 50,310 5,325 8,214 14,915 78,764 Communication Travel 30,232 4,011 9,890 14,919 59,052 44,913 6,012 1 0,1 00 1 8,1 36 79,161 Consultant 42,811 0 0 0 42,811 External/Int. Audit 10,000 15,222 0 0 25,222 105,763Other E NSCS 69,702 9,801 8,070 1 8,1 g0 otal 450,944 51,096 58,107 114,090 674,227 % lnput 67% B% B% 17o/o 100% YEAR 4: BUDGET 2001 $1.00 US = 65 Naira E N UGU/ANAMBRA/E BONYI STATES ln U.S Dollars Personnel 119,219 0 14,89012,111 146,219 Capital Equipment 0 820 0 0 820 Supplies 34,790 1 ,160 6,050 15,972 57,972 Training 29,875 2,O12 5,961 1 7 764I 55,512 Education/Mobilization 40,115 1,899 7,952 18,212 68,177 Travel 25,060 1,976 6,134 14,141 47,311 Communication 40,218 1,083 5,071 16,933 63 305 Consultants 34,835 0 0 0 34,935 External/Int. Audit 10,000 2 1 82 0 0 12,192 Other Expenses 49,965 4,895 9,730 17,976 82,566 Total 384,076 16,026 52,909 115,899 568,ggg % lnput 680/o 3o/o 9% 20% 100% YEAR 4: BUDGET 2001 $1.00 US = 65 Naira EN UG U/ANAMBRA/EBONYI STATES ln U.S Dollars Personnel 119,218 0 12,111 14,890 146,219 Capital Equipment 0 820 0 0 820 lies Training 34,790 1 ,160 6,050 15,972 57,972 29,875 2,012 5,861 17,764 55,512 Education/Mobilization 40,115 1,898 7,952 18,212 68,177 Travel 25,060 1,976 6,134 14,141 47,311 Communication 40,218 1,083 5,071 '16,933 63,305 Consultants 34 B35 , 0 0 0 34,835 12,182External/lnt. Audit 10,000 2,182 0 0 Other E,xpenses 49,965 4,895 9,730 17,976 82 566 Total 384,076 16,026 52,909 115,ggg 56g,ggg Io//o t 680/o 3% 9o/o 20o/o 100% YEAR 5: BUDGET 2002 $1.00 US = 65 Naira EN UG U/ANAM BRA/EBONYI STATES ln U.S Dollars Personnel 123,112 0 2,090 87211 137,064 Capital Equipment 0 0 0 0 0 Supplies 20,110 0 1,970 9,981 32,061 Training 19,816 0 2,890 14,750 37,446 EducationiMobilization 19,971 0 2,240 12120 34,331 Travel 14,702 0 2,110 9,915 26,727 Communication 10,197 0 2,896 13,210 26 303 Consultants 25,188 0 0 0 25,199 External/Int. Audit 10,000 1,982 0 0 98211 Other Expenses 29,840 4,993 2 006 , 1 0,1 90 47,029 Total 272,936 6,975 16,192 82,038 378,131 % Input 72o/o 2% 4% 22% 100o/o 55 BUDGET RATIONALE lntroduction Enugu/Anambra/Ebonyi Project has been in existence since 1gg5, as a result most equipment are obsolete. ln writing this proposal, the functionality of the equipment was considered and the need for replacement is apparent. For virtually every line item discussed, the expenditure is expected to be higher in thefirst year and decreases steadily over the five-year period. This trend has becomepossible because of the strategy being adopted to empower collaborating partners, namely, State, LGA and Communities, to take on greater responsibilities of running theprogramme beyond the ApOC's five years, assistance. The initial capital expenses in purchasing the equipment, vehicles, etc., are one time expense. 56 Personnel The budget for personnel reflects the need for staff at various levels to,support the distribution activities of the CDD at the community level. Although the programme isbased on community directed treatment, this cannot be possible without the lupport of NGDO, MOH and LGAs staff who play very important roles. The NGDO's (GRBP) personnel within the country shall provide special technical assistance to the programme. Each person has a specific percentage of time to be allotted to the programme which has been costed (see table) Srmilarly, staff of the Ministry of Health and LGAs whose basic salaries will be paid bygovernment will be providing specific technical assistance to the community. This callsfor extra input by the officers and therefore require 50% incentive in addition to their basic salaries which has been computed to ApOC. The personnel cost begins to drop from the third year, as the process of devolution begins. This necessitates for reduction in staffing and hours put into the programme at various levels. A portion of salaries of GRBP staff has been factored as technical assistance under APOC in view of the fact that apart from providing these technical assistance, GRBp has also borne a greater percentage of capital cost (see under capital), which under normal circumstances, APOC would have provided. EA Budget details for Enugu/Anambra/Ebonyi States Line ltem PERSONNEL APOC Position (National Office) Source Annual Salary/Benefit # Staff Total Salary Explanation 1.- GRBP National Director APOC 8,500/yr 1 8,500.00 Technical Assistance 30% time2. GRBP Asst. Nat. Director 5,500/yr 1 5,500.00 -ditto- 15% time3. GRBP Fin. Director 5,500/yr 1 5,500.00 " 20o/o lime4 GRBP Admin Manager 4,000/yr 1 4,000.00 " 2Oo/o time5 GRBP Prolect Administrator 13,000/yr 1 13,000.00 " 100% time6 GRBP Project Secretary 9,000/yr 1 9,000.00 " 100% time7. GRBP Accountant 12,0001yr 1 12,000.00 " 100% time8. La Scientist 8,000/yr 1 8,000.00 " 100o/o time9. Finance officer 8,3751vr 1 8,375.00 " 100% time 10 Laboratory Assistant 4,0001vr 1 4,000.00 " 100% time 11. Clerks 3,500/yr 2 7,000.00 " 100% time 12 GRBP Drivers 2,5001vr 7 17,500.00 " 100o/o time 13. House Keeper 2,500/vr 1 2,500.00 " 100% time 14. Gardener 2,000|vr 1 2,000.00 " 100% time 15. cRBP Security 2,000(yr 4 8,000.00 " 100% time Sub Total 144,875.00 NGDO Posrtion (NOCP/GBR? Trng Centre) Source Annual Salary/Benefit # Staff Total Salary Explanation GRBP Trarnrng Specialist APOC 2,500tyr 2 5,000.00 Technical Assistance 10% time Sub Total 5,000 00 MOH Position Source Annual Salary/Benefit # Staff Total Salary Explanation SPO APOC 750lyr 3 2,250.00 Technical assistance 100% timeSOCT 350/yr 15 5,250.00 -ditto- 100% time Data Clerk 415lyr 1 415.00 " 100% time Sub Total 7,915.00 LGA Position Source Annual Salary/Benefit # Staff Total Salary Explanatton PHC Coordinator APOC 119.40|yr 47 5,612.00 Technical assistance '15% timeAsst Coordinator 100lyr 47 4,700.00 Technical assistance 25% limeLOCT 50/yr 141 7,050.00 Technical assistance 75% time S rvrsor for Health 50/yr 47 2,350 00 Technical assistance 25o/o limeSub Total 19,712.00 TOTAL 147,502.00 5B Capital Equipment The availability of equipment for proper functions of the programme at all levels of operation ts highly necessary, hence, the budget for capital equipment. At present, most of the capital equipment we have are not fully functional, therefore, the need for replacement. The creation of Ebonyi State also necessitated the establistiment of an additional state office. The underlisted capital equipment are to facilitate the work of LGA, MOH and NGDO staff. . Mobility (vehicles and motorcycles) . Accurate and efficient record keeping and data analysis (Computers, Printers) . Neat and accurate duplication of work (photocopier) . Storage of documents (filing cabinets) . Trarning/retraining (TV, VCR, OHP, slide projector, white boards) o Provision of power (generator) Expenditure on capital items are concentrated in the first 2 years of the programme and declines thereafter. lt is worth noting that under the NGDO budget column, provision has been made for capital expenditure in years two and three amounting to about $84,782, in additron to the $256,923 in the first year capital budget, bringing the total capital budget under NGDO to $341,705 It is worth noting here that GRBP has provided 71o/o of the total cost of capital equipment that the programmes require, which othenr,rise would have to be borne by APOC. t 59 Budget Details for Enugu/Anambra/Ebonyi States Line ltem: CAPITAL IPMENT APOC NGDO Vehicle N Vehicles ot Moto cles La Com Com Expense item/Activity Description Source Unit Cost of Item/Activity # Units Total Cost Explanation Vehicles (New) APOC 38,000 4 152,000.00 Field Travel/Trans port Desktop Compgler (New) 2,300 2 4,600.00 MIS Data Ana of Re rts Printers (New) 2,311 2 4,622.00 Doc/R Motorcycles (New) 3,000 10 30,000.00 Field monitoring/supervision Photocopier (New) 4,500 2 9,000.00 Doc. duplicqtion Sub Total 200,222.00 Expense item/Activity Description Source Unit Cost of Item/Activity # Units Total Cost Explanation NGDO 38,000 4 152,000.00 Field Tlavel/Tra nsport 14,500 3 43,500.00 -ditto- 1,000 10 10,000.00 Field supervision 1,050 1 1,050.00 MIS Data Analysis 2,300 2 4,600.00 -ditto- P r 2,700 1 2,700.00 Document dupliction TV/VCR 500 1 500.00 Audio visual presentation White board 338 1 338.009 Training/retraining Overhead prolector 1,255 1 1,255.00 " 100% time Generator 8,800 1 8,800.00 Extra power/mobile power Colour monitor 1,0s0 2 2,1 00.00 Computer aqcessory Wall Clock 70 2 140.00 Office entut Fiti cabinet 400 3 1,200.00 -ditto- Binatone volt ulator 150 6 900.00 Air condrtioner 400 7 2,800.00 Chairs 90 36 3,240.00 Office furnrlure Tables 100 17 '1,700.00 Office equipment 600 6 3,600.00 r 1,000 1 1,000 Traini inin Gas burner 500 1 500.00 Gubai Safe 1,200 1 1,200.00 Security purposes tOlympus microscope 1,400 1 1,400.00 I\rlicroscope analysis isecti mt 1,400 1 1,400.00 Ana ical balance 1,500 1 1 ,500 00 Special analysis Fan 200 6 1,200.00 Office UI ent fixturesL 2,000 1 2,000.00 Fax machine 1,250 1 1,250.00 Communication Com rinters 1,2s0 2 2,500.00 GIS IBM Electric r 500 1 s00.00 Slide 1,000 1 1,000.00 Training/reuqining La com er o 1,050 1 1,050.00 Computer Sub Total 256,923 00 Laboratory

60 MOH LGAs Expense item/Activity Description Source Unit Cost of Item/Activity # Units Total Cost ation Fan MOH 320.66 3 962.00 Office ui ent Tables 150 15 2,250.00 Chairs 70 9 630.00 Sub Total 3,842.00 Expense item/Activity Descriptron Source Unit Cost of Item/Activity # Units Total Cost Explanation Fan LGA 325 22 7,150.00 Office ent Tables 150 23 3,450.00 Chairs 25 142 3,5s0.00 Drawers 23 44 1,012.00 Sub Total 15,162.00 '61 Supplies Consumable supplies are essential inputs for efficient use of capital equipment which enables successful running of the entire programme. The budget is prepared with a view to APOC providing consumables like, photocopier toner, printer ink, printer toner, calculators, photocopying papers, staples, punches, diskettes, measuring sticks, etc. All these consumables are required for accurate accounting purpose and data calculation. As the programme progresses, the demand for supplies declines over the years. APOC and GRBP will shoulder higher responsibility in the early years, whiie the LGAs/MOH become progressively responsible for the programme's supplies during the APOC funding period, and thereafter, continues to provide the minimal basic requirements for the programme. The budget is designed such that APOC/GRBP would provide the initial supplies in the first year with no contribution from the MOH and LGAs to ensure smooth take-off of the prolect. All these consumables are required to ensure proper utilisation of the office equipment A) t Budget Details for Enugu/Anambra/Ebonyi States Line ltem: SUPPLIES APOC NGDO Expense item/Activrty Description Source Unit Cost of Item/Activity # Units Total Cost Diskettes APOC 53 60 pkts 3,180.00 DocumenUData entP Toners 116 56 6,496.00 lnk for thePrinter lnk/Toner 6'1 90 5,490.00 lnk for rintersCalculators 113 100 11,300.00 Add ing treatment and financial resPhotoco 15 250 3,750.00 File holders 3 4,380 13,140.00 ers/ 39 60 2,340.00 Note books 10 150 1,500.00 Punches fasteners 14 61 854.00 Meas sticks 5 2,s00 12,500.00 Pencil n 2 4,000 8,000.00 Erasers 2 4,000 8,000.00 S ers 2 4,000 8,000.00 Cards/Forms 1 120,00 0 120,000.00 Bathroom scales 9.13 15 137.00 Others 13 2 26.00 Sub Total 204,713.00 Expense item/Activity Description Source Unit Cost of Item/Activity # Units Total Cost anation Printer lnk/Toner GRBP 150 15 2,250.00 lnk for ersPhotoco rS 100 55 5,s00.00 Office useCalculators 100 15 1,500.00 Diskettes 60 12 720.00 Bathroom scales 12 10 120.00 Others 11.1 20 222.00 Sub total 10,312.00 ExplSnation '63 Training Training is an essential tool in the management of a programme for the achievement of goals. lt is an activity that needs to be carried out on a continuous basis at all levels, as new staff members are recruited, and the old update their knowledge and keep abreast of new developments. From our experience, training and retraining of all personnel (SPO/SOCT/LOCT/CDD) provide another mode of motivating them and sustaining their interest in the programme. Training is a costly activity. Funds are required for regular workshops as well as for printing of training and field materials. The MOH/LGAs are to provide part of the training funds, while APOC/GRBP provides the rest. In addition, GRBP is to provide the facilitators and overall supervisors. APOC is also to fund computer training for staff in areas like GIS and MIS to facilitate better management information for the project. 64 Others Budget Details for Enugu/Anambra/Ebonyi States Line ltem. TRAINING APOC NGDO MOH LGA Expense item/Activity Descri Expense item/Activity Description Source Unit Cost of Item/Activity # Units Total Cost Explariation Computer Training APOC 250 7 1,750.00 G lS/MlS Computer Traininq SOCT/Management Training 400 47 18,800.00 Facilities/Refresh ment Wshop for LOCTffraini f'g 250 141 35,250.00 CDD Training 50 1 330 66,500.00 PRI NTI NG oF TRA IN I NG & FI ELD MATE R IALS a) Trainer Flipchart 50 120 6,000.00 VisualAid b) Trainer curricular guide 15 141 2,1 15.00 Curricular guide c) SOQT Field guide 15 141 2,1 15.00d) LOCT Field guide 12 141 1,692.00 e) CDD Field guide 12 2,660 31,920.00 Others 2 502 1,004.00 Sub total 167,146.00 Expense item/Activity Description Source Unit Cost of Item/Activity # Units Total Cost Explanation SOCT/Management Training GRBP 400 3 1,200.00 Facility Refreshment for Wshop Training materials 150 50 7,500.00 Handouts, etc 176.50 I 1,412.00 Sub Total 10,1 12.00 Expense item/Activity Description Source Unit Cost of Item/Activity # Units Total Cost Explanation LOCT Training/Retraining Wshop MOH 42.28 47 1,987.00 Faci lities/Refreshment Wshop for Sub total 1,987.00 Source Unit Cost of Item/Activity # Units Total Cost Explanation CDD Training/Retraining LGA 5 1,330 6,650.00 Faci lity/Refreshment materials Training materials 807 4 3,228.00 Sub total 9,878.00 '65 Education/Mobi lisation ln Enugu/Anambra/Ebonyi project, greater emphasis shall be on tracking defaulters and mobilising communities towards maintaining high enthusiasm and demand for Mectizan treatment. This is an important activity that creates awareness and build a base for public support which ultimately ensures sustainability of the programme. Education and Mobilisation take the form of advocacy campaign for opinion leaders. Education of the media is carried out through the use of brochures, health education flipcharts, calendars, newsletters and press kits. Similarly, visit by the programme personnel to government authorities at the National, State and Local Government is aimed at strengthening this activity. Activities such as Oncho Day creates awareness in the wider society, but need to be consolidated by such techniques as the distribution of calendars, newsletters, and brochures. Oncho Day activities also give workers a feeling of participation in a wider effort and so it goes a long way to boost their morale. APOC/GRBP is to fund mobilisation campaigns and also to provide for materials While MOH/LGAs contributions are initially small, these continue to increase up to year 4, with the 5th year witnessing a decrease. As greater awareness is created within the communities, the cost of education and mobilisation will also decrease to a point where both the MOH/LGAs can now be fully responsible. 66 Budget Details for Enugu/Anambra/Ebonyi States Line ltem: EDUCATION & MOBILIZATION APOC NGDO MOH LGA Expense item/Activity Description Source Unit Cost of Item/Activity # Units Total Cost Explanation State Training Orientation APOC 100 141 14,100.00 LG Council ldader campaign advocacy -ditto- 100 141 14,100.00 State -ditto- PRINTING OF MATERIALS a) Press Kits 350 47 16,450.00 Packets of information for media PRINTING OF FIELD MATERIALS a) Health Education flipchart 600 22 13,200.00 Health education visual aids b) Healt! education posters 600 22 13,200.00 -ditto- c) Brochures 750 22 16,500.00 For schools/public education Calendars 600 22 13,200.00 Message calendars to leaders Newsletters 500 14 7,000.00 Updates for leaders State training orientation 200 22 4,400.00 Advocacy campaign State training VHC 1,500 12 18,000.00 VHC leaders advocacy Oncho day activities 3,873 1 3,873.00 Oncho activities Sub total 134,023.00 Expense item/Activity Description Source Unit Cost of Item/Activity # Units Total Cost Explanation State Training Orientation GRBP 7,451 1 7,451 LG Council leaders campaign advocacy -ditto- 4,380 1 4,380.00 State -ditto- Sub Total 11,831.00 Expense item/Activity Description Source Unit Cost of Item/Activity # Units Total Cost Explanation Qncho Day Activities SMOH 324 1 324.00 l4pQla coverage Oncho day programmes 663 1 663.00 Publicity, Radio, Television Sub Total 987.00 Expense item/Activity Description Source Unit Cost of Item/Activity # Units TotalCost Explanation LGA Traininq orientation LGA 4,271 1 4,271.00 Facility/Refresh ment materia ls Oncho Day Activities 3,121 1 3,121.00 Ii/ledia coverage/Entertain ment Q4cho Week programmes 2,600 1 2,600.00 Health education in schools Sub total 9,992.00 '67 Communication Communication is essential for the implementation and sustaining of the programmes. Most of the expenses on communications are being borne by APOC/GRBP. This is to ensure prompt distribution of programme document. The MOH is also to contribute to the expenses in the first year which increases in the subsequent years. 68 Budget Details for Enugu/Anambra/Ebonyi States Line ltem: COMMU ICATION APOC NGDO MOH Expense item/Activity Description Source Unit Cost of Item/Activity # Units Total Cost Expldnation Courier services (lnter) APOC 700 2X3X 12 50,400.00 Urgent docs to APOC/GRBP Telephone (lnter) 700 12 8,400.00 Communication APOC/GRBP to Fax (lnter) 700 't2 8,400.00 -ditto- Regular mails 130.80 12 1,570.00 Not urgent docs to and from field Courier services (Dom) 520/month 't2 6,240.00 Comm. To Zones State, NGDO, Telephone (Dom) 200/,month 3x3x 12 21,600.00 -ditto- Fax (Dom) 300/month 2x3 x 12t 21,600.00 Sub total 1 18,210.00 Expense item/Activity Description Source Unit Cost of Item/Activity # Units TotalCost Explanation IDD/Telephone maintenance GRBP 4,214 1 4,214.00 Maintenance/servicing of IDD telephone Sub Total 4,214.00 Expense item/Activity Description Source Unit Cost of Item/Activity # Units TotalCost Explanation Telephone SMOH 313 3 939.00 Communication to Zones, State, NGDOs Courier 233 3 699.00 Urgent docs to field Rgular mails 78 3 234.00 Not urgent docs to field Sub total 1872.00 c LGA Expense item/Activity Description Source Unit Cost of ' Item/Activity # Units Total Cost Explanation Telephone LGA 1,345 3 4,035.00 Comm. To LGA, State, NGDOs Courier services 1 ,518 3 4,554.00 Urgent docs to field, State, etc. Regular mails 1,134 3 3,402 Not urgent docs. To field Local messages 73.6 3 221 Local messages Sub total 12,212.00 '69 Travel lVobility of programme staff is imperative in a large project area such as Enugu, Anambra and Ebonyi States. Travel is expensive, ranging from expensive vehicle maintenance to relatively high cost of local travels from State to Local government headquarters and to the communities. Travel is required for advocacy visits, training and retraining, supervision, monitoring and evaluation, as well as other activities required for effective programme implementation. LGAs are to bear local travel expenses, while APOC/GRBP is to bear most of the expenses involved, which will include: funds for fuelling of vehicles and motorcycles, vehtcle and motorcycle maintenance, as well as some domestic air travels, accommodation, and per diem /travel allowance, etc. Eventually as the programme stabilises, both the MoH and LGAs will be fully responsible for the less frequent travels. O 70 Budget Details for Enugu/Anambra/Ebonyi States Line ltem: TRAVEL APOC NGDO MOH LGA -ditto- Fuelli of vehicles Tra Expense item/Activity Descri ption Source Unit Cost of Item/Activity # Units Total Cost Expldnatiqn Vehicle maintenance (oldj APOC 5,000 7 35,000.00 Servicing/Repairs Vehicles maintenance (New) 3,s00 4 14,000.00 -ditto- Fuelling 4,500 11 49,500 Fuelli of vehicles Motqrcycle maintenance (old) 1,500 10 15,000.00 Servicing/Repairs Motorcycle maintenance (New) 1,000 10 10,000.00 -ditto- Motorcycle frlelling 800.85 20 16,017 Fuelli of moto ES Air travels (domestic) 350 18 6,300.00 Air travels Perdiem/Travel allowance 45 18 810 Feeding/incidentals Accommodatin 45 18 810 Tra llgPerdiem/Travel allowance 55 159 8,745.00 Feeding/incidentals Accommodation 55 159 8,745.00 Trave Perdiem/Travel allowance 30 1411 4,230.00 Part-timers Accommodation 30 141 4,230.00 -ditto- Sub total 173,387.00 Expense item/Activity Description Source Unit Cost of Item/Activity # Units Total Cost ation Vehicle maintenance GRBP 1,000 7 7,000.00 Servicin rrs Motorcycle maintenance 300 10 3,000.00 Fuelling 102.40 10 1,024.00 Travel/Perdiem 30 98 2,940.00 Sub Total 13,964.00 Expense item/Activity Description Source Unit Cost of Item/Activity # Units Total Cost Explanation Fuelling of motorcycles SMOH 99.90 10 999.00 Fuelling of ES Sub total 999.00 Expense item/Activity Description Source Unit Cost of Item/Activity # Units Total Cost Explanation Motorcycle maintenance LGA 300 10 3,000.00 Servicing/Repairs Fuelling of motorcycles 300 10 3,000.00 Fuelling of motorcycles Travel/Perdiem 29.09 141 4,101.00 Travel/Perdiem Sub total 10,101 .00 '71 Consultants Consultants will be utilised for certain activities, for example, computer maintenance and related aspects of computer work. ln the area of health education, consultants will be required to, in addition, help in the development and refinement of Health Education and other materials. Consultants will be involved in Management lnformation System(MlS) evaluation. APOC is requested to fund the total cost for the five years. 72 Budget Details for Enugu/Anambra/Ebonyi States Line ltem: CONSULTANTS APOC Expense item/Activity Description Source Unit Cost of Item/Activity # Units TotalCost _ErylariarionHealth Education Consultants APOC 500 47 23,500.00 Developing & Refining of H/Education materialsZonal Staff Consultants 500 47 23,500.00 Review of MIS/H.Edu Forms er Consultants 2,630.60 3 7,892.00 Bas i c Com uter malnten an ceSub total 54,892.00 '73 External Audit Auditing by internal and external firms/individuals is necessary to ensure that funds disbursed are as budgeted and for the achievement of desired objectives. APOC is being requested to bear the cost of external auditors while GRBP will bear cost of internal auditors. 74 Budget Details for Enugu/Anambra/Ebonyi States Line ltem: EXTER AUDIT APOC NGDO Expense item/Activity Description Source Unit Cost of Item/Activity # Units Total Cost Expldnation Air travel APOC 1,716 2 3,432.00 Air fare/travels Accommodation 250 2x7 3,500.00 Per diem 150 2x7 2,100.00 Feeding/lncidentals Audit 484 2 968.00 Audit fees sub total 10,000.00 Expense item/Activity Description Source Unit Cost of Item/Activity # Units Total Cost Explanation Travel GRBP 76.34 3' 229.00 Road tra Accommodation 40 7 280.00 Lodging Per diem 40 7 280.00 Feeding Sub total 789.00 Lodging '75 Other Expenses These other expenses include bank charges, sentinel evaluation, distribution, courses at the management training centre, operational research and general operational charges. These costs (other than office/renUmaintenance by GRBP) are being requested from APOC. 76 Budget Details for Enugu/Anambra/Ebonyi States Line ltem: OTHER EXPENSES APOC NGDO LGA Expense item/Activity Description Source Unit Cost of Item/Activity # Units Total Cost Explanation Bank charges APOC 4,000 1 year 4,000.00 Transaction charges Sentinel Village Evaluation 2,000/week 12 weeks 24,000.00 Program monitoring Distribution 1,800/month 6 months 10,800.00 Dosing supervision & MIS Management Courses 9,111 1 year 9,111.00 Management courses SPOs/SOCTS/LOCTs for Operational Research charges 12,000 1 year 12,000.00 Charges General charges 15,000 1 year 15,000.00 -ditto- Laboratory services 12,000 1 year 12,000.00 -ditto- Follow-up management supervisory visits of participants 11,000 1 year 11,000.00 Participants' su pervision Sub total 97,91 1.00 Expense item/Activity Description Source Unit Cost of Item/Activity # Units Total Cost Explanation Office renUmaintenance GRBP 8j23 1 8,123.00 Office renUmaintenance Sub total 8,123.00 Expense item/Activity Description Source Unit Cost of Item/Activity # Units Total Cost Explanation Office maintenance LGA 318.57 47 14,973.00 Maintenance of Office space Sub total 14,973.00 23 SUPPORTING DOCUMENTS 1, DEVOLUTION FORMS IN USE TIMELINE FOR DEVOLUTION OF IDP BETWEEN 1997 AND 1999 RESULT OF SENTINEL VILLAGE EVALUATION EXERCISE CONDUCTED IN 1995 TO ASCERTAIN MF INTENSIry OF INFECTION FOR ENUGU/ANAMBRA MAPS SHOWING THE COMMUNITIES IN EACH OF ENUGU ANAMBRA & EBONYI STATES. 4 t\ IE lEd H la I'J l5 IFrJ I -l z z t ,A) a 7r \ r-i o\ 5 (]) f.J O \D @ --l c\ 5 (, l.J .l o ,l r. o 5 Ic s OJ o) oCn oF J E(lJ zoF -.1 lJr o Z -i(n E aoc 'lA o zHa A zoF >J E o EdL d z a s U) o C F.-i z e s zoF 'lE z Ho F tr{ E U tr, E I x U) *l €X z oFH E oo F 2 6g c) 'l 5(n (])s {N) Ooo -t f..){ \o O s @u) NJ@ N)@N) {(..) o\ \)o\ 5l..J \o o o\}.J r,J +- { hJ ,i,o 5 O oo @(,-) (,.)\o @ !tt) cr. ! + \oo s"r'.*t',.Jl' 8,,#sB.- Er,rH ,Sil4 .,t" -t,.ii' ..1. . z s Itl >J \ Nb-\ o TI.1 C4 \) N! 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UM UODAMA ANI KE Ii D I aO O (,O O N) O O O Percent Prevalence AIo (n O O O)O O --JO O AMOFU UGAN FZI IFITEORA ANIKE i I ; I I OMAS -T1 T -Io 0) o o o Po TI o -l U) x' a o !f. q 5 o)(o o a rn (a 0) :lJ CI -lp .IJ o I I o 'T1t- I I : I I -o o (D o UM UODAMA N O OO bO O O IO J Microfilarial Load \r a a \r- ( oo o a o o a 'a a a I a'aa a a. a \ aa a oa a O3 o 'Qo 'a a aaaaa aa a a a a a aa a aa o o a o o ao aa a ENUCU STATE SHOWING 195 COMMIJNITIES NSUKKA IGBO-EZE AWGU UDENU a a a o a o a oa ISI-UZO o a a aa ENUG{.J NORTH UDI a a a a @ a a oa a a a a EAST a 4.. a S. IGBO-ETITI FZEAGU a a o a a a a a ao a ao a a o a a O a a o @ -aa aa a a o a a a a aa a ao OO ' tt a NKANU W a a a a o a a o ao oaOII RIVER a a a a a aa ANINRI a o a o a 5 o 'r-I o a o o AYAMELUM a oOa ANAMBRA STATE SHOWING 186 COMMUNITIES ,A c li a a \_-.. a t o a a o a IHIALA I a ANAMBRA W l-/ o a a a f I o ao o a o aI a a o \, o o a o .{\rKA S. o o o o a a a ao o a a oo ao a a oo o aa o o o a a l' ea NNEWI S. AMBRA E. oYt AIJflKA N ca a a a @o aO a o o IDEMILI JIKOKAON. S. o c O a oa o o aa a o IDEMILI oa o a o a EKW N ao o a o o o a a a oo o o AGUATA NNEWI N ORUMtsA S o a o o a a o a o ao o a o o o a o I o a o o a O a ot o a a Ot a OGtsARU ON .1O3 COMMUNITIES a 1I a a a e a a a a o o o ISHIELU a IbtrMI a o aa a o aOaa a a a a ao a o a a o a a o o C ao a a a a a a oo o a a a o aa a a a a a a a C G a o o o a a O e a a tlt . ilKm-l O o ooo a o ll t AFIKPO S. aG e o a ao O a a o IEZ-TII t GLOBAL 2OOO * * * * Thursday, January 22, 1998 To The Chairman of the NOTF: This is to confirm The Global 2000 River Blindness Program's intention to participate in the proposal for APoC support of Imo Abia, Enugu, Ebony and Anambra States. We look forward to collaborating with APOC and the Ministry of Health in making this a successfu I partnership. Sincerely, a 17 {, :, ., /v/r,$,,iii ::"'''* .--- Donald R. Hopkins, MD Associate Executive Director for Control & Eradication of Disease The Carter Center cc: Dr. Emmanuel Miri, Chairman NGDO Coalition, Nigeria TFIE CARTER CENTER ' ONE COPENHILL . 153 FREEDOM PARKWAY . ATLANTA, CEORGIA 10307 . (404) 420.3830 . FAX (404) 874.5515