IAfrican Programme for Onchocerciasis Control (APOC) Programme africain de lutte contre I'onchocercose JAF'-FAC I JOINT ACTION FORUM Office of the Chairman JOINT ACTION FORUM Third session Livemool. 4-5 December 1991 FORUM D'ACTION COIvIMUNE Bureau du Pr6sident JAF3/INF/DOC.4 ENGLISH ONLY October 1997 REPORT OF THE INTERNATIONAL WORKSHOP ON T]IE PHILOSOPHY OF THE AFzuCAN PROGRAMME FOR ONCHOCERCIASIS CONTROL (APOC), CONCEPT AND HARMONIZATION OF COMMTINITY-DI RECTED TREATMENT WITH IVERMECTIN (CDTI) PROJECTS IMPLEMENTATION ENUGU (NIGEzuA),zt - 2s APRIL 1997 t ? Ia AFzuCAN PROGRAMME FOR ONCHOCERCIASIS CONTROL NIGERIA TANZANIA INTERNATIONAL WORKSHOP ON THE PHILOSOPHY OF THE AFRICAN PROGRAMME FOR ONCHOCERCIASIS CONTROL (APOC), CONCEPT AND HARMONIZATION OF COMMUNITY-DIRECTED TREATMENT WITH IVERMECTIN (CDTD PROJECTS IMPLEMENTATION. ENUGU, NIGERIA 2l-25 APRIL. 1991 3I. TNTRODUCTION 2 RATIONALE FOR THE NOTF/APOC WORKSHOP OPENING CEREMONY TECHNICAL SESSION 4.1. Opening remarks: 4.2. The workshop design 4.3. Objectives of the workshop 4.4. The Bxpected Outconrcs of the workshop THE SESSIONS: 5.1. Partnership 5.2. Rapid epidemiological nruppins @EMO) 5.2.1. Recommendation 5.3. Review of guidelines for national plans and project proposals 5 .3 . I . Planning the writing of project proposals 5.3.2. Writing of project proposal 5.3.3. Participants views on current APOC Guidelines for the development of national plan and project proposals 5.3.4. Recommendation: 5.4. Budget and financial management of APOC funded projects . . 5 .4.1 . Budget:Budget Portion of the Proposal 5.4.2. APOC guidelines for budget preparation 5.4.3. Recommendation: 5 .4.4. Guidelines on Financial Administration 5.4.5 . Financial management of APOC funds . 5.4.6. Auditing NOTF account 5.4.7. Technical assistance to NOTF 5 .4.8. Recommendation 5.4.9. Country financial flow charts 5.5. Drug procurement and circuit of delivery to communities 5.5.1. Mectizan flow 5.5.2. Recommendation 5.5.3. Storage and Safety of Ivermectin 5.6. Approachittg tlre community and distribution 5.6.1. Recommendation 5.7. Integration into the health service 5.7.1. CDTI activities for integration 5.7.2. Steps towards integration 5.7.3. Benefits of integration and sustainability of CDTI projects 5.7.4. Recommendation 5.8. Health education and training 5.8. I . Harmonization of Training Methods and Materials 5.8.2. Recommendation 5.9. Recording and reporting al all levels . 5.9.1. Recommendation OTHER CONCLUSIONS AND RECOMMENDATION 6.1. AI'OC videos on health education/truining und advocrtcy 6.2. APOC Project Mottitoirtg forms J 4 5 2 2 J J 3 4 4 5 5 6 6 6 I f 6 7 7 7 8 9 9 10 10 10 10 11 l1 l1 11 t2 t2 t3 t4 l4 l5 15 t6 T6 t6 16 11 17 6 I8 18 18 I 6.3. Desigrting corrtrrtunication nuteials witlt ntral women SUMMARY OF RECOMMENDATIONS 7 .1. Rapid epidemiological mapping (REMO) ( page 7 .2. Review of guidelines for national plans and project proposals 7 .3. Budget and financial management of APOC funded projects 7.3.1. Guidelines on financial administration of community directed treatment with ivermectin 7 .4. Drug procurement and circuit of delivery to communities 1.5. Storage and safety of ivermectin 7 .6. Approaching the community and distribution 1 .7. Integration into the health service 7 .8. Harmonization of training methods and materials 7 .9. Recording and reporting at all levels 7.10. Other conclusions and recommendation 8. ACKNOWLEDGEMENTS ANNEX 1 ANNEX 2 ANNEX 3 ANNEX 4 ANNEX 5 ANNEX 6 ANNEX 7 ANNEX 8 ANNEX 9 19 a7 19 19 t9 19 19 20 20 20 2l 21 2l 22 List of participants by countrY Workshop agenda Exercise on calculating populations Participants vie'uvs on current APOC Guidelines Gurdelines on WHO Financial Regulations and Administrative conditions precedent to disbursement of APOC Funds Financial Flow chart of Nigeria, Tanzania, Malawi, Uganda Key elements for health education Training and health education materials: target audience, objectives, messages and techniques Recording and reporting at all levels 23 24 28 JJ 35 36 39 4l 42 43 a -Y 1. INTRODUCTION Onchocerciasis is a major infectious cause of blindness, and is present in 34 countries of Africa, the Arabian peninsula and the Americas. As a public healttr problem, the disease is most closely associated with Africa, where it constinrtes a serious obstacle to socio-economic development. Onchocerciasis also causes severe skin disease associated with grave and unremitting itching. The African Programme for Onchocerciasis Control (APOC), the new regional programme is an ivermectin-based control programme which aims to eliminate onchocerciasis as a public health problem in nineteen endemic countries in Africa. To control onchocerciasis as a public health problem, ivermectin needs to be given at least once per year to the population of all seriously affected communities. Since ivermectin treatment has only limited effect on transmission of the parasite, annual large scale treatment will have to be continued for a very long time to ensure sustained control of the disease. The main challenge facing the APOC, an ivermectin-based control programme, therefore, is to develop and implement simple and effective methods of its delivery which are sustainable within the context of the socio-economic constraints of the endemic African countries. In order to provide objective scientific information on the effectiveness and sustainabiliry of different approaches to community-based ivermectin treatment, the Task Force on Onchocerciasis Operational Research of the Special Programme for Research and Training in Tropical Diseases (TDR), in collaboration with the OCP conducted a multi-country study on corrmunity-based treatment with ivermectin, now known as Communiry-Directed Treatment with Ivermectin (CDTI). The srudy showed that if communities are allowed to direct the treatment with ivermectin, higher coverage is achieved and regular treatment could probably be achieved for a long time. 2. RATIONALE FOR THE NOTF/APOC WORKSHOP There were two interdependent broad issues which lead to this first workshop and influenced the agenda. First, was the need to ensure effective and uniform implementation of the Community-Directed Treatment with Ivermectin in all participating countries. Second, in reviewing projects submitted to APOC, the Technical Consultative Committee and APOC management recognized that there were still misconceptions about APOC objectives and strategies. Therefore, there was a need to provide a forum to reach a corrrmon understanding of the APOC philosophy as well as the concept and implementation of CDTI and agree on ways to re-orient on-going country activities. Workshop participants (sixty-eight; Annex 1) were drawn from four APOC Anglophone countries: Malawi, Nigeria, Tanzania and Uganda. The participants were made up of Nationai Onchocerciasis Coordinators, Chairmen of NGDO Coalitions, Ministry of Health officials working on Onchocerciasis, representatives of NGDOs, UN agencies, APOC management staff, facilitators including two rnernbers of the Technical Consultative Cornmittee (TCC) of APOC and scientists from Universities and Research lnstitutions in Nigeria. 3. OPENING CEREMONY Tlre opening ceremonv took place on 21 April, 1997 at the Convention Hall of the Nike Lake Resort Hotel, Enugu, Nigeria, the venue of the workshop and was attended by important dignitaries that f 2included the Acting Military Administrator of Enugu State, Lt. Col. Isaac Onyenannia; Honourable Minister of Healtli, Dr. Ihechukwu Madubuike; WHO Representative in Nigeria, Dr. E. K. Njelesani; the Odezuluigbo II of Nike, Igwe E. Nnaji; representatives of the University of Nigeria, Nsukka, Chairman TCC, Professor O. O. Kale and members of the press. The traditional ruler of Nike community where the workshop was held, Igwe E. Nnaji welcomed participants and wished them a fruitful meeting. Goodwill messages were received from the Sole Administrator of University of Nigeria, Nsukka and from the Chairman, Nigerian NGDO coalition, Dr. E. S. Miri. The WHO Representative in Nigeria, Dr. E. K. Njelesani reminded the participants of the high endemiciry of Onchocerciasis in Africa in general and Nigeria in particular. He noted that this disease which has become an important public health problem consdnrtes a serious obstacle to socio-economic development. He stressed that this workshop which seeks ways of eliminating the disease through active community participation in ivermectin delivery system could not have come at a better time. The Hon. Minister of Health pledged Nigeria's support for APOC programmes in the country. He reiterated Nigeria's preparedness to host the secretariat of APOC. In declaring the workshop open, the Acting Administrator of Enugu State noted the burden of Onchocerciasis, especially in Enugu State and pledged the support of the State government to control efforts, donated land for the construction of APOC headquarters and wished participants fruitful deliberations. The vote of thanks was delivered by the Nigerian National Onchocerciasis Coordinator, Dr. J. Y. Jiya. 4. TECHNICAL SESSION 4.1. Opening remarks: In his key note address, Professor O. O. Kale (Chairman, TCC) reiterated that the workshop was necessitated among others by the urgent desire to correct the misconceptions in the proposals for consideration by APOC Trust Fund. In addition, he stressed the following issues: (i) the cost of controlling onchocerciasis in APOC countries should be cheaper than in OCP countries.(ii) the need for NOTFs to note and adhere strictly to APOC guidelines for CDTI implementation(iii) long term sustainability is critical to the ultimate success of APOC. The WHO Representative in Nigeria, Dr. E. K. Njelesani delivered the message of the APOC Management to the participants when he delineated the challenges and obligations of the National Task Forces after this workshop as: a (i) ( ii) (iv) (v) Training communiry selected distributors and beginning with acrual irnplementation of APOC projects (distribution of ivermectin) between now and Decettrber 1997 . ) Ensuring that in the 19 APOC countries in Africa, ivermectin is given free of charge tcr rnillions of affected persons, most of whom are poor, voiceless but suffering under the burden of this terrible disease. Ensuring that in all the communities affected, very eligible individual receives the right dosaqe and swallows ivermectin once a year. Promoting ownership of APOC projects by the comnrunity. Demonstrating that contribution frorn APOC Trust Fund has increased treatment coveragc in (iii) JI the countries. Reporting these achievements to the governing body (The Joint Action Forurn) at its next meeting in December 1997 in Liverpool. 4.2. The worksltop design This workshop format was participatory in design to allow fbr as much input as possible from participants. The agenda (Annex 2) was determined by the objectives and expected outcome of the workshop. Formal presentations and discussions on key topics were followed by group discussions, either by country or in mixed groups and plenary sessions for conclusions and recommendations. Held in a local setting, participants had adequate time to interact and share experiences with counterparts from other countries, The objectives and expected outcome of the workshop was presented by Dr. Amazigo 4.3. Objectives of the workshop (i) Provide a forum for all partners in APOC participating countries to share their views and improve communication' Reach a common understanding on what APOC wants to achieve in implementing CDTI projects in participating countries. ln particular'. -- Establish community-directed treatment systems in which the community owns the project and is responsible for its design and execution. -- Build sustainable community-directed treatment projects (iii) Collectively streamline the modalities for re-orientation and implementation of the CDTI strategy, including such issues as education, mobilisation, training, monitoring and delivery methods. (iv) Prolnote collaborative efforts to avoid duplication of resources and minimize costs at all levels of CDTI; (v) Improve the standard of the National Plans and Project Proposals; (vi) Streamline procedures for financial and administration management of CDTI in the spirit of APOC partnership; ( ii) 4.4. (i) (ii) ( iii) (iv) (v) The Expected Outconrcs of the worksltop: Country teams would now be in a position to improve the standard of funrre National Plans and Project Proposals. The spirit of partnersirip would have been strengthened among the implernentors of the CDTI in APOC countries. Participants would have a clear understanding of the concept of CDTI, which would enable them revise their current strategies, and to achieve APOC's objectives. Country tearns wilI come up with concrete suggestions on how best to integrate CDTI into existing hcalth systenrs for sustainability. Clear indications would emerge as to the way forward, regarding the re-orientation of current 4projects and the harmonization of views among partners on CDTI It is worthy of note at the outset that the exchange of ideas, insights and experiences among participants (NGDOs, MOH staff and researchers) was extensive, constructive, informative and beneficial. The cross-fertilization of ideas especially at group work sessions resulting from bringing to a common forum representatives of NGDOs and MOH was particularly enriching. 5. THE SESSIONS: This report synthesises the presentations, discussions at plenary and group work undertaken over the five days of the workshop under nine main themes: Partnership Rapid Epidemiological Mapping (REMO) Review of guidelines for National Plan and Project Proposals, Budget and Financial Management, Drug procurement and circuit of delivery to communities Approaching Communiry and Ivermectin Distribution Integration of CDTI into the health service, Health Education and Training, Recording, Reporting and Monitoring. 5.1. Paftnersltip Multiple Partnership +" It is a learning process, painful at the beginning x It takes tinre and must be allorved time * If it must succeed, everyone must work towards that success" - Facilitator The problern of partnership is at the heart of all APOC operations at both national and international levels. This topic was introduced by Dr. Etya'a16, the NGDO Coordinator, who first provided the historical background and rationale for launching the APOC partnership. The presentation highlighted the need for countries to assume full responsibility of CDTI; the importance of group work and efficient coordination of in-country activities; sharing experiences and resources among partners and joint mobilization of resources in support of CDTI. The importance of strengthening the multiple partnership tlirough more dialogue and better coordination at all levels was recognized by all to be critical to the success of APOC projects. The following were emphasized in the presentation: (i) APOC is a rnultiple partnership involving participating governments and their aft'ected communities, NGDOs, World Bank, WHO, other UN agencies donor communities; ln each participating country this partnership is operationalised through the National Onchocerciasis Task Force (NOTF) in which governrrents and their partners (NGDOs and other ageucies) and the comrnunities are all represented. : 0 t 0 t I o t I t (ii) !5 (iii) In keeping with the APOC philosophy of partnership, emphasis should henceforth be placed on NOTF rather than on individual players. Consequently, (iv) The NOTF should be the focal point for all onchocerciasis control activities in all APOC assisted countries. (v) All partners should therefore ensure that any success achieved will be through and with the NOTF. 5.2. Rapid epidemiological mappine REMO) An illustration by Dr Noma using REMO maps from Nigeria and Cameroon provided the participants insights into the power of REMO and Atlas GIS as application tools and opened discussions at length on the benefits of using REMO as a tool in designing CDTI, for determining endemicity levels and planning control activities in each country. In particular, REMO/GIS provides information on: (i) Where and how urgent to treat(ii) Population to treatr (Annex 3)(iii) Rough estimate on number of Mectizan tablets to be requested from Merck & Co. Inc In addition, REMO is a prerequisite for consideration by APOC/TCC of national plans and project proposals. APOC management expects participating countries to have their REMO concluded by the end of 1997 and before new proposals are submitted. It was made clear that REMO is essential for prioritizing APOC projects. General and specific issues and weaknesses in previous proposals relating to REMO were highlighted. A few examples were taken from reviewers comments without disclosing source. As a proposal reviewer noted: " A thorough analysis of existing data on endemicity (specifically including REMO data) is required as part of the project documentation to lustify the prioritization of operations" - A Reviewer The concern expressed by some participants on the financial implications of the need to continuously refine REMO map, which require financial support from APOC, was addressed during the plenary session. 5.2.1. The group recommended that (i) In each country REMO data needs to be continuously refined and the GIS map updated in close collaboration with TDR/CTD/APOC. ( ii) APOC managelnent should ensure that all activities related to the above are well supported. In particular, adequate support should be provided for the transfer of capacity and resources to assist the countries in generating essential data and maps, and ensure that they are widely available to all partners. -lhrs rclers to the target glpulation dcfined as the total number of people living in meso and hyperendemic communitics and targeted for mass treatment. 6a 5.3. Review of guideltnes for national plans and project proposals The main aim of this review was to assess participants' understanding of the guidelines, provide clarification where and as needed and agree on ways to ensure that all future projects are solid, well written and reflect the various skills and resources available in the country. Discussions centred particularly on the following: 5.3. I . Planning the writing of project proposals The conclusion drawn from the discussions at plenary and group work was that proposal writing team should include all partners in the project at all operational levels, government and NGDO representatives from the Zone, State and Local Government or District. The needs of the affected communities and the concerns of the donors should also be fully considered during the entire process. 5.3.2. Writin_q of project proposal At plenary, the type and quality of information required by the Technical Consultative Committee (TCC) to approve proposals were discussed and suggestions provided by the workshop facilitators. Several weaknesses in the qualiry of previous proposals were highlighted. The APOC staff and TCC members stressed also the importance of early submission before the deadline. Reviewers of the APOC proposals submitted thus far made the observations that (i) There was insufficient provision of information about target and/ or eligible population(ii) Cross border issues need to be addressed in more details;(iii) The proposals showed little or no evidence of integration into the health systems(iv) No evidence of financial commitment of the participating governmenr(v) Lacked innovation;(vi) Greater need to dialogue with communities in approach;(vii) Inapplication of REMO/GIS results ,,DISUPLINING PEOPI,E WHO DO NOT COME FOR TREATMENT WOULD BE A SURE WAY TO KILL THIS PROGRAM. TREATMENT MUST BE VOLUNTARY IF PEOPLE AT RISK ARE NOT CONVINCED TO BE TREATED WITH IVERMECTIN, THAT tS OUR FAULT. NOT THEIRS ". - A Reviewer 5.3.3. Participants views on current APOC Guidelines for the development of national plan and pro.iect proposals In qencral. participants were satisfiecl ilith the guidelines set up b),thc Technical Consultatile Cotnrnittee (TCC). It was suggested that project proposal guidelines could be further streamlined to 1avoid areas of repetition. This will reduce the volume of the proposal. For example, participants noted that there is an overlap between section 3.1 and 9.3. Other areas which as pointed out need to be rephrased or replaced are presented in Annex 4. At group work participants explored carefully ways the quality of the proposals could be improved. Participants agreed that the following should be considered in the writing of project proposals and national plans: (i) Full justification for selection of proposed project areas should be provided, based on REMO.(ii) There is the need for projecs to demonstrate integration into the existing health system to ensure sustainability of CDTI. The proposal should clearly define and describe "Primary Health Care" (PHC) or "Health Care System" as appropriate for the country;(iii) APOC will provide specific guidelines for countries submitting proposals in project areas, where there is need for focal vector elimination; (iv) APOC may provide funds for innovative operational research activities within the CDTI project where these are properly justified. Approval of such research requests will be coordinated between APOC and WHO/TDR. 5.3.4. Recommendation (i) Provision should be made to ensure that community input is incorporated into the proposal (ii) NOTFs should set up a committee to review project proposals before they are submitted to the APOC headquarters; (i ii) National Plans should be reviewed and updated as the need arises. The document must provide a basis from which all project proposals should be developed thus providing continuity and consistency. 5.4. Budget and financial management of APOC funded projects 5 .4.I . Budget:Budget Portion of the Proposal Dr. Befidi-Mengue introduced the subject by highlighting the pivotal elements of a budget and important details that should be borne in mind when preparing the budget for APOC-funded projects. These include: I Prerequisite for making a budget t APOC guidelines for preparing budgets for: National Office; Projects I Aspects of cost not covered by APOC Funds i Justification of the budget 0 Costing community participation lt was also reiterated that 75% of the total budget for a project rvill be borne by APOC while the renraining 25% wlll be paid by the MOH/NGDOs. "Can APOC pttll ottt after five years whett the district carurct support the project?" - Participant 6The need to reflect community involvement and ownership of the projects in the proposals was also emphasised, especially with respect to the roles the communiry can play in reducing or sharing costs Community contribution to be considered in preparing a proposal budget were highlighted. These include: - determination of its population (census) - collection of drugs from the nearest health facility - drug distribution - recording - monitoring for adverse reaction after ivermectin treatrnent and referral of patiens to the health facility; transfer of patients to the hospital - transportation of community chosen ivermectin distributors to the place of training. Dr. Befidi-Mengue and Mr Miller in their presentations stressed the importance of descriptive justification of every budget line item as it helps the reviewer to examine the relationship between inputs and outcomes. Thus, the proposed use of all funds budgeted for, needs to be justified in detail. As emphasised by Befidi- Mengue " Justification is made easy if the prerequisites for budgeting are respected" . As expected, several questions were raised by participants on budget. For example, a participant argued that: " the management team at the national, regional/zonal and distict/state levels should be given additional incentives/topping up, to avoid cutting corners" Partictpant Signihcant problems concerning the completion of the budget section were noted and deficiencies in this area of the proposal were highlighted. A participant asked: how can the budget drop when you start wtth one district or LGA and you have 20 districts or LGAs within the five year period to worry about? The TCC members explained that expansion in treatment coverage does not necessarily mean increase in cost per person treated. To deal with the above concern and other questions pertaining to the five year budget, Dr Befidi-Mengue outlined the essentials as below: o Prerequisite for good projects that will help to justify the budget (i) rvell defined activities and requirements(ii) known size of the population to be treated(iii) known distances to be covered(iv) requirements for activities to be carried out effectively(v) type of strategy to be used for administering treatment(vi) what are existing resources?(vii) Justification of the budget must be detailed for each line iteru 5.4.2. APOC -quidelines for budget preparation Furthermore, participants were inforrned that more detailed guidelines will be provided by APOC rltanagement for preparation of all future budgets. Information in the new guideline sltall include: (i) Aspects of cost rtot covered by APOC: Basic salaries, office space. rentals, renovaticln, laboratory equipnlent.(ii) Aspects of partiul support by APOC: ! 9Materials for training, meetings/workshops, consultancies, capital equipment (iiD Parlners could receive assistance from APOC for the funding of: Transportation of drugs from the entry point within the country to the health centre level; materials for training; meeting allowances; travel cost and allowances of workers; equipment lcapital equipment; vehicles, purchase, insurance, fuel and maintenance; monitoring and evaluation; supervision; consultancy/technical support or assistance. Clarifying the notion of salary Dr. Befidi-Mengue explained: "This being a project to be integrated into the Primary Health Care structure, il is unrealistic for PHC personnel serving in this project to be considered as full-time workers for CDTI and consequently for their salaries to be 100% budgeted for except where the existing onchocerciqsis programs in the country are vertical". - Facilitator Participants discussed at great length the difficulties encountered in using the current guidelines. It was felt the initial guidelines provided did not sufficiently clarify what TCC expected in the budget section. To address this concern, APOC was also requested to provide specific guidelines for the budget section of the proposal. It was also pointed out that, further dialogue and clarification is needed on when an NGDO should pull out or devolve its activities in a project as there remains confusion in this regard. A participant asked: "Are we expecting the NGDOs to prtll out after five years? What happens afier and the conmtuniry is not sensitized enough"? - Participant 5.4.3. Recommendation (i) The proposal should show a decrease in cost per person treated, decrease in external support, an increase in government support, and in the number of persons treated over the five year period; (ii) The community contribution to the CDTI should be monetised, described and where appropriate, costed but not included in the 25% national contribution from NOTF to the project budget; (iii) Support requests for central office should be provided separately from individual pro.iects budgets; (iv) Cost per treatment should be not rnore than 20 cents per person treated per year by the 5th year 5.4.4. Guidelines on Financial Adn-rinistration Mr Miller started the discussion by highlighting the various stages through which a proposal passes before it is approved for funding. Given that a project has been approvcd, he outlined thc necessary procedures for disbursing funds as: (i) ( ii) ( iii) 10 signing Letter of Agreement recruiting accounting personnel opening bank account a 5.4.5. Financial management of APOC funds Mr Miller also emphasised that all disbursements had to meet the requirements of WHO's financial regulations. Below are some of the key elements of financial management of APOC funds which Mr Miller shared with the participants (see Annex 5 for the outline of his presentation).(i) Financial management of APOC funds, the WHO Imprest Accounting System is strongly recommended as the system of choice. For this sytem:(ii) WHO will provide the necessary procedures along with appropriate forms/software for finance reporting. Also, back-up services will be available in the nearest WHO Representative's Office.(iii) Central/states/Local government/district/NGDO bank accounts must be properly set up to receive and administer funds.(iv) Financial flows from the central offices (NOTF) to the projects need to be set up with at least two signatories for each account.(v) Signatories at the central level may be up to four to ensure that bank transactions are not held up by unavailabiliry of a signatory. The WHO Representative is a very acceptable signator.(vi) Capital equipments will be purchased by WHO, either through the central Purchasing Office in Geneva for overseas purchases or through the WHO Representative for local purchases within the country.(vii) All projects are subject to periodic WHO or APOC audits. 5.4.6. Auditing NOTF account On auditing, Mr Miller noted that APOC funds are subjected to WHO internal and external auditing, and APOC scrutiny. Participants were advised that budget proposals for the central NOTF offices should be made separately from project budgets. Also, participants were encouraged to submit project budgets to APOC on diskettes, as well as on paper. 5.4.1. Technical assistance to NOTF On the issue of technical assistance, participants stressed that to avoid misallocation of funds, ample attention must be directed to details and clarity in the guidelines on the nature of technical assistance. The group requested that detailed information on this issue be circulated to all NOTF partners by the APOC management. Sorne participants observed that the messages, explanations and presentations have been very informative. It was resolved that local technical experts should be involved and preferred rvhere they are available. 5.4.8. The group also recommended that: (i) No partner should taiI to contribute to the project. Full participation of government is to be achieved through high power advocacy. Governrnent of participating eountriL-s to institute duty free systern lor procuremeut of ivermectin in country as in the signed memorandum. (ii) ll 5.4.9. Country financial flow charts During the country specific group work session, each country delegate reviewed its proposed financial reporting system as an aftermath of the dialogue during plenary. Country rapporteurs presented at the next plenary session their proposed financial flow charts Annex 6) for APOC funds from the central to district/LGA levels and their proposed administrative/financial reporting system. On this note, following the presentation by the Malawian delegates, participants raised a concern about the signing, approving and/or clearing of bank checks by the same accountant. According to good accounting practice, the accountant should not be both the authorizer and signatory to the same payment document. There was also the concern raised about the non-involvement of the NGDO at the district level account. It was not clear why the NGDO partner was not involved at the district level. Unfortunately, this issue could not be addressed since no NGDO representative from Malawi attended the workshop. 5.5. Drug procurenrcnt and circuit of delivery to communities 5.5.1. Mectizan flow The delivery system of ivemectin had already been established in the four countries before the workshop. Participants rvere briefed by delegates from the countries on the choice of delivery system. It was expected that the chosen method is not vertical to existing circuit of delivery; is efficient, safe; ensures timely delivery to the communities. The forum provided another oppornrnity for participants to re-examine the proposed method of delivery during group work and in a few cases modification were proposed. For example, to cut down the expenditure in the delivery of ivermectin from central to district, participants from Uganda at this workshop suggested a modification which allows the District Medical Officers (DMOs) from the affected districts to collect ivermectin together with other drugs from the National Medical Stores in Entebbe or from the Office of the National Store in Kampala and will be authorised to deliver directly to the Health Unit stores (health facilily closet to the communiry) By this method two levels would be by-passed cutting down cost and improving on speedy delivery. 5.5.2. During plenary, participants recommended that: (i) The NOTF partners should ensure timely delivery and accurate retirement of Mectizan previously supplied. ( ii) In order to better synchronize availabilily of Mectizan with distribution in the field, the NOTFs should submit early applications to Mectizan Donation Program (MDP) (at least 5-7 months before anticipated delivery). ( iii) Decentralization of drug collection point in country is essential (like the vaccines distribution system). (iv) The procurement of Mectizan needs to be streamlined, efficient and rvith rapid deliverv to the community. This process should be regularly reviewed. tz 5.5.3. Storage and Safety of Ivermectin Country-specific group reports on Mectizan procurement, storage and delivery indicated many similarities between participating countries. Participants recommended on the following: (i) Appropriate storage facilities should be provided at all levels/points to ensure that the potency of the drug is retained. (ii) Efforts should be made at all levels to minimize diversion of drugs into the open market. There is a need for adequate security. (iii) Provision must be made for the safe keeping of Mectizan in the communiry for one month to allow the treatment of the temporary ineligible and absentees. (iv) Mectizan supplies should be stored away from direct sunlight Adequate training should be given to the distributors to ensure Correct dosage Adherence to eligibility criteria Adequate management and referral of adverse reactions Adequate information is passed to the community members 5.6. Approaclirtg tlrc community and distribution of ivermectitt "The problem in the field is not at the communiry level, it is somewhere else. The community have the disease. They appreciate the programme" - Parlictpant In Uganda, Malawi and Tanzania, rapidly spreading decentralization process through health sector reform and development of local health systems should fuel the process of communify participation in and ownership of Communiry Directed Treatment with Ivermectin ( CDTI). In Nigeria, decentralization measures are already in place although other elements (e.g commitment from government) are needed to help shore up the process of community participation in CDTI. It was agreed that, community participation will be realised but a lot depends on the composition of the team and the manner of approach during the first and subsequent visits to the communities. Sustainment of community participation sliall depend on the performance of other partners. "CDTI will succeed if communities are allowed Io excrcisc authority and control over decisions and resources"- Facilitator "Comnunities are the backbone of APOC partnership". This message lrom the APOC training video was reiterated by the 'uvorking groups during the presentations centred around the following thenrcs: O o o o 13 - Re-orientation of attitude of all implementors to consider ownership of CDTI at different levels - How to orient field staff: CDTI is not a means to accruing per diems/ allowances - Approaching communities: the right way and the right messages - Getting communities to assume fully their responsibilities in CDTI implementation - Payment or not of Community-based distributors ( CBDs); Cost-sharing and cost-recovery - Guaranteeing communiry compliance for several years (i.e beyond the period of the "feeling of well-being)" 'lf cost sharing is an issue, community should determine in what way they would share in the cost. In case of cost recovery, community must make the decision what its contribution would be". Participant PresenLations from group work showed the needs and concerns of the community were firmly placed at the forefront of the discussions. The need for advocacy at all levels echoed in all the presentations. 5.6.1. In view of the CDTI approach, participants recommend the following action to be undertaken (i) Orientate existing and new Onchocerciasis Control Programmes to the new strategy of full community participation in and ownership of the project. (ii) Ensure that communities and other partners accept responsibilities related to CDTI and assure compliance over a long period; adequate and consistent advocacy and health education should be provided at all levels. (iii) Encourage non- payment of incentives to CBDs by external sources, rather communities should be allowed to decide on the issue of compensation/incentives for their distributors. (iv) Use Communiry-based trainers and supervisors of o*rer health activities for CDTI supervision (v) Encourage ownership of the CDTI at all levels of implementation not just at the community level. It was suggested that by so doing, actors at levels above the community would begin to identify with CDTI as their program and refrain from taking undue advantage of the projects through per diems and allowances. Further, the group recommended that (vi) The socio-culnrral norms and practices of the people should be taken into consideration when approaching the community to introduce the concept of CDTI. The team approaching the community should be as simple as possible, without giving impression of overt wealth (e.g. moving with a large convoy of vehicles). t4 Don'ts to approaching communities - don't go to the village with too many vehicles - don't present yourself rich - don't by pass local authority - don't impose yourself, your ideas - don't promise payment of CBDs - don't exploit the people - Recommendation 5.7. Integration into the health service A systematic neglect of health facilities located at the level of the community was of concern to participants. The second concern related to scarce resources of the health facilities. Integration of the projects into a weak and non-functional system may jeopard:r;e the success of CDTI some argued. "We know that ivermectin is ffictive, that the community is not the problem. The inability of the health system in the regton to assume fully its responsibilities as a partner, is our concern ". Clarifying these concerns further a participant asked: Is there any room for disaster in APOC funded projects? Why should we integrate CDTI into a non-functional PHC system? At plenary and group work sessions, participants discussed at great length the benefits and drawbacks of integration into existing health care systems. Participants referred to the political and logistic difficulties in achieving sustainability of CDTI projects through integration into PHC/health care systems. It was argued also that the benehciary district or Local Authoriry are often short of resources even where the political support is transparent. Sorne supported the idea that CDTI projects should be the springboard for strengthening the existing health systems. Others were afraid the risk may be disastrous. " How to ensure that both the central and secondary levels assunrc leadership responsibility (irtcludingfinancial) , tltis is our nlost serious problem" - participant In addressing these concerns, some of which were ethical, the facilitators emphasised that for sustainability of CDTI, projects need to be integrated into existing health services; tltere should be no vertical systenl. 5.1.1. CDTI activities for integration Activities which ought to be integrated into the health service include among others (i) ( ii) (iii) (iv) (v) Storage of ivermectin at the health facility nearest to the communit-v Supervision of the ivermectin distribution exercise Assisting with the training of community chosen distributors Management of cases of severe reaction and referral of these cases to hospitals Record keeping and reporting to the district levels l5 5.7.2. SIqDS towards irftepration It was stressed that health workers should be sensitized to be active in CDTI, trained and assigned to carried out the above functions as part of the integration of the process of CDTI into existing health service. Communities should be encouraged to support and help revive the health system nearest to them During group discussions, the following steps toward integration were identified: (i) (ii) (i ii) (iv) (v) (vi) Identification of health structure/institution Identification of level of integration (i.e. district or LGA) Sensitization of health staff/re-orientation Advocacy to health planners and managers Where PHC/health system is functional, use existing strucrures and resources on the ground for the implementation of CDTI activities e.g use village health workers Where PHC/health system is not functional, use CDTI as an entry point upon which PHC/health system could be built. In this case, train CBDs, involve community based organizations; where village health committees do not exist create one. Integrate training of CBDs into existing training activities for other health progralrlmes. Using existing or setting up health communities for CDTI as well as PHC/health services (vii) (viii) 5.7 .3. Benefits of integration and sustainability of CDTI projects The benefits of integration were also highlighted. An example of the benefits is the use of data collected from ivermectin distribution for planning and implementation of immunization services. It was asserted that implementation of APOC assisted onchocerciasis control activities in an area where there are no health services should provide an opportuniry for the communiry to develop grassroots support for liealth services. Participants also observed that: (i) Linking CDTI with other community-based health activities will further enhance sustainability.(ii) By involving district/village health communities as interface between existing health care system and CDTI activities a productive integration can be achieved.(iii) Re-orientation, training and education of health care staff at community level, giving them some supervisory roles will give them a sense of belonging. Finally, the group agreed:(iv) It rvas important to ensure that CDTI is integrated into a health system that is self-sustainable (v) The closer the integration is to the community the lesser the cost and inversely, the higher the level of integration the higher the cost. (vi) A carefully designed CDTI will help strengthen the existing health care delivery system at the cornrnunity level. (vii) Integration will enable supervisors such as Community Health Extension Workers (CHEWs), and health surveillance assistants, etc to take an active part in supervision, management of adverse reactions and training of trainees for sustainability. r6 5.1 .4. Participants recommended that: (i) For long term sustainability, CDTI be integrated into existing health systems. Such an integration will ernpower the communities and encourage them to own and cater for their own health needs.(ii) Efforts should be made to integrate at levels close to the community in order to reduce costs and ensure sustainability.(iii) Basic principle of integration should be same for all countries but the culhrral and political structures should be reflected.(iv) Political will by government and intense advocacy and mobilisation at that level, explaining APOC strategy of CDTI will facilitate or enhance integration. 5.8. Health education and traintng 5.8.1. Harmonization of Training Methods and Materials Community Directed Treatment fails without community participation. If participation is missing or is inadequate, it is because the health education and training components failed to achieve the set objectives. A joint presentation by Jeff Watson and lfeoma Umolu on Training and Health Education materials for CDTI was based on the Nigerian NOTF's endeavour since 1994 to harmonize almost all aspects of training and health education materials from all on-going distributions.The presentation enumerated steps necessary for producing standardized Health Education and Training packages . These include:(i) Planruing: - Constituting a comminee at the NOTF level which should compnse of representatives at the field levels - Set objectives - Set up commtttees and subcommittees to be drawn from all levels - Identifying consultants ( within or outside the country)(il Implenrcntatiotr: - Hold meetings - Revierv existrng IEC and training materials - Make appropriate recommendations - Pretest - Evaluate - Production and ctrculation of the standardised materials to the various levels(iiil Evaluatiort: - Pretest and harmonisation Working groups deliberated on defining various target and key audiences, messages, methods including pretesting of Training and Health Education materials (Annex 7,8). This provided general framework to enable different countries to modify the training methods and materials according to their localities. 5.8.2. In conclusion, participants recommend action to (r) Itstabhsh a NOTF subcomrnittee to develop ne w materials that may be needed. In this cas, the NO'[F may require thc services of a consultant from or outside the country.(ii) Select and standardize training materials and submission of materials to the NOTF for rcvicw/approval.(rii) Freld Test approved materials; furlher revision and modihcation to be carried out by the NOTF u,ltere necessaty.(iv) Mass produce standardrzed training matcrials fbr usc by all partners rn the country. I t7 5.9. Recording and reportitrg at all levels Recording and reporting are core to the success of the CDTI. Proper records of drug administration and retirement are of utmost importance since these determine our continuous receipt of Mectizan from Merck & Co. Inc.. This was a message from Dr E. Elhassan who gave a brief introduction on the relevance of the recording and reporting to the success and sustainabilify of APOC operations. Dr Elhassan elaborated on essential points such as identiffing the various levels of recording and reporting (details in Annex 9) The expectations at the various levels have to do with what to report, who is to report, when to report, the tools to report with, whom to report to and how to carry out quality control. Expectations at the community, LGA/District, State/Regional and the Zonal./NOTF levels were emphasised. The participants then broke into five different working $oups for discussions. At the end of the working group reports were presented. Difficulties with recording and reporting at the level of the community were highlighted. Participants deliberated on feasible solutions and suggestions were provided either by the partner NGDOs drawn from lessons learned from on-gorng proJects or by the facilitators. The delegates were advised to seek for local solutions or revisit past failures. For example, it was also argued that poor recording by the communify may be because communities do not understand the reporting system designed by external partners; communities method of recording events may be different from that demanded fiom them. Also, communities may not understand why they should record, what they will gain by recording and reporting or why they should adopt external method in place of familar traditional methods especially in areas where the systems of recording already exist. The NOTFs were therefore encouraged to include such issues (e.g identifying acceptable but local methods of recording and reporting) in CDTI project proposals under operational research. In conclusion, it was agreed that recording and reporting is not only an integral part of CDTI but the core and important for the sustainability of CDTI. 5.9.1. In view of tlie difhculties experienced on the part of the CBDs to fill out Management Information Systern (MIS) forms for recording and reporting on drug distribution, participants recommended that: More tinre be aliocated for the training of CBDs-at least three days in the initial training and possibly less for retraining sessions. (i i) There should be close monitoring of the CBDs by supervisors to ensure appropriate filiing of the forms. Minimum and simple information should be requested from the CBDs At least three CBDs per community of 250 persons should be trained so that there q,ouid be tu,o at any given time. [{orvever, one CBD should be prepared to treat alrproximately 250 persons. (i) (iii) ( ir') (v) (ui) (vii) (viii) t8 As many CBDs as possible should be trained in each community to reduce the load on the cunent CBDs. CBDs shouid use only the register or a simple notebook for recording and reporting. The note books should be affordable by the communities. The notebook should contain the following information: o Head of household o PHC number of household o Information on members of household-(Name of household head, information on members of household - name, sex, age) o Exclusion criteria. The community should be given the possibility of designing their own way of recording and reporting of their activities. This could help to further sustain the programme. For the purpose of uniformity of reporting and recording, it is recommended that NOTF should design a simple and uniform MIS form for the upper levels of the CDTI (LGA/Distnct levels). t (ix) From the observations of some participants on the problem of using measuring sticks lor dosage determination, it is recommended that each local group should develop acceptable measuring tools. Participants agreed that the use of a marked wall is acceptable to most communities. (x) Recommendation is also made that proper training of District/ LGA personnel be carried out for proper completion of MIS summary forms. (xi) The Quality Control exercise is to be based on the activities of the supervisors at various levels. This include supervision of the actual distnbution, completion of the note book or MIS forms. Monitoring of immediate subordinate during the distribution exercise is very necessary. (xii) It was suggested that evaluation indicators be included in the MIS summary forms 6. OTHER CONCLUSIONS AND RECOMMENDATION 6.1. The workshop welcomed the APOC videos on health education/training and advocacy. In this connection participants recommended that: The video on advocacy in Nigeria (Public Service Announcement for urban Audience) be refined and sirnilar versions for other countries produced. The production for other APOC countries should also be locally adapted for effective impact. 6.2. The participants reviewed APOC Project Monitoring forms. It rvas suggested that these need to be further modified and field tested. The final version should be completed once a year. at9 6.3. Designing communication materials with rural women A presentation from Drs Ejembi and Tamani of theTDR/ Gender Task Force, on development of communication materials with rural women, was well received by participants. During the plenary session following the presentation the group recommended that: o In the development of health education materials, especially concerning gender disparities in the control of disease such as onchocerciasis, communiry participatory approach should be used to promote and enhance greater acceptance and participation by women and community ownership of the programme. 7. ST]MMARY OF RECOMMENDATIONS 7.1. Rapid epidemiological mapping (REMO) ( page 5) (i) [n each country REMO data needs to be continuously refined and the GIS map updated in close collaboration with TDR/CTD/APOC. (ii) APOC management should ensure that all activities related to the above are well supported. In particular, adequate support should be provided for the transfer of capacity and resources to assist the countries in generating essential data and maps, and ensure that they are widely available to all partners. 7.2. Review of guidelines for national plans and project proposals (page 7) (i) Provision should be made to ensure that community input is incorporated into the proposal (ii) NOTFs should set up a committee to review project proposals before they are submitted to the APOC headquarters; (iii) National Plans should be reviewed and updated as the need arises. The document must provide a basis from which all project proposals should be developed thus providing continuity and consistency. 7.3. Budget and financial management of APOC funded projects (pages 9 & 10) (i) The proposal should show a decrease in cost per person treated, decrease in external support, an increase in government support, and in the number of persons treated over the five year period; (ii) The community contribution to the CDTI should be monetised, described and where appropriate, costed but not included in the 25% national contribution from NOTF to the project budget; (iii) Support requests fbr central oftlce should be provided separately frorn individual projects budgets; (iv) Cost per treatment should be not more than 20 cents per person treated per year by the 5th year 20 (v) No partner should fail to contribute to the project. Full participation of government is to be achieved through high power advocacy. Government of participating countries to institute duty free system for procurement of ivermectin in country as in the signed memorandum. (vi) 7.4. Drug procurement and circuit of delivery to communities (page 11) (i) The NOTF partners shoutd ensure timely delivery and accurate retirement of Mectizan previously supplied. In order to better synchronize availabiliry of Mectizan with distribution in the field, the NOTFs should submit early applications to Mectizan Donation Program (MDP) (at least 5-7 months before anticipated deliverY). (iii) Decentralization of drug collection point in country is essential (like the vaccines distribution system). (iv) The procurement of Mectizan needs to be streamlined, efficient and with rapid delivery to the community. This process should be regularly reviewed. 7.5. Storage and safety of ivermectin (page 12) Participants recommended the following: (i) Appropriate storage facilities should be provided at all levels/points to ensure that the potency of the drug is retained. (ii) Efforts should be made at all levels to minimize diversion of drugs into the open market. There is a need for adequate security. (iii) Provision must be made for the safe keeping of Mectizan in the community for one month to allow the treatment of the temporary ineligible and absentees. (iv) Mectizan supplies should be stored away from direct sunlight (v) Adequate training should be given to the distributors to ensure Correct dosage Adherence to eligibility criteria Adequate management and referral of adverse reactions Adequate information is passed to the comrnunity members 7 .6. Approaching the commupity and distribution of ivermectin (page 13) (i) Orientate existing and new Onchocerciasis Control Progratntnes to the new strategy of full community participation in and ownership of the project. (ii) Ensure that communities and other partners accept responsibilities related to CDTI and assure compliance over a long period; adequate and consistent advocacy and healtlt education should be provided at all levels. a (ii) a o O a ,a 2l (iii) Encourage non-payment of incentives to CBDs by external sources, rather communities should be allowed to decide on the issue of compensation/incentives for their distributors. (iv) Use Communiry-based trainers and supervisors of other health activities for CDTI supervision (v) Encourage ownership of the CDTI at all levels of implementation not just at the community level. It was suggested that by so doing, actors at levels above the community would begin to identify with CDTI as their program and refrain from taking undue advantage of the projects through per diems and allowances. Further, the group recommended that (vi) The socio-cultural norms and practices of the people should be taken into consideration when approaching the communiry to introduce the concept of CDTI. The tearn approacliing the communiry should be as simple as possible, without giving impression of overt wealth (e.g. moving with a large convoy of vehicles). 7.7. Integration into the health service (page 16) (i) For long term sustainabiliry, CDTI be integrated into existing health systems. Such an integration will empower the communities and encourage them to own and cater for their own health needs.(ii) Efforts should be made to integrate at levels close to the corununiry in order to reduce costs and ensure sustainability.(iii) Basic principle of integration should be same for all countries but the cultural and political structures should be reflected.(iv) Political will by government and intense advocacy rnobilisation at that level, explaining APOC strategy of CDTI will facilitate or enhance integration. 7.8. Harmonization of training methods and materials (page 16) (1) Establish a NOTF subcommittee to develop new matenals that may be needed. In this cas, the NOTF may require the services of a consultant from or outside the country.(ii) Select and standardize training materials and submission of materials to the NOTF for revieu,/approval.(iii) Field Test approved materials; further revision and modification to be carried out by the NOTF rvhere necessary.(iu) Mass produce standardized training materials for use by all partners in the country. 7.9. Recording and reporting at all levels (page l7) (i) More time be allocated for the training of CBDs-at least three days in the inrtial trarnrng and possibly less for retraining sessions. 'fhere shouid be close monitoring of the CBDs by supervisors to ensure appropriate filling of thc fon-ns. a 22 (iii) Minimum and simple rnformation should be requested from the CBDs. (iv) At least three CBDs per communify of 250 persons should be trained so that therc would be two at any given time. However, one CBD should be prepared to treat approximately 250 persons. (u) As many CBDs as possible should be trained in each community to reduce the load on the current CBDs. (vi) CBDs should use only the register or a simple notebook for recording and reporting. The note books should be affordable by the communities. The notebook should contain the following information: o Head of household o PHC number of household o Information on members of household-(Name of household head, information on members of household - name, sex, age) o Exclusion criteria. (vii) The communiry should be given the possibilily of designrng their own rvay of recording and reporting of their activities. This could help to further sustain the programme. (vrii) For the purpose of uniformity of reporting and recording, it is recommended that NOTF should design a simple and uniform MIS form for the upper levels of the CDTI (LGA/District levels). (ix) From the observations of some participants on the problem of usrng measurtng sticks for dosage determinatron, it is recommended that each local group should develop acceptable measuring tools. Participants agreed that the use of a marked wall is acceptable to most communities. (^) Recommendation is also made that proper training of Districti LGA personnel be carried out for proper completion of MIS summary forms. (xi) The Quality Control exercise is to be based on the activities of the supervisors at vanous levels. This include supervision of the actual distnbution, completion of the note book or MIS forms. Monitoring of immediate subordinate during the drstribution exercise is very necessary. (xii) It was suggested that evaluation indicators be included in the MIS summary tbrms 7.10. Other conclusions and recommendation (page 18) (i) 'fhe video on advocacy in Nigeria (Public Service Announcenrent fbr urban Audience) be refined and similar versions for other countries produced. The production for other APOC countries should also be locally adapted for effective impact. ( ii) The participants reviewed APOC Project Monitoring forms. It rvas suggested that these need to be further nrodified and field tested. The final version should be completed orlce a year. t I I23 (iii) In the developtnent ol health educatiott lllaterials, especially concerniuq genclct' disltaritics in tl)c c()ntrol 0l'discasc such as onclt()ccrcillsis. cottttttultity participatol'-t approach should be used to promote and enhance greatcr acceptance and community ownership of the progralnme. 8. ACKNOWLEDGBMENTS The APOC Management and the members of the National Onchocerciasis Task force, Nigeria, wish to thank the country delegates from Malawi, Nigeria, Tanzania and Uganda for the dedication and participation at the workshoP. Our special thanks ro Dr. E. Miri and the Gobal 2000 River Blindness Foundation, Nigeria, the Sight First, Nigeria, the World Health Representative/Nigeria- Dr. E. K. Njelesani, Dr. Lola Sadiq, administrative staff and the drivers of the Office of the World Health Representative, Lagos, Dr. Josephine Namboze- Office of the World Health Representative, Entebbe and Dr. F. Kigadye, Christian Social Services Commission, Tanzania, without whose logistic and administrative support this first international workshop would not have been successful. We remain also in-depth to Mrs Patricia Ogbu-Pearce, Dr. Ethassan, Jeff Watson, Ifeoma Umolu, Dr. Nwoke, the facilitators- Drs. E. Gemade, Kale Feyisetan, Henry Edeghere, Rich Umeh and the two members of the APOC Technical Consultative Committee (TCC), Professor O.O Kale and Dr. Rose Befidi-Mengue, rvhose teclinical support was imrnensely valued by the participants. a 24 WORLD HEALTH ORGANIZATION AFRICAN REGION ORGANISATION MONDIALE DE LA SANTE REGION DE L'AFRIQUE AFRICAN PROGRAMME FOR ONCHOCERCIASIS CONTROL (APOC) PROGRAMME AFRICAIN DE LUTTE CONTRE L'ONCHOCERCOSE B.P. 549 OUAGADOUGOU, Eurkina Faso T6169r.: ONCHO OUAGADOUGOU rd (226)302301 -3023 12-3023 13T6lex: ONCHO5241 BFFax.(226)3021 47 ANNEX 1 APOC WORKSHOP ON COMMUNITY DRECTED TREATMENT WITH IVERMECTIN Enugu, Nigeria, 21-25 april 1997 List of participants by country Malawi 01 Dr H. Sonlanje. Ministry of llealth, Mrvanza-lt4alari,r, P O. Box 80 Mn,anza, Malari't 02. N'Ir Fedson Nkhoma Budala, Malamulo Hosprtal PlBag2. Makrvasa-Malau'i 03 N{r Leson S. Katambo, Mrvanza District Ilosprtal. P.O. Box 80, Mu,anza, N'lalau'i 04. N{r Aubrey Fumu l\'[vula, Thyolo Drstrict Hosprtal. I).O. Box 21.'fhyolo. Malarvt 05 N{r Laston D. Sitima. Thyolo Distnct l-losprtal, I' O L]ox 21, 'l'hyolo, Malau't 06. MrPhillimon A.J.Tambala,Thyolo DislrictHosprtal. P.O. Box 21,'fhvolo. Malau,t, Tel: (265) 624448,Fax (26s) 624s26 Nigeria 01 Florence Bashur. Alrrcare, IJomo State. IlltJ.-fel 076-850192 08. Dr. Saka Y.A.. NOCP HQ Lagos, F.M O lJ Lagos. Tel (01-684095 olflce) 09 Dr lbrahirn A Ilalgwi.S M.O II Oncho (--ontrol [)roSramnrc. N{aidugurr 10. Ukam E. Oyene. SMOH CRS CALABAR Nigena, Onchocerciasis Control Progranr, P.O. Bor 2,5,11. Clalabar. N igeria, Tel/Fax. (22281 2) I I. Franca Ukrvunna, Mission to Save the I{clpless Natroual l)rtlect Cordinator. No. 19 Mojidi Street Of[Toyin Street Ikeja Lagos Nigcria, P.O Box l654lkeia. Tel: cio CJR[3P l-agos No 01-4926943-5. F-ar 0l-4926945 t2 I{.Y. Datti;Onclto Unit. MOH Niger I{eadqLrartcrs, \'lrnna Nrgcr.Statc. [)horrc (liorrre ) ()66 ]224.51 I' O []or l5 \lLirrrrr 13 [[eonra Unrolu, i1)lnternational Eye Foundation, Nol Golf Course l{rl Kaduna.'l'elrl;ax.062 231924. (2) CIobal 2000 Rivcr Rlinrlncss Proqramme, Jeka Kadirna St Jtts. Platearr State.'l cl 071-4(;0097/461S()l 1'l l)r' I,'liz:rhcl lr I" llt :tss:r rr \1,,fl1 S11r'r'1 < J11r,'r',rr i.,., I .l e l/['ax 062 2 ]til60 ,li-f',i,r',. I),\,,1 I.' , 1,,,., \,,r 15. 16. 11. 18. t9. 20. 21. 22 23 24. 25. 26. 25 Philip Sankwai, oncho coordinator, Ministry otHealth, Kaduna, Nigeria, P.M.8.2014, Kaduna Ganyu Kareem, Africarc Nigeria, P.O. Box 852, Loko.Ja Clressed Godly, Atiicare , Adatnawa, P.O. Box 4999, Itmeta, Yola, 'lc[: 015-62405] Husseni M. Hong, State coordinator (Oncho) Ministry of Health, Adamawa, Oncho Unit, MOH, P.O.Box 2078, Yola, Tel: 01 5-624003, 626022 Dr U.E. Udol'a, NOCP/I.-N'IH, NOCP, Zonal Office, Enugu, P.O. Ilox I04,'lel: 042-258441 Mr J.A. Adedipe, State Oncho Coordinator, Ondo State, Ministry of t{ealth, Akure, Ondo State Mr T.Y. Olaoy'e, Ministry of Health, Ibadan, Ministry of Health, Ibadan, Oyo State I\{r T.O. Adefarakan, State Oncho Coord. OSHOGBO, Ministry of I-Iealth, Osun State Mr 8.O.0[ominu, World Vision Intemational, Ogbomosho, Oyo State, Tel:038-72001 1. Fax l20104 Chin1ve U.T. Uva, State Oncho Coordinator, Epedem-tological Unit, Mrnistry of Health, Makurdi, Benue State; or P.0. Box 665, Makurdi, Benue State, Telfax: 044-533121 or 044-53i813 Dr J. Jiya, National Cloordinator, NOCP Nigeria, Federal Ministry of FIealth, Lagos, Tel:01.684095 (officc)- 01 -680943 (Ilouse) - 090-404163 (Mobile) Dr J.L. Akoh, Zonal Programme Manager, NOCP Zonal Office, BauchiFederal Ministry of Health, PMB 0291, Je ka Road, Bauchi, Nigeria or c/o Department of BiologicaI Sciences, University of Agriculture, Makurdi, Nigeria Dr Jolrn lbenu, Oncho Coordinator, Ministry of Health, Lokola, Kogi State, P.O. Box 622,Loko1a or P.l\4.B 1068 [-oko1a, Tel: 058-2204E0. 220 i 55, 220481, 22004 1 Dr Kenrreth Korve, Global 2000 River Blindness Program, Nigeria, P.O. Box 1172, los, Tel: 073-46 1 86 l. 460097. Fax 013-460091 Dr Obadiah A.N{., State Co-ordLnator-faraba Oncho Control, Minisky of Health, Jahngo, Taraba State, Niqcria or c/o CBM Office, 3rd (lor.un'ahk, C--losc, Jos, Nigeria. Tel: 073-456578, Fax:079-23305 Dr Yemi Fayorui, Assistant Zonal Programme Manager, N.O.C.P. Zone C, I Golf Course Rd, Kaduna Tl,rone Gaston, Afl.icare Nigeria, Country Representative, 38 Adeola opervell, Victoria Island, Lagos, Nigeria, Tel.234 (l) 262-0648,Fax 234 (1) 262-0618, e-mail: Afrinig(a)infoiveb.abs.ne t I,rof B.E.B. Nn'okc, NOCP Zonal Coordinator, School of Biological Scienccs, Imo State L)niversity, Ori,crri. PMII 2000 Orverri. Nigeria, -l'cl: (234) 83-230686, F'ax: c/o IINICEF Enugu (234) 42-252100 Mrs['.Ogbu-['carcc.NOCP, ZoneD,JahunRoad,PMB.029l,Bauchr,'l'eI 077--543769Bauchi 1\,lr A.O. JaiS,cotra, I'erleral Ministry of Health, Oncho Control Programnrc. Il-Zonal Office, 2 Olade.lo Adigun [{oad. Jcricho, Ibadan I)r Clara Ladi lljenrbi, Deparhlent o1'Con'rrnunity Mcclecine, Alir.naclu llcllo Ljniverstly, Zarra, I'el: 069-50280 a 21 1n 29 30 31 32 33 1+ _l -5 ,36. 31 38 26 Mr Watson Jeffrey S., Christoffel Bhndenmission (CBM) 3A Gomwalk Close, Jos, Nigeria, Tel 234-13-456578, Email <Jeffwatson@maf.org> Tamani Yusuf, Kaduna State Media Corporation, Tel062-238707, Kaduna Mr. Tom Ubuane, AfricareAiigeria, 38 Adiola Hopewell, Victoria Island, Lagos, Tel 234-l-2620648 40 Tanzania 39 Dr S. B. Katenga, Tanzania, National Onchocerciasis Control Coordinator, Ministry of Health, P.O. Box 9083, Dar-es-Salaam, Tel:255-51-23676,Fax:255-51-39951, Email IMATZ@MAF.ORG Mr G.M. Kassiga, Project Coordinator Kilombero and Manager Districts, St. Francis Dislrict Desrgnated Hospital, P. O. Box 7 3, Ifakar a, Morogoro-T anzania, Emai I : sysop@tanz.healthnetorg 41 Dr Glen R. Brubaker, REP. IMA, I077GYSY Hill Road, Lancaster, PA-17602,717-391-1411, Email GRBRUBAKER@AOL.COM 42. Dr Kabuka W.A., Ruvuma Onchocerciasis Control Pro.1ect, P.O. Box 5 SONGEA,Tanzania,Telr:635-2698 43 Dr Kigadye F.C., Director, Christian Social Services Commission, P.O. Box 9433,Tel: 051-21120 & 051- 1 12918, Fax: 05l-44866, Email CSSCTZ@MAF.org. Dr Kirumbi E., Deputy National Onchocerciasis Control Programme Coordinator, P.O. Box 9083, Dar-es- Salaam, Tanzania Uganda 45. Mr Byarullanga Cosmas, District Onchocerciasis Co-ordinator, P.O. Box 67, Tel 0465120207 Masrndi, Uganda 46. Edrvard Banoba, District Oncho Coordinator, Ministry of Health, P.O. Box149, Kasese, Uganda 47. Steven Kasolo, Oncho Programme Coordinator, Sight Savers Intemational, P.O. Box 21249, Kampala, Uganda 48. B),enume Fredrick, District Onchocerciasis Co-ordinator, P.O. Box 73 Hoima,Uganda 49. Okwero Peter (Dr), Sight Savers International (Uganda), P.O. Box 21249 Kampala, TeVFax 256-41-542536, Email Savers@ Starcom.co.ug 50. Ruzaza Christopher , Ministry of Health Uganda, Vector Control Division, P.O. Box 1661, Kampala 51 Dr Ilichard Ndl,omugyenyi, NOCP Coordinator, Uganda, P.O. Box 166 I. Kampala 52. Dr J. Namboze, Disease Prevention and Control Medical Off iccr, Wf{O/Uganda 53. Dr D. Mutabazi, Global 2000 Representative, Uganda Facilitators Dr. E. I. Gemadc, IINICEF,30 A Oyinkan Aba1,omr. Drive. Ikovi. Lasos,]'el.(2341) 2690276-80, lrax: (2341) 2690126) 44 54 60 21 55 Dr. H. Edeghere, NOCP Zone C Kaduna Nigeria, I Golf Course Rd. Kaduna, Nigeria, T el: (0 62-21 3 432; 237 925, Fax : (0 62-237 924), Home : (0 62 -2 | ll 64) 56 Dr. B.J. Feyisetan, Dept. of Demography and Soc. Stat. Obafemi Awolowo University lle-Ife, NIGEzuA, Tel/Fax 234-36-231071, e-mail bfeyiseteogu.net 57 Dr. R.E. Umeh; Dept. of Ophthalmology College of Medicine, Universily of Nigeria Enugu Campu, Enugu, Tel: 042-455841, Fax: 042-455841 58. Emmanuel S. Miri, Global 2000 River Blindness Program, Jeka Kaduna Jos, Plateau State TCC MEMBERS 59 Prof. O.O. Kale, Chairman TCC/APOC, University College Hospital, Tel/Fax: 234-2-81003971234-2- 8 I 03563, Ibadan, Nigeria Dr Rosa Befidi-Mengue, TCC APOC, National Epidemiology Board, Cameroon,8.P.4416, Yaounde, Cameroon, T el: (237 ) 22 - 64 -09, F ax: (237 ) 22- 64 - 12, E- mail RB EFIDI@Cam. health. org. APOC STAFF, GENEVA 61 . Daniel Etya'ale, WHO/PBD/APOC, Geneva 2l , CH 121 1, Srvrtzerland APOC STAFF Dr Uche Amazigo, OMS/APOC, P.O. Box 549, Tel: (226) 30-23-12130-23-13130-23-01, Ouagadougou. Burkina Faso 63. Mrs Edith Kabore, OMS/OCP/APOC, B.P. 549,Tel:30-23-12, Fax: 30-21-47, Ouagadougou, Burkina Faso Dr Mounkaila Noma, OMS/ONCHO/APOC Ouagadougou, P.O. Box 549, Burkina Faso Tel:(00226) 30-23-01 Email noma(@.ocp WRs OFFICE LAGOS 6s Dr L.K. Sadiq, WHO, Lagos, P.O. Box 53649, Falomo. lkoyi, Lagos, Tel: 861504 (office), 2692495 (home) Fax:01-2694903 66. Moses Nwaogugwu, WHO, Lagos, P.O. Box 53649, Falomo, Ikoyi, Lagos, Tel: 861504 (office) 61. Audu Erakhifu, WHO, Lagos, P.O. Box 53649, Falomo, Ikoyi, Lagos, Tel: 861504 (office) 68. Kola Agbeye, WHO, Lagos, P.O. Box 53649, Falomo, Ikoyi. Lagos, Tel: 861504 (otfice) SECRETARIAT WOIIKSHOP 69. Mr. N. Umeh, 2 Braithewait Avenue, Universily of Nigerra, Enugu Campus, Nigeria N{s Comtbrt Onoh, Ophthalmology Department Unrversity of Nrgeria Teaching Hosprtal, P.M.B. 01129 I:nLrgLr, Nigcrra 62 64 70 5 28 ANNEX 2 WORKSHOP AGENDA : *ondav 2tt04te7 r 1. Opening Ceremony--------- 08H00 -09H00 Chairman: Dr. E. K. Njelesani (WHO Representative in Nigeria) Rapporteurs: Mr. T. Ubuane (Africare, Nigeria) : Mr. Laston Sitima (Malawi) Workshop Agenda, Objectives, Expected outcome (Dr.U. Amazigo) Keynote address by TCC Chairman (Prof.O. O. Kale) APOC Training video film-- Z. Plenary session (Discussion) Coffee break: 10H30 - 10H45 3 Partnership and REMO Chairman: Dr. Rosa Mengue-Befidi ( Carneroon, TCC Member) Rapporteurs: Mr. P.tzaza (Uganda) Mr. O. Jaiyeoba (B Zone, Nigeria) Partnership: by NGDO Coordinator- Dr. D. Etya ale A Review of Proposals submitted by NOTFs - Dr Uche Amazigo Rapid Epidemiological Mapping (REMO): Dr. M. Noma Information collection for database at APOC HQ 09H30-10H30 10H45 - 11H20 11H20 - 13H00 14H30 - 16H15 1(rH30 - 17H.30 Discussion 4 Lunch break : 13H00 - 14H30 National Plan and Project Proposal Guidelines on National Plan and Project Proposal 5 Working groups by country teams Coffee break: 16H15 - 16H30 5. CoLLntry Working Groups session on National PIan and Projcct proposarl continue.( Writing of country reports/ comments) Presentation of Reporls by Country Rapporteurs (Guidelines on National Plan and Proposal) 6 I 7H30 - 18H30 Chairman: Rapporteurs: 29 Dr. P. Okwero (Sight Savers International, Uganda) Mr. L. Katambo (Malawi); Dr. Y. A. Saka (Nigeria) 7 Tuesday 22104197 Budget and Financial Management....... 8H00 - 10H30 Chairman: Prof. O. O. Kale (Chairman, TCC APOC) Rapporteurs: Mr. E. Banoba (Uganda) Dr. J. I. Akoh (Zone D, Nigeria) Mr. U. Oyene (Zone A, Nigeria)(i) Budget (the Guidelines): Dr. Rosa Mengue- Befidi (TCC Member)(ii) Guidelines on WHO Financial Regulations (e.g Letters of Agreement)(iii) FinanciaVAdministration/ Reporting System of APOC projects from Central to District Levels -Mr. D. Miller (Chief of Administration/ Finance OCP) Coffee break: 10H30 - 10H45 8. Budget and Financial Management ( continued) r0H4s - r3H00 Working groups by country teams on:(D Financial Flow-chart from Central to District levels(ii) Administration/FinancialReportingsystems Lunch break: 13H00 - 14H30 9 Reports from country teams on : Financial Flow-chart & Financial reporling system Chairman: Dr. L. K. Sadiq (WHO, Lagos) Rapporteurs: Mr. Glen Brubaker (Tanzania) Mr. Byaruhanga (Uganda) Coffee break: 16H00 - 16H15 Working Groups by country teams) on: Drug Delivery and Distribution --------j-- Plenary sessior-r (i) Post test by participants(ii) Recommendation (iii) Other Administrative and Budgetary matters Wednesday 23104197 Approaching the Community; Community involvement and ownership of CDTI 10 11 14H30 - 16H00 t6Hl5 - 17H30 17H30 - 18H30 t2 8H00 - 10H30 I I, t 30 Brief Introduction - Dr. B. Feyisetan Chainnan: Dr. R. Ndyomugyenyi (NOTF, Uganda) Rapporteurs for the session: Dr. Kubuka (Tanzania) Dr. A.M. Obadiah, (Nigeria) Working groups on: Approaching community Community involvement and ownership of CDTI (l4tith special reference to reorientation of on-going proiects Lessons front participating NGDOs) Coffee break: 10H30 - 10H45 13 Reports of the working Groups on:Approaching community Community involvement and ownership of CDTI Cl'rairman: Dr. R. Ndyomugyenyi (NOTF, Uganda) Rapporteurs: Dr. Kubuka(Tanzania) Dr. A.M. Obadiah, MOH, Taraba State 14 Working groups on Storage and Safety of ivermectin Plenary sessiort orz Storage and Safety of ivermectin at all levels Introduction by: Dr. E. Gemade Mr. Fedson Nkhoma Budala (Malawi) Chainnan: Dr. E. Kirumbi (Tanzania) Rapporteurs: Dr. Elizabeth Elhassan (SSI, Nigeria) Ms. Franca Ukwunna (Mitosath, Nigeria) Lunch break: 13H00 - 14H30 15 Integration into the Health Service---- Brief Introduction - Dr. J. Jiya and Dr. S. Katenga (Tanzania) Chairman: Dr. J. Namboze (WHO, Uganda) Rapporteurs: Dr. H. Somanje (Malawi) Dr. Y. Fayomi (Zone C, Nigeria) 16 Working groups on integration into Health Service--------- Coffee break: 16H30 - 16H45 17 Plenur.v sessiott or Integration into the Health Service--------- Plenary sessior-t on Monitoring/Evaluation Fonn-- Working Group session on Monitoring/Evaluation Form 10H45 - 11H30 11H30- t2H30 12H30 - 13H00 14H30 - 15H00 15H00 - 16H30 16H45 - 17H30 18 17H30 - 19H00 31 Thursday 24104197 TRAINING AND HEALTH EDUCATION Plenary on Harmonization of Training /Health Education methods and materials Brief Introduction by Ms. [feoma Umolu 08H00-08Hi5 Chairman: Dr. P. Tambala (NOTF, Malawi) Rapporteurs: Mrs. P. Ogbu-Pearce (Zone D, Nigeria) Mr. Banoba (Uganda) Brief Discussion: What we expect from the working groups 08H15 - 08H30 I t9 zt 22 I 20 Working groups: Training & Health Education methods and materials Presentation by Dr. Ejembi and Tarnani Yusuf (Developing communication materials with rttral women) Coffee break: 10H30 - 10H45 Recommendation on harmonization of Training methods and materials Chairman :Dr. E. Miri (Chairman, NGDO Coalition) Rapporteurs: Mr. Kasolo (Uganda) Mr. G. Kareem (Africare, Nigeria) Mr. G. Kassiga (Tanzania) RECORDING AND REPORTING AT ALL LEVELS Brief introduction by Dr. E. Elhassan Working groups on Recording and Reporting ( at all levels) Chairman: Dr. J. Jiya (Nigeria) Rapporteurs: Dr. J. Ibenu (Zone C, Nigeria) Dr. H. Somanje (Malawi) Lunch bresk: 13H00 - 14H30 Recotnmertdatiotrs Recording and Reporting ( at ull levels) Chainnan: Dr. J. Jiya (Nigeria) Rapporteurs: Mr. Mr. Byemunumi (Uganda) Dr. Y. Fayomi ( Nigeria) 23 24 08H30 - 10H15 10H15 - 10H30 10H45 -i 1H15 1Ihl5 - 11H30 r tH30 - 13H00 25 Coffee Break: 16H15 - 16H30 14H30 - 16H00 26 27 Departure by the Uganda and Tanzania delegations Report writing by country teams------- (Nigeria, Malawi) Coffie break: 10H30 - 10H45 28. Reporl writing by country teanrs continue--- Lurtch break: 13H00 - 14H30 29 Review of country team recommendations Other matters SUBMISSION OF COLTNTRY REPORTS SUBMISSION OF FACILITATORS REPORTS Saturday 26104197 - DEPARTURE 32 Plenary /Cottclusions and Recommendatiorts :------------- 16H30 - 19H30 ( major workshop issues) Presentatiotts by Facilitators: SUMMARY OF THE WORKSHOP SUBTHEMES Chairman: Dr. Katenga Rapporteurs: Mr. Jeff Watson (CBM, Nigeria) Prof. B. E. B. Nwoke Friday 25/04/97 I 07H00- 07H30 09H30 - 10H00 10H45 - 13H00 14H30 - 16H00 16H00 - 19H00 tJJ ANNEX 3 EXERCISE ON CALCULATING POPULATIONS - by Prof O. Kale The LGA/District of JOLLOF in the Province/State of ISIEWU has an established (census) population of 100,000. There are 64 discrete villages/communities in JOLLOF. Out of these 48 are known to be endemic for onchocerciasis. No transmission is known to occur in the remaining 16. The population of the 16 no n- endemic villages is 20,000. A Rapid Epidemiological Assessment (REA) conducted as part of REMO showed that20 of the onchocerciasis endemic villages/communities were hyperendemic, 10 mesoendemic and 18 hypoendemic. The combined population of the 18 hypoendemic villages/communities in 30,000. The CDTI programme project opts to institute treatment in only the hyper and hypoendemic communities, in accordance with APOC Guidelines. In these "to be-targeted" villages/communities 20% are made up, at the time of treatment, of (i) children below 5 years (ii) mothers in the first week of lactation and (iii) people classified as very sick. The total number of persons treated in our cycle of ivermectin treatment was 30,000. Please answer the following questions I 1 2 J 4 5 6 What is the TOTAL population? What is the "AT RISK" population? What is the TARGET population? What is the ELIGIBLE population? What is the TREATED population? What is the % COVERAGE? in how many villages? in how many villages? in how many villages? in how many villages? in how many villages? in how many villages? POPULATIONS-GETTING THEM RIGHT Scenario AII the people of a district/LcA or any specified geopolitical unit make up the TOTAL POPULATION. There are 100 villages/communities settlements or any specified unit of conglomerate habitation. Out of these 100, onchocerciasis is endemic (i.e. cases are known to occur, and transmission is presumed to take place in 80. The total population of these 80 villages represent the population "at risk" of onchocerciasis. Following REMO and Rapid Epidemiological Assessment 40 of these 80 villages are classified as hyperendemic for onchocerciasis; 25 as mesoendemic and 15 as hypoendemic. 34 A CDTI projecr in accordance with APOC guidelines decides to limit it's ivermectin distribution prograrnme to the hyperendemic and mesoendemic communities only. The combined population of the 40 hyperendemic and 25 mesoendemic communities constitute the TARGET population (i.e. population targeted for mass ivermectin treatment). This "target" population is made up of children and adults men and women, pregnant women lactating women and well and sick people. When the Mectizan exclusion criteria are applied, children under 5 years or less than 15 kg or shorter than 90 cm, as well as lactating mothers, in the first week of lactation, as well as those who are very sick will NOT be given Mectizan. All those left in the 65 villages after exclusion criteria have been applied, constitute the ELIGIBLE population i.e. Target population minus those excluded. After a cycle of treatment has been concluded the number of (eligible) persons treated equals the TREATED population. COVERAGE for the given cycle of treatment is calculated by the equation No. of persons treated x 100 No. target population Note that even though the more appropriate denomination is "eligible" population, this is not used because it is an infinitely more difficult (and innately less accurate) figure to obtain. It is conceded that populations with a large number of ineligibles, (like children under five), will tend to record smaller "coverage" rates than those with fewer ineligibles, even though the proportions of eligibles treated are the same in both settings, because the denominator is proportionately larger in the former. Answer to the exercise on calculating populations I I 1 2 3 4 5 6 What is the TOTAL population? 100,000 What is the "AT zuSK" population? 80,000. What is the TARGET population? 50,000. What is the ELIGIBLE population? 40,000. What is the TREATED population? 30,000 What rs the % COVERAGE? 60%... in how many villages?. in how many villages?. in how many villages?. in how many villages?. .in how many villages? 64 48 30 30 30 ,l 35 ANNEX 4 PARTICIPANTS VIEWS ON CARRENT APOC GAIDELINES Background information (page 9):- i) Instead of what is the PHC system in your country; it should read:- Describe the PHC system in your country. Some participants further argued that the concept of PHC should be broadened to "health services" ii) Instead of what is the estimated population at risk; it should read: Define population in terms of a) Total population b) Population at risk c) Target population d) Eligible population ii i) Time plan:- We need to rephrase the question to cover all aspects. In section J.,l:- The following addition was suggest: indicate the source of funding iv) On Budget Add:- If there is an existing ivermectin distribution programme mention the current expenditure including capital equipment present on ground. v) Appendix 2:- Total budget should be provided Participants suggested modifications in the following sections: 36 ANNEX 5 APOC WORKSHOP ON COMMUNITY DIRECTED IVERMECTIN DISTRIBUTION - ENUGU, NIGERIA. Guidelines on WHO Financial Regulations and Administrative conditions precedent to disbursement of APOC Funds Presentation by M. D.E. Miller, CAM - OCP/APOC -22 Apnl1997 - 1. INTRODUCTION : THE GENESIS OF A PROJECT PROPOSAL Think of a project and write it up. It could be a humanitarian project, a govelrlment investment project. You may even write up what you are already doing, as a project proposal. (b) Submit it to a sponsor or funding agency. The first sponsor, takes so long to answer, you submit it to a second and third funding agency without success. t I (a) (c) (d) The fourth sponsor says yes, but could you rewrite it a little differently, so that his Committee or Board will pass it for funding. (e) Then you rewrite it to keep what you want and add what that agency policies can accept. You may even leave out some items which they cannot accept, but which you can get funded by another means, e.g. the goven-tments. (0 Then the funding agency says "YES". The project is approved for funding 2. GUIDELINES ON WHO FINANCIAL REGULATIONS (a) Your project has at this point been properly prepared and approved for funding. (b) So you write to the funding agency a nice letter saying piease send me a cheque for tire amount of the project. This letter sets off a whole nerv system. People who have no technical knowledge of your project, now enter the process. (c) The accountant in the funding agency says he needs some kind of signed document, on the basis of which he can write a cheque. In WHO this document could be a "Letter of Agreernent" or a "Technical Sen,ices Agreement" or sornc othcrs rvirich need not detain us here. I wish simply to show the group assembled here the Letter of Agreement signed by Uganda. So it will happen. Other people in this room will certainly be signing Letters of Agreement in the near future. (d) 37 This is the first "CONDITION PRECEDENT TO DISBURSEMENT". If it is not met, there will be no disbursement. No cheque. I a (e) There are other conditions precedent to disbursement. If you are an NOTF or an NDGO, you must exist as organisation. You must have named officers who can be identified. You must have an address and office infrastructure and means by which you can be contacted during normal working hours. APOC insists that you must have a bank account; WHO prefers to pay monies into bank accounts, to lay down an audit trail. It is from the record of this bank deposit, that the audit of the use of the funds will start. APOC also insists that a viable accounting system must exist. WHO is accountable for the funds entrusted to its care. So there is some correspondence between yourself and APOC to establish that the "Conditions precedent" have been met. The accountant has been appointed, the bank account has been established and the signatories have been named, etc... Now APOC has to decide HOW MUCH they should transfer to your bank account. The WHO rule says that if the amount to be paid to the NOTF in a year exceed $ 100,000, it must be paid in installments. So looking at the cash flow set out in your budget, APOC may decide to make the first installment to cover 6 months expenditure. 0) I will return to the question of your detailed budget a little later After you have spent the two-thirds of this first installment, you will apply to APOC for more funds, because the first installment is really an imprest. (l) APOC wishes the amount requested to be the re-imbursement for the amount you have already spent, up to the limit of the total amount approved for the year. The expenditure made must be justified by your accountant to the satisfaction of the WHO-APOC accountant. (m) WHO has an IMPREST accounting system, which can be run on a micro-computer. It reports expenditure EVERY MONTH. It is used in all WHO Representatives Offices. For this reason, APOC would propose this WHO IMPREST ACCOLTNTING SYSTEM as the preferred choice. If there is a technical or accounting problem, you can get help from the WHO Representative's Office, in any of the countries. (n) The question of six-monthly financialreports willbe easy, if you use this accor.rnting system. This is a normal accounting system. All the NOTF zrccountants who have looked at it, are llappy to adopt it. The documentation is simple. When you pay for something, it should be documented that you ordered it, that you received it, that it was approved for payment and finally that it was charged out against the correct itern in thc budget. (0 (e) (h) (i) (k) t_ 38 3. BUDGET AND AUDIT (a) The budget proposals which were sent in by Uganda, Malawi and Nigeria were done on micro computers using spreadsheets. It is clear that everyone was familiar with budgets, budget lines and cash flows. We did not have any problems at that level. (b) We would appreciate a copy of the diskette with the budget, when possible, indicating whether it is done on Lotus or Excel or ??? whatever spread sheet software you used. (c) We had problems with the 4 Nigeria projects because they did not explain the amounts put into the budget for each project. They simply said "Please refer to the National Plan" which contained the unit costs and the global totals for say vehicles. Sometimes it was difficult to unravel a particular amount in the budget. Some items will not be accepted for FLINDING by APOC. So they will be deleted fron-r the colum for APOC funding. Dr Befidi has explained already that office rental, office furniture, refurbishing of buildings etc will not be accepted for APOC funding. I (d) (e) APOC will purchase the capital equipment through WHO's world-wide purchasing system. We will ask the WHO Representative to purchase locally, the small items such as photocopiers, and hand them over immediately to the NOTF. Title of ownership will pass to the NOTF immediately. Vel-ricles we are likely to buy through WHO headquarters since we will not pay $ 76,000 for a vehicle which we can deliver for $ 38,000. These are actual figures. WHO buys by competitive bidding. This is why we ask for 2 or 3 proforma invoices from local companies. The presence of a local proforma invoice is reassuring in that it suggests that after sales service will be available. Whenever APOC approves local purchase at a higher cost, the goods must be already in thc country and the additional cost must be justified, (usually on the basis of time being saved), and payment must be made in local currency. These are a few thoughts on BUDGET. AUDIT In accordance with WHO rules, all expenditures of funds entrusted to APOC are subject to WHO Internal Audit, WHO External Audit and APOC local Audit. For the local audit APOC rvill use well known naffIes in the audit field. In all countries, the APOC localaudit will start ffom the arrivalof funds in the NOTF account and will trail the funds to the final payment. When you are preparing the FLOW CHART for monies from the NOTF to the final expenditure, this should be borne in mind. I thank you for your patience and stand willing to dialogue with the participants on any subject in the area of adrninistration and finance. -i : (0 (g) (h) (i) 0) (k) Distributed to participants at Workshop 39 Annex 6: Financial Flow charl of Nigeria. Tanzania. Malawi. Ugar-rda. COUNTRY: Nigeria roPlc: FINANCIAI- FLOW-CllARI t-ROM CITNTRAL TO DISTRICT a Signrrod€s ' NOCP C@rdiortor - NCDO.hdmrn - ltR (rn! rwo siSartoriq but NOCP Cmrditr!lor corld k Sigf,atodes Zotr!l Coordinalor ' NGDO Rcp (all signalories) Projed Oncho C@rdinrror 'NGDO Rep Proj€d PHC Dir(ror (NGDO R€p md rdv ofrhc sro) COUNTRY 1'ANZANIA I:INAN('IAI- III-OW CIIART FROII APOC FUNI)S Signriodcs - .\srnanc€ Chicf Nledical Omci.r for prc!.nttr'. s.nices - Coorditrrtor for NOCP rod - ksrgnated NGDO r€pr.scnr!ti\e or rh. ba(k up. dcsignat€d NCDO rcprcsenlarh r wHo NOTFPRG'EC'T ACCOUNT ZONE A ZONE B ZONE C ZONE D PRUECTS IN EACII ST,T]'I] L I A POC NO',I t oicDo + t\tott) ll()lI N(;DO NIOII NGI)O i\loH + NGDO ' Ikdical \utc^ isor Projrct (mrdrnrtor IGIX) 40 APOC TRUST FUND Through WHO omc€ --+ DISTRICT ACCOUNT l NGDOs I COtINTRY: I\{ALAwl FINANCIAL FLOW CIIART I COUNTRY: UGANDA FINANCIAL FLOW CIIAR'I' APOC TRUCT roND l hrouEh \\'R l DISTRICT ONCIIO ACCOTINT DISTRICT ONCIIO ^C('OUNT A P.S- ^tOtt' NOTF Coordimtor NCD0 (fIIAN - C.A O, - D.iLO. 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"dacU uv-2 r'F,z d EB aa.gr O b Oo 6/() pOJcZ 43 Anncx t RtrCORDING AND REPORTING AT ALL LEVELS Population trcatedI } e I{ouscholds in community . Population Ccnsus -Tables collectcd . Treatrnent records .Referal ofreactions . Tables used . Tablets reservcd A.R-l incligibles Abscntccs Refusals Reactions _ scvcrc nrild . Collation of l{ousehold treatrnen( . Preparation of community . Summary fomu\ . Ccnsus .Tablcs collccted .Treatrnent records .Referal ofreactions .Tablets used .Tables reserved .Tables needed for nel:t rourd .Collation of community summary forms .cgrsus . tablets collected .treatment recorded .referal ofreactions .tablets used .table6 reserved .tables nceded for next round . Collatiou of L,GA reporu . COLL"A.TTON OF SI'ATE RtrORTS . CTOLL^ATION OFSTATE REPORTS BY NOIF Communities districts r.GA STATE NGDO Tare NOTF I I I
Всемирная организация здравоохранения (ВОЗ / WHO) · Technical Documents
Report of the international workshop on the philosophy of the African Programme for Onchocerciasis Control (APOC), concept and harmonization of Community-Directed Treatment with Ivermectin (CDTI) projects implementation Enugu (Nigeria), 21 - 25 April 1997
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