Report of the
External Malaria Review Team
with spoial reference to
Integration of Malaria Control Servioes
into General Health Services
Ministry of Health Ethiopia
25 April - 28 May 1977 1. I TRODUCTI 1 of Maiaria Fradication, later In Ethiopia, the activ'ties Services (MCS), were the subject converted into Malaria Control last internal and external. Tne of p-riodical evaluation both took place in April 1972. independent external evaluation with the projeuted uh' nes The Ministry of Health in line at which aims, among other things, in its overall health policy general health all special oampaigne into piroressive integration of of its Malaria out an external review services, decided to carry with the othv long standing Control Services, in collaboration WHO and USAID. pr.rtners in this programe, with three proposed for this review A speoial team was therefore, from the Ministry of side of the OCoverinlent (two representatives from the from WHO (an epidemio Planning Commission), two Health and one f'rom the from USAID (a management specialist), and two logist and a public health NatI6.;ial all unconnected with the consultan'. and an epidemiologist); unbiased appreach ° the past, so as to give an Malaria Coritrol Ser"ices in nte problem. u) lines: the team ran en the follo-rwing The terms of reference for for plan of action a) provide recommendations/guidelines and and 1971 (i.e. G.C. 2.978 for the years, E.C. 1970 Government's decision t. effect 1979) in keeping with the Control Services tlgradual functional integration of Malaria
with the Basic Health Services",
of administrative, t ohn.cal b) review the nature and extent to MCS and recommend and operational problems related its integration into appropriate solutions to facilitate Basic Health Services,
requirements of the malaria c) study the future financial control operations, and
needs in relation to d) study and reoomend on training of malaria central possible changes in the methodology the integrated service. as well as the requirements of - 2
av-, to reasons of serious illness in the family and ,t2mv. ji.0li.e-,' circumstnceus, the designated members of USAID had to rvturn prernatu.i6y. A,- the other members were already on the spot, and the time was short to r.arr:.ge for new representatives from USAID, the Government deciclud w,,. Tie ro.,'iew w Aild proceed with the members of the teal, as constituted below: Mini: try of Health 1. Dr. Mesfin Demessie, Dy. Director, ALERT (Convener) 2. Ato Yemane Tekeste Programme Manager, Smallpox Eradication Planning Commission 3. Ato Solomon Ayalew Economiet and Planner WHO 4. Dr. R. Kouznetsov Epidemiologist
5. Dr. K. Scmeswara Rao Public Health Cptialist. A paper defining the Government's position in relation to integratior. of MCS
into Lasic Health Services and distributed to the members. The docume:. . refers to the iuiterplay of multiple social factors in perpetuating diseases 1iie malari'a an,' points out the necessity for para.lel development in social rind economic areas for any control programmes to be effective. It reaffirnj the Governmnt's intention to bring about the needed integration, alluding to some of tie measures already initiated in this direction. It also expresses the belief that no real integration would result as long as V10.S continued to exist as a separate and autonomous entity, no matter what innovaions are given to its form or name. While pointing out the enormous benefits that such integration would bring about in the quantity and quality of Biisic He,,ith Services, it recognizes the need to retain and strenthen, where af-,.oprlr te, the technical capabilities for the control of malaria within e very services.
MethoA of Work The team began its task by acquainting itself with all aspects of thc problem by studying the numerous documents made available by the Government and the WHO Representative in the country. To supplement this infonation, a series of di. in.:-'.ons were also held with the National Health Authorities .t diff'eron levels, USAID director and his staff and WHO Btaff indicated as resource personnel by the (ov--rment. The list of persons met in this connection is given in annex 1. To famillarize tdiemsolves With the prevailing statuz of Basic }.,-alth Services or, one hand and the malaria oontrol servJ cs on ".410 other, f':;ld visits w,re undertaken to a number of places. These included one Regional Halth Department, two health centres and two health sc.ations from the Health Services side and two zone offices and three sector offices of the Malaria Control Services. Care was taken to include some of the above facilities from art,as where a beginninp is said to have been made towards tntegration ef NC$. in Basic Health Servi uces.
~. i: RAL BACKGROUND Integration into Basic Health Services was *ne of the set ubjectxres of Malaria Eradication Programme even at its very inception 4- 1966. With the growing recognition of the difficulties in P,;hieving total oradic;ation in a limited time, the need for integrtteh, hec-ae moru obvious. In fact, in countries where funds and rther health resource art not boutiful, such iittgration was a neoessity te cope irth the long drawn out and expensive malaria control activities. It is in the '.ight of the above considerations that the Strategy Review Team, in _:,& -s well -isthe Independent Malaria Evaluation Team in 1972 emprnaoized the :'gency fcr bite ration of malaria an,. basic health services in Ethi-pia. From time to time in the last ten years, several meetings ai,d discu.;sons were held; speciai Committees were organized to study ways and meanus of .,ringing about the integration and even integration officers were appointeA in some areas. Despite these efforts, no concrete or lasting measures have emerged and no firm decision towards integration has been taken until recently. The new policy of the Ministry of Health of the Privisional Military Government of Socialist Ethiopia, as evolved by a "Study Cemmittee" specially appointed for this purpose (1975), aims chiefly at expanding tie delivelr, ef health care to the 'broad masses' by involving people in various types of'health activities and establishing a link between the community and the health services through the creation of 'health agents' chosen by t.ie cormi,unity from among themselves. The existing health services will be so reoriented as to support this general effort and unify curative and preventive care. Integration of the various special disease contril programme including malaria is one )f the stated objectives of tfIs policy to accomplish the above goals. The Government has already taken some initial steps to implement its policy. A rural health development programme for shie years 1i.76-80 has been prepared with an outline of plan of action.
Guid, .ines for the training of different categories of health workers including the village 'health agents' have been brought out. TraiJ.n of 'health agents' has also been initiated in selected areas. The national determination for implementing the new policy is thius evidc_-+, which makes it most opportune twi proceed with Lhe L)ng awaited integration of "'ISand Basic Health Services.
4. FR.'NCIPLES GOVE1NING INTEFPATICN
In the light of the Government's desire for complete inte-..+'on and of the concensus obtained in the course of the interviews ith sevt ra.) national authorities, the team has adopted the followir.- general principles in proposing future lines of integration: a) The aim should be total integration covering administrative,
functional and staff components at tne different levels of health services.
b) Integration should be nowrefui]ly planned and properly :.-ha.ed to accomplish the above goal without any reversals in the gain.- achieved. c) The process of integration should also ensure that future antimalaria activities are improved and extended, as necessary. d) It should significantly contribute to the development of comprehensive health services in the country. With the above principles in mind, the team proceeded to analyse the present situation and possible solutions in relation to its terms of reference.
5. Administrative Aspects
5.1 Actual Situatin: Although on the recommendations of the past Revf-,; Committees, the Malaria Eradication Service was converted into a Malar.a Control Service, it continues to retain many features typical of the Lin, -limited eradication progran e. MCS remains as an independent set-up with three operational levels, central, zonal and sectoral (peripheral). It is headed by a General Manager who is directly responsible to the Minister of Flealth, and is vested with full authority for the direction asd implementation of tihe programme. Dy decree, he is to be guided by the decisions of a Malaria Advisory Board, which has not met since 1972. MCS has its own administrative department with several units independent of the corresponding set-up of the Ministry of Health. It also adopts its own budgeting and financing prveedures w ioh are 0 0 5 6 0
a.,:,-ding streamlinud to facilitate smooth running of antimalaria activitfis Pntire budget T11V to the time targets. The Genera Mana ,er controls the vided for the operations. Procedures ,.,d facilities have also beci' establish(d to ennsure i'ree and unfettered flow of supplies, equipment traj.ort etc. Land their maintenance to meet the 9perational demanas. Phere is a total of' 11 zone (or sub-zone) offices, the areas coverti by some of' which does not correspond to the general administrative -egious of the country. The actual uperationF are conduc'ed from the 5) sectoral offices, to .,.any of which arg over-stR.fed \as at other levels) because of the need accommnodate personnel trained with a view to extend malaria aIctivitius to all effec'.ed area.;. T e distribution of sectors, having followed the stage-wise extension of the eradication and contrel. progy-mrrae, remaii.. ; uneven. Th sector staff has a ood outreach into the sur-, 'z;,dJng remote areas but .nly for timt iimited operations. A sat4if'actory system of supervision frr level to level h.3s also been developed. The general health services arm oxcanized at four different . levelui., central, regional, zub-:ev-:4)no. !-Taja)and district (woreda). de- Yet no' er leveJ of service closer to the communities (Kebel3) is being veloped in keeping wit, the present political system. The central and regional levels are chiefly concerned with planning, programming, evaluation and general health administration. Actual basic health services are- delivered th-rough health centres mainly situated at awraja level L-xid health stations (also called clinics) located at woreda level. The budgeting, financing and procurement procedures of the ,ini.6,ry of :Iea'th follow the general administrative rules and regulations of the Gover_ment, which are complicated and outdated. Once the budget, is approied, the running expenses of the health establishments at different .evels have to be drawn every month from the carresponding govenrunent :reasury offices looated in the a reas, which in turn obtain their funds normally from local collection of revenues, or central governrent subsices which usually take time. Such an arrangement sometimes is likely to result, especially at the lower echelons of administration, in scarcity of furls, a ;.*Ltuation not conducive to mount promptly the time-targetted operations, il,, for example, the spraying activities of malaria programme. It is unfl .stood that the government intends to improve these systems in the near futurt 6
°- "like general i1tot'-.iaY Apart from the above, th#enr av. vt-her pt-ohbem of materials, velhicee.2 etc. due to of funds, undue delays in the supply vojit:. oeo.p]l 'a ,,-d prol,-'etineit :in are gIeIrrlly iimited C.... I .... ; for h,.alth i tiATies exist. Part of thi ;PC',bcm ever..Xn locAiit1e. where r ,aci cor, lunications maintenance systtr~i. Alti s'uj; all h,:altl 4s dU(e 'o lacV ('t' adequate repair and vehicle, this is not always I,e case, uentre, atre UxpctO, to have at least one with basic heiilth care.. there .4ow noming to the esablisments ooncerned and lONc health stations said to bn :.,e 100 health ceritres in the 102 awrajas, the country. However, sinc- these cre or less evenly distributed throughout or bigger towns, 70 or &;L' of the facilities are usually confined to smaller poorly served. rural coiim.initi's who live cattered are Gondar trained teams, .. Jieh Health" ce-ntres are staffed by one or more nursr.7 E sanitarian, several co!..ist of one health officer. tw, corrmunity other ancillary staff. A health heal h assistants (previously dressers) and By and large the activities zta.' ion is run by one or two health assistants. medicine. Supervisi.,n and of tl.'se units are ore oriented towards curative gfidance from higher levels is very limited.
administration T!>..:, while MCS has developed a reasonably efficient of the programme, it is capable of promptly meetjjIg the requirements services already Rvaliole single-purpose orinted. It duplicates several Although many of t- , in the Mi istry of Health and has excess staff. to trairin. on the techlical side (excluding squad chiefs) are exposed activities, they cnnt'nue cou"ses tD enable them to undertake ether health only. For a considerable to cxercise their original unipurpose skills have little to do. The part of' the time in the year the field personne). to have contributed to a continuation of ,CS as a separate entity seems be little interest on •eeling of "we and they" and there appears te to the other side. :ither side to assist people on problems that belong insufficient The Basic Health Services, on the other hand, are grossly and outrearch to covering only 15 to 2C5 of rural population. Home visiting done on the pre the conmmunities is very li-mited and still less is being are meagre with poor ventive side. Iidgets and facilities for field travel .vision cf thc activities. them There is thus, muc, to be gained on both side.: ty merging and to~?~.,ti, as each ,ervice has a lot to contribute to the resources actfivi'ies or the other. • 7 .
5.2 (udelines for Administrative Integration: A3 already stated, integration rs-ould take place horizontally
echelons. At tle all Iev.rls a:hi v-rtIcal.y tiuo. th different merging of the ioca2 or operaticn!al levul,i shou-.l1~r- be complee so that the :iealth of staff to comper',tt . oa.;other'; s 'ill.new and old) whole. However, as :,l.'ia t::,-. peopi' 1is 2 :r.sP 0 and catered to as a t a(;ivities directed towaros Jll a ma'ur.ealt., problem in the country, equal attenticn. iL. 2orntlr)l alld eventual elimination should continure with direct To .. uTe this. therte is need for careful planning programming, zf lmr....Iria in,,i 27ntion in case of emergencies, supervision and evaluation Af the needed oontr i opetrations, for which a comprehensive nucleus and central. ex*'1 1tj should be retained at higher levels, i.e. regional disease Ultimat,:ly, thes, nuclei should form part of the communicable sayir. control divisions at the corresponding levels . It goes without lhe that the care-takers of malaria prograrrme should be involved in surveilla.nce and control of other conmmunicable diseases. Starting from XCS as it exists today, the above structural and fun: 'onal set-up can only be reached gradually. Evidently, there are mergin certaIn critical steps that need tm be taken to promote smooth uf th, 'wo services. The most Imp#rtant of them i-re: a) Training of concerned staff at different levels to prepare them for the new tasks and b) Adoption of such administrative measures and procedures that would ensure a smaith flow of funds and supplies for the time targeted malaria operations. '.am Si as to achieve a progressive inteeration by phase, the propose the following general guidelin?:: a first step towards 5.2.1. Central Lebel: It is noted that as inte:,-rafion, the MCS has already been placed under the Permanent Secretary of Hct] 'h. As a next ,tep, the technical component of MCS may be placed as a seprat. Malaria Control Division witnin the 14epartment of Health Services. This step is recommended bpcause, firstly, the Communicable Disease Control Diision is yet in its infancy, secondly, malaria personnel withc-ut necessary retraining may not effectively contribute to the develpthent of the latter and lastly, the team felt that there is a need at this stage to provide an opportunity for the two divisions to learn to work
o./ tojl.ur and coordinate this activ.tles under a unified leadership. With tLe ,r rience thus gained and comple4 ion of necessary staff training . th .,eanti.me, it olhould be possible .'or both these divisions at the centre to erget- toigetlher in tht, next. 2 - 3 year-s to form % cvi-iontin,le of Epide-niougical S0urveillance id Control. of Communicable ,ist-aser. As already contemplated, the Health Education and Public .. tins Division of MCS should be integrated with the Training Division of the Ministry of -->alth. Coming to the administrative sections cf MCS (finance, personnel, supply, and property, and transport and maintenance), there should be no serious difficultev to integrate them with the corresponding sections of th Ministry of Health, as long as appropriate safeguards are adopted to ensuie timely availability of funds and supplies for malaria control operations. In fact, the transport section cf MS is already taking .- re of repai aid maintenance of the Ministry's fleet and has the require, staft' and facilities to become the transport section of the Ministry. Personnel section of MCS will assist in completing the needed f-... lities for absorbing malaria personnel into the health servicrz. Af,- completion of this task, the &nlything required is to transfer a s.,aleal staff of malaria persarinel section to the Ministry to meet the add.L[ Lcial workload. 'Ierging of the two supply and property sections also appears re laLivel, easy. However, it is essential to retain the off-shore and internal procurement procedures adopted by the malaria service and make the merged malaria group responsible for the smooth running of the supply system, in the interest of the programme. A major problem in the way of integration is in the area of budgeting, financing and accounting. The system adopted by MCS is espeiwlally tailored t, facilitate the time limited mperatisns. As mentioned earlier, the Ministry is actively considering administrative reforms in its oim system, but until such time that this is accomplished, or a .oitc.bl.e alternative is worked out, it seems desirable that the present Inancial system of MCS is maintained. The person is charge of the ,.ilaria Progranmme at the Ministry level will centrc.l the use of the funds; f'urther dutails for the administration of these funds at other levels may be worked out by the proposed Integration Steering Connttee (see wuluox 2).
so/ As an alternative, ccnsiderations may also be given to 'the >, hnent of a specla. epidtmi- ccrntrol fnd. This fun can \ ./ r, ' to t}e control of net 2] : <,.oria but other corJ.unicable
,,:;.. ,,id ti. ,e~ tlo: of sc h a ftnd be possih,'le then the
:alary o ,:_; the !.2,:rJt'1 malaria j,,r:cnne1 can be i:rtegratc(I into th:e re ular bu, iget of the Mi'ni, try.
5.2.2. Reiionol Tvve2. Presently, the Jurisdictions R, ional H]ealth Dupartnnt:- and the Ialaria Zone Offices are no- alwa'-. ide:. lcal For administrative convenience and proper inte-ration.
oa rucs::ary to eliminate these differences and adopt only rej-ional
LtuioJ>l e 4n future. /,; a first step, We malaria zone office will be placed uncder he ad,.'..Jtrative coordination of the Regional MediLa! Officer of Hea.th, • wil hereafter be resp,.nsible for malaria operations in his region, aJcled by the ralaria zone chief. The present -ialaria zone chief shou_'A 1-,.labomtate with- the Regienal .edical Officer in the utilization c.f nmlaria s-taff and iacilitit3 forcther health activities especially in the ff Id sf comminicable disease contrel. I th.i transitional period, which should be as short as :.ible, the olowing steps should be taken: a) Determining the size and ctmposition o.' the uiit needed for the management of regional malaria pro~gamme Ln the on tand and for strengthening the cormrunicable diseases control an the other. b. Retraining of staff' according to their future placement (see secti n on functional integration). c. Reassignment of staff to their respective new posts. By the end mf this process, thu proposed communicable disease contrl sections will hww'been established at the regional level. in whi p'. case the malaria .units will merge- with them. Otherwise, these units may c.,, stJ1tute the bases for the creation of Comnunicable Disease Control Section:;. In the regions where there were no malaria zone offices, the bove described malaria ,ults may be established according to need, with tl.e surplus personnel found as a result of this reorganization and in Legration. The malaria admnJnistratin staff will gradually be absorbed into the Regional AdIministrative System. Among other duties, they will continue ike care of' the adminiktrative and supply aspects of malaria. 5.2 .3 Local (Operationall 1,2ve1 Merging of PCc ancd -2 at tW.,e 4 to operational levc1l i: the morz impcrtan-. objective of integ'ation, .lp increase h efective-ess ;nd ef cUenIcy of both the .:;,ice:;. level iri a 'he team believe thr.t 'i is possihle to start at this r.latively short eri ,l The operation:-l units on the health servi - :ide, as a]reacy health stations mei.ioned, are hea]th centres at "awradja" level and offices. a'1. :woreda" level. In Whe case of malaria, they are sector from 10 - '0 per sector. Thie ':tter have different skilled workers ranging free time could be The;:. constitute an i nmense potentiality, whose community, after appropriate fu1 y , cupied for t1e i alth benefits of the retra" aing. coordination and Tnorder to complete the chain of malaria pregramne technicians . be management, the sector chief ith one or more malaria aiid respor.s*._l-.ties assigied to the health centre. The working relations will be on tho same of the sector chief and the head of the health centre this unit ax.. ealth l. es as at the regional level. The actual size of be worked out, cfentr :; to which such units should be attached will have to the above staff, in ar ordance with local needs and conditions. In assigning malarious pr! "ity should be ,Iven to health centres situated in highly expected that frc ; zones, or areas i..ith, new development schemes. It is areas can be the pre sent studies undertaken by MCS, highly malarious celineatied in the neai future. iwo Prom the balance of the malaria sector office staff, units oi squad chiefs with or without malaria technicians should be assigned in mo;;t t
'1LP ,.t .- SP)I.IJio ... bc available f':' other purpose.- -o'r a cc:.: tooe:
Iart ,I' ti,',. ;,::art. T.e., ..,J bIl ., I.riblited at ui ffi ven i. evols cCOPdiL1y- to :.,:-u
Eftorts ill c mad,: to unalgamate the malar-ia .7tore- viith hos, of Rgional ,r ik~nltJ. (",k1ztrt7 Sto'vs, wh re appzrpriat(.
'i -hnicalAspects: (.1 Actual Situation: The technical objective!. and activitle.; ef the r. -ri' C :itrol S3ervices are broadly outlined in the Plan of Operations /1}y. 7). The yearly Plan of Action defines the programme of acti vities for the succeeding year. TMe long-range objectives as outlined in the Plan of Operati0ns. remairl:,i the saxie as for Eradication. However, the short-range .ctives of 1,K4S, although more closely related to the immediate needs of the country were not comprhensive. The Plan of Operations does not spell out measurable targets for ac ,,jvingthe objectives and only recently provisional targets have bees: iitioduced into the Plan of Action to select areas for spraying ac:.lvities and their evaluation. IThe prograrme continues to rely mainly on indoor spraying with DFYT (2,/m'-). At present however, the spraying operations are being cari ied out on a selective basis. For this purpqse, all areas covered by t.e progranne are di"idud according to epidemiological indications, into non-malarious areas and malarious localities with 0, 1 anL 2 rounds of :-praying. Utilisation of this rational approach nas reduced the vo2.ume of spraying operations substantially. Extension of operations into new a:eas , nrt been cormensurate with the economies thus gained in terms of funds, in., clticides and manpower. 'Thegeographic reconnaisance precedes extension of spraying operations 1ji-o i i areas, and in other localities it is updated during spray rounds. Chemotherapeutic measures are used by MCS on a very limited 3cale. Presumptive treatment is carried out only during spray-rounds and survey visits both of which, as already mentioned, are limited to selected localities. Mass drug administration is being carried out for combating epidemics and in certain problem areas. Radical treatment is given only to those pat.nts who return daily to zone or sector offices. .. 12'*
The- ef orts- made -byMCS--to_, develop-.a neohan1.rrr-fortmly ______,c"etection of focal malaria outbrt-aks through passive ct~se dutection posts and voluntary collaboratora have only been partially su',cessful and requires to be strengthened in future. Practically, no efforts have been made to study the use of othtiz anti malarial measure. The programme evaluation has been diffoCU.t for inadequacy of pre-tradication data, constant changes in evaluation techniques and for lack of correlation between the areas of entomological and parasitological studies. CompariSonso based on sh , " chta are liable to erroneous interpretations. The new strategy adopted for selection of areas for spraying, which Is based on the results of seasonal Blood Survey (SBS) in representative .ocalities carA-d out at the height of malaria transmission together with a ioasideration of epidemiologic, geographic and 3lirmatic featurez: of the area, appears satisfactory. The prograiinte has no means of monitoring the impaut of the anti mal&-ia measures in vogue on specific morbidity and mortality, and earlier attempts to involve Basic HealthServices in these acivities have not born fruit due to lack of cooperation between the two services,. Careful scrutiny of all the data available over the last 12 .ar,-s shows that anti-malaria measures carried out during this period have considerably influenced the malaria situation in the country. Malaria prevalence in the areas under operation has been brought dovn in most of the localities frmm meso-hypo-endemic levels to lower ranges of hypo endimicity. Presently, with the data oellected on representative localities from areas considered most malarious, one could say that only about 4% of these localities have parasite rates over 5%, In 1976, out of an estimated 12.8'million population living in the malarinus areas, 2.8 million are being protected with spraying ard another 5 million are under the'vigilance of M . n The team feels however that more could be achieved if the programme: a) Adopts more comprehensive objectives fv.r the Oantrol of the problem as detailed below. b) Liberates itself from the methodology inherited from the time limited malaria eradication, and i)Works through the Basic Health Services for extending anti malaria activities to all people living in vulnerable areas. .. 13 ..
6.2 Guilelines for'Technical Integration: In the light of what hac been said, the team proposes the following set of objeotlves wid methodL ti achieve them.
Objectives:
Long-term: To eventually eradicate malaria Iron the country by :neans of carefully planned, gradual expansion of effe.Ave oontrcl measures through te incresilng net-work of Basic Health Services as mll as through action parti cipation of community organizations such as famers ast(ciations.
:led. x-term: To reduce ma-.aria to such levels tjtt it ceaos to be a iiaJor public health problem. Short- term:
1. To reduce speoift mortality and the pmriod of incapacity by rwaking anti malarial drugs available to all patients.
2. To reduce further malaria prevalanoe and in ocnsequenoe specific mortal ity ana ,morbidity by improving the operations in the areas .mder oontr~l. 3. To extend organized anti-malarial activities into new development areas and other populated centres not so far ooverod,
4J. To detect epidemics in their early stages and take remedial action. 5. To protect the most vulnerable segments of the population - pregnant u1d lactating women and children under five years in highly endemic areas. 6. To develop applied research to determine more effective and euvnomio means of malaria control. Methods:
Preparation of Plan of Operations and yearly programme of activitins as well ac supervision and evaluation will be carried out by the core of technical staff x.tained at different levels. :., following methods are suggested to accomplish the above objectives. To rt.educe -,pecific mortality, single dose treatment with 4 andinoquino lines (.I r;./kg) should be administered to all sispected cases, not only through the existing health Ins3titutions, but al, o by malaria technicians and squad chie"s, who, tCom their new positions of' operr.tion, will regularly (once a month) v~lnit loc-.llt; a-signid to them and as It progres;es, through the village .es]tJ h at ;
For Purt'lter r'ducticin of speciflc morbidi ty and mortality, it 1,; suggested Lhat I.. I1dition to Improving the current spraying operations in areas ,;elected accon"clif to p'eserit criteria, mans dr.g administration, anti-larval ard othler ine iures should 1- emplo:yed where necessary. Extension of anti-malaria activities into new areas will be accoriing to al eady established technical prv'oedures. "or early detection of malaria outbrecwas, the squad chiefs durir. their rt-e ular rounds shoald, keep a watui. for any tuu.n-ual rise in fever rutj.'. W' -n -ucl: 'is, discovered eith-r through them or other re,1-., na's-blocd examination .nd :iass drug a(JrinIstration should be catried out,. fuilowPo( by other rmeedi neas ur(es once laboratory oonfirs ation is cbta.ned. For protection of vuLlnerable groups in highly rmalario>us areas, chemoprnphylxi (4 aminoquinolines, 5tag/kg of body weight bi-weeklyt -,nould be attemt .d. Thme same Is applicable for the productive lcbour force in areas of hin'. malaria risk. ~r'~:ps -ctudies should aim at, among other things, the stratification of' the f yea i,:ording to their malaroqune potential inorder to determine ecifi: ,ent~re targets, the possibility of reducing the dosage of insecti ' inies u--as -f unstable malaria, use of alternative methods of malaria 7. Operational Acn'ects: 7.1 Fresent Position: Much has already been said about the way Malaria Control and Basic Healtl Services now fur.ction in isolation, the former confining broadly to malaria oprations o f spraying and surveys and the latter restricting itself o curative medicine with limited and casual preventive work. Beth the services have failed to develp any epidemiological monitoring. Little o:. acts were developed between the two even in towns where their establishments were located nearby. Inorder to promote closer collaboration as a first step towards in. tegration, two special seminars were nonducted for the concerned officers from the regional level. In two of the regions (Kafft and Tigrai) such collaboration has been initiated. Some of the team members, 410 visited Kaffa Region observed positive developments in this direction. During non operational periods some of the malaria personnel are placed at the disposal of the lbgional He alth Administration to assist in laboratories, hospitals and health stations etc. Similarly, malaria vehicles are also being used to tL,, advantage of both services. Kaffa being one of the first regions in initiating rural health services through village "health agents", both Malaria Control Sorvices and Baio Health Servioes have joined hands in planning and organizing their training. The latter effort is in its initial stages; the limited exprienoe with theo trained "health agents" however., reveas encouraging pro;peots for expansion of malaria control activities as part oi. Primary Health Ciue. *. 15 .. The above two developments in the same region, thouh in ve? - initial stages, give an insight into the sonpe for integration and how the integrated services can be extended right down to the comunities through the medium of village health agents. ,.2 Guidelines for Operational Integration: integration will have l-ittle meaning if it doei not contribute to an improvement in the soope of activities as well as efficiency of the services that are integrated. It must be oleais by now that by merging Malaria Control Service with Basic Health Servioos, the Maaria Prog.amme in Ethiopia will benefit in a number of ways. By placing its staff in the opeiational units of Basic Health Services, it gets closer te.the communities and develops more regular contacts; will exploit these health service facilities fully to improve case finding and early detection of epidemics and to expand prop]ylactic and therapeutic measures against ma.aria. The Health Services on the other side will gain by the outidaoh facilities (mobility and staff) of malaria, will acquira the habit of systematic supervision, will be better equipped to extend itself into the ot.mmunities and organise or improve such programme as immunization, duca oollection and disease monitoring and control, health and nutrition e-uoatOl and so on. The staff of the Basic Health Services would surely gain more time ' de. te themselves to MCH and preventive work. With appropriate training whdch,will be referred to in a latter section, staff integration on the following lines should facilitate the process of mergin- as well as the output of the combined services. P t the Central, ]Regional and District (Awraja) levels, as already in dicated, an appropriate number of senior malaria staff will aonstitute the 'technical core who, retain their specific responsibilities of planning, coordination and especially supervision in relation to malaria programme. In addition, they will undertake, in collaboraticn with the staff of epidemiology or communicable disease control sections where available, cozmon programming for the surveillance and control of infectious-nnd parasitic diseases on a national basis. Where epidemiological services are inadequate, malaria personnel wculd assist in organizing or strengthening them. The surplus of senior malaria staff at the central and regional offioes should be redistributed according toneed t* the new malaria programme units Lt the rigional level or health centre level or may also be utilized to improve staff position of Communicable Disease Control Sections. .. 16 .. Entomological staff at the OCntral and Re ionC1 IsII lnl- ... Ii to exeroise their functions in r lation to the Malaria Programne. Howev, r, after additional training bearing on other vector borne diseases in the country, such as trypanosomiasis, schistosomiasis, yellow fever, leibhmaniasis etc. they should be able to meet the technical rqu-ir(inents of the future Division of Surveillance and Control of Cor.unicbl Diseases an. eventually constitute a unit of vector control within its folds. Tihe Malaria Microscopists are now concentrated at the MCS Z..ne Offi3es, their services being limited to staining and examination of slides from the seasonal blood survey, Lmmdiate training of these workers in the identification of other oominnoabhe(oapecially tuberculosis, re lapsing fever, trypanosomiasis etc.) and parasitic diseases as well as in simple 1echliques of urinalysis, blood and stool examination would considerably enlarge the scope of their usofulness. Besides, their redistribution on a more rational basis will not only assist the health service establishments but also permit regular monitoring of malaria .nd other communicable diseases. It is therefore proposed that while re taining one or two microscopists at the regional level fbr cross checking of malaria slides and other assistance, the rest should be re assigned to health centres located in malarious areas. There seem no great advantage in retaining several microsoopistz for cross-checking purpc es at the Central Level since this function is now delegated to .regional offices, However, 3 to 4 senior laboratr7 staff should be retained at the centre for special studies, training and supervision in this field. The operational s taff at the present malaria sector offices include ever 260 malaria technicians and 550 squad chiefs, who together constitute 75-80% of technical personnel employed by this service. The possible places for the.ir future assignment have already been stated. Although they shawe dif!erent responsibilities towards the malaria programme, in view ef their close proximity to the communities, and of the fact that they serve as a regular link be tween the health services and village health agents, it is desirable that, to start with they are Jointly trained in practical aspect. of communicable diseases detection and control measures and in areas of primary health care. The duties expected of them, in addition ta the present ones, wuld be to make more regular visits on a monthly basis to the communities uovered by the health station, 'ring which they could: .. 17. other fever, a) Collect information n, Inallri', tiberculodif, leprosy etc. for laboratory b) Collect slides, sputum and other specimens studies. tuberculosis, a) Distribute drugs for the control of mularia, leprosy, trachoma etc. d) Carry out imunizations. render . :,vice on d) Participate in health and nutrition education, simple latrines, water purification etc. f) Assist village health agents. supervise the above activities Malaria technicians in general should prevalence of communicable diseases. and also compile reports relating to the Health Service Units at t:he 8. Physical Integration: The MOS and wherever adequate physical different levels shoiuld be amalgamated, that such physical inte-ration facilities are already available. It seems towns where units of tie wojild be possible in some of the cities and however, that in several both systems exist together. It is recognized delayed until such time that places physical integration will have to be the needed facilities are arranged. for Malaria Control: 9. F'uture Financial Resource Requirements last three years nave The average expenses incurred by MCS in the requirements of the teen the 'oasis for protecting the future financial into considerations the programme. These estimates however, do not take salary structires etc. nossible changes in prices, perdiems, wages, in the fut-Le In the light of some of the changes recommended travel by field workers ru-laria control activities, such as, more regular therapeutic measures, arid supervisors, widespread use of prophylactic and on travel and perdiem, drugs inteasive training of personnel etc. the costs However, with the grow and t.-aining would increase in the coming years. associations or ing cullaboration and participation expected of farmers, some costs on hired simnilar cormunity organizations, it is also likely that labour (wages) will decrease. progra=ime As significant territorial expansion of the malaria to be consolidated, occured during the current fiscal year, which needs during the next no substantial expansion into now areas is contemplated two years. It is expected that future extension of anti-malaria structure. activities will be through the basic health service * .18.. It is noted that MXS has built-tp adaquate resouroes of drugs .nd inseccicides, to last for the next 2 to 3 years including any projected expansin. Similarly, adequate supply of sprayers, transport and spare parts exists, which, in the light of' the past experience need to be replaced aT the rate of 10 to 15% oi existing stock. In the light of the above considerations, the team forecast; .'e pattern of financial resource requirements on the following lines. 1978 1979 1980 (In Ethiopian Bjrr) Staff and Operational costs* 7,000,000 7,250,000 7,500,000 Additional needs 5n: a. travel, perdiem 1,000,000 1,000,000 1,000,000 b. training 500,OOC 500,000 500,000 c. drugs available available available d. insecticides e. Replacement of cars, sprayers, etc. at 15% 5W0,000 500,000 50C,000 (*Pj vides for 5% increase on salary increments of staff). It may be mentioned howerver, that provision should be made for drugs and insecticides, as the current stocks get exhausted In the next 3 years. It is tstimated that on present prices, a provision of Eth.Birr.2,000,000 per year wou.d be needed for this purpose (Birr 500,000 on drugs and Birr 1,500,000 on inseuticides). These are based on the assumption that spraying activities will ccntinue more or.less the same, 4iile the drug consumption is plm-med to increase six fold. The programme will need a foreign exchange component in tn.u budget on drugs, insecticides, replacement of vehicles, sprayers and spare parts; the total of which would be about Eth.Birr 2,500,000 from 1981 inwards. 10. Ti aining Needs: Staff retraining is an important prerequisite for an orderly ,ntegration. Such training should be directed to the staff of both the sides ":-at are involved in the process. Previously, some courses were aonducted but they were restricted only to certain categories of malaria personnel. The training courses have to be tailored to the functions expected of the personnel fitted into different positions in the process of integration. Apart from in-service training that follows the oomplution .. 19 .. staff should be pianrr a . hi of initial courses, continuing education of the h , It, service order to gradually channel them into appropriate re-.1:>r 'or their Training needs of different categories of MCS personnel stated in the section integration into general health services were briefly duties and responribilities. on ftuictlonal integraticn in relation to the new and regional T',, malaria technical staff retained at central orientation training levels (zone chiefs, supervisors etc.) should receive infectious and parasitic in epidemiology, surveillance anid control of services and their diseases endemic in Ethiopia as well as in the health into Basic Health Oervices, administration. For others undergoing integration sumarized in the table the new functions, training requirements etc. are attacntd to this section. the units of )n the health services side, technical personnel of at the Central and communicable disease control and basic health services and their deputies ::,gionai Levols, the Regional Medical Officers of health should all have refresher a. well as health officers at the health centres and on their respective c,,irses (or seminars) on malaria control activities responsibilities in relation to such activities. be given short The staff of health stations (health assistants) should organizing ca e courses cowering malaria control operations their rcle in of other detection, slide collection, compilation of data, and control health care ,ervlces commu.cable and parasitic diseases as well as in primary throu,ai village health age'+s. by the Tie curriculae for different courses should be develped Jointly and Zasio Malaria Control Service and the Divisions of Communicable Diseases of 3 - 6 Health Sei rices, P'ssisted if need be, by a consultant for a period workers in months. Operational manuals should be developed to help field their Jobs. The facilities of Malaria Training Centre in Nazareth could be utilized Levels, for training of technical personnel from the Central and Regional chiefs, including h OH and his deputy, malaria zone chiefs, supervisors, sector nicr'z.opLsts, technicians and entomological staff. The training of health assistants and squad chiefs can perhaps be organized in the regions with the help of the senior staff trained at Nazareth. Consideration should be given to arrange for key personnel involved In integra'ien, short study tours to countries where programmes of integration are in progress. Tanzania, Syria, Nepal, Viet Nam, are some of the countries suggest.-d for such visits. 42 V k"~ ~. 14* 0 *rj 0 .v.. . 41 . o 0 r4 fIQ 434 ~~,- 0~. 0 ge l 14vl'~~ 0 i92 - I- *1 ~ 4 P* Ax~~~ I ZI - * r0 to IQ 4 ;X4. 0 10j co0[ +3+ -1 4l r 4 0 '41 1 ''.9 09 41 4)P ... * 4J ** .c...4 ,.* i* I44 r+4 4 ' , , 4 oC,: o, ...... , .. 4 I 0 0 0 0 i.- 0o -H0 0 (D4-) a) H4 01 1 r4 r 4 £4 ;4 r +~1 +) 0. 4- +34 C) 0 ) 0 ov 0 0 ;-' 0 + + L + .+ *1'' **+ r + ++ ++ ; - . m .-' -4. . 4- +) (d co -1 4 r.q I * + ++ + + A + t , 1- i++ •• 0 + C~/ V0 .. 2a2 ** 11. Gen:eral Recommendations: teo,.ioal, A number of specific guidelines referring to admnistrative, with in the operational and training aspects of integration have been dealt might facilitate text of' the report. Here some general recommendations which General Health the procesL. of integration of Malaria Control Sexvices into Services are presented in brief. MCS 1. The team believes that the Government's decision to integrate as soon as -nd BHS is very opportune and that a beginning should be made sector office st&aL possible at the operational level by re-assigning the malaria would at onu'- benefit to health centres and health stations, sincou such integration and-be benefited by the Government's Rural Health Development Programme. to prevent 2. Integration chould be carefully planned and phased so as as such aim totally ar.; reversals; and while the Malaria Control Services the r rd,, an effective malaria ountrol programme should be retained within h ,alth services. the appropriate 3. Towork out the numerous logistic details, to determine to steer the timing of the phases of integration, to follow-up its progress and should process to its successful conclusion, an "Integraticn Steering Committee" and terms be imediately set up by the Government. Suggestions on its composition of reft.. noe are attached (annex 2). 4. Similar Committees at the Regional Level consisting of Malaria Zone his doputy Chief and hLs assistant, the Regional Medical Officer of Health and region. should toon start preparing plans and proposals for integration in each These shouc include delineation of malarious areas of different intensities, stations if possible, in each region, identification of health ceuL es and and in each of them,analysis of the physical facilities available or needed, not proposals for staff training and re-assignment. These preparations should take more than 6 - 9 months and should be passed en to the Integration Steering Committee for its review and reoommendations to the Minister for the needed actlon. are 5. The promising efforts at integration in the Kaffa Region Whioh developed through olozer collaboration between the chiefs of the two services, should be Ifurther strengthened and put on a firm and formal basis ,;, -ai1ly as possible so that other regions could seon benefit by this experience. 6. As staff training of both Basic Health Services and Malaria Control Services is a key issue for successful integrationk it should be given top priority. Various training courses referred in the text should be developed at an early date. In view of the dearth of &eaching staff, the training should be concentrated at one centre. The old Malaria Training Centre in Nazareth has oonsiderable facilities (Physical and Staff) and 1o most suited for the purpose. a a/ - 23 4 idontfl3ed, the jetailed 7. Although goneral training needs are categories of curriculun oontent for the courses directed to different to their fumctions and national workers Wij.l have to be evolved in relation services of a short term health priorities. It is recommended that the obtained to assist in pre consultant in health training and education be to be trained and in paring the detailed job descriptions for those organizing appropriate ourriculae. malaria 8. To collaborate in the development of the futuie malaria technical programme as indicated in the report and in ensuring period of integration operations without reversals during the trensitIonal it is very desirable as well as to assist the Integration Committe in its task, in public health th.at thv services of a Malaria Expert with extensive experience WHO or other service). cf vice-versa are obtained for the next 2 - 3 years (through that 9. To elicit the collaboration of all conoerned, it is necessary Malaria Crntrol the personnel at all levels in the General Health Services and decision and Ii.asures Service are made aware and kept informed of the Ministry's towards integration through circulars, meetings or joint seminar. the 10. New Plan of Operations for Malaria Programme in line with preparation ob -ct .ves and recommendations given herein, and at a later stage the Diseases of e Pan of Operations f~r Surveillance and Control of Communicable ineludlnz; malaria should be of value in helping the prooess of integration. Lkiidelines for Plan of Action for the years E.C. 1970 - 1971 (G.C. 1978-197c, me sumarized in the following table: - 24 rian of Action for E. C. 1970-1971 (1978-197.9) S.97 T L 1979 9 0. (L16tS) .9 3 6 .9 2 _ 6 9 12 Appointmnent cf Interation . X X XX X XXXXX .XXXXXXXXXXXXXX XX X X X X X X X X X Cam.ittee Re_.ional Conuriittees ,X X X XX X XX X X X X XX X X if necessar,, SIntegrto:ineration - Kaffaaf 'X.X X XX XX X X X X XX X X X!XX XX X X X X XX X X X XX X X X x Staff Training (Centre) Prepararoty work .X x x x x x x x x X X XX X X X X X X X X Xx X"X ' Consultant (in training) XXXX XXXXXXXXXXXX XXXXXXXXXXXX XX * I ireparation of Manals " XXXXXXXXXXXXXXXX-X Fromote Awareness Among H. S. Staff I x x x:x xx I I I Operational Integration (other regions) x xxx x x x X:x x x x x x x x x X X ! _ !Advisory Services 2K XXX XXX XXX XXX XXX XXX XXX XX.x ; Popatation of lan 'of rj Opeatisms ' I., (a)'la. ia XX X (b) Colm. Dis. €ontrol j ,xx Study tours (Key personnel) Ixxxx .#25.. Acknowledgements The Team are most .gratef'ul to H.E. Dr. Teferra Wonde, Minister of Health of the Provisional Military Government of Socialist Ethiopia-, fo his kind invitation to undertake this important task and for placinb at their disposal all the facilities needed. The Team equally wish to express their gratitude to Atc Wegayehou Sah.'u, Permanent Secretary, Ministry of Health, for his great interest and enthusiasm, and are particularly thankful for arranging all the conta(.-;s and making himself available at all times at short notice. The Team are delighted to extend their special thanks and gratitude to Ato Tilahun Abebe, General Manager, Malaria Control Services, Ato Felade, Tsegaye, Head, Health Services, Dr. Haile Mariam Kassaye, Head, Administration, Ministry of Health and their respective staff for their frank discuaions and considered views withaut which little could have been accomplished. Grateful thanks are due to all field personrel contacted in the course of this Mis.on, free and frank discussions with whom have given the team an insight into the practical problems and possible solutions. The members wish to place on record their profound appreoiation and gratitude for the collaboration received from WHO resource personnel, Dr. Sam Street, WR, Dr. A. Catipovic and Mr. C. Webster. Thanks are also.due to Dr. Princeton Lyman, Director, USAID and his collaborators for their interest, briefing and suggestions. S0/, .. 26 .. Re fe r enc e z 1. Development of Basic Health Services in relation to Malaria Eradc6-ation Programme in Ethiopia. September 1965 - December 1966. Ehsan Oliah Shafa, WHO Public Health Advisor. 2; Plan of Operations for the National Malaria Eradication Serviuc of the Ministry of Health (1966 - 1980). 3. Report of a Strategy Review Team, May 6 - 27, 1970. 4. Report of an Independent Malaria Review Team in Ethiopia, 24 May - 2 June 5. Plan of Operations for the National Malaria Eradication Service of the Ministry of Public Health (1972 - 1977). 6. The aims and Policy of the Ministry of Public Health, the study results of the Study Committee, Yekatit 1967(g.C), February 1975 (G.C.) Addis Ababa. 7. Rural Health Development Programme (1968 - 1972 E.C.), (1976-1980 G.C.) Tekemt 1967, October 1975. 8. Guidelines for Education of Health Workers. Ethiopia, October I'(6. 9. Report o4 a visit to Ethiopia. 23 March to 9 April 1976, Dr. L. Delfini, Regional Malaria Advisor and Mr. G. Shidrawi, Regional Entomologist, WHO/EMRO. 10, Plan of Action for FTY Hamle 1968 - Sene 1969. Malaria Centrol 3orvioe. 11. Position Paper with regard to the Integration of the Malaria C-,.trol Service into Basic Health Service. Provisional Alilitary Government ef Soialist Ethiopia, Ministry of Health, Apr-'l 1977. 12. Directory of Health Services in Ethiopia (under publication). Annex T Fersons contacted; TI.E. Dr. Teferra Wonde, MAnister of Health At- Wegayuhou Sallu, Pt-rrainu:nt S0crtar'y Miniptry of Health Dr. Haiie Marlam Kassaye, Head, Administration Ato Fekade Thegaye, Head, Health Services Ato Stephanos Teckle, Head, Epidemo!logy Division Ate Getanhew Abegaz, Head, BasicHealth ~ervices Ato Tilahtu, Abebe, General MIanager, Malaria Control Service Ato Yoseph ai,,hen, Head, Technical Services Department ;to Delege Meluria, Head, Administration, Malaria Control Services AUe Negussie Gebre Mariarp, Chief, Operations Division, M9, Ato Belachew Habte Michael, Chief, Finance Division, MCS, Ato Berhane Habte Mariam, Chief, Supply and Property Ato O1i Djirata, Chief of Epidemiology Division, MCS, Ato Mulugetta Gebre, Chief of Statistics Division, M S, Ato Fessehaye Sehele - Zone Chief, Nazareth Ato Kiros Sereke - Zone Chief, Jinma Ato Asnake Gebre Giorgis, Provincial Medioal Officer, Jima International Staff Dr. Sam Street, WHO Representative Dr. A. Catipovic, WHO Advisor, Health Planning , Mr. C. Webster, Sanitarian, WHO, MCS, USAID Dr. Princeton Lyman, Chief, USAID Mr. J.I. French, Deputy Chief, USAID Mr. Peter Strong, Programme Coard-Inator, USAIfD Mr. L. Cowper, USAID, Washington nnex 2 In3 etration Steering C~mit SureostedComp~osition: This Committee wcuJ :! consist of the Gerneral .:agcr o" W.13, Director of H{ealth Servicus, one o" two national muL5'Q; of te present Review Te( uri, one Zone C},i f of Malaria ejisato Regional Medical Officer of Health, ieaded the PI:1,rL' Sectary of Health, (others from the Millistry iny be invitti 'i partl1cllar discussions as needed). One of the mc:bers of th:i:; ; tti' should be designated as its secretary, with a makiate, t, report, to tfhe Mnister on the progress of te once every 2 or I months. '., rms of Reference: . To study the nature of the financial, aocounting and urocurement problems that tmy hinder smooth progress of malaria control operations, and evolve appropriate practical silutions. 2. Towork out 'n detall the size raid composition of the tecwu,- .I malaria units r.,,rcd at differnt echelons of health services fox pnarinw, prugraminIng,. upervision aid evaluation of ma2arl;. prograrinit, arid to (d-terminc thd: appropriate tinting for the merging ,f these units. 3. To keep -t close watch on the proigress of integration and suggest practical solutions to the problem.-, encountered from time to time. 4. To work out channcls of coumunications and lines of authority etos in the Integrated 'systCm. 5. To attend to tiny ether related matters.