JPC-CCP Bureau Du Pr6sident

Onchocenlasis Coatnol Prograome ln Wcst Aftica pnogranne de tuttc contre I'Oachoccecoe en Afriqrrc defotrcst

JOINT PROGRAMME @MMITTEE C0I,IIIE @NJOINT DU PROGRAITTME Off,cc of ttre Chataan JPC-CCP Bureau du Pr6sident

a I I I JOI}IT PROGRAI{UE CO}II.IITTEE JPCl 1 .8 (A) Eleventh session ORIGINAL: FRENCH ; Gqnakry, 3-6 llecenber 199O Septenber 1990

Provisional nda item 9

PR(rcRAUl'lE FOR SLTRVEILLAIICE AllD CONTROL OF ONCUOCERGIASIS AtlI) TEE OTtrER HA.IOR B{DEIIC DISEASES IN EE REPT'BLIC OF BHTIiT

I REPUBLIC OF BENIN Ministry of PubIic Health Office of the Minister National Directorate of Health Protection

PBOGBATI'IE FOB STBVEILTAICE AtlD OONIBOI OF ONCIIOCEBCIASIIS rlID TIIE OTHM HA,JOB BIDilIC DISBATIES IN ffiE BEPTIBTIC OF BENIN

June 1990 TABLE OF CONTENTS

Paqe

SUMMARY. I a 1. INTRODUCTION.. 2

2, GENERAL SITUATION IN THE COUNTRY. )

2.1. General presentation. . ) 2.2, Denographic and econonic indices 4 2.3. HeaIth policy and organization chart of Ministry... 5 2,4, Personnel and facilities..... 8 2.5. Cost and financing of public health services. 10 z. o. Functioning and'resources for epidemiological and entomological surveillance...... 10

3. EPIDEMIOLOGICAL SITUATION OF ONCHOCERCIASIS AND OTHER ENDEMIC DISEASES.. 11

3. 1. Pre-control situation of onchocerciasis. 11 3,2. Present situation of onchocerciasis ..... t2 3.3. Risk of recrudescence of transnission - ivernectin treatment...... L2 3.4. Onchocerciasis control prospects...... L2 3. 5. Other endenic diseases. 12

4. SURVEILLANCE AND TREATMENT WITHIN THE FRAMEWORK OF THE DEVOLUTION PLAN.. 14

4. 1. Onchocerciasis surveillance and control strategy... 14 4.1.1. Objectives...... 14 4.7.2. Activities.. 14 4,t.2.1. Active screening and treatnent. 14 4,1.2.2. Passive screening and treatnent L5 4.2. Strategy for surveillance and control of other endenic diseases.... L5 4.2.t. MaIaria. L5 4,2,2, Bi lharz ia L' 4.2,3, Leprosy. t5 4 ,2,4 , Tuberculosis.. t5 4.2.5. Dracunculos is. 15 4,2,6, Trypanosoniasis. 16 4.2,7, Sexually transnitted diseases STDs,/AIDS. . 15 4.2.8. Cerebro-spinal neningitis...., :,,. 15 4,2.9. EPI target diseases.... 16

5. OBGANIZATION. 16

5.1. Hunan resources 16 5.2, Material resources L? 5. 3. Cost of progranne for five years. L7 5.3.1. Capital costs t? 5. 3. 2. Recurrent costs. t? 5. 3. 3. Total cost. L? 5. 3. 4. Benin's contribution to the financing of the Devolution activities.... 18

6. TIMETABLE OF ACTIVITIES 19 Pacc ANNEXES

1. Adninistrative map and health facilities.... 20 2. Health system organization in Benin. 2L 3. Trend in Budget of Ministry of Public Health from 1981 to 1987 22 I 4. Pre-control prevalence of onchocerciasis. 2)

5. Prevalence of onchocerciasis in 1989 24

6. Estimated cost for five years.... 25 7, List of health centres to be provided with laboratories 28 8. List of laboratory equipnent...... 29 -1-

ST'}I}TABY

The activities of the Onchocerciasis Control Prograume in Benin cover two distinct zones: (1) The initial area, where the operations started in 1978, is in the northern part of the country. It is the zone that .concerns devolution.

(2) The southern extension areas, where the operations began in 1988 and are still in the active phase under the responsibility of ocP.

Before the beginning of vector control, onchocerciasis constituted a priority public health problen to Benin. Today, the transnission is being brought under control in the northern zone througlh larviciding. Ivermectin treatment trials have been started in this zone.

The epideniological situation of the other endenic diseases with which onchocerciasis control wiII be conbined calls for the taking of appropriate actions to reduce their effects on the populations.

The onchocerciasis surveillance strategy wiII conprise active and passive screening of new cases, a uapping of the disease, and necessary interventions. As regards the other endemic diseases, i.e., ualaria, bilharzia, dracunculosis, Ieprosy, African hunan trypanosoniasis, sexually transuitted diseases (STDs/AIDS), cerebro-spinal neningitis, and the target diseases of the Expanded Progranne on Inounization (UU;, the surveillance strategy will be based on the strengthening of actions already in progress by bringing into play the resources required within the franework of this devolution plan.

All these activities wiII be carried out by a group of personnel found in the appropriate health facilities, right fron the central leve1 (Ministry of Public Health) to the nost peripheral level through the internediate facilities, i.e., the Technical Intervention Units (TIUs) of the Departnental Directorates of Health of Borgou and Atacora. Personnel training, strengthening of health facilities and health education of the populations concerned are necessary for the successful inplenentation of this prograune. The total cost of the project is 838,000,000 (eight hundred and thirty-eight uillion) CfA francs, i.e., US $ 2,940,350 (two nillion nine hundred and forty thousand three hundred and fifty US dollars). -2-

1. INTBODUCTION Onchocerciasis constitutes a serious obstacle to the socioecononic developnent of vast fertile lands in the Volta basin. To elininate this scourge, a control progranne was designed and set up in 1974 in the whole zone concerned and at the beginning covered Benin, Burkina Faso, C6te d'Ivoire, Ghana, MaIi, Niger and Togo. Subsequently, the. Progranme was extended to other countries, viz., Guinea, Guinea-Bissau, Senegal and Sierra Leone.

Originally planned to last 20 years, the nandate of the Onchocerciasis Control Progranme (OCP) has been extended to 1997 and even beyond so as to take into account the tine required for the activities to be carried out in the western (the four above-mentioned countries) and southern (southern Benin, Ghana and Togo) extension areas.

With a view to allowing each of the Meubers States to safeguard the achievenents of OCP as it cones to an end, achievements which have proved to be very satisfactory, it has been decided to progressively transfer to each of the countries concerned responsibility for the diseasets residual control activities. This progressive transfer will be lade within the franework of a plan called Devolution Plan whose iuplenentation should be integrated harnoniously into the national health facilities. Thusr the devolution will be integrated into activities generally undertaken for the control of other connunicable diseases like trypanosouiasis, bilharzia, nalaria, etc. This docunent therefore aius at outlining the franework within which this progressive transfer of responsibility has to be nade. Thus, special enphasis will be laid on the following aspects:

1 General situation in Benin which wiII be centred on the following points: - geographic data - denographic and socioecononic indices - facilities and resources of Ministry of Public Health - Surveillance and resources for epideuiological surveillance. 2, Epideuiological situation of onchocerciasis It wiII concentrate on the disease before OCP, its present situation, the risks of recrudescence of transuission and epideniological trend predictions. 3. Surveillance and treatnent of onchocerciasis and the other endenic diseases.

The strategy for the surveillance and treatuent of onchocerciasis and the other principal endeuic diseases will be outlined here. 4. Organization of surveillance and treatnent This section will develop the resources required for the five- year inplenentation of the devolution plan. 5. Provisional tinetable This will concern the establishnent of the tinetable for the iuplenentation of the devolution plan.

The developnent of all these sections will lead to a coherent group of -3-

activities whose inplenentation in five years wiII enable Benin safeguard and strengthen the excellent results recorded by the Onchocerciasis Control Progranme since its beginning in 1974, However' to better integrate the river blindness control activities into the national health facilities and avoid these activities being carried out isolatedly' which would lead to the wastage of the already linited resources, onchocerciasis control will be coubined with the control of the other preoccupying endenic diseases in Benin.

2. GEI{EBAL SITT'ATION IN TIIE COUI{TBY 2.1. General presentation Benin lies in the south-eastern part of West Africa, in the GuIf of Guinea, in the equatorial zone. It has an area of 1121622 sq. km. It covers 750 kn fron north to south and bordered to the south by the Atlantic 0cean, to the west by Togo and Burkina Faso, to the east by Nigeria and to the north by Niger.

The relief is characterized fron south to north firstly by two plateaux which follow each other: the first is nade of ferruginous clay with an altitude of less than 400 retres interspersed with swanpy depressions. The second, of a silico-clayish nature, is bounded by the hills in the central part of the country and the Atacora lassive which reaches 800 netres at its highest point. This systen ends with the Borgou and Kandi plains which descend progressively towards River Niger.

Fron a clinatic viewpoint, two different zones can be distinguished: - the south is doninated by the subtropical type of clinate with two rainy seasons: frol Aprir to JuIy and fron uid-septenber to october ending and two dry seasons: fron Novenber to March and fron JuIy to nid-Septenber.

In this zone, the rainfall varies fron 700 to 1200 DD and the tenperature frou 20' to 34'C. The plant cover is quite dense with a few forests. - The north is characterized by the sudano-saherian type of clinate with a dry season fron Novenber to May and a rainy season fron June to October.

The rainfall there ranges between 400 and 800 nn and the tenperature between 8' and 42'C, The vegetation is of the shvanna shrub and grass type with gallery forests along the watercourses.

The river systeu is quite dense with two networks (southern and northern) and two big lakes in the south.

The southern networt couprises three big rivers which flow towards the Atlantic Ocean. They are the Ouere (400 k!), the lrlono (360 kn) and the Zou (150 kn).

The northern network couprises four rivers: the Mekrou (250 kn), the Alibori (360 ktr) and the Sota which flow into River Niger, while the Pendjari (380 kE) flows towards the Oti and the Volta.

Lake Nakoue is linked to the Atlantic by the Cotonou canal. Lake Ahene is found farther to the west. 4

2.2. Dercgraphic and econoric indices 2,2,L, Deaographic indices As regards demography, Benin, has a total population estinated at 4,6061224 on lst January 1989. This population presents the following characteristics: - A young population with a very fast growth rate estimated at 3.142 in 1988. - Birth rate of 50 to 54 per 1000 - Overall fertility rate of 219 per 1000 - Infant nortality rate of 150 per 1000 live births - Child nortality rate of 24 to 28 per 1000 (1 to 5 years) - Life expectancy at birth: 48 years for nen and 51 for women - Rate of nasculinity: 92.1 nen per 100 women - I{ouen of child-bearing age: 257 of the total population - Rate of schooling: 59;8?I (1987) - Rate of urbanization: 352 (1985). 2,2.2, Socioecononic indices 2,2.2.t. Prinary sector activities Eighty per cent of the population are engaged in agriculture.

The nost inportant food crops are csssava, yan and corn whose tonnages produced in 1986/1987 were 827,000, 870r200 and 483,500 tonnes respectively. The countryts principal cash crops are oil pah, cotton and groundnut.

To a lesser extent there are also shea butter allonds, cashew nuts, castor oils seeds, copra, coffee and tobacco. Aninal husbandry covers only 622 of the requirements. It conprises cows, sheep, goats and pigs. Inland fishing (lakes and lagoons) constitutes 871 of the total fishing. There is a national wood office which is responsible for the developnent of' forest industries.

The GNP is US 3 260 per capita, which places Benin arong the least developed countries, ' 2,2,2.2. Secondary sector activities Particularly as regards rining and industries, these activities include: - exploitation of the Seue oil field - the ceuent works of Onigbolo - the nanufacture of oils and glyceride - Sav6 sugar factory - cotton spinning and weaving factories E

2,2.2.3. Tertiary sector activities This sector is nainly dominated by trade which is a very inportant traditional activity in Benin. 2,2,3. Adninistrative data Administrativell', Benin is subdivided into five types of districts (see Annex 1), viz.: - Departnents: They are the biggest adninistrative districts in the country. They are six in nunber: Atacora, Atlantic, Borgou, Mono, Ouene and Zou. - Urban Districts and Subprefectures: They are the subdivisions of the departnents. They are 7? in aII including 10 urban districts and 67 subprefectures.

- Coununes Each district is divided into conuunes of which they are a total of 17 in the whole country. - Villages Villages are subdivisions of connunes in rural areas. They are 236? of then in the country. - Town suburbs They are subdivisions of urban comunes. They are 1011 in nunber.

2.3. Health policy and organization chart of lrtiuistqf of Rrblic Health 2,3,1. Health policy in Benin The essential points of this policy were defined in 1972 and ain at the following objectives: - the putting in place of an adequate public health systen infrastructure covering the whole country and particularly the rural areas; - the priority of preventive ledicine over curative nedicine; - the census' highlighting and integration of traditional nedicine in conjunction with nodern oedicine.

The ilplenentation of these general objectives has been specified in two docunents, viz,, Health Planning in Benin (1982-1991) and Operational Strategy (1985-1989). These docurents try to implenent the prinary health care strategy through the following 14 eleuents: (1) Personnel developnent through a systenatic planning of training and retraining (2) Developnent of essential activities as regards the control of the najor endeuic diseases as part of the prevention and health pronotion

(3) Introduction of primary health care into training programmes (4) Obtention of conuunity participation in health activities 6

(5) Potable water supply and sanitation (6) Supply of essential drugs (7) Integration of health activities into the country's socioecononic developnent projects (8) Search for resources to strengthen motivation at aII levels (9) Establishment of an infornation and health education systen

(10) Inprovenent of rationalization of resources Danagement (11) Construction of new health centres (12) Adaptation and strengthening of existing facilities (13) Strengthening sf technical equipment and logistic resources (14) Effective decentralization of aII central services It has not been possible to inplenent this policy fully because of the countryts econonic and financial difficulties. Thus, as part of the structural adjustnent progranne, the orientations of a new national health strategy have been redefined for the period 1989-1993 with the following objectives: - Prevention and control of the uaior endelic diseases - Vaccination, naternal, child and farily planning activities - Infornation, education and connunication for health - Strengthening of curative services - Rehabilitation of existing facilities - Prevention of sexually-transnitted diseases (STDs/AIDS) - Coununity participation (Banako Initiative). In this context, the governnent has undertaken to: - reforn the systen's structure - iaprove the aanagenent of the systen at all levels - rcbilize additional resources through 8 better participation of the private sector in health services, cost of efficacy of internal and external allocations - rationalize the investlent budget and the borrowing policy. 2.3.2, Organization of the ltinistry'of htblic Health. As part of the restructuring of the national systen, the nunber of Directorates in the Ministry has been reduced fron 13 to 7, Thus' the following directorates are attached to the Office of the lt{inister: - Sub-Directorate of Office of the Minister - Directorate of Chief Executive Assistant' Office of the Minister - National Directorate of Health Protection - Directorate of Pharnacies and Laboratories - Directorate of Hygiene and Sanitation - Directorate of Infrastructure, Equipnent and Maintenance. Besides, at the internediate level is the Departuental Directorate of Health which is the organ that coordinates the country's decentralized health policy in each d.eparhent. -?-

This restnrcturing ls ained at ensuring better urma€:euent of tbe sSrsten. lDars, the organisation chart of the Mlnistry of htblic Eealth is now as foLlows:

MINISTRY OF PUBLIC HEALTH

PRESS ATTACHE SPECIAL ASSISTANT SECRETARIAT

DIRECTOR, OFFICE OF THE MINISTER

INTERNAL AUDIT SERVICE ADMINISTRATIVE SECRETARIAT

CHIEF DEPUTY

EXECUTIVE DTRECTOR

. ADMINISTRATIVE SECRETARIAT . ADMTNISTRATIVE SECRETARTAT . ADMINISTRATIVE AFFAIRS . STUDIES AND SYNTHESES DEPT. . PROGRAMMING AND CONTROL DEPT. AND PERSONNEL DEPT. . HEALTH STATISTICS AND . FINANCIAL AFFAIRS DEPT. DOCUMENTATION DEPT. . TECHNICAL COOPERATION DEPT.

DIRECTORATE DIRECTORATE OF NAT. DIRECTOR DEPARTMENTAL DIRECTORATE OF OF PHARMACTES INFRASTRUCTURE, OF HEALTH DIRECTORATES HYGIENE AND AND EOUIPMENT AND PROTECTION LABORATORIES OF HEALTH SANITATION MAINTENANCE

. ADMINISTRATIVE SECRETARIA . ADMINISTRATIVE SECRETARIAT . ADMIN. SECRETARIAT . DEPT. OF PREVENTIVE . DEPT. OF STUDTES .INFRASTRUCTURE DEPT. ACTIVITIES AND PLANNING . EOUIPMENT DEPT. . HOSPITAL HEALTH . DEPT. OF FINANCIAL AND AND CARE DEPT. ADMINISTRATIVE AFFAIRS . MAINTENANCE DEPT. . lEC DEPT. . DEPARTMENTAL HEALTH . DEPT. OF EPIDEMIOLOGTCAL PROTECTION UNIT SURVEILLANCE AND . DEPT. OF PHARMACIES & LABO ADMIN. SECRETARIAT OPERATIONAL RESEARCH ADMINISTRATIVE SECRETARIAT TNFRASTRUCTURE DEPT. DEPT. OF PHARMACIES EOUIPMENT DEPT. LABORATORY DEPT. BLOOD TRANSFUSION DEPT. . MAINTENANCE DEPT. STUDTES AND DOCUMENTATION DEPT. 8

2.4. Personnel and facilities 2,4,1, Personnej

The Ministry of PubIic Health has 4118 workers in different categories distributed as follows in the public sector: - Medical and para-nedical personnel 3113 (75,5921 - Adninistrative staff 361 (8.762) - Technical and supporting staff 644 (15.632) Furthernore, the private sector has its own personnel. lledical Officers,

The ltlinistry of PubIic Health has 338 nedical officers distributed as foI lows: - First-Iine services (urban district or sub-prefecture health centre) 120 - Second-Iine services (departrental hospital) 52 - Third-Iine services (national teaching hospital) 59 - Central adrinistration and departnent services 31 - Undergoing specialization 76 In addition, 42 ledical officers in the private sector work in urban areas while 1?9 are in the rural areas.

There is one uedical officer for 250 inhabitants in urban areas &s against one nedical officer for 2923L inhabitants in rural areas. Nursing staff The ltlinistry of Pnblic Health has 881 nurses distributed as follows: - First-Iine services (urban district or sub-prefecture health centre) 562 - Second-Iine services (departnental hospital) 129 - Third-Iine services (national teaching hospital) 93 - Central adninistration and departnental services 97 68 nurses work in the private sector including 31 in urban areas and 37 in rural areas.

In urban areas, there is one nurse for 448 inhabitants as against one nurse for 2834 in rural areaa.

Midwives

The lr{inistry of Public Health has 299 nidwives distributed as follows: - First-Iine services (urban district or sub-prefecture health centre) 189 - Second-Iine services (departnental hospital) 59 - Third-tine services (national teaching hospital) 42 - Central adninistration and departuental services 9 32 uidwives work in the private sector, including 28 in urban areas and 4 in rural areas. -9-

In urban areas, there is one nidwife for 576 inhabitants as against one midwife for 7385 in rural areas. Health nurses

The Ministry of Public Health has 679 nurses distributed as follows: - First-Iine services (urban district or sub-prefecture health centre) 523 - Second-Iine services (departnental hospital) 63 - Third-Iine services (national teaching hospital) 51 - Central administration and departnental services 42 53 health nurses work in the private sector including 35 in urban areas and 18 in rural areas.

In urban areas, there is one health nurse for 1567 inhabitants as against one for 1105 inhabitants in rural areas. Nursing assistants

707 nursing assistants work in the l{inistry of Public Health including: - First-line service (urban district or sub-prefecture health centre) 432 - Second-Iine services (departuental hospital 90 - Third-Iine services (national teaching hospital L23 - Central adlinistration and departnental services 62

In the private sector, 120 nursing assistants work in urban areas and 36 in rural areas. 2,4.2. Facilities Health care services are provided to the population by a pyranidal type of health network lade up of: Peripheral level: - 2?l village health units - 244 connunity health couplexes - 10 urban district health centres and 67 sub-prefecture health centres Internediate level: - 4 departnental hospitals - 6 departuental directorates of health National level: - 1 teaching hospital and a nunber of specialized centres - I neuropsychiatric centre - 1 pneunophtisiology centre - 1 national blood transfusion centre - I naternal and child health centre In addition, there are 12 private and denouinational hospitals in the country. -10- 2.5. Cost and financing of public health services The financing of Benin's public health system depends on several sources:

- State budget - Conmunity participation - Bilateral, nultilateral and non-governmental cooperation. 2.5.1, State Budget

Between 1982 and 1987, the proportional share of the health budget in relation to that of the State remained around 6Z (see Annex 3). It is noted, however, that the iten personnel takes 66-752 of the budget allocation for the operating expenditures of the Ministry of Health. Recourse to other sources of financing is therefore necessary for the developnent of curative and preventive activities.

In 1987, the operating budget was, 1,264,575,000 CFA francs. 2,5.2, Connunity participation As part of the Banako Initiative, public health services constitutes a considerable but difficult to quantify contribution. It consists of the contribution of hunan (first-aid workers and birth attendants) and financial (construction of dispensaries and naternities, purchase of drugs, connunal labour) resources.

2.5.3. BilateraT, aultilateral and non-governoentaL cooperation In 1987, the contribution of the financial backers anounted to 1,392,4601000 CFA francs for investnents and 1,953,490,000 CFA francs for recurrent costs to which ghould be added 164,400,000 CFA francs for vaccines and drugs.

An average aaount of 3166010001000 CFA francs is expected every year frou this cooperation. The principal financial backers are Francer Federal Bepublic of Geruany, Switzerland, Japon, China, North Korea, Italy, United States, Canada, Belgiun, the Netherlands, etc.

The nultilateral donors nainly include the United Nations System and the European Econoaic Comunity. Non-governuental organizations (NGOs) are also actively involved in the financing of the health systel. 2.6. hrnctioning and resources for epideriological and entorological surreilla,nce

2.6. 1 . Epideniologcal surveiLlance In Benin, epideuiological surveillance covers epidemic and najor endenic diseases: target disease of the Expanded Progranne on Innunization (oeasles, whooping cough, diphtheria, polionyelitis, tetanus, tuberculosis), nalaria, diamhoeal diseases (including cholera)r sexually-transnitted diseases and AIDS, cerebro-spinal ueningitisr yeIlow fever, Ieprosy, -11 - trypanosomiasis, onchocerciasis, bilharzia, dracunculosis and blinding diseases. Routine notifications nade in urban districts and sub-prefectures (conmunal conplexes and health centres) 'are forwarded to the departnental Directorate of Health whose specialized unit, Technical Intervention Unit (TIU), conpiles and analyses the data collected. They are sent to the central level, i.e., to the Department of Statistics and Docunentation of the Ministry of PubIic HeaIth. In case of epidemiological emergency, the TIU is nade to intervene immediately before inforning the National Directorate of Health Protection which has a specialized surveillance unit: Epidemiologcal Surveillance and operational Research Unit. In such & case, declaration of the pestilence is nade weekly. 2,6,2, EntonoLogical surveillance

Entomological surveillance is carried out by the Directorate of Hygiene and Sanitation in conjunction with the National Directorate of HeaIth Protection and the specialized units in Benin:

- Entomological station of Organization for Coordination and Cooperation in the Control of the najor Endenic Diseases (OCCGE) based in Cotonou; - Entomological Office of the Onchocerciasis Control Progranne (OCP) in Parakou.

3. EPIDEXilIOTOGICAI SITUATION OF ONCIIOCEBCIASIS fiTD THE O'IIIEB ENDMIIC DISEATTES In Benin, two zones are particularly affected by onchocerciasis:

- In the north, the endeuic zone covers 561000 sq. kn, from the border with Niger to a line frou Djougou to Nikki. Four watercourses are concerned: the Sota, the Alibori, the Mekrou and the Pendjari. - In the south, an area of 251000 sq. kl is concerned. It stretches frou the Djougou-Nikki line to the confluence of the Zou and the Ouene. Five watercourses are affected: the Zou, the Oueue, the Mono, the Okpara and the Koffo. The devolution progranne does not cover this second zone. 3.1. Pre-control situation of onchocerciasis

initial studies nade in 1963, 1965 and 1969 by Ovazza, Soley and Touffic showed that cyst-carriers were Dore than 402 along the principal watercourses.

- In 1975 (Falzon), 1976 (Prod'hon) and 1977 (Ba)1 r€w surveys enabled the inportance of the disease to be neasured. Skin snip, urine exanination and visual acuity test were the main screening techn iques.

Different evaluations by OCP nade it possible to record prevalence rates ranging fron 252 to 982 depending on the localities. The blindness rates were between 1 and 3Z in the hyperendemic areas and less than LZ everSrwhere else in the nesoendenic areas. -12- 3.2. Pregent situation of onchocerciasis

Started in 1978 in the northern zone of Benin, OCP's vector control has had a very positive epideniological impact whose results have been reported through large-scale evaluation surveys. A regular and periodic nonitoring in this zone has resulted in a significant reduction in the prevalence of the disease over the years (see Annexes 4 and 5). To date, vector control is being continued so as to stop transnission conpletely in the southern areas. Since February 1988, the extension of vector control operations to the southern zone of the focus has enabled the results to be inproved in the northern zones that are usually reinvaded. 3.3. Risk of recrudescence of translission and ivenectin treatrent Difficulties reuain despite the encouraging blackfly control results observed. Certain zones under control are exposed to reinvasion by blackflies fron non-treated watercourses. This phenonenon is particularly preoccupying in the Sota and Ouene basins where infiltration by blackflies constitutes a risk of recrudescence of the disease and in addition to blackfly control, OCP has, since 1988, started Dass ivernectin treatnent of the populations suffering fron onchocerciasis. 3.4. Onchocerciasis c-ontrol prospects

Larviciding stoppage cannot be envisaged at present in aII the zones under control. This decision can only be taken when epideniological and entonological surveys show that transnission has reached a negligible epideniological threshold.

3.5. Other r4jor enderic disea.ses They are nalaria, bilharzia, Ieprosy, tuberculosis, dracunculosis, trypanosoniasis, sexually-transmitted diseases (STDg/AIDS), cyclically cerebro-spinal ueningitis in the country's two northern provinces and the diseases of the Expanded Prograrne on Inrunization. 3.5.1, llalaria It is the country's principal endeaic disease. 195r659 c&ses were recorded in 1986 with an incidence rate of 3790 per 100,000 inhabitants (nost recent statistics), a figure which is uarkedly underestinated. To this perranent scourge should be added the problen of chloroquine-resistance in the coastal areas. 3.5.2. Bilharzia Urinary bilharzia is endenic, with an annual averege of 4000 cases in the zones concerned with the devolution progranne. 3.5.3. Leprosy This disease is decreasing progressively. There were 20r000 patients in 1982, 14,869 in 1985r and 6,307 in 1988, i.e., aprevalence rate of 1.37I. Multibacillary patients represent 26,82 of the leprosy-sufferers enumerated. The real introduction of polychenotherapy in the country's provinces r+iII accelerate the diseasets regression phenonenon. -13_ 3.5.4. Tuberculosis Tuberculosis has always been a public health problen in Benin which the rapid developnent of HIV infection could increase considerably. .In 1988' 2050 tuberculosis patients (aII forns) were screened (including 1407 positive for BK) as against 1938 cases in 1987. Anti-tuberculosis short treatuent is being extended rapidly to the whole country. 3.5.5, DracuncuJosis

Dracunculosis is a najor endenic disease in the Zou departnent but also affects the southern part of the Atacora department and the northern part of the Atlantic, Mono and Ouene departments. This incapacitating parasitic disease affects an average of 50r000 patients. A national control plan was prepared in 1989. It wiII be inplemented in the coning nonths and envisages the progressive elinination of Guinea worn. 3.5.6, African huaan trypanosoniasis

The Atacora departnent has for a long tire been a seat of African hunan trypanosoniasis. The prevalence has been decreasing considerably since 1960. Fron 1979 to 1988, 16 cases of confirued patients (T+) were recorded in this region. Recent studies conducted in May 1986 and June 1989 nade it possible to screen uore than 7 r?00 persons in the usually exposed sub-prefectures: Tanguieta and Itlateri. The epideniological situation seens to have becone stable despite the discovery of a nunber of sero-positive subjects without an apparent clinical disease.

The vectors identified are G.P. Ganbiensis and G. Tachinoides. A flexible but continuous surveillance is therefore necessary so as to prevent and control an eventual recrudescence of the disease. 3.5.7. Sexually transaitted diseases (STDs/AIDS)

They are a uajor coDtron probler in all the countries of the subregion. This problen, which is at present not weII defined in Benin, has been particularly couplicated by the elergence of AIDS in the inter-tropical region. To date (3t/12/89 ), 84 cases have been recorded in Benin according to a very rapid progression (threefold increase in patients every year). The sero-positive in blood donors increased fron 0.16 in 198? to 0.432 in 1988. The epideniological situation of this disease is therefore evolving rapidly. A national control prograntre has been set up, since Novelber 1987, to check this disease. 3.5.8. Cerebro-spinal oeningitis The Borgou and Atacora departaents, which are in the Lapeysonian belt, are exposed every to the risk of cerebro-spinal neningitis in the dry season. On average, 200 to 300 cases are screened every year. But epidemic outbreaks are not r8re. Thus, 2411 cases were recorded in 1989. 3.5.9, EPI target diseases Unfortunately. sone of the six preventable infections diseases taken as targets by WHO through the Expanded Progranue on Inmunization have very high rates. This concerns, in particularr whooping coughr tetaqus and neasles: the following were recorded in 1985 - whooping cough: 2646\cases \ -14- wt th l0 deathsl tetanus: 636 cases with 105 deaths; neasles: 13,413 cases with 67 deatshs. It is obvious that these figures are far below the epidemiological realities.

4. SURVEITUINCE AND TBEATIIETIIT TIITHIN THE FBA}TEI{ORK OF THE DEVOII,TION PLAN 4.1. Onchocerciasis surveillance and control strategy 4.1.1 , Objectives

The principal objective of the devolution progrenme is to naintain the achievenents of OCP and continue its activities so &s to ensure a pernanent control of the disease. Once OCPts objectives have been attained, onchocerciasis surveillance and control will be progressively integrated into the national health systen according to a strategy of active and passive detection and treatnent. 4,1,2, Activities

They will be placed under the responsibility of the Epideniology and Operational Research Departrent of the National Directorate of HeaIth Protection. The technical respondents of this Departnent in the field are the Technical Intervention Units (TIUs) in each province. Thanks to the functions of this unit, the progressive integration of onchocerciasis control into the national health systen wiII be acconplished. The functions of TIU are: - organization of vaccination activities - screening and treatnent of local endenic diseases - interventions in case of epidenic and disaster - water control - environnental sanitation - periodic epideniological evaluation Furthernore, a ceII for reflection and nonitoring of activities inherent in the devolution plan will be set up and put under the authority of the Ministry of Rrblic Health (Epideniology and Operational Research Departnent). This cell will aake use of the services of the required personnel (epideniologists, ophthalnologists, health educators, planners, conputer scientists, etc. ) fron different origins (llinistry, Faculty of Health Sciences). Fron this ceII wiII energe an organ for the day-to-day Danagetrent of the devolution plan whose 'responsible officerr EII epideniologist, wiII be the head of the Epideniology and Operational Research Departnent. This organ wiII also include a^n adninistrator a^nd an I.E.C. special ist. 4.1.2,1, Active screening and treatoent

(a) Detection of new cases. It wiII be uade through regular surveys (3 years) using skin snip in the population of 32 indicator villages scattered along the watercourses concerned. The final selection of indicator villages, whose population wiII have been censused according to OCP nethodologyr will be nade in close collaboration with this organization. (b) Epideniological uapping of the newly infected foci. I{hen new cases are detected, additional surveys wilI be conducted around the indicator _1r_

village concerned in order to prepare a detailed epidemiological map of the focus. This mapping wilI be used for decision-making concerninB possible interventions if the risk of recrudescence of infection and appearance of the disease is considered alarning. (c) Mass ivermectin treatnent. In case of intervention, ivermectin treatment wiII be established according to OCP protocol. The treatnent wiII be repeated every year for a duration of 15 years.

(d) Evaluation of intervention. In areas where this treatment wiII be applied, it will be necessary to nake sure that the intervention strategy adopted has been effective. A longitudinal skin-snip survey will have to be carried out for that purpose. 4,L,2.2. Passive screening and treatnent

It will be made in aII the health centres during daily consultations. Parasitological confiruation will be uade in the urban district or sub- prefecture health centres of the onchocerciasis zones which will be provided with a oininun of technical equipnent for that purpose (see detailed estinated cost and list of Iaboratory supplies and equipnent). 4.2. StrateEnf for surveillance and control of other enderic diseases This strategy is based on active and passive screening with treatlent of cases. 4.2.1. llalaria The passive screening nade in all the health centres of the national health systeu is still essential. A systenatic treatnent of fever attacks wiII be nade whenever necessary. Preventive treatlent will be reserved nainly for pregnant wonen. Concouitantly, vector control will be undertaken through vast public awareness and inforuation ca^npaigns and the supply of nosquito nets. 4,2,2. Bilharzia Parasitological uonitoring will be regularly nade in the known foci. Infected patients will be treated. lrlalacological control will conplete this series of leasures. 4.2,3. Leprosy

The control strategy is based on the scrdening of new cases and the treatuent of patients by polychenotherapy. Screening can be done passively by the presentation of new cases to any health centre and actively by a survey in the fanily or neighbourhood of the screened case. The therapy applied willr in tiue, depend on the dosage for the bacteriological classification. There wiII be a systenatic prevention of handicaps. 4.2.4, Tubercujosis

The screening of patients is first and forenost based on bacilloscopy. Patients detected during routine consultations will be put under treatnent acccording to the current national protocol (two-nonth standard treatnent in quadritherapyr four-uonth naintenance treatnent in bitherapy). A fanily -15- and/or household active screening has to be made.

Prevention by BCG vaccination will be intensified as part of the EPI/PHC progranme. 4.2.5. Dracuncujosis A national programme for the control of this dise&se w&s prepared in 1989. It is based on the linitation of contanination of the environment, destruction of cyclops, prophylaxes, treatment of the population exposed to the risk, and potable water supply. 4,2,6, African huaan trypanosoniasis In addition to passive detection of patients, a systeuatic screening of the whole population of the recognized foci r*iII be nade through inmunological tests ( IFI-CATT). This screening could be oade during integrated prospections by using blood serun tests. Confirned patients wiII be treated in the appropriate centres according to I{HQ protocols. Vector control using traps and screens wiII be undertaken as part of primary health care. 4.2,7, SexuaLly-transaitted diseases (STDs/AIDS) As in aII the countries that have adopted a national STD/AIDS control prograDne, the following are the control strategies: - screening, treatnent and follow-up of patients - safe blood transfusion - proaotion of use of condons - intense health education 4.2.8. Cerebro-spinal neningitis The control strategy is based on: - strict epideuiological surveillance during critical period (weekly declaration of cases) - rapid vaccination in case of outbreaks - treatnent of patients according to sinple and standardized protocols. 4,2.9. Target EPI diseases They are fully taken into account in Benin's Expanded Progranne on Innunization. The strategy is based on day-to-diy vaccination in aII of the countryts health facilities as weII as a strategy for the less accessible 8F€ES. The surveillance of the target diseases is based on the obligatory weekly declaration of the diseases concerned.

5. OBGANIZATIOI{ 5.1. Huran resources For the successful inpleuentation of this progranne for the surveillance and control of onchocerciasis and the other endenic diseases, the Ministry of Public Health wiII nake use of the services of the national personnel of the following: _t?_

- Epideniology and Operational Research Department (EORD) of the National Directorate of Health Protection. Under the supervision of this departnent, a national ceII for reflection and nonitoring of the devolution wiII be set up. An organ for the day-today managenent of the said plan wiII emerge from this cell; - Technical Intervention Units of the Atacora and Borgou departmentsl - Peripheral health centres, i.e., conrnunal health conplexes and urban district or sub-prefecture health centres. However, since it is a matter of strengthening and integrating as best as possible activities for the epideniologlical surveillance and control of the major endenic diseases, it wiII be necessary to use nore specialized personnel, i.e., epideniologists, health educators, conputer scientists, etc., whose nuuber should be supplenented by an appropriate training progranne.

The TIU teams based in Parakou and Natitingou will be responsible for active screening and supervision of the treatnent of all cases of the endenic diseases concerned.

The training of the personnel of the peripheral facilities will be strengthened by the TIU teans with a view to facilitating the passive screening of cases of onchocerciasis and the other endenic diseases. Like the TIU teausr this personnel will also carry out public awareness campaigns and health education on these diseases for the populations coning within their province.

5.2. llaterial resources AII the planned activities will necessitate the acquisition of technical equipnent for nedical analysis, field trip, equipment data collection and analysis, as well as for transport.

5.3. Cost of prograne for five lreara (in CPA francs) 5.3.1, Capital costs

- Training, retraining and public awareness raising...... , ZT rZ00r000 - Construction and laboratory equipnent..... 265,5001000 - Vehicles .. o...... 5610001000 - Field trip equipuent...... Zr4Z4.OOO

5.3.2, Recurrent costs

- Vehicle laintenance...... 38,000,000 - FueI and lubricants. 24 , 200,000 - Office supplies...... 20,000,000 - Drugs...... 249, 500,000 - Per dien and allowances...... 79 ,000,000

5.3.3, Grand total

351,124,000 4 10 , 700 ,000 -18- Total 761,824,000 Contingencies: 102...... 76'1821400

Grand total ..... 838'006'400

Rounded off to...... 838,000,000

Eight hundred and thirty-eight million CFA francs (US $2,940'350). 5.3.4, Benin's contribution to the financing of the devolution activ ities The cost of Benints devolution progranne for five years anounts to 838,000,000 CFA francs. The financial participation of our country to the inplenentation of this progranne is estinated at 187'000'000 CFA francs, i.e., US $656'140 broken down as follows: (1) Construction of laboratory for 18 urban district or sub-prefecture health centres in the devolution zone: 6,000,000 CFA francs x 18 = 108'000'000 CFA francs (2) Per dien for central coordination and developnent of activities as weII as nanagenent allowances

79,000,000 CFA francs the details which are given in the devolution plan. This participation of Benin represents 22.312 of the total cost of the prograrne. -19_

6. TI}IEiTABLE OF ACTIVITIES

ACTIVITIES

YEAR

1 2 3 4 5 1. Establishment of national coordination cell and Danagenent organ in EORD 2. Procurenent of logistic resources 3. Construction and equipment of laboratories 4. Procurenent of field-tri p equipnent

5. Training: - Epideuiologist 1 1 --- - Ophthalnologist I I --- - Entolologist 1 I --- - Health educator I

6. Retraining: - Irledical officer - Health workers - Laboratory technicians 7. Inforlation Education Couunication 8. Putt rn ace of ivernectin 9. Active screening and treatrent of new caaes

10. Passive screening and treatrent of new caseg

11. Epideliological surveillance of onchocerciasie and the other endeaic diseases 12. Collection and analysis of _epideniological data 13. Supervision of personnel of peripheral centres 14. Evaluation of progra^DDe - half-way - end of progranae Lo

AAJNEX I MAP OF HEALTH FACILITIES IN BENIN

t e N c EA

SUPKITVA FASSO

lrorouoro

Olondl a t,t t tDo,! o a Iot l 9O.aerlur O. ohudro ojoll Gtlutcuntxio t"'rjE' . E--'; gstaeiarj lerlr- I Br.**d.;

Eft., Olotrt. g.r.dl gr&*i Oqrlru

qrtarlrou lr. I D-.lla \ ?ataarrruI q

ouirri (g .O .Olara o

r o qcreri .g lrr 3crai, oEt \ f. () 6frtrrrj o eXotlonot t ochlng rro.pt?ot L ! D.port.m.it ho.pltol o3ltfi % O U?bon dlatrlct o? auD-pr.Lclora haortr caatL o comrnunlt, iaolth cadr. 92.r.-.. O lO aO aO tootr lrrrtt aO

C r -2t-

lnuE( 2 ORGANIZATION OF HEALTH SYSTEM IN THE REPUBLIC OF BENIN

MINISTRY OF NATIONAL LeVeI PUBLIC HEALTH

Technlcal Dlrcctoratcs Natlonal Teachlng Hospltal

DEPARTMENTAL DIRECTORATE DEPARTEMENTAL Level OF HEALTH

Ttu

Tcchnlcal Unlts Departmental Hospltal

URBAN DISTRICT OR SUB- URBAN DISTRICT OR PREFECTURE HEALTH CENTRE SUB-PREFECTURE LEVE

Urban Dletrlct or Drugrtorc Sub-Prcfccturc Horpltel

COMMUNAL HEALTH COMMUNE Level COMPLEX

Dlepensary Matcrnlty Drugetore

VILLAGE HEALTH UNIT VILLAGE Leve|

Health care hut Chlldblrth hut Vlllage drugetorc -22-

ANITEI 3: TBEND IN BT,DGEI OF }IIIISIBY OF PIIBLIC IIEALTI{ (in current CFA francs)

DUDGIT OI I'INISTBY OI JIIALTH llealth Heslth HeaIth nerlth cxDCn- bud!et Ycrr Netlonal Pcrsonnel op.ratinE Total diturc l{etio- ludget BudEat ludgct BudgGt per nrl inhsbi- budget trnt (z)

l9El 42 . 563 . ?79 .000 I .717 . ?13.000 a6{ .503.000 2.tEz.116 .000 s95 5. 13

1982 r? .863 . {90 .000 2 . 158 .938 .000 5?a . 133 .000 2 ,733,071.000 ?58 5.71

19E3 60.59a .715,000 2 , 60{ , {76 ,000 825 , 5{? ,000 3,a30,333,Eoo 927 5.66

198{ 55 .9la .5t9 .000 2,{09.{E3,000 E25,5a7,000 3 ,235 ,030 ,0oo E25 5. ?0

l9t5 50 . 76E . {00 .000 2 .2a9 . 298 .000 825 . 730 .000 3 .0?5 . 028 .000 ?64 s.05

19E6 {5 . 260 .013 ,000 z , {{2 . 079 ,000 695 ,678 ,600 3 , 137 , ?57 .000 ?57 6.93

1987 45,930,{11,000 2,782,277 ,OOO 1 , 26{ , 575 ,000 { ,0{6 , 852 ,000 0{6 8.81

Source: Ministry of Public Health - Directorate of Studies and Planning o)O^

o r. >Eo o o L- o z o5 o EOctt oo z Bs oUJ -oE o o \-o>E o ri or oY c oL i oo o o C 6 ooo ltil () o E, o UJ o o oo oC) o Oj - zC) o oo o o o oE C1 oUJ o z o o lrjJ o o t trlrJ (L o o o o o (E o zF o o oo () c o I oo lrJ ,O o O tr o ooo (L o a o o o o OO E o oo a H o cC' x o zUJ o il H$i z e o. O CCO LY

o oI >EE o o o L-f, E3 o z= 3g oo UJ -otr o tD }Ec o o tE, @ o 39. I o L 5_ o I= o o q o oo ll:{ () (ts o otd oo o o o o o oo L)= Z o oo o o o o l! o OO UJ zc) lrJ oo o J o o g (rUJ (L o o o o o o oo o o oo o 9O o oeo o o o o o OO o E o o Ho (, xE a UJE $ H $i z: o coo -25-

ANI{EI 6

ESTI}IATED OOST OF MOGBAI'ITIE FOB FIVE YEABS

1. CAPITAI COSTS

1.1. Training, retraining 8nd awareness raising t - Training health educator 1 x (3 months) x 400,000 1 ,200,000 - National internal seninars t Seminar for uedical officers 10,000,000 Seninar for health workers 10,000,000 Seminar for B technicians 1 ,000,000 Information, education, conmunication 5 ,000,000 Total 27,200,000

1.2. Construction a,nd equiprent Construction of laboratory for the 18 urban district or sub-prefecture health centres in devolution zone 6,000,000 CFA francs x 18 108 , 000 ,000 Laboratory equipnent 18 urban district of sub-prefecture health centres and 2 TIUs - 6,600,000 CFA x 20 132 ,000,000 Data processing equipnent, softwares, stabilizers 3r500r000 x 3 10,500,000 Docunent reproduction equipnent 10,000,000 Office furniture 5 ,000,000

TotaI 265 ,500, ooo 1.3. Yehicles

Toyota Land Cruiser 81000,000 x 3 24 ,000,000 (one for each of the two TIUs and one for the central celt) Toyota Pick-up 6,000,000 x 2 12,000,000 (one for each of the tro TIUs) Itlotor cycle 1,000,000 x 20 20,000 r 000 (one for each of the urban district or sub-prefecture health centres and one for each of the 2 TIUs)

TotaI 56,000,000 1.4. Field visit equiprent (for 2 TIU tears)

Canp-bed and bedding: 501000 x 22 1, 100,000 Folding tables: 20,350 x 20 407,000 Chairs: 7,250 x 30 2t7 ,OO0 Adjustable stool: 301000 x 10 300,000 Cooking equipnent: 801000 x 5 400,000 i TotaI 2 1424 rO00 1.5. Surrary of Capital costs

Training, retraining, awsreness raising 27 ,200 1000 Construction and equipuent 265,500,000 Vehicles 56,000,000 Field visit equipnent 2,424,000 *

Total 351,124,000

2. BECT'BBEI{IT @STS

2.1. llaintenamce, repair vehicles and generators (5 years)

Vehicles (5) SOO,000/year 12,500,000 Motor cycles (20) 250,000/year 25 ,000,000 I Electric generator (2) 50,000/year 500,000

TotaI 38,000,000 h 2.2. Fuel and lubricants

Fuel (vehicle) 16' 200 000 FueI (notor cycle) 4, 000 000 Lubricants 4, 000 000

Total 24 ,200,000 2.3. Office supplies and riscellaneous

Supplies and others 5 ,000,000 I{aintenance of f ice equipuent 15,000,000

Total 20,000 ,000

2. {. Dnrgs

2. 4,L, Onchocerciasis treataent

Iveruectin - Treatuent side-effects 4,500,000 2.4.2, Bilharzia treatoent

Prasiqua"ntal (box of 11000) 4000 patients to be treated per year, i.e., 80 boxes 375,000 x 80 30,000,000 2.4,3. Treataent of cerebro-spinal nengintis Prevention 2001000 doses of vaccine per year, i.e., 1,0001000 doses 50,000,000 for five years Curative treatnent Chloralphenicol in oily suspension 3,000 bottles'per year 60,000,000 2.4.4. l{aLaria treatnent

Chloroquine - (151000 boxes of 10001 - 7,000 x 15,000 105 ,000,000 TotaI 249,500,000 ra 2.5. Per dier and allowaoces Per dien central coordination (cell inMinistry) - 40 x 5 x 5 = 1r000/day/5 years 10,000,000 Irlanagenent allowances (uanagenent organ) 50,000x3x12x5 9,000, 000 Per dien TIU tean 60, 000 000 _2?_

( 10 days/person/nonth) 120 days/person/l2 months, i.e., 600 days/per/S years 600 days x 10 pers., i.e., 6,000 days Total 79,000,000 2.6. Surrary of recurrent costs

Vehicle maintenance 38 000 000 FueI and lubricant 24 2 00 000 ,) Office supplies 20 000 000 Drugs 2 49 5 00 000 Per dien 79,000,000

TotaI 410, 700,000

Total Capital costs 351,124,000 Recurrent costs 4 10 , 700 ,000 761,824,000 102 contingencies 76, 182 ,400 Grand total 838,006,4oo Rounded off to 838,000,000

Eight hundred and thirty-eight uillion CFA francs, i.e., US $2,940,350 (two nillion nine hundred a^nd forty thousand three hundred and fifty United States dollars ) . -28-

AllI{EX 7

LIST OF TIBBAN DISTBICT OB STIB.PBEFECruBE IIEILflI CENMES TO BE PBOVIDED I{ITII U$ORATOBY

ATACORA DEPARTMENT - Tangui6ta - Matr6ri - K6rou - Cobly - Toukountouna - Natitingou - Boukounb6 - P6hunco

BORGOU DEPARTMENT

- Beub6r6k6 - Gogounou - Kalal6 - Nikki - Kandi - Parakou - Segbana - P6r6r6 - N'DaIi - Sinend6 -)Q- nPc',( {, Lk) ANNEI 8 LIST OF TIIBOBAIOBY MUIHENT TND SUPPTIES FOB 18 I'BBAIT DISTBIC:T OB SUB-PBEFtCTUBE HEALIH CEIBES A}{D TtlO TIUs

ITEM QUANTITY

Holth's punch 36 SIides, with holder 72 Eppendorf pipette with nozzles 18 ) Lancette 36 Slides, ordinary 540 Microtitre plate 360 Straight scissors 36 Curved scissors 36 Kocher punch 36 Bectangular ena^uel tray 36 Haricot enanel tray 36 Bathroou scale 36 Tensioneter + stethoscope 36 Therloneter 360 Iveruectin lonitoring kit 36 Gas/electric refrigerator l8 5 nI syringe 96 Assorted needdles for syringes (the set) 20 5-Iitre non-comodible basin 20 1.5 r latex tube int. = 7 rrr ext. = 10 ll 40 Scale 2 pans, I kB, 0.5 g 20 Filter paper (50 sheets) 20 tlanual centrifuge 20 Graduated tube for ranual centrifuge r60 Mirror binocular licroscope 20 Separate lighting for licroscope 20 Itticroscope slide (box of 1000) 20 Itlicroscope coverglass (box of 50) 400 Slide etorage case 20 Optice-cleening paper (packet of 50) 100 250 nl laboratory balloon-flask 40 500-rI laboratory balloon-flask 40 250-nI Erlenneyer 40 180-ll graduated urine bottle 300 1-lI graduated pipette 40 2-ll graduated pipette 40 5-rI graduated pipette 40 10-rI graduated pipette 40 Pasteur pipettes (box of 250) 20 10-nl pipette (dropping) 40 Rubber bulbs for 2-ll pipette I00 Test-tube (box of 100) 20 Stoddart clip for test-tube 40 Wooden support for 12 test-tubes 40 Test-tube basket 20 Heaolysis tube with cover (bV 50) 20 Supply of products and reagents (Benedikt,Gielsa, 20 sulphosalicytic acid, sodiul citrate, aethylene blue, etc. ) Capillary tubes, non-heparinized (box of 600) 20 Capillary tubes, heparinized (box of 600) 20 Low fora beaker (set of 5) 20 75 rn dian. watch glass 40 Petri dish 40 500-nl reagent bottle 80 -30-

1000-nl reagent bottle 20 250-rI reagent bottle 80 l3-uu diar. brush 40 35-un diau. brush 40 50-un dian. brush 40 50-nl graduated test-tube 20 100-nl graduated test-tube 20', 500-nl graduated test-tube 20 I 100-nn "fluted" plastic funnel 40 i 250-nl polyethylene waste bottle 80 I AIcohoI lanp 20 Bunsen burner 20 Gas cylinder 40 Lab. therloueter - 10'C + 110'C 20 Urine densileter 20 60-linute tirer 40 Red felt pencil 100 BIue felt pencil 100 Blood Lancet (box of 1000) 20 I{estergreen pipettes 160 Support for 6 l{estergreen pipettes 20 Rhesuscope 20 Laboratory lanual 20 SshIi hearoglobinoneter 40 Sahli hearoglobinoleter tube 100 Sahli pipette 40 Esbach albulinineter 40 Filter, S-Iitre reservoir 20 Metallic cupboard 20 Laboratory stool 40 Vinyl-chroliul chair 20 llall curtain hook 20 Office supplies 20 l{riting case 20 Hard-cover reElisters (set of 5) 20 llhite coat 60 60 x 40 cr hand towels 80 15-Iitre non-corrodible dustbin 20 Thora GB pipette 40 Thora GB pipette 40 Haerocytoreter 20 Itlanual cells recorder 20 Levy cell 20 It[alaseez cell 20 Glass staining trough 20

E E E