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.;.