JPC .CCP

II Il

JOINT PROGRAT\'IME COMMMTEE

Office of the Chairman

JPC .CCP

^{CON/IITE CONJOINT DU} PROGRAIVIME Bureau du Pr6sident

JPC11.8(D)

ORIGINAL: I.RENCH

Septenber ^199O

a

JOINT PROGRAUT'E COUMITTEE

Eleventh session

Conakry,

3-6

^{December 199O}

Ero,i

sio!,a!

^ege444

j!gr_9

PLAN FOR DEVOLUTION OF ^PROGRAU}M FOR SURVEILLANCE AND CONTROL OF ONCHOCERCIASIS AND HYCOBACTERIOSES IN TOGO

\

I

i

Epidemiological

Division

PL/IN FOB DEVOLUTION OF TIIE ONCIIOCEBCIASIS AND }fY@BACTERIOSES STJBVEILTIINCE AND COI{TBOL PBOGRA}II'TE IN TOGO

August 1990

SUMMARY

1.

INTRODUCTION

2,

^GENEBAL SITUATION IN THE COUNTRY

General

presentation . ...

Demographic and economic indices

Some

sociocultural

data 2.3.

2,4, 2,5, 2,6,

Health

policy

and

organization of the Ministry of

Health Personnel and

facilities

2.L.

2,2,

2.7 ^,

5. 3.

6. 1.

6,2,

1 2

2 2

)

4 5

?

? 9

Cost and

financing of ^public health

services

Functioning snd resources

for

epidemiological survei Ilance

3.

EPIDEMIOLOGICAL SITUATION OF ONCHOCEBCIASIS, LEPROSY AND TUBERCUIOSIS.. ¹⁰

3.1. Situation of

onchocerciasis before

the

beginning

of

^vector

control ...

Present

situation of onChocerCiaSis ... ...

Risk

of

recrudescence

of transnission

and

ivernectin treatnent..

.

Onchocerciasis

control

prospects

.

Present

situation of the other

diseases

4,

SURVEILLANCE AND TBEATMENT AS PART OF DEVOLUTION

4.1.

Onchocerciasis

surveillance

and

control

strategy

4.1.1.

Objectives

4,L,2. Activities

4,2.

Leprosy and

tuberculosis surveillance

and

control strategies 5.

MONITORING AND EVATUATION

Coordination and

uonitoring of the

programne

Supervision Evaluation

6.

^{RESOURCES AND COST OF} PROGRAITIME

3.2 3.3 3.4 3.5

10 10 10 11 11 L2 12

t2

L2 13 14 14 14 L5 L9 15

t5

L5 L5 15 16 15 15

t?

5.1.

5,2,

Personnel

Material resources

f devolution plan for five

^years

.

Investments

Becurrent Evaluation

Overall

cost

6.4.

^Togo's

contribution to the financing of devolution activities..

Cost o

6.3.1 6,3.2 6.3.3 6.3.4

6. 3.

expenditure

?.

TIMETABLE OF ACTIVITIES

I.

II.

III.

IV.

v.

vI.

Administrative

nap

of

Togo

....

Organization

chart of Ministry of

PubIic HeaIth EpidemioloSical

situation

Prevalence

of

onchocerciasis (Pre-control) Prevalence

of

onchocerciasis ⁽¹⁹⁹⁰⁾

Five-year progranne cost estinate

18 1g 20

2l

22

2)

SUMMARY

The operations

of the

0nchocerciasis Control Progranne have been ^going on

in the initial

area

of

^{Togo since 1977 and}

^the epideniological situation is

^such

that it is

^planned

to integrate this

major disease's

surveillance

^and

control activities into the prinary health care

systen

after it

has been

strengthened and

into the

progrannes

that

have been prepared

already for

Ieprosy and

tuberculosis control.

At the tine the

Programne was

started (vector control), the

studies conducted showed

that

onchocerciasis ^was

a public health

problem and even an

obstacle

to

socioecononic development. Transnission has been

interrupted

at present

in a large part of the initial

^area.

A

mass

ivernectin

^{treatment campaign has been}

instituted in certain

zones.

The nycobacterioses

⁽

Ieprosy and tuberculosis) have a

^known

epidemiological

situation

and

their

progranne has been prepared.

Onchocerciasis

surveillance

and

treatnent wilI

be

active

and passive.

The leprosy and

tuberculosis surveillance strategy will

be based on an active and

passive

screening

by bacilloscopy

and

the treatnent applied will

be polychemotherapy.

The

bulk of the devolution activities will

^be

carried out by all

the

structures of

the

health pyranid, but nainly

^by the mobile tean based

in

^Kara

and supervised

by a coordinator

^who

is

responsible

to the

Epideniological

Division of the

General

Directorate of Public

Health.

Personnel

training,

strengthening

of

resources

(logisticsr

technical

equipnent, facilities) and operating costs are indispensable for

^the

inplenentation

and success

of the

devolution process. The

estinated cost of

the

plan is

?9?,?08,670 ^(seven hundred and ninety-seven

nillion

^{seven hundred}

and

eight

thousand

six

hundered and seventy) CFA

francs, i.e.,

^US $2,659,029 (two

nillion six

hundred and

fifty-nine

thousand and twenty-nine ^US

dollars).

INTRODUCTION

Onchocerciasisr

or river blindness, affects Togo too where

the socioeconomic consequences

of the dibease, in particular its

negative influence on development, no longer need

to

be demonstrated. While

isolated activities

had been undertaken

by the country in the past to control

the disease, Togo has since 1977 been

benefitting

from

the

implementation

of

the Onchocerciasis

Corrtrol

Progranne

r+hich, today, covers almost the

^whole

country.

Howeverr as was

to

be expected, and

to

safeguard

the

achievenents

of

the Progranme, Togo would

like to

integrate onchocerciasis

control activities progressively into its ^primary health care

system

after it has

been

strengthened.

It nust be ^pointed out that this devolution plan covers only

the

initial

Progranne

area, i.'e., a

zone

of

18,000

sq kn

whose estinated population

is

555r000. This

nainly

concerns the

Oti river

basins ^(Keran, Kara and

Mo). While it is true that transnission

has been

interrupted in

the northern

part of the

zone

(Oti basin), reinvasion fron the nore

southerly

part of the

Progranne

still reigns in

the southern

section of the Oti

basin

(Mo, Kara and Keran basin).

Ivernectin treatnent is therefore

necessary.

But do the ^gains

of

the Progranme

not

run

the risk of

being compromised

should the place

of

onchocerciasis be taken by

other

avoidable diseases

rife in the

same areas which

are also great obstacles to

development? Having adopted

food self-sufficiency

and

security as a primordial _and

innediate

objective, the

Togo governnent, through

its Ministry of Public Health, is laying

enphasis on an

integrated

^progranme

for the control of

these curable diseases.

Thus, the

Ministry of Fublic

Health

wiII set

up

a

connittee whose nain

responsibility wiII

be

the real iupleuentation, follow-up

and

evaluation of this

^plan.

The

strategy will

be

principally

based on

three

main

lines:

- screening/active treatnent

through

sinple epideniological

surveys, using bloodless

skin snip,

leading

to a

nass ivermectin treatment or

-

notpassive screening

in health centres

in.

the

regions and prefectures

- evaluation of first-line villages

every

three

years.

Entonological and

nedical

surveys based on

parasitological

and,

in

the

future, innunological

techniques

wiIl

be used

for the surveillance.

Leprosy and

tuberculosis control will follow its usual

methodology,

being started in the hanlet by the village health worker

supervised by

intermediate workers and

the subdivisional chief

medical

officer.

2.

^GENERAL SII'TIATION

IN

^{THE COUNTRY}

2.1.

General presentation

Togo

is a

West

African

country

with a

naxinun

length of

710 km and a

naxinun breadth

of

120

kn. It

has a

coastline of

^{50 km.}

It is

bounded

in

the

north

by Burkina Faso and

in the

south

it is

^washed

by the Atlantic

^Ocean.

Bordered

to the east by the

^Republic

of

Benin and

to the

west by Ghanar the

t

country covers an area

of

56,785 sq

kn.

^Togo

is

located between the Greenwich

neridian

and

neridian

1'40'E.

Togo

is

separated

into

two

undulating plateaux

zones

by

a

from

the

mountain KpaI ime

ridge

^(average

altitude of

⁷⁰⁰

netres) which

stretches

region

through

the

Kara

region to the

Republic

of

Benin.

The country has an

inter-tropical

climate

with

two

rainy

seasons

in

the south (March-July, Septenber-October). The nountainous regions

receive

the

greatest rainfall ^(about

21280

nn). In the north, the climate is of

the

tropical type,

marked by

only

one

rainy

season

(April-0ctober).

The tenperature ranges, in ^general,

between

25' (south) and

³⁴

(north).

The Mono

is the ^biggest river in the south,

and

the Oti the

nost

inportant in the north.

The

Togoville,

Zoula and Anecho

lakes are

navigable throughout

the

year.

The dense

forest

which

stretches fron

the Bepublic

of

Guinea

to

Central

Africa is

^absent

in

Togo. Of

the prinitive forest, only

a few

"fetish-trees"

renain.

The

forests

cover 102

of the country's

area.

2.2.

Detographic and econoric indices

2,2,7,

Deoographic indices

As

at

1 January 1989,

the total population is estinated at

^3,3891172

inhabitants with a

density

of

59.68

inhabitants/sq kn,

one

of the highest in Africa. This figure varies

depending on

the region:

1,841

inhabitants/sq.

kn

in the GuIf prefecture as against 47 in the Oti. It is a rapidly

^growing

young

population with a natural rate of 2,92 and capable of

reaching 3,409,700

in

1990 and 4,519,700

in the year

2000. Under 15s and wonen

of child-bearing

age represent about 70.43L

of the

population.

Crude

birth

rate

Fertility

rate Death rate

Infant nortality

rate

Life

expectancy

at birth for

nen

for

^wonen

45. 312

194

per

1,000 182

90

per

1,000 42 years 50 years

2.2.2.

A few econonic data

Resolution 17/12

of the

General Assenbly

of the United

Nations has,

since

1988,

classified

Togo aDong

the least

developed

countries.

The ^gross

donestic product is

370.8 thousand

nillion

^CFA

francs, i.e.,

^{113,000 CFA}

francs per

capita.

The

uain natural

resources

are

phosphater

clinker

and narble.

Maize,

nillet,

sorghun, cassava, yan,

coffee,

cocao and cotton

are

the

nain agricultural

^produce.

Phosphate

nine,

cenent

factory, brewery, textile factory

and

steel

works

are the principal industrial activities.

The country is subdivided into five

econonic

regions

^(Maritine,

I

Plateaux, Central,

Kara

and

Savanna)

and conprises 27 prefectures,

²⁰⁹

cantons and 5,575

villages.

The regions concerned

with devolution

are:

-

^{Central Region}

Capital:

Sokode

Prefectures:

-

^Tchamba

-

^Tchaoudjo

-

^{Kara Region}

Capital:

Kara Prefectures:

-

^Asso1e

-

^Bassar

-

^Binah

-

^Doufelgou

-

^Keran

-

^Kozah

-

Savanna Region

Capital:

Dapaon

Prefectures:

- ^oti

-

^Tone

The road network comprises about 7r500 ku ^(1r375 km

of

asphalted road,

71125 kn

of earth

road

utilisable

throughout the year and 5'000 km

of track difficult to

use

in ^the rainy

season).

The

railway transports

passengers (21000,000 per

year)

and goods

(7

_to

12

nillion

tones

per year)

on 436 km and

ore

on 80 kn.

Two

airports

and

a port

open Togo

to the

^world.

As

of

^{1990, 20}

of the

21

prefecture capitals

had been

electrified.

The satelitte station and a wireless bean ^system facilitate

connunications. There

are

nore than 9,000 telephone subscribers.

The country has two broadcasting

stations

and one TV

station.

2.3.

A few

sociocultural

data

Togo has nore than 40

ethnic

^groups

classified into

three

nain

^groups.

However,

there is a very great interrelationship

between

the ethnic

^groups:

-

^Ewe

-

^Adja

-

^{Ouatchi and Gen}

group

447

-

^Kabye

-

Ten and Losso

group

^277.

-

^Pana

-

^Gourma

group

^767.

Animisn

(592), Christianity ⁽²⁹²⁾

^and

Islan ^{(122) are the three}

^nost

important

religions.

In 1988, there were

10,483

pupils (1 teacher for 32 pupils) in

kindergatens, 527,853

pupils (1

teacher

for

⁵²

children) in

^primary schools;

in the

sane

year, _there

were 93,911 students

in junior

^{secondary schools (1}

teacher for ²⁸ pupils),

14r646

students in senior

^secondary

schools

⁽¹

teacher

for

20 students) and 6,972 students

in the university

and schools of

higher

education

(1

teacher

for

^{23 students).}

The

overall

school attendance

rate is

around 652.

In reality,

^however,

in certain

regions

this rate

does

not

exceed 29,42 r+hile

in others it

^reaches

902.

The

literacy rate

(percentage

of population aged 15 or

^{more and}

Iiterate) is

^{around 192.}

2.4.

Health

policy

a.nd

organization of ltlinistry of

^Health

2,4.7,

Togo's heafth ^poLicY

Recognizing

the right of aII

^Togolese

to health, the

governttlent has

subscribed

to the strategy of

^primary

health

^care

that

^was adopted

in

AIna-

Ata

^(USSR)

in

1978. However

the rightr

and even

the duty, of the

^Togoglese

to participate in the

naintenance and inprovenent

of his physical

and nental

state is

encouraged

by the State.

The

national health policy is

therefore based on

welll-defined principles

and

objectives.

2.

4.7,L,

Fundanental

principles

-

^{The Togo} government

adnits that

"people

constitute

the

starting point

and

the finishing point of the

developnent process".

- It affirns that

"people

uust

have use

of aII their

^productive

capabilities

be

they physical or intellectual".

To guarantee

this state of well-being, the State wiII

develop preventive nedicine and

curative

nedicine.

- ^In

^Togo,

^health is

thought

of in terns of

a

social

novenent

that

^goes

beyond

the

framework

of the

governnental

function,

the

speciality of a

few governnent workers and

of charitable

organizations.

2.4,7.2,

^General.

objectives of

Togo's heal.th

policy

They are:

- to

^ensure

^the greatest possible

treaith'coveraEle

of the

country;

- to

strengthen

infornation,

education and prevention

activities

^{on the}

doninant diseases;

- to

encouraEle

the private sector to contribute to the

inprovenent

of the health

a"nd

technical

coverage

of the

country;

- to

^ensure

^the

^supply

of essential

drugs

to all the health

centres;

- to

^encourage

^applied

^research

into traditional

^nedicine;

- to

undertake personnel

training, favouring that of village

^health

workers.

It

^goes

^without

^saying

that the attainnent of

these

objectives calls

for the real participation of

the populations

in

the decision-making processt

right

from

the identification of

^problens

to the evaluation of results.

2.4,7.3. Political

^connitnent

The

political

commitment

is reflected in:

- ^the ratification of the

Charter

of

Health Developnent

in the

African Region

by the

^year 2000;

- ^the

^adoption

of the

primary

health

care strategy;

- essential care for all;

- the organization of a national

education and

public

awareness campaign

with a

view

to obtaining their full

support

for the

^ner+

strategy.

2,4,1.4.

^The

health

^planning

objectives, the strategy,

the

standard facilities and functions, health personnel (standard tean

^and

function), the plan of action for the inplenentation of

^primary

health

care

in the prefectures

and

the principal

ongoing progranmes

are described in

reference documents.

2,4,2,

Organization

of

the

Ministry of

Health The

country's health structure

^presents

three levels:

- ^{a central}

^leve1 comprising:

- the 0ffice of the Minister of Public

Health

-

^{the General}

Directorate of

Public Health which groups together

eight divisions:

- ^Division of Adninistrative

and

Financial

Services

- ^Division of Public

Hygiene and Health Pronotion

- ^Division of

Epideniology

- ^Division of

Medical Assistance and Primary Health Care

-

Mother and

Child Division -

^Pharnacy

^Division

-

Teaching and Professional

Training Division -

Laboratories

Division

It is at this

^leve1

that the health polity is

elaborated:

- a regional leveI ^{which groups} together the regional

^health

directorates'and the regional hospital.

- a peripheral level

^with:

- prefecture

hosPitals

-

^medical centres run by

uedical officers -

dispensaries

run the State registered

nurses

- health posts

^which

are the responsibility of the

conmunities and where

village health

^workers

are

^enployed.

A reorganization

of the health

systen

is currently

being

carried

out

with the collaboration of the

^Wor1d Bank.

2.5.

Personnel and

facilities 2,5,1.

^PersonneL

In

1988,

there

were 263

nedical officers in the public

and

private sectors in

^Togo,

i.e.,

one medical

officer for

^12,539 inhabitants.

To

that

should be added:

6 64 3 36 122 50 348 1125 275 214 66

dental

^surgeons pharmacists

sanitary

engineers

senior sanitary

engineering technicians medical assistants

senior laboratory

technicians midwives

nurses

Iaboratorz

assistants hygiene assistants

kines i therapi sts-orthopedi

sts.

2.5 Hospita)s

2, Facilities

In

each

prefecture,

which corresponds

to the health subdivison,

there

is a hospital with a

^general oedicine

service

and a

naternity.

However, some

hospitals

have

specialized

service (surgery, gJrnaeco-obstetrics, etc.

).

^There

are

18 secondary

hospitals.

In

each econonic

region, there is a nore conplete

regional

having, in addition, ophthalmology,

otorhinolaryngology education/orthopaedy

services. There are four hospitals.

The

referral hospital is the

Lone Teaching Hospital.

hospital and re-

national

In

1988, there were 5,275 beds

in all the hospitals in

^Togo,

i.e.,

^one

bed

for

⁶²⁵ inhabitants.

Other services'.

,ispensaries. There were 317

in

^1988,

i.e.,

one dispensary

for

0,403

inhabitants.

-

Maternal and

Child

Health

Posts.

There were 348

post for

9,476 inhabitants.

in

^1988,

i.e.,

^one

-

^Regional

Sanitation

and Health Education

Services.

Certain

problens

are

impeding

the real

operation

of

these

services

at

regional level.

-

Pharnacy. The Procurenent Pharmacy

(State)

_and

_the

National Pharnacy

Office are the

two

principal

pharnaceutical

structures.

There

are

nany

private

pharmacies too.

2.6.

Cost and

financing of ^public health

services

-d

1

The

health

system

is

financed

fron

several sources

including the

State

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c

oo E

sOON pue Jolces

elealld'elels

to A1tlqlsuodser;1n3 uollnquluoc c,Auunuuoc eql qllfi\

budget, community

participation, bilateral, nultilateral,

and non-governmental aid.

The budget

of

the

Ministry of

Pubfic

Health,

which represents about 4Z

of

the

overall

State budget, gives an average per

capita

expenditure

of

^1'804

CFA francs.

Table

of trend of State

budget compare

to that of

Health (thousand

of

CFA francs)

Conmunity

participation is

expressed

nainly

through "hunan investments"

and by

the

bearing

of certain recurrent costs as

regards:

- construction of health

^posts and dispensaries

- participation in the

operation

of

these

facilities -

^support

to

some

of the village health

workers

- participation in the

assunption

of responsibility for certain

accomnodation expenses

of the health

^personnel

The

external partners (international organizations,

glovernnents and NGOs) intervene alongside the Togo governnent

with

regard

to short

and long- term

activities.

The connonest exanples

are those of

^{WHO, UNDP, UNICEF'}

USAID, FAC, EEC and

other aids.

Howeverl

before

1988,

these contributions

were

not

evaluated

in the

Health

statistics.

In

1989,

the available date

^showed

the following

CFA francs:

UNICEF l{H0 USAID CUSO GTZ FAC

353, 790,000 1r452,000,000

1 ,660,000,000

71 ,604,000

1 ,261 ^, 732,500 200,000,000

2,7.

Functioning and resources

for epideriological

surveillance

The

first ten

causes

of norbidity are nalaria, traunatisns (with

or

without fracture), diarrhoeal

diseases,

skin

diseasesr

intestinal ^parasitic diseases, tonsilitis, measles, tetanus, tuberculosis,

^{whooping cough,}

cerebro-spinal meningitis, poliomyelitis, conjunctivitis

and

nalnutrition.

Aurong

the

endemic

diseases in Togo, leprosy,

^yawsr dracunculosis, trypanosomiasis, onchocerciasis, schistosomiasis,

tuberculosis

and sexual-1y

transmitted

diseases should be mentioned.

Year

State

Budget Health Budget

HeaIth

x

¹⁰⁰

State

1980 1981 1982 1983 1984 1985 1986

1 987 1988

1 989

67 ,27

4,7Ll

70 ,658 ,081 66,454,224

75 _, 600,000 76,890,000

81 ,890,014

g7 ,282,784 89,090,742 99,692,076 92,486, 169

2 2 3 3 3 3 3 3 4 5

t837,944 724,053 488, 144

792,925 298,773 937,309

97 4 ₁₂₂₀ 9411220 758, 140

126,471

t t ,

4 3 5 4 4 4 4 4 5 5

36 .85 ,25 ,20 ,29 .90 .55 ,42 .30 .54

0n

the

whole,

the health situation is

doninated by:

-

vector-borne diseases,

infectious

diseases,

intestinal

diseases,

malnutrition

and

other nutritional deficiency

diseases

-

^problems

^related to the health level of the population

(especially

the

under

15s), facilities,

equipment, personnel, budget and

management system.

Epidemiological

surveillance covers the epidenioligical

and endemic

diseases and

follows the pyranidal structure of the health

services.

Each

health facility

has a

consultation register in

which

all

^synptons

and diagnosis

of patients for

the day are recorded. A weekly

forn

concerning diseases under

epideniological surveillance is thus sent regularly

with feedback from

the top to the

bottom,

i.e.,

from

the

dispensary through the

other

intermediate

structures to the

General

Directorate of Public

Health.

In

^case

of epidemic, notifications ^are

^nade

by aII available

neans

(bicycle, motor cycle, telephone,

radio-nessage, etc.

) ^{and steps}

^taken

innediately to control it.

3.

EPIDEIiIIOTOGICAT SITT,ATION OF ONCIIOCEBCIASIS, LEPBOSY AI{D TT,BERCULOSIS

3.1. Pre-control situation of

onchocerciasis

Before the start of the Control

Progranue,

studies

conducted by

different authors, notably fron

OCCGE,

estinated the rate of carriers of

onchocercal

cysts at

about 402. These studies were conpleted by OCP through the

evaluation of

17

villages

according

to the

Progranne's

current

standard nethodology.

Atl

these

investigations

showed

that the

disease was unequally

distributed

along the watercourses concerned, the prevalence ranging between 252 and 892 depending on

the localities.

^The blindness

rate varied fron 1 to

3Z

in the

hyperendemic

areas;

elsewhere,

it hardly

exceeded 12.

3.2.

Pregent

situation of

onchocerciasis

The

inpact of the vector control, that

was

started in

1977, has been

neasured

by the regular

and

periodic evaluation of

about 17 representative

villages in the

zone. Thus,

after

12 years

of larviciding, the analysis of the

data

collected

has nade

it possible to divide the initial

area

of

^Togo

into

two

distinct

^zones:

3.2.1. A northern

zone,

which nainly

concerns

the Oti

^basin.

There,

transnission

has been completely

interrupted.

The prevalences which ranged between

54 and

721

are

^now

less than 5Z

everywhere. The highest

connunitynicrofilarial load

^(CMFL) recorded

in

^{1989 was}

only

0.12 as against 30

at the

beginning

of the

Progranne

in

^{7977. The} incidence

of

onchocercal

blindness is nil

today

in this

^zone.

3,2.2.

A southern zone, southern

linit of the initial

^Programme

area, covering the Mo, Kara and

^Keran

basins. This

zone

is subject to reinvasion nainly from the southern extension area of Togo.

There,

transnission has not

been

completely interrupted despite a

considerable decrease

in

prevalence,

of

the order

of

25

to

602.

Likewise, the

highest CMFL

recorded

is only

4.82 as

against

more than 39

at

the

start of the

Progranne.

This

zone has been brought under invermectin

treatnent since

1988.

3.3.

Risk

of

recrudeacence

of translission

and

iverrectin treatrent

The

risk of

onchocerciasis recrudescence

in the initial

^{Programme area}

in

Togo

wiII

become

nil

as soon as:

(1) the northern

zone

is

completely freed;

(2) _the larviciding

which has been going on

in the

southern extension area

since

1988 produces

very

encouraging

entonological results;

(3) the reinvasion

zone

is ^put

under ivermectin

treatment; this

^was

started in

^1988.

3.4.

Onchocerciasis

control

prospect

While

it is true that the

northern

part of the country is ^perfectly under control, transnission has not

been

conpletely interrupted in

the

reinvasion

and southern extension

areas.

The cornbined

effect of

ivermectin

(reinvasion

zone) and

larviciding (reinvasion

zone

+

extension

area) wiII certainly lead to the interruption of

onchocerciasis

transnission in

the whole

of

Togo

in the next fen

^years.

3.5.

^Present

situation of the other

diseases

Most

of the tropical

diseases concern

the skin. Several clinical manifestations of onchocerciasisl leprosy and, to a lesser

^extent,

tuberculosis

could be

easily

^{seen on}

the skin.

^Moreover,

it is

recommended

that the health

worker who

in the differential

^diagnosis

of

onchocerciasis

elininates leprosy should also be able to recognize other

conmon skin diseases

in our

region.

As regards

the feasibility of the control, it is ^possible for

one and

the

same nurse

to be interested in the three

diseases by:

-

diagnosing then

- treating the patients detected,

and undertaking

the follow-up

and

surveillance of

these diseases.

With regard

to the

ueans

of intervention, the Ministry of Health is

already

preparing a

unique

plan of action against the

two

bacterioses

^and

partners

who could support

this

progranne have

also

been

identified.

3.5. t

,

Leprosy

Leprosy

is

endenic

in

Togo. The

country

has been

fighting against it for

several decades now.

After

the ^peaks

of

25,000 and 16r000

patients of

the 50s and

60s, the registers of the

Leprosy ^Programne have

only

4r873 patients

for

1989. Between 1978 and 1988,

the

prevalence

feII fron

5.13

to 1.58

^per 1000 and

the

incidence decreased Dore

than threefold:

from

0.53 to

0.12.

Polychenotherapy

will

cover the whole

country in

1993. Thus, Togo

wiIl

enter

the

year 2000

with the smallest

ever nunber

of

leprosy

patients.

3.5.2.

TubercuJosis

Tuberculosis

is

endenic

in

Togo and present

in all the prefectures

of the

country.

Although

there is

a

relentless fight against

the disease,

it is still a

preoccupying problem

in

Togo

and characterized by the following

indices:

-

^Nunber

of

counted patients

1 987

1 988 1989

183 1 ,902 7,723

-

Prevafence

per

100,000 inhabitants

-

^Incidence

^per

^100,000 inhabitants

1987

1 988

1 989

54 54.

I

50. 6

1 987 1988 1989

28.

I

27 ,2 27.6

1 987

1 988 1989

2.5 2,97 1,23

-

^Crude

mortality rate per

100'000 inhabitants

4,

ST'BVEILTANCE AND IBEAT}IENT AS PABT OF DEVOLUTION

4.1.

Onchocerciasis

surveillance

^anrd

control

strategy 4.1.1

,

^Objectives

The

principal _objective of

the devolution ^progranme

is the

safeguarding

of the

achievements

of

OCP

in order to avoid any

recrudescence

of

the

disease. To that end, the surveillance

and

treatment activities wiII

^be

progressively integrated into the national health

systen.

4.1.2, Activities

The Epidemiological

Division of the

^General

Directorate of

Public Health

wiII

coordinate

alI

the

activities;

^a

senior officer of this Division wiII

be appointed Coordinator.

A

nobile teau

enanating

fron the

Regional Health

Directorate of

^Kara

will be based in the regional capital

^and

^cover aII the three

^regions

concerned

with devolution (Central,

Kara and Savanna

Regions); it will

^be

composed

of an

epidemioloEiist/team

leader,

two

or three nursesr a

^census

clerck, a laboratory technician,

and

eventually an entonologist and

^an ophthaluologist.

This ^{tea^n}

witl

be responsible

for active

pcreening and nass

ivernectin treatnent.

The personnel of the health subdivisions wilI carry out

^passive

screening and

treatnent but will

be

involved in

the

activities of the

nobile tean working

in its subdivision; the

^sane

applies to the

^personnel

of

the

nedical

^{centres and} dispensaries.

The

village health worker, with the participation of the

community,

will inforn his

superior

of

any anonaly

or

event

that

occurs

in the village:

arrival of ^migrants,

presumptive

signs of onchocerciasisr

^presence

of blackflies.

Furthernore, he

will nobilize his

connunity

during

surveys and mass

treatments.

Information, public

awareness and education

wiII

be undertaken by

aII

the levels of the health

^pyramid.

4,7,2,1, Active surveillance

and treatnent

The

surveillance of

the disease

wiII

be made by the

periodic

evaluation (every three years)

of

about 60 representative

indicator villages (first-line villages)

selected

jointly by the Ministry of Public

Health and OCP.

As mentioned above,

this surveillance wiII

be

carried

out by the mobile tean based

in Kara. It will

^comprise:

-

^screening

of

^new cases by

skin snip

and perhaps

in future

by immunodiagnos

is;

- detailed

epidemiological mapping

of the

zone ^{where new} cases have appeared.

The discovery

of

new casesl

i.€.r the

resunption

of transnission, wiIl

Iead

to

^mass

ivernectin treatnent in the

zone concerned.

An evaluation based on

longitudinal

studies

will

be conducted

to

assess

the efficacy of the treatnent.

4.7,2,2,

^Passive

surveillance

and treatnent

Passive surveillance wiIl be uade in aII the ^pernanent

^health

facilities

(presumptive

clinical

diagnosis and/or

parasitological

diagnosis) as

well

as

treatnent.

4,2,

Leprosy and

tuberculosis suryeillance

and

control

strategy Leprosy and tuberculosis

also

cover the onchocerciasis devolution zone.

The

activities for the control of these bacterioses are in line with

^a

national strategy,

based mainly on:

-

screening!

(active

_and

passive,

bacilloscopy)

- ^treatnent of ^patients (in

general by polychenotherapy)

- ^follow-up of ^patients

^{who need} medico-social

rehabilitation - follow-up

and

evaluation of the

^progranne.

Since

the nain objective to be attained is the integration of

these

activities into the countryts primary health care systen,

more

fornal

Deasures have

to

be taken

in the

devolution zone

to

^guarantee

the

success

of the operations.

The

following

have

to

be done as

a priority:

- motivation

and

nobilization of the

populations

in the

zone

(infornation,

education and connunication) ;

- detection

and

follow-up of

the

greatest

possible nunber

of ^patients;

-

strengthening

of the

diagnosis services

by inproving the

technical resources;

- raising the

competence

of the

workers concerned

to

an acceptable

Ievel

through

training;

-

^making

available the right

nunber

of

workers.

4.2.1. Mobilization of

the population

Regularity is a very inportant factor in ^the

treatment

of leprosy

and

tuberculosis.

HeaIth

infornation

and education

are

the keys

to this

success.

It wiII therefore be

necessary

to

accord

a place of choice to

community

mobilization during the visits of the

teams.

The advantages

of

polychenotherapy would be explained

to

each

patient.

Inforned in this

way,

the patient will

understand

that "his health is

also

his

problem" and

will collaborate freely.

However,

in a

few

rare

cases where

regularity wiII not

be

obtained'

nonotherapy

will

be

the

order.

4.2.2.

^{Detection and}

follow-up of ^patients

Each

patient is

exanined according

to the instructions given in

^the

basic

^documents

and explained during refresher courses.

Bacilloscopy

determines the classification of the patient (multibacillary

^or

paucibacillary)

according

to

the standards accepted by WHO. Detected patients automatically

enter

the programme's computerized Danagenent systen and leave

it only after the tine limit

defined by the General PubIic HeaIth Directorate and

the current

^protocols.

4,2,3,

Strengthening

of

diagnosjs servjces

The

prenises

and

technical

and

logistic

^equipnent

^allocated for

the diagnosis

of the

progranDets

patients will be

strengthened

if

^necessary.

Enphasis

is

being

laidr

as

a priority,

on

bacilloscopy

and biopsy equipnent

without neglecting the

accessories.

4.2,4.

Conpetence

of

^{uorkers concerned}

Short-duration training, retraining and infornation sessions

are envisaged

to

"update" the knowledge

of

the progranne's workers

at aII

leveIs.

5.

^{FOLIOW-UP ATTD EVALUATION}

5.1.

Coordination a.nd

follow-up of the

Prograue

Just as for

any

other health activity in the country, the

General

Directorate of

Publi.c

Health is directly

responsible

for the

implenentation

of the devolution plan.

However,

it will often act

through

the

Coordinator and

the

National Onchocerciasis Connittee

but both of

them can

only

report

to the Ministry of Public Health through it. This coordination which is

intended

to

be

effective

necessitates:

- the training of

^two

high-level epideniologists;

- ^the training of three nedical

entonologists;

- short-duration

courses on

health

^progranne Darlagenent, data processing and

laboratory

techniques;

- Iogistic

and equipnent support (four-wheel

drive vehicles' field- visit, ^technical

and conputer equipnent, etc. );

- ^putting in

^place

of a

Health Radio system (supply and

installation).

5.2.

Supervision

It starts right fron

the canton coordinatorsr ^passes through

the chief health post nurse, gets to the chief ^health subdivision nedical officer,

reaches

the

Regional

Public

Health

Director

and ends

with the

Coordinator.

It is transnitted to

^{the General} PubIic Health

Directorate

which

inforns

the

Ministry of Public Health. In the

^mean

tine, nass ivernectin

treatment

decision could be taken at the regional level in conjunction with

the

Coordinator. It

^goes

without saying that there wiII be close relations

between the

Ministry of

Public

Health,

the General Public Health Directorate,

the National

^{Connittee and OCP}

for the taking of inportant

decisions.

The data bank established

in

the EpidenioloEly

Division will

contain the

fanily cards,

surveys and ivermectin

treatnent files

^and

aIl

data concerning

the

Progranne. The

entry

^and analyses

are to be

^made

at the

sane time.

However, manual processing

could

be made

at

any

level.

^Feedback

after

^the

computerized data processing

will

reach any person and any

level

concerned

with the

programne. OCP

could lend

support.

5.3.

Evaluation

Two evaluations

will

be necessary:

- ^the first,

half-way through

the

progranme,

i.e., during the third

year

- ^the

^second,

^the final, during the fifth

^year.

The

first evaluation will

neasure how

operational the activities

are and

the extent of integration, while the

second

will

assess

the

control

results,

exanine

the najor obstacles,

and

note the

achievements

of

the

Programme and

its influence

on

aII the

new problens _and those recognized

at the

beginning.

The preparation

of

the teans and

the

resources

to

be made

available

to

them

are the responsibilities of the Ministry of Public Health.

However,

it

would be

desirable for it to

be assisted by partners

at least during the five

years

of the

Plan.

HaIf-yearly and annual reports on the state of ^progress of

the

activities will

be prepared by the National Onchocerciasis Comnittee and sent

regularly to the Ministry of Public

Health and OCP.

6.

RESOT'BCES AiID COST OF PBOGRA}TIIE

6.1.

^Personnel

In principler the inplenentation of the devolution plan is

incumbent

upon the available personnel of 'the regional directorates and

health

subdivisions.

However,

the

nunber and conpetence

of this

^personnel

will

be

strengthened

through training and, if ^possiblel

^D€w

recruitnents,

naking

possible for the tine

being

the training of

a

nobile

^team which

wilI

be based

in

Kara.

6.2. llaterial

resources

The acquisition of technical and field-visit equipnentr logistic support and an increase in operating costs wiII be

necessary

for

the reinforcement

of surveillance in the

zone. Construction and equipnent

of

the

Directorate of

Major Endenic Diseases Service

in

Lone,

the regional

health

directorate in

Kara, and

a laboratory in

Kara

are

necessary.

6.3.

Cost

of the devolution plan for five

^years

6.3.1

,

Investnents

Constructions and equipnent

Logistic

support Technical equipnent

Field-visit

equipnent

Training, retraining

and

public

awareness

raising

349,000,000

61 ,000,000 3,985 _, 700 804,000 149, 950,000

Total

6,3,2,

Becurrent expenditure

Maintenance and

repair of logistic

support and

Iectric

^generator

FueI and

lubricants

Drugs and

laboratory

supplies Per diem and allowances

Office

supplies TotaI

6.3.3

,

Evaluation

6.3.4, Overall

cost Investnent

Recurrent expenditure Evaluation

564,739, 700

42, 750 _, 000 22,750,000 40, 750,000 36, 700,000 4,000, ooo 146, 950 _, 000 10,000,000

564,739,700 146, 950,000 10,000 _,000

TotaI 721 _, 689, 700

72 rt68,970 Contingencies 102

Grand

total

793,858,670

Seven hundred Fnd

ninety-three nillion eight

hundred and

fifty

eight thousand

six

hundred and seventy CFA

francs

^(US $2,646,196).

6.4.

Togo's

contribution to the financing of devolution activities Alnost aII the salaries of the

personnel

involved in

onchocerciasis

control,

naintenance, renovation

of health facilities (froo the health

post

to hospitals), water

and

electricity

supply and storage

costs,

and

travel

expenses and allowances

will

^{be borne} by

the

State.

7.

TII{ETABIE OF ACTIVITIES

I

ACTI VI TI ES 1st

year year^2nd 3rd

year 4th

year 5th year

1.

Real establishment

of

a

Coordinator,

the

National Oncho Connittee and

the

mobile teasr

2.

Constructions and equipment

-

Major Endenic Diseases Service

-

^Regional

Directorate

^(Kara)

-

Laboratory ^(Kara)

3. Acquisition of logistic

support and

technical

and

field-visit

^equipment

4.

Training

-

Epideniologist/doctors

-

Dernatologist/doctors

-

Entomologists

-

Epideniology technicians

-

^Conputer technicians

-

Progrrrnme nanagement

technicians

-

Nurse,/epideniologists

5.

Retraining

-

Laboratory assistants

-

^I{orkers

of leprosy

^and

tuberculosis

services

6.

^Seninars

-

^{Begional (Kara and Savanna)}

- Chief nedical officers

^and

other

personnel

-

^{nurses involved}

7. Public

awareness

raising

8. Field activities

-

^Supp1y

of ivernectin

-

^{Passive screening and}

treatnent

- ^Selection of indicator villages

- Epideniological

surveys

in indicator villages

-

FoIlow-up and supervision

9.

Evaluation

of

^progranne

ANNEX

I

MAP OF

^TOGO

LEGEND

+ ++ +

o

o o

tloL Doundo?y

t.abml ^boondo?t Pr.f.ctor. boundory l[DO?lAil ^nDod CQltol ^, R.Corol sogltot

?rafac?ul. coPl?ol

O 20 .O CO eO ^loOttt

,**

+

+ ₊

BURKINA.FASO

+ ₊ ++

+*f**

_I ^{I t}

DAPAONO

{ it+++r

* *

r

I AVANN-A-

\

I+

t

+ ++ +a

r

t

{

I

rI

RE roN

r

+

+I

,

_I

ltt ++

*

+

t+

I

'x

+ t'*

z

-

(9

I_xDon0oudo KARA

REGION

\

₊

t+

+

t+ f *r,

^{( .+}

*

+

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