Design and Planning of PHCs

Vanakomi Child Health Program Proposal April 2018 Page 1

Maternal, Neonatal and Child Health

Program Vanakomi Division

Bokka Province, Comabengi Country Program Description September 5, 2018 - August 31, 2021 Submitted to: World Welfare Association April 15, 2018 Alfred William Simpson, Ph.D. Executive Director Simsburry International Health Coordinators 134 West Sherman Avenue, Suite 300 Aubergine, NA 10055

SIMSBURRY INTERNATIONAL

HEALTH COORDINATORS

Vanakomi Child Health Program Proposal April 2018 Page 2

Contents

PROJECT SUMMARY ......................................................................................................... 3

SECTION 1 PROJECT LOCATION/BACKGROUND ................................................. 4

SECTION 2. PROJECT DESIGN/DURATION .............................................................. 6

SECTION 3. HUMAN RESOURCES ........................................................................... 10

SECTION 4. MONITORING AND EVALUATION .................................................... 11

SECTION 5. IMPLEMENTATION TIMELINES ......................................................... 12

SECTION 6. FINANCIAL PLAN ................................................................................. 15

SECTION 7. SUSTAINABILITY STRATEGY ............................................................ 18

SECTION 8. COLLABORATION.................................................................................. 19

SECTION 9. APPENDICIES .......................................................................................... 19

APPENDICES:

A. Resumes of Key Staff

B. Letters of Support

C. Most Recent Evaluation

D. Beneficiaries

E. Health Center Description

F. Pediatric Injury Survey Synopsis

G. Lessons Learned in previous survey

H. Letter of agreement Comabengi Ministry of Health

I. Letter of agreement with Bokka Provincial Health Commission

Vanakomi Child Health Program Proposal March 2018, Page 3

PROJECT SUMMARY

The SIHC Vanakomi, Comabengi Maternal, Neonatal and Child Health Program has the overall goal of

reducing morbidity and mortality among children under five and women of reproductive age through establishing

Health Centers and training MOH health personnel and mobilizing and training community health workers for

improved quality and coverage of services and promotion of preventative health practices. During the past two

years of the pilot project implementation, efforts have focused on strengthening community capacity and local

infrastructure so that gains in child and maternal survival can be sustained and continuously improved. This

application for scaling up will enable SIHC to build on its two-year old program built around one health center

by adding three new health facilities and integrating additional interventions, namely ARI and HIV prevention,

and further strengthening its partnerships for capacity building with the local government and communities.

During the 3-year project initiative, SIHC will transfer skills and system support activities to its partners thus

building their capacities as well as introduce cost recovery mechanisms to ensure sustainability.

The Goals of the project are to:

1. Reduce morbidity and mortality among neonates and children under 5 and women of reproductive age 2. Empower communities and develop health infrastructure to scale up child and maternal health activities

and practices.

The Objectives of the project are the:

 Prevention and management of diarrheal diseases;

 Promotion and adoption of appropriate infant and child feeding practices;

 Sustaining of current immunization rates and increase measles immunization coverage;

 Prevention and management of acute respiratory illnesses;

 Reduction in the incidence of environment-related illness and injuries;

 Increasing the acceptance and utilization of family planning and birth spacing;

 Prevention of AIDS and other sexually transmitted infections.

Under a collaborative agreement between SIHC and the Ministry of Health, three new SIHC-built

fee-for-service health center (opening 11/18) will provide free immunizations, oral rehydration therapy

treatments, family planning, antenatal care, and growth monitoring as well as offering basic curative services at

an affordable cost. The project will also provide community-based education about sexually transmitted

infectious infections, family planning methods, infant nutrition, and infectious diseases of childhood, and family

environmental health and safety issues in addition to monthly growth monitoring by trained community health

nurses and CHWs. A total of $1,277,881 is being requested from WWA with a 28% match of $327,819

provided by SIHC. The project will directly benefit 72,777 children under five and women of reproductive age.

The total project area population of 244,059 will also benefit from HIV prevention and environmental health

activities.

Requested from World Welfare Assn (WWA) $1,277,881

Provided by PVO: $327,809

Total Average Annual Budget: $545,229

Total Length of Project Budget: 3 years

Vanakomi Child Health Program Proposal March 2018, Page 4

1. PROJECT BACKGROUND AND LOCATION

A. Project Location

The Maternal, Neonatal and Child Health Project is located in Vanakomi, the most eastern division of Bokka

province, near Comabengi’s border with Drongostan. SIHC focuses on three locations of the Vanakomi division:

Madagali, Etinan, and Ikot-Abasi, which together comprise a peri-urban area with a mixed urban-rural

character in a rapidly urbanizing division. These locations were chosen for the following reasons:

 The communities identified a need for primary health care interventions

 It is densely populated with rapidly growing squatter settlements

 No other NGO has addressed health needs in these three area

 The MOH specifically requested that assistance be provided to this province

 Comabengi is a WWA Maternal, Neonatal and Child Health Emphasis Country

B. Area Health Problems

General: Three years ago the National Census found that Comabengi's under 5 mortality rate was 92/1000,

infant mortality rate was 71/1000, maternal mortality ratio 250/100,000 live births and crude birth rate was

65/1000. The National average for HIV seroprevalance two years ago was 7%, but this survey was limited to

women attending antenatal clinics in urban areas. An ARV treatment program started five years ago with

technical assistance and funding from CDC and financial support through PRPFAR. An estimated 41% those

known to be infected are included in treatment, though the number on treatment is steadily increasing.

Three years ago, in conjunction with present project activities, a SIHC household health-seeking behavior study

found that among children under two, the prevalence of diarrhea (past 2 weeks) was 19%, and pneumonia

(previous 4 months) was 25%. The prevalence of global malnutrition in children under-2 was 23%. According to

the Ministry of Health and local experts, there is no significant Vitamin A problem in the nation,,. The crude

birth rate was 65. Family planning (all modern methods) was reportedly practiced by 17% of the women of

child-bearing age, with unmet needs at 39%. There are cultural and religious barriers to be overcome in

promoting family planning. Currently there are no sites in the project area where HIV voluntary counseling and

testing (VCT) is done, although at several private clinics in Bokka City, and at the University hospital VCT is

being offered. There is discussion about more wide scale VCT, as antiretroviral therapy is now available in

several clinics and several public-sector hospitals. Several studies also point to the need to increase the

availability of ART in the areas of focus of this project, which is now limited to the university hospital and a few

private clinics.

Our Knowledge, Attitude,

Practices (KAP) Survey serves

as the basis for our new

interventions. The

immunization rate for children

aged 12-23 months was 52%

for DPT3 and OPV3, and 48%

for measles. Thirty-one

percent of mothers reported

that their child had a "severe

cough" in the previous 2

weeks. More than 50% of

mothers treated diarrhea

incorrectly, and 43% of

women stopped breastfeeding before 12 months. Mothers’ knowledge of HIV transmission and prevention was

very low. One study in the project area showed than more than 60% of the mothers sought counsel from either

traditional healers or shop keepers for illnesses in children under five years.

Vanakomi Child Health Program Proposal March 2018, Page 5

Pediatric Injury Survey (two years ago) (See Appendix F) also serves as the basis for our new interventions.

Mothers of 213 children reported 73 injuries afflicting 30% of children. Burns comprised 63% of all injuries in

children less than ten years of age, and poisoning occurred primarily in children aged zero to five years of age.

Drowning accounts for 18% of deaths in Comabengi. Seventy-four percent of all injuries occurred within the

household, and 8% of the injuries resulted in persistent functional impairment or death. Automobile accidents

are an increasingly important cause of deaths and injuries among children.

C. Current Programs in the Impact Area

A Bokka City Commission health center in the peri-urban Madagali township area provides immunizations and

family planning services. There are no diarrhea corners in the clinics, no organized efforts for the control of

diarrheal diseases, nutrition, or other health education or intervention programs in our target area. Aside from

our current and projected projects, there are no community based health care or outreach programs in our target

area. We have been assured by the Provincial Governor that the proposed services will not duplicate existing or

planned provincial services.

D. SIHC Infrastructure and Programming

SIHC currently has an established community-based health program in the Vanakomi Division, in conjunction

with its existing clinic which consists of clinical staff, a community health worker training program, a network

of community health committees and operations centers for health monitoring, training and communication.

Between now and the beginning of the new project period, the following accomplishments will have been

achieved: a baseline health survey will be complete, four health committees will be meeting monthly, ten to

fifteen CHW trainers will have completed Trainer of Trainer (TOT) programs, and two hundred CHWs will be

trained and working in the communities.

The community-created network of health committees includes: Combined Committee (35 members), Madagali

Area Health Committee (11 members), Etinan/Essahoun Area Health Committee (19 members), and the Ikot-

Abasi Area Health Committee (15 members). In addition, a community based management board and Board of

Governors has been established for the health center.

SIHC has a center of operations for meetings and communications in each of the two locations. The three newly

completed health centers will be the sites for MCH interventions. It also has a large classroom for CHW training

which will replace a rented house which was used to train the first CHWs.

SIHC is now increasing the technical personnel available to this project. We have recruited and trained 5 TOTs

and have nearly completely trained 82 CHWs. More than 90 new CHWs have been recruited for the next

training sessions, this winter and spring. By the time expansion grant funding is received, the staffing will

consist of Project Director (expatriate), Project Officer (Comabengi national), Assistant Comabengi Project

Officer, Health Center Assistant Administrator (Comabengi National), Health Center Assistant Administrator

(expatriate volunteer) Health Center Charge Nurse (Comabengi Registered Nurse), one Physician (expatriate

volunteer), one public health nurse and epidemiologist, six Community Health Nurses, 10 to 15 Trainer of

Trainers, and 200 Community Health Workers. Three Clinical Officers will be seconded by the MoH.

Programming will be provided through the integrated activities of CHWs and the health centers. CHWs will

educate mothers in their homes, provide training in oral rehydration and zinc therapy, check health cards for

defaulters, and make referrals to the health center. The health center's community health (CH) nurses will

administer immunizations, provide antenatal care, monitor growth, and promote family planning/birth spacing.

The new interventions will be administered through the same programs. CHWs and health center personnel will

be trained in case management related to ARIs and environmental health and safety. During the new grant

period SIHC will strengthen existing community institutions (health committees, CHW organization, health

center operations) so that it can phase out at the end of the third year. SIHC will also train the shop keepers and

Vanakomi Child Health Program Proposal March 2018, Page 6

traditional healers in recognition and referral for danger signs for common childhood illnesses.

E. SIHC Experience

SIHC is a US-based organization that was founded in 1952 by Wing Commander (Ret) Ambrose Swat and the

Right Reverend Josiah Fitch to encourage the involvement of US citizens in health and development activities

abroad. Since it was founded it has carried out primary health care, water and sanitation, and agro-forestry

projects in 26 different countries. SIHC is supported by a combination of individual donations (28% in 2016),

foundation grants (39%), WWA funds (25%) and miscellaneous sources (8%). Its approach of introducing

piranha fish to control human infection with Schistosoma haematobium is still considered a model of its kind.

It’s work in Central Asia helping communities meet the escalating worldwide demand for camel’s milk yogurt

has been widely emulated as a revenue generating activity.

Over the past two years, SIHC has introduced a number of programs and formed effective collaborative

relationships with the target communities in Comabengi that will enable us to complete the goals and objectives

of this proposal. We have learned from the two community health surveys we conducted as part of the previous

project. The data from these have not only clarified the community's health needs but also been an essential

means to introduce us to community leaders and to familiarize them with their communities' needs. These

relationships have been reinforced by visits to the homes and areas of village elders that have been very effective

in promoting effective relationships between SIHC staff, CHWs, and the constituencies of the community

leaders. This regular, visible presence in the community is essential to community health programming of this

type. The four community health committees are an effective means of community outreach and help identify

persons for TOT and CHW recruitment. We have developed collaborative relationships with the Ministry of

Health and other NGOs. Appendix G details the lessons SIHV have learned.

2. PROJECT DESIGN –GOALS AND OBJECTIVES

A. Duration: 36 months

B. Goals, Objectives, Outputs:

The project goals are to:

 Reduce morbidity and mortality among children under five

 Empower communities and develop health infrastructure to sustain and scale up child and maternal

health activities and practices.

The objectives of the project are to:

1) Increase awareness of:

1.a Prevention of diarrhea and ORT and Zinc treatment of diarrheal diseases,

1.b Family planning and birth spacing,

1.c Proper nutrition, weaning practices, and improved growth monitoring for the under 2s

1.d Methods of transmission of AIDS and other sexually transmitted diseases;

2) Sustain current immunization rates and increase measles coverage;

3) Reduce environment-related illness and injuries,

4) Reduce acute respiratory illnesses in children.

5) Augment community health expertise and infrastructure.

The planned outputs are:

1. At least 80% of mothers will be able to describe correctly how to administer ORT at home by end of year two (1200 in year 1, 2400 in year 2, 2400 in year 3).

Vanakomi Child Health Program Proposal March 2018, Page 7

2. At least 75% of mothers will be practicing family planning by end of year 3.

3. Thirty CHWs will receive supplemental training for community-based distribution of family planning products each year.

4. 70% of mothers will know at least three practices for preventing HIV infection. 5. Growth monitoring will be done for 2400 children under two by the community health nurse at the

health center in the first year, 2900 in year two, 3400 in year three.

6. At least 75% of mothers will be breastfeeding beyond one year of age by end of year 3.

7. The incidence of malnutrition (defined as weight-for-age below 80% predicted) in children under 2 will decrease to 10% by the end of year 3.

8. At least 75% of children aged 10 and older will have participated in a classroom discussion or CHW home discussion of AIDS and STIs by end of year 3.

9. Immunization for measles will increase from 67% to 90% by end of year 3 (2400 fully immunized

in first year, 2900 in year two, 3400 in year three). CHWs will review children's health cards

and refer defaulters to the health center for free immunizations.

10. The incidence of diarrhea in the previous two weeks in children under 2 will decrease to 17% by

end of year 3.

11. Mothers will administer zinc to children with diarrhea for at least two weeks

12. At least 30% of the shop keepers will have adequate stocks of ORS and Zinc

13. At minimum of 90% of households will be using appropriate pit latrines and rubbish disposal by

the end of the year 3.

14. The incidence of burns in children under age two will decrease by 25% during the project period. 15. CHWs will teach mothers to recognize signs of pneumonia and to refer such cases to the health

center.

16. The incidence of hospitalization for ARI will decrease by 25% during the project period. 17. An additional 100 CHWs, above the 200 will be trained and working in the communities. 18. CHWs will make 12,000 home visits in the first year, 18,000 in year two and 18,000 in year three.

Outputs relevant to sustainability are described in more detail in Section 7.

Vanakomi Child Health Program Proposal March 2018, Page 8

C. Proposed Interventions

Intervention Percent

Effort Methods

Childhood Diarrheal Diseases 20% CHW ORT and Zinc training, home visits and education, and

distribution of ORT solution

Family Planning /

Birth Spacing 20%

Supplemental training of some CHWs to teach family planning, support

for their work in the community and for distributing materials.

Nutrition/Growth Monitoring 15%

Community health nurse training and salary support, CHW training in

breast feeding advocacy, support for growth monitoring activities by

CHWs and at the health center.

Immunizations 15% Training and support for CHW to make home visits, maintain health

cards, and staff the center to provide immunizations.

Environmental Health and Safety 10% CHW training and support for home and community based instruction in

use of clean water, latrines, garbage pits, and burn prevention

HIV/AIDS and other STDs 10% CHW training and support for classroom and home visit education,

Clinical staff training in VCT and the management of STDs

Acute Respiratory Infections 10%

CHW training and support for home and community based education to

teach mothers to recognize signs of pneumonia and to refer such cases to

the health center. Clinical staff training in proper case management.

D. Specific Strategies

1. Direct services:

a. Curative Services (e.g. Diarrhea, ARIs, STDs) – services will be provided by Clinical Officers

b. Family Planning Services – conducted by CHWs with supp. training and CH nurses

c. Immunizations - CH nurses will conduct

d. Growth Monitoring - CH nurses will carry out these

e. Antenatal Care - CH nurses and midwives

2. Public sector assistance:

a. The health centers will assist the Ministry of Health by administering immunizations for CEPI.

b. The health centers will assist the Department of Family Health by disseminating family planning

materials.

c. Ministry deployed clinical staff will receive clinical in-service training and community based health

care training.

d. Lab services will be available for Bokka City Commission health center, and perhaps the other centers

to support testing for HIV and STIs.

e. Health centers will train medical students from the University of Comabengi School of Medicine

3. Maternal, Neonatal and Child Health will be promoted by 300 CHWs who will make regular home

visits, educate mothers about the key interventions, and refer cases to the health center.

E. How new activities represent a change from the current situation:

SIHC's current program has organized the communities, established a community based health care

program, recruited and trained health workers, built a health center, established a formal relationship with the

Ministry of Health, and begun to implement the five original interventions.

The new program will complete the integration of the newly established community based health programs

into the community and add CHWs to new areas as well. It will expand and enhance the training and experience

of the CHWs, between the community based program and the three new health center, and prepare the

community to take over sustainable health centers and community based health care program so that SIHC can

completely and successfully phase out.

Vanakomi Child Health Program Proposal March 2018, Page 9

F. Strategic Alignment

Government of Comabengi: The Ministry of Health supports ORT programs and commits to supply our

program with free ORS packets. There have been initial indicators that zinc supplementation will be included in

the national policy for diarrhea prevention and treatment. SIHC will be the first organization to introduce this

intervention and provide insights for national implementation. The Ministry is committed to free immunization

services through the CEPI program. The Ministry strongly promotes family planning services and will provide

free supplies to our health center. The new environmental health and safety intervention directly responds to new

government program initiatives.

WWA: Four of the initial seven interventions which are to be strengthened in the period of the expansion

grant are part of WWA's Strategic Objectives (SO) for Comabengi. The two new interventions are justified as

community needs by surveys presented above. Since environmental interventions are not a WWA priority, SIHC

will use its PVO match to fund this component.

SIHC’s ongoing efforts: SIHC's current program has organized the communities, established a community

based health care program, recruited and trained health workers, built a health center, established a formal

relationship with the Ministry of Health, and begun to implement the five original interventions. The new

program will complete the integration of the newly established community based health programs into the

community and add CHWs to new areas as well. It will expand and enhance the training and experience of the

CHWs, between the community based program and the three new health center, and prepare the community to

take over sustainable health centers and community based health care program so that SIHC can completely and

successfully phase out.

G. Partnerships important for this project

Two relationships are critical to the sustainability of current and expansion of existing efforts through this

project:

1. Ministry of Health (MOH) - has agreed to support the activities of the health center by the following

(See Appendix H.):

 deployment of clinical officers

 provision of drug kits at the public sector concessionary rates

 provision of free family planning materials for MCH services

2. Gopalans Bright Futures Foundation - As our Comabengian partner, this Foundation has provided funds

($45,000) and logistical support for building the health center and wants to establish income-generating

projects for long-term sustainability.

We have established working relationships with these agencies which will provide expertise,

support, and community ties which will enhance the survivability of the project.

3. MOH - Provincial Medical Office - deployment of HC staff.

4. MOH - Division of Family Health - agrees to support ORT program with educational materials and free

ORS packets.

5. MOH - CEPI - agrees to supply free vaccines.

6. Bokka City Commission - assisted us in establishing cooperative ties with nearby health centers.

7. University of Comabengi - plans paediatric rotation at health centers to train medical students (see

Appendix B).

8. Family Planning Association of Comabengi - will train CHWs to distribute family planning materials at

no charge.

9. Mammon Pharmaceuticals has agreed to provide free zinc supplements for 2 years.

9. WWA Comabengi - We have a working relationship with our local WWA mission Health and

Population director.

Vanakomi Child Health Program Proposal March 2018, Page 10

H. Resources and Priorities of the Community

The priorities of our community based health care program and the need for the health centers were

initially identified by the community, increasing the likelihood that the community will successfully take

over the project after SIHC phases out. The major resource that the community offers to the project is labor.

Volunteerism reduces program costs and increases the likelihood that the project will be self-sustaining after

SIHC phases out. To date, 45 health committee members, 5 trainers of trainers, and 82 CHW volunteers

have been identified by the communities. We estimate the contribution of free person-hours by the

community residents during the past year as follows:

Health Committees 360 person-hours $ 720

Combined Health Committee 1080 person-hours 2160

Trainers of Trainers 900 person-hours 2700

------

$5580

By the end of year one, CHWs will be donating 30,000 person-hours per year (2 hours/week X 50

weeks x 300 CHWs). Volunteer members on the Board of Management will contribute 3 hours per month,

for a total of 430 person hours (2,150) per year. The Bokka Provincial Health Department will provide land

(about $40,000, see Appendix I for sublease agreement). The community will raise funds to build a security

wall around the health centers - estimated value: $18,000.

I. Private Sector Support

SIHC will continue to recruit private sector support from and mobilize community support to increase

the likelihood of an ongoing relationship. Section 8 describes our collaborative approach. These private

sector agencies are presently involved in our project, and it is expected that the working relationship further

developed during the expansion grant period will solidify the opportunity for continuing collaboration after

SIHC phases out. Project private sector partners include the following:

a. Gopalans Bright Futures Foundation - financial and logistical support as described in Section 6.

b. Third World Research Consultants- (TWRC) TWRC trained our Trainers of Trainers through their

TOT program, advised us on the community based health care program, and has provided technical

support on organizing our health center services.

c. National Council of Population and Development - assistance with population statistics and surveys.

d. Voluntary AID - assistance with health center planning and operations.

e. Generations of the Future Foundation will offer technical support for scaling up the community based

programs in other districts.

e. Joint Partners for Development - advice and assistance with project planning and evaluation. Will

provide external evaluations throughout the life of the project, as an in-kind donation.

3. HUMAN RESOURCES

A. Key Positions in Proposed Project

1. Comabengi Project Director - CPD (Expatriate, 36 Project months (PM) - Overall supervision,

project planning, administration, and financial management.

Vanakomi Child Health Program Proposal March 2018, Page 11

2. Comabengi Project Officer - CPO (Comabengi national, 36 PM) - Supervise the community based

health care program, train CHWs, and relate with community leaders and groups.

3. Assistant Comabengi Project Officer (Comabengi national, 36 PM) - Assist CPO in all activities.

Must be trained as CHW program facilitator and experienced in community based health care.

4. Assistant Administrator for Health Services (Comabengi national, 36 PM) - Directly responsible for

financial management of the existing health center and the three new clinics. Must be a resident of the

target area and experienced in administration and bookkeeping.

5. Charge Nurse of Health Centers (2) (Comabengi national, 36 PM) - Responsible for supervision of

clinical activities of each health center and supervision of CH nurses. Must be a Comabengi Registered

Nurse with supervisory experience.

6. CH nurses (6 Comabengi nationals, Comabengi Enrolled Nurses, 216 PM) - Responsible for

providing maternal-child health services in the health center and supervising CHWs.

7. Community and Health Facility Coordinator: Responsible for coordinating activities with the

community and health facilities especially for scaling up best practices and training of shop keepers

8. American Volunteers (3 Expatriates, 63 PM) - Responsible for providing assistance and technical

support in both the community based health care program and the health center. Should have

administrative and/or clinical experience (MD, MPH, RN)

The Comabengi Project Director and Comabengi Project Officer are currently in place (see Appendix A

for resumés). The other positions will be filled before the beginning of the grant period.

B. Roles of Key Staff

1. Planning/Administration of Project - CPD with assistanceof CPO. 2. Project Financial Management - CPD with assistance of health center assistant administrator and

HQ staff.

3. Technical Content - CPO with assistance of American volunteers and home office.

4. Health Information System - CPO with assistance of CH nurses, CHWs, and American volunteers.

5. Administrative support - Executive Director, Finance Director, and others from the Home Office.

6. Technical support - Medical Director and Project Support, Medical Advisory, and Academic

Committees at the Home Office.

Ratio of full time equivalents at home office staff and volunteers to projects is 2:1.

C. Health Services Personnel

1. Health Services Delivery

CH nurses (8, full time) - deployed by Ministry of Health (MOH). Provide maternal-child health

services and supervision of CHWs (2 hours each afternoon). Directly accountable to charge nurse

for health center activities, and to the CPO for community based health care activities.

Vanakomi Child Health Program Proposal March 2018, Page 12

Clinical Officer (3, full time) - deployed by MOH. Responsible for diagnosis and treatment of ill

patients at the three new health centers.

2. Supervisory Personnel

Comabengi Project Officer and Assistant (full time) : supervise CHWs, trainer of trainers, and

work of CH nurses in the community based health care program.

Charge Nurse (3 full time): supervise work of clinical staff, including CH nurses providing MCH

services in each of the clinics and service areas.

3. Health Promotional Personnel

Volunteer CHWs (300) - recruited from communities, contribute 2 hours/week,

accountable to the CH nurses.

Volunteer Trainer of Trainers (15) - recruited from communities, 4 hours/week,

accountable to CPO.

4. Seconded Staff

Six nurses, four Clinical Officers, a pharmacy technician, and a laboratory technician will be

deployed by the Ministry of Health. The Ministry will pay the salaries and benefits for four CH

nurses and three clinical officers.

4. MONITORING AND EVALUATION

A. HMIS Information System Budget

Approximately 6 percent of the country budget or $93,300 will be dedicated for project monitoring and

evaluation, including a baseline survey, annual reports to WWA, midterm and final evaluation.

B. Indicators

 Output indicators will be collected through CHW reports: 1) CHW home visits, 2) Mothers taught ORT

and Zinc, 3) Home teaching sessions, 4) Vital events = births, deaths, 5) Cases: diarrhea, measles, tetanus,

accidents

 Output indicators will be collected through health center records: 1) Treated, pediatric acute respiratory

infections, 2) Vaccinations given, 3) Children monitored for growth, 4) Children treated by ORT, 5)

Women given family planning counseling, 6) Antenatal visits

 Outcome indicators will be collected by annual surveys: 1) % infants/children (0-59 months) with

diarrhea in the last two weeks treated with ORT and zinc , 2) % children (12-23 months) vaccinated by age

12 months with DPT, OPV, and measles vaccine, 3) % infants (0-11 months) being breastfed and receiving

other foods at an appropriate age, 4) % women (15-49 years) currently practicing family planning.

C. Monitoring Schedule

1. CHW Reporting (Output Data):

CHWs will compile monthly reports.

CPO will compile quarterly reports, beginning at month 4.

2. Health Center Reporting (Output Data):

Monthly reporting by CH nurses.

Quarterly Compilations by charge nurse, beginning at month 4.

3. Surveys (Outcome Data):

Baseline Comprehensive Survey: start in month 2

KAP Surveys: month 2 and Month 14

Vanakomi Child Health Program Proposal March 2018, Page 13

Final Comprehensive Survey: August (month 33)

D. Technical Assistance for M&E

1. CHW Reporting - We have enlisted the technical assistance of AHRC for developing a reporting

system for CHWs.

2. Health Center Reporting - No technical assistance necessary.

3. Comprehensive and KAP Surveys - We will work with the University of Comabengi Department of

Community Health and Ouagatown University's Institute of International Development, both of which

we collaborated with on our first baseline and KAP surveys.

4. Project Evaluations - We will work with Joint Partners International, the Ministry of Health, TWRC,

and another private sector consultant in these evaluations. We have successfully collaborated with these

consultants previously.

E. Reporting

Output data collected by CHWs will be compiled quarterly by the Comabengi Project Officer. Output

Health Center data will be collected by CH nurses and compiled quarterly by the charge nurse. The

CPO will review and summarize the above information and forward to the home office quarterly.

Survey data of outcomes will be compiled annually under the direction of the Monitoring and

Evaluation Officer and forwarded to the home office to be forwarded by them to the WWA Child

Health office.

5. IMPLEMENTATION TIMELINE

A. Timeline

The Activities Table presents the schedule of activities to be undertaken.

B. Possible Constraints to Timely Completion of Activities

1. People - Volunteer drop-out rate may be higher than anticipated. We believe that our community

relationships and our compressed training period (8 hours per week for 3 months) can limit the drop-out

rate for CHW trainees to less than 10%. Response would be to increase rate of training and re-examine

incentives for participation.

The MOH may not have the clinical officer staff to provide to the health centers when they are

needed. Response would be to hire locally and pay the employees out of health center income, adjusting

service fees as necessary.

The supervisory structure for the CHWs may prove to be inadequate. Response would be to enlist

the assistance of TOTs in field supervision especially in making field visits with CHWs, and to consider

increasing the nursing staff in the health center.

2. Financial Resources - The health centers may not generate enough income to subsidize the

community based health care program. Response would be to place a greater emphasis on other income

generating projects and discuss further support from the Ministry of Health.

3. Community Involvement - If this process lags behind the projected timetable, efforts should be

redoubled at training personnel, examining incentives, and strengthening participatory management of

the project.

Vanakomi Child Health Program Proposal March 2018, Page 14

Activities Table by Quarter Year 1 Year 2 Year 3

1 2 3 4 1 2 3 4 1 2 3 4

1. Personnel in Position

Project Manager ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓

Technical-(volunteer MDs, MPHs) ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓

Community/village health workers ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓

Support staff (asst project officers) ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓

Others (trainers of CHWs) ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓

2. Detailed implementation plan (DIP) due

Design/planning ✓ ✓

Preparation of DIP ✓ ✓

3. Health Information Systems (HIS)

Design/preparation of HIS ✓

Consultants/contract to design with HIS ✓

Baseline Survey ✓

Design/preparation ✓

Data collection ✓

Data analysis ✓

Dissemination and feedback to community and project management

✓ ✓

Registration/record system ✓

Design/preparation ✓

Ongoing implementation ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓

Dissemination and feedback to community and project management

✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓

4. Training

Design and preparation ✓ ✓ ✓ ✓ ✓ ✓

Training of trainers ✓ ✓ ✓ ✓ ✓ ✓

Training sessions ✓ ✓ ✓ ✓ ✓ ✓

5. Procurement of Supplies ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ Year 1 Year 2 Year 3 1 2 3 4 1 2 3 4 1 2 3 4

6. Service Delivery

ORT and Zinc ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓

Immunization ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓

Nutrition ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓

Growth Monitoring Promotion ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓

Nutrition Education ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓

ARI ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓

HIV/AIDS ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓

Environmental Health ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓

High Risk Births ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓

7. Technical assistance

HQ/Regional office visits ✓ ✓ ✓ ✓ ✓ ✓

Local Consultants ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓

External Technical assistance ✓ ✓

8. Progress reports

Annual project reviews ✓ ✓ ✓

Annual reports ✓ ✓ ✓

Mid term evaluation ✓

Final Evaluation ✓ ✓

6. BUDGET

Vanakomi Child Health Program Proposal March 2018, Page 15

A. Line-item budget

See next pages for Estimated Country Budget

B. Budget narrative:

1. Procurement

a. Equipment

1). Office equipment will be upgrading computer equipment and printer.

2). Health Center medical equipment will be supplied by SIMC

2). One of the project's vehicles, which we carried over from the Luanra project, will be

needing replacement.

b. Supplies

Include supplies for general office, training, communications to health committees, and supplies

for CBHC and clinic that are not covered by fees collected by the clinic.

c. Services: None

d. Consultants

The field staff has been receiving free advice and assistance from local NGOs such as AHRC

and Joint Partners. To continue to expect free consulting services for another three years seems

unrealistic. These staff have been assisting with various aspects of the project, including

participation in the mid-term evaluation.

2. Human Resources

Planned personnel inputs are as follows: Months Per Year

Year1 Year2 Year3

Technical:

Clinic physician (vol)* 12 12 3

MPH/Nurse (vol)* 12 12 -

Nurse/Coordinator 12 12 12

Clinical officer (3) 36 36 36

Charge nurse (3) 36 36 36

Community Health Nurses (3) 36 36 36

Pharmacy technician (3) 36 36 36

Lab technician (3) 36 36 36

Administrative:

Project Director* 12 12 12

Clinic Administrator (vol)* 12 - -

Project Officer 12 12 6

Clinic Assistant Administrator 12 12 12

Office Staff (3) 36 36 36

Other:

Domestic (2) 24 24 24

Security (3) 36 36 36

Expatriate staff includes:

Vanakomi Child Health Program Proposal March 2018, Page 16

Project Director, fulltime, at annual salary of $55,000 and $900 per year for individually

purchased health benefits, and SOS medical evacuation

3 health care professional volunteers, fulltime, at monthly stipend of $60 plus $100 per

quarter for individually purchased health benefits, as well as air fare and SOS medical

evacuation.

Country national staff includes:

Project Officer, fulltime Comabengian, at $15,000 per year including salary and benefits.

Nurse Coordinator, fulltime Comabengian, at $8,000 per year including salary and benefits.

The remaining listed staff will be employed at the health center, integrating services and health

education provided at the health center with the CBHC program. Some of them will be MOH

seconded staff, others will be paid from health center revenues. Anticipating patient revenue

shortfalls during start-up operations, these salaries are subsidized by the project at $10,000

first year, $8,000 second year, and $3,000 third year.

2. Evaluation

b. Consultant/Contract: The Baseline Survey and Final Evaluation will be contracted with local consultants to provide external evaluations of the project.

c. Travel and per diem for home office staff to assist with program evaluation and reporting. Round trip airfare from New York City to Bokka is calculated at $2300..

3. Indirect Costs

Indirect Costs cover home office expenses associated with new program development; public education

audiovisuals, handouts, and newsletter; SIHC's annual meeting; the annual audit of our financial

statement; and general and administrative costs including domestic travel, copying, postage, rent,

utilities, and insurance. (See explanation of provisional indirect cost rate in Appendix 4 of Part A.)

4. Other Program Costs

a. Travel and Per Diem

1). Short-term: For in-country travel to conferences and workshops.

2). Long-term: Round trip travel for expatriate volunteers to the project. Airfare is

calculated at $2300. Six month volunteer terms are assumed.

3). Other Direct Costs include housing for expatriate volunteers and staff,

communications, repairs and maintenance of vehicles and equipment, gas and some

insurance, TOT training costs, rental of meeting halls, bank charges, local

transportation.

Vanakomi Child Health Program Proposal March 2018, Page 17

Abbreviated Budget (standard WWA format)

Year 1 Year 2 Year 3 TOTAL

WWA SIHC WWA SIHC WWA SIHC WWA SIHC I. PROCUREMENT

A. Equipment

Office/Clinic equipment 27,500 15,000 42,500

Office furniture 15,000 10,000 25,000

Vehicle, replacement 32,000 32,000

Subtotal equipment 32,000 12,500 32,000 67,500

B. Supplies

Office supplies 15,000 8,000 8000 31,000

Vehicle fuel & maint 12,000 10,000 11,000 33,000

Subtotal supplies 27,000 18,000 19,000 64,000

C. Services

Rent and utilities 15,000 10,000 16,000 11,000 17,000 12,000 48,000 33,000

Subtotal services 15,000 10,000 16,000 11,000 17,000 12,000 48,000 33,000

D. Consultants

Local consultants 8,000 9,000 10,000 27,000

International consultants 15,000 5,000 12,000 5,000 16,000 43,000

Subtotal consultants 23,000 5,000 21,000 5,000 26,000 5,000 70,000 15,000

II EVALUATION

Consultant-surveys 15,000 13,000 28,000

Consultant-Evaluation 12,000 16,000 28,000

Home office support 19,000 21,000 0 23,000 63,000

Subtotal evaluation 15,000 19,000 12,000 21,000 29,000 23,000 56,000 63,000

IV OTHER PGM COSTS

A Personnel

Technical 87,200 14,500 91,560 15,225 96,140 16,000 274,900 45,735

Administrative 45,250 25,000 47,500 26,250 49,900 27500 162,650 78,750

Support staff 29,300 12,000 30,750 13,000 32,300 14,000 92,350 29,000

Subtotal Personnel 161,750 51,500 169,810 54,475 178,340 57,500 539,900 153,485

B. Travel, per diem

International travel 25,000 12,000 15,000 9,000 22,000 5,000 62,000 26,000

Local travel 5,500 0 6,200 0 7,500 0 19,200 0

Per diem 8,500 3,000 6,000 3,000 6,500 2,500 21,000 8500

Subtotal travel 39,000 15,000 27,200 12,000 36,000 7,500 102,200 34,500

C. Other direct costs 45,000 10,000 47,000 12,000 52,000 13,000 144,000 35,000

Subtotal other costs 45,000 10,000 47,000 12,000 52,000 13,000 144,000 32,000

III INDIRECT COSTS

subtotals 357,750 109,500 311,010 115,475 357,340 118,340 1,056,100 327,858

IDC rate at 21% 75127.5 65312.1 75041.4 221,781

Sub total indirect costs 75127.5 65312.1 75041.4 221,781

GRAND TOTAL 432,878 109,500 376,322 115,475 432,381 118,340 1,277,881 327,858

Vanakomi Child Health Program Proposal March 2018, Page 18

C. Project Justification and Beneficiary Cost Analysis

In year 3, the estimated WWA cost for the Maternal, Neonatal and Child Health program in Vanakomi

is $432,381, including field and home office expenses. The target population of women of child-bearing age

and children under five is projected at 92,777 providing a cost/beneficiary of $16.77. This cost includes

seven interventions: ORT, immunizations, nutrition, prevention of AIDs and STDs, high risk births, ARIs,

and environmental health and safety. However, the health center which will be providing primary care, and

at least two interventions (prevention of AIDs and STDs and environmental health and safety) will impact

the larger population as well. The total population in the service area is projected at 244,059 providing a

cost per beneficiary of $6.37. With high inflation in Comabengi at the present time, we believe that this is

an excellent cost/beneficiary ratio. The strategies outlined herein are expected to be cost-effective in

enabling the Vanakomi community to maximize their health resources and prevent unnecessary childhood

disease, disability, and death.

7. SUSTAINABILITY STRATEGY

The primary task in the expansion funding period will be to turn the project over to the community so

that SIHC can phase out without undermining the health care institutions and programs. The sustainability

of the Vanakomi Maternal, Neonatal and Child Health Project rests on two pillars - Volunteer Community

Participation and three Private Fee-for-Service Health Centers.

Community Participation - SIHC has consistently stressed volunteer community involvement to reduce

costs, to encourage community "ownership" of its health services, and to increase the survivability of the

program after SIHC departs. The health committees, formed in collaboration with local leaders, are critical

to the sustainability of this program. The proposed interventions address priorities which were expressed by

the communities at the outset of the original grant, particularly the need for environmental health. The health

center also addresses an expressed need, and its completion has mobilized the community behind the

project. The use of volunteers increases the cost effectiveness of the community based health care program

and is a key element of sustainability.

Fee-for-Service Health Centers - The focus of sustainability efforts will be on income generation. A

unique feature of our program is the use of three fee-for-service supported health centers as a site for health

programming, and CHW training, to support the project after SIHC departs. The health centers are designed

to recover costs related to curative services as well as the community based health care program. The

community has suggested that additional revenues may be generated from renting large tents for weddings

and funerals, a kiosk to sell refreshments outside the health center, a day care nursery on the health center

grounds. SIHC is exploring the possibility of setting up retail pharmacies to generate income for project

activities.

The following table outlines the timetable for SIHC's phaseout of the project

Vanakomi Child Health Program Proposal March 2018, Page 19

TIMETABLE FOR SIHC PHASEOUT MONTHS 0-12 MONTHS 13-24 MONTHS 25-36

INSTITUTION Begin SIHC phase out. SIHC attends as an observer

SIHC no longer attends meetings regularly but reviews minutes and confers with leaders

SIHC no longer participates at all.

HEALTH COMMITTEES

Encourage/ support local initiative

Encourage support local initiative

Committee depends completely on local initiative

CHW Supervisory Structure

CHWs report to CH nurses who report to CPO. 100 new CHWs trained

CPO begins training charge nurses to supervise CH nurses

Charge nurse supervises CH nurses in community activities. Emphasize CPO phase out.

HEALTH CENTER SIHC supervises operations. HC administrator and charge nurse report directly to CPO

Less visible SIHC supervision, emphasizing staff development and autonomy.

HC administrator and nurse in charge report to Management Board. SIHC is an advisor only.

BOARD OF MANAGEMENT

SIHC participates actively, emphasizing HC management.

SIHC participates actively, emphasizing board member development.

SIHC attends meetings but meeting is run by members.

8. COLLABORATION

There are no other NGOs or donor activities in the target area. SIHC has held discussions with the

administration of the Madagali Health Center to coordinate community based health care activities in Waithaka

with the health center nurses. It is expected that residents who live near the existing health center in Bokka City

Center will continue to receive MCH services there, and those living in the catchment areas of the new centers at

Madagali, Etinan and Ikoti-Abasi will receive curative services from these clinics. ..

9.APPENDICES

Recognizing that reviewers are extremely busy, we have gone ahead and summarized the key points of the

Appendices below. If selected for funding, full details will be provided for all Appendices listed.

Appendix A: Summary of resumes of Key Staff

Project Director. Suggested name: Helmet Schneider. Dr Schneider holds an MPH from University of

Heidelberg, Faculty of Medicine, and a PhD from the Tropical Institute, Antwerp. He has previously headed

primary health care programs in Zaire, Cameroon, Sri Lanka and Laos. These programs averaged $1.5

million per year in budgeted amounts. For the past five years he has worked for SIHC, where he has had a

distinguished record. Before that he has worked with the World Health Organization as a field research

manager, and IFRC as head of delegation in several countries. His areas of interest have included maternal

child health, community development, and disease control programs.

Project Officer. Suggested name: Ise Swartmon. Ms Swartmon holds a BA in Agronomy from the

University of Comabengi, and a Teachers Certificate from the Bokka Normal School. Previously she

worked for seven years in the Community Relations section of the Bokka City Commission. She has worked

with community development organizations, trained community mobilizers and facilitated projects

undertaken by community based organizations.

Assistant Administrator for Health Centers. Suggested name: Ikus Ilfent. Mr Ilfent was trained at the

Comabengi Polytechnic, receiving a Certificate in Accounting six years previously. He worked for several

private general trading firms before joining SIHC two years ago as a bookkeeper at the new clinic in Bokka

City. He possesses the skills needed to oversee the existing health facility as well as the three new facilities.

His job would be to oversee both administrative and financial management of the Health centers, and to

Vanakomi Child Health Program Proposal March 2018, Page 20

assist the Project Director in the financial management of the entire Child Health Program. He is a member

of the Bokka Rotary Club and past committee chair for community programs.

Appendix B Letters of support

Letters of appreciation for the excellent work SIHC has previously done were included from the Mayor of

Bokka City, and from the Governor of Vanakomi Division. Letters testifying to the assistance to the country

in earlier projects are provided from the Comabengi Council of Voluntary Agencies, and the Comabengi

Red Crescent Society.

Appendix C Most Recent Evaluation

The executive summary from the Final Evaluation of the Bokka City Community Health Project completed

less than a year ago. The evaluation report includes the following points:

1. The Project fulfilled the objectives in the proposal 2. The methods followed closely those set out in the original proposal 3. The project was able to achieve the outcomes originally anticipated 4. Results of the project have received high marks from the community leaders 5. Financial management of the project was uneven, without compete records for a number of

transactions

6. The curricula used for training CHWs was a non-standard curricula, and the amount of in-service training this cadre of personnel received was probably not adequate

7. The turnover of community volunteers was high 8. Community resources available to support this project were probably less than anticipated 9. Surveys were done well, however the data were not fully utilized. 10. Monitoring could have been improved 11. The mid-term evaluation was particularly thorough, and the recommendations were carefully

followed up in the last half of the project

Appendix D Beneficiaries

The beneficiaries of this project include those living within the catchment area of the three health

centers to be constructed, and the current center in Bokka City. These include 92,777 women of child

bearing age and children under age 5. The total population in the service area is projected at 244,059.

these are data based on the recent national census. In addition to the SIHC facilities, there are

approximately 25 traditional healers, and 18 private practitioners in the service areas. Some of the

private practitioners are formally trained medical practitioners, but the quality of care provided by the

others in uncertain. With improve roads, many people will travel to urban areas for treatment, and it is

hoped that the new clinics will reduce this by making better access available locally.

Appendix C Health Center Description

The Health Centers follow a standard design developed by the Ministry of Health, and adapted by

Bokka Health Department. This consists of a large waiting area with a large overhanging roof, but open

on the sides to ensure adequate ventilation. This can be divided for use in teaching for antenatal and

immunization clinics. There is a central registration desk, and behind this there are 5 consulting rooms,

which can be used for routine clinical services or for immunization or antenatal clinics. A small

laboratory is present, and a records room. There is a large injection room, which can be used for minor

surgical procedures. Near the reception area there is a dispensary where medications are provided to

patients as they leave the facility. There are staff and patient toilets in an adjacent outside structure.

Appendix F Pediatric Injury Survey Synopsis

Data from this survey were recently published Comabengi Medical Quarterly. These data were

Vanakomi Child Health Program Proposal March 2018, Page 21

obtained from a 30 cluster 7 household survey carried out throughout Bokka Province. The data were

augmented by information obtained from health facility records. In the end, the facility records did not

provide that much additional data as many were incomplete, especially for more minor injuries. Among

the more minor injuries, lacerations were the most common, usually associated with falls from trees or

bicycles. Likewise fractures were commonly seen during the mango, citrus and papaya seasons. Burns

were common, especially in the cold season. In parts of Bokka Province epilepsy seems unusually

common. Many of the burns reported were associated with falling into fires during fits, perhaps with the

flickering flames initiating the seizure. Poisonings were also common, though there were a variety of

substances felt to be responsibility. Many mothers believe poisonings were associated with witchcraft,

so the exact nature of these was hard to ascertain. Drownings and near-drownings were common,

especially in the rainy seasons, though limited to the riverine areas. Communities identified injuries,

especially burns as a major health issue for children.

Appendix G Lessons Learnt

From the initial project in Bokka City, the following lessons were learned, and best practices

developed.

1. Growth monitoring. This worked well in conjunction with immunizations. However, when immunizations were completed for a child, the mother would not bring the child back for grown

monitoring unless there were other incentives such as food provided to take home. When a child

was identified as being wasted or having marasmic kwashikor, supplemental food was always

provided. However, unless large amounts were provided to the family member accompanying the

child. Those children who improved often relapsed before the next harvest.

2. Antenatal services. It was possible to increase the numbers of women attending antenatal clinics to as many as three visits per pregnancy. However, the major challenge was to get women to attend

during their first trimester. Also the schedule for tetanus toxoid was very confusing for mothers, and

also for clinic staff.

3. Access for the poorest of the poor. Although the clinical services had specifically targeted this population, it was difficult to separate them from other persons who could pay for services.

Attempts were made to get community leadership to make these decisions, but this was not very

successful. Leaving these decisions to the health worker was not successful. An alternative strategy

is badly needed.

4. Preventive services. It was difficult for communities to understand the importance of community services. However, once curative services were well established and meeting community

expectations, then communities were better able to absorb many of the preventive messages which

the clinic had attempted to promulgate from the beginning.

5. Community Health Workers had the most success working in households of the more educated. The many messages and training materials developed, just seemed to have limited impact on the very

poor.

Appendix H Letter of support from the MoH (attached)

Appendix I Letter form the Bokka Provincial Commission (attached)

Vanakomi Child Health Program Proposal March 2018, Page 22

Republic of Comabengi

Ministry of Health Headquarters

Directorate of Primary Health Care Independence Way

PO Box 230 Fanguzi City

+786 (0)22 32 10 99 [email protected]

www.moh/phc.gov

REF 32893/VOLII/SIHC/23

15 February 2018 Mssrs. Simsburry International Health Coordinators

Dear Sirs,

As a follow up to our discussion of Thursday last, I would like to confirm the support of the Ministry of Health from you plans to expand Primary Health Care services in three locations within the Vanakomi division of Bokka Province. This is an area of great

unmet needs which has long been of major concern to the Ministry. As this the home area of the current Ministry of Health, you can be sure that developments with your project will be followed with keen interest. As agreed, the Ministry of Health will second 3 clinical officers to the project for up to 18 months each to help the new clinics start their clinical and outreach services.

We wish you the very best as you submit the proposal for what we see is an important undertaking. Yours faithfully

Lendo Mafazi, MD, MPH (Johns Hopkins) Director of Primary Health Care

Vanakomi Child Health Program Proposal March 2018, Page 23

Province of Bokka Provincial Health Commission

PO Box 22  Bokka City  Comabengi

Office of the Commissioner

Ref 2456 Vol IV

26 February 2018

Alfred Simpson

Simsburry International Health Coordinators

PO Box 2995, Fanguzi

Dear Mr. Simpson.

It was a pleasure to meet you during your recent visit to Bokka City. As I mentioned at the time

your visit, we have been delighted for your support as we strive to meet the health needs of people

in Bokka. We are delighted that your organization will be tackling the health problems of adoescents

in the Vanakomi Division as a serious commitment. As stated at the time of your visit, we are

prepared to grant your organization temporary title to the land being considered for clinic

construction. As you your self indicated, it is the intent of your organization to pass the ownership

of these clinics back to the Ministry of Health at the completion of your work in Bokka along with

funding to sustain them for the first year of independent management. Until that time we are happy

to provide SIHC with title to the clinic land. I have asked the Commissioner of Lands and Surveys

to draw up the necessary documents to see that this is accomplished without delay.

We thank you very much for your continuing support to the people of Bokka.

Yours Sincerely,

Allepo Afunzi, MB ChB, MPH, FRCS

Commissioner of Health