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					   COOPERATIVE AGREEMENT TO THE PAN AMERICAN
   HEALTH ORGANIZATION (PAHO) TO INITIATE POST-
     HURRICANE RECONSTRUCTION OF THE PUBLIC
  HEALTHCARE SYSTEM IN CENTRAL AMERICA AND THE
                   CARIBBEAN




                                         28 July 2000
                                         revised 12 October, 2000




CENTERS FOR DISEASE CONTROL AND PREVENTIONPROGRAM ANNOUNCEMENT NUMBER 00021
                                                                         TABLE OF CONTENTS



I.        INTRODUCTION ..............................................................................................................................................2

II.       BACKGROUND AND NEED............................................................................................................................2

III.          GOAL AND OBJECTIVES ..........................................................................................................................3

IV.           METHODS AND OPERATIONAL PLAN ..................................................................................................4

V.        COORDINATION AND PERSONNEL ......................................................................................................... 11

VI.           EVALUATION PLAN ................................................................................................................................. 12

VII.          PROGRAM MANAGEMENT .................................................................................................................... 13

VIII.         HUMAN SUBJECTS ................................................................................................................................... 13

IX.           BUDGET ....................................................................................................................................................... 13
      CONSOLIDATED BUDGET .......................................................................................................................................... 13
      BUDGET JUSTIFICATION ........................................................................................................................................... 13
      PERSONNEL: ............................................................................................................................................................. 13
      TRAVEL: .................................................................................................................................................................. 14
      EQUIPMENT: ............................................................................................................................................................. 14
      SUPPLIES: ................................................................................................................................................................. 14
      CONTRACTUAL: ....................................................................................................................................................... 14
      OTHER: .................................................................................................................................................................... 14
        TABLE 1: SUMMARY BUDGET ........................................................................................................................ 15
        TABLE 2: BUDGET JUSTIFICATION ............................................................................................................... 17
        ANNEX 1: OVERVIEW ...................................................................................................................................... 18
        ANNEX 2: LABORATORY PLANNING MEETING APHL, CDC, & PAHO – MAY 23, 2000 .......................... 19
        ANNEX 3:SUMMARY OPERATIONAL PLAN ................................................................................................... 20
        Annex 4: PAHO .................................................................................................................................................. 28
           Cooperative Agreement to the Pan American Health Organization to initiate the
      Post Hurricane Reconstruction of the Public Healthcare System in Central America
                                        and in the Caribbean
                                 [Program Announcement 00021]

I.       Introduction

         The following project proposal has been prepared in response to the United States Department of Human
Services, Centers for Disease Control and Prevention, Program Announcement 00021: Post Hurricane
Reconstruction of the Public Healthcare System in Central America and the Caribbean.
        The proposal is aimed at providing assistance to rebuild or strengthen national and subregional health
systems which will facilitate prevention and control of morbidity and mortality from communicable diseases.
         The project is mainly of a subregional nature, i.e., it will carry out activities which address problems and
solutions that are common to the area and should benefit the following countries affected by hurricanes Mitch and
Georges (1998): Dominican Republic, El Salvador, Guatemala, Honduras, Nicaragua. In addition, and for reasons
explained further on, the project includes a national component for three specific countries: Costa Rica, Haiti, and
Honduras.


II.      Background and Need

         In the wake of hurricanes Mitch and Georges, countries in Central America and the Caribbean have become
extremely vulnerable to infectious disease outbreaks, due to the disruption of public health, water and sanitation
services, displacement of population groups and the impact on the environment. Cholera and diarrheal disease,
dengue and leptospirosis, in addition to other vector-borne diseases, pose a significant risk to the peoples of these
regions.
          The toll in deaths, injuries and missing persons can be deceiving in relation to the intensity of hurricanes
Mitch and Georges. In any event, the figures of 10,000 deaths and 4,300,000 people affected, demonstrate the
vulnerability of the population affected. The damages to the health infrastructure were unparalleled. In Honduras,
the water supply system in 23 hospitals was either damaged or destroyed; 123 health centers were affected. In
Nicaragua, 90 health centers and 400 health posts were damaged. In El Salvador and Guatemala, 16 and 50 health
centers, respectively, were affected.
          In general, endemic communicable diseases continue to be a major source of disability and death. The
socioeconomic development of Central American nations, Haiti and the Dominican Republic is crippled by the
burden of these diseases, which cause huge losses in foreign currency and income from food trade and tourism, as a
result of epidemics of diseases such as cholera, malaria and legionellosis. Another case in point is dengue, which in
recent decades has reemerged with dramatic force, and is now endemic in most of the Americas. During 1999 alone,
more than 400,000 cases of dengue were reported with the consequent losses in productivity and impact on health
services.

         Prior to the hurricanes, countries in this subregion had recognized that the epidemiological information
generated by health services had limited use to orient public health interventions, especially at local level. In
addition, there was a lack of adequate intersectoral coordination to define disease control priorities.

         The disruption caused by the hurricanes has impacted further the operation of public health surveillance
systems which need to provide consistent and timely information regarding the occurrence of health problems that
require prompt preventive and control interventions. Moreover, information from these systems is crucial for disease
control program adjustment (reprogramming of resources) following changes in environmental risk factors and
population displacement. Laboratory services at department and district levels, usually located in hospitals and
health centers, and crucial to the provision of quality epidemiological surveillance, were directly affected both in
terms of their infrastructure, and the availability, or lack, of supplies and equipment maintenance.

         Infectious diseases in Central America and the Caribbean have been approached –and appropriately so– by
countries and PAHO from a subregional perspective, since they do not affect countries in isolation. The enormous
increase in the frequency and speed of international travel and the displacement and migration of populations across

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borders facilitates the introduction of diseases into previously unaffected areas in a matter of hours. Furthermore, in
disaster situations, countries have a shared risk, and should, therefore, share in their preparedness.

          Given its prior experience in working with countries and organizing subregional activities in the aftermath
of the hurricanes, PAHO implemented a daily reporting system to ensure early detection of disease outbreaks of
communicable diseases or any increase in their incidence. Thanks to this system, which shared its results via email
and fax to participating countries, it was possible to monitor patterns of diarrheal disease, cholera, dengue,
leptospirosis and malaria. These activities, in turn, contributed to steer collaboration between national surveillance
professionals. PAHO was already involved in technical cooperation for the establishment of an information and
communication network in the subregion with communicable diseases surveillance as a first module. Moreover,
mobilization of resources to affected countries by PAHO made it possible to train national outbreak response teams
using standard protocols, and to exchange results of outbreak investigations and control activities. Specifically for
cholera, a disease that mainly affected Guatemala, Nicaragua and El Salvador, PAHO coordinated with UNICEF
and national governments a prevention and control project that addressed epidemiological surveillance (including
laboratories), sanitation, food protection and social communication. Subregional workshops were held to harmonize
prevention and control guidelines and exchange information on cholera occurrence focusing on border areas. The
latter used PAHO longstanding projects developed at border areas between Guatemala, El Salvador and Honduras,
Honduras and Nicaragua; and Costa Rica and Nicaragua.

         The political changes towards democratization, decentralization and public accountability in Central
America, together with its opening to global markets and the impact of the global economy, make cooperation
between various types of international aid agencies (international banks such as The World Bank and IDB, bilateral
agencies such as USAID, DFID, EU, NGOs and the UN system easier and more efficient. Moreover, in Central
America, PAHO has a history of leadership in formal international cooperation in development. This cooperation
must be applied now to strengthen the subregion’s capacity to prevent and control major public health threats,
especially infectious diseases with epidemic potential.

III.        Goal and objectives

        Goal
        Given the priority expressed by the ministers of health at the Meeting of Central American Countries and
Dominican Republic Health Sector (1999), the main goal of the project is to rebuild or strengthen systems,
networks, units, and groups already existing in each country, and at a subregional level, to prevent and control
morbidity and mortality from communicable diseases.

         For an overview of this Cooperative Agreement goal, objectives and activities please refer to ANNEX 1.
         Because the socioeconomic and public health development in the countries involved is not the same across
the board, the project will have a more focused approach of subregional activities in three countries: Costa Rica,
Haiti, and Honduras. In Costa Rica, a program of structural adjustment and restructuring of the public sector resulted
in major reductions in the public health infrastructure and its functions. As a consequence, the health information
system cannot detect disease outbreaks in a timely manner nor take early or effective control measures.

         A more focused approach is also justified in Haiti because of the country’s unstable political situation and
socioeconomic conditions which cannot support a stable public health infrastructure. Socioeconomic conditions
have also hindered Honduras’ capacity to perform public health functions satisfactorily. By having a more focused
approach in these countries, the project will integrate them to the subregional approach in its different activities.

            Objectives
         The project has five objectives directly related to the four intermediate results indicated in CDC’s Program
proposal to assist in Post-hurricane reconstruction of the public health care systems of Central America and the
Caribbean. These objectives are listed below under the corresponding CDC Program Proposal’s intermediate result
(IR). They are directed, but not limited to a subregional approach to strengthen the capability for infectious diseases
surveillance in the public health sector.

IR1: Disease surveillance rehabilitated and information used for public health decisions

       Objectives

       a)   To establish an operational subregional network on communicable disease surveillance with 50% of
            countries participating by the end of the first year and 100% by the end of the second year;

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      b) To conduct performance measurements of essential public health functions in 50% of the beneficiary
         countries by the end of the first year and 100% by the second year, in order to identify gaps in public health
         infrastructure that constitute constrains to public health practice and to improve public health decision-
         making.

IR2: Increased availability of trained epidemiologists

       Objective

      c)   To assess and enhance participation of academic institutions in training of public health workers in
           epidemiology and public health interventions in 50% of identified institutions during the first year and
           100% during the second year.

IR3: Infectious diseases and environmental health laboratory capacity rehabilitated

      Objective

      d) To establish a functional regional laboratory network with reference centers for at least three diseases by
         the end of the second year.

IR4: Capacity of ministries of health to design and implement community-based prevention and control programs of
disease established.

      Objective
      e)   To provide assistance for the development of a disease prevention and control program for one priority
           infectious diseases by country in 50% of countries by the end of the first year and in 100% of countries by
           the end of the second year.
          The aforementioned objectives will be accomplished by developing coordinated subregional
epidemiological surveillance networking, including the analysis and dissemination of information. Supporting
elements to the latter included in the proposal are: laboratory capacity strengthening and involvement of academic
institutions in sustainable epidemiology training.

         Furthermore, these three elements  epidemiological surveillance, laboratory, and training will support the
development of disease prevention and control programs for priority diseases. The proposal will include an element
of performance measurement of essential public health functions, which will provide as an end product an easy
methodological tool for monitoring and evaluating changes observed at the health services as a result of massive
resource investment in the beneficiary countries.

         Finally, with the purpose of integrating all the countries targeted in this proposal, Haiti, Honduras and
Costa Rica will receive technical expertise and training support to become full partners in the subregional approach
and activities of the project.

IV.        Methods and Operational Plan

          Integrating the technical strengths and experience of PAHO, CDC and the Ministries of Health is a vital
part of the project. Close collaboration at technical and management levels will be enriching, both internally for the
organizations involved and as a support to the governments and other partners from civil society who will be
implementing the project.

         The use of integrated project planning and implementation, and appropriate coordination mechanisms as
well as to strengthen existing structures is considered essential. By improving the means of communication among
the partners involved, the end result of the project will make it possible to analyze and develop more efficient
control strategies at local, national and sub-regional levels.

        Sustainability will be supported by involving country partners in the design of activities to raise ownership,
and by continuing to reinforce local capacity and existing networks.

         PAHO will focus on a subregion-wide strategy to achieve the objectives of this Cooperative Agreement.
This strategy is based on the integration of the five objectives of the project, coordination among participating
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institutions, and full country participation, in particular, in all sub-regional activities. The operational plan for each
activity is detailed below and responds to the project objectives detailed in the previous section. These are repeated
here for easier reference.

IR1: Disease surveillance rehabilitated and information used for public health decisions. Objectives: a) To establish
an operational subregional network on communicable disease surveillance with 50% of countries participating by
the end of the first year and 100% by the end of the second year; and b) To conduct performance measurements of
essential public health functions, in 50% of the beneficiary countries by the end of the first year and 100% by the
second year, in order to identify gaps in public health infrastructure that constitute constrains to public health
practice and to improve public health decision-making.

Activities to meet objective a):

1.   Coordination of sub-regional communicable disease surveillance and laboratory networks
2.   Establishment of systematic virtual grand rounds to share information and discuss outbreaks
3.   Establishment of a sub-regional steering committee for communicable diseases
4.   Cooperation at the country level for the assessment of surveillance systems
5.   Cooperation for the organization of annual sub-regional epidemiological/laboratory scientific conferences and,
6.   Cooperation for the revision of public health surveillance/laboratory protocols after disasters
7.   Rehabilitation of Health Information System in Haiti
8.   Rehabilitation of Health Information System in Honduras
9.   Rehabilitation of Health Information System in Costa Rica

Activity 1. Coordinate subregional communicable disease surveillance/laboratory networks, including
analysis and dissemination of health information

         PAHO assigns priority to the coordination of the subregional disease surveillance and laboratory networks.
This requires a consensus building process to define and identify the data to be shared, standardize case definitions,
select priority diseases, geographic area and, most importantly select and standardize analytical protocols. It is
expected that a subregional disease surveillance plan and guidelines will be developed and adopted by participating
countries.

         For consensus building, PAHO will develop a series of subregional activities and organize meetings to
obtain the commitment of ministries of health to participate in the network. PAHO will assess information
technology use and develop an inventory of equipment and technical capabilities.

          The electronic platform network on communicable diseases for the subregion will be improved by defining
data users and data use protocols, and establishing protocols to analyze and present subregional and border area data.
To do so, PAHO will provide the technical expertise necessary to enhance and support the electronic platform
network as a web page and internet application; organize and convene meetings, as necessary to coordinate
activities. PAHO will provide the training, logistics, methodology, equipment and materials to support the network.
The laboratory component will be added to provide the integration of data on diagnostic results linked to morbidity
on selected diseases and alert the emergence or reemergence of pathogens. These activities and efforts will support
the development of a subregional surveillance plan and guidelines. Training will be provided with emphasis on data
analysis and data presentation for public health use. Also, existing data that has never been analyzed will be
reviewed. Essential logistics and equipment support will be provided depending on each country’s needs.

Activity 2. Establish systematic virtual grand rounds to discuss outbreaks and other EID-related problems

        PAHO will facilitate and coordinate data sharing, epidemiological discussions, outbreak and other
important disease events discussions in a collegial atmosphere through telecommunications. As a result, there will
be an increase in infectious disease information exchange, both qualitative and quantitative. In addition, it is
expected that the quality of data analysis and accuracy will be enhanced.

         Virtual grand rounds will consist of a series of sessions chaired in a rotating basis by participating FETP
countries and ministries of health. PAHO will convene a working group to develop norms and procedures for
carrying out the sessions, including a two year program and a list of suggested topics and presenters for selected
topics, which will include but not be limited to subregional priority diseases. Sessions will occur every two months,
and after each session, reports and agreements on recommendations regarding infectious diseases threats will be
circulated. It is anticipated that some countries will require support to update telecommunication capabilities.

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Activity 3. Establish a subregional steering committee for communicable diseases surveillance in close
collaboration with reference laboratory diagnostic centers

         PAHO will establish a subregional steering committee to facilitate and coordinate activities under objective
a) Participating countries and institutions will be represented in this committee. Its purpose is to provide for the
long-term sustainability of activities under objective 1, and to promote effective collaboration between laboratory
services and surveillance personnel.

         The first step will be the selection of committee members according to selection criteria to be developed by
PAHO and agreed upon by participating countries and institutions. Roles and responsibilities will be defined, as well
as the meeting procedures. The committee will basically advocate for agreement on subregional priorities, on
diseases subject to sub-regional surveillance, priority diseases, standards and norms for disease reporting, including
case definitions, and disease-specific indicators.

Activity 4. Cooperation at country level for the assessment of surveillance systems, including laboratory
services, and development of updated national surveillance plans

          While communicable diseases surveillance systems exist in all countries, a systematic evaluation process is
still missing.

          PAHO will collaborate at country level in the assessment of surveillance systems, including laboratory
services, and the development of updated national surveillance plans, especially for those diseases selected as
priority. It is expected that an updated national plan for surveillance of infectious diseases will be available in each
participating country and follow guidelines and standards set by the subregional surveillance plan mentioned in
objective 1.

         A protocol will be developed based on WHO’s guidelines for the assessment of surveillance systems and
with the participation of national professionals. This protocol will be field tested and adjusted as needed. Once
finalized, each country’s surveillance system will be evaluated by a team of national and international professionals.
One major outcome of the assessment process will be the preparation of a comprehensive plan of action for the
development of an epidemiological surveillance system that addresses identified weaknesses.

Activity 5. Cooperation for the organization of annual subregional epidemiology/laboratory scientific
conferences

         The organization of annual subregional epidemiological /laboratory scientific conferences is seen as an
important step toward the rehabilitation of health information and disease surveillance systems. These meetings will
also strengthen the analysis and use of information for public health decisions. It is expected that a culture of data
analysis could be nurtured through this mechanism.

         PAHO will provide technical and financial support, and expertise to promote infectious disease
surveillance analysis, data presentation, and the utilization of the information generated for public health decision-
making. Papers on field investigations, outbreaks, epidemics and public health emergencies will be produced
following PAHO’s and participating institutions’ guidance for peer review, and presentation in subregional
conference. Selected papers will be further developed as a manuscript for publication in peer reviewed journals and
presentation in international conferences on the subject matter. Conference proceedings will be produced, published,
and circulated in the subregion. A database of papers on field investigations will be created and posted in the
subregional surveillance web-page.

Activity 6. Cooperation for the revision of post-disaster public health surveillance/ laboratory protocols

          PAHO will collaborate in the revision of public health surveillance/laboratory protocols on disaster
situations. Through the years, PAHO has participated in disaster relief operations and has accumulated invaluable
experience and expertise in disaster response and coordination. Many of the lessons learned will be incorporated in
this revision and strengthened or new disaster response surveillance protocols will be developed for the sub-region.

        PAHO will convene a working group among participating countries and institutions to review lessons
learned on surveillance after disasters. Disasters common to the region, such as floodings, hurricanes, and
earthquakes will be prioritized. Surveillance protocols for emergencies will be updated. The effects of disasters
might not be preventable under existing conditions of poverty and low socioeconomic development in the subregion.
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However, surveillance can help to monitor health conditions, behaviors, and attitudes, and these data may be used to
minimize or prevent the most serious effects of a natural disaster: disease outbreaks, epidemics, and deaths.

Activities 7 through 9. Rehabilitation of Health Information System in Haiti, Honduras, and Costa Rica

          PAHO will collaborate in the rehabilitation of health information systems of three countries identified as
priorities due to a weak public health infrastructure. A series of country-specific steps have been planned to this end.

          Haiti has well defined restructuring activities that include rehabilitation of epidemiological units,
equipment acquisition, epidemiological information dissemination, and training for system users. Haiti’s health
information system is not operational, and the emphasis has been placed in disease surveillance. Nowadays, disease
surveillance is implemented via sentinel sites. However, collection and transfer of collected data are expensive, and
only a few sites are operational. Haiti will establish a radio communications network, train public health surveillance
officers, and target specific diseases for surveillance. One priority is measles surveillance, in light of the epidemic of
this disease in the country. Measles surveillance will be used as a leading disease upon which others will be later
included. The information will be analyzed at the regional and central level, and initial control and prevention
measures will be applied at the regional level.

          Honduras will strengthen its health information system. The region of Olancho has been selected as a pilot
area for the system to be designed and implemented. The emphasis in Honduras is on standardizing data collection,
transmission, and analysis. The initial work will entail workshops on case definition, disease surveillance indicators,
data reporting and collection formats, and training of health personnel in the new system. The model system
developed in Olancho will later be replicated in two other regions of Honduras. The laboratory and the Hospital
Escuela, the main public hospital in the country will be integrated into the system.

         Costa Rica will redefine its health information system. The main emphasis is on coordinating information
flux from three parallel systems: Social Security, Ministry of Health and Laboratory. A system evaluation will lead
to the definition of roles and responsibilities, data collection and data reporting needs, and analysis integration. An
analysis unit at the central level, with participation and coordination among the three institutions, will be created and
replicated at the subordinate levels. Initial work will be in the Central Pacific Region of the country. Training to
system users is another key element of the Costa Rican activity.

IR1: Objective b) under IR1 addresses the improvement of public health practice, including decision-making
processes and the strengthening of public health infrastructure through the performance measurement of essential
public health functions (EPHFs). This objective has been incorporated into IR-1 with the vision of establishing
baseline results of the state of public health practice and infrastructure in each country, as well as providing a
sustainable evaluative tool to measure improvements in public health infrastructure and practice.

    Since PAHO, CDC (PHPPO) and Centro Latinoamericano de Investigaciones en Sistemas de Salud (CLAISS)
have developed an instrument for performance measurement of EPHFs that has already been pilot tested in Jamaica,
Bolivia and Colombia, this objective will concentrate on the application of the instrument in all the beneficiary
countries.

Activities to meet objective b):

10. Training of public health officials in each country on the methodology developed by PAHO, CDC and CLAISS
    for performance measurement of EPHFs;
11. Application of the instrument in all of the affected countries;
12. Analysis and reporting of each of the country’s results; and
13. Development of a plan of action for improving public health practice and strengthening public health
    infrastructure.

Activity 10. : Training of public health officials on the methodology for performance measurement of
essential public health functions
          To best establish baseline results of the state of public health practice under Activity 10, public health
officials from each of the beneficiary countries will undergo training with the following objectives:

             Definition of EPHFs
             Mechanisms for responding to the instrument
             Uses for measuring the performance of EPHFs
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             Identifying gaps in public health infrastructure based on the results of the instrument
             Using the results of the measurement for identifying gaps in public health infrastructure, strengthening
              public health decision-making, and improving public health practice process.

         The training sessions will be implemented by way of holding subregional courses and seminars addressed
to key public health officials involved in the areas represented by each of the EPHFs included in the instrument.
This training process will consist of a two-tiered process, involving an initial training of national public health
experts and officials in a subregional workshop to help facilitate and coordinate the application of the instrument in
each of the beneficiary countries in conjunction with the PAHO-Washington staff and PAHO country offices.

         The second-tier will involve seminars facilitated in each of the countries by the trained national public
health experts and officials, as well as by PAHO staff, that will address key public health officials in familiarizing
them with the methodology. This is an important prelude to the application process because it will allow for optimal
planning and coordinating within the country to best implement the instrument, as well as for prior familiarization
with the rationale and objectives of the instrument and the application process.

Activity 11. Application of the instrument in all of the affected countries

          Activity 11 consists of the application of the instrument in each of the countries afflicted by Hurricanes
Mitch and Georges. This instrument will compile information on EPHFs, in order to identify gaps in public health
infrastructre. These will include the following:
           Health information and disease surveillance;
           Training of public health workforce and human resources;
           Infectious disease and environmental health laboratory capacity; and
           Capacity to implement community-based programs of disease prevention and control.
         The performance measurement instrument has been developed by PAHO in an iterative development
process that includes the collaboration of the Public Health Practice Program Office (PHPPO) at CDC and the
Centro Latinoamericano de Investigaciones en Sistemas de Salud (CLAISS). The preliminary version of the
instrument has thus far been pilot tested in three countries and, based on the results of these pilots, the instrument is
being adjusted and refined.

          Once the instrument is adjusted and finalized, a training component will be incorporated to capacitate each
of the countries to promote and effectively use the instrument and its results. Further changes based on strengths or
barriers to implementation will be incorporated if necessary. The instrument will be administered to key informants
and stakeholders from the national, intermediate and local levels in the participating countries. It is important to
note here that the objectives of measuring public health infrastructure and practice are not to “rank” or “grade” each
of the participating countries. Rather, this meant to serve as a baseline diagnostic of the country’s state of its public
health infrastructure and practice, as well as a sustainable tool for public health decision-making and strategic
planning.

Activity 12. Analysis and reporting of each of the country’s results

          Activity 12 consists of the analysis and reporting of the results gathered by means of the application of the
public health performance measurement instrument. The instrument used to gather the data will use sound survey
measurement methodology that is scientifically-based. The data generated will be analyzed using qualitative and
quantitative methods (i.e. Epi-Info 2000). A country-specific report on the baseline status of public health
infrastructure and practice, in terms of EPHFs, will be produced for each of the participating countries which will
also include country-specific recommendations, in addition to regionwide recommendations to improving public
health infrastructure and practice. The country-specific reports will be used by each of the countries to identify gaps,
improve public health decision-making and, consequently, plan for the improvement of public health infrastructure
and practice.

Activity 13. Development of a plan of action for public health practice standards and to improve public health
practice

          Activity 13 consists of providing recommendations for a plan of action for each of the countries, as well as
for the sub-region as a whole, to adopt and incorporate public health practice standards into their current health
sector actions. This plan of action will contain strategies to improve public health practice in participating countries.

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          Stakeholders and key actors in each of the countries will convene in a series of workshops to discuss and
plan for strategies to delineate interventions that will improve and/or strengthen public health infrastructure and
practice. Mid term process indicators and project outcome evaluation indicators will be available through from the
baseline results, particularly those related to human resources, surveillance development and community-based
disease prevention and control programs that will be promoted and supported by this Cooperative Agreement
proposed by PAHO.

IR2: Increased availability of trained epidemiologists. Objective c): To assess and enhance participation of
academic institutions in training of public health workers in epidemiology and public health interventions in 50% of
identified institutions during the first year and 100% during the second year.

Activities to meet objective c):

14. Development of needs assessment for strengthening of human resources in field epidemiology and disease
    surveillance
15. Development of subregional plan of action for establishing permanent field epidemiology and disease
    surveillance training
16. Establish a network of Training Institutions in Public Health

Activity14. Development of needs assessment for strengthening of human resources in field epidemiology and
disease surveillance

     This activity will include the characterization of the situation of health systems in field epidemiology and
disease surveillance of the countries of the subregion; the identification of key problems and challenges; a
preliminary assessment of countries and subregional needs in human resources development and the existing
capacity of training institutions. This activity will be performed with the participation of deans and professors of
epidemiology of the major Training Institutions in Public Health (TIPH) of each country of the region (6
institutions); PAHO Country Office Professionals, representatives of FETP, the network of surveillance/laboratory,
the Ministries of Health, and invited schools of public health from outside to the subregion.

     A formal commitment of the 6 TIPH to develop a subregional and sustainable plan of action for the
development of human resources in field epidemiology and disease surveillance will be obtained. To operationalize
this collaboration terms of reference of a future plan of action will be prepared. In addition, a coordinating group
with focal points from each TIPH will be established.

Activity 15. Development of subregional plan of action for establishing permanent field epidemiology and
disease surveillance training

     A working group facilitated by experts will develop a subregional and sustainable plan of action for each
institution for the development of human resources in field epidemiology and disease surveillance. The latter will be
accomplished in collaboration with the coordinating group and in close relation with relevant stakeholders to ensure
political, organizational and financial feasibility. The working group and its collaborators will establish a data bank
of existing training resources such as training materials, experts, case studies, training sites, technological
infrastructure for communication, and distance learning. A strategy for communication between partners will be
established and basic equipment for distance learning will be procured.

Activity 16. Establish a network of Training Institutions in Public Health

     Once the plan of action is developed under Activity 15, a structured network with TIPH membership will be
established to facilitate exchange of faculty, students and educational technology. Training workshops for members
on distance learning and strategies for resource mobilization to ensure full implementation of the plan of action will
be priorities for the network.

IR3: Infectious diseases and environmental health laboratory capacity rehabilitated. Objective d): To coordinate the
development of a functional regional laboratory network with sub-regional reference centers for at least three
diseases functioning by the end of the second year.

         The coordination of the laboratory network will be based on the establishment of subregional reference
centers and with specific standard operating procedures and external evaluation of performance for participating
countries. The planning, monitoring and evaluation of activities linked to the stated objective will be performed in


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coordination between PAHO and APHL, through biweekly meetings. The result of the first two meetings that
already took place is presented in ANNEX 2
     Activities to meet objective d):

17. Participation in the subregional communicable disease surveillance network
18. To coordinate the development of a functional regional laboratory network with reference centers for at least
    three diseases by the end of the second year.

Activity 17. Participation in the subregional communicable disease surveillance network

         The laboratory network is a component of the subregional surveillance/laboratory communicable diseases
network. The tasks will be carried out in close collaboration between the Essential Drugs and Technology and the
Communicable Diseases Programs of PAHO and the Association of Public Health Laboratories (APHL), whose
members have the greatest responsibility of supporting national public health networks within this project (with
national epidemiology programs and in-country PAHO staff).

          Four tasks have been planned in order to pursue this objective. Although the proposals from countries
participating in the project identify the diseases of major local concern, it is necessary to reach a subregional
consensus on diseases that because of the public health importance in all or most of the participating countries,
should be the subject of subregional surveillance. This consensus was reached in a meeting that brought together the
directors of the seven national public health or central laboratories and epidemiologists. The participation of PAHO
facilitated subsequent inter-country communications and follow up. Once the priority diseases have been identified,
it is necessary to agree on case definitions, laboratory methodologies to be used for the study of either human or
environmental samples, and means of reporting results. A built-in component of these issues is quality assurance
(QA). Therefore, a quality assurance program will be outlined. Subregional reference laboratories are to be proposed
as responsible for implementing the QA measures in the Subregion. A three-day meeting will be held in Central
America as soon as funds are made available to PAHO.

         Once the consensus on priority diseases, QA program, and reference laboratories is reached, subregional
standard operating procedures will be developed. The initial step is to design a standard format in which the
procedures will be written and, using basic methodologies as examples, produce models than can then be replicated
in each of the countries. Based on the country proposals, it is anticipated that media preparation, sample collection
and antibiotic susceptibility will be included in the initial three-day workshop.

          In order to support the subregional approach, it is estimated that both diagnostic specimens and infectious
substances will have to be shipped from one laboratory to another, both within and among countries. According to
international requirements, only appropriately trained and licensed personnel should handle, ship and receive such
materials. Following the international recommendations, three authorized trainers will conduct a three-day course
for two members of each of the seven public health/central laboratories. At the end of the course, official licenses
will be awarded to all the trainees that fulfill the requirements. This course will be open to local carrier/airline
personnel who will cover their own expenses.

         Lastly, to determine the subregional needs of diagnostic reagents/kits that need to be procured, a consultant
will carry out a specific assessment. The initial phase involves the preparation of survey and inventory forms, and a
protocol to compile the information. The collection of data will be carried out during a seven-week period (one week
per country), and the preparation of a report and proposal on the alternatives for reagent procurement during the
following month. Additional discussions with national authorities and suppliers to finalize the proposal for
procurement will take two months.

Activity 18. Quality assurance in subregional public health laboratory networks

         In regard to the quality assurance component, two lines of action have been planned: one deals with the
managerial aspects of public health laboratories, and the other with programs for external evaluation of performance
and internal quality control. Public health laboratory managers will participate in two one-week workshops custom-
designed and held at the George Washington University. The first workshop will cover quality, human resource,
financial, and information systems management. National laboratorians will then develop plans for managerial
strengthening of their respective institutions, which will be implemented during a 12-month period. After this
period, a second workshop will be held, to address the weaknesses identified during the implementation phase.
GWU and PAHO will award laboratory managers who complete the plan satisfactorily a joint diploma.


                                                         10
         An issue of paramount importance is biosafety. Protection of both the community and laboratory personnel
is a major concern when working with infectious diseases. A 5-day course to produce the subregional guidelines on
handling and disposal of infectious materials will be held. Needs for biosafety equipment and devices, for facility
design and local training will be addressed with the help oh three international experts.

         The subregional quality assurance program requires standard protocols and gold standards to adjust local
and current methodologies. During a 12-month period, efforts will be focused on developing the subregional
capacity to produce/distribute those primary, gold standards, to produce and distribute biologic reagents for external
evaluation of performance (EEP), to analyze the results of the EEP surveys, and to prepare the consolidated reports.

IR4: Capacity of ministries of health to design and implement community-based prevention and control programs
of disease established. Objective e): to provide assistance for the development of a disease prevention and control
program for one priority infectious diseases by country in 50% of countries by the end of the first year and in 100%
of countries by the end of the second year.

Activities to meet objective e):

19. Conduct a comparative analysis of selected diseases epidemiological situation and the community-based
     prevention and control programs being implemented by countries;
20. Establish subregional goals for communicable diseases prevention and control;
21. Develop and apply community based strategies so that local and regional health services may meet the goals
     established under activity 20, above.

Activity 19. Conduct a comparative analysis of selected diseases epidemiological situation and the
community-based prevention and control programs being implemented by countries

         Communicable diseases control programs have been implemented in the subregion with varying degrees of
community involvement. The nature of the participation of the community is sometimes questioned regarding the
true community ownership and partaking from program planning to evaluation. Tasks under this activity will
encompass a comparative analysis of selected diseases epidemiological situation and the community-based
prevention and control programs being implemented by countries, including program norms and procedures. In each
country, specific consultants will prepare background documents using lessons learned that will then be used for the
comparative analysis prepared by a task force and presented as a report to be distributed to the countries.

Activity 20. Establish subregional goals for communicable disease prevention and control

        The report from Activity 19 should serve as input for the establishment of subregional goals for
communicable diseases prevention and control at the community level by a consultative group whose proposal will
be submitted for endorsement to participating countries, that will subsequently participate in a sub-regional
consensus meeting for negotiation and final approval.

Activity 21. Develop and apply community based strategies so that local and regional health services may
meet the goals established under activity 20, above.

          As a demonstration of strategies to be used by local and regional health services using community-based
strategies to accomplish the goals established under Activity 20, training will be provided for countries to be able to
support local and regional health services at the community level to prioritize diseases to be intervened and select
the most effective community-based strategy. These strategies will be developed, piloted and personnel trained for
their implementation for selected diseases and geographical.

         For a summary of the operational plan please refer to ANNEX 3. Data presented in ANNEX 3 include:
time schedule, activities, tasks, indicators, responsible staff and expenses related to each activity.

V.       Coordination and Personnel

         Within PAHO, the objectives and activities proposed in this Cooperative Agreement application, and
described in more detail in the previous sections, will be achieved by the interprogrammatic involvement of several
programs. Dr. Stephen J. Corber, Director, Division of Disease Prevention and Control, will have overall
responsibility for the Cooperative Agreement. For each objective, a PAHO staff advisor, will be responsible for the
implementation of activities as follows:

                                                          11
          Communicable Diseases Program (HCT)[Division of Disease Prevention and Control], Dr. Marlo Libel,
will be responsible for objective a) and e);

        Organization and Management of Health Systems and Services Program(HSO) [Division of Health
Systems and Services Development], Dr. Daniel Lopez Acuña will be responsible for objective b);

         Human Resources Development Program (HSR) [Division of Health Systems and Services Development],
Dr. Charles Godue will be responsible for objective c);
         Essential Drugs and Technology Program (HSE), [Division of Health Systems and Services Development],
Dr. José Ramiro Cruz will be responsible for objective d);

          PAHO’s country representative office in each of the seven beneficiary countries will take direct part in the
activities developed in the subregion; focal points are: Dr. Patricia Ruiz (Guatemala), Dr. Mario Valcarcel (El
Salvador), Dr. Luis Gerardo Castellanos (Honduras), Dr. Delmin Cury (Nicaragua), Dr. Ariel Depetris (Costa Rica),
Dr. Pedro Luis Castellanos (Dominican Republic) and Dr. José Moya (Haiti). The Office of the Assistant Director,
represented by Dr. Hugo Prado, in charge of Central American subregional initiatives, will provide liaison with the
Sistema de la Integración Centroamericana (SICA).

         For position and lines of command, please refer to ANNEX 4

         The primary counterparts for the activities proposed will be the ministries of health. Other partners in
countries will be social security agencies, academic and professional institutions, and NGOs. In addition, external
collaborators will include the CDC, the Association of Public Health Laboratories, and the Training in
Epidemiology and Public Health Intervention Network (TEPHINET).

          PAHO will focus on a region-wide, multi-country strategy to achieve the objectives of this proposal. The
historic spirit of collaboration among beneficiary countries has been the subject of a long-standing collaboration
between PAHO and Central American integration bodies (SICA, ISCA, RESSCAD, COMISCA) potentially
extending beyond the target countries, as well as the country-specific level.

         PAHO is a member of CDC’s Hurricane Mitch reconstruction program Coordinating Committee which
allows for integrated planning and monitoring of progress towards achievement of goals and program objectives.
Moreover, because of PAHO’s deep-rooted relationship with Ministries of Health in the sub-region and the history
of successful collaborations between PAHO and CDC, PAHO has been a most active partner to help CDC
coordinate and facilitate this ambitious program.

          PAHO recognizes that many institutions (DFID, UNICEF, IDB) are contributing to the reconstruction
efforts following Hurricanes Georges and Mitch, and that coordination among them will be crucial to assure success
and avoid duplication of efforts. PAHO has executed together with countries of Central America reconstruction
projects aimed at building a national capacity for surveillance and respond to health threats of outbreaks of
infectious diseases, in general, and of cholera in particular.

         The tasks related to laboratory capacity building will be carried out in close collaboration with the
Association of Public Health Laboratories (APHL) as stated before.

         A task force with the participation of the regional advisors mentioned above has been established to assure
full coordination of activities under PAHO’s responsibility. The regional advisor will work closely with the
collaborating units at CDC to implement and evaluate the Cooperative Agreement activities. In addition, PAHO’s
country office focal points will be part of a listserv where planning, implementation, monitoring and evaluation
issues will be shared.

          It is anticipated that the establishment of a cooperative agreement between the PAHO and CDC will make
possible the implementation of activities aimed at re-establishing and sustaining the capacity for assessment of
health status, for early detection and effective response to outbreaks, and assessment of changes in disease patterns.

VI.      Evaluation plan


         The evaluation of results of individual tasks and the overall progress towards the objectives of this
Cooperative Agreement will be made through several mechanisms. The evaluation plan will consist of a mid-term
task level review at the end of the first year and another consolidated review at the objective, activity, and task level
                                                           12
at the end of the two-year period. The purpose of the evaluation plan is to measure the status of implementation and
achievement of the different stated indicators of the operational plan. A panel of national and international experts
may be convened to advise on the results on the mid-year evaluation report; seeking insight on recommendations for
adjustment, if necessary.


VII.     Program Management

         The Division of Disease Prevention and Control, Pan American Health Organization will be the overall
executive unit for this Cooperative Agreement and will act in coordination with the Division of Health Systems and
Services Development, and PAHO Country Representative Offices in beneficiary countries. Responsibility for the
implementation of specific activities are identified in item V above.

         Progress will judged against the task level indicators that are presented in ANNEX 3. Written progress
reports will be provided every six months. Field supervision through PAHO country offices and missions to each
country by consultants and PAHO regional advisors will follow up on progress reports and ensure that budgeted
resources are available to carry the programmed activities and that these resources are used appropriately.



VIII.    Human Subjects

        PAHO/WHO has developed a “Guidelines and Review Procedures for research Involving Human Subjects”
which follows the principles established by the Helsinki II Declaration of the World Medical Association, the
Standards of Conduct for Research carried by or under the auspices of the World Health Organization, and the
CIOMS general guidelines and principles. In addition, PAHO has an Ethical Review Committee (PAHOERC)
which function is to provide a mechanism for the assessment of ethical implications of research projects.

          The project being submitted under this application does not involve research with human subjects. Some of
the surveillance activities consist of patients who will seek medical care in the health system of the different
beneficiary countries and will have blood samples taken and possibly other specimens (stools, throat swabs, spinal
fluid, etc) for laboratory diagnosis, as dictated by clinical manifestations and health authorities guidelines; these are
routine procedures usually followed as part of the medical attention provided to patients.

IX.      Budget

         Consolidated budget

         The consolidated budget is presented on standard form 424A GRANT APPLICATION, enclosed. An
additional summary of the budget (Table 1) is provided to inform on how each proposed expense relates to the
proposed activities.

         Budget justification

         Two ways to justify the proposed budget are presented. The first is given by Table 2, where detailed data is
provided to enlighten on how the costs were derived for each line item. This information was aggregated
notwithstanding the variation that exists within the same line item (i.e., number of days or participants per workshop
and duration of consultant-contracts). The second is given below where a description by budget line item is
provided.

         Personnel:

         Personnel and consultants specifics are not available at this time, however, potential candidates for these
positions were identified pending the final approval of this Cooperative Agreement. Potential candidates are: Luis
Beingolea MD, MPDH-Peru, Charlotte Carneiro RN, MPH-USA, Clovis Tigre MD, MPH-USA,Vicente Bayard
MD, MPH-Panama,Washington Lum MD, MPH-Panama, Marilia Bulhoes MD,MPH-Brasil, Jeanette Alonso
MD,MPH-Honduras, Fernando Muñoz, MD, MPH-Chile, Soledad Ubilla, MD-Chile, Mario Boyer MD, MPH, and
Luis Ruiz, MD, MPH.




                                                           13
         Personnel proposed in this line item consist of full time equivalents needed for the planning, coordinating,
monitoring and support of the implementation of the proposed activities at subregional level. The required staff
includes both technical and administrative support. Refer to Table 2 for a detailed breakdown of this line item.

         Travel:

         Due to the subregional nature of the Cooperative Agreement, the proposed activities rely heavily on the use
of collective work by way of seminars, workshops, committee meetings, etc., requiring that project staff travel
throughout the subregion in order to participate and fulfill their tasks accordingly. Travel expenses in this line item
are inclusive of airfare and per diem costs

         Equipment:

         Information technology equipment needed to strengthen existing or newly established networks will be
procured. Basic telecommunication equipment will be needed to ensure and facilitate easy exchange of information
and operation of surveillance systems. For laboratory services, equipment to upgrade reference centers and establish
communication and data management within and among laboratories will be obtained. Community-based disease
control interventions (education, vector control, water/food control and sanitation) will be require specific
equipment.

         Supplies:

        Supplies needed to implement activities are: general office supplies for initial operation of the surveillance
network, laboratory supplies for priority tests at reference centers and field operations to be carried out in
community-based disease control interventions.

         Contractual:

        Included in this budget line item are short-term consultants (remuneration + airfare + per diem), contracted
for 6 months or less, and contractual services agreements.

         Due to the subregional nature of the Cooperative Agreement, the proposed activities rely heavily on the use
of collective work by way of seminars, workshops, committee meetings, etc., requiring that consultants travel
throughout the subregion in order to participate and fulfill their tasks accordingly. Travel expenses in this line item
are inclusive of airfare and per diem costs. Detailed specific information on the proposed consultants will be
submitted at a later date.

         Other:

          This line item includes consultant fees and travel expenses, as well as national participant costs to travel
and attend subregional meetings and seminars. Due to the subregional nature of the Cooperative Agreement, the
proposed activities rely heavily on the use of collective work by way of seminars, workshops, committee meetings,
etc., requiring that, national participants travel throughout the subregion in order to participate and fulfill their tasks
accordingly. Travel expenses in this line item are inclusive of airfare and per diem costs. Please note that, on the
average, 2 national participants will be travelling in order to partake in tasks requiring the aforementioned collective
work.




                                                            14
                                                                                       TABLE 1: SUMMARY BUDGET

Int.         Act.    Personnel      Fringe      Travel                  Equipment*     Supplies     Contractual(a)*    Other(b)                            Subtotal     PSC       GRAND
Result                             Benefits     Airfare     Perdiem                                                     Travel     Perdiem    Miscel.    Dir. Charges             TOTAL
Object.
      1/a       1         33,000       6,600        3,600      49,500         23,500       23,000             50,750      21,000     18,900                   229,850    32,676      262,526
                2                                                             20,000       14,000             40,000                                           74,000     2,940       76,940
                3                                                                          13,000              8,450      16,800      8,400                    46,650     8,022       54,672
                4         33,000       6,600        3,600      49,500                                                     16,800     49,350      4,000        162,850    34,199      197,049
                5                                                                          10,000                         16,800     21,000                    47,800    10,038       57,838
                6                                                                          10,000             33,900       8,400      8,400                    60,700     5,628       66,328
                7                                                             62,500       20,000             42,000      50,000     50,000      5,000        229,500    26,250      255,750
                8         66,000      13,200                                  35,500       20,000             67,000      52,000     49,000                   302,700    42,042      344,742
                9                                                             55,000       31,000           100,000       32,500     32,500                   251,000    20,160      271,160
      1/b      10         12,000       2,400                                                                  17,500       6,000      6,000                    43,900     5,544       49,444
               11         24,000       4,800                                                2,600             25,000       7,200      7,200                    70,800     9,618       80,418
               12         12,000       2,400                                                3,000              9,000                                           26,400     3,654       30,054
               13                                                                           3,000             17,500       7,800      7,800                    36,100     3,906       40,006
      2/c      14                                                                                                         12,600     12,600                    25,200     5,292       30,492
               15                                                                          10,000             27,000       9,000      9,000                    55,000     5,880       60,880
               16                                                                                                                               10,000         10,000     2,100       12,100
      3/d      17                                   6,000       7,500                       6,450             15,000      28,200     34,800     14,050        112,000    20,370      132,370
               18                                  13,200      16,200         15,275       66,270                         30,580     50,280     73,350        265,155    52,475      317,630
      4/e      19                                                                                             22,500       8,400     19,500      8,000         58,400     7,539       65,939
               20                                                                                              2,500      12,600     14,700      4,000         33,800     6,573       40,373
               21                                                                          70,000                          8,400     10,500   257,600         346,500    72,765      419,265


TOTAL                   180,000       36,000       26,400     122,700        211,775      302,320           478,100      345,080    409,930   376,000       2,488,305   377,670    2,865,975

(a)    Includes short term consultants, temporary advisors and contractual service agreements and their travel/perdiem
(b) (b) Includes participants
* No PSC is being assessed on these categories, as per the PSC US Government rate (HQ/FO96-17 dated 21 November 96)




                                                                                                         15
                                               TABLE 2: BUDGET JUSTIFICATION

Int.          Act.              Personnel        Fringe      Travel       Perdiem     Contractual(a)*             Other (b)        Perdiem
Resul. Object                      (P)          Benefits     Airfare                                               Travel

     1/a              1      11p/m x 3,000    P x 20%      6 x $600    330d x $150    20p/m x $2,500         35 x $600        126d x $150
                      2                                                               16p/m x $2,500
                      3                                                               3p/m x $2,500          28 x $600        56d x $150
                      4      11p/m x 3,000    P x 20%      6 x $600    330d x $150                           28 x $600        329d x $150
                      5                                                                                      28 x $600        140d x $150
                      6                                                               14p/m x $2,500         14 x $600        56d x $150
                      7                                                               17p/m x $2,500         83 x $600        333d x $150
                      8      22p/m x 3,000    P x 20%                                 27p/m x $2,500         87 x $600        327d x $150
                      9                                                               40p/m x $2,500         54 x $600        217d x $150
     1/b             10      4p/m x 3,000     P x 20%                                 7p/m x $2,500          10 x $600        40d x $150
                     11      8p/m x 3,000     P x 20%                                 10p/m x $2,500         12 x $600        48d x $150
                     12      4p/m x 3,000     P x 20%                                 4p/m x $2,500
                     13                                                               7p/m x $2,500          13 x $600        48d x $150
     2/c             14                                                                                      21 x $600        84d x $150
                     15                                                               11p/m x $2,500         15 x $600        60d x $150
                     16
     3/d             17                                    10 x $600   50d x $150     6p/m x $2,500          47 x $600        232d x $150
                     18                                    22 x $600   108d x $150                           51 x $600        335d x $150
     4/e             19                                                               9p/m x $2,500          14 x $600        130d x $150
                     20                                                               1p/m x $2,500          21 x $600        98d x $150
                     21                                                                                      14 x $600        70d x $150

    (a)    Includes short term consultants, temporary advisors and contractual service agreements and their travel/perdiem
    (b) Includes participants
    * No PSC is being assessed on these categories, as per the PSC US Government rate (HQ/FO96-17 dated 21 November 96)
                                                                                        ANNEX 1: OVERVIEW


                                                                         Goal: To rebuild/strengthen pre-existing systems,
                                                                         networks, units, and groups in each country at a
                                                                         sub-regional level so as to control and prevent
                                                                         morbidity and mortality from communicable
                                                                         diseases.

                                                                                                c (IR2)
OBJECTIVES




                     a (IR1)                              b (IR1)                                                                 d (IR3)                          e (IR4)
               Establish operational              Conduct performance                Assess/enhance participation of    Coordinate the development
                                                                                        academic institutions in                                         Assist in developing disease
               sub-regional network               measurement of essential                                                of a functional regional         prevention and control
               on communicable                    public health functions               training of public health        laboratory network with
                                                                                      workers in epidemiology and                                        programs for one priority
               disease surveillance                                                                                          reference centers               disease per country
                                                                                              interventions

                  Coordinate sub-regional            Train public health                 Development of needs                Participate in sub-            Cooperate in analysis of
                  communicable disease               officials on methodology            assessment to strengthen            regional communicable          priority diseases of
                  surveillance and                   developed by PAHO,                  human resources in field            disease                        community-based
                  laboratory networks                CDC and CLAISS for                  epidemiology and disease            surveillance/laboratory        prevention and control
                                                     performance measurement             surveillance                                                       programs
                                                                                                                             network
                                                     of EPHFs
                  Establish systematic                                                                                       Coordinate the
                  virtual grand rounds to                                                Development of sub-                 development of functional
                                                     Application of EPHFs                                                                                   Establish sub-regional
                  share information and                                                  regional plan of action for         sub-regional laboratory
                                                     instrument in all affected                                                                             goals for communicable
                  discuss outbreaks                                                      establishing permanent field        network with reference
                                                     countries                           epidemiology and disease                                           disease prevention and
                                                                                                                             centers                        control
                                                                                         surveillance training
                  Establish sub-regional             Analysis and reporting of
                  steering committees                performance measurement             Establish a network of
                                                     of each country                                                                                        Cooperate with countries
                                                                                         Training Institutions in
                                                                                                                                                            in the implementation of
                  Cooperate with country                                                 Public Health                                                      community-based, priority
ACTIVIVITIES




                  for the assessment of                 Development of a plan of                                                                            communicable disease
                  surveillance systems                  action for improving                                                                                prevention and control
                                                        public health practice and                                                                          programs
                                                        strengthening public
                  Cooperate to organize annual
                                                        health infrastructure
                  sub-regional epidemiological
                  and laboratory scientific
                  conferences

                  Cooperate for the revision of
                  public health surveillance
                  laboratory protocols after
                  disasters

                                                                                                    18
                  Rehabilitate the Health
                  Information System in Haiti,
                  Honduras and Costa Rica
                                     ANNEX 2: LABORATORY PLANNING MEETING APHL, CDC, & PAHO – MAY 23, 2000

Type/Focus of Sub-Regional         Location (City, Dates (Mo-Yr), Technical:             Funding:       Next Steps - APHL
Activities                         Country)        Days           Responsible            Responsible
                                                                  Agency(ies)            Agency(ies)
                                                                  1             2        1       2
 Laboratory Management             Wash., D.C., +   8/4/2000, 7   GWU,          PAHO     PAHO           APHL to work with GW on course design and faculty
Training (for the Director of      U.S. State       days          APHL                                  selection. Identify member to take lead. Confirm state
each central laboratory)           Laboratory                                                           lab for 2 day session/tours


Quality Control - External         In Sub-region     March 2001, 5 PAHO         APHL     PAHO APHL      APHL to identify one/two members to work with
Performance Evaluation,                             days                                                PAHO on course topics, faculty and materials
Training and Consultation
(Overview)
Standard Operating Procedures In Sub-region         3 days        PAHO          APHL     PAHO    APHL   APHL to identify one/two members to work with
Manual Development                                                                                      PAHO on course topics, faculty and materials
Workshop (General process,
not disease specific protocols)
Information Management             In Sub-region    November,     PAHO,   APHL           USAM           APHL to review draft assessment questionaire and
Training and Equipment                              2000          USAMRID                RID            give feedback to PAHO by June 2, 2000. Receive
                                                                                                        copy from PAHO of USAMRID plans.

Biosafety and Shipping and         In Sub-region    October,      CDC           APHL     PAHO           APHL to identify one member to participate in
Handling of infectious agents                       November 2000                                       workshop and be available for country level follow-
(Workshop)                                                                                              up.

Disease-specific subregional       In Sub-region    December,     APHL          PAHO     APHL           APHL to identify one/two members or other resource
training programs in Dengue,                        2000 and                                            individuals to develop each training program and
malaria, leptospirosis and M.                       beyond, 6-day                                       locate appropriate faculty. Explore what training
tuberculosis (include SOPs at                       each training                                       resources already exist within the U.S. or region in
diff. Levels, reference testing,                    programs                                            these areas. Develop standardized training topics and
antimicrobial resistance, QC,                                                                           resources.
equipment, supplies. New
technologies, Train-the-trainer
mechanisms




                                                                                    19
                                                                 ANNEX 3:SUMMARY OPERATIONAL PLAN


 Intermediate Result #1: Health information and disease surveillance rehabilitated and information used for public health decisions.
 Objective a) Establish an operational sub-regional network on communicable disease surveillance


     Date                                    Activities                                                         Indicators                                   Responsible    Cost

                                                                                                                                                          HCP/HCT/PAHO
                 Activity 1: Coordinate sub-regional communicable disease
                                                                                                                                                          In coord. with
                 surveillance/laboratory networks, including analysis and
                                                                                                                                                          HSP/HSE/PAHO,    $262,526
                 dissemination of health information
                                                                                                                                                          SHA/PAHO,
                 Tasks:
                                                                                                                                                          EPO/CDC
Sep00-Dec01          Enhance electronic platform network on communicable                 Data use and users defined
                      diseases surveillance in Central America
Sep00-Nov00          Obtain MOH commitment for national participation in the             7 countries participating in the system
                      network
Oct00-Nov00          Define data users and uses                                          Operational electronic communications system for
                                                                                           infectious disease surveillance and laboratory serving 7
Dec00-Feb01          Establish protocol for analysis and presentation of sub-             countries
                      regional/border area data                                           # of persons per country trained on data analysis and
Apr01-Jun01          Training on data analysis and presentation                           presentation
                     Provide countries with logistic and equipment to increase           Analyzed information produced and posted in the
Oct00-Feb01           MOH capability to contribute to the network                          Internet, once a month

                 Activity 2: Establish systematic virtual grand rounds to
                 discuss outbreaks and other EID-related problems                                                                                         HCP/HCT/PAHO     $76,940
                 Tasks:
Jan01-Dec01          Design norms and procedures for meetings                            Virtual grand rounds meet once a month
Dec00-Jul01          Support countries needs regarding telecommunications                Reports of rounds discussion circulated monthly
Jan01-Feb01          Prepare one year program, presenters, invited experts               Coordinated sub-regional responses to infectious disease
                                                                                           threats among participating institutions and countries: two
                                                                                           coordination meetings per year
                 Activity 3: Establish a sub-regional steering committee for                                                                              HCP/HCT/PAHO     $54,672
                 communicable disease surveillance in close collaboration with
                 reference laboratory diagnostic centers
                 Tasks:
Oct00-Nov00          Select committee members                                            Established permanent committee to guide sub-regional
Jan01-Nov01          Conduct advocacy meetings with MOH to obtain agreement               surveillance activities in the sub-region with participation
                      on sub-regional priorities for disease reporting                     of two persons per country
Feb01-Apr01          Establish standards and guidelines (including case                  Established agreement on diseases subject to sub-regional
                      definitions) for diseases subject to sub-regional surveillance       surveillance, standards and norms published and
                                                                                           distributed to 7 countries.




                                                                                           20
     Date                                  Activities                                                         Indicators                                 Responsible    Cost

               Activity 4: Cooperation at country level for the assessment of                                                                          HCP/HCT/PAHO    $197,049
               surveillance systems, including laboratory services, and                                                                                in coord.
               development of updated national surveillance plans                                                                                      HVP/PAHO,
               Tasks:                                                                                                                                  SHA/PAHO,
                                                                                                                                                       EPO/CDC
 Sep00-Oct00       Adapt WHO assessment protocol, with country participation           Comprehensive national plan for surveillance of
                   Evaluate national surveillance systems using standardized            infectious diseases available in each country
 Dec00-Nov01        protocol.                                                           Evaluation of one surveillance system per country (7
                   Prepare, with participating countries, a comprehensive               systems evaluated)
 Dec00-Nov01        national plan for epidemiological surveillance of infectious
                    diseases.
               Activity 5: Cooperation for the organization of annual sub-                                                                             HCP/HCT/PAHO    $57,838
               regional epidemiology/laboratory scientific conferences
               Tasks:
Oct00-Dec01        Provide technical and financial support to promote                  Papers on field investigations, epidemiology practice peer
                    infectious disease surveillance expertise and coordination,          reviewed: two per country
                    with participation of health workers (services/university),         Two conference proceedings published
                    especially clinicians interested in infectious disease
                    surveillance
               Activity 6: Cooperation for the revision of post-disaster                                                                               HCP/HCT/PAHO    $66,328
               public health surveillance/laboratory protocols                                                                                         In coord.
               Tasks:                                                                                                                                  AD/PED/PAHO
Jan-Feb01          Review lessons learned on surveillance after disasters              7 Protocols for public health surveillance in post-disaster
Mar-Apr01          Revise and update surveillance protocols for emergencies             situations updated
                    after disasters
               Activity 7: Rehabilitation of disease surveillance system in                                                                            PWR/HAI/PAHO    $255,750
               Haiti
               Tasks:
Sep00-Feb01        Rehabilitation of epidemiological services at the central and    Epidemiological services at the central and peripheral levels
                    peripheral levels                                                 operating
Nov00-Apr01        Disease surveillance workshops at the central and peripheral     Workshop procedures circulated
                    levels                                                           Epidemiological units reporting increased to 80%
 Nov00-Jul01       Surveillance system evaluation and monitoring                    Supervision and evaluation in place
                   Development of national guidelines for disease surveillance      Guidelines published and distributed
                   Printing and distribution of surveillance guidelines             Guidelines available in 100% of epidemiological units
Sep00-Feb01        Development of an emergency response plan                        Emergency plan operational
Oct00              Publication of epidemiological and laboratory bulletin           12 epidemiological bulletins published per year
Sep00-Jul01
                   Equipment acquisition for the system                             Acquisition of Risographe
Sep00-Feb01                                                                          Acquisition of radios and services for 3 years (5 bases and 4
                                                                                      posts/base)
                                                                                     Acquisition of cellular phone services for 3 years
                                                                                     12 fax machines in place
                                                                                     Computer equipment in place
                                                                                     Acquisition of 4 wheel drive vehicle




                                                                                         21
      Date                               Activities                                                   Indicators                              Responsible    Cost

               Activity 8: Rehabilitation of Health Information System (IS)                                                                 PWR/HON/PAHO/   $344,742
               in Honduras
               Tasks:
 Nov00-           IS evaluation                                                 IS evaluation in Tegucigalpa, Juticalpa, Catacamas
                  Definition of IS priorities                                   Training, laboratory, and community integrated to work
                  Selection of IS country regions                                plan
                  Revision of Health Indicators                                 3 Regions and 1 central hospital selected Revision of
                  Selection of Basic Health Indicators                           110 Health Indicators
 Nov00-Feb01      Selection of IS working group in Olancho                      Selection of 25 Basic Health Indicators
                  Collection and revision of 140 reporting formats              Working group (7 physicians- 3 nurses) established in
                  System Analyst identified                                      Olancho and roles and responsibilities defined
                  Computer Interface design                                     Unification of reporting formats in 5-10 basic formats
                  Computer needs assessed                                       System Analyst STC
                  Hospital Escuela and Laboratories IS work plan                Computer Interface established
 Nov 00
                  Selection of DDM trainees                                     10 computers to Olancho and Tegu.
 Dec00-May01
                  DDM training modules in basic epidemiology, statistics,       Integration of Hospital Escuela and Laboratories to
 Dec-May01         communications, and management                                 system
                  Selection of IS working group in another two regions          30 trainees selected central and regional level
                  Replication of IS in two new regions                          DDM training for 30 trainees
                                                                                 IS operational in two new regions

               Activity 9: Rehabilitation of disease surveillance system in                                                                 PWR/COR/PAHO    $271,160
               Costa Rica
               Tasks:
Sep00-Jun01       Information system design                                     Indicators by health administration level defined:
                   Phase I                                                        Format, information flow, data entry, data sharing,
                    Conceptual Design                                             integration
                   Phase II                                                      Software and Hardware purchased
                    System requirements                                          Data entry defined and operational
                    Software                                                     Analysis format operational
                    Hardware                                                     Reports generated by the system and bulletins published
                    Interface                                                     (4 bulletins per year)
                   Phase III                                                     Evaluation recommendations made, adapted, and system
                    Analysis and product                                          replicated
Oct00             Evaluation of the system                                      Outbreak response teams operational
Jan00-Oct01       Training for the new system and replication                   3 workshops organized
Dec00             Purchase of software and hardware
Feb-Oct01         Outbreak response teams training
                  Epidemiological Information available
                  Workshops to other institutions on the new system




                                                                                  22
Intermediate Result #1: Health information and disease surveillance rehabilitated and information used for public health decisions. (CONT.)

Objective b) To conduct performance measurements of essential public health functions, in 50% of the beneficiary countries by the end of the first year and
100% by the second year, in order to identify gaps in public health infrastructure that constitute constrains to public health practice and to improve public
health decision-making.
   Date                                     Activities                                                     Indicators                          Responsible    Cost

            Activity 10. Training of public health officials on the methodology
            for performance                                                                                                                                  $49,444
                                                                                                                                             HSO/HSP/PAHO
            Tasks
                Training of national public health experts and public health                 Performance measurement instrument
Sept 00 –        officials from each of the countries in a subregional workshop on             developed
Nov 00           facilitating and coordinating the application of the instrument (Haiti       1-2 persons per country trained to
                 receive its own intervention due to language).                                facilitate and coordinate the administer
                                                                                               the instrument
                Training of key public health officials, in each of the countries, by        Key public health officials assist
Oct 00 –         trained national public health experts to familiarize and orient them         training to facilitate the implementation
Dec00            on the methodology of the performance measurement instrument.                 of the performance measurement
                                                                                               instrument.
            Activity 11. Application of the instrument in all of the affected
            countries                                                                                                                        HSO/HSP/PAHO    $80,418
            Tasks
               Application of the performance measurement by way of seminars                 Finalized instrument to be implement in
Dec 00 –        and personal interviews in each of the beneficiary countries                   the 7 beneficiary countries
Aug 01                                                                                        Instrument administered in the 7
                                                                                               beneficiary countries
            Activity 12. Analysis and reporting of each of the country’s results
                                                                                                                                                             $30,054
            Tasks                                                                                                                            HSO/HSP/PAHO
Mar 01 –       Analysis of responses (data) collected in each of the countries               Reports on each of the beneficiary
Sept 01                                                                                        countries’ baseline status of public
                Preparation of reports on the status of public health practice in             health practice in terms of EPHFs.
Aug 01 –         terms of EPHFs in the individual countries and based on the                   produced and distributed in 7 countries
Dec 01           analysis of the results of the application of the instrument.                Final report consolidating the principal
                                                                                               results of the beneficiary countries
                                                                                               distributed in 7 countries
            Activity 13. Development of a plan of action for improving public
            health practice and strengthening public health infrastructure                                                                 HSO/HSP/PAHO      $40,006
            Tasks

Dec 01 –        Discussions with stakeholders and key actors of each of the                  Action plans and steps to be taken by
July 02          beneficiary countries to delineate plans of action to improve and/or          each country to improve public health
                 strengthen their fulfillment of EPHFs                                         practice produced.
                Assist each beneficiary country in developing a plan of action to            Action plan implemented in each
                 improve and/or strengthen public health practice, which includes              country
                 public health workforce training




                                                                                              23
 Intermediate Result 2: Increase availability of epidemiologists in the region and the training of other level of health workers by these epidemiologists.

 Objective c)To assess and enhance participation of Trainig Institutions in Public Health in training of public health workers in field epidemiology and
 disease surveillance in 50% of identified institutions during the first year and 100% during the second year ;

    Date                                Activities                                                     Indicators                                Responsible       Cost

               Activity 14: Development of needs assessment on                                                                                 HSP/HSR/PAH
               strengthening of human resources in field epidemiology                                                                          O
                                                                                                                                                                  $30,492
               and disease surveillance                                                                                                        School of Public
               Tasks:                                                                                                                          Health COR
 Jan01             Prepare needs assessment and terms of reference for          Characterization of the key problems, challenges and needs
                    plan of action on human resources in field                    for regional human resources development in field
                    epidemiology and disease surveillance                         epidemiology and disease surveillance available and
                                                                                  disseminated.
                                                                                 A formal commitment of the 6 TIPH to develop a regional
                                                                                  and sustainable plan of action for the development of
                                                                                  human resources in field epidemiology and disease
                                                                                  surveillance obtained;
                                                                                 The terms of reference of the future plan of action
                                                                                  prepared;
                                                                                 A coordinating group of the initiative operational.

               Activity 15: Development of regional plan of action for                                                                         HSP/HSR/PAH
               institutionalization of field epidemiology and disease                                                                          O
                                                                                                                                                                  $60,880
               surveillance training                                                                                                           Coordinating
               Tasks                                                                                                                           group (TIPH)
 Feb-Apr01          Preparation of plan of action                               Plan of action developed
                    Development of data bank of existing resources              Data bank of existing training resources (training
                     (training materials, expertise, case studies, training       materials, expertise, case studies, training sites,
                     sites, technological infrastructure for communication,       technological infrastructure for communication, distance
                     distance learning)                                           learning)
                    Establish capacity for distance learning                    Communication strategy between partners and basic
                                                                                  equipment for distance learning established


               Activity 16: Establish a network of Training Institutions                                                                       HSP/HSR/PAH
               in Public Health                                                                                                                OCoordinating      $12,100
               Tasks                                                                                                                           group (TIPH)
Jun-Aug01          Workshop on structure and functioning of a training          Plan of action adopted by TIPH
                    network on field epidemiology and disease surveillance       Training workshop of the members of the coordinating
                                                                                  group
                                                                                 Structure of the training network established
                                                                                 Strategy developed for resource mobilization of future and
                                                                                  more complex phases of the plan



                                                                                      24
Intermediate Result #3 Infectious Disease and Environmental Health Laboratory Capacity Developed

Objective d)To coordinate the development of a functional regional laboratory network with reference centers for at least three diseases by the end of the
second year.
   Date                                  Activities                                                  Indicators                             Responsible    Cost

               Activity 17: Participation in the subregional communicable                                                               HSP/HSE/PAHO in
              disease surveillance network                                                                                              coord. APHL and   $132,370
              Tasks:                                                                                                                    CDC
                  Sub-regional meeting of public health laboratory directors       One sub-regional meeting organized and
                   with epidemiologists. (In collaboration with APHL)                consensus on diseases of major concern
                                                                                     reached.
                                                                                    Quality assurance program outlined, published,
                                                                                     and distributed to 7 countries.
May01            Subregional workshop on standard operating procedures (In         Sub-regional reference laboratories proposed: 3
                  collaboration with APHL)                                           reference labs.

                                                                                    SOP’s on preparation of media, sample
                                                                                     collection and processing, and antimicrobial
Nov-Dec00        Training of laboratory and transportation personnel on             resistance testing prepared, published and
                  shipping and handling of diagnostic specimens and infectious       distributed in 7 countries.
                  substances (In collaboration with CDC)
                                                                                    Trained and licensed national trainers and
Oct00-           Determining subregional needs of diagnostic reagents/kits,         inspectors: 2 per country.
Mar01             and identification of mechanisms for effective procurement.
                  (In collaboration with APHL)                                      Inventory of materials that can be
                                                                                     negotiated/purchased jointly and proposal(s) for
                                                                                     their procurement prepared and agreed upon by
                                                                                     7 countries




                                                                                     25
Intermediate Result #3 Infectious Disease and Environmental Health Laboratory Capacity Developed

Objective d)To coordinate the development of a functional regional laboratory network with reference centers for at least three diseases by the end of the
second year. . (CONT.)


   Date                           Activities                                          Indicators                            Responsible    Cost

              Activity 18: Quality Assurance in Subregional                                                            HSP/HSE/PAHO in
              public health laboratory networks                                                                        coord. APHL, GWU   $317,630
              Tasks:                                                                                                   CDC
Sep00            Two workshops on managerial aspects of              Trained public health laboratory managers and
                  public health laboratory networks (In                plans for managerial strengthening developed
                  collaboration with APHL and GWU).                    and assessed: 3 per country.

Oct-Nov00        Subregional workshop on biosafety (In               Subregional guidelines for handling and
                  collaboration with APHL and CDC)                     disposing infectious materials, and for
                                                                       protection of lab personnel and the community
                                                                       developed, published and distributed in 7
                                                                       countries.
Dec00-           Preparation and Shipment of materials for
Nov01             External Evaluation of Performance.                 Subregional Program on External Evaluation
                                                                       of Performance established for diseases of
                                                                       major concern: external evaluation to 7
                 Printing and distribution of written materials       countries performed
Nov00-
Mar01                                                                 Subregional guidelines, standard operating
                                                                       procedures, and manuals available to public
                                                                       health laboratory networks in 7 countries.




                                                                                    26
 Intermediate Result #4: Capacity of Ministries of Health to design and implement community based prevention and control of disease improved.

 Objective e)To provide assistance for the development of a disease prevention and control program for one priority infectious diseases by country in 50%
 of countries by the end of the first year and in 100% of countries by the end of the second year.


     Date                            Activities                                                 Indicators                              Responsible    Cost

                Activity 19: Cooperate in the analysis of priority
                diseases community-based prevention and control
                                                                                                                                       HCP/HCT/PAHO   $65,939
                programs
                Tasks:
Apr01-Oct01         Comparative analysis of priority diseases              Sub-regional status report on priority communicable
                     (dengue, cholera, malaria, leptospirosis)               diseases epidemiology and interventions published and
                     epidemiological situation and community-base            distributed in 7 countries
                     interventions among countries                           Documented assessment of similarities/differences on
May01-Nov01         Comparative analysis of goals, norms and                countries approach to disease control shared and
                     procedures of community-based prevention and            reviewed by 7 countries
                     control programs for priority diseases among
                     countries
                Activity 20: Establish sub-regional goals for
                communicable disease prevention and control                                                                            HCP/HCT/PAHO   $40,373
                Tasks:
Sep01-Oct01         Consultative group proposal for sub-regional           Consultative group established with participation of 3
                     goals for communicable disease prevention and           persons per country
Nov01                control                                                Sub-regional consensus on goals for communicable
Dec01               Dissemination of the proposal of goals to               diseases prevention and control reached.
                     countries
                    Sub-regional consensus meeting on sub-
                     regional goals for communicable disease
                     prevention and control
                Activity 21: Cooperate with countries in the
                development and implementation of priority
                                                                                                                                       HCP/HCT/PAHO
                communicable disease community-based                                                                                                  $419,265
                prevention and control programs
                Tasks
Feb01-Apr01         Training on analysis of health problems and            Selected personnel with skills for health problem
                     priority setting at the local level                     analysis and priority setting
Apr01-May01         Workshops on selecting sound, appropriate              Strengthened local capacity for decision-making: plan
                     health strategies and interventions to prevent          of action implemented 7 countries
                     and control communicable diseases at the local         Sentinel surveillance for priority communicable disease
Feb01-Dec01          level                                                   established in selected sites: 1-2 sites per country
                    Support implementation of community-based
                     sentinel surveillance using health facilities and
                     community informants (casas base)




                                                                                      27
                                                             Annex 4: PAHO



Assistant                                           Governing Bodies
Director



        Central American                                  Director
        Coordination,
        Prado H.
                                                       Deputy Director

                                                                                                                        Admin.


             Health and               Health     Health Systems      Health and      Disease        Vaccines and   Special Program
              Human                 Promotion    and Services         Environ-      Prevention      Immunization   of Health
            Development                and       Development,          ment        and Control.                    Analysis
                                                                                    Corber, S.                     Castillo-Salgado, C.
                                    Protection   Lopez-Acuña, D.

   Emergency
   Preparedness/Disaster                         HSR, Goude, C.                   HCT PC, Gusmão, R.
   Relief                                        HSE, Cruz, J.                    HCT, Libel, M.
                                                                                  HCT, Salvatierra-González, R.
Caribbean                  PAHO/WHO
Program                    Representative          COR, Depetris, A.
Coordination:              (PWR) Offices           HON, Castellanos, L.
Barbados                                           DOR, Castellanos, P.
                                                   ELS, Valcarcel, M.
             Field Office:                         NIC, Cury, D.
            El Paso, Texas                         GUT, Ruiz, P.
                                                   HAI, Moya, J.




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