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PROGETTO

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PROGETTO

    PROPOSAL

    FOR A TWINNING PROJECT

    BETWEEN

    REPUBLIC OF BULGARIA AND REPUBLIC OF

    ITALY

    Twinning Project reference number

    BG/2005/IB/SO/01

     Strengthening of the National Surveillance System for

    Communicable Diseases

    PHARE INSTITUTION BUILDING

    TWINNING PROPOSAL FOR PARTNERSHIP

    Strengthening of Communicable Disease Surveillance.

Member State: REPUBLIC of ITALY

MS body responsible for implementation:

    MINISTRY OF HEALTH - GENERAL DIRECTORATE FOR EUROPEAN UNION AND INTERNATIONAL RELATIONS

Acting with the following partners:

    I.N.M.I. (NATIONAL INSTITUTE FOR COMMUNICABLE DISEASES) ISS (NATIONAL INSTITUTE OF HEALTH)

Contact persons:

    -DR.SSA MARIA PAOLA DI MARTINO. DIRECTOR GENERAL FOR EU AND

     INTERNATIONAL RELATIONS MOH. PIAZZALE INDUSTRIA 20

     00144 ROME. TEL.+0659942716 FAX FAX +0659942541

     E- MAIL mariapaola.dimartino@sanita.it

    -DR. NICOLA SCHINAIA. RESEARCHER, MEDICAL EPIDEMIOLOGIST

     DEPARTMENT OF INFECTIOUS, PARASITIC AND IMMUNO-MEDIATED

     DISEASES

     ISTITUTO SUPERIORE DI SANITÀ, 299 VIALE REGINA ELENA, 00161 ROME

     Tel +0649902032, Fax +0649902558 E-mail: schinaia@iss.it;

     alba2000@iss.it

Beneficiary Country: REPUBLIC of BULGARIA

Sector: HEALTH

Twinning Reference Number: BG/2005/IB/SO/01

Index

A. Services proposed by Member State as required by the Bulgarian Fiche

     Additional Service: e-learning

    B. Methods and organisation

    C. The Partner Organisation

    D. Comparative advantage

A. Services proposed by Member State:

The aim of the project is to improve the health status of the people of Bulgaria through

    targeted interventions to prevent the causes as well as to reduce the morbidity and

    mortality from communicable diseases (CD).

    The overall objective is to contribute to a sustainable improvement of policies for CD

    control, through a comprehensive action for each activity area. Special emphasis will be

    placed in the relevant European Union (UE) policies concerning this important area.

    The specific purposes envisaged to reach the goal are:

    - the review of the current system for CD surveillance,

    - the suggestion of improvement measures,

    - the test the new system

    - the enhancement countrywide of the capacity of the relevant staff, that will manage the

    system.

    The project will focus as an overall result to the re-organization and the strengthening of

    the services involved in the CD surveillance and control.

The Italian Partner will give to its Bulgarian counterpart the support of its long and in

    many instances successful experience not in the form of advises or, here and there,

    technical assistance, but in the form of co-operation and support to achieve through joint

    effort and commitment the results entailed in the Fiche, which will be better defined in the

    Twinning Working Plan.

    The components of the proposed cooperation plan are:

    1) Cooperation in reviewing the current system of CD surveillance;

    2) Assistance and cooperation to improve redesign local and territorial health

    services in the surveillance system network;

    3) Definition and design of the relevant IT tools involved in the network for the

    CD surveillance;

    4) Assistance and cooperation to design and initiate the creation of a network of

    isolation facilities;

    5) Preparation of a comprehensive of training plan, according to the analysis of

    the needs of the new system and services;

    6) Production of the appropriate set of guidelines and manuals for the

    management of the surveillance system countrywide;

    7) Plan the necessary workshops and meeting as well as the dissemination

    material and events;

    8) Planning and development of the methodology to establish an on-going

    programme on social communication and health promotion, targeted to

    lifestyles involved in the occurrence of CD;

    9) Development of initiatives to prepare the appropriate legislative interventions

    to implement the present laws and to introduce new legislation.

    Such components will be characterized by the following actions described in the

    present document in a very concise form, according to their development in time.

First phase of activity, identified with the designing of the Twinning Work Plan (TWP).

The Bulgarian and Italian Partner will jointly proceed in the examination and validation of

    preceding studies and analysis, on the basis of which the proposed Twinning Project has

    been drafted and produce the operational programme. Specifically the joint activities will

    concern the:

    a) Analysis and assessment of the protocols, methods and outcomes of the currently existing surveillance system.

    b) Preparation of a comprehensive evaluation of the need for methods and tools in the area of collection and management of epidemiological data, and of the methods of

    communication between and among public services involved in the functioning of the

    health sector, especially the emergency sector.

    d) Review of the Bulgarian legislation and Regulations especially in what concerns the Laboratories

    e) Design of a project in which will be clearly identified the four “W”: who does - what -

    when - where, in order to allocate appropriately from the beginning the tasks and

    responsibilities, and have a clear and shared time table.

    f) Work out of the appropriate methods and tools for an initial ex ante evaluation of the Twinning Work Plan, for the evaluation in itinere and for its feed back into the

    implementation process.

    g) Selection of the appropriate indicators:

    - of achievement, to control the performance in reaching the programmed steps towards the attainment of the expected results;

    - of result, to measure the direct and immediate effects;

    - of impact, to evaluate the long term effects (structural changes);

    h) Assessment of the needs for conventional and innovative training and plan the related

    activities to fulfil them.

    i) Identification of the priority target groups, toward which to address activities of awareness and coordination, to achieve the result of strengthening the surveillance of

    Communicable Diseases as indicated in the Twinning Fiche.

    Specifically the involved Italian expertise will convey a comprehensive approach in the

    CD surveillance and control, that has been developed over the last 15 years, in close

    cooperation with the 15 EU Member States (MS): the response to CD occurrence has

    increasingly been a concerted European pursuit over the last 15-20 years, when it

    appeared clear that emerging and re-emerging CD were becoming an ever increasing

    global threat to the world‟s population.

    On the basis of epidemiological and social data coming from the Bulgarian situation and

    the most appropriate similar Italian situations, a correlation matrix will be prepared to

    facilitate the identification of crucial target groups more vulnerable to specific

    communicable diseases, for which to address ad hoc actions.

In this regard the appointment of a Resident Twinning Adviser (RTA) with a mixed

    background, both legislative, health sector oriented, with programme management

    experience seems of the greatest value to harmonize the multidisciplinary activities

    entailed by this project;

Second Phase, the start up phase of implementation of the Twinning Project.

     The Italian Partner cooperation will be immediately addressed to the support of activities

    concerning:

    i) Organization of targeted training, in this regard our experience, built up through

    activities in Italy and in similar cooperation projects within neighbouring countries, has

    taught that there are various patterns of training programmes and a combination of topics

    in the area of CD surveillance and control. As a consequence the Italian Partner, also in

    consideration of the problems exposed in the Bulgarian Fiche, envisages as first step the

    focus on the specific professional profiles operating at central level (MoH, NIHI, NICIPD,

    reference hospital for CD) in the CD surveillance and control sector.

    Afterwards, the different levels of training will be developed towards the countrywide

    health professional profiles, bearing in mind from the beginning the need of homogeneous

    criteria and goals and involvement of all the personnel (doctors, nurses, technical

    personnel, epidemiologists, laboratory personnel) ;

ii) actions aimed to the implementation of the CD surveillance system in Bulgaria, in all

    its aspects: notification level, reporting, analysis, feedback and ultimate use for action. In conjunction with the Bulgarian counterpart, a set of diseases will be selected and a mixed

    set of surveillance methods implemented.

    The following diseases are likely to be dealt with priority:

    - viral hepatitis,

    - tuberculosis and other potentially epidemic-prone emerging airborne diseases (eg avian

    influenza),

    - HIV/AIDS/STIs (Sexually Transmitted Infections),

    - illicit drug use related infections, and zoonoses.

    The improvement of the CD information system, and a model for the development of the

    CD-oriented social communication to the public will be the system improvements entailed

    by our project;

iii) actions aimed to the support of the design and initiate the creation of a network of

    isolation facilities. They will include the following tasks:

    ? to develop, share and document good practices ( through real and virtual meetings, by

    development of consensus guidelines)

    ? to develop accessible, complete and accurate inventories of the infectious diseases and

    isolation facilities

    ? to facilitate the access to the Italian maximum containment laboratory for the

    diagnostic of level 4 agents

    ? to standardize the procedure for transport of biological samples from patients with

    dangerous pathogens

    ? to develop training (by development of an agreed core curriculum) on management of

    isolation facilities and highly infectious diseases, by defining isolation facilities by

    level of security, defining criteria for „highly infectious‟ diseases

iv) innovative training and community actions aimed at the creation of a programme of

    continuous medical education (CME), as well as the involvement of community-based

    organizations (CBOs) as an added value for the empowerment of the population or the

    prevention of CD.

    Third Phase, the Implementation Phase of the Project In this phase, on the bases of the results reached in the two preceding one the cooperation

    of the Italian Partner will be focused in assisting the Bulgarian partner in:

    ? final elaboration of regulation for participation of Labs in data collection for CD

    purposes;

    ? development of standard Operating Procedures on CD labs surveillance according

    to EU norms and accepted international standards;

    ? regulation for involvement of private labs in the CD surveillance;

    ? regulation for quality control of private labs in the CD surveillance with regard to

    TB - HIV/AIDS;

    ? development of national standard protocol on CD laboratory surveillance

    ? updating guidelines for specimen collection, packaging and transportation and

    rapid response;

    ? updating of existing legislation.

    The Italian partner, due to its own experience will be in condition to give a specific

    contribution in organizing the network of computerized laboratories to interact with each

    other and rapidly transmission of results and information.

    At this regard the design of an unified network will based on the “hub and spoke” model.

    According to such a model all the centres act following pre-defined hierarchy procedures

    respecting the goals and the strategies mutually agreed among all the labs of the system. In

    other terms this is a hierarchical system in which specific pre-defined rules govern in any

    moment the relations among all the centres and the role of each one of them. This will

    guarantee, as already tested, the best performance also in case of emergency.

    The National Reference Laboratory for Tuberculosis will be de facto the hub of the

    network that will be created for this specific disease.

E-learning - Constructing a system of continuous education based on open distance

    training and e-learning methods and tools and preparation of the website.

    During this phase the Italian partner offers as an additional service the designing and

    implementation of an e-learning system. The activities of the project should also be

    addressed to capitalize on the possibilities offered in the field of teaching by Information

    and Communication Technology (ICT) to make an even larger impact through the

    progressive development of a web community addressed to the so called “continuous

    education”.

    The Italian proposal therefore includes making a web site, producing a so called web

    community of scholar and the setting up, using ICT, an authentic forum for debate,

    discussion, learning and dissemination to support:

    i) the development of competences on Communicable Diseases and risk

    communication procedures;

    ii) a Geographic Information System (GIS) finalized to the mapping of the general

    situation and especially the monitoring of the most affected areas.

    In fact some of the modules of the above described training programmes mentioned

    before can be diffused to a larger number of persons. This activity will be established

    during the time life of the project also developing a permanent link between the Italian

    and Bulgarian institutions involved in the project.

    This continuous education centre will be open primarily addressed to:

    ? representatives of the national, regional and local health administrations

    ? representative of health supervising institutions;

    ? research institutes;

    ? representative of the public and private service sectors;

    ? schools and education institutions.

    Fourth Phase, concerning evaluation and diffusion of the results. With the collaboration of the Evaluation Group Of the Ministry of Health internal

    evaluation procedures will be carried on with regard to:

    - the process of implementation and

    - the out put of the project.

    The results will be examined with special regard to quality.

    The set of indicators used will be the one established and shared between the partners

    already in phase one.

    As to the diffusion of the results, the requirement of the European Union will be respected.

    Particular attention will be given to the diffusion of the guide lines and other operational

    materials. Workshops and conferences will be organized for the dissemination of the

    results.

Methods and organisation

A) Methods: a multi-method approach will be requested, both in the activities of

    cooperation which are offered in each phase, and in the activities of certain phases.

    The following strategies will be employed:

    ? Organization of training workshops and seminars in Bulgaria, involving relevant

    professional profiles, as above outlined

    ? Involvment of relevant Bulgarian staff, both as trainers of trainers, and as trainees,

    as well as contributing to the development of the activities entailed in the workplan

    for the CD surveillance system

    ? Regular visits of selected experienced Italian staff, to run the training seminars,

    and to oversee the unfolding of the planned activities, acting as one-to-one (or one-

    to-few) tutor of the Bulgarian professional counterparts.

    ? Targeted short-term visits of selected Bulgarian health professionals in selected

    institutions in Italy, to gain first-hand insight in specific techniques relevant to CD

    surveillance and control

    Some information will be provided in the ensuing paragraphs about such strategies.

a.1. Specifically, the first phase requires methods generally called of multicriteria analysis

    and involves conceptual tools such as S.W.O.T. (Strengths; Weaknesses; Opportunities;

    Threats) analysis to explore more in details the critical aspects stressed in the Twinning

    Fiche and examine them in reference with the attainment of the goals of the project.

    Matrix enlightening the conditions of congruence with European standards will be proposed as important starting from the initial phase of making the Twinning Work Plan (TWP).

    At the end of the first draft of the TWP a Method for ex ante evaluation, defined by the Evaluation Group of the Ministry of Health, will be used to validate the plan and to advise, if necessary changes and additions.

    At this regard the collaboration with the institutional Bulgarian partners from the health governmental and non governmental institutions operating both at the national, regional and local in the field, will be essential.

     Existing data and information will be collated, exchanged , and discussed. definitions, guidelines, inventories, training modules as scheduled will be developed, which be reviewed by participants with relevant organisations at national level

a.2. In what concerns the monitoring activities, the important aspect is to define the set of

    indicators of achievement according to which the implementation of activities and /or the performance as to be evaluated.

    In collaboration with the Bulgarian partners, there will be a selection of the relevant indicators more adequate to the characteristics of the Bulgarian society, which will also be confronted with Italian and generally European one.

    A specific attention will be given to the sector of serum - epidemiology, for a most accurate monitoring of the diffusion of contagious diseases.

    Avviare un'attività di studi di siero-epidemiologia, per un più accurato monitoraggio della

a.3. Drawing from the intensive experience of the Italian Partner the training courses will

    be innovative in character, because based on active participation of the trained. Different methods will be used: the traditional classroom lessons will be included in a minimum number and include tools such as self evaluation. In addition specific subjects will be discussed using non traditional learning such as discussion group and goal oriented debates.

    a.4. The methods proposed for evaluating the completed project, will derive from European as well as Italian experience of ex post evaluation. In this regard the indicators selected and shared during the TWP will be crucial and they will, themselves be evaluated. The result of such evaluation, especially in regard of taking into account factors and characteristics of the Bulgarian context, will constitute an important input for planning the successive experiences.

    The methods and actions of diffusion of the results will be advised according to other experiences of European projects. Specifically, the Italian partner will cooperate in the preparation of materials and actions addressed to the target groups defined at the TWP phase. Among the tools for diffusion should be stressed the creation of a website in English and Bulgarian.

a.5. Expected Results

    The medium-term outcome of this twinning programme are envisaged to be the following systems accomplished and put in place:

    ? Improvement of the CD surveillance systems and of the protocols for the operative

    action of the ISPs‟ epidemiologic regional offices

    ? Improvement of the Bulgarian experts‟ professionalism

? Continue assistance of ISS in order to join to the European standards

B) The Partner Organisation:

Partner Contact Point:

    The Ministry of Health, General Directorate for EU and International Relations (DG

    RUERI) - Ms. Di Martino is the General Director for EU and international relations at the Italian

    Ministry of Health within the Department of the Prevention and Communication. Her

    Sector is responsible, among other, for bilateral agreements and in implementation of

    international policies and partnerships actions. She holds a senior position in the Ministry

    of Health, and has a coordination role within the Evaluation Group of Investments at the

    Ministry of Health.

Project Leader

    Dr. Nicola Schinaia (CV attached) is proposed as Project Leader.

    Dr. Schinaia is a senior professional at the Italian Health Institute (ISS). He has a long

    standing experience of collaborative projects in the field of CD surveillance, and has

    served several times as WHO Consultant in the same field.

Deputy Project Leader

    Dr. Massimo Ciccozzi (CV attached) is proposed as Deputy Project Leader.

    Dr. Ciccozzi is a senior professional at the ISS. Within the Epidemiology Unit of

    Department of Infectious, Parasitic and Immune-Mediated Diseases is the focal point for

    the improvement of diagnostic tools for the CD surveillance at global level

Resident Twinning Adviser.

    Dr. Manuel Bressan (CV attached) is proposed as RTA of the Project.

    Dr. Bressan has a legal and diplomatic background, as well as first-hand experience in

    international projects management in the health sector.

Italian Human Resources Involved

The Italian Ministry of Health will ensure the overall coordination of the various

    professionals involved, as well as will retain the political profile entailed by the bilateral

    diplomatic agreement, that has been signed in 2005. The following key professionals will

    be involved as medium term experts:

    ? prof. arch. Simona Ganassi Agger (CV attached), member of the Evaluation Group

    for public Investments of the Ministry, involved in coordinating the experts activities.

The Italian Health Institute (ISS, Istituto Superiore di Sanità) will contribute

    professional expert in the field of CD surveillance, both notification-based, as well as

    laboratory-aided, either directly or through networked institutions:

    ? CD Surveillance Principles, with the supervision of the Director of the Epidemiology

    Unit dr. Giovanni Rezza (CV attached);

    ? Disease-oriented CD Surveillance, with the involvement of the Head of the

    HIV/AIDS/STI surveillance dr. Barbara Suligoi (CV attached); ? Data collection and management expertise, will be coordinated by dr. Mario

    Figliomeni (CV attached);

    ? Logistics of project activities implementation expertise, will be coordinated by dr.

    Cristiano Bumbaca and Luca Avellis (CV attached); ? Social communication expertise will be coordinated by prof. Tommaso Pilato, also

    representative of a non governmental organization active both in Italy and Bulgaria

    and neighbouring countries (BALNE);

    ? Training delivery and scientific communication strategies will be coordinated by

    dr. Sergio Bianchi, also representative of a non-profit organization active in Italy and

    abroad (AGENFOR) for methodological issues of training courses

The National Institute of Infectious Diseases “Lazzaro Spallanzani”, in particular, will

    coordinate, implement and oversee the hospital and laboratory-based activities of CD

    surveillance, with special emphasis for containment of spread of serious threats. A team of

    its experts will be involved, comprising:

    ? Doctor Giuseppe Ippolito, Scientific Director of the NIID

    ? Doctor Vincenzo Puro, (CV included),

    ? Doctor Enrico Girardi, (CV included).

Comparative advantage:

As it was indicated before, Italy has been improving its national CD surveillance system

    several times over the last decade, adapting to the rapidly changing needs of the

    occurrence of emerging and re-emerging CD. Moreover, this has been a Europe-wide

    process (culminating with the very recently established European Centre for CD

    Surveillance in Stockholm); Italy has been and still is a very active member of such

    process, which has increased our country‟s attitude towards international cooperation.

    Furthermore Italy presents similarities to Bulgaria both in terms of geographically

    disadvantaged areas with clearly different patterns of CD incidence, and in terms of social

    and economic composition.

    The Italian Partner will give priority attention to ensure that the programme receive

    support and visibility to the health and social issues which are its focus. The high profile

    of Project Leader will be instrumental to assure full attention in the Italian as well as

    European context.

    To further emphasize the appropriateness of the collaboration between Italy and Bulgaria,

    it should be reminded that the Bulgarian and Italian Governments have signed in October

    2000 a Memorandum of Understanding in the field of Health and Medical Sciences which

    has been followed on March 2005 by a Program of Cooperation in the Health sector. This

    Twinning experience would be one of the many contributions to such high profile political

    agreement.

    Such diplomatic agreement may also ensure the sustainability of the activities

    implemented in this project even beyond the time span of this Twinning Programme, as

    well as to include additional areas within the CD surveillance and control (eg animal

    health and food borne infections). Finally, our twinning institutions are established

    partners of collaborations with bilateral, and multilateral projects with other countries or

    WHO in the area of CD surveillance and control.

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