Committee of Sponsoring Agencies (CSA): report of the hundred and third session Washington DC, 2 and 3 October 2003

RESTzuCTED APOC CSA103 THE AFRICAN PROGRAMME FOR ONCOCERCIASIS CONROL (APOC) COMMITTEE OF SPONSORING AGENCIES (CSA) Report of the hundred and third session Washington DC, 2 and 3 October 2003 Draft,20.10.03 2A. OPENING OF THE SESSION 1. The 103'd session of CSA was held at the HQs. of the World Bank with Bruce Benton in the Chair. He expressed his regret that two of the Members of the Committee failed to attend the session, the dates of which had been agreed upon at the 102nd session in March 2003. B. ADOPTION OF THE AGENDA 2. The proposed agenda dated 21.08.03 was adopted after modifications and as reflected in the current report. C. APPROVAL OF THE CSAlO2 REPORT AND MATTERS ARISING THEREFROM 3. The Committee approved the draft report (21.08.03, Rev.l) with "allocated budget" in line 1 of paragraph 17 being modified to read "the available financial resources". D. PROGRESS OF APOC 4. In reporting on the progress of APOC, the Director of the Programme up-dated the situation regarding REMO now almost completed in the Democratic Republic of Congo and Angola with refinement carried out in Cameroon and Congo-BrazzaviTle. REMO was also carried out extensively in Southern Sudan. 5. As a consequence to these REMO exercises, new CDTI project proposals were elaborated by Angola, DRC, Sudan (Southem Sector), Cameroon and Congo Brazzaville. 6. There were therefore now 96 CDTI projects with, or expected, APoc-funding (as against a total of 85 CDTI projects foreseen in the Programme Document for Phase II and the Phasing-out Period) as well as 7 NOTF HQs. and 4 vector elimination projects being financed by the Programme. 7. Reference was made to projects withoutNGDO partners, now the situation in Ethiopia, DRC and Sudan (see also paragraph 34 below). This situation was of particular importance in Sudan in so far as HealthNet Intemational (HNI), which had coordinated support to oncho-control in Southern Sudan, channelled ivermectin supplies and taken care of the administration ofAPOC-funding in that area, maybe closing down soon. The Carter Center had been approached by the Programme Director recommending that it takes over the oncho-related functions of HNI while continuing its ongoing support to control in Southern Sudan. It was suggested that a similar request be addressed to the Christoffel Blinden Mission (CBM). Although in principle the administration of APOC funds should preferably be undertaken by WHO, administrative limitations and the involvement of two Regional Offices - AFRO and EMRO - would pose problems. However, the Programme Director would soon address a formal request to that effect to the WHO Representative for South Sudan based in Nairobi. 8. The Programme Director informed the Committee about the innovation of field visits undertaken by the WHO Internal Auditor; the direct audit support received from the World Bank; and the suggestion that the administrative staff dealing with imprest account returns be increased (although this would not seem feasible given that the APOC budget for management and administration would already increase to 3l5% of the total budget after cessation of OCP support). Like the Intemal Auditor, it might be useful for the Extemal Auditor, to visit APOC operations in the field. 9. The Committee was informed that the vector elimination project in the Itawara focus (Uganda) had made good progress with the Simulium neavei vector having been absent during now six years and that the Programme was getting ready to undertake the certification exercise. Aerial larviciding in the Bioko focus had commenced in the period of January to May 2003 to be completed next year. Regular entomological evaluation was still going on in the focus. 10. It was pointed out that the Management in average reduced budgets proposed by the projects by 25 to 30 per cent. Also, the implementation of CDTI projects was frequently below the planned level due to such constraints as co-endemicity of Loa loa and civil unrest. Given that lately initiated projects might have received less than five years of APOC support by 2010, thought might be given to the possibility of support beyond that date funded by the APOC Reserve Trust Fund without any extra funding from the Donors.. 11. Other comments from CSA Members included doubt as to the effectiveness in some cases of the "Information cascade" approach to preparing health staff and others for detecting and dealing with Serious Adverse Events (SAEs) as well as the issue of interference of alcohol with ivermectin treatment, the latter to be further considered through operational research. E. ONCHOCERCIASIS CONTROL IN THE "SPECIAL INTERVENTION ZONES" (SIZs) 12. The Committee was informed that the activities of the Special Intervention Team (SIT) were well under way. The re-enforced CDTI process was being implemented throughout the SZs, including in Sierra Leone, with full NGDO partnership. Aerial larviciding had resumed in the neighbouring foci situated in Togo and Benin. Since the closure of OCP the usual producer of temephos for that Programme had ceased its production while the cost of replacement by Bt.Hl4 was on the upper side. However, it was expected that the cost of SIT operations would remain within the allocated budget. CSA was reminded that its concem with this agenda item was one of information onlyandthat anydecisions/recommendations would emanate from its WHO and World Bank Members without the approval by the Committee as such. F. CLOSING.DOWN OF OCP 13. Boakye Boatin presented a draft final report on the closure of OCP. All personnel issues brought to the attention of the Closure Team hadbeen resolved. Appropriate copies of the original landtitle deeds had been obtained for two plots and lodged with the APOC Management, the WHO Legal Office and WHO AFRO. Only a few outstanding debtors and creditors remained for further follow-up and only one possible litigation case might come up at a later date for which a financial reserve was to be kept in the books. Transfer of the garage, the fleet of vehicles and the hydrology beacons had been completed. Finally, the updated VCU Data-Manager and the sets of OCP manuals had been finalized in the two languages and distributed to all interested parties. 14, The total expenditures of the closure were expected to be less than the financial resources earmarked for the exercise. The issue of a transfer of US$ 2 million to WHO from the OCP Trust Fund of which so far only half had been transferred was considered by the Committee with the suggestion that the remaining US$ I million should eventually be retained to the World Bank in the OCP Trust Fund for use in the Special Intervention Zones. 415. CSA once again congratulated Boakye Boatin and his Team on a job well done G. THE MULTI-DISEASE SURVEILLANCE CENTRE 16. The Committee was informed by Sam Bugri about the progress of the Centre. The final draft of the project document was with the WHO Legal Counsel to be submitted to Dr Samba. The staff was now in place and the Centre had started receiving batches of black flies - although mostly in insufficient numbers - from all former OCP countries except Ghana and Benin for screening at the MolecularBiology Laboratory. The infection rate had been zero inthe batches received so far. The Centre was also available for screening within the SIZ and APOC areas. 17. Visits had been paid to several countries and planned to other countries in West Africa to discuss future collaboration with the Centre with the technical staff concerned, and invite the national health authorities to communicate epidemiological information on the MDSC target diseases to the Centre. However, the response had until now been rather disappointing and it was suggested that the Centre might assume a pro-active approach by contacting the countries concemed reminding them about their obligation to provide WHO, and in this case the MDSC, with the epidemiological information required forthe Centre to function according to its Terms of Reference, possibly making sure that this information was actually reflected by the countries. The importance of effective oncho-surveillance by the MDSC in the former OCP countries was underlined as a means of safeguarding the investment in attaining the success of OCP. H. INTER-COUNTRY COLLABORATION AMONG OCP AND APOC COUNTRIES 18. The Committee had before it a paper setting out the following options for ensuring furure collaboration among former OCP and APOC countries in order to "facilitate periodic stocktaking, data- based discussions of onchocerciasis trends and the tackling of common technical issues" (recommendation l0 of the 2002 OCP Extemal Evaluation Team): (i) information-sharing through exchange of reports; (ii) inter-country discussions at JAF sessions; and (iii) inter-country discussions at the sessions of the WHO Regional Committee for Africa. 19. The Committee was informed that the Director of APOC had already invited former OCP Coordinators to meetings organized by APOC Management for the Special lntervention Zones and for APOC countries, thus allowing for discussion on onchocerciasis issues in general. 20. CSA suggested that APOC might consider inviting a limited number, say five, of representatives of former OCP countries to attend JAF sessions, setting one day aside for discussion on onchocerciasis issues. Such attendance would be organized in rotation among the former OCP countries. High/technical level of attendance would be expected and, if necessary, financed by APOC with the possibility of representatives attending at their own cost. Another suggestion was to affiliate former OCP country representatives with the Board sessions of the MDSC. I. PROPOSAL FOR THE GATES FOUNDATION Zl. At the "oncho-team"s meeting with officials at the Gates HQs, it was made clear that the Foundation policy was not to finance ongoing programmes such as APOC (although the Foundation allocated funds to OEPA) but it might be possible for the Gates Foundation to considerthe financing ofthe research component of the proposal submitted to it (search for a macrofilaricide, , operational research on CDTI, studies on the impact of ivermectin treatment on the transmission of onchocerciasis). 522. Given the unlikely availability of Gates funds for APOC operations, Bruce Benton would make special efforts to close the gap of US$ 26 million over the next seven years. He intended to approach OCP Donors who had ceased contributing to onchocerciasis control, such as Italy, Switzerland, Japan, Saudi Arabia and the European Commission stressing also the APOC role in promoting "add-on" activities. J. TCC17 (SEPTEMBER 2003) 23. Following a summary of the recommendations and findings of the Technical Consultative Committee by Director, APOC, particular attention was given to the issue of CDTI operations in co- endemic onchocerciasis and Loa loa areas concluding that decisions on CDTI in Loa loa areas should reflect informed decision-making at all levels. It was expected that CSA would receive a copy of the report of the deliberations on the Loa /oa issue by the Mectizan Expert Committee at its forthcoming session. 24. Regarding the TCC request to CSA to facilitate fundraising for the study on elimination of transmission with ivermectin, CSA was of the opinion that, while awaiting the final decision of the Gates Foundation on this issue, partial financing of the transmission elimination study by APOC could not be excluded, if possible. 25. CSA welcomed the TCC recommendation to hold an ad froc session on CDTI sustainability in Addis Ababa in January 2004 and suggested that the topic be examined also as a health component of overall national sustainability. K. PREPARATION FOR JAF9 26. CSA congratulated APOC Management on the excellent affangements made for the session and approved the documentation for transmission to participants in the session (see however paragraph 30 below). 27. It was suggested that emphasis be given to the "add-on" activities which should be monitored by the Participating Countries in collaboration with APOC, awaiting the outcome of the TDR study. The "add-on" approach within PHC based on comDT and enhancing the probability of sustainability was an item that should be highlighted at the JAF session for Participating Countries to expose experiences and new opportunities. Vitamin A distribution would lend itself particularly well to this approach. L. CDTI SUSTAINABILITY 28. The importance of following/monitoring the implementation of post-APOC sustainability plans was underlined with the expectation of an early determination of the duration of ivermectin treatment to arrive at a conclusion as to the eventual importance of the sustainability process. 29. The paper submitted by Eleuther Tarimo and Detlef Prozesky entitled "Evaluating the Sustainability of CDTI Projects: Progress and Prospects" (document JAF9.9) was reviewed in detail by the Committee and a series of amendments/modifications were incorporated. 30. It was decided to strengthen item 1l of the JAF9 Provisional Agenda to read: "special session on Sustainability: (i) Introduction, (ii) Evaluating the sustainability of CDTI projects, (iii) Country perspectives (iv) General discussion". It was agreed that the overall introduction should provide a conceptual framework for the subject, setting the scene for the Tarimo/Prozesky presentation of their paper 6followed by more than an hour discussion. The time tentatively allotted to the consideration ofthis agenda item would therefore be significantly increased. 31. The absence of disease indicators (prevalence and incidence) in the sustainability evaluation was brought up with the explanation that the exercise was determined solely by the objective of APOC i.e. to "establish ... effective and (self-)sustainable, community-directed ivermectin treatment ... ". A first impact evaluation taking account, among others, of the impact of Programme operations on skin and ocular manifestations, would be conducted during the coming year and would be brought to the attention of JAF attendants. M. NGDO STATEMENT 32. Adrian Hopkins, newly elected Chair of the NGDO Coordination Group, summarized the conclusions and recommendations of its 8-10 September session at WHO HQs. 33. The NGDO Group noted with satisfaction that support to former OCP programmes was being maintained, that partners active in the Special Intervention Zones had been identified in 5 countries with .increasing support to Sierra Leone and that .progress was made with the post-APOC sustainability plans. 34. With the rapid increase of APOC projects there were still many projects needing NGDO support and it was noted that several new projects did not (yet) have an NGDO partner. Most of the members of the NGDO Group were now stretched financially to their limit and the possibility of revisiting in a smaller group theZ5Yo Government/NcDo contribution might be considered in particular for such countries like Sudan and DRC where contributions from governments were unlikelyto be forthcoming. Furthermore, the technical contribution of NGDOs was important even if the financial support might be at a lower level. CSA confirmed its support to NGDO partnership as a general feature of APOC operations although the point could also be made that the absence of a partner might eventually be seen as an element in favour of sustainability. N. OTHER MATTERS 35. The Committee was informed that APOC had been selected as a subject for the Shanghai Conference in2004. 36. CSA was also informed that the World Bank intended to convene a Donors' Conference on APOC funding at the World Bank Office in Paris on 21 and 22 Aprl|2004 to address the issue of the current US$ 26 million shortfall. O. DATES AND VENUES OF APOC MEETINGS 37. The Committee will hold its 104th session in conjunction with the JAF session in Canada on Tuesday 2 December with the possibility of a post mortem session during the aftemoon of Friday 5 December in time for departure by ovemight flights. 38. CSAl05 will be held at the APOC HQs in Ouagadougou on 22 and23 March2004 (following the NGDO Coordination Group session in Nairobi from 9 to 11 March in Nairobi, TCC18 in Ouagadougou during the week 15-20 March and preceding the Donors' Conference in Paris on 2l and 22 April). 71 2 Annex I Conclusions Approach to CBM to "take over" from Health Net lnternational (paragraph 7). The possibility of alcohol implication in the occurrence of SAEs following ivermectin treatment to be considered by the MDSC (para. l1). The MDSC to strengthen its proactive role in ensuring receipt of epidemiological data from Participating Countries (para. 17). lnvitation of representatives of former OCP countries to JAF and/or MDSC-Board sessions for dialogue on onchocerciasis matters (para. 20). Special effort to include former OCP Donors in the APOC donor community (para.22) Strengthening of the JAF9 item on sustainability with an increase in the time allocation (para. 30). Revisit the 25Yo clause (para. 34) CSA104 to be held on 2 December in conjunction with JAF9 in Canada and CSA105 to be held in Ouagadougou on 22 and 23 March 2004 (paras. 37 and 38). 3. 4. 5. 6. 7. 8. 8Members: Attending in ex ofJicio capacity: Specially invited: Secretariat: Annex 2 List of participants World Bank: WHO: NGDO Group: Merck: Bruce Benton (Chair) Bernhard Liese Sam Bugri Adrian Hopkins Brenda Colatrella Azodoga S6k6t6li Boakye Boatin Jesse Bump Ole Worm Christensen (Secretary) Kyalo Kibua Christina Noviaskey