Onchocerciasis Control Programme external evaluation 1997

Onchocerciasis Control Programme in West Africa Programme de Lutte contre l'Onchocercose en Afrique de I'Ouest JOINT PROGRAMME COMMITTEE Office of the Chairman JOINT PROGRAMME COMMITTEE Eighteenth session Liveroool. 1-3 December 1997 Provisional asenda item 8 JPC - CCP COMITE CONJOINT DU PROGRAMME Bureau du Pr6sident JPCI8.8 ORIGINAL: ENGLISH September 1997 ONCHOCERCIASIS CONTROL PROGRAMME EXTERNAL EVALUATION 1997 rf ONCHOCERCIASIS CONTROL PROGRAMME EXTERNAL EVALUATION 1997 October 1997 2ONCHOCERCIASIS CONTROL PROGRAMME EXTERNAL EVALUATION 1997 TABLE OF CONTENTS List of abbreviations Executive summary 1. INTRODUCTION 1.1 General objectives of OCP 1.2 Expected benefits by 2002 1.3 Brief history of OCP and major developments along the road to devolution . . I.4 Major achievements since L974 . 1.5 Previous reviews of 1990 and 1994 1.6 External Evaluation 1997 . VECTOR CONTROL AND NUISANCE CONTROL 2-l Retrospective review of Phase IV 2.2 Prospective review of Phase V PIan of Operations 2.3 Nuisance control 2.4 Ecological Monitoring IVERMECTIN DISTRIBUTION 3.1 Retrospective review of Phase IV 3-2 Prospective evaluation of Phase V 4. EPIDEMIOLOGICALEVALUATIONANDSURVEILLANCE 5 RESEARCH AND ITS APPLICATIONS 5.1 Technical research 5.2 Behavioural and systems research 5.3 Macrofil MANAGEMENTISSUES ... 6.1 Human resource management . . . . 6.2 Financial management. . . . 6.3 Scientificandmanagementplanning. . . .. .. 6-4 Communication and information systems 6.5 Transport 6.6 Management evaluation and control 6.7 Management within the national health services 6.8 APOC 6.9 Training Page 9 10 10 11 T2 t2 t4 15 16 4 5 9 9 9 2 3 t7 L7 19 .21 22 22 23 23 24 24 25 25 26 26 27 27 27 28 6 J7 TRANSFER 7.1 7.2 7.3 7.4 7.5 30 31 3t 33 34 36 Transfer strategy Progress in transfer Prospective evaluation of Phase V Information, Education & Communication (IEC) PosrOCPlnter-country collaboration . . . . . . . Appendix 1 Appendix 2 Appendix 3 List of members of External Evaluation Team Terms of reference Profile and job description 38 39 40 4LIST OF ABBREVIATIONS AFRO APOC CDTI EAC EET ICF IEC IRSP JPC KAP MDSC MPH NGDO NPO OCP OCT PET SSA wHo WHO Regional office for Africa African Programme for Onchocerciasis Control Communiry-Directed Treatment with Ivermectin Expert Advisory Committee External Evaluation Team lnter-Country Facility Information, Education, Communication Institut r6gional de Sant6 publique Joint Programme Committee Knowledge Attitude Practice Multi-Disease Surveillance and Control Master of Public Health Non-Governmental Development Organization National Professional Officer Onchocerciasis Control Programme Onchocerciasis Chemotherapy project Planning, Evaluation and Transfer Special Services Agreement World Health Organization 5EXECUTIYE SUMMARY About to embark on its fifth and last Phase (1998-2002), OCP can look back at a successful fourth Phase during which most targets were achieved and considerable progress was made with the transfer of capabilities for onchocerciasis surveillance and control to the Participating Countries. The External Evaluation Team (EET) is impressed by the output and impact of the Programme which is the combined result of its clear, focussed objective, its relative autonomy, its competent and highly motivated staff, strong transparent management allowing for flexibility in approaching constantly changing situations, and continuous attention to cost-effectiveness - all of this supported by a long term commitment of Donors and Participating Countries. Transmission has been eliminated in the core area, where vector control no longer takes place, apart from a limited number of residual foci and one newly discovered area of transmission (Bougouriba). The rotational use of insecticides has proved to be fully successful in limiting the impact of insecticides resistance and the cost-effectiveness of vector control operations has continuously improved. The Programme must make a critical assessment of the cost-effectiveness of continued vector control in those few residualfoci where it appears far from certain, that interruption of transmission can in fact be achieved by the year 2002. The same applies to northern Sierra Leone in the Western Extension area where the security situation has necessitated the suspension of control activities for some time. Most of the extension zones are covered by vector control in combination with annual ivermectin distribution, which is expected to require 12years of controlto interrupt transmission instead of l4 years with vector control alone. With the discontinuation of vector control in the core area and as a consequence, the return of the blackfly, the renewed biting is perceived by some communities to be a significant nuisance. The EET supports the policy of OCP to discourage larviciding for nuisance control but recognizes that the issue cannot entirely be ignored. Very little is known about the actual nature and extent of the problem. Research should be initiated to establish this and to link human behaviour and economic activity to entomological and clinical parameters. The extent of the environmental monitoring and the close involvement of the Ecological Group in the development of suitable larvicidal strategies has made OCP exceptional (if not unique) in its regards for its ecological impact. Publication of the large amount of data concerning ecological monitoring would act as a valuable reference for other development programmes. Any future external evaluation should include the expertise to be able to assess the ecological impact of OCP. During Phase IV, significant progress has been made in estimating the epidemiological impact of ivermectin treatment and to make predictions as to its ability to interrupt transmission. Studies on various modes of ivermectin distribution have led to the introduction of Community-Directed Treatment with Ivermectin (CDTI), it being more cost effective and efficient than treatment by mobile teams. The EET fully endorses this decision. It illustrates once more OCP's capacity to stimulate the research for its needs and subsequently incorporate the results into its strategies without delay. Further research into the socio-cultural factors determining the success of CDTI and above all its sustainability is however, required. 6OCP has supported the Participating Countries during 1996 in organizing workshops during which National Plans of Action were developed based on CDTI which is already well established in some countries while others are beginning to introduce it. NGDOS play a significant role in ivermectin distribution. Governments should ensure that the right conditions prevail for NGDOs to operate effectively but under the control of the health district authorities. It appears doubtful whether CDTI can be generalized in all Participating Countries by the end of 1998 as intended, given the many organizational constraints at the national level. In most countries no adequate system of supervision of the volunteers in the villages distributing the drug is in place, and the Team came across several instances where villages had been exposed to the last ivermectin distribution round more than l6 months ago, i.e. at least four months behind schedule. OCP is aware of these constraints and will during Phase V continue to monitor and evaluate the situation. The ability for countries to properly organize ivermectin distribution will be proportional to the quality of the multidisease surveillance and control service of which onchocerciasis control is to be part. The EET has observed that in several countries a lot of work still remains to be done in this respect. For OCP this means, that it is faced with the difficult task to provide support to countries when needed, but at the same time wihout prejudicing the process of transfer of responsibilities to the Participating Countries. Up to now, OCP has procured ivermectin on behalf of the Participating Countries and delivered the drug to the national coordinators. It is planned that ivermectin procurement will be done by the countries as of 1999. It is urgent, that countries take steps to enable them to import the drug duty-free because the manufacturer supplies it free of charge, and to establish appropriate distribution channels. Epidemiological evaluation to monitor the impact of vector control in the extension areas continues to be carried out by national teams with OCP support. Three-yearly surveillance in the core area in order to detect recrudescence is the responsibility of the countries themselves, which are at various levels of changing from national to regional or district surveillance teams. Apart from the training of such teams, there is a need for the development of algorithms which show each level how and to whom to report and which action is to be taken should recrudescence occur. In most countries these issues will have to be looked at in the context of an integrated system fordisease control. Countries should address them - supported by OCP - with some urgency in order to ensure that the required mechanisms are in place in 2002. The accompanying moderate financial requirements should not be an excuse for countries not to act. The presently available alternative to the skin snip for the diagnosis of ir-rfection, the DEC patch test, should be introduced as soon as possible while further research on alternative diagnostic methods with a greater sensitivity in detecting early infections should have a high priority. The same applies to tlre further development for use in the field of a DNA test which detects Onchocercq volvulus in large batches of flies. The Programme has shown an excellent ability to identify and respond to operational needs by commissioning or carrying out research. Apart from the research already mentioned, the EET would encourage tlre continued development of ONCHOSIM and the research for which Macrofil is responsible, i.e. the search for an effective, safe, easy to administer macrofilaricide and the study of the mechanisms of ivermectin resistance. The EET recommends that OCP continues to participate in the financing of Macrofil. The Team is impressed by the efficiency with which the Programme delivers high quality work. The financial control is strict and continuing efforts are being made to cut costs. There is a constant 7conversation in the organizaiion about effectiveness, efficiency and quality. However, senior and middle management staff appear to be overburdened. Further decreases in these categories of staff could be destructive. The apparent inability for countries to take financial responsibility for the Special Service Agreement (SSA) category of onchocerciasis control staff is cause for concern. Apart from the consequences this has for the individuals concerned, their skills and experience will get lost if they are not going to be absorbed in the national health care system. The Programme runs an effective data collection, storage and analysis system. A start has been made in transferring the relevant elements of this information system to Participating Countries, but much work is still needed to integrate onchocerciasis into the different levels of the national health information systems, so that surveillance data is effectively used to make decisions on the need and nature of control measures. Tlre ability of countries to manage onchocerciasis control after 2002 depends on a strong home for such activity, probably within a Public Health/Multidisease Surveillance and Control sub-programme of the Ministry of Health. In order to facilitate this, more active management of the transfer process is going to be required. The EET strongly supports the arrangement under which APOC has its base at OCP headquarters. The present joint directorship of OCP and APOC is working well and should be continued. Training has formed an integral part of tlre development of OCP since its inception. The training required has logically, been planned on the basis of the Programme's operational needs and the presumed needs of the countries. The main thrust for the coming five years should be to enable countries to undertake all onchocerciasis control activities themselves. Suitable training manuals on epidemiological surveillance, CDTI, health education and management of a mutidisease surveillance and control service should be ready as soon as possible before 2002in English, French and Portuguese. These modules should not only deal with content but also with the method for teaching. It is recommended that a thorough training needs assessment be carried out as soon as possible in each country at each operational level. Training courses in Africa will have to be located to meet them and if no suitable course is available, the establishment of new, "tailor-rnade" modules will have to be negotiated with training institutions. The OCP bursary scheme should be focussed on the needs identified. In all countries of the Programme the principle of integrating onchocerciasis control into the national health system has been adopted. National Devolution Committees have been set up but in many countries they are no more functional than the National Onchocerciasis Committees they were supposed to revitalize. Most of the devolution plans are overambitious, unnecessarily costly and relying, to a large degree, on external funding for their implementation. The EET is also concerned that in some instances this "integration" may result in a mere juxtaposition of three or four programmes with parallel activities, each having its own vertical approach. For the process of transfer to be successful, enabling the Participating Countries to take complete charge of all onchocerciasis-related activities by the year 2002, not only skills and equipment should be transferred but also full responsibility for those activities through a process of integration of onchocerciasis control into the national public health system. Information, Education and Communicatiorr (lEC) activities have been an integral part of many of OCP's activities during Phase lV. There rvas no fixed programme, but education of communities was conducted in a common sense kind of way. At this juncture the transfer of the IEC component has to be planned and executed witli the same care as the other activities to be transferred. OCP should work with the official in charge of IEC activities in the health services of each country to decide on the messages 8to be transmitted , by what method, the suppoft materials required and how services offered by NGDO,s could be incorporated. There is considerable urgency in developing the onchocerciasis input to the national IEC activities: the changes in the ivermectin tablet strength and the fact, that the re-emerging blackflies are no longer dangerous, need to be broadcasted widely in the immediate future. Training in IEC is needed because the pool of persons skilled in IEC is limited in several Participating Countries. It appears doubtful whether all Participating Countries will be adequately positioned to take full charge of onchocerciasis control by the year 2002 if OCP is not providing a range of support for transfer which is broader than purely the transfer of technical skills. OCP is in an excellent position to do this but its present staff has neitherthe tirne northe required health services management expertise for it. The EET recommends the recruittnent of a senior staff member to facilitate this process. By the year 2002 Pa(icipating Countries are likely to be faced with the need for continuing ivermectin distribution in some areas, for entomological evaluation during two years after the discontinuation of vector corrtrol and for three-yearly epidemiological surveillance in order to detect recrudescence. The couutries should also have the capacity to control any recrudescence that may occur. Intercountry collaboration rvill be essential for the exchange of information and in respect of training, operationalresearch and the provisiorr of shared laboratoryfacilities. There is a need for a specialfocal point for tlrese activities. The E,ET sees an obvious role for WHO and suggests that WHO/AFRO support a subregionalcentre which u'ould provide the expert assistance the Participating Countries willrequire for onchocerciasis control. It rvould be logical to locate such a centre at the present OCP headquarters in Ouagadougou. It seems wasteful to dismantle the OCP research laboratory in Bouakd after the Programme has come to an end. If maintained bevond 2002,its mandate should be expanded to other endemic diseases. For such a high quality, internationally recognized research laboratory to function well it should be attached to an existing, larger institr.rtion in one of the Participating Countries with high class facilities for molecular biology, immunology, rnicrobiology and parasitology and with a proven ability to attract external funding. 91. INTRODUCTION 1.1. General objectives of OCP The overall objective of the Programme zrs approved by the Joint Programme Committee in 1990 is to eliminate onchocerciasis as a disease of public health importance and as an obstacle to socioeconomic development throughout the Programme area and for the Participating Countries to maintain th is achievement. 1.2 Expected benefits by 2002 The health benefits of OCP operations expected to accrue by the year 2002 can be summarized as follows: ca 40 million people protected; about 600 000 people prevented from going blind or from developing severe visual impairment, 1.8 million people fully recovered from onchocercal infection; and 12 million children born since 1974 spared the risk of onchocercal infection. On the economic side, 25 million hectares of fertile land has been made available for food production, sufficient to feed l7 million people. Furthermore 800 staff members have acquired managerial experiences and more than 400 fellowships have been granted by the Programme. 1.3 Brief history of OCP, including major developments along the road to devolution In July 1968 the Joint USAID/OCCGE/WHO Technical Meeting on the Feasibility of Onchocerciasis Control, held in Tunis in July 1968, concluded that large-scale controlof the disease by means of aerial larviciding was feasible. As a result, a Preparatory Assistance Mission to the Governments of Dahomey (Benin), Ghana, C6te d'Ivoire, Mali, Niger, Togo and Upper Volta (Burkina- Faso) - the PAG Mission - developed the overall plan for the Onchocerciasis Control Programme in the Volta River Basin area which started operations in 1974 and covered by 1978/79 764 000 km2 within the seven countries. In order to control the invasion of infective blackflies into the original seven-country area from breeding sites outside that area, aerial larviciding was extended as from 1986 into an additional four countries (Senegal, Guine4 Guinea Bissau and Sierra Leone) as well as into the southern parts of Benin, Togo and Ghana, thus increasing the Programme area to I 235 000 km2 and the length of rivers under control to 50 000 km. The name of the Programme was consequently changed to the Onchocerciasis Control Programme in West Africa. At the same time, the Programme implemented a scheme of rotational use of larvicides which has successfully overcome the then rapidly emerging problem of blackfly resistance to organophosphates. Another milestone in the development of OCP control has been the introduction since 1988 of large-scale ivermectin treatment in conjunction with larviciding, or alone as in the northern part of the Western Extension area. Besides having a significant impact on skin and ocular manifestations of the disease, ivermectin given together with vector control reduces the duration of control required to eliminate the human parasite reservoir. The advent of ivermectin has made it possible to operationalize the concept of devolution i.e. the transfer of OCP residual activities to enable Participating Countries to detect (by epidemrological/entomological surveillance) and to apply control measures (by ivermectin treatment) in any instances of recrudescence of infection/transmission that may occur. The major challenge during 10 the Phasing-out Period (1998-2002) will thus be for the OCP partners to ensure that Participating Countries will be able to maintain the achievements of the Programme. 1.4 Major achievements since 1974 Perhaps the most important achievement of OCP has been its ability to adjust control activities to meet and successfully overcome operational problems as exemplified in the preceding section. Much of the Programme's achievements in this respect has been the result of field-oriented applied research conducted by, or supported by, OCP. At the time of preparing the present report, the targets for 2002 enumerated under I .2 above are close to being met. Thus, more than 33 million people are protected; about 370 000 have been prevented from going blind or suffering from severe visual impairment; 1.5 million have recovered from onchocerciasis infection; and 10 million children have been spared the risk of onchocercal infection. Also, the findings of OCP-directed or supported research have found their immediate application in field operations and contributed substantially to the success of the Programme. This applies to such issues as identification of blackfly species and parasite strains; mapping of Simulium- migration/reinvasion; the search for new larvicides; determination of resistance and development of rotation schedules; field testing of ivermectin for large-scale application; and the development of the ONCHOSIM epidemiological model. The Programme has also acted as a research-stimulus and thus gained significant advantage from research instigated and carried out by other organizations 1.5 Previous reviews of 1990 and 1994 An External Review of OCP was carried out during 1990 and presented to JPC in December of that year. The findings and recommendations of the Review can be briefly summarized as follows: transmission had been virtually eliminated in the Original seven-country OCP area; significant achievements in improving vector control technology, epidemiological surveillance and treatment of onchocerciasis; need for continued support to the effective institutional arrangements of the Programme; need for strong support to devolution; continued search for a macrofilaricide; arran gements for post-OCP intercountry co I laboration ; support to socioeconomic development in onchocerciasis-freed areas. The External Review ascribed the success of OCP to a clear operational objective; realistic timeframe and long-term commitment of Donors and Participating Countries; cost-effective technology; high degree of autonomy; delegation of authority; transparency; strong vertical management; and high quality staff. At the request of JPC, EAC carried out in 1994 a Mid-Term (Phase IV)t Prospective Evaluation of OCP. The Committee while fully endorsing the findings and recommendations of the 1990 External Review made a series of specific recommendations: that the search for additional larvicides should no longer be an OCP priority concern; ' Fourth Financial Phase (1992-1997) 11 that the Terms of Reference of the Ecological Group be expanded to encompass wider environmental issues; that special efforts be made to develop diagnostic methods alternative to skin snipping; that entomological surveillance be considered for devolution programmes; that OCP have available expertise in health services management, health economics and information sciences. In respect to the Phasing-out Period, EAC concluded that OCP should continue control operations until 2002 after which they would cease; that the number of rotational larvicides be reduced to four during the Phasing-out Period; that devolution/devolved activities be undertaken as an integral part of national Multidisease Surveil lance and Control programmes. 1.6 External Evaluation 1997 The present External Evaluation Team (EET) concludes, that the observations in respect of OCP's performance and achievements made bythe External Review Team in 1990 equally apply to OCP anno 1997 . Like its predecessor, the Team is impressed by the output and impact of the Programme which is the combined result of its clear, focused objective, its relative autonomy, its competent and highly motivated staff strong, transparent management allowing for flexibility in approaching constantly changing situations and continuous attention to cost-effectiveness considerations - all of this supported by a long-term commitment of Donors and Participating Countries. The observations and recommendations of the EET laid down in this report are aimed at contributing to a successful end of the Programme and to be of help to the Participating Countries to prevent onchocerciasis from ever again becoming a significant public health problem. The External Evaluation Team consisted of five members, with different professional backgrounds (see Appendix l). Evidence was collected from a wide variety of sources including, l) formal briefing and inforpal interview with OCP staff in Ouagadougou,2) participation in part of the annual round of OCP meetings (National Coordinators Meeting and EAC),3) published literature,4) unpublished documentation supplied by OCP either proactively or on request, 5) discussion with ex-OCP staffmembers, 6) visits to all eleven Participating Countries to observe OCP and national onchocerciasis operations, their position in the national health services, to interview field staff, and to have discussions at all levels of the national health sen,ices. This wide exposure was essential in enabling the Team to make the necessary judgements. Since country visits would have to be undertaken by different individuals, an instrument was developed which enabled team members to collect standardized information at the different levels of the health service in the eleven countries. The Evaluation Team members express their appreciation for the openness and efficiency with which information was supplied to tlrem. They are also grateful for the practical help they received at all levels, and the unfailing courtesy they met with, during visits to Ouagadougou and the Participating Countries. t2 2. VECTORCONTROL 2.1 Retrospective review of Phase IV General stated objectives The plan of operations for the fourth Financial Phase (1992-1997) laid out a strategy of continuation of vector control for l4 years interruption of transmission untilthe parasite reservoir was eliminated in all areas with a potential for blinding onchocerciasis. Ivermectin would be distributed for 5-7 years for effective morbidity control and maximum clinical benefits. This strategy was envisaged to cover the whole OCP area, including extension zones, except the northern part of the Western extension, where ivermectin alone would be continued indefinitely. The entomological and epidemiological criteria for cessation of control were clearly stated. It was envisaged that there would be no new areas brought under control, and there would be a steady and planned decrease in the areas already under control. Vector control in the old core area was planned to be discontinued by 1994, within the20 years allowed for the original Programme. Vector control would continue throughout the extension areas for the duration of Phase IV. Concomitant with the reduction of vector control operations there was proposed a reduction in the entomological surveillance organization, including closure of sectors, etc. Further improvement of cost-effectiveness of vector control operations was to be sought. The major risks for the Phase IV vector control strategy were seen as insecticide resistance, and invasion of infective flies from outside the vector control areas especially in conjunction with a potential colonization of savanna-type onchocerciasis into deforested areas south of the OCP area. Major changes in vector control strategy During the course of Phase IV results from model simulations (ONCHOSIM) indicated that vector control combined with community distribution of ivermectin for 12 years would be sufficient to eliminate the parasite reservoir, and this was adopted as the general strategy for OCP. In Sierra Leone results from operational research indicated that southern Sierra Leone was not expected to be a significant source offly reinvasion, and given the operational expense ofvector control in the very large rivers this area has been excluded from vector control, and onchocerciasis control relies exclusively on disease control by ivermectin treatment. The existing system of flexible seasonal aerial larviciding in the extension zones has been developed significantly to include supplementary ground-based larviciding by national teams at periods when the rivers are low and breeding sites are minimally productive. Achievements during Phase IV Excluding Sierra Leone (where the security situation interfered with control operations) the major vector control objectives for Phase IV have been achieved in over 90Yo of the OCP area. Larviciding has ceased throughout the core area with the exception of a few trouble spots, and is continuing according to plan in the extension zones (excluding Sierra Leone). Flies have returned to the now uncontrolled core area, but transmission has not started again, and with only one exception (Bougouriba - see below) there has been no recrudescence of the parasite. It is true to say that in around 90% of the core area onchocerciasis has now been eliminated. This is a very major achievement and should be seen as a general validation of the effectiveness of the control strategy adopted by OCP. The 13 epidemiological and entomological indicators in the extension zones are generally in conformation with expectation. The strategy developed by OCP of rotation of insecticides to limit the impact of insecticide resistance has proved to be fully successful throughout Phase IV. This is a major achievement for OCP, and represents the most successful management of insecticide resistance in any vector control programme ever. There is no strong evidence that a savanna-type epidemiology of onchocerciasis is moving south as a result of deforestation (or any other cause), although such a movement might be rather gradual and hence it would be difficult to detect. In any case further mass reinvasion of infective flies into the control areas from the south has either proved not to be a great problem (southern Sierra Leone) or is being dealt with by ivermectin distribution (southwest Ghana) and not by further extension of vector control. During Phase IV OCP has continued to improve vector control tactics and technology, and as a result both the effectiveness and the cost-effectiveness has continued to improve. Control tactics have never been better. For example, the beacons which transmit river discharge data have very much reduced the problem of both underdosing (and consequent control failure) and overdosing (resulting in unnecessary expense), and the routine use of ground-based control has reduced the number of flying hours. Problems and failures in the core area By the end of Phase IV, throughout the old core area of OCP both vector control and mass distribution of ivermectin should have been completely finished. However, there are a small number of places where it has not been possible to finish because they exist as either residual foci where transmission was never interrupted, or where control operations have had to be resumed because of recrudescence2. The five residual foci are Sota/Alibori in Benin, Oti tributaries (Kara) in Togo, Bui (Black Volta) and Kulpawn/Mole in Ghana, and Dienkoa in Burkina Faso. The one area of 'recrudescence' is Bougouriba in Burkina Faso. OCP is fully aware of these areas (and in some cases has been aware for some period of time), however the fact of their existence represents in some way a failure of control strategy. OCP analysis of the causes of the residual foci and the recrudescence area have shown that there were no common causes. They have been caused variously by a miss-placed entomological surveillance site, immigration of people, immigration of infective flies, nature of the terrain, early stopping of larviciding and physical modification of the environment (creating perennial river flow). However, whilst it is clear that these instances do represent some sort of localised failure of the control strategy, they should also be seen as successes for the monitoring/surveillance systems developed by OCP. Because they have no common causes, they do not indicate a need for a general change of strategy, and they do not indicate a failure of OCP to apply its own control strategy in a rigorous and critical manner. They should be viewed as inevitable in a large complicated programme such as OCP and the lesson to be learned is that further instances may occur in the extension zones near the end of Phase V. 2 It is not always easy to distinguish these two phenomena, and there is now very strong evidence that the Bougouriba 'recrudesence' is in fact a 'residual focus' (EAC, 1997). However, in this report we will continue to refer to it as a 'recrudesence', largely for the sake of continuity with earlier OCP documents. T4 Problems and failures in the extension zones In the extension zones the combination of vector control and mass distribution of ivermectin has been operational for at least seven years, and entomological/epidemiological parameters would be expected to reflect this according to ONCHOSIM predictions. There is currently no evidence that this is not generally true, with the important exception of Sierra Leone where the security situation has necessitated suspension of control activities for some of the time. In southern and northem Sierra Leone mass distribution of ivermectin should have been carried out since 1990, but in all river basins this has been intemrpted for a number of years. In northern Sierra Leone vector control should have been operational since 1 990, but has had to be suspende d for 2 years. The result is that by the year 2002 Sierra Leone will not have achieved elimination of the parasite reservoir anywhere in the country, and the whole country will be a residual focus. However, the suspension of vector control does not seem to have created a problem for Guinea as a result of potential reinvasion by infective savanna vectors. When the security situation improves in northern Sierra Leone it will be possible to resume vector control, but the benefits will need to be re-evaluated at that stage. Even if aerial larviciding could be restafted this year there will only be five years of unintemrpted vector control, and 10 years in total. Sierra Leone does not seem to be a serious source of infective flies reinvading Guinea, and the epidemiological benefits within northern Sierra Leone might be minimal compared with control based solely on Community-Directed Treatment with lvermectin. In view of this it should be seriously considered whether the funding is cost effective that could otherwise be saved by a permanent discontinuation of vector control in northern Sierra Leone. At the same time community- directed distribution of ivermectin must be properly established in the health system, and this may require more resources than is currently estimated in view of the collapse and partial destruction of the health system in parts of the country during the security alert. Other potential residual foci include the basins of the rivers Pru, Tinkisso and Mafou. 2.2 Prospective review of Phase V Plan of Operations Stated objective and strategies As far as vector control is concerned the specific objective of Phase V is stated as 'to maintain effective control with larviciding until the conclusion of the Programme operations'. The important strategies include a predicted time scale for phasing out vector control in different areas after l2 years of combined vector control and mass/community distribution of ivermectin. At the same time, clear epidemiological/entomological criteria have been defined to confirm that cessation of control in any particular area will not pose a risk of recrudescence. Logistical and infrastructural support for aerial operations (number of capture points, sectors, aerial contract, etc.) is planned to be gradually reduced through Phase V as vector control ceases in different areas at different times. When larviciding ceases in any area entomological surveillance is planned to continue for two years or up to 2002 to confirm that transmission is not continuing. Prospective review lgnoring the potential problem of drug resistance in the parasite, the Extemal Evaluation Team is optimistic about the potential for ivermectin to slowly reduce and eventually intemrpt transmission, but this is as yet unproven. It is clear that the only certain strategy to eliminate the parasite reservoir from an area within a defined period of time (and thereby eliminate onchocerciasis as a public health problem) is through vector control. 15 The External Evaluation Team recognizes that OCP will take a flexible approach to the Phase V plan of operations (as it did with the Phase IV plan of operations), and that this is entirely appropriate to take account of the changing situation. In particular it is recognized that some of the proposals for dealing with the known residual foci have already changed in the light of new operational research. OCP's strategy to rely on 12 years vector control with mass/community distribution of ivermectin allows control in major parts of the western extension and all the southern extension (excluding trouble-spots) to be completed at the end of Phase V in 2002. However, this strategy carries some risks. Firstly, it has been proven that 14 years of vector control will eliminate the parasite reservoir, and 12 years vector control with mass/community distribution of ivermectin is predicted by ONCHOSIM to have the same effect, but this remains unproven. It will be known by the year 2000 for some areas, but in the worst scenario this leaves rather little time to deal with any problem. The second problem with the 12 years combined control running up to 2002 is that OCP will be unable to evaluate the success of the strategy for each and every area by the normal policy of continuing entomological surveillance for two years post-control. This is a cause for considerable concern. The planned reduction of vector control and subsequent gradual reduction of logistic and infrastructural support through the course of Phase V will save money, and is planned in such a way so as not to put the achievements of OCP at risk. The 'trouble spots' which have become apparent during the course of Phase IV are of great concern. The importance of the 'trouble spots' is that they lead us to expect more to appear during Phase V, and OCP is actively researching strategies for dealing with them, and that these strategies will be transferable in2002. The strategies for the different'trouble spots' as outlined in the Phase V PIan of Operations may not be adequate in all cases, but it is recognized that OCP is adopting a flexible approach, and in the light of continuing operational research some of these strategies have already changed or are expected to change in the near future. It is expected that some of the actual'trouble-spots' in the core area will remain beyond 2002. OCP recognizes that post-OCP strategies against'trouble- spots'will by preference use only ivermectin and must be fully transferable in2002. However, it remains possible that in some instances ground-based larviciding may be appropriate, and OCP will need to transfer not only the technical skills but also the appropriate managerial skills for this. The EET supports the view of OCP that any possible post-OCP larviciding should utilise only temephos and B.t. H-14, although it should be noted that resistance to B.l. H-14 is known to have evolved in other insects. Whilst it is accepted that post-OCP strategies to control continuing trouble-spots will not normally involve larviciding, there remains the question as to what is the best control strategy for OCP to adopt during Phase V, so as to leave the affected countries in the best position in2002. It has been argued (see above) that in northern Sierra f,eone OCP should carry out a critical cost-benefit analysis before deciding whether or not to include aerial larviciding. In some of the residual foci of the core area (for example Bui and the upper Oti basin) it is also not clear as to whether the costs of continued vector control are justified by the expected benefits. It is important that OCP looks critically at this question to assess (by ONCHOSIM, etc) the benefits expected. 2.3 Nuisance control In many parts of the world various species of anthropophilic Simuliidae can present a very serious'nuisance', not because they transmit pathogens but because they occur in such large numbers that the accumulation of bites is itself intolerabte. It is well documented that in such areas economic activity can be seriously interrupted. With the exception of the Abu Hamed focus in Sudan, it has never been seriously considered that Simulium damnosurn presents this sort of problem in spite of anecdotal evidence to the contrary. In view of this the OCP Plans of Operations for Phase IV and for Phase V did t6 not address the possible use of larvicides for the purpose of biting nuisance control, or the transfer of skills to make this possible. However, during the course of Phase IV, as larviciding activities have been discontinued in more areas and flies have returned, OCP has received requests from communities which perceive the renewed biting as a significant nuisance, and there is a strong perception in the National Teams that the biting nuisance is a real problem. OCP now recognizes that if it ignores this there is Iikely to be a future problem with spontaneous and improper use of larvicides with consequent damage to the aquatic environment, including fish stocks, and possibly human health. The External Evaluation Team supports the policy that OCP is currently developing. That policy aims, firstly to avoid doing any sort of larviciding itself for nuisance control, and secondly to discourage national efforts except in areas of specific economic importance where use of insecticide may otherwise be carried out spontaneously. To ensure that ground-based larviciding is done properly in such areas, OCP is transferring the necessary technical skills. The third arm of OCP policy is a consideration of 'personal protection' from bites, including use of insect repellents, suitable clothing, etc. The External Evaluation Team takes a serious view of the potential for spontaneous and damaging larviciding activities, and considers that this potential is partly an unavoidable consequence of OCP success. In view of this it should be considered to be a responsibility for OCP to actively seek to minimise the potential post-OCP problem, but it is obvious that almost nothing is known about the actual nature and magnitude of this potential problem, and this must be tackled in the same way that OCP has tackled the other challenges which it has faced. Firstly defining the problem through research and proposing solutions, and secondly implementing them, with operational research to monitor the process. An initial program of research should seek to link human behaviour and economic activity to entomological and clinical parameters. OCP should also initiate a programme of active research into the acceptability and efficacy of 'personal protection'. The Team has no doubts about the ability of OCP to transfer the technical skills for ground based larviciding, but it will also be necessary to transfer the management skills, and this will first require significant dialogue with the eleven countries. 2.4 Ecological monitoring The extent of the environmental monitoring, and the close involvement of the Ecological Group in the development of suitable larvicidal strategies, has made the OCP exceptional (if not unique) in its regard for its ecological impact. In this respect OCP has been proposed as a model for other development programmes, and it would be careless not to take a continuing advantage of this experience for development projects within the oncho-freed areas. It is within neither the terms of reference nor the expertise of the External Evaluation Team to suggest how this might be achieved either through a formal Ecological Panel (which is the suggestion of the Ecological Group, supported by the EAC) or through bilateral negotiations on a project by project basis. It is noted that over the years OCP has been instrumental in training a cadre of hydrobiologists for its own use, and many of these are continuing to apply their skills within various non-OCP institutions in several of the eleven Participating Countries. It is noted that there is a large amount of data concerning the ecological monitoring that is still to be published, and the EET considers that this would act as a valuable reference for other development programmes. It is because of the "model" that OCP has provided that EET is of the opinion that any future external evaluation should specifically include the necessary expertise to be able to assess the ecological aspects of the OCP 3. 11 It is notcd lhal In nlatty parts of thc extension zones larviciding u,ill ncr1 cease belore 2002. post- cotrtrol surveillalrcc to confirln the environmental recovery is essential and Participatr,g Countrics lrave the trained manpo\vcr to do rt. 3.1 IVERMECTIN DISTRIBUTION Retrospective reyiew of Phase IV At the begrrtnrng of the OCP Programme, the strategy used to control onchocerciasis was exclusively based on larviciding. The discovery of ivermectin in 1987 opened up new prospects forOCP' Today, in the absence of a macrofilaricide, chemotherapy with ivermectin treatment rernains both the only alterltattve to lan'tcrdrng and an asset forachieving the objectives sel by OCp Proposed gcncral strategies Apaft frorll llle Ilorllterll parl of the Western Extension area, rl,here large-scalc rycrnrectipdistribution is tlrc sole corttrol Ineasurc, it was envisaged withrn the global ,troi"g1, ol the plan of operatlons as a cotllpletllclltary ltteasure. Given that ivermectin does not lrave thc capactt)/ to rrrterrupt the translnissiorl of the parasrte the main oblective of its use was to control ocular morbidrtl,as q,ell as the skin manifestatrons ol onchocerciasis. Treatnletll u'rth Iverntectin rvas to last six to seven years and be carried out either through large scale distributiorr (b1'mobrle teams) or through a passive mode of treatment. After the first treatments initiated in 1989. thc distribution rvas to gradually decrease, and come to an end in l99j. According tothe projections madc the rtulrber of individuals to be treated would decrease fronr 400,000 in I992 to50,000 in 1991 . llsrvsver, the 1990 extental review had strongll, recorlrlended fu(her invcstigations on the impact of tvcrtnecttn on transmission and research on the relative effectiveness of thc different methods of ivermecrin drstribution. Scientific and tcchnical achievements During Phase IV, significant progress was made in estimating the epidcmiological impact ofivermectin treatrl)en1 'l-he use of the oNCHoslM model made it possible to make predictions on the efficacy of the drug rn interrupting transmission, Data collected at Asubende on the pru rn Ghana, Irave shown that after each treatment with ivermectin, the microfilariae return u,ithin ten to cleven months,but at a reduced level Model simulations indicate that in areas rvhere the CMFI- rvas around 20 mf/sbefore any lntervelltion. distnbutron of ivermectin twice a year for ten years, rvould reducc thc risk of recrudescence to Irear z-ero IJorvcver, this result can only beachieved if ivermectrn treatmcnl coverageis at least 65 7o thrortghout the enttre period. Other simulations based on data collected in thc basin ofthe Kulpawn (Ghana) Ilavc shorvn that the introduction of ivermectin four ycars before the ccssation of vector colltrol atld t:onttnuation of tvermectin treatment for ten years afler it. u,ould lcad to theinterruption of lratlstrltssion irr thrs basrn. Lastly, the trials carried out at thc OnchocerciasisChemotllerapY Rcsearch ('etltre rn llohoc, Ghana have shown tliat high doscs of rvcrmeclrn wrll notproduce atly hartll[ut ellects IJorvever, these high doses have not been shor'n to have alrymacrofilaricidal ef fcct abovc that of the standard doses. Studrcs oll \/arrotts t-Ilrldes of Ivermectin distribution havc led to the conclusion that cornrnurritybascd distribtltr<ln *'as fcasiltlc, appropriate, nrore efficient, ancl nrorc cost-cl-fccti'c thap large-scalclreatlrlellt b]' lllol)rlc tcar)rs It rnav also offer a better chancc ol-sustainabrlrt,,, l'hrs lras lcd OCI) t,revise tts stratcg\ .l t'urt.ectrrrdrstrrl,urrorr and adopr corrrr.ru.rtr,-;;;.,.;;i:;:.,,,,i;;;,'rll,,lr I'cr^ecrirr (r C r8 (CI)'l'l ) as tltc method olchorcc, tltus detnonstrating oncc nr()rc- O('P's capacitl,to qutcklt,put research results rnto practrcc lrET fulty endorses tlris decision Besides its usc in arcas at high risk of ocular disease. ivcrrnectirr trcatnrent is now uscd as an adjurrct to vector control in thc troublc-spots of the core area rvherc vector control on rts own has been unsatisfactory, and in the extenslon areas in order to reducethercquiredperiodof larvicidingfrom l4to l2years Ivenrcctinrsprobablytheonlytool tobe uscd lor rccrudesence control. Asscssment of performance Durtng Phase IV, ivermectin drstribution was carried out mainly by the natronal teams with financial and Iogrstrcal support from OCP. A few NGDOs also Ient their support in some of the countries. TIte treatments tvere carried out through large-scale distribution. Contrary to the forecasts of the plan of opcratlons, ivenncctin treatment expanded considerably wrthrn the five-ycar time period. Iletrt'ecn 1 992 and I996. the nutlber of ind iv iduals treated rose frorr close to one rn r llion to more than ts'o and a half rnrllion 'l-hrs spectacular developmcnt of rvennectin treatrnetrt u,as due to the satisfactory results obtarncd, in Lernrs olnrorbidity and prevalencc ol- infection and especiallv tlrc ONCIJOSIM predrction that in combirtation ivermcctin could reducc the duration of larvrcrdrng front l4 to i2 years. Mean covcragc was rnore tltan l5 o/o and the drug rvas u,ell tolerated Ivenlectrn's capacity to kilt intestutal \\,orn.ls is an appreciated side effect. Following the rdentification of CDTI as the method of choice for the distribution of ivermectin, OCI) Iras supported the Pa(icipating Countries during 1996 in organizing rvorkshops during which National Plans of Action u,ere developed which aim at replacing ivermectin distribution by mobile teams rvith comnrunity directed treatment before the end of 1998. To date. most of the Participating Countries Itave alreadv inrtiated training programmes forthe various categoncs of personncl rnvolved (medical officcrs, Iturses, assrstant nurses and community health rvorkers/distributors). These training sessions, organized in such a rvay that each level trains those who are one leve I belorv it. havc begun to bear fruit. Most of the courrtrres now have well trained and motivated communit),voluntcers for ivermectin distributron. The field visits undertaken by the evaluation teanr have allowed the tearn members to assess thc quality of the training received by these community healtlt rvorkers Those that were met by the evaluators proved to have full know-horv of the work they, are expected to do as community distributors. This u'as confirmed by the results of the two studies on ivermectin distribution, according to which the distributors perform their rvork well most of the time (compliance with exclusion and dosage criteria). Community-directed treatment is already well established in a few countries and is beginning to be rrrtroduced in the others. In 1996,29o/rof the eligible population received ivermectin through this method. IJowever, the EET notes with concern that this process is behind schedule rn several countries. This nreans that for large numbers of target villages the gap betweerr the last distriburion of ivermectin under the old strategl'(drstribution by mobile teams) alrd the new one (CDTI) lras nori,exceeded ayear or evcrt l8 ntonths ln some countries only some of tlre regions were lound to be trarncd, and these had not vct startcd to trarn therr drstricts, who would stilI need to train tlte health centres u,ho would in turn havelolocatcandtraurdrstrrbutorsinthevillages. ItseernsthatthecomplcxrtyofoperationofCDTI rvas tttll fullvapprecrated by both sides rn cornparison rvrth tlrc operatron of OCP drrected tean.ls visiting all the vrllaqes thclnselves Il'ermecli n management Ilp to nou'. OCP has procurcd rvernrectin on behalIof thc I'articrpatrng (-rtuntrrcs and delivered the drtrg 1o tlte natlonal coordinators, the latter in turn srrltplv rl to the rclevant urrrts 'l'his activiry is planncd to be lransferrcd to the countrres rn 1999 0 a t9 The Evaluation Team noted during its country visits that countries have taken no steps to take over this responsibility. Yet, ivermectin management is a delicate issue because it is provided free of charge. It is urgent, that countries take steps to enable them to import the drug duty-free and establish an appropriate distribution channel which ensures its proper handling and storage as well as an adequate supply of the peripheral health centres where community health workers must collect their stock. In countries implementing a policy of cost recovery, care must be taken that ivermectin is not on the list of drugs to be paid for. OCP should continue to emphasize the importance and urgency of the issue for the Participating Countries. The partners The contribution of NGDOs in ivermectin treatment (IEC and distribution activities) was found to be appreciable, and at the moment their participation is indispensable for countries to reach an adequate coverage. However, there are also some negative aspects. Some NGDOs pay ivermectin distributors, while the Ministry of Health is developing CDTI through unpaid volunteers. In addition, NGDO's often work in isolation and do not fit their activities in with the national work plan for devolution. This may jeopardize the long-term development of the ability to run a fully integrated ivermectin distribution service. Governments should ensure that the right conditions prevail for NGDO's to operate effectively, but under the control of the health district authorities. 3.2. Prospective evaluation of Phase V Objectives and strategy The continuation of ivermectin distribution through the community-directed method as well as operational research in this field are among the main objectives of the Plan of operations for Phase V (1998-2002). To attain these objectives, the strategy of OCP consists of putting in place a mechanism to monitor and evaluate the evolution of community-based ivermectin distribution programmes, whilst continuing and refining operational research aimed at improving the application of diagnostic tools and methods of ivermectin delivery as well as refining the ONCHOSIM model, and lastly, continuing to assist the countries with ivermectin procurement. Critical review of the strategic objectives The EET doubts whether CDTI can be generalized in all the Participating Countries by the end of 1998 given the many constraints, such as the lack of financing or, where it is available, delays in the disbursement of funds, shortage of human resources at the level of the national devolution coordinators, problems with ivermectin supply, cumbersome administrative procedures, lack of communication between the central and peripheral levels, slackness and confusion in the restructuring ofthe national health system, etc. In some instances, the EET found officials at the district level not adequately informed about ivermectin distribution and oncho-surveitlance although they are expected to play a key role in the process (training of health workers, planning of activities, supervision, etc.). In most countries no adequate system of supervision of the ivermectin distributions is in place (one Team member was told by a health official: "we train them, we put them in the field and that is it"). The Team also came across instances where villages had been exposed to the last ivermectin distribution round more than l6 months ago, i.e. at least 4 months behind schedule. This is a cause for concern. OCP is aware of these problems and should monitor the situation carefully, and conduct an assessment of the possible epidemiological consequences and identify any implications for duration of larviciding and the 2002 end-date. OCP should provide support if necessary, but without prejudicing the process of transfer of responsibility to the Participatin g Countries. 20 An additional reason for OCP's continuing involvement is that ivermectin distribution is going to be the overall responsibility of a multidisease surveillance and control service. The ability to properly organise the ivermectin distribution will be proportional to the quality of this service. The EET has come to the conclusion that in many countries still a lot of work remains to be done in this respect. The continuation of operational research is also pertinent as the diagnostic tools currently available are not sufficiently sensitive to detect low levels of infection and are largely invalidated by ivermectin administration. Current methods of ivermectin distribution require close monitoring and more experimentation in order to improve their performance. In particular the sustainability of CDTI requires further study. Community-directed treatment with ivermectin Considering that ivermectin may have to be given for many years, the methods of distribution must be simple, efficient, cheap and sustainable. Community-based distribution better fulfills these conditions than large-scale delivery by mobile teams as has been shown by a study conducted by OCP and TDR. In this approach, it is the community itself which makes the decisions as to who is responsible for the running of the system including the choice of the distributors, and decides on the mode of treatment of all eligible villagers. The study provided evidence that the communities are willing and capable of developing methods which are adapted to their own context and that this approach led to higher coverage and compliance rates than annual distribution by mobile teams. In addition, it holds more promise of sustainability. However, the approach is dependent upon a number of factors, some of which are external to it, e.g. regular supervision and drug supply, and, to a lesser extent, upon internal factors such as the high illiteracy rate among the rural populations which limits the choice of distributors (who preferably must be literate) and their motivation. In most instances the EET found the distributors to be satisfied with their situation and ready to continue performing this task. Sometimes, however, they wondered why they were not being paid for their services. The issue of their remuneration requires further study. Whether paying the distributors for their work will promote or endanger sustainability will also depend on the specific socio-cultural context, which may be different from one village to another. EET members found that there was a very high degree of satisfaction among communities with the immediate health benefits of ivermectin (eg. relief of itching, purging of intestinal woffns, a feeling of wellbeing). Even side-effects are seen to be a sign of the drug's potency. At present therefore communities do not have to be continually motivated to use ivermectin. It appears that the main factors determining the quality of performance and the sustainability of CDTI include the participation of the community in the design of the distribution system and in the choice of the distributor, the abilitv to change the system of distribution according to local contexts and constraints, the availability of ivermectin where and when it is needed, the availability of adequate transport for motivation, training and drug delivery, the presence of a trustworthy distributor, the integration of the programme into the national health system, the socio-political stability of the community, the recognition of the community of the advantages of ivermectin and the availability of local resources to keep the system running. The activity of training and supervising village distributors must be added to the minimum package of activities prescribed by the State for health centre level. Above all however, supervision and support of all levels is a crucial factor in determining sustainability, and this includes supervision and support of the distributors by health centre staff, the health centre staff by the district, the district by the regions, and the regions by Head Office. 2l Given the cultural specificities prevailing within each country, the various models of CDTI should be compared in relation to the communities' sociocultural environment. 4. EPIDEMIOLOGICALEVALUATIONANDST]RVEILLANCE Epidemiological evaluation has been part of the Programme since its inception while epidemiological surveillance using essentially the same methodology (diagnosis of infection by skin snip) has been instituted in the core area after vector control was discontinued and is planned to be in place in all extension areas as of2002. Epidemiological evaluation continues as before to monitor impact of vector control in the extension areas and to decide on the cessation of larviciding. This remains to be done by national epidemiological teams with OCP financial and logistic support till the end of the Programme. OCP remains responsible for the programming, coordination, supervision and for ensuring comparability of data and their analysis. Epidemiological surveillance takes place in order to detect recrudescence for which a 3-year cycle appears to be an acceptable compromise between what is desirable and what is feasible. Epidemiological evaluation and surveillance is difficult with the present skin snip technology in areas covered by mass ivermectin distribution, the results entirely depending on incidence among young children and untreated adults. Field training in surveillance techniques is also becoming difficult, because positive skin snips will be rare if control has been successful. Adjuncts such as the use of a video and/or skin snips taken from cattle, should be considered. The team has found in some countries that resistance against skin snipping among the population is increasing because of the perceived risk of HlV-infection. The DEC patch test as replacement of the skin snip should be introduced as soon as possible. Because of the development of a DNA test to detect Onchocerca volvulus in the fly which can be used to screen large batches of flies, entomological surveillance has now become a realistic possibility for countries to carry out after 2002. Once it has become operational - hopefully within the near future - its ability to detect transmission at an early stage, should be compared with that of the DEC patch test both in theory (ONCHOSIM) and in practice. Apart from its potential of detecting transmission at an early stage, it has the advantage of its results not being confounded by ivermectin distribution. Once its technical feasibility has been established, it will be important to study its operational feasibility. In this context it will be of great value to the Participating Countries to have entomological staff presently employed under SSA conditions, absorbed into the employment structure of the national health service. It has been suggested, that volunteers in the villages may be asked to collect flies for dispatch to a cental laboratory facility but it appears highly questionable whether they can realistically be expected to do so. It is encouraging that the Bougouriba recrudescence was detected by the Burkina Faso national team. However, after OCP has ceased its operations more is needed not only in the application of well established surveillance techniques and the management and analysis of the collected data, but also in having the reporting mechanisms in place which are needed for those data to reach the relevant level for their interpretation and action to be taken. Presumably, this would be the responsibility of an integrated disease control unit, onchocerciasis surveillance data being fed into an integrated health management information system. It willto a large extent depend on the number of villages to be subjected to oncho surveillance whether this activity is carried out at regional or district level, but in any case onchocerciasis control, 22 including surveillance with the laboratory support this requires and community directed treatment with ivermectin should be part of the "minimal package" for the relevant level. Participating Countries are at various levels of changing from national teams to regional/district teams but in only very few countries are the district teams actually doing the surveillance. Apart from the training of such teams, there is a need for the development of algorithms which show each level how and to whom to report and which action is to be taken should recrudescence occur. For such a system to be effective, good communication between the central and peripheral level is essential, a condition which the team found not to be fulfilled in several Participating Countries. The above issues should be addressed by the Participating Countries supported by OCP with some urgency in order to ensure that the required mechanisms are in place by the year 2002. Onchocerciasis control is to be part of an integrated system for disease control. Therefore the financial requirements, though not entirely negligible (equipment, transport), should not be very substantial and should not be an excuse for countries not to act. 5. RESEARCH AND ITS APPLICATIONS The Programme has shown an excellent ability to identify and respond to operational needs by commissioning or carrying out technical and other research. The differentiation between cattle and human Onchocerca by the molecular biology laboratory in Bouake, the establishment of the effectiveness and safety of ivermectin, and the feasibility of community directed treatment with ivermectin form a clear illustration of the essential role that research can and should play in a disease control programme, and the ability of the Programme to capitalize on it. Such research is typically of high quality, goal-orientated and has been without question essential for the continuing success of the Programme. There remains significant behavioural, operational and health systems research to be done to facilitate effective operations during Phase V and post-OCP, but there appears to be rather less technical research needed before 2002. However, an indispensable part of the responsibility of OCP is to leave the Participating Countries in a position to maintain the achievements of OCP, and it is clear that this means that OCP should continue to fund technical research that will be valuable in the post-OCP era, even when it might not be of significant value before 2002. ln view of this it is seriously doubted whether OCP can be asked to reduce its research budget without affecting the post-OCP era in a disadvantageous manner. 5.1 Technical Research Additional research into the long term effects of ivermectin on transmission would be invaluable to the post-OCP (and APOC) countries. The continued development of the DNA and immunodiagnostic tests should be strongly encouraged, as should the DEC patch test, as a priority. Research into personal protection against biting nuisance should be instigated as an alternative to ground-based larviciding. Research into the magnitude and nature of biting-nuisance perception should be carried out. The continued development of ONCHOSIM is essential, including the introduction of geographical elements to identifo conditions that promote the spread of recrudescence. The development of strategies for the management of residual foci and recrudescence are a priority, and these will involve both the predictive assessment of possible strategies using ONCHOSIM and the validation of chosen strategies in the field at Bougouriba and the residual foci. The distinction between blinding and non-blinding (savanna and forest) onchocerciasis is of decreasing operational significance in view of the increasing awareness of the gravity of the skin manifestations of the disease. However, the future control of onchocerciasis will continue to be dependent upon a thorough understanding of the transmission and epidemiology of the 23 disease, and to this end it is recommended that research into the molecular (DNA) distinction between the Onchocerca strains and the Simulium cytospecies be continued. Besides the research that it has commissioned or executed itsell OCP has been able to take advantage ofresearch initiated and executed elsewhere, and such research has undoubtedly played a major and direct part in the success of OCP. In view of this it is very much to the benefit of OCp to disseminate its own results as quickly and as widely as possible. Much technical information that would be of great value in stimulating outside research is not easily accessible. The EET would like to see OCp investigate ways of increasing the public availability of technical information, by either unpublished (eg internet) or published means. There would seern to be no clear reason why internal research reports, committee reports and consultancy reports should not be routinely posted on the internet. Publishing should be encouraged not only in international, but also in regionaljournals. 5.2 Behavioural and systems research Studies in these areas are the prime research requirements in the final phase of OCP, because of the fact that the post-OCP control strategy (to be applied by the countries themselves) will be based on community-directed treatment with ivermectin. Valuable research has been carried out by OCP and TDR on ivermectin distribution approaches, which has led to the selection of Community-Directed Treatment with Ivermectin as the method of choice. However, additional research is needed which compares the various models of community- directed distribution and tl-reir relation with local sociocultural factors. Above all, factors which contribute to or interfere with the sustainability of the community-directed approach need to be identified. To increase the chances of success of the Community-Directed Treatment with Ivermectin, it is indispensable that it be actually integrated in the national health system, hence the necessity to study the organizational structure of the health systems of the countries, their operation, their strategies, the resources available, the involvement and the role of health services in distribution activities, etc. If onchocerciasis activities are to be successfully integrated into the national health systems it is not only necessary to understand the structure of these systems, but also to understand the factors which promote or detract from the motivation of staff at all levels. The freeing of river basins from onchocerciasis brings about a spontaneous resettlement which exposes these areas to recrudescence. Therefore, it is necessary to study migratory movements into these areas (migratory itineraries, types of displacement, duration, motives, health status of the migrants, place of origin, etc.) in order to be able to determine their impact on ivermectin distribution (the low compliance rates are attributed to the great number of absences), recrudescence, degradation of the envrronment, etc. 5.3 Macrolil By the year 2002 Participating Countries are expected to be in a position to sustain OCP's achievements. Mechanisms for the detection of recrudescence will be in place and tools for its control will be available. The major tool for the control of recrudescence is ivermectin, which will have to be distributed among the entire population of the villages concerned at least once a year for a period of many years. This is a significant burden for the health services. Additionally, over the years there is a distinct possibility of the evolution of ivermectin resistan ce in O.volvulrzs. Recrudescence control would be a great deal easier if an effective, safe, easy to administer, affordable macrofilaricide would be 24 available. It would also make it possible to eliminate the remaining "trouble spots" within a much shorter period. Macrofil and its predecessor OCT were designed to address these issues by contributing to the development of a safe, effective macrofilaricide. At the same time it has played an important role in the introduction of ivermectin for onchocerciasis control and it is looking into mechanisms of ivermectin resistance. Today, Macrofil's objectives are just as relevant as they were in 1982 (for OCT). One of OCP's objectives is to enable Participating Countries to maintain OCP's achievements. Therefore, even while it is highly unlikely, that a macrofilaricide will become available before the Programme comes to an end, it is within OCP's mandate to continue supporting Macrofil. The EET has considered the recent review of Macrofil and discussed its findings with one of the members of the Review Group. The Team has concluded that OCP should continue its financial support till the end of the Programme. If it is joined by APOC and TDR for the same amount as has been proposed in OCP's plan of operations for the fifth financial Phase, it will be able to continue to operate at the same level of financing as in 1997. Every effort should be made to ensure that the work presently being pursued by Macrofil will be continued beyond 2002. A substantial propoftion of Macrofil's annual budget is being allocated to the Onchocerciasis Chemotherapy Research Centre in Hohoe. The Centre has played an indispensable role in the clinical testing of a number of therapeutics and there are few comparable high quality centres for clinical trials of chemotherapeutics against tropical diseases in the endemic countries. There will continue to be a need for such centres and urgent consideration should be given, in the first place by the govemment of Ghana, which provides the core financing, to the Centre's position and mandate beyond 2002. 6. MANAGEMENT ISSUES 6.1 Human resource management A culture of discipline, self-appraisal and pursuit of excellence continues to be a feature of OCP staff. The staff office at Ouagadougou appears to operate highly efficiently and WHO staff procedures are strictly observed. Whilst appreciating the stringent efforts to cut costs through downsizing, rationalisation and hiring of temporary workers, the EET notes with concern the additional burden on staff that this is causing (especially in the management cadre, especially at Headquarters). The evidence collected by Team members forces them to conclude, with concern, that the staffing situation at Ouagadougou is now close to the critical level where effectiveness could start being impaired. Virtually all existing activities of the Programme are to continue until 2002, with the addition of a much intensified programme of activities related to transfer and further additional activities related to the orderly closing down of OCP itself. It is the opinion of the Team that further decreases in senior and middle management staffwould at this stage be destructive. The EET approves of the programme of support to staff that OCP is offering, to prepare them for post-OCP careers, and it urges that this be extended to staff within the countries: 25 the SSA category, which has to re-enter the national health services and face even now considerable losses in income (70%o or more, once the 50Yo supplement, per diems and social supplements are lost) the national onchocerciasis team members, some of whom have recently lost most of their per diem income due to the end of the campaign of mass ivermectin distribution through their teams, and who after many years of specialisation in onchocerciasis find themselves outside the mainstream of their profession and perhaps less likely to be promoted. There is a potential problem with motivation of health workers at different levels in the national health services of Pafticipating Countries, which may negatively affect their effectiveness to accept and carryr out new tasks related to onchocerciasis control. It is recommended that a programme of research be initiated into the level of motivation of staff, and factors which promote and detract from it, at different levels of the MDSC services in Participating Countries. A greater understanding of the phenomenon will enable the Programme to deal more thoroughly with problems in the area of staff motivation. Of the countries of the original area of operation, only one has so far taken financial responsibility for the SSA category of onchocerciasis staff. Although all the other countries recognize their responsibility in this regard, they appear to be hampered by budgetary constraints and prohibitions against new employment under structural adjustment agreements. If SSA category employees are not employed by the State their skills and experience will be lost to the MDSC service. Urgent steps are needed to promote their absorption. Similarly care must be taken to ensure that trained members of the current national onchocerciasis teams are included in the planned regional MDSC teams -their skills are par excellence those that will be needed after 2002. 6.2 Financial management The WHO financial control system is in use at all levels: Ouagadougou, zones, sectors and the laboratories. Control is strict: monthly financial reports are an absolute requirement (from sectors lzones to Ouagadougou, from Ouagadougou to Brazzaville); zones, sectors and sub-sectors are subject to twice yearly inspection from Ouagadougou; there is a yearly internal and external audit; equipment and stores are tightly controlled using standard stores and stock record systems and a strict condemning procedure. Administration costs are limited to l5%o of overall Programme running expenses. The EET recognizes the continuing efforts to cut costs: the use of the WHO central purchasing system; and (more recently) contracting out services such as cleaning and security; changes in staffing conditions of OCP employees to SSA (Special Services Agreement) and now NPO (National Professional Officer) status; replacement of staff on retiring or resigning by workers on temporary contract; and renegotiation of insecticide and aerial spraying prices. 6.3 Scientific and management planning The EET notes with appreciation the organization's carefully structured six yearly and yearly planning cycles, in which objectives are linked to specific activities and specific budget allocations. There is a constant conversation in the organization about effectiveness, efficiency and quality. This is embodied formally in a cycle of meetings/ seminars for reflection and planning, involving Programme stafi national staffand outside experts (EAC). The Team also notes the continuing development of the ONCHOSIM model, its critical usefulness in management planning as well as scientific decision making and its status as an example for similar models for the control of other diseases. 26 At present almost all the planning and decision making in the organization takes place at Ouagadougou. Plans are put into action through the system of lettres d'accord. In the coming five years this activity has to be transferred to the existing or emerging MDSC services in the eleven Participating Countries. There is a need to develop clear routines for the analysis of surveillance data, and clear algorithms to interpret the results and decide on courses of action. 6.4 Communication and information systems An effective communication system has been built up within the organization (the radio network, the teletype network and the courier system) as well as structured efforts to communicate with relevant outside groups and individuals (the publication 'Oncho Information', the meeting for Ministers of Health). The data collection system is effective, and the software has been developed and acquired to store, analyse and present this information in such a way that it is regularly and systematically used for decision making in the programme. Any additional information that the Team requested in the course of the evaluation could usually be Iocated and made available. However, there does not seem to be a central archive (which could be in the library for example) where research reports, such as consultancy reports, are stored and can be referred to. Analysis and utilization of data takes place almost exclusively at Ouagadougou. A start has been made in transferring the relevant elements of this information system to Participating Countries (for instance through the training of natiorrals in the standard OCP software packages). Much work is still needed though to integrate onchocerciasis into the different levels of the national health information systems in Participating Countries, in such a way that regularly and systematically collected surveillance data is effectively used to make decisions about the status of the disease and the need for and nature of control measures. In addition to the large amount of information stored and available in the resource centre at Ouagadougou, there is a mass of documentation stored higgledy-piggledy in zones, sectors and sub- sectors. Decisions need to be taken soon about the future of all of these. It is recommended that the exact nature of this information is investigated; the likely future need for it; where it should be made available; who could be made responsible for maintaining it; and which format would be most suitable. Once this information is available the necessary decisions and actions can be taken. Regarding the teletype and radio networks, the following suggestions were received during country visits for their redeployment: place within the WHO-Rep offices in each country place within the office of the public health/ MDSC manager for each country, with the remainder in important regional MDSC offices. In either case continued inter-country communication in matters regarding MDSC will remain possible (see also Section 7.5). Practical considerations are likely to determine the final decision (e.g. easier maintenance and repair if WHO based). 6.5 Transport Use of transport is strictly controlled, using the standard WHO routine. Each trip has to be authorised. Problems have been experienced in this regard when senior members of national health services wish to use OCP transport for activities like supervisory visits to health centres, and cannot understand why available transport cannot be shared. Servicing of vehicles is a local responsibility, which takes place according to a fixed written routine. Spares, tyres and lubricants are purchased 27 centrally and their ordering, storage and use strictly controlled. A recent OCP innovation has been a highly successful training course and motivational package to limit motor vehicle accidents. The constraints to which OCP vehicles are subjected make it difficult, if not impossible, to avail them in the framework of integrated disease control programmes for activities not exclusively related to onchocerciasis. This situation fosters some frustration in health workers who often accuse OCp of promoting a one-way integration in the field, to its sole advantage. 6.6 Management evaluation and control Activities directly under the control of OCP are carefully controlled and regularly evaluated (for example, the aerial and ground larviciding, epidemiological surveillance, and training). These activities are evaluated through regular radio contact, written reporting, receiving and analysing data collected, and on-site visits from time to time. However, it became clear during country visirc that there u,ere not always enough of the on-site visitations. National teams and national coordinators sometimes experience problems, and leave things undone (like supervision and evaluation), and more regular visits from senior OCP staffwould address these issues earlier. Activities which are not under direct control of OCp, like Community-Directed Treatment with lvermectin, are less well controlled, since OCP is dependent on one or more intermediaries for supervision and information, and not surprisingly these activities exhibit more shortcomings than the OCP controlled ones. 6-7 Management within the national health services of Participating Countries The ability of countries to manage onchocerciasis after 2002 depends on a strong home for such an activity, probably within a public health/MDSC sub-programme of the Ministry. At present the situation in the Participating Countries varies widely: the health services find themselves at different stages of decentralisation of management; integration of services, and development of the MDSC services. During the June 1997 EAC meeting the following problems were stated to be facing MDSC seryjces: policy is lacking/confused; a weak resource base; a weak surveillance service; weak support systems (information and supervision); probtems with motivation of staff involved in preventive services. In order to facilitate the development of a'strong home', a well managed MDSC service in each country, more active management of the transfer process is going to be required. Two important steps need to be taken in this regard: research into the status qzo of MDSC programmes at all levels in each country; and the allocation/ appointment of a senior person/persons to manage transfer/IvlDSC service dbvelopment more actively. Th"." t*o recommendations are addressed in more detail elsewhere in the report. 6.8 APOC To date APOC has been heavily dependent on OCP for administrative and technical support. Although APOC has been reimbursing OCP for staffcosts where staffhas been fulfilling joint functions, the downsized OCP senior management cadre has been considerably strained by the additional responsibilities. Recently APOC's staff situation has improved, and this is already leading to greater technical selGsufficiency. APOC's dependency on OCP for administrative matters will however continue in the medium term, for instance in its use of the ocp personnel office. 28 There is agreement between senior management in OCP and APOC that, for the time being Ouagadougou is a sensible base for APOC (free accommodation; access to OCP expertise and experience) the present joint directorship is working well and should continue. The EET strongly supports this arrangement, since it optimizes the use of available resources Although collaboration between the two bodies is desirable in cases where both stand to benefit from it, there can be no question of 'common responsibility' - each programme has its specific responsibilities and activities. In particular, APOC cannot be seen as a successor to OCP in any way. Equally, in the coming five years APOC will have to develop its technical and administrative capacity to be completely self-sufficient well before OCP comes to an end in2002. 6.9 Training Training has formed an integral part of the development of OCP since its inception, in support of its activities at all levels of operation. It has generally been approached in a thoroughly systematic way, especially as far as control activities in the field are concerned. Training conducted by OCP OCP has continued to provide training where its operations require it, and where its own staff is capable of providing it. Members of the national onchocerciasis teams of the Participating Countries have been involved as well, and are often assisted and supervised by OCP staffwhen they are. This kind of training is usually aimed at providing particular competencies (for example, Community-directed Treatment with Ivermectin, prevention of motor vehicle accidents, vehicle maintenance), is of short duration, and takes place in the practical situation. The teaching methods are suited to the objectives. Overall the quality of this training has been very good. Two weaknesses have been noted though: learning is not systematically assessed in some cases too much is attempted in a short time (for instance in the training in computer skills conducted for senior national staff at Ouagadougou, where retention and subsequent application of skills is low). . Training materials produced by OCP for use by trainers Training modules in English and/or French have been produced for most of the onchocerciasis control activities currently being practised. These are generally of a satisfactory standard, although some are more like textbooks in that they focus on the content of training only, without also giving guidelines on how the training should take place. Trainers in the periphery report finding them easy to use. The basic activities that countries will have to continue with for onchocerciasis control are well known: epidemiological surveillance; Community-Directed Treatment with Ivermectin; health education; and management of a MDSC service (with ground Iarviciding and entomological monitoring perhaps added in some cases). For each of these suitable training manuals need to be ready as soon as possible before 2002, in English, French and Portuguese. These modules should contain not only content (knowledge and skills to be learnt), but also the methods for teaching these. 29 Training conducted for OCP by outside institutions OCP has used other institutions to provide some of the training it requires. In accordance with decisions of EAC preference has been given to institutions in Africa, particularly those supported by WHO. There are two broad categories of such courses: Training required by OCP for specific activities in the field. Such training is predominantly practical; is relatively short; and produces specific competencies. The training methods are relevant and students are able to apply a large part of what they learn. The benefit of such training to OCP has been direct and clear. More general training, aimed at increasing the pool of persons in Participating Countries who have knowledge and skills related to onchocerciasis (e.g. entomology, ophthalmology) or to management of a MDSC service (e.g. MPH or epidemiology training). Such training has been generally longer and more theoretical. Teaching methods used encourage deep Iearning, but in one case particularly the curriculum is much too full to achieve mastery, and prioritisation of material is poor. Students however report being able to use almost all of what they learn in their subsequent work. The benefit of such training to OCP has been indirect and not clear. Training needs assessment The training required by OCP has to date been planned on the basis of the organization's operational needs (very logically), and presumed needs of the countries (rather more vaguely). The main thrust of the coming five years is the enabling of Participating Countries to undertake all onchocerciasis control activities themselves, within the framework of their public health/MDSC programmes. Since these vary from country to country, and training is often inappropriately used when problems are caused by deficits in the performance system rather than a lack of knowledge or skills, it is recommended that a thorough training needs assessment be carried out as soon as possible in each country at each operational level. This should be done in conjunction with the study of the status quo of the health service as mentioned under Section 6.7 . It is likely that the major need will prove to be in the fields of management of a MDSC service (especially at the middle level), and IEC/social mobilization - knowledge and skills for most of the field control activities are already present in abundance in Participating Countries. " Once the training needs have been established, training courses in Africa will have to be located to meet them. Existing courses must be scrutinized carefully and may have to be adapted - for example: the 'Cours r6gional en communication/mobilisation sociale' at the Institut R6gional de Sant6 Publique (IRSP) in Cotonou will have to become less theoretical and more competency- based to suit the programme's IEC and social mobilisation needs the higher level epidemiology/public health courses at Bamako and the IRSP need to provide more field practice in management (which will mean leaving out modules such as theoretical statistics). If no suitable course is available the establishment of new, 'tailor-made' modules will have to be negotiated with training institutions. It is worth bearing in mind that such needs are likely to persist for many years, in view of the mobility of staffwithin the health service, which makes it worthwhile for an institution to establish a new course. Such investment will not only be to the benefit of onchocerciasis control, but also of general benefit to the region and a stimulus to the continued development of the national integrated health services. Agreements must be reached with public service commissions in 30 each country for due professional recognition to be given to such training. A special effort will have to be rnade to identify courses in Portuguese for Guinea-Bissau (possibly in Mozambique, Brazil or Portugal). To date OCP has not had much input into under-graduate training of health workers who will have to deal with onchocerciasis in their work (medical officers, nurses, health inspectors/ assistants, laboratory technicians). A concerted effort has to be made to identify the bodies responsible for controlling the curriculum of each cadre in each country, so that inclusion of up-to-date and relevant material on onchocerciasis is ensured. Training institutions and tutors themselves must be approached and encouraged to use the training modules OCp has developed. The OCP bursarv schemc Application for bursaries is made according to the standard WHO procedure. It was found that in about half the cases the applicants themselves decide to apply; and not the managers of the system. The screening by local Ministries of Health is not always very discriminating, and the final decision has to be made by OCP headquarters staff. These persons have a mental list of courses available (mostly in Africa), and an understanding of the needs in each country derived from their day-to-day work in OCp, and they allocate places accordingly. Names of successful candidates are submitted to AFRO to be finally approved according to WHO procedure, which is usually a formality. There is no obligation placed on beneficiaries in terms of service delivery after qualification. In the allocation of bursaries to countries a figure of two per country per year was mentioned. In reality this has not been the case, nor slrould it have been - some countries have larger populations and greater onchocerciasis prevalence, and therefore require more skilled persons on the ground. However some countries appear to have had proportionately too many places or too few. Equally, some disciplines appear to have been under-represented (IEC, health service management). IIr a recent study by the PET unit of beneficiaries of OCP bursaries, 690/o could be traced. Of these33%o are working in onclrocerciasis control,52yo in otherparts of the health service and 15% in other disciplines. It is difficult to say whether this is a reasonable return on an investment or not. However, in view of the large amount allocated to the bursary scheme every year (around US$ 660,000) and the pressing need to transfer otrchocerciasis control activities to the Participating Countries, a more focused use of bursaries for fie last five years is recommended. Training and trainees indicated by the training needs analysis mentioned above should be targeted. A commitment to service for a specified time should be included in the bursary contract, even though this may be hard to enforce. 7. TRANSFER To its merit OCP perceived very early the need for the Participating Countries to eventually take over the programme's activities in order to safeguard the achievements of the OCP, when OCP finally comes to an end. As early as 1981 the notion of transfet' was conceived, although it was only more recently that it became possible to put the concept into practice (because of the advent of ivermectin as a major tool). 3 Until recenlly OCP referred to the concept of "devolution", but now it prefers to talk about "transfer" so as to avoid any possrble suggestion of hierarchy. 31 By 'transfer' is meant a two-way process. On the one hand OCP passing on to the Participating Countries the responsibilities, understanding, skills and material resources required for the implementation and the management of surveillance and control activities, and on the other hand, the Participating Countries voluntarily appropriating them. The primary objective of this chapter is to examine the transfer process, and only to refer briefly to the actual activities to be transferred, because in general these activities are considered elsewhere in this report. For example, the EET noted with approval that OCP is still actively seeking to develop improved and appropriate diagnostic tests for epiderniological surveillance, and EET is confident that OCP will in due course be able to develop appropriate recrudesence control algorithms. However, these sorts of technicalities of epidemiological surveillance are considered in Chapter 4. 7.1 Transfer strategy By 2002 it is intended tltat onchocerciasis will have been eliminated throughout the programme area, and afterwards the Parlicipating Countries will maintain this achievement through the transferred activities. The two activities proposed are epiderr-riological/entomological surveillance and recrudesence control. With regard to epidemiological surveillarrce. it is to be carried out actively and regularly by rnultidisciplinary rnobile teams fully integrated into the national health system, and will be focused on the frontline communities of preidentified sentinel villages in the high risk areas. It also comprises a passive component at the level of health care facilities. Recrudesence control also requires that onchocerciasis control activities are fimly integrated in the public health systems of the countries having centraland intermediate multidisease control centres which are effective (ie. capable of planning and conducting surveillance operations in the field, and analysing tlie data collected in order to quickly put in place control operations where they are needed). 7.2. Progress in transfer Transfer of epidemiological sur-veillance activities In the OCP core area active surveillance is carried out regularly by the national teams in selected villages once every three years for each village, and basically the same activities are carried out by the national teams in the extension zones for'evaluation' of the continuing control activities. The excellent quality of the survey reports produced by the national teams demonstrates their capacity to collect data as well as, in some countries, a certain ability to interpret the results. However, the villages in which epidemiological surveillance is to be carried out are basically selected by the management at the Programme's headquarters in Ouagadougou on the basis of entomological parameters the analysis of which often escapes the understanding of the national teams. Similarly the interpretation of the evaluation/surveillance results is also performed in Ouagadougou. It is worth noting that the liberty given the national teams to add other villages to the list established by OCP has sometimes been exercised without any scientific gain having been produced to justify such a decision. This represents only the first step in the transfer process, because surveillance activities must be fully integrated into each of the national MDSC systems before 2002, and this has hardly begun. Transfer of activities for recrudesence control OCP is still in the process of testing and developing strategies for the control of the residual foci and the Bougouriba recrudesence, and EET is confident that in due course OCP will transfer the appropriate strategies and techniques. 32 Transfer of understanding and skills The strategy adopted by OCP has been to transfer understanding and skills through an extensive programme of training (see section 6.9). Devolution Plan antl Integration In all the countries of the Prograrnlne, the principle of integrating onchocerciasis control into the nationalhealth system has beeu adopted. ANational Devolution Committee has been set up in all OCp countries and each of tlte coutttries has now been able, u,ith assistance from OCP, to develop a National Devolution PIan. However, in many countries, the National Devolution Committees are no more functiorral than the National Committees for Onchocerciasis Control that they were supposed to revitalize. Furthermore, very ferv devolution plans have secured funding and have started to be implemented. Most of the plans are actually overan-rbitious, too costly and almost exclusively relying ott otttside funding for their implementation. Thev were developed in a context characterised by massive interventiott from Donors and a certain u,ithdrawal fronr their responsibilities by the countries. In some cotttrtries its application does not seenl to be a preoccupation for many officials. Nevertheless, itt sorne of the countries. at thc central level, an effort has been rnade to bring under the responsibilitl' of tlre same department the control programmes of three or four endemic diseases. In these same countries at both intennediate and peripheral levels, the activities of the national teams are now carried out in partnership rvith the national health system management. However, the understanding of the process of integration has been complicated and retarded, because the health service management in all countries is ttow involved in a process of decentralization. The principle of integration seems to be differently understood by different participants, and it is to be feared that in man)' cases integration appears to lnean a mere juxtaposition of thrce or four programmes with parallel activities, each having its orvn vertical approach, with the foreseeable collsequence that at the peripheral level this results in an unsustainable work overload for the health district officer and/or post head nurse. Hence a serious risk of dysfunctioning of the entire disease control system. Transfer of material support to the Participating Countries Diagnostic equiprnent (skinsnipping punches, magnifoing glass, microscope) is available in all the countries of the Programrne although sometimes uot in sufficient number. Vehicles have been withdrawn frorn the OCP fleet to be given to some countries to strengthen their own fleet. However, these vehicles have been, in most cases, heavily used and long written-off, with maintenance costs that actually put a serious strain on the operating budget of the recipient health units. Transfer of Responsibility and Management The overawareness that OCP staff have of their responsibilities with respect to transfer and other oncho activities causes them sorne concern that the countries might not be able to assume all of their responsibilities from day to day. This unfortuuately lras sometimes been reflected by too much taking of charge and too much interventionism on the part of this staff in the management, particularly in the planning and the taking of responsibility. 7.3. 33 Prospective evaluation of the Fifth Financial Phase D The Plan of Operations defines the Fifth Financial Phase as the period of gradual but actual phasing-out ofOCP from the onchocerciasis control process. The process oftransfer covers three areas which would allow true autonomy in decision-making: a) The transfer of understanding and skills. This is proposed through production and distribution of specialist protocols/algorithms, and through an extensive and pragmatic training programme, partly carried out according to the operational needs of OCP and on the basis of in-service training. The EET has no doubts as to the willingness and technical ability of OCP to carry out these activities, but it is seriously questioned as to whether OCP has a sufficient understanding of the national health systems to be able to target the transfer in an effective way for integration. The EET does not consider it sufficient for OCP to sirnply offer such technical assistance, and then to leave it up to the National Devolution Committees and their National Plans to decide how to use it appropriately. Firstly, the National Devolution Committees are largely defirnct in most Participating Countries, and secondly the sort of training and the way in rvhich the protocols/algorithms are offered should depend upon a good understanding ofthe structures in which onchocerciasis control will be incorporated. b) The transfer of responsibilities. The importancc of this is not always fully recognized, but it is of course essential if the countries are to plan and manage onchocerciasis control themselves. Such a process can be supported by management training. OCP appears to have no developed strategy for the transfer of responsibility, other than the idea that with the provision of suitable training and an appropriate National Devolution Plan (which is largely the responsibility of the Participating Countries), transfer of responsibility will be automatic. It should be emphasized however, that at a time of instability within the health delivery systems of all the Participating Countries as a result of decentralization, an intensive, continuous dialogue between the Programme and the countries is essential to ensure that the Participating Countries fully understand what taking over of onchocerciasis control and its integration into the health service entails. c) The transfer of equipment and materials. With the assistance of other partners such as WHO/AFRO and World Bank, OCP intends to support the Participating Countries materially and technically in order to strengthen their respective national public health systems. This is one of the most important prerequisites for the success of the policy of integrating onchocerciasis activities within the multidisease surveillance and control systems. Support to the Participating Countries for transfer and integration Before the integration of onchocerciasis surveillance and controI activities into the national Itealth systems, it is necessary to redefine the devolution plans with more responsibility laid upon the countries with respect to their health management structures. An integrated approach to onchocerciasis control can only work in a health system which has an efficacious and efficient structure and management, and where the various onchocerciasis activities are absorbed at an appropriate level. This type of integration supposes the irnplementation of activities according to local priorities, therefore intensive decentralization i.e. moving from a highly centralized system to a number of decision-making centres with some autonomy at the intermediate and peripheral levels is increasingly important. The transfer and integration of onchocerciasis control into the national public health system is clearly a complex process. 34 The EET is concerned that several Participating Countries may not be adequately positioned to take full control of it by the year 2002, if transfer is purely seen as a process by which the required skills are turned over to the countries. OCP should cover a broader range in its support to countries. Onchocerciasis surveillance and control cannot be looked at in isolation but should be considered as a part of the country's public health system. OCP is in an excellent position to provide this wider range type of support during the next five years but its present staff neither has the tirne nor the required health services management expertise to do it. The EET recomlnends the recruitment of a senior staff member who is well acquainted with the requirements of onchocerciasis control, has a good understanding of health care systems in general and those of West African countries in particular and is capable of convincing health workers by the power of persuasion rather than authority. A staff profile and job description for the post is attached as Annex 3. It emerges front the information available that the principle of WHO/AFRO assistance to the transfer process through the appointment of a senior staff to be posted in Ouagadougou rentains accepted and that a budget line yet to be funded has been created to this effect. 7.4 Information, Education, Communication (IEC) IEC in Phase IV IEC activities were an integral part of many of OCP's activities during Phase IV. There was no fixed programme, but education of communities was regularly and fairly effectively conducted, in a common sense kind of way, by the Programme's field workers: u,henever they could see that they needed community cooperation for various activities (eg. skin-snips, set up a depot for the helicopters, distribute ivermectin etc.). at times of the year when they were less busy (e.g. the dry season) talks were given in villages and in schools. The technique used was the 'health talk' Concerning the development of materials in support of health education, the situation varied ffpm country to country: The posters developed by OCP are to be found in various offices and health premises in the Participating Countries. Their rnain purpose appears to be to advertise the existence of the problem and the programme. They do not form part of a concerted IEC plan. In some countries NGDO's like Helen Keller International have been working to produce a'box' of health education materials for primary eye health workers. In some cases the national onchocerciasis tearns and coordinators were involved in the planning workshops, but the final product is not yet available. ln other countries nothing has been developed specifically for onchocerciasis. IEC in Phase V There is only a brief mention of IEC in the plan of operations for Phase V, in connection with support for community-directed treatment with ivermectin (par. 9.27). National staff at different levels (coordinators and field staff) voiced their concern about the future performance of necessary IEC activities. a a a a a :l 35 Like epidemiological surveillance, ivermectin distribution and overall planning of the onchocerciasis programme, IEC activities will no longer be carried out by national teams under OCP direction but are becoming the responsibility of the different levels of the national health services of the Participating Countries. National onchocerciasis teams seldom go out into the community now; so onchocerciasis related IEC will have to be carried out by the existing health care system (the IEC component of which may or may not be functioning effectively). The transfer of the IEC component therefore has to be planned and executed with the same care as the other activities to be transferred. Information is needed for sensible planning of the transfer of IEC activities a The IEC service and IEC activities must be included in the research which is to be conducted about the state of the health service of each country. Information is needed on the nature of the present IEC system; existing policy regarding IEC; channels being used (mass media; the health workers in the district etc.); methods used; availability and quality of visual aids; nature of messages being transmitted; involvernent of NGDOs; and (crucially) to what extent IEC is actually taking place. It would be helpful to have knowledge about the present state of knowledge and practice in corrlnunities affected by the programme; among village health rvorkers and traditional birth attendants; and among the health workers in the District. This can fairly easily be obtained through KAP studies. They have to pass on messages (and in some cases skills) to villagers - themselves, or by training village health workers and traditional birth attendants to do it. This activity will also have to be added to their official 'minimum package of activities'. To enable them to perform this IEC task effectively and to ensure that onchocerciasis is added to their list of messages, they will need a package of instructions, in-service training (learning techniques other than the health talk) and supporting materials. This will have to be transmitted from Head Office via the Region and the District, both of which levels will have to be motivated and involved. The Region and District level have a further role to plan in the supervision of MDSC related IEC in the health centres. Such IEC must be added to the relevant supervision checklists. At Head Office level OCP will have to work with the official who is responsible for IEC activities in the health service (there appears to be at least one of these per country). The following has to be undertaken in cooperation rvith this person: o Deciding what messages have to be transmitted; their relative priority; and their target populations (this can be done globally for the programme, but will have to be refined within countries). . Deciding on the method of choice for their transmission (health workers at different levels; the mass media - especially radio). o Deciding whether and how the services offered by NGDOs should be used. . Support materials have to be located and/or developed and distributed: posters, pictures, radio messages etc. OCP can assist in making an inventory of what has been developed or is available elsewhere, so that countries can share good material. . The official in charge of Multi-Disease Surveillance and Control (MDSC) services will also have to be involved in these discussion and decisions, since onchocerciasis will have to be part of a joint MDSC package of method and messages. The major actors in IEC are likely to be the frontline health workers in the PHC services of each country, in the health centres and units: a a a a 36 There is considerable urgency in developing the onchocerciasis input into IEC in the countries of the Programme. Two new messages have to be transmitted widely in the immediate future; the changes in the ivermectin tablet strength; and the fact that the blackflies which are now reinvading in lnany areas are no longer dangerous. The pool of persons skilled in IEC is limited in several of the Participating Countries. Accordingly training in IEC is needed, particularly for those responsible at Head Office or regional level. The local courses that were evaluated dealt with IEC on a mainly theoretical level. OCP therefore needs to negotiate with local training institutions to provide short, targeted, competency based IEC courses, for managers arrd practitioners, in English, French and ideally also in Portuguese. 7.5 Post-OCPinter-countrycollaboration By the year 2002 Participating Countries are likely to be faced with the following situation Continuing ivermectin distribution in various trouble spots and in the north western part of the extension area. As a consequence there will be a need for regular assessment of the epidemiological situation, including ophthalmological examination. Vector control will have been stopped throughout. In many parts of the extension area this rvill rrot happen before 2002. ln those areas there is a need for at least two subsequent years of etttomological evaluation (as has been done for two years after the discontinuation of vector control in the core area). In this context it should be noted that the strategy for the interruption of transmission (vector control for 12 rather than 14 years, combined with annual ivermectin distribution) is based only on model predictions. The need for 3 yearly epidemiological surveillance in order to detect recrudescence. It appears likely, that there will also be a place for entomological surveillance now screening of masses of flies for O.volvulr.s DNA has become possible. It is unlikely, that no recrudescence will ever be detected, hence the need for countries to be able to handle such a situation. Intercountry collaboration amongst others in respect of the follorving topics is highly desirable: the exchange of information on recrudescence detection and control and if needed collaboration in control activities. Training Operational research aimed at improving the effectiveness and efficiency of all activities related to onchocerciasis control, including the application of new research findings and the introduction of nerv diagnostic or therapeutic tools. the provision of shared laboratory facilities for molecular biology and immunology in support of onchocerciasis detection and'control. There is an apparent need for a special focal point for the activities outlined above. The 1990 external review tearn and the 1994 midterm review by EAC called for a separate Inter Country Facility (ICF) after OCP has come to an end but JPC 94 did not see the need for a new structure. In the Plan of Operations for the fifth financial phase the suggestion is made to have tlie WHO representatives in the eleven Participating Countries act as a collegiate body which would play a coordinating and supporting role. The EET considers it unlikely, that such an informal body, with a continuously changing membership, will be able to adequately and forcefully address the issues discussed in this paragraph. However, there is an obvious role for WHO. WHO/AFRO could support a subregional centre, which would provide the expert assistance that the Participating Countries will require for onchocerciasis surveillance and control, and to promote inter-country collaboration after 2002. lt should also house OCP's documentation centre and radio network facilities. The raison d'etre for such a centre would be I 37 to assist Participating Countries to maintain OCP's achievements, and initially it should focus on that objective. However, it is envisaged that its mandate will be logically expanded to cover those countries participating in APOC, and indeed the centre could develop further into a WHO endemic diseases surveillance and control centre for subsaharan Africa. The OCP laboratory in Bouak6 currently carries out routine work (diagnostic tests, quality control of insecticides) and developmental research. The first activity can also be carried out in some existing national laboratories but it seems wastefulto dismantle it as a research laboratory. If maintained beyond 2002 its mandate should be expanded to other endemic diseases. A high quality, internationally recognized research laboratory dealing with tropical diseases located in the endemic areas rather than in Europe or North America is an invaluable asset. Its management and professional staff should be international; it should aim at the highest standards, closely collaborating with research institutes in the South and in the North. It should play a (sub) regional role for diagnosis as well as for research capacity strengthening. Its research should be directly relevant for the solution of important disease problems in West Africa. For such a laboratory to function well, it should be attached to an existing, larger institution with a proven ability to attract external funding and high class facilities for molecular biology, immunology, microbiology and parasitology in one of the Participating Countries. In addition, the availability of international conference/workshop/training facilities and a close proximity to the ICF would be of great advantage. 38 APPENDIX 1: LIST OF MEMBERS OF EXTERNAL EVALUATION TEAM Dr Ibrahima L. Diop Coordinateur de Programme Union pour I'Etude de Ia Population Africain BP21 007 DakarPonty Senegal Dr Achille Alhin Massougbodji Professeur de Parasitologie Faculte de Sciences de la Sante Universite National du Benin BP 188 Cotonou Benin Dr Alexander S. Muller (chairman) Emeritus Professor of Tropical Health of the University of Amsterdam Zandpad 42 3621 NE Breukelen The Netherlands Dr Rory James Post (secretary) Associate Keeper Department of Entomology The Natural History Museum Cromwell Road London SW7 5BD United Kingdom Dr Detlef R. Prozesky Professor of Community Based Education Faculty of Medicine University of Pretoria PO Box 667 0001 Pretoria South Africa t39 APPENDIX 2: TERMS OF REFERENCE The terms of reference for the Evaluation are 1. to review and evaluate the performance of the Programme to date with particular emphasis on operations since the 1990 External Review and the 1994 Mid-Term (Phase IV) Prospective Evaluation; this review will include control activities; research and application of its hndings; training; transfer of know-how to Participating Countries; and management of OCP; when appropriate, recommendations will be offered for improvement; 2. to evaluate the achievements of the Programme, including preparedness of the Participating Countries to detect and control recrudescence, and to determine their relevance and adequacy for OCP to meet its objective; 3. to review the Plan of Operations to ascertain the likelihood that its implementation will bring the Programme to a lasting and successfulend and, possibly, to make recommendations to the Director that might enhance the implementation of the PIan. 40 APPENDIX 3: PROFILE AND JOB DESCRIPTION OF OFFICER IN CHARGE OF STRENGTHENING THE TRANSFER PROCESS Profile Specialist in public health. Farniliar with all aspects of onchocerciasis control. Fluent in French and English. A working knowledge of Portuguese would be an advantage. At least five years experience in the rnanagement of public health programmes and systerns Capable of corrrtlul.ticating and working with decision-makers at the central level, and with all levels of health staff in the periphery. Job description To identify tlte decision-tnakers in the health care system and the process of decision implernentation in each Participating Country; to contribute to the development of an overall policy of disease control in each country of which onchocerciasis control forms an integral part; to stimulate reflection and research on the health policies and systems of the different countries, to assist national paftners in identi$ing the strengths and weaknesses of their health policy and health system; and to stimulate the process of its improvement, leading to a fully operational, integrated disease control system which assures the sustainability of the achievements of OCP. The incumbent will be based at OCP's headquarters in Ouagadougou and will be responsible to the Programme Director. I I