Onchocerciasis Control Programme in the Volta River Basin Area: towards devolution; how, when and with what means

)IvORLD HEr\LTH ORGANIZATION AFRTC/U\ REGION ORGANISATION I{ONDIALE DE LA SANTE REGION DE L.AFRIQUE ocP/EAC6.5 ORIGINAL: ENGLISH ONCHOCERCIASIS CONTROL PROCRA.TttME IN TIIE VOLTA RTVER BASIN ARE,A PROGR^!\IIIE DE LUTTE CONTRE, L'ONCIIOCERCOSE DANS LA REGION DU BASSIN DE, LA VOLTA E)GERT ADVISORY COMMITTEE Sixth session Ouagadougou, 10-14 June 1985 ONCHOCERCIASIS CONTROL PROGRAI'IME IN I'TIE VOLTA RIVER BASIN AREA TOWARDS DEVOLUTION: HOW, IJIIEN AND WITII WHAT MEAIIS I ONCHOCERCIASIS CONTROL PROGRAMME IN THE VOLTA RIVER BASIN AREA Towards Devolution: How wEAn and with what Eeans 1. General considerations 1.1 The final operational ain of OCP is to bring control to a level at which the participaEing CountrLes concerned will be able to carry out themselves what is left of malntenance activlties. L.2 At that stage there will be very litt1e to do ln terms of onchocerciasis surveillance and control and it wtll hardly be justified to malnEain an lnfrastructure solely for that purpose. I{hen, therefore, the Participating CountrLes, Eogether with OCP, work out plans and progranDlres for the process of devolut,ion, ways and means will have to be found to ensure that such surveillance operatlons are conducted ln the most cost-effective Danner. 1.3 The obvious response to this challenge will be for the Participating Countrles to make onchocerciasis malntenance an integral part of prinary health care (PHC) activltles. Furthermore, countries would, for this purpose, be well advised to nake full use wlthln their own territories of the existing gCP network which over the years has proved its technical and managerial competence. Some of the OCP sector and sub-sector staff have the basic qualtfications for, and can easily be retrained to undertake, such additional tasks as will be requlred at the tine when the operations move fron OCPdirection to natlonal managenent. Furthermore, the availabiltty of sector and sub-sector centres, transport, laboratory and other equipment could help to strengthen the national health care systems. L.4 Obvlouslyr any health programme naklng use of the existing OCP structure w111 need to functton in relation to the already establlshed health systems of the countryr €.g. rural health centres and MHC cllnlcs. Although initlally t.here could be some dlfferences in functions betveen those based on the OCP structure and those of the "traditional" infrastructurer the two systems should be viewed as operating ln a complementary and mutually supportive nanner with the final alm of developing a single prinary health care (PHC) network. 1.5 The extent of the existing oCP network witl not aIlow for a complete 'population coverage" even lf the Easks of the staff were kept at a miniuum. The outreach to the population could be both stationary and noblle. There will be a need for referral faclllties at an lntermedlate level and from there to the more central, speciallzed centres. The plannlng, prograrnming and overall supervLslon of the system (including a sirnple, baslc health education programme) as well as its logisttcs would obvlously be the responsibllity of the Ministry of Health. 6c:f0il-e"s D1.6 The increasing understanding of devolut,ion as a Process aimed at supporting the Participating CounErles ln their efforts to strengthen theirpiiil"ry hEalth ""t" "yiteros calls for a strong lnvolvement and parEicipation of the Wortd Health Oiganizatlon both in Eerms of supporting I'Iernber States in West Africa in PHC devEloPnent and in respect of its constiEutional role to dlrect and coordinate relited inter-country health activities. Also, the devolutlon process, as lt ls now conceived, will provide an oPerational framework wlthin,ti"h bilateral collaboration ln the PHC field can be developed in a realistLc manner. L.7 An examinatlon is made ln the followl-ng sections of the rePercusslons on the Progr6mme and its partners of utl1lzlng it. OCp sector/subrsector network to promote ghe development of national health care sysgems; the process of ldentification of the tasks which could be undertaken ln this context isUif.ffy referred toj and details of inpleuenting the systen in oCP operational zonel 01 are provided. ussions on the Pro amme and its ners of usi devolution and OCP netwo in support of Primary alth care evelopment 2 t The Pr ramme Z.L The re-orlentatlon of the OCP neEwork t,owards PHC development will have lnpllcations for the Prograrnme itself. ocP will arrange, through wHo AFRO and ln agreement with the governments concerned, that the Programme staff in qrr."ilo., be trained Ln those asPect,s of primary health care in which they will ultlnately be engaged in a nati;nal adninistraEion. Also, with the support of $IIIO, such staff could carry out surveys and research & developnent (k & D) "trril"" to provide orlentatlon for future PI1C actlvitles. 2.2 It wllI be inportant that the trainlng programme suPPorted by ocP and wlIO in close collaboratlon wlth the Partlcipatlng countri-es be adapted to the local conditions and requirements of these countrles. The increase in workload in connectlon wLth the preparatl.on for and support to the devolutlon/pttC systeB w111 necessitate a strengthening of the "Public HealthUnlt" in Ouagado-,rgorr, possibly by WIIO/AFRO staff working under the supervislon and controL of the Programme Director' I Ar, OCp Operational Zone (OOZ) ls a geographical area t'hroughout which present enionological and epideniological conditions are relatively unlform and past and preEent OCP oplrations have followed a simllar Pattern' It can be expected furthermore, that each ooZ will continue to disPlay thls unfioicrfty and slmllarliy. OOZ Ol covers most of Burklna Faso, the OCP sector of Nlger, the eastern fralf of the part of Mali iocluded in the Programne and a .pockEt" in 1lorth Benin. JPC5 decided that a devolut,ion plan for OOZ 01 and a tinetable for devolution in the other ooZs be presented to JPc6 (December 1985) together with the Plan of Operations for the third Financial Phase ( 1986-1-991) . \ tWIIO AFRO 2.3 The Reglonal Office of WHO for Africa will play a crucial role in the development and support of the devolutlon process which will nake a substantlal conErlbution to prfuoary health care in West Afrlca. In this respect AFRO will esEablish a representation within OCP so as to be able to catalyze collaboratlon between the Onchocerciasis Control Program'e and the national health authorities. 2.4 It could also be foreseen that WHO would avail itself of the opportunity to build on the oCP inter-count.ry structure to exPand cooPeration in the health fleld between countries in West Africa. 2.5 Flnally, lt can be expected that w[lo, in addition to playlng its constitutional, eoordinating role ln regard to the technical asPects in thls atea, could asslst the Partlcipating countries in solicitlng external financial and material suPPort. Particl t Countries 2.6 The use of the OCP network for health systens development will obviously have important repercussions in the Particlpating Countries wltigh will reap the beneflts of tiris approach but at the same time be faced with the financial responsibllity for OCP- itatt once they are established in their new positions withln the nat,ional health care systems. 2.7 It may be worth stressing that the devolution process will In all likelihood develop geographically according to OOZs. This ni1l ln some instances mean that certain areas within a glven country will be devolved while others are still ln the OCP supported nalntenaoce phase, that is, there could be a staggered lmplement,ation of devolution. Donor communitY 2.8 It ls clear that a great deal of reliance will have to be placed upon the donor community in order to help the Particlpating Countries to meet the cost Lnherent in the devolutlon/PHC process. Several Donor Countries have already expressed an interest in supporting their OCP partners in strengihening their health care systems. In so doing, it would be extrenely luportant that donors, as ls the case with OCP, commit theuselves, at least in priuclple, to contributlons in cash or klnd for extended periods so as Eo allow the recipient countrles to prePare medium-term Progra nres. 2.g Several categories of activltles and of material requirements lend thenselves to assistance from the donor gemmunity: transPort, laboratory equipment, drugs, traLningr etc... 3. Identlflcation of tasks that could be undertaken within a health care system integrating former OCP struct,ures The gutdtng principles for the ldentlfication of such activities should3.1 be: conforuiEy with the PHC concept and approach; selectlon accordlng to Priority needs as exPressed by the community and good potentiality for successful intervention; qsmmunity particlPatlon as and when feasible; concentration on a few well defined and f.airLy siuple tasks so as not to "overload" the system. 3.2 In order Eo identify the future activitles a survey night be carried out to determine ln the populations concerned what is required In terms of health-proruoting activities and disease control, and to what extent t,he comnuniiies themselves are prepared to contribute to the solution of their health and health-related piobleus. The gulding principles for such surveys could be established by WHO/AFRO in collaboration with all parties. Research & development (R & D) sEudies would ensure that the most aPPropriate activities are inlluded and that effective nethodologles are applied. 3.3 Although the eventual selection of tasks (which should remain flexible) viIl depend on the surveys referred t,o above it would seem reasonable to suggest, that such activities as IICH care, suPport, to improvement of sanitation ".rJ-rrt., supply, medical care including the supply of drugs' and ' i.n general, dfslisl control should flgure anong those most frequently selected' In respect to dlsease control one or several of the following would be includld among the tasks to be undertaken : schlstosomiasls, Guinea-woru infectlon, trypanosomiasis, malaria, diarrhoea and trachoma, wlEh onchocerciasis uaintenance-surveillance which must be given apProPriate attenEion irrespective of whlchever coublnatlon of tasks is decided upon. An important activity should be the actlve suPPort to and direct involvuent in the countryts Expanded Programme of Immunization' 3.4 The importance of health education should be underlined as an lntegral part of the work of all the staff involved In PIIC operations. Also, the potenttal contribution of the network to epideniologlcal surveillance and to tn. U,rttalng up of a functional health inforrnation sysEem ls worth stressing. 4. Inplernentati on of the devolut, lon/PHC scheme in OCP Operational Zone 01 4.I As an example of how and wlth what means the devolut,ion process could develop, an analysis has been made of the Present sltuation in OOZ O1 as a basis for converttng the OCP i.nfrastructure iuto a health developurent systeu. 4.2 The devolution/PHC systep, being a natural continuation and extension of OCp actlvitles, will be re"atty Lntegrated within the already existing health infra'tructure of the countrles concerned (I"ICH centresr rural/urban health centres, mobile health servicesr etc.r.). This will i-ncrease the "population coverage" and with an ongolng strengthening of ghe healt'h infrastructure as a whole, those countries will extend the scoPe of activities towards a comprehensive and functlonal prinary health care system throughout their terrltories. 4.3 A suggested outline of an implementat,ion schedule for the devolutlon/pttC pio"."" f"-6OZ Of is presented below. It should be stressed, however, that Lh" "t"p" fiEi-auea and thelr implementation dates are tentative and can only , D L be finally idenrlfled after the results of R & D studies conducted jointly by OCP and Burkina Faso, are in hand. 1986 1987 : 1988 - reorientation of entomological surveillance (e.g. closure of catching points); - training of sub-sector staff in the PHC approach; - lncreasing association of national staff wlth epideuiological evaluation and entomological surveillance; - OCP entomological surveillance confined to a few "high-risk Points"; - training of sub-sector staff ln the PHC approach; - close association of natlonal staff with OCP oPerations; - PHC related R & D; transformation of OCP sub-sector staff into devolution/PHC Teaus whlch, under national directlon in close collaboratlon with OCP, will contlnue "high-rlsk polnts" surveillance and epideniological evaluation wiUh Ehe understanding that OCP w111 continue trend analysis and speclal studles in selected villages; -PHC-relatedR&D; 1989 : - entouological surveillance and epideulological evaluation by devolution/Pttc Teams as in 1988; - primary health care by devolution/pttC Teams; 1990 : - as in 1989; 1991 : - as in 1989. 5 leuentatton of devoluti PHC devel t in the reuainder of the ogralnme area 5.1 Ttre devolution process ln the remalning part of the OCP area, geared as lt will be to the strengthening of the national priEary health care systems, wlll be syncronized wlth health 6ystem6 developnent ln the countri-es concerned. 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