APOC: at the vanguard of the neglected tropical diseases policy in Africa: action plan 2006-2010

(9} APOC: at the Vanguard of the neglected tropical diseases policy in Africa: Action plan 2006-2010 APOC Management, 20 June 2006 APOC: at the vanguard of neglected tropical diseases policy in Africa APOC: at the vanguard of neglected tropical diseases policy in Africa: Action plan 2006-2010 Introduction and Rationale l. APOC (African Programme for Onchocerciasis Control) has, and will continue, to facilitate effective and sustainable control of onchocerciasis throughout the endemic areas in the 19 participating countries in Africa by Community Directed Treatment with Ivermectin (Mectizan@) (CDTI). The four localised vector-elimination projects have been scheduled to be completed by December 2008. 2. The number of persons treated yearly in participating countries has increased: o 1997:14.58 million o 2000: 22.00 million o 2AQ2:28.45 million o 2005:40.00 million. 3. Therapeutic coverage (the number of people treated each year as a percentage of a country's population) has increased r AveragingT}%o for five countries (2004). In addition to the cases of blindness prevented (43,000 annually duringthe current life of the programme (1996-2010)), the alleviation of unbearable itching and elimination of unsightly skin diseases APOC (like OCP before it) has enabled socioeconomic development in some of the poorest regions of the world and brought the poorest of the poor within the remit of self-determined strategies for healthcare, helping to make these people active partners in their own health viz. . 261,000 Community-Directed Distributors (CDDs) (2005) Sustainability demands that for the future of onchocerciasis control individual communitieJ in each country are empowered to continue to seek CDTI in a politically meaningful way, helping to ensure governments in the participating countries are ."rporrire and have the political will to provide and administer an adequate budget for the CDTI programmes in their countries, maintaining the previous prioritization and over US$1.5 billion investment (to date) in onchocerciasis-control. Sustainability will also be achieved by maintaining the solidarity demonstrated by the donors and further evidenced by the work of APOC's other partners who remain responsive to the future needs of the programme as they have done in the past. APOC's strength lies in its diverse partnership including: o I17,000 disease-affectedcommunities o 20 donors . 19 African national governments . I multinational pharmaceutical firm o l6 national and international NGDOs Health, development and economic experts now agree that Close-to-Client Community- Directed Treatment (ComDT) pioneered by CDTI for onchocerciasis control represents a proficient and highly cost-effective mechanism. Quantifiable measures for CDTI: o Economic rate of retum l7%o . $0.58 per treatment 4. 5. 6. 7. APOC Management, 20 June 2006 8. 9. t0. 11. APOC: at the vanguard of neglected tropical diseases policy in Africa . $7 per Disability Adjusted Life Year (DALY) averted (thanks to Merck & Co's donation of Mectizan@) APOC's infrastructure provides a proven mechanism and best value for introducing health interventions against other neglected tropical diseases (NTDs) in Africa: ascariasis, trichuriasis, hookworm, schistosomiasis, lymphatic filariasis and trachoma. In addition to the health and poverty burden of onchocerciasis and these other woffn infections specific indicators for the benefits of deworming are documented for the control of malaria morbidity. Supporting APOC and its continued activities (including potential leadership in the Neglected Tropical Diseases Coalition and Malaria Quick Impact Initiative) is thus an investment in social empowerrnent, improved health and poverty alleviation amongst the world's most deprived people. APOC's enforced experience in continuing some delivery of health care in conflict and post-conflict situations demonstrates that it is possible to cope in such circumstances and represents a body of knowledge that can be transferred to others facing similar difficulties. Aware of the responsibility represented by APOC's path-breaking role in neglected tropical diseases policy in Africa and working to maximize the current programme (with thJ goal of sustainability at the fore) APOC commissioned the 2005 External Evaluation Report. This provided the opportunity for an assessment of the current status of APOC and how best to iake the programme forward. It has informed this strategic Action Plan and where appropriate the Expected Outcomes. The heading dates are initiation dates only, not completion dates. o APOC: at the vanguard of neglected tropical diseases policy in Africa, Action Plan 2006 to 2010. APOC Management, 20 June 2006 APOC: at the vanguard of neglected tropical diseases policy in Africa Action plan currently in progress and to continue: APOC and Partners l. APOC is advocating for and supporting the training of key CDTI staff, particularly district coordinators and project managers, on methodologies and other key aspects ofoperational research. 2. APOC is intensiffing communication with project staff at various levels and with partners e.g. enhancing field visits to promote shared understanding of problems encountered and their possible solutions. 3. NOTFs are intensiffing sensitization and mobilization to o Encourage communities to select more CDDs. o l,, ffi:l'.:iJlf8r;i:fi'",Ti3l .",,", ' a decreasing workload for individual CDDsI an improved level of coverage. . Increase communities'selection of Women CDDs.r Remindi' [iHtdf#:::;.. ' the Public . political leaders about the basics of CDTI, particularly the need to continue ivermectin treatment for many years after symptoms disappear and the progress of the disease has been halted. Expected Outcomes: for . onchocerciasiscontrol r other neglected tropical diseases' the participating countries. . Data collection ' CDTI implementation. . increased CDDs per population ratio of for ivermectin distribution . increased treatment coverage . reduced demand for incentives' onchocerciasis comPonent. APOC Management, 20 June 2006 APOC: at the vanguard of neglected tropical diseases policy in Africa Action plan for 2006: APOC and partners l. APOC will synthesize the monitoring and evaluation experiences of CDTI projects appraised to date (in 10 countries) to identifu lessons that could benefit individual projects. Expected Outcome: 2. APOC will convene an ad hoc meeting of experts on the criteria for certification of vector elimination in all the Vector Elimination Projects (VEPs) and consider the best way to report on and publicise the success of the vector elimination at Itwara, Uganda. Expected Outcomes: Itwara focus represents for APOC and the health of Africa's poor. 3. APOC will prepare an analytical position paper for review and decisions by Technical Consultative Committee (TCC) and Committee of Sponsoring Agencies (CSA) on issues related to the NOTFs' responsibility for providing 25% of a project's ivermectin- distribution costs. r The PaPer will: o Ensure that efforts in monitoring contributions by participating governments and NGDOs (in compliance with their obligations under the APOC Agreement) are enhanced; o And lead to: o Development and implementation (with NOTFs) of a mechanism whereby planned and actual contributions by local partners can be better examined. o A mechanism to trigger corrective action by NOTFs and, if needed, by APOC, e.g' targeted advocacy measures within or outside the country. Expected Outcome: F The development of a position paper on participating governments' and NGDOs' contributions to ivermentin distribution costs. 4. APOC will collaborate with WHO headquarters to find a responsive solution for retaining STPs whose contracts cannot be converted into fixed-term status, including ways that permit APOC management to continue to employ essential professional staff. Expected Outcome: 5. NOTFs will formulate a plan to provide for the budget needed to sustain and enhance capacity building. APOC and partners can then ensure adequate funds are available, as n"Ld"d, for projects that have completed their fifth year. The plan should incorporate: . Needs for training and retraining of health workers and CDDs, . Review and revision of Information, Education, Communication (IEC) materials. Expected Outcome: F Country NOTFs will produce new and revised IEC materials to lead the programme forward at the local human level and allow appropriate funding allocation. APOC Management, 20 June 2006 APOC: at the vanguard of neglected tropical diseases policy in Africa 6. APOC will ensure that the system (developed by MEC/TCC) for dealing with Severe Adverse Events (SAEs) is rapidly made available to countries with a high risk of SAE. The system will be further updated when validated new information are provided through Rapid Assessment of Loaisis (RAPLOA). Expected Outcomes: onchocerciasis and Loaloa. 7. APOC will develop a plan for the transfer of functions to the participating countries with the goal of sustainability. The plan will o Define areas of activity to be transferred . Speci& participants' roles e.g. NOCPA{OTFs, WHO country offtces (APOC expects WHO support to be provided on a Country-by-Country basis tailored to local needs), NDGOs. o Delineate workable timeframes for achieving an effective transfer before APOC closes. Expected Outcome: F Action Plan (with timeframe) for decentralization of APOC HQ functions (Ouagadougou) concerned with managing the APOC Trust Fund to the participating countries and WHO country offices. 8. APOC's will ensure that optimal technical assistance is provided to the Tukuyu (Tanzania) VEP project, both for treatments and for entomological evaluation. By the end of operations, the procedure should be similar to that in Bioko (Equatorial Guinea). g. APOC's VEP at Mpamba-Nkusi (Uganda): one more annual larvicide treatment round is expected to be performed, and intensive entomological monitoring continued. At the end of 2005 this VEP was deemed likely to repeat the success at Itwara (Uganda). Itwara and Mpamba-Nkusi could serve as pilots for future elimination of S. neavei foci in East Africa. ApOC has given the projects all the support needed for a successful conclusion, notwithstanding the 2005 deadline for completion of larviciding. Expected Outcome: . Mpamba-Nkusi(Uganda) . Bioko Island (Equatorial Guinea) . Tukuyu (Tanzania). 10. Be alert to and immediately investigate reports of 'leakages' of ivermectin, and promptly take corrective action. Expected Outcome: APOC Management, 20 June 2006 APOC: at the vanguard of neglected tropical diseases policy in Africa Action plan for 20072 APOC and partners l. APOC will initiate a detailed review (with help from WHO headquarters staff and/or outside consultants as necessary) on staff adequacy for implementation of the 2005 External Evaluation Report recommendations and take follow-up actions, where appropriate. Expected Outcome: 2. NOTFs to organize special meetings to deliberate and reassess the current status of 'incentives': without these CDTI may be unsustainable' Expected Outcomes: ' Regional ' CountDr-specific 3. ApOC will enhance Learning-by-Doing through a meeting of national and local project coordinators involved in projJcts in their 3'd year of phasing-out to o Pool experiences o Draw lessons o Share results. Expected Outcomes: Evaluation Report's recommendations and sustainability. and utilization ofshared results, lessons and experiences. 4. ApOC will analyze the process of developing and implementing sustainability plans, with a view to determining standards for CDTI budgets. Expected Outcomes:) Guidelines for CDTI budgets for implementing and sustaining these projects' practice in cDTI sustainability will serve as an example for others. 5. ApOC will document experiences and lessons on CDTI in conflict situations and offer greater help in conflict/post-conflict situations so that regardless of the number of years a [roject has been in eiistence, CDTI will be considered to be in its initial phases, reniembering that most work cannot be done until peace is restored. Such experience could lead to guicLlines useful for countries that might move into conflict situations in the future. Expected Outcomes: CDTI. World i"pt,t on beit practices in drug delivery for Neglected Tropical Diseases. countries to implement the 2005 External issues related to CDTI incentives and APOC Management, 20 June 2006 APOC: at the vanguard of neglected tropical diseases policy in Africa 6. APOC remains aware that effective partnership will be essential for sustainability of CDTI, and in view of the phasing-out and eventual closure will o Formulate plans (collaborating with WHO where required) for increased involvement of WHO country offices in CDTI activities (December 2007). o Formulate similar plans with any other organisation, such as UNICEF, which could make a substantive contribution to the sustainability of CDTI. o Define clearly and in good time the role, contribution, and willingness of other partners - current as well as those yet to join the partnership - within the overall obj ectives of post-APOC activities. Expected Outcomes: 7. APOC vector elimination at Bioko will maintain entomological monitoring over another two-year period. If the biting fly reappears during this period, a protocol will be worked out for a national project. Expected Outcomes: D Development of nationals' capacity to conduct vector elimination monitoring activities. surveillance operations. 8. APOC will introduce the impact assessment protocols for monitoring human infection (as already carried out on a national basis by some APOC-countries) to all participating countries. ln countries with only one sentinel site the number of sites will be increased. Expected Outcomes: F New sentinel sites established in all participating countries for impact assessment of human infections. r Fact sheets . Publications . Advocacy Reports APOC Management, 20 June 2006 APOC: at the vanguard of neglected tropical diseases policy in Africa Action plan for 2008: APOC and partners 1. APOC will advocate with governments asking them to examine their role at each administrative level in the country, and identiff programme-related areas for strengthening in preparation for transferring functions to individual country governments. 2. APOC will develop a plan for the transfer of its functions to the participating countries with the goal of sustainability. The plan will o Incorporate a Learning-by-Doing approach that begins by intensiffing support to a small number of countries whose experience will serve to inspire and provide practical help to others. 3. APOC will give greater priority to operational research and enable active APOC participation in scientific discussions at national and international meetings. Expected Outcomes: F Ensure the inclusion of onchocerciasis control on major regional political agendas and at high profile conferences. evaluation of good practice in decentralization and plans for the exit of APOC can be demonstrated. key research needs. 4. APOC will work with programme financial and administrative assistants stationed in WHO offices (whose responsibilities are clearly defined), to ensure they are able to . Play a role conducive to decentralizing certain APOC functions o Alleviate the administrative burden on APOC headquarters in these matters. o Expand the responsibilities and authority of such officers, among other things to o Screel and recommend approval or otherwise of project expenditure statements o Advise on oPerational budgets o Take part in operational audits and reviews o Provide training. Expected Outcomes: F Establish guidelines for WHO country offtces' responsibilities. APOC Management, 20 June 2006 APOC: at the vanguard of neglected tropical diseases policy in Africa Action plan for 2009: APOC and partners 1. APOC will encourage NOTFs to o Ensure that all projects go to scale with community self-monitoring. o Ensure adequate investment is made in follow-up REMO studies: the programme urgently needs updated information on onchocerciasis endemicity in selected areas. o Enhance information sharing among all stakeholders and strengthen communication among partners by establishing APOC-funded country-onchocerciasis-websites. Expected Outcomes: countries diseases (NTDs) will be produced. Country-by-country case studies on Rapid Epidemiological Mapping for Onchocerciasis (REMO) for disability estimates on onchocerciasis and other NTDs will be produced. Technical support will be provided to countries enabling them to implement health impact assessment. Country-by-Country websites for APOC activities. APOC's example as the path-finder for neglected tropical diseases, appropriate financing mechanisms, research priorities and surveillance can by publicised and shared. 2. APOC requests that the Ministries of Health in the participating countries and their partners: o Work to ensure that CDTI is fully integrated into the health systems of all the participating countries in Africa, with levels of therapeutic coverage to be kept as high as possible and at least at 65+oh. o Strengthen their collaboration with other partners (including donor agencies), to find ways of enhancing integration of health services and developing an appropriate strategy and plan. Expected outcomes: through collaboration with regional organization such as WAHO' other NTDs. 3. APOC requests that the International NDGOs: o Actively take part in future joint planning exercises dealing with the longer-term future of CDTI, because their past experience in APOC's development represents a resource for the future. o Envisage strengthening their support even further, as required by current and emerging projects. o Jointly with NOTFs, identifu local NGDOs with the potential to act effectively on their own after training and capacity building. Expected Outcomes: NGDO Coalition. the participating neglected tropical APOC Management,20 June 2006 APOC: at the vanguard of neglected tropical diseases policy in Africa 4. APOC requests that our Comrttittee of Sponsoring Agencies/.lAF partners: o Arrange for an expert review of the stratery and research on MACROFIL. . Ensure there is active support to find and prompt use of new drugs and technologies, particularly macrofilaricides and alternative drugs to Mectizan @. o Extend APOC Trust Fund support, on a decreasing scale, to 2015 to o Compensate for the delays that a number of CDTI projects have experienced o Ensure that the remaining projects - some of which will operate under difficult post-conflict environments - are brought to satisfactory conclusion. o Enhance effectiveness and quality of its deliberations on sustainability by inviting resource persons, possibly country representatives on a rotation basis, to participate in deliberations on relevant agenda items. o Alleviate the heavy workload on Programme management by rationalizing and reducing statutory and other meetings. Expected Outcomes: conflict situation. 10 APOC Management, 20 Jurre 2006 APOC: at the vanguard of neglected tropical diseases policy in Africa ACRONYMS APOC African Programme for Onchocerciasis Control CDD Community Directed Distributor of Ivermectin CDTI Community Directed Treatment with Ivermectin ComDT Community-Directed Treatment CSA Committee of Sponsoring Agencies DALY Disability Adjusted Life Year IEC Information, Education, Communication NGO Non-Governmental Organization NOCP National Onchocerciasis Control Programme NOTF National Onchocerciasis Task Force NTD Neglected TroPical Diseases OCP Onchocerciasis Control Programme REMO Rapid Epidemiological Mapping of Onchocerciasis SAE Severe Adverse Effect STP Short-term Personnel TCC Technical Consultative Committee (of APOC) VEP Vector Elimination Project WAHO West African Health Organization WHO World Health Organization 11 APOC Management, 20 June 2006