Committee of Sponsoring Agencies (CSA): report of the hundred and eleventh session Amsterdam, 19-20 October 2005

/' /. RESTRICTED APOC CSA 117 THE AFRICAN PROGRAMME FOR ONCHOCERCIASIS CONTROL (APOC) COMMITTEE OF SPONSORING AGENCIES (CSA) Report of the hundred and eleventh session Amsterdam ,19-20 October 2005 OPENING OF THE SESSION 1. The lllth session of the Committee of Sponsoring Agencies (CSA) was held on 19 and20 October 2005 at the Dutch Royal Tropical Institute (KIT) in Amsterdam. In the absence of Dr Anarfi Asamoa-Baah, chairman of CSA, the meeting was chaired by Dr James Mwanzia, Director of the Division of Disease Prevention and Control of the WHO Regional Office for Africa who was attending the CSA for the first time. Dr Mwanzia expressed delight to be associated with the "oncho partnership" and stressed the need to focus on surveillance in order to safeguard the achievements made in onchocerciasis control. A complete list of participants is attached as Annex l. ADOPTION OF THE PROVISIONAL AGENDA 2. The provisional agenda attached as Annex 2 as well as the corresponding annotated agenda were adopted without modifi cations. CONSIDERATION AND ADOPTION OF THE DRAFT REPORT OF CSAllO 3. The draft report of CSAIl0 held last July in London was approved with minor amendments to paragraphs 84 & 85. CHAIRMANSHIP OF CSA 4. Following his reassignment to new responsibilities within WHO, Dr Asamoa-Baah will no longer be able to continue as chairman of CSA. The Committee acknowledged his invaluable contribution to the work of the Committee and thanked him for his strong leadership. It was agreed that WHO should however continue to chair CSA sessions untilthe end of 2005. The decision on the chairmanship of CSA for 2006 was postponed to allow for further consultations among members. INAUGURATION OF THE ONCHO STATUE 5. The working session of CSA was preceded by the inauguration of an "Oncho statue" on l8 October 2005. The statue, placed at the entrance of KIT is one, and the last of five statues, inaugurated in recognition of the unfailing support of the donor community to onchocerciasis control and particularly, to thank the Government of the Netherlands for its long and exceptionally strong commitment to OCP and APOC. Mr Robert de Vos, Deputy Director-General for International Cooperation of the Netherlands, who also represented the donor community, unveiled the statue. Six speakers at the ceremony (representing KIT, donor community, Merck, NGDOs, World Bank and WHO), all hailed the achievements of OCP and APOC, briefly highlighted the role of their organization or institution in the "Oncho partnership", expressed delight in being part of this unique partnership and stressed the need for the achievements of the programmes to be protected. They encouraged that the lessons learnt from the success of OCP and APOC should be used to promote implementation of other donor-funded health interventions and to improve access of essential health care services to remote communities. The partners echoed the pledge to continue their support to the partnership until the end of APOC and to ensure that appropriate mechanisms are put in place for a ] 2 sustainability. The statements of Mr Robert de Vos on behalf of the Kingdom of theNetherlands and of the donor community and that of Mr Michel Iguer of Merck & Co Inc. are attached as Annex 3a and Annex 3b respectively. 6. The ceremony was followed by a roundtable discussion of the crucial issues relating to onchocerciasis control, a summary of which is also attached as Annex 4. 7. Prior to the inauguration of the statue, an informal meeting was also held with Mr Robert de Vos, the Dutch Deputy Director-General for International Cooperation, to brief him on APOC operations, and to emphasize the need for APOC operations to extended beyond 2010. APOC Management informed Mr Robert de Vos that Dutch funds were being used to promote integration of other health interventions into CDTI; and in this regard, KAP studies on maternal and child health have been carried out in Cameroon and Nigeria and a national policy on integration was being developed by the Government of Tanzania. 8. Mr Robert de Vos commended the efforts of APOC Management in the area of integration and warned against the risk of burdening the CDTI structure and losing focus on onchocerciasis control. He was reassured that a study was being carried out in 9 sites on add-ons to ensure that additional health interventions along with CDTI would not jeopardize operational effectiveness. FOLLOW-UP ON THE ROUNDTABLE 9. CSA emphasized the need to strengthen national health systems; improve the national human resources capacity through recruitment of additional staff and training; improve financial accountability and encourage more participation of civil society. 10. Given the implications of the process of strengthening of national health systems, Dr Roungou suggested that it might be necessary for a special session of TCC to look into the issue and advise on appropriate action to be taken. It was also agreed that integration was a crucial issue and should continue to be on the agenda of subsequent CSA sessions. THE 26TH SESSION OF THE NGDO COORDINATION GROUP I l. According to Drs Tony Ukety and Adrian Hopkins, respectively Coordinator and Chairman of the NGDO Coordination Group, the main focus of the Group's discussions, among other issues, was on: the proposed extension of APOC until 2015 without extra funding. The Group felt that the extension should perhaps be considered to go up to 2020 (and not 2015) in order to complete implementation of planned CDTI projects. CSA warned that extending APOC operations until2020 had even greater implications and donor fatigue should be taken into consideration. The World Bank was to verify the maximum duration for which the APOC Trust Fund could be extended; ll. integration of other health interventions (the Guinea experience of reproductive health); JaJ lll lv. vl ll. ll1. delays in the release of funds by APOC Management which seemed to be affecting the credibility of APOC at the project level; APOC Management explained that the longest delays were those attributable to the processing of the Letters of Agreement (LOA) which require that certain WHO financial and accounting conditions should be fulfilled in advance. Dr Jean-Baptiste Roungou, acting Director of APOC suggested that other options should be explored to accelerate the release of funds to projects such as going through the WHO country offices; or disbursing funds according to the Plan of Action (POA) of the projects; the need for a coordinating body for onchocerciasis control in the whole of Africa; the need to review the structure of CSA to better reflect the current partnership. This will necessitate the revision of the APOC Programme Document; the availability of funds at MDP for operational research on the impact of ivermectin treatment on the affected communities; TCC expressed great concern about the serious implications on APOC operations of the WHO policy on the use of short-term staff and the need for US$2.5 million for APOC Management to be able to convert the current 10 STP posts to fixed-term positions; TCC urged that requests received by MDP for ivermectin for clinic-based treatment of onchocerciasis from institutions outside of the Ministry of Health in Loa loa endemic areas should be supplied through the NOTFs and that those institutions be made aware of the risks of SAEs; TCC unanimously endorsed the proposal of APOC Management to request donors to authorize the extension of the APOC Trust Fund until 2015 at no extra financial cost to donors in order to complete the implementation of delayed CDTI projects. TCC also endorsed the following options proposed by APOC Management for the future of APOC activities: a) to extend the geographic scope of APoC to include all onchocerciasis-endemic countries in Africa; b) to expand the mandate of APOC to include the control of other neglected diseases; Delays in the release of funds by APOC Management to CDTI projects have been explained to be mainly due to late submission of financial returns by the projects, non compliance of WHO financial procedures, the heavy workload on the APOC financial vil where the security situation hinders access to an area for the assessment of a given situation, the Group suggested that APOC Management should consider using available reports of other APOC partners on that situation, to which APOC Management agreed. CONCLUSIONS AND RECOMMENDATIONS OF TCC2I 12. Dr Laurent Yameogo, presented the main conclusions and recommendations of TCC2I held from 12-17 September 2005 in Ouagadougou as summarized below: lv +4 vil vt vlll tx. x. xl. staff and to some extent, the inadequate national capacity to deal with the increasing number of projects; The World Bank peer review team of the APOC cost per treatment study endorsed the methodology and findings of the study. The recommendations of the peer review team have been incorporated in the final report of the study which was distributed to TCC2I. The Committee also recommended that APOC Management should send a copy of a cost manual developed by the cost study team to each NOTF and to request the assistance of the NOTFs in identifying projects (in the 5th year and beyond which are not in conflict or post conflict areas) to field test the manual on a voluntary basis; TCC requested TDR to convene a consultative meeting of experts to address the issue of "nodding disease" as it relates to the implementation of CDTI; TCC recommended that a research team be commissioned to develop and implement a protocol for studying incentives and their effect on performance (coverage and CDD attrition) and their potential for sustainability of CDTI projects; TCC recommended that the 12 CDTI projects in DRC whose implementation had been interrupted following SAEs could now resume in accordance with the plans of action outlined by the National Coordinator, the TCC/MEC guidelines and a number of conditions spelt out by TCC; TCC reviewed a total of 37 annual technical reports, accepted 35 reports and rejected 2 reports. It also reviewed 4 operational research proposals and recommended the rejection of all 4 proposals to be revised in the light of TCC observations and resubmitted to the next TCC. The Committee however accepted reports of 4 KAP studies in Nigeria and noted 2 progress reports from Burundi and Congo; TCC recommended that the 3 proposals from Tanzania for integration of Vitamin A Supplementation into CDTI should be revised to address the concerns of TCC as communicated to the NOTF and be resubmitted to APOC Management as soon as possible. If necessary, APOC Management should provide technical assistance in revising the proposals; TCC22 will meet from 13-17 March 2006 and TCC23 from l1-15 September 2006, both to be held in Ouagadougou, Burkina Faso. 13. Dr Mwanzia remarked that the current WHO short-term time-limited contractual policy did not affect only APOC and SIZ staff but many other WHO programmes and a global solution was being sought by the WHO Administration. In the meantime, APOC Management was advised to invite the AFRO Regional Personnel Officer to Ouagadougou as soon as possible to explore possible solutions to the APOC and SIZ staff problems. a5 REPORTS OF EXTERNAL EVALUATIONS The APOC External Evaluation 14. Before the main presentation, the 2005 APOC External Evaluation Team (EET) represented at CSAIll by Dr Tarimo, Team Leader, and Dr Philippon, remarked that, in order to facilitate follow up action, it would be useful for future evaluation teams to receive from APOC Management, not only copies of reports of previous evaluations, but also a plan of implementation of the recommendations of those evaluations. 15. Dr Tarimo summarized the objective of the evaluation which was to assess: l) whether APOC was making progress towards meeting its 2010 objectives; 2) what measures should be taken to fulfill those objectives; and 3) how best can CDTI be sustained after 2010 to ensure the elimination of onchocerciasis as a public health problem throughout APOC countries. 16. The findings of the EET were presented under 3 main headings, namely l. Implementation of the CDTI Strategy; 2. Programme Management 3. Partnership 1. Implementation of the CDTI strategt 17. The EET commended APOC staff and partners for the impressive achievements made by the Programme and highlighted a number of issues, some of which are summarized in the subsequent sub paragraphs: there is inadequate mobilization of communities to increase the number of CDDs;to motivate them by providing the necessary incentives; and lack of standard policies on the provision of incentives to community volunteers in the countries. The EET recommended that NOTFs and CDTI projects should intensify sensitization and mobilization for more CDDs, pa(icularly, women, and to organize special meetings to reassess the situation on incentives; although most projects evaluated are doing well in supervision, monitoring and evaluation, they lacked standards for developing CDTI budgets. The EET recommended that APOC and NOTFs should intensify their efforts to ensure that all projects embark on community self- monitoring and that each NOTF should formulate a plan including the budget needed to sustain capacity-building. APOC should also analyze the process of developing sustainability plans and all the resulting plans that have been developed up to date, with a view to setting standards for drawing CDTI budgets at the country level; iii. there is a danger of averages (data analysis is weak at all levels); impact assessment of ivermectin treatment in l4 sites in APOC show good results but need to expand monitoring of human infection to all participating countries and include socioeconomic parameters in the assessment; lv. i6 vl compliance with long-term treatment with ivermectin; APOC is funding a study in this regard; delays in project implementation due to conflict and SAEs. In view of the importance of ensuring that all projects are brought to a satisfactory conclusion, the EET recommended that the APOC Trust Fund be extended to support those projects up to 2015 on a decreasing scale; vll there is a rapid turnover of staff at the Ministry of Health in the participating countries, resulting in frequent loss of health staff trained in the CDTI approach; vill the current capacity of TCC and APOC Management to support research is inadequate. The relevance of the strategy adopted and the quality of research on a macrofilaricide were not quite understood in the field. The team therefore recommended that CSA should arrange for an expert review of the strategy and quality of research on Macrofil. The EET further recommended that APOC Management should give more priority to operational research and suggested, in that regard, the creation of one senior research officer post at the APOC/HQ to coordinate APOC research activities and to scientifically promote the Programme at the international level; lx. although vector elimination in two foci (ltwara and Mpambu-Nkusi) seemed to be achievable, it was difficult and uncertain in Tukuyu and Bioko foci where some management issues were also noted. The EET recommended that entomological monitoring be maintained in Bioko for another two years and a protocol be worked out for a national project in case the simulium reappeared. The team also recommended that APOC should ensure that optimal technical assistance is provided to the Tukuyu focus both for treatments and entomological surveillance. For those countries that wish to embark on their own, on vector nuisance control (which is not in the mandate of APOC), the EET recommended that APOC should provide the necessary technical assistance. 2. Programme Management 18. A number of issues were noted by the EET in the area of Programme Management, among which were: the repeated absence and role of UNDP (one of the sponsoring agencies of APOC); the great demand on APOC management, and the high number of meetings. To alleviative the heavy workload on APOC Management, the EET also suggested that CSA should rationalize and reduce the number of statutory and other meetings. 19. Despite some increase in the number of staff, there was still heavy workload on APOC Management staff particularly with regard to the number of financial statements to be reviewed/cleared and the processing of Letters of Agreements (LOAs). It was necessary for APOC Management to take a more closer look at the impact of the current arrangements and to explore alternative solutions. The EET recommended that a detailed review should be undertaken, possibly by WHO Headquarters or external consultants, of APOC's financial management systems and of the adequacy of staff; and to address the contractual issues of the short-term staff. The review should also make appropriate recommendations to assist APOC Management in its tasks and the implementation of the findings of this evaluation. I7 20. The team also noted that CSA is taking more interest and leadership in issues of sustainability of CDTI projects and recommended that in order to enhance the effectiveness and quality of CSA's deliberations on the issues, CSA should consider inviting resource persons, possibly representatives of NOTFs, on a rotational basis to participate in deliberations on relevant agenda items. 21. The EET also remarked that TCC has now been relieved from financial assessments of CDTI projects, and technical reviews have been much standardized. Therefore, should TCC now be focusing its attention on innovation and operational research issues. 22. The evaluation revealed that although APOC had a good governance structure, communication between levels, and partners particularly in the area of financial management was weak. 3. Partnership 23. The critical role of the NOTFs as a coordinating mechanism was recognized and their future role after APOC was being debated. According to the APOC Memorandum, NOTFs are expected to come up with 25Yo of the cost of CDTI activities. There was inadequate data on funding at country level for the EET to better assess the capacity of countries to meet this requirement. The EET requested that APOC Management should prepare an analytical position paper on the issue for review and decision by TCC and CSA. Perhaps experience from monitoring of sustainability plans could be helpful in this exercise. 24. Decentralization was being discussed without a clear strategy as to how it should be carried out. The EET requested that, drawing on the experiences of other programmes and agencies, APOC Management should prepare a position paper on decentralization of selected functions from APOC/HQ to the country level. 25. The evaluation noted that APOC has been forceful in promoting integration through CDTI and that communities had the choice of what they want to integrate. The problem was found to be at the higher level in the countries. The recent APOC initiative to support high-level meetings on community health interventions was therefore highly commended. The EET stressed the need for WHO to take the lead and recommended that CSA and JAF should organize consultations with partners (governments, international organizations, donor agencies and NGDOs) at an early stage on ways to support CDTI after APOC comes to an end. Perhaps envisage the creation of an international coordinating and surveillance mechanism to be effective by 2010. 26. NGDOs have also been critical to the success of CDTI. It was reported that NGDOs were very willing to continue their support to CDTI projects after APOC. One of the challenges is to promote the involvement of national NGDOs and to intensify their participation in planning for the future of CDTI activities. 27. The logistical and financial management support provided by the WHO country office was also acknowledged. The EET stressed the need to continue the dialogue in order for WHO and other UN agencies such as UNICEF to increase their support to CDTI after APOC. 28. The EET concluded that on the whole, APOC is moving towards the achievements of its objectives, but the target of 2010 will not be achieved because of delays, particularly related to T8 29 conflict situations. Onchocerciasis control needs to be sustained after APOC comes to an end and for that, all partners involved (JAF, CSA, APOC Management and all participating countries) needed to put in place adequate measures through appropriate global/regional partnerships and high-level advocacy to maintain public awareness and to secure sufficient funding from participating countries and other sources. The Mid-Term Review of SIZ and ex-OCP countries The objectives of the mid-term review were to review the: i. Management of SIZ; ii. CDTI, vector control and surveillance activities in SIZ countries; iii. Surveillance activities in the ex-OCP countries; iv. Prospects for sustainability of onchocerciasis control beyond 2007; and v. Need for ongoing support to ex-OCP countries. Management of SIZ 30. The team reported that although the structures and staff have been in place since the beginning of SIZ, the National Onchocerciasis Committees (NOCs) were not functional and countries remarked that the technical assistance received from SIZ/HQ was weak. SIZ Management therefore needs to increase technical support to the countries and to encourage countries to revive the NOCs. The contractual status of the SIZ staff was also an issue of concern for which WHO needed to give due consideration by retaining the current staff until the end of SIZ activities in 2007 . 31. CSA expressed concern about the effect of the application of the 4-year-limited short-term contracts on the SIZ staff. If the rule were to be applied, the contracts of all SZ staff would be terminated on 3l December 2006, that's a year before the planned end of SIZ operations. It was recommended that the special case of the SIZ staff needed to be highlighted given the timeframe for the remaining SIZ activities and the expertise of the staff involved. APOC/SIZ Management was requested to prepare a paper for CSA to make a case with the WHO Administration. CDTI, vector control and surveillance in SIZ countries 32. CDTI activities are smoothly ongoing and communities have taken ownership of ivermectin distribution. Ivermectin is readily available and coverage is high. The main issues are related to CDD motivation, delay in reporting, the rationale for 2 annual treatment rounds and, the poor geographical coverage noted in some countries (Ghana, Togo and Sierra Leone). 33. The team recommended that countries should be encouraged to discuss and work out with communities mechanisms for suitable incentives to CDDs. SIZ Management should ensure continued capacity-building at the community level; and should check the relevance and the cost of 2 rounds of treatment. National teams should also be requested to verifythe real reasons forthe delay in reporting. 34. Vector control activities (larviciding and entomological surveillance) are ongoing in the defined areas with significant improvements in the Annual Biting Rates (ABR) and Annual Transmission Potential (ATP) in the Oti basin. There were however concerns in the Oudmd basin a9 where ABR and ATP rise high during the rainy season. The origin of the flies and residual transmission was still unknown. Problems of integrated data analysis were also noted. 35. The Review team recommended that larviciding should continue in the SIZ countries until 2007 and the origin of the persistent transmission in the Ou6m6 basin be verified. SIZ Management should also undertake in-depth and joint analysis of entomological, epidemiological and therapeutic coverage data to better understand the situation. S urvei I lance aclivit ies 36. In 3 of the 5 SIZ countries, CMFL has been maintained below the threshold which indicates a positive impact of combined vector control and ivermectin treatment activities. Despite some indication of local problems, there was an overall prolonged decline in prevalence. With the exception of Sierra Leone, the epidemiological results were satisfactory in the 4 countries outside the SIZ area where there was no socio-political unrest. 37 . The team also noted a number of issues which included the non respect by national teams of the initial protocol established by OCP for surveillance; inadequate financial resources in non-SIZ countries; lack of integrated data analysis and the pool screening network and technique which was not operational. The review team recommended that SIZ Management should ensure that national teams use imperatively the initial protocols defined for epidemiological surveillance. SIZ Management, MDSC and other onchocerciasis control experts are requested to urgently reflect on ways to improve the pool screening technique which, for the time being, was not helpful to countries. The SIZ Management should also ensure that epidemiological, entomological and CDTI data analysis are all integrated. Pr o s p e ct s for s ust ain o bi I ity 38. The review found that onchocerciasis was well integrated at all levels in most countries and there was a well-developed partnership between NGDOs, Merck/MDP, World Bank, WHO, communities and countries). However, the main challenges included the decreasing funding from governments and NGDOs; integration of CDTI and other health intervention activities; and the weakness in operational research. 39. The Review team recommended that SIZ Management should track all partner contributions and ensure that countries establish a core budget for CDTI activities. Countries and SIZ Management should also give priority to operational research. Need for ongoing support 40. Obviously, at the end of SIZ in2007, CDTI will continue in the current SIZ countries and ex- OCP areas; and there will be need to prolong support to Sierra Leone, COte d'lvoire and Guinea Bissau to continue CDTI activities. It would also seem necessary to establish a kind of collaboration between all ex-OCP countries in the field of CDTL In this regard, the team recommended that there was need for an intercountry mechanism to strengthen support to ex-OCP countries in order to safeguard OCP achievements. The Review team felt that APOC appears to offer the most adequate platform for such intercountry mechanism. al0 41. The review team concluded that national teams and communities in SIZ and ex-OCP countries were doing an impressive job and should be given more support in order to secure CDTI coverage and maintain the good epidemiological trends. 42. It was remarked that since the closure of OCP onchocerciasis has not been considered as a priority disease in some countries and was not on the list of diseases for integrated surveillance. In this regard, sensitization campaigns, such as those recently undertaken in Mali, Senegal and Guinea, needed to be reinforced in all ex-OCP countries. BRAINSTORMING ON APOC EXTENSION 43. At its last session, CSA suggested that more time be devoted to looking into the scenario, and particularly, into the cost estimates of the proposed extension of APOC operations beyond 2010 in order to allow for the completion of the implementation of the delayed CDTI projects. A brainstorming session was held in this regard and it was agreed that, at this point, it would be advisable to submit only a vision paper to JAFI I for comments. The content of the vision paper was agreed upon and the World Bank agreed to draft and present the paper at JAFI I in December 2005. FINANCING OF ONCHOCERCIASIS CONTROL ACTIVITIES IN AFRICA 44. Dr Tony Ukety, presented the 2004 contributions of CBM, MITOSATH and SSI to APOC- supported projects which totalled an amount of US$l 861 959. Most of these contributions was related to direct field cost and supervisory cost. 45. Dr Bangoura reported that, as at 30 September 2005, a total of US$9 274 959 had been received into the APOC Trust Fund and an amount of US$10.3 million had been disbursed to WHO for APOC operations. The APOC funding gap for the total Phase was now less than US $10 million. The World Bank also contributed an amount of US$ 400 000 to the Multidisease Surveillance Centre (MDSC). 46. It was remarked that the sum of partner contributions did not always match those declared by projects. CSA once more stressed the need for a tool for tracking partner contributions. If no tool existed already which could be adapted by APOC, the World Bank was willing to help design one. It was also suggested that it might be advisable to have someone in APOC Management specifically in charge of tracking partner contributions. UPDATE ON PREPARATIONS FOR THE TECHNICAL AND MINISTERIAL MEETINGS OF THE EX-OCP 47. CSA was informed that the West African Health Organization (WAHO) Ministers meeting which was scheduled to be held in October 2005 in Nouakchott, Mauritania had been postponed until further notice. The meeting was expected to offer an opportunity for the Ministers of Health of ex- OCP countries to meet and discuss onchocerciasis surveillance activities in their countries. all 48. The difficulty in convening a meeting of the ex-OCP countries indicated once more the need to have a platform, some kind of intercountry facility to coordinate the activities of the ex-OCP countries. It was recalled that at the closure of OCP in2002, one of the recommendations of the final communiqu6 was for WHO to organize a special meeting of the Ministers of Health of the ex-OCP countries during the AFRO Regional Committee meetings. CSA stressed and requested APOC and SIZ Management to liaise with AFRO to ensure the implementation of this recommendation. The World Bank is willing to contribute to funding such parallel meetings of ex-OCP Ministers of Health at AFRO and WAHO meetings. 49. The dates of the next World Health Assembly and the WAHO meetings were to be taken into consideration in planning for the proposed APOC Donors' Conference next year. TCC MEMBERSHIP 50. CSA suggested that consideration of the TCC membership be postponed until the next CSA session in December 2005 to allow APOC Management to better prepare and submit to CSA a concrete proposal of the membership. UPDATE ON THE NEGOTIATIONS WITH EVERGREEN HELICOPTERS OF THE AERIAL LARVICIDING CONTRACT AND PROGRESS REPORT ON SIZ ACTIVITIES 51. Dr Yameogo informed CSA that WHO currently pays US$1225 per hour for the aerial larviciding contract with Evergreen Helicopters Inc. (EHI). For the extension of the contract for 2006-2007, EHI had increased its rate to US$1500 per hour which was rejected by WHO. It was emphasized that the budget of SIZ was restricted and cannot absorb any increase in cost. Negotiations were still under way to come to an agreement with EHI on the rate. REVIEW OF JAFll WORKING DOCUMENTS 52. The draft working documents of JAFI I were submitted to CSA for review and comments. The Committee particularly spent considerable time on the Progress Report and the Plan of Action and Budget (PAB) for 2006 and made substantive suggestions for improving the presentation of the budget trend over time. 53. With regard to the PAB, the World Bank remarked that the cash balance held by WHO was often high (US$8 million) and this was explained by the fact that actual expenditure tended to be less than the approved budgets. It was cautioned however that it should be understood that delays in spending approved budgets did not constitute savings but deferred expenditures. For ease of accounting, the World Bank also requested that requests from WHO for disbursement of funds from the APOC or OCP Trust Funds should be accompanied by actual expenditures. 54. Endorsing a recommendation of the External Evaluation Team, CSA requested that APOC Management should request TDR to provide expenditures of the APOC annual contribution in support of Macrofilactivities, at least, for2004. tt2 55. Given the particular attention paid to the scrutiny of the PAB by CSA, it was suggested that in future it would be appropriate for CSA to submit to JAF, along with the PAB, its views and recommendation on the PAB. The World Bank agreed to prepare the draft reflections of CSA to be presented to JAFIl and will circulate the draft to CSA members for comments. UPDATE ON MDSC 56. Professor Koumar6, Acting Director of the MDSC gave an update on the activities of the Centre over the last 6 months, mainly outlining the onchocerciasis and meningitis surveillance activities, the Scientific Committee Meeting, the perspectives and main constraints of the Centre. 57. Professor Koumard reported that the first meeting of the Scientific Committee of the MDSC was held from 4-5 October 2005 in Ouagadougou to review, among others, a l0-year strategic plan of the activities of the Center. However, it was decided to delay review of the strategic plan until early next year to allow for further improvements on the document. 58. The microbiology and bio-molecular laboratories were now fully functional. Entomological surveillance of onchocerciasis was ongoing as well as an enhanced surveillance of meningitis in Africa, both of which were backed respectively by the production of monthly and a widely disseminated weekly bulletin. Training in surveillance, entomology, laboratory and data management, and mapping were also being carried out. 59. The MDSC hoped to sustain the ongoing surveillance activities and to expand them to all countries as necessary. The Center will also develop operational research activities to better explain the epidemiology and control measures of priority diseases. 60. The main challenges of the MDSC remained: funding forplanned activities, human resources development, infrastructure and equipment; and staff contract issues. 61. CSA commended the MDSC for the progress made and hoped that the strategic plan will be reviewed and made available as soon as possible. The World Bank remarked that WHO should give latitude for a broader partnership within the MDSC. It also suggested that APOC and MDSC should make an effort, during their country visits, to liaise with the World Bank offices in the countries to promote collaboration and reinforce the partnership with the World Bank at the country level. DATES AND VENUES OF CSA112 AND CSA SESSIONS IN 2006 62. The Committee agreed to hold its 112th session on 5 December in conjunction with JAFII in Paris from 16.00-18.00 atthe Centre Kleberand to hold a post-mortez session on 9 December2005 after the closure of JAFll. CSAll3 is scheduled to be held from 20-22 March 2006 in Ouagadougou, Burkina Faso. al3 LIST OF PARTICIPANTS l. Dr James Mwanzia, DDC, WHO/AFRO (chairman) 2. Dr Lorenzo Savioli, WHOAITD 3. Dr Ousmane Bangoura, World Bank 4. Dr Ok Pannenborg, World Bank 5. Mr Bruce Benton, World Bank 6. Dr Bj<irn Thylefors, MDP 7. Ms Brenda Colatrella, Merck & Co. Inc. 8. Mr Ken Gustavsen, Merck & Co. Inc. 9. Dr Adrian Hopkins, NGDO chairman 10. Dr Tony Ukety, NGDO Coordinator I L Dr Jean-Baptiste Roungou, Acting Director, APOC 12.Dr Mounkaila Noma, APOC 13. Dr Uche Amazigo, APOC 14. Dr Laurent Yameogo, APOC 15. Prof Brehima Koumar6, Acting Director, MDSC 16. Dr Bernard Philippon, External Evaluator, APOC 17. Dr Andr6 Yebakima, External Evaluator, APOC 18. Dr Eleuther Tarimo, External Evaluator, APOC 19. Mr Abdulai Daribi, AFRO/APOC Liaison Office, WHO (Secretary) Annex 1 It4 Annex 2 PROVISIONAL AGENDA HLINDRED AND ELEVENTH SESSION OF CSA 18-20 October 2005 Royal Tropical Institute (KIT), Amsterdam, The Netherlands l. Opening 2. Adoption of the agenda 3. Consideration and adoption of the draft report of CSAI l0 4. Chairmanship of CSA 5. Review of the programme of events relating to the oncho statue unveiling ceremony 6. Meeting with Mr Robert de Vos, Dutch Director-General for International Cooperation (DGIS): i. Progress report on APOC and SIZ activities highlighting the role of partnership and the contribution of the Netherlands; ii. Discussion on integration of CDTI and some components of Reproductive Health activities and results achieved so far; iii. Options for the extension of the duration of APOC and prospects for future support to APOC by the Netherlands. 7. Unveiling ceremony of the oncho statue 8. Roundtable: Issues will include: i. Introductoryremarks ii. Background on the Onchocerciasis Partnership and its Achievements iii. Bringing APOC to a successful conclusion - the challenges iv. Integration into CDTI of other health interventions v. Conclusions of the roundtable 9. Reflections on the roundtable of the oncho statue unveiling ceremony 10. Feedback from the 26th meeting of the NGDO Group I l. Conclusions and recommendations of the twenty-first session of the TCC 12. Reports of the APOC External Evaluation Team and the Mid Term Review of SIZ and ex-OCP countries 13. Brainstorming on the scenario for extension of APOC operations until2015 I15 14. Financing of the onchocerciasis control programmes in Africa i. Status of the APOC Trust Fund ii. Status of the OCP Trust Fund iii. Support from NGDOs iv. Tracking of financial contributions of participating countries 15. Update on negotiations of the aerial larviciding contract for the activities in the Special Intervention Zones of the ex-OCP. 16. Update on preparations for the ministerial meeting of the ex-OCP countries 17.TCC membership 18. Preparations for JAFI l, Paris i. Update on practical arrangements and logistics ii. Reflections of the CSA iii. Review of the working documents 19. Other matters 20. Dates and venue of CSAI 12 and CSA sessions in 2006 Geneva, 6 October 2005 al6 Annex 3a Statement by Mr. Robert de Vos Deputy Director-General for International Cooperation (DGIS), Dutch Ministry for Foreign Affairs on the occasion of the unveiling of the Oncho statue, KIT, Amsterdam, the Netherlands, 18 October 2005 It is with pleasure that I accept the Oncho statue on behalf of the Netherlands and on behalf of the donor community that was involved in supporting the OCP and APOC programmes. The Netherlands has a long history with river blindness control and the relationship is not limited to the Ministry in the role of a donor. Various persons have been involved as advisers or as scientists and some of the people, who are present here today, can confirm that. Therefore I would like to extend the gratitude also to these persons in the Dutch Oncho community. The statue is already enjoying the Dutch hospitality for some time. But for the unveiling ceremony, we needed to find a convenient occasion and for the statue an appropriate home. This year the statue has found its final location. I would like to thank the Royal Tropical Institute for taking up the role of guardian of the statue, a role that the Institute on behalf of the Netherlands often also played towards the Oncho programme, and for providing the statue a very suitable place in their gardens. At this location, many people can see and enjoy the statue and be witness to what it stands for. It also acknowledges the fact that a much wider group of people in the Netherlands has been involved with Oncho control than the Ministry itself. OCP is generally considered a very successful program that has achieved the eradication of a serious public health disease in major parts of Africa. I will not dwell on all the factors that have contributed to this success and much has already been said. But I would like to highlight a few aspects that have my specific interest. One of the factors of success in OCP and subsequently APOC is the fact that it is a global Private Public Partnership (PPP) with a very clear division of labour and responsibilities: between international and national partners, between public and private and NGOs. Nowadays there is not only a lot of debate on PPP and on the role they can, and should, play in development co-operation but there are numerous ongoing global health initiatives, involving often a large coalition of partners: RBM, Global Fund, Stop TB, just to mention a few major ones. We see how they operate at national and international levels and we are not always pleased by what we see. Collaboration is still hampered by a lack of clarity in the mandates of the various partners leading to duplication of efforts and missed opportunities. Though there is broad support for a better role division and more co- ordination within the UN family, in reality we often see a fragmented and inconsequent UN response. It has become more and more a challenge to find the right design and steering principles in other to get an effective international aid architecture that is able to deliver on the ground. As part of the aid effectiveness agenda, harmonization of the bilateral aid has already been taken up. More recently, there have been efforts to improve the co-ordination in the international HIV/AIDS system. The PPP practice, in combination with the APOC approach of providing support to national programmes tt7 seems to be a positive example of how members of the UN family and other stakeholders work effectively together, each from their comparative advantage. WHO has flourished in its role as executing agency bringing in the technical and scientific expertise, while the World Bank has concentrated on the fund raising and management part. The international world could maybe revisit the lessons from the OCP and APOC case and apply them for their own purposes. Allow me to sidetrack a little. Recently we witnessed the devastating effects of the Katrina Hurricane in the US. What we also saw was a disaster response system that had serious shortcomings. Help did not reach the people in the intended way. What is interesting in this respect is that those who were able to deal with the disaster and the failing emergency response were the people that were effectively organized at the very local level. This situation is not so different from what we normally see in most developing countries where broader support systems are often weak and where people have to rely on their own initiative. Whether it is natural disaster or a serious public health threat, what is crucial is the enorrnous importance of having well organized communities to handle the basic activities needed to deal with the problem. Distinctive from the OCP approach, APOC established effective treatment structures at the community level. It is important that these are sustained and possibly made to use for broader development objectives. I am pleased to know that in some countries promising initiatives are taking place (malaria, HIV/AIDS, other communicable diseases). Of course at the same time we need to invest in the supportive structures and health systems. A major challenge in the context of the MDGs is how to scale up our services. I would like to recall the special conference the World Bank devoted on this topic in Shanghai 2004 during which APOC was mentioned as one of the successful programmes in this respect. One of the central messages is that strenghening the basic health care services is key in scaling up. However for complex disease interventions, some vertical structures of delivery might be needed. In short, we still need to learn more on the proper combination of disease-specific interventions on the one hand and integrated service structures on the other, specified for each disease. One of the amazing features of onchocerciasis control is that it has successfully sustained international support for period of 30 years in times when policy priorities are increasingly politicized, and having a much shorter time frame. It appears that people already talk about the 'ivermectin approach' when they refer to long-term financial commitment. It indicates that the programme has a convincing message, combined with an efficient fund-raising component. Still recent years have shown however that APOC increasingly has to compete with other development goals in assuring funds. This is a political reality that the programme has to face. Aligning APOC with other development intervention might indeed be a sensible strategy for the long-term, including investing in health systems. On behalf of the donors, I thank all partners in the Oncho community for the statue and I wish APOC a sustainable future. l8 Annex 3b Statement by Mr. Michel Iguer on the occasion of the River Blindness Statue Dedication Ceremony at the Royal Tropical Institute (KIT) Amsterdam, the Netherlands, 18 October 2005 Distinguished guests; Members of the press; Ladies and gentlemen; Good afternoon. It is an honor for me to represent Merck at this important event. Merck is a global, research-driven pharmaceutical company that discovers, manufactures and markets a broad range of innovative products to improve the health of patients worldwide. Our first priority is to discover and develop novel medicines and vaccines - however, another critical priority is the pursuit of programs, paftnerships and policies that help bring medicines and healthcare to people around the world who most need it. Perhaps the best example of Merck's commitment to access to people around the world is the Mectizan Donation Program. Since 1987, Merck has donated our drug Mectizan to partners to fight river blindness in the Americas, Africa and the Middle East, and is committed to donate it until river blindness is eliminated. Worldwide, Merck has donated more than one billion Mectizan tablets, and more than 45 million people - that is 2.5 times the Dutch population - are treated with Mectizan each year. In fact, every tablet of Mectizan is produced a few miles from here in the Netherlands, at Merck's state-of-the-art manufacturing facility in Haarlem, where 900 employees work every day to produce dozens of products to improve the health of patients and to ship them around the globe. The fight against river blindness is too overwhelming for any single organization to address alone - experience has taught us that it can only be successfully won through a broad and comprehensive partnership. Today we commemorate the unique and important role of financial donors in the partnership -- appropriately represented by the kingdom of the Netherlands. Donors have been key actors in the successful global partnership to fight river blindness. Through the APOC and OCP organizations, the consistent support from donors like the Netherlands has been crucial to sustaining the delivery of Mectizan to communities affected by river blindness. Placing this statue here gives us an appropriate reminder of what was once an all-too-common scene before the river blindness partnership began, and serves as a challenge to all the partners to sustain the partnership to ensure this scene is never repeated. It9 We are proud that one of the five other river blindness statues placed with representative members of the partnership greets visitors to Merck's world headquarters in the United States, open testament to Merck's commitment to putting patients first through programs like the Mectizan Donation Program. Merck has applied the lessons learned in the Mectizan Donation Program to other health challenges, most notably in the area of HIV/AIDS. The accelerated access initiative, for example, is a public-private partnership that joins 7 pharmaceutical companies, including Merck, with several multilateral agencies such as the WHO, UNAIDS, LINICEF, LINFPA, and the World Bank, to accelerate access to anti-retroviral (ARV) medicines in the developing world. The results of this program and partnership have been impressive, allowing several hundred thousand people living with HIV/AIDS to be treated with ARVs - and as a result, live longer, healthier and more productive lives. In another HIV/AIDS program, in Botswana, Merck has partnered with the Government of Botswana and the Bill and Melinda Gates Foundation, as well as with dozens of public and private organizations, to mount a comprehensive HIV prevention, care, counseling and treatment program. Currently more than 45,000 patients are enrolled in this program, with 2,000 new HIV positive patients added each month. This program serves as a useful model for other developing countries. One of the strengths of the Mectizan Donation Program has been the central role of more than 80,000 communities in directing their own health care activity. River blindness programs have also proven to be successful platforms on which to build other appropriate health interventions. Already, we've seen the successful integration of lymphatic filariasis prevention, vaccination programs, census taking, Vitamin A distribution and additional eye health programs with community Mectizan distribution activities. As we will explore further in today's discussions, appropriate and proven opportunities for additional integration should be considered - when the fit is right and all partners agree, to enable this already successful partnership to reach its full potential. These examples clearly demonstrate the power and possibilities of strong, transparent and creative public-private partnerships in helping to address the enormous public health challenges facing developing countries today. Thankfully, with the continued commitment of allthe partners, the long chain of generation after generation of people affected by river blindness will be broken -- onlyto be remembered by future generations through statues like this one. Thank you ### Jt 20 Annex 4 ROUNDTABLE ON THE OCCASION OF INAUGURATION OF THE ''ONCHO STATUE'' AT THE ROYAL TROPICAL INSTITUTE, AMSTERDAM Summary of discussions l. The roundtable was chaired by Ms Catherine Hodgkins, Director of the Dutch Royal Tropical Institute who welcomed participants to the discussion. 2. To set the tone for the discussion, brief presentations were made by Dr. James Mwanzia, Director of the Division of Disease Prevention and Control of the WHO Africa Region, by Dr Ousmane Bangoura, Manager of the Onchocerciasis Coordination Unit at the World Bank and by Dr Uche Amazigo of APOC Management. 3. Dr Mwanzia underscored the need to sustain the achievements of both Onchocerciasis Control Programme in West Africa (OCP) and the African Programme for Onchocerciasis Control (APOC) through continuous donor support and innovative operational approaches. Dr Bangoura further outlined the achievements of OCP and APOC which, in economic terms, have achieved remarkable Rates of Return of 20Yo and lTYo respectively. 4. In APOC, 75Yo of CDTI projects evaluated are judged to be making progress towards sustainability. Dr Amazigo emphasized the 3 most critical indicators for sustainability (ivermectin supply, monitoring/supervision and HSAM') and the need to advocate for governments to invest more financial resources into these indicators, among others. 5. Several issues regarding APOC operations were underscored among which, are a. social and political unrest b. delays in implementation of some CDTI projects c. how to increase coverage d. bridging the funding gap of US$10 million e. the risk of SAEs 6. The activities of the Special Intervention Zones of ex-OCP (SIZ) and of the Multidisease Surveillance Centre (MDSC) were also reviewed globally. However, it now appears that the US$6.4 million contingency reserve of ex-OCP is inadequate to finance the SIZ activities. Similarly, more donor support is still required for the MDSC to be fully operational. 7. An ongoing study on compliance is expected to help determine how long ivermectin may need to be taken by an individual in order to eliminate the disease in the community. In the meantime, it was remarked that some people take ivermectin for its added benefits such as its effects against intestinal helminthics, scabies and ticks. I Health education, sensitization, advocacy and mobilization I I ; {,t 2t 8. As to whether CDTI can be used as a vehicle for promoting other health interventions, preliminary findings of an ongoing study on community directed intervention (CDI) indicated that communities are willing to add on other health interventions, particularly, malaria. The front line health facilities (FLHF) who were reluctant some years ago are now also supportive of the new role of the communities. What activities should be added on depends on the complexity of the intervention. 9. Success of OCP and APOC has been partly due to the focus on their objectives and the crucial role of operational research in shaping control strategies. Focus should now be on integration and sustainability, particularly, at the district level. However, one must be selective in what should be added onto CDTI in order to avoid losing the focus on programme objectives. Possible add-on activities include: Vitamin A Supplementation, ITN and home management of malaria. 10. It was stressed that WHO should take the lead to create a platform for exchange of experience between technical programmes at the global level and to pool synergies. Countries should be encouraged to use the Sector-wide Approach (SWAP) and to contribute more to CDTI activities. In other words, there is a need for consolidation of the various partnerships at global, country and district levels. ll.In conclusion, the CDTI approach is a model to learn from and to build on, in order to strengthen, particularly the FLHF. The creation of a platform would promote or improve exchange and consultation between various health intervention programmes and save cost. Sustainability will depend, to a large extent, on the integration of CDTI into the national health system where there is a need for comprehensive national planning. I