Report of the fourth session of Joint Action Forum: 9-11December 1998

JOINT ACTION FORUM AFRICAN PROGRAMME FOR ONCHOCERCIASIS CONTROL Fourth session 9-11 December 1998 REPORT JAF4 HJAF4 JOINT ACTION FORUM AFRICAN PROGRAMME FOR ONCHOCERCIASIS CONTROL Fourth session 9-ll December 1998 REPORT CONTENTS 1 OPENING OF TI{E SESSION ELECTION OF OFFICERS ADOPTION OF TI{E AGENDA REFLECTIONS OF T}IE COMMITTEE OF SPONSORING AGENCIES PROGRESS REPORT OF THE WORLD HEALTH ORGANZATION REPORT OF T}IE TECHMCAL CONSULTATIVE COMMITTEE REPORT OF A SPECIAL FORT'M ON APOC OPERATIONALTZATION IN THE CONTEXT OF ONGOING I{EALTH SECTOR REFORMS IN AFRICA 7 REPORT OF TI{E NGDO COORDINATION GROUP FOR TVERMECTIN DISTRIBUTION INCLUDING SIIPPORT OF TI{E GROUP TO APOC'S ACTIVITIES AND TO LOCAL NGDOs 9 COLINTRIES REPORTS l0 t0 REPORT OF AN INVESTIGATION INTO THE LOCATION OF TTM HEADQUARTERS OF APOC t2 I 1 CONSIDERATION OF NATIONAL PLANS AND PROJECT PROPOSALS 13 12 OPERATIONAL RESEARCH 15 13 REPORT ON THE LONG-TERM ASSESSMENT OF APOC OPERATIONS 16 REPORT OF THE INDEPENDENT MOMTORING OF CDTI PROJECT IMPLEMENTATTON IN MALAM, MGERIA, SUDAN AND UGANDA 17 2 2 2 3 6 2 J 4 5 6 7 8 8 ; a l4 15 PLAN OF ACTION AND BUDGET FOR 1999 21 I l6 -ll- FINANCING OF THE AFRICAN PROGRAMME FOR ONCHOCERCIASIS CONTROL 17 OTHER MATTERS 18 DATE AND PLACE OF THE FIFTH SESSION 19 APPROVAL OF THE FrNAL COMMLTNIQUE 20 CLOSTIRE OF T}TE FOURTH SESSION 21 ANNEX I LIST OF PARTICIPANTS ANNEX II CSA REFLECTIONS FOR JAF4 ANNEX III STATEMENT BY DR RALPH HENDERSON, SPECIAL ADVISOR TO THE DIRECTOR-GENERAL OF WHO 24 ANNEX IV REPORT OF TTIE JOINT SESSION OF JPC I9 AND JAF4 25 ANNEX V F INAL C OMMLTNIQTIE INCLUDING CONCLUSIONS AND DECISIONS 26 ANNEX \rI CLOSING REMARKS BY THE CFIAIR OF THE FOURTH SESSION OF JAF 22 24 24 24 24 25 3722 23 39 4l 5l 46 i I JAF4 Page 1 l. OPENING OF THE SESSION: Agenda item I I I The fourth session of the Joint Action Forum (JAF) of the Afiican Programme for Onchocerciasis Control (APOC) was held in Accra at the kind invitation of the Government of the Republic of Ghana. The session was opened at the Accra lnternational Conference Centre and the working sessions took place at the State House Banquet Hall (the list of participants is attached as Annex l). | 2 At the opening, Dr Kofi Ahmed, Director of the Onchocerciasis Division of the Ministry of Health, welcomed the participants on behalf of the Minister of Health, Honourable Samuel Nuamah Donkor. Dr Ahmed stressed the importance ofthe current JAF session during which the Assembly would take stock of the progress made, plan future activities and ensure that the gains be maintained. He paid special tribute to the trryo Ghanaian oncho-pioneers, Drs Ebrahim M. Samba and K. Yankum Dadzie, for their efforts to rid the continent of this dreadful disease. He further thanked the manufacturer ofivermectin, Merck & Co., for making the drug available free of cost for as long as needed. Dr Ahmed finally referred to the partnership in ApOC as an example-setting approach to public health endeavours, and to the contribution of the APOC community-direction of field operations to primary health care development and to the health sector reform. 1.3 Representing the Chair of the third session of JAF, Mr Phil Mason emphasized the fact that APOC had clearly demonstrated its capacity to decide on what to do and how to do it and at the same time show the necessary flexibility in decision-making. He was confident that the Programme would spearhead a wider role of the communities in the conduct of health progriunmes, thereby contributing to the health sector development. He considered the Programme amodel for other drug distribution/donation activities givenits minimumbureaucrary, its effective management and its cost-effective field operations. 1 4 Dr Dadzie, Director ad interim of APOC, saw the presence at the session of representatives of the various groups concerned with the Programme as proof that the unique partnership in APOC was a sound foundation for APOC which had now moved from infancyto a fully grown operation which was moving fast. There were challenges and the APOC management looked forward to receiving guidance from members of the Forum. Dr Dadzie concluded by thanking the Ghanaian authorities for hosting the fourth session of JAF under such excellent conditions. 1.5 The Director of the WHO Regional Office for Africa (AFRO), Dr Samba, expressed his confidence that APOC would succeed as it based its operational strategy on that of the Onchocerciasis Control Programme in West Africa (OCP) which over a quurt.. of century had showed that success was possible when all involved assumed fully their responsibility. ttre effective integration of onchocerciasis control in comprehensive national health piogro,,-., *u, a challenge for both APOC and OCP and the two Programmes could count on tti" support of AFRO in that direction. Dr Samba finally expressed his thanks to Ghana for inviting the governing bodies of OCP and APOC to meet in Accra. JAF4 Page2 1 .6 Dr Ralp Henderson, Special Advisor to the Director-General of WHO, Dr Gro Harlem Brundtland, conveyed her greetings and best wishes for success to participants in the Forum. Dr Henderson emphasized four aspects of essence for the success of lAF, i.e. partnership, community involvement, integration and continued operational research and suggested that these fundamental aspects of the Programme could very well lend themselves to application also in other large-scale public health undertakings. He particularly stressed the importance of APOC being conceived as an operation integrated within the national public health systems. Dr Henderson finally recogntzed,the importance ofthe close collaboration between OCP and APOC to the benefit of the two Programmes. Dr Henderson's statement is attached as Annex II. 1.7 In welcoming participants to Ghana, Dr lrrlary Grant, Member of the Council of State, pointed out that her country had always been a strong supporter - and beneficiary - of international efforts to control river blindness as witnessed by the holding ofthe Planning Meeting on Onchocerciasis Control in the Volta River Basin in Accra during Octob€r lgT2wellbefore the start of OCP field operations. As onchocerciasis was no longer a problem of public health importance or an obstacle to socioeconomic development in Ghana, it was now up to the country itselfthe maintain that achievement and Dr Grant pledged the full support ofthe Government and health authorities to meeting that challenge. She concluded by expressing her pleasure that the OCP experience was now being extended to nineteen African sister nations through the ApOC initiative which should eventually lead to the elimination of onchocerciasis from Africa. 2. ELECTION OF OFFICERS: Agenda item 2 2.1 The Central African Republic was elected to the Chair (held by Dr Fernande Djengbot, Minister of Health and Population). 3. ADOPTION OF THE AGENDA: Agenda item 3 (document JAF4.1, Revision 3) 3. I The provisional agenda as reflected in the present report was adopted. 4. REFLECTIONS OF THE COMMITTEE OF SPONSORING AGENCIES: Agenda item 4 4.1 The Chair of the Committee of Sponsoring Agencies (CSA), Mr Gana Fofang of UNDp, congratulated, on behalf of his Committee, APOC on the speedy progress made in fielding no less than 45 projects in more than half of the l9 Participating Countries during the past two years. The Committee was, however, concerned that the staff was overreaching although it noted with satisfrction that the WHO Regional Director for Afiica had assigned a staffmember experienced in tropical diseases control to the OCP and APOC headquarters. CSA was also impressed by the fact that no more than 9 per cent of the budget of the Programme was spent on administration. 4.2 The Committee underlined the importance of the extensive partnership, including direct community involvement of the target communities, on which APOC relied for successful operations. Mr Fofang mentioned, in this connection, the importance of support from, and collaboration with, WHO-AFRO. In the opinion of CS.\ this close synergistic partnership which was, indeed, innovative could stand as a prototype for other public health activities. JAF4 Page 3 4.3 The Committee paid a special tribute to the Members of the Technical Consultative Committee who made recommendations concerning the acceptability of project proposals, had launched independent monitoringlevaluation ofAPoC-assisted projects and in August organized a special meeting on the Programme and its contribution to the health s€ctor reform underway in APOC countries. 4.4 On the budgetary side, CSA expressed concern about a potential shortfall in financing the first phase of APOC operations and called upon the donor community to make the necessary efforts to fill any current and potential gaps that might arise. The Committee was pleased that the OCP and APOC managements had made special efforts to ensure a reliable management and accounting of the funds so far released for approved projects. 4.5 Mr Fofang, in referring to the collaborative arrangements between OCP and APOC, reported that CSA endorsed the recommendations made by an independent conzultant regarding the location of the APOC Hqs suggesting that the current collaboration in Ouagadougou continue for the time being and that the situation be reviewed towards the end of OCP operations. 4.6 Concluding his statement, Mr Fofang referred to the new prograrnme for global elimination of lymphatic filariasis regarding which CSA had expressed satisfaction that the operational strategy would be based on community-directed distribution as spearheaded by @P and APOC. The reflections of the CSA are attached as Arurex III. PROGRESS REPORT oF THE woRLD HT'ALTH oRcAltrzATroN: Agenda item 5 (documents lAF4.2, JAF4/INFiDOCs.|,2,3,4 and 5) 5 I A brief summary of the activities during the reported period: 16 Communiry-directed Treatment with Ivermectin (CDTI) projects and 3 National Plans approved; 35 Leners of Agreement signed with 9 countries; over 12 million people treated h 9 countries; vector elimination activities readied for start mid-1999; support to National Onchocerciasis Task Forces(NOTFs) for completion of Rapid Epidemiological Mapping of Onchoicerciasis (REMO) and integration of REMO data into the Geographical Information System (GfS); long-term impact studies started; monitoring of l2 CDTI projects; operational research with TDR on sustainability of the CDTI strategy; and workshops on the philosophy of APOC and the concept of CDTI for l9 countries. 5-2 Between April 1996 and September 1998 joint APOC management, WHO/AFRO and Non-governmentalDevelopment Organizations (NGDOs) missionsvisited Cameroon, bquatorial Guinea, Central African Republic (CAR), Chad, Malawi, Nigeria, Uganda, Sudan, Tanzania and the Democratic Republic of Congo (DRC). The teams assisted the NOTFs to prepare National Plans and CDTI proposals and helped in the completion of REMO exercises. Substantial reductions of APOC contributions to the five year project costs were achieved during the visits. In 7 out of l0 countries budget lines for onchocerciasis control had been established. 5 3 From November 1997 to September 1998 the OCP Finance Officer and the APOC Administrative Officer visited Tanzania, CA& Chad, Cameroon and Equatorial Guinea to train NOTF accountants following which funds were transferred to 2l projects in 7 countries for start- IAF4 Page 4 up actrutles 5 4 The first of two workshops, orgaruzed in 1998 in collaboration with WHO AFRO and NGDOs, was held in Douala (Cameroon) with participation from Angola, Burundi, Cameroon, Congo Brazzaville. DRC and Rwanda. The second took place in Nairobi attended by repres€ntatives from Kenya, Ethiopia, Liberia, Mozambique and Sudan. With the three workshopi otgaruzed during the preceding year, all 19 countries had thus been sensitized to the APOC philosophy and informed about the planning, implernentation and financial management ofCDTI projects. In all334 persons had attended the five workshops. 5.5 On the public relations and training side, a training manual for distributors, an information pamphlet, lnformation-Education-Communication (IEC) pamphlas and different videos were produced during the period under review. 5.6 With the technical support from the WHO CTD/tlealthMap, the initial Mgeria REMO maps were refined and the Rapid Epidemiological Assessment (REA) data validated while REMO was completed in Tanzartta and Chad. REMO exercises were carried out in the Uele and Kasai regions of the DRC and national staffin Mozambique were trained in REMO procedures. 5'7 Through downscaling by the APOC Management of the proposed budgets in the thirry five (35) Letters of Agreement signed during the reported period, the originally proposed ApOC contribution of a total of US$ 9,179,850 had been reduced to US$ a)g7,wi byinow to bepaid from the 1998 budget. 5.8 Eight of the first approved project reported success in active community participation, government commitment; training of community distributors, mobilization and education of target communities aided by local women's groups; and actual coverage rates. In alt 6 424 distributors from I 741 illages had been trained during the period under review in the eight projects in question with an overall treatment coverage of 560/o. 5 9 Among the constraints reported by the eight first approved projects were lack oflinadequate primary health care (PHC) infrastructure; settlement patterns; transportation difficulties, social unrest; and late disbursement of APOC funds largely due to delayed ..rponr" by NorFs to queries by the Technical consultative committee (TCC). 5 l0 With 16 CDTI projects and 3 National Plans approved in 1998 a total of 36 CDTI projects, 4 vector elimination projects and 5 Hqs support projects have been approved for l l countries since 1996. In 1998, I I.7 million people were treated as compared tolast year'figure of 7.5 million persons treated. By the end of lggg, 15 million people would be treated and 40 million by the year 2002 as planned by ApOC. 5. I I In Decembet 1997,JAF3 approved a budget of US$ 162s2l for vector elimination in the Itwara focus in Uganda, later revised to US$ 28 186 for a oneyear regular monitoring of the focus and larviciding/monitoring ofthe sub-foci. Furthermore, US$ rcaigt had been earmarkedfor a feasibility study in the Mpamba-Nkusi focus. These activities would start late 1998. In the Tukuyu focus on the Tanzania/Malawi border vector elimination operations were expected to commence before end-1998 while preparatory vector elimination activities would start on the IAF4 Page 5 Bioko Island in Equatorial Guinea during October-November 1998 5.12 The Programme continued to support, and collaborate with, TDR in carrying out operational research concerned with the sustainability of CDTI and its integration into health services; with the marketing of Programme activities; and with rapid monitoring of iverrnectin delivery 5. 13 An effective collaboration had been established with the WHO Regional Office for Africa which provided technical and administrative support through its country offices. Furthermore the AFRO RegionalAdvisor on Other Tropical Dseases had been assigned to Ouagadougou where he participated actively in OCP and, particularly, in APOC activities. Also, a close collaboration continued with WHO'Hqs and, in particular, with the NGDO Coordinator who participated in country visits and workshops. 5.14 The Programme continued to receive important backing from OCP in zuch fields as administration of personnel; budget and finance; biostatisticVinformation support; supplies; transport; and communication, meetings, translation and documentation. *** 5 15 APOC Management was congratulated by JAF members for the tremendous volume and the quality of the work performed during the period under review. 5 l6 JAF noted that the denominators used by the participating countries to compute treatment coverage rates in projects' areas varied: most used the eligible population while some few used total population as recommended by the programme. For uniformity as well as for the sake of comparing treatment coverage among projects and between countries, the forum urged all participating countries to use henceforth the total population ofthe projects' areas as denominator in calculating the treatment coverage. 5 17 The forum also noted in some instances with great concern a dramatic increase up to l0 fold in ploject target populations from the first to the fifth year. The forum urged the countries concerned to realistically review (e.g.:DRC) such figures. 5 18 JAF advised the participating countries to accord priority in project proposals development and CDTI implementation to areas as defined by REMO and the rtn., located in the eastern flank of the ocP area (zones between Nigeria and Benin). 5. l9 The forum noted with great satisfaction that APOC management is not only making good use of the national capacity previously developed with TDR support but it is improving Frin., what already exists while endeavoring to train new national experts in every urp"Ct of the programme implementation. 5.20 Given the increasing workload and considering the very lean professional staffat APOC Management, JAF encouraged the programme to make more use ofthe WHO country offices as backstop in administrative and financial management of the projects. 5 2l Cross border issues were once again raised during the discussions on WHO progress report. In effect, some countries were concerned that their neighbors were not undertaking p-p., lp.F4 Page 6 actions at the other side of common borders to control onchocerciasis (e g eastern border of Uganda with DRC) thus perpetuating the transmission of the disease on both sides Coordinated efforts on both sides of common borders were strongly recommended to participating countries confronting such a situation. 6. REPORT oF THE TECHNICAL CONSULTATT\aE COMMITTEE: Agenda item 6 (documents JAF4.4 and 4.5) 6.1 The Chair ofthe Technical Consultative Committee (TCC), Professor O. Kale, informed the Forum that during the reported period his Committee met in Ouagadougou, 30 March to 2 April and at WHO Hqs.,24 to 28 August during which latter session a special meeting was held on APOC and the health sector reform. 6.2 The TCC recommendations for approval of project proposals made during the two sessions have been summarized (see para I l). In addition, the Committee considered certain issues of relevance to APOC operations for which recommendations are summarized in the following: - onchocerciasis distribution and endemicitytobe reviewedwhenREMO rezults conllicted with historical and other data; - earlier submission of revised budgets for the next year of ongoing projects to avoid disruption, - funding of subsequent years of APOC-financed projects subject not only to satisfactory TCC review but also to satisfaction of the Management regarding financial returns; - sites for impact assessment to be reduced to 13; - implementation ofjoint supervision of APOC projects to be funded by the Trust Fund or the World Bank oncho unit; - approval of APOC financial support to already well-run ivermectin distribution projects conditioned by strong justification with focus on elements requiring strengthening to achieve sustainability. *+* 6.3 The issue of burden of reporting on field personnel was debated by the forum which agreed and requested that this aspect be streanrlined. The APOC Management together with the NorFs were asked to look into this problem and make suggestions to the TCC. 6.4 While recognizing that the first year of any CDTI project may require a relatively important arnount of funds for investment (capital equipment, vehicles, to name a few) rezulting in a high cost per treatment during that period, the forum was concerned about the fact that onci APOC comes in to support ongoing ivermectin distribution projects, previously funded by NGDOs and with low costs per treatment, the costs per treatment tend to skyrocket. The forum saw in that phenomenon a reflection of a possible rejection by the national project managers of the norms set by TCC in view of containing costs and ensuring sustainment of the projects. 6.5 The forum expressed its appreciation to the TCC for the rigor exhibited in the assessment of project proposals submitted by the participating countries However, when looking at the increasing number of new project proposals submitted to the TCC, the consideration of the IAF4 Page 7 budgets for subsequent years ofalready approved projects as well as the technical and financial reports of these projects, JAF realized the burden this has put on the secretariat. Although this situation has not reached a crisis point yet, the forum requested that mechanisms and strategies should be found to ease the work of TCC and APOC Management in that regard. 6.6 Conditions to be fulfilled by the NOTFs before funds are released by APOC Management for the implementation of the projects include: (i) Satisfactory fulfillment of conditions posed by the TCC when it recommends any project for approval by CSA. Until these conditions are satisfied, the APOC Management cannot establish the Letters of agreement which constitute the legal basis of disbursement of funds by WHO as the executing agency. (ii) Each NOTF must open a new special bank account into which money from ApOC Trust Fund will be transferred. Without such a bank account op*.d funds will not be transferred for the implementation of the projects. (iiD A reliable system for managing the funds is to be put in place; this includes: - the appointment of accountant, - the training of the accountant in the wHo imprest system. (i") Appointment of two official signatories for the special bank account . 6.7 The fulfillrnent ofeach ofthe above conditions has been so far subject to delay in a number of instances which has impacted on the disbursement of funds to the projects concerned. The responsibility in such circumstances is shared between the NOTFs and the WffOfapOC. Efforts are underway to minimize or eliminate the delay in disbursement of funds for project implementation. 6.8 The Forum recommended that one per cent of the funds released to finance ApOC supported projects be allocated for appropriate operational research on specific issues ofinterest to the Programme. 7. REPORT OF A SPECIAL FORUM ON APOC OPERATIONALIZATION INTHE CONTEXT OF ONGOING HEALTH SECTOR REFORMS IN AFRICA: Agenda item 7 (document JAF4 6) 7 | In response to a request by JAF at its third session in December 1997, a special Forum was held in August 1998 during the sixth session of the Technical Consultative Corirmittee to consider the potential contribution of APOC operations, and particularly CDTI projects, to health sector reforms. During the one-day Forum, reports on country experiences *.r! pi.r.nted; short papers on health sector reforms were introduced, and a general diicussion, leading to conclusions and recommendations, took place. 7 '2 In the absence of an official WHO concept of health sector reform, the following definition was proposed: "a sustained process of fundamental change in policy and institutional iurangements to improve the functioning ofthe health system, and therebyp"opl"r' health,,. Four responses to health systems change were identified: responding to change irom outside the health ]AF4 Page 8 system; resistance/adjustment on single issues; reform to health-specific, sustained change; and rebuilding a health-specific, disrupted system. 7.3 During the discussion several pertinent issues were raised, including. - the training of health workers at all levels to meet the real needs of the communities; - the need to provide community-directed treatment with ivermectin (CDTI) with sustained support, ensure integration of CDTI into existing structures to be strengthened, - instability of key staff and very limited financial resources for innovation, - need for continued WHO-AFRO support to APOc-initiated activities beyond 2007, - importance of research into the magrritude of CDTI costs. 7 4 The main conclusions agreed upon during the discussion were - onchocerciasis control to become an integral part of the health system, included in the minimum package; advocacy to be targeted to the district level and local governments; - partnership with communities to be strengthened with full involvement of health workers, - the unique partnership in APOC in tune with priorities of the WHO Director-General; - priority research objects in Participating Countries: recurring cost of ivermectin distribution, role of health education for sustainability, impact of fee on coverage; nature and cost of financing district and health centre level; and the impact of the financial situation of health workers on their motivation to be involved in CDTI activities. **'t 7 5 JAF commended TCC and the APOC Management not only for having been able to organize and hold the special session on'the health sector reform in the context of APOC operations" but also for the constructive and fruitful deliberations that took place during that session. 7 6 JAF welcomed the report on the special forum on APOC operationalizationin the context of ongoing health sector reforms convened in response to the request made by JAF during its third session. The forum could not agree more with the presenter, Prof Prozesky, that health services is the engine that drives community participation. It encouraged APOC to continue this work. 8. REPORT OF THE NGDO COORDINATION GROUP FOR TVERMECTIN DISTRIBUTION INCLUDING SUPPORT OF THE GROUP TO APOC's ACTIWTIES AND TO LOCAL NGDOs: Agenda item 8 (document JAF4.8) 8 1 During 1997, the NGDO Coordination Group facilitated ivermectin distribution to 12.5 million people in APOC countries and 1.26 million in OCP countries. During two meetings held in I998, the Group agreed on certain aspects ofNGDO work in relation to APOC and OCP operations. - to make special efforts to minimize future losses of ivermectin; - to request TCC to call for reporting procedures that would avoid delay in agreements and disbursement of funds for next year's operations; JAF4 Page 9 - to streamline reporting procedures so as to reduce the workload in the field; - to propose guidelines on the eligibility of local NGDos for Apoc support. 8 2 NGDO staff participated in joint preparatory visits to APOC countries and in the ApOC organized workshops held in Douala and Nairobi. Furthermore, the NGDO Group provided the services of a Coordinator and his office in support to the APOC management. *** 8 3 Concern was raised as to the roles of, and the place accorded to, the communities in the process of CDTI. Some JAF participants actually believed that the longer the list of partners in the implementation of CDTI the thinner the role of the communities will be. However, the roles of the communities will be expanding as CDTI projects evolve while NGDOs' (international and local) interventions will be diminishing. 8.4 The forum has also noted that NGDO support for ivermectin distribution is not covering at the moment all the participating countries. This situation was mainly attributed to the limited pr.r-"nt network ofthe NGDO Coordhation Group and funding restraints. Therefore, JAF encouraged new mechanisms and strategies for securing funding so as to allow the expansion of NGDOs' support to all the APOC countries which have not yet benefitted from such support (e.g.: Mozambique, Ethiopia). 8.5 Additional possible ways of overcoming capacity constraints of NGDOs' involvement in CDTI projects include. (i) encouraglng western countries which are not Donors to APOC to provide support to ApOC projects through NGDOs, (ii) development of mechanismVprocedures whereby international NGDOs will link up with effective local NGOs in view of supporting CDTI project implementation. In so doing international NGDOs will contribute to build up local capacity that will carry on project activities when they withdraw. 8.6 200.000 Mectizan tablets were lost out of a total 83 million tablets shipped this year by Mer&Co. to OCP and APOC participating countries. This represents less than O Z5o/o loss and was not deemed to have reached a critical point. Moreover, the loss was not seen as a specific phenomenon to ivermectin but instead a general problem affecting any other drugs because of the lack of these commodities in the areas where armed conflicts p..r"il. Htwever, .d.t, are underway to set up an accountability system for mectizan delivery and management in order to reduce the level of losses. 8 I women in seclusion as well as some minority ethnic groups were said to be difficult to reach rvith ivermectin Innovative approaches are therefore called for not only to expand treatment to those unreached above but also to facilitate their participation in GDTI process - JAF4 Page 10 9. COUNTRIES REPORTS: Agenda item 9 9.1 9 out 19 APOC participating countries attended the fourth session of the Joint Action Forum and gave brief reports on the implementation of onchocerciasis control activities. As a general observation, it was felt that it is more difficult to reform an existing project into the CDTI approach than to establish a new true CDTI project. An intensive health education programme is needed to ensure that the reform will take place. 9.2 In some severely affected areas undergoing special circumstances (armed conflicts, famine, drought, flood) water and food may be most needed than ivermectin or any other drugs. Moreover, in the context of civil war, corrmunities are not free and this can impede their participition in CDTI process and ultimately influence negatively community ownership of CDTI 9.3 Some of the lessons learned from the implementation of CDTI in areas confronting social unrest include: (i) there is a need of flexibility in the definition of a community as well as rn the prucess of selection of CDDs by the community; (iD it is crucial to have a good relationship with the army so that they can give a hand in ivermectin distribution; (iii) incorporating CDTI into PHC should be gradual so as to prevent the collapse of the whole system; (iu) training and retraining is crucial for the success of CDTI Evidence of government commitment in CDTI activities as per country reports include (i) office accommodations (ii) establishment of an oncho day for the purpose of advocacy and awareness raising; (iii) payment of salaries of all national civil servants involved in onchocerciasis control activities(e.g: Nigeria spent this year 5 million naira only for the personnel at the federal level) (ir) cash assistance is provided at the federal, State and local government level (e.g. 100 000 USD for Nigeria; l0 000 USD for Liberia) (u) Participation of government officials in community mobilization and sensitization 9.4 The delegation of Cameroon informed JAF that the Ministry of Health has decided to extend the implementation of the CDTI strategy to all reoriented and non reoriented districts of the meso and hyper-endemic areas. JAF4 Page I I g.5 The delegation of Cameroon also expressed the willingness of its government to host the JPC and JAF sessions of 2000 9 6 As per the presentation of the delegation of Cameroon, it was noted that cost recovery is being applied in ivermectin distribution as an element of sustainability of CDTI projects. However, the treatment coverages presented were generally lower compared to the treatment coverages observed in projects implemented in other countries where such a policy is not applied. However, some few target districts did achieve pretry high treatment coverage (up to 73%). *** 9 7 JAF was interested to know not only the level ofthe performance ofthe cost recovery policy in ivermectin disribution but also the real cost of treatment per person from which the proportion to be recovered is to be derived. In addition, there is a need to document thoroughly the effect of individual payment for ivermectin with a view of knowing who are those left out. 9.8 There are other means of community cost sharing which can be tried in the context of ivermectin distribution. The provincial solidarity fund was mentioned as an example by the delegation of Cameroon. 9.9 The Forum strongly recommended that the issue of cost recovery/cost sharing be addressed through operational research by the countries concerned in collaboration with the APOC Management and TDR. 9.10 Concerning REMO, exercises will be conducted with support from APOC Management during the period of 28 December 1998 to I 5 Febru uy 1999 in Liberia l5 January to 20 February 1999 in Kenya 9 l l JAF noted that Air Care [nternational has committed itself to complete REMO exercise in Mozambique. As regards the Repuplic of Congo, REMO field activities previously stopped because of the social unrest have resumed and are being supported by OPC, the NGDO partner. 9.12 The Forum noted with satisfaction the progress made in the Rapid Epidemiological Mapping of Onchocerciasis and encouraged the countries and the APOC Management to continue their efforts towards a complete coverage of all Participating Countries as soon as possible. 9.13 SSI reported that it has requested a special permission from its Executive Council in order to lend support in onchocerciasis control in Liberia. This is because Liberia is not a member of the Commonwealth which is the focus of SSL The decision of the Executive Council on this matter was expected soon SSI intends to link up with CHAL, a local church based NGDO. 9.14 Dr Stefanie Meredith, Director ofthe Mectizan DonationPrograrnme (MDP), informed JAF that there have been problems recently with the importation ofMectizan into Ethiopia: NGDOs and individuals are no longer allowed to import drugs (including Mectizan) into Ethiopia The forum requested APOC and MDP to work with the government of Ethiopia to formulate a solution in the near future 9.15 The Forum noted with concern that contrary to the understanding reached, some countries JAF4 Page 12 still imposed various forms of import duties and taxes which resulted in delays in release of Mectizan lor use in control programmes. The Forum therefore urged that all Participating countries ensure the importation of Mectizan be done without any levies. 9.16 The issue of delay of release of funds for projects implementation was discussed once more under the current agendaitem (see section 6.7 and 6.8 above). The Forum encouraged WHO and the NOTFs concerned to make all efforts to minimize and even avoid such delays in future 9.17 The Forum wished to receive a list ofthe problems raised in the country reports and that the partners likely to help solving thern be identified and contacted through proper channels. IO. REPORT OF AN INVESTIGATION INTO THT'- LOCATION OF THE HEADQUARTERS OF APOC: Agenda item l0 (document JAF4/INF/DOC.6) l0 I The independent consultant, Professor Detlef Prozesky, summarized the findings of his investigation as follows: - there were wide-ranging benefitVadvantages ofhaving APOC Hqs situated within the OCp compound both technically (professional dialogue between staff of the two programmes); administratively (APOC benefiting from the OCP infrastructure); and financially (shareJ facilities, economies of scale); - the disadvantages were fewer and less widely felt: OCP possibly dominating inappropriately; travel more difficult and costly than from a more centrally situated country; ana , it coUa'Ue saia, the host country, Burkina Faso, getting an.tlnfair,,advantage; - the financial gain of APOC Hqs located within the OCP compound was calculated at US$ 240 000 ayea\ - the disadvantages of moving APOC Hqs would be serious and include the disruptive effect of establishing a new administration; the existing expert administration having to be reilaced; and important additional costs (US$ 80 000 for thetransfer, US$ 96 000 for capital-expenditure and US$ 500 000 annually for ongoing expenditures). 10.2 Professor Prozesky concluded by recommending that APOC Hqs continue to be based in Ouagadougou for the time being and that this decision be re-assessed in relation to the end of OCp operations. *** 10.3 JAF members highly appreciated the quality of the investigation as well as the report itself and were happy with the conclusions and the recommendations. Ao*.,rrr, the report was criticized for the following reasons: (i) the sample of the investigation was too narrow to safely allow far reaching inferences (ii) very few (only 5) NOTFs were surveyed. (iii) nothing was said about the downscaling ofOCP and how it will affect the cost of maintaining APOC/HQs in Ouagadougou and how it is accounted for JAF4 Page 13(iv) The investigation failed to look into the conceptual development o[ the interrelationship between OCP, APOC and the lorthcoming centre for multi-disease surveillance and control (tripartite marriage) (v) Though the emphasis of the investigation on the operational aspects of APOC was considered appropriate by most of the JAF participants, some said the basis of the decision on the location of the HQs of an orgaruzation has always been political and cannot be otherwise. 10.4 One of the delegations from the Participating countries therefore suggested that the question ofthe location ofAPOC/HQs be formally put by writing to APOC Participating countries which will find the proper way of consulting among themselves on the subject matter. The issue would be revisited at a later time. 10.5 It was reported that donors' srrpport to APOC has been growing very rapidly because of the remarkable beginning this programme has had. This is due, among other factors, to the close and efficient collaboration between APOC and OCP which are learning from one another. This situation has led to a convergent strategy for both progrmrmes with the strategy in OCP countries starting to parallel that of APOC countries. Such an evolution was deemed highly desirable especially as OCp is entering its devolution phase. 10.6 From the standpoint of Donors as reported by Mr Bruce Benton of the Wor.ld Bank, considering the shortfall of funds for the APOC phase I of US$ 9 million, the extra costs of millions of dollars for setting up a new administration as well as the foreseen disruption of the programme's operations for 6 months or a year, it wifl be unforrunate if the HQs of APOC has to be moved to another location for only political reasons. l0 7 In view of the above, the Forum: (i) recommended that consultations be pursued with the interested parties before further consideration be given this issue in relation to the end of oCp activities; (ii) decided that for the time being the Headquarters of APOC would remain in Ouagadougou at the OCP premises. I l. CONSIDERATION OF NATIONAL PLANS AI{D PROJECT PROPOSALS: Agenda item 1 I (document JAF4.7) I l.l The report showed the evolution of the number of projects approved since 1996 as follows: (i) In 1996, 4 projects were approved: Malawi(l) and Uganda(3) (ii) ln 1997,25 projects were approved: Uganda(l), Nigeria(10); Sudan(3); Tanzania(3); Cameroon(6); Chad(l) and CAR(l) (iii) In l9e8: Second year budget were approved for I I projects for the 1998 budget: IAF4 Page 14 Malawi( 1 ), U ganda( I ) ; Nigeria(5); S udan (2), T anzania(Z) 9 new projects were approved in April for thel998 budget: Uganda(l); Ni geria( 5 ) ; T anzarua( l) and Equatorial Guinea(2 ) "7 new projects were also approved in october but for the 1999 budget Uganda(l); Nigeria(3); D R Congo(Z) and Gabon(t) 11 .2 Altogether, 45 projects have been approved since 1996 (i) 36 CDTI projects (ii) 5 HQs support projects (iii) 4 Yector elimination projects I 1.3 The total projects' budget submitted for JAF ratification during its current session was summarized as below. (i) 2,927,28 6 USD rvere requested from the APoc l 99 8 budget of which 1,23 9,7 z I v sD will cover the second year projects' budget and 1,688,565 USD will be allocated to the 9 new projects approved in April 1998 (ii) 1,365,466 USD were requested for 7 new projects approved in October 1998 with the understanding that the Management will revise the budgets submitted by the NOTFs and downscale them as appropriate. ll.4 the Management was commended a. rn. present format of the document on the consideration of national plans and project proposals which successfullv put together the key points for each project including the cost per treatment; I 1.5 the variability in the cost per treatment between projects rangng from I USD to 2USD, was questioned by some JAF members; I 1.6 more attention was called for when considering the cost per treatment as it can be used for the process of improving budgets and as a predictor of sustainability; ll.7 the forum noted with satisfaction the economy of scale realized through the process of the revision of projects' budgets (33% reduction); I I 8 concern was expressed as to the l0 fold increase in the number of persons to be treated in the Kasai CDTI project (D R.Congo) from the first to the fifth year resulting in a cost per treatment of 2 cents at the fifth year; I I 9 The APOC Management advised JAF members to be cautious in interpreting the cost per treatment presented as these are projected figures. The actual figures will be calculated us ih. projects are implemented. JAF4 Page 15 I I l0 The approval by the CSA of all the national plans and the project proposals contained in document JAF 4.-/ ,were ratified by the forum 12. OPERATIONAL RESEARCH: Agenda item 12 12.1 Prof. O. Kale, the acting Manager of the TDR Task Force on Community-Directed Treatment gave a brief report on the following points: (i) REMO/GIS is now installed at APOC Management level, (ii) rapid mapping of lymphatic Filariasis using clinical parameters (scrotal hydrocele, lymphoedeoma ) is ongoing It has been shown in study conducted in 8 countries that there is a good correlation between the results of night smear and those using the Circulating Filarid Antigen test(CFA) in the detection of lymphatic Filariasis infection. The sensitivity of CFA test was estimated at97oh. However, the sensitivity was found lower in India. Therefore, 2 to3 more tests are needed to establish the sensitivity level of the CFA test in that country The phase II of the community Directed Treatment with albendazole and ivermectin or DEC will determine whether the strategy is feasible, (iii) studies are ongoing to determine loa loa prevalence using clinical sign (calabar swelling) in Cameroon where coinfection with onchocerciasis and severe adverse reactions to ivermectine treatment have been reported, (i") simple tool to be used by the community to monitor CDTI activities has been developed by researchers in Nigeria and validated in Mali. This tool is being handed over ro APOC Management for the generalization of its use, (") reporting is still a problem. Pictorial forms are being experimented for use by illiterate cDDs to accurately report on a limited number of events in GDTI, (",) study on sowda was commissioned in communities where this form of onchodermatitis prevails and where nodule rates do not reflect sowda as a measure of communitv in need of mass treatment. 12.2 During the discussion, the ,rru, o, *un.iuf and human resources needed for the implementation ofall the studies mentioned above was raised. APOC and OCp were mentioned by the Manager of the Task Force as major contributors to the aforesaid studies. As regards human resources TDR has trained over 400 scientists in the African region who are participating in many research activities including the studies mentioned above The task Force *irr.qr.rt.d to synchronize its research agenda with countries needs. 12.3 The Joint Action Forum acknowledge with satisfaction the fruitful collaboration between APOC and TDR in the field of operational research 12.4 Regarding CDTI, JAF recommended that the TDR Task Force contacr directly ApOC Participating Countries to develop action plans for seeking answers to questions oi specific interest to each country. The Forum encouraged the Task Force to pursue the search for reliable and efficient reporting tools for use at the community level. IAF4 Page 16 13. REPORT ON THE LONG-TERM ASSESSMENT OF APOC OPERATIONS. Agenda item 13 13. I Following the approval by the forum of the protocol of the long term impact assessment of APOC operations during the Liverpool session, the activities below have been carried out. (i) The Management of the programme developed a plan of implementation of the studies and appointed 2 coordinators: one for the English speaking selected countries (Prof Eka Braide) and the other for the French speaking ones (Dr Boussinesq). (ii) A coordination meeting was held in Ouagadougou from 9-13 February 1998. The meeting was affended by the two coordinators and APOC staff. During that meeting, l5 study sites were selected instead of 22 as initially proposed in the protocol approved at JAF 3. Four teams of 4 members each (a total of l6 members) were constituted. (iii) A workshop was held in Douala in April 1999 to standardize the methods and the data collection instruments. The workshop was followed by a field test. Each team had the opportunity to meet and define the timetable of its field activities (i") Field activities started in June 1998 14 out of 15 sites initially selected satisfied the criteria set forth in the protocol of the study and were eventually retained [Uganda (l), Sudan (l), Tanzania(l), Nigeria(3), Ethiopia(l), Gabon(l), D R Congo(2), CAR(2), Cameroon(2)]. As of the date of this JAF session, 7 out of 14 sites were completed in 6 countries [Uganda(l), Sudan(l), Tanzania(l), Nigeria(r), cameroon(2), and D.R Congo(1)l 13.2 A data analysis workshop is planned to take place in Ouagadougou in June 1999 I 3.3 The total cost of the studies is estimated at 400,000 USD, 50% of which has,already been obligated. Transport and personnel were reported to be the prominent consumers ofthe budget 13.4 Concerns were raised as regards the proposed 5 years time laps berween the three planned cross sectional assessments. Mainly because some JAF members thought an interval of 5 years was too long and were likely to increase the attrition rate, to introduce biases and confounders in the interpretation of the study findings. After discussions it was considered, however, that a five year interval was appropriate particularly if one expects to see significant changes in the lesions of the posterior segment of the eye as a rerult of ripeated treatment with ivermectin on the one hand and adequate number of true new cases of chorioretinitis (incidence) and not further development of existing cases on the other hand. 13.5 The selection of the assessors was deemed as a crucial factor in dealing with the issues of attrition rate and intra variation bias. t4 JAF4 Page 17 REPORT OF THE INDEPENDENT MONITORTNG OF CDTI PROJECT IMPLEMENTATION TN MALAWI, NIGERIA, SUDAN AND UGANDA: Aqenda item l4 (documents JAF4/INF/DOCs 7 to l0) 14.1 1998 has seen the first exercises of monitoring CDTI projects in four APOC countries: Malawi, Nigeria, Sudan and Uganda. The report on Malawi was given by Mrs Msuya-Mpanju from the World Bank who took part in the study, whereas the summary report on Nigeria, Sudan and Uganda was presanted by Dr Akoguq one ofthe independent scientist who performed the exercises. In Malawi, the exercise was carried out during the first quarter with technical assistance from the World Bank using a participatory approach The focus of the exercise was on 5 components of the project. (i) planning and implementation of CDTI (ii) integration of CDTI into the existing heath system (iii) prograrnme management (iv) social and cultural influences on CDTI (") cross border issues between Malawi and Mozambique 14.2 The main findings of the exercise in Malawi can be summarized as follows: (i) the project was in transition from the old CBTI to CDTL However, a significant knowledge of the disease was found in the community visited, (ii) there was a limited involvement ofhealth personnel (at the district and community level), (iii) it was noted that project management needed further strengthening to ensure long term sustainability, (it) the major and unique role of the Tea Estate in ivermectin distribution was acknowledged 14.3 It was considered that participatory monitoring offered a unique opportunity to the NOTF to learn to constructively listen and interact with the community. It wis also seen as a means of building ownership of CDTI within the community. 14.4 In Nigeria, Sudan and Uganda, the exercise was carried out by 23 independent scientists in September. As part of the process of monitoring CDTI projects by independent scientists, a two-day workshop was organized in Ouagadougou and brought togethei lO of 23 monitors selected. During the workshop, the sampling procedure were discusr.a *a adopted. The data collection instruments were also developed. l1 5 4 sites in Nigeria, 4 sites in Sudan and 3 sites in Uganda were monitored The objectives of the exercise were (i) to document how ivermectin distribution was undertaken in samples of communities, JAF4 Page 18 (ii.) to determine constraints in implementation of CDTI approach, (iii) to make recommendations to APOC Management and NOTFs for improving CDTI process, (iv; monitors should address specific questions such as: is distribution of ivermectin taking place in projects sites ? are community members involved in CDTI implementation ? how was training of CDDs carried out by project implementors ? was treatment supervised ? did health staffparticipate in CDTI implementation ? what are the constraints of the CDTI approach ? assessment of treatment coverage assessment of the reliability of records at all levels including district and village levels what is the community perception of CDTI and its degree of satisfaction with prograrnme activities ? 14.6 In general (i) the process of CDTI implementation was found similar in the three countries with minor variations between projects, (ii) there were records of treatment in all sites; however, the quality of the records varied widely, (iii) the communit-v perceived the programme: as owned by government in Nigeria (except in Cross River where it is considered as owned by community) as owned by the government and the NGDOs in Sudan as belonging to the government in Uganda. This perception is much stronger in Uganda than Sudan and Nigeria 14.7 The strengths of the prograrnme were described as follows (i) NGDOs are playing major roles at all levels, (ii) community interest was very high, (iii) health personnelwas very much involved in CDTI implementation. There was no place where health staffwas not involved in CDTI, (iu) The commitment of CDDs was found to vary fiom one place to another, (u) CDDs' treatment records were available JAF4 Page 19 l4 8 The weaknesses were summarized as below (i) non- treatment of absentees was common (almost all the projects monitored) This was mainly attributed to the factthat the implementors were in a hurry to hand overto the higher level treatment records, the quality ofthe CDDs and health stafftraining wasgenerally poor. Emphasiswas rather plac*d on measurement , dosage determination, referrals and little attention was paid to community mobilization, ( ii) (iii) some specific groups of population were excluded from participation (to be selected as CDDs, attendance of meeting) but not from treatment (iv) community awareness of responsibility was rather low which accounts for marginal involvement or participation of community members in the selection of CDDs, contribution to CDDs maintenance during treatment periods. (") Though records were found everywhere, their quality was rather poor, ("i) no feedback is provrded, the only level this is taking place is from APOC Management to the national control programme office, ("ii) 149 (i) (ii) (iii ) (i") (u) ("i) (vii) t4 l0 (i) ( ii) ( iii) duplication of training manual and/or translation of IEC materials was not budgeted for Constraints to CDTI implementation identified by the monitors were the following: delay in the release of funds absence of functional health services in some project sites demand for incentives by CDDs (major problem in Uganda) poor financial support at the local level social and political instability in different areas accessibility/transportat ion cost covery policy (e.g. payment of 1OOshgs per person treated) some innovations in cDTI implementation were observed and included: military involvement in CDTI process (in Sudan, they released their jeeps and provided TV set for mobilization), appointment of non-health personnel as an element of social mobilization, purchase of an adverse reaction kit by the community (Cross fuver) JAF4 Page 20 14 1l rhe recommendations of the monitors were the foflowing: (i) emphasis should be placed on process building at this stage and not only on achieving high treatment coverage (ii) bureaucracy concerning funds transfer to project sites should be streamlined, (iii) Continuous monitoring by project implementators should be encouraged (iv) Feedback should be provided to all levels including the community level 14-12 The forum noted with satisfartion tfr. i**n.n, and useful information collected by the teams of scientists commissioned for this task in connection with the follow up of CDTI projects. The findings of scientists were considered by JAF participants as significant and near to the reality The forum commended the APOC Management, the NOTFs and all the scientists involved in this exercise and expressed the wish that the recommendations listed in the reports produced by the different teams be carefully studied and promptly implemented if appropriate. 14.13 However, some concerns were raised as to the issrre of (i) timing and partnership in the conduct of this first exercise of monitoring by independent scientists, (ii) the community which did not see clearly its responsibilities in CDTI implementation, (iii) the need to develop simpler tools which community can use for self monitonng of CDTI activities; (ir) absentees not getting treated because possibly drugs are not kept sufficiently long in the community and possible ways of overcoming this problem (e.g.: need lor an alternative packaging) 14.14 The Forum therefore recommended that the involvement of communities be enhanced in all projects and expressed the wish that a speedy solution be found to the problem of treatment of absent members of the community 14.15 JAF approved the proposal to develop a simple tool for use by projects and cornmunities to carry out self-monitoring of CDTI actvities. 14 16 The Management of APOC informed the forum on the following points: (i) Ietters have been sent to the NOTFs requesting them to react on the reports of the monitoring teams; (ii) two meetings will be convened next year further to this first monitoring exercise: one will bring together the scientists involved in this exercise so that they can refine all the data collection instruments, develop and adopt uniform procedures for data analysis as well as a single format for report writing. In so doing the IAF4 Page 21 quality and reliability of the data during subsequent exercises will be further improved; the other will gather national coordinators, representatives of NGDO partners, local/district CDTI project mangers, all the scientists involved in this first exercise as well as APOC staffto further discuss the lessons learned and develop plans of action to implement the recommendations set forth by the independent scientists as well as the points raised by the forum. 15. PLAN OF ACTION AND BUDGET FOR 1999: Agenda item 15 (document JAF4 3) 15.1 For I999 it was planned to implement and manage in l4 countries 49 CDTI projects, 4 vector elimination projects and support to 8 national secretariats in all 6l projects of which 45 already approved and I 6 new to be prepared before 3 I January 1999 at the latest. 15.2 Workshops on CDTI project management and improvement of community-distributor training would be organized as would the training in Rapid Epidemiological Mapping (REMO) and in the Geographical Information Systan (GIS) The integration of REMO data into the GIS fi.les would be technically supported by WHO Hqs. 15.3 Independent monitoring of CDTI projects would continue and mid-term evaluation of projects having reached their third year ofimplementation would be initiated. Also the collection and analysis of baseline data for the APOC long-term impact study would continue 15.4 The Programme would collaborate with the Special Programme for Research and Training on Tropical Diseases (mR) in operational research activities and contribute together with OCP and TDR to the cost of the Macrofil project. 15.5 The management would continue its collaboration with the WHO Regional Office for Africa and its country offices, with WHO Hqs. and with the NGDO Coordination Group (payrng half of the salary of the secretary of the NGDO Coordinator and his travel cost) 15.6 The APOC Manager would participate in the sessions of the Committee of Sponsoring Agencies (CSA) and arrangements would be made for holding two sessions of the Technical Consultative Committee during 1999 15.7 The proposed budget for 1999 operations of APOC amounted to US$ 14 984 000 *** The discussions focused on the followin.g main points 15.8 According to some JAF participants some line items were lacking in the distribution of the expenditures (contingencies, translation ofthe training manual into local languages, etc). The APOC Management justified the absence of contingencies line item in the general budget of APOC as follows: the budget of the first phase of the prograrnme has a deficit of 9 million USD; the budget submitted is based on the experience of last year; there is a contingency line in each project budget. IAF4 Page 22 As to the translation of the CDTI training manual in local languages, the Management admitted that it was not accounted for in the budget but this expenditure can be dealt with without increasing the budga 15.9 Some delegates queried whether vector elimination implementation in Tanzarua and Equatorial Guinea was not more expensive than initially planned ? The answer was that on.ly Equatorial Guinea may be concerned by this issue. However, no significant variation was expected in the costs of the implementation of the vector elimination project in Bioko island because APOC will borrow from OCP a great deal of the equipment and materials needed. I 5. 10 A decrease of 25,000 USD in the propose d 1999 budget compared to the 1998 approved budget in connection to the NGDO liaison office in Geneva was noted and some delegates wondered why ? The explanation provided by the Representative of WHO/He was that the decrease on this budget line is due to the foreseen decrease in the activities of tire office (less travel for technical support to participating countries for the development of national plans and CDTI project proposals). l5 1 I Some JAF delegates questioned the 9%o adnnrustrative costs of the programme and argued that this figure would rather reflect the fact that the lean professional staffis tapped to the maximum limit of its capacity. While recognizing that g/o administrative costs partli ieflect the limited staffof APOC , the Management also pointed out that the efficient collaboration with OCP in part accounted for thrs 9%o administrative costs. However, if the prograrlme were to recruit say one administrative officer, an epidemiologist and a social scientist, this figure of 9%o may no longer stand, the APOC programme Manager said. 15.12 The REMO budget line was found to be increasing steadily over time: 10,000 USD more n 1997 compared to the figure of 1996, 82,184 USD in lg98, Z5O,O00 USD proposed for the 1999 budget. If the last figure is approved as part of the 1999 budget, the forum would expect to have a more detailed report on REMO/GIS next year. 15 l3 The forum queried about the budget absorption capacity of the programme and was assured that most of the approved 1998 budget as well as the proposed teee budget will be utilized. I 5. l4 The Forum approved the proposed Plan ofAction for 1999 and the corresponding budget in the amount of US$ l4 984 000 16. FINANCING OF THE AFRICAN PROGRAMME FOR ONCHOCERCIASIS coNTRoL Financial situation 16. I The Manager of the World Bank Onchocerciasis Unit, Mr Bruce Benton, informed the Forum that an average annual amount of US$ 19 million would be required for OCp (199g- 2002) and APOC (199s-2007) together, i.e.l5o/o less than for OCP alone during the past decade with a sharp decline, however, from the year 2001. 16.2 To finance APOC, Donor contributions of US$ 66 million would be required during Phase I (1996-2001), and US$ 60 million for Phase Il (2002-2007) with an average of US$ 10. j million per year over the life of the Programme. The donor contributions of the iwo phases are JAF4 Page23 now estimated at US$ 126 million i.e 5 million less than initially projected From the point of view of the Bank, the resulting savings is attributable to the ef;[ective work of the management of the programme and the rigor of TCC in projects' consideration l6 3 To meet the financial requirements for Phase I (US$ 66 million), Donor contributions totalling US$ 56.9 had been secured to which should be added US$ 0.4 million in investment income. The financial gap for APOC Phase I was thus estimated at US$ 8.7 million. So far, five OCP Donors had not yet committed to APOC, and their support was in serious doubt. Special efforts were underway to bring new Donors into the Programme and three new Donors had recently joined APOC. However, without additional new Donors in the Programme, the current donor community would need to increase its total contributions to Phase Iby 14 o/o in order to fully fund that Phase. Nevertheless, APoc appeared to be fully funded by 1999. 16.4 Mr Bruce Benton also reported that the Bank has not been able so far to build up a contingency reserve for APOC because of the pace of the implementation of the prograrnme. As a matter of fact, as soon as money comes into the Trust Fund it leaves out for project implementation. Unless the 9 mitlion deficit were filled through an increase in the current financial support, the present growth rate of implementation of APOC funded projects could not be sustained and ongoing CDTI activities might have to be curtailed. 16.5 JAF therefore recolrlmended that the current efforts to increase the number of financial contributors be persued. 16.6 As the upper limit for APOC financing was set at 75yo of the total expenditures, the remainder would be financed by the Participating Countries and by the Collaborating Non- governmental Development Organizations. 16.7 The supply by Merck & Co. of ivermectin free of cost constituted a major contribution, ranging in the hundred of millions of dollars, which considerably reduced the financial burden on Donors. Pledgine of Donor contributions 16 8 Once finalized, the list of pledges will be transmitted to participants in the Forum. 16.9 The Bank proposed to convene a donors'meeting next year tentatively October 6-7, 1999 in Paris to discuss how the 9 million USD shortfall can be met over the coming years. 16 l0 Although all the Representatives of the Donor community reiterated their firm commitment to continue to support APOC, some did mention that budgets allocated by western countries for North-South cooperation are constantly going down. This constitutes a threat to the financing of APOC operations. 17. OTHER MATTERS 17 I A joint session of JPC l9 and JAF4 was held in the morning of Wednesday 9 December, the report of which is attached as Annex 4 IAF4 Page 24 18. DATE AND PLACE OF THE FIF"IH SESSTON l8 I Gven that negotiations concerning the venue of the session were still gorng on, the place and date would be communicated to JAF participants at a later date. The likelihood was that the session would be held during the first or second week of December I 999 le. AppRovAL oF THE FINAL COMMUNIQUE 19.1 The final communique with the attached conclusions and decisions adopted after the consideration of each agenda item, was approved with a few modifications (see Annex 5). 20. CLOSURE OF TIIE FOURTH SESSION 20 1 Following a statement by the Chair, the session was declared closed (see Annex 6) IAF4 Page25 ANNEX I LIST OF PARTICIPANTS JAF MEMBERS Belgium Dr. Jacques A. LARUELLE Charge de Programmes, Ministdrre des Aftires Etrangdres, du Commerce Ext6neu r et dela Coopdratior au Ddveloppemef,It, Admrnistration gendrale de la Coqeration au D6veloppement, Rue Brederode 6. B- I 000 Bruxelles, Belgique Tel.32-2- 519 0752/32-2-519-0211 - Fax: 32-2-519 0s70 - E-MAIL: m4.vnu@badc.fgov.be Burundr Dr. Thaddee BUZINGO Duecteur du Projet de Luue ccrrtre les Maladies Transmissibles et Carentielles (LMTC), Ministire de la Sartd, B.P. 1820 ou Projet LMTC B.p. 1355, Bujumbura, Burundr Tel:257 22 18 13 ou257 2291 95 -Fax:257 229t 96 Cameroon Prof. Gctlieb Lobe MONEKOSSO Ministre de la Sant6 publique, Ministdre de la Santd publique, yaound6, Cameroun Tel: 237 22 35 25 -Fax:237 22 02 33 Dr Boubakan YAOU Inspecteur Gdn6ral. Ministdre de la Sant6 publique, B.p. 12266. yaoundd, Cameroun Tel:237 22 87 94 -Fax:237 22 87 94 Dr Basile KOLLO Directeur de la Sant6 Communautaire, Ministdre de la Sant6 publique, Yaound6, Cameroun Tel 237 23 33 84 ou237 23 93 50 -Fax..237 ZZ 4419 Mr. TATAH Solomon Enoma Diplomat, Ministry of Extemal Relations, Yaound6, Cameroon Tel 237 21 15 99 -Fax:237 20 25 9t Canada Ms. Sylvia BARROW Health Specialist, East, Southem and PanAfrican Divisions, Afrrca and Middle East Branch, Canadian lntemational Development Agency, 200 Promenade du Portage, Hull, Quebec, Canada KIA 0G4 Tel: 819 953-0732 - Fax: 819 997-5453 - Email: sylvia_barrow@acdi-cida.gc.ca Ceutral Afrrcan Reoublic Mme Fernande DJENGBOT Mrnistre de la Santd publique et de la Population, Ministdre de la Sant6 publique, B.p. I344, Bangui, R6p ublique Centrafricaine Tel:236 6l l6 35 - Fax: 236 61 70 99 JAF4 Page26 Annex I Equatorial Guinea Dr Anacleto N. SIMA Directeur national du Programme de lune ccntre l'Onchocercose, Mrnistdre de la Santri pub;que a Bien- Etre Social, Malabo, Guinee Equatoriale Tel.240 9 26 86 Finland Mr. Mikael SJOVALL lfiachd, Mrnistry for Foreign Aftirs, Department for International Development Coorperation, Katajanokanlaituri 3 - 00160 Helsrnkr, Finland Tel: 358-9 13416316 - Fax: 358-9 13416200 - Email: mrkael.slovall@formrn.fi Germanv Dr. Andreas GRUEB German Development Coqeration, German Technical Cooperation (GTq,Rural Heahh Services, Brcng Ahafo Regron, P.O. Box 473, Sunyani, Ghana Tel:233 61 73 76 -Fax'.233 61 73 76 Gulbenkian Foundation Mr. Joao VIEIRA fusistant Director, Av. Bema 45-A, Lisbon, Porhrgal Tel: 351 I 793 5l3l - Fax: 351 | 793 0676 Kuwart Dr. Abdul-Redha M. BAHMAN Agricultural Advisor, Kuwait Fund for Arab Economtc Development. P.O. Box 2129,13030 Safat, Kuwart Tel: 965 2468800/965 2418709 - Fax: 965 2436289 Liberia Dr. BARTEE Nataniel S. Depury Minister of Heahh & Social Welfare, Ministry of Heahh & Social Welfare, p.O. Box 10-9009 1000 Monrovra 10, Liberia Tel231 22 63 17 - Fax: 231 22 63 17 Dr. Samuel T. DOPOE National Onchocerciasis Control Programme Coordurator, Muristry of Heahh and Social-Welfare, c/o World Healtlr Organization, P.O. Box 316, Monrovra, Liberia, Tel: 231 226 208 - Fax: 23 | 226 208 Dr. Fatorma K. BOLAY DiseasePrevention and Control Officer, c/otheWorldHeahh Organization, P O Box 316. Monrovra, Liberia Tel: 231 226 208 - Fax'. 231 226 208 - E-mail: WHO@LIBERIA NET JAF4 Page 27 Annex I Luxembourg Mr. Stanislas MYCK Inspecteur, Direction de la Coop6ration au D6veloppement, Mrnistr)re des Affaires Etrangdres, 6 rue Congr 6gation, L-2440 Luxembourg Tel. 352 478 2440 -Fax: 352 222048 - E-mail: stanislas.myck@mae.dat.lu Malaw Rt. Honourable Chenda MKANDAWIRE ffP) Deputy Minister of Heahh and Population, P.o. Box3o377, Lilongwe 3, Malawi Tel:265 335255 -Fax:265 ?8 3109 Mr. Phillimon A.J. TAMBALA Natiqral Coordinator, Natimal Onchocerciasis Programme, c/o I.E.F., P.O. Box 2273,Blantyre, Malawr Tel: 265 620 535 or 265 624448 - Fax: 265 624526 Netherlands Mr. Johannes Clemens M. VAN DER HORST sector-specialist Health at the Dutch Embassy in Mali, Bp zz2o Bamako. Mali Tel:223 21 95 72 -Fax:223 21 3617 - Email janhorst@malinet.ml Nieeria Dr. Abubakar Ali GOMBE Miruster of State for Heahh, Federal Ministry of Heahh, 3d Floor New Federal Secretariat Complex, Martama-Abuja Tel 234 9 6228 -Fax.234 9 523 t1t3 Dr Jonathan Y. JryA National Coordrnator. National Onchocerciasis Ccntrol Programme, Federal Ministrv ofHeahh. Federal Secretanat,Ikoy, Lagos Tel:234 | 269 6013 -Fax:234 1 2696013 Mr. Victor Garba ZARAFI Prurcipal A&ninistrative Officer, National Onchocerciasis Control Prograrq 3d Floor, Federal Ministry of Heahh, Federal Secretanat, Maitama-Abuja Tel'.234 9 523 1197 Mr. Aliyu MOHAMED Protocol Officer, FederalMinistryofHeahh, 3d FloorNew Federal Secretariat Complex, Maitama-Abu.yaTel 234 9 523 5228 - Fax: 234 9 Dr. Idris GARBA Technical Adviser to the Honourable Mnister of State for Health, Federal Ministry of Heahh, 3d Floor New Federal Secretanat Complex, Martama-Abuja Tel:234 9 523 6228 JAF4 Page 28 Annex I Sudan H E. Dr Thomas ABWAL CHIDI Federal State Minister of Heakh, Federal Mmistry of Health, P O. Box 303, Khartoum, Sudan Tel: 249 11 776776 - Fax.249 11 780652 Mr. Bashir IBRAHIM MIJKHTAR First unders@retary, Federal Ministry of Heahh, P.o. Box 303, Khartoum, sudan Tel: 249 ll 77 85 97 - Fax'.249 ll 780652 Prof. Mamoun Mohamed Ali HOMEIDA National Coordinator & Chairman of the NOTF, Academy of Medical Sciences, P.O. Box 12810, Khartoum, Sudan Tel.249 ll 72 47 62 or 249 ll 72 33 85 - Fax: 249 11724799 - E-mail: ASMS@Mamoun Swrtzerland Mr Frangois RODUTI Chef adjoint de la Section Afrique occidentale, Directisr du Ddveloppement et de la Coop6ration @DC) DFAE, CH-3003 Beme, Suisse. Tel: 4l 31 322 3474 - Fax: 41 31 324 1695 - Email frangois.roduit@deza.admin.ch Uganda Dr. Cnspus KryONGA Mrnister of Heahh, Ministry of Heahh, P.O. Box 8, Entebbe, Uganda Tel'. 256 41 232170 - Fax: 256 41 348339 Dr. Richard NDYOMUGYENY-I National Onchocerciasis Coordrnator, Vector Control Divisiqr, Mrnistry of Heahh, P.O. Box 1661, Kampala, Uganda Tel'. 256 41 348332 - Fax'. 256 41 348339 - E-mail: notf@rmu.com. Unrted-Kingdom Mr. Phil MASON Deputy Head, Heahh and Population Divrsion, Departrnent for Intematronal Development (DFID), 94 Victona Street, London SWIE 5JL. Tel: (+44) 17l 917 0050 - Fax: (+44) t7 | 9t7 0174 - Email ps-mason@dfid.gtnet.gov.uk Unrted States of America Dr. Robert POND TAACS Advrsor to the USAID Mission ur Ghana, P.o. Box 1690, Accra, Ghana Tel: 233 21 22 84 40 - Fax: 233 21 23 t9 37 JAT4 Page29 Annex I NON-GOVERNMENTAL DEVELOPMENT ORGANIZATIONS Afrlcare Mr. Gabnel DANIEL Country Representative of Africare, P.O. Box OS/210g, Accra, Ghana Tel: 233 21 76 53 4l or 233 21 76 53 40 - Fax: 233 21 76 53 40 - Mobile: 233 24 31 9t 40 - E-mail : afncar@$tana. com Arr Care lntemational Ms. Cyuthia SLEOR Epidemiologist, Air care Intematimal, p.o. Box4r7, Goleta, cA 93116, usA Tel: 805 685 4144 - Fax: 805 685 8772 - Email: aircare@silcom.com Dr May KHADEM Director, Eye Programs, Heahh for Humanrty, 467 Jackson Avenue, Glencoe, Illinois 60022 USA Tel: (+l) 847 835 5088 - Fax: (+1) 847 835 7088 - Email: Heahh@usbnc.ory Mr. Eyong TATAH A&ninistrative Director, BASED OnchoPrgect (Littoral II), c/o BASED B.p 4230, yaounde, Cameroon Tel'. 237 23 05 75 - Fax. 237 2 t 09 89 Dr. Fisseha ESFIETU gto Unrry College, P.O. Box 6422 Addts-Ababa, Ethiopia Tel: 251 I 614108 - E-mail: UNlTy.edu@elecom.net.et Mr. M. Sylvain MOREKOISSE Coordonnateurdu Programme BAHA'I sur I'onchocercose, Institut AYEMIKHAH, B.p. l4l l, Bangui, R6p ublique Centrafricaine Tel:236 61 44 75 -Fax:236 6l l0 89 Global2000 Riverblin&ress - Carter Center Dr. Frank RICHARDS Technical Director, Global 2000 River Bhndness Program, the Carter Center, one Copenhill, Atlanta,GA-30307, USA Tel: (+1; 404 420 3830 - Fax: (+l) 404 874 5515 - Email Frrl@ccrc.sov Christoffel Bl indennussion Dr. Adnan Dennis HOPKINS Medrcal Consuhant of CBM, P.O. Box 1772, PNLOC Bossangoa, Central African RepublicTel'236 65 00 35 -Fax:236 65 00 35 Mr' JeffS' Watson, Onchg Control Programme Coordrnator, Chnstoffel Blindenmission, 34 GomwalkClose, Jos, Plateau State, Nigeria Tel'. 234 ?3 456578 - Fax:234 73 456579 Email Jeffiratson@maf.org IAF4 Page 30 Annex I Ms. OLAMIJI Onyeka Francisca CBMA{ITOSATFI/Nigena, MITOSATH Rrverblmdness ControlProgram, l9 Mo.lidi St OffToyn St Ikeya, Lagos, Nigeria Tel'.234 I 492 6945 - Fax'.234 I 492 6943 BOSH I GIMPERA Foturdation Dr. Enric DL]RAN University of Barcelona, do Ministry of Foreigrr Affairs, Valryo Diplomatico Spanish Embassy , Malabo, Equatorial Gurnea ,Plaza Provincial 1,28012, Madrid Espafra Tel:240 9 3156 -Fax:240 9 3156 Mr. Miguel Angel ECHEVERRIA IJnrversity of Barcelona, c/o Ministry of Foreigrr Aftirs, Valryo Diplomatico Spanish Embassy, Malabo, Equatorial Guinea ,Plaza Provincial 1,28012, Madrid Espafra Tel.240 9 3156 -Fax:240 9 3156 HeahhNet lntemational Ms. Irene GOEPP Programme Manager, Southem Sudan OV Control Program, Suguta Rd, Kileleshwa, P.O. Box76133, Nairobi, Kenya Tel:254 2 573 704 -Fax.254 2 574 452 - Email: hnetnbo@rbnet.co.ke. Helen Keller lnternational Dr. Jordan KASSALOW Director of Onchocerciasis, l0 West 66 Street New York NY 10023, USA Tel: (+l) 212 943 0890 Ext: 805 - Fax: (+l) 212 943 1220 - Email Ikassalorvrzr,r.\dl conr Mectizan Donation Program Dr. Stefarue MEREDITH Director, Mectizan Donation Program, Task Force for Child Survrvaland Development, 750, Commerce Dnve Suit 400, Decatur, GA 30030, USA Tel: (+1; 404 371 1460 - Fax: (+l) 404 371 I138 - Email smeredrt@taskforce org Merck & Co.. Inc Ms. Brenda D. COLATRELLA Manager, Product Donations, Merk & Co.,Inc. WSIAF-35, Whitehouse Station NJ 08889-0100, USA Tel: (+l) 908 423 2047 - Fax: (+l; 908 423 1987 - Email: Brenda_Colatrella@Merck com Mr Charles T. FETIIG, Senior Director, Human Heahh Division Merk & Co.,lnc. WSIAF-35, Whitehouse Station NJ 08889-0100. USA Tel: (+l) 908 423 6937 - Fax: (+l) 908 735 1334 - Email: charles_fettig@merck.com IAF4 Page 3 1 Annex I Organization for Prevention of Blindness (OPC) Prof. Patnck QUEGUfNER Directeur des Programmes, 9 rue Mathurin R6gnier, 75015 Paris, France Tel: 33 I 40619905 - Fax 33 I 406101 99 Emall opcecrte(@txique.fr Sight Savers Intemational Ms Catherine CROSS Director, Overseas Programmes, Sight Savers International, Grosvenor Hall, Bolnore Road, Hayrards Heath, West Sussex RHl6 4BX, England Tel: (+44)1444 446600 - Fax: (+44) lM4 446677 - Email ccross@sightsaversint.org.uk Ms. Pamela Suzanne DRAMEH Regimal Director, West Africa, Sight Savers Intemational, P.O. Box 18190 Airport, Accra, Ghana Tel:233 21774210 -Fax'.233 21774209 - -Email: pdrameh@SStWA.AFRICAONLINE.com.GH Dr. Elisabeth O. ELHASSAN Country Representative, Sight Savers Intematronal, 1 Golf Course Road, Kaduna, Nigeria Tel: 234 62 238 360 or 234 62 238 973 - Fax'. 234 62 238 360 - E-mail: SSlNG@tnfoweb.abs.ner SmithKline Beecham SB Dr. Brian BAGNALL Director, Lymphatic Filanasis Project, SmithKline Beecham, One Franklin plaza. p.O. Box 7929. Philadelphia, PA 1910 I -7 929, US A Tel: (+l) 215 751 6168 - Fax: (+l) zt5 751 4046 - E-mail: brian.bagpail@sb.com Unrted Nations Children's Fund ILNICEF) Mr. Chip LYONS, President, US Commiuee for United Nations Children's Fund (JNICEF), 333 East 38u Street, New York, NY 10016, USA Tel: (+l) 212 922 2500 - Fax: (+l) ztz 867-5991 - E-mail: CLYONS@LTNICEFUSA.oRG Ms. Jacqueline DORANTE Director, Corporate Relations, US Committee for Unrted Nancns Children's Fund (INICEF), 333 East 38s Street, New York, NY 10016, USA Tel: (+l; 212 922 2510 - Fax: (+l) 212 779 lo29 - E-mail: jdorante@unicefusc.org Dr Emmanuel I. GEMADE Project Officer, Healtl, Unrted Nations Children's Fund ([INICEF), Nigeria Country Office, 30A, Oyrnkan Abayomi Dnve, Ikoyr. Lagos, Nigeria Tel'.234 1269 027680 or 234 t 269 2EO -Fax.234 | 269 0726 - E-mail: egemade@uniceforg SPONSORING AGENCIES Food and Agnculture Organization of the United Nations (FAO) Mr Bamidele F. DADA Assistant Director-General, Regional Representatrve for Africa, Food and Agnculture Organization,(FAO) Regional Office for Africa, p.O. Box 162g, Accra, Ghana Tel:233 21 66 53 43 - Fax: 233 2t 66 8427 IAF4 Page 32 Annex I Mr Moise SONOU, Senior Water Resources Officer, Food and Agriculture Organtz*ion (FAO) Regronal Office for Africa, P.O. Box 1628, Accra, Ghana Tel: 233 21 244051- Fax: 233 21 66 84 27 - E-mail: Moise.Sonou@fao.org Mr. Rene WRIGHT Fqrctionnaire Charg6 de Politiques et Programmes, FAo, P.o. Box 1628, Acnra, Ghana Tel 233 2l 244 051 - Fax: 233 21 233 999 - E-mail: Renewright@fierdfao.org United Nations Development Proeramme (UNDP) Mr. Abdoulie JANNEH Reside,nt Representative, United Nations Development Programme (LlNDP), P.O. Box 1423, Acnra, Ghana Tel:233 21 77 ?8 3 I - Fax: 233 21 77 38 99 Mr Gana FOFANG Policy Adviser, LINDP Africa Bureau, I UN Plaza, New York 10017, Uruted States of America Tel: (+l) 212 906 5989 - Fax: (+l; 212 906 6478 Ematt gana.fofang@un@.org Mr. Paul DERIGUBAA Programme Speciahst, UNDP, P.O. Box 1423, Accra, Ghana Tel:233 21 773 890 - Fax: 233 7l 773 899 World Bank Mr. Birger FREDRIKSEN Sector Director, Human Development, Africa Regrm, the World Bank, l8l8 H Sreet, NW, Washington, D.C.20433, U.S.A. Tel: (+l) 202 473-5033 - Fax. (+) 202 477 29OO - lntemer: BFREDRIKSEN@WORLDBANK.ORG Mr. Bruce BENTON Manager, Onchocerciasis Coordination Unit, Afrrca Regton, the World Bank J l0-047, l8l8 H Street, NW, Washington D.C. 20433, U.S.A. Tel: (+l) 202 473 5031 - (+l) Fax: 202 522 3ls7 - E-marl: BBenton@worldbank.org Dr. Bemhard LIESE Director, Heahh Servrces, MC-C2429, the World Bank, l8l8 H Street, NW, Washington D.C. 20433, U S.A Tel: (+l) 202 458 4491 - Fax: (+l) 202 522 t6t6 Dr. Philip COYNE Medical Consuhant, the World Bank, Africa Regron-Onchocerciasis Unit, l8l8 H Street, N.W, Washurgton D C 20433, USA Tel: (+l) 202 458 l5l I - Fax: (+l) 202 522 3rs7 - E-mail: pcoyne@worldbank org Ms. Haiyan Ellen SUN Cofinancing Specialist, the World Ba*, Africa Region-Onchocerciasis Unit, l8l8 H Street, N.W., Washurgton D.C. 20433, USA Tel: (+l) 202 458 8296 - Fax: (+l) 202 522 3157 - E-mail: HSUNI@,.ivortdbank.org JAF4 Page33 Annex I Ms. Joyce MSUYA-MPANJU Health Specialist, the World Bank, Afrrca Regron-Onchocerciasis Unit, l8l8 H Street, N.W., Washrngton D C 20433, USA Tel: (+l) 202 458 7712 - Fax: (+l) 202 522 3157 - Emailjmsuya@worldbank.org Ms. Marlune ALEXIS Program Assistant, the World Bank, Afrrca Regron-Onchocerciasis Unit, l8l8 H Street, N.W., Washrngton D.C. 20433, USA Tel: (+l) 202 473 4400 - Fax: (+l) 202 5223157 - E-mail: Malexis@worldbank.org World Heahh Organization Dr. Ralph Hale HENDERSON Special Adviser to the Director€e,neral, 20, Avenue Appia - l2ll Geneva 2'1, Gqrewa, Switzerland Tel. 4122 791 2388 - Fax: 4122 791 0746 Mr Claude-Henri VIGNES Legal Counsel Emeritus, WHO/[IQ, 20, Avenue Appia - 12ll Geneva 27, Gaeva, Switzerland Tel: 4122 791 4754 - Fax: 4122 791 4158 Dr. Bjorn THYLEFORS Dnector PBD, wHo/HQ, 20, Avenue Appia - l2ll Geneva 27, Gaeva, switzerland Tel. 4122 791 2697 - Fax: 4122 791 4772 Mr. Clas SANDSTROM, Actrng Director BFI, WHO/[IQ, 20, Arrurue Appia - l21l Geneva 27,Gqeva, Switzerland Tel'. 4122 791 211I - Fax: 4122 791 4855 Dr. O. Oladele Olusr.yi KALE Actrng Manager, Special Programme for Research and Training in Tropical Diseases ODR), World Heahh organization, 20, Ave,nue Appia, cH-l2l I Geneva 27. Geneva, Switzerland Tel: 4122 791 2l I I - Fax: 4122 791 4774 WHO/AFRO Dr. E.M. SAMBA, Regional Director, WorldHeahh Organization, Regioral OfficeforAfrrca, CWARD, Medical School PARRENIYATWA Hosprtal, P.O. Box BE 773,Belvdere, Harare, Zrmbabwe Tel: 263 I I 403 495 or I 407 733 9201 - Fax: I 407 ?33-g}g0 - E-mail: Samba@WHOAFR.org Dr. ALEMU Wondrmagegrrehu, World Heahh Organization, Responsible for Integrated Disease Surveillance, Regional Office for Africa, CWARD, Medrcal School PARREI.IYATWA Hospital, p.O. Box BE 773, Belvedere, Harare, Zimbabwe Tel.263 4 706 951 or 263 4 707 493 -Fax:263 4 7OO 742 - E-mail: Alemuw@WHOAFR.org WHO Secretanat Dr K. Yankum DADZIE Acting Director, Afrrcan Programme for onchocerciasis control, ouagadougou Dr Uche AMAZIGO scientist, African Programme for onchocerciasis control programme, ouagadougou IAF4 Page34 Annex I Dr. Hyacrnthe AGOUA Chief Administrative and Technrcal Servrce, EaglZone, Onchocerciasis Control Programme, Kara Dr. Lao K.B. AKPOBOUA A.g. Coordinator, Director's office, onchocerciasis control Programme, ouagadougou Mme A. BLU Onchocerciasis Cqtrol Programme, Ouagadougou Dr Boakye A. BOATIN Chief of Planning, Evaluatior and Transfer Unit, Onchocerciasis Control Programme, Ouagadougou Dr Ole W CHRISTENSEN Cotsultant, Onchocerciasis Ccmtrol Programme Liaison Office, WHO, Geneva, Swrtzerland Tel:4122791 2lll - Fax: 4122791 0746 Dr. DanielETYA'ALE NGDO Coordinator, PBDAVHO, Geneva, Swrtzerland Tel. 4122 791 2642 -Fax: 4122 791 4772 Dr J.-M. HOUGARD chiefl vector control unit, onchocerciasis cmtrol Programme, ouagadougou Pr. M. KABORE Translator, Onchocerciasis Control Programme, Ouagadougou Mr. Georges KOULISHER Consultant, Onchocerciasis Control Programme, Ouagadougou Dr. J. LAZDINS Manager, Filariases R & D (Macrofil) 20, Avenue Appia - l2ll Geneva 27, Geneva, Swrtzerlmd Tel: 4122 791 2ll I - Fax: 4122 7914190 - E-mail: <lazdrnsj@vho.ch> Dr M. NOMA Epidemilogist and Biostatistician, African Programme for Onchocerciasis Control programme, Ouagadougou Ms L. RAVELONANOSY Programme Officer, Office ofthe Director, Onchocerciasis Control Programme, Ouagadougou Dr J.-B. ROLINGOU Conseiller R6gional pour les autres maladres tropicales, (OTD), WHO/AFRO, c/o OCp Ouagadougou Tel. 226 30 23 0lll2l13 - Fax 226 30 2t 47tZZ6 34 26 48 DT A. SEKETELI Programme Manager, African Programme for Onchocerciasis Control (APOC) and Coordrnator, Office of the OCP Director, Ouagadougou Dr L. YAMEOGO Coordinator of Hydrobiological Evaluation, Onchocerciasis Control Programme, Ouagadougou EX OFFICIO PARTICIPANTS Technical Consultative Committee Professor (Mrs) Adenike ABIOSE Medical Director, TheNational Eye Centre, P.M.B. 2267,Kadwra, Nigena Tel 234 62 239 373 (Flome) - Fax: clo Dr. E. Elhassan 234 62 238 360 abiose@info. web. abs.net JAF4 Page35 Annex I E-mail OBSERVERS Ghana Hmourable Samuel Nuamah DONKOR Minister of Heahh, P.O. Box M.44, Accra, Ghana Tel: 233 21 66 61 5l - Fax: 233 21 66 0l 76 or 233 2t 66 38 t0 Dr. Kofi AHMED Director, Ondro Cmtrol, Ministry of Heahh, P.O. Box M.44, Accra, Ghana TeL 233 21 665421E*.. 4212 -Fax:233 21 66 01 76 Mr. James Ko.yo FOSU Execwive Director, National Onchocerciasis Secrehriat, Minlstry of Finance, P.O. Box M.76, Accra, Ghana Tel:233 21 6664934 -Fax:233 21 6688'11 Mr. Fred BUATSI Deputy Director, National Onchocerciasis Secraanat, Mrnistry of Fmance. P.O. Box M.76. Accra, Ghana Tel:233 21 66 64 93/94 -Fax: 233 66 88 7t Dr. WURAPA Frederick Kwadjo Heahh Dev. Consultant, P.O. Box LG 713,Legon, Accra, Ghana Tel:233 21 50 72 00 - E-mail: WURAPAF@AFRICAONLINE.COM Dr Bemard PHILIPPON Directeur, Unit6 Sant6 et Polrtiques de D6veloppement, ORSTOM,2I3 rue Lafayette, 75010, paris, France Tel: 331 48 03 78 06 - Fax: 331 48 03 77 09 - Email Lafrtte@pans.orstom fr IRD (ORSTOM) JAF4 Page 36 Annex I OTHERS Professor Detlef PROZESKY Factulty of Medicrne, University of Pretoria, P O. Box 667 , Praoria 0001, Republic of South Afirca Tel.27 12 354 I 148 - Fax.27 12 354 1758 - Email: proznsky@meaic.up.acza Dr. Oladele AKOGUN Parasite and Tropical Heahh Research , Federal Universrty of Technology, Yola, Nigeria Tel: 234 75 626 467 - Fax'. 234 75 626 467 IAF4 Page37 ANNEX II CSA REFLECTIONS FOR JAF4 Excellencies, Ladies and Gentlemen, Since the inception of the African Programme for Onchocerciasis Control inlate 1995, the committee of Sponsoring Agencies has taken on the responsibilities ofoverseeing operations, management and financing of APOC and approving individual APOC projects. I am therefore pleased to report to JAF on the major issues regarding APOC considered by CSA during its four sessions in 1998 Madame Chair, CSA is impressed by the rapidity with which APOC has prepared and launched projects. The first year of the life ofthe Programme - 1996 - was spent on establishing APOC structure and preparing for field operations. We noted that 45 projects in eleven of the nineteen Participating Countries have been approved and are under implementation. This progress exceeds our expectations. But this rapid development has only been possible because the staffat headquarters has worked overtime throughout the year. As I understand it, action is currently being taken to recruit a full+ime Director. The Committee has also noted with some satisfaction that the WHO Regional Director for Africa has assigned a staffmember experienced in communicable diseases control to the OCP and APOC management groups in Ouagadougou. This will to some extent alleviate the workload on the current staff CSA wishes to underline, in connection with the staffing situation that not more than 8 per cent of the budget of APOC is spent on administration. [n comparison with operations of similar nature it is a note worthy achievement. The cornerstone of APOC is partnership. CSA would like to stress that the programme in a very short time has established effective collaboration with its partners rangiig fronParticipating Countries and numerous local communities actively involved in APOC op"*iionr, the health services, the donor community and Merck &Co., to the UN syster4 scientists and, not the least, non govelffnental development organizations. Another important partner is the WHO Regional Office and the WHO country network which provides administraiive and managerial support to APOC field operations. In the opinion of CS,\ this synergistic partnership is indeed innovative and could very well serve as a model for other major pubiic health initiatives. CSA would particularly like to pay tribute to the Members ofthe Technical Cons.rltative Committee who during their twice annual sessions lay the ground for the work for ApOC and provide technical opinion and recommendations regarding the acceptability ofproject proposals. AIso, this Committee has been instrumental in preparing for, and iuun"l,ing, ut tt ir earty stage independent monitoring and eventual evaluation of ApoC -assisted projects. Madame Chair, at the request of your Forum at its session in December last year, the TCC held a special meeting on the issue of APOC and health sector reform. That report is before you at this current session. CSA would like to draw your attention to the primary conclusion of this meeting that the APOC operations are compatible with, and will reinforce ongoing health sector reform, through the emphasis on partnership with the heath services, communities, non governmental development organizations and pharmaceutical industry. It was stressed that many of the priorities of the newly elected Director-General of WHO are reflested in the APOC programme ]AF4 Page 38 Annex II On a less optimistic tone, CSA wishes to draw the attention of JAF to the funding situation. Mr. Bruce Benton of the World Bank will inform the Forum in some detail so I shall only emphasize that there is a considerable gap in the financing of the first phase of APOC operations and that a shortfall is projected for the immediate future and additional contributions are urgently needed. The Committee remains optimistic that the donor community will act soon to ensure that this programme which has had such a remarkable start and holds such promise for integrating disease control in Africa rural areas, is not undermined solely by financial shortfalls. As regards financial management of approved projects, CSA would like to stress the cost- effectiveness and financial soundness ofthe Programme. The Committee is pleased to note that APOC.and OCP managements working with the NGDO group have made a special effort to enhance the capacity of National Onchocerciasis Task Forces to satisfactorily manage and account for funds disbursed for the first round of approved projects. This important managerial issue will be further developed in the presentation of the Progress Report. Madam Chair, let me refer briefly to the collaboration between OCP and APOC and, more specffically, to the location of APOC HQ. The report of an independent Consultant will be considered by JAF at this session. The CSA has had an opportunity to scrutinize this report and endorses fully the recommendations ofthe investigator. The Committee initiated the idea of a combined headquarters when APOC came into being and has since 15.n lsalized that the advantages of sharing headquarters far surpasses the CSA's initial expectations. tn CSA's estimation, it would be prudent and advantageous to continue the present collaboration in Ouagadougou with the understanding that the situation be reviewed once OCP is brought to a conclusion at the end 2002. My final point relates to the item on the agenda for the joint JPC-JAF session this morning which dealt with the control of the lymphatic filariasis in Africa. As members of the Forum were told during that session Merck and SmithKline Beecham have offered to donate ivermectin and albendazole respectively to control lymphatic filariasis in Africa. CSA has noted with satisfaction that the operational strategy of controlling lymphatic filariasis is entirely compatible with that of OCP and APOC and the advantages of addressing lymphatic filariasis through the same community-directed treahnent systems used for onchocerciasis should be fully explored. In closing, I would like to wish the Joint Action Forum a successful session. CSA will continue to give APOC all possible support required to attain its objective in the Participating Countries. Thank you, Madame Chair JAT4 Page 39 ANNEX III STATEMENT BY DR RALPH HENDERSON, SPECIAL ADVISOR TO TEE DIRECTOR.GENERAL OF WHO, TO THE FOURTH SESSION OF THE JOINT ACTION FORUM OF TEE AFRICAN PROGRAMME FOR ONCHOCERCIASIS CONTROL Excellencies, Ladies and gentlemen, The Director-General of WHO, Dr Gro Harlem Bruntland, has asked me to convey to you her greetings and best wishes for success in your deliberations during the coming two and a half days. I would like in this brief address to refer to four aspects ofAPOC which are, to my mind, of essence for success of the Programme namely partnership, community involvement, integration and continued operational research. Successful implementation of public health programmes requires close and active collaboration among the interested parties, although zuch collaboration is often constrained by lack ofcreative communication and by managerial shortcomings. APOC, I believe, has overcome these constraints. Its constructive partnership is clearly demonstrated in the Joint Action Forum in which all the partners are represented. They all contribute on equal teffns to the setting of policy, the determination of strategy and the continuing monitoring and evaluation ofprogress. Furthermore, this partnership is reflected also in the National Onchocerciasis Task Forces which included country expertise and non-governmental development organizations, the main actors moving the Programme to the field. The Task Forces are supported by the ApOC management to ensure that project implementation conforms with the decisions ofJAF. I would suggest that this close and effective partnership at the central and operational level could serve as a prototype to other large -scale public health undertakings. Another fundamental aspect of APOC operations is the reliance on comrnunities for the distribution of ivermectin. Community-directed Treatment with Ivermectin, spearheaded by APOC and OCP, is now recognized as the most cost-effective mode of distribution. It reaches the greatest number of people with the highest expectation of attaining sustainability. Involvement of communities is fully in line with the concept of primary health-care and ApOC therefore has the potential to strengthen primary health care systems in the participating Countries. Again, I am confident that the APOC - and OCP- approach to.community involvement lends itself to application to other activities in the public t.utm A.tA. I wish to stress that APOC is not another vertical programme. It forms part of, and is integrated within, the national public health systems given that community delivery ofivermectin depends on, and is supervised by, Iocal health ..ri..r. AIso, monitoring and surveillance ofAPOC supported projects will, with time become an integral part of comprehensive multidisease surveillance and control systems now being developed *itnif,e support of WHO-AFRO. l/.F4 Page 40 Annex III AJthough APOC has been launched on a solid scientific and sound technical basis, there willalways be room for improving operations in the field. The Programme is therefore involved in operational research activities oriented to enhancing the prospect of zuccess and improving cost-effectiveness of control. An important field research project, supported by APOC and coordinated by TD& deals with the issue of ensuring sustainability of community-involvement in drug distribution. Before closing, I wish to congratulate the APOC Management for the considerable progress made during the last year in expanding the activities of the Programme.Today 45 projects are being fielded in more than half of the l9 Participating Countries. Knowing what it takes to bring a project to the operational stage, I appreciate that this opansion could not have been achieved without putting a heavy workload on the secretariat. ln this connection, I would also like to recognize the importance of the close collaboration between OCP and ApOC in scientific, technical and administrative matters which has been made possible by the location together of the two headquarters in Ouagadougou. I wish to express the gratitude of WHO to all the Partners in APOC without whose support and participation, the Programme could not, and will not, succeed. And finally, let me thank our host country, its President, government and people for the warm welcome extended to all the participants in this session of JAF and for the excellent arrangements made to ensure its success. Thank you JAF4 Page 41 ANNEX IV JOINT PROGRAMME COMM ITTEE OF THE ONCHOCERCIASIS CONTROL PROGRAMME IN WEST AFRICA and JOINT ACTION FORUM OF THE AFRICAN PROGRAMME FOR ONCHOCERCIASIS CONTROL JOINT SESSION Accra, 9 December 1998 Report l. Participants in the nineteenth session ofthe OCP Joint Programme Commiuee (JPC) met together with participants in the fourth session of the APOC Joint Action Forum at the State House Banquet Hall during the morning of Wednesday 9 December 1998 with Mr Samuel Nuamah-Donkor, Minister ofHealth of Ghana, in the Chair. A summary is given in the following of presentations of the iszues on the agenda. 2. Macrofil 2.1 Dr Janis Lazdins, the manager of Macrofil (OCP/APOCiTDR jointly financed project), defined as the primary objective of the project the discovery and development of safe and effective drugs for the treatment of onchocerciasis and lymphatic filariasis. Such drugs should kill the adult worms after a single treatment cycle, be easily field applicable and potentiate or synergize ivermectin as regards efficacy or prevention of resistance. The secondary objectives of the project are: a) discovery and development of a back-up microfilaricide to ivermectin that could be more advantageous (e.g.. longer interval betweem treatments) or that could be a substitute for ivermectin in case of resistance, and b) development of a molecular biology diagnostic tooVmethod that could beused to detect Onchocercavolwlus resistant to ivermectin. 2.2 The Macrofil project had now been fi.rlly integrated within the operational, administrative and managerial structure of TDR/TDP, which had one drug discovery steering committee for all TDR diseases. This integration yielded synergistic use of resources available at TDR as well as in disease endemic regions. It also resulted in an enhanced partnership with industry and NGOs. Macrofil benefited from the availability of TDR in-house professionals in the fields ofchemistry, planning, pre-clinical and clinical activities. The progress assessment of Macrofil sponsored activities was conducted on a monthly basis through a TDR R&D Committee. 2.3 Resulting from the above restructuring of the project the following achievemenis have been made: - a meeting aimed towards identification of molecular targets for the discovery of new drugs against filariases was sponsored by Macrofil, the conclusions of this meeting constituted the basis for soliciting for novel grant applications for innovative drug discovery projects. - the drug screening strategy in animals has been modified to allow assessment ofa larger number of chemical entities in a faster mode (since March 1998:725 compounds evaluated, four new "leads" are currently under evaluation) IAT4 Page 42 Annex IV - the flow of chemical structures from several sources (Walter Reed Army Institute of Research, GlaxoMellcome and several academic institutions) has been optimised through the use of a company that provides the logistic support as well as with the "in house" availability of a chemistry expert - identification / evaluation of a private company that can provide a relevant high throughput in vitro parasite screening system. The use of this facility could allow the eventual "bridging" of the high throughput molecular screen and the moie time consuming animal screening systems. This company could also provide access to chemical libraries of synthetic and natural products. - moxidectin (a registered product for veterinarian use from American Cyanamid) is currently being examined in the dog and cattle animal disease models. While having. ri*i1., mechanism ofaction as ivermectin (potent microfilaricidal) it has shown a significanlly different pharmacokinetic profile with a longer halflife. This has resulted in clear sterilizing effect of adult female worns as well as death of adults in some models. If current observationi are validated, moxidectin could be a candidate for evaluation in humans n lggg - oxytetracycline has been shown by Macrofi.l sponsored researchers to have an effect on killing adult worms in the animal models. This action is presumed to be mediated tkough the effect ofthe antibiotic on a misro organism (Wolbachia) prisent in the filarial parasites, inctaing Onchocerca. Further ongoing studies (in animals) are addressing selection of optimal antibiotics as well as determination of minimal dose and treatrnent regimens; these studies could lead to the rapid evaluation in humans - work on UMF 078 compound has been terminated due to prohibitive gene toxicity - in the clinical field Macrofil was currently sponsoring the evaluation of combinations ofivermectin with other drugs as potential macrofilaricidals in the Onchocerciasis Chemotherapy Research Centre (OCRC) in Hohoe, Ghana. In this context OCRC in collaboration with a specialised laboratory addressed the pharmacokinetics parameters ofivermectin and albendazole when combined- This work, the first of its kind, is not only important for onchocercisis but is essential to support the use of drug combination in lymphatic filariasis. OCRC also had conducted a safety study examining the combination of levamisole plus ivermectin or albendazole. This study would be further extended during 1999 with the aim to evaluate the macrofilaricidal potential ofthis novel combination. Through the support ofa TDR expert in Good Clinical Practice OCRC is conducting the above studies adherin.q to the GCp standards - Macrofil continued to support basic research to elucidate at the genetic level changes associated with parasite resistance to ivermectin. In this context Macrofil had liased the researchers from academia with those on the field towards focussing the above studies on Onchocerca volvulus. As well as to identify potential partners for the eventual development of a diagnostic tool able to detect ivermectin resistance in patients. t TAF4 Page 43 Annex IV I 2 5 Professor David Molyneux, Chair of the OCP Expert Advisory committee, in commenting on the progress of Macrofil, suggested that EAC should be more directly involved in the decision-making process for drug development. In addressing the ivermectin resistance activities he proposed that Macrofil should ensure the possibility of assessing "retrospectively" the genetic status of Onchocerca volvulus material representative from endemic regions with different exposure to ivermectin. This could be achieved by creating a "parasite repositoqy''at the molecular biology laboratory in Ouagadougou. 2.6 Professor Molyneux finally recommended that OCP and APOC define the various scenarios for the use of a macrofilaricide including identifying priority areas and undertaking modelling to provide ffirmation for the introduction of a new drug for control. 2.7 Members of the JPC and IAF indicated that the results and achievements presented by Macrofil were in line with the mandate of OCP and APOC. It was recommended that the reported obsefrations should be zubmitted for publication and made available to the scientific/medical community as soon as possible. 3. Integration 3.1 In the past, many public health prograrnmes targeting specific health problems had tended to operate independently each with its own structure, staffand facilities with little attempt at coordination, not to say integration, of activities. 3.2 Increasingly, the move now, was towards joining together separate programmes using polyvalent staff and common facilities to carry out integrated control of the health problems, hitherto tackled on an individual basis. 3 .3 Integration resulted not only in economies of scale, but made also for increased consumer satisfaction, given that the target populations would no longer be exposed to separate visits of different teams. A potential move towards integration at the consumer level was being spearheaded by OCP and APOC which, through the community-directed treatment with ivermectin (CDTI), opened the door for similar approaches to drug delivery in control of other public health problems. 3.4 The Regional Director of WHO AFRO, Dr Ebrahim M. Samba stressed that Africa was in the lead in integration by applying a wholistic approach to public health measures. 4. Sustainability of CDTI 4.1 The importance of ivermectin treatment being continued for as long as needed and at the required coverage was stressed as a conditio sine qua non for the success of APOC and OCP. Both coverage and duration oftreatment bore on the reduction ofmorbidity and, to some extent, of transmission and needed to be maintained at the required level. Furtherrnore, sustained control was required uniformly across district, provincial and national boundaries. 4.2 Indicators to measure sustainability included community involvement, flexibility to change CDTI approach according to local experience; availability of ivermectin and credible JAF4 Page 44 Annex IV distributors; leadership and integration within local health systems; community stability; perceived benefits of ivermectin; and availability of local resources to maintain distribution. 4.3 The findings of APOC independent monitoring teams as regards conditions for success were summarized as follows: availability of sufficient govemment funds to continue operations after five years without depending irrealistically on NDGO contributions; reinforcernent of Primary Health Care systems for CDTI integration; prompt release of funds; adequate counterpart support within health systems; intensification of health education; and enhanced involvement of women. 4.4 As to the advocacy for sustainability the following targets were identified: decision- makers at the national and provincial levels; NGDOs and National Onchocerciasis Task Forces; national managers and district health teams; and the beneficiary communities. 4.5 The following keylspecial issues of importance to CDTI operations were listed. ownership; role ofhealth centres; cost effectiveness/benefit; funding commitment; drug delivery systems; cost recovery/cost sharing; and incentives. 4.6 As major threats to sustainability the presenter, Professor Oladele Kale, singled out unreliable volunteers and inadequacy of incentives; instability of key staff at district level; dependence on outside funding; inadequate commitment and funding at the national level; and donor fatique at the international level. 5. OCP-APOC collaboration 5.1 This collaboration operated at the management level, in the field of administrative support; and in respect to technical issues, including operational research. As regards management, the Director of OCP and the Manager of APOC spoke with the same voice when it came to advocacy and awareness building. The Director, whenever travelling, spoke for both progralnmes and promoted fundraising, together with the World Banh for both OCp and APOC. There was constant exchange ofview for decision- making between the Director and the APOC Manager. This close partnership resulted in economy of scale of the two operations. 5.2 The support from, and collaboration with, the OCP administration had made it possible for APOC to launch 45 projects in record time. The administrative staffof ApOC had tapped the OCP experience in their domaine and APOC continued to benefit from administrative assistance from OCP in such fields as personnel matters, budget and finance; purchase of supplies and equipment; and transport - not without imposing a considerable workload on the concerned staff of OCP to which APOC provided financial compensation. It was stressed that when it.came to the implementation of projects, the APOC management was solely responsible for execution. 5.3 On the technical side the two programmes shared field experience and expert advice. The initiation ofthe CDTI approach by OCP had thus laid the basis for APOC operations. Both OCp and APOC participated in the work of the TDR Task Force on Sustainability and contributed on equal terms to the Macrofil project. IAF4 Page 45 Annex IV 6. Lymphatic filariasis elimination 6. I More thal120 million persons in 73 countries, including countries in the OCP and APOC areas, were infected by lymphatic filariasis transmitted by mosquitoes and causing disabling swelling of the legs and genitals. 6.2 The elimination of the disease in individual communities - and its eventual global eradication - appears feasible by annual treatment of the affected communities with either albendazole together with ivermectin as in Africa or albendazole in combination with DEC in other parts of the world. [t was expected that annual treatments over a period of four to six years would stop disease transmission. Such treatment would, however, not alleviate the symptoms of those already infected. For those patients much of the pain and suffering could be prevented by good hygiene and remedial exercise. 6.4 To launch the eliminalion programme, SmithKline & Beecham would provide albendazole free of cost for as long as required together with other support, and Merck & Co. would supply ivermectin at no cost to the implementation of the elimination progra.mme in Africa. These commitments were confirmed to the Joint Session by Mr Charles Fettig ofMerck & Co. Inc. and Dr Brian Bagnall of SmithKline Beecham. 6.5 In continuing his presentation, Dr Ralph Henderson, Representative of the WHO Director-General, commented on synergy. He referred to OCP and APOC as pioneers in community-directed drug treatment, the lymphatic filariasis elimination programme would adopt this approach, possibly starting in Africa in communities with OCP or APOC CDTI prograrnmes. Other potential similarities between this new programme and OCP and APOC could be the use of rapid epidemiological assessment and the use of geographical information systems. It might therefore eventually make sense to place the additional staffneeded for regional coordination and monitoring with OCP and APOC Hqs staff 6.6 Although not all communities included in OCP and APOC operations suffered from lymphatic filariasis, they practically all had a problem of intestinal parasitosis - affecting in particular the physical and mental $owth of the child - which would be alleviated by trearment of pre-school and school children with albendazole and ivermectin. This would be another synergy to take advantage of 6.7 Non-governmental development organizations (NGDOs) would have an important role to play in the elimination prograrnme, especially in supporting community-directed treatment through the establishment of community self-help groups. 6.8 For a progralrlme like lymphatic filariasis to succeed, partnership between the countries concerned, who would play the principal role, the bilateral development agencies, the UN system and NGDOs would be essential. I IAF4 Page 46 ANNEX V AFRICAN PROGRAMME FOR ONCHOCERCIASIS CONTROL JOINT ACTION FORUM (JAF) Fourth session, 9-l I December 1998, Accra, Ghana FINAL COMMUNIQUE The fourth sessim ofthe Joint Acticn Forum (JAF) ofthe African Programme for Onchocerciasis Control (APOC) was held in Accra at the kind invitation ofthe Govemment ofthe Republic of Ghana. The session was atended by delegaticns from the Participating Countries, from the Dmor community, from members ofthe Commiuee of Spmsoring Agencies ([JNDP, FAO, the World Bank md WHO), from Non{ovemmental Development Organizaticns, fromthe Carter Center and fromthe Mectizan Dcnaticm Programme (the list of participants is attached as Annex 1). Participants were welcomed by Dr Kofi Ahmed who read a statement on behalf of the Minister of Heahh ofGhana, Mr SamuelNuamah Donkor, followedby statements by Mr Phil Mas@, r€preseming the Chair of JAF3, Dr K. Yankum Dadae, Director ad interim of APOC, Dr Ebrahim M. Samba, Regional Director WHO-AFRO and Dr Ralph Henderson, Representative of the Director€eneral of wHo The key+rote address was delivered by Dr (Mrs) Mary Grant, Member of the Couhcil of State, who turderlined the inportance of a true partnership, so crucial for the success of APOC, a'pa.tr e.ship exemplified bytheparticipation ofrepreseutatives ofthe various groups attlis assembly in a cmstructive dralogue. Dr Grant also referred to the full participatior of the communities in the Programme, of which they are the principal stakeholders, as an essential element for the success of APOC. She finatly wished the Forum full success in its deliberations. A vote of thanks was moved by Miss Yaa Oforiwaa-Acquah. The agenda for the session is attached as Annex 2. For each of the items for which conclusions were arrived at, and/or decisions made, a bnef summary is given in the following pages. At the closure of the session, the Jornt Action Forum expressed its gratitude for the warm welcome extended to the participants, the hospitality received and the excellent arrangements made by the host courtry for the organization and deliberations of the Forum. f Participants wlll receive the full report of the session at a later date. JAF4 Page 47 Annex V Conclusions and decisions PROGRESS REPORT oF THE woRLD HEALTH ORGANIZATION (agenda rtem 5) The Forum expressed rts satisfaction wrth the quallty and tlmeliness ofthe developmant of APOC supported proJect proposals since the Iaurching of the Programme. JAF commended the APOC Managemant and all the NOTFs concemed for the good results obtained. The Forum also greatly appreciated the team spint prevaihng wrthm the Apoc Management and cotgratulated its staff for the quality and harmony exhibited in the prese,ntatior ofthe 1998 progress report. To ease the work load of the APOC Management team, JAF recomme,nded that WHo Represe,lrtatims in the Participating Countries become more involved in the technical, financial and managerial support to APOC prgect activities. The Forum recommended that the denominator applied by NorFs to compute mass treafinetrt coverage rates be tre total populaion figure to allow comparison between proJects and countries. REPORT oF THE TECHNICAL CONSULTATTVE COMMITTEE (agenda rtem 6) The Forum recommended that I (one) per cent of the fi.urds released to finance APOC supported proJects be allocated for apprrynate operational research cm specific issues of interest to the Prograrnme. REPORT OF A SPECIAL FORTIM ON APOC OPERATIONALZATION IN THE CoNTExr oF ONGOING HEALTH sEcToR REFORMS IN AFRICA (agarda rtem 7): 6 . JAF welcomed the report on the special fonim on APOC cperatioralization rn the context of ongoing health sector reforms convened in response to a request made by JAI during rts third session. It encourages APOC to continue this work. REPORT OF TFIENGDO COORDTNATION GROUP FOR IVERMECTIN DISTRIBT]-TION INCLUDING SUPPORT OF THE GROI.]P TO APOC'S ACTIVITIES AND TO LOCAL NGDOs (agenda rtem 8): The Forum noted wrth satisfactron the sigrrificant contnbution of urtemational NGDOs to APOC operations. It welcomed their commrtment and urged all partners to promote closer collaboration with the local NGDOs. JAF recommended that the APOC community (CSA and the NGDos group) undertake efforts to extend NGDO support to all those APOC countries wfuch have not yet benefrted from such support. JAF nctes the firnding restraints to NGDO expansion and encourages new mechanisms and strategies to secure firndurg necessary for such expansion. 2 3 4 5 7 8 t JAF4 Page 48 Annex V COI-INTRY REPORTS hgenda rtem 9) I The Forum noted wrth satisfaction the decision taken by Cameroon to extend the implementation ofthe CDTI approach to all reonented andnon-reoriented districts ofthe meso- and hyper+ndenuc areas. t0 JAI acknowledged the progress ma& by some Participating Countries in the applicatior of cost-recovery in ivermectin distribution programmes as an element of sustainability rr CDTI projeas. However, given the results presentd the Forum expressed concem about the possible negative effect ofthis policy on the crveruge rate of mass treamert and therefore strcngly recommended trat the issue be addressed through orperatiural research by the countries cmcemed in collaboration with the APOC Management and TDR ll The Jomt Actiqr Forum commended the natimal teams for the several issues raised by the delegaims presert, the mobilization and commitment of the communrties, the commitnent of govomments and the initiation oftlre CDTI process even in communities facing social urrest. However, the Forum wished to receive a tist ofthe problems raised m the country reports and that the parhers likely to heip solving them be identified and contacted througb prcper channels. t2 The Forum noted the factual explanation ofthe APOC Manageme,nt cmcemmg the factors which delayed the release of funds for project implementation. It encouraged the Executive Agency (WHO) andthe NOTFs concemedtbmake all efficrts to minimrze and even avoid such delavs in firture. l3 The Forum noted wrth satisfactim the progress made in the Rapid Epidemiological Mapprng of Onchocerciasis and encouraged the countries andthe APOC Management to continue their efforts towards a complete coverage of all the Partrcrpating Countnes as soon as possible. 14 The Forum noted with concem tlat contrary to the urderstanding reached, some countries still imposed various forms of rmport duties and taxes wtrich resuhed in delays in release of Mectizan for use in control progftlrnmes. The Forum therefore urged that all Participatrng countries ensurethatthe importation ofM ectizanbe done wrthout any levres. REPORT OF AN INVESTIGATION INTO TTM LOCATION OF TT{E HEADQUARTERS OF APOC (agenda rtem 10): t5 The Forum, after study of the report ofthe investigation concemrng the locatron of the headquarters of APOC, recommended that consuhations be pursued with the interested parties before further consideration be given to this issue rn relation to the end of oCp activrties; decided that, for the time berng, the headquarters of Apoc would remarn rn Ouagadougou. I f IAF4 Page 49 Annex V CONSIDERATION OF NATIONAL PLANS AND PROJECT PROPOSALS (agenda rtem I t). l6 The Jount Aaion Forum ratified the approval of the naticnal plans and pro;ect proposals contained in document lAF4.7 OPERATIONAL RESEARCH (agenda rtem t2): 17 The Joint Action Forum acknowledgd with satisfaction the fruitful collaboration between APOC and TDR in the field of orperational research. l8 Regarding CDTI, JAF recommended that the TDR Task.Force cfrltact drrectly APOC Participating Countnes to develop actior plans for seeking ans^rers to questims oispecific nterest to each courtry. The Forum encouraged the Task Force to pursue the search for reliable and efficient reportrng tools for use at the community level. REPORT OF TTM TNDEPENDENT MONTTORING OF CDTI PROJECT IMPLEMENTAN ON IN MALAWI, NIGERIA, SUDAN AND UGANDA (agenda item l4): 19. The Forum noted with interest the important and useful information collected by the teams of scientists commissicnred for this task in ccnnectim with the follow-up of CD'iI projects. While commending the APOC Manageme,nt, the NOTFs and the scientists involved in this exercise, the Forum expressed the wish that the recommendatims listed in the reports produced by the different teams be carefirlly studied and promptly implemented if appropnate. 20 The Forum further recommended that the involvement of communrties be enhanced in all projeas and expressed the wrsh that a speedy solution be found to the problem oftreatrnent of absent members ofthe community. 2l . JAF approved the proposal to develop a simple tool for use by prqects and communities to carry out self-monrtoring of CDTI activities. This would contribute to rmproving and strengthening the participation of both the communities and the parhers x1 the monitonng of project activrties. PLAN OF ACTION AND BUDGET FOR 1999 (agenda item l5): 22 The Jont Aaion Forum approved the Plan ofAction for 1999 andthe correspond.ing budget ur the amount of US$ l4 984 000. FINANCING OF THE AFRICAN PROGRAMME FOR ONCHOCERCIASIS CONTROL:(agenda rtem l6): Z) The Forum noted the report of the World Bank on the financurg of Phase I ApOC and took note also of the estimated us$ 9 million furd-g gap stated ur the report The Forum pofirted out that unless this defictt were filled thr*d, an increase rn the current furancial support, the present growth rate of the implementation of ApOC funded projects could not be sustarned and ongoing CDTI activities might have to be curtailed. 24 JAF4 Page 50 Annex V 25 JAF therefore r@ornmended that t}re current effiorts to increase the number of financial contributors be pursued DATE AND PLACE OF THE FIFTH SESSION (agenda item l8) The date and place of JAF5 would be communicated to JAF participants at a later date. The date would likely be erther dunng the first or second week of December 1999. 26 , a IAF4 Page 51 ANNEX VI CLOSING REMARKS BY THE CHAIR OF THE FOURTH SESSION OF JAF Your Excellencies the Ministers of Health of the participating Countries; Honorable Representatives of the Donor Countries; Mr Representative of the Director General of the World Health Organization; Distinguished delegated of the APOC Member Countries; The Director a.i. of the APOC Programme; Ladies and Gentlemen Representatives of the Non Governmental Development Organizations; Ladies and Gentlemen. First' allow me to express on behalf of this august assembly and in my own name our deep gratitude and sincere thanks to the people and the Government of the Reiublic of Ghana for the warn welcome and brotherly hospitality they have bestowed upon every one us since we set foot in this nice and wonderful country. Next, allow me, Excellencies the Ministers and Honorable Delegates of the participating countries, and you Distinguished Representatives of the Donor community, to tell yo, t o* honored my country and myself have been by the trust you have placed in us-in electing me for one year to the Chair of this Programme which, hardly after its birth, is already our pride and joy because of its inspires and gives not only to us all who are gathered here bui first and foremost to the rural populations faced with the ravage of this dreadful disease called river blindness Our deliberations which are about to end have inspired me a few reflections which I would like to share with you. I had the feeling that all of us gathered here are embarked on a true pioneering venture. Indeed, this strategy of mass treatment through the community directed appioach is providing us in the vast field of public health, a unique opportunity for cieation, for contributini to a reorientation of health care activities and approaches to hope to reach the noble objectives of the programme in our respective countries despite their diveise situations Pioneering work, or rather three month old baby as one of the Distinguished Delegates put it, all this may sound like fumbling for words. And yet, at a closer loo( it G not so. In fa'ct, in listening t.o both the participating countries and the other speakers, we have all been impressed by thedistance already traveled and especially by the solid -foundations which have been laid. Of course the difficulties and obstacles which are not lacking when one embarks on such a venture have been widely referred to. However, it was my impression that far from intimidating us, they were unanimously considered as stimulating, as a call for greater efforts, creativity, wise flexibility and refusal of complacency. t ! IAF4 Page 52 Annex VI together we will win the battle against river blindness and achieve the alleviation of poverty in the affected rural areas. I have come to understand that the involvement of the rural community, the sustainability of CDTI projects and true partnership are the tripod ofthe success of our programme. Therefore, it is within the framework of partnership that must operate the "third commitment " referred to in one of the documentaries we have watched during this session. As every one of us knows, this pioneering venture could not have seen the light without the charitable donation of ivermectin by Merck & CO to the populations exposed to river blindness. That is the reason why I would like once again to express our sincere gratitude to Merck for its generous donation. This may sound repetitious and boring but I am firmly convinced that we will never express enough thanks for such a major contribution whish is in fact aupital asset graciously made available for the development of our countries' rural areas. Turning to the NGDO Group whose action on the side of the NOTFS and APOC Management gives us hope in overcoming onchocerciasis, we wish to not only express our thanks but also encourage them to pursue and expand their action so that all the Participating Countries become covered. We realize how difficult their task is but we rernain convinced that together we will tread the right path. Excellencies the Minsters, Honorable Delegates, before I conclude my remarks, I would like to make two wishes: The first is that by the next session of the Joint Action Forunq the governments of the Participating Countries will have increased their financial contributions to the activities of the APOC supported projects. My second wish is to see the 6l approved projects to be implemented next year in 14 of the Participating Countries yield satisfactory results. This is extremely important and cannot but contribute to strengthen our hope and convictions. Allow me, Ladies and Gentlemen to take this opportunity to congratulate the APOC Management for their brilliant performance. Ladies and Gentlemen, let us live up to the ambitions and expectations ofthe concerned populations who themselves are already mobilizing for victory in the framework of CDTI projects I wish you all a safe journey back to your respective homes and I declare the deliberations of the fourth session of the Joint Action Forum closed. Thank You a a