Strategic plan of action and budget 2016-2025 for elimination of onchocerciasis in Africa

@ Copyright African Programme for Onchocerciasis Control (WHO/APOC), 2012. All rights reserved. Publications of the WHO/APOC enjoy copyright protection in accordance with the Universal copyright Convention. Any use of information in the Strategic Plan of Action and Budget 2016-2025 should be accompanied by acknowledgement of WHO/APOC as the source. For rights of reproduction or translation in part or in total, application should be made to: Office of the APOC Director, WHO/APOC, BP 549 Ouagadougou, Burkina Faso dirapoc@oncho.af ro.who.int WHO/APOC welcomes such applications. Strategic Plan of Action and Budget 2016 -2025 for Elimination of onchocerciasis in Africa This document has been prepared at the request of the seventeenth session of the ]oint Action Forum of APOC held in Kuwait City, Kuwait, in December 2011. For more information please contact: dirapoc@oncho.afro.who.int tsr October 2012 AFRICAN PROGRAMME FOR ONCHOCERCIASIS CONTROL Strategic Plan of Action and Budget 2016 -2025 for Elimination of onchocerciasis in Africa This document has been prepared at the request of the seventeenth session of the Joint.A,ction Forum of APOC held in Kuwait City, Kuwait, in December 2011. For more information please contact: dirapoc@oncho.afro.who.int (g/ October 2012 AFRICAN PROGRAMME FOR ONCHOCERCIASIS CONTROL "JAF reaffirmed its endorsement for the Programme to pursue the elimination of onchocerciasis in Africa as well as co-implementation of preventive chemotherapy interventions for other selected NTDs in the context of increased support to community-level health systems strengthening. The Forum therefore requested the GSA and APOC management to submit a detailed new plan of action with costs reflecting the new expanded strategic direction for the programme beyond 2015 for consideration by JAFl8." (APOC, 17rh session of the Joint Action Forum, Final Gommuniqu6) Table of contents Abbreviations Executive summary 1. Ovenriew of onchocerciasis control to date 5 6 1.1 The Disease 11 1.2 The Onchocerciasis ControlProgramme inWest Africa (OCP) . tz 1.3 The African Programme for Onchocerciasis Control .. .. . 12 2. Business Case: Orienting APOC to eliminate Onchocerciasis, address selected PCT-NTDs and strengthen community health systems ls 2.1 C o-endemicity of Onchocerciasis, Lymphatic Filariasis and Loiasis 2. 2 C as e for intensifying j oint eff o rts f or eliminating Oncho c er ciasis 11 andLymphaticFilariasis .. . ..... ... 2.3 Benefits to other NTDs and health systems 3. Policy Framework 3.1 Policy orientations..... .... . 3.2 Focus from 2016-2025......... .... . 3.3 Objectives for the periodfrom 2016-2025 3.4 Guiding principles 4.Plan of Action Objedive 7: Eliminate Onchocerciasis in 80% of endemic countries in Africa by 2025 Objective 2: Collaborate with relevant programmes and p artners to impleme nt community - dir e ct e d interv entions to control/eliminate selected PCT-NTDs in all onchocerciasis endemic countries in Africa Objective 3: Collaborate with relevant programmes and partners to strengthen community health systems in aII onchocerciasis endemic countries in Africa 76 79 21 2t 22 22 23 25 25 35 38 5. Specific deliverables by 2025 6.Value for money and impact attribution. ... ... 7. Monitoring and, evaluation S.Management 9. Probable risks and mitigating measures 10. Budget estimates for APOC 11. log frame on objectives and critical success indicators 12. Annexes AnnexT: Disease- specific protocolsfor neglected tropical diseases .. .. . Annex 2: Planned interventions towards elimination of onchocerciasis 201 6 - 20 25 47 47 .43 43 44 47 52 .54 54 Htv Abbreviations APOC African Programme for Onchocerciasis Control CDDs Community-Directed Distributors cDt Community-Directed lntervention CDTI Community-Directed Treatment with lvermectin csA Committee of Sponsoring Agencies Human lmmunodeficiency Virus HSAM Health Education /Sensitization /Advocacy /Mobilisation lnsecticide-treated bed nets Joint Action Forum (APOC governing body) Lymphatic Filariasis MDA Mass Drug Administration MDGs Millennium Development Goals MDP Mectizano Donation Program NGDOs Non-Governmental Development Organisations NOTF National Onchocerciasis Task Force Neglected Tropical Disease ocP Onchocerciasis Control Programme in West Africa PCT Preventive Chemotherapy PHC Primary Health Care RAPLOA Rapid Assessment Procedure for Loa loa Rapid Evaluation and Assessment REMO Rapid Epidemiological Mapping of Onchocerciasis Special lntervention Zones TA Technical Assistance TAS Transmission Assessment Survey TCC Technical Consultative Committee (APOC scientific advisory group) Special Programme for Research and Training in Tropical Diseases sponsored by UNICEF/UNDP/World Bank/WHO TRC Technical Review Committee Transmission Zone Transmission Zones Assessment WHO World Health Organization WHO/AFRO World Health Organization Regional Office for Africa lTNs JAF LF NTD REA stz TDR TZ TZA Executive summary Progress in onchocerciasis control has resulted in the imminent elimlnation of the disease. For a considerable number of years the dlsease hindered economic development, caused chronic lifeJong disability, and impaired development in poor and disenfranchised communities. Where are we? Between 2005 and 2011, APOC spent time collecting evidence on progress towards elimination. Following the successful treatment of the disease using ivermectin with the active leadership of communlties the microfilaria load in humans decreased significantly. The flrst results showing that ivermectin treatment can stop and that transmission is Iikely to have been broken were produced in three selected foci in Mali and Senegal.In 2011the CSAAdvlsory Group on Elimination produced modelled maps predicting end game dates. Their models suggests that by 2015, assuming recommended geographical and therapeutic coverage is met, all APOC participating countries can achieve controi targets and with appropriate support, sustain control activities beyond 2015. It is estimated that 12 project areas with a population of 7.4 million have already been freed of the disease. When the modelling was extended to 2020, Angola, Burundi, Cameroon, Chad, Congo, Ethiopia, Malawi, Mozambique, Nigeria, Tanzania, and Uganda had a positive prospect of elimination. In conslderation of the positive outlook, the lndependent evaluators in 2010 recommended that closlng APOC in 2015 will be too costly in terms of return on investment. The Communique from JAF 17 on the Future of APOC endorses the recommendation of the independent evaluators: "IAF reaffirmed its endorsement for the Programme to pursue the elimination of onchocerciasis in Africa as weII as co-implementation of preventive chemotherapy interventions for other selected NTDs in the context of increased support to community-level health systems strengthening. The Forum therefore requested the CSA and APOC management to submit a detailed new plan of action with costs reflecting the new expanded strategic directionfor the programme beyond 2015 for consideration by lAF18." The Strategic Plan of Action and Budget 2016-2025 for the elimination of onchocerciasis in countries was prepared based on the above dlrective for the consideration of IAF 18. The vision of the plan of action is to eliminate onchocerciasis in 80 percent of African countries.Implementation of the plan will also help strengthen health systems at community level while implementing CDI wlll help scale-up interventions agalnst other NTDs to the benefit of the wider national health systems. What is going to be different? In the context of a renewed global commitment for tackling neglected tropical diseases the African Programme for Onchocerciasis Control (APOC)will be repositioned to address the new orientation, shifting from a control programme to an elimination one,l and pursuing the following objectives for the period from 2076-2025: 1. Eliminate Onchocerciasis in 80% of endemic countries in Africa by 2025. 2. Collaborate with relevant programmes and partners to implement communitlr- directed interventions to control/eliminate LF and other selected PCT-NTDs in all onchocerciasis endemic countries in Africa. 3. Collaborate with relevant programmes and partners to strengthen communlty health systems in all onchocerciasis and LF endemic countries in Africa. In limited geographic areas Lymphatic Filariasis MDA has reached 75% of the people living in an endemic district and 100% of endemic districts in seven countries in Africa. When other preventive measures are associated with MDA, such as vector controi and the consistent use of bed nets, the number ofyears required for elimination of the infection may be reduced particularly in areas with low endemicity. By 201.6 and with a scaled up effo/c in collaboration with other partners it is estimated that a total of 200 million people in 20 countries can be reached, escalating from 30 to 106 million people treated. MDA for LF will have prevented the same number of new infections; saved about one million new born everyyear from infection and averted or arrested clinical progression of 600 000 cases of Iymphedema/hydrocele. This however will result in only seven (7) out of forty (40) countries (Tanzania, specifically for Zanzlbar, Comoros, Gabon, Gambia, Burkina Faso, Malawi and Ghana) being removed from the LF Africa endemic countries list by 20T6.Implementing the programme for another five to seven years, wili ensure that at Ieast seventeen (17) additional affected countries can hit elimination and certified by 2025.With a focused plan working with other partners, two major and related intervention diseases - onchocerciasis and Lymphatic Filariasis will have seen elimination under the current plan of action in at least twenty countries. The proposed activities emphaslse systems and communities resilience against unpredictability and central system weaknesses; the importance of maintaining focus on onchocerciasis and Lymphatic Filariasis ellmination and its contributory effect on other selected Neglected Tropical Diseases; transformation of the CDTI framework into community heaith systems;the need for continulty in legal undertakings (Memoranda of Understanding), and the importance of increased country ownership, financial commltment and graduating them off the programme. A Iog frame has been developed showing clearly the indicators for measuring progress against each of the objectives.In areas where Onchocerciasis and Lymphatic Filariasis are co-endemic the two programmes will carry out joint interventions to update disease mapping and to scale up treatment, particularly in untreated onchocerciasis (low endemlcity) areas where Lymphatic Filariasls is prevalent. Sharing data and coordinating mass treatment and epidemiological evaluations will allow significant cost-saving and more efficient programme planning. I The programme name may be changed in the future accordingly. What are we getting? Benefits of the LF and Onchocerciasis progrumme in poverty reduction are directly related to the disability prevented by the medication. This includes the prevention of the full clinical manifestations in infected adults and days lost due to severe itching, fever, blindness and lymphadenitis which affect infected patients. The loss of productlvity of infected people compared to healthy people is of 58%. Through mass drug administration of ivermectln or diethylcarbamazine citrate (DEC) together with albendazole (from GlaxoSmithKline)the Global Programme to Eliminate LF has treated almost 2 blllion people over the past 8 years, thereby averting 32 million disability-adjusted life years, and at a cost of only $14-$30 per DALY averted.2 The active transmission of LF has also been lnterrupted in severa] countries. So far the number of DALYS averted by Onchocerciasis programme is estimated at 7.5 million as every infection averted constitutes a saving of 0.07 DALYS according to WHO and recent studies.t The elimination of oncho and LF using this strategy will be one of the most cost effective interventions ln public health and a step forward to poverty reduction. By 2025 the repositioned APOC will have averted an estimated additional 6 million Disability Adjusted Life Years (DALYs) over the period as a result of onchocerciasis and an additional4 million for Lymphatlc Fiiariasis. Further, the'off-target' effect of ivermectin and albendazole on other diseases may add another 1 million DALYs (13%). By 2025 an estimated total of eleven (11) million DALYs averted is antlcipated. This will drop the current APOC cost per DALY averted of approximately US$ 48 to just about US$i4 per DALY averted. The funds to be provided by sponsors will leverage and provide resources for the implementatlon of national activities to intensify treatment and phase out of MDA in onchocerciasis endemic countries. Specifically: . Mapping, Transmission Assessment Survey (TAS) and Transmission Zones Assessment (TZA) undertaken, bottlenecks analysis done and projected end dates for onchocerciasis and Lymphatic Filariasis concluded. . All onchocerciasis endemic countries except a few foci in Central African Republic, Democratic Republic of the Congo and South Sudan by 2025 and additional 16 countries for Lymphatic Filarlasis will be removed from the respective diseases endemic country map. This will significantly reduce to just under 20 million or approximately 8% of the at rlsk population from the estimated 150 million at start of2076. . National and community health systems strengthened with over 500 000 community health workers trained to deliver integrated PCT-based through at least 170 integrated community health system based on the CDI model. . Capacities of seven NTD laboratories will have been revitalised, and integrated lnto a regional network to assure quality control. This network will also be capable of providing key laboratory services (microscopy, entomology dissection, serology and PCR). Laxminarayan R, Mills AJ, Breman JG, Measham AR, Alleyne G, et al. (2006) Advancement ofGlobal Health: Key Messages from the Disease Control Priorities Project. Loncet 367: 1193-208. Lesong Conteh, Thomas Engels and David Molyneux: Socioeconomic aspects of neglected tropical diseases. Lancet 2010;375:239-47 . Forty (40) health professionals will have received their masters or doctorates in an NTD and community health systems management field and jolntly published at Ieast 40 research papers on NTDs and health systems Do we have value for money? Given a project estimated cost of US$ 151 800 000 over the 10 year period this is US$ 14 per DALY averted which is less than34% of the cost so far incurred by APOC per DALY averted. This is about 10 cents per treatment over the period and makes the new strategy proposed very cost effective and efficient in delivery of a much higher amount of services. The lower cost however should be seen as a result of the accumulated gains made over the years by the APOC programme and other partner interventions. This cost can be reduced immediatelyto half when extra benefits of MDA other interventions co-implemented and systems strengthened are incorporated. When medicines are factored in, the cost to sponsors of the initiative will be in the range of 0.16 cents per treatment, 0.40 to 0.80 cents per person treated should they receive two MDA rounds. This monetary contribution will be matched by the effort of the communities in country;bearing 60-90% of the actual costs of the treatment in terms of economic costs q and the provision of drugs by the pharmaceuticals company estimated at an annuai value of circa USD$ 1 billion.s The plan of action and budget assumes that certain foundational and key actlvities necessary to prepare countries towards ehmination started since 2012 and will continue through 2015. These activities are contained in separate plans of action and budget.It is also important to note that the focused activities may be reviewed following the 2015 independent evaluation which should be conducted to have a better understanding of achievements. Ann S. Goldman et al: National Mass Drug Administration Costs for Lymphatic Filariasis Elimination. PLoS Neglected Tropical Diseases (www.plosntds.org). October 2007; Volume l, lssue 1, e57 This includes the donation of 1 20 million tablets of DEC by Sanofi, Esai and Bill and Melinda Gates Foundation, 600 million tables of Albendazole by GSK and unlimited number of lnvermectin by MSD (http://www.dfid.9ov.uk/Documents. United to combat NTDs; table of commitments.

1. Overview of onchocerciasis control to date 1.1 The disease Onchocerciasis also knonm as river blindness, caused bythe filarial worm Oncho c erc a volvulus, is transmitted through the blood meal of infected Simulium damnosum or black fly that breeds in fast flowing streams and rivers. Infection in humans Figure 1. Life cycle of the Onchocerco volvulus parasite Blackfly stages o ff*y.ffir'ssiimirium) (Ul bruestsutewMdl a Adults orcduco unshealthed|El micrcfiiariae that tipically are found in skin and lymphaaics of connective tissu€s, but also _ occasionally in periph€ral blood, n**,*risprituni.l** \ manifests as intense itching, disfiguring dermatitis, and eye lesions and over time leads to blindness. Xconomically, onchocerciasis leads to loss of productive labour and abject poverty. The life cycle of the parasite is shovrrn below. Human stages o 3S3.i'J'-*'" g Adqlts in subcutanoaous ^ Miorate to head andGl Uickfly's proboccis G) us larvae ^ If,!, Ll larvae ^ Microfi lariae o€neilrats19 utact<flyt midgut and migrate to thoracic muscles * lnfective stage ** Diagnostic stage Sou rce: CDC (www.dpd.cdc.gov/dpdx) About 99 percent ofthose infected wlth Onchocerca volvulus reside ln 31 endemic countries in Africa. The WHO Expert Committee on Onchocerciasis estimated that 17.7 million people were infected in 1995;6 rapid epidemiological mapping of Onchocerciasisz (Noma and others, 2002) by the African Programme for Onchocerciasis Control (APOC) estimated that about 37 million people were lnfected in 1995, whlch corresponds to an estimated 1.99 million DALYs lost. 1.2 The Onchocerciasis Control Programme in West Africa (OCP) Onchocerciasis control strategies have evolved significantly over the Last three decades. The Onchocerciasis Control Programme in West Africa (OCP),launched in 1974, used aerial larviclding of vector breeding sites in river rapids. In 1987 Ivermectin became accepted as an efficacious drug on the microfilaria and registered for the treatment of human onchocerciasis. Merck & Co.,lnc. developers of the drug, pledged free donation ofthe drug to fight the disease so long as it was needed. This transformed the way in which the disease was tackled. The new intervention design focused on the human phase of the life cycie of the disease. The multi-track approach helped in controlling the debilitating effect of the disease, reclaiming arable Iand for economlc activities and freeing human capital of disability that affected their productivity. In 2002, OCP ceased Jan H. F. Remme, Piet Feenstra, P R. Lever, And16 M6dici. Tropical Diseoses Targeted for Elimination: Chogos Disease, Lymphatic Filoriosis, Onchocerciasis, ond Leprosy, page 433-449. Rapid Epidemiological Mapping of Onchocerciasis (REMO): its application by the African Programme for Onchocerciasis Control (APOC): Anna ls ofTropical Medicine and Porositology, vol.96, supplement no. '1, s29-S39 (2002). all operations and had succeeded in controlling the disease in ten of the eleven countries.8 It focused on achieving the following in 28 years of activity. . Protected an estimated 40 million people from Onchocerciasis. . Prevented about 600 000 persons from becoming blind. r Reclaimed 250 000 sq kilometres of previously abandoned land that could now be occupied and farmed. . Made a net value of gains estimated by the World Bank as equating to about?]% return on investment. Among the countries covered by OCP, Sierra Leone feIl behind because of civil conflict. Four areas were declared Special Intervention Zones (SIZ) within the controlled countries where prevalence and intensity of infection had declined but the entomological situation remalned unsatisfactory. These were the Pru river basln in Ghana; the tributaries of Oti river in Togo; the Mafou and Tinkisso rlver basins in Guinea. Sierra Leone was added to the SIZ because of its peculiarity. 1.3 The African Programme for Onchocerciasis Control In May 1994 the World Health Assembly adopted resolution WHA47.32e on "Onchocerciasis control through ivermectin distribution". The resolution emphasised sustaining the achievements of OCP and the engagement of all stakeholders to promote ivermectin distribution in tackling the drsease. The African Programme for Onchocerciasis Control Benin, Burkina Faso, Cote d'lvoire, Ghana, Guinea, Guinea-Bissau, Mali, Niger, Senegal and Togo. Hbk Res., Vol. lll (3rd ed.), 1.1 6.3.3(Fourteenth plenary meeting, l2 May l994-Committee A, fourth report). (APOC) emerged as the institutional framework for implementation. APOC activities originally covered nineteen (19) countries.io With South Sudan, the Programme covers 20 countries. APOC is a programme managed through a dynamic governance partnership. The formal engagement is based on a Memorandum signed by partners as a legal agreement. An APOC Trust Fund managed bythe World Bank has been established. The APOC Secretariat serves as the nexus for managing the partnership and provides both technical guidance and financial support to countries. A multi-country study undertaken by the Secretariat in 1997 to ascertain the most cost effective way of getting the drug to the target population found that Community- Directed-Treatment with Ivermectin 10 Angola, Burundi, Cameroon, Central African Republic, Chad, Congo,The Democratic Republic ofthe Congo, Equatorial Guinea, Ethiopia, Gabon, Kenya, Liberia, Malawi, Mozambique, Nigeria, Rwanda, Sudan, The Republi< ofTanzania and Uganda. (CDTI) was a reliable and cost effective approach. APOC has since supportedthe establishment of CDTI in countries as a flagship strategy of the Programme. Over 17 years APOC has helped the disease-endemic countries to successfully extend CDTI coverage to a total population of approximately 70 million people, as ivermectin (Mectizano) reaches over 140 000 communities in APOC participating countries. Approximately 77% of the population at risk has been treated as of 2011. b G'(' GI aI o cl E o-G =q 6G <f2o l.(, Ir82{JG6It r{ h IEl..d rCi; ,gd,* -ii=* l--l-- AGE I .' I HT NAMES IN FULL I i Y. ?i '1 'I ',! Z.Business case: orienting APOC to eliminate onchocerciasis, address selected PCT-NTDs and strengthen community health systems 2.1 Co-endemicity of Onchocerciasis, lymphatic Filariasis and Loiasis About 1.4 billion persons are living with at least one of the neglected tropical diseases. Seven of the major Preventive Chemotherapy bas ed-NTDs (PCT-NTDs) represent about 90% of the total burden. These are Ascariasis (8 07 million infected), Trichuriasis (604 million), Hookworm (576 million), Schistosomiasis (207 mlllion), Lymphatic Filariasis (120 million), Trachoma (84 million) and Onchocerclasls (37 million).11 Sub-Saharan Africa is home to about 50% of the estimated global burden of NTDs. Unfortunately, most of these are incompletely mapped across the region. There are existing technologies and medicines that are effective against many of the conditions as shown in the table marked Annex 1 with commitment for medicines supply from manufacturers. Efforts are currently being made to eliminate or control NTDs that have affected the poorest and most deprived members of the communities for centuries. Twenty nine partner 1l Global NetworkforTropical Disease Press Center (htt:// globalnetwork.orglpress; End the Neglected Blog (http:// www.endtheneglect.org); Madhuri R, Sudeep SG, Sunila RK, et al. Oral Therapy for Multiple Neglected Tropical Diseases: A Systematac Review..lAMA 2OO7; 298 ('16\:1911- 1924 [l'.|. organizations came together on 30 January 2072to state their commitment to ensure NTDs are eliminated by 2020. Global health organizations, the governments of the UK, US, UAE and Brazil among others, pharmaceutical companies and non-governmental and non for profit organizations are together in this effort. Endemic countries in Africa and Asia are also streamlining their programmes and increasing their efforts to ensure communities at risk in their territories are identified and treated. Onchocerciasis Onchocerciasis as indicated earlier has had the longest running intervention. The success of the Programme to achieve elimination depends on the strength of Mass Drug Administration (MDA), functionality of the Community Directed Intervention (CDI) systems, and the accurate reporting ofthe geographical and therapeutic coverage. The target is to achieve and sustaln 80% therapeutic and 100% geographic coverage in all endemic areas. To achieve Onchocerciasis elimination using ivermectin treatment, the CSA advisory group on Onchocerciasis elimination has advised that current population coverage might have to be increased by about 20 percent to include areas not initially covered by CDTI and that have nodule prevalence above5%". Lymphatic Filariasis (LF) Lymphatic Fllariasis is endemic in 42 African countries which is approximately 36% of the g1obal burden. The disease prevalence ranges from as low as 3%to as high as 50% in communities. The disease is not fully mapped. A rapid assessment of the geographical distributlon of fiiariasis is being used to provide a basis for developing country speciflc elimlnation programmes. So far Benin, Burkina Faso, Ghana, Tanzania and Togo have mapped LF distribution and have started MDA activities using a combination of ivermectin and albendazole. The disease is targeted for elimination by 2020. To achieve this, MDA has to hit 80% therapeutic and 100% geographic coverage for five to six consecutlve years. A significant advantage of recently advanced filariasis control strategies is that, they can be easily co-implemented using pre-exsting Community Directed Intervention prognmmes aimed at other public health problems such as onchocerciasis, malaria, and intestinal parasites. Loa loa Loa loa or loiasis is a disease transmitted by chrysops species. The disease has been shown to be present mainly in the Democratic Republic of the Congo. Treatment with ivermedininLoa loa patients can result in the occurrence of encephalopathy and this has impeded the use of Mass Drug Administration with combination drugs to treat Lymphatic Filariasis and onchocerciasis where any of these diseases is co- endemic wllhLoa loa.The diseases are therefore managed according to the MEC/APOC/TCC guidelines including a case by case approach at health facility Ieve1. 2.2 Case for intensifying joint efforts for eliminating Onchocerciasis and Lymphatic Filariasis Both onchocerciasis and Lymphatic Filariasis have established systems for determining breakpoints for elimination and when and how to stop treatment. However, for onchocerciasis to be certlfled in areas where it is co-endemic with LF, which is more of the norm than the exception, treatment for Lymphatic Filariasis should have been suspended following a Transmission Assessment Survey (TAS). The TAS process is very similar to the Transmission Zones Assessment (TZA) process approved by Joint Action Forum as the "Conceptual and operational framework of Onchocerciasis elimination with ivermectin treatment"12 as shown in Figure 2. Eliminating onchocerciasis Under the Onchocerciasis programme, progress and effectlveness of Community-Directed Treatment with Ivermectin (CDTI)coverage is the primary determinant of the success of elimlnation. The APOC partnership has helped onchocerciasis endemic countries to successfully extend CDTI coverage to approximately 80 million people in 2011as ivermectin reached 742 338 communities in 16 countries across sub-SaharanAfrica that year.lt has treated approximately 77% of thelotal population including communities of several countries affected by security issues. Between 2009 and 2011there has been a significant improvement in therapeutic coverage from 64%to76% in countries in or emerging from conflict. 12 APOC: Conceptual and operational frameworkof oncho- cerciasis elimination with ivermectin treatment Ouaga- dougou: African Programme for Onchocerciasis Control; 2010. . History of CDTI (number of years, cove- rage) . Surveys (are entomological and epidemio- logical criteria satisfied) Figure 2. Four stage activities towards onchocerciasis elimination When the areas of programme intervention (lvermectin treatment areas) are overlaid with known areas of disease prevalence, there is a striking convergence that is attributed to the effeCrive implementation of the programme by community health workers. This gave more than (Source: APOC Mid-term Evaluotion Report 2010) anticipated outcomes as shown in Figure 3. Using available baseline nodule prevalence data and treatment coverage results reported by countries to map progress, APOC generated evidence suggesting the onchocerciasls Figure 3. Current ivermectin treatment areas with pre-control prevalence levels . Krigging REMO map with nodule prevalence . National consultatiYe meetings (tentative delination of TZ\ . Assesment and validation in survey . Entomological and epidemio- logical survey, 3 years after stopping CDTI . Elimination certification when results of survey satisfy criteria . Resume treat- ment when results indicate recrusdescence (Source: Report of the CSA advisory group on onchocerciasis elimination, 2011) prevalence map of Africa has shrunk signifi cantly. Results of epidemiological evaluations in 2008-2011 in participating countries showed that in 12 evaluated sites with a total population of 7.4 million people, onchocerciasis elimination has probably already been achieved. This wiil be confirmed once the on-going entomolo gical evaluation studies are completed in those sites. In 2008 the ioint Action Forum approved an additional objective for APOC, namely"to develop the evidence base forwhen and where ivermectin treatment can be stopped", and provide guidance to countries on how to prepare for and evaluate cessation of treatment where feasible.l3 The APOC Secretariat using the Kriging method and the CSA Advisory Group on Elimination 2011 produced modelled maps predicting end game dates. The models suggest that by 2015 assuming recommended CDTI coverage are met, all APOC prognm countries can achieve control targets and with appropriate support, sustain control activities beyond 2015. However, none of these countries will achieve elimination in 2015. When the modelling was extended to 2020, Angola, Burundi, Cameroon, Chad, Congo, Ethiopia, Malawi, Mozambique, Nigeria, Tanzania, and Uganda had a positive prospect of elimination as shov,rn in Figure 4. The new policy for onchocerciasis elimination is to extendtreatment to hypo-endemic and the patches of areas where CDTI had not yet been initiated and for nodule prevalence ovet SY".This brings the annual estimate of population to be covered under the onchocerciasis programme to approximately 113 million.'a By end 2020, the total population at 13 APoc 2oo8 Addendum for the plan of action and budget 2008-2015; Ouagadougou, APOC/WHO 14 Report ofthe CSA Advisory Group on Elimination; September 201 1 Figure 4. Country-level onchocerciasis elimination in African countries: projections for 2015 and 2020 (source: The projections ore bosed on those made by the CSA Advisory Group on Elimination, September 20i.1, com- pleted by informotion received from counties during the notional onchocerciosis programme coordinators' meeting, September 2012) taCa{ri J cOnongor.g ! ncfilrr'iltrGtrrd ! tcanrc.gorl'la.r risk will be approximately 37 mlllion mainly in Democratic Republic of the Congo, Central African Republic (CAR) and South Sudan. By 2025 it will be possible to have post treatment stoppage surveillance in Democratic Republic ofthe Congo project foci in Bandundu, Bas Congo, Katanga North and South, Lualaba and Ueles. CAR, Gabon and Equatorial Guinea will have started post-treatment stoppage surveillance but not yet confirmed elimination. South Sudan wil1be the only country with entire transmlssion zone still under assessment. This will significantly reduce to just under 20 million or approximately 8% of the at risk population at start of 2026. Detailed chart is attached as Annex 2. Eliminating Lymphatic Filariasis In Iimited geographic areas Lymphatic Filariasis MDA has reached 75% of the people living in an endemic district and 100% of endemic districts in seven countries in Africa. V1y'hen other preventive measures are associated with MDA, such as vector control andthe consistent use ofbed nets, the number of years required for elimination of the infection may be reduced particularly ln areas with low endemici\r.15 By 2076 and with a scaled up effort in collaboration with other partners it is estimated that a total of 200 million people in 20 countries can be reached, escalating from 30 to 106 million people treated. LF MDAwill have preventedthe same number of new infections; saved about one million new born every year from infection and averted or arrested clinical progression of 600 000 cases of lymphedema/hydrocele. This however will result in only seven (7) out of forty (40) countrles (Tanzania, specifically ls WHo: Weekly Epidemiological Records, No 5 August 2011,341-351 for Zanzlbar, Comoros, Gabon, Gambia, Burkina Faso, Malawi and Ghana) being removed from the LF Africa endemic countries list by 2016. Implementing the programme for another five to seven years will ensure that at least seventeen (17) additional affected countries can hit elimination and certified by 2025. With a focused plan working with other partners, two major and related lntervention diseases - onchocerciasls and Lymphatic Filariasis will have seen elimination under the current plan of action in at least twenty countries. 2.3 Benefits to other NTDs and health systems The technical competencies and tools developed for mapping the two diseases can be used to effectively support the mapping of other vector-borne and soil-transmitted diseases. In 2008 APOC conducted epidemiological inte grated mapping of the NTDs, including training of surveyors and health techniclans in Equatorlal Guinea. REMO/REA, RAPLOA, ICT, urine filtration and Kato techniques were used for onchocerciasis, Ioiasis, Lymphatic Filariasls,Schistosomiasis and STH detection, respectlvely. Cross- sectional surveys were conducted in 90 villages, communities and schools, selected all overthe country (10 in the Island and 80 in the Mainland). The work was co-financed by APOC, the Sabin Institute, Erc<on Mobil and Liverpool Center for NTDs. In addition, APOC contributed to the integrated/ coordinated NTD mapping of selected NTDs in Angoia, Cameroon, Chad, Congo, Democratic Republic of the Congo, Liberia and South Sudan. Onchocerciasis and LF actlvities and surveys can also be used to assess the impact of bednets (coverage and usage) after two consecutive MDA and compared to the regular Malaria Roll Back or MICS coverage to ascertain the impact of community education and information. The drugs used to address the onchocerciasis and LF are potent and efficacious against a wide range of lntestinal worm infections with the added benefits of reducing anaemia. The combination of MDA with preventive measures (distrlbution and promotion of use of bed nets) will contribute to infection control of vector-transmitted diseases, including malaria. APOC and country partners have had considerable experience with co- implementation for surveys and use of the Community Directed Intervention (CDI) approach. Figure 5 shows the programmes using the CDI platform for co-implementation and the population reached as of December 2010. The CDI structure provided entry point for other health interventions such as Vitamin A supplementation, child health and nutrition days, EPI, Polio and distributlon of Insecticide Treated Nets (ITNs) for malari.a. Figure 5. Health interventions delivered by APOC CDDs (in millions) LF Malaria (lTN) STH Malaria (HMM) Vitamin A deficiency (VAS) Schisto Cholera, Helminthiasis (Hygiene) Polio, measles (EPl) Trachoma HlV/AtDS Cataracts 5 No. 48, 2011, 86, 541 -556) The 2010 APOC Mid-term Evaluation report approved by IAF acknowledged that the CDI model holds strong promise for transforming national and community health systems. Ground realities require that the existing CDTI projects are restructured in order to fit country administrative context. However, a dedlcated effort will be requlred to ensure that the CDTI projects remain strong and resilient to continue to carry the rest of the countries through at least another five years with minimal risk. The model has been systematically analysed and translated into a step-wise approach for training and establishing an effective and efficient health system and will remove the need for every partner attempting to establish their own delivery systems because country systems are weak. There are also on- golng laboratory and human resource capacity building and researches into new technology, diagnostic and treatment innovations that have long term benefits to vector borne and other conditions. These include the DEC-patch test; OV 16, pheromone laced fly traps and macro fllarlcide against the adult onchocerciasis causlng worm. 0.4 (Sou rce : Weekly ep i d e m io I og icol Reco rd, 3. Policy Framework 3.1 Policy orientations Three external evaluations have so far been undertaken on APOC. The 2000 evaluation found that APOC's CDTI Strategywas "a timely and innovatlve strategy for fighting a wide-spread scourge". The second, conducted in 2005, identified substantial achievement of APOC goals particularly in conflict and post conflict areas. The report also suggested, based on ONCHOSIM modelling, that eiimination may be achievable ln about 20 years. New orientations were provided to guide implementation of the plan. 1. In 2006 the Yaounde Declaration of African Ministers of Health on Onchocerciasis Control expressed their commitment to pursue the ellmination agenda across the region. 2. The decision to phase out APOC by 2015 was made following the adoptron ofthe Phase II and Phasing- Out period - PIan of Action and Budget in 2007. 3. At the 57h Session of the WHO Regional Committee for A,frica held in 2007 the Ministers of Health requested that A.POC should move from a single disease to a multl- disease approach, which proposal was adopted by subsequent Joint Action Forum meetings. The third external evaluation was conducted in 2010, and the report presented to the 16th session ofthe loint Action Forum, signalled that closing APOC in 2015 may be pre-mature given the real posslbility of elimination. The science was now better understood.15,17 However, APOC cannot be business as usual and it was time for change. After careful deliberation JAF16 requested the Committee of Sponsoring Agencies (CSA) to interrogate the evidence and make recommendations on the future of APOC. Three CSA working groups were set up and their recommendations submitted to the 17th Session of the Joint Action Forum.IAF 17 endorsed a generai way forward on the Future of APOC as follows: . The onchocerciasis programme should not close in 2015 as that would be untimely, given that none of the 3l endemic countries would have achieved elimination bythat date. . The Programme should pursue the elimination of onchocerciasis in Africa including twice yearly treatment with ivermectin to speed up elimination in problematic areas. . Supportco-implementation of preventive chemotherapy interventtons for other selected NTDs in the context of increased support to community-level health systems strengthening. . The CSA and APOC management to submit a detailed new plan of action with costs reflecting the new expanded direction for the programme beyond 2075 for consideration by JAF 18. The orientation provided a challenge that required APOC to reinvent itself to reflect and address the needs of the current rapidly changing NTD 16 Diawara L, Traore'MO, Badji A, Bissan Y Doumbia K, et al. (2009) Feasibility of Onchocerciasis Elimination with lvermectin Treatment in Endemic Foci in Africa: First Evidence from Studies in Mali and Senegal. PLoS Negl Trop Dis 3l7l: e497. doi:10.'1371 /journal.pntd.0000497 17 Traore MQ Sarr MD Badji A, Bissan Y, Diawara L, et al. (201 2) Proof-of-Principle of Onchocerciasis Elimination with lvermectin Treatment in Endemic Foci in Africa: Final Results of a Study in Mali and Senegal. PLIS NeglTtop Dis 6(9): el 825. doil 0.1 371ljournal.pntd.00Ol 825 environment while remaining relevant to countrles in the ten years after its current mandate (beyond 2015). 3.2 Focus from 2016-2025 Based on the decision of the JAF, APOC will focus on Onchocerciasis elimination and particularly support Lymphatic Filariasis elimination. The programme will also contribute to the control of Schistosomiasis, trachoma and STH; develop capacity of countries to establish and operate robust and resilient surveillance and community health systems, and exit in 2025. A new name will be adopted to reflect the shift in focus. 3.3 Objectives for the period from 2016-2025 In line with the poliry orientations provided byJAF 17, APOC will aim at achieving the following obj ectives : Eliminate Onchocerciasis in 80% of endemic countries in Africa by 2025. Collaborate with relevant programmes and partners to implement community- directed interventions to control/ eliminate selected PCT-NTDs in all onchocerciasis endemic countries in Africa. Collaborate with relevant progmmmes and partners to strengthen community heaith systems in all onchocerciasis endemic countries in Africa. 2. 3. 3.4 Guiding principles The following guiding principles underpin APOC's Strategic PIan for the period 2076-2025: o Community ownership and empowerment: This focuses on the CDTI process which holds the key to attaining elimination and hinges on communities dlrecting and managing the intervention process. . Country leadership and programme integration: With the focus on elimination and co-implementation, countries will take leadership in formuiating policies and integrated NTDs strategies. . Intensificationandacceleration of operations: Countries and partners will prloritise and intensify interventions for elimination of onchocerciasis and other targeted NTDs. . Evidence-based decision making: Decision making at every level of responsibility will be based on evidence including where to intensify treatment activities, introduction of new technology and when and where to stop treatment. These will go along with operational research to increase efficient delivery of programmes. Independent evaluation: External independent evaluations and the opinion of external experts and the Technical Consultative Committee will continue to informthe decisions of the Committee of Sponsoring Agencies and the Joint Action Forum. At field level independent evaluations wlll be regularly undertaken to assess progress and timely implement corrective measures where needed. Partnership for implementation and governance: The enduring APOC partnership celebrated as an important element for the success of the Programme will continue to retain all its elements at the community, national and international level.In addition, it will work with other NTD stakeholders. Gender sensitivity: The programme will ensure gender is mainstreamed in all its activities.

4. PIan of action The plan of action translates the objectives stated above into activtties and tasks to deliver the outputs and outcomes estimated in the business case. OBJECTIVE 1 Eliminate Onchocerciasis inSO% of endemic countries in Africa by 2025 One of the the focus of this objective is to sustain the momentum and keep all staleholders at countrylevel informed and committedto the goal and urgenry of elirnination. For all countries, appropriate onchocerciasis and IJ elimination strategies integrated into an NTD strategic plan will be developed. Ttre prograrnmes will recognise the strengths and weaknesses of country CDIs. Thorough assessment of the cost implications and the commitment of the government towards elimination will be secured. Ttre emphasis is on countryJed approaches with the harmonisation and alignment of all NTD progmmmes and activities. The planned activities should aim at achieving and sustaininglOO% geographic coverage and at least 80% therapeutic coverage levels in all onchocerciasis transmission zones. The other focus will be on surveillance systems strengthening. There will be need for entomological and epidemiological assessment with collaboration from competent laboratories supervised and supported by the rebranded APOC experts and consultants to avoidthe risk of wrong endpoint decision making. The repositioned APOC wiII develop guidelines in collaboration with partrrers and train in-country programme managers, disease control and sunreillance officers and resource persons from universities, agricultural extension worker agencies, research institutions, and community partners in onchocerciasis epidemiological and entomological evaluation techniques. Country disease control officers will also be trained to perform evaluation activities. As APOC will operate for ten (10) years and shut down, a number of liquidating activities will be performed and this wiII begin early to ensure a smooth transition. Those activities relate to the work of dosule committees, final evaluation reports, find financial audit, personnel liabilities and legal costs, transfer of premises, title deeds and its associated legal costs, equipment, vehides, and other chattels inventory and disposd process fees and bank closure. In 2022, the CSA will constitute into an APOC closure standing committee. It will develop a closure plan with the support of a consultant and APOC management and will make "Ptogtess towards APOC closure" a permanent item on the JAI agenda annually from that date. ACTIVITY 1 Raise profile and advocate resources for onchocerciasis and Lymphatic Filariasis elimination and other selected NTDs activities in countries Implementing the programme for another 10 years will require sustained awareness creation and maintaining the momentum.It is imperative that strong advocacy be undertaken within countries and globally to make oncho elimination and NTDs control a priority agenda of governments' resource allocatlon and financing. APOC in collaboration with WHO/AFRO, NGOs and Civil Society Organisations (CSOs) will act as a facilitator for this drive. Main tasks e Develop advocacy materials targeted at policy and legislative decisi.on makers to promote policies and public health regulations that enforce service provision activities and budgets almed at eliminating LF and other targeted NTDs and use these materials in opportunitles offered by NTD global forums. . In collaboration wlth WHO/AFRO monitor the implementation by countries ofthe Yaounde declaration'8 of 2006 towards increasing the proportlon of the total health expenditure on health allocated to NTDs; and produce progress reports for the attention of the WHO Regional Committee for Africa sessions. . Support in-country dialogue between the Ministries of Finance, Foreign Affalrs and Health and donors to include progress in achieving NTD 18 Declaration ofAfrican Ministers ofHealth participa- ting in the Special Summit of Partners of the African Programme for Onchocerciasis Control (APOC) held in Yaound6, Cameroon, from 26-27 September 2006 to discuss the future of river blindness (onchocerciasis) in Africa. targets in their health assessment indicators and other requirements for fundlng health programmes. . \y'y'here feasible, advocate for private sector involvement in financlng NTD programmes as part of their corporate responsibility towards the communities they work in. ACTIVITY 2 Support integrated NTD policy and strategy development in endemic countries Given the new developments and the need to expand coverage, all countries will be required to develop and regularly revise policies and strategies for onchocerciasis elimination as part of an integrated NTD policy and strategy. This will be based on system-wide approach reflecting alI inputs and work of varlous partners with increased emphasis on harmonised activities and integrated disease control, adoption of innovations and effective communi.ty engagement. Main tasks . IncollaborationwithWHO-AFRO, support countries to revise national NTD strategic plans and financing requirements incorporating evidence from mapping and country needs assessments towards elimination. For onchocerciasis, this will include implementing alternative approaches where determined to be necessary. . Supportthe integration ofthe strategic plans into annual plans of action that can be incorporated into national budgets and for use as resource mobilisation tools. . Support the integration of NOTFs into national systems and activities for the effective management of programmes including supervision and monitoring. . Support countries to develop systems for effective monitoring, evaluation and reporting. Whlle integrated policy and strategy development is desirable, the focus on onchocerciasis elimination will be retained to ensure that weaknesses in other NTD programmes will not derail achieving onchocerciasis elimination. ACTIVITY 3 Build capacity for the delivery of Community Directed lnterventions (CDl) in all onchocerciasis and Lymphatic Filariasis transmission zones Capacity building will be essential in ensuring that skills are continually upgraded and matched to the emerging needs. Emphasis will be placed on the training of community health workers and volunteers as well as health workers at the district and heaith facility levels including management of adverse effects of treatment for targeted NTDs. Given the known situation of high staff turnover a larger pool of staff will continue to be trained. Main tasks . Provide structuredtraining for health professionals in collaboration with locally accredited institutions based on updated CDI training manuals. . Support selection and training of poiyvalent Community Directed Distributors (CDDs) using CDI manual to meet increased emphasis on scaling up activities and lntegrated NTD service delivery. o Provide focused training for supervisors and trainers in countries to enhance their support activities to fleld workers. This will cover government and NGDO personnel involved in CDI management and programme delivery including information management. . Provide technical support to collaborating training institutions to integrate CDI in their curriculum and train health professionals at the post-graduate 1evel in Community Health Systems Strengthening based on the APOC experience and support the trainlng of two professionals each from Angola, Mozambique, Democratic Republic of the Congo, Central African Republic, Sierra Leone, Gabon and South Sudan. . Create technical capacity through the recruitment of community health systems experts, financial and relevant personnel for Angola, Democratic Republic of the Congo, Central African Republic, Sierra Leone and South Sudan till 2020. ACTIVITY 4 Provide logistic support to countries and communities to undertake effective CDTI activities It is anticipated that all CDTI activities will be undertaken with the support of APOC to ensure that resource Iimitations do not interfere with the positive traj ectory towards elimination. The focus however will be to complement governments and development partners' efforts rather than absorb governments of their responsibilities. In 2011 logistics and equipment were provided to 14 APOC and 6 former OCP countrles, including vehicles, birycles and motorrycles.By 2076 these wlll all have aged and reached replacement point. Main tasks . Provide vehicles with PA systems, motorrycles, birycles, boots, rain gear, torch lights, batteries and generators to project districts and communities. All vehlcles, motorcycles and bicycies above five years will be replaced. Other equipment and logistics will be provided on a biennial basis. . Develop communication support materials to reinforce health education, sensitlsation, advocacy and mobilis atlon (HSAM) activities including support to communities to undertake community mobillsation and sensltisation activities for targeted NTDs. . Provide Information Communication and Technology support including computers and simple mobile phones to facilitate quick and reliable communlty level data capture, transmission and processing. ACTIVITY5 Undertake programme monitoring and evaluation activities CDTI projects are evaluated by (i) an lndependent participatory monitoring exerclse; (ii) an annual lnternal self- monitoring exercise and; (iii) evaluation for systems viability. Every active CDI project will undergo the fulI cycle at least once everytwo years. This will be extended to cover LF projects. All projects will undergo intensive mid- term evaluation in the fifth year of implementation of this PIan of Action and Budget. Main tasks . Review existing and, if required, develop new monitoring and evaluation tools and guidelines for undertaking CDI monitoring and systems viability evaluations. . Support country programmes to undertake annual monitoring of all CDI programmes and systems evaluation in the country once every two years. . Undertake data quality assessments of country registers and reporting of therapeutic and geographic coverage annually and provide technical assistance where capacity is weak in keeping community registers. . Support cross border activities including meetings to harmonise efforts and assess the effectiveness and progress in geographic and therapeutic coverage. These issues will be discussed at the sub-reglonal Ministerial meetings organized by the Regional Economic Communities. ACTIVITY6 Manage elimination process Within NTDs control and elimination frameworks, APOC will develop formal mechanisms of engagement with countries and provide technical backstopping to ensure commitment to the goal of onchocerclasis elimination and health systems strengthening at community level and provide the needed evidence and tools for implementation. Main tasks . Revise the existing APOC agreement with countries to ensure it i.s consistent with onchocerciasis elimination goal. r Manage the continuing mapping of onchocerciasis and PCT-NTDs in all endemic countries to determine prevalence levels and develop regional scenarios for transmission zones and country classification. . Update guidelines for safely stopping ivermectin mass distribution and formulating country exit strategies at the end of the programme. . Provide suitable estimates of breakpoints of transmission with the different indicators of infectlon and transmission (e.g. mf prevalence, CMFL, DEC patch test, OV16, or outcomes of PCR based screening of pools of flies). Collaborate with research institutions in the development of innovative diagnostic, treatment and surveillance tools, methods and techniques. Support operational research to address questions remaining on: i. feasibility of elimlnation in different ecolo gical zones; ii. valldationofpost-surveillance activities and period in different epidemiological settings; ii. the effect of treatment in hyper- endemic areas on untreated low- endemic areas in river basins; iii. response to treatment and anaiysis of long term effect of mass ivermectin treatment; lv. Confirmation of speed of recrudescence in case of failure to achieve elimination and determine the cost effective approaches for post elimination survelllance; v. Deslgn and changes required for co-implementation programmes ; vl. Publish research results in scientific journals and APOC publications; vii. Undertakesupportive monitoring and supervision visits to all endemic countries to provlde technical advice and leverage partnerships at the country level. ACTIVITY 7 Support strengthening of country level integrated disease surveillance systems The focus of strengthening country level capacity for monitoring and surveillance incorporates the need to (i) systematically transfer monitoring and surveillance capacities to countries and (il) integrating onchocerciasis monitoring and surveillance into national lntegrated disease surveillance systems. This wiil form part of APOC's contributlon towards health systems strengthening. Main tasks . Develop and disseminate guidelines on onchocerciasis surveillance activities and processes and provide in-service and practical training. . Establish sentrnel sites and strengthen country specific disease control and surveillance systems including provision of laboratory equipment to ten coliaborating laboratories. . Organize training for two health information managers per country in the use of computer simulation models to map and predict progress in NTD control and elimination. . Provide short andlongterm fellowship to train two professionals each from Angola, Mozambique, Democratic Republic of the Congo, Central African Republic, Sierra Leone, Gabon and South Sudan in integrated NTD surveillance and monitoring till2020. . Providetechnical supporttoAngola, Mozambique, Democratic Republic ofthe Congo, Central African Republic, Sierra Leone, Gabon and South Sudan to support integrated NTD surveillance and elimination activities till 2020. ACTIVITYS Undertake epidemiological and entomological evaluation for onchocerciasis Epidemlological and entomological evaluation of endemicity levels in all transmission zones will be conducted to determine if the breakpoint has been reached and communlties are sensitized prlor to stopping treatment. Main tasks . Support countries to develop a country framework for epidemiological and entomological evaluations that reflect the country specific situation. . Support countries to plan and implement entomologlcal and epidemiolo gical evaluation and map out country specific progress including updating of transmis sion zones and the trend towards breakpoint. . Provide countries with logistics to conduct epidemiological and entomological evaluations (Skin snip punches, mlcroscopes, or any other evaluation/surveillance tools, sterilizer, DEC patch test, OV 16, PCR based screening of pools offlies, etc). . Modelonchocerciasistransmission breakpoints . . Support countries to establish elimination advlsory committees to work with country partners to carefully assess the various parameters of analysis identified and confirm that breakpoint prior to stopping treatment has been reached. ACTIVITY9 Undertake post treatment stoppage surveillance to confirm elimination The final processes for confirming elimination require rigorous monitoring and surveillance activities for three years after treatment has stopped. These will be paced carefully to avoid inconvenience to the target population and managing the national process while re-enforcing the systems strengthening actlvities withln countries. Main tasks . Support countries to perform annual surveillance activities to carefully assess the various parameters of analysis and confirm that elimination has been reached. . Supportthe preparation of independent reports and manage the processes for declaring elimination of the disease;this will include facilitating the meeting of the technical committee responsible for approving elimination status. . Support safe exist of the programme from each country by ensuring that guidelines exist that inform a1l stakeholders of their post elimination responsibilities and support mechanisms available to them. ACTIVITY 10 Gontribute to the setting up and maintenance of a WHO African NTD information repository and management system at country and regional level Overthe years WHO/AFRO NTD and APOC will convert all of the available NTD samples Iibrary materials and generated reports into a digital library and make this avallable on llne. This will include all evidence generated based on analysis made byAfrican and international laboratories and scientists in the targeted NTD areas so they may be easily accessible globally through a hub such as the African Health Observatory where each country system will be linked to a central repository. This will promote research and advance knowledge and innovation. Main tasks In collaboration with WHO/AFRO: . Review and map existing NTD informatlon system on Africa including technology, management, human resource and institutional arrangements. . Convert the over 40 years onchocerciasis data from OCP and APOC into digital form. . Update NTD integrated data management tools as necessaryfor a web-based repository. . Support the establishment or strengthening of country level decentralised database management system for past and newly generated evidence and reports. . Strengthenthe capacityof country NTD health professionals in the use of statistical and spatial analysis software, the management and analysis of data as weli as the interpretation of results and publish a semi-annual bulletin. . Organize country specific mid-term evaluation of programmes and develop a'State of Onchocerciasis Elimination in Africa: Mid-Term Progress Report' for consideration of IAF in 2021. ACTIVITY 11 Manage the personnel, records, estates and transport systems of APOG An effective personnel and administra- tion correspondence and filing system will be retained in-house. The manage- ment and maintenance of estates and the transport systems including the management of international travels will aiso form an essential part of the organisational system. Generally most of the services wllI be outsourced and overseen by permanent staff. Main tasks e Engage a competent travel and tours agency to manage all international travel and airport reception protocois on behaif of the organisation. . Contract out the facility cleanlng and ground work services to a competent cleaning agency. . Undertake maintenance and refurbishing of the office building and lts surroundings. . Manage APOC personnel, the official correspondence and flow and the filling systems of the organisatlon to ensure accuracy, maintenance of standards and professionalism. . Engage a competent organisation or staffto provide courier services for within country communicatlon. ACTIVITY 12 Provide inputs for the effective running of APOC The organisation will be incurring running cost to be able to function effectively over the perlod. This wlll lnclude basic travels for international conferences that emerge as essential for advancing the work of APOC and office consumables. Main tasks . Purchase offlce consumables such as stationery pen drives, staplers and pins, value books, pins among others. . Maintain or replace broken or worn out furniture, safes, cabinets and other storage equipments for the office. . Maintain or replace obsolete equipment such as air conditioners, fridges, computers, printers, fans. . Support field trips, international conferences and seminars attended by personnel ofthe organisation. . Hire, run, undertake malntenance or replace existing vehicles of the organisation. The organisation shall at all times own not more than one motorcycle, two four wheel drive vehicles and two saloon cars and shall replace the motorcycle, one four wheel and one saloon care once during the project lifetime. The rest shall be hired on as requlred basis. . Pay for utilities including electricity, water, telephones, internet connectivlty and other data management and hosting service providers. ACTIVITY 13 Manage the Information Communication and Technology systems Information technology will be used widely within the organisation to limit paper use, encourage instant access to information and data processing, and to ensure reliability of work flow confidentiality and communication between the countries, collaborating partners and the organisation. Main tasks . Develop standards for and manage all the information technology equipments and software of APOC to ensure a versatile uninterrupted services and workflow. . Purchase and maintain ICT equipment including telephones, computers, printers, projectors and their accessories. . Support the deployment of software packages developed or introduced by APOC as part of systems strengthening in countrles. . Develop and maintain an APOC webpage and other social media sites including Facebook, Twitter and similar sites. . Establish and manage an Africa NTD and Community Health Systems Repository for five years in collaboration with WHO/AFRO. . Identify and work with one School of Public Health or research institution to become an NTD and community health systems Centre of Excellence in,Africa and transfer the repository to it. This will be chosen from the institutions strengthened for laboratory and training identified earlier. ACTIVITY 14 Effectively manage and account for all APOC resources All resources received, dlsbursed and expended have to be properly accounted for. In the same way every country accounting systems needs to be robust and efficient enough to galn development partner and national government confidence to want to channel resources and supplies through the recipient institution over the long period. Main tasks . Maintain an efficient accountlng, banking, treasury and auditing system, receive and properly account for all resources received and spent by APOC, according to WHO procedures. . Recruit, post and manage qualified accountants in endemic countries till 2020 to support and build capacity of accounting personnel to manage resources until certified Budget Management Centres (BMC) are developed. . Manage the personnel and reward system of APOC linked to the WHO system. ACTIVITY 15 Establish efficient working mechanism for oversight, advocacy and resource mobilisation APOC partnership structure contin- ues to work well. The system will be retained including its representative nature which provides for the effective and equal participation of countries and sponsors except that other NTD coor- dinating bodies will now be invited to participate in the Technicai Coordinat- ing Committee meetings and provided observer status on the other bodies. AIl existing arrangements for the fund- ing of meetings and attendance by all participants will also be malntained. The fund management arrangement as reviewed before the commencement of the repositioned APOC will appiy. Main tasks . Develop technical papers and support the organisation of Technical Coordinating Council meetings. . Develop or commission technical reports and support the organisation of CSA meetlngs. . Develop or commission technical reports and support the organisation of JAF meetings. . Support advocacy and resource mobilisation activities of governance members including hosting, reception and media events. . Support the conduct of CSA and IAF commissioned reviews and mid-term evaluation reports. . Recruit an Executive Director and office manager to manage the corporate affairs, technical professionals and operations of APOC. ACTIVITY 16 Transfer residual responsibilities At the end of 2025 Central Africa Republic, Democratic Republic of the Congo and South Sudan are unlikelyto fully reach oncho and LF elimination. However specific foci will have attained elimination even within these countries. The expectation is that no more than ten (10)foci sites wiil have remained live. The difficulties in relation to loiasis based on current technology also make this imperative. For these countries the technical functions will need to be sustained in one or multiple agencies so as to provide programme stewardship. APOC will secure commitments for the following roles and responsibilities which remain relevant: Main tasks In collaboration with WHO/AFRO: . Work with country experts to ensure each ofthe countries has an updated map on NTDs indicating likely break- points where feasible by 2023. . Work with partners to ensure that each country has an updated NTD Financial Sustainability and Systems Strengthening Plan and Programme of Work starting 2023. The period should allow for adequate time to address all country needs. . Support UN agencies, NGDOs and development partners working in the Central Africa Republic, Democratic Republic ofthe Congo and South Sudan and any other countries falling behind due to unforeseen reasons to develop a memorandum of understanding with government to commit to financing NTD control and elimination activities beyond 2025. . Secure a WHO Regional Committee for Africa resolution calling for the continuing monitoring and reporting on the targeted NTDs. ACTIVITY 17 Undertake audit, inventory and disposal of chattels and estate To ensure a smooth transition, only encumbered expenditures made in 2024 may be paid by end of March 2025. No new programme expenditures will be made in 2025. Main tasks . The CSA on the direction of the IAF will, starting from 2023, commlssion a final audit of APOC accounts in all countries and culmlnating at the Regional level to be completed by March 2025,in accordance with WHO procedures. . Make an inventory of all office equipment, vehicles, estate infrastructure and unused office consumables and donate all vehicles, office equipment belowfive years and unused office consumable to an institution to be approved by CSA. A11 donations should be completed by March 2025. ' Engage a scrap dealing institution to scrap all unserviceable vehicles and equipments and dispose of them safely by March 2025. ACTIVITY 18 Transfer estates and hold closing down CSA and JAF meetings Main tasks Engage a legal consultant to manage the transfer of deeds of agreement coverlng all that estate which is occupied by APOC to the WHO Country Office or another suitable recipient entity. Organise a loint CSA and Technical Coordinating Councii (TCC) Meeting to evaluate the final report and provide orientations for countries and partners to assume responsibility by July 2025. Collaborate with WHO AFRO to prepare a "State ofonchocerciasis ln Africa Report" to be presented at the WHO Regional Committee for Africa and announce imminent closure. Hold a Flnal CSA meeting in July 2025 and a final JAF meeting in November 2025 where JAF will adopt the final technical and financial report and announce closure. It will provide guidance concerning the new roles and responsibillties post-APOC. Transfer all the library and repository to the collaborating training or research institution in Africa based on a memorandum of understanding and in collaboration with WHO and partners declare the institute as a WHO collaborating centre an "NTD centre of excellence and Repository " in Africa. Appolnt a consultant to work directly with an APOC team, in accordance with WHO procedures, to submit a final financial and auditor's report to the World Bank and World Health Organization by end March 2026. OBJECTIVE 2 Collaborate with relevant programmes and partners to implement community-directed interventions to control/eliminate selected PCT-NTDs in all onchocerciasis endemic countries in Africa Co-implementation with other diseases particularly PCT-based NTDs is a natural progression from the successes the onchocerciasis control and lymphatic Filariasis prognmmes have achieved. Lymphatic Filariasis, Schistosomiasis, STII and Trachoma are the PCT-based NTDs that work with the CDI platform and can support each other with epidemiological mapping and analysis, drug distribution and system intervention. The programme will include all 3l oncho endemic countries with specific focus on countries in need. APOC will collaborate with WHO/AFRO to engage the various constituents at the countryr, regional and globd Ievel to develop a harmonised approach to addressing the targeted NTDs and offer its competences to support elimination and control activities. The activity will link and }iaise any new activity for integrated NTD control within the new resources made available to countries directly. Within this objective National MDAs and material such as ITN and Vitamin A distribution will be enabled. For some countries the provision of funds may cover the total cost of mapping and surveys while resources to other activities vary between 10-100% of total costs. ACTIVITY 1 Raise profile and advocate resources for co- implementation activities in countries It is imperative that strong advocacy be undertaken within countries and globally to make co-implementatlon of NTDs a priority agenda of governments' resource allocation and financing. APOC, in collaboration with WHO/AFRO, NGOs and CSOs will act as a facilitator for this drive. Main tasks . Develop partnerships with global and regional drsease specific NTD coordinating bodies and forums to mobilise resources and advocate to attaining eliminatron and control targets. . Contribute to the development, deployment and application of tools for integration planning in budgeting for co-implementation and reporting of results. ACTIVITY2 Support the integrated mapping of selected PCT-NTDs Currently, the mapping of Onchocerciasis, LF, Schistosomiasis and STH has been completed ln Equatorial Guinea and Liberia with APOC support. All areas suspectedto be at risk of Loaloa were mapped including non- APOC participating countries. APOC in collaboration with WHO/AFRO is working with countries to finalise plans to suppori all onchocerciasis and LF endemic countries co-endemic with other diseases to complete the integrated mapping of the NTDs. Assist in completion of mapping of Schlstosomiasis, STH and Trachoma in all endemic areas targeted for Onchocerciasis and LF elimination will be done through skills training of natronal officers. Main tasks . Support the assessment of the burden of Loiasis, Schistosomiasis, STH and Trachoma and produce an African and country by country map on progress; delineating or updating transmission zones where appropriate. Two groups of countries will be targeted. . The first group ofcountries to be targeted are those endemic wlth LF, Loa Loa and other NTDs just about to begin or ln various stages of maturity of the national programmes but with the highest burden of disease in Africa. The countries likely to be included in this category are Burkina Faso, Nigeria, Cote d'Ivolre, Liberia, South Sudan, Sierra Leone, Democratlc Republic of the Congo, Malawi. i. APOC will deveiop or update feasibility studies and maps and undertake assessment of impact of previous NTD interventions. It will support the national programme to plan and complete MDA. ii. Provide TA for Transmission Assessment Surveys and budget support in coordinatlon with other partners, avoid duplication and achieve efficiency in planning and implementation. This group estimated to constitute 50% of the programme. The second group of countries are those with potential of scaling up interventions but are yet to attain strong control systems in all or some of the target NTDs. The countries which include Comoros, Tanzania, Ghana, Gabon, Gambia, Burklna Faso, Malawi are likely to have a number of support agencies working or just completed ceased work on them. They may have completed mapping and have national programmes in place but without the required level of capacity or funds to move towards updating and full scale national MDA and hence achieve control targets required. i. Engagement with these countries wiil start in the first year of the programme. APOC will provide capacity building, technical, implementation and budgetary assistance to scale up activities. ii. Undertake operational research and bottleneck analysis on challenges to attaining control and elimination goals, provide technical and programme management advice and weaned countries in this category off by 2020. Organize planning workshops to harmonise and align pollcies, planning, supply chain management and service delivery activities to promote co-implementation. Where possible undertake joint development of communication support materials for HSAM Directly support co-implementation of activlties in fifteen (15) countries ending 2020. ACTIVITYS Contribute to capacity-building for integrated PCT-NTD management within Africa A fundamentai problem plaguing all countries is adequate institutional, management and human resource capacity to address the complexity of the changing NTD environment and elimination protocols. This requires a complex network of different technologies and data systems. APOC will support the development of need-based professionals and technical capacities oriented to meet the demands of NTD elimination and control. Main Tasks . Contribute to the development of a structured district and community integrated NTD programme management, surveillance and reporting in-service training programme and implement it in collaboration with country programmes. Support the training of six country participants in Public Health at masters and doctoral level . Provide national reference laboratories and at least 10 collaborating NTD centres of excellence with logistics, inputs and reagents to support NTD diagnostic, analysis and research activities. Collaborate with the regional health organizations and Non- Govemmental Development Organisations in the development of health policies and advocarywork. OBJECTIVE 3 Collaborate with relevant prognmmes and partners to strengthen community health systems in all onchocerciasis endemic countries in Africa Weak health systems have been one of the main difficulties countries faced in attracting resoruces and executing interventions to achieve NTD elimination and control goals. Development partners willing to support countries are usually concerned about accountability systems to manage inputs and deliver services. APOC and development partners over the years have served as a proxy recipient by sometimes directly managing supplies and recruiting accounting and technical staffposted in countries to deliver senrice delivery. At the implementation level, APOC has achieved an enviable reputation of building Community Directed Interventions (CDI) that provides a platform for integrated community health care delivery and co-implementation. The framework provides a template that can be used to transform community hedth systems and enable countries build resilience for sustainability. This objective aims to translate and mainstream the experiences into permanent country systems. ACTIVITY 1 Gollaborate with country certified Budget Management Gentres (BMC) Under this activity APOC will support the building and establishment of sustainable accounting systems to enable development partners have confidence in providing NTD resources, adopt and use country led financial accounting and reporting systems. This wiil reduce the need for developing parallel reporting systems as a resuit of each partner requiring their ornm reporting systems to gain synergy, value for money and allow countries to be effective at funding lnterventions. Main tasks . Collaborate with an accounting consulting firm to undertake budgeting, budget management and accountability systems assessment to establish basellne capacity and technical support needs for country institutions that handie NTD funds. . Support the implementation of guldelines for establishing strong accounting systems and an institutional assessment and certlflcation criteria in participating countries. . Contribute to the development of an NTD and systems costing tool (software) in collaboration with other partners, make it freely avallable and train at least a core of six professionals as trainers from each country on its use. ACTIVITY 2 Promote CDI as a community health systems strengthening platform for PHC Promoting community health systems ls acknowledgement of the work CDDs are doing with programmes otherthan NTDs and the need to promote the principles of using established health systems for servlce delivery. The goal is to contribute to the strengthening of the health system to deiiver basic package of interventions beyond NTDs to communities in a sustainable manner. Main tasks . CollaboratewithWHO/AFRO and development partners in the design and development of guidelines for Community Health Systems Strengthening and conduct structured training to implement the plan in the Africa region. . Actively support the transformation of LF and oncho CDI programmes being weaned offinto Community Health system strengthening (Comm-HSS) sites in countries as the programme contribution to Health System Strengthening (HSS) and Primary Health Care (PHC), while carefully documenting the process, implementation experiences and impact and disseminate widely. . Support workshops aimed at the harmonisation of planning, budgeting and service delivery activities at the community level to promote systems strengthening. o Sponsor other country health systems professionals to undertake cross country Iearning attachment in countries where CDIs have been transformed into Comm-HSS. ACTIVITY 3 Contribute to strengthening the information management, monitoring and evaluation systems Accurate reporting of health data is only as strong as the health information systems is strong at all levels and how those collecting the data regard the usefulness and ability to use the data. Evaluation also helps assess the effectiveness of the effort being deployed and provides an incentive to sustain and improve performance. APOC will contribute to building health information systems that facilitate control and elimination assessment while creating the platform for reporting on other health sector interventions. Main tasks . Develop a standard protocol for establishing a functional Health Information, Monitoring and Evaluation Unit. This should include software recommendation, equipment, basic staffing norm and information technolo gy. . Provide each countrywith computers software and accessories based on the protocol that enables countries revitalise their information management systems at the national level. Where country systems are extremely weak, countries will be encouraged to nominate a university or NGO to host the Unit for five years, conduct biennial trainlng of trainers'workshops to equip a core of critical professionals and support them to conduct national training in countries on health rnformation, monitoring and evaluation. . Provlde two fellowships each to countries to train health professlonals in integrated disease health information management and reporting and supervision of CDDs reporting. . Collaborate with country based research institutions and health workers to review country data and publish in scientific journals and produce poliry briefs for countries. ACTIVITY4 Support comprehensive institutional development and training to benefit NTDs and health systems This activity emphasizes the systems transformation at the country level focusing on the targeted NTDs being added to the existing onchocerciasis established national institutions and broaden the function of onchocerciasis country structures. It offers partners at the country level a common rallying point for joint action on specific interventions and a platform for common monitoring and evaluation of outputs and outcomes. Main tasks . Facilitate the transformation of onchocerciasis structures into Technical Review Committees (TRC) and provide financial support for operations in countries annually. Develop and manage a grant giving mechanism for Comm-HSS for NTDs and co-implementation. Support the re-launch of CDI in continuing projeCrs and support training of Community Drug Distributors (CDDs) for effective co- implementation. Manage all fellowship prograrunes that have been initiated under the repositioned APOC. Initiate, coordinate and manage the structured training programme of essential health workers on managing integrated NTD progmmmes and co-implementation at all levels. Support country-focus and cross border NTD advocary missions, meetings and workshops. Design, develop and provide HSAM materials for advocary and education in endemic countries. 5. Specific deliverables by 2025 All the onchocerciasis endemic countries will have been mapped and countries provided with updated onchocerciasis, Lymphatic Filariasis and Schistosomiasis maps including projected end dates for onchocerciasis and LF by 2020. A1l onchocerciasis endemic countries except Central African Republic, Democratic Republlc of the Congo and South Sudan will be removed from the endemic country map by 2020. Additional 16 countries for LF will be removed from the respective diseases endemic country map by 2025. Capacities of seven NTD Iaboratories will have been revitalised, and integrated into a regional network that assure quality control and expertise in entomology dissection and PCR testing. Developed, dlsseminated and implemented a Health Systems Strengthening strategy based on the CDI model and curriculum integrated it into regular curricular in Publlc Health and Nursing Training Schools. Fofty (40) health professionals will have recelved their masters or doctorates in an NTD and community health systems management field and jointly published at least 40 research papers. Benefits ofthe LF and onchocerciasis programme in poverty reduction are directly reiated to the disability prevented bythe medication. Thls includes the prevention as the fuli clinical manifestations in infected adults and days lost due to severe itching, fever, blindnes s and lymphadenitis which affect infected patients. The Ioss of productivity of infected people compared to healthy people is of 58%. Through mass drug administration of ivermectin or diethylcarbamazine citrate (DEC) together with albendazole (from GlaxoSmithKline) the Global Programme to Eliminate LF has treated almost 2 billion people over the past 8 years, thereby averting 32 million disability-adjusted life years, and at a 5. Value fot money and impact attribution Through careful analysis and costing, a budget for the perlod has been produced. The total amount required is approximately US$ 151 800 000. This reflects the sliding scale used to graduate projects and countries off the programme once breakpoint and elimination has been achieved. The main areas of emphasis ln the budget include the need to intensify activities in 20 countrles with expanded focus for areas with prevalence rates of nodules above 5% for oncho to ensure that whole transmission areas are cleaned. In the elimination phase, surveillance activities increase to ensure that all parameters are carefully assessed to support evidence-based decision making. cost of only US$ 14-3 0 per DALY averted.'e The active transmission of LF has also been lnterrupted in several countries. So far the number of DALYS averted by Onchocerclasis programme is estimated at 7.5 million as every infection averted constitutes a savlng of 0.07 DALYS according to WHO and recent studies.'o APOC currently runs a much higher cost per DALY averted of approximately us$ 48. By 2025 the repositioned APOC will have averted an estimated additional 6 million Disability Adjusted Life Years (DALYs) over the period as a result of onchocerciasis and an additional 4 million for Lymphatic Filariasis. Further, the 'off-target' effect of ivermectin and albendazole on other diseases may add another 1 million DAIYs (13%). By 2025 an estimated total of eleven (11) million DALYs averted is anticipated. This is approximately US$14 per DALY averted which is less than 34% of lhe cost so far incurred by APOC. This makes the new strategy proposed very cost effective and efficient in delivery of a much higher amount of services. The lower cost however should be seen as a result of the accumulated gains made over the years by the APOC programme and other partner interventlons. This cost can be reduced immediately to half when extra benefits of other interventions co-implemented and systems strengthened are incorporated. It is estimated that by end 2025 this level of cost will be US$ 4.5. The current estimated value is favourable compared to crude calculations for control programmes on other NTDs, but will 19 Laxminarayan R, Mills AJ, Breman JG, Measham AR, Alleyne G, et al. (2006) Advancement ofGlobal Health: Key Messages from the Disease Control Priorities Project Lancet 367: '1 193-208 20 Lesong Conteh, Thomas Engels and David Molyneux: Socioeconomic aspects of neglected tropical diseases. Lancet 2010;375: 239-47 rapidly decline over the coming years, especially when elimination is achieved in countries. To reach this stage billions of dollars in funds, time and efforts are belng spent. The value ofthe donated products for NTDs is of the order of US$ 2-3 billion per year. Over the years this comes to about US$ 8-12 billion. It is estimated that the value of drugs within this package will be US$ 1.5-1.9 billion per year from Merck & Co., Inc., GSK and ESAI from 2013. For Mass Drug Administration service delivery endemic countries bear a fair share of between 60-90% of the national programme costs." APOC and partners had invested not less than US$ 3 billion to get to this stage. Whlle it is important to secure these investments, it is also rewarding to be counted as being part ofthe success story achieved and progress being made with NTDs in Africa. When mediclnes are factored in, the cost to sponsors of the inltiative will be ln the range of 0.16 cents per treatment, 0.40 to 0.80 cents per person treated should they receive two MDA rounds. This monetary contribution will be matched by the effort of the communities in country; bearing 60-90% of the actual costs of the treatment in terms of economic costs" and the provision of drugs by the pharmaceuticals company estimated at an annual value of circa US$ 1 billion.'r 21 Lesong Conteh, Thomas Engels and David Molyneux; Socioeconomic aspects of neglected tropical diseases. Lancet 2010;375: 239-47 22 Ann S.Goldman etal: National Mass Drug Administration Costs for Lymphatic Filariasis Elimination. PLoS Neglec- ted Tropical Diseases (www.plosntds.org). October 2007; Volume 1, lssue l, e67. 23 This includes the donation of 'l20 million tablets of DEc by Sanofi, Esai and Bill and Melinda Gates Foundation, 600 million tables of Albendazole by GSK and unlimited number of lnvermectin by MSD (http://www.dfid.gov.uk/ Documents. United to combat NTDs; table of commit- ments. 7. Monitoring and evaluation The \t[HO guidelines will be used to assess and monitor progranunes. The emphasis wiII be on measuring therapeutic and geo graphic coverage and bottlenecks to attaining elimination in both onchocerciasis and Lymphatic Filariasis prograrunes. This should help keep the countries and APOC firmly on the elimination agenda and trajectory. Data from accessment with country reports will provide an estimate of the numbers of people at risk treated. Value for money will be calculated, 8. Management The repositioned APOC will operate an efficient Secretariat that wiil support the governing partnership which will be adopted for the programme. The programme will recruit consultants on a need basis to deliver on country programmes chosen in consultation with partners and the countries. The emphasis is to rapidly build the capacity of countries and collaborating agencies to gain the required expertise and institutional competenry to take over and manage NTDs sustainably. Assets ov,rning will also be minimal to ensure low overhead cost and lessen the burden of disposing of chattels at the imminent end of the programme in 2025. using a cost effectiveness analysis, the monetary cost of the programme related to its main outcome and the number of persons at risk treated, to establish the cost per person treated. In line with promoting equity, gender mainstreaming and the pro-poor considerations of the programme the gender mix and socio economic profile of beneficiaries will be assessed by obtaining gender and socio-economic disaggregated data. 9. Probable risks and mitigating measures Treatment gaps and coverage failures A gap of concern is the limited informatlon on ex-OCP countries. For example, a survey conducted in 2008/2009 in Ghana observed a prevalence of 27.9% with a CMFL of 0.65mf/skin snip in Ekumdipe in the Daka river basin. The survey team also observed worrying prevalence rates found in the Pru river basin particularly at Dumanaf o 14.4%, Damongo 9.3 %, Je rus ale m 72.4%, Blta Akura 77.2%, and Akrakuka 3.2%.The Ghana mapping also brought up the discovery ofnew Onchocericsis foci that have no access to Ivermectin. These are the Afram Plains district of the Eastern regi.on, Ho municipal in the Volta region, and Amansie Central district in the Ashanti region. These districts have not officially been known to be endemic for onchocerciasls, and so, were not exposed to Ivermectin treatment. There are also concerns about the quality of data reported from some countries that can directly affect the models and prediction for stopping treatment dates. A,POC is putting in place an intensified programme to fully map out the transmission zones and rejuvenate and establlsh effective CDI programmes in these areas. Cross border activities will be intensified between Ghana and Togo and Ghana and Cote d'lvoire. Sierra Leone is also being targeted for intensified intervention. Recrudescence and possible resistance to ivermectin Another challenge occuring on probably the blind slde of everybody is the risk of transmission from hypo-endemic areas that fall between the cracks of active intervention Ieading to recrudecense. Community-directed treatment with ivermectin for onchocerciasis control is targeted by APOC policy for meso and hyper-endemlc areas in Africa (nodule rates estlmated by REMO at >20%). Below that threshold, communities were considered hypo- endemic and mass treatment was not recommended. As policy begins to shift from control to elimination, the role of hypo-endemlc areas'+ in maintaining Oncho c e r c a v olvulus is being re-examined for all areas with nodule prevalence above 5 %. APOC will be mapping all areas to ciearly delineate possible transmission zones. Currentlythere is emerging evidence though not yet conclusive about the possibility of resistance of O. Volvulus to ivermectin. If this is confirmed, it would undermine the Programmes ability to achieve elimlnation based entirely on mass treatment with ivermectin. The alternative is to quickly develop a drug that can act effectively on adult form of Onchocerca volvulus. 24 Katabarwa etal. Does onchocerciasis transmission take place in hypoendemic areas? A study from the North Region of Cameroon.Journal of Tropical Medicine and lnternational Health 2010; l5:545-52 Conflicts and strife APOC ls concerned about the consequences of conflicts and strife on pro gramme implementation. Countries emerging from years of conflict could have coverage problems due to flints of war Ieft behind that can rekindle. Technical officers will be recruited and posted in post-conflict countries to ensure they are adequately covered as and when it ls safe to do so. Where needed, alternative approaches will be implemented in orderto improve treatment coverage. Severe adverse events The severe adverse events which can occur inLoa loa infected persons constitutes another challenge and have led APOC to undertake rapid epidemiological assessmer*. of Loa /oa (using the RAPLOA method) in areas where community-directed treatment with ivermectin is indicated. RAPLOA has been conducted in 11APOC participating countries. A total of 4798 villages were surveyed in Angola (222 villages), Cameroon (812), CAR (173), Chad (111), Congo (195), Democratic Republic ofthe Congo (2516), Equatorial Guinea (84), Ethiopia (28), Gabon (65), Nigeria (381) and South Sudan (211). Operational research will be undertaken to find approprlate strategies for the effective use of alternative treatment approaches. In the mean time, technlcal support will be provlded to train health workers in the areas at risk of occurrence of SAEs on faciltty-based management of co-endemic patients. Financing the programme By 2015, APOC partners will have committed at least US$ 257 million towards onchocerciasis control and elimination efforts. Countries are showing good will towards budgeting and spending funds in support of onchocerciasis control. Data available suggests that the percentage of approved and disbursed funds has improved in recent years hlttlng 82% in 2009. By 2009 governments of participating countries have taken responsibility for coordination and management of national Onchocerciasis Pro grammes. Reported government financial contributions to CDTI core activities increased annualiy from 1.6 million US$ in 2008 to 2.3 million US$ in 2009 and to 3 million US$ in 2010. The overall proportion of expenditures of the partners (Governments and NGDOs) to CDTI core activities, equipment and salaries increased from more than 25% in 2008 to30% (US$ 2 253 974from governments and US$ 700 250 from NGDOs)in 2009 and almost 39% (US$ 3 428 331from governments and US$ 3 012 750 from NGDOs) in 2010. However another 10 year is likely to whittle down enthusiasm and many country NTD projects are already faced with difficulties in accessing funds, spending and accounting for the funds they receive both from APOC and from their own government budgets. Already NGDOs contributions decreased from US$ 700 250 in 2009 to US$ 415 581in 20i0. Wlth the global economic recession and governments and development partners having fewer resources to spend, there are concerns that domestic funding sources may dry up all together and reverse the significant gains made. The reality is that as progress is made the per capita expenditure will be higher as effort to incidence costs gets higher in trying to get the last victims cleared. The evidence will need to be robust if interest is to be sustained. In countries such as Burkina Faso, Ghana, Niger, Nigeria, Togo, and Uganda, where integrated efforts to control neglected tropical diseases are under way additional challenges may include temporary break in the supply chain management systems and weak local capacity. Efforts will be pursued to increase government and NGDOs contributions above 25% of total cost for oncho elimination activities. The Executing Agency and the Fiscal Agent will develop a proactlve resource mobilisation agenda in collaboration with NGDOs, development partners and clvil society groups to mobillse adequate resources into the APOC Trust Fund during favourable times. It will secure commitments from governments to earmark and protect funds targeted for the elimination of onchocerciasis and other NTDs. 10. APOC estimated budget 4.1 Eliminate onchocerciasis in 8O7o of endemic countries ACTIVITY 1 Raise profile and advocate resources for onchocerciasis and LF elimination and other NTDs activities in countries ACTIVITY 2 Support integrated NTD policy and strategy development in co- endemic countries ACTIVITY 3 Build capacity for delivery of Community Directed lnterventions (CDl) systems in all onchocerciasis and LF transmission zones ACTIVITY4 Provide logistic support to countries and communities to undertake effective CDTI activities ACTIVITY5 Undertake programme research, monitoring and evaluation aciivities ACTIVITY 6 Manage elimination process ACTTVITY 7 Support strengthening of country level integrated disease surveillance systems ACTIVITY 8 Undertake epidemiological and entomological surveillance for onchocerciasis and LF to determine breakpoint ACTIVITY 9 Undertake post treatment stoppage surveillance to confirm elimination 525,000 435,000 535,000 30,000 9,419,000 4,524,000 4,540,000 2,895,000 3,450,000 3,050,000 8,770,700 5,830,700 5,952,000 2,710,000 6,8{t0,000 3,850,000 4,850,000 3,580,000 ACTMTY IO Contribute to the setting up and maintenance of a WHO African NTD information repository and management system at country and regional level ACTIVITY II Manage the personnel, records, estates and transport systems of the organisation ACTIVITY I2 Provide inputs for the effective running of APOC ACTTVITY 13 Manage the lnformation Communication and Technology systems AGTIVITY 14 Effectively manage and account for all APOC resources ACTIVITY 15 Establish efficient working mechanism for oversight, advocacy and resource mobilisation ACTIVTTY t6 Transfer residual responsibilities ACTIVITY 17 Undertake audit, inventory and disposal of chattels and estate ACTIVITY 18 Transfer estates and hold closing down CSA and JAF meetings 2J95,000 2,040,000 1,774,000 1,624,000 1,970,000 1,470,000 763,000 663,000 2,456,0(X) 2,456,000 3.528.000 3.028,000 920,000 700,000 5.875,000 4.2 Collaborate wlth relevant pro- grammeg and partners to imple- ment communlty- dlrected lntervon- tlons to controy slaminato solected PCT-]{TDo ln all onchocorclasis ondsmlc countries in Alrica 4.3 Collaborate with relevant pro- grammos and part- ners to strengrthen communlty health systems in all onchocsrciasls endemac countries ln Africa ACTIVITY 1 Raise profile and advocate resources for co- implementation activities in countries ACTMTY2 Support integrated mapping of LF and other PCT-NTD ACTIVITY3 Contribute to capacity building for intograted LF and other PCT-NTD management within tho region and in countries ACTIVITY I Collaborate with country certified Budget Management Centres (BMC) ACTIVITY 2 Promote GDI as a community health systoms strengthening platform for PHC ACT|VIWS Contribute to strengthening the information management, monitoring and evaluation systems ACTMTY4 Support comprehensive institutional development and training to benefit NTDS and health systems 2,0741000 1,624,000 8,500,000 2,880,000 5J16,000 3,458,000 2J24,OOO 1,624,000 3,872,000 2,598,000 2,364,7OO 500,000 6;128,000 s,082,000 GRANDTOTAL @ Figure 6. Budgetary allocation by period (in USS) I zorc-zozo I zoz't-zoza Figure 7. Budgetary allocation by objective 2016-2020 (in USS) OBJECTIVE 3 CDI for strengthening HSS 15,088,700 (17o/ol OBJECTIVE 2 PCT-NTD co-implementation 15,590,000 (18%) OBJECTIVE 1 Eliminate onchocerciasis 57,5i17,7OO (657"1 Figure 8. Budgetary allocation by objective 2021-202S (in USS) OBJEGNVES CDI for strengthening HSS 9,804,000 115'/.1 OBJECTIVE 2 PCT-NTD coimplementation 7,962,00 (13%) Figure 9. Functional area analysis (in USS) APOC personnel Managemont and institutional support 20,878,000 111W lnformation monitoring and research 12,161,000 l8'/ol operations budget and equipments 14,273,q10 (9olo) Closing APOC 7,495,000 (5"/rl OBJECTIVE 1 Eliminate onchocerclasis 45,680,700 172W Governance and advocacy e516,000 l5V"l Policy change and planning 865,000 l1w CDI HR training and systems strengthening 27,625,7OO fl8%l NTD innovations and co-implementation 7,216,000 (5y") Surveillance for elimination of oncho, LF 53,773,400 (35o/o) 11. log frame on objectives and critical success indicators Political commitments secured and policies and action plans implemented 120 functional CDI projects established in all oncho endemic countries Epidemiological and entomological surveillance undertaken % of oncho and LF endemic countries implementing integrated actions that include oncho elimination % NTD programme managers responsible for onchocerciasis (Baseline to be determined 2015) % change in government heahh expenditure on NTDs per capita Updated CDI manual 1:100 trained CDD to population ratio in 71 prolects 100% geographic coverage 80% therapeutic coverage Annual epidemiological and entomological surveillance done for 71 projects 40 projects fully assessed 12 countries exited o/o of oncho and LF endemic countries implementing integrated actions that include oncho elimination % NTD programme managers responsible for onchocerciasis % change in government health expenditure on NTDs per capita Updated CDI manual 1:100 trained CDD to population ratio in all remaining treatment areas 100% geographic coverelge 80% therapeutic coverage 100% Annual epidemiological and entomological surveillance done for 3'l projects 16 profects fully assessed 5 countries exited Annual government public expenditure tracking Date of manual in use Annual reports and biennial rapid assessment Annual rapid assessment Annual rapid assessment Annual reports from countries and APOC Breakpoint project validation report Technical committee report Govemment allocation to health nominally increasing over the period Adequate financial and technical resources and inputs fully secured All capacities built and training on elimination guidelines undertaken with projects properly implemented Ceased all operations and closed safely Resources mobilised and Programme efficiently managed Advocated for and supported NTD mapping CDI strategy implemented in all participating countries for other PCT-NTD elimination Suppori HSS for PHC HSS grants established 100% tunding secured 100% funds accounted for with value for money established lF and Loa loain 20 APOC countries fully mapped and to date 40 CDI projects transformed into Comm-HSS 30 health professionals trained at Masters level in Comm-HSS from 19 countries Six laboratories capacities built Developed manuals and disseminated guidelines Call for proposals and programme initiated Closure committee established 100% funding secured 100% funds accounted for with value for money established Final programme, financial statement/ audit and legal status reports submitted to JAF in December 2025 Annual financial and audit reports NTD Maps and report published Mid and end-term evaluation reports Mid and end-term evaluation reports Mid and end-term evaluation reports Mid and end term evaluations Mid and end term evaluation All processes towards closure successfully executed without any liabilities outstanding Stable economic environment and partner commitment to elimination NTDs in Africa fully mapped and to date 31 CDI projects transformed into Comm-HSS 16 health professionals trained at Masters level in Comm-HSS from 3 countries A centre of excellence and repository developed BMCs trained and certified A minimum of 20 Grants worth not more than US$ 2 million effectively concluded Collaboration between the various stakeholders Cooperation between the various stakeholders secured ISO grade attained in 50% of laboratories Resources acquired Countries have capacity to effectively implement innovations ANNEX 1: Disease-specific protocols for neglected tropical diseases*'t c .96 EiiF oEE.- oy ED!JO<s .Er OLOF tr OC .2 r=il> >I>E -OF6U oi 6aE> o= c:QI F ilNF<Oir >x 6+ 9= oH E =><C.tA; F @7 - -= cI r:hlX .-L .90 6;x= .6e F C:: F tr:U R-i;:+ 6 c!u N= I 'E - .1.1 9EdoS rr !-ro- '6 o< o 0L!IO =u CS(/): Esg >= -. oPa A u1 3:tJ B =Xo!c- o -o c< -- At6 3 o,,:.o 5rE soo ! 6 =rE> .9 !d c J=yc o ** >ct F bE: g E E !< oQE Lr ci, , -. oEoo gouJo- loo< o s geeEEgBcegE,EcEEgg'Es e8E eEE C,S=seE g : .Ec= E qcEEEBsE -t =$E=E EEE :E*i.p € Et €FEE:'* Tt!- $HEEE$*$*#EfiEEEEEEE o .9,o .9= JO= '=Yo -o9oi5db .9* o E.E >EXEE EEgtgi gEE o)o(!b9 *o_ Io.9oo= .PEPfr! 6' i5 8b gE-HH ! E bq I # r # .s =!= * o< o F F E SqlEE "s E? E* 3e Z Bt?$rxc Fe [B-ErEtE tr{Ee5 s€EgeEtgEigE;E$Hg$[E$ ^tr P E bbE* 4 EE . E EE gEE=sIgrgggggEEEggE= p,'At EEEI.EIE'gEE'Eg ANNEX 2: Planned interventions towards elimination of onchocerciasis 2016 -2025 Elimination confirmed! continuing treatmen, ! Post stoppage surveillanc" I 1 Bengo 2 Huila - Kuandoo Krbango 4 Lunda Norte 5 LundaSul 6 Moxico 7 Uige 8 Kwanza Norte I Benin 3,249,893 2016 tO BurkinaFaso 2't1,530 1994 2017 16,029 2010 2022 862092 2007 2017 126,781 2007 2019 384,245 2006 2020 231,091 2005 2017 254,268 2007 2019 495,575 2012 2022 3,116 2012 2022 352,728 u2,277 n4,599 2006 2016 2015 2016 2005 2006 470,290 2004 2018 427,330 1999 2015 434,318 2001 2020 102,229 2001 2020 330,088 1999 2020 120,562 2005 2019 285,148 2005 2015 285,080 2006 2020 152,081 2000 2020 639,404 't999 20't5 830,687 2004 2020 303,594 2005 2020 398,034 1999 2019 1997 1l Bururi Cibitoke 12 Bubanza 19 Rutana l4 Mamaoua 1 15 Adamaoua2 16 Centre 1 17 Centre 2 18 Cefire 3 19 Est N Far North A Littoral I 212 Littoral ll M Northerna Frovrnce 24 Northwest ?S South Province 26 South West I Continuing treatment South West ll Western GAR Chad Congo Extension Congo 1 Elimination confirmed 27 2A N 30 3'l s2 33 COte d'lvoire 1,835,787 34 Bandundu &5 Bas - Congo 36 Butembo-Beni 37 Equateur-Kiri 38 lturi Nord 39 lturi Sud 40 Kasai 41 Kasongo 42 Katanga Nord 4g KatangaSud 44 Lualaba 45 Lubutu 48 Masisi Walikale 47 Mongala 4A Rutshuru-Ngoma 49 Sankuru 50 Tshopo 51 Tshuapa 52 Ubangi Nord 53 Ubangi Sud 54 U6l6s 1,406,032 873,653 1,161,091 1,174,844 1,073,931 1,135,000 10,073,103 1,261,862 586,255 649,359 210,631 312,882 980,637 '1,363,615 617,641 999,225 1,492,560 1,329,879 748,833 '1,263,110 1,473,O48 2003 2018 2004 2020 2008 2030 2006 2030 2008 2030 2012 2030 2001 2028 2007 2025 2006 2025 2006 2025 2006 2025 2008 2030 2008 2030 2006 2027 2006 2030 2003 2030 2003 2028 2006 2025 2006 2030 2006 2030 2002 2028 ! eo",stoppagesurveillance I 270,883 2001 2019 1,664,277 2001 2019 1,832,523 1999 2028 1,992825 1998 20'15 5,938 2004 2015 838,718 2001 2018 55 BiokoT|DC 83,432 2000 2025 ! Continuing treatmen, ! Post stoppage surveillanc" I 56 West Wollega $l Kelem Wollega s8 f*""."Kemasnr 59 Bench Maji 60 East Wollega or il,Li&T"' AZ West Shoa 6ll Gambella 64 lllubabor 65 Jimma Kafa-Shekkaoo cDTr 67 Metekel 68 North Gondar 69 70 71 Gabon Ghana Guinea 7g 74 75 Southeastem Southwestern Lofa, Bong, Nimba Thyolo, Mwsnza Malawi Extension 72 Guinea Bissau 180,797 11,717 1999 2025 2,294,913 3,117,244 1996 Ellmination confirmed 805,025 882,4ff 58,U2 710,113 756,213 49,871 309,516 103,896 1J01,197 2,165,594 't,233,117 156,942 304,737 489,/t61 705,572 1,740,475 899,168 1,178,544 2044 2020 2012 2020 2012 2020 2003 2015 2004 2020 2012 2020 2012 2020 2004 2015 2004 2020 2004 2020 2001 2015 2004 2015 2004 2020 2016 2006 2006 2000 1999 2019 2019 2016 2015 2015 70 tt 78 Mali 2000 Continuing treatment Elimination confirmed 80 Adamawa 8l Akwa lbom 82 Bauchi gI Benue 84 Bomo 85 Cross Biver 86 Edo, Delta g7 Ekiti gg Enugr, Anarn- ora, EDony &9 FCT 90 Gombe 91 lmo, Abia S2 Jigawa 9{l Kaduna 94 Kano 95 Kebbi 96 Kogi 97 Kwara 9g PlateauNassarawa 99 Niger tOO Ogun 101 Ondo 1O2 Osun 108 Oyo lO4 Tamba 105 Yobe 10O Zarrrtara 1Cf Senegal ! no", stoppage surveiltance I 1,714,764 2000 2016 29,3s8 2004 20'16 1,756,890 2001 2016 3,464,91s 2001 2018 'f ,381,135 2000 2018 1,252,279 2000 2015 1,609,999 1999 2016 2:t75,474 1999 2016 2,392,351 1999 20'15 502886 1998 2016 1,909,032 1999 2016 1,518,824 1999 20'16 357,517 1999 2016 991,209 1999 2016 208,279 19t,9 2016 1,789,685 1998 2018 1,s12,636 1999 2A1A 1,s3s,047 1998 2016 2,659,049 1999 2016 344493 2OO2 2016 1,370,293 1999 2016 1,616,644 1998 2016 1,1A2,528 1999 2016 1,662928 1998 2016 616,8M 1999 2016 286,292 1999 20'13 108 Sieira Leone 9,047,253 ! continuing treatmen, I Post stoppage surveillanc" I l@ EastBahrEl 110 East Equatoria 1ll Upper Nile 1r2 Hrl*'u 118 West Equatoria 550,02s 2005 97E,183 2006 s12,573 2006 2,966,286 2006 699,670 2005 403,516 1998 514,408 2042 20'15 504,400 1998 2019 361,040 2004 2015 398,574 1999 2018 312,693 2000 2014 114,432 2001 2A16 124,085 2005 2020 685,215 386,731 1998 2416 750,508 1999 2016 '1,384,313 1999 2016 783,579 1SSC 2016 504,549 20't2 2020 Elimination confirmed 2023 2024 202 2023 2027 114 Northem S6ctor 115 Kibsa 116 Mahenge 117 Morogoro ttg Ruvuma ItS Tanga 12O Tukuyu l2l Tunduru 122, Togo 12[, Phase I 124 Phase ll 1;E Phase lll 126 Phase lV 7?I/, Kitgum Pader 2015