Devolution-situation paper

WORLD HEALTH ORGANIZATION AFRICAN REGION ORCANISATION }TONDIALE DE LA SANTE REGION DE L'AFRIQUE ONCIIOCERCIASIS CONTROL PROGRAMME IN TIIE VOLTA RTVER BASIN AREA PROGRAMME DE LUTTECONTRE L'ONCHOCERCOSE DANS LA REGION DU BASSIN DE LA VOLTA NATIONAL ONCHOCERCIASIS COMMITTEES Eighth meeting adou ou 5-7 June 1984 NOCs/4 DEVOLUTION SITUATION PAPER NOCS/4 DEVOLUTION - SITUATION PAPER Definition Devolution, within the context of the Onchocerciasis Control Progronme (OCP), rnay be defined as the process whereby some of the activities of the Progranrme will be progressively taken over by the Participating Countries when the health structures of these countries have acquired the technicat, organizational and financial capability. Coordination of these activities will initially continue to be the responsibility of OCP but eventually be assumed by an appropriate intercountryfacility which will undertake control measures against the vector as and when necessary so as-to ensure that there is no recrudescence of the disease. PAG Mission Report The report of the Preparatory Assistance to Goverrunents Mission (PAG), presented in 1973, defined the strategy'and detailed the plan of action for the launching of OCP and outlined requirernents-for its des{gnated 2O year lifespan due to expire in 1993. By then it was'envisaged that the disease would be under controL but not eradicated. The long term maintenance and future transfer of OCP to the Partieipating Countries rras not considered. However, it is now recognized that, if no surveiltrance is carried out and control available when OCP has fulfilled its mandate, there could be a resurgence of the disease in the area. Independent Corrnission Report This problem was first highlighted in the report of the Independent Comuission (1981). In its consideration of the long-term prospects of the Progranrne, the Cormission stressed that, as wel-1 as extending the area te dininish the impact of reinvasion frorn outside and deveLoping new drugs to provide a second line of attack against the disease, ultimate security could only be found in having the surveillance activities maintained by the Participating Countries with coordination of these activities and vector control, as necessary, being the responsibility of an intercountry body. The Comission also emphasized that devolution should be inplenented gradually and progressively; if carefully planned and successfuLly accom- plished, devolution would make these countries rnore self-sufficient, in itself an importanE development achievement. ert Advis Conmittee These views were fully supported by the Statutory Bodfes of the Progranme. The Expert Advisory Conrmittee (EAC) in its second session in 1981 underlined the need to strengthen the training programne of OCP in prospect of devolution. It considered that vector surveillance activities should be devolved only during the maintenance phase of OCP and be integrated, in the long term, into the national health progr*r'mes. Since then the EAC has continued to address the concepE of devolution at each of its sessions. '1 NOCS/4 Page 2 In 1982 the EAC reconnnended that OCP undertake studies to dete:mine the type of infrastructure to provide the suweillance and paintenance services required, to identify resource needs for such an infrastructure, to establish standards and to develop methods within the Epidemiological Evatuation Unit and Vector Control Unit for an early warning system. The EAC considered the most efficient infrastructure woul-d be in the form of a uuLtidisease surveillance and control unit. In its fourth session in 1983, the EAC, noting the satisfactory progress being made in planning devolution, recomtrended that, in preparation of such plans, there was a need to consider carefully a number of factors. These included the folLowing: - the Programme elernents which would be devolved, eriteria for their selection, the order in which devolution wiLl be implernented and the tfune frames invoLved; - the need to establish criteria and standards which must be met by national structures of Participating Countries before the activities concerned eouldi be devolved. This was necessary to ensure that the efficiency and/or effectiveness of Progrerrme activities would not be inpeded by devolution; - the need to fully involve Participating Countries in all aspects of the devolution process, from planning through implementation; - the need to develop and have in pLace necessary physical infrastructures and managerial capacity prior to initiation of devolution; - the relat,ionship of devolution to multidisease controL progrrrnmes, prinary health care and deveLop,ment programtres; - the role to be played by National Ouchocerciasis Conrmittees, and academic and national research institutes in Participating countrids; - the need to train national staff so they wouLd be able to take over responsibility for Progrenme operations. Development and implementation of adequate career structures Eust aLso be considered; - the need to recognize that control action, or lack of it, by a given Participating Country coul-d have profound effects, on disease control in others; - the development and maintenance of an intercountry facility which would carry out certain activities after OCP ceases operations; - how to effectively Danage, in ways which would ensure continuance of disease control-, the critical ttphase in-phase outtt aspect of devolution, when OCP was winding down and Participating Countries gearing up. '-rk EI'+:- ^ +'.{' ,'- 't-F' <.]-,il- rrtnl NOCs/4 Page 3 gomittee of Sponsoring Agencies In its deliberations the Co'r,mittee of Sponsoring Agencies (CSA) has Likewise given due emphasis to devolution. At the beginning of L983 the CSA underlined devolution as being the most important factor to be con- sidered within the cont,ext of the Long-Term Strategy being developed for the Prograunle. It reeognized that not all countries would be ready to assLme responsibility for a1L (or many) of the activities at any one time and, although devolution was foreseen by the Independent Co'r-ission to take place around l-990-1993, preparations had to start i'n-ediately. By the end of 1983, the results of the Prograrr-e indicating remarkable progress, the CSA advised the Joint Progrenrme Conmittee (JPC) that the Progrenrme would reach a stage around the niddLe of the third financial phase, where, in its core area, minimal- controt operations would be needed although surveilLance and other maintenance activities would have to be continued. Accordingly, the possibility for the transfer of appropriaEe activities to the Participating Countries was more irminent than considered heretofore. It recomnended that, although devolution would introduce potential incrementaL costs to the Participating Countries, consideration should be given to analysing how it coul.d become a factor beneficial to the countries within their overall development progrernme. Joint Programe Conrnittee At its second session in 1981 the JPC, while giving support to the idea of devoluLion as presented by the Independent Cornmission, considered more attention should be given to the possibility of gradual devolution. It recognized the need for externat funding to promote devolution and associated activities and for requisite training to be given to health staff at all 1evels. In 1982 the JPC again stressed the importance of the gradual transfer. of responsibilities to the Participating Countries, sueh devol-ution being essential to the Long-Term success of the Progra'r'-e and a necessary complement to any extension of operations. It considered devolution should be linked to the primary health care system. National Onchocerciasis Conrmittees At the joint meeting of the National Onchocerciasis Cournittees (NOCs) in 1982 the delegates affimred that it, was up to the Participating Countries to take over the activities of the Progra.rrme in order to ensure the nainte- nance of- results acquired and so ensure Lhe continuation of development projects. However, the countries insisted that not be handed over a situation which was beyond the r capability to maintain. In t s context, technical discussions should be held to prepare a calendar for devolut 10n and the methods to be emptoyed, and to identify measures to be taken irmediately in the field of training and the means necessary to ensure an efficient take-over by the national services. \ N0c8/4 Page 4 At its subsequent meeting in 1983, further consideration was given to the implications of devol-ution for the Participating Countries, the level of activity foreseen in these countries as well as the types of national structures and the forrn of the intercountry facility. Regarding the latter, it was suggested that such a facil-ity could be a modification of the present OCP rather than the implantation of a completely new organization. For its part the Progranrme has responded to the various concerns and recorrmendations of the Statutory bodies. The Progra'n'ne Director has had regular consultation with WIIO Headquarters, the Regional 0ffice for Africa and with the Participating Countries to determine the most effective courses of action. !,Iith the intention of ensuring the full collaboration of the Participating Countries and their involvement in every step of the devolution process each country was invited to nominate two senior officiaLs as focal points. A working group involving one expert from each Part,icipating Country was heLd in Novernber 1982 to consider the impLication of devolution for the count,ries and prepare recormendations for follow-up. These rrere as follows: For OCP to search for an easy and appLicable technology; to identify the 1evel of OCP activities in each country; to define the national structures envisaged, their antici- pated rol-e and requirements; to study the national mechanisms and the type of support needed; to study acceptable level-s which can be maintained by the countries in case of reinvasion or recoLonization; .,/ to estimate the potential for the countries to integrate OCP activities and the risks involved; to evaluate the prospect of international aid; to detemine the level of epidemiological- eval-uation currently carried out by OCP in each country, and the possible partici- pation of nationals in these surveys; to set up an evaluat.ion mission to visit each of the Partici- pating Countries with the above as terms of references and to prepare recormendations acceptable to at1 parties concerned; to appoint a working group composed of technicians from each of the Participating Countries to study criteria and standards necessary for the transfer of OCP activities to the Partici- pating Countries and to prepare terns of reference of future missions in charge of studying the capability of each country to take over OCP activities. The Prograrme ,-!-, f.-- + r-a.r N0c8/4 Page 5 For the Participa ting Countries - to make a definite political comitment to devolution and define a clear national" policy towards assumption of responsibilities; - to select the necessary trained staff and appoint a secretariat; - to create the required national structures; - to identify onchocerciasis as a priority within the national health services; - to reorganize and strengthen the NOCs; - to study the possibility of coll.aboration amongst countries within the same river basin; - to maintain the OCP methodology after devolution. For WHO (Regiona1 Office for Africa) - to irrciease training fellowships; - to provide support to nationaL technicians through inter- country projects; - to assist in setting up surveillance structures; - to enable the Special Progre'r'me for the Research and Training of Tropical Diseases, Division of Mal-aria, etc.participate in the integration of OCP activities into the National Health systems. to Internal meetings involving OCP technical staff have been convened in order to define what should be the standards and criteria to be reached before any particular activity could be devolved. For hydrobiological monitoring, experienced te:m.q belonging to nationaL institutes in the countries concerned have already taken over responsibility for carrying out the prescribed schedule of activities and collecting the requisite data, all being coordinated by OCP. Epidemiological sunreillance could be, perhaps, the next activity to be handed over but again there would be the need for central coordination to ensure comparability of data.. Ilowever, it was emphasized that the detailed study of the evoLution of the disease in relation to the vector control operations should continue wittr OCp meantime. Because of its complexity and the continual demand for infomation vital to ensuring PromPt and appropriate action against the vector, the entomological surveill- ance system would be the last activity that could be devolved and then only when the Local situation is seen to be secure after several years in the meintenance phase. The format of the inter-country facility (ICF) which will continue a role similar to that of the present OCP in coordinating the activities in the various countries and providing a control input as necessary is under regular study by the Prograrme with the help of a consultant. N0c 4 6 8/ Page The Prograume organized a second working group of nationaL experts which prepared terms of reference for teams to visit the Participating Countries to evaluate the potential of each to undertake responsibility for different activities, to examine the present structures and Lo identify possible shortfalls and training needs. This intensive R and D study was launched at the beginning of 1984 and lg being undertaken progressively by a team visiting each count,ry in turn. This team is composed of a consultant and a staff member who link up with the two senior officials nominated as focal points in the country visited and joined by one of the focal points from a neighbouring country. When these review visits are completed a report will be written and reviewed at a joint meeting of the focal points so providing guidelines to the types of assistance these countries will require to build up their national heal-th structures to the level necessary to continue maintenance activities. Meantime, the Prograrme has recruited another consultant to help draw up a schedule of training and fellowships which should be available through the Progr:rrrme to the countries concerned for the period 1984-1993. This will cover a broad range of disciplines e.g. entomology, epidemiology, ophthalmology, hydrobiology, statisties, heal-th economics, sociology and mtnagement, all of which will be necessary for the countries to assume responsibility at devolution and to respond to deveLopment needs thereafter. The need for an independent group to dete:mine when specific activities should be handed over to the national authorities is a safeguard recognized by the Progranrme and the countries concerned. The role of impLement,ing and monitoring the actual transfer of OCP activities to the countries could probably best be undertaken by a group drawn from two of the statutory bodies e.g. the Expert Advisory Conrmittee and the Joint Prograrune Cormittee. Future The Long-Tert strategy currently being prepared to carry the Prograrrme through to the period when its objective wiLl be met leads naturally int,o devolution for the maintenance of activities necessary to prevent a recru- deseence of the disease. The timetable for devolut,ion varies substantially from one area to another but from the continuing success of vector control in 9OZ of the control area, and as recorded by the CSA, it could be more irmrinent than had originally been anticipated. With this in mind, the devolution process must be progrArrrmed very carefully and coordinated with the absorptive capacity of the countries concerned who must continue to be involved every step of the way. The uanner in which it is being pursued, that is by close collaboration among the Programrner the Participating Countries and the Statutory bodies, is sufficientl-y flexible to accornmodate each country according to its particular constraints and in reLation to its national heaLth progr.arme.