Devolution

a\\,ORLD IIEALTI{ ORCANIZATION ORGANISATION MONDIALE DE LA SANTE ONCI{OCERCIASIS CONTROL PROGRAMME IN WEST AFRICA ptrocRAMME DE LUTTE CONTRE L'ONCHOCERCOSE EN AFRIQUE DE L'OUEST EXPERT ADVISORY COMMITTEE Eleventh session Ouagadougou^ I l-15 June laaO ocP/EAc r r.5 DEVOLUTION ,t I. INTRODUCTION In December 1990, all the seven (7) Participating Countries in the initial OCP area will have already prepared and presented their Devolution Plans. The implementation of each of these plans is the responsibility not only of the Participating Countries but also of the Donor Community and the Sponsoring Agencies. It calls for support, solidarity and coordination because its failure will lead to serious consequences for the whole area. 2. DEFINITION The concept of Devolution has evolved since it was raised for the first time in l98l by the Independent Commission. Today, devolution is defined as the taking over of residual activities of the Onchocerciasis Control Programme and integrating them into the national health system using mainly epidemiological and entomological surveillance and ivermectin treatment. 3. ACTIVITTES, FRAMEWORK AND ACTORS The objectives of devolution are specific: - to prevent any recrudescence of transmission of the disease; - to contribute to the maintenance of the achievements of OCP 3.1. Ac(ivities As expressed clearly in the definition, the activities to be transferred are epidemiological surveillance, ivermectin treatment and, to a lesser extent, entomological surveillance. All the Participating Countries have decided to integrate these activities into those of programmes for the control of major endemic diseases. 3. I. I E pidentiological surveillance - Passive screening. It is to be undertaken in permanent public and private health centres and will consist in detecting suspected cases as patients present themselves spontaneousll,. These cases may or may not be confirmed by parasitological examination of skin snips. The arrival of migrants could also be reported. - Active screening. The appearance of abnormally high new infections in an area will require an active screening by mobile teams. The extent and seriousness of the problem are deternrined by establishing a detailed epidenriological nrap of the area concerned (prevalence, community microfilarial load) on the basis of skin-snip surveys. Furthermore, OCP and the Participating Countries will jointly select indicator villages rrhich rvill be monitored regularly every three years. It is inrportant to detect any recrudescence rapidly so as to undertake iverntectin treAtrllent. Studies should therefore be carried out to develop a specific and susceptible immunological test. 3.1.2. Entontological survcillancc. The community will serve as a sentry post and report any abnormat presence of blackflies to the higher level (health centres, district) which will take the appropriate steps: catches, dissection, possible spraying from the ground, report to ittterntediate level. central level and OCP for decision-making. -J.1.-1 . lvcrnrcctin trcalntcnt aud posl-t,'catntent survctllaucc. lvermectirt shoukl be nvailatrle to any ortclrocercias is- pnticnt, anyt irrre, an 1,where. -'l-reatment of individual cases. lt is to be made in pcrmantrnt health ccntres. a2 - Mass treatment. tt will be decided after the detection of new infections and the epidenriological mapping of the area. It will be undertaken by mobile teams half-yearly or yearly depending on the gravity of the infection. The post-treatment surveillance will be for at least 36 hours. After a mass treatment, an evaluation will be made every three years to judge the efficacy of the treatment and the evolution of the infection. 3.2. Framework and actors The appropriate framework for the implementation of these activities (a framework designed and accepted by all the Health Ministers of the African Region and therefore of the Participating Countries) is the peripheral (district) level of the health development scenario. The visit to some district health centres justifies this option. Human, and sometimes nrflterial, resources exist. One only has to organize them and use them judiciously. Some centres need to be improved. All skills will be used: - community and village health workers - health centres with paramedical personnel - the district with medical and paramedical personnel They will get technical support from the intermediate or regional level and strategic support from the central level. OCP collaboration will be required. 4. PLANS 4.1. Preparation Burkina Faso, Mali and Niger prepared and presented their Devolution plans in 1988 and 1989 respectively. The plans for Benin, COte d'Ivoire, Ghana and Togo will also be prepared and submitted for approval to the Joint Programme Committee (JPC) which will hold its annual session in Decentber 1990 in Conakry, Guinea. 4.2. Financing Since the mode of financing, similar to the Onchocerciasis Fund, which was recomntended b5, the Participating Countries has not been approved, bilateral aid is now being sought. All opportunities should be seized to get the Donors involved and accelerate the financing. '[o that effect, the World Bank, through its consultations, and the United Nations Developnrent Programme, through its round-table talks, can and should play an important role. All the Participating Countries accept to participate financially in the implementation of their plan and some, without waiting for aid, have started carrying out certain devolution activities: training, epidemiological evaluation and ivermectin distribution. t a 3 5. ROLE OF PARTNERS Each partner in this devolution process should have a clear and well-defined role. 5.1. Role of Participating Countries It is the responsibility of the first partner to implement the plan by collecting relevant information, mobilizing all available resources and looking for those necessary. - Inventory of facilities and personnel; this phase is carried out partly during the prepartion oI the plans. - Strengthening of facilities especially at district level - Personnel training and retraining - Sensitization, information, education and mobilization of the communities so that the5' e76u16 always bear in mind the possibility of return of the disease and also not take the return of the blackfly as that of the disease. In this connection, contacts have been made with the Public Health Training Centre ol' Lortte (Togo), which is a WHO institution, for the retraining or training of technicians in health educatiort. - Surveillance and treatment activities - Progress reports - Taking into account of recurrent expenditures - Inclusion of a "Devolution' section in their WHO regular budgets 5.2. Role of Non-governmental Organisations (NGOs) - Strengthening of facilities - Personnel retraining - Additional activities (epidemiological evaluation if possible and ivermectin distribution) 5.3. Role of OCP - Collaboration, coordination and supervision of devolution activities - Vector control, if necessary - Personnel training and updating of manuals -Research, improvement of devolution tools (immunodiagnosis) and dissemination of inl'orrnatir.rrr. 5.4. Role of \YHO/AFRO - Formulation of policies - Collection, analysis and dissemination of relevant technical information - Strengthening of facilities - Personnel training - Mobilization of internal (ordinary budget) and external resources - Coordination and supervision of activities - Evaluation in collaboration with Participating Countries and OCP 5.5. Rolc of Sponsoring Agencies As mentioned above, the Sponsoring Agencies should help the P:lrticipatirtg Countrics lotrk lirr financing for the Devolution plans. 6. TRAINING OCP has always paid attention to the training of nationals of the Participating Courttric's rr ith a view to Devolution. a1 6.1. Informal tralning Since the advent of ivermectin,28T workers of six Participating Countries have beert given field-training by OCP in the methodolog;" of epidemiological evaluation, ivermectirr distributiorr and post-treatment surveillance: Benin 26 Burkina Faso 195 C0te d'lvoire 12 Ghana 12 Mali l0 Togo 32 To that should be added five Niger nationals and five Malians who were given training in tlris same methodology in the National Medical and Pharmacy School, Bamako (Mali). 6.2. Formal training 208 nationals of seven Participating Countries have received fellowships offered by OCI'l'or training in onchocerciasis-related disciplines. Discipline Country Entomology Hydrobiology Public Health Epidemiology Parasitology Ophthalmology Total Benin Burkina Faso Cote d'lvoire Chana Mali Niger Togo t0 t2 r6 IO 42 5 l6 5 3 3 4 5 2 I 5 3 8 5 I I 20 2 : 6 6 2 2 4 I 2 2.1 4(t 2r 2r (ri lt 2r Total ilt 22 23 29 23 208 6.3. Strengthening of training institutes in the African Region Contacts have been made with certain governments and training institutes (Nationnl lr4erlical and Pharmacy School of Bamako, Mali, and University of Ghana, Accra) to study ways antl rllelans of strengthening them to make possible the training of senior officers in epidemiologl,. This strengthening is the wish of some Donors as well as the Participating Countries. OCP will continue with its policy of training of senior officers and technicians. which is cenrlect on formal training as well as retraining and field training. 7. CONSULTATIVE MEETING Consultative meetings have been instituted between the Participating Countries. OCP and WHO/AFRO, which is an ideal framework for discussing Devolution problents. 7.I. wHO-AFRO/OCP meeting It was held from 3l October to 3 November 1989 in Brazzaville. tr was presided over b1,the WHO Regional Director for Africa and enabled all the ourlines of Devolurion to be del'inccl (scc the document 'Devolution of Onchocerciasis Control Programme (OCP) in the Framework of rhe Three-phase Health Development Scenario for African Region"). 57.2. Briefing mission WHO/AFRO has designated an epidemiologist in the Office of Subregion I (Bamako) to monitor problems related to the Devolution process. He visited the OCP headquarters in Ouagadougou front 19 to 23 February 1990. He was given relevant information by the different OCP Unit Chiefs. A mission report has been prepared. 7.3. Meeting of National Onchocerciasis Committees (NOCs) The l4th meeting, which was held in Ouagadougou from 29 to 3l May 1990, was devoted to health problems: progress report on devolution, devolution plans and health education.