Plan of operations for the fifth financial phase 1998-2002: the phasing-out period

WORLD HEALTH ORGANIZATION ORGAMS^TION MONDIALE, DE LA SAN|E, ONCHOCERCIASIS CONTROL PROGRAMME IN WEST AFRICA PROGRAMME DE LUTTE CONTRE L'ONCHOCERCOSE EN AFRIQUE DE L'OUEST EXPERT ADVISORY COMMITTEE Sixteenth session Ouagadoueou. 5-9 June 1995 OCP/EACI6.5 ORIGINAL: ENGLISH PLAN OF OPERATIONS FOR THE FIFTH FINANCIAL PHASE 1998-2002 (THE PHASING-OUT PERIOD) DRAFT No.2t 11.05.95 WORLD HEALTH OR6ANIZATION ONCHOCERCIASIS CONIROL PROGRAMME IN WEST AFRICA PIAN OF OPERAT]ONS FOR THE FIFTH RNANCIAL PHASE I99t-2m2 GHE PHASINGOUT PERIOD) In rcsponsc to a rcguest by the Joint Programrnc Comrnittee at irs 1994 session that OCP consider rhe possibiliry o[ starring in 1995 thc process of prcparationt for the Phasingout Period, the Programme Dirccror has the honour to subrnit to the Committec a firsr draft of thc Plan of Operations covering that Pcriod. Ihc proposcd tert rcflccts @mmcnts and suggesrions madc by the Comminee of Sponsoring Agencies (CSn1 and the Expcn Advisory C-ommiuec (EAC) on previous drafts prepucd by thc senior staff of ocP. Thc Prograrnmc Direcor invites mcmbers of the Joint Programme C-ommincc ro express opinions on rhis first draft of thc Plan of Opcruions. A sccond draft, includlnt as appropriate thc comments of JPC. will then bc lcmdnircd by CSA and EAC before irs submission to the 1996 scssion of rhe Joint Programme Commitree for cvcaual approval. * This draft no.2 takes into account CSA's first cotnnrents. (D:rart no.2 - Il-.Oi.9r) WOR LD HEALTH ORGAN]ZATION ONCHOCERCIASIS CONTROL PROCRAMME IN WEST AFRICA PLAN OF OPERATIONS FOR THE FIFTH FINANCIAL PHASE l99E-2002 (THE PHASTNC-OUT PERIOD) CONTENT A EXECUTNTE SUMMARY BACKGROUND . 2. Oachoccrcbsts, tts traasmisston and control 3. Thc Onchoccrciosis Control Progmmmc in lilcst Africa 4. Achicycncn$ of thc Progrotune . . - 5. Cosu of Programme operationr . . . . 6. Phnning ond cvaluation INTRODUCTION 7. Thc significancc of thc Phaslngout Pcriod t. Preparatton ol thc Plan of Operottons THE EAC MID-TERM (PHASE Iv) PROSPECTTVE EVALUATTON9- Coaclusions rcochcd by EAC rcgording Progmmmc opcmtions during thc 1995-2002 pcriod and corrcsponding budgctory forccosts PLANNED OPERATIONS AND BUDGETARY FORECASTS FOR THE PHASTNG-OUT pERtOD (199t - 2002) crHE FIFTH FTNANCTAL PHASE)10. Opemtional forccasts for thc I99t-2002 Pertod I l. Thc proccss of phasiag-out 12. Ltanagement of thc phasing<u, . . . 13. Rcsourcc rcquircmcats and budgcury lorecasts for the lggE-2002pcrid F. RISKS AND SAFEGUARDS 14 Potcntial 'troublc spotP.'. , . . 15. Rcisbncc to lvcrmcctin I6- Shotugc oJfinancial rtsources G. BENEFTTS 17. Health bcnqfits I t. Social bcnqfrts 19. Economic bcncfiu POST{CP INTER-COUNTRY COLLABORATION20. Extcnt oJ collabomdon 2l- SuppoA b inter-eountry collabomtlon B Pate 4 4 5 t2 t2 I4 c D E t6 l6 l6 l7 l7 25 !9 l9)) 21 29 29 30 3r 3l ll J/ 37 H l.l ll 3i Annexes (ti) Map of the Programme area Organizational chart List of Donors as at l994lliste des Bailleurs de Fonds en 1994 OCP Fellowships . VCU plan of operations for 1998 VCU plan of operations for 1999-2002 . . . Sectors, Subsectors and Operational bases 1998 Sectors, Subsectors and Operational bases L999-2002 I 2 3 4 5 6 7 8 35 36 37 38 39 40 4t 42 ONCHOCERCIAS]S CONTROL PROCRAMN{E IN \\'EST AFRIC^ PLAN OF OPERATIONS FOR THE FtrrH FINANCIAL PIIASE: I998-2002 OIIE PH^SING-OUT PERIOD) A. E]CECUTIVE SUMMARY l.l Thc acrivities outlincd ln Part lltof thc present documcnt havc becn planncd with a vicw to sccoring thc succcssful cnd of Programmc opcrations by thc ycar 2002. l.Z The Phasingour Period (1998-2002) - fifth Financial Pha_sc - will be characterized by a conrinued wlthdrawal by OCP from field 'activiiies conilucfcd by the Participating Countries themsclves, cxccptin8 vcctor control which continucs as an OCP operation until the Programme corncs to an end. 1.3 During the Phasing-our Period the acrivities at OCP HQ, supportcd by Programme sta[[ in thc scctors znd subsectors. will focus on support to thc Participatrng Countries in their efforts to prcpsre for cffecrivc recrudcscence detection and con(rol. lntroduction 1.4 The significance of the Pharing-out Period il set forth in paragraphs 7.I to 7.5 stressing its crucial importancc for finally attaining the objectivc of thc Programme. 1.5 A summary of rhe conclusions and recommendations of the 1991 EAC Mrd-Term (Phase IV) Evaluation is givcn in paragraphs 9.1 to 9.15. Morc particularly, paragraphs 9.10 to 9.12 provide the justificarion for EAC'S recommendation to ccase OCP opcrations by thc yeu 2002 Ooerational forccasts Control 1.6 lt Is cxpcaed Orat aerial larvlcidine, which remainl thc responsibility of OCP (paragraph 10.2), will be confined to thc Errcnsion ucas with an rpprcciable reduction in coverage during 1998/1999 1ft31 which operations remain pr8ctically without change until Orc end of the h,ogramrne (paragraphs 10.5 and 10.6) Conscquent rcdudlon in tlrc cntomological surveillancr network in 1998 and 1999 with no funhcr changcs until 2002. 1.7 Post-control entomological cvalurtion curied out in drc Original Programme af,ca to obtain assurancr thu transmission has definitivcly ceascd u'ill not apply to the Extension sreas (paregnph 10.12). t Norc: Pen I of Ore document describcs Orc background, structure, operarions and achicvemcnts of OCP. lt is intendcd first and foremost for rcaders who are not familiar wirlr the Progrrmmc. 1 .L 1.8 Tcchnical support will be providcd to gror:nd lrrvicrding undcrtakcn locally for thc pur?osc of nuisancc control in areas wherc such nuisance has becn dcternrined ro impedc sociocconomic dcvelopment (paragraph 10. l3). 1.9 In applicuion of the cnlargcd mrndatc of the Ecological Group, national hydrobiological rcams will continuc studics of the cnvironmental effccrs of incrcaslng population prcssurc (paragraph 10.14). l.l0 Roserrch wlll bs llnrited to thc scrrch for lmprovcd formulations of B.r. H-14 (paragraph t0.15) rnd it ls planned to evcnturlly lncrcare Oe activities of thc BouakC lnscctlcide Rcseqrch Unit (tRU) to cncompass othcr public health tasks (paragraph 10.16). l.ll lvermectin control will continue simultaneously with larvJciding and ln the norrhcrnhalf of thc Westcrn Extension arca (paragraph l0.lt), cariied our by nrtionat teams supported financlally by OCP (paragraph 10.20). 1.12 Emphrsit will be given to communiry sclf-trearmenr and OCP will conrrnue ir collaboration wih N@s (paragraph t0.19); rhe Programmc rvill procurc ivcrmccrin from thc manrfacurrcr on bchalf of thc OCP countrics (puagraph 10.21) l.13 Foldemloloslcnl cvaluation. conflned to the Extcnsion arcas end carrled out exclusivcty by nu.lonal teams, will reccivc financial suppon from OCP (paragraph 10.23 and t0.2oi; coidemioloelcsl survcillance. carricd out in thc Original Programme area, will remain thc cntirc rcsponsibiliry of thc countries concerncd. opcratlonally and flnancialty (paragraph 10.25). l.l4 OCP will rctrin a small team of technicians to csrry our training and qualiry rcsring of nuional staff (puagraph 10.28). Other activities l - 15 Tralnins for post-OCP rctlvities will continuc (prragraph 10.30); rescarch wllt be rcduced to e minlmum (paraSrrph 10.31); and CSA will suppon socioeconomic development with FAO es lead sgcncy (puagrrph 10.32). Thc nhesinq-otrt orocess l.16 Efforu to PreParc the Partlcipalng Countries to undertate recrudesccnce dctecrion anrl control (dcvelullst Jrrtru trlcto) wlll contlnue (prragrrph I1.3) whilc rupport ro nationat hcatrh rystcnu dcvclopment ro cnable -ahrorption' of onchocercal epldemioloticat surreiltance and corurol (dovolution srrLru lato).ttlls oursidc oCp'r mrndate (puagraph li.ol, l-17 OCP will lct Es a llnk betwccn WHO/AFRO and the Paniciparing Counrrlcs in rcspccr ro cnsuring lntcgratlon of devolution.(crtr'u grlcto rctiviri6 wirhin comprchensivc heatrh serriccs, through iu 'inrcgrrlion' secrion paid for by AFRO (paragraphs I1.5 to I1.7). l.lt Another function will bc suPpo( !o community enromotogicat monitoring based on collcctlon of bhckfllcs to bc scnt ln batches for DNA probing to dctermine abscnce or prctence of infcctivc flicr for Ore purpose of dctcctln3 possiblc insuncer of rccurring onchocerciaslr tnnsmission (puagraph I l. I l). -) Minagcnrent of ohasins'otrt l.t9 Nationri Onchoccrciasir Coordinators will continue to play a crucial rolc in devolution and constitu6 natlonal foci for thc phasing-out Proess (paragraph 12.2). l.2O OCP opcrations and communications nctworkr will be gradually turncd over to gowfruncnts ar Protrrmmg rcrivitics come o an cnd (puagraph 12.4). Such transfcr will follow ccruin approvgd guidlng principlil (paragraphr 12.5 to l2.t)' Besourcc reouircments and budcetarv forecasts for I9aE ' "002 l.2l The rcsource rcquircmentl and budgcr cstlmatcs arc spccified by activitics in paragraphs l3.l to l3.tO rnd rummarizcd in purgraphr l3.ll and 13.11, ir bcing cxpectcd that opcrations during thc Phasingout Period might bc conducted ai a'total cost of apprQximately US $ 67 million. Risks and safcsuards l,Z2 Thc Plan of Opcruionr identifics ccrtain circurnscribed areas whcre cpidemiological dcvelopments src 'bciind schcdulc'. at thc samc time prescribing correctivc action to overcomc tlrc probtcmi so as !o ensurc succcssfultcrmination of thc hogramme (paragraphs 14.2 to 14.5). rl 1.23 Panicular mcntion is made of Sicrra lronc givcn Oc lpccific naturc of the operational problems cncounered ln that country (paragraphs 14.7 to l4'14). 1.24 Menrion is rlso madc of thc risk of rcsistancc dcvelopping to ivermcctin (paragraphs 15.l ro 15.7) es urcll as o the nccd for continued ftnanclal rupport to tlris last Phasc of thc Prograrnmc (paragraphr t6.l to 15.5). Bcnefits 1.25 A listof the tcquired end expccted health, social and economic bcncfits/impact of OCP opcrerions is given in paragraphs l7.l t,o 19.4. Port-OCP intercountrv collaboration 1.26 Following thc delibcrrtions rt thc 1994 Joint Progrilnme Commitrce. thc role of OCP in dcvolution,wrs clrritied as being confrncd to support to Participating Countrics to dcvelop cffcctive rccrudesccncc detcction and control (dcvolution s?Nu strie.o). l-27 OCP should not be concerned with multidisease zurveillance and control (MSC) activities as a framework for onchocerciasis recrudescence detection and control or support to MSC within the context of post-OCP inter-country collaboration (devolution sensu lato). 1.28 ' Such intcr-country collabomrion should reccivc suppon and assisunce from WHO/AFRO end ottrcr incrgorcrnrnental organizationr such rs dre World Bank intercste{, in hpalttr dcvctopmcnt es urclt es bilatent agcncics (paragmphs 21.4 and 21.5). Thcrcfore.iffietd to crcarc a ncw structurc such rs rn 'lnter'Country Facility' (prragraph 21.4). L.79 Tho sug3esdon is mrde that thc group of OCP National CoorClnanrs be rctarned to suppon posr-OCP lntcrcountry collaboration (paragraph 21.6) and Orat a nuclcus of OCP dcvotution strff mlght continuc working with the coordinarcr troup (parrgraph Zl.7) -4 ., PART I' (the prst) B. BACKGROUND 2. Onchoccrclasis, As utnsmission and coulrol Thc dlsease. i(s manlfestailons and rencrcussions 2.1 Onchoccrcirsis ls caused by r parasirc, Onchocerca wlwluc, of which rhc adutt femate mrcrotilrrlr (4G-{5 cm long) lodgos in nodulcr under tie human rlln wherc during ls tlferimc,, rvcrsSint 12 years, it produces rnilllons of cmbryos (microfilarlae). about 0.3 mm in length. Tho microfrluiae live for tome Nro yeus durlng which rimc rhcy movc around rhe human body, rcachihg rlrc the cyc; thcy are 0tc actuat agen$ of onchoccrcat manifcstations. 2.2 The manifcsrations of thc disqse comprirc visual impalrnrent, lncluding blindness; intenstly iiciiry rrsher end dcpigmcntetion of rho rkin; lymphadcnirls: .nd gun.r.t dcbilitation. 2.3 The colloquld nrmc 'rivcr btindners' dcnotq borh the cndcmic locatlon urd Oc most scrious meniferndon of dre dlscasc. Mlcrofilarirc arc trrnsmincd from onc pcrson to rnohcr by orc blackfly, bclonglng in Afrlca o the Slnullum domo.rran spcclcs complir, whlch .Uouio ncar the rivers. l, dlstinctlon is madc bctwccn the scverc bllnding form of the disease in 6re sEvann arcas end thc 'forest' type which hrs onty llmited ocutar manlfertstlonr. 2.4 , Fcnilc rivels;t arcas arc thercfore oftcn dcscned through fear of the diseasc so thar onchoccrciasir, in rddition to bcing r major public heath problcm, constitutes a lerious obstactc to sociocconomlc dcvclopmcnt. 2.5 ' Bleclcfly tarvac marure in fasr-flowing rlvers: 0rc rimc from taying the cggs.ro rhe adutrs cmcrge verics ftom cighr to twclvc dayr. Blackfllcs live folp to iori wecki'and can cover scvcral hundrcd kilontetrcs in fllght. A few of the mlcrofilarlac ingcsted during a bloodmcal(rrcccssary for thc maturation of the blackfly'r cggs) from rn infcc-rcd person develop in rhe ve€tor into infective larvae (Ll) before transforming in the pcrson nerr birr.n inro adul mates and femdc u/ornrs (macrofi larlac,). 2.6 Thc rlmc bcttrrccn the cntry of L3 larvre and hc rppcarancc of onchoccrcat symproms(lnorbatlon pcrlod) vrri$ ber*tcn onc ud thrcc yern. Ttrc-tcverly of he dlserse urd rhe rlskof oculs mrnifcsutlont corrclttc with rhc locel prcvrtcnco of onchlcerciasls but morc ro wirhthc inansity of infection rs well rs rhe dcnsity oi urc blackfly popularlon. Control 2.7 Trclmcm by dierhylcarbamuiru (DEC) which kltls mlcrofilarirc (microfilericide) rndturtmin' r mecrofilrlcidc (kills rhc rdult worm), ncccslutc mcdicrt rup"rrtrion gir.n th.scrbur rldecffcqs. urd ir rhercforc unsuiubte for trrgc-rcrlc rpplicarion. Put I is first rnd forernost intendcd for rcrdcr who rre nor lrmlliu wirh the hisrory, organizrtion, opcrrtioru rnd rchlcverncntl of thr progrrmme 2.g On the other hand. ivermecrin (l',tcctizan r Merck & Co.) a nricrofilartcide a''ailable for humanuearment lincc 1988. has provcd iuelf to bc a valuablc therapeutic a8,en(, easily dispenscd under ficld condirionl but wirhout the originally hoped for dccisive impact on transmission although morc reccnt experience seems to indicate a limitcd reductron of onchocercal transmission by largc.scrlc ivermccrin distribution. The drug, given oncc a yeu in tablet form, rcduccs the microfilarial loed to practically nil wirhin a month or so, afGr which thc load gradually increascs rc hrtf of the prc-reatmcnt tcvct aftcr thc first l2 monhs. lvcrmectin Oterefore nceds to bc given regularly ovcr ur cxtcndcd pcriod. The benefits ln terms of rclief from skin manifestations and prcvcnrion of eye lesions are impressive. 2.g Inremlption of transnrission lr obtaincd by dispcnsing inscaicidcs to kill thc blackfly tarvac zr rheir brecding sires in fast-flowing rivers. Aerial larviciding. the principal means oI OCP conrol. is now bcing combincd with communily-v7ids-ivermcctin disuibution within the kogrunmc 1.ce to rccurc the imrncdlasc bcncfits of Orc drug. Alro,-adding ivermectin distriburion rc larviciding reduccs ttrc total period of control from l4 to [2 yerrs as e rerult of rtrc drug's limired reducrion of transmission rcfcrrcd to tn the preccding paragraph (sec also para. 3.2t below). Gcoqranhical distribution of onchocerciasis 2.t0 Onchoccrciaris is prcvalcnt in tropicd Africa, Ycmen and pan of l-arin Amcrica wi0t en csrimercd 30 to 35 mitlion pcoplc infeaed by O. wlvuftts. Bcfore the start of OCP opcrations in 1974 West Africrn countrics urcre the most seriously rfflictcd with up to 60% of 0re poputaion infecrcd wtrilc in cc(rin villages one-tcnth of thc adults w?re blinded by thc diseasc. 3. l7l.c Oachoccrclasit Control Prcgmmmc ln Wcst Africo Preoarations 3.1 A joinr US.ilDI/OCCGBAI/HO TcchnicrlMcering on thc Feasibility of Onchocerciasis Control hetd in July 1958 in T\.rnir, Tunlsia, rccommcnded that e luge-scrlc control Prograrnmc based on ransmission control rhrough aerial larvlciding bc implenrcnted in West Africa given the pgticularly scrious situation prcvailing in that rrca: rrcre than gne million pcoplc suffcring from thc discasc of wtrom l0O 000 presented scrious cyc manifcstations-including 35 000 blindcd by thc discasc. 3.2 A Prep4rory Assisrance Mission o hc Governmcnts of the Participaring Counuies, co- sponrcrcd by UNDP, FAO. thc World Burk and WHO, then prepared a programrnc of. opcruions in thc ttycn counrrlesr locaed ln tlrc Original OCP rrca laying do,r'n 6r" control ttnuttC/, dcfining thc duntion of thc hogrammc .I twcnry years aM cstimating the resorcc requlrements. OCP opcratlonl comnrcnccd in t974 with WHO as thc Erecuting Agency whilc hc World Burk tssumcd rcsponsibillry for fund-raising rnd mutagcmcnt o[ thc Onchocerciasis FuOd. Agcncy for Imernrtiond Devclopmcnt of the United States of Amcricr OfgenisrtiOn dc Coordinrtion c( dc C@p0ratron pour Ia lutte @ntre les Grardes ErddnLies. , , Benln. Burkinr Frso, C0tc d'lvolrc, Ghanr. Mall. Nigcr and Togo -6- Prosramme area 3.3 ,.ft," e.ogrirnrmc lrca wu cncndcd in l9E6 to inctude also parts of Guinca, Guinea- Blssau; Sicrre lronc and Scncaal rs wcll .s Orc routhern pans of Bcnin, Togo and Ghana (map in Anncr l) incrcaslng Oc opcnrional arer to t 235 000. km:, wirh a total populatlon of 30 milliont. In Orc Ertcnslon arcar 2.2 to 2.4 mlllion pcople harboured the parasitc end 100 000 urcrc btind duc to onchocerciasls. The srcrl under control are 0rosc whcrc Orc 'savanna' blinding form of drc diseasc prcdominates. Prosrammc strucntrc ri3.4 : Thc overall ruthority for policy making. plannlng. progrrmmlng, lmplementation, linancing and cvaluUion of OCP opcrations ir vcltcd ln Orc Jolnt Progremrnc Cornmittee (JPC1 wbosc.rncmbcrship conlists of reprcreniatlves of'thc Participatin! Counries, the Donors and thc Sponsbring Agcncicr (UNDP, FAO, tlrc World Bank and Wt{O). JPC mecr once 3 year. 3.5 Thc indcpendcnt Expcn Advisory Comnrirtee (EAC), made up of not more than 12 scicntists,,csrrics out annual esscssnrcnl of OCP operations rnd provides achnlcal and scicntific rdvicc to JPC and to the Progranrme Director. A sub-committcc of EAC, thc tive-membcr EcoloEical Grgup, monitors thc cffect of larviciding on thc aqustic environmenr. Its Terms of Refcrcncc havc reccntly becn cnlargcd to cover studics of thc rivcrs in respeo o cnvironmcnrat dcgrrdation duc to chuSes in land usc as r result of increiscd population prcssure following rescnlenrcu ln areas frecd from 0re threu of onchoccrciasis. 3.6 Reprcscnurliws of UNDP. FAO, thc World Burk and WHO constirute the Commitree of Sponsoring Agocies (CSA) which mects three or four timcs a ycar ro moniror Programme oPcrilioilI, consider mrnrgemcnt lssucs and rcvlcw documenmtion for JPC. CSn can proyisionslly ruthorize supplcrnenury budgers and approvc transfer bcawccn budger lines. The Commiuec alrc supports dcvolution cfforts and sociocconomic dcvelopment of fie oncho- controllcd arcas. 3.7 Sincc r rccint rcorganizatlon rt OCP hcadqu.rtcrr in Oragrdoutou. Burkina Faso, lhe Progremmc stnrcalrc now comprlscr thrcc tcchnicd rnd rdmlnistretlvc unlts derting with vector contfol, suppon to devolurion (cpidcmioloiial cvrluarlon, lvcrmcctin Ec11mcnt, blostarlsticrl analyrir, oPerltionrl rcscerch,lrcatmcnt, tuppon to lntegrrtlon and trrlning) and admintstration urd suppon scrvicct (orgurlzetionelchrn in Anncr 2). Thc OCP/TDR Chemotlrerrpy Rcscuch(Macrolil) unlt rnd an OCP llalson offico uc locrtcd 8t WHO/HQ, rhc formcr to bc direstabllshed er rn OCP.fundcd project u from 199t. 3.8 ,, The Prograrnme ls firunccd by Donor countrics, lntcrnarionat development burks, mukilncrd instiurtlons lnd UN tgencics. Puriclpliry Counries mrkc suff rvrilable to OCp. proviUc oflca sprcc urd offcr ope-rrtional facilirici. flnanclal contributionr rrc dcposlcd in thc Onchocerciasis Fund whic:h ls rdmlnisurcd by thc World Bank. Plcdging of Donor contriburions ukes phcc during &c urnual scsslon of thc Jolnr Prognrnme Commirtec. A list of Ore currcnr Dooors can bc found in Anncx 3. F-xtcnsion into sourhern c6re d'lvoire ook ptacc atrcady in 19?9/1990 13.9 Medium-tcrm plans rnd budget forccasts arc laid down in sir-yearr Plans of Operations corresponding to 'Finencial Phascs' cach covcred by an Onchoccrciasil Fund Agrecment signed by rtrc 'Conributing Panics'. which constitu(er thc legal basis for the funding and opcrations of thc Progremme. A Mcmorandum of Agreemcnt, describing thc institutional and operational rrnngcmenu of OCP and signcd by WHO and cach of thc Puticipating Countrics forms part of Orc Oncioccrciasls Fund Agrccmcnt. Programme obiective 3.10 'To eJiminatc onchoccrcirsir as a discasc of public hcalth imponancc and as an obstaclc to sociocconomic devclopnrcnt throughout the OCP area and for the Participating Countries to maintain dris achievcrncnr'. Proeramme operarions 3.ll Acrid opcfiuions arc carried out by a fleet of hclicopters (in 1997 up to 12) rvailablc on commerciel contracl Wcckly flight ptans urd dosagc schcdulcs for larvicidcs are worked out on thc bryis of cmomologial urd hydrological datl, collecrcd by the Programme-wide cntomological rurrclllenca ncturorkr shici are communicrtcd to thc opcratlonal baser by means of Orc OCP radio rystcm rnd rehycd to pllotl by means of instant ground-to-air communicarion. Recently. a compucrizcd rivcr discharge forccasting sysrcm has bcen put into opcration allowing for Ore nost cost<ffccrive sclcction of larvicides taking into account their carry, purchase and tr.nsportrion cost es well es thc potential for rcsistance dcvelopping. 3.12 Thc survcilhncc nctwork consiss of scaors rnd rub-scctors manned by cntomologisrs. laborrtory rcdtnicjrns, vector collcctors, radio operarors rnd drivers. Hydrological conditlons(uaer hvcl end disclrargc ratcs) arc monitorcd et 200 ttations, half of which make usc o[ eutomatic dcvices in rivcrs and telcransmit thc dara via satcllite to thc opcrational centres. By t997 the nctwork will consritutc 5 scctorr. 7 sub-sectors rnd l2 opcrarional'bases locarcd in rhe Wcscra Frtcosion rrca- 3.13 Sincc 19$/t9 whcn larviciding bccame a pcrmancnt fearure in tlre Extension arcas, rhe hogrrrn no rret btr. for thc purpose of vcctor control, bcen divldcd ino the Eastcrn Opcrarional Arcr (EOA) wldr opcrnionrl hcrdqulrtcrs in Krn, Togo, rnd thc Wesrcrn Opcnrionat Arer (WOA) widr heedqurrtcri in Bamalo, Mali. Thc acrid bases ore located in Kara and Odienn6, Cotc d'Ivoirc. Thc OCP ccnuc for tcstin3 of larvicidinS (thc Insccticidc Rescarctr Unit (tRU)) ir locrtod in BourkI, C6tc d'lvoirc. Routinc monhoring of larvel susccptibiliry to larvicidcs in currerrt uro ir crrrird out wirh thc eid of ficld tc.rnt locrtcd ln Karr. Bouak6, Odienn€ and Btmeto. Ncrv insccicidc fiormuladons rre tcstcd u a ficld statlon in Soubrc on thc SassaMre river in COtc d'lvtire. Thc lcngth of river under vector control varies bctwecn 2 000 km during thc dry tc8,son snd l0 000 km u thc height of thc reiny scrson. Tbc prscnr Plur of Operrtions for Oc Phasingout Perrod covers live ycars only -6 3.14 OCP bcnefits from tlrc advice of $e Ecological Group and the suppon of 'd Programmc- wide rrcrwork of rquuic monitoring stalions in is cfforu to ensure tlrat Oc cffcct of lrrviciding on rhc non-Le,rgst fu:nr rcmrins insignificurt. Thc OCP hydrobiological servicc monitors invcncbrues at t sitcs u,hilc 6 otherr ue monitorcd by nationrl rcams which also survcy fish populuionr ar l0 stetions. 3.15 Vcstor control ln thc Orilinrl OCP arca rcsultcd in prrctically complete interruption of trensmls;ion es rhown by thc valuo of thc Annurl Bitlng Rrtc (ABR)| and rhe Annual Transmission Potentid (ATP)'. Sincc larvlciding ccascd tn rhc mrjor psrt of Orrr arca afrcr l4 yc:rs of control, spccld cfforts havc bccn made to demonsrarc 0rat transmission no longcr occurs wi$rin Orst rc1 Blackflics uc 0rus collccted for disscction at predctermincd sltes during nro yeer following thc ccrutlon of vcctor control. Thc rerults hrve bccn entlrcly satisfactory insofu er ln only I fcw riur dld this post-control survcillance dcmonsuste infccrive blackflies ebovc Orc threshold bvelt ncccssiuring rimc-llmited rcsumprlon of lervicidiig. 3.16 ln thc Extcnsion Ereas. rnd in hose circumrcribcd zoncs wlthln the Original arer stiil undcr cgntrol, the rddltion of ivcrmcctin distribution ro larviciding has accclcrarcd rhe decrcesc in morbidiry rates and resultcd in an earlier prcvcnrion of ocular manifestations Oan Orat obtaincd by veaor controlalonc. Dcvolution 3.17 Thc conceot^ nature and imolications of devolution, - cssenrial for attaining thc sccond Pul +f thc Progrtmmc objectivc - hrve becn clrrified fotlowlng rhc rdvcnt of lvermcctin. Concc'pnrally, devolution should bc secn as nulonal malntcnancc of OCP achievcments through actlwcpiderniologicsl survcillancc aiming at carly detection of foci of infcction/discase,.and the tirncly conrol of such infection by lvcrmectin treatment ro rs to prcvent recrudesccnce. 3-18 ln ordcrto clarify the roles and rcsponsibiliries of rhc dlffcrcnt p:mnerr involved in Orc dcvoludon PKrccst e dlsrinalon ls mrde bctwccn dcvoturion s?Nu srlcto rnd dcvolution scar!lato- Thc formcr conlists of identifying, claboiating, rnd trrinlng in orc mcrhodology(recnrdcsccncc detcctlon and control) as ncll rs cnsuring rhar such merhodology Uc duty arr-d effcctivcly incorporled into comprchcnsive hcelth sysrcms. Devotution being a narionat pro..rs, thc ulttmac responrlbility rots wirh hc hcrlth authoritier conccrncd, promor"d and rechnlcalty supported by Orc Programrnc. Thc numbcr of blrckfly bites I person would rccclve if bc or rho wcre ro rir rr thc rivcr brnl for l l horru I dry, 365 days r yerr. Thc totcnbillry level ls rct rr ur ABR of 1000 r critcrioa ro be rppliod ln rssocirrion whh Orc below ATp limit. , Thc numbcr of infccrlvc trrvrc (L3) which mlght hrvc bccn rransmlucd ro the pcrson uttdct t thovc hy tbc birlng flles. Thc lcvcl of tolenbiliry hrs bccn ser u m arp oi roo correpondint to thc limit helow whictr thc risk of contrriting serlous onchoccrcat ocutar lcsioar ir rcrnotc. Onc lnfcstive blrckfly pcr 1000 prrout fcmrlc bhckflies.t 93.19 Dcvotulion Jrrlrl/ loto, on the other hand is seen as thc process whereby national hcalth aurhoriticr dcvctop epi-d.emlological surveillancc and contro[ sys(ems ,o 2 l6vcl allowing for the lnrcgratlon ln ruch tysrcmr. on a suitainable basis. of effcctive onchoccrciasi! recrudescence detccrion and control. tnsofar rs ruch developmcnt lr part olthe strenSthcninS o[overall hcalth systcnu any suppon rcquired should bc providcd by WHO/AFRO. thc World Brnk and other irucrnafomt urd bilareral organlzations. The role of OCP through its devolutlon unit could bc o rtinnrlarc srch imegralon urd make availablc wtren rrccessary and if Potsible its lnfrastructure and krow-honr to hclp accclctine thc wholc Proclss. 3.20 All cleven Participadng Countries have preparcd devolution plans and thc process il undcr implerrr^rrion et vrious srsget in thc majoriry of the countriet. otrtsidc financial suPPort provided by Orc World Bank and other natlonat/bilatcrel ortmizations hu bcen Suuantccd in one crse WHGAFRO etso provides frnanciat lupport for the implementation of cenrin actlvities of thc devotution ptrns of somc countricl- National Dcvolution Coordlnators have bccn rppointd iu ell thc hrticipuing Countriet. 3.21 Thc OCP-financed fcltowship programme is now almost entirety orlentcd to thc training of nmioruts in dcvolurion lcliviries wi0r emphasis on such disciplincs as cpidcmiology and hcalth rcnrices rneDagemcnt (for dcails see Anncx 4). 3-22 Eoidemiotosical cvahtation, an inrpor[ant component of devolution, rclies on repeated cxaminerion of indistor villages consirting of .simple evaluations' (search for microfilariac in rkin-snipl and visual tcsring) and 'detaited evaluations' (ophthalmological examination added). Mon of rhis nork is now carricd out by OCP-trained narional rcarnr financially SuPPortcd by thc hogramme- The dan obrained from thc evaluations in indicator villages allow for thc compuution of thc incidencc. prcvalence and community load of infection. Thcse indices. which con3tiorc the clenrcntt for trend anelysis and tsrctimcnt of the impact of vector control have rzken oo edded importancc in thc Orlginal Programmc rrce where they are used to determine u,herc rnd wtren onchoccrciasis has reached the levcl below rvhich larviciding can cease. 3.23 Ar skin-mipping mcets wirh lncreasing rcsistancc unong tlrc populations crarnined (no pcrccived bcnefitr of submintng{@-snipping and fear of transmission of hepatitis and AIDS) and . has lirnircd senshiriry in lo.,-tevel infection situadons, the search for ahernative diagnostic rncrhods uc bcing intensified. Field rcstin3 of a ui-cocktail antigcn of potcntial usc for immunodirgnosis ir under way. Alrc, e roplcd DEC (skin) test and DNA scratch test capable of dercaing onctroccrcel infecrion rre being evaluated for thcir posslble usc by thc Programme. 3.24 Thc capabltity of the OCP laboratory in Bouak6 (lRU) to rpply Oc DNA methodology to teparerc thc fores (lcss scvcre) from the savanna Olinding) O. volvulus pansite and from thc .-rle preshc (O- ochcaX,il has helped vecor control to focus on those areas where ondroccrciesir giws rise o lerious eye manifestations. 3.25 Ivcrrncctio dinribution ls rpplicd in rll rreas under vector control in thc two Ertcnsion lreu. Thc drug ir dro distrlbuted in thc uppcr half of the Wcstern Extension lret 8s the sole rtrelnr of conrol Olannuat tnBatmcnt in cenain foci) rnd in r few circumlcribed zones within thc Orlgirul hogremnrc rrcr" Thc rcsultt rre encoun8ing u demonstrated in 0rc Gembir basin (twie.yearly trearrrrent) wtrcre no new infections havc occurred crpccirlly rmon8 children below 5 ycars ofege- - t0- 3.26 L:rge-scalc distribution of ivermcctin has for sevcral years bccn entirely narional with logistical and (rnancial support from OCP, whilc the community self-trcatmcnr approach has expandcd in most of the Prograntme area. ln all. ovcr two milllon people were under trca(mcnt during 1994 wi0r an avcrag,c covcraS,c of 70 pcrccnt rnd a compliance rtte of morc than 80%. 1.27 The section of the OCP'dcvolution unit conccrned with biosruisrical and informarion Iystems givcs suppon ln thc antlysis of opcrationrl data and in rhe plurnint and evatuarion of field surdics: providcs Gchnicrl brckstopping for the OCP computerizcd information systcm: and rrains hograrnme suff in its usc. Thc computcr nenvork coyers OCP hcadquaners and all opcruional statlons. 3.28 A mrjor rchicvcment has bccn 0re consrruction of I computcrizcd transmlsrion modct, ONCHOSIM wtrlch is crpable of producln3 cpldcmtologlcal forccrsts undcr vrrying control sccnrrios. Modcl rlmulatlons hrve thus shown thrt t4-yeirr of trrvlciding il-rcquircd o climinatc thc human rcscrvoir of thc onchocctcrl pararitc but rtrat thc durrtlon of veaor conrol can bc redued by rwo yeus if larviciding is combincd with lvcrmectin distribution given rhe now rccognizcd, ekhough limircd. control of trusmlssion by the drug. 3.2g As rcgards rccrudcsccncc. computcr iimutations havc led to rhe conclusion that afrer 14 years of succcssful larviciding (unaccompanicd by lvcrmccrin conrrol). the risk'of rcappearancc 9f t" diserse ir rlmost nil i.c. lcls Orn I t6. Howevcr if conrrol ls reduccd ro li'ycus oflarviciding only. the Community Microfilarlrl Lord (CMFL) wilt rcrch bctwcen S% anit l0% of thc prc-control value within 15 years rnd l00t of thar valuc afrer about anorhcr 15 ycus. Thc modcl prediuions olso suggests thrt u rnnuat lncidcncc of morc rhan 1.0% ro 1.5 1, among adults berwccn surveys cvery thrce yerrr woutd resutt in recrudesccnce. The modet furthei ,prcdicts thet ruch an occurrcncc o[ rccrudcsccncc, lf dctectcd carty, coutd bc controltcd wirh annusl ivermcctin trearmcnr givcn for u lcast l5 yearl. Manaiement 3.30 Thc ovcralldircction of OCP. inctuding inrplemcntarion of gcncralpolicy and programme Iruna8clllcnt, ls cntrustcd to thc Dircctor's Officc. Chief, Adminiltration rnd buppon Scrviccs, is on hls ride rcsponsible for budgct and finuce ma[ers. personnct. cquipmeni and supplics, Irsnspon end co mmunications. 3.31 To obain 0re bcst possiblc cosUefficicncy rrrio of Pro3rammc operulons, a clore watch is kcpt on dl activitics at alt lcvcls to ensuro ttrc grcatest bencfir ar tirc towcsi cost. In 6ris conncctiort. continuing tralning imbues opcration.l rnd rdministrativc staff with a high degrec o f cost-consciousncll. 3.32 In prcparation for Participating Countrier to rsrumc responsibility for maintainlng rhe achicvemcrur of OCP whcn Programmc operations comc to an.ni, Orc majtriry of rlre ,"r.lr,lng Programmc ruff is now in nationd employment rssigncd 19 OCp durts. Thus. 552 sraff mcmbcr arc cmploycd nationally rgainst 190 on wHo/ocp coarlct. ll Rcscarch 3.33 Thc OCP rcscarch prograrnmc has always aimcd at cnhancing thc quality of operations rnd their cosr-cffcctivcrrss in line with the rccommendationr made by Orc Expcrt Advisory Commirtcc. Thc rescarch priorities focur on rix major opcrarional issues: vector cont.rol(Sltailiua bionomics and lrrvicides); identification of parasitc strains; diagnostic rcsting: drcrnoberapy (scarch for t macrofilaricrde, cffecr of ivermcctin on transmirsion (alone or in combinadon with vcctor control)); and modclling. 3.34 An cramplc of thc opcr.tional impacr of rescarch and ficld invcstigation is rhe contlnuing rcrrci for ncw insecricidcl applicablc in thc OCP vccror conrrol protramme and rhc cffons madc to improvc formulations of larvicides already in usc. Thc Programmc surted off with only orrc insccticidc, cmephos, to which resittrncc-dcveloped aftcr scveral ycars of opcradon. Additional produas to bc uicd in rotation ircri rherefore n"ccsr.ry rc as ro overcome thc risk of lourercd rensitivity in 0re larval populetion. Thc scarch, carricd out in the tield by thc Bou*C lnscaicidc Unlt har rcsultcd ln sevenl insccticides now being avaitable which has virtully climinarcd thc problcm of rcsirtancc in reccnt ycars. Conscqucntly. thc rearch for ncw insccttcides has come to rn end end thc rcscarch focuses on the improvemcnt of Bacitlus thwinI,ictrsis H.-14 (&r. H-14) formulations (see also parrgraph 9.8). 3.35 By ttrc cnd of 1997 rhe joinr OCP/TDRr-flnaned Maoofil projecr wilt comc to an cnd with thc crpcctation $at TDR will continuc financing Macrofil rcsearch aiming at making evailablc a ficld-applicrble macrofilaricide for usc ln onchoccrciasis/lymphatic lilariasil conrrol. Suooon to sociocconomic develonment 3.36 OCP taivitics in this licld have bccn limiad ro the collecrion of data rcguired for rsrcssing thc impan of Progranune operEtions on rociocconomic dcvelopmcnt. The Comminec of Sponsoring Agcncies has becn charged by .the Joint Programrnc Committee to deal with Dsttcrs rclaing to sociocconomic devclopmcnt in oncho-frced zones. 3.37 As r first rtcp, CSA sponsored a re3ional rrudy rc identify, wirhin arcas under OCp control, thc zorrcs with promising dcvclopment poantial; rnd to prepare fotlow-up rction. Thc second stcP wils e srudy of rcscnlcmcnt designcd to provide guidelines for promoting susrainrble, ruionel dcvclqpmc.t in oncho-conrolled zones. Thc rhird activity consisrcd of an in{epur enrlysir u the nrtional lcvcl !o constitutc the basis for thc formuletion of devclopment plans for cecl country't ondloccrciasis area. In Oc mc.ntimc. CSA has rponsorcd a pilot projecr on cnviroamenul imprcr asressrpnr in the oCP arcr funded by thc N.e0rerlands.r Eqlllus thuriagle.nsis H-l{. tcrncphos. phorim rnd pyrrclofos (organophosphorous compotrds), permalrin (r pyrethroid), crrbosulfen (r crrbemare) and ctofenpror (a psa.rdoayrahroid) WHOTNDPAYoTId Bank Special Progrrmme of R.eserrch end Training in Tropical Dise:ses , t hblishe! ln the World Bank Scries on Onchocercralis Conrrol -12- 3.38 More rccently, thc Committee organized a Ministcrial Meering on Sustainabie Settlcment "n61 psvelopmcnr of r}e Onchoccrciasis Con(rol Programme atca hcld rn Paris in April 199a. Thc mccting rcached s consensus on a set of policy guidclincs to bc rpplied st thc national levcl. Thcse guidelincs havc sincc been widcly disrributed. Milestones ln thc devclooment of thc'Programme 3.39 During rhc firsr Finrncirl Phrso (1974-1979) vcctor conrol, brscd cxclusivcly. on tcmephps, cxpandcd gradualty &roughout the seven-country Orlglnal Progremrhe arce with the result drat trensmislion was controlled in rwo thirds of that atca. Thc second Financial Phasc (198G,1985) was chrncterircd by contlnued larviclding, troubled by thc cnd of the Phase by such op€rarlontl problcmr $ rcinvaslon and circumscribed lnstanccs of resistance to orgenophosphorour compounds. Thcsc problems wcrc lcccntuttcd_ rt thc beginnlng of the third Finurcial Phasc (19861991) but successfully'ovcriome by lhc ortenllor of vcctor control to 0re rourccs of rclnvasion in 6e South-cast and ln the West and by lnstiruting a rotatlonal schcmc for rhc applicarion of thc fivc larvicidcs then rvrilable. Also, thc end of that Phasc saw thc advcnt of ivermcctin as an cffcctive mcrns of control of onchoccrcal murifestatlons. During Orc four0r Financld Phesc (1992-1997) vcctor control ceascd ln the Origlnal hogromme arca as thc OCP objcctlvc hrd becn met throughout $at arca. lrt the Ercnsion arcas larviciding was combincd with ivcrmectin trcrtment resuking in an early supprcsslon of clinical manifestations of the discas't and in a shonening of rhe larvlciding period requlicd to ellmlnatc the human puasire rescrvoir. 4. AchkvctacnE of thc Progtanmc 4.1 Onchoccrciasis ir no longer a problem of public hcalth imponance or an impedimcnr to rcciocconomic devclopmcnt within Orc Panicipating Countrles. The diseasc has pracricrlly disappcued ln thc scvcn-country Origlnal Programmc arcr whcrc vcctor control has ceased and thcrc is virturlly no risk of onchoccrcal bllndness in the Erlension areas where, howcver. larvicidlng nccds to bc contlnucd for uothcr few ycaps to eliminate rhc human pamsitc rcscrvoir givcn thc 'lstc start' of vector control in rhat arca. 4.2 Exprcsscd in figurcs, l0 nrlllion childrcn born within rhc OCP arca since rhc sran of OCP opcrationt hovc bccn sparcd the risk of onchocercal blindncss; morc than 30 million people arc prorccrcd from lnfcction by the discase; 250 000 hrvs Ssgn prevenrd from going btind; 1.5 mjllion hrw lost their onchocercal infcction: and 2.1 million hrvc rsccivcd ivcrmecrin treatmenr. 4.3 On Src socioeconomic sidc, 25 million hccurcs of fertile riverain land, previousty uninh$hcd'through fcar of lnfcctlon by rlrc discrsc, hrvc becn 'libcrated' for rescnlemcnt and rasumcd cultivrdon crpectcd to produco cnough food for l7 million peoplc annualty. 4.4. To mainuin Orc achlcvcments of thc Programme, rhc Paniciparing Countrics have instirutcd cffccrive onclroccrchsis rccrudcscencc dcrcction rnd control or ile in 0rc proccsr of prcparing, for such dcvolution 8ctiyitier. 5. Costs of Prcgmmnc opcmtioat 5.1 I Thc cosu of 0rc hogramrnc by Financial Phascr utd princlpet activirler are prcsenred in the followin3 ublc: - 13 - v'l re -\o -?E$ I t !? e.a nl( rr1 ({ -\o aiR -tR n!aci9 OEQ;= arRod r:*O-r 3 .q3 EE -& x .:, c.: cr :* =8 :a olao- ..: a \9. le ntt.i - r. tQOcr 9*Orr E 8? -& x o $.t <, a{ !. tRto ct -\o \0 l3 -! .o .{ fQ !q a- r:* c.:9 saf asR O f\t ateo- ? .r! BE -& xr, 9a -oa{ \o \o lR -rt cla c{lQ -l- c<!t 6F \g!t -i- :IQo- q* O t-r EE Ex()3 t $ _. yl Ei crr lt qIocj Is qrQ! :a 9ter,,l al Ia\a H lrBad,iif,B EO\ tt l- q!e O .tffi l\ 6* <i 'o qn t!t 1$ \o _=; trR *Oa 369(DE S3C:.aEfg!o o\ a t\lY or \oo qa ta- vrBjrr I -8cj r' ntt c': !e aEe 3eL,Fc oa 6€I := \o v-t qre O.{r+ r\ 9le t\l r/t rr lR oi! 9reo- n.lr-a y-r EI 3osc '.9 €c4o r. B= u o.! a ?l EII sl ol r.J IUI >t =.gb! o -Eo L_si '=a rii i E o {} .I 5 .EiXEEi c .9 a E 'd ts r= e l)(€ 2 -(cu -=l , .jJ rJclJ -c{ ..JLI1!l -da .dcl 4 .gb ar.= sE iJerdaCl -t d ol (J LlqJ clolJ clld v1CIu o s '6- -U o o ) o d.tr c o .9: J o l& -. 1) ! d 3 -{Oo v()trl:P: dqt-^rl eqOU E6 a ooC .!€'=E.: s ara. I - l4 - 6. Planning and cvaluarion 6.1 Thc basic srategy for OCP's activitics, ccntered on larviciding for the conrrol of uansmissioil. wES lald down by thc PAG Mirion rnd rcinforccd by thc adoption in l9E4 by JPC of a t4ng-Ternr Stratcgy (LTS) which outlined the opcrrtionr rcqulrcd to bring thc Programmc !o z sucoessfulend. Conrrol operations and their rcsource rcquircments are worked out in some detail in the sir-yeuly Plans of Opcrations and funher deoiled in Orc annual Programme Budgct documcnrs prcsented to Jrc for its approval. 6.2 Thc mein thrust of the LTS wrs trc erpanslon of OCP ac(ivities into the Soutlrern and Western Ertcnsion ercas intcnded borh to protcct 0tc populations in those arcas end to prcvent reinvasion of infcctlvc blackflies into Orc Original Progrrmme area. 6.3 A WHO Indcpcndent Conrmission on tht lon3+erm- pr6specrs of the Onchocerciasis Corrrol Programmc. set up in 1979. rccommcndcd lwer olia in itr l98l rcpon thar OCP opcralions bc gndually crtendcd rrrcrtwards (thc routhwerd Gxtenslon had tlrcady bcen approved h principle): tlrat funds bc provided to pharmaccullcal companics to scarch for a macrofitaricide; tha a transrnission/conrrol nrathemarical modcl bc claborated: 0rar devolution sran as from l99l: utd tha Ore Programme bc cvcntually transformed into an inrcrcountry discase surveiltancc rraining and sdvisory ccntre. 6.1 In 1985 the US-AID undenook an impact asscstmcnt,of thc Programme wirh a view atso to cxamining thc cxtcru to vhich OCP erpcriencc mighr be of use in planning futurc AID- supportcd Progrsmmct. The Agcncy concluded lhat '... tlrc OCP, to date, must be considcrcd onc of thc morc succcssful multi-donor programmcs in thc shorr hisrory of dcvelopmenr tssistancc.' 6.5 Thc AID Mission luggcstcd that lower-cost vcctor controt methodotogies. morc amcnable to dcvolution. should bc looked for; that national involvemcnt should be increascd wirh a view to full inrcgration of thc OCP vcrtical opcrotlons within thc narional hcalth dclivcry systems: that Orc scarch for chcmothcrapcutic agents bc continued; rhat rraining be rcinforced; rhat immunodiagnosit bc dcvelopcd; thrt tlrc Progrrmmi contlnue to addrcss socioeconomic issuer: rnd tru therc would be I nccd for an 'lnter-Counrry Frcility' u an OCp succcssor body. 6.6 In [990, an Extcrnal Revicw concludcd th8t rrsntmlssion had bccn vinurlty ctiminated in thc Ori3inal tcven-country OCP ucr; Oat major obsurclo of resistancc and reinrrrlon had bccl succcssfully oycrcomc: that therc hrd bcen rignlficurr achievcmenrs in lmproving larvicidlng tcchnology, in ccological monitorlng, ln cntomoloticat rescarch, in cpidemiologicaliurvcillurci 8nd ln trerlment of onchocerciasis; thrt there wu r necd for continued donor ruppon for ar leasr 14 ycan froin tho stert of lerviciding in ury givcn uer u wcll l,s r need for continucd support for dtc cffective lnstitutlonal arrangcmens, includint turonomy, fleribitiry and lnrcrnat checks and balanccs. 6.7 Thc Rcvicw furthcr concluded Oat thc succcrs of OCP coutd be arrriburcd to: clear objcoivc; rcalistic timcfrrmc; choice of best rvril$lc iccinototy; contraqint out of highly spccielhcd usks; priorlry Slvcn to opcratlonal rcrcarch; htgh degrcc of ruronom-y; dclcgatlon of authority: lon3-term commirmcnt of Donors and Panicipatlng Counrrics: rpecified mcdium.tcrm Sods in sk'ycer financial phnnlng cyclcs; transparcncy rnd free informarion flow amont cDnstirucnt bodies: rtront vcrtical manag,cmenr; and high qualky traft. - 15 , 5.E Thc report also strcssed thc nccd for strong support to dcvolutron. (a) rnstirutronal strengthening in rhe Paniciparing Countrics with special attention to training and management, (b) crarion of a Devolution Unit at Programmc headqurrterr and (c) dcvolution-orienred opcralional rcsearch as wcll as tlre nccd for conrinued search for a ficld-applicable macrolilrrlcide. Panlcular ancntion was paid to a rccommindation to prepare an intercountry faciliry to provide a framework for post-OCP intcrcountry collaborarion. The Review finally called for continued collaboration among CSR, Panicipating Countrics and Donors ro supporr socioeconomic dcvelopmcnt in onchocerciasis-frecd arcas. 6.9 The finding! and rccommcndations of the Expert Advisory Commrttee in its Mid-Term (Phasc IV) Prospectiye Evaluation rcpon arc sunrmarized in scoion 9 bclow. -t6- C. 7 PART II (phasing-out) INTRODUCTION Thc signlficaacc oJ thc Phasing-out Period From Orc inccption of OCP the duration of opcrations has bccn rimc-timitcd. tt was erpec.d rl that timc Orat thc Programmc would comc to an cnd by rhe year 1994. In 1974 it wzs anricipstcd Uat the human rcservoir of the pensirc would havc dicd out Olroughout Orc Original scvcn-country Programme aree aftcr 20 ycars of larviciding. 7.1 Ho'urevcr, vcctor control actually cemc ro an cnd tn rnost of .thc Original OCp arca rvcll bcforc 1994, the rceson being rhat opcrationil erpericncc."supportcd by computer simulatlons, hrd shorrn tiu the duration of vector control nccessary for achicving the aim of thc programrne could Dc rcduced from 20 to 14 ycars. 7.2 Mori reccntly, it has been dcntonstrared rhat rhe durarion of conrrol can be further rcduccd if larviciding is combincd with ivcrmcctin treatment. Thus, simultaneous vecror comrol/ivermectin dittribution during r l2-ycar period sufficcs ro bring Orc human puasitc rcservoir rc sn cpidcmiologically insignificanr lcyel (rcf. pangraph 9.1 t). 7.3 Insofar, thercfore, thrt larviciding combincd with lvermectin dlstribution started as tate es 1990 in penr of tho Ertcnsion areai, O-CP conrrol opcrarionr can only come to I completc hrttin thc ycar 2002 lf 0re lirst pan of rhe Programmc objective is ro bc mct i.e. 'to .timlnat, onchoccrciasis as t discasc of public hcalth importance and as an obsracte to sociocconomic dcvclopmcnr drroughout fte OCP area". 1.4 As rcgardl 3ttainint the sccond part of thc objccrive - ro cnsure rhat $re partrcipating Counuics "mainuin (the Programme's) rchievcments''- it can bc confidcntly assumcd tfrar ty theycar 2002 thc countricl conccrned, witlr thc support of OCP. WHO and orher interisred organl:rtions. will bc fully capablc of dercctin3 and controlling any instances of onchoccrcat recrudesccnce thu mitht occur. 7 -5 Conrrol oPctations durin3 thc phasing-out ycars will bc of crucial ilnportancc for rhc cvcnrual ourcornc of Src Programntc. The activities dcscribcd in thic documcnr have becnpluurcd urd programmcd by erpcricnced OCP staff with one considerarion in mind: to bring gre ProSremmc.to. tucccssfulend at the lcas cost and within rhe shortcst time. whcn ocp closes down in trc ycu 7CF,2 it must bc with thc conviction of atl conccrncd 6rrt 6re job has bcen well done rnd dra oc considcrablc investments oycr an exceptionatly long pcrioi havc bccn fullyjustifrcd. 8. fucpntba ol rtc Pbn ol Opcrations t.l ln responso to . rcqucst by thc Joint Progrtmme Commluee (JPc1 thrt thc programrncDirccor considcr thc possibillry of snrting the proccss of prepaiing the prcscnr ptan ofOperuionr onc yclr earlicr then had bccn oc cuc fbr thc prcprntion oiprcviJur plurs, ir wasdccidcd thu r dnfl would bc rubntitad to tFC rlrcady in Dcccmbcr 1995, Commenrr rnd suggcstionr madc by thu Committec would then bc reflecred ln a finrtproposat for conside.rion and cvcntual approvrl rr rhe 1996 JPC session. -t] 9 8.2 Thil timing will also pcrmit negorrattons on lhc ncrt Orrchoccrcrasrs Fund rlgrccmcn( to bc conduocd in 1997 on the basrs of an approved Plan of Operattons allowrng for the slSnature of the Agrecrrrcru by the end of rhar ycar bcJorc rt cnters rn(o forcc on I January 1998. On previousoccrsions.dreFundAgreementwassignedafcwmonthslftcrthccorrespondtngPlan of Operaions, approycd letc during the last ycar oIthe preccding Financial Phase. had alrcady bccomc opcretional- t.3 During 1995 and 1996 successive draf(s of the Plan of Opcrations will be scrutinized and commedcd on by tlre Committec of Sponsoring Agcncles (CSA) and the Expcn Advisory Committcc (EAC); rhcir commcnts and sutgcstlont will bc reflectcd, as appropriate, in the documcnL D. THE EAC MID.TER,M (PHASE l\r) PROSPECTIVE EVALUATION Coacluslons rcochcd fu EAC regording Progmmmc opcrations durlng thc 1995'2002 , perlod and arnsponding budgeary lorccatts 9.1 In Deccmbcr 1994 rhc Joint Programme Committec approved the findings and recomrncndarions conuined in thc report of the Expcrt Advisory Conrmiuec o0 thc Mid'Tcrm (Phasc IV) Prospectivc Evrtuation wirh the undersanding that TDR would continue Macrofil rcserdr bcyond 1997 and Oru WHO/AFRO would snrdy the possibilities of institutional arrt lgerrcms for post€CP intercountry collaboration. 9.2 Aftcr exprcssing its entire satisfaction wirh the performurcc. Progress and achicvcments of thc hogfrmme EAC stressed that current controt stratcgies rhould rcmain valid for future openrbos end made rhe foltowing opcrationat rnd budgetary forecasts for the latter half of tre Founh Finencid Phasc and for the Phasing-out Pcriod. Laner half of the founh Financial Phase 9.3 As regardr rhe 1995.199? period, rhc Committee cndorsed the corresponding Plan of Opcrations ro u,triclr it added lr.'.fetryspecific recommcndations. EAC rhus suggestcd that tie sarch for additionat larvicides was no longer an OCP prioriry conccrn as sevcn oPerational inscalci&s 'werc now availablc: that Ore Terms of Reference of thc Ecological Group be crpand€d to cncompass widcr environmental issucr; that OCP financial rnd logistics 3uPp.ort to large-scrle iverrre-crin distriburion would cease in 1997t: that epidemiological cvalurrion/survcillancc become an crclusively natlonat re3ponsibility as from l99tt; thrt Ge OCP financid connibution to Mrcrofil ccasc by the end of 1997: and that dre OCP BoualC laboratory cwnudly cover referencc dlrgnostics of other tropical infections. vcctor/parasite uxonomy idcraification. drug resistance, end routinc drug assays. - 9.a ln respecr to devolurion. tre Expert Advisory Committce rciteratcd the imponance of rccnrdcsccncc deEcrlon and controt bcing firmty anchored in effcqive comprehcnsive epiderniologicet survcillancc and control systems. ln this conncction. the Committee stressed dte ncod for enhrncing heatth systems devclopmenl in the Panicipating Countrles and the loint ko3rmnrc Commituc decided u lrs Deccmbcr 1994 session that any ouridc suPPort in rhis respect to c-osunc succcssful devotutlon, devolution san-su laro, fell ouuide OCP's mandatc whlch wtr resrrlocd to cnsuring that the Puticlpatlng Countrles werc fully capable of effective detection of onchoccrci"sis recrudesccncc and its control i e. devolution scruu stricto. :$"' IlptE: EAC.l6/Jrc.15 wlll be requested to reconsider these recommcndalronsI - t8 - 9 5 EAC fur thermore drew up a lrst of cri(erre and condl(ions lor succcssful and sustarnlblc der'6lg11on including tesourcc availability;'--integrarron; communiry parlicrp3tron; cornpe(enr staff. sltisfactory epidemiological surverllance systems; effccttve ivernrectin disrribution: collaboratron snd dau cxchargc with otJrcr counrries; and rcgular internal evstuation. 9.6 ln thc ficld of biostatistics and information systcms the Comrnittee'undertined rhe crucial role played by ONCHOSItT{ prcdictions, and rhe comptiance of epidemiologlcal trcnds rhcrewirh. in dccision-meling rcgarding cessation of larviciding. 9-7 Also, ONCHOSIM simulations would continue ro help in predicting rhe impacr of combined vcclor control and ivermectin distriburion on the duraiion of larviciding; the possibte macrofiluicidal cffect of high-dose ivermectin on the fccundfuy of Orc paralhci and thc requircmcnLs for dre cvenruat controt of any rccrudescencc that mighr occur. 9,8 The Committee considered r}at most of rhe Programme'rresearch activities had bccn complcted. I{owever. several studies uould srilt be required ln such fields as DNA probes to idcntify Ore remaining species of the Simulium domnosum comptcr; testint of recombinanr srrains o[^Bactlltt-c thurlniientrr H-14 and ncw Bocillus strains; diagnosric mcrhodologics; acccptabiliry of rcpeated testing: tinrc interval bctween cpidemiological sirreyr; and ivcrmectin dclivery. 9'9 EAC wrs srtisfied thar rhc proposed acrlvirlca forrhe 1995-1997 perlod could bc fundedwioin thc budger cslimates originally'set our for Orar period in rhe ptan of Opcrarions for rhefounh Finencial phasc. The Phnsine-out Period 9-10 In rccommcnding the year 2002 rs thc cnd of all OCP operarions. EAC focussed on Oe time srill requircd to bring onchocerciasis to an epidcmiologically insigni[rcant levcl in rhose pans of the kogrammc aret whcre this had nor yet been achicved, 9- l I The Commincc thcn took in cognizance reccnr conclusions. based on ONC11OSIM simularions, that combincd hlgh gualiry vector conrrot and efficlent ivermccrin distrlbution (60* coverage) luting l2 ycars seemed sufficient to bring rhe risk of rccrudescencc to lcss rhur l%. 9. 12 . Insofar as pan of the Western Exrension area came under concomitanr larviciding/ivermectin treatment as tatc as 1990/91, the Commirrec rccommended. ur(,JpC oncurtod, thrr Progremmc opcrerions should continue until fic year 2002 rhhough in'vcry limitcd rrcrs during rhe tast year. The two-year post-conrrol cntomologicat rurvelilancc applicd to the Orlginal OCP rrea would not bc lmptemented in 0re Ertenslon irrear. 9.13 EAC strcssed that if OCP ccased operEtions bcforc thc year zWZ, 'transmission would r:sume locrlly in he southcrn pan of the Wesrcrn Extension arja teading ilro to rclnvasion into thc Ori3inel OCP arct', r dcfcat whlch woutd 'give rise to u immenro -dil.ppolntmcnt and lorr of confidcncc ln health programmes ln gencrat.. :. l4 Control oPerstlons durlng oe Pharlng-our Pcrlod (1998.2002) would continue on dre sam?llncr rs thosc forcsccn for thc lrtter half of rhe fourrh Flnanclat phrsc. Comblned vcctor/lvcnncctln control u,ould bo limlrcd to thosc pans of rlre Ertenslon 13e11r wherc opcrarlons strnd only in 1990/91. 9'15 More spccilically, the Committee rccommended that OCP would retain four insccricidcsfor rourional usc (pcrmerhrin, tcn)cphos, pyraclofor rnd g.l. H-r4). 9.16 Bascd on erpccrcd human and material rcquircmcnts, EAC madc budgerary forecasrs for OCP opcrations during thc Phasing-out Pcrlod whlch arc summarizcd in thc rable shown in paragraph 13.13 bclow. t9 - E. PLANNEDOPERATIONS AND BUDGETARY FORECASTS FOR THE PHASINC{UTPERIOD (1998 - 2002) cffiE FIFIH FINANCIAL PHASE) 10. Opcrttional lorccasts for thc 1998-2002 Pcrlod Control aclivities 10.1 Sincc the ctart of OCP operations tlrc control of onchocerciasis within the Prograffne area hns been based on aerial laniciding and cpidcmiological surveillancc/evaluation with the addition as from 1987 of ivermcctln disuibution. lO,2 During the Phasing-out Pcriod the control strategy will c-ontinue unchangcd but with different degres of nJional invotvimcnt. Vcctor iontrol, apartTrorir ground treatment in ccrtain cases, will remain the entire responsibillty of OCP with no atlcmpt at transferring this activiry to thc Panicipating Counries. 10.3 On'thc othcr hand, ivermcctin distribution wilt bc carried out by the countrics hcmsclvcs. Financial and loglrticr rupport witl be providcd by the Programme given that thc control of oncfioccrciasis by ivcrmccin is an essential clcment of the OCP strarcgy. lO.4 Epidcmiological surveillancc/evaluation takes an intermediary position. In the Extcnsion arcas, r.ietional tcams will carry out cvaluation of villagc communitics for thc purposc of epidemiological trend anatysis with OCP financial and logisrics tupport. Survcillance of scntincl villagcs in thc Original programme Brca to deEct instances of onchoccrcal recrudescence and ensure Oreir control will bc the entiie rcsponsibility of the countrics conccrned without any OCP suPPort. Vector control tO.5 The cxrcnt of larviciding during 199E, thc first year of thc Phasing-out Period, is outlined in the i.p pr"r"nted in Annex 5. In 1999 it is erpccred to cease aerial larvicidingxr'ln the lower Bandama, Como". lowcr Nzi and Sassandra rivcrs and ground larviciding is planned to be discontinued at the Niger river and in tributaries near Bamako (sec map in Annex 5). lO.5 During thc following ycsrs and untit thc Programme comes to an end tlte coverage of aerial larviciding wlll be more or less the salne as that of 1999- lO.? During the latrer half (1995-1997) of thc fourrh Financial Phasc. scveral scctors and subscctors wl1 havc becn ctoscd foltowlng the gradual reduction of vcctor control within thc Programmc arca. Thus at the end of 1994 scvcn scctors and 13 subsectors were still ln operation while at the end of 1997 thc network had becn rcduced to five sectors and ? subsectors. The situation in the Western Extcnsion area remained practically unchanged (12 operationrl bascs) during the same period. Furtlrer reductions are anticipatej in 1998 and 1999 after which rhe enrcmotogical nerwork will remain uttchartgcd until thc crrd of operations in thc ycar 2A02 (scc Anncxcs 7 and 8 for deuils). l0.t A restructuring of the network carricd out in 1996 involvcd thc translcr t'rf thc operationrl headquarters of the Western Operational Arca (wOA) from Bamakrr to (Xicnrtc whilc thc vector conlr()l ..tiriii.. previously conducted by thc Barnako subscctor wcrc Lhcn to bc conducted by the national tearn of Mali from a new operational base incorporared in the Westcrn Extcnsion ercr lO.9 Thc number ot'capture poinrs (144 rn I998) wrll hc matnt.ttnctl ar I06 dtrrtng tltc rcmatnJcr ol thc Pcriod. 20- I0,I0 Following the recommendation of EAc, thc numbcr of larvicidcs in rotational trse will continue ;;; ;-i; poisibre to bc timitcd ro B.r H-14 (up to l5m!/scc. of river flow). tcmcphos (up to 500mr/scc), pyraclofos (from l5 mr/sec up ro 300m'/scc.) and pcrmcthrirr (from 70m1/sec. exceeding 500mt/scc. - rcstricted to 5 applications per year)' lo.l I To cury our aerlal opcrations as planncd durtng-1998 ,2J00 flying hours wlll be required [n the West and 2,136 in the ga.lt, a total of 4,830 hours. With thc reduction ln coverage of larviclding as from 1999 tiic number of flying hourg will dimlnlsh to a total of 3.695 (2,020 in thc Wcst and 1,675 ln rhe EasQ. During the last y.ar of thc Phasing-out Period (2002) the requlrement will be further rcduccd o a toul of 3,090 (West: 1,675, East: 1,415)' 10.12 The cntomological cvaluation carried out during the two years following thc ccssation of tarviciding within the 6riginat Programmc arca to obtain reassurance that transmission had ln fact come ro an end, has not been aiplicd to -thc Ertension arcas is tlrc orrgoing iystematlc lvermectin distributiorr would have made the findlngs unreliable. 10.13 The programme has during reccntycarsprovidcd, and will'corrtinue to provide. technical supPort to ground larviciding carrled our for tho purporc of the control of blackfly nuisancc, including training of Gc local staff involved. priority wilt bc givcn to sinrations whcrc nuisance jeopardizes socioeconomic development. To avold the occurrence of rcslstancc cngendercd by this form of vcctor control which could ipread to othcr areas under control, B.r H-I4 ls thc larvtctde of choicc. 10.14 As regards cnvironmcntal surveitlancc, the monitoring of rivers to etlsure the absence of danraging effccts of larviclding on non-terget feuna wlll conlinuc although wlth less intcnsiry. Thc field work will conrinuc to bc carrlcd out wkh technical support from OCP. Particular attcntion will bc given to the cffccts of pcrmerhrln and pyraclofos. The national teams wlll also undertakc - in accordancc with thc cxpandcd mandate of the Ecotogicat Group - studics of the effecrs of lncreasing population prcssurc in thc oncho-frccd zoncs. Extcrnal support to mccting thc financial obligations incurred in conncctioh with thc application of thc crpanded mandate will be sought outside OCP. lO.l5 The,research component of vector control will be lirnitcd to thc scarch for inrproved. formulations of B.r. H-14 and for new stralns of Bactllus and to thc research connccted with DNA applications. The quatity confrol and susceptibiliry tests ln the baslns still undcr larviciding will bc continued. lO.15 Ir ls intended to lncrease the activitics of t]rc Bouakd Insccticidc Rcsearch Unit (lRU) to encompass othcr fields than fiosc hirhcrto undcrukcn on behalf of OCP. This could during the post' OCp ptriod includc lmmunology, drug reslstance tesa (lncluding lvermcctin and malaria) and diagnosis of trypanosomiasis. Ivermectin d istribution i 10.17 By thc end of rhc fourth Financial Phase (1992-1997) it is expected that tjre epidcmiological situarion in thc fcw foci in Orc Original Programme Arca still under ivermectin trcatment will have rcached a tevel at which rhe counrrles will bc able to takc full rcsponsibility for strcngthcning thc achievcmerlts with conlinued ivermectin distribution. : lO.lg Throughour the 1998-20O2 pcriod (rhc fifrh Financial Phase) control by ivermectin will continuc rn' rhe Errenslon areas wherever aerial larvlcidlng is undcrtakcn. Also, ivcrmcctin distribution will conrinuc untit thc cnd o[ thc Phasc in the northern half of the Wcstern Extcnsion ar'cn whcrc no OCp vcctor control is carried ou(. 71 10.19 [n order to obtain - and retain - the highest level of coverage and sustatnabiliry of ivermectin distribution, emphasis will be laid, whenever feasible, on corlmuniry self-treatment altltough not to the exclusion of other methods of distribution, be they active or centre-based. OCP will continue its collaboration with non-governmental development organizations in support of national distribution prograrnmes. 10.20 lvermoctln dlrtrtbution rupportcd financlally and loglstically by OCP will bc carricd out in the fictd eolcly by thc ndtonal tcuns who will slso monitor for any tevere adverse reactions. Thc dlnrlbution piogramm" wilt bc monitorcd by OCP and conclusions rcgarding optimal strarcgies and tcchniques witt Uc comrnunicatcd to thc countrics conccrncd. This would include findings regardlng frcquency of trcatmcnt and. atthough unlikcly, dre occurrence of resistancc to ivcrmcctin. lO.Zl OCp will continuc to procurc ivermectin from Mercf d. Co. on bchalf of thc Participatlng Countrier. Ic is cxpectcd that thc numbcr of pcrsons trcatcd by ivcrmectin in the Programrne arca will increasc from 3 million to3.2 million betwecn 1998 and 2Cf.2. Egidemiological su rvei llance/evaluntion lO.Z2 Ar men6oncd earlier, cpidemlological support o control consists of monitoring thc trend of such indicators as prevatencc, CMFLT rnd lncidencc (cvduation) and of detecting any instances of recrudcsccnce that might occur (survciIlancc). 10.23 Eoidemioloeical cvaluation, csrricd out exclusively by national teams with OCP financial and logisties support wil continue until the end of the Phasing-out Pcriod. The purpose is twofold: to **ur" the cffect of combincd larviciding/ivermectin control and of ivermectin distribution alone and E contributc to declsion-making regarding ccsration of control. Ophthalmological cvaluations in selecred follow-up vlllages to monitor changcs in ocular morbidiry will be pursued- 10.24 This activtty, which during the Phasing-out Pcriod @ncerns only thc Extcnsion areas, will conrinue to rely on trend analysls oflpidemiological indicatorr bascd on longltudlnal exantlnations of prc- determirrcd indicator villageJ. When dctcrmining thc timc of ccssation of larviciding, these trends and thcir actual tevel arc retatld to those projected by the oCP epidemiological model (ONCHOSIM). 10.2S Effcctive coidemiolosical survcillancc gcared O thc carly detection of possible instances of recurrcnce of onchoccrcal infection in the Original kogramme area will be carricd out by tltc panicipating Countries without any tcchric8l. financial or logistics suPPon by OCP. A network of scntlnet vlllagcs are cxarnined at rcgutar -thrcc year - intcrvals as an activity integrated within the @untries' epidemlological surveillance systems. 1.0.25 Unril the end of OCp operuions, cpidemiotogical survcillancc will trc confined to the Original hogramrnc area whcrc tarviciding ccascd bcforc the Phasing-out Period. once oCP conrrol in the ExtJnsion areas closes down by the yeal. 2002, nationat onchoccrcal surveillance will becnme a pcrmanent feature in all tlre Panicipating Countries. lO,Z7 Any lnstancc of focatizcd recrudescence detected by nationat epidcmiological sul'vcillancc I'canrs in the Ori!inal OCp area will bc eliminated by intenrive ivernrectin trea(ment trf the population concerned. As tong as thc programme is in existcncc it will suppor'( thc national cfforts to control such focal rccrudcsccnct if cver occurring. ) Communiry Micr ofi larial L,oad 1') 10.2g As has bccn strcrscd abov.c, lvcrmectin distribution and epidemlglogical survcillancc/cvaluation wlll contlnue to bc carried out by nalional rtaff wior no dircct involvement of oCP. Howevcr. in order , .*r" comparability of findings and rcsulu collected by national tcams in the field, the Programmc wil maintain juring the phasing-out Period a smalt group of technicians who will carry out quality tesu and traln natlond staff. lO,Zg Alro, rrugcmcnts will condnuc for oCP to reccivc from thc national Onchoccrciasis fiorainrrri rcguh; reporr and opcrational dara so as to allow for an cffcctivc ovcrall monitoring and cvatuation of alirtre aaivitles that iuc carricd out undcrthe auspices of thc Programnrc. Other activities 10.30 Although OCp ls rcaring it! crd and a conslderable nulnbcr of national staff have rcccivcd f"fio*rf,ipt ln-preparation for postOCP suivcilturce and"control activitics (see Annex 4), additional cfforu *itt b" made in dru diricrlon but on a rcducirrg scalc during thc 1998-2002 pcriod. Howevcr, ,p."f"f cmphasir wilt bc put on in-rervlce trainlng ln thc fictd of cpidemiology, public health and managcmcrit. 10.31 Durlng the phasing.out Period, ocP financcd research will reducc considcrably from that carried iut-prcrio"sl!. Arcas thrt could tcnd themselvcs to continucd investigation would includc improved B;i1us tlurlngierctr H:14 formul*ions, field applicable diagnostic mcthodologics, DNA probing, ONCHOSIM forccasting and operarional rcscarch. lO.3Z Supportto sociocconomic devetopment in onchoccrciasis frccd areas will continue to bc of dircct @ncern to tt " Commlttcc of Sponsoring Agcncies with FAO as a lead atcncy in that rcspect. tl. The pruce$ qf Ptleslngou Transfer of aaivities and OCP suooort I l.l In the preccding scction a description is givcn of the national involvement and that of OCP iaclf in onchocerciasis rontrol in West Africa during rtre Phulngout Period. It is stressed that practically all fictd activities. exccpt yector contr,ol, witl bc carried out by national tcamr.ryiltr,B.pP assuming what will csscntially bc a suPPortive role. ll.2 The proccss of dcvolution has developed gradually over thc years and rcsulted in the countrics having already, as menttoned aboye, rssumcd opcrational responsibiliry for ivermcctin distribution ud cpidciriotoglial cvaluation/surveitlancc. Whet is tcft of dcvolution to be carried our by the hogrammc durine the-1998-2002 period wilt drercfore consist of transferring to thc Participating Countries the r"maining/activities undcrtaken by OCP. exccpting vector control. 11.3 The essence of devolution, as zupported by the Programme consists of ensuring that the participating Countries develop the capacity to effectively undertake onchocerciasis surveillance and control and that this activity become operatiornlly irserted in national epidemiological surveillance and control systems. ll.4 Thls activity. devolution.sda.ru strlcro, must bc seen in conjunction $'ith dcvolution sensu lato' support to Orc integrarlon urpcct through thc strengthcning of nationat healrh systcms - which falls *'ithin rhe mandatc of WHO in collaboration with other inrer-govcrntncntal and bileter'al organizations intcrcstcd in'health dcvelopment. e.8. thc World Bank. -23 - 11.5 Hordever, to assistcounuies in integrsting the survcillene and control of onchoccrciasis in thcir i*r,r, ,yr*1nt, cjcp n.r sct up an "Inregratlon Sectlon' wlthln the Devolution Unit which shoutd bc seen ;;;;1hh$ig'r link bctwrcrr oCp snd the wHo Regional office for Africa (wHo-AFRo) on the one il; ;J tf,. n.niripatlng Counrrlcs on thc other. To undcrline the preponderant role of WHO in ,uoportin' health syst mr d.velopment in the counrries conccrned, AFRO has agrccd to dcfray thc cost of'tire snff of tho'lntcgration Scctlon'. 1.6 Thls support of WHO ln connectlon wlth devolution ls underlincd in paragraph 3 of ttb ii.,nor.na,lr oCAgrorncnt sttschcd to thc Onchoccrclasls Fund Agrccmcnt (1992'1997) which reads: ,VHO ls also rcsponslble for advlslng countrla ln thc carrylng out of ttrcir rcsponsibilitics as thcy rclate r,', the programme operations and malntenancc of diseasc control and for coordinatlng any lntcr-country effo(s that may bc requircd ln this conncction'. ll,7 The "Integrstion Section* will undertakc,s survcy of the -opcrational clements of thc national fr"J,f, scrviccs relivant to rccrudescenct detection and control wirhln thc contcxt of WH6/AFRO support io oevotutlon scrur, hto Gruegraph 11.4 refcrs). More spccifrcally, tlris scction will irt consultation with National Coordinators and WHO lnrer-country teams, prepare a mlnimum package of lntegrated activities aplticaUte ?t the dirtricr levcl and cstabtish a mcchanism for thc supcrvision, monitoring and cvaluation of such actlvities- I l.t To carry out thc tssks involved in support to dcvolution, thc units of Epidcmiological Evaluation, prvotutton ard Blott"tlstlcr/lnformatlon Syetcmr wcrc mergcd ln 1996 lnto a new 'Devolutlon Unlt" *t f.n conslsrs of 4 scctlons dealing wlth lntcgratlon (paragraph I1.5 abovc) cntomological monitoring (scc paragraph 11.11 bclow) blosaristlcs and opcrational rescarch and eplderniologlcal cvaluatlon, diagnosis utd trcatmcnt. I1.9 The activities supporting the devolution process, most of which have been referred to in previous sections of this documentlnclude support to the preparation of implementation plans and to obtain finarrcial aid for their implementation: to ensure that recrudescence detection and control be effectively maintained'; to sensitizb thi populations and national authorities to the importance of onchocerciasis control arid surveillancb; to carry out devolution oriented training; to assist Participating Countries'in-bpidemiologichl surveillari'ii of onchocerciasis and to assist in decision-making when ionfirming cessation of larviciding; to undert4[te qrrality control of national teams to ensure comparability of national data; to monitor ivermectinl'distribution and encourage community self-treatment; to support operational research related ro systems of distribution of the drug and to its epidemiological impact, including making use of longirudinal ophthalmological surveys; and to search for diagnostic methods in replacement of skinsnipping. 11.10 OCP will furthermore ensure the transfer of OCP's epidemiological data to the Participating Countries and the analysis and interpretation of such data by the national staff. Likewise, the Devolution Unit supports other OCP units in data processing and analysis as well as bibliographic retrieval activities. ,ill.ll Ftfratty, support will bc givcn to communlty cntomologlcal monitoring for the purpose of J.r."ring iojsible -insunccs of renewed onctrocercal transmission, possibly throtrgh pooling of a consider-atie numbcr of blackflics to bc dcspatchcd to a spccializcd labororory for DNA probe tcsting to detcrminc'the prcsence or not of infective blackflies' t2. Minagcmcnt of rtc Phastnfout t1.l During thc fourth Financial Phasc (1992-1997) all thc Parricipating Countrics appointcd OCP Nationat Coordinators who havc since comc to play a crucial rote in thc devolutiort pr.:cess itself as well 14L.+ as in drc control opcratlons whlch, as mentioncd czrlier, arc almost cntircly conducrcd by national suff with the exccptlon of vedor conrol. lZ,Z Thc National Coordinabrs havc bccn trained in practically all aspects of the OCP mcthodology and arsume responslbiliry for thc planning, implemcntation and monitoring of nationally conductcd control activiticr. [n lhort, thc coordinator3 8rc thc agcntr of dcvolution and national foci for the pharlng-out pnoccr rt thc nartonrl levct, at thc remc tLnc as they constltutc an cffcctivc link bctwccn furc erogrammc and thc authoritie!. of the Panicipating Countrles. LZ.s On ttre OCP sidc prcparations for dcvolution, lcading progrcssively to tltc phasing'out of the programme, has bccn on ltc way rincc Ore beginning of the fourth Financial Phasc and will continue its courseuntil thccndofthe l99t-2002pcriod (sccparagraphs ll.l to ll.ll above). 12.4 As OCP activities in given areas come to an" erlJ, the Programme-wide operations and communications network (radio, computers, vehicles, offtce equipment and material, etc.) will be turned over to the participating Countries in sufficient guantiry and quatity to permit a meaningful contribution to the strcngthening of health services in those countries. The measures are already being taken in the original prbgramme area as zubsectors and sectors arc being closed. LZ.5 This is in sccordsncc with dtc agrccmcnt that OCP vchiclcs, matcrial, cquiprnent and supplics sha1, u rhe cnd of opcraions, and aftcr consultation bcturccn the Participating Countrics and WHO, ,normalty bc transfcrrcd'to the Panicipuing Countries or to cntities nominated by thern when... required for continued opcration of Ore Programme or for activities following directly there from". However, WHO may, st its discrction. rctain titlc to part or all of thc matcrial, cquipment urd supplies in qucstion (section l0 of rhc Memorurdum of Agrccment auachcd to thc Onchoccrciasis Fund Agrccnrcnt (1992- le97)). 12,6 The guiding principles forthls transfcr are that radio installations remain in the country with OCP bcing risponsibtc for thcir rc-locating and rc-installing; drat a sclcocd numbcr of vchicles arc transferrcd to Govtrnment ownerlhlp for dcvolutlon rctivltles; that the Programmc tranrfcrs o national reams such officc equipmcnt rvallablc on OCP prcmiscs as typcwriters, photocoPying urd facslmile machines, computcrs and air-conditioners; and that OCP providcs thc equivalent of one ycar supply of office *-.,.maprials 12.7 At the end of the Phasing out Period, the most important infrastructure will be OCPs premises and garage in Ouagadougou. As the Programme comes to a close, these installations could gradually be turned over to WHO to administer and utilize. Remaining vehicles, if any, could also be turned over to WHO or, as an alternative, be donated to health related organizations zuch as hospitals and universities. The radio system might remain with WHO to help monitoring the devolution aspects of the Programme. 12.8 WHO as executing agency of the Programme will nrakc surc that all the ncccssary administrativc measurcs arc utkcn to avoid any cxpcnditure in the context of OCP after 3l December 2001. 13. Rcsourcc rcquircments ond bud*tory forccasts for lhc 1998-2002 perid l3.l The fotlowing table summarizcs the expcctcd rcquircmcnts of WHO/OCP personnql for vcctor control opcrstions during the Phasing'out Period: :LT -25 - l 1 Profcssionals Crcncral Servicc Total 59 48 46 46 46 13.Z Allowancc will bc made for thc employment of Short-tcrm Profcssionals (in atl 259 months). 13.3 Thc budget cstimares for vcctor control during thc l99E-2002 period is summarized hereunder: us$ 11,341,200 8.192.560 8,167,550 8,157,560 6,207,800 Total: 42,066,6E0 13.4 During rtrc l99t-2002 period, rhe pcrsonncl of thc DcyqhIja.E-ILEjI will rcnrairr at thc level of thrcc profcssitnals, two short-tcrm Profcssionalr urd 1l Gcncral Scrvicc staff. l3.S Thc cstimaad budgctary provtsions for thc Unit durlng ttrc Phasing-out Pcriod arc 8s follows. 1998 9 50 1999 4 44 2000 4 42 2001 4 42 2002 4 42 1998 1999 2000 200r 2W2 1998 1999 2000 200r 2W2 us $ (000) l 651 r 581 I 45t l 391 I 39t Toul 7 475 13.6 ,As in the past yc8rs, rhe central tr3[A8,iEtAI facllitles of thc Programrne wlll aim ar the best possibl$ cosr/cffeciiv.ntrr rarlo in lmplcrncntlng the annual Plans of Actions and Budget of the Phasing' trr st uctur", Senior staff members will continue to look out for opporrunitics to cnsurc a cost- consciousness &pproach at the operational lcvcl tlrroughout the Programnte 13.7 In tinc with the decrcase ln vector control operarions durlng thls Phasing-out Period, an equally imponant rcduction is anticipatcd in thc corc cstablishmcnt at HQ ln Ouagadougou. The central activities and servlccs provlded at thar levcl will requlrc thc maintaining of'a skelcton staff to suppon the Programrnc's smooth mantgement process in the two remalning operational bases in Kara (To8o) and OdiennC (C6tc d'lvoire). 13.g Efforts will continue to fill posirions ar all levels in rtrc Programmc with prescnt OCP mcmbers ,[o*ing ,"reatile ekills and abilitjes because of rhe ever growing need to have on hand people who can easily trorrate divcrrifiCd typel of work. Thir rhou[d b€ ceCn as anothcr major contribution of OCI' to ,Ir; ;t;;;,h;ning of natlonal administrations and, ultimately. to ensuring tltc succcss of devolution. t3.g Ir lr cxpcacd that ore numbcr of posu in managemenr, admlnistrdion and suppon scrviccs will ir*L stable during thc Phuingout Pcriod l99t-2002, rcducing whcn compared with the staffing in iilgj,-fi", l0 to ?-professlonali and from 53 !o 39 Crcneral Scrvices staff. The number of staff under' ip".i.iS..riccs Agrecnrnrs (ssA) would atso be rr/,ue:A. Thc following tahlc sumnrarizcs the planned rtafting of thc Managemcnt Unit: 26- Phasirigoirt Pcriod PROF GS ssA Director's Officc (including Macrofil Administruion and Suppon 3 5 2 4 v 28 Total 7 39 30 13.t0 Thc cstimatcd cost of muagcmcnt during thc Phasing-out Pcriod are l99t: 1999: 2000: 200r: 2A02: us $ (000) r t00 r 450 l 430 I 420 I 350 13.1 1 Total: 7 450 Total staff reouircments for thc Phasing-out Period (all units) Vector control Devolution Muagement 59 I qot r6 46 I qqq 48 l6 46 2@ 46 t6 46 2001 q6 l6 .16 2002 46 l6 45 Total (wHo/ocP) "Harmonizcd' staff National tcams r2l t32 365 lt0 98 359 r08 98 359 108 98 359 108 9E -t) 9 )1 13.I2 The'harmonized'staff (in national status and pald by OCP) will con(inue to be financed during rhe Phaslng-out Period by thc Programme. It is cxpcctcd howevcr tlrat ttrc purely &minisrativc rakc- ovcr by chc respcctivc countrics of former OCP ltaff members now included in tris 'harmonlzcd" csregory will be concluded in the l99t-2002 Pcriod. Summary of total estimated.ces$s for the Phnsino-out Period (loat-'402) 13.13 Thc. budgctary forccasts for the 1998-2002 period irre surnmarizcd in the tible below. These csrimatcs ari bascd on: a) costs uscd for thc 1995 Plan of Action urd Budgct, applying a dollu/CFA exchange rarc of 525, b) atsumptions madc for pricc contingencies for annual cost tncresses/dccrcases in thc various categories of cxpendirurcs and c) assumptions made for annual decreases in the various categories of consumablc commoditics. 1998 1999 2000 - Z00i ZW} Totar Vecor cgncrol ,I Dcvolution Muragcmcnt Toul Total (includlng 5% r-: ^.tingency incrcasc) . ,'cCicrtons by LlC tn lU I 994 Pro gresslvc Ewluulon 1l 341 l 65r I t00 t 192 r 58r I 450 t 158 I 461 I 430 E 158 I 39r L 420 5 20t I 391 r 350 42 067 7 4'.15 1 450 14'192 t5 532 tL 223 lr 784 lt 059 Lr 6t2 t0 969 1r 518 t 949 9 397 56 992 59 r43 15,981 14,665 13,36/, 12,i,30 l0,tgs 67,022 13.14 Tho initial launching Phasc (1974-1979)was concludcd at a cosr of US$ 56,t million, while the second Phaso (198G1985) came to 106,9 mlllion and thc thlrd Phase (198&1991t pcaked ct L7'1,4 million; thc total cost of opcrations of thc fourth Frnanclal Phase (1992-1997) ls ctrpcctcd to como to 146,4 mlllion, already a slzcable rcduction as comparcd to thc figures of Orc 0rlrd Phare. The Phasing-out Pcriod whlch covcrs fivc ycars (199E-2002) is proposcd at a cost of some 59.t million or roughly rhc equivalcnt of the launching pcriod when taking into consideration inflation facrors ov6r thc past 20 yearu. 56. I t 06.9 177.a t(6.( (le7('197e) (19E0-t965) (l9!6-1991) (1e92-1997t ( r996 -2102 ) 13.15 Thc main conccrn in drawing up thc prcscnt Plan o[Operations hss bccn to.prcsent the towcst possiblc budga pcrmitting to mcct thc corrcsponding rcsourcc roquirementr with a r4inlmum emount of control over the operarionr for this Phasing out pcrlod. It lr thcrcforc obvious Orpt arry funlrcr rcductlon in thc budget would have immediate effects on 0re planncd opcra(ions as wcll ss thc control strategy for rhc pcriod in guestion. trl -28 13.16 As Showa in *re abovc surnrnary tablc, the cstimated costs of Programme oPerations reduce by approximately onc third &om ttrc first ro the lasr year of the Phasing-out Period. This reduction is almost cniirety due to thc gradual decrcasc in vcctor control activitics, by far thc largcst componenl of the budget forecasts. lg.l7 Thc major drop ln larviciding ir cxpcctcd to takc placc bctwecn 1998 and 1999 as rcflccted in thc budgct table, whltc aftcrwards vcclor control operations will rcmain at Practically the same level until thc end of the Programmc- 13. tt The cost estimates for rupport to devolution show only a moderate decline durirtg the Phasing-out pcriod as thc s6ff and othcr rcqulrcmcnts for this activity which remain cruclal for thc cvcntual success of OCp, havc bccn rcduccd to thc minlmum compatiblc with thc cxpccted demands on the unic concerned. 13.19 As regards management support to Programme operations the budget estimates reflect the need for a core estabtishment capable of providing the services required to ensure smooth operations. It is worth noting that a ponsiderable reduction in expenditures on this activity is expected to take place from 1997 to the frrst year of the Phasing-out Period. l3,ZO Given thc possibility of unforesccable advcrsc cvcnts occurring, ir would secm justified to Increase the Onchoccrciasis Fund rcserve by US $ ... million availablc to meet unpredictable expcndlnrres. l() i. ( RISKS AND SAI-EGLIARDS I { ." Pote nrtnl "troublc spott" l4.l rWhcn in 2001 the Programme comes to an end, thc likelihood Urar onchocerciasis will reappcar within thc clcvcn OCP countries is remotc but should ir happen in somc fairly disturt furure. thc countries tiemselvcs will bc capablc of detccring and conrrotling such isotated insunccs of focslird recrudescencc. 14.2 Thcrc erc howevcr a fcw dcfined arcal which descrye parlicular ancntion, cven before Orc cnd of thc Progremmc, given a certain delay in rcaching a satisfacrory epidemiological levcl due to opcraional problcmr of diffcrenr narurc. ln Oc following, a dcscriprion is madc of such potenrial -troublc spots'and thc mcasurcs to be taken. if not already under wry. in order to minimizc or rcmovc thc thrcat ro the cventual succcsr of.the-Programnre. l{.3 I At the time of prcparing thc prcscnr document (carly 1995) the epidcmiologicat situation in a icw foci wirhin thc Original Programme area whcre larviciding had bccn carricd out contirluousfy during l8 to 20 y..rs *.s not yct fully satisfacrory. I4.4 In thc Sotr/Alihori basins, the infiltration from ncighbouring Nigcria of infcctivc bleckflies continues to Posc a problcm which cannot bc solvcd by aerial larviciding. However, intcnsificd lvcrmccrin disrribution is crpccred to improvc the situation. l'1.5 Ar rcgrrds the Kuloawn/Mole basins wherc thc epidemiological indrces arc stiI at an unsatisfactory lcvel. continuation of acrial lrrviciding would be untikcly ro have any further impacr wtrilc biannual ivermcctin distriburion is likely ro redrcst rhe srtuation. 14.5 Rccent cpidcmiological evaluations in thc Dui arca (Ghana) havc derecrcd a probablc rcinvasion of infectivc blrckflics, most likely cmanatlng from sourccs atong he rriburarics (Tain, Tano) toqtcd south of the area covcrcd by OCP conrrol. tn rhc .rca ioncerncd, ivermectin dirtribution wlll bc carricd out thrcc to four timcs a ycar whilc the ghanaian aurhorir.ies will be encouragod to commcnce control oI the Tain/Tano foci through ivcrmectin rrcarrncnt. The hogrammc will continuc to pay puticular a(ention to the situation in mired savanna-forcst zonct. 14.7 Thc situation in Sierra lcone dcserves spcciat 8(ention, given thc problcms faced in Orar counrry er rcgrds onchoccrciasis conrrol. l4.t Frorn thc point of vicw of cpidemiology and transmission of rhe diseasc, Sicrra Lconc prescntr trro disilnc [cas. Thc rou0ern half of thc country is characrcrited by foci of Ore seriorrsly bllnding form of onchoccrciasis uansmitted by Simultun leonerce. a vcoor which does not'trtwl bcyond tlre confincl of tlat arca, The risk of rcinvasion into Cuinea is Orcrefore pracicrlly nil. 14.9 Although onchocercal epiderniology in thc nonhern half of Sierra lonc is less serious rhan in thc aouth, Ore posribility of transmission into ncighbouring countries cannot be exctudc'd if veclor control it lnrcrruptcd during crtcnded periods. Thc vector ln question, Simuyunt slrbanumil cageblc of covcring considerablc disrences in fllght. 14.10 Sincc April l99a scrial lu'viciding has vinually ccased rhroughour Sierra l.cone as a rct{lh of Oe lnsccure rituation currcnlly prcvailing ln the country. Epidemiological cvaluation erd llvormcain dlstributlon heve etso becn suspcnded sincr Dcccmbcr 1994. 30 l4.l I Should. thcrefore. veclor control and iverntcctrn distrrbution conttnue to bc impcdcd rn Sierra Lcone, thc risk that infectivc blackflics invade Cuinca from thc uppcr half o[ Stcrra Ltone nccd to be considcrcd. 14.12 In crsc such reinvasion takcs placc. vccror control and ivcrmcctin distribution in the conccrned zonct conductcd by,'or under the eusplccs of, OCP would prolcct Orc afflictcd populrtionr ln the rcinvrded :rrees. Obviously. oncc thc conditions in Sicrrr Leone so pcrmit, lenviciding rnd ivcrmcain disribution will rcsumc. t4.t3 Howcvcr. if rhc rcsumprion of onchoccrciasis control in Sicrra l-eone should occur with e dclay of two or mors ycerr, rhe bcnefits of fivc ycars of larviciding in the nonh of the country would bc panly tost znd drc expected improvcment in Oc epidcmiological situation would suffcr a delay- It would rhcn be ncccssary to rcview thc corrcctivc measurcs to be taken. Onc stratcgy could bc inrensivc ivcrmccrin distribution twice ycarly durifrg a pcriod determincd by model prediaions. 14.t4 Should a field-appticablc macrofilrricidc bc fonhcoming wirhin the ncxt fcw years. large' rcele epplicrrion in Sierra [:one might hclp that country ro recuperate tts delay and dcfinitivcly rcrnovc thc risk of rcinvasion of infected flies into neighbouring countries. [To be updrtcd in thc light of futurc dcveloPmentsl 15. Rctistoltcc lo ivcrmecrin l5.l Thc imporunce of ivermectin in OCP control opcrations has bcen cver increasing since h was frrst distributed on a large scalc in l98E within the Programmc arca' Not only is the drug effcctive in rcducing considcrably skin and ophrhalmological manifestations. it also rcduces the duiaion of vcctor control from l4 to l2 ycars, when applied in conjunction with larviciding, as well as bcing rt rhe prcscnt time the only fasiblc means of coping with any future instances of onchoccrcel recirrd csccncc. 15.2 No nced. thcrefore. to srress rhc considerable ncgarive impact a possible lowercd susccptibility of thc parasite to ivermcctin would have on the progress of the Programme itself or on rccrudcsccnce control during thc post-OCP cra. Fortunatcly, however, thc likclihood thar such . devclopmcnt nlighr impcde OCP operetions or bring the attainmcnt of thc Programme objectivc ln pcril, ls vcry rcmoc indced. 15.3 Stud'ics on ivcrrnectin rcsistance in parasitic nematodcs havc utilized spccics wrth a gencrnion time of 3-4 days (C cleSons) or 6 wccks (H. contortus). By comparison the gencrerion timc of O. wlvulus is l2-18 months, and this in itself cnsurer that any possible sprcad of resistent tcrEt through the population of onchocerca worms will be slow. 15.4 Additionrlly, in cxpcrimcntal induction of ivcrmectin transmrssion in C. c/egaas, he mo$ corunon form of resisterrce is low levcl (5-20 timcs lcss scnsitivc to ivermccrln) and produccd by r sirgle rccessive tenc. High levcl resistance (100 times less sensirive to ivcrmccrin) in rcmrtodcs is cxtrenrcly rare. and usually requires resisturce in rwo genes. 15.5 Through the Mecrofil Project. OCP is supportint rcsearch to rdcntify the gcnes generating ivernrcain resisnncc in parasitic nemuodes. and developing tcchniques to rdcntify such gcnes in O- wlwlu-r. - 3l - 15.6 Should. ho*cver, against all expcctations, lowercd susccpribilrry to ivermecrin devclop, it is fornrnatc rhat rlre drug can be givin in doscs up ro t00 fitk1bodyweighr -'i.c. 5 ro 6 times rhc dosrgc currently in usc - without any side-effccts of publlc hcalth imponancc, It would thcreforc bc porsiblc. and fersiblc, to climinate pockets of rcslsrancc by increasing thc dosagc up o thc approvcd maximum. Also, the emergence. if cver, of r ticld.applicable macrofitrricrde as e rcplaccmcnt urould, obviously, rcsolve problcms of ivermectin resistance. 15.7 Even if, ss mcntioned. the probebility of O. wlvu&rs dcveloping resistance to ivcrmcctin ir rcmotc, it will be necessary to maintain r systcm of moniroring rhe levct of surccptibiliry also aftcr OCP opcrrtions comc to an cnd. The frcltitics of rhe OCP Bouakc laboratory mighi wcll be considercd of usc in rhis conncction (sce also paragraph 9.3 above). i 16., Shotugc of fiaonciol rcsources rO.r Thc onchoccrciasis Controt Progranrme hes beiefiirco rrrroughour irs iibrc rhan 20 ycars of crisrcncc from the Eenerous luppon of a donor community whosi membership has rcmaincd on dlc whole rcmarkably stablc evcr sincc the Programme carne lnro bcing. OCp opcrarions havc ncycr bcen hindcred by insufficient funds. lq-2 Thcrc would scem to be threc main rcasonl why donor support ar the requircd lcvel hasbern forhcoming durlng thil cxceptionatly.tory pcriod. Firsr, ihl programme was originally *t":* rs a long{asting opcrarion and perccivcd as such by borh thc contiiUuring prrtics and rhePaniciprring Countrlo. G. BENEFITS t9:3 E4ually imponant har bccn thc ctcar definition of rhc finat objccrive with irs intcgraredpublic health and socioeconomic contponcnts asiwett as rhe easily iemonst.ble operationit edticvcments ln terms of rcoching prcscr time-siruucd; targcrs. And, frnaly, the imponance rnachcd to rnaining the lri3hcsr posslbtc degrce of cosUeflicicncy ln rlt pro!r.*. actlviries which hes rclsstrrcd rhe Donors of thc soundncss of thclr invcstmenr. 16.4 Howcycr, givcn rhc currcnr wortdwidc ilmrtuion of funds avartabrc for support to rccioccortomic dcveloPnlcnt, OCP rcmrtns ln compctirion whh orher dcvclopmcnt prolictl forthc rtuacrion of finsncial resources. Thc Progrrmml witl thcrefore continue its efforts ro achicvethc mrrimum at thc lowcst posslbte cost so as to remin the inrercsr -O ruppor, of the donorcommunity 16-5 Thc cnd of OCP is now ln lighr. Pr_ogmmmc opcntionr will gradually reduce during rhcPhesingout Pcriod and thc corrclponding financial rcqutremcnr wili bc relirively insignilicanr comgrrcd to tlrc lot t invessmcnl to drtc. As polnrcd our by Oe Expert Advircry iommiitcc, tlrc cost/cftcrriYcncss of thi!, the last, invotmcni 'nccdr no funhcr eirborarion.. ' 17. HrcW bcacSts 17'l The rablc betow sumnurlzes oe bcnefrts accrucd, or expectcd to accrue, in 6re frcld ofhcrlth es r result of OCP controt opcrarions. 3t91a-t991 t9e6-2002 t9?4-?002 zooJ-}olx . 1974-zolz (oo0) Nucrbs of PoPte Protccrd .i Numbcr of poPlo Prttartad froo going blind Nuobc of poPlc hrviaS hcr r.hair oocbocarcel infocrioo Nugrbcr of childruo born rinco 1974 sprrcd rhc oncbcctEtl ri* 300 I 800 600 24@ 2 000 12 000 4 000 t6 000 > t0 0001 >33 000: 25O r 500 t0 000 6 000 350 cr. 40 00O 500 12 0@ 600 > 50 000 l2m l1..Z 'Alhough mr a dircct heahh bcncfit. OCP has demonsuated that a m4jor African undenaking in ttrc ficld of health can be lucccssfully atcoinplished and drat severat UN organizetions can rrrork harmoniously togcthcr ln support of such undcrtaking. 18. \orirfi benqfils 18.1 The cffcct of the Programme on the social lifc in the arcas under control has been appreciable- The rcrurn of entire communities from drc barren hlghlands to the fertile riverain zoDclr has in lsclf resulad in social beccrmcnt rs dcmonsrated by the constructlon of schools and hcalh centres in thc areas prcviously dcserted in fcar of contrac:ing onchoccrciasls. It.2 Atso u the morc restricted fanrily levcl has 0re control of the diseasc bccn of imporuncc. The dgpcndency of young blindcd people on their rclativcs is bccoming a social burden of the pasr ss is thc stigma unavoidably attached to the skin disfigurcments caused by river blindness. ,t 19. . Economlc bcncfiu I9.l In r reccnt publicetion ("Cost-Bencfit Analysls of thc Onchoccrciasis Conrrol Programme (OCP)'! Achyung Klm and Brucc Bcnton concluded thrt $re cconomic rciurn of lnvcstment ln thc Programme could bc estimared et20* .8 rcturn $,hich compared vcry favourably wkh projects in eny scdor urd in any rcgion ln thc devcloping world. I l9-Z ,Thc analysis identificd as bcnefits accrued from OCP control ttle agriculrural output producod ar e rcsulr of tltc crua labour forcc and rgric.ultural land madc availablc through rhc control of onctroccrclas is. r97+1985 2 t 19861997 to be publishcd as part of a World Banl( serics on rivcr blindncss control in West Afriq. - 55 - 19.3 The bencfirr wcre cxprcssed in ternts of nct prcsent valuc (NPV)' and internal ratc of rcorrn (lRR)' whilc the period 1974-2012 was selccted as thc projcct horrzon givcn Orat thc bcncfiu atc cxpccted to conrinuc accumulating for at least l0 ycars after thc closure of dre Progremme cvcn if no funher action were 1akcn to maintain control. lg.1 As mcnrioned carlicr. 25 million hcctarcs of fcrtitc tand has bccn made availabte for food prdudion cnough to fccdlT million people annually. H. POST.OCP INTER.COUNTR,Y COLLABORATION 20. Ertcnt of collaborution 2O.l Onc of rhc promincnr fcaures of OCP which ul a lsrgc extcnt has contributcd to its succcs3 har bcen thc closc collabontion berwecn Orc Participating Countries undcr tJre auspiccs of rhe Programmc. This hts rllowed for control being erricd out across national fronticrs; thc collcdion rnd analysis of information and drta on an inter-country basis; and casy transmission of opcruional cxpericnce from onc country to another. 20.2 lt is imponeil that such collaboration continuc during thc post-OCP cra. The spread of onchoccrciagis knows no frontiers and. thcrefore. any instancc of rccurrcncc of the discase. even if focalizcd, carries thc inhcrcnt risk, if unchcckcd, to spread into a ncighbouring country. lnstanr communicsrion and inrcrcountry collaboration in control is thcrclbre of essence tf serious rccrudcsccncc is to bc avoidcd. 21. Suppoa ro it t t-country colhbomtion 2l'.t The issue of crtcrnal support to the srrcngthcning of nationrt public healt}r services to cnrunc cffcaivc onchocerciasis surveillance and control (devolution sensu lanl has been crrcnsively debatcd tvithin OCP. 21.2 keviorsly. crrcrnrl reviews and cvaluatip.ns.havc*callcd for the creation of an 'OCP fotlow-up' $nrcrure rcfcrrcd lo as ln 'lntcr-Country Facility (lCF)" rcsponsiblc for such rctivitics rs coordinating onchoccrciasis survcillencc at the rcgional levcl; ensuring inter-country collrbondon ln thc frcld of onchoccrciasis rcserrch; ud supporting training and tcchnical dcvclopmens. 21.3 Also, proporals'ercrc made to cntru$ e fururc lnter-Country Facility with ectivities of a morc ggn {:rt public health nature such rs promoring rnd sustaining nrtionrl Multidiseasc Survcilhncc end Control programmes capablc of cffccrivcly 'accommodating' onchoccrciasis rccrudcsccncc dcEcrion and control. Prescrrt vlluc o[ thc ttream of net returns (bcnefits mlnus costs) of a project during tts cconomic lifc. , I Thc rrrc of inrercsr which mrkes rhc NPV cqurl ro zcro -34- ZL.4 This lssue was agaln brought up 8t the Deccmber 1994 scssion of the Joint Prograrnme, Committcc u/hich concluded that rherc would not seem to bc a need for crcaling a new scructure on thc lines of an ICF insofar as its suggcsted funqions wcre already within the maMate of Ore World Health Organization. Thc Committee was reassurcd that WHO/AFRO. in closc collaboraion wlttr other intcrnational and bilateral organizations including the World Bank, would undcrtake thc usks listcd as those of thc proposcd ICF. Zl.5 As r fr6t stcp in this dircction, AFRO has undertaken to put at the disposal of thc OCP Devotution Unfu 0re full-tlme scrviccs of a medical officcr and a tcchnician rcsponsible for stimutating thc Parricipuing Countries to lntegratc rhc residual onchoccrciasis control activities (rccrudesccnce dctcalon and conrrol) within their health systcms. zl-G ln thic connecrion considcration mlghr be glvcn-o the possibilicy of maintaining the Narional Onchocerciasis Coordinatots as a post-OCP group to supPort continued inter-country collaboration by facilitating comrnunication emong the national authoritics; by following closely rhc dcvctopment of onchoccrciasis detection and control in the countries concerned'with a view 19 advising national au0rorities about corrcctivc acrion in case of necd; and by making rccommcndations concerning thc insertion of recrudesccncc deEcrion and control within mulddisasc surveillancc and control (Irrsq programme. 2t.7 It is funhermorc suggcsted drat WHO/AFRO might consider retaining a nucleus of the OCP dcvolution staff after Ore Programrnc comes to an cnd which would work together with rhis group of Coordinators t(, cnsurc continued intcr-country collaboration and help countries to dcvclop thclr MSC progranlmes. Such rupport would bc an cxtcnsion of thc financing by WHO/AFRO of the Intcgration secdon of thc Devolution Unit alrcady approved by the Regional Director (scc paragraph I t.5 abovc). 35- - Anne,x .1 /Annexc i q) x 0)cc x o)cC :) oz oFoo q UJ =Hz tU oJ =s o-() o Fa tu =o :J tUo tx =ot TL z. [rJ hr@ og) H, TUoot C) z,9d[rJ Y E oo IU Fi)IJ ulo TU =E.(9 o E. o- + il oI 9 E, LL F U) UI =z UJ = d(, ot o- odFz oo 9. c/) Eod [rJo o :troz o doo z -)o co E o = ( trJ a -.t z 3ot- u, tLlEt! t.Y z oo J otu z tUq cn ea lrj? 5(5 f,a zIoz a o U'z ul k TU ztr tu Ffo l o(9 =oo o l o I o u) il = Y 0(f,a oY = Gt lU = =t ootr(L :)o IU tr = z tU a '. ut ',::E ,...j.,{ .:ul fo zI CN I U)z UIFx lU z x. , tl T ,st, .o ]. , j6 _ Anoey 2(\ x C)tr r6; c El a fro 2A O,{ < d5&st-<zz 8P 22,caN<= -la(r<Ur\ BXo- ,l{Uzo U7 C d a e3 87JiZ o=d ZUY e'xfrta62 az o N zd l! F o zJO<tr< a<d@d< <Hv o 6zaoLoEox _< X-< !.a i Eeld.* l) YF(JYzoVUJ iz-,OUEd,i< dfr Bd c,) PE()L eg J a @ Zdoi 1-Z <rIJd= B5 o o oJ od azo tr d, otll 1- = 6 zE zoos oo EEaEE >=2 r= EEEEE 3{z oN zd, EI F qj , 63 g=x EgEEdz frqJ 3aOF oa =FP?z tIJ zo trDJ o t! o co EE o5 EtO =< =:gd d A 2.<= ?. z-!l o(J EE# E 6' E o z Fd, oe z E z o tr U z J Zco22 Lq@i9E =ok<<trtil6E FUgl o= 9.2.ra.bt-. z<-uto4z =E3JOzo U o 1a a3 JdAOLq fq o z<t zl)O= Fd <alqFe 2d zo c> <q zu1 <U ,U E= :)L )t Al'ili-ff ) Lrst ol'Dorrors as at 1994 / Listc dcs llailleurs cle lirnds cn 1994 A t'rrcart Developruent Bauk/l:r B:rnquc' al'ricainc tlc Ddveltlppenlent Bclgrunrila Belgique Calt'ruste Gulbenkian Foundation/la Fondatiorr Calouste Gulbenkian Dennrark/le Danernark European Cournruniry/la Cornnrunaute europ6enue Frarrce/[a Francc Gernrany/l' A I lerriagne Ita lr,/l'l talie Japan/le Japorr Rcpublic of Korea/la R6publique de Cor6e Kuri,ait/le Korveit Luxernbourg/le Luxernbourg Netherlands/les Pays-Bas OPEC Fund for Internatiorul Developrnent/le Fonds de I'OPEP pour le D6veloppernent Porrugal/le Porrugal Saudi Arabia/l'Arabie Saoudite Swiuerland/la Suisse UNDP/le PNUD United Kingdonr/le Royaume-Uni LISA/les Etats-Unis d'Arndrique wHo/l'oMS World Bank/la Barrque rtrortdiale 6J -<^<Fxdov(:'F Ir- (>rt, . <, N<lt\. ro @h \o G l'- ro ?-- N N o RN: @ rt <, l'- 6.o 6(o @6 o I FTttg ur (lON{ Ir} m -t xJO<,oFOrL -& a\ c, Or r.t € <,N nl & o i.l tOls .\l ra' F ra, ?a\j l\l cEO GG00 -3 ! ui C'. c, o cco -EO €Ea <F ca J CI ct c E,EUA -gtG' atc -GI a:l F (,F N €F .\l . 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