Addendum for the plan of action and budget 2008-2015

AFRICAN PROGRAMME FOR ONCHOCERCIASIS CONTROL fIEIEIEH[]UI,I FI]F: THE l-,Lftt'{ r_lF fir::TlrlH flHEr BUBTI;ET EEEE-EF-,IE I I t 'd:,j, ', d' .', ... ..',^'l - .}\ / -t J ., )* d .'{| ." i.l{" ,rlit-','-= t fq :f ,t J I.€F I aI e $,tY'.-7!ra I I f ' 't I 2;9, ,\+ " r. I H fri"u.,1' t .t\6j' ,: ;.), "j- r:ai w' J,tl;, t ,t .2Au rq, @ - World Health 0rganization I I r twa s- 'a ti l ! \ t t t I ..+ \ a. ' ar / E tt F l-'.1 I I:: fi f'{ I, F; tl t_; l-'.1 tt l-l I'l E rlt:rHTF;':rl_ Addendum for the plan of action and budget 2OO8-2O15 F t:t I? tl H Il H I:r t:: E l-'.1 I::Ift EIE Tfl E LE Il F r::'-l 1'{TEHT= 1. lntroduction 5 2. Rationale 3. Objective 1: lncreasing support for Community- directed treatment with ivermectin (CDTi) in (post) conflict countries s 3.1. Strengthening the infrastructure 11 3.2. Strengthening human resources 11 7 3.3. Monitoring and evaluation 12 U) o N t o o o N ooE oq cI l', o cg 0. oC o E =E c oEE o c o U .g o .9 u oI oc u c o o o E E o B o o c og 2 3.4. Some specific issues related to conflict 12 4. Objective 2: To implement onchocerciasis control activities in conjunction with other health interventions (co-implementation) ls 4.1. lssues related to integration 17 4.2.lssues related to training 17 4.3.lssues related to coordination and advocacy 18 4.4.Community-directed intervention (CD!) with LF 4.5.CDl and malaria - Home management of malaria (HMM) and lnsecticide-treated nets (lTN) 4.6.CDa with other Mass drug administration (MDA) 18 18 19 n o NI o o oN oBEf o 6 c .9 U o c o E o3 o E E c oEE o c o u o o E(, oI oC u c o o o E E o o o 0. c og 3 5. Objective 3: To determine when and where oncho- cerciasis treatment can be stopped 5.1. Lead studies on elimination of onchocerciasis transmission in Africa 21 22 5.2. Conceptual and operational framework for elimination of transmission - Mapping trends towards eliminotion endpoints - Endgome strotegies 22 23 23 5.4. Operational research on strategies and tools 24 5.5. Field evaluation of moxidectin 24 6. Mainstreaming gender in APOC operations 27 7. Human resource, Management, administration and support services 7.1. Programme Headguarters 28 29 7.2. Personnel 29 7.3. Fixed-term staff 29 7.4. Temporary staff 29 7.5. Administrative support services, Iogistics and infrastructure 30 7.6. Consultants' services 30 8. SUMMARY BUDGET 31 U) oNI o o o N ooE a oq c .9 u o cg 0. oC o EfEc oEE o c oU o o .9 u o(, oG o c o o o E E o B o L c og 7 \ 4 A.r_,-: ':':' "Al IHTI-'.t r_IBUTITIEH Delivery of quality health care in Africa is particularly challenged by the weak health systems due to various underlying problems, including inadequate national budgets for health. This situation works against high bur- den of disease confounded by high poverty levels and vice-versa, and hence a vicious cycle of disease-poverty-disease. The challenge is especially great for poor rural populations living "at the end of the road" where diseases like onchocerciasis are endemic and where access to health services is severely restricted as health facilities are often not available or affordable to them. A recent analysis by the African Programme for Onchocerciasis Control (APOC) of more than 300 onchocerciasis endemic communi- ties in Congo Brazzaville showed that half of them were located between 6 and 21 kilome- ters away from the nearest health facilities. Most African countries are far from achieving the Millennium Development Goals the world leaders committed themselves to. One of the major reasons is the lack of access to available interventions: "...we face o formidoble gap between innovations in heolth (vaccines, drugs and strategies for care) and their delivery to com- munities in the developing world..." (Madon et al, Science,2007). But, in its 12 years of opera- tions, APOC has made significant progress in closing this gap through the use of an innova- tive strategy of empowering communities to manage and supervise the distribution of a safe microfilaricide, ivermectin (Mectizano). ln 2OO7, commu nity-directed distri butors trained by the health services with support from donor funds and NGDOs treated 54 million eligible persons in 15 countries, using the strategy of community directed treatment with ivermectin (CDTi), in areas where there are no roads, no doctors, no drugs and where hunger is greatest. By maintaining a focus on people-centered approach, strong community participation, ownership and accountability, APOC has em- powered 112000 communities to take charge of their own health and to be responsible and accountable for the distribution of ivermectin tablets in their community. Since inception of the community-directed treatment strategy in 1997, communities have distributed and accounted for more than 550 million ivermec- tin tablets kept under their care. Community census registers kept by the 470,000 ivermec- tin distributors are being used by Ministries of Education and other health programmes to provide services. The APOC partnership has demonstrated that a solid governance structure can be estab- lished for effective programme implementa- tion and the building of trust among partners. The annual reports (1997-2007) ofthe external audits on APOC management and country-led operations demonstrate that APOC supported country projects have respected a high level of transparency and accountability as required by the partnership. To ensure effective onchocerciasis control, ivermectin has to be given annually for many years. Hence, the main objective of APOC is to establish sustainable community-directed distribution systems. ln keeping with this tar- get of sustainability, the APOC management and national onchocerciasis Task forces have consistently monitored and evaluated CDTI projects through periodic visits and indepen- dent participatory monitoring and evalu- ations. Currently, 70olo of the 58 evaluated projects in l0 countries are judged sustain- able at the community level. A comprehensive report on sustainability of projects which will be released in December this year shows that the large majority of APOC projects have achieved and sustained high ivermectin treat- ment coverage, and describes how communi- ties themselves have taken charge of failing projects to ensure their members continue to receive ivermectin annually (APOC report on sustainability of CDTI, 2008). n o N I o o oN ooE , oq c .9 l) o trg I oC o E aE tr oEE o c o u o o .g(, o u oE(, c o o o E E o o o 0. c o .9 5 u't o N I o o o N ooE a oq c .9 (, o c o E os o E)Ec oEE o c o u o og(, Q' o os o c o o o E E o o o I c o .9 6 This sustained high treatment coverage has significantly reduced the burden of disease. ln2007, over I million disability adjusted life years (DALYs) were prevented by iver- mectin treatment, and it is estimated that by 2015 APOC will have prevented over 15 million DALYs through CDT|. The cost per Daly prevented is estimated at USS 7, making Community Directed Treatment with iver- mectin one of the most cost-effective health interventions in the world. ln addition to this progress with elimination of onchocerciasls as a public health problem, evidence has emerged in 2007 and 2008 that 15 to 20 years of annual ivermectin treatment can eliminate onchocerciasis transmission and infection to the extent that treatment can be safely stopped. The key to why onchocerciasis control works and at low cost is that the system relies on community decision-making and resources, particularly the unpaid volunteers selected by communities from among their own ranks. These individuals, APOC has shown, are capable of distribution and record keeping and their motivation is by gains in recognition, self-esteem, and knowledge, rather than cash incentives, which makes their commitment sustainable and robust. ln a bid to avoid the'dependency syndrome' and push towards greater country owner- ship and sustainability, APOC through several initiatives, country and regional meetings in Uganda (2001), Tanzania (2003), Nigeria (2003), DRC (2004) has created awareness in two main areas: the importance of full integration of onchocerciasis control programmes into ex- isting health systems agenda to achieve coun- try ownership, and financing of onchocerciasis control through direct government fiscal budgets and the PRSPs. These are vital to the sustainability of CDTI and thus, the elimina- tion of onchocerciasis in the sub-region. Robust plans for effective and sustainable integration are being put in place by APOC to safeguard the past decade's hard-won gains. Firstly, devising an exit plan was one of the conditions on which APOC's mandate was extended from 2010 to 2015 by the.Joint Action Forum. Three countries (Uganda, Tanzania and Cameroon) have already devel- oped strategic plans on how APOC Trust fund can exit from their territory, thereby reduc- ing the dependence of community-directed treatment projects on APOC financial support Three other countries (Congo Brazzaville, Ethiopia, Nigeria) will complete their plans in the first quarter of 2009. Progress with establishing CDT| has not been equal in all APOC countries. The External Eval- uation of APOC was concerned about the lack of sufficient government resources in post conflict countries. The evaluation also noted that due to extensive population movements that take place during as well as after conflict situations. the difficulty of reaching persons requiring treatment with ivermectin is likely to continue for some time. Furthermore, taking into account the movement of the black fly vector, capable of crossing country boundar- ies and re-infecting freed zones, increased attention and allocation of extra funding to onchocerciasis endemic post-conflict coun- tries was considered imperative in order to safeguard the gains of their neighbours. The benefit of onchocerciasls control to the countries has extended beyond the reduc- tion in the burden of the disease and the associated social economic returns. The most important control operation is strengthening the health system in areas where it is currently weakest. The quality of life of communities will greatly improve and lead to enhanced performance and productivity and conse- quent economic benefits at household and national levels. II I F: ftTIrl f'{ ft LE ln2007, APOC governing body approved a paradigm shift from single to multiple disease focus; and the use ofthe strategy of com- munity-directed treatment to bring multiple health interventions and commodities to onchocerciasis endemic hard-to-reach popu- lations while maintaining clear focus on the Programme's original mandate - the elimina- tion of onchocerciasis as a public health and socio-economic problem. The encouraging results of the programme some of which are summarized above resulted in the commit- ment of the donor community and additional pledged funding expressed at the.Joint Action Forum (JAF) in December 2007 in Brussels. The extra pledged funds presented in this addendum willenable APOC to develop and strengthen critical aspects of the programme to a level not foreseen in the original Plan of Action and Budget 2008-2015. Following the review of the original Plan of Action and Budget 2008-2015, the Joint Action Forum - the governing body of APOC recommended to strengthen and clearly demonstrate programme impact in the following three areas relating to the first three Programme objectives that will require ad- ditional financial support: OBJECTIVE 1: To establish sustainable onchocerciasis control programmes in all countries where they are needed, with special reference to (post)confl ict countries. OBJECTIVE 2: To implement onchocerciasis control activities in conjunction with other health interventions (co-implementation) OBJECTIVE 3: To determine when and where ivermectin treatment can be stopped. The JAF also recommended mainstreaming gender in programme control operations. Due to the importance of this issue, it has been ad- dressed in this addendum and will in addition be addressed in the annual work plans, specifi- cally for activities related to objectives I and 2. The measurable indicators on gender will be identified and annual progress reported to the Joint Action Forum beginning December 2009. This proposal to use the additional pledged funds to support strategies to achieve the three objectives mentioned above, to strengthen gender aspects ofoperations and strengthen the capacity of APOC manage- ment is informed also by the observations and recommendations of the External Evaluation of APOC in 2005. The External Evaluation expressed concern about the heavy workload of staff in the APOC headquarters in Ouagadougou. As APOC enters it's final and exit Phase and the number of projects in post conflict countries increases due to successful completion of REMO in previously inaccessible areas, more projects are launched, and the work load of Pro- gramme management staff has redoubled. The External Evaluation observed: "...there is o serious potentiol problem in staffing just when APOC activities are their peok ond a full comple- ment of well-quolified ond knowledgeable stoff is required for mointaining progromme perfor- mance." To improve the staffing condition and efficiency, we propose additional support to APOC management. Finally, in determining the cost of APOC from 2008 to 2015 and rationale use ofextra funds, it is important to adjust the current budget taking into consideration the global inflation rate of 3olo annually and the dramatic fluctua- tion of the dollar exchange rate. The attain- ment of the objectives of the onchocerciasis control programmes in Africa will significantly improve the socio-economic well being of '120 million people, save more than 15 million DALYs by 2015 and contribute to the attain- ment of all of the MDGs, except 7 (ensure environmental sustainability). This addendum presents the allocation and justification of the extra USS 36.4 million for the three objectives mentioned above, mainstreaming gender in APOC operations and strengthening APOC management. o oNI o o o N ooE) oq cp (, o cg 0. oC o E aE c oEE o c o(J .9 o EI o U oC() c o o o E E o o o 0. c o u 7 II rlE._JEr::TIUE I lncreasing support for Community-directed tr with ivermectin (CDTi) conf lict cou nt ries e i a n tment(post) APOC has, and will continue, to facilitate effec- tive and sustainable control of onchocerciasis throughout the endemic areas in the 19 par- ticipating countries in Africa by Community Directed Treatment with lvermectin (Mec- tizan@) (CDTI)and will provide time limited funding ( up to 2012) and technical assistance to 4 ex-OCP countries where the epidemio- logical situation has remained unsatisfactory. The Programme has spearheaded a series of strategies and activities to get CDTI started in conflict areas, under very difficult circum- stances. Drug procurement and distribution is an area of great success in APOC and so is community leadership role in the distribution of ivermectin. Thus even under the difficult circumstances in post conflict countries, community leadership is strong and CDTI is used to bring multiple interventions to very remote communities (Lo ncet, 2007). This is evidenced by the involvement of com- munities in planning for CDTI, large number of CDDs trained, and sufficient availability of drugs. Two countries, Chad and Burundi (WHO/ APOC Progress Report 2008) have achieved a steady increase in therapeutic coverage. But in Sudan, Angola, Liberia and DRC, allof which are recently out of conflict, coverage has been generally below 650lo and variable coupled with the late start of some projects. For these and other post conflict countries, the External evaluation recommende d " Regord less of the number of years o project has been in existence, in some conflict areas APOC should consider CDTI os in its initial phases...." Because the "main" APOC support is for 8 years - i.e., the initial 5 years, followed by three years of "phasing out" during which sustainability plans are implemented - it is foreseen in the Plan of Action and Budget 2008-2015 that at least 35 projects would have to continue distribution of ivermectin and or a macrofilaricide if available, after the exit of APOC. Thus, APOC and partners will redouble efforts to build the capacity of nationals in post conflict countries quickly for each coun- try to be in a position to bring the control to a successful conclusion. 1. Africa has experienced an increase in the number of countries seen as fragile or failing states and directly or indirectly affected by conflict. Looking at APOC and OCP coun- tries, conflict has affected and still affects ten countries. These are severely hampered in their onchocerciasis control efforts because ofthe effects of recent or ongoing conflictsr. Conflict has a detrimental effect on several aspects ofAPOC s work, such as: i. Delays in the completion of REMO sur- veys and thereby preventing the launch of the three remaining projects with serious consequences on geographical coverage and also leaving unprotected areas that can remain as persisting reser- voirs of infection; ii. Delays in the implementation of mass treatment because of obstructed roads due to mines, and displace communities due to rebel activity rendering health interventions inaccessible to communi- ties who need them the most2; iii. Health systems are deprived of the basic infrastructure needed to support the CDTI strategy and to maintain commu- ' APOC: A Strotegic Overview of the Future of Onchocerciosis Control in Africo, August 2006. 2 This is why the REMO survey and launch in Angola was completed eight years later than initially anticipated. 6 c o U .9 o .g u o u oC(, c o 0 o E E o B o 0. q t0 U 9 Figure 1: Main activities relating to CDTi in post-conflict countries 6 tr o ug a3 u 0t(, ot u c o o o E E o o o 0. c o .9 10 nity commitment to the health sys- tem-community partnership that CDTI requires; iv. lnsufficient and/or weak health sector human resource workforce v. Difficulties with providing the statutory 2570 government contribution to CDTI projects and thus increasing the propor- tion offunds that have to be taken from the APOC Trust Fund [or from NGOs]l vi. Deterring all partners from entering certain onchocerciasis-endemic areas to support CDTI projects.4 Foremost action with the extra funds is build- ing and /or strengthening the capacity of the health system to manage CDTI and bring Mectizan@ to all eligible hard-to reach com- munities. APOC has indicated that building alliances with organizations such as UNHCR who are experienced in working in conflict areas will help mitigate the negative impacts of the above.s The Programme will solicit the involvement of the Ministries of Environment and Agriculture in onchocerciasis control in all 3 This is the situation regarding CDTI projects in the Central African Republic, Chad, the Democratic republic of the Congo, and southern Sudan. 4 APOC Working Droft Phosing Out ond Exit Strotegy 2008- 2015, p.38. 5 APOC Working Draft Phosing Out ond Exit Strotegy 2008- 2015, p38. countries, in particulal those in post conflict situation in building the capacity of countries before the cessation of APOC operations. APOC's necessary experience in continu- ing some delivery of health care in conflict and post-conflict situations shows that it is possible to cope in such circumstances and represents a body of knowledge that can be transferred to other control programmes fac- ing similar difficulties. Despite some achieve- ments recorded in post conflict countries, there is need for more flexibility or modifica- tion of the control strategy in ten of the on- chocerciasis endemic (post) conflict countries to rapidly improve the onchocerciasis foci epidemiological situation in these countries. To safeguard the gains in countries where transmission has stopped, it is considered important to increase the amounts allocated to re-launching and sustaining CDTI in (post) conflict countries (Figure 'l). ln a (post) conflict country, the weakness of government structures means that country level coordination mechanisms need to be streamlined to reduce transaction costs. ln order to ensure sustainable development in (post) conflict countries the following extra activities (Figure 1) are required. CDTI in post-confl i(t (ountri€5 Appropriate vehi<let motorbikes and other l..nsport inf r.r<trwturc Jtretrgthening Communic.tio.s equlpment Health information iystems strengthening Additonal staff ruppoil Extarnal t8htri<al advisort Human resour<e rticngthening Tr.ining o, mor€ CDDt Managamrnt trrining Monltqltrg.nd av.lu.tion Est.bliihlng/itrengthening approprlate ME ry5tcmt Crosr-bordor s<tlvlti6 confiid spc<i6< i$ue5 lntermlly dirpla(ed persons Developing appropri.te partnershipt p1. Strengthening the infrastructure ln most (post) conflict areas the infrastructure has been destroyed, including office equipment and supplies, electricity and water networks, the telephone and postal systems. ln many cases even the roads have been destroyed or mined making travel extremely difficult. a. To create functional administration of the projects, additional investment is needed in the purchase of suitable equipment, like generators or solar panels and other office equipment. Further, the running costs of the office will be more expensive than nor- mal, due to the cost for diesel for genera- tors and alternative water supplies.. b. lnvestment in suitable vehicles of the required number adds to programme costs but will enhance the ability to monitor and evaluate programmes on a regular basis. c. lnvestment in communications equipment (Thuraya telephones, Codan radios and satellite communications for e-mail - VSAT) will add to the cost of the programme. Good levels of communication come with a cost - usually this cost is considered to be a fair investment given the ability to commu- nicate effectively with project partners (and the ability to receive reports promptly). As shown above in the case ofCongo Braz- zaville, some male and female CDDs trek more than 10 kilometers to collect ivermec- tin and later to return treatment reports to health facilities. The Programme is explo- ring more efficient, less time demanding communication methods to reduce the number of hours such CDDs spend on ivermectin distribution. This may require increasing the number of CDDs provided with bicycles. This will reduce the rate of attrition and demand for incentives. d. Support to the NOTFs through manage- ment systems and reporting. Often these are weak because of conflict and they take time to rebuild post-conflict. Enhanced ma- nagement systems for onchocerciasis will also support the development of similar systems across the health ministry. e. ldentify new mechanisms to secure the fi nancial commitment of governments. 2. Strengthening human resources During periods of conflict an emigration of qualified staff occurs that depletes the coun- tries ability to reconstruct the government health care services. For those who remain behind during the conflict, training has not been possible. Human resources will need to be built up again and extra resources will be required to strengthen the participation of women as CDDs, who especially have been disadvantaged due to the war. a. Due to limited resources, following conflict, extra allowances for national staffwill be required to support governments in rebuil- ding their human resource base. b. At present, Technical Advisors (contract or temporary) provide support to the country for a period of two years. This will not be suf6cient to address the needs ofthe country to develop a sustainable program- me. lt is proposed to extend this service for another three years. c. Workshops on CDTI strategy will be organi- zed for all sub-district health staff there to improve the supervision of CDDs by health staff from onchocerciasis or non-oncho- cerciasis endemic districts, irrespective of frequent transfers of health staff. Emphasis will be to train many nationals on the CDTI strategy including those working on other NTDs as a means of promoting the use of the strategy by health systems. d. Women especially will be encouraged to be trained as CDD. Special culturally sensitive packages will be developed to support women in managing the health of their families, to take charge of their own and their children s health. e. Extra resources will be needed to train managers at all levels to be able to respond to the needs of the programme and priority will be given to females. I 6 E oU o 6 .g u oI oE(, tr o o o E E o o o I tr o(, 11 3. Monitoring and evaluation Support in terms of monitoring and evalua- tion in conflict areas is at the very best difficult to achieve. Proper structures need to be put in place. Due to conflict, education and capac- ity development of staff in the field has been lacking. Therefore much closer monitoring of programmes is required. APOC will invest in training and capacity building of middle level health personnel. a. APOC will on annual basis provide scho- larships to health staff selected by the Ministries of Health to M5c and diploma courses in areas relevant for onchocerciasis control in the country. b. Recently, several of the WHO and UNICEF programmes in post conflict countries have recruited of para-medical and medical doctors for monitoring, evaluation and sur- veillance activities. APOC will collaborate with these agencies and train these cadres of staff on the CDTI strategy irrespective of whether or not they are posted to oncho- cerciasis endemic districts. Special moni- toring tools will need to be developed and more frequent visits to field are necessary to follow progress. New tools for evaluation are required where there is no established community structure and the current tools developed by APOC are not sufficient. 4. Some specific issues related to conflict a. Conflict often spills over into neighbou- ring countries and therefore border areas are particularly prone to instability and population movement. Enhancing cross border collaboration in these difficult cir- cumstances will improve coverage in these areas and help to promote understanding between countries at the health level.6 b. Support to the treatment of internally displaced persons (lDPs).Treatment helps to maintain social cohesion within the com- munities or camps and helps to establish (or re-establish) a sense of community. Those trained as CDDs will usually return with their communities to take up their activities within their homeland. c. A wide range of partners is required to ensure project delivery. Some of these are outside the current APOC partnership.They do, for example, involve UN peace missions (i.e. UNAMIL in Liberia and MONUC in DRC). It is estimated on the assumption that peace in these countries will be sustained, additional USS 6 million (Table 1) to achieve the objec- tives and bring the projects in the countries to the level so that elimination of transmission (end point) studies can begin in 2011. 6 Examples of this are the regular CDTI meetings of the Manu River Union; Sightsavers also funded a Health for Peace lnitiative between some countries of the West Africa Sub Region. Table 1: Budget for increasing support for CDTi in (post) conflict countries E c ou o o .gI atI os lJ c o o o E E o l, o G c o .9 12 ussActivity lnf rastructure strengthening Operational equipment Appropriate vehicles/transport equip. Communication equipment HIS strengthening Human resource strengthening Management training External technical advisors (add 3 yrs) Training of additional CDDs Allowances for field activities Monitoring and Evaluation Establish/strengthen appropriate M&E systems Conflict specific issues Cross-border activit ies Treatment of lDPs Developing appropriate partnerships lncluded in PAB 2008 - 201 5 lncluded in PAB 2008 - 201 5 1,100,000 550,000 420,000 1,080,000 660,000 1,300,000 450,000 lncluded in PAB 2008 - 201 5 490,000 lncluded in PAB 2008 - 201 5 6,0s0,000Total tJl o N I o o o N d cI u o cg 0. o3 o EfE tr oEE 13 I - Il E.-J E t::TI1"l E E e ; m \r 't,. -.<\ 6 nnrLir ,,i,ffirilfsfi,fEr l.* ' ,.4,[hi,it- tT.',Sffiffi.lliffi -affi; \ ;l I- !i Y/+ ,\ I s{ B I I \ f -. -.) r ,/l- --r I unilliltr I rr I :' a " r._li4 n Pqt To implement onchocerciasis control activities in conjunction with other health interventions(co-implementation) I I The CDTI process developed by APOC has been a major breakthrough in enhancing community involvement and ownership of health care interventions. And it is now widely acknowledged that the network of commu- nity distributors of ivermectin established by APOC can achieve far more than its initial mandate - by providing a delivery mechanism for the large-scale provision of multiple health interventions. The limited accessibility to rural Africa implies a need for community human resource services to remain as an extension of health services after APOC funding ends, particularly in countries where conflict has decimated what structures were in place. Many severely underserved onchocerciasis endemic communities will be able, through co-implementation with other health inter- ventions, to achieve the greatest improve- ments in health-service access. Vitamin A supplementation Schistosomiasis Lymphatic filariasis Deworming 9s2'.A34 Trachoma 508'683 lncreasingly, other interventions are being co-implemented with ivermectin distribution in existing CDTi projects (Figure 2). Further- more, a large TDR multicountry study has recently provided convincing evidence of the effectiveness and efficiency of using the community directed intervention approach for the integrated delivery of multiple health interventions in areas where APOC has already established CDTi for onchocerciasis control. Already during a successful meeting organ- ized by the MoH of Uganda and APOC in 2001, it was concluded that co-implementation of disease control measures using CDTI as a ve- hicle is an affordable and extremely effective way to organise primary health care. Since then, the message has spread to many other countries, among them Democratic Republic of Congo, Cameroon, Congo, Ethio- 4',317'.237 3'77A',991 12',s55'347 2'498'055 Figure 2: Most frequently health interventions co-implemented with ivermectin distribution using CDI as reported by 43 projects in 7 countries in 2007 lnsecticid treatment bed nets distribution Home management of malaria I I I I I i tr .9 c o o s ,.o**.S.uasr*St.uSt.."o"tr.a"""r".a Number of persons reached 15 E c oU g o .9(, o(, oc o c o o o E E o o o 0. E r!p n o NI o o o N E C oU o 'a o '6 o(, os(, t o o at E E o l, o 0. c o U 16 pia, Nigeria, Malawi and Tanzania.|n2007, over 13 million people in 7 countries received 3-4 health interventions through the CDT| co-i mplementation networks. |n2007, the expansion of the mandate of APOC by its governing body, the Joint Action Forum to include co-implementation, and to demon- strate programme impact in co-implementa- tion of CDTI with other interventions, present opportunities to countries and the Programme, Some of the opportunities have been present- ed in the original Plan of Action and Budget. APOC will further assist countries to: a. Develop a nationalaction-oriented policy on NTDs linked to health system agenda and the Millennium development Goals (MDGs). b. The Mapping of the overlap of onchocer- ciasis and other NTDs and provision of baseline data for future measurement of the impact. c. Develop national plan and guidelines and intersectoral programmes that are holistic with evidence of country ownership and sustainable government fi nancial commit- ment and establishment of result-based programmes. Recently, APOC has supported high-level meetings of programme managers in three countries involved in community interven- tions. This is a promising development. ln one of the countries, the CDTI strategy was adopted as a national policy for all communi- ty-based programmes in the country. While this approach straddles the border between APOC and MoH mandates, it is likely that the momentum being built is unique. ln the past, such integration could not be achieved by many programmes, including Primary Health Care whose progress was derailed by such technical aspects as developing essential health packages. The new APOC initiative has the potentials of being one of the most important contributions of APOC and CDTI to health systems, but it has to be nurtured. The number of projects co-implementing CDTI with other health interventions in- creased significantly with additional financial and technical assistance of the partner NGDOs (Carter Center, CBM, Sight Savers lnternational, Helen Keller lnternational, lMA, MITOSATH) presently in five countries- DRC, Ethiopia, Nigeria, Tanzania and Uganda. Given the decision of the 13'h session of the IAF in 2007 mentioned above, APOC needs to further expand its role as agent of preven- tive chemotherapy in Africa more than what has been envisaged in the approved PAB 2008-2015. Although some funding exists for the expansion it should be clear that the mandate of APOC is not to enter into full scale integrated Neglected Tropical Disease (NTD) control but to facilitate coordinated activities where they are appropriate and where there is a community desire to do so. Thus, through the expansion activities, APOC will: a. Promote task shifting and building work- forces in communities deprived of health care services. b. Promote equity of access to medicine and treatments especially for the rural poor. c. Support health systems in health promo- tion and information in hard-to reach areas. d. Engage projects and document the impact of combined CDTI and other NTD control initiatives on health systems and MDGs. A natural fit exists between mass drug ad- ministration (MDA) for onchocerciasis and for lymphatic filariasis and vitamin A supplemen- tation. A strong felt need of many communi- ties is for the home management of malaria and access to insecticide treated bed nets. Other NTDs using MDA could also use the CDI strategy but this may have to be modified to target different populations, e.g. school children. While current interest in NTDs and the possi- bilities of funding MDA is driving the integra- tion agenda it must not be forgotten however that each disease has its specificity and the control measures need more than just MDA. Real lntegration can bring success where all factors are considered and actions are based on solid evidence, which may still need to be produced. lt should also not be forgotten that without new tools ivermectin for onchocer- ciasis control will continue to be distributed probably beyond the life of some of the NTD I l I i i Figure 3: Main activities relating to co-implementation lntegration Trrlnlr4 GGneral iJsucs Coordimtis and odvocacy with lymph.ti< fr l.rlarir CDI and m.l.ri! (HiiM & ITN) lnt.grrtcd m.pplng lng.gr.t.d monitqing rnd evaluation lnt.grution of morbldity mn.gf,mst wh.r..ppropri.te Tr.ining for int.grated CDI Tr.inino and tc(hni(.l arrirtrn(e for CDI in non.6<ho rreat Coo.dln.tion with other rel.lcd hc.lth initi.tlves Advxacy for supportives pollci€. for CDI Advocacy for <oordi.nted poll<ier fo. voluntcqrs ircqntlvet Co-fn.nclng of CDI where there arc no NGDO partn€rt a Additlon of albendazole in <o-endemi< atear Expansion ofCDTi +.lbend.zole to (over remaihing _ areas ln co-endeml( distri(ts D.velopmcnt.nd co-6nancing of <ommunity-dir.cted mal.rla cont.ol .<tivitl6s lnclusion oI CDI in n.tional guidelines for malaria (ontrol Txhni<al arsl5trn<. and co- fin.ndng of lntsgr.t.d MDA through CDI in ocho eres Commuoity hr.lth promotion for rsl.l.d b.hlvidr ch.nge c. Tools for integrated monitoring and evalu- ation need to be developed and applied in the field using multi-disciplinary teams. d. Strategies and training materials for inte- gration of morbidity management must be developed where appropriate e.g. lymphoedema management and hydro- coele surgery in lymphatic filariasis and eyelid surgery for trachoma. APOC will seek to develop strategies for community morbidity control using CDl. 2. lssues related to training a. Reinforce gender balance of CDDs and finance (re)training to include the extra training required for co-administration of ivermectin, albendazole, vitamin A sup- plementation and malaria control activities. According to community priorities add training for schistosomiasis and trachoma control. b. ln areas that are not co-endemic with Onchocerciasis, in view of the expertise of APOC in CDT|training, APOC will render technical assistance to partners in the field to implement CDI strategies to foster com- munity participation and ownership. ICo-implementation CDI with other MDA projects. Therefore, the sustainability of CDTI must not be sacrificed for the sake of short term NTD gains. ln order to facilitate and support co-imple- mentation the following issues need to be addressed (Figure 3): 1. lssues related to integration Communities, Health Districts and Govern- ments will have to work on establishing their own priorities. APOC will be flexible in its approach whilst making sure that the focus on onchocerciasis is not lost and that interven- tions remain evidence based. There are sever- al general issues related to co-implementation that need to be taken into account. a. The currently ongoing integrated map- ping of NTDs needs to be expanded and maps showing where various NTDs overlap need to be developed for large countries (Nigeria, DRC, Ethiopia etc.) b. lntegration of other NTD drugs into national drug supply chains or use of the ivermectin supply chains to bring other drugs and commodities in a timely manner to underserved populations. I ) a o NI o o o N oBE a o 6 cI (, o tr o E os o EfE c oE r, 17 6 c o rJ o a o '6 o u oE(, c o o o E E o o o o. c o u 18 3. lssues related to coordination and advocacy a. Where co-endemicity of onchocerciasis with other tropical disease exists, and the programme is active, work with partners to expand the CDTI activities to include other interventions. b. Advocate for CDI and where necessary as- sist governments to utilise CDI as a tool for health delivery and gender equality. c. Advocate for equity for Community Vol- unteers engaged in different health and development activities. Different pro- grammes, even within the same Ministry use community volunteers in different ways with or without monetary incentives, and this becomes even more complicated when other development Ministries are involved with multiple partners working in the field. APOC will consult within countries and with different partners under the Min- istry of Health to encourage the establish- ment of national policies. d. ln endemic areas not receiving the financial and technical support of NGDOs where on- chocerciasis is also a public health problem, co-finance the co-administration of ivermec- tin with other health interventions, including necessary operational research to provide a good evidence base for interventions. 4. CDI with lymphatic filariasis (LF) Many areas of co-endemicity of Onchocer- ciasis and lymphatic filariasis (LF) exist but integrated treatment is not yet ongoing, there are three possible scenarios a. Where LF endemic villages are located in a CDTI area, and within an LF implemen- tation unit, there will be co-financing of albendazole and ivermectin distribution by GAELF and APOC. b. lf the necessary funding is made available to APOC, the Programme will expand the CDTI area to include albendazole distribu- tion to cover also all LF villages outside the CDTI area but within an implementation unit. The decision will be on a case by case basis. c. Where LF areas are not co-endemic with onchocerciasis, in view of the expertise of APOC in CDTltraining, APOC will render technical assistance to partners in the field to plan and implement CDI strategies. 5. CDI and malaria (HMM and ITN) Malaria is the highest cause of morbidity and mortality in Africa yet effective tools are available for its prevention and control. Most of these tools are limited to those that have access to health facilities and this excludes about half of the population in need of such services. The home management of malaria (HMM) strategy was developed to improve access to treatment and other malaria control strategies better delivered at community level. This has been slow in uptake in most countries were this strategy is required. ln a recent TDR multi-country study it was shown that CDI significantly increases coverage for HMM, lTNs, and Vitamin A supplementation. The CDI approach yielded better results, both in the treatment of fever in children under five years old and in the use of insecticide treated nets (lTNs). Further, treatment coverage of ivermectin improved with co-implementation with malaria control. The network of community-directed imple- menters, over 470,000 in 16 countries to date that have been trained in onchocerciasis con- trol programmes represent a potential entry point that may be used for co-implementation of home management of malaria, the com- bined distribution of ivermectin and treated bed nets. The house-to-house ivermectin distribution method is a good opportunity for the network of community directed imple- menters of onchocerciasis control to assist with the hanging of insecticide treated bed nets, document and report on the use ofnets by household. Co-implementation of malaria and onchocerciasis using the CDI approach is strategic, in that it will present an opportunity for greater ownership of malaria programmes by communities, which will in turn encourage sustained interest. lt will also both increase coverage of interventions required for malaria control and increase ivermectin coverage and enhance sustainability of CDTI. I a. Develop and co-finance co-implementa- tion of malaria control and CDTI activities. This will include choice of suitable CDDs, underscoring gender issues, training in distribution and use of lTNs, and the home based management of fever in children and document experiences. b. Work with different partners and countries to encourage the adoption of CDI as a policy for implementation of HMM com- munity programmes, where appropriate; develop a set of tools that will allow Roll Back Malaria projects to adopt CDI; system- atically work with countries in the region to ensure that the CDI strategy is incorporated in the HMM training manuals at country level and jointly develop a monitoring tool with malaria programme. Soil Transmitted Helminths and Trachoma. The treatment strategies for these diseases depend on the prevalence, sometimes target- ing whole populations, more often just target- ing children of school age or perhaps also pre-school children. These diseases still need to be mapped in many areas. Coordinated strategies need to be explored where there is CDTI, school delivery systems, Mother and Child Health Days, and NlDs all co-existing. Vitamin A supplementation to children under five will also be included. a. Work with partners to develop suitable integrated MDA policies and strategies and set up multi country pilot projects to mo- nitor their efficacy. Assist some countries already doing CDTI to scale up MDA. b. Use CDI for education for behaviour change. Develop strategies for MDA and morbidity control using CDl. ln Table 2, an additional budget for strength- ening co-implementation of CDTI with other interventions is provided. 6. CDI with other MDA Apart from Onchocerciasis, LF and malaria control, there are other important NTDs ap- propriate for MDA including schistosomiasis, Table 2: Budget on additional activities relating to co-implementation E c o U o a .g(, at u oE IJ tr o o @ E E o E, o L c o(, L 19 Activity us$ 1 lntegration and co-implementation a lntegrated mapping b lntegrated M&E c lntegration of morbidity management 2 Training a Training of integrated CDI b Training and tech assistance for non-oncho areas 3 Coordination and advocacy a Coordination with other health initiatives b Advocacy for supportive policies for CDI c Advocacy for coord policies for volunteer incentives d Co-financing of CDI where there are no NGDO partners 4 CDI with LF a Add albendazole in co-endemic areas b Expansion of CDTI to cover lmplementation Unit c Expansion of CDI to non-oncho areas 5 CDI and malaria a Dev and co-fin community malaria control activities b lnclusion of CDI in the guidelines for malaria control 6 CDI withotherMDA a Technical assistance and co-financing of integrated MDA in oncho areas b Community health promotion for related behaviour change 300,000 WHO Geneva 300,000 250,000 650,000 100,000 250,000 lncluded in PAB 2008 - 2015 1,200,000 50,000 900,000 1,000,000 lncluded in PAB 2008 - 201 5 100,000 TOTAL 5,600,o00 250,000 250,000 ll E.-J E I::TI l.,l E 3 r F. I tk ,1. I I. q } t _4 - t I I \- I\ \ a!4, t .t 'J I I Ft f\ \i' t a ) ,gtF I Y t, ) "'11il8 l ,lI ( -. I a i r/"\ .L!a a. -{ \I 1: i;. :it 'ti ,t \ , To determine when and where onchocerciasis treatment can be stopped APOC's control strategy is based on ivermec- tin treatment. When the Programme was launched in 1995, it was known from clinical and community trials that the drug is effective against the microfilariae that cause the severe manifestations of the disease, and that mass treatment with ivermectin is an effective strat- egy for eliminating onchocerciasis as a public health problem. The main limitation of the drug is that it has limited effect on the adult worms and that re-treatment is required at an- nual intervals. Early research had also shown that mass treatment with ivermectin reduces but does not interrupt transmission during the first years of intervention, and it was therefore concluded that annual treatment needed to be continued for a very long period of time. Hence APOC's objective was to establish "sustainable community-di rected ivermectin treatment in all endemic areas". Achieving this objective would ensure the elimination of onchocerciasis as a public health problem. However, the question whether transmis- sion of the parasite could be eliminated and ivermectin treatment stopped remained unanswered. This question was deferred to a future stage when sufficient evidence would have been generated to determine whether ivermectin treatment could ever be stopped or not. The first evidence is now available. A study in onchocerciasis foci in Senegal and Mali with 17 years of ivermectin treatment has pro- duced the first evidence that onchocerciasis transmission can be eliminated with ivermec- tin treatment and that treatment can be safely stopped without recrudescence of infection and transmission. Furthermore, available data from other onchocerciasis foci in Africa with over 15 years of ivermectin treatment indicate that the results from Senegal and Mali are not unique and that significant progress towards an endpoint scenario has been made in other foci where infection levels are now close or equal to zero, e.g. in foci in Guinea Bissau, Guinea, Togo and Nigeria. The new evidence has introduced a new paradigm for onchocerciasis control in which elimination of infection and transmission can be achieved through long-term ivermectin treatment, thus creating a definite solution to onchocerciasis. Based on preliminary results from the study in Senegal and Mali, the Working Group on the Future of Onchocer- ciasis Control in Africa anticipated this and proposed an additional objective for APOC to "develop the evidence base on when and where ivermectin treatment can be stopped, and provide guidance to countries on how to prepare for and evaluate cessation of treat- ment". This new objective was accepted by JAF12 in December 2006. However, as the proof of principleof elimination had notyet been established at that time, the operational and budgetary implications were not yet defined. The new objective adds a fundamentally new element to APOC that has major implications for its operations. To the current focus on evaluation of coverage and sustainability of ivermectin delivery, a major new activity has been added to evaluate the long term impact of ivermectin treatment on transmission and infection, to map the trends in infection levels in different areas of the programme towards elimination end points, and to ensure sound decision making on stopping treatment in each area. This is a significant new responsibil- ity which will involve extensive activities that have not been budgeted for but that are criti- cal to bring onchocerciasis control to the final stage of elimination of infection and transmis- sion (Table 3). 6 E ou .g o .9(, o u oc Uc o o o E E IU o o 0. c o .9 21 Figure 4: Main activities towards elimination of onchocerciasis transmission and stopping ivermectin treatment L"ad rtudlcr on cllmlnadon(S.ncf.Ul,Lll) kddprklpl.ddlmimrb fHd t6d Fcdurs td itorrln8 uea(mt Ellmlnatlon of onchocerclaslj transmliilon wlth lYeremectln '10 r.r tr sfrry in iil ^POC p.oFR ff sry in d6td OCP ..car Etrkacy lMttdnl &e.d PO( For<c -' APOC for<B ri$ 1st ustffir #nl 1996'20m trPcM(tu Atra3rlnl trcndr and rtopplni tr..tmcnt Operational rearch on rtrlt d"s rnd t@lt Figure 4 provides an overview of the main activities that are required to achieve elimina- tion of onchocerciasis transmission in Africa and a short description of each of those activi- ties is given below. A timeline for the different activities is shown in the Gantt chart (page 26). 1. Lead studies on elimination of onchocerciasis transmission in Africa The study in Senegal and Mali has gener- ated the first evidence of the feasibility of elimination by demonstrating the absence of onchocerciasis infection and transmission two years after stopping ivermectin treatment in clusters of previously hyperendemic vil- lages in the core of three onchocerciasis foci. Treatment has now been stopped in all other villages in these foci and further evidence will be generated over the next two years. The studies will also produce tested field proce- dures for stopping ivermectin treatment. The research activities are managed by TDR and fully funded by the Gates Foundation. C@ceptull rnd oprradonal ,_ p6ftDl6 / rerM/ th.d6fr.mewqk for "llmlnltlm kalBMh c{hhtb66FLB Endpdt f pihrdotic.l .od mtdogrGt CcUo oi uotttht ._ d.lutio of int6tio/lr..si$h rlt6 a65(im of treatmnl Ol(HOSIM 1r.nsmillm l#tiq bpid tu9n68 .nd mrptng of rEldul hf<tb c6t-effft uve &aluaum lvategB o1tfsstl.(d d motrlq up 3lrrtsis 2. Conceptual and operational framework for elimination of t ra ns m ission Based on the general principles described in this document, a more detailed conceptual framework and operational plan will be de- veloped. This will involve the development of more accurate timelines based on a detailed assessment of the treatment history and geo- graphic scope of each APOC project, as well as the operational and financial implications of different scenarios with respect to evaluation methods and endgame strategies. The devel- opment of this framework wlll be driven by APOC in consultation with experts in relevant fields. An expert meeting will be held early 2009 to review and finalize the plan, taking into account interim work on specific ele- ments of the plan, the first results of explor- atory surveys in advanced APOC projects, and the outcome of the JAF in December 2008. E C oU o o E u oI o ,c U C o o at E E o B o o. c ol, 22 9t@rni 3. Assessing epidemiological trends and stopping ivermectin treatment Mapping trends towarrJs *timinmtion endpoints A first priority will be to assess the trends in infection levels in different APOC projects and predict when these will drop below levels where treatment can be safely stopped. Except for a dozen sentinel sites, APOC is currently not monitoring trends in onchocerciasis infection in APOC projects. However, there is a growing realization that such data are needed and JAF has already called for more data on the impact of ivermectin treatment in APOC. With the new objective of elimination, such data become even more imperative as shown from the experience of the OCP where longitudinal data on epidemiological trends in different river basins were instrumental for decisions to stop vector control. These OCP data were based on skin snip surveys undertaken at 3 year intervals in indicator villages in each river basin. Given the improved understanding of onchocerciasis infection and transmission dynamics, such regular surveys may no longer be necessary, but it remains essential to understand for each APOC project whether the infection levels are declining as expected and to predict when they will drop below the threshold for stop- ping treatment. Such trends will vary between projects according to initial endemicity level and treatment coverage. Model predictions of the impact of ivermectin treatment indicate that after 10 years of treatment, the reduction in infection levels should be so pronounced that it would be relatively easy to assess whether treatment has the expected impact and make more refined predictions when infection levels in each project would reach the elimination endpoint when treatment may be stopped. Based on the OCP experience and the results of the study in Senegal and Mali, an average of 10 villages per project is considered adequate to assess and map the trends in infec- tion levels throughout APOC. ln several areas in the former OCP countries in West Africa, onchocerciasis control also relies on ivermectin treatment and in most of these areas treatment started more than 15 years ago. Available data indicate that infection has fallen to very low levels in most areas. However, there are some exceptions where treatment has been incomplete, e.g. in Cote d'lvoire and Ghana, and where only few epi- demiological surveys have been undertaken after the closure of OCP. There is therefore also a need to undertake exploratory surveys in such areas to complete the epidemiological assessment in ocP countries. The "10 year" surveys in APOC projects and the exploratory surveys in OCP countries will also be used for monitoring ivermectin ef- ficacy according to a newly established proto- col in which a sample of skin snip individuals will be re-examined 3 months after treatment. The parasitological material collected in these surveys will be used by a TDR network of molecular biologists that are working on the development of molecular markers of pos- sible ivermectin resistance. Endgame strateqies When an APOC project has reached the predicted endpoint, another round of surveys will be done in the same villages surveyed at the "10 year" evaluation. lf these confirm that infection levels are below the elimina- tion threshold, the moment has come to consider stopping treatment. This will be a major decision that requires considerably more evidence from surveys in a larger spatial sample of villages to ensure that there remain no residual pockets of infection that could lead to renewed transmission. Based on the experience of the study in Senegaland Mali, it is estimated that a minimum sample of 70 vil- lages on average would need to be surveyed per APOC project before a final decision to stop treatment can be made. Furthermore, in onchocerciasis foci that had initially the high- est level of endemicity, and where therefore the risk of renewed transmission is highest, a system of entomological evaluation will be introduced with fly catching at two carefully selected catching points per project during E c o U v o .g u o u oc(, c o o o E E o o o 0. c o(, 23 E c oU o o .g(, o(, oC(, C o o o E E o It o 0. tr og 24 the year before stopping treatment and the first year after stopping to validate that the decision to stop was correct. The timelines in the attached Gantt chart (Figure 5) show when the above activities are expected to take place in different onchocer- ciasis endemic areas in Africa. Based on the results of the Senegaland Mali studies (where the epidemiological threshold for stopping treatment was already reached after some 15 years treatment) it is assumed for plan- ning purposes that treatment can be stopped after 15-17 years in each project. ln a dozen of APOC projects, the first rounds of ivermectin treatment were provided through the support of NGDOs before the launch of the APOC programme in 1996, and these projects are predicted to reach the treatment endpoint first. Another 40 APOC projects started treat- ment between 1996 and 2000, and these are predicted to reach the end point for iver- mectin treatment before the closure of APOC in 2015. The remaining APOC projects that started treatment after the year 2000 are pre- dicted to reach the end point after 2015. APOC will ensure "l0year" progress evaluations in all APOC projects, and support evidence- based cessation of treatment in half of APOC projects. APOC will prepare the remaining projects for cessation of treatment after 2015, and train and equip national teams for on- chocerciasis surveillance in all APOC countries. ln the OCP countries in West Africa, APOC will also assist evaluation activities relating to cessation of treatment and it is expected that by 2015 onchocerciasis transmission will have been eliminated and ivermectin treatment stopped in virtual all onchocerciasis foci in the OCP countries. The above activities involve a very significant amount of epidemiological and entomo- logical evaluations that have not yet been planned and budgeted for. However, they are essential to ensure that the achievements of decades of onchocerciasis control are not jeopardized by premature cessation of ivermectin treatment, but consolidated by sound decision making and confirmation of the elimination of the risk of onchocerciasis for future generations. 4. Operational research on strategies and tools Operational research has contributed signifi- cantly to the success of onchocerciasis control in Africa and it will also play a critical role in the final elimination efforts. The ONCHOSIM computer simulation model will be used ex- tensively in the analysis of the epidemiological trends and to predict for each project when it will reach the elimination endpoint when treat- ment can be stopped. Another operational re- search priority will be to optimize and develop more cost-effective methods and strategies for the epidemiological evaluations. This will involve studies to determine the most effective use of the DEC patch test, as a replacement of or combination with the skin snip method, and to develop innovative approaches to mapping residual infection levels. This will be combined with research on endgame strategies to shrink the treatment map, identify and mop up residual infections and shorten the tail of the treatment period. As in the past, the operation- al research agenda will be flexible and address new research needs when they become appar- ent as the elimination efforts progress and new challenges emerge. 5. Field evaluation of moxidectin A second reason for optimism on the feasibil- ity of onchocerciasis elimination in Africa is the promise of a drug that may significantly reduce the survival and reproductivity of the adult onchocercal worm, thus bringing the goal of elimination many years closer. ln the past 12 years, the APOC Trust Fund, TDR and OCP until its closure, through a tripartite agreement, supported the search for the development of a safe macrofilaricide. Several products have failed but the product moxidectin, presently undergoing Phase ll clinical trials, appears to have a potential not seen in the previous drugs, and thus deserves further investment. TDR will find funding elsewhere to cover the cost of the Phase lll clinical trials of moxidectin. lf so war- ranted by the results of the clinical trials, APOC will support large-scale Phase lV transmission trials to begin in 20]1. Table 3: Budget for activities on elimination of transmission and stopping ivermectin treatment E c o U q o .9(, 0t() oC o c o o o c E o o o 0. c o .9 25 ussActivity 1. Lead studies on elimination in Senegal and Mali 2. Conceptua! and operational framework 3. Assessing trends and stopping ivermectin treatment 3.'1. APOC countries Equipment and training of national epidemiological survey teams Advanced APOC projects with first treatment before 1996 Exploratory surveys Endpoint surveys Cessation of treatment and epidemiological/entomological validation APOC projects with first treatment between 1996 and 2001 "10 year" evaluation + efficacy monitoring Endpoint surveys Cessation of treatment and entomological validation APOC projects with first treatment after 2001 "10 year"evaluation + elficacy monitoring 3.2. OCP countries OCP areas with 15+ years treatment Endpoint surveys Cessation of treatment and epidemiological/entomological validation OCP areas with incomplete treatment Explorarory surveys Endpoint surveys Cessation of treatment and epidemiological/entomological validation 4. Operational research + strategy adjustment ONCHOSIM transmission modelling and prospective analysis Rapid diagnosis and mapping of residual infection Cost-effective evaluation strateg ies Differentiated treatment and mopping up strategies 5. Field evaluation of moxidectin Funded by EMGF 70,(xn 7'702'160 632',000 180'000 819',000 274'000 s20'000 3',m'000 987',160 6s0'000 2',824',O00 728',OOO 296',000 312',000 1',092',000 396',000 r'445',000 3s0'000 470',000 175'000 450'000 2',000'ooo 14',O41',160TOTAL I I I i I I I EEE- gEPEBg IE9,EEE6s&E2t .Lr3X< sEEXEEE!ETEEEEEeBcBiHE=EE€€S6XEE9€o EgIcfiEaO-OOdOo> r 5sRo! : 5 5-i E E:E ie iiP P E I EIE gEE E : EEE Ei i EEE EEE E i EiE ; E g- E!: EE: E I EEi E;,i8$EEE$E€E$E E$E!ESE -X;Z::EZ::6e:gllcdlf EiEefiiiE;iiE;!E;EEe;g,E FE $ H F E $ p = E $ [ E .3 b ur u o at t o , o E! c "9 a & o ! c a -f oooE oo Gi P f oI a o 'a oo E6io EEi €E*EEE;Eg &ss'rEs E9: .sE.E aEa sEE o6GgE$ a o .9E .: to o -9a!o c o E lE A) c .E (, E (u .u E'T c 'a CL o I,c o c .9 .9 E c o o c o o .= E ul ,ii o .9 1 u't o N I o o o N oo1' =o d c .9 u o c o d o .E o E E c oE1' o c o u .g o o 6 o(,, oC u c o o o E E o B o 0. c o .g 26 l",l ftIHETI-,.t Eftl,l It{l_; lI;EHETEI-,.1 I f'{ ft I-, I-l I-r tJ I-, E l-'.t ff TI Il H E Gender roles can affect participation in a pro- gramme. ln the CDTI strategy, the roles and responsibilities of the stakeholders including communities are clearly defined and respect- ed. Collection of ivermectin from the nearest health facility or agreed collection point is the responsibility of communities. Also, decisions related to drug distribution including selec- tion of ivermectin distributors and supervisors are also the responsibility of communities. These responsibilities were defined from the onset of APOC mass drug distribution 12 years ago based on the results of the TDR multi-country study on CDTI. The experience, since then, has shown that when given the chance communities select trusted persons as distributors from among their own ranks. Because of their socially and culturally con- structed roles and relationships, men and women have different opportunities and constraints related to their overall participa- tion in CDTI activities. ln 2002, monitoring data of projects consisting of 109 focus group discussions (FGDs), 6069 household survey respondents and 89 interviews with ivermec- tin distributors were analyzed to gain insight into the attitudes and behaviors of men and women in relation to ivermectin treatment, and their participation in CDTI. Although there are no statlstically significant gender differences in coverage rates for ivermectin treatment, culturally prescribed gender rela- tionships influenced the ways in which men and women expressed treatment-related be- haviours. Decision-making in communities on the selection of distributors followed socio- cultural hierarchies. Few ivermectin distribu- tors (21olo) were women in that year, 2002. Whilst in subsequent years, this proportion has significantly increased in most districts in Uganda and Ethiopia in other countries, some CDTI projects have less than 15olo of the distributors as females. ln 2005, the ExternalEvaluation of APOC observed that religion and age-old traditions of male dominance in many cultures, as well as illiteracy, have seemed to work against the involvement of women in CDTI. lnformation from projects'technical reports and the CDD treatment registers show that where women have been selected as CDDs, their perform- ance is equal to that of their male counter- parts. Another positive trend observed in some projects was that of "pairing" male and female CDDs, to the benefit of the commu- nity served. lmproved health education was shown to improve the participation of women in drug management and distribution activi- ties and women when involved as distributors achieved higher treatment coverage. Studies also showed that the community directed intervention approach had broader effects on the role of women in endemic com- munities and significantly strengthened their involvement in the decision-making proc- esses at the community level. Over time, more women attended community meetings; they became more outspoken and participated more actively, insisted that implementation strategies be modified to meet their specific needs, and demanded that more responsibili- ties be assigned to them. With the additional funds available APOC will: a. Encourage and support projects to carry out operational research to determine the preferences of communities, improve health education, encourage the participa- tion of females in allCDTl activities while respecting the decision of communities. b. Support countries to develop strategies that recognize gender differences will have important implications for long-term com- pliance to treatment and the overall quality and sustainability of the programme. c. Support the national onchocerciasis task- forces to submit data on capacity building at community level disaggregated by sex. n o N t @ o o N ooEf oq c .9 u o cg G oC o EfEc atEE o tr o U o o .g(, o u oC u c o o o E E o o o 0. c o u 27 r n oNI o o o N ooEf oq cI l', o cg G o3 o E =E c oEE o c oo o ]i s l', o o o (, c o o o E E o o o o c og 2a d. The Programme willfrom 2009 include in the annual progress report data on training and treatments disaggregated by sex. e. Support an in-depth analysis and review of available 1O-year data of over 100 projects in 15 countries by sex. f. NOTF and CDTI projects will be supported to intensify sensitization and mobilization to encourage communities to select more CDDs to increase the CDD/population ratio, alb Table 4: Budget for promoting gender activities Budget line items Operational research on gender issues including compliance to treatment in onchocerciasis control Support national onchocerciasis taskforces in data collection by gender - partially budgeted in PAB 2008-201 5 Collection and reporting of training and treatment data disaggregated by sex from 2009 Support an in-depth analysis and review ofavailable 10-year data Support NOTFs in community sensitization and mobilization strategies inclusive of minorities and women in CDTI Scholarships to women for higher level training in epidemiology, entomology, programme management and other disciplines (at USS 500,000 per year br 7 remaining years of APOC) decrease workload and improve coverage. Community sensitization and mobilization for inclusion of minorities and women in CDTI will be encouraged. g. More scholarships will be given by APOC in order to correct the current gender imbal- ance. Women will be given priority in the selection for MSc or diploma training in disciplines (e.9. epidemiology, entomology) relevant to onchocerciasis control. Amount 250,000 c 250,000 Already in approved PAB Already in approved PAB 100,000 3,s00,000 d e f s Mainstreaming gender in APOC operations us5 4,100,000TOTAL I i H U H ff H l-.t E:= rl U F'.t r::E, l,l ff r'{ ft r= E l,{ E H T, ftE I'{IHIETI''.] ftTII-]H ftT.{EI EUF, l-, llF;T EEI-,;[,t Ir]EE For three important reasons, further strength- ening of the capacity of APOC management deserves favoura ble consideration. Fi rstly, the mandate of APOC has changed with a paradigm shift from single to multiple disease focus; therefore, there is a huge increase in the tasks of APOC management staff in Ouagadougou. Secondly, because core CDTI activities are carried out by communities and frontline health facilities often in hard-to- reach areas, weaknesses in communication between hierarchical levels of the programme and projects including close supervision as well as addressing health system issues need to be addressed during this Phase ll and Phasing-out Period. A health system specialist will be useful in the integration of Programme actlvities into national health systems. Thirdly, is the need to begin transferring programme technical, administrative and financial man- agement activities to countries and reinforc- ing countries'capacity to manage these after the exit of APOC in 2015. ln this regard, the External Evaluation of2005 also observed that "...there is o serious potentiol problem in stoffing just when APOC activities ore their peok... and odditional stoff moy be oppropriate because specific ond consideroble effort is now needed for properly tronsferring programme activities to countries." Programme Headquarters For the Programme statutory meeting, the Technical Consultative Committee (TCC) has been relieved from undertaking financial evaluations; and the processes for conducting technical reviews have been standardized. However, the number of projects in APOC has increased significantly, which also entails the need to review many more annual technical reports by the TCC, a process facilitated by Programme management staff at the head- quarters. A signiflcant asset would be the creation of one Senior Staff Research post at the HQ for the coordination of APOC research activities to reduce the notorious overload on APOC management. This concern was addressed in the Plan of Action and Budget 2008-2015 and a short-term staff(P4) has been recruited in 2008. Personnel "APOC should intensify communication with project stoff ot vorious levels ond with partners. This could be done, for example, through en- honced field visits to promote o shared under- stonding of problems encountered and their possi b I e sol uti ons." - Exter n o I Eva I u ati o n, 200 5. For this recommendation to be efficiently im- plemented there has to be an increase of staff and more importantly; an attractive package offer of not below professional staff level P5 must be given serlous consideration. ln keeping with the above, and we propose additional increase of the professional staff (technical, administrative and financial) at the APOC headquarters to manage the imple- mentation of the original Plan of Action and Budget 2008- 2015 and this addendum to the PAB. FIXED.TERM STAFF In the revised Phase ll and Phasing out period of APOC (2008-2015), 15 professional staff members were budgeted for. Among the '15 professionals, only seven are scientists to support the implementation of the 117 projects in 16 countries. The budget for the revised Phase ll and Phasing out period of APOC was submitted prior to new findings that interruption of transmission of onchocer- ciasis is achievable. APOC management will need to be strengthened to undertake this important task, which we now know will add an additional scientific burden. With the expansion of the Programme's activities decided by JAF13 as documented in the present Addendum, it became necessary U) o N I o o o N f ooE oq c .9 I o cg 0. oC o E =E c oEE o c ou o o .g u o l., oC(, tr o o o E E o o o o t o l', 29 I n o NI @ o o N oott a oq c .9 o o cg 0. os o EfE c oEE o c o U .9 o .g(, o(, o .C uc o o o E E o o o o tr o .9 30 to review the staffing, mainly technical staff but also administrative and financial staff to be able to reduce the already heavy workload of the present staff. Therefore, in addition to the two epidemiologists being recruited in the framework of the approved revised Phase ll and Phasing-out document, it is planned to hire one Health system specialist (at P5) and one socio-scientist (at P4) for the SDD unit, one Finance officer (at P3), one Programme Officer in charge of meetings and reporting (at P2) and a Deputy Coordinator (at P4) in the COORD unit. Most of these staff members will be maintained up till 2012 at least when, with significant reduction in APOC funded projects, the number of professional staff should decrease. Temporary staff During the Phase ll and Phasing out period (2008-2015), APOC will, on temporary basis en- gage the services of experts to support man- agement in transfer/decentral ization activities (03 months/year), modelling (02 months/year), epidemiological assessment of onchocercia- sis and loiasis (07 months/year), entomology and programme management (05 months/ year). Therefore, for a total of 17 months per each year the Programme will have support to handle all three objectives mentioned in the Addendum. ln addition, general service tem- porary staff will be hired as drivers (4 months/ year) clerk (4 months/year) and multipurpose support staff (4 months/year) to support the new staff members, epidemiological assess- ment exercises and ensure replacements dur- ing the holidays of the existing staff for a total of 12 months/year. Administrative support services, logistics and inf rastructure For the additional professional staff, it will be necessary to prepare office space and equip- ment and make provision for computers (06) and their accessories. The general running costs of the offices will be increased by 3o/o. Consultants services Budgetary allowance will be made for the employment of consulta nts/tem pora ry advisors whenever necessary. The consult- ants/temporary advisors will be recruited to provide support to the Headquarters office as well as to countries in technical, financial and administrative management of onchocerciasis control and nuisance control projects. About 98 men/month of consultancy will be needed for the period 2009-2012. It is estimated that additional USS 6,64 million will be required for engaging new technical, administrative and finance staff to support APOC management up to 2012. Table 5: Additional budget for human resource, management, administration and support services Strengthening human resources, management, administration and support services uss PERSONNEL SERVICES Professi o n a I fi xe d-tet m st aff 3 Scientists & 1 Administror (P4- P5) 2 Finance & Programme officers (P2 - P3) Temporory staff Consultants/Short term staff Gerneral Services staff ADTIII N. SUPFORT, TOGISTICS AND I il FRASTRUCTURE Vehicles Ofhce space & equipment 2,585,000 1,560,000 977,OOO r43,000 100,000 80,000 TOTAL 6,640,OOO I E U l-l l-l ft I-'t !-{ E U tt tI; ET A summary budget of this addendum below presents the allocation of the extra US$ 36.4 million for the three objectives mentioned above, mainstreaming gender in APOC operations and strengthening APOC management. Table 6: Summary budget The management of APOC presents this addendum to the Plan of Action and Budget 2008-2015 for consideration and approval of the.Joint Action Forum. u't o NI @ o o N oortJ oq c .9 I o c o d 0,G o E =E c oEE o c o u o o .! u o u oC u c o o 0t E E o o o 0. C o u 31 Addendum: Summary budget uss 2 3 A B Budget line items lncreasing support for CDTi in (post) conflict countries To implement onchocerciasis control activities in conjunction with other health interventions (co-implementation) To determine when and where treatment can be stopped Mainstreaming gender in APOC operations Strengthening human resource, Management, administration and suppon services Amoum 6,050,000 5,600,000 1 4, 041,1 60 4,100000 6,640,000 36,431 160TOTAL For more information please contact: d irapoc@oncho.afro.who.int o APOC/WHO 2008 Graphic design: Lisa Schwarb Photos: Hannah Brown, WHO/TDR/Craggs AFRICAN PROGRAMME FOR ONCHOCERCIASIS CONTROL African Programme for Onchocerciasis Control (APOC) World Health Organization 8.P.549 - Ouagadougou - BURKINA FASO Tel: +226-50 3429 53 I 503429 59 I 503429 60 Fax: +226-50 342875 I 503426 48 di ra poc@oncho.afro.who.i nt www.who.int/apoc