Onchocerciasis control programme external evaluation 2002

Onchocerciasis Control Programme in West Africa Programme de lutte contre l'Onchocercose en Afrique de I'Ouest ! JOTNT PROGRAMME COMMITTEE Office of the Chairman JOINT PROGRAMME COMMITTEE Twenty-third session Ouagadougou- 4-6 December 2002 JPC - CCP coMIrE coNJoINr DU pRocRAMME Bureau du Prdsident JPC23.9 ONGINAL: ENGLISH October 2002 Item 7 of the Provisional Agenda ONCHOCERCIASIS CONTROL PROGRAMIVIE EXTERNAL EVALUATION 2OO2 Evaluation Team : Oladele Kale (Chair) Jorg Grunewald Georges Koulischer Achille Massougbodji Paramjit Sachdeva I II t l a ABR AFRO APOC ATP BIS B.t. H-14 CDD CDTI CMFL CSA DPT DNA EAC ECOWAS EET EG EPI ERR GEF HKI ICF IDS IEC IRD JPC MDSC MOA NGDO NOTF OCP OCRC OCT OPC PAG LIST OF ACRONYMS Annual Biting Rate WHO Regional Offrce for Africa African Programme for Onchoccrciasis Control Annual Transmission Potential Biostatistics and Information Systems Unit (OCP) Bacillus thuringiensis serotype H-l 4 Community-directed Drug Distributor Community-directed Treatrnent with Ivermectin Community Microfilarial Load Committee of Sponsoring Agencies (OCP) Diethylcarbamazine patch test Deoxyribonuclcic Acid Expert Advisory Committee of OCP Economic Community of West African States External Evaluation Tcam (2002) Ecological Group (of OCP's Expert Advisory Comminee) Epidemiological Evaluation Unit (OCP) Economic Rate of Return Global Environmental Faci lity Helen Keller International Inter-country Facility Intcgrated Disease Surveillance Strategy Information, Education and Communication Institut de Recherche pour le DCveloppement (ex-ORSTOM) Joint Programme Committee of OCP Multi-Disease Surveillance Cente (AFRO) Memorandum of Agreement Non-govemmental Development Organisation National Onchocerciasis Task Force (APOC countries) Onchocerciasis Control Programme (of West Africa) Onchocerciasis Chemotherapy Research Centre (Hohoe, Ghana) Onchocerciasis Chemotherapy Project Organisation pour la Prdvention de la Cecit6 Preparatory Assistance Mission to the Govemmens (of the 7 countries of the OCP "Original Programme" area) Planning, Evaluation and Transfer Unit (OCP) Rapid Epidemiological Mapping of Onchocerciasis Special Intervention Team Special Intervention Zones Special Service Agreement Sight Savers Intemational Short Term Consultant UNDPAMoTId Bank/WHO Special Programme for Research and Training in Tropical Diseases West African Freshwater Biodiversity Conservation and Ecosystem Management West African Health Organisation World Health Organisation World Health Organisation Country Representative REMO SIT Sru SSA SSI STC TDR PET WAFEM WAHO wHo WR ONCIIOCERCIASIS CONTROL PROGRAMME EXTERNAL EVALUATION 2OO2 TABLE OF CONTENTS Acknowledgements Executive Summary... 1. Introduction Page .......I-vlll z Assessment of OCP Achievements. . . .. 2a. ProgrammeAchievements..'.'. 2b. Training and Fellowships....... 3. OCP's Secondary [mpact on National Health Systems 3a. Areas of Secondary ImPact. 3b. Ecological Studies...... 4. Impact of winding down of ocP Activities on National capacity to Detect/Control Onchocerciasis Recrudescence. . . . . .. . . 4a Assessment of National Capacity. 4b. Future National and Inter-Country Requirements......... Relationship of National Onchocerciasis Detection/Control with the AFRO Multi-Disease Surveillance Centre (MDSC). .2 ,2 l0 l6 ...t7 ,.,17 5 6 7 5a. MDSC Functions 5b. RelationshipwithNationalOnchocerciasisProgramlnes Need for, and Modalities of, NGDO Collaboration with Participating Countries after 2002. 6a. Current Role ofNGDOs.. 6b. Future Role of NGDOs... Institutional, Financial and Operational Aspects of Residual Onchocerciasis Activities after 2002.. 7a. Special lntervention Zones. 7b. Winding-down of OCP. Conclusions and Recommendations 8a. Conclusions 8b. Recommendations. t9 l9 .19 .....,.'.,.23 ,..,..,....24 ...,....,.,27 ..30 ..30 ..32 ')) ..22 ..22 8 I l3 l5 Boxes: Charts: Page ..1 .3 .4 ..5 .6 .8 1l l5 .35 .36 t. 2. 3. 4. 5. 6. 7. 8. 2. The External Evaluation Team's Terms of Reference..... Onchocerciasis Control Programme (OCp)-Basic Facts Institutional Arrangements for OCP... OCP Funding and Expenditures........... Flexibility of the Programme in Strategy and Operations.. OCP's Operational Research Activities. .. Fellowships and On-the-job Training provided by OCp OCP's Ecological Monitoring System. History and Evolution of Control Strategy Development in OCp Operational Research in OCP. Maps: t. 2. 3. 4. 5. 6. 7. Annual Transmission Potentials: Pre-Conhol Annual Transmission Potentials-20O I . . . Operational Situation Existing in the Programme Area in 2001. Pre-control Prevalence of lnfection....... Prevalence of microfilariae in villages evaluated between 2000 and 2ool... Proposed Special Intervention Zones.. OCP Areas of Large-scale Ivermectin Distribution (2002) ..,,37 ..38 .39 .40 .4t .42 .43 D ACKNOWLEDGEMENTS The External Evaluation Team (EET) greatly appreciates the excellent cooperation received from staff of the OCP, the Participating Counties, Donors, AFRO, and NGDOs who provided the wealth of information and documentation upon which this assessment is based. We are particularly grateful to the national health authorities, district, and local-level health services staff and communitydirected drug distributors who responded to our inquiries during field assessments in the nine Participating Counkies visited by two rnembers of the EET. We also wish to thank the Chairs and members of the EAC and CSA who provided opportunities for intensive interaction, and thus helped refine our observations and conclusions. OCP staff and resource persons have been particularly helpful. They are too numerous to list separately, but we wish to thanlq in particular, Dr. Boakye Boatin, Director of OCP, and his staff at Ouagadougou; Dr. OIe Christensen and Mr. Abdulai Daribi of the OCP Liaison Unit at WHO, Geneva; Mr. Bruce Benton, and his staff of the Onchocerciasis Coordination Unit at the World Bank, Washington, D.C.; Dr. Azodoga Seketeli, Director of APOC, and his staff at Ouagadougou; Dr. Samuel Bugt , Manager of MDSC, Ouagadougou; Dr. Bernhard Liese of the World Bank, member of CSA; Dr. Adenike Abiose, Chair of EAC; Dr. Hans Remme of the TDR" Geneva; Ms. Pamela Drameh, NGDO Intemational Coordinator, Geneva; Mr. Tom Topping of WHO, Geneva; Dr. Janis Lazdins of the Macrofil Project, OCT, Geneva; Prof. David Molyneux of the Liverpool School of Tropical Medicine, Liverpool; and Dr. Bernard Philippon of IRD, Paris. We also thank the CSA, particularly staff of the WHO and World Bank, who entrusted us with the important and exciting task of assessing the OCP. We are gratified that our terms of reference included not only an assessment of the Programme's past achievements and current actions in anticipation of winding down from December 2002, but also the strategic actions needed for ensuring the future sustainability of OCP's considerable achievements. EXECUTryE SUMMARY Erternal Evaluation of the Onchocerciasis Control Programme (OCP) a) In accordance with its terms of reference, the External Evaluation Team (EET) presents in this report its assessment of the achievements of OCP against the Programme's stated objectives. It also reviews: . The secondary impacts of OCP on Participating Countries' health systems; . The implications of the winding down of OCP; . The modalities of interactions between non-governmental development organisations (NGDOs) and Participating Countries, after 2002; and r The institutional, financial and operational implications of residual conhol activities, after 2002. In doing so, the EET has reached conclusions and made recommendations for the Joint Programme Committee (JPC) meeting scheduled for December2002 (JPC23). b) The extemal evaluation is based on a review of the extensive documentation provided by OCP; field visits to nine OCP countries by two EET members; and interviews of key staff of OCP, APOC and MDSC. We have also benefited from interactions with the OCP Expert Advisory Committee (EAC) at its meeting in March 2002, and with the Committee of Sponsoring Agencies (CSA) at its meetings in July and September2002. c) The EET concludes that OCP objectives have largely been met. Onchocerciasis has been virtually eliminated as a public health problem in participating countries, and as an impediment to socio-economic development. Devolution to Participating Countries has been effectively undertaken. CounEy nationals seem able and willing to maintain OCP achievements in the coming years. d) The winding down of OCP activities is progressing satisfactorily, but some residual activities need to be undertaken urgently. These activities relate, in particular, to: ' The proposed Special Intervention Zones (SIZ; covering the basins of the Pru in Ghana, the tributaries of the Oti and Upper Ou6m6 in Togo/Benin, and the Mafou and Tinkisso rivers in Guinea); , The resumption of the oncho control program in Sierra Leone, and ' The WHO Regional Offrce for Africa (AFRO) Multi-Disease Surveillance Centre(MDSC). Faster progress is awaited in relation to these aspects. e) Looking to the future, the EET: . Expects satisfactory winding down of OCP from December 2002; ' Expects that "wrap up" activities at OCP headquarters will be completed by March 31,2003; ' Believes that Participating Countries are capable of undertaking oncho-control activities, after 2002; ' Endorses the proposed activities in the SIZs and Sierra Leone, and supports continued strengthening of MDSC, while noting a few concerns and suggestions; Expects continued collaboration among Participating Countries, and continuing support to them from AFRO, MDSC, APOC, NGDOs, and Donors; and Believes that there are sufftcient indications that OCP achievements can be maintained for the foreseeable future. OCP Achtevements f) The Programme's sustained efforts since 1974 have had a significant impact on the prevalence of onchocerciasis in the I I Participating Counbies. As reportea Uy OCf : ' Prevalence rates and the annual transmission potential have fallen dramatically to levels that no longer pose a major health problem in most river basins in the Programme areas; ' 40 million people have been protected in participating countries; . 600,000 cases ofblindness have been prevented; ' 25 million hectares of arable land have been freed of onchocerciasis; . l8 million children have been spared the disease; ' The land area freed of the disease will help feed an estimated 17 million people; and ' The Programme has achieved a20Yo economic rate of return (ERR) on the US$556 million committed by donors to the programme. OCP's secondary impact on national health systems g) National health systems have been strengthened in Participating Countries. Specifically, OCP has facilitated human resources development through haining of polyvalent staff who now work on onchocerciasis as well as other diseases. Surveillance tools prepared by OCP, such as detailed manuals and guidelines, serve as models for surveillance of communicable diseases in an integrated health system (such manuals have been prepared by Benin, Guinea, and Mali). A suitable "data management culture" has been diveioped to take advantage of the training materials and manuals; and there have been collateral improvements in data management. Vehicles and equipment (such as computers, corneo- scleral punches, and hydro-biological equipment) have been provided, are being used within an integrated national health service structure, and will need to be maintained by countries. h) More broadly, the Onchocerciasis Control Programme has facilitated health sysrems reform. It has served as a model for decentralization of the health system; has provided an entry point for other health Programmes; and has stimulated community-drivin health service delivery. The ecological studies conducted under the auspices of OCp's Ecological Group have helped expand the knowledge of aquatic fauna -of rirers, and of the management of biodiversity of lotic ecosystems, but the ecological database needs to be better utilised. I lt Impact of OCP winding down on nationel capacity to detecUcontrol onchocerciasis recrudescence i) There seems to be suflicient national capacity to undertake onchocerciasis confol after 2002. Training and fellowships provided by OCP have made a difference, and have enabled the devolution of epidemiological and entomological surveillance to national oncho teams. National capacity to undertake ivermectin (Mectizan @) distribution has been built with OCP support. These activities could continue for as long as necessary. After 2002, aerial vector contol will continue only in one of the SIZ areas for the next 5 years; but ground larvidicing for nuisance (but not vector-) control can be undertaken by national staff, if needed. However, EET field visits revealed that integration of oncho activities with other aspects of the integrated health service delivery system is stronger at disfiict and sub-district levels than at regional and national levels. The roles of WHO Representatives (WRs) and NGDOs will remain important aftet 2002. Inter-Country Collaboration j) Countries have long recognized the need for inter-country collaboration and coordination. The EET commends OCP for is major contribution in this, throughout its existence. We also note that in December 1995 the Meeting of Ministers of Health of Participating Countries urged the establishment of an "inter-country facility". The Participating Countries have since recognized their own continuing responsibility for inter-country col laboration, fac ilitated by Regional partners. k) We expect AFRO would continue to serve as a catalyst for developing strong inter- country cooperation, using all its resources--WRs, MDSC and APOC, according to their technical competencies and the countries' requirements. The West African Health Organization (WAHO) would facilitate and contribute as well, as appropriate. l) Specifically, we believe the WRs have a continuing role in establishing inter-country links, through AFRO; and there is a strong need for active information sharing between OCP and APOC countries, for the mutual benefit of all countries. The areas to be covered include Community-directed Treatment with Ivermectin (CDTI), epidemiological and entomological surveillance, detection of recrudescence, and in formation, education and communication (IEC). m) We recommend that a Forum within the ambit of APOC and in conjunction with MDSC be established, to facilitate meetings for periodic stocktaking, discussing oncho trends, and tackling technical issues. After 2002, inter-country interaction would be enhanced by the OCP staf?expertise absorbed by APOC and MDSC. Relationship of national onchocerciasis control with MDSC n) The EET believes that the MDSC should be able to respond to the needs and requests of the countries in surveillance, research, data-bank development, information sharing, training activities in support of country needs for effective disease control Programmes, ,i tlt and inter-country dialogue and resolution of issues of mutual concern in the priority(disease) areas, including onchocerciasis. o) The MDSC is establishing contacts with WAHO--a specialised institution of the Economic Community of West African States (ECOwAS)-for the mutual benefit ofboth organisations, and for avoiding duptication of efforts. Enhanced cooperation and communication is foreseen by these two organisations. p) The EET believes the MDSC also needs to maintain active cooperation among the OCp and APOC countries:particularly for ensuring effective quality control and helping maintain oCP achievements--for the mutual benefit of all oncho-endemic countries in 4fri9". The process of engagement and dialogue among the countries would befacilitated by the expertise of some OCP staffptanned to be absorbed into MDSC. NGDO collaboretion with OCp countries q) The EET recognises the important role that the NGDOs have played since theintroduction of ivermectin, before and since the advent of CDTI. These organisations have not been involved at all in vector control activities. We believe that NGDOs will continue to promote/provide CDTl-related oncho control activities in participating countries, after 2002. r) The EET believes that NGDOs would not expect nor be expected to replace OCpfunctions or funding. They would instead serve as partners witir governmeni, and their operations would continue in the spirit of cooperation with all other staieholders. International NGDOs are encouraged to help identifi and develop the potential of localNGDOs that are active in oncho control activities. These organizations should have access to relevant documents, including training manuals p.ep"red by ocp. Institutional aspects of onchocerciasis control activities after 2002 s) The EET comrnends OCP for a very comprehensive and syslematic "plan of Operations for. the Phasing-out Period 1998-2OOZ-. itris document has provided a sound'basis for satisfactorily winding down of the programme. 0 We believe that for Participating Countries to maintain OCp achievements on a sustainable basis, the following oncho-control activities will need to be maintained in OCP countries: ' Community-directed treatment with ivermectin (CDTI) throughout the OCp- Programme and other areas, as needed; . Ongoing epidemiological and entomological surveillance; ' oncho data collection and management, and software maintenance; ' Training and re-training of public health staff working on onchocerciasis; . Information, education and communication (IEC) activities; ' operational research, as needed, with TDR support (e-g., for testing a suitable macrofilaricide, sustainability of CDTI, determining ionditions und., which tv ivermectin disnibution for onchocerciasis could be safely discontinued, and the feasibility of intemrpting transmission with ivermectin alone); Information-sharing with parfirers (including in other countries); In the Special Intervention Zones, enhanced CDTI, as well as aerial larviciding in limited focal areas in Togo and Benin; and Resumption of the oncho contol programme in Sierra Leone. Institutional aspects of SIZ activitles u) In general, OCP's August 2002 proposal for the SIZ provides a sound basis for moving forward. The EET notes that the proposed SIZ covers a very small percentage of the population and geographical area of the OCP countries; and that the remaining areas will Le the responsibility of national authorities. We are satisfied that residual conffol activities, io be canied out by national health teams in conjunction with Special Intervention Teams (SIT), are needed in the proposed SIZ. For technical reasons, these could not have been undertaken before December 31,2002. Detailed comments on the actions needed to launch SZ activities are included in the main report. Financial aspects of"residuel" oncho-control activities efter 2002 v) The EET expects that residual activities in the SIZ will be adequately funded from the Reserve of the OCP Trust Fund. Because oncho is no longer a public health problem in OCP countries, supplementary bilateral-funding may be needed for oncho control in case of funding shortfalls at the national level. The EET expects that adequate funding of MDSC and other inter-country oncho-related activities would be available. w) For Sierra Leone, the EET was informed that the Reserve of the OCP Trust Fund would be used to resume oncho control efforts that were disrupted due to civil unrest. This will help reduce the risk of reinvasion of infected flies into areas already freed of onchocerciasis, particularly in Guinea Operational aspects of "residual" oncho-control activities after 2002 x) The EET is satisfied that operational aspects of phasing down of OCP are being handled fairly and expeditiously, including the proper disposition of the human, financial, physical, and information resources of the Programme. When formulating measures for winding down, OCP has given full attention to the process of transfer of capacity and assets to Participating Countries and other concerned parties. The EET believes that efforts made by OCP for its staff in anticipation of winding down, as well as support from the AFRO Regional Director in this respect, are commendable. OCP's success has important lessons for the future y) The EET believes that OCP's success is due to a number of factors, acting in concert: . Flexibility in strategy and operations; . A science-based, results-driven Programme, effectively utilizing operational research; ' A strong counbry focus, and a responsive Programme with emphasis on capacity- building; ' Pooled finances, which enabled the "non-tied" Trust Fund mechanism to facilitate flexibility; ' A regional approach, which generated a strong feeling of collective responsibility; and ' Collaboration and partnership among the Participating Countries and alt other stakeholders (including NGDOs, Donors, Merck & Co., and Sponsoring Agencies). z) Organizational and managerial factors have also played an important part. The Programme has benefited greatly from: ' OCP's facilitative/catalytic role in producing effective inter-country collaboration; ' Well-defined and clear roles, responsibilities, and accountability of various actors(governments, NGDOs, WHO, World Bank); ' lransparency and equity in decision making, based on mutual trust; and ' OCP's unique organisational features-its internal culture, staff,, leadership, technical excellence, effective governance, and consistent donor support. aa) The sustained commitment and untiring efforts of national onchocerciasis teams, health services staff at all levels, community workers--and, of course, the communities themselves--have_b-een enormously significant as well. The exemplary manner in which this diverse set offactors has been managed/orcheshated by all concerned can serve as a model for other multi-country public health interventions inAfrica and elsewhere. Pending issues after December 2002 bb) Some issues will remain after December 2002. The major "residual" activities, such as the launch of activities in the Special Intervention Zones, resumption of oncho conhol in Sierra Leone, and the need for rapidly establishing an effective MDSC have been noted above. Other issues include: ' Further refinement of the DEC patch test--this simpler, non-invasive tool is more acceptable than the skin snip when low prevalence levels have been reached in the community; ' operational research, as needed, with rDR support (e.g., for testing a suitable macrofilaricide, sustainability of CDTI, determining ionditions und.r which ivermectin distribution for oncocerciasis could Ue safety discontinued, and the feasibility of intemrpting transmission with ivermectin alone); ' Efforts to deal with the "vector nuisance" problem, due to continuation of bites by blackflies; ' Studies on socio-economic aspects of the resettlement of cleared areas; and ' Ensuring the use of B.t. H-14, an ecologically-suitable insecticide, as stipulated in OCP guidelines (if countries decide to continue ground larviciding to deai with this issue). The EET expects that OCP countries and their partners in onchocerciasis control-primarily AFRO, NGDOs, and donors-will continue to effectively address these and other issues. vt ! Conclusions cc) To recap, OCP's main achievements are: 40 million people protected, 600,000 cases of ' blindneis prevented, 18 million children spared the disease, 25 million hectares of arable land freed of oncho (and will help feed 17 million people), and an economic rate of return of 20%. dd) As a result, within the Original Programme area, the number of people newly-infected with onchocerciasis is practically nil, and vector control has almost ceased. In the extension areas, prevalence rates and the annual tansmission potential (ATP) have been greatly reduced, except in a few focal areas that are proposed to be included in the Special Intervention Zones. ee) The EET concludes that OCP has largely achieved its objectives. Onchocerciasis has been virtually eliminated from the Programme area as a disease of public health importance and as an impediment to socio.economic development. Participating Countries seem able and willing to maintain the achievements of the Progtamme after 2002. f0 We commend OCP staffand Management, the Participating Countries, Donots, NGDOs, and other collaborating agencies that have supported the launch, implementation, and conclusion of one of the most successful inter-country public health interventions in Africa. Recommendations gg)To help ensure that OCP's considerable achievements are sustained, the EET recommends that: l) Each country take stock of key programmatic issues of onchocerciasis surveillance and control, and plan to address them systematically within the context of an integrated health service. 2) National governments, MDSC and NCDOs continue to emphasize the training and re- training of health staff and others involved in onchocerciasis control, and adequate funding of future training activities be secured. 3) Operational research be encouraged at the national and local levels in all OCP countries, as is done in APOC-funded projects; and research on the DEC patch test, the conditions under which ivermectin distribution for onchocerciasis control could be safely discontinued, sustainability of CDTI, the feasibility of intemrpting transmisiion with ivermectin alone, and a suitable macrofilaricide, including its effective distribution, be undertaken with support from TDR. 4) Studies of socio-anthropological and economic issues related to onchocerciasis be continued. vll 5) The residual oncho control activities in the proposed Special [ntervention Zones be undertaken as planned, with careful oversight and monitoring, so as to achieve their objective of eventually transfening full responsibility for oncho conhol to the countries themselves; oncho control activities be resumed in Sierra Leone; and the Special Intervention Teams be used flexibly to respond to oncho control requirements outside the SIZ, as needed. 6) MDSC's continued progress during the current period of transition be carefully monitored. 7) OCRC administrative oversight be transferred from OCP to APOC, to ensure continuity of operations and key staff. 8) Governments ensure that customs duties and any other taxes are waived for ivermectin importation and distribution. 9) Recognizing that oncho-control would be undertaken within the framework of an integrated national health system, and that the National Onchocerciasis Task Force (NOTF) has proven useful in APOC countries, the government of each OCP country establish a similar'National Onchocerciasis Group". l0)Inter-country cooperation among OCP as well as APOC counEies be maintained, with AFRO and WAHO serving as catalysts, and a Forum be established within the ambit of APOC (in conjunction with MDSC) to facilitate periodic stocktaking, data- based discussions of onchocerciasis trends, and the tackling of common technical issues. l1) tn December 2002, goverffnents of Participating Countries sign a joint declaration of continued support to onchocerciasis control, as part of their national as well as inter- country responsibility for public health management. vltl ONCHOCERCIASIS CONTROL PROGRAMME EXTERNAL EVALUATION 2OO2 I. INTRODUCTION l.l. In accordance with its terms of reference (Bor 1), the External Evaluation Team (EET) presents in this report its assessment of the achievemens of OCP against the Programme's stated objectives. It also reviews: . The secondary impacts of OCP on Participating Countries' health systems;I The implications of the winding down of OCP; . The modalities of interactions between non-govemmental development organisations (NGDOs) and Participating Countries, after 2002; and . The institutional, financial and operational implications of residual control activities, after 2002. In doing so, the EET has reached conclusions and made recommendations for the Joint Programme Committee (JPC) meeting scheduled for December 2002 (JPC23). I Box l: Thc Externrl Eveluetlon Team's Terms of Reference To assess the achievements of OCP against its statcd objectives (of eliminating onchocerciasis as a problem of public health importance within the Programme area and as an impediment to socio-economic development; and ensuring that the Participating Countries will be in a position to maintain the achievements of OCP); To review the secondary impacts of OCP on Participating Countries' health systems, inler alia, on health information and surveillance systems, human resource capacity, drug distribution systems, and the contribution of CDTI in maintaining oncho control and in strengthening community ownership of health issues; To review the implication of the closure of OCP, viz. on the capacity of the Participating Countries to detect and control oncho recrudescence, including the proposed relationship and interactions with the Multi-disease Surveillance Centre and to review mechanisms to allow countries to remain in close communication; To review the need and modalities of the interactions between NGDOs and the Participating Countries post-OCP; To review the institutional, financial, and operational implications of the residual control activities, which need to be executed after the closure of the Programme; and To formulate conclusions and recommendations for consideration by the JPC23 in 2002. 1.2. The EET has interpreted reference to "closure" of OCP to mean the "winding down" of activities after 2002. 1.3. The externalevaluation is based on a review of the extensive documentation provided by OCP; field visits to nine OCP countries by two EET members; and interviews of key staff of OCP, APOC and MDSC. We have also benefited from interactions with the OCP Expert I II Advisory Committee (EAC) at its meeting in March 2002, and with the Committee of Sponsoring Agencies (CSA) at its meeting in July 2002. 1.4. The EET concludes that OCP objectives have largely been met. Onchocerciasis has been virnrally eliminated as a public health problem in participating countries, and as an impediment to socio-economic development. Devolution to Participating Countries has been effectively undertaken and country nationals seem able and willing to maintain OCP achievements in the coming years. 1.5. The winding down of OCP is progressing satisfactorily, but some residual activities need to be undertaken urgently. These activities relate, in particular, to: . The proposed Special lntervention Zones (SlZ); covering the basins of the Pru in Ghana, the tibutaries of the Oti and Upper Ou6m6 in Togo/Benin, and the Mafou and Tinkisso rivers in Guinea); ' The resumption of the oncho confrol programme in Sierra Leone; and . The AFRO Multi-Disease Surveillance Centre (MDSC). Faster progress is awaited in relation to these aspects. 1.6. Looking to the future, the EET: a) expects satisfactory winding down of OCP from December 2002; b) expects '\rrap up" activities at OCP headquarters will be completed by March 31,2003; and c) believes that Participating Countries are capable of undertaking oncho- control activities after 2002. We also endorse the proposed activities in the SIZs, and support continued strengthening of MDSC, while noting a few concems and suggestions. The EET expects continued collaboration among Participating Countries, and continuing support to them from AFRO, MDSC, APOC, NGDOs, and Donors; and believes that there are suflicient indications that OCP achievements can be maintained for the foreseeable future. 2. ASSESSMENT OF OCP ACHIEVEMENTS 2a. Programme Achievements 2.1. Because OCP achievements are well documented in various Programme documents, this section highlights selected trends, milestone events, and overall achievements. Chart I schematically outlines the history and evolution of "control strategy development" in OCP-- highlighting the key technical and operational events as well as the major govemance and management decisions that have shaped the Programme since its inception. 2.2. Of particular importance to Programme operations were: . The reinvasion of blackflies in 1978-79 from outside the Progralnme areas; , The first trials of ivermectin in 1984; . The JPC agreement in 1985 to expand the scope of operations of the Programme into the Western and Southern Extensions; The development in 1991 of the ONCHOSIM model, and the strategy of combined larviciding and ivermectin distribution; . The launching in 1997 of the Community Directed Treatrnent with Ivermectin (CDTI) approach; . The detailed elaboration in 1997-1998 of the approach for devolution; and . The JPC approval in 2001 of the plan for winding down of OCP from December 2002. 2 2.3. When the Onchocerciasis Control Programme (OCP) was launched in 1974, it initia[y covered l0 million people in 7 counries. Upon addition of the "Extension areas" in 1985-86, it covered 30 million persons in I I "Participating Countries"--Benin, Burkina Faso, COte d'Ivoire, Ghana, Guinea, Guinea Bissau, Mali, Niger, senegal, Sierra Leone, and rogo. [By 2002, the number of persons covered by the Programme had increased to 40 million.] 2.4. The Programme has undertaken oncho-control activities over a vast geographical area, using two main strategies: ' Large-scale aerial larviciding of rivers and water basins, to reduce the population of blackllies that tansmit the awftl disease; and ' Mass distribution of the drug ivermectin (Mectizan @), to reduce morbidity, including blindness as well as debilitating skin disease and tenible irching, in infected humans. These and related Programme activities have been supported by non-governmental development organisations (NGDOs) working closely with the Participating Counties, and with the OCp staff headquartered at Ouagadougou, Burkina Faso. 2.5. The Programme's "basic facts" are outlined in Bor 2. Its "institutional arrangemelfs"- the Agreements that provide the legal basis for its institutional, financial, and operational aspects-are listed in Box 3. An overview of its funding and expenditures during the Z9-year period (1974'2002) is provided in Bor 4. Since inception, donoifunding has beeln shble; and has totalled $556 million. a Bor 2: Onchocerciesis Control Progrrmme (OCP)-Besic Frcts OCP's objectives are to eliminate onchocerciasis from the Programme area as a disease of public health importance and as an impediment to socio-economic development, and to ensure that the achievements of the programme are maintained. OCP was launched in 1974, with the Original Programme area covering 7 countries, with a total population of l0 million. When the Programme was expanded i 1986 to cover the Westem and Southern Extension areas, the population coverage increased to 30 million. By 2002, over 40 million persons were covered. The total geographical area covered is 1.235 million square kilometres. There are eleven Participating Countries: Benin, Burkina Faso, cote d'Ivoire, Ghana, Guinea, Guinea Bissau, Mali, Niger, Senegal, Sierra Leone, and Togo. I From 1974-87, the basic Programme strategy consisted of rcducing the population of the blackfly (which lives up to 4 weeks) to a levet where transmission of Onci or"rca volwtlus microfilariae was excluded, and maintaining that level until the macrofilariae in humans died out. This was achieved by aerial application of insecticides, to destroy the black fly's breeding sites in rivers, regularly and for a period of 14 yrs. Several insecticides were used in rotation to overcome the resistance of the blackfly to the commonly-used insecticide. After ivermectin was registered for human use in 1987, it became the primary means for controlling morbidity in humans. Ten years later the Programme adopted the novet straregy of Community-directed Treatment with lvermecrin (CDTI). In most of the extension are-as of OCP, vector control was combined with large-scale ivermectin distribution undertaken by the communities themselves, with supervision and supporl by local heatth services. 3 'l , Ivermectin is given free for as long as needed to as many as need it by the manufacturer Merck & Co. The adult worm lives, on average, 14 years in the human body; and a single dose of ivermectin administered once a year kills 95% of the microfilariae in the body with negligible side effects. Donors have contributed suflicient funds to bring OCP to a successful and lasting conclusion. A total of US$556 million has been committed during the 29-year period, 1974-2002. A large number of Donors and NGDOs have supported the Programme. The cosponsors are UNDP, FAO, the World Bank (as fiscal agent), and the WHO (as executing agency). l i Bor 3: Instltutionel Arrangements for OCP A "Preparatory Assistance Mission to the Governments [of 7 countries] r, referred to as the "PAG', prepared "a strategy for a hogramme destined to control onchocerciasis in the Volta River Basin area"2 , which led to the creation of the Onchocerciasis Contol Programme (OCP). The institutional, financial, and operational aspects of OCP rest on the following Agreements: The "Agreement governing the Operations of the Onchocerciasis Control Programme in the Yolta River Basin Area", signed on I November 1973 by the seven Governments concemed, and by WHO; often referred to as the Basic Agreement. Upon each (6-yex financial) Phase of the Programme: a "Memorandum of Agreement on the Onchocerciasis Control Programme" (usually refened to as the Memorandum of Agreement) signed by Participating Countries, initially the seven of the Original Programme Area, to which Western Extension countries were added from 1986 onwards. The "Protocol of the Memorandum of Agreement on the Onchocerciasis Control Programme between the Government of ... and the llorld Health Organization" signed with the Govemment of each Participating Country. The"Onchocerciasis Fund Agreemezl" signed by the donor parties upon the beginning of each Phase, starting in 1975 - incorporating the Memorandum of Agreement '\vith the same force and effect as if [its provisions] were fully set forth herein". Annually, or several times a year, with each country: "Technical Semices -Letter of Agreement", signed between OCP and National Teams, for entomology, epidemiology, hydrobiology, ffid hydrology activities, setting out the purpose and respective contributions. Issuance was centralised in OCP uarters to2002 inclusive. ! I Benin, Burkina Faso, C6te d'Ivoire, Ghana, Mali, Niger, Togo 2 "Onchoccrciasis Control in the Volta River Basin Area-Report of the Preparatory Assistance Mission to the Govemments of; Dahomey, Ghana, Ivory Coast, Mali, Niger, Togo, Upper Volta", submitted under the auspices of the Unitcd Nations Development Programme (UNDP), Food and Agriculrure of the United Nations (FAO), International Bank for Reconstruction and Development (IBRD), and World Hcalth Organisation (WHO), Geneva 1973, Synopsis, first paragraph 4 Box 4: OCP Funding end Expendltures Since 1974, the Programme has been fundcd in six-year financial "Phases", each covered by the Onchocerciasis Fund Agreement signed by donors, which constitutes the legal basis for OCP's funding and operations. The Programme funding has been in fivc (6-year) financial Phases as follows: Phase l: US$56.1 million; Phase 2: $106.9 million; Phase 3: $177.4 million; Phase 4: $145.9 million; and Phase 5: $69.7 million. Total for the 5 Phases: US$556 million. A Plan of Action and Budget proposal for the following ycar is approved at the annual session of the Joint Programme Committee (JPC), during which donors make their pledges. In recent years, ofthe total expenditures, vector contol has accounted for almost 66Yo, all other Programme activities for just over 20o/o, and management and administration for the remaining l4%. Each person has been protected at an annual cost ofless than $1. In addition, Pa(icipating Countries contribute in cash or in kind, for cxample, making available office space and other facilities as well as nationally remunerated staff. 2.6. At the start of OCP operations in 1974, of the l0 million persons in the Programme area, more than one million were suffering from onchocerciasis, of whom 100,000 presented serious eye problems, including 35,000 cases of blindness. About a decade later--when control operations expanded into the Extension areas--of the 30 million population covered by the Programme at that time, about 2.2 to 2.4 million were infected with onchocerciasis, and about 100,000 were blind or severely visually-impaired. In the OCP areas, pre-larviciding data show that prior to operations, only 9%had an Annual Transmission Potential (ATP) lower than 100-- the acceptable level--almost 35% had an ATP from 100 to 800, and 56% of the "catching points" had an ATP higher than 800. This data signified an extremely high potential for transmission of onchocerciasis (Map I; "Annual Transmission Potentials: Pre-Control"). 2.7. The Programme's sustained efforts during the past 29 years have had a huge impact. By 2001, OCP reports indicate that the ATP had been reduced dramatically (Map 2; "Annual Transmission Potentials-2001); and much of the Programme area had been freed of onchocerciasis. Map 3 ("Operational Situation Existing in the Programme Area in 2001") compares the pre-control and the latest entomological and epidemiological results in various areas. It indicates the control stategies followed, and shows the changes in ATP and prevalence rates in each major area. (The figures shown are general averages; no "global figure" for the whole Programme area can be produced because control started (and ended) at different times in different places3). Map 4 shows the "pre-control prevalence of infection" while Map 5 shows the "prevalence of microfilariae in villages evaluated between l99l and 2001". 2.8. The Programme has continually adjusted its strategy and plan of operations as new threats and opportunities emerged. The main threats included: 3 Based on discussions with country offrcials during our field visits, we believe that OCP data is accurate and reliable. However, we nole that the EET has no other sources of data for "indepcndently" verifring OCP program achievements 5 I The reinvasion by blackflies from ouside the Programme areas--necessitating an extension of the programme area in the late-1970s; and The development of insecticide resistance in the early-1980s--to which the Programme responded by introducing alternative insecticides and a strategy of their rotational use. The main oppornrnities for major breakthroughs were represented by: The identif,rcation of ivermectin in the mid-1980s as a highly-effective and suitable tool for conholling morbidity due to onchocerciasis-to which the Programme responded by developing a new strategy combining larviciding and ivermectin dishibution; and The increasing interest in the 1990s of Donors as well as Participating Countries in devolution to national governments-to which OCP responded with a systematic effort, including training and capacity building of national staff. I a ! 2.10. An overview of this responsive strategy is given in Bor 5. The EET considers this adaptive approach-which involved great resourcefulness and systematic planning by OCP staff, Management and the EAC--noteworthy. Bor 5: Flexlblllty of the Programme in Stratcgy and Operetions There is a need for flexibility in the conduct and management of operation in any large-scale and long-lasting undertaking. The Programme has been distinguished by the substantial amount of flexibility that enabled appropriate adjustrnents to be made, as necessary over time. A few examples illustrate OCP's readiness and ability to adjust its operations. Geogrephlcel Extension A serious adverse development, which threatened the successful outcome of OCP operations, was the phenomenon of invasion of the Programme area by infected savanna blackflies emanating from sources outside its boundaries. This reinvasion occurred each year at the beginning ofand during the rainy season. The origin of invading flies was sought by treating all rivers south and west of reinvaded areas. It was found that savanna species Simulium damnosum/S. sirbanum are able to migrate several hundred kilometres by flight. As a result, in early 1979 the Programme area was extended to the south in COte d'Ivoire and later to southern Ghana, Togo, and Benin (Southem Extension area) and then to Guinea, Guinea Bissau, Senegal, Siera Leone, and Western Mali (Western Extension area). With the beginning of larviciding in the extension zones the problem of reinvasion was greatly reduced. Insecticide Resistance In 1980, lowered susceptibility of one vector species to the organophosphate temephos emerged in the south of Cdte d'Ivoire and rapidly spread to the entire Programme area. OCP established a method to evaluate the susceptibility of S. damnosum s./. larvae to insecticides. At the same time an extensive insecticide screening programme was launched, which led to the identification of 7 insecticides belonging to different chemical groups, avoiding cross-resistance. OCP succeeded in getting insecticide resistance under control by the shategy of rotating insecticides in 1987, taking into account cost/effectiveness ratio, toxicity to the environment and non-target fauna, and water discharge rates. The improvement of the helicopter spraying equipment and the installation of satellite radio-transmitters at the hydrometric stations for continuous recording of water levels and discharge rates strengthened the cfficacy of the insecticide application. 6 In lgEE ivermectin was introduced as an effective tool, suitable for mass administration, to control the morbidity of onchocerciasis, in eligible parts of OCP countries. OCP set up a strategy to use ivermectin in combination with vcctor ionroi or alone for morbidity control depending on the area' Although neither macrofilaricidal action nor trinsmission intemrption was directly demonstrated for this drig, ivermectin playcd an important role in the management of onchocerciasis to suppress In lggl the WHO Independent Commission suggested that devolution of oncho control to participating Countries should begin during ttre eaity l990s..The External Review Team paid particuiar alention to the issue of d-evolution in its report to the I lu session of the Joint Programme Committee (held in Deccmber 1990 in Conakry, Guineat;. In implementing the Review Team's recommendations, the OCP Director establishii a new devolution unit which was geared to supporting participating Count i", in prcparing and initiating thcir devolution Programmes, including thi provision of technical cxpertise as and when required' Introduction of Ivermectin (Mectizen@) recrudescence Devolution 2.11. By 2O02,as a result of effective implementation of Programme strategy, about 40 million people have been protected from the disease, and up to 600,000 cases of blindness have been ir.u"nt.d. perhaps the most gratiffing achievement is that about 18 million children born since operations started have been lpr.i ttri rist< of onchocercal blindnesst. By eliminating the threat of blindness and other onchocercal manifestations, ocP has opened the way for resettlement in fertile river valleys, pieriously deserted because of the threat of the disease. Twenty five million hectares of arable land has been freed of onchocerciasis for food production. The "new" land will help to feed an estimated 17 million people. In terms of cost/efficacy, the Programme has been hig'hly successful as wcll. Taking inio account the total population "covered" by OCP, each person has been protected at an a-nnual cost of less than one-US dollar6' ff e^191lmic rate of return (ERR) on the funds provided by the Donors is estimated at an impressive 20%7' Z.IZ. Besides these achievements in public health, OCP has also contributed significantly, through a very comprehensive and effectively-utilized operational research programme, to new scientlfic knowledgi and control tools that will remain important well after the Programme winds down. An overview of the main areas in which operational research was undertaken, and the results achieved, is provided in Bor 6. These are summarised in Chart 2' ' Joint Programme Comminee (JPC) document, JPC I I '9, 1990 'JPCl7.8, 19966 Benton & Skinner, 1990 , ;rc"ri-sr"rfiienalysis of the onchocerciasis Control Programme (oCP)", by Aehyung Kim and Bntcc Benton' World Bank Technical Paper No- 282, 1995 7 Box 6: OCP's Operational Research Activities OCP has made significant conributions to science, culminating in hundreds of scientifrc publications. These are based on 29 years of carefully-planned data collection for operational and scientific purposes. OCP research was cxclusively oriented towards solving operational problems and improving cost/efliciency of field activities. A few of the important results of opcrational research undertaken by OCP iself, by Short Term Consultants (STC), or in collaboration with intemational scientific institutions are highlighted hereundert. The Vectors ln 1974, at the beginning of OCP, knowledgc of the vectors, Simulium damnsoum s./. and parasite, Onchocerca volwtlus was limited. By the method of cytotaxonomy, OCP was able to establish that in West Africa the Simulium damnosum complex consists of 9 species regrouping 17 forms. Other methods like morphological and morphometric identification, and the identification of isoenzymes by electrophoresis and methods of molecular biology (heteroduplex), assisted cytotaxonomic identification. The precise identification of species allowed further studies on the bio-ecology, behaviour (e.g., migration), distribution, vectorial role, and susceptibility to insecticides of each vector species. These studies were crucial to OCP's success. The Psmslte For many years, the available tools did not allow for a reliable identification of the parasites found in the vector during dissection. Larvae of animal filariae, also transmitted by S. damnosum complex species, could not be distinguished from O. volvulus larvae. As a result the Annual Transmission Potential (ATP)-which is used for evaluating Programme achievement--was overestimated, because it included, without distinction, all the parasite larvae found during dissections. The development of DNA probes allowed the differentiation of animal and human Onchocerca species and also the differentiation between O. volvulus savanna shain, that cause the blinding form of the disease and O. volwlus of the forest shain, the less blinding form. The accurate identification permitted a better estimate of ransmission of onchocerciasis in the Programme area. DNA detection of O. volwlus, in batches of crushed heads of S. damnosum s./. females will play an important role in entomological surveillance by national teams after 2002. Study of the life-span and population structure of O. volvulus female worms was made possible by the technique of digestion of nodules by collagenase which frees the worns without harming them. In long-protected areas, the worm population is old and shows a very poor reproductive life. No juveniles were found. The average length of the reproductive stage had been overestimated at the beginning of the Programme but is now estimated to be 9-l I years, with a maximum of 13-14 years for95%o of the adults. a t For a comprehensive review with refercnces see: OCP/WHO, "Twenty years of vector control in West Africa, 1974-1994". 8 i I I tImmunodirgnostlc Test / DEC petch Test (DpT) In 1987, the EAC recommended the development of an immunodiagnostic test to detect low level parasitism which escape skin snip tests. In this phase of the Programme (and after 2002) an immunodiagnostic test would allow national teams to detect any recrudescence of the diseasc. A "tricocktail" of antigens was produced which, however, did not perform as desired. Studies continue to detect IgG4 antibodies to Ov-16 antigen, which would eventually lead to an eflicient immunodiagnostic test. Beside an immunodiagnostic test, a DEC patch test has been developcd as a tool to detect infcctions. Comparison between DEC patch test and the skin snip test has shown practically cqual sensitivity, whilc the specificity of the patch test is lower than that of the skin snip. Field studies on the DPT will commence in 2003. Chemotherepy Development Project (OCT) Onchocerciasis control in West Africa has been based on the elimination of the vector because there existed no drug that could be used in a mass campaign to control O. volntlus in man. From 1982, special funds were earmarked by OCP for a chemotherapy development project (OCT) managed within the Macrofil Chemotherapy Project of TDR. The main objective of OCt is to devclop a macrofilaricide which would kill or pcrmanently sterilise the adult wonns of O. volwlus and which would be cheap and effective in small doses, and safe for large-scale administration. In 1987, Ivermectin (Mectizan@) was introduced for the treatment of clinical manifestations of onchocerciasis. After completing the lirst study on clinical safety there is a strong belief that Moxidectin may be the macrofilaricide that is needed for control. Eflicacy study wilt soon commenc€, and provided thc dnrg successfully passes the various trials, it could be expected to be registered for use in humans within the next four years. Biostatistics and Informetion Systems from the beginning of the Programme till 1985, all entomological, epidemiological, andhydrobiological data were processed with the mainframe computers at WHO Headquarters in Geneva. After that period, when micro-computers became available, the tr€afinent of data was transferred to the OCP Headquarters in Ouagadougou. This transfer led to the creation of the Biostatistics and Information Systems Unit (BIS). BIS not only ensured the entry, validation, updating and integrity of all VCU and EPI data bases but also facilitated the financial management of the Programme. Epidemiological modelling was introduced in OCP in response to evaluation and decision- making problems. A model called ONCHOSIM was developed in collaboration with the Public Health Institute of the Erasmus University in Rotterdam. The model allows for the long-term prediction of epidemiological trends after the cessation of vector control, and of the impact of large-scile treatment with ivermectin alone or in combination with larviciding. The model has been improved and its sensitivity systematically tested. ONCHOSIM covers the dynamics and interictions in the transmission cycle of onchocerciasis between the three populations concemed-humans, vectors and parasites. It has made it possible to determine when larviciding could be intemrpted without running the unacceptable risk of recrudescence of infection. 2-13. The EET believes that operational research needs to be continued after 2002. Some research areas of direct operational relevance include the following: the conditions under which ivermectin distribution for onchocerciasis control could be safely discontinued; the feasibility of intem-rpting transmission with ivermectin alone; sustainability of CDTI; continued search for a macrofilaricide; research on the DEC patch test; the implications of possible resistance to 9 ivermectin; and socio-economic studies related to oncho control. All these areas are of continued interest to both OCP and APOC counEies, as well as to TDR, and merit serious consideration for funding and programme support. 2b. Training and Fellowships 2.14. Besides a technically-sound strategy, the importance of training, as a key element in the successful transfer of activities to the Participating Countries, has also been emphasised by OCP since its very beginning. The Report of the Preparatory Assistance Mission to the seven Governments (in 1971-1973), stated that: "The traintng activities will also cottstitute an important component of the control Programme both to solve the stafing problems at all levels and to ensure that a standard methodologt will be used in all investigations and surveys ... The need to ffain addittonal national stalf from the Programme area able gradually to take over the responsibility for survsys and operations and subsequently to run the Programme itself has also been taken into account."9 2.15. Accordingly, the Programme's (basic) Agreement in 1973 provided that, as a long-term objective: "The Programme will provide trainingfor personnel at all levels in Simuliurucontrol, in the epidemiologt and chemotherapy of the disease, in aerial treatmenl, and in environmental protection." to 2.16. Since then, fellowships and training have featured prominently in OCP's plan of operations, activities, and budgets. The fellowship system was, from the beginning, intemational in character. It was decided that studies would take place in universities and institutions in Africa, with exceptions duly justified by the nature of the studies (some 5o/o were in fact undertaken in France, Switzerland, U[! and USA). Often, fellows completed their training or studies in the OCP area, in countries other than their own. 2.L7. Until the mid-nineties, OCP staff had the main say in selecting candidates awarded fellowships, with final approval by AFRO. The countries now prepare national training plans for health services (including onchocerciasis), and have established national selection committees within their respective minisfries of Health. The international perspective is retained: WHO Country Representatives are part of the national selection committees, actual placement in institutions is done by AFRO (which thereby has a final say), and studies are often undertaken by students outside their own countries to take advantage of the best that can be offered internationally, with emphasis on institutions in Africa. 2.18. The EET notes that training and fellowships provided by OCP have been extensive, relevant, and of high quality. Fellowships, on-the-job training, and country workshops have been e "Onchocerciasis Control in the Volta fuver Basin Area--Report of the Preparatory Assistance Mission to the Governments of Dahomey, Ghana, Ivory Coast, Mali, Niger, Togo, Upper Volta", under the auspices of UNDP, FAO, IBRD, and WHO. Geneva 1973, document OCPtr2.l. Chapter V (Programme for the control of onchocerciasis and plan ofoperation), pg. 45 'o "Agreement goveming the Operations of the Onchocerciasis Control Programme in the Volta River Basin Area", Part II (Programme objectives), pg. 2 l0 organized since OCP's inception-but were increasingly emphasized as the programme developed. The EET further notes another positive feature: the volurne of training condulted by OCP itself in a number of fields-epidemiology (for nurses and other health agrntsy, entomology and ground treatnent (blackfly collection network and early detection of recrudescence), impact of ivermectin on transmission, other scientific and technical fields, managerial training, and computer data-processing and analysis. 2.19. Retraining and refresher courses have also been conducted. In each country, OCp-trained national coordinators and oncho teams have served as trainers in surveillanr. und control, and have supported on-the-job training activities. Through a cascading process, doctors, nurses, paramedics, and entomologists were thus able to train large numbers of staff and volunteers at the district and cornmunity levels (Bor 7). Bor 7: Fellowships end On-the.job Training provided by OCp a) In total, over 590 fellowships were granted by oCp, in the following lields of study: Field of study No. of students percentage L Entomology ZZI 37 2. Epidemiology 88 15 3. Public health 75 13 4. Health management 59 l0 5. Parasitology S0 8 6. Ophthalmology 44 7 7. Hydrobiology and environment science 36 6 8. Administration 15 39.IEC I JTotal 5gf f00 b) In the 1990's, in support of devolution and transfer, fellowships in Public health and Health management were substantially increased. The Programme provided 2 fellowships in public health before 1990, and 6lthereafter; and 5 fellowships in health management before iggO, anA 46 since then. c) Most of the fellowships were shorter than one year; but about a third were for one year or more Duration of study No. of students % of fellowships Fields of study (of the 591 total) (Numbered as above) 19 1,2,3,4,5,6,7,9,9 9 1,2,4,5,6,9 4 3,5,6,7 I 1,6,7 3l d) On+he-job training was provided to a large number of health service staffand volunteers:Medicaldoctors ZSONursedtechnicians 2,500 Community distributors trained./retrained 55,000 Of these, through a reinforcement in 2001 alone: Community distributors trained/retrained 34,000 Health workers trained/retrained Between I and2years Between2and3years Between3and4years Over 4 years Total I Il 5l 25 5 t92 I ll 2.20 The EET also notes that training was envisaged as a flexible tool that evolved as needs changed. While fellowships and training in basic fields continued throughout, increasing attention was placed on fields connected with devolution/transfer. During the 1990s, fellowships in public health and health management increased significantly; and in recognition of new developments in various disciplines, some fellowships were awarded in molecular biology (parasitology), hydrobiology with emphasis on environmental surveillance, and IEC. 2.21. In addition, an impressive array of training materials has been developed by OCP. It is available in sufficient quantities, and is being used in Participating Countries by national coordinators and other partners. These include haining modules for epidemiological evaluation, onchocerciasis confrol management within national integrated-disease-management systems, training of community workers in CDTI, and integrated data management. On the vector control side, two manuals exist-for training entomological technicians and national entomologists. 2.22. Training procedures are an integral part of each manual or training module. All these materials, printed in the form of copybooks, are now being reviewed for reprinting in a more practical and user-friendly format, with high-quality print and illustrations. Ultimately, all the materials will also be available on CD-ROM. Manuals produced by OCP have been used by Participating Countries to prepare their own manuals for other diseases. As far as IEC is concerned, each country has developed its own messages and material, sometimes with support from OCP and NGDOs. 2.23 Training in organisation and management has enabled country nationals to advance from "taking instnrctions" to "taking initiatives". The EET's field visits showed that in some instances, this "can do" attitude has had a welcome spill-over effect on even those who were not directly trained by OCP. The EET thus views very positively the training activities undertaken under the aegis of OCP, as well as the results achieved. We note, in particular, the quantity and quality of training given, the training of trainers, and the competence and receptivity of the trainees--all of which have helped build national capacity to maintain the training effort after 2002. 2.24 A few points, nevertheless, need to given careful attention by OCP, before December 2002: The new versions of the training manuals and modules need to be finalised by OCP before end-2002. If progress is slower than anticipated, very tight anangements must be made by OCP to ensure that there are no further undue delays; and During the EET country visits, some national stafI, at different levels, voiced concern regarding the insulliciency of their preparedness for taking over data-management functions. They expressed a desire that courses on data management be upgraded and reinforced before December 2002. The EET understands from OCP that plans are in place for fully training one high-level statistician per country, along with some specialists in data transfer and management. 2.25. In addition, after 2002, all involved in oncho control will need to maintain the haining effort. In particular, there is need to secure funding of further haining activities. To maintain OCP achievements, it will be important that national governments and NGDOs continue to t2 n emphasize the haining and re-training of health staff and others involved in onchocerciasis control. This training should cover technical as well as managerial and financial aspects of control activities. 3. OCP'S SECONDARY IMPACT ON NATIONAL HEALTH SYSTEMS 3,1. The direct primary impact of OCP--as manifested by the drastic reduction in the disease burden and the consequential socio-economic benefits accruing from the removal of the disease as a major constraint to development-has been noted above. Not so well known is the equally important and decisive "secondary impact" of the Programme on the health systems of the Participating Countries. 3.2. The EET examined this aspect of OCP by reviewing various Programme documents, as well as the reports of visib to nine OCP Participating Countries (Benin, Burkina Faso, Cote d'Ivoire, Ghana, Guinea, Mali, Niger, Senegal and Togo) by two members of the team. The key areas of secondary impact are human resource capacity, material resources, surveillance tools, and health systems reform. Also, OCP's prograrrune of ecological studies is impressive. 3a. Areas of Secondary Impact 3.3. Development of Human Resoarce Capacity: This involved the training of personnel, at all levels, in relevant skills, and the corresponding development of training materials and manuals. The training provided polyvalent competencies that enabled such staff to be of use in other non-onchocerciasis health Programmes. This considerably enhanced the move towards the integration of the onchocerciasis conhol Programme with other disease control programmes and into the health systems. 3.4. A significant collateral benefit noted during the country visits was the extensive use of data management skills for a broad spectrum of health problems, beyond onchocerciasis. It is to be noted, however, that inevitably there has been some "wastage" of trained personnel, involving the loss to the Programme. However, some of the trained staff who no longer work specifically for onchocerciasis control now hold responsible decision-making positions at central and other levels of the national health services structure, and thus continue to provide valuable services. 3.5. Material Resources: In the winding down process, OCP equipment, materials and communication networks are to be handed over to the Participating Countriesll. Whereas the transfer of most of the equipment, including Programme-specific items like comeo-scleral punches and hydrobiological ones have indeed taken place over time, the expectations of some countries in respect of vehicles intended for transfer to Government ownership to support surveillance and control activities have apparently not been fully met. Nonetheless substantial multi-purpose equipment, like high-performance computers, have been provided, and are of value beyond onchocerciasis control but within the integrated health service structure. 3.6. Surveillance Tools: The development and use of relevant surveillance tools are tangible manifestations of the secondary impact of OCP. For example, through the inspiration of the " "Plan ofOperations for the Phasing-out period 1998-2002", JPC 17.8, 1996 t3 OCP, the National Onchocerciasis Control Programmes (NOCP) in Benin, Guinea and Mali have prepared a document for the integrated surveillance of several diseases, including onchocerciasis. e tiigtr standard of data management has been established by OCP, and was apparent during the country visits. These skills have demonskably become part and parcel of a wide range of progratnmes, and will continue to strengthen the evolving health systems of Participating Countries. 3.7. Health Systems Reform: The onchocerciasis Programme has been a successful model for the processes of decentralisation and integration within the context of health sector reform. OCP's approach to decentralisation - wherein authority and responsibility for operational, financial, and administrative matters was appropriately devolved to "oncho coordinators" and staff suitably-located within the oncho-endemic zones, at district and village levels - has served as a model of "good practice" that is being emulated by other health programmes. The Programme's approach to integration of operational activities with other health services - which was undertaken particularly well at the periphery (compared with the central level), and involved close support from social workers, school teachers, and women at the village level, has similarly served as an example worthy of replication by other disease control programmes. 3.8. In most member countries, OCP activities have thus been used as "entry points" for initiating reform of other health Programmes. National and district health plans have increasingly been developed in consultation with affected communities, and have utilized OCP software for "mapping" the incidence of disease . kt 2002, onchocerciasis surveillance tools were discussed in workshops in Benin, Burkina Faso, Guin@, and Mali as models for the development of integrated disease surveillance tools. OCP's emphasis on evaluation as an essential component of the programme planning process has likewise served as an example of good practice for other prograrnmes. 3.9. Over the years the operations of the OCP have positively evolved from being merely "communit5r-based" to being "community-driven". The use of CDTI has required a reorientation of approach to local health service delivery, and has given new impetus to decentralised stnrctures of "co-management". There was ample evidence during the country visits that the Programme has helped mobilize communities, and has sensitized and motivated them to cope with their health problems. 3.10. Public health authorities in partnership with village communities have thus been able to take joint responsibility for addressing local health concerns. As a result, interactions between health staff at the periphery and the oncho-affected communities have become more intimate and mutually beneficial. Village health nurses are supported by the chiefs and other local leaders, and are backstopped technically by the district medical officers and other health professionals, in a supportive role. t4 3.I l. Before evaluating the effect of insecticides on the environment, it was essential to collect information on the composition of the aquatic fauna of rivers in the Programme area. For this, the Programme put in place an impressive system for ecological monitoring/2 lBox 8). 3b. Ecological Studies Bor t: OCP's Ecological Monitoring System When OCP was launched, there was a considerable evidcnce of biological and ecological consequences of large-scale use of pesticides. With the awareness of these consequences, the international community, the Participating Countries, Donors and thc Committee of Sponsoring Agencies (CSA) had reasons to fear that many years of repeated applications of larvicides in the watercourses would cause a serious disturbance of the river ecosystems. Consequently, CSA set up an independent advisory structure, the "Ecological Panel", which later became the Ecological Group (EG), attached to the EAC. Its role has been to study the ecological consequences of the use of insecticides by the Programme, and to make recommendations to the Programme for effective protection of the environment. In 1974, following a proposal by the EG, the Programme established an aquatic monitoring Programme of rivers that were planned to be regularly treated with insecticides. The aquatic monitoring Programme was executed, first by hydrobiologists of France, Ghana and the United Kingdom, to initiate the Programme, but soon the entire monitoring activity was conducted by the Participating Countries. This was the first activity to be devolved to Participating Countries. As a result, all insecticides used by the Programme were degradable, had an acceptable mammalian toxicity by WHO standards, and did not cause mortality of fish or crustacean at doses and discharge rates at which they were used. The impact of non-targct insects on aquatic larvae was acceptable, and was characterized by a reduction in density; but in most cases, there was a retum to the pre- larviciding sBtus after the cessation of larviciding due to recolonization from untreated watercourses and reaches. 13 By eliminating the threat of blindness, OCP has made possible the repopulation of those river valleys which had formerly been deserted for fear of onchocerciasis. However, OCP's success could be put in jeopardy by ttre use of the freed land in environmentally unsafe manner. A pilot study conducted in the Leraba area, COte d'Ivoire, at the request of the EG, showed that75%o of the originalwooded savanna was cleared for agricultural development and the settlement of villages. The riverine forests of many small rivers were destroyed; and on some of the river banks, signs of soil erosion are now visiblera. '' OCP/WHO, "20 Years of Onchocerciasis Control in West Africa, 1974-1994"tt ibid 'o Baldry, Calamari, Yam6ogo, "Environmcntal impact assessment of se ttlement and development in the Upper L6raba Basin",. World Bank Technical Paper No. 302, 1995 l5 ! The EET endorses EG's statement that "It is therefore necessary to both take measures and sensitize it " ,irerin" populations on the need for environmentql protection and biodiversity management along with the'development of agricultural activities."rs We support the WAFEM project (West African Freshwater Biodiversity cinservation and Ecosystem Management), proposed to be funded by the Global Environmental iacility (GEF), whose objective is to preserve the biodiversity of the oncho-freed zones and to promote a rational management of nafural resources in these areas. 3.12. All results recorded during the environmental monitoring have been constituted into a database. This database on the ecology of West African rivers generated over a period of 29 lruo ir a unique heritage. It has leilio the production of ryany publications_on the effect of insecticides on the fish and invertebrate fauna, that, supported by iconography, have been useful for improved surveillance. Furthermore, considerable information was collected on the dynamics ofvarious species. 3.13. These studies made major contibutions to the knowledge of the bio{iversity of lotic ecosystem in West Africa. fni Bnf is, however, of the opinion that the knowledge generated could still be more effectively and proficiently disseminated to those involved in the international health and agriculture sectors. The ecological datasets obtained by the monitoring teams--covering the ,rsponr" of fish and non-target invertebrates to pesticides, and the faunal biodiversity *1 tu*onomic data collected over the duration of the progralnme-should be archived electronically and widely disseminated. [t is particularly important that the 'biodiversity community", including such agencies and organisations as the Millenium Assessment, GBIF (Copenhagen), and Conservation lnternational, be able to easily access this database, and b."o*. u*u.. of the high quality and comprehensiveness of this unique archive. 4. IMPACT OF WINDING DOWN OF OCP ACTIVITIES ON NATIONAL CAPACITY TO DETECT/ CONTROL ONCHOCERCIASIS RECRUDESCENCE 4.1. Recognizing the fundamental importance of national capacity for detecting and controlling onchoCerciasis recrudescence, in 1995 OCP supported "country workshops" for policy ."k"o, technicians, and national onchocerciasis cooidinators 16. Participants reviewed pUrr for devolution, decentralisation, and integration; identified sources of funding; and developed detailed national plans for devolution, including operational forecasts of resources needed until 2002. '' OCpllVHq "Preserving the environment: a major OCP concern over the past twenty-five years"' OCPiEG/02.1' 2m2 '5 In I 995, the Meeting of Health Ministers of the Participating Countries of the Onchocerciasis Control programme in West Africa (OCP) discussed the takeover by the States of onchocerciasis control activities (Washington, 5 December 1995) l6 4a. Assessment of National Capacity 4.2. There seems to be suflicient national capacity to undertake onchocerciasis control after 2002. As noted earlier, training and fellowships provided by OCP have made a difference, and have enabled the devolution of epidemiological and entomological surveillance to national oncho teams. National capacity to undertake ivermectin (Mectizan @) distribution has been built with OCP support. These activities could continue for as long as necessary. 4.3. In all Participating Countries (except Siena Leone and Guinea Bissau) communities are able to implement CDTI without the direct intervention of OCP staff. Epidemiological Mapping of Onchocerciasis has been completed in all OCP countries. [The technique of Rapid Epidemiological Mapping of Onchocerciasis (REMO) was used in a small area - south of Guinea, C6te d'lvoire and Southem Ghana]. All eligible communities are receiving ivermectin using the CDTI approach. Both the level of geographical and therapeutic coverage by CDTI are generally satisfactory, though they vary a lot between the different sites, as expected. The affected communities are empowered to run the Programme, and communities actively collect the drug from the nearest health facility. Supervision is built into the CDTI system, and there is a satisfactory interaction between the communities and their "supervisory" peripheral health facilities. 4.4. Community-directed drug distributors (CDDs) of ivermectin are increasingly being trained and used-both as service providers and trainers--in other health ProgrammeS, €.8. poliomyelitis and guinea worn eradication, malaria control, expanded programme of immunization, and Vitamin A distribution. Under OCP, drug management was done by the CDDs. This included the planning, ordering, storage, and distribution of ivermectin. CDDs have also assisted in the evaluation of health issues in the community, and have facilitated better interaction between the community and staff of the public health service. 4.5. However, the CDTI instrument for data collection needs improvement. There is also a need to ensure a high level of motivation of CDDs supporting CDTI and other field-level activities. 4b. Future National and Inter-Country Requirements 4.6. [n the future, onchocerciasis control will be undertaken within the countries' integrated health systems. Technical staff have been trained, have acquired polyvalent skills, and function within an integrated health care Programme. Epidemiological surveillance has been effectively devolved to national onchocerciasis teams. So has entomological surveillance. lvermectin distribution will continue for as long as necessary using the CDTI approach (which superseded both the mobile and the community-based ivermectin distribution). Aerial vector control will continue as an inter-country activity in one SIZ area beyond 2002. 4.7. For oncho-related activities to yield their full potential in the future, an inter-country approach will be essential. The main activities that will need to be undertaken are: . Enhanced CDTI programmes and ivermectin distribution in the Special Intervention Zones, and aerial larviciding in one of the zones (Oti-Oueme basin--an operation limited in time and scope); . Operational research, utilizing shared laboratory facilities; t7 ' Support of epidemiological and entomological surveillance in the OCP areas afler 2002; and . Organized exchange of information between countries on matters of common concem' 4.8. The role of WHO Representatives (WR) will remain important. In the performance of their traditional roles, it is envisaged that WRs will provide appropriate support to the countries, especially with regard to inter-country interaction; and that WR budgets would reflect the needs of onchocerciasis, as jointly agreed with the respective countries in their "plan of operations" (which we understand is prepared by the WR in consultation with country health officials). The EET believes that the role of WRs and MDSC would be to ensure that countries continue to give adequate attention, priority and funding, to onchocerciasis control. 4.9. We expect that the WHO's Regional Office for Africa (AFRO) would continue to serue as a catalyst for developing strong inter-country cooperation, using all its resources--WRs, MDSC and APOC, according to their technical competencies and the countries' requirements. The West African Health Organization (WAHO) would facilitate and contribute as well, as appropriate. 4.10. Specifically, we believe the WRs have a continuing role in establishing inter-country links, through AFRO; and there is a strong need for active information-sharing between OCP and APOC countries, for the mutual benefit of a/i countries. The areas to be covered include CDTI, epidemiological and entomological surveillance, detection of recrudescence, and IEC. 4.1l. We recommend that a Forum, within the ambit of APOC and in conjunction with MDSC be established, to facilitate meetings for periodic stocktaking, discussing oncho trends, and tackling technical issues. After 2002, inter-country interaction would be enhanced by the OCP stafVexpertise absorbed by APOC and MDSC. 4.12. The OCP countries themselves would have primary rasponsibility for all oncho control activities within their national borders. But since "the blackfly knows no border and therefore readily conveys infection from one country to another, continued inter-country collaboration is also a must."l7 4.I3. The EET commends OCP for its major contribution to inter-country collaboration and coordination, throughout its existence. We also note in this context that at the Meeting of Health Ministers of the Participating Countries of the Onchocerciasis Control Programme in West Africa (OCP) on the takeover by the States of onchocerciasis control activities" (Washington, December 1995), passed a Resolution that urged "the Participating Countries to ensure the setting up of an inter-country facility which will carry on the coordinating role hitherto played by OCP". The Participating Countries have since recognized their own continuing responsibility for inter-country coll aboration, facilitated by Regional partners. ' ' "25 Years OCP- I 974- 1999", World Health Organi zation, Onchocerciasis Control Programme in West Africa, Chapter 6 (The Future) t8 5. RELATIONSHIP OF NATIONAL ONCHOCERCIASIS DETECTION/CONTROL WITH THE AF'RO MULTI-DISEASE SURVEILLANCE CENTRE (MDSC) 5a. MDSC Functions 5.1. In orderto attain the second objective of OCP, which is to maintain the achievements of the Programme after its cessation, Participating Countries will need to continue the distribution of ivermectin at a sustainable high level of geographical and therapeutic coverage, and will need to institute effective epidemiological surveillance systems for the detection and control of recrudescence of onchocerciasis should it occur. These are primary aspects of the Programme of devolution which were addressed by the 1997 External Evaluation report, where it was stated that: "The [participatingJ countries should also have the capacity to control any recrudescence that may occur. Inter-country collaboration will be essentiat for the exchange of information and in respect of tratning, operational research and the provision of shared laboratory facilities. There is a need for a special focal point for these activities. The EET sees an obvious role for WHO and suggests that WHO/AFRO support a sub-regional centre whtch would provide the expert assistance the Participating Countries will require for onchocerciasis control. It would be logical to locate such a centre at the present ocP headquarters in ouagadougou."'t 5.2. In September 1998, the Regional Committee for Africa adopted Resolution AFRO/RC48/R2 on Integrated Disease Surveillance Strategy (IDS). Since then, a Multi-Disease Surveillance Centre has been established in facilities being gradually vacated by OCp in Ouagadougou, Burkina Faso. 5.3, When fully functional, the MDSC is expected to provide, among other things, high technical support to Member States in the area of onchocerciasis surveillance and control as and when required. In order to carry out the tasks related to this, the MDSC would establish and update an epidemiological database that would strengthen the epidemiological surveillance systems of the sub-region. The Centre will undertake support for entomological surveillance in member counfies. MDSC will also organize training sessions in disease surveillance in discharge of its capacity building mandate. 5b. Relationship with National Onchocerciasis Programmes 5.4. The relationship of National Ochocerciasis Control Programmes (NOCP) to MDSC revolves around two main factors: the capability of the former, the Participating Countries, to support and carry out the activities necessary for sustaining onchocerciasis control after 2OO2; and the effectiveness of MDSC in providing "quality control" support to member countries. The former varies from country to country, while the latter would ultimately depend on the adequacy of the Centre's resources for discharging its responsibilities. 5.5. The EET notes that the activities of MDSC rvill start in the West African sub-region, to which OCP Participating Countries belong. It also notes that a substantial number of the l8 "Onchocerciasis Control Progranrme External Evalualion 1997", JPC 18.8, September 1997 l9 pioneering technical and administrative staff of the MDSC is being drawn from the pool of experienced OCP staff. These developments augur well for a rapid and sustainable take-off of the onchocerciasis surveillance activities in the sub-region after 2002. 5.6. EET also notes that although the mandate of MDSC does not include intervention activities, these have not been explicitly ruled out. The EET recognizes the need for the Centre to be able to respond to the needs and requests of the counkies in the following fields: surveillance, research, development of data-bank, information sharing, training, and inter-country dialogue and resolution of issues of mutual concem. 5.7. In this regard, the MDSC is well positioned to assume some of the critical roles hitherto performed by OCP that need to continue after 2002, Notably, the MDSC (with APOC, where appropriate) should provide a meeting point for OCP countries to maintain relevant Programme links and a channel of communication and cooperation as may become necessary after 2002. The MDSC should also be able to project and reflect a regional perspective on target diseases, through access to and aggregation of the epidemiological data from member countries. 5.8. The dissemination of information among member countries will be substantially enhanced with the acquisition by MDSC of the communications facilities of OCP. These include a radio network connecting all OCP countries as well as telephone and electronic communication with an Internet server. 5.9. The MDSC also needs to maintain active cooperation between OCP and APOC countries for the mutual benefit of all oncho-endemic countries in Africa. The onchocerciasis component of the MDSC mandate appears to be a potentially credible and viable model for ultimately upscaling and expanding the ambit of the Cenffe's activities, in respect of onchocerciasis and other target communicable diseases, to the other sub-regions of the AFRO region. 5.10. The MDSC is expected to forge new, and strengthen existing, partnerships with a variety of 'organisations whose goals and objectives coincide with those of the Cenfre. To this end, the EET recognizes the important contributions that NGDOs have made and can continue to make in collaboration with OCP countries to sustain oncho conffol after 2002. This is particularly so in respect of the (community-directed) distribution of ivermectin. The EET believes that it would be advantageous if the Programme structure as well as the mode of operation of members of the NGDO Coalition in APOC counhies is adopted for the Participating Countries, after 2002. 5.1 l. One of the important attributes and strengths of OCP has been its ability to operate across national boundaries. It is envisaged that OCP member countries will continue to use the traditional channels, Iike the Country offices of the WHO, for bilateral or multi-lateral consultation. The EET recognizes that the MDSC is well placed to assume some aspects of the cross-border coordination role of OCP whenever the need arises. It is desirable that the annual OCP-sponsored meetings of OCP-trained scientists who carry out the national hydrobiological monitoring activities in most member countries, be continued. 5.I2. Comparablc inter-country Programme links should be established as the need arises after 2002. Collaboration with national and inter-country instirutes and laboratories is envisaged, and is a sine qua non for the effective discharge of the MDSC mandate. The EET recognizes that the performance and effectiveness of the oncho control programme in one OCP country has potential 20 consequences on neighbouring countries, and that the repercussions of this would be very critical after 2002. To this end, the EET urges Participating Countries to ensure the setting up of an inter-country facility, which will carry out the coordinating role hitherto played by OCP. 5.13. During the EET country visits, concerns were expressed by the national interlocutors that there could be some redundancy and unwitting overlap of activity profiles between the West African Health Organis.ation (WAHO) and MDSC. The former is, at this juncture, better known to them than the latterle. WAHO has been created for "the attainment of tnr highest possibte standard and protection of health of the peoples in the sub-region through the harmonisation of the policies of Member States, pooling of resources, cooperation with one another and with others for a collective and strategic combat against the health problems in the sub-region". In view of this mandate, which is very relevant to MDSC concerns, the latter is establishing contacts with WAHO for a better mutual benefit of both organisations, and for avoiding duplication of efforts. Enhanced cooperation and communication is foreseen. WAHO coutd serve as one ofseveral catalysts for developing the strong inter-country cooperation required to maintain OCP achievements. 5.14. National control teams have been trained to mount effective surveillance systems. The information generated from such surveillance will provide timely information for undertaking appropriate action, but eflorts will be needed to ensure quality control of epidemiological and entomological surveillance, as well regular supervision of these activities by the countries' health authorities. IEC materials as well as training and operational manuals have also been produced by OCP. With time, new tools and procedures will become available for onchocerciasis control. Member countries of OCP will require to be brought abreast of contemporary developments in the field of onchocerciasis control. A link with APOC is one mechanism for ensuring this. Another is through MDSC. The EET suggests that the MDSC's capacity for producing these materials be strengthened, and that a mechanism for interaction between OCP and APOC countries be established. 5.15. In sum, the EET believes that there is a sound basis for concluding that once it has become fully operational, the MDSC will be in a position to fulfil its obligations in support of member countries of OCP, all of whom have demonstrated, to varying but generally satisfactory degree, their capacity for taking on their responsibilities after 2002. The presence of many seasoned and experienced OCP staff on the MDSC team fosters this optimism. Nevertheless, MDSC's continued progress during the period of transition needs to be carefully monitored. 'e WAHO is a specialised insritution of the Economic Communiry of Wesr African Sratcs (ECOWAS). It serves sixteen countries, which inctude all eleven OCp countries 2t 6. NEED FO& AND MODALITIES OF, NGDO COLLABORATION WITH PARTICIPATING COUNTRIES AFTER 2OO2 6.a Current Role of NGDOs 6.1. The EET recognises the important role that the NGDOs have played since the inhoduction of ivermectin, before and since the advent of CDTI. These organisations have not been involved at all in vector control activities. [n the Participating Countries, the international NGDOs involved in onchocerciasis contol are Helen Keller Worldwide (HKW), "Organisation pour la Pr6vention de la C6cit6" (OPC), and Sight Savers International (SSD. They are present in one or more countries, but a few counhies in the OCP area do not have any international NGDO working in oncho control. The EET believes these countries and NGDOs could consider establishing such presence, as needed. 6.2. The international NGDOs involved in onchocerciasis control work closely, in a well- coordinated manner. They have a confirmed role in one or more of the following fields: . Facilitating the procurement, storage and distribution of ivermectin; . Training, supervision and evaluation of community-directed drug distributors (CDDs); . Provision and strengthening of data management; and . Support to the production of IEC materials, particularly the development of training materials such as manuals, brochures, flip charts and posters. 6.3. More broadly, the NGDOs help to address issues of programme management, capacity building, and sustainability of activities. In their work, they draw guidance from training manuals prepared by OCP. The activities of NGDOs are generally more demanding in areas that have been under exclusive ivermectin heatrnent, than in those with combined larviciding and ivermectin. The EET notes that one of the NGDOs is engaged in small-scale agricultural projects that can be sustained by local populations in oncho-freed areas. 6b. Future Role of NGDOs 6.4. After 2002. NGDOs would not expect nor be expected to replace OCP functions or funding. Yet, the EET can see a clear role for them in continuing the activities outlined above, in support of the implementation of country policies and strategies. NGDOs would thus serve as partners with governments--which have the responsibility for maintaining Programme achievements. The EET notes with satisfaction that NGDOs are willing to stay for the long haul, upon request of the governments, in the spirit of cooperation with all other partners and stakeholders. 6.5. Also, it is expected that NGDOs' support of the intercountry dimension would be relevant after 2002 through their international network. At the same time, they are encouraged to help identify and develop the potential of local NGDOs active in oncho control activities, and to make sure that these organizations have access to relevant documents, including already- published OCP manuals. The EET notes that some NGDOs have expressed uncertainty regarding the scientific criteria that would determine, in due course, the cessation of their involvement in onchocerciasis activities. 22 6.6. As a recent development, certain countries, notably Niger and Mali, have indicated a desire that NGDOs also get involved in the epidemiological and entomological surveillance that will be necessary for maintaining OCP achievements, as well as in blackfly-nuisance control (a continuing need, because of the increasing presence of blackflies in some of the Programme areas). The EET understands that some NGDOs would respond favourably to a request for their involvement in surveillance, and would consider assisting with nuisance control if this activity is justified within their own mandate of blindness prevention and conffol. Of course, if such interventions by NGDO's were to be initiated, it would be important that the NGDOs familiarise themselves with existing OCP manuals and guidelines before embarking on the new activities. 6.7. The EET recognizes the need to facilitate and enhance partnership between governments and NGDOs. In this regard, therefore, the EET recommends that each of the OCP countries consider the establishment of a structure similar to the National Onchocerciasis Task Force (NOTF) in APOC countries, which performs successfully the function of a high level coordinating body and acts as a suitable meeting point for partners and stakeholders. Such a structure could play an efficient and valuable role not only in mobilizing and coordinating the activities needed for maintaining OCP achievements, but could serve as a model and an entry point for initiating similar action on other diseases and health problems, within the wider framework of integrated national health systems. INSTITUTIONAL, FINANCIAL AND OPERATIONAL ASPECTS OF RESIDUAL ONCHOCERCIASIS ACTIVITIES AFTER 2OO2 7.L. The EET commends OCP for a very comprehensive and systematic Plan of Operations for the period 1998-2002, which has provided a sound basis for satisfactorily winding down the Programme. 7.2. We believe that for Participating Countries to maintain OCP achievements on a sustainable basis, the following oncho-control activities will need to be maintained in OCP countries: r Community-directed treatment with ivermectin (CDTI) throughout the OCP- Programme and other areas, as needed; ' Ongoingepidemiological andentomological surveillance; . Oncho data collection and management, and software maintenance; . Training and re-training of public health staffworking on onchocerciasis; . lnformation, education and communication (tEC) activities; . Operational research, as needed, with TDR support (e.9., for testing a suitable macrofilaricide, the conditions under which ivermectin distribution for onchocerciasis control could be safely discontinued, and the feasibility of intemrpting transmission with ivermectin alone); . lnformation-sharing with partners (including in other countries); and , In the Special lntervention Zones, enhanced CDTI , as well as aerial larviciding in limited focal areas in Togo and Benin. 7.3. The EET's detailed comments on the SIZ, and on OCP's activities for "winding-doln", follow. 7, 23 7a. Special Intervention Zones 7.4. Throughout its existence, OCP has constantly had to establish priorities for its operations in light of finite financial resources and a large and complex Programme. Through careful use of ,rroLr.s, OCP has largely met its objectivei; but thereiemain about 550,000 pirsons 20 in fou. different zones still in need of enhanced oncho-control efforts after December 2002,,i.e. less than 1.5% of the 40 million people protected in Participating Counties. (in addition, there is need for resuming oncho control in Sierra Leone, which could thus be considered a Special Intervention Zone a.s well). 7.5. On the basis of detailed entomo-epidemiological findings, OCP Management has identified zones for special intervention, in which enhanced CDTI and/or aerial larviciding would continue after 2002- These areas, referred to as "special Intervention Zones" (SlZ), are the basins of the Pru in Ghana, the tributaries of the Oti and Upper Ou6m6 in Togo/Benin, and the Mafou and Tinkisso rivers in Guinea (Map 6). A special Task Force of OCP's Expert Advisory Committee has subsequently made specific recommendations for the implementation of such control2l, based on the main characteristics of each of the SlZs-including relevant entomological, epidemiological and socio-demographic information, reports on vector control and ivermectin distribution, and the predictions of ONCHOSIM on the effects of the proposed interventions after 2002.22 7.6. Based on the characteristics of each basin (including, where available, each of the following variables: population, prevalence, incidence, CMFL, ABR, ATP, year of beginning of vector control and of CDTI), the EAC has recommended a high level of therapeutic- (80 to 85% according to the zone) and geographical coverage (up to l00%) with ivermectin for all Zones until 2012. In addition, the EAC considered it essential that aerial larviciding be undertaken for the tributaries of the Oti and Upper Ou6m6 for 5 years from December 2002 (for this recommendation, predicted levels of prevalence after 5 years, according to ONCHOSIM simulations, were taken into account). The Joint Programme Committee (JPC) of OCP commended the EAC on this work on the Special Intervention Zones, and agreed that intensive, focused interventions in these zones were required ". Map 7 shows the OCP areas of large- scale ivermectin distribution (2002). 7.7. The EET has been informed by OCP that this "residual" problem could not have been satisfactorily resolved earlier for a number of reasons, which apply, in varying degrees, to the various zones. Notable among these reasons are: a) intensity of human migration (including of infected people) due to socio-economic development, and in search of gold; b) difficulty of access to disease foci in remote areas; c) harmful suspension of treatment in areas bordering conflict zones (e.g. Mafou, adjacent to Sierra Leone); and d) selective treatments in adjacent areas, with damaging consequences for the zones in which control efforts remain incomplete. 7.8. The EET has noted that the high coverage rates expected in the SIZ have not necessarily been attained in all Programme areas where OCP's objectives have nevertheless been met. For 2(' Leaving aside the particular case of Sierra Leone 2' Joint Programme Committee, document 1PC22.3, July 2001, Annex 7, paragraph A.I '2 ibid2l " Final Communique", Twenty-second scssion of thc Joint Programme Committee, Washington D.C., USA, l0- I I December 2001 24 the proposed SIZ, however, OCP staff consider these coverage rates achievable through special efforts, despite the remoteness and diffrculty of access of certain areas. They beiievi that enhanced CDTI supported by an increased commitment of the local popuiations, better surveillance and access to local foci, as well as the organisation of rp""iui campaigns for ivermectin distribution, and last but not least, the technical competence of all those-in-charge, will converge to yield satisfactory results. 7.9. The EET considers that the justification for continuing enhanced CDTI in rhe Special Intervention Zones, and larviciding in one of them, beyond the end of OCp, is the result of a careful review process undertaken by OCP Management and the EAC. The objective of the SIZ proposal--to reduce the danger of recrudescence to zero or to a very low level according to the zones, and where larviciding will be undertaken, to virtually eliminate transmission - is appropriate; and the proposed activities take into account the financial constraints after 2002. Further, the EET is assured that monitoring of ongoing interventions, as well as a final evaluation, in 2007, of the results achieved, will be undertaken with the same scientific rigor that has characterized OCP operations. 7.10. The establishment of an inter-country unit, called a Special Intervention Team (SIT), is planned for executing control activities in the Special Intervention Zones, in support of national efforts' Based on a proposed Plan of Action, a budget has been drawn up, whictrdoes not exceed the amount remaining in the unspent Reserve of the OCP Trust nund. This budget will cover costs of staff, larvicides and aerial operations for vector control in the applicabG zone, CDTI operations including haining, other program and operational costs, and operational research. Use of these funds, will of course be subject to agreement of the Donors. A five-year life-span is foreseen for the SIT, after which it is expected that any further special efforts iequired (e.g., in terms of CDTI) would be carried out by national authorities, as elsewhere in oncho-freed areas, As far as vector control is concerned, the five-year period will allow a continuation of the aerial operations already underway in that zone, thus cxtending the larviciding in that area to about l0 years. 7.11. A crucialdeterminant of success of the SIT willbe competent and dedicated staff, as was the case for the OCP. The EET was not in a position to scrutinise the qualifications of the proposed SIT (since its members have not yet been identified), but was informed that staffof the right calibre, mostly locally-recruited, will be selected to fill the positions. We understand that some OCP staff will become part of the SIT; and that one part-time senior international staff member, based in Ouagadougou, will oversee the team, which will iself operate from bases in Kara (Togo) and Parakou (Benin). The EET has also been informed that the SIT will devote sufficient resources to quality control, training/ retraining, and supervision. Based on these assurances, and because national capacity to support the SIT exists (in part due to the thoropgh kaining provided by OCP), the EET is confident that the approach outlined in the SIZ p.opor.l could work. 7.12. Although the main control strategy in the SIZs rvill be enhanced-CDTl, combined rvith aerial larviciding in one zone only, the latter will absorb trvo thirds of the budget. This is an unavoidably high proportion, given the costs of larv'icides and, especialll., aerial operations. However, for the latter to be started from early 2003 as planned, a contract for aerial operations will need to be signed by the end of 2002. It was clear during discussions berrveen WHO and the 25 EET that this is a somewhat complex matter, and that a number of ideas are under consideration, including such aspects as: . The procedure for selecting the company for aerial larviciding (the present contractor or any other if available); . The adjustment of the current contract to the new circumstances of a considerably smaller operation; . The signing of an agreement between the countries concerned, which would include, inter alia,cross-border overflight and landing rights; and . The approval of continued fin'ancing by donors before the contract for aerial operations can be signed. The EET urges speedy action on all these pending issues. 7.13. The SIT will also require appropriate institutional, operational, and administrative frameworks to carry out its activities. The institutional and operational arrangements are yet to be finalised (as of Carly October 2OO2); but a suitable agreement on this is foreseen between the SIZ countries, the World Bank (as fiscal agent), and the WHO (as executing agency). This Agreement is expected to provide an institutionaVlegal basis for programme activities, including foi such operational requirements as overflight and landing rights, where applicable, and the free importation of ivermectin. 7.14. For the administrative aspects, it is expected that staff in APOC will provide the administrative support needed by the SIT. Since APOC has thus far benefited from similar support from OCi--and after 2002 will acquire a full-fledged administrative team mostly comprised of former OCP staff--the proposed administrative arrangements appear to be logical and iound. The direct "supervisor" of the SIT Team-leader will also need to be identified; and will presumably be appointed by the AFRO Regional Director, on behalf of WHO, the executing .geriy. This designated supervisor will presumably be a senior WHO staff member based in Ouagadougou. In any event, the SIT leader is expected to work closely with APOC and MDSC. 7.15. For ensuring maximum benefit from the proposed SIZ activities, the EET believes it would be necessary for the SIT to organise periodic meetings of the SIZ countries and their neighbours to discuss concems relating to the cross-border implications of oncho-control activities. More generally, once the SIT structure is in place, it could also, if requested by WHO, play a useful catalyic role in other aspects of the oncho-control programmes of OCP countries - particularly "specialized risk-management interventions" in support of national efforts. As new entomological and epidemiological surveillance data are collected and analysed, new foci/zones for "special intervention" could be identified by national health staff or MDSC, and these could be adtressed with support from the SIT. For Sierra Leone, the EET was informed that the Reserve of the OCP Trust Fund would be used to resume oncho control efforts that were disrupted due to civil unrest. This will help reduce the risk of reinvasion of infected flies into areas already freed of onchocerciasis, particularly in Guinea- 26 7b. Winding-down of OCp 7.16. The EET considered it essential to look closety at the winding down operations, because the orderly transfer o!lCn capacity and activities is eisential for the maintenance of programme achievements. The EET is satisfied that the operational aspects of the winding down of headquarters activities are being handled in an orderly manner, fairly and expeditiously. This includes the proper disposition of the human, financia1, physical, "nd info.*ution resources at headquarters. 7.17. An AFRO/OCP/APOC Joint Working Group for the winding down of OCp was established in early 2001, to study all aspects and to submit recommendations to the AFRO Regional Director for approval. A schedule for the winding down activities was prepared in November 2001, and progress has been carefully monitored Uy OCf iself and the Joint fuorking Group, as applicable. 7'18. A great deal of attention has appropriately been given to OCP's human resources. Some 40Yo of the 250 OCP staff have WHO contracts, i.e. aie governed by WHO Staff Rules. The remaining 600/o arc local staff who were employed throughout the Original Programme area in a status closer to national employment conditions, under in arrangement caltedi'special Service A-greement" (SSA). This arrangement was introduced in OCP on a large scale from January 1993, in line with plans for devolution, and also for budgetary reasons. The expectation at thit time--which did not eventually materialise--was that such staif would ultimately be taken over by their own governments. 7.19. As a result, the 250 OCP staffare presently in search of placement as of the end of 2002. Some 20% of these staff, carefully selected from OCP's administrative and technical units, willbe absorbed by APOC or MDSC-and will thus contribute to much-needed administrative strengthening of these two organisations (which have thus far relied on OCp support for day-to- day administration and finance). AFRO has already taken some OCP staff; and a small number of nationals of Participating Countries, seconded 6y their governments, will be taken back by their respective parent ministries. For all the others, a varie-ty of placement services continue to be provided by oCP, including kaining in various fields (secietariit, documentation, informatics, vehicle maintenance, finance, and laboratory work). Their cuniculum vitae (Cvs) are also being submitted--under the aegis of, and with support from, the AFRO Regional Diiector--to other organisations (WHO, other United Nations agencies, NGDOs, and the private sector) for employment considerations. 7-20. The EET also notes that a "sensitization group" was created in 1998 from among the oCP stafl including Personnel Services, to counsel staff in anticipation of the winding down of the Programme. Such efforts to counsel, train and place staff are important; but ultimately the onus rests on the staff members themselves. Depending on the employment prospects of individuals, reduced motivation is to be expected. o-e managers will thereftore n""d to make an extra effort to ensure that OCP's high standards of work and devotion ro duty are retained till the Programme ends in December 2002. It is noteworthy that AFRO/OCP, with supporr of WHO Headquarters, are considering additional termination benefits for OCp staff (beyond the amounts strictly due), especially to those working under SSAs. )'1 7 .Zl. Besides these 250 staff working directly under OCP, there are over 170 staff working in National teams in the Western Extension areas. These staff work under National Coordinators, one for each country. They are engaged in entomological and epidemiological surveillance, hydrology, and hydrobiology, as weil as in togistical and administrative support (as mechanics una a.iiiir, and in adminisfation and finance). As full-fledged government employees (or contract employees engaged by governments), these staffhave been working under the technical and administrative rup.ruirion o1OCp--*trich added a lump sum to their salary as an incentive, paid a daily subsistence allowance for duty travel, and provided for some capital equipment and ^operating coss. It is expected that after December 2002, govemments will fully capitalise on such reservoirs of expertise. 7.22. The OCP/APOC Documentation Centre in Ouagadougou, comprising a wide range of scientific, technical and administrative publications collected throughout the life of OCP, has evolved into a sophisticated, computerised unit with staff trained by specialists from WHO Headquarters specialists. The Centre will be transferred to MDSC, along with the extensive collection of databases, samples, reports etc" 7-23. A transfer of administrative oversight of the Onchocerciasis Clinical Research Centre (OCRC; at Hohoe, Ghana) from OCP to APOC would also be appropriate Afte1 2002, the key ituk.hold.o are the Government of Ghana (which owns the building in which the Centre is located, and pays for the local Ghanaian staff), and the World Health Organisation (which owns the equipment iherein and pays for the research carried out, including the emoluments of the head if'the Centre). The ricommended transfer of OCRC administrative oversight to APOC would ensure continuity of operations and,key staff' 7.24. In the coming months, much attention will need to be paid to financial issues. Financial management has thus far been the responsibility of a highly competent team, with fully centralised authority at Ouagadougou. Most members of the team (except the Chief of Administration and Finance) are still with OCP. Financial implications of terminal emoluments are being calculated, a reserve for contingent liabilities for staff claims is foreseen, and preparations are being made for a financial audit' 7.25. OCP has invested in various types of infrastructure throughout the Programme areas'- civil works, garages, vehicles, technical and data-processing equipment, and fumiture. Complete inventories, with valuations, have been taken, and plans for transfer to Participating Countries'*, APOC, MDSC, and National teams have been prepared. Contracts in Ouagadougou (for example for maintenance of premises, insurance, services) will be taken over by APOC' Proper maintenance of expeniive equipment, such as corneo-scleral punches (which need to be changed frequently) wilt aiso be needed. Some countries have requested information from OCP on potintial future suppliers and service facilities for the specialised equipment and supplies needed for oncho control. 7.26. Transport and telecommunications infrastructure will receive special attention. The OCP garage in Ouagadougou, an effrcient outfit with full maintenance and repair facilities run by 2{ Appendix I. l0 of Memorandum of Agreement (1998-2002) foresees that "Prior to the completion of the projramme, the participating Govemments and the Executing Agency shall consult as to the disposition otall project equipment provided by the Programme" 28 skilled staff, will be managed by the Office of the WHO Representative in Burkina Faso. It will also serve APOC, MDSC, and the Special Intervention Team in the Special Intervention Zones, all of whom will cooperate in the day-to-day administration of residuit activities. Financing oi the garage will be on a cost-sharing basis. There is a detailed plan for allocation of the remain'ing(more than one hundred) vehicles to the Participating Countries, APOC, MDSC, the Special Intervention Zones, and the Office of the wHO Representative in Burkina Faso, with a small reserve retained with the garage itself. 7.27 . During the EET country visits, various national staff noted that a number of vehicles are "tired"--which is true, since none of the vehicles is less than 3 years old, and many have operatedin harsh road and weather conditions. However, the EET is lnformed that the OCp gaiage in Ouagadougou will do its utmost to refit these vehicles to the maximum extent possible bifore handing them over. It will then become important for vehicles to be properly maintained by the recipients. For this, mechanics and drivers have been trained by'OCP in the participating Countries. 7.28. The telecommunications infrastructure, with its maintenance and repair workshop attached to the garage, will mainly go to MDSC, and will help facilitate inter-country collaboration for disease control, including for onchocerciasis. In addition, participating Countries will need to ensure that ivermectin continues to be imported free of customs duties and other taxes, and that efforts are made to ensure that stocks do not run out due to administrative or other bottlenecks. This will be especially important because CDTI will need to be continued in these countries for the foreseeable future. 7.29. A small "winding-down" team, possibly headed by a senior Team Leader with prior OCP experience, would handle outstanding mattirs during tlie winding down of the programme. Such arrangements would be required up to 3l March ZO-03. Residuaiactivities relating to OCp winding down will cover a wide range--including general administration, personnel, budget and finance, transport and communications, supplieJand services, as well as activities required by the winding-down of operations connected with vector control and various aspects of OCp's information systems. The financing of these activities-including the staffing, travel, and some operating expenses--would be provided from the Reserve of the OCp Truit Fund, subject to agreement of the Donors. A designated staff member of APOC will have specific ."rponribility for overseeing and managing the team, which will report to the AFRO Regional Director. TheEET believes that these measures can work, and that the winding-doin of OCp can be satisfactorily completed, as planned. 7.30. Finally, the "temporary" nature of OCP and the continuing responsibility vested in the Governments of the Participating Countries was made clear in OCp alcuments from the very inceplion of the Pro8ramme. The "basic Agreement" (noted earlier in Box 3) foresees a ,.twentyyear Programme" " and specifies the undertaking of the Participating Govemments .,upon th; withdrawal of international assistance at the conclusion of rhe Programme, to consolidate and maintain its achievements in the public health and socio-e.onorni. development sectors.'i )iSimilar provisions appear in every Memorandunr of Agreement (MoA) theriafter. The cunentMOA, covering 1998-2002, stipulates that "Each Participating Government undertakes....as far r "Agrecment goveming the Operations of the Onchocerciasis Control Programme in thc \/oha River Basin Area,,,Part I, l. lntroduction 26 ., . ,IDM 29 as its territory is concerned, to maintain the achievements of the Programme, to ensute that any recrudescencl of the disease that might occur in its area following cessation of the operations implemented by the Programme is promptly_detected and effectively controlled and to promote and support sotio".ono-ic development," 2T The appendices to the MOA are relevant as well: "During-the fifth phase of the Programme, the Participating Governments shall be responsible for undertakng activities to deteci and control recrudesience of infection 2E; and for the Participating Govemments to maintain this achievement"2e 1a key objective of OCP]. 7.31. The EET has been informed that to preserve the spirit of "oneness" that has prevailed among OCP and the Participating Counhies throughout the Programme, and to emphasise the countries' readiness and willingness to maintain Programme achievements, these countries may envisage signing a declaration of their intent to continue support for onchocerciasis control after 2002,isp"rt oftt"i. national responsibility for effective public health management. This would be a consensus text which would give concrete expression to the Participating Countries' determination after 2002 to continue onchocerciasis control efforts, and to provide the operational facilities required for undertaking the oncho control activities within each country, as well as in support of the inter-country dimension, as needed. The EET strongly encourages this initiative. 8. CONCLUSIONS AND RECOMMENDATIONS 8a. Conclusions 8.1. Within the Original Programme area, the number of people newly-infected with onchocerciasis is practically nil, and vector conhol has almost ceased. In the extension areas, prevalence rates and the annual transmission potential have been greatly reduced, except in a few focal areas that are proposed to be included in the Special Intervention Zones' 8.2. The EET concludes that OCP has targely achieved its objectives. Onchocerciasis has been virhrally eliminated from the Programme area as a disease of public health importance and as an impediment to socio-economic development; and OCP countries seem able and willing to maintain the achievements of the Progralnme. 8.3. Further, the EET believes that there are sufficient indications that: a) the few residual activities proposed for the Special Intervention Zones can be undertaken satisfactorily in the next 5 years; b) oncho control activities can soon be resumed in Sierra Leone; c) OCP countries plan to undertake the oncho-control activities (mainly CDTI) that need to be continued for the next 15 years or so; d) MDSC would be strengthened and would receive support, as needed, from OCP Lountries, APOC, and NGDOs; and e) together, these activities would help ensure that the gains achieved by OCP are sustained for the foreseeable future. 8.4. The team believes OCP's success is due to a number of factors, acting in concert. Some of these have been noted earlier, for example: flexibility in strategy and operations (Box 6); a 27 Memorandum of Agreement on the Onchocerciasis Control Programme in West Africa ( 1998-2002)' Part I' General Provisions 2E Appendix I. I I (Contributions of the Participating Govemments) 2e Appendix II, first paragraph 30 science-based, results-driven Programme, effectively utilizing operations research (Box 7); and a {rong country focus with a responsive Programme emph-asi}ing capacity-building (Box g).Other noteworthy features were: ' A global partnership that capitalized on the respective comparative advantages of various stakeholders--thus generating considerable synirgy, and "nubling a bundlin! ofresources through a system of pooled finances that heipedihare the burden widely (i-he ..non-tied', Trust Fund mechanism greatly facilitated flexibility); and ' A regional approach, that generated a strong feeling of collective responsibility that enabled cross-border issues to be addressel, and was conducive to the effective utilization of the large-scale donation of ivermectin. 8'5. The EET recognizes that holding together these global and regional partnerships, despite the diversity of interests represented, was not simply a matter or poJting financial resources. [t required active maintenance of cooperative relationitrips by liberally sp[ading recognition and credit for the Programme's success, and instilling trust among partners. The ref commends the efforts made by all concerned - the Participating Countries, dono.r, Merck & Co., NGDOs, and various OCP bodies (the JPC, CSA, EAC, Ecological Group, and the Programme Management, in particular) - for effectively discharging the weil-delineatJ roles and reslonsibilities eipectej of them-at all stages of the Programme, and for the execution and conclusion of one of the most successful inter-country public health initiatives in Africa. 8'6. The sustained commitment and untiring efforts of national onchocerciasis teams, health services staff at all levels, community workers - and, of course, the communities themselves-- have been enormously significant as well. The EET notes that the involvement of nationals at alllevels.of oCP operations has been particularly beneficial in the transfer of manageriat and op-erational expertise. _Over time, foreign expatriates were gradually and effectively replaced byAfricans in the scientific and technical areas of ocp operat6ns. 8'7' A number of organizational and managerial factors have also played an important part. The Programme has benefited greatly from: ' OCP's facilitative/catalytic role in producing effective inter-country collaboration; ' Transparency and equity in decision making, based on sustained commitment to common objectives; and ' OCP's unique organisational features, particularly its results-oriented collegial culture, dedicated staff, effective leadership and goue.n.nie, technical excellence, and consistent and committed donor support. 8'8' The exemplary manner in which this diverse set of factors has been managed/orchestratedby all concerned can serye as a model for other multi-country public health lnterventions inAfrica and elsewhere. 8'9. After 2002, however, some pending issues will remain. The major "residual" activiries, such as the launch of activities in the Special Intervention Zones, resumption of the oncho control program in Siena Leone, and the need for rapidly establishing an efiective MDSC have already been noted. Other issues include: ' Further refinenlent of the DEC patch test (DPT)--this simpler, non-invasive tool is more acceptable than the skin snip when low prevalence levels have been reached in the community; 3l . Operational research, as needed, with TDR support (e.g., for testing a suitable macrofilaricide, sustainability of CDTI, determining conditions under which ivermectin distribution for oncocerciasis could be safely discontinued, and the feasibility of intemrpting transmission with ivermectin alone); . Efforts to deal with the "vector nuisance" problem, due to continuation of bites by blackflies; . Studies on socio-economic aspects of the resettlement of cleared areas; and . Ensuring the use of B.t. H-14, an ecologically-suitable insecticide, as stipulated in OCP guidelines (if countries decide to continue ground larviciding to deal with this issue). 8.10. The EET expects that OCP countries and their partners in onchocerciasis control - primarily AFRO, NGDOs, and donors - will continue to effectively address these and other issues afrer 2002. 8b. 8.1 l that: Recommendations To ensure that OCP's considerable achievements are sustained, the EET recommends l) Each country take stock of key programmatic issues of onchocerciasis surveillance and controt, and plan to address them systematically within the context of an integrated health service. This stock-taking of the staff and equipment on the ground in each country should identiff the current and future shortfalls (including in haining/retraining, database management, software development etc.) vis-i-vis the needs of each country to carry out and sustain oncho control Programmes, and prepare plans for bridging the gaps within an integrated health service framework. 2) National governments, MDSC and NGDOs continue to emphasize the training and re-tralning of health staff and others involved in onchocerciasis control, and adequate funding of future training activities be secured. This training should cover technical as well as managerial and financial aspects of control activities. The EET expects that future training, mainly for CDTI and IEC, and fellowship requests would be addressed to, and responded by, AFRO and MDSC and national governments with support of NGDOS. 3) Operational research be encouraged at the national and local levels in all OCP countries, as is done in APOC-funded projects; and research on the DEC patch test, the conditions under which lvermectin distribution for onchocerciasis control could be safely discontinued, sustainability of CDTI, the feasibility of interrupting transmission with ivermectin alone, and a macrofilaricide, including its effective distribution, be undertaken with support from TDR. Also, although routine ground larviciding has been discontinued, its use as a strategy for dealing with vector nuisance problems should be carefully studied within the guidelines prepared by OCP; and the knowledge and databases generated by the Ecological Group should be better utilized and disseminated to those involved in the international health and agriculture sectors. 4) Studies of socio-anthropological and economic issues related to onchocerciasis be continued. The EET expects that these studies--like the operational research funded by 32 APOC in projects supported by it - would be encouraged at the national and local levels in all OCP countries. There is need for socio-anthropological studies on migration patterns and their effect on CDTI; studies of the appropriate duration and sustainability of CDTI; and sfudies on the so-called "non-responders" deemed to be a reflection of parasite resistance to ivermectin. The EET further expects that with the winding down of OCP, funds will be sourced to bridge the gap created by cessation of OCP funding; and priorities may need to be re-established in light of funds available for research. 5) The residual oncho control activities ln the proposed Special Intervention Zones be undertaken as planned, with careful oversight and monitoring, so as to achieve their objective of eventually transferring full responsibility for oncho control to the countries themselvesl oncho control activities be resumed in Sierra Leone; and the Special Intervention Teams be used flexibly to respond to oncho control requirements outside the SIt as needed. 6) MDSC's continued progress during the current period of transition be carefully monitored. The EET is convinced that once it has become fully operational, the MDSC will be in a position to fulfil is obligations in support of member countries of OCP, all of whom have demonstrated, to varying but generally satisfactory degree, their capacity to undertake their oncho control responsibilities after 2002. 7) OCRC administrative oversight be transferred from OCP to APOC, to ensure continuity of operations and key stalf. With the winding down of OCP, the key stakeholders of the Onchocerciasis Clinical Research Centre (OCRC) at Hohoe are the Government of Ghana and the World Health Organisation. A transfer of administrative oversight of OCRC from OCP to APOC would be in the mutual interest of key stakeholders. 8) Governments ensure that customs duties and any other taxes are waived for ivermectin importation and distribution (in some countries, ivermectin could be included in the essential drugs list to ensure this waiver). tn OCP countries, in collaboration with communities and NGDOs, it would probably be necessary to continue ivermectin distribution (CDTI) and related activities for l5 more years, as per predictions of the ONCHOSIM model. Countries should ensure that there is free importation of ivermectin, health departments do not have to pay customs duty, and there is no cost recovery from users. lnclusion of ivermectin in the essential drugs list could facilitate this; but the EET recognizes that each country must find its own solution. 9) Recognizing that oncho-control would be undertaken within the framework of an integrated national heelth system, and that the National Onchocerciasis Task Force (NOTF) has proven useful in APOC countries, the government of each OCP country establish a similar "National Onchocerciasis Group". The EET expects that in the future, all components of the oncho control Programme would be appropriately merged with the integrated national health service. The recommended "Oncho Group" in each of the OCP countries would play a useful and catalytic role, as a high-tevel coordinating body and forum/meeting point for partners and stakeholders. It would mobilize and coordinate efforts towards maintenance of OCP achievements, and also serve as an entry 33 point for similar actions on other diseases, within the broader framework of integrated national health systems. l0)Inter-country cooperation among OCP as well as APOC countries be maintained, with AFRO rnd WAHO serving as crtalysts, and a Forum be established within the embit of APOC (in conjunction with MDSC) to facilitate periodic stocktaking' data- based discussions of onchocerciasis trends, and the tackling of common technical issues. Inter-country cooperation has been effectively coordinated by OCP over the years. Participating Countries have been sensitised to and endorse the view that inter-country cooperition- is needed for tackling public health problems effectively. Benin, Burkina Faso, Ghana, Niger and Togo are already undertaking multi-lateral inter-country meetings on onchocerciasis, and a similar tipartite initiative exists between Guinea, Mali and Senegal. The EET expects that AFRO and WAHO would serve as catalysts for developing strong inter-counky cooperation; and recommends that because discussions wouldiover more than surveillance issues, the proposed Forum be established under the aegis of APOC, but be closely linked to MDSC. I l) In December 2002, governments of Participating Countries sign a joint declaration of continued support to onchocerciasis control, as part of their national as well as inter-country responslbility for public health management. The declaration would be a consensus text which would give concrete expression to these countries' determination, after 2002, to continue onchocerciasis control efforts, and to provide the operational facilities required for undertaking oncho-control activities within each country, as well as in support of the inter-country dimension, as needed. 34 rlils a 8I IIIIrI II!gI g EI ,II fftl'ii * titB IltiIl Tt c. 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EEIot #sEcl Jb<t)ouJ69o=Jao= EaFz ltJ 3 J(, U m3PT!l^ E=i9 -tt: E: -. ut.(, u, o EI tr u,l E o o rJ E 6 C lrJoo o -EhuJ ETo->o fri eoEoo A C' o =o IIJo 6 olrlo = zI c, UT o. o ulI IL o tuof 2oF ot ur - EI lrlo5 o o -J P = E 5 E E E ETEEiEifi llJo2 Lo UJtr tt o o =o.AI o2 o =E, o E =o - 36 Carte / Map 1 : POTENTIELS ANNUELS DE TRANSMISSTON ANNUAL TRANSMISSION POTENTIALS PRE - CONTROL Airc initirle /Originel OCP rrcr (1973-1971) Ertcnsion sud / Southcrn cxtcnsioo (197*19791 Extcnrion Oucst / lVcstcrn ertension (l9tGt9t9) O .tm O rooree(D zoosce O roozce O'eoo - Ljmrt rdmlbocP(.tr.tniti.L,ubn*maou6t, lrd at oncfiorco.. d. brat) Ptaaant OCP boundary (orignel, w.3t m, .oulham rnd brait orEho cxtln$o.l boundary) ___ Llmrt! rllr intt.la / Onginal P,og.amrp alr boundary - Lhita ,rod ct rud cn rxbnrion ou6t (br fait.m.nt! LrvkidrJ Norolcm and touttcm limit ol lrrvriling n *lstem Gxtcnsirr w!!bm lxl aoutham cxGn3on rrra boundan s / Lmita (b3 rxbnap.t3 0{rorl ct 3ud _ Nrfo.ral boundari.r/Fronlia,lg 37 a C ,o tlnJ a C a (l lI aa ttl a t, a elO ra7 I I aCarte / Map 2 : POTENTIELS ANNUELS DE TRANSMTSSTON ANNUAL TRANSIT'IISSION POTENTTALS Jan.2001 - Dec.200l Erplccr du complorc simulium demnosum infect0cr prr oncboccrce votvulus Simulium drmnosum compter rpccics infccted with Onchoccrce votvulus C <too C toGigg o 20G3e9 O ,t00-799 o >E00 C} Arret dca 6v.lu.tionrcntomologiqucs A p.rtir do 1992. Lo3 r6lultata atsicnt cxcollcnt PAT =0 Entomoloeical cvrluction ccelcd ag from '1992. R.rulb wrra cxcollcnt:ATp - 0 dh@ Evaluation cntomoloehu€ cxplrimentale dans h Bougourba. Le PAT prnid cn 1995 cct 6911 126 Expcrinlcntrl rntofipbgicsl evalultion in Bougouriba. 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