The World Health Organization: year 8 progress report, 1st September 2007- 31st August 2008

f u'- ''-'! / JOINT ACTION Oflice of the Chairman JAF-FAC: FOURTEENTH SESSION Kampala - Uganda, 8-11 December, 2008 D'ACTION COMMUNE Bureau du Pr6sident tl African Programme for Onchocerciasis Control Programme africain de lutte contre l'onchocercose The World Health Organtzation Year 2008 Progress Report: l't September 2007 - 31'tAugust 2008 JAF I4.5 ORIGINAL: ENGLISH September 2008 Eo o- ot oooL o) o (L E c oo .9oo '6 ooo -coco Lo o E E E o) oL(L coo L : I F-l 0 .f, <, D t o a. otr at, o o E') o o- E o o .9, to .c o oo o o o o o E E(! o, oL(L (E o L \t CDI: a strategy for Revitalizing Primary Health Care in Africa By its proven effectiveness, the community-directed intervention approach, capitalizing on the desire by communities to help themselves, has become a powerful tool for low-cost delivery of multiple health interventions in Africa. Already, programmes in 20 countries have adopted this approach, empowering communities and strengthening health systems. @Copyright African Programme for Onchocerciasis Control (WHO/APOC), 2008. All rights reserved. Publications of the WHO/APOC enjoy copyright protection in accordance with the Universal copyright Convention. Any use of information in the WHO/APOC Progress Report should be accompanied by acknowledgement of WHO/APOC as the source. For rights of reproduction or translation in part or in toto, application should be made to the office of APOC Director, WHO/APOC, BP 549 Ouagadougou, Burkina Faso, dirapoc@oncho.afro.who.int. WHO/APOC welcomes such applications. JAF14.5 Poge i Table of contents List of tables, figures and annexes List of Abbreviations/acronyms ..., Executive summary health interventions I .5 . I Integration of onchocerciasis into health systems ..... 1.5.2 Co-implementation of CDTI with other health interventions ... 2 THE YEAR IN REVIEW: Research and Evaluation............. 2.1 Health impact assessment 2.2 Operational research: expanding use of CDI ........ 3 THE YEAR IN REVIEW: Prospects for sustainability 3.1 Are government's committed? 3.2 Monitoring sustainability.............. 3.3 Independent Participatory Monitoring of CDTL... 3.4 Sustainability evaluations............... ........ i i ....... iii ........ I Introduction: 2008 and beyond .......................3 1 THE YEAR IN REVIEW: Progress in Community-Directed Treatment with Ivermectin (cDrr) 4 4l.l Overview of achievements ........... 1.2 Improving coverage of ivermectin treatment 1.3 Mapping at-risk populations and areas.......... ...5 ...8 1.4 Training of health workers and community-directed distributors (CDDs) of ...10 1.5 Integration of onchocerciasis control and co-implementation of CDTI with other ...... l3 ...... l3 ...... 13 ......15 ...... l5 l5 t6 ............. 16 ............. l8 ............. l8 r9 3.5 Sustainability plans ...... 19 3.6 Monitoring the implementation of sustainability plans... ......................20 3.7 Sustainability conclusions .............. .................21 4 THE YEAR IN REVIEW: Programme Management, Finances, and Partnership...........22 4.1 An extended mandate .....................22 4.2 Renewing human resources... .......22 4.3 Financial activities.... ......................22 4.3.1 Decentralising financial management............... ..........23 4.3.2 A new tool: the Global Management System.. ............23 4.4 Direct support to countries ............24 4.5 APOC's statutory meetings.... ......25 4.5.1 The Joint Action Forum ........25 4.5.2 Technical Consultative Committee................ .............25 4.5.3 Committee of Sponsoring Agencies................. ...........25 4.5.4 Other meetings .......................25 4.5 .5 Monitoring of drug efficacy in large-scale treatment programmes for Onchocerciasis ........... 4.6 Advocacy activities 4.7 Partnership and collaboration......... 5 LOOKING AHEAD: Elimination of transmission of onchocerciasis.................. 5.1 Cessation of ivermectin treatment 5.2 Macrofilproject....... 5.3 Vector elimination activities 5.4 Preparing for the exit of APOC............... 5.4.1 Country exit plans ANNEX E o o- o)t aa o o) o (L E c oo a a o 'p o(.) oEoc o Lo o E E(E o) o o- coo L I ivermectin. 25 25 26 27 28 ..........29 E o EL o tr. o oo tr) o o- E oo .9, o .g o o)o o o o o q, E E(E g) o G o o trAFt4.5 Page ii List of tables, figures and annexes Tables Table I : Summary of ivermectin treatment in APOC countries, 2006 and 2007 ...................... 5 Table 2: Number of health workers and CDDs trained/retrained in 2007 by NOTFs............. I I Table 3: Number of activities co-implemented (including ivermectin distribution) and targets reached by 43 projects which reported data, in 7 countries, in2007 .....14 Table 4: Percentage of funds disbursed by item line by governments in 2007........................16 Table 5: Governments'financial contributions (in US$) to CDTI activities in2007..............17 Table 6: Summary of sustainability evaluation results, 2002 - 2008 t9 Table 7: Number of projects* which benefited from APOC Trust Fund in2006,2007 and 2008 23 Table 8: Missions undertaken by APOC Management and Consultants from lst September 2007 to 29th August 2008 .............24 Table 9: List of NGDO partners by country Figures Figure l:Number of persons treated between 1997 and2007 in APOC countries...................4 Figure 2: Geographical coverage (%) in stable and post-conflict APOC countries in2007 .....6 Figure 3 : Therapeutic coverag e (%) in stable and post-conflict APOC countries in 2007 ........ 6 Figure 4: Villages covered by REMO surveys in APOC countries ........................8 Figure 5: Trend in the number of SAEs reported by NOTFs of Cameroon and DRC during 2006 and 2007 ivermectin treatment campaigns............... ....................9 Figure 6: Distribution of onchocerciasis, lymphatic filariasis, loiasis, schistosomiasis and soil transmitted helminthiasis in Equatorial Guinea ............... 10 Figure 7: Location of communities distributing ivermectin and health facilities supporting them in the four CDTI woredas (districts) in Jimma zone, June 2008...................12 Figure 8: Most frequently health interventions co-implemented with ivermectin distribution using CDI as reported by 43 projects in 7 countries in2007 .............. l4 Figure 9: Funds (US $) disbursed in2007 by national, regional and district/sub-district governments. 17 Figure l0: Trend of therapeutic coverage of projects after evaluation of sustainability and substantial reduction in APOC Trust support (2002'2007) ............ .......................21 Annex Annex l: COUNTRY PROFILES OF CDTI IMPLEMENTATION (YEAR 2007).'..'..........29 Annex 2: Trend of geographical coverage of projects after evaluation of sustainability and substantial reduction in APOC Trust support (2002-2007) ............ .......................37 Annex 3: Percentage of funds disbursed by govemments to support core CDTI activities in 2007 5t JAF14.5 Page iii List of Abbreviations/acronyms African Development Bank WHO Regional Office for Africa African Programme for Onchocerciasis Control Bureau des Etudes, de Liaison des Actions Caritatives Central African Republic Christoffel-B lindenmission (German NGO) Comprehensive Council Health Plan Community-Directed D istributor Community- D irected I ntervention Community-Directed Treatment with Ivermectin Christian Health Association of Liberia Canadian International Development Agency Catholic Relief Services Committee of Sponsoring Agencies Disability Adjusted Life Years Direct Financial Cooperation Directly Observed Treatment Short-course Democratic Republic of Congo Global Management System Health Impact Assessment Helen Keller International Health Education /Sensitization /Advocacy Avlobilization Information, Education, Communication Intemational Eye Foundation International Foundation for Education and Self-Help Inter-church Medical Assistance Independent Participatory Monitoring International Rescue Committee Joint Action Forum (APOC governing body) Letter of Agreement Local Government Area Millennium Development Goals Mectizan@ Donation Pro gram Mission To Save The Helpless Non-Governmental Development Organization Non-Governmental Organization National Onchocerciasis Control Programme National Onchocerciasis Task Force Neglected Tropical Disease Onchocerciasis Control Programme in West Africa Organisation pour la Prdvention de la C6citd Other Tropical Diseases Rapid Assessment Procedure for Loa Loa Rapid Epidemiological Mapping of Onchocerciasis Severe Adverse Event Southern Sudan Onchocerciasis Task Force AfDB AFRO APOC BELACD CAR CBM CCHP CDD CDI CDTI CHAL CIDA CRS CSA DALYs DFC DOTs DRC GSM HIA HKI HSAM IEC IEF IFESH IMA IPM IRC JAF LA LGA MDGs MDP MITOSATH NGDO NGO NOCP NOTF NTD OCP OPC OTD RAPLOA REMO SAE SSOTF E o o-q) E. ao o)L c}, oL(L 6 c oo o '6 o '6 q) o oEoc o L o o E E o o) o (L c oo o CL otr tt oq) o, o o- 6 o o .9 o .c o Lq) o o ! o o o o E E(! o) o (L (E o L JAF14.5 Page iv SSI TCC TDR Sight Savers Intemational Technical Consultative Committee (APOC scientific advisory group) WHo-based Special Programme for Research and Training in Tropical Diseases Technical Service Agreement United Front Against River-blindness United Nations Children's Fund United State Agency for International Development West African Health Organization World Health Organization see OCP see TDR TSA UFAR LINICEF USAID WAHO wHo WHO/OCP WHO/TDR JAFT4.5 Page L Executive summary During the past 12 years of its operation, the African Programme for onchocerciasis Control (APOC) has made substantial progress towards the overall goal of treating 90 million people annually, protecting an at-risk population of 120 million, and preventing over 40 000 cases of blindness each year in its 19 participating countries. Key to its success is the Community-Directed Treatment with Ivermectin (CDTI) delivery strategy, which, by using community distributors to carry out and record the annual treatment rounds, empowers local communities to fight river blindness among their families, friends, and peers. . During the period under review, lst September 2007 to 31st August 2008, APOC continued to help countries expand access to ivermectin through training of more community drug distributors, improving mapping of at-risk areas, providing technical support to expand treatment projects, and helping to sensitise both health workers and community members and to prepare the exit strategy. The specific achievements of these efforts include: . Rapid epidemiological mapping of onchocerciasis was completed in 108 villages in Angola and a nation-wide epidemiological mapping of four neglected tropical diseases (NTDs) was completed in Equatorial Guinea. . 342,765 community members were newly trained or retrained for ivermectin distribution; this brings the total community members serving as Community-Directed Distributors (CDDs) in 15 countries to more than 500,000. . One hundred and one (101) CDTI projects in l5 countries reported treatment figures. . Fifty-four (54) million people were treated in 115,957 communities in the 15 countries. This is a 9 .2%o increase over number of persons treated in 2006. . Overall, 87Yo geographical coverage rate and 6lYotherapetrtic coverage rate were achieved. . The treatments provided by 101 projects represent 67.3% of the programme projected treatment (79,186,044 persons) for 2007. . There was a78oh decrease in severe adverse events (SAEs) in2007. . ln 7 countries, 181,892 CDDs treated almost 14 million (13,962,103) persons in 69,000 communities with ivermectin co-delivered with 3 to 4 other health interventions. . Building on the significant results of a 3-year multi-country study which showed that Community-Directed Intervention (CDI) is much more effective than currently used delivery approaches for malaria treatment, vitamin A supplementation, and improves ivermectin treatment coverage, APOC provided funding to districts and local government authorities in Nigeria and Uganda where the CDI study was carried out to expand the CDI approach for integrated delivery of a broader range of appropriate health interventions to all CDTI communities including those not selected for the study. . Over 21 missions were undertaken by APOC management staff, Temporary Advisors and consultants to participating countries and other partners, to provide strategic guidance on collaborations, technical issues, and priorities associated with integration. . All statutory meetings including Joint Action Forum (JAF), Technical consultative Committee (TCC), National Onchocerciasis Task Forces (NOTF) annual meeting, and the Committee of Sponsoring Agencies were organized. Policy, strategic and implementation issues were discussed and guidance provided to the management and the countries for the smooth running of the control activities. . To streamline its operations with those of other WHO agencies, the APOC has joined the WHO system-wide "Going Live" Global Management System (GSM), with the result that all key documentations and payments for control activities axe now centralised and processed online. The old Letters of Agreement (LA) between APOC and the NOTFs for the execution of CDTI projects in countries have been replaced with the Direct Financial Cooperation (DFC) instruments. E o o- ot oo o)L O) o (L EL c o C) .9ao 'p ooo oc o Lo o) E E(U L o) e(L c(E o .E o o. ot. o oo E') o o- 6 o o .9, o .g o o o o (, o o q) E E(E o L (E o JAF14.5 Page 2 . APOC management participated in the meetings of NGDOs, Mectizan Expert Committee, NTDs and other partners including the Bill & Melinda Gates Foundation. Partnerships and other strategic issues on the control of onchocerciasis and other NTDs were discussed at these meetings. Management continues its sustained efforts to strengthen collaboration with partners including NGDOs, other WHO agencies and the World Bank. . However, key to the effective future operation of onchocerciasis control through CDTI is the financial support of national governments of endemic countries. Even though community-directed distribution of drug requires far less capital investment than other forms of health intervention, some funds will always be necessary to support the essential training and retraining activities, supervision, sensitization, record keeping, and logistics of drug distribution. APOC management has therefore assessed the extent to which governments are complying with their pledges to offer this essential support. ln 2007, govemments of 13 APOC participating countries allocated US$25,667 million for the treatment of 51.7 million people at an average cost of less than a dollar (0.50 US $) per person. This amount includes salaries paid to onchocerciasis MoH personnel. . A final part of APOC's exit preparations is the devolution of responsibilities and activities to countries. To this end, a consultant was hired to prepare a strategic document on decentralization of technical, financial and administrative functions of APOC headquarters to countries and WHO country offices. . It is important to note some significant achievements of the Programme. Since APOC adopted the use of the rapid epidemiological mapping (REMO) to determine the level of endemicity of onchocerciasis and delineate areas for large-scale treatment, REMO has now being completed in total of 11,200 villages in 19 countries in sub-Saharan Africa. . APOC is preventing one million disability adjusted life years (DALYs) per year. . Fifty-eight (58) CDTI projects have been evaluated for sustainability. Out of these, 25 projects from which substantial APOC Trust funding has been withdrawn were monitored to assess governments and NGDOs commitment towards sustaining the projects. 84Yo of these 25 projects have maintained over 70%otherapeutic coverage for four years, and 160/ohave fluctuating coverage rates between 2003 and 2007. APOC management is devoting significant time and energy to helping countries to put in place plans for the sustainability of CDTI activities and the exit of APOC trust fund. One aspect of this support is direct assistance in the preparation of exit plans, detailed below. . Recognising both the programme's potential for success and the scale of the remaining challenges, particularly in those onchocerciasis endemic countries that suffered recent conflict or remain in states of civil unrest, donors and ministerial participants at the thirteenth session of the Joint Action Forum, APOC's goveming body, agreed to a 5-year extension of the programme to 2015. Acknowledging the challenges and opportunities presented by the new mandate of the Programme, an addendum to APOC Strategic action plan and budget 2008-2015 was prepared during this reporting year for consideration by JAF 14. This progress report looks ahead to the future as well as reviewing the past year's achievements and actions and in particular, the challenges of low geographical and treatment coverage rates in five ofthe seven post-conflict countries. JAF14.5 Page 3 lntroduction: 2008 and beyond The African Programme for Onchocerciasis Control (APOC), responsible for coordinating national efforts to combat river blindness in sub-Saharan Africa, was established in 1995 to spearhead a community-driven strategy of mass drug administration to prevent the parasitic disease's devastating health, social, and economic effects. APOC includes 19 participating countries and insists on the active involvement of both Ministries of Health and affected communities. During the past 13 years, it has made substantial progress towards the overall goal of treating 90 million people annually, protecting an at-risk population of 115 million, preventing over 40 000 cases of blindness each year and gaining one million disability life years (DALYs) per year that would have been lost to onchocerciasis. This report is a summary of the efforts of stakeholders to position APOC within the rapidly changing landscape in global health. Acknowledging the opportunities and also challenges presented by the newly extended mandate to 2015, this progress report looks ahead to the future as well as reviewing the past year's achievements and actions on drug coverage, integration, co-implementation of CDTI and other health interventions, government financial contribution and sustainability, building a community data base for countries and partnerships. Scientific studies and practice are increasingly showing that CDI built on the CDTI of APOC is an effective model and an irresistible tool for the delivery of multiple health interventions, even in post-conflict situations. In this forward-looking report, therefore, APOC management is strongly advocating co-implementation of multiple interventions, the use of this approach by other control programmes, especially those targeting neglected tropical diseases. However, looking to the promising future of the CDI strategy also necessitates a note of caution: while APOC and partners continue to mobilize and deploy resources and expertise to establish sustainable control programmes in all countries where they are needed, it is imperative that governments increase their financial contributions to boost control activities as well. Participating countries must assume ownership of onchocerciasis control as APOC gradually devolves its functions to them ahead of the programme's exit date of 2015. *APOC has achieved many signiJicant successes in onchocerciasis control, and premature closure of the programme would lead to the loss of many of the benefits derived from the activities of the last several years which provide an ffictive platfurm for the delivery of other health interventions which are needed by millions of unserved people in Africa and which address the MDGs". - Working Group on the Future of APOC and Onchocerciasis Control in Africa,2006 E o o- otr oa o o) oL(L 6L c oO a '6 o '6 Lq) o o .CoC o L o o) E E oLq) oL(L c oo .E E o CL ou th .o o E' o o 6 o o .9,(n .g o o, o o o o o O.) E =(! gl o o- ag o L JAF14.5 Poge 4 1 THE YEAR lN REVIEIIU: Progress in Community-Directed Treatment with lvermectin (CDTI) 1.1 Overview of achievements By its proven effectiveness, the community-directed intervention approach, capitalizing on the desire of communities to help themselves, has become a powerful tool for low-cost delivery of multiple health interventions in Africa. Already, programmes in 20 APOC and ex-OCP countries have adopted this approach, empowering communities and strengthening health systems. Community-directed treatment with ivermectin (CDTI) is at the heart of APOC's work for the elimination of onchocerciasis as a public health and socio-economic problem in endemic African countries. It focuses on empowering communities to take responsibility for ivermectin delivery, deciding how, when and by whom the ivermectin treatment should be administered. This low-cost strategy has taken community involvement in public health to a level that few programmes had done before. ln 2007, APOC continued to help countries expand access of very remote communities to ivermectin through training of more community drug distributors, improving mapping of at-risk areas, providing technical support to expand treatment projects, and helping to sensitise both health workers and community members. The specific achievements of these efforts include: . Almost 54 million (53,865,599) people were treated across 15 countries (Figure 1). . Overall 87%o geographical coverage rate Nfi 65oh therapeutic coverage rate, in line with goals were achieved, representingag.2oh increase over the number of persons treated in 2006. . There was a'78%o decrease in the number of severe adverse events reported in 2006 Figure 1: Number of persons treated between 1997 znd 2007 in APOC countries 60,000,000 50,000,0(x) 40,000,000 30,000,000 20,000,000 10,000,000 t,o (U E otr0o o EL o oltc z ',742 53,865,599 48,685,267 40,349,477 37,361,888 32,936,100 28,609,656 24,632,547 20,420,t50 16,694,044 t4,079,654 0 1997 1998 {999 2000 2001 2002 2003 2001 2005 2006 2007 tr AFL4.5 Page 5 1.2 lmproving coverage of ivermectin treatment APOC continues to support countries in their, often extensive, efforts to improve the proportions of known endemic communities who are treated with ivermectin. Of the l0l CDTI projects which reported treatment figures for 2007, there was an overull87Yo geographical coverage rate, corresponding to 115 957 treated communities out of a total 133 345 meso and hyper endemic communities on record. In all, 53 865 599 people benefited from ivermectin treatment (Table 1) out of a total of 82 404 250 persons targeted, representing average therapeutic coverage of 65.4%o. This percentage is an increase of 9.2o/o over the number treated in 2006. Subdividing these numbers, it is important to look at the two different social contexts of stable and post-conflict countries because the presence of civil unrest can have an extremely detrimental effect on onchocerciasis control, conversely, where the need to improve treatment coverage in a stable country deserve special attention. Countries are classified as stable when the absence of armed conflict or social unrest has enabled CDTI to progress smoothly. Nine APOC countries---Ciuneroon, Congo, Equatorial Guinea, Ethiopia, Gabon, Malawi, Nigeria, Tarzania and Uganda--fall in this category. Conflict or post- conflict countries are experiencing repeated social/civil unrest and/or armed conflict or are emerging from these states into a reconstruction phase. For the reporting period, all 7 post --conflict countries--- Angola, Central African Republic, Chad, Burundi, DRC, Liberia, and Sudan--experienced delay in CDTI implementation. Table 1: Summary of ivermectin treatment in APOC countries,2006 and 2007 Country Approved projects Projects reporting 2006 2007 15 5J 15 15 11 11 22 15 15 I 99 Communities treated Population treated Angola Burundi Cameroon CAR Chad Congo DRC Eq. Guinea Ethiopia Gabon Liberia Malawi Nigeria Sudan Tanzania Uganda Grand Total 3 2 27 6 4 101 J 2 27 6 7 4 96 6 l3 15 1 1 ,, 20 1 9 I 3 2 27 6 7 4 108 2006 360 368 9,159 3,500 3,250 770 21,239 20,625 3,546 2,786 33,803 1,444 5,766 4,799 110,804 2007 1,489 368 9,445 3,195 3,250 770 21,853 129 22,486 2006 123,453 756,833 4,748,276 763,715 1,203,716 405,868 8,219,542 3,665,682 2007 414,965 860,416 4,427,481 724,791 1,389,921 449,171 9,230,951 50,064 4,135,538 2,442,167 1,546,433 22,839,983 1,499,137 1,684,667 2,169,926 53,865,599 4,370 2,186 33,924 1,710 5,848 4,934 115,957 1,516,586 1,489,491 27,780,998 1,028,334 7,553,476 2,029,957 48,685,267 E ooq)t aa oL o) oL(L 6L c o C) o '6 o 'o L oo oEoco L o o E E E o)oL(L Coo L o CL oE o o o E) o o- o o o .9, o .c o L(, o o o o o o E E(u tr) o (L a! o tr AFL4.5 Page 6 Figure 2: Geographical coverage (%) in stable and post-conflict APOC countries in2007 tm $ D :f ;70o 5eo ooEo ! e e.oa Rreo c, 20 t0 0 ConlLct port coflict cqrntric3 Figure 3: Therapeutic coverage (%) in stable and post-conflict APOC countries in 2007 s!%ftijffidr- *o of "€5l"*,e,f' ..p -""+,i""*:dd ,S "€ ord"df .t' 65% to $ t0 azo aItioot >E50(, 3{o33r0 F20 t0 0 rh$dd CofifictfDort coiltlct coilrbr JAF14.5 Page 7 Stable countries In2007,79 722 communities were treated out of a total targeted 81 376 meso and hyper endemic communities in the stable countries, representing geographical coverage of 98.0%. Nigeria, Ethiopia and Cameroon were the only countries not to have achieved optimum geographical coverage (100%) (Figure 2). These 8 stable countries treated 37 303 257 people out of a total 48 266 776 targeted individuals (a therapeutic coverage of 77 .2%). Only two CDTI projects out of 67 in the stable countries did not exceed the threshold therapeutic coverage of 65%o. These were Littoral I (61.8%) in Cameroon, and Akwa Ibom (56.1%) in Nigeria; elsewhere, the therapeutic coverage was above 70oZ (Figure 3). Notable milestones in CDTI implementation - 100% geographical coverage was achieved in Burundi (3 CDTI projects) and in Chad (one project) ' despite ongoing conflict -overallgeographicalcoverageinstablecountriesrcached98o/o ' - Thr". post-conflict countries, Liberia, Burundi, and Chad recorded a therapeutic coverage greater I than the threshold 65%. - In stable countries, only two out of 67 CDTI projects did not exceed the threshold therapeutic coverage of 65oh Post-c onflict co untries The figures in unstable regions are significantly less encouraging. During the reporting period, 36 235 communities were treated out of 51 969 targeted communities in the conflict/post-conflict countries, representing a mean geographical coverage of 49.0%o. A 100% geographical coverage was achieved in Burundi (which has three CDTI projects) and in Chad (with one project); elsewhere the geographical coverage ranged between 30.8% (Sudan) and 93.8%o (Angola) (Figure 2). The lowest percentages for geographical coverage in conflict/post-conflict countries in 2007 were recorded in Sudan (30.8%) and Central African Republic (63.7%). Overall, despite the instability in these nations, 16 562 342 people were treated out of a total targeted population of 34 137 47 4 in 2007. These numbers represent a mean therapeutic coverage of 48.5yo, which is far below the threshold of 65%o. But, encouragingly, three post-conflict countries recorded atherapeutic coverage greaterthan the threshold 65%; these were Liberia (66.50A), Burundi (70.60 ), and Chad (81.8%) (Figure 3). The therapeutic coverage remained below the 65Yo threshold in Angola (50.7%), CAR (45.2%), DRC (43.5%) and Sudan (38.3%). Appraisal of results The 2007 average treatment coverage of 77.2% for CDTI projects in the eight stable countries is higher than the 68.8% projected in the Programme's Exit Plan of Action and Budget 2008-2015. However, post-conflict countries do not seem to be faring so well against the targets; the 49Yo treatment coverage rate in these regions is lower than hoped. Also, although in 2007 the total at risk population for the l5 countries for which treatment data is available is 82 404 250, and the programme objective was to treatS4Yo(69 219 562 people), the actual number of persons treated in these was 53 865 599; a77.8Yo performance rate. Reasons for the poor attainment of treatment objectives in conflict/post-conflict countries include delayed launching of CDTI activities in Angola, DRC, and Sudan. By 2007, one project had not begun ivermectin distribution in Angola due to landmines and five projects had not been launched in DRC because of insecurity. Geographical coverage of meso and hyper endemic communities remained low in Central African Republic and the DRC. t o o- ot aaq) L o) oL(L 6L c o C) .9.a o 'g oo oEoc o L o o E E E o,oL TL c oo .E E o EL otr o o o t, o o- o o o .9 o .s o o o o ! o o L o o E E(E o) o (L ct(, L JAF14.5 Page 8 1.3 Mapping at-risk populations and areas In order to expand the reach of CDTI, and ensure all communities at risk have access to treatment, APOC is helping countries continue to identiff areas where the disease has not yet been accurately mapped. The technique used is called rapid epidemiological mapping of onchocerciasis (REMO), which involves the use of geographical information--- particularly the presence of river basins---to identif communities likely to be at high risk of infection, from which a small sample of individuals are assessed for the presence ofonchocerciasis. Ifmore than 20Yo ofthe adults assessed have nodules, then mass treatment is deemed to be required. In addition to helping countries identifr previously untreated populations, the REMO results are also being updated taking into account population re-settlement following movements of intemally displaced people and refugees after the return of peace to places like northern Uganda and Sudan in 2007. With financial support of APOC Trust Fund, nationals of l9 APOC countries, African scientists and staff of NGDOs supporting Onchocerciasis control and APOC management have surveyed over 11,200 villages in 19 countries as shown in the earth goggle map below. The yellow dots (Figure 4) are villages where REMO was carried out between 1997 -2007. Figure 4: Villages covered by REMO surveys in APOC countries Loiasis Although the once yearly administration of ivermectin remains the internationally endorsed strategy for combating onchocerciasis, it is not without problems. In areas where onchocerciasis is co- endemic with loiasis, a filariasis also called African eye worm, individuals treated with ivermectin can, albeit rarely, develop serious side effects. Therefore, to help monitor these events, protect the treated population, and increase the possibility of rapid and effective treatment, APOC continued to map areas of loiasis endemicity. With careful and phased expansion of ivermectin mass distribution in onchocerciasis and Loa /oa co-endemic areas, the incidence of adverse events is much lower than in 1999 (Figure 5) when the first cases were recorded in Center III project in Cameroon. Ln2007, an incidence rate of 0.08 SAE i t' sI e ,q \ 4 I AFt4.5 page 9 cases per 10 000 persons treated in Cameroon and 0.04 SAE cases per 10 000 persons treated in DRC were recorded. These rates are lower than the predicted expected number of severe adverse events in co-endemic areas where onchocerciasis and Loa loa are highly prevalent, reinforcing the success of the strategy. Figure 5: Trend in the number of SAEs reported by NOTFs of Cameroon and DRC during 2006 and 2007 ivermectin treatment campaigns i168 /\ +DRC - ! Cameroon 67 53 26) 8 I rt 't30 122 Q246 Q3S 04{6 Q1{7 Quart .s of yoar m07 Q247 Q$07 ofr7 A total of 72 severe adverse events (SAEs) following ivermectin mass distribution were reported in 2007 by 30 CDTI projects in Cameroon and Democratic Republic of Congo (Figure 5). This represents a decrease of78%o ofthe number ofSAE cases reported in 2006 (324 cases). Integrated disease mtpping In line with APOC's overall aim to ensure sustainability of onchocerciasis control by supporting its integration with control strategies for other diseases, APOC management coordinated a project, co-financed by Exxon Mobil, George Washington University, APOC and the Liverpool School of Tropical Medicine, to undertake integrated mapping of five neglected tropical diseases: onchocerciasis, lymphatic filariasis, schistosomiasis, loiasis, and soil transmitted helminths. During 2007, this pilot strategy was applied to Equatorial Guinea (Figure 6) but will be expanded to cover additional countries in the near future. In a similar vein, the WHO regional office in charge of Other Tropical Diseases (WHO/AFRO/OTD) and the Management of APOC have initiated a joint review of data to delineate areas where onchocerciasis and lymphatic filariasis overlap, and to define joint co-intervention zones for control of the two diseases. '180 160 1& l,,oo6. o fl'* o ui .,80 o .oE5soz 4 0 Q1-06 E ooq) u ao oL c') o L EL c oo a a o '6 o)o oE C)c o Lo o E E E o, o (L coo L t o CL otr ooo cD o o- 6 o o ,9 o .g o o o o o o L o o E E(o ct) o (L (! o ! Ehob6yinxrc0m9en0 Nsak NSDltD Nef.r{ Artsok Xongrm Xbini Akonih Ko0o I\60?k Akuenfn t, .- at ait a -a ;!1 rll :*iiffi::li:!;:: ffiC - rt'..t Laatra ", !r.-r!.tr'-,ti.._-..' a laatirtl at t'a' .ja'4..1 .a',aallDa'att r. a. aat. -la'.-a ta It -rr.r t..-.rr -t' :ittlt'.' J AFL4.5 Page 10 Figure 6: Distribution of onchocerciasis,lymphatic filariasis,loiasis, schistosomiasis and soil transmitted helminthiasis in Equatorial Guinea Malabo 'lJ[e ftaba I ,e84. t ''- * onch ocer ciasis+ L F Hffil onchocerciasis+LF+Loiasis EIs gp+1s;ssis o o Schistoso m i asis endem ic d istric'ts STH endemic distric'ts Actions to improve coverage During the reporting period, APOC Management and the National Onchocerciasis Task forces have: o Completed integrated mapping of five Neglected Tropical Diseases in Equatorial Guinea o Conducted a combined survey to determine the endemicity of Onchocerciasis and Loiasis in Angola . Allocated funds to Uganda's National Onchocerciasis Task force to complete the mapping in the recently conflict-scarred Nothern part ofthe country bordering Southern Sudan. . Provided technical and administrative support to the Southern Sudan's Onchocerciasis Task Force (SSOTF) to map in areas inaccessible during the long period of armed conflict in the country o Hired resident technical advisors to Central African Republic, Democratic Republic of Congo, Liberia and South Sudan 1.4 Training of health workers and community-directed distributors (CDDs) of ivermectin The training of health workers, conducted in a cascade manner at regional, district, and health centre or posts levels, was carried out in 2007 as in other years to strengthen the capacity of health personnel on programme management. Aspects covered in the training sessions included: health education, mobilization of communities, advocacy for greater involvement of community leaders in onchocerciasis control, the CDI strategy, management of severe adverse events, supervision of CDDs, inventory of ivermectin, community self-monitoring, stakeholder meeting (SHM), data collection and analysis, and, finally, report writing. A total of 36 887 health workers from all levels were trained under the coordination of the national onchocerciasis task forces. This number represents a 35.4Yo increase over the 2006 performance, with around 42o/o of the trainees leaming about CDTI for the first time. The highest ) 8da JAF14.5 Page 11 number of health workers trained for the first time on CDTI was in Nigeri4 which reported 11 137 new leamers, followed by DRC with 1770 and Ethiopia with 899 (Table 2). A total of 342,765 CDDs were trained or retrained in 1 15 957 communities in 15 countries for 2007. This number represents 20oh increase over the 285 017 trained/retrained in 2006. 38o/o of trained/retrained CDDs in 2007 were introduced to CDTI for the first time (Table 2). Within the reporting year, as in past years, only a proportion of serving CDDs are retrained (210, 796) out of the total number available. To date, with the training of 130,410 new CDDs, there are over 500,000 community members serving as CDDs in l5 countries. Table 2: Number of health workers and CDDs trained/retrained in 2007 by NOTFs A special initiativefor capacity building ln 2007, the "Special Country Initiative" continued as part of efforts to improve the performance of CDTI projects with unsatisfactory treatment coverage or poor CDD/population ratio, and especially increasing the number of CDDs. This initiative is ongoing in Nigeria with financial support from the APOC Trust Fund and implemented through NOTFs and NGDO partners. Within this initiative 23 815 CDDs, 3541 health workers, and 5375 community supervisors were trained/retrained for 8 CDTI projects in Nigeria. A total of 5321 communities were also mobilized and sensitized in these project areas. I nfo r matio n, e du c atio n, an d c o mmu n ic at io n mat e r ia ls During the reporting period, APOC Management encouraged national onchocerciasis task forces to submit proposals for developing new, or revising old, information, education and communication materials. These sensitisation aids are used to enhance efforts to maintain individual and community compliance to ivermectin treatment over the long term. As of June 2008, US$ 84 669 was made available to Nigeria to support 7 CDTI projects in developing these materials. The control programme of Tanzania received US$ 135,662. These countries have projects which have provided ivermectin for several years and community members are beginning to refuse treatment because of the absence oftroublesome itching and disappearance ofskin lesions. The projects need to develop new Information, Education and Communication (IEC) materials with emphasis on individual and community compliance to long-term ivermectin treatment. Information, Education and Communication (lEC) materials, including posters/stickers (27 000), CDD brochures (29 433), flip Charts (4 060), and CDD reporting forms (66 249), were also produced. Health workers trained or retrained CDDs trained or retrained Re- 7o newly Projects Re- 7o newly Projects Trained trained Total trained reporting Trained trained Total trained reporting Angola Burundi Cameroon CAR Chad Congo DRC Eq. Guinea Ethiopia Liberia Malawi Nigeria Sudan Tanzania Uganda Grand Total 205 2,645 467 201 177 3,962 l6 ) )1\ 317 1,612 22,982 48.3 t7.3 0.0 33.8 35.0 44.7 0.0 39.5 29.0 16.9 48.5 15 I 1 2 t6 I 9 J 2 27 7 4 91 2,315 4t6 40,838 20 6,s32 3,128 1,449 39,551 4,000 901 15,702 8,125 17,208 3,407 417 1,449 28,209 367 45,276 13,859 5,768 51,727 1,168 10,128 23,688 1,559 10,278 30,613 3,407 ) 1?) 1,865 69,047 387 5 1,808 16,987 7,217 91,278 5,168 11,029 39,390 20.9 43.8 0.0 84.7 22.3 59. l 5.2 12.6 18.4 20.1 43.3 77.4 8.2 39.9 38.0 5 J 15 I 1) l5 I 9 J 2 26 6 ,l 4 100 Country ., ,7650 68 62 1,770 26.2 36.7 42.1 99 457 s83 7,445 36,887 899 92 272 ll,l37 153 531 15,540 106 2,1 88 467 133 ll5 2,192 1,376 225 1,340 I1,845 430 914 2,153 13,405 E o o- o)(. aoq) o) oL[L 6L coo o '6 o '5 !oooEoC o o o E Eo o)oL(L c oo .E t o EL otr o ooL CD o o- 6 o o ,9, o .g o o, o o o o o (l, E E(g q) o o- (! o L J AFT4.5 Page tz Establishing a commanity database During the reporting year APOC Management continued to provide funding, equipment and special technical support to countries to develop a comprehensive community database with coordinates on CDTI. The ultimate goal is to improve the quality of data on over I 17,000 communities available in 15 countries. Community database will be useful in assessing the health impact of control operations, provide more accurate data for calculating the burden of onchocerciasis, monitoring the efficacy of ivermectin studies and studies on interruption of transmission of the disease. When completed, the database will be made available to other programmes. Every year, community-directed distributors (CDDs) of ivermectin record and update household treatment census and treatment registers. To date there are over 200,000 CDD treatment registers available in 16 countries in Africa. In the reporting period, projects in 9 countries---Burundi, Congo, DRC, Cameroon, Ethiopia, Malawi, Nigeria, Tanzania and Uganda---were funded for the completion of community data collection along with the recording of geographical coordinates for communities and health facilities in four CDTI project areas in Ethiopia. Figure 7 below shows the outcome of this exercise: the geographical location of communities distributing ivermectin and of health facilities supporting the mass drug administration in the four CDTI woredas (districts) in Jimma zone in Ethiopia. Figure 7: Location of communities distributing ivermectin and health facilities supporting them in the four CDTI woredas (districts) in Jimma zone, June 2008 x'€qt x'sgt 37'0 0t ljnu xose rl Sema Gomr Gera t Oilomda o +f .t Ginbo Lniin T.lotbch. IryBta Ger[ Eb (xoira) amTch. !7'OgE Srroct + lxdth faclllter Udramrtda Scka Ycucda Dedo worcda ShGbG Scmbouoltda l/llorcdm boundarlcr Zorpr boundrrlcr rT-rT'l--rTrl---r + 0 4,5 I Zl Rm IAFL4.5 Poge 13 1.5 lntegration of onchocerciasis control and co-implementation of CDTI with other health interventions 1.5.1 lntegration of onchocerciasis into health systems In June 2008, APOC and WHO/AFRO (ATM) co-financed and organized an international meeting on the integration of onchocerciasis control into national health systems and co- implementation NTDs control with some components of malaria. This meeting held in Addis Ababa was attended by top-level policy and decision-makers on health from six countries - Ghana, Nigeria, Sierra Leone, Tanzania, Uganda, the host country Ethiopia, WHO Africa Region (AFRO/OTD), as well as representatives of donors, NGDOs, and other health system support groups. The attendees included Directors of Disease Control and Public Health, Programme Managers of Onchocerciasis and Malaria control, as well as representatives of the USAID, the Carter Center, Liverpool School of Tropical Medicine, Sight Savers International and ChristoffBlinden Mission (cbm). The meeting was hosted by the Ministry of Health, Ethiopia and WHO Country Office. The meeting reviewed achievements by countries since the first integration and co- implementation meeting inBrazzaviLle Congo, in February 2007 and the International conference on Primary Health Care and African health systems, held in Ouagadougou, Burkina in April 2008. The meeting highlighted the need for increased country and intemational commitment and initiatives to improve the status and health security of the world's population, especially in Africa, noting that integration and co-implementation of compatible health interventions would improve coverage, bring equity to health service delivery. The meeting observed that a number of countries with the support of health partners were integrating the control of onchocerciasis and other NTDs into health systems and co-implementing components of malaria control. Ethiopia was as example of effective integration and co-implementation system using the country's Health Extension Workers (HEWs). The meeting identified challenges to integration and co-operation among programmes to include leadership and harmonization of activities. Counties should integrate all NTDs into the PHC system, adopt national policy, strategic plan of action on NTDs and malaria control; put in place management structure, mobilization resources, and solicit increased support from donors and partners. Stakeholders, especially countries and disease control programmes should leverage the health systems support such as the US Presidential Initiative involving US $350 million for the control of NTDs with the target of treating some 300 million people over five years countries in Africa, Asia and Latin America in five years. A full report of this meeting is available as JAFl4/INF/DOC.2. 1.5.2 Co-implementation of CDTI with other health interventions By extending the programme duration, APOC's governing body has recognized that the changing dynamics of disease control and the need to roll-out the community distribution strategy to other neglected tropical diseases---including lymphatic filariasis, loiasis, soil-transmitted helminths and malaria among others---necessitate inclusion of co-implementation in APOC's mandate and exit strategy. During the reporting period, APOC Management strongly advocated for regional recognition of the potential of the community-directed treatment approach in strengthening community participation as a key component of the ALMA ATA declaration and strengthening of health systems in Africa. As a result of the high level advocacy, researchers and representatives of TDR presented the findings of the multi-country multi-site study to the International Conference on Primary Health Care and Health Systems in Africa held in Ouagadougou, in April 2008. CDTI projects have by their performances made a strong case on the centrality of CDI to effective public health care delivery, noting that given its proven effectiveness, the strategy seems indispensable in efforts by countries to achieve the health Millennium Development Goals (MDGs). To help sustain the gains made in some Local Govemments Areas (LGAs) in Nigeria as well as to serve as models for the country for programme expansion, APOC participated and made contributions to the debriefing and planning meeting in Abuja on the up-scaling of the results of CDI study in 3 states. APOC has provided funding to the districts and local government health services in Uganda and Nigeria in which communities were involved in the multi-country study to continue with, and expand the interventions to all CDTI communities. Similar financial support will be provided to E o o- 0)t oo oL o) oL(L E C o() a '6 o '6 L o)o o -coc o o 0) E E(E o)oLL c(u o ts o CL o E. o o o E" o o- 6 o o ,9, o .g oL o o o o o o o E E o o) o L(L (! o J AFL4.5 Page t4 Cameroon in 2009. The results and lessons of scaling up the research findings by the Ministries of Health of Nigeria, Uganda and Cameroon will be presented to the JAF in2009. From evidence shown in Table 3 and/or Figure 8 below, it is clear that through the network of community distributors APOC has established control operations far more than its initial mandate---by providing a mechanism for the large-scale improvement of primary health care. As shown in Table 3, 43 CDTI projects in 7 countries, which provided information, were involved in co-implementation of multiple health interventions. ln 2007 , 1 8 I ,892 CDDs reached almost 14 million (13,962,103) persons in 69,000 communities. Not all projects submitted results. It is interesting to note that more CDDs and projects were involved in the distribution of insecticide treated bed nets and home based management of malaria than other interventions. Figure 8: Most frequently health interventions co-implemented with ivermectin distribution using CDI as reported by 43 projects in 7 countries in 2007 lnsectlcide treated bed net distribution Home management of malaria \rlrtmln A supplementation Schistosomiasis Lymphatic filariasis Dewoming Tr?choma .9 o Eo " """0' C C C C ...-. C ".$ us C C .r..t" Number of perons reached Table 3: Number of activities co-implemented (including ivermectin distribution) and targets reached by 43 projects which reported data, in 7 countries, in2007 3,778,991 508,683 2,555,347 2,498,05s 952,834 5,307,809 4,317,237 Countrv Burundi Cameroon Ethiopia Nigeria RDC Tanzania Uganda Total Number of projects co- implementing 2 10 7 8) 5 4 38 No. of Districts Involved l4 133 53 164 tt4 1l 27 516 No. of CDDs Involved l6 814 36 155 32 661 52398 32 018 7 881 3 96s 181 892 No. of Communities reached 568 15 258 14 344 15 493 t7 367 291 5 678 68 999 No. of persons reached t 3s9 265 3 404 702 3 694 310 538 941 r s20 053 1 439 409 2 005 423 13 962 103 J AFI4.5 Page 15 2 THE YEAR lN REVIEW: Research and Evaluation 2.1 Health impact assessment Although many of the key measures of success of the CDTI strategy axe process related--- numbers of CDDs trained, coverage rates, and communities involved---APOC is also committed to investigating and documenting the real health and social impact of the past decade's mass drug administrations. To this end, a group based at Erasmus University in Rotterdam, the Netherlands, is working on an in-depth Health Impact Assessment of APOC and its activities. Coverage is a crucial determinant of APOC's health impact. So the first in-depth analysis to attempt to quantiff the programme's health impact used APOC's detailed community-level data about CDTI coverage in Malawi. All available data were scrutinized and thorough quality checks were done. The database was not quite complete but, nevertheless, it provided important information about coverage patterns. The reported therapeutic coverage for 2006 was usually between 75-80yo. A limitation of the currently available database is the inconsistency in spelling of village names, which hinders accurate assessment of geographical coverage and of time trends in therapeutic coverage at village level. For one region, the data allowed the assessment of time trends in about 1/3 of the villages. Although many villages reported a low coverage in one or two years, only l% of the villages reported a systematically low coverage. In the large majority of villages CDTI seems to be functioning very well. ONCHOSIM The Rotterdam group is also undertaking a revision of the ONCHOSIM simulation model, which predicts how onchocerciasis will change in prevalence and incidence as interventions continue to be applied. The computer program will be modemized and adapted to the requirements of APOC and the Health Impact Assessment (HIA) over the coming year or two, including an update to the JAVA programming language. An advantage of this modern language is that the model can be made available via the internet to countries, which can run the model while maintenance remains in Rotterdam. The new computer program will simulate blindness, vision loss, and skin disease providing detailed output about the occurrence of difflerent clinical manifestations of onchocerciasis and including information about the overall burden of onchocerciasis-related disease in terms of disability adjusted life years (DALYS). Ongoing work further concentrates on better packaging of health impact predictions, for optimal communication of the results to the main audiences. 2.2 Operational research: expanding use of CDI The experience with CDTI coupled with the growing need to improve overall access of Africa's poor to other critical health care tools, prompted APOC's governing body, JAF, to commission a study to examine whether an expanded stratery of "community-directed interventions" (CDI) might be used to combat other diseases in communities with prior experience with CDTI. The resulting 3-year multi-country study carried out by WHOiTDR was launched in 2005, funded in the first year by APOC Trust Fund and subsequently by Bill and Melinda Gates Foundation. Four additional interventions were selected to be examined alongside ivermectin distribution. They ranged in complexity from relatively "simple" interventions such as Vitamin A supplementation, to more complex, such as distribution of insecticide-treated bednets, directly-observed treatment of tuberculosis, short course (DOTS), and home-management of malaria. The study has now been completed in seven research sites in three countries: Cameroon, Nigeria, and Uganda. Each research site included five participating health districts for a total of 35 health districts covering 2.35 million people. AII sites already had several years of experience with CDTI, so were familiar with the theories behind the strategy. During the first year of the study, one new intervention was added at each trial district, a second new intervention was added during the second study year, and in the third year, all five interventions (including the ongoing ivermectin treatment) were delivered through the CDI process in E o o- ot aaoL o)oL(L I C oo .9.a op q) o oEoc o L o o) E E o o) oL(L c oo E o CL o e. o an(l, E) o o- 6 o o ,9 o .g o L o o o o o o o E E o g) o (L (E o I AFL4.5 Page L6 all trial districts. In the comparison districts, all interventions continued to be delivered in the conventional manner. The CDI approach was shown to be much more effective than currently used delivery approaches for all studied interventions except DOTS. With respect to costs to the health system, CDI was more efficient than conventional delivery systems and achieved higher coverage without any increase in implementation costs at the health district or front line facility level. At the community level, there was an increase in 'oopportunity costs" with CDI, reflecting the greater time commitment needed from community implementers. Intrinsic incentives for doing this sort of work, e.g., recognition from peers, status, knowledge, and skills gain, were perceived as more powerful motivators than material incentives. The researchers concluded that integrated delivery (also called co-implementation) of different interventions through the CDI process is perfectly feasible. Based on the study results, APOC is now recommending that areas with experience in community-directed treatment for onchocerciasis control should also try to use the CDI approach for integrated delivery ofa broader range ofappropriate health interventions to communities. The final report of this study has now been published and will be made available to JAF in December 2008. 3 THE YEAR lN REVIEW: Prospects for sustainability 3.1 Are government's committed? Key to the effective future operation of onchocerciasis control through CDTI is the financial support of national governments of endemic countries. Even though community-directed distribution of drug requires far less capital investment than other forms of health intervention, some funds will always be necessary to support the essential training and retraining activities, supervision, sensitization, record keeping, and logistics of drug distribution. During the reporting yetr, APOC management assessed the extent to which governments are complying with their pledges to fund these essential CDTI activities. The clear message to governments from this report is that ivermectin treatment directed by communities is a cheap and affordable strategy for controlling a public health problem. As Table 4 below shows, the implementation of the four core activities accounted for29.8%o of the contributions made in 2007 by national governments. Table 4: Percentage of funds disbursed by item line by governments in 2007 Country Total disbursed (us$) 107,982.0 8,404.1 7,930,766.6 79,228.0 121,586.0 80,996.0 193,182.0 Not available 2,840,043.0 19,612.0 7 54,715.0 17,920,186.0 Not available 1,501,200.0 l r9,820.0 Angola Burundi Cameroon CAR Chad Congo DRC Equatorial Guinea Ethiopia Liberia Malawi Nigeria Sudan Tanzania Uganda TOTAL 7.2 8.8 0.7 0.3 86.6 3 1.8 85.3 97.4 2.0 0.8 9.7 Percentage offunds allocated to Core CDTI activities Equipment 53.6 0.0 4.8 39.0 34.1 30.0 26.6 0.0 50.6 12.4 16.0 25.0 84.1 0.0 Saleries 46.4 56.2 3s.9 73.4 37.0 59.0 15.9 85.5 75.5 60.5,720.7 6.2 59.4 14.0 2.3 12.5 23.7 29.8 JAFT4,5 Poge t7 In2007, governments at various levels in 13 APOC countries allocated more than US $25 million to treat 51.7 million people at an average cost of less than a dollars (0.50 US$) per person. This low cost of treatment is affordable by countries. The challenge now is the need for countries to sustain and increase their contributions to the control programmes towards eliminating onchocerciasis as a public health and socio-economic problem in endemic countries. Countries will present comprehensive findings on this subject to the JAF14 under agendaitem 72. Table 5: Governments' financial contributions (in US$) to CDTI activities in 2007 Figure 9: Funds (US $) disbursed in 2007 by national, regional and district/sub-district governments. National Regional Oistrict rSubdistricts 0 5000000 10000000 15000000 20000000 2s000000 Amount (US $) disbursed It is important to note that govemments at district /sub-district levels disbursed the highest rate of funds to CDTI activities in2007 (Table 5 and Figure 9). Out of the total US $ 25 677 721disbursed by govemments, district /sub-district govemments released 85% (US $ 21 981 465) to CDTI activities. troo o ot,c P.8 e'; ltoo6 E o .E oo 5 oo Country Government levels disbursing funds for CDTI activities National Regional DistricUsub district Total Eq. Guinea Sudan Angola Burundi DRC Liberia Malawi Uganda Cameroon CAR Chad Congo Ethiopia Nigeria Tanzania TOTAL 107,982.0 8,404.1 193, 1 82.0 79,612.0 49,332.0 33,933.0 368,069.5 27,426.0 24,962.0 50,154.0 137,751.0 312,560.0 123,255.5 1,456,623.L 461,664.3 23,100.0 20s69 4,867.0 681,906.0 1,034,914.2 12,612.0 2239,632.4 705,383.0 85,887 7,107,032.7 28,702.0 76,055.0 25,975.0 2,020,386 16,572,711.8 1,365,332.5 21,981,465.0 107,982.0 8,404.1 193,182.0 19,612.0 7 54,715.0 119,820.0 1,930,766.5 79,228.0 121,586.0 80,996.0 2,840,043.0 17,920,186.0 1,501,200.0 25,677,720.6 $1 456 623 $2 239 632 $21 981 E o o-q)t oo o)Lq) o L E co() @ '6 o 'p oootoc o o o E E E o) oL(L c oo ,E E o CL o E. o o o cn o G 6L oo .2 o .s o q) o o o o o o E E(! t'l o o- G' o JAF14.5 Page 18 Breakdown of national funding The percentage of funds allocated to each of the core CDTI activities is based on priorities identified by countries. The Annex 3 shows that 22.6%o of the US$1,888,513.1 disbursed by governments in 2007 was allocated to mobilization, advocacy, sensitization, and health education. These activities were given a particularly high priority by Uganda and Nigeria, which allocated 54.1oh and36.lYo of the funds respectively to core CDTI activities in 2007. Training and retaining of community distributors and health workers accounted for 18.5% of the total amount disbursed by national govemments to core activities. Malawi (49%) and Liberia (54%) identified this activity as a priority.26.3% of the funds disbursed by national governments in 2007 were allocated to supervision, monitoring, and evaluation. Tanzania (44yo), Ethiopia (38%), DRC (58%) and Congo (38o/o), did not only accord priority to this activity but allocated more funds to it, Govemments allocated 32.7% of the funds in2007 to ivermectin distribution and management of severe adverse events. Cameroon, with projects located in areas where onchocerciasis and loiasis are co-endemic, allocated 670/o, which is double the 33Yo average allocated to this core activity. Central African Republic (CAR) allocated 70%o of the funds to this activity. The delivery system of ivermectin in CAR is being reorganized and this may explain why priority is given to this budget line. In summary, countries are making efforts to ensure sustainability of CDTI projects through national funding, but this effort must be stepped up and maintained. 3.2 Monitoring sustainability To identiff challenges and opportunities in the implementation and sustainability of CDTI, APOC has developed tools for (i) independent participatory monitoring, (ii) evaluation of sustainability of CDTI projects and (iii) monitoring of governments' implementation of sustainability plans developed by countries following the evaluation of projects. . Under monitoring and evaluation, there have been: . Independent participatory monitoring of 70 CDTI projects in 13 countries. . 70 sustainability evaluations completed covering 58 projects in l0 countries. . 64 plans for future sustainability prepared by countries and submitted to APOC. 3.3 lndependent Participatory Monitoring of CDTI In the year under repo(ing, six Independent Participatory Monitoring (IPM) studies were conducted in two countries. In Cameroon, five CDTI projects in East, Far North, Littoral I, South and Adamawa I Provinces were monitored. In Burundi, independent monitoring took place in the Cibitoke-Bubanza CDTI project. IPM involves interviews with key individuals along with focus group discussions to examine the implementation process of CDTI at various levels, including communities, health facilities, district health management teams, and at government level. Indicators of CDTI activities including mobilization and sensitization of communities, community participation, training, supervision, record keeping, ivermectin procurement, partnership, integration, gender issues participation of women and minorities, and resource mobilization are assessed. Results of these investigations done in 2007 showed that the mobilisation and sensitization level of communities ranged between 70o/o and l00oZ, with East Province CDTI project in Cameroon recording the lowest score. The monitoring results also indicated that community participation and ownership of CDTI activities were strong in the Cibitoke-Bubanza CDTI project in Burundi, with 80% of CDDs for the projects chosen by the communities themselves, but reported to be weak in four out of the five CDTI projects monitored in Cameroon. This was partly due to poor mobilisation and sensitization of communities. Nonetheless, the monitors reported that attrition of the Community Drug Distributors (CDDs) was reassuringly low and most of the communities received ivermectin supplies on time. tr AFL4.5 Poge L9 In the five projects monitored in Cameroon, health workers and CDDs were trained on integration of CDTI into the health systems as part of the monitoring process. In Burundi, co- implementation of CDTI activities with other neglected tropical diseases is also evolving. Record keeping was reported to be improving, and ivermectin supply largely sufficient and drugs were delivered in a timely way in most projects monitored---except in the Far North province where l0%o of communities reported late supply of the treatment drug. The monitors noted that government financial contributions were weak for four out of the six CDTI projects under evaluation, with much of the official support limited to payment of health workers' salaries and provision of infrastructure. Most communities did motivate their CDDs by use of in-kind incentives, and in all the projects monitored, NGDOs and partners played their roles. 3.4 Sustainability evaluations During the period 2002 to 2008, 70 individual sustainability evaluations have been conducted, with Nigeria and Cameroon having the greatest density of evaluations. Some 90o/o of these countries projects underwent this assessment. Encouragingly, 55 of the reports resulted in the outcome "making progress" (Table 6). Table 6: Summary of sustainability evaluation results, 2002 - 2008 Country Number of evaluations conducted t2 2 2 J J 2 29 I 5 t1 70 Assessment of sustainability Making progress NOT making progress 102 02 11 30 30 1l 227 01 41 ll 0 55 15 Cameroon Chad Congo DRC Ethiopia Malawi Nigeria Sudan Tanzania Uganda Grand Total ln 2007, two CDTI projects were evaluated for sustainability and both were judged to be making satisfactory progress. The 8 years old South West II project in Cameroon had already been evaluated in 2003, but at that time was assessed as not making progress, so last year's evaluation was a reassessment,. The other site, the North West Cameroon project, had not been evaluated before. Two problem areas were identified and subsequently fed back to the Regional and District health Management Teams with recommendations for programme sustainability. These were: . Financing, which affects transport and ability to provide training materials and carry out some activities such as internal monitoring and supervision r Management - relating to record keeping, supervision and preparation of detailed plan. Recommending strategies to tackle these issues, the monitors suggested that strong advocacy could improve the release of funds to projects, to enable continuation of training, retraining of CDDs, and community mobilization and education on compliance to long-term treatment with ivermectin. Training in management, including record keeping, planning, and supervisory techniques should also be stepped up to improve project performance, the monitors said. 3.5 Sustainability plans Individuals charged with carrying out the evaluations of sustainability of CDTI projects are primed to give feedback to district health management teams and help them in developing a project sustainability plan. APOC is progressively building the capacity of senior district health managers to t o o- ot ooo C,) oL(L 6L coo .9.o o '6 L oo o -c C)c o Lo o E E o o, o (L cGo .E L o o. ot o oq) q) o o- E o o ,9, ta .g oL o o o (,, o o o E E(E q) o o- (E o L 3.6 Monitoring the implementation of sustainability plans ln 2004, a special meeting of APOC partners on sustainability of CDTI projects *CDTI octivities in on area are was held in Ouagadougou, Burkina Faso. sustainable when they continue to function The meeting adopted thJ above definition of effectively for the foreseeable future, with high sustainability, reviewed the performance of treatment covetage' integrated into the available 35 CDTI projects, and agreed on the tools for health care service with strong communi$t monitoring how participating governments ownership, using tesources mobilized by the are sustaining projects. Following this community and government." APOC partners meeting, APOC management put in place a meeting on sustqinability' 2004. mechanism for monitoring the implementation of the projects' sustainability plans after the 4th or 6th year of project that had been evaluated, whether the project is receiving further APOC financial support or not. To date 27 CDTI projects have been monitored to measure the implementation of sustainability plans. Between September 2007 and August 2008 implementation of sustainability plans of 5 projects in Edo, Adamawa, Enugu, Anambra and Bauchi States, Nigeria were monitored. There are some encouraging lessons from this exercise. First was that the ivermectin procurement and delivery system was effective. Communities appreciated the benefits of ivermectin treatment and were supportive of and actively involved in CDTI activities. Community participation and ownership was adjudged to be improving, with strong adherence to ivermectin treatment, as well as willingness by some communities to fund training activities themselves and provide incentives to CDDs. However, there were also several negative observations: supervision and monitoring activities of the health systems were irregular, with checklists of supervision not always used; training was done but was restricted in scope; and timely release of allocated budgets by governments was identified as a major challenge to project sustainability. Monitors recommended prompt release of funds to facilitate internal monitoring, supervision, and training activities. There should also be high-level advocacy to the relevant authorities to improve JAF14.5 Page 20 prepare and implement sustainability plans, thus maintaining the achievements of the onchocerciasis control programmes. Between December 2004 and August 2008, regional and district senior health staff in 10 countries have acquired skills to develop sustainability plans of CDTI projects, in workshops organized as part of evaluation of the sustainability of CDTI projects. Since the inception of this activity in 2003, 56 of the 58 CDTI projects evaluated have submitted either three or five-year sustainability plans. These plans consist of 486 sub-plans submitted by regional and districts management teams, the operational level of CDTI. More than 1540 policy and decision makers and onchocerciasis coordination teams in 11 countries have participated in the feedback meetings and in developing sustainability plans of community-directed treatment projects. The process of developing sustainability plans takes 5-7 days. This includes training sessions for participants, discussion and development of work plans and budgets for long-term financing of ivermectin distribution by govemment at the central, district and sub-district levels. The district leaders and evaluators share the results of the evaluations, review ownership of CDTI by the community and health system. They assess the monitoring mechanisms and define alternative sources of support from government for sustainable financing henceforth and after the cessation of APOC and draw plans. Provincial and district health management teams considered the training to develop sustainability plans an important initiative for financial sustainability of Onchocerciasis control and other programs. Through development of sustainability plans, governments with the support of NGDOs have in some instances adopted realistic strategies of financing onchocerciasis control activities. For example, CDTI activities such as training/ retraining of frontline health workers and CDDs and supervision are integrated into district activities or are being co-implemented with other health intervention activities. lAFl4.5 Page 2L the critical funding situation and an increase in the number of CDDs to the recommended threshold ratio of l:100 persons. Given the importance of sustainability of annual ivermectin distribution to the control of onchocerciasis, we present in Figure 10 and Annex 2 the performance of all 25 projects since the withdrawal of substantial financial support of APOC Trust Fund. A full report on the performances of these projects, lessons learnt and challenges is submitted as a document for agenda item 8. 3.7 Sustainability conclusions In summary, lessons learned from the evaluations of projects and monitoring of implementation of sustainability plans show that the following indicators: training; health Education/Sensitization/Advocacy/\4obilization (HSAM); monitoring and supervision; and ivermectin supply and distribution have a direct impact on treatment coverage and sustainability of projects. Since 2006, the management of APOC has been supporting projects performing poorly in these indicators, including those no longer receiving substantial financial support from APOC. These activities have led to the initiation of the ongoing "Special Country Initiative" on HSAM and Training. Figure 10: Trend of therapeutic coverage of projects after evaluation of sustainability and substantial reduction in APOC Trust support (2002-2007) Ehiopia ]Gfa-ShekkaCDTI cameroon south west I Malawi ECension A Phase lV III Phase lll I lg E Phase ll IE E" Phase I Tukuyu Focus CDTI Tanga FUvuma Mahenge Focus Adamawa Eo, Iblta lmo, Abia Plateau Mssarawa hugu, Anam bra, Ebony f t o E6F (! $z I r"r"u" I "ross Rver I Kaduna a2002 r2003 a2004 I 2005 I 2006 a2007 01020 80 90 100 E o o- otr ooo o, o (L 6 co o <t a o (-) Lq) o oc C)c o Lo o E E E o) oL TL c(U o .E t o a. oE oo o q) o o. o o o .9, o .g o o o o o o o o E E(! g, o (L o o JAF14.5 Page 2? 4 THE YEAR lN REVIEW: Programme Management, Finances, and Partnership 4.1 An extended mandate In December 2007, the Joint Action Forum, which was held in Brussels approved APOC's Strategic Action Plan and Budget 2008-2015 and extended APOC closing date to 2015. This change reflects the strength of APOC's partnership in onchocerciasis control and the history of encouraging results over the past decade's interventions. However, it is also a reflection of the confidence partners and donors alike share in the notion that APOC's methods can, with a little more time, significantly impact on the populations remaining at high disease risk during recent or ongoing conflict. 4.2 Renewing human resources ln 2007, APOC converted four more temporary professional positions to fixed term posts at the Ouagadougou headquarters, continuing the task laid out in WHO's rules and regulations goveming recruitment, to which APOC, as a WHO special programme, is bound to adhere. Out of five positions which were transformed to fixed term posts at the headquarters, two have already been filled and the process for filling the remaining three is advanced. Two positions that made the transition to fixed term posts at WHO country offices in Cameroon and Nigeria have been filled, and the process of converting temporary positions to fixed term posts for Administrative and Finance Assistants for Angola, Democratic Republic of Congo (DRC), and South Sudan are ongoing. The recruitment process for administrative and finance assistants at WHO country offices is also in progress for Ethiopia, Tanzania, and Uganda. Technical advisors for post-conflict countries, currently temporary positions although in line for transformation to fixed term posts shortly, were recruited for Central African Republic, DRC and South Sudan, while the process is ongoing for Liberia and Chad. In addition, over 50 nationals were involved in monitoring, evaluation and project support missions during 2007, and since most hailed from APOC or ex-OCP countries, these activities also contribute to knowledge sharing between health personnel in different countries about CDI implementation. Also, a number of candidate secretaries completing their secretarial courses at universities and various higher institutions in Burkina Faso were offered intemships. 4.3 Financial activities In the reporting period, APOC activities were funded as required by WHO's new financial rules and procedures, which are based around the principle of delivery of goods and services within the fiscal year in accordance with the annual expenditure. 107 CDTI projects, and 7 National Onchocerciasis Task Force HQ support were funded (Table 7). For smooth implementation of the field activities, between 50Yo and 70Yo of the approved amounts were released to projects as a first instalment as soon as Letters of Agreement were signed between the projects and the Management of APOC. The second and final instalments were released to projects after submission of the financial returns for the first release of monies. ln 2007, US $ 13,5 million approved under the APOC Plan of Action and Budget was disbursed. It is important to note that two project in North Sudan were not funded due to the lack of plan of action and budget submitted by the projects. All projects that complied with WHO/APOC financial rules and procedures received appropriate funds for their activities from the APOC Trust Fund. JAF14.5 Page ?3 Table 7: Number of projects* which benefited from APOC Trust Fund in 2006, 2007 and 2008 Country Nigeria DRC Cameroon Taruania Ethiopia Angola Uganda Sudan Burundi Liberia Equatorial Guinea Congo Malawi Chad CAR Total 2006 25/28 t7lt7 t6/16 09/09 02110 06106 06t06 06106 03103 03/03 02102 02102 02102 01 /01 0/01 L00 I ttz 2007 28128 21121 16t16 08/09 l0/10 06107 06/06 05107 03/03 03/03 02/02 02102 02102 01 /01 01/01 LL4 I LL8 2008 28128 21122 16lt6 08/08 10/10 06/08 04105 05107 03t03 03103 0l/01 02102 02t02 01 /01 0l/01 ttt I tt7 * projects include CDTI, Vector elimination and NOTF HQ support 4.3.1 Decentralisingfinancialmanagement With the closure of APOC now looming just 7 years in the future, the programme is continuing to decentralise of some of the functions previously carried out at the Ouagadougou headquarters to the countries themselves. 73%o of the projects in six post conflict countries already have administrative and financial assistance for their staff paid by the programme at the country level. The conversion of the contracts of two administrative and financial assistants to fixed term positions in Angola and South Sudan is underway. Since these changes require training and capacity building of national staff in financial procedures, a meeting on the analysis of project proposals and the preparation of Letters of Agreement was organized by APOC. Attended by nationals from Burundi, Malawi, DRC, Angola, Ivory Coast, Nigeria and Sudan, the meeting was intended to improve compliance with WHO financial rules by countries. A training session was also organized in the Central African Republic for more than 34 project accountants and managers. Financial reviews of APOC operations in DRC, Nigeria, and Ethiopia were conducted during 2007 with recommendations and guidance provided to the project coordinators to help them better comply with the financial procedures. In total, 837 financial retums were received from the projects arrd 471 have been analysed for feedback. A lot of improvement has been noticed in the financial returns during the reporting period. 4.3.2 A new tool: the Global Management System To streamline its operations with those of other WHO agencies, APOC has joined the WHO Global Management System (GSM), with the result that all payments for onchocerciasis-related activities are now controlled from the WHO Global Service Centre in Kuala Lumpur, Malaysia. Under the online system designed to facilitate transactions, the old Letters of Agreement for the execution of APOC CDTI projects have been replaced with Direct Financial Cooperation instruments. The GSM process was launched at APOC after training of staff and efforts are ongoing to sensitize staff at all levels, including in countries, to make relevant individuals aware of the new system. t o o- ot oo o o) oL(L EL C oo a(lt o 'p oo o -coc o L o o E E(u o)oLIL c oo L o CL ot. o o o, E' o o. 6 o o ,9, ah .c o o o o C' o o o E E .g E') o (L (! o JAF14.5 Poge 24 4.4 Direct support to countries Despite its lean staff during 2007 APOC Management continued essential sensitisation, advocacy, monitoring activities, and funded support missions to participating countries and partners. Over 21 missions were undertaken to 14 APOC and ex-OCP countries either for the purpose of attending meetings or to provide strategic guidance on collaborations, technical issues, and priorities associated with integration (Table 8). These support missions undertaken by management staff, temporary advisers and consultants, mostly from the African region, also provided an opportunity for discussions with policy makers on the disease situation, integrated approaches for control, to clariff the role and contribution of different partners, and to review the administrative and financial operations of CDTI projects. The overarching objective of country visits such as these is to stimulate CDTI activities within countries, offer training on APOC philosophy, CDTI strategy, and data collections, as well as training of CDTI project accountants in the WHO accounting system. Table 8: Missions undertaken by APOC Management and Consultants from lst September 2007 to29th August 2008 Activity Specific task Disease mapping Country (areas) Mozambique Equatorial Guinea Angola (Bengo, Kwanza Norte, Benguela, Uige, Zaire) Angola (Bengo, Kwanza Norte, Uige) Angola (5 provinces) C6te d'Ivoire B urundi : (Cibitoke-Bub ann) Cameroon: (Adamaoua I, East, Far North, Littoral II, South) Cameroon: (North province, South west II project) CAR Ethiopia Nigeria Ghana Liberia DRC ( Butembo-Beni, Katanga Sud and Rutshuru Goma CDTI projects.) Number Number of of nationals advisors who participated 39 233 119 REMO Mapping of NTD Combined implementation of RAPLOA/REA Training of focal point and health workers of in Management of SAEs. Training of health workers Training of trainers in CDTI activities. Independent participatory monitoring of CDTI projects. 2ning 2 I l0 5 27 and 1 5 1 Sustainability evaluation Support to CDTI Support to implementation of implementation CDTI Support to implementation of CDTI Review of CDTI data. Field study of geographical and therapeutic ivermectin coverage Fact-finding mission ve Collection and analysis of al) and Imprest returns I 8 l6 11 1 8 )Z 164 48 1 I JAF14.5 Page 25 4.5 4.5.1 The Joint Action Forum The Thirteenth session of the Joint Action Forum (JAF) of APOC was held in Brussels, Belgium in December 2007. The session reviewed reports on the key activities of countries, NGDOs and WHO in 2007,: amendment to APOC's Memorandum of Understanding; the strategic Plan of Action and Budget (2008-2015) and the Plan of Action and Budget, 2008. 4.5.2 Technical Consultative Committee The 25th and 26n sessions of the Technical Consultative Committee (TCC) of APOC were held in September 2007 and March 2008 in Ouagadougou, Burkina Faso. The meetings received updates from the 30m meeting of the NGDO Coordination Group for Onchocerciasis Control, and on th,e implementation of the recommendations of 24n session of the TCC and reviewed annual technical reporti of 138 and 91 projects during the 25tr and266 sessions respectively. 4.5.3 Committee of Sponsoring Agencies Three meetings of the Committee of Sponsoring Agencies (CSA) took place in the reporting period. The meetings received updates on APOC operations and its financing, 2007 and 2008 activities of the TCC, NGDO Group, 39e Mectizan Expert Committee/Albendazole Expert Committee, the Special Intervention Zones in former OCP countries and phasing-out and exit strategy action plan and budget (2008-2015). The CSA also reviewed the addendum to the Phase II and Phasing out Plan of Action and budget 2008-2015. 4.5.4 Other meetings In addition to the statutory meetings, the Programme organized 11 meetings and workshops either at the country level or at the headquarters during the period of review. The meetings were integration of CDTI activities into the health systems and co-implementation of Neglected Tropical Diseases and some components of malaria control, as well as the review of early detection tools for resistance, strategic direction of the Programme, Onchocerciasis surveillance tools, and integrated community-directed approach. 4.5.5 Monitoring of drug efficacy in large-scale treatment programmes for Onchocerciasis A WHO-World Bank meeting on Monitoring of Drug Efficacy in Large-Scale Treatment Programmes for Human Helminthiasis was held at the World Bank Headquarters in Washington DC, 31 October - 2 November 2007. An outcome of the meeting was the decision to establish Working groups to create standard operating procedures for surveillance tools for the different drug/parasite, and clear definitions for the early detection of drug resistance. The Working group on monitoring of drug efficacy in large-scale treatment programmes for onchocerciasis control, coordinated by APOC management held its meeting, co-sponsored by APOC, TDR and NTD/Genevain Geneva, from 3 to 5 March 2008. The report of the meeting is available and will be presented to the Joint Action Forum in December 2008. 4.6 Advocacy activities The year, 2007 marked the launch by APOC Management of the programme's new website (http://www.who.int/apoc/en), which is designed to provide up-to-date comprehensive information about the programme as well as data and resource materials. It is also a forum for the sharing of knowledge and ideas that would give visibility to the control activities. This timely new website is part of APOC's repositioning strategy for the attainment of the Programme's mandate and overarching objective - the elimination of river blindness as a public health and socio-economic problem by 2015 in endemic countries in Africa. The website promotes the CDI strategy as a powerful tool and vehicle for effective disease control and delivery of multiple health interventions. APOC's statutory meetings to o- ot o @q) o) oL tL bL c oo a ah o '6 L oo oEoco Lo o E E(E o) oL .L c oo L o CL o E, o oo g, o o- o o(, .9, o .g o o, o o o o o o E E(E ql o I .! o L J AFI4,5 Page 26 Within the period under review, through advocacy undertaken by APOC Management, The Kitasato Institute in Tokyo, Japan, has approved US$ 50 000 for the APOC website and production of related multimedia and communication materials/activities. 4.7 Partnership and collaboration During the year under review, APOC management has continued to strengthen links with the NGDO Coordination Group and international partners including the World Bank, African Development Bank, WAHO, UNICEF, USAID, CIDA, the Mectizan Donation Programme, the Bill & Melinda Gates Foundation, The Sabin Vaccine Institute, The George Washington University, the Liverpool School of Tropical Medicine, M6decins Sans Frontidres, and many other NGDOs. The management attended the tripartite meeting of the NGDO Coordination Group for Onchocerciasis Control in conjunction with the 2nd NGDO Lymphatic Filariasis Network and the Intemational Coalition for Trachoma Control. Key recommendations of the meeting were related to integration of CDTI activities into national health systems, co-implementation of onchocerciasis contiol with other neglected tropical diseases, and malaria control. The Programme hosted the 39ft session of MEC and co-authored the supplement from the 10'h anniversary of Mectizan@ Donation Program (MDP). In May 2008, the African Development Bank (AfDB) and APOC Management had working sessions for the strenglhening of APOC activities towards the achievement of the Programme's objectives in stable and conflict/post-conflict countries. This mission focused particularly on onchocerciasis surveillance, strengthening gender aspects in control activities, CDTI implementation package for post-conflict countries and the co-implementation of multiple health interventions. Table 9: List of NGDO partners by country e!6&dr Yl' t'l. *. llars*ffi t'^ P v ,btu. / :.. Bre. tries- Dvt Q. u r. ,b.Jd. Iue*<* r.6rwrnr ts{!!d,Fr, d*.,U' ry..il.t r'rdi r. pce.t" G.ffiffiH(ffi} ,"9I- @ oIthrld lleahhorganiation Country Angola Burundi Cameroon CAR Chad Congo Brazzaville D.R. Congo Ethiopia Equatorial guinea Gabon Liberia Malawi Nigeria Sudan Tanzania Uganda NGDO partner Sole, World Vision CBM HKI, IEF, Perspectives, SSI, The Carter Center CBM BELACD OPC CBM, CRS, HKI,IMA,IRC, Lions Club, UFAR The Carter Center, Light of the World OPC SSVCHAL, UNICEF* IEF CBM, HKI, MITOSATH, SSI, The Carter Center, UNICEF*, CBM, The Carter Center HKI,IMA, SSI CBM, SSI, The Carter Center * US Funds for UNICEF r: --r rl1! r-i JAF14.5 Page 27 5 LOOKING AHEAD: Elimination of transmission of onchocerciasis Even with the newly extended mandate taking APOC activities up to 2015, elimination of the public-health burden of onchocerciasis still requires the consideration of other methods for the potential elimination of onchocerciasis transmission. It is widely thought that sustained and successfully implemented CDTI activities can intemrpt transmission if ivermectin administration continues for long enough. Studies in Mali and Senegal, where CDTI has been ongoing for at least 17 years, are the first to attempt to back up this hypothesis with evidence. Another possible candidate method for interrupting disease transmission is the development of a drug that targets the adult form of the parasitic worm which causes onchocerciasis, a potential ivermectin, the drug used for mass administration in CDTI, does not have. The first patients to be enrolled in the MACROFIL project began treatment this year. Finally, APOC continues to investigate the potential utility of eliminating the vector of the O. volvulus parasite, the black fly. Although this intervention is not suitable for all countries in which the disease is endemic, vector elimination activities including monitoring the effectiveness of elimination are still ongoing in four areas. 5.1 Cessation of ivermectin treatment Longitudinal field studies are being undertaken in three hyper-endemic onchocerciasis foci in Senegal and Mali where mass treatment with ivermectin has been given for 17- 18 years at annual or 6- monthly intervals. The first phase of the study has shown that the ivermectin treatment programme has reduced onchocerciasis infection and transmission to such low levels that cessation of treatment was considered justified. Hence it was decidedin2007 to stop treatment in the core areas of each of the three onchocerciasis foci. Epidemiological follow-up data that were collected 2 years after the last treatment round in 2006 showed complete absence of infection in the villages where treatment had been stopped. Furthermore, the large-scale entomological evaluation that was undertaken in the study areas during the rainy season of 2007 (with more than 250 000 blackflies collected and analyzed) also confirmed that there had been no recrudescence of transmission, and not a single infective larva was found among the flies collected from the catching points in the areas where treatment had been stopped. This information provides the first evidence that elimination of onchocerciasis transmission by ivermectin treatment is feasible in hyper endemic foci in Africa and that ivermectin treatment can be safely stopped. During the annual investigators meeting in March 2008 it has been decided to stop treatment throughout two of the three foci (river Gambia and river Bakoye), but to proceed more slowly with stopping treatments in the river Faleme basin where the baseline data in the southem section of the focus were less favourable than in the other two river basins. In all three river basins, the infection and transmission levels will be monitored for at least another two years to provide definite evidence that the decision to stop was correct. 5.2 Macrofil project The first phase II study of the moxidectin used to treat individuals infected with O. volvulus completed enrolment in June 2008 at the Onchocerciasis Chemotherapy Research Center (OCRC) in Ghana. Although data on the macrofilaricidal effects will not be available until early 2010, the results so far from this study show that the safety and microfilaricidal activity of moxidectin is comparable to that of ivermectin. Based on this preliminary data, preparation of the phase III study in ivermectin- naive populations has been initiated at the OCRC in Ghana, in Lofa County in Liberia, and in North Ituri and North Kivu in DRC. These preparatory steps include an investment of around US$2.3 million into: l) building a Clinical Research Center in Lofa County and Nord Kivu and renovating buildings to serve as a Clinical Research Center in Nord Ituri; 2) provision of all study equipment including satellite-based intemet access to all study sites; 3) building national capacity in good clinical and clinical laboratory practices; 4) building capacity of nationals in clinical study monitoring according to Good Clinical Practice; and 5) preparation at the sites, including community sensitization and training of members of the local national health service, by the study teams. Ethics Committee and Ministry of Health E o o- o(. oaq) (,) oL(L E c o C) o '6 o '6 L oo o ! oc o Lo o E E E o) o (L c(U o .C L o EL otr o oo E" o o- E oo ,9, o .g() o o o o o o o E E(g tr) o L(L (! o L IAFL4.5 Poge 28 approval is being sought. WHO/TDR/Macrofil will provide more detailed information on the status of Moxidectin development in December 2008 during the 14th session of the Joint Action Forum. 5.3 Vector elimination activities There remain four areas where mass treatment for onchocerciasis has been supplemented by activities to eliminate the blackfly vector: in Uganda (Itwara, Mpamba Nkusi), Tanzania (Tukuyu), and Equatorial Guinea (Bioko). Elsewhere in APOC countries, vector control is not feasible or cost- effective, but in these four isolated foci, vector elimination is a realistic target. The method of choice has been ground larviciding except for Bioko where ground larviciding was combined with aerial spraying using environmentally safe insecticides. APOC is funding monitoring the areas in Uganda, and providing financial and technical support for entomological surveillance in Bioko to confirm the elimination of the onchocerciasis vector. Reinforcement of community-directed treatment with ivermectin is expected to lead to rapid elimination of onchocerciasisin these foci. In the reporting period, APOC management has commissioned a documentary film on the activities and successes of vector elimination in Uga:rda and Equatorial Guinea. The report and film will be presented to the 14ft session of the Joint Action Forum. 5.4 Preparing for the exit of APOC In preparation for the drop in funding support from APOC that will inevitably follow the programme's end in 2015, the management team is helping countries to put in place plans for the sustainability of CDTI activities. One aspect of this support is direct assistance in the preparation of strategic plans, but APOC is also addressing emerging issues in the country activities to resolve problems while it can. In this regard, management is gathering evidence on the question of incentives to community volunteers, which has become a critical issue in the co-implementation of health interventions. APOC has undertaken a study on external monetary incentives policies in 10 sites in Nigeria, Cameroon, Uganda, and Ethiopia, the findings from which were presented to the JAFl3. Phase I of the study suggests the need to formulate a policy at the national level to guide the implementation of monetary incentives CDDs. A phase II study by WHO/TDR would shed more light on the situation at the operational level, especially the dynamics triggered by external monetary incentives. This will guide APOC and partners on the way forward in terms of management policy. A final part of APOC's exit preparations is the decentralization/devolution of responsibilities and activities to countries, supported by WHO Country Offices, which will manage ivermectin distribution in future with support of the NGDO Coalition. 5.4.1 Country exit plans Uganda was the first country to submit its country strategic exit plan (2007-2010) to APOC Management and this document has now been approved. To achieve onchocerciasis elimination, the Uganda Exit Plan (2007-2010) suggests that annual treatment with ivermectin should continue in 10 districts and that epidemiological studies should be conducted in districts outside the bi-annual treatment zones. Activities that have so far been funded principally by APOC will continue to receive funding, but this will decrease, as APOC decentralizes and devolves its functions to countries and their partners. This is in line with APOC's Phasing-Out and Exit Strategy Plan of Action and Budget 2008-20 1 5. The Tanzania National Onchocerciasis Control Programme (NOCP) has also developed an exit plan for APOC, incorporating core CDTI activities into the Comprehensive Council Health Plan, and allocating resources for CDTI implementation so as to sustain the programme after APOC's exit in 2015. Cameroon has forwarded the strategic exit plan to APOC Management for consideration. APOC Management has engaged two consultants to assist other countries to produce their strategic exit plans. JAF14.5 Page ?9 ANNEX Annex 1: COUNTRY PROFILES OF CDTI IMPLEMENTATION (YEAR 2007) Country ANGOLA 't 00 90 80 70 50 50 40 30 20 t0 0 I I G.ographlc @vcragc (%) tr2006 tr2006 I2OO7 Thcrap.utia oov.r.g. (%) Fieure A-1: Geoeraphical and Therapeutic coverase. 2005-2007, Angola 14 51 41 16 Year CDTI was first launched Number of CDTI projects - approved - being implemented - distributedivermectin in2007 6 5 5 Communities treated 1,489 Persons trerted 414,965 Number of CDDs - newly trained - retained - totaltrained/retrained r,559 Number of health workers - newly trained - retrained - totaltrained/retained Government linancial contributions: $ 107,982 NGDO partners: World Vision @projectwhereonchocerciasisandLoiasisareco-endemic.Strengtheningcapacityofnationalsin APOC philosophy and CDTI strategy Countrv BURUNDI 100 90 80 70 60 50 40 30 20 10 0 E ? G@gr'phic covorag€ (y') o2005 E 2oo. t 2oo7 Therapeutic cowrags (%) Figure A-2: Geographical and Therapeutic coverage, 2005-2007, Burundi 43 71 29 Year CDTI was first launched 2005 Number of CDTI projects - approved - being implemented - distributedivermectin lrl.2007 3 3 ., Communities treated 368 Persons treated 860,416 Number ofCDDs - newly trained - retained - totalfrained/retrained 2153 8125 t0,278 Number of health workers - newly trained - retrained - totaltained/retained 99 106 205 Government financial contributions: $ 8,404.1 NGDO Christoffel Blinden Mission Sustain conditions to enhance CDTI activities. Increase to activities E oo ot aao O) o L 6L c o C) .9.a(E '6 L oo o -coco L o q) E E oL o) o L c oo L W JAF14.5 Page 30 couNTRY PROFILE OF CDTr TMPLEMENTATION (YEAR 2007) L o o e. o o o) g, o (L 6 o o .9, o .g o L o o o ! o o o o) E E(E f, o o. (E o Country CAMEROON t0o 90 80 70 6o 5o il0 30 20 l0 82 71 45 G.ognphlc @Eag. (.,() Thrnpcullc coEng! (%) tr19!19 D2000 B2qrl 82002 tr2003 o 200,t E2005 O20OG l2OO7 Figure A-3: Geographical and Therapeutic coverage, 1999-2007, Cameroon Year CDTI was first launched 1 998 Number of CDTI projects - approved - being implemented - distributedivermectin in2007 15 t5 l5 Communities treated 9,445 Persons treated 4,427,481 Number of CDDs - newly trained - retrained - totaltrained/retrained 13,405 17,208 30.613 Number of health workers - newly trained - rehained - totaltrained/retained 457 2188 2645 Government financial contributions: $ 1,930,767 prrtners: The Carter Center, International Eye Foundation, Helen Keller Intemational, Sight Savers contributions to CDTI activities Country CAR 100 90 80 70 60 50 it0 30 20 t0 0 Geog.aphic coEEge (%) ThGrap€utic cowEge (%) El1999 82000 82001 O2002 42003 Sl200it tr2005 E2006 t2007 Figure A-4: Geographical and Therapeutic coverage, 1999-2007. Central African Republic 8,1 7674 91 Year CDTI was first launched 1998 Number of CDTI projects - approved - being implemented - distributedivermectin in2007 1 1 I Communities treated 3,195 Persons treated 724.791 Number of CDDs - newly trained - retrained - totaltained/retrained 3407 3407 Number of health workers - newly trained - retrained - totalhained/retained 461 467 Governmcnt financial contributions: $ 79,228 NGDO partnerc: CBM Challenges: Sustain peaceful conditions to enhance CDTI activities. Increase govemment financial contributions to CDTI activities -.l i JAF14.5 Page 31 couNTRY PROFILE OF CDTI IMPLEMENTATION (YEAR 2007) Country CHAD 1oo 90 EO 7o 50 50 6 30 20 l0 0 Th.rapestic covgr.g. (%) !1996 E 1999 E 2000 E 2001 E 2002 tr 2003 E 2004 tr 2005 E 2006 I 2007 Figure A-5: Geographical and Therapeutic coverage, 1998-2007, Chad Year CDTI was first launched 1 998 Number of CDTI projects - approved - being implemented - distributedivermectin in2007 I I I Communities treated 3250 Persons treated 1,389,921 Number of CDDs - newly trained - retrained - totaltrained/retrained 23t5 417 2732 Number of health workers - newly tained - retrained - totaltrained/retained 68 133 201 Government financial contributions: $l2r.586.0 NGDO BELACD Sustain and to activities Country CONGO 100 90 80 70 60 50 4 30 n 10 o I Gogr.phic @8r.9" (%) Th.rapantic @vcngc (%) t2001 n2002 82003 82004 u 2005 tr2006 r2007 Figure A{: Geographical and Therapeutic coverage, 2001-2007, Congo Year CDTI was first launched 2001 Number of CDTI projects - approved - being implemented - distributedivermectin in2007 2 2 2 Communities treated 770 Persons treated 449.171 Number of CDDs - newly trained - retained - totaltrained/retrained 4t6 1449 1865 Number of health workers - newly trained - retained - totaltrained/retained 62 ll5 177 Government financial contributions: s80,996.0 NGDO Dertneru: Orsanisation pour la Prdvention de la C6cit6 (OPC) Challenges: Sustain high treatnent coverage and government commitnent to CDTI activities E o o- ot oaoLq) oLL E c oo a ah o 'p 0)o ococo o q) E Eo o)o (L c oo .E _.1 74 JAF14.5 Page 32 couNTRY PROFTLE OF CDTI IMPLEMENTATION (YEAR 2007)to ot o oo ol o (L o o o ,9 o .g C) o o o () o L o o E E o o) o o- (I, o L Country DRC 100 90 80 70 60 50 40 30 20 10 0 Geographic coverage (%) Therapeutic coverage (%) E 2001 E 2002 EI 2003 tr 2004 A 2005 E 2006 I 2007 Figure A-7: Geographical and Therapeutic coverage, 2001-2007, Democratic Republic of Congo 91 72 68 45 44 39 Year CDTI was first launched 2000 Number of CDTI projects - approved - being implemented - distributedivermectin in2007 20 20 15 Communities treated 21.853 Persons treated 9.230.951 Number of CDDs - newly trained - retrained - totaltrained/retrained 40,838 28,209 69,047 Number of health workers - newly trained - retrained - totaltrained/retained 1770 2192 3962 Government financial contributions: $r93.182.0 NGDO Dartners: CBM. CRS. HKI. Lions Club, UFAR Challenges: Onchocerciasis and Lioasis are co-endemic in I4CDTI project areas. Improve geographical and therapeutic coverage. National Provincial and district govemment to contribute frnancially to CDTI activities. Country EQUATORIAL GUINEA 100 90 80 70 60 50 40 30 20 t0 0 Goographic covcragc (%) Thcrapcutic covcragc (%) Et,1999 D2000 E]200't E2002 a2003a2001!2005 tr2006 r2007 Figure A-8: Geographical and Therapeutic coverage, 1999-2007, Equatorial Guinea Year CDTI was first launched I 998 Number of CDTI projects - approved - being implemented - distributedivermectin in2007 I 1 1 Communities treated 129 Persons treated 50.064 Number of CDDs - newly trained - retrained - totaltained/retrained 20 367 387 Number of health workers - newly trained - retrained - totaltrained/retained l6 Government financial contributions: NGDO none Challenges: Ensure featnent m of the endemic communities every year. Involvement of national CDTI activities. Govemment to take in onchocerciasis control activities s ! t4 E 68 7'l 53 II t,A. Jiffi JiHE JAF14.5 Page 33 couNTRY PROFILE OF CDTI IMPLEMENTATION (YEAR 2007) Country ETHIOPIA 100 90 EO 70 60 50 4 30 20 10 0 :r Ii Geographic coverage (%) Therapeutic coverage (or 82001 r.2002 E 2003 B 2004 E 2005 E 2006 r 2007 Figure A-9: Geographical and Therapeutic coverage, 2001-2007, Ethiopia Year CDTI was first launched 2000 Number of CDTI projects - approved - being implemented - distributedivermectin in 2007 9 9 9 Communities treated 22.486 Persons treated 4, I 35,538 Number of CDDs - newly trained - retrained - totaltrained/retained 6,532 45,276 5 1.808 Number of health workers - newly trained - retrained - totalhained/retained 899 1376 2275 Govcrnment financial contributions: $2,840,043.0 NGDO partnerc: The Carter Center Challenges: Sustain high treaunent coverage. Country LIBERJA 100 90 80 70 60 50 lo 30 20 10 0 Goographic coverage (%) Therapeutic covorage (%) tr1999 u2000 82001 82002 12003 S2004 E2005 E2006 !2007 Fisure A-10: Geographical and Therapeutic coverage, 1999-2007, Liberia 42 1 ,| Year CDTI was first launched 2000 Number of CDTI projects - approved - being implemented - distributedivermectin in 2007 J 3 J Communities treated 4.370 Persons treated 2,442,161 Number of CDDs - newly trained - retrained - totaltrained/retrained 3 128 l 3,859 16,987 Number of health workers - newly trained - retrained - totaltrained/retained 92 22s 317 Government finencial contributions: $19,612.0 NGDO rrartnens: Sieht Savers Intemational (SSD Challenges: Sustain peaceful conditions to enable teatnent of endemic communities. Increase government financial contributions to CDTI activities Eo o- ot ooo q) o (L 6L c oo o '6 o '6 oooEoC o L o o E E E C,)oL(L coo L aJAF14.5 Page 34 couNTRY PROFTLE OF CDTI IMPLEMENTATION (YEAR 2007)Eo o- oi ah oo g) o o- 6 oo .9,tt .g(, c, o o o o o o E E(g gl o o- (g o L Country MALAWI r00 90 80 70 60 50 40 30 20 10 0 s r Geographic coverage (%) Therapeutic coverage (%) r1997 81998 D1999 82000 tr2001 A2002 El2003 8r2004 Er2005 tr2006 12007 Fieure A-ll: Geosraphical and Therapeutic coverase. 1997-2007, Malawi 83 52 43 1 Year CDTI was first launched 1997 Number of CDTI projects - approved - being implemented - distributedivermectin in2007 2 2 2 Communities treated 2t86 Persons treated t.546.433 Number ofCDDs - newly trained - retained - totalhained/retrained 1449 5768 7217 Number of heelth workers - newly trained - retrained - totaltrained/retained 272 1340 t6t2 Government Iinancial contributions: $754.715.0 NGDO partners: Sight Savers International Challenges: Sustain high featment coverage Country NIGERIA 100 90 80 70 60 50 40 30 20 ,t0 0 E t Geographic coverage (%) Therapeutic coverage (%) 81999 tr2000 s2001 A2002 D2003 S2004 82005 E2006 12007 Fieure A-12: Geosraphical and Therapeutic coverage, 1999-2007. Nigeria Year CDTI was first launched 1998 Number of CDTI projects - approved - being implemented - distributedivermectin in2007 27 27 27 Communitics treated 33,924 Persons treated 22,839,983 Number of CDDs - newly trained - retrained - totaltrained/retrained 39,551 51,727 91.278 Number of health workers - newly tained - retrained - totalhained/retained I 1.137 I 1,845 22.982 Government financial contributions: $ 17.920,186.0 NGDO Dartner"s: CBM. The Carter Center. HKL SSI, UNICEF, IFESIUUNIVA, MITOSATH Challenges: Sustain high heatrnent coverage JAF14.5 Poge 35 couNTRY PROFILE OF CDTI IMPLEMENTATION (YEAR 2007) SUDAN Year CDTI was first launched 1997 100 90 80 70 60 50 4 30 20 10 0 Number of CDTI projccts - approved - being implemented - distributedivermectin tn2007 6 6 6 Communities treated l7l0 Persons treated I 137 Number ofCDDs - newly tained - retrained - totaltrained/retrained 4000 I 168 5 168 Number of health workers - newly trained - retrained Government linancial contributions: Geographic coverage (%) Therapeutic coverage (%) 81998 t1999 82000 m2001 82002 trl2003 82004 A2005 tr2006 t2007 A-13 and 1998-2007, NGDO to all meso/hyper endemic communities- Ensure high therapeutic coverage-Strengthening capacity in CDTI Country TANZANIA 100 $ m 70 & s q s 20 10 0 ! Geographic coverage (%) o1998 81999 02000 82001 D2002 82003 S2004 A2005 E2006 r2007 Fisure A-14: Geographical and Therapeutic coverage, 1998-2001, Tanzania Year CDTI was first launched 1998 Number of CDTI projects - approved - beirrg implemented - distributedivermectin in2007 7 7 7 Communities treated 5848 Persons treated l,684,661 Number of CDDs - newly hained - retrained - totaltrained/retrained 901 10,128 tl,029 Number of health workers - newly trained - retained - totaltrained/retained 153 430 583 Government financial contributions: $ 1,501,200.0 NGDO Dartners: SSI. HKI. IMA Challenges: Sustain high treatrnent coverage t o o- ot oo o o) oL(L 6 c oo o "6 o '5 L o)o oEoc o L o 0) E E E o, oL(L c oo L Countnz Therapeutic coverage (%) aJ AFL4.5 Page 36 couNTRY PROFILE OF CDTI IMPLEMENTATION (YEAR 2007)Eo a. ot oo o, E' o o- 6 o o ,9, o .g o o o o o o o o E E(g o (L (E o L Country UGANDA '100 90 80 70 60 50 40 30 20 10 0 Geographic coverage (%) Therapeutic coverage (%) En1999 82000 EI2001 82002 o2003 tr200'1 42005 tr2006 12007 Figure A-15: Geographical and Therapeutic coverage, 1999'2007, Uganda Year CDTI was first launched 1996 Number of CDTI projects - approved - being implemented - distributedivermectin ilt2007 4 4 4 Communities treated 4,934 Persons treated 2.169,926 Number ofCDDs - newly tained - retrained - totaltrained/retrained 15,702 23,688 39,390 Number of health workers - newly trained - retrained - totaltrained/retained 531 914 1445 Government financial contributions: $119,820.0 The Carter Center, SSI Sustain teatrnent communities where clinical manifestations of the disease have decreased a 80 JAF14.5 Page 37 Annex 2: Trend ofgeographical coverage ofprojects after evaluation ofsustainability and substantial reduction in APOC Trust support (2002-2007) Ethiopia Cameroon Kafa€hekka CDTI South West I Malawi E:<tension Phase lV Phase lll Phase ll Phase I Tukuyu Focus CDTI Tanga Ruvuma I a!EI g f + 1 .g (E E .EF I 6 E,z 42002 I 2003 I 2004 t2005 ! 2006 o2007 Mahenge Focus Adamawa Edo, Delta lmo, Abia Plateau Nassarawa Enugu, Anambra, Ebony Taraba Cross River Kaduna 010 20 30 40 50 60 70 80 Geographical coverage (%) 90 100 Annex 3: Percentage of funds disbursed by governments to support core CDTI activities in 2007 Core CDTI activities Mobilization, advocacy, sensitization and health education Training/retraining of CDDs and health workers Supervision, monitoring, Evaluation lvermectin distribution and management of severe adverse events Total disbursed for core CDTI activities us $ 5256,752.70 16.6 5617,931.60 32.7 51,549,872.30 100.0 51,888,513.10 100.0 Year 2006 Amount Year 2OO7 Amount 5429,200.20 s397,952.60 5465,966.80 5426,066.00 s348,545.80 5495,969.70 o/o 27.7 25.7 30.1 o/o 22.6 18.5 26.3 E o o- o)t oo o) O) o (L 6 c o() .9oo 'p oo oEoc o L o o E E E c,) oL TL c oo L aa I