Report on the
First meeting of the Steering Committee for the GEF-supported project in the Eastern Mediterranean Region
Muscat, Oman 4-5 March 2006
World Health Organization Regional Office for the Eastern Mediterranean Cairo 2006
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Document WHO-EM/RBM/327/E/04.06/27
CONTENTS EXECUTIVE SUMMARY ........................................................................................................ 1 1. 2. INTRODUCTION ............................................................................................................. 3 BRIEFWG ON THE WHO/UNEP/GEF PROJECT PROPOSAL ON DEMONSTRATION OF SUSTAWABLE ALTERNATIVES TO DDT ..........................5 2.1 EMRO/UNEP/GEF project to demonstrate sustainable alternatives to DDT 5 through IVM ............................................................................................................ 2.2 Summary of experiences of GEFDDT projects in the context of the Stockholm . . Convent~on in other regions ..................................................................................... 6 2.3 Discussion ..............................................................................................................8 TECHNICAL PRESENTATIONS .................................................................................... 9 3.1 Implementation of vector control and the process to establish national 9 intersectoral action .................................................................................................. 3.2 Incremental cost analysis: a requirement for GEF funding ................................... 11 3.3 Introduction of regional and country plans ............................................................ 13 3.4 Introduction to VCNA tools and guidelines ........................................................... 13 3.5 Criteria for identification of demonstration districts .............................................. 16 3.6 Review of the programme for the first regional meeting on the EMROIGEFsupported project .................................................................................................... 17 CONCLUSIONS ............................................................................................................ 18 RECOMMENDATIONS ............................................................................................. 1 8 CLOSING SESSION ..................... . . ............................................................................. 18 Annexes AGENDA .............. . . ..................................................................................................... 19 PROGRAMME ................................................................................................................ 20 MEMBERS OF THE STEERING COMMI'M'EE ........................................................ 21
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EXECUTIVE SUMMARY A project entitled "Demonstration of sustainable alternatives to DDT and strengthening of vector control capabilities in Middle East and North Africa" is being implemented by the World Health Organization's Regional Office for the Eastern Mediterranean (WHOEMRO) and the United Nations Environment Programme (UNEP), with financial support from the Global Environmental Facility (GEF). This regional project (2006-2007) covers the following countries of the Eastern Mediterranean Region: Djibouti, Egypt, Jordan, Islamic Republic of Iran, Morocco, Sudan, Syrian Arab Republic and Yemen. A total of US$ 650 000 has been made available to support these countries to develop full project proposals for submission by March 2007. Access to full project support is based on the country having ratified the Stockholm Convention. The Islamic Republic of Iran and Sudan will need to have ratified the Convention at the time of proposal submission. The first meeting of the Steering Committee for the GEF-supported project was held in Muscat, Oman from 4 to 5 March 2006. Fourteen Steering Committee members from seven different countries were in attendance; four members were unable to attend. The objectives of the meeting were to: review the work plan of the project development facility B (PDF-B) phase of the EMROIGEF project, including a number of specific elements for its implementation; review the outline and format of the national work plans for the implementation of the EMROIGEF project; review the vector control needs assessment (VCNA) guidelines and its associated tools for their technical quality and feasibility as part of PDF-B activities; agree on the Steering Committee's position on issues on the agenda of the first regional meeting of GEF-supported countries in the Eastern Mediterranean Region (Muscat, 6-8 March 2006); prepare recommendations that would enhance the overall implementation of PDF-B activities.
Recommendations 1. The scope of the project documents should be expanded to include all vectorborne diseases rather than malaria exclusively. Priority should be given to strengthening capacity in countries of the Region under the PDF-B and the subsequent project in order to ensure effective networking, information exchange and a stronger negotiation position for the countries. Under the PDF-B phase, WHO should develop a clear model for intersectoral collaboration that countries can adapt to their local needs.
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The final project proposal should be based on sound statistical evidence, for which programme models with proven success, e.g. tuberculosis, can be utilized. The expertise of a health economist should be included in undertaking the financial and economic analysis required for the project proposal. The VCNA should be a comprehensive, not a rapid, assessment in order to ensure that the real needs of countries in the Region in terms of vector control are identified. It should be conducted periodically as part of a process of ongoing assessment and adjustment against evolving programme targets. With respect to the final update and completion of the VCNA guidelines: WHO guidelines for pesticide management should be reflected as an integral part; a community participation section should be developed and included; a stronger orientation towards regional coordination of efforts should be reflected; a user-friendly format should be ensured, following the example of the health impact assessment training materials; the opinion of country delegates should be sought at the first regional meeting concerning the desirability of the scoring method as part of the guidelines. Consultants should be given orientation on the methodology proposed for the implementation of the VCNA guidelines at country level so that an effective and regionally harmonized approach is ensured. These consultants should have a broad public health perspective, and could be backed up by specialists in specific areas of relevance. The budget for the PDF-B should be adjusted in order to reflect the current realities of country contributions and to cover the costs of the additional technical inputs required.
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1.
INTRODUCTION
A project entitled "Demonstration of sustainable alternatives to DDT and strengthening of vector control capabilities in Middle East and North Africa" is being implemented by the World Health Organization's Regional Office for the Eastern Mediterranean (WHOIEMRO) and the United Nations Environment Programme (UNEP), with financial support from the Global Environmental Facility (GEF). This regional project (2006-2007) covers the following countries of the Eastern Mediterranean Region: Djibouti, Egypt, Jordan, Islamic Republic of Iran, Morocco, Sudan, Syrian Arab Republic and Yemen. A total of US$ 650 000 has been made available to support these countries to develop full project proposals for submission by March 2007. Access to full project support is based on the country having ratified the Stockholm Convention. The Islamic Republic of Iran and Sudan will need to have ratified the Convention at the time of proposal submission. The first meeting of the Steering Committee for the GEF-supported project was held in Muscat, Oman from 4 to 5 March 2006. Fourteen members of the Steering Committee were in attendance; four members were unable to attend. The objectives of the meeting were to: review the work plan of the project development facility B (PDPB) phase of the EMROIGEF project, including a number of specific elements for its implementation; review the outline and format of the national work plans for the implementation of the EMROIGEF project; review the vector control needs assessment (VCNA) guidelines and its associated tools for their technical quality and feasibility as part of PDF-B activities; agree on the Steering Committee's position on issues on the agenda of the first regional meeting of GEF-supported countries in the Eastern Mediterranean Region (Muscat, 6-8 March 2006); prepare recommendations that would enhance the overall implementation of PDF-B activities. After a welcome by Dr El Fatih El Samani, WHO Representative in Oman, Dr Zuhair Hallaj, Director, Communicable Disease Control, extended thanks to the Government of Oman for its hospitality and reminded participants that Oman had successfully demonstrated that it was possible to reduce reliance on insecticides for vector control while successfully eliminating malaria as a major public health problem. Dr Hallaj observed that the Eastern Mediterranean Region had a disproportionate burden of vector-borne diseases, in response to which countries had scaled up their vector control efforts and adopted the principles and practices of integrated vector management (IVM). Key elements in these efforts were intersectoral collaboration, community participation and evidence-based decision-making. However, he noted that there were deficiencies in these areas that required effective
WHO-EMIMAU327E Page 4 capacity building. The Fifty-second Session of the Regional Committee for the Eastern Mediterranean had provided a strong policy basis to address this through the resolution made regarding IVM. The start-up phase of the EMROIGEF project "demonstration of sustainable alternatives to DDT and strengthening of national vector control capabilities in the Middle East and North Africa" provided solid opportunities to move this agenda forward. Dr Hallaj thanked the members of the Steering Committee for contributing their expertise to the regional project, as part of a process that had been set in motion through joint WHO/United Nations Environment Programme (UNEP) workshops in Tunis and Amman in 2003. He reminded members of the Steering Committee that their overall task was to provide guidance to the PDF-B phase until the time of submission of a full project proposal (the project brief). This implied various planning, design, technical cooperation, analysis and evaluation responsibilities. Dr Hallaj noted that the first meeting would review the project and PDF-B work plan, the national work plans and the VCNA guidelines and other tools to achieve the objectives of the regional and national work plans. It would make specific recommendations on how to enhance the overall implementation of the PDF-B work plan. It was understood that countries had access to GEF support only if they had ratified the Stockholm Convention. To date, six of the eight countries (Djibouti, Egypt, Jordan, Morocco, Syrian Arab Republic and Yemen) had completed the ratification process, while it was well under way in the Islamic Republic of Iran and in Sudan. Dr Hallaj put the objectives of the meeting in a broader historic perspective, recalling how excessive reliance on DDT and other insecticides had led to the rapid development of vector resistance, which had undermined the feasibility of the global malaria eradication programme. He also noted that where the eradication efforts had met with (often spectacular) successes, political leadership had frequently shifted resources to other public health issues without leaving in place effective monitoring and surveillance capacities and well-resourced plans to respond to outbreaks. As a result, many vector-bome diseases had re-emerged in the Region. Historically, the concern about the impact of excessive reliance on insecticides on the environment post-dated the malaria eradication era. While these concerns were genuine and supported by evidence, Dr Hallaj noted that the majority of insecticides (especially those directly affecting the environment) had originated from agricultural rather than public health activities. There was now, however, a clear and common understanding between environment and health specialists that reduction of reliance on insecticides for vector control was a necessity and that such a reduction should not lead to an increased burden of malaria and other vector-borne diseases. In fact, the process leading to the reduction and eventual elimination of DDT offered ample opportunities to strengthen vector control efforts so that transmission risks and disease burdens would be reduced.
WHO-EMIMALl327lE Page 5 Dr Hallaj concluded by observing that two important realizations had followed from the events of the past 50 years. The first was that the control of vector-borne diseases, including vector control, was not a time-limited activity. The second was that vector control measures should be optimally geared to local conditions and needs, and that they had to be regularly adjusted to evolving situations. Dr Z. Hallaj was elected as Chairperson of the meeting, and Dr R. Bos served as Rapporteur. The agenda, programme and list of members of the Steering Committee are included as Annexes 1 , 2 and 3, respectively.
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BRIEFING ON THE WHO/UNEP/GEF PROJECT PROPOSAL ON DEMONSTRATION OF SUSTAINABLE ALTERNATIVES TO DDT EMROIUNEPIGEF project to demonstrate sustainable alternatives to DDT through IVM Dr A. Mnzava
2.1
During the Fifty-second session of the Regional Committee for the Eastern Mediterranean, Member States endorsed the regional strategic framework for integrated vector management and issued a resolution (EMiRC52iR.6) on integrated vector management. In the resolution, the Committee requested Member States to strengthen national capacity to plan and implement IVM, including ensuring adequate human and financial resources, establish a functional intersectoral mechanism for the collaboration and coordination of all related sectors, and develop national IVM strategies and plans of action for all vector-borne diseases. Member States requested WHO to support integrated vector control activities, including providing technical support to countries as necessary. Indoor residual spraying is the main vector control intervention in most countries of the Region. Dichlorodiphenyltrichloroethane (DDT) is used only in Morocco, where its use is restricted to emergency purposes. It is clear, however, that unless sustainable alternatives are made available in the Region there is a potential threat to revert to use of DDT. This takes into account the challenges countries face in implementing alternatives in the context of IVM for epidemiological impact, such as the lack of adequate local capacity (including financial resources) to effectively design, apply and manage the use of pesticides. Therefore, WHO and UNEP have initiated joint activities to address the problems. One such activity is the EMROKJNEPIGEF project to demonstrate sustainable alternatives to DDT through IVM. WHOiEMRO is the implementation agency while ministries of health work as the national executing agencies in Djibouti, Egypt, Islamic Republic of Iran, Jordan, Morocco, Sudan, Syrian Arab Republic and Yemen. Oman and Saudi Arabia are participating countries in terms of sharing their experiences in reducing reliance on DDT.
WHO-EMlMAU327E Page 6 implementation) lasting 4 years and supported by US$ 8.5 million. The funds from GEF will: complement current national efforts to implement alternative strategies to DDT in different eco-epidemiological settings; support the systematic incorporation of altematives to ensure countries do not revert to DDT; strengthen national capacity to review and choose appropriate altematives to DDT within the IVM framework and design alternatives based on the good practices that already exist in some countries in the Region. During the preparatory phase, WHO will work with project countries to: build consensus on processes and activities for the preparation of the full project proposal; complete national needs assessments; submit a report that reviews capacity strengthening needs and how to address them; select demonstration sites and activities based on agreed criteria; plan replication activities with information on how funds will be spent, beyond the project; develop country reports and work plans to implement activities that reduce reliance on DDT and strengthen vector-home disease control programmes; submit a completed GEF project brief, including incremental costs, cofinancing, stakeholder analysis and a comprehensive monitoring and evaluation plan, i.e. an implementation framework that utilizes and strengthens existing partnerships. Less reliance on the use of DDT and other pesticides is key to the implementation of IVM. The commitment of countries to promote and implement IVM and to strengthen national capacity to implement sustainable and cost-effective alternatives will be complemented by GEF funding. It is expected that the implementation of altematives to DDT will lead to reduction in vector-borne disease burden in the Region.
2.2 Summary of experiences of GEF/DDT projects in the context of the Stockholm Convention in other regions Dr J. Williams The production and use of DDT for disease vector control, in accordance with WHO recommendations and guidelines, is permitted under the Stockholm Convention on Persistent Organic Pollutants. Countries are, however, to be supported in the development of national action plans, which should include: regulatory and other mechanisms to ensure compliance in the use of DDT;
WHO-EMIMAU327E Page 7 implementation of suitable alternative products, methods and strategies; research and development of alternatives posing less risk to humans and the environment; strengthening health care and reducing disease incidence. The Convention advocates incentives and the use of multiple-source funding mechanisms to strengthen country capacity in order to promote, utilize and evaluate vector control alternatives. In this connection, a number of GEF-supported regional and country projects are being executed by WHO, with UNEP as the implementing agency. The GEF project cycle is initiated by the submission of a concept paper which, when approved, leads to a PDF document. WHOAJNEP projects are categorized as B, with a funding ceiling of up to US$ 1 million. Upon successful completion of the PDF-B, a multi-year full project protocol is developed and funded, if approved by the GEF Council. Projects under implementation
WHO Regional Office for Africa: the project "demonstrating cost-effectiveness and sustainability of environmentally sound and locally appropriate alternatives to DDT for malaria control in Africa" has a budget of US$ 11.8 million, of which GEF is contributing US$ 5.8 million. Beneficiary countries are Ethiopia, Eritrea, Madagascar, Namibia and South Africa. The PDF-B has been completed and the 5-year project was approved by the GEF Council in September 2005 and is expected to begin by June 2006. WHO Regional Office for the AmericasIPan American Health Organization: the project "regional programme of action and demonstration of sustainable alternatives to DDT for malaria vector control in Mexico and Central America" has a budget of US$ 11 million, with a GEF contribution of US$ 7.5 million. Beneficiary countries are Belize, Costa Rica, El Salvador, Guatemala, Honduras, Mexico, Nicaragua and Panama. The full 5-year project is currently being implemented. WHO Regional Office for the Eastern Mediterranean: the project "demonstration of sustainable alternatives to DDT and strengthening of national vector control capabilities in the Middle East and North Africa" has an estimated budget of US$ 16-21 million, with a proposed GEF contribution of US$ 8.5 million. PDF-B implementation was initiated in March 2006. Projects in the pipeline
WHO Regional Office for South-East AsialPan American Health Organization: the project "demonstrating and scaling-up sustainable alternatives to DDT and strengthening national vector control capabilities in Southeast Asia and the Pacific"
WHO-EMIMAU327E Page 8 has an estimated budget of US$ 33 million, with a proposed GEF contribution of US$ 13 million. Beneficiary countries are the Indonesia, Marshall Islands, Myanmar, Papua New Guinea, Republic of Korea, Solomon Islands, Sri Lanka, Thailand, Vanuatu, Viet Nam and Philippines. The PDF-B document is being finalized and the expected start date is June 2006. India: the project "reduction in use of DDT by enhancing capabilities through the implementation of IVM" has an estimated budget of US$ 11.8 million, with a proposed GEF contribution of US$ 5.8 million. The concept has been approved and the PDF-B document is being finalized. The expected start date is June 2006. Projects under preparation
WHODuke UniversityISystemwide Initiative on Malaria and Agriculture (SIMA): the project "strategies for malaria control: a policy framework for evaluating health, social and environmental impacts and trade-offs" has an estimated budget of US$2.5 million, with a proposed GEF contribution of US$0.995 million). 2.3
Discussion
As had been highlighted in the opening session, capacity building, intersectoral collaboration and community participation are all important to the PDF-B project. However, it was agreed that the aspect of community participation in the VCNA guidelines would be further strengthened, with greater focus on community empowerment. With respect to intersectoral collaboration, it was observed that advocacy and recommendations had proved insufficient and there was a need to provide clear incentives. Participants agreed that capacity building should not be at national level alone, but also at regional level. Strengthening the network of WHO collaborating centres was cited as one possibility. It was confirmed that GEF was in favour of reenforcement of the regional dimension and that sharing of success stories should not be confined solely to countries funded by the project. It was further confirmed that networking and information exchange activities at the regional level required a strong regional secretariat. Such regional strengthening would improve the negotiating position of the countries and provide a multiplier effect in activities aimed at promoting alternatives to DDT. The importance of sustainability was noted, and the countries were reminded that insecticides are not merely a source of pollution but are also an important resource whose lifespan needs to be extended maximally (i.e. through judicious use and resistance management) so that future generations may benefit from them. Concern was raised over the scarcity of effective and viable alternatives, and the inadequate level of investment in their development. Models for drug development for
WHO-EMIMAU327E Page 9 human immunodeficiency viruslacquired immunodeficiency syndrome (HIVIAIDS) and malaria through publiclprivate partnerships could also apply to expanding the arsenal of vector control products and measures. It was clarified that preparations were under way to raise this issue at appropriate forums, such as the annual World Economic Forum in Davos, Switzerland.
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TECHNICAL PRESENTATIONS
3.1 Implementation of vector control and the process to establish national intersectoral action Dr R. Bos Sectors represent societal interests that have gained sufficient political weight to claim a mandate with clear, well-defined boundaries, linked to an appropriation of public resources. Therefore, intersectoral collaboration in principle goes against the system, as sectors must compete for limited resources. While opportunities for synergies and economies resulting from collaboration were apparent from a wider perspective, the actors in the sectors themselves would be disinclined to transfer some of their mandate and responsibilities to other sectors, or even to share them. Similar obstacles exist within the sectors themselves, with communication between different departments often less than optimal. Information sharing is often limited to that which is absolutely necessary, or within, for example, ministries of health. Thus, even with broad agreement about the benefits of intersectoral collaboration for health (the opportunity to improve the health status of communities in a cost-effective manner and help reduce the resource drain on the health sector) these concepts were, by themselves, not strong enough to maintain momentum for intersectoral action and more tangible incentives were needed. Clearly, a conducive policy framework was the first prerequisite. Intersectoral collaboration should be a government-wide policy (decreed by the Prime Minister's ofice or the Planning Ministry) and health considerations should be incorporated into the policies of non-health sectors. In order to engage other sectors in vector control activities of an environmental management nature, the policy framework component needed strengthening in the proposal through, for example, the inclusion of national policy seminars. Institutional mechanisms for intersectoral collaboration need to build on already existing structures. In most countries, economic and social planning councils were present that could bring together all sectors. In addition, environmental protection agencies worked cross-sectorally and science and technology councils emphasized multidisciplinary research. In this context, the health sector can learn from the environment sector, which has been very effective in promoting its cause through existing structures.
WHO-EMIMAW327E Page 10 With a policy framework and institutional arrangements in place, the human resource component still requires strengthening. As a result of training, professionals have been conditioned to focus on their area of technical expertise. This technical focus often hinders a broader managerial approach and effective communication with professionals in other sectors. There is, therefore, a need to develop the skills of professionals in management and decision-making positions so they will be able to participate effectively in intersectoral negotiations and decision-making, irrespective of their sectoral affiliation. The aim is for professionals in the different ministries to learn to collaborate with colleagues from other sectors on the basis of mutual respect and reliance. Clearly, these were issues that had to be resolved before an IVM approach could be embarked upon successfully, and alternatives to DDT and other insecticides deployed to their maximum potential. It required a shift from a focus on technical issues to an adaptive management approach whose functioning was based on agreed criteria and procedures relevant to local settings. Discussion It was observed that with technological advances there was also a trend towards further compartmentalization, and that boundaries between sectors became harder to cross. Complementary to the intersectoral mechanisms existing in most countries, there had been positive experiences with the establishment of specifically-tasked intersectoral committees, established under the Prime Minister's office and well resourced to perform tasks. Wherever this approach has failed, it has been as a result of lack of funding. In any intersectoral endeavour, no sector would be willing to share its limited resources at the onset of collaboration. Separate funding served to start the process, until the participating sectors realized the added value accruing from investing in the continuation of their joint activities. Clear arrangements between the sectors were also seen to be essential: no grey areas or overlaps should remain and all responsibilities should be spelled out clearly. Finally, adequate and continuous supervision was critical in maintaining the intersectoral process. It was agreed that the PDF-B phase and subsequent project offered an important opportunity to revive intersectoral action for vector-borne disease control. Countries required a model and guidance on how to implement it, with WHO taking the lead in developing the model and the guidance materials. Attention was drawn to the fact that intersectoral collaboration should also occur at the various levels of government, from national to local, anywhere where competition for resources created sectoral divides. In this continuum, community participation has a role: involvement of community members and intersectoral collaboration were believed essential to the success of any action undertaken at community level. This partnership could mobilize the energies of communities towards improving their quality of life. At the other end of the spectrum, there should
WHO-EMlMAU327E Page 11 also be intensified intersectoral action between international agencies, to set the example for national governments. While health is an issue that crosses several sectors, in many instances the health sector is not ultimately in control. Other sectors therefore need an incentive to collaborate with the health sector. The communication for behavioural impact (COMBI) approach for dengue vector control has shown that small amounts of seed money can create the momentum necessary to secure the involvement of other sectors. Similarly, a settings approach could help focus these efforts, as is shown by various successful healthy cities and healthy villages initiatives in the Region. Any effort to support intersectoral initiatives should ensure that it is an educational experience for the policy- and decision-makers. By the end of a pilot period they need to be convinced of the value of, and need for, continued intersectoral action.
3.2 Incremental cost analysis: a requirement for GEF funding Matthias Kern The cost of GEF-eligible activity in a project should be compared to that of the activity it replaces or makes redundant. Incremental cost is a measure of the future economic burden on the country that would result from its choosing the GEFsupported activity in preference to one that would have been sufficient to the national interest. To estimate incremental cost, the analyst must estimate both the expenditure on the activity in question and the cost-saving on activities that, as a result of the GEF activity, will no longer be needed. The burden of an activity on a country is the activity's economic cost. This economic cost could be higher than the financial cost of the activity (e.g. when inputs are subsidized) or lower (e.g. when inputs are taxed). The global environmental benefit of "alternatives to DDT" projects is derived from the objectives of the Stockholm Convention on Persistent Organic Pollutants, i.e. the reduction in the releases of DDT and its metabolites to the environment. The national benefits can be calculated from savings on the health systems resulting from reduced impact of malaria in the areas of demonstration projects. All participating countries of the Middle East and North Africa (MENA) project are already engaged in national and regional actions to control malaria vectors. These activities contribute directly to the baseline in the incremental cost analysis. The baseline analysis draws upon existing studies and sustainable development plans at the country or sectoral level. Such an approach helps to ensure that GEF-supported activities become an integral part of countries' own efforts to protect the environment and helps to maintain mutual understanding. The baseline analysis also determines the amount of cofinancing coming from the country. Significant co-financing is available in many countries from malaria control programmes which meet part of the expenses related to the demonstration projects by malaria programme budgets. The co-financing provided
WHO-EMIMAU3271E Page 12 by national budgets is estimated from malaria control programmes specifically oriented to the population of the specified project areas.
Discussion The explanation of the concept of incremental costs raised a number of questions concerning the obstacles countries might encounter in their calculations. Firstly, it was apparent that there needs to be clear criteria for the selection of demonstration sites that address the issue of incremental costs. Secondly, as countries may be inclined to revert to the use of DDT not just for malaria vector control but also in response to other vector-borne diseases, the scope of the calculations should be allinclusive for vector-borne diseases. For some of these diseases, vector control remained the only intervention option. A key concem was whether countries were in a position to produce adequate vital statistics about disease burden and their intervention programmes to support the assessment and calculations. Experience from tuberculosis assessments of needs until 2015 showed that this could be done, and the modelling approach applied in the case of tuberculosis could be adapted and applied to vector-borne diseases.
Regarding the allocation of funds in the PDF-B budget, it was clarified that the country funds were all existing (rather than new) funds, but that the amounts needed updating to the 2006 situation. The regional allocation was reflected under the coordination and management component; this component was the responsibility of the executing agency (WHOiEMRO) and 90% of the amount was covered by GEE It was apparent that the incremental cost calculation would need close attention, to ensure that calculations for both financial and economic costs were properly performed. Clearly, alternative interventions were not equivalent in their economic aspects, e.g. environmental management measures of an infrastructural nature required large capital investments. In general, and perhaps also in the context of this project, they were at a disadvantage in comparison to interventions of a recurrent nature, such as indoor residual spraying, because of the practice of discounting. The GEF calculations were, in this respect, simplified to some extent. However, it was recommended that the services of a health economist be used to ensure that the outcome would be robust.
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3.3 Introduction of regional and country plans Dr A. Mnzava In regard to regional and country plans, concern was expressed over the timeframe of the PDF-B phase. It was queried whether it could realistically be expected that countries would complete an in-depth VCNA and develop the proposal in the period of time allocated. It was clarified that these were not two separate items: the implementation of the VCNA would provide the baseline and other information required for the formulation of the project brief, and that formulation was, in fact, an integral part of the VCNA. It was acknowledged, however, that time would be needed to appraise all country proposals at the regional level, to ensure there were no serious discrepancies between countries and to consolidate the country proposals into one regional project brief. Based on the experience of other regions, the timeframe was considered realistic. It would, however, require strict monitoring to ensure that objectives were met in time. The timing of some items, in particular the organization of Steering Committee meetings and intercountry meetings, should remain flexible and be linked to progress made in the delivery of tangible outputs. As a resource-saving measure it was agreed that the two planned Steering Committee meetings would be organized back-to-back with the two planned country meetings.
3.4
Introduction to VCNA tools and guidelines Dr J. Williams Countries face significant challenges to vector control, such as: ineffective national intersectoral action to properly address the causes of local disease burdens; diminishing resources available to national programmes, which limits their management and technical scope; constraints to the implementation of cost-effective and sustainable interventions, resulting from increasing vector resistance to pesticides and inadequate national capacity for the evaluation of local eco-epidemiology of diseases.
In order for vector control to be effective it should address the vector carrier of the dsease, the human target of the disease (individual and community), and the milieu within which at-risk individuals and communities live. The implementation of vector control needs to be innovative, enabling the scale-up of cost-effective and sustainable interventions through delivery systems that are responsive to changing local situations and which protect the continued utility of existing tools. This is in agreement with the policy of IVM advocated by WHO. National action to improve vector control will only be realistic if it is based on a comprehensive assessment of needs and opportunities within the context of current and predicted vector-borne
WHO-EMIMAU327lE Page 14 disease burdens. VCNA is, therefore, a rational first step to establishing effective national IVM. The framework proposed by the guidelines is both comprehensive and flexible. It permits adaptation to suit the existing stage of national programme development or complexity, and allows discrete evaluations on specific vector control aspects as well as general system-wide evaluations. The outline of the VCNA guidelines is as follows. Chapter 1 (Introduction) covers the purpose, specific objectives and scope of the guidelines, as well as the intended users. The guidelines (i) provide a framework for assessing needs for introducing or improving vector control programmes, (ii) propose a national processes, and methodology and tools for the needs assessment, and (iii) provide guidance on the use of assessment outcomes for improving vector control programmes. The intended targets are government officials, who are normally charged with the planning and design of health sector programmes. Chapter 2 (Assessment procedure) defines basic concepts and principles, and discusses procedures for conducting the VCNA. A three-phase assessment approach is proposed. Firstly, a preparatory phase which covers the establishment of intersectoral mechanisms for overseeing the conduct of the VCNA, national consultation and consensus building. The second phase involves the actual conduct of the assessment and a third (or follow-up) phase proposes procedures for using the assessment outcomes to develop IVM strategies and plans of action. Chapter 3 (Tools and methods) describes specific tools and methods for conducting the VCNA. Firstly, priority areas for situation analysis are proposed, each with primary information requirements as well as methodologies for collecting the needed information. Then, methodologies for identifying the major constraints faced by the national vector control are proposed, citing the root causes of major constraints, and determining the needs and opportunities for establishing or strengthening the national programmes. Finally, the primary products of the VCNA are outlined. Chapter 4 lists the references and suggested further reading. The following observations and clarifications were made in response to the presentation. VCNA includes the assessment proper, the development of strategic approaches and the formulation of the full GEF project proposal. VCNA is not a one-time event but a periodic process that will be repeated when agreed targets have been achieved and with new targets defined. VCNA is not a rapid assessment, it has to be sufficiently in-depth to allow proper follow-up through agreed targets and indicators.
WHO-EM/MAU327/E Page 15 Certain aspects, such as intersectoral action and community empowerment, are not yet adequately covered in the guidelines and need to be addressed. The situation analysis will be the first and critical step of the VCNA. It requires a strong knowledge base and the capacity for vector mapping, which are lacking in many countries of the Region. Situation analysis is, therefore, a considerable challenge. Discussion It was observed that the guidelines were very detailed on some issues and more superficial regarding others. For example, the questions addressing the policy framework were quite detailed, but those assessing research capacity and needs required further elaboration. It was felt that the questions should be suitably detailed in order to ensure that the needs assessment was sufficiently in-depth. Wherever possible and appropriate, information from other WHO guidelines should be integrated into the VCNA guidelines. There was discussion regarding the scoring system contained in the questionnaire. It was understood that scoring - was relative and that the figures assigned were arbitrary. Scoring methodology is common in these types of assessment to allow for comparison and prioritization of the elements that require capacity building. Scoring also permits capacity-building trends to be followed over time. It was agreed that the opinion of country delegates on this issue would be sought and that if a scoring system was included in the assessment, it should in no way be used as a ranking exercise at the regional level. In the context of the Stockholm Convention, it was expected that any efforts to replace DDT should be provided with a solid evidence and knowledge base. This should address the cost, effectiveness and safety of alternatives. Only once this knowledge base had been strengthened could scaling-up of the alternatives be initiated. Although the guidelines and their associated questionnaire would be fully comprehensive after further review and completion, it was still considered necessary to enrol consultants to assist the countries in implementation of the VCNA. This would ensure consistency in the exercise, and allow harmonization of the process and of the national outcomes at the regional level. At the start of the PDF-B phase, these consultants should go through a briefing and induction session to prepare for the task. They should be public health experts with a broad background, and not specialists in specific sub-areas of vector biology and control. It was acknowledged that the inclusion of consultants would call for adjustments of the budget lines. The Steering Committee agreed that the guidelines and associated tools were valuable instruments to perform the VCNA, but still needed further development
WHO-EMMAY3271E Page 16 before they could bc applied at the national level. The members planned to bring the points raised to the attention of the country delegates at the subsequent meeting. It was also agreed that individual Steering Committee members would put their specific comments on the VCNA guidelines in writing, contribute substantial parts wherever this was appropriate in the document and submit these comments two weeks after the meeting.
3 . 5
Criteria for identification of demonstration districts Dr G Zamani
According to the accepted GEF proposal, each country should select two demonstration sites. However, it is questionable whether this proposal can be extended to all countries due to the tremendous variation in the population size, area and complexity of the eco-epidemiology. Criteria for the selection of demonstration districts include: size, in terms of population and area; accessibility of the district for implementation and supervision; health system structure, including vector-borne disease programmes and health information system for planning, implementation and monitoring and evaluation; availability of human resource and possibility of their training; infrastructure and human resources and possibility of their training; epidemiology of vector-borne diseases and the possibility of multiple disease control approach; entomological surveillance system, including insecticide resistance monitoring; intersectoral collaboration and community participation potential. During the selection process, factors ensuring sustainability, such as financial support, presence of expertise and agreement with other key partners, are of paramount importance. Likewise, the presence of pesticide stockslobsoletes in the candidate districts will influence the comprehensiveness of the project.
Discussion The selection of the demonstration site(s) will be primarily determined by the outcome of the VCNA. The Steering Committee members agreed that demonstration projects were not intended as basic research projects with a major statistical component and randomized control groups. The projects aimed to build on existing situations where DDT was (or potentially could be) used and were intended to demonstrate the practical feasibility of alternatives in terms of their cost-effectiveness in transmission reduction. The result should provide information on incremental costs/savings and incremental transmission changes as a result of introducing alternative vector control methods.
WHO-EM/MAU327/E Page 17 There was also discussion about the geographical boundaries of the projects. The definition of districts would vary from one country to another, and the administrative boundaries would not necessarily coincide with the transmission stratification according to eco-epidemiological parameters. Countries should be able to select their demonstration "sites" (as it was decided they should be referred to) based on the VCNA, but the criteria applied in their selection should be upfront and transparent. The criteria for selection should include, but not necessarily be limited to, the following elements. The existence of an ongoing vector control programme to which the project will provide significant incremental activities and potential benefits. Indoor residual spraying with DDT should be a real or potential component of this vector control programme. A representative scenario of the country vector control situation, so that lessons learnt from the demonstration would have the best chance of successful replication in other parts of the country. This could include: the presence of major vector-borne disease(s) which could make possible an appropriate introduction of alternative intervention to DDT, preferably within the context of a multi-disease control approach; opportunities for joint N M and IPM implementation; opportunities for proactive community participation and empowerment. At regional level, the various national demonstration sites should make up a comprehensive and fully representative picture of the ecotypes that sustain vector-borne disease transmission. Opportunities to implement major activities and outcomes envisaged in the project (PDF-B) document. The presence of critical mass and range of local technical expertise to assure sustainability of efforts and benefits, both during and after project implementation. Although the project indicates two demonstration sites, it is reasonable to expect that in some countries a single demonstration site be chosen rather than two. The recommendations concerning the demonstration sites will require clear justification, with reference to the criteria. The final selection of the demonstration sites will, however, need the concurrence of the project Steering Committee at its second meeting.
3.6
Review of the programme for the first intercountry meeting on the EMROIGEF project Dr A. Mnzava
Minor adjustments were made to the programme for the first regional meeting, reflecting the discussions of the Steering Committee. The programme was approved by the Steering Committee in its adapted form.
WHO-EM/MAU327/E Page 18 RECOMMENDATIONS The scope of the project documents should be expanded to include all vectorborne diseases rather than malaria exclusively. Priority should be given to strengthening capacity in countries of the Region under the PDF-B and the subsequent project in order to ensure effective networking, information exchange and a stronger negotiation position for the countries. Under the PDF-B phase, WHO should develop a clear model for intersectoral collaboration that countries can adapt to their local needs. The final project proposal should be based on sound statistical evidence, for which programme models with proven success, e.g. tuberculosis, can be utilized. The expertise of a health economist should be included in undertaking the financial and economic analysis required for the project proposal. The VCNA should be a comprehensive, not a rapid, assessment in order to ensure that the real needs of countries in the Region in terms of vector control are identified. It should be conducted periodically as part of a process of ongoing assessment and adjustment against evolving programme targets. With respect to the final update and completion of the VCNA guidelines: WHO guidelines for pesticide management should be reflected as an integral part; a community participation section should be developed and included; a stronger orientation towards regional coordination of efforts should be reflected; a user-friendly format should be ensured, following the example of the health impact assessment training materials; the opinion of country delegates should be sought at the first regional meeting concerning the desirability of the scoring method as part of the guidelines. Consultants should be given orientation on the methodology proposed for the implementation of the VCNA guidelines at country level so that an effective and regionally harmonized approach is ensured. These consultants should have a broad public health perspective, and could be backed up by specialists in specific areas of relevance. The budget for the PDF-B should be adjusted in order to reflect the current realities of country contributions and to cover the costs of the additional technical inputs required.
WHO-EMIMAU327/E Page 19
Annex 1
AGENDA Opening session Implementation of vector control interventions in Eastern Mediterranean countries and the process to establish national intersectoral action An overview of the EMROIGEF project proposal to demonstrate sustainable alternative to DDT through IVM Summary of GEFDDT project experiences in other regions Incremental cost analysis: a requirement for GEF funding Review of regional and national work plans for PDF-B activities Review of guidelines and tools for carrying out VCNA as part of PDF-B activities Criteria for the identification of districts for demonstration activities Conclusions and recommendations
10.
Closure of the meeting
WHO-EMiMAU327fE Page 20
Annex 2
PROGRAMME Saturday, 4 March 2006 Registration Opening session Opening remarks Introduction of participants Adoption of the proposed agenda and programme Election of Chairperson and Rapporteur EMROIGEF project proposal to demonstrate sustainable alternatives to DDT through IVM Summary of experiences of GEFDDT projects in the context of the Stockholm Convention in other regions Discussion Implementation of vector control and the process to establish national intersectoral action Incremental cost analysis: a requirement for GEF funding Discussion Introduction of regional and country plans Discussion, review and finalization of regional and country plans Introduction to the VCNA guidelines and tools Discussion Dr Z. Hallaj
Dr A. Mnzava Dr J. Williams
Dr R. Bus Dr M. Kern Dr A. Mnzava
Dr J. Williams
Sunday, 5 March 2006 09:OO-11:30 11:30-1200 12:OO-14:45 14:45-15:15 15:15-15:30 15:30-16:OO 16:OO Discussion and endorsement of the VCNA guidelines and tools Criteria for identification of demonstration districts Discussion of criteria Review of the programme for the first regional meeting of countries supported by the GEFlEMRO project Discussion Conclusions and recommendations Closure of the meeting
DI: G Zamani Dr A. Mrzzava
WHO-EM/MAU327/E Page 21
Annex 3
MEMBERS OF THE STEERING COMMITTEE Dr Farah Ali Ainan* Secretary-General, Ministry of Water and Irrigation Djibouti DJIBOUTI Dr Salim Al-Wahaibi Director, Environmental Health and Malaria Eradication Ministry of Health Muscat OMAN Dr Gamal Abdo Allozy* Environmental Adviser, Qatar Armed Forces Environmental Security Department Doha QATAR Dr Btissam Ameur Head, Vector Control Service, Directorate of Epidemiology and Disease Control Ministry of Health Rabat MOROCCO Dr Hoda Atta (WHO Secretariat) Regional Adviser, Roll Back Malaria WHO Regional Office for the Eastern Mediterranean Cairo EGYPT Dr Robert Bos (WHO Secretariat and Rapporteur) Scientist, Water, Sanitation and Health, Department Public Health and Environment WHO headquarters Geneva SWITZERLAND
Dr Keith Chanon* Scientist, Commission for Environmental Cooperation Secretariat Montreal CANADA
* Unable to attend
WHO-EM/MAU327/E Page 22 Dr Rogerio Fenner Project Officer, Stockholm Convention Secretariat UNEP Chemicals Geneva Dr Zuhair Hallaj (WHO Secretariat and Chairman) Director, Communicable Disease Control WHO Regional Office for the Eastern Mediterranean Cairo EGYPT Dr Ali Nasser Hassan Temporary Adviser WHO Regional Office for the Eastem Mediterranean Cairo EGYPT Dr Matthias Kern (GEF Secretariat) UNEPIGEF Programme Officer Nairobi KENYA Dr M.Z. Ali Khan Coordinator WHO/EMRO Centre for Environmental Health Activities (CEHA) Amman JORDAN Dr Abraham Mnzava (WHO Secretariat) Scientist, Vector Control, Roll Back Malaria WHO Regional Office for the Eastern Mediterranean Cairo EGYPT Dr Eli1 Renganathan (WHO Secretariat) Director, WHO Mediterranean Centre for Vulnerability Reduction Tunis TUNISIA Dr Agneta Sunden-Bylihn* Scientist, Stockholm Convention Secretariat UNEP Chemicals Geneva
* Unable to attend
WHO-EM/MAU327/E Page 23
Dr Jacob Williams (WHO Secretariat) Scientist, Roll Back Malaria WHO headquarters Geneva SWITZERLAND Dr Morteza Zaim (WHO Secretariat) Scientist, Pesticide Evaluation Scheme, Prevention and Eradication WHO headquarters Geneva SWITZERLAND Dr Ghasem Zamani Temporary Adviser WHO Regional Office for the Eastern Mediterranean Cairo EGYPT