www.who.int/apoc JAF19.7 CONCEPT NOTE Transforming APOC into a new regional entity for Oncho & LF elimination and support to other PC/NTD November 2013 PrOvisiONAL AgeNDA iTem 11 AFRICAN PROGRAMME FOR ONCHOCERCIASIS CONTROL © Copyright African Programme for Onchocerciasis Control (WHO/APOC), 2013. All rights reserved. Publications of the WHO/APOC enjoy copyright protection in accordance with the Universal copyright Convention. Any use of information in the Concept Note should be accompanied by acknowledgement of WHO/APOC as the source. For rights of reproduction or translation in part or in total, application should be made to: Office of the APOC Director, WHO/APOC, BP 549 Ouagadougou, Burkina Faso dirapoc@oncho.afro.who.int WHO/APOC welcomes such applications. CONCEPT NOTE Transforming APOC into a new regional entity for Oncho & LF elimination and support to other PC/NTD November 2013 AFRICAN PROGRAMME FOR ONCHOCERCIASIS CONTROL APOC African Programme for Onchocerciasis Control CAR Central African Republic CDD Community-Directed Distributor CDTI Community Directed Treatment with Ivermectin CSA Committee of Sponsoring Agencies DEC Diethylcarbamazine-citrate DRC Democratic Republic of Congo GAELF The Global Alliance to Eliminate Lymphatic Filariasis GPELF The Global Programme to Eliminate Lymphatic Filariasis GSK GlaxoSmithKline JAF Joint Action Forum LF Lymphatic Filariasis M&E Monitoring and Evaluation MDA Mass Drug Administration MDP Mectizan Donation Programme MOH Ministry of Health NGDO Non-Governmental Development Organization NTD Neglected Tropical Diseases OCP Onchocerciasis Control Programme (in West Africa) PC Preventive Chemotherapy PHC Primary Health Care REA Rapid Epidemiological Assessment REMO Rapid Epidemiological Mapping of Onchocerciasis RPRG Regional Programme Review Group SAE Serious Adverse Event TCC Technical Consultative Committee WB World Bank WHO World Health Organization WHO/AFRO WHO Regional Office for Africa and Technology Abbreviations 2 A fr ic A n P r o g r A m m e f o r o n c h o c e r c iA s is c o n t r o l (A P o c ) • C O N C E P T N O T E 2 0 1 3 Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 THe CONCePT NOTe 1. The broader context of global commitment to defeat Neglected Tropical Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 2. The burden of lymphatic filariasis and onchocerciasis . . . . . . . . . . . . . . . . . . . . . . . . . 6 3. Key developments in the efforts to end onchocerciasis and lymphatic filariasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 4. The opportunity to eliminate onchocerciasis and lymphatic filariasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 5. Joint approaches to solve common challenges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 6. Opportunities to contribute more broadly to overcome the impact of other NTDs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 7. Building country leadership and stronger health systems . . . . . . . . . . . . . . . . 16 8. Partnership opportunities arising from new strategic direction . . . . . . 16 9. The role of a new regional entitiy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 10. Scenario for a new regional entity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 11. From Concept Note to Action Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 12. Legal implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 13. Financial resources for the Strategic Action Plan 2016-2025 . . . . . . . . . . . . . . 20 Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Table of contents 3 A fr ic A n P r o g r A m m e f o r o n c h o c e r c iA s is c o n t r o l (A P o c ) • C O N C E P T N O T E 2 0 1 3 4A fr ic A n P r o g r A m m e f o r o n c h o c e r c iA s is c o n t r o l (A P o c ) • C O N C E P T N O T E 2 0 1 3 ThE CONCEPT NOTE 1. The broader context of global commitment to defeat Neglected Tropical Diseases In May the Sixty-sixth World Health Assembly adopted resolution WHA66.12 (1) on 17 neglected tropical diseases1 (NTDs). Among other measures, the resolution urges Member States to: • ensure country ownership of preven- tion, control, elimination and eradication programmes; • expand and implement interventions and advocate for predictable, long-term inter- national financing for activities related to control and capacity strengthening; • integrate control programmes into primary health-care services and existing programmes; • ensure optimal programme management and implementation; • achieve and maintain universal access to interventions and reach the targets of the roadmap. This landmark resolution underlined the growing commitment to tackle these diseases which affect more than one billion poor people and cause suffering, stigma and social exclusion – particularly for women 1 Buruli ulcer disease (Mycobacterium ulcerans infection), Chagas disease (American trypanosomiasis), cysticercosis, dengue, dracunculiasis (guinea-worm disease), echinococcosis, endemic treponematoses, foodborne trematode infections, human African trypanosomiasis (sleeping sickness), leishmaniasis, leprosy, lymphatic filariasis (elephantiasis), onchocerciasis (river blindness), rabies, schistosomiasis (bilharziasis), trachoma and soil- transmitted helminthiases. and children. This commitment has grown at national, regional and global levels. At national level countries are taking up the challenge to develop integrated national plans for the control and elimination of NTDs under the guidance of the World Health Organization (WHO). A high degree of global support has been generated around the WHO Strategy and “Roadmap to overcome the impact of neglected tropical diseases (2)” and around the London Declaration(3), signed by an unprecedented group of partners around a common commitment to the control or elimination of NTDs identified by WHO. The The WHO Regional Office for Africa (WHO/ AFRO) has developed and adopted a Regional Strategy for NTDs (4) with a vision of “Africa free of NTDs”. A number of new partners and partnerships have formed around this commitment and ambitious targets and milestones have been set. Increased support is evident among Member States and is also seen in the increased availability of medi- cines donated by pharmaceutical companies and support from key donors and the NGDO community. This concept note was developed at the request of the expanded APOC Committee of Sponsoring Agencies (CSA); which consists of a broad group of partners working in the field of lymphatic filariasis, onchocerciasis and neglected tropical diseases. This concept note identifies ways in which partners can best work together to strengthen their work and achieve the elimination of lymphatic filariasis and onchocerciasis. It identifies key issues and opportunities ahead and analyses challenges and considers how to overcome them. The concept note also considers implications for partnerships and the way forward. 5 A fr ic A n P r o g r A m m e f o r o n c h o c e r c iA s is c o n t r o l (A P o c ) • C O N C E P T N O T E 2 0 1 3 The original version of the concept note was drafted to explore the need for increased collaboration and the best way to realize this. The original draft was discussed by partners at a meeting of the expanded CSA in Tunis in July 2013 and has been updated to include comments from Stakeholders and the conclusions of that meeting. The concept note lays the ground for the development of: • an action plan that fully reflects the new level of ambition, expected results and milestones; • a new financing plan; • new working arrangements and an appropriate legal and managerial frame- work for activities 2016–2025. 2. The burden of lymphatic filariasis and onchocerciasis Globally it is estimated that 40 million people are chronically disabled by lymphatic filariasis, making this disease the leading cause of physical disability in the world. Onchocerciasis causes intense itching, disfiguring dermatitis, and eye lesions that can result in blindness. Globally it is the second major infectious cause of blindness. The diseases not only affect peoples’ physical health, they are also a major cause of stigma and social isola- tion. People affected by the diseases are often unable to work and withdraw from economic activity leading to losses in production, increased poverty and risk of famine. Where the prevalence of blindness is high, young, able-bodied people (fearful of contracting onchocerciasis) leave their villages, often abandoning rich farmland. Approximately 40% of the global disease burden for lymphatic filariasis occurs in Africa and 99% of the disease burden for onchocerciasis2. The huge impact of disability caused by lymphatic filariasis has meant that efforts to interrupt transmission of the disease have gone hand-in-hand with efforts to care for those who already suffer from its effects. This two-pronged approach aims to free future generations from this disa- bling disease whilst reducing the suffering it currently causes.2 3. Key developments in the efforts to end onchocerciasis and lymphatic filariasis The control of onchocerciasis is widely acknowledged to be one of the major public health achievements of recent decades in Africa. This success has been made possible by a powerful and successful partnership which has brought together communi- ties, policy makers and health workers in endemic countries, the UN system and donors, Non-Governmental Development Organizations (NGDOs) and Merck & Co. Inc. The African Programme for Onchocerciasis Control (APOC) serves and facilitates this partnership and has been at the heart of successes achieved3. This partnership is now at a turning point and must develop strategies to implement major decisions about involvement in the broader NTD agenda and to respond to the possibility of onchocerciasis elimination. • The original ambition of APOC was clearly time-bound and limited to the set-up of 2 Peter J Hotez and Aruna Kamath, “Neglected Tropical Diseases in Sub-Saharan Africa: Review of Their Prevalence, Distribution, and Disease Burden.,” PLoS Neglected Tropical Diseases 3, No. 8 (January 2009). 3 Initially efforts were led in West Africa by the Onchocerciasis Control Programme (OCP) which closed in 2002. Since 1995 the African Programme for Onchocerciasis Control has led the partnership which was launched to establish sustainable community managed systems for ivermectin distribution in 19 countries where the disease was a significant public health problem. 6 A fr ic A n P r o g r A m m e f o r o n c h o c e r c iA s is c o n t r o l (A P o c ) • C O N C E P T N O T E 2 0 1 3 an effective and sustainable drug distribu- tion system for the control of onchocer- ciasis in Africa by 2010. This was extended to 2015 to allow additional progress to be made in countries that had started late or were lagging behind as a result of co-endemicity with loiasis, or civil unrest. Recently, scientific evidence has accumu- lated to demonstrate that ivermectin can not only control but, in many areas, can eliminate onchocerciasis infection and interrupt transmission (5). Treatment can safely be stopped where interruption of transmission has been demonstrated. This has given rise to a more ambitious goal: the elimination of onchocerciasis in Africa. Achieving this would mean that future generations would be free from the threat of the debilitating consequences of the disease. • As outlined above, the commitment to address other NTDs has grown and ambitious targets and milestones have been set at global, regional and national level. These developments have brought forward questions about partnership and improved collaboration to achieve the targets for other PC NTDs. In particular, onchocerciasis and lymphatic filariasis treatment programmes are already very closely linked. Strategies to control several other NTDs depend on mass drug administration and build on the experi- ences with onchocerciasis and lymphatic filariasis. The developments briefly described above are evidence of success, and present part- ners with important opportunities to contribute to lasting health gains. These developments also present major challenges and require new approaches. The APOC Joint Action Forum (at its meeting in 2011) agreed, in principle, that APOC could extend its operations beyond 2015 in order to pursue coordinated efforts for the elimination of onchocerciasis while supporting co-imple- mentation of preventive chemotherapy for other selected NTDs and increasing support to community level health strengthening. Rising to these challenges will require a new approach geared to elimination, new ways of working, new administrative and finan- cial arrangements, new strategies, tools and guidelines and new resources and partner- ships. The JAF requested a full action plan and budget for the period up to 2025 that would encompass this changed orientation. The Global Programme to Eliminate Lymphatic Filariasis (GPELF), which was officially launched in the year 2000 is the most rapidly scaled-up medicine adminis- tration programme in public health history. In Africa alone, the number of people under mass drug administration for the elimi- nation of lymphatic filariasis increased from around 240,000 in six implementa- tion areas in 2001 to around 113 million in 771 implementation areas in 2011. This major scale up was achieved through a well concerted effort between drug donation companies, implementing partners and strong country driven programmes, with the coordination and technical guidance of the regional office of WHO. There are two aims to the current global programme: to interrupt transmission using MDA, and to help people suffering from the symptoms by providing access to the basic care needed to manage morbidity and prevent disability. Lymphatic filariasis and onchocerciasis are both caused by filarial worms susceptible to a common medicine: ivermectin. This medicine is used to treat both diseases and has been made freely available for the control of onchocerciasis since 1987 and for the elimination of lymphatic filariasis since 1997. In 30 countries in Africa, where both diseases are endemic, lymphatic filariasis MDA involves treatment with ivermectin donated by Merck and albendazole donated by GlaxoSmithKline (GSK). In other coun- tries Diethylcarbamazine-citrate (DEC) is used in combination with albendazole. The donation of sufficient quantities of iver- mectin and albendazole has made rapid scale-up possible. 7 A fr ic A n P r o g r A m m e f o r o n c h o c e r c iA s is c o n t r o l (A P o c ) • C O N C E P T N O T E 2 0 1 3 4. The opportunity to eliminate onchocerciasis and lymphatic filariasis Initially Community Directed Treatment with Ivermectin (CDTI) was an innovative intervention to control onchocerciasis. From the start ivermectin was known to act on the microfilariae rather than the parent worm (macrofilariae), thus halting the disease and relieving symptoms but offering no clear prospect of elimination. Initially it was not known how long treat- ment would be necessary, although it was clear that repeated treatment over a number of years would be involved. Since 2008 APOC has conducted epidemiological evaluations to assess progress made, and to ascertain if, and when, it would be possible to stop treat- ment. As of 2012 the findings from 45 sites suggest that onchocerciasis elimination may have been achieved in 20 of the sites and an additional eight sites have a prevalence of infection of close to zero. There is still discus- sion about the accuracy of these projections and additional research may be needed (6), but recent APOC data analysis shows that 12 APOC countries may achieve national elimination by 2020. If ex OCP countries are included another 11 countries should achieve elimination by 2020. This recent evidence has shown that elimi- nation of onchocerciasis is not only a possi- bility but is, in fact, already being achieved in a number of sites and can be achieved by 2020 in 23 out of 31 of the countries in Africa in which it is endemic; thus freeing their people and future generations from the threat of the disease. The same projections show that all countries with the exception of South Sudan, The Democratic Republic of the Congo (DRC), the Central African Republic (CAR), Gabon and Equatorial Guinea (main land) will have eliminated the disease by 2025. For this last group of countries accel- erated actions and special strategies are being developed to speed up their progress towards elimination by 2025. Formally, elimination can only be deter- mined at a national level and after inde- pendent validation by WHO and verification that elimination target guidelines have been met. This is clearly within reach for many countries and the prospect of elimination throughout Africa is real although the chal- lenges are considerable. The global target for the elimination of lymphatic filariasis is 2020. To achieve this, annual rounds of MDA have to reach 80% Figure 1: Current predictions for onchocerciasis elimination in Africa using current strategies (Source APOC Strategic Plan 2012). 8 A fr ic A n P r o g r A m m e f o r o n c h o c e r c iA s is c o n t r o l (A P o c ) • C O N C E P T N O T E 2 0 1 3 9A fr ic A n P r o g r A m m e f o r o n c h o c e r c iA s is c o n t r o l (A P o c ) • C O N C E P T N O T E 2 0 1 3 therapeutic and 100% geographic coverage for five to six consecutive years. As in the case of onchocerciasis, elimina- tion of lymphatic filariasis can only be determined nationally, after treatment has been stopped, post treatment surveillance carried out, and an independent verification process has verified that elimination targets have been met. The 2013 report on the WHO targets reaffirms that by 2020, 70% of coun- tries should be certified as free of the disease and the other 30% will be in the process of post treatment surveillance. Achieving this requires acceleration of the massive scale-up effort to ensure that mapping is complete and all countries have started treatment by the end of 2015. Meeting the elimination targets for both diseases requires a new level of ambi- tion and the development of common approaches. There is a considerable overlap in the population targets for each disease and the elimination of both diseases is inex- tricably linked as it is impossible to verify elimination of one disease if treatment for the other is still in progress. Decisions about when to treat, and when to stop treatment, have to be coordinated. Joint approaches to common challenges will help to speed up progress and keep elimination efforts on track. 5. Joint Approaches to solve Common Challenges The most important challenges to elimina- tion have been jointly identified and oppor- tunities to overcome them with joint work are briefly described below. Overlapping onchocerciasis and lymphatic filariasis areas. To date it has been very difficult to get reliable data on the overlap of onchocerciasis and lymphatic filariasis treatment areas and develop an accurate estimate of the target popula- tion. As stated above the total population at risk for both is estimated at about 190 million in 2016.4 Joint work is resulting in a much clearer picture and when this work is completed it will be possible to optimise decisions about when and where to treat and to ensure optimal medicine supply (avoiding both waste and shortages). Harmonizing treatment units. Histori- cally onchocerciasis control has worked in project areas where the disease is hyper- and meso- endemic. Lymphatic filariasis programmes have worked within Imple- mentation Units (IUs) which cover entire administrative or health districts. This will allow for more efficient and effective treat- ment and collection of compatible data sets. Work has already started to introduce harmonized IUs, and new population treat- ment targets are being developed. This will allow for more efficient and effective treat- ment and collection of compatible data sets. Completing scale-up for elimina- tion. Whilst lymphatic filariasis scale-up has been rapid it is not yet complete and the change to the goal of onchocerciasis elimination requires treatment in hypo- endemic areas that have not yet been included. Starting treatment in these areas requires harmonizing and redefining the guidelines about starting and stopping treatment and developing MDA delivery systems that are compatible with the need for accelerated scale-up; together with the M&E and surveillance systems that these require. These guidelines need to be jointly developed and introduced. mDA in areas co-endemic for onchocer- ciasis/lymphatic filariasis and loiasis. In areas co-endemic for onchocerciasis and loiasis, cases of severe adverse reactions (neurological signs, encephalopathy and 4 These figures include an estimate for areas not yet mapped for lymphatic filariasis and for people living in areas which are hypoendemic for onchocerciasis and will require treatment as part of en elimination strategy. 10 A fr ic A n P r o g r A m m e f o r o n c h o c e r c iA s is c o n t r o l (A P o c ) • C O N C E P T N O T E 2 0 1 3 coma) have been reported as the result of treatment with ivermectin. After the first cases were reported, measures were taken to avoid and deal with this problem. In areas where lymphatic filariasis and onchocer- ciasis are co-endemic with loiasis, different MDA strategies will be needed. Research is still on-going about the best strategy for these areas. In the meantime, WHO has developed interim guidelines on treatment of lymphatic filariasis in areas co-endemic for loiasis. These guidelines, which should be implemented quickly, recommend the use of albendazole twice-yearly for MDA and mass distribution of insecticide treated nets. For onchocerciasis the strategies for treat- ment in hypo-endemic areas still need to be defined. In the near future, a test and treat strategy will probably enable a large propor- tion of the population to receive ivermectin. For those with Loa loa microfilaremia too high for ivermectin it will be necessary to consider the use of alternative therapies such as the use of doxycycline daily for five weeks. Detailing the map of transmission and level of endemicity of loaisis may help to identify areas of hyper-endemicity for loiasis where the risk of severe adverse events is highest and thus “shrink” the areas where alternative strategies are needed. Finan- cial resources to develop and implement alternative strategies will be needed. Some areas will require intensive support and monitoring to cope with complex patterns of co-endemicity in the safest and most effective way. mDA in countries affected by conflict. In some countries treatment has been severely disrupted, or made impossible, by conflict and civil unrest. As situations stabilize, partners have done much to work through these situations and to help coun- tries catch up. In countries where localized conflicts delayed treatment rounds, an accelerated treatment schedule has been developed to help the national programme to catch up. In other countries, such as DRC, treatments take place but irregularly and displaced populations often miss treatment rounds. To support these countries there is a need for alternative delivery strategies for accelerated impact, and additional financial resources to meet the demands of working in challenging and unstable situations. These strategies and the support to imple- ment them will be developed and delivered jointly for both diseases. High burden countries. There are a number of high burden countries in which intensive support will be needed to achieve elimination. The scale of the challenge of achieving full coverage is very consider- able and the complexity of the logistics, the human and financial resource needs and managerial challenges are such that addi- tional support will be needed. This support can best be planned together for both diseases. Countries falling in this category include those with high endemic popula- tions and those with high disease intensity. Newly identified and late starting areas. In addition to the areas in which treatment has been disrupted, there are also areas which have only recently been identi- fied as needing treatment or where scale-up is still happening. In these areas treatment programmes are still very young and may require the use of accelerated and flexible approaches to enable catch-up. Guidelines to deal with these areas and additional resources will be planned for both diseases. Addressing under-performance. There are a number of areas which are well into treatment programmes, and which report adequate coverage data, but which do not achieve the expected results in epidemiolog- ical evaluations. The reasons for underper- formance are not always clear. Explanations could lie in a variety of factors including the validity of coverage data; differences in vector species and biting rates or in a reduc- tion in drug efficacy. A detailed analysis is needed so that specific remedial actions can be identified in a timely fashion. 11 A fr ic A n P r o g r A m m e f o r o n c h o c e r c iA s is c o n t r o l (A P o c ) • C O N C E P T N O T E 2 0 1 3 Cross border issues. Cross border collab- oration is important in achieving and sustaining progress towards elimination. Where there is local transmission, cross- border foci and long-distance vector migra- tion, epidemiological and entomological evaluation is needed and ivermectin treat- ment should be extended to cover the total targeted population at risk. To achieve this objective, cross-country intervention teams should be set up and trained for joint moni- toring and evaluation (M&E) of the impact of treatment. Political advocacy is needed to promote cross border collaboration. These activities can be most effectively carried out for the two diseases together. vector control and entomological surveillance in the elimination of lymphatic filariasis and onchocer- ciasis. Vector control is known to be an effective tool for the interruption of both lymphatic filariasis and onchocerciasis transmission, either as a single strategy or as a complement MDA. Integrated vector management can be an additional inter- vention in areas where effective and safe PC is not possible, (e.g. in areas where ivermectin usage is not possible due to hyper-endemicity with loiasis5) or, where PC programmes have started late or are under-performing, and acceleration of elimination needs to be achieved. Coordi- nation with malaria programmes can help to give priority in bednet distribution to areas where the burden of both lymphatic filariasis and malaria is high. For onchocer- ciasis, selective vector control can be used as an additional tool with MDA, in transmis- sion hot spots, if MDA is judged insufficient to interrupt transmission.5 evaluation and surveillance. Achieving elimination requires meeting criteria estab- lished by WHO and carrying our post treat- 5 Provisional Strategy for Interrupting Lymphatic Filariasis Transmission in Loiasis-Endemic Countries. Report of the meeting on lymphatic filariasis, malaria and integrated vector management. Accra, Ghana, 5–9 March 2012. WHO/ HTM/NTD/PC/2012.6. ment surveillance for a number of years. The M&E and surveillance approaches for onchocerciasis and lymphatic filariasis need to be harmonised. Elimination places major technical and scientific demands on programmes, and maintaining the ento- mological and epidemiological expertise to carry out these integrated tasks is a chal- lenge that requires investment in human resources. Meeting elimination criteria will require considerable epidemiological and entomological input. Expertise and human resource capacity is critical, is essentially common for both diseases, and should be maintained and where necessary augmented. morbidity management and disability prevention for lymphatic filariasis. A significant proportion of the public health problem represented by lymphatic filariasis is due to morbidity and disability related to lymphoedema (elephantiasis) and hydro- coele. Therefore, national programmes must focus on managing morbidity and preventing disability, as part of a continuum of care, as well as on providing MDA. These activities are important to meet the needs of lymphatic filariasis patients and they help to improve coverage with drugs. Addressing stigma management and the mental health impact of NTDs are essen- tial components of comprehensive NTD programmes. Both onchocerciasis and lymphatic filariasis can cause serious disabilities which impact on wellbeing and livelihoods. Management of morbidity and disability in lymphatic filariasis requires both secondary and tertiary prevention. Secondary prevention includes simple hygiene measures, such as basic skin care to prevent infections and the development of elephantiasis. For management of hydro- cele, surgery may be appropriate. The long standing community networks used to establish MDA can be used to promote case identification, community care and self-care as well as integrated foot care. 12 A fr ic A n P r o g r A m m e f o r o n c h o c e r c iA s is c o n t r o l (A P o c ) • C O N C E P T N O T E 2 0 1 3 Table 1: Overview of key challenges and solutions in developing and implementing an integrated approach to onchocerciasis and lymphatic filariasis elimination in Africa Challenge Nature of remaining challenge Role for regional coordination Overlapping LF and Oncho endemic and treatment areas Technical: Estimating population for MDA but considering previous treat- ment for any of the two diseases. Managerial: Bringing together avai- lable data on endemicity and treat- ment for both diseases. • Promote additional mapping to clarify overlap of endemicity and treatment. • Estimate population for MDA taking into account the overlap of endemicity. • Support the definition of MDA packages according to patterns of endemicity and overlap of disease endemicity. Harmonizing Implementation areas Technical: Defining compatible; implementation Units (IU) for both diseases; estimating new population treatment targets. Admin i s t r a t i ve : Rede f i n i ng programme implementation admi- nistrative areas. Managerial: Defining adequate management structures for inte- grated MDA. • Support country redefinition of IUs to consider lymphatic filariasis and onchocerciasis concomitantly. • Support countries to select the most adequate MDA strategy for the “harmonized” IUs. • Harmonize M&E methodologies for oncho and LF, in line with the WHO M&E framework for PC diseases. Scaling up to cover untreated LF areas and oncho hypo- endemic areas Technical: Redefining the decision- making process to start and stop MDA; harmonize M&E and surveillance; design MDA delivery systems that are compatible with accelerated scale up and impact. Managerial: Organizing new MDA programmes. Financial: Resources to extend to an estimated additional 19 million. • Lead the review of guidelines to address the elimination of both diseases at the same time. • Motivate countries to integrate planning and monitoring of the implementation of interventions against both diseases. • Assist in resource mobilization. MDA in areas co-endemic for onchocerciasis/LF and loiasis Technical: To detail the mapping of loiasis co-endemic areas to improve demarcation of areas with potential problem of adverse effects; difficult implementation of the test and treat strategy; twice a year albendazole not effective for onchocerciasis. Financial: Resources to implement alternative strategies where necessary. • Technical support for more detailed mapping of loiasis endemic areas. • Technical advice on the selection of the most adequate treatment strategy. • Closely monitoring the efficacy of the selected strategies. MDA in countries affected by conflict Technical: Need for adequate and flexible delivery strategies for acce- lerated impact. Managerial: Stability of the established intervention delivery systems. Political: Recurring instability. Financial: Accelerated approach will require additional resources. • Define strategies for catch-up together with countries. • Facilitation of cross border collaboration. • Resource mobilization for catch- up activities. 13 A fr ic A n P r o g r A m m e f o r o n c h o c e r c iA s is c o n t r o l (A P o c ) • C O N C E P T N O T E 2 0 1 3 Challenge Nature of remaining challenge Role for regional coordination High burden countries Technical: Scale up MDA with adequate coverage. Managerial: Manage logistics and supervision of large scale up; presence of adequate human resources to manage large implementation programmes. Financial: Lack of resources for scaling up. Political: Issues of decentralization of power. • Secondment of technical assistance to accelerate scale up. • Management training of dedi- cated staff. • Resource mobilization. • Advocacy. Newly identified and late starting areas Technical: Identifying accelerated and flexible approaches to enable catch-up; identify and address the determinants of late starting areas. Financial: Accelerated approach will require additional resources. • Support country specific situa- tion analysis to identify alterna- tive approaches for accelerated scale up. • Support country in estimating resource needs and mobiliza- tion Improve MDA treatment and geographic coverage moni- toring. “Under- performing” areas Technical: Identification of reasons for poor performance. Research and reme- dial actions need to be implemented. Political: Advocacy required to moti- vate countries to have the right people at the right place to tackle problems with urgency and efficacy. Financial: Research and remedial actions require additional resources. Strategies to achieve and maintain high geographic and therapeutic coverage. • Operational research support to identify root problem. • Resource mobilization for problem areas that threaten elimination objective. Cross border issues Technical: Harmonize timing, moni- toring and evaluation of interventions across the borders. Political: Advocacy required to promote cross border collaboration and facilitate cross-country activities. • Promote and support joint plan- ning on starting, stopping and MDA impact monitoring. • Promote regular cross-border technical meetings. Evaluation and surveillance Technical: Harmonization of M&E and surveillance approaches for LF and oncho. Managerial: Integration of M&E tech- nical capacity to address both diseases simultaneously. Financial: Resources to establish inte- grated M&E capacity. • Standard setting and coordina- tion of results in line with the WHO M&E framework for PC diseases. • Advocacy to ensure that elimina- tion goals are embraced. • Capacity building. • Resource mobilization for weaker countries. • National capacity building for operational research. Morbidity manage- ment and disability prevention for LF Technical: Case identification and integration into community based programmes. Financial: Resource mobilization to increase access to care. • Develop guidelines for integra- tion. • Capacity building. • Advocacy. Table 1: Continuing 14 A fr ic A n P r o g r A m m e f o r o n c h o c e r c iA s is c o n t r o l (A P o c ) • C O N C E P T N O T E 2 0 1 3 15 A fr ic A n P r o g r A m m e f o r o n c h o c e r c iA s is c o n t r o l (A P o c ) • C O N C E P T N O T E 2 0 1 3 6. Opportunities to contribute more broadly to overcome the impact of other NTDs In relation to other PC NTDs, there are areas around which collaboration can be orga- nized and synergies achieved. However there is less of an operational overlap than there is between onchocerciasis and lymphatic filariasis programmes. Oppor- tunities for closer collaboration occur at the level of local implementation (where districts increasingly work in NTD teams rather than in disease specific teams) or in the more general areas of advocacy, resource mobilization and overall policy and strategic planning. WHO/AFRO is playing a lead role in supporting the national master plans for NTDs and it is important that these efforts are fully supported. In some countries the National Onchocerciasis Task Force is being transformed into a National NTD Task Force and this is a positive development which will promote the development of sustain- able integrated national programmes. Collaboration with the other PC NTDS (onchocerciasis, lymphatic filariasis, soil- transmitted helminthiasis, schistosomiasis, trachoma) can be developed particularly in the areas of drug delivery, logistics and surveillance. Other areas in which collabora- tion could be important is through sharing and promoting lessons learned from expe- riences in disease mapping, and in moti- vating communities to play a lead role in drug distribution beyond 2015. 7. Building country leadership and stronger health systems The sustainability of health gains depends on a continent-wide elimination effort. This is necessary to ensure that recrudescence does not occur as a result of cross-border migra- tion (either of people or the vectors). Even more, it depends on promoting strategies that build country leadership and strength- ened health systems with efforts against NTDs integrated into national budgets, national implementation programmes and national health information systems that monitor key health indicators. Any efforts to eliminate NTDs need to be country led and country owned but regionally coordinated for maximum impact and efficiency. 8. Partnership opportunities arising from new strategic direction The prime responsibility, for efforts to eliminate onchocerciasis and other NTDs, lies with governments of endemic coun- tries themselves. Increasingly their work is guided by a national integrated NTD Master Plan with strategies developed to reach the WHO Targets. Work on lymphatic filariasis and onchocer- ciasis has been characterized by strong partnerships and the long term involve- ment of a core group of donors and NGDOs. The new global commitment to NTDs has also attracted new partners and funders. Increased commitment and involvement from new partners is very welcome. It also makes coordination increasingly important as there is a risk of fragmentation. Agree- 16 A fr ic A n P r o g r A m m e f o r o n c h o c e r c iA s is c o n t r o l (A P o c ) • C O N C E P T N O T E 2 0 1 3 ment about who does what, and which organizations are responsible for particular areas of work is one condition of effective and efficient collaboration. Joint commitment to the WHO/AFRO mile- stones and strategy, together with clear agreement about responsibilities, comple- mentary work programmes and coordinated resource mobilization and allocation will create a unique opportunity for partners to work together and assist countries in achieving historic public health goals. 9. The role of a new regional entitiy APOC was set up as a unique instrument to facilitate onchocerciasis control through the rapid upscaling of CDTI in affected member countries. APOC has developed and main- tained strong and direct lines to country programmes and Ministries of Health as well as to donors and others in the partner- ship. Other PC neglected tropical diseases have less direct coordination. Control or elimination of these diseases is more directly decentralized to the country level with inputs and support from WHO, Global Alliances, donors, donation programmes and specific NGDOs. Decentralization has the advantage of clearly putting countries in the lead, but also results in less direct support and less regional action in areas where coordination is required. These areas include: developing support mechanisms for monitoring and surveillance, development of guidelines, capacity building and joint learning, mapping and advocacy. New strat- egies and plans will be needed to optimize both national ownership and global and regional support. The expanded CSA agreed on the need for a joint approach to the elimination of lymphatic filariasis and onchocerciasis. They also agreed that there was a need for a regional entity to promote and coordi- nate such an approach. Various scenarios were considered, in particular regarding the focus of such a regional entity. (The range of options included the continuation of a single disease focus, as well as a widening of the focus to include all PC NTDs.) The specific interdependency of lymphatic filariasis programmes and onchocerciasis programmes led to the conclusion that the regional entity should focus primarily on these two diseases, but that this focus should be seen in the context of the wider NTD agenda and in support of the wider NTD agenda. The expanded CSA also considered it essen- tial that the regional entity should be a fully joint initiative that draws on the existing institutional framework established for APOC. This institutional framework will be substantially reformed and streamlined to reflect the common approach of the partner- ship, the new urgency associated with the elimination goal, the current policy frame- work and the long term commitments of partners. It will draw on the expertise, the strengths of, and lessons learnt from, both programmes. It should have a new name to reflect the new orientation. 10. scenario for a new regional entity The preferred scenario envisaged a new entity that will be responsible for the coor- dination of the elimination of onchocerciasis and lymphatic filariasis in Africa. It will also support interventions for other PC NTDs in Africa within the context of national PC programs and in line with the WHA resolu- tion 66.12, WHO NTD road map, the London Declaration and the WHO Regional Strategy for NTDs. This entity will build on the existing imple- mentation capacity of partners working in the field of onchocerciasis and lymphatic filariasis and other NTDs to provide a coor- 17 A fr ic A n P r o g r A m m e f o r o n c h o c e r c iA s is c o n t r o l (A P o c ) • C O N C E P T N O T E 2 0 1 3 dinated approach to control and elimination efforts. The Guiding Principles for this Partnership will be that: • Country ownership and leadership is of paramount importance. • WHA resolution 66.12, WHO NTD road map, the London Declaration and the WHO Regional Strategy for NTDs provide the overall guiding frameworks. • All partners are motivated and will be flexible to develop working arrangements based on evidence and best practice. The entity will build upon existing partner- ships and strengths recognizing that: • The diseases are often co-endemic. • Those involved in combating these diseases are mutually dependent on each other for the success of their elimination and control ambitions, and this reinforces mutual commitment and the imperative to work effectively together. • The institutional arrangements of the APOC programme can be a value and will be adapted to meet the needs of national integrated programmes. • The programme will continue to draw on the support of partners and donors – and will benefit from the expanded drug donations. A strategic plan of action and budget will be prepared to reflect a phased approach in the implementation. The phases will include lymphatic filariasis and onchocerciasis and will identify specific areas in which syner- gies can be developed with the broader NTD agenda. The strategic plan will target all countries endemic for lymphatic filariasis and/or onchocerciasis. The main purpose of the strategic plan will be: to serve and promote effective integrated country-led programmes for the elimination of onchocerciasis and lymphatic filariasis and contribute to the broader PC NTD agenda on the basis of clear comparative advantage and country demand. This may include: • Establishing multi-disease technical working groups. • Harmonizing approaches where necessary • Learning from best practices in other programmes. • Fundraising for elimination and control agenda. • Developing new governance mechanisms Within the overall context of the WHO Roadmap and plan it will provide support and coordination in: • Mapping • Implementation (MDA, drug supply chain management, vector control where neces- sary and morbidity management). • Data analysis, management and timely reporting. • Monitoring and evaluation of inter- ventions. • Addressing the end point including post treatment surveillance. Conditions of success The success of this plan will depend on the ability of partners to build and rein- force country leadership and build trust and consensus around the partnership, creating a buy-in for all partners. Technical competence must be translated into work- able and agreed guidelines on key issues for elimination. Data should be shared and analysed to develop evidence-based tools and guidelines. Effective governance mecha- nisms should be developed from those that exist already and these should reflect and promote trust. In addition, the success of the strategic plan will depend on the ability to attract sufficient resources and a continued flow of donated drugs and the capacity to deliver them in-country. 18 A fr ic A n P r o g r A m m e f o r o n c h o c e r c iA s is c o n t r o l (A P o c ) • C O N C E P T N O T E 2 0 1 3 Potential gains This scenario was considered the most effec- tive in terms of strengthening the chance of eliminating onchocerciasis and lymphatic filariasis and contributing to efforts in rela- tion to the other PC NTDs. In this way it would help to secure long-term gains in health (and cost savings) for generations to come. It will serve to reduce duplication and increase the efficiency of programme efforts. It should be able to build on sustained donor commitment and will help to build and maintain a critical mass of support for NTD work. 11. From Concept Note to Action Plan The Strategic Action Plan and Budget (2016- 2025) will present details of how partners will operationalize the new strategic direc- tion and details of the resource needs involved. A period of intensive preparation has been started to ensure that partners agree on key issues and on strategies to maximize chances of success and mitigate risks. Onchocerciasis and lymphatic filariasis partners will need a period of consultation and priority setting. Initial steps will be outlined and a timeline developed to guide resource mobilization and ensure that any necessary changes to the legal structure and the existing memo- randum of understanding which governs the partnership are made in time. The Stra- tegic Action Plan will be developed in full consultation with partners and presented to the JAF. Work packages developed around key objectives From this main purpose a number of key objectives will be agreed and work packages developed around these objectives speci- fying: results, indicators and milestones as well as resource requirements and an anal- ysis of risks and how these can be mitigated. Deliverables and milestones will be linked to the existing framework set out in the WHO NTD Regional Strategic Plan so that it is clear how the Strategic Action Plan contributes to the overall regional plan. The Strategic Action Plan will also include a process map for the reform of governance, management and financial mechanisms. This will ensure: • continuity of programme activities • that mandates are in line with ambitions, • that endemic countries and other partners have a say in selecting strategies, priority setting and resource allocation • that plans made are backed by the appro- priate human and financial resources • that management mechanisms are geared to the needs of the Strategic Action Plan • that decisions can be followed through and that programs are accountable to governance bodies and the broader NTD community. An Integrated M&E framework The Strategic Action Plan will also contain an M&E framework which will provide the basis for regular monitoring and periodic evaluation. This will take full account of existing M&E tools and frameworks and will give all partners the opportunity to track progress in achieving milestones and agreed objectives. It will generate regular reports so that specific challenges are identified in a timely fashion and remedial action can be taken where necessary. 19 A fr ic A n P r o g r A m m e f o r o n c h o c e r c iA s is c o n t r o l (A P o c ) • C O N C E P T N O T E 2 0 1 3 12. Legal implications Any role for APOC beyond 31 December 2015 requires a new legal undertaking by stake- holders which should cover the following main issues: • Stakeholders involved (Governments, donors, NGDOs, sponsoring agencies, etc.) and their respective roles and obligations in the functioning of the entity. • Basic institutional framework: (a) a high level stakeholders meeting (); (b) a smaller executive body; (c) a technical commit- tees). For each of these bodies, the compo- sition, functions and operations should be specified. • Role and composition of the secretariat of the entity. • Definition of the main purpose. • Modification of name and geographical scope. • Financing mechanisms and the role of the Trust Fund. The new direction will require close and immediate consultations between the World Bank (as Fiscal Agent) and WHO (as Executive Agency). It will be necessary to review possible changes to the financial arrangements described in Part I of the current Memorandum, including the APOC Trust Fund. 13. Financial resources for the strategic Action Plan 2016-2025 The APOC financial model currently involves budgeting for two areas: 1) funding for regional and country-level technical assis- tance for training, sharing good practices, etc.; and 2) funding of operations in coun- tries. This has proven to be an effective model and should be the basis of planning going forward. Nevertheless, given the changing scope, changes within these two areas might be anticipated. Funding for regional and country level technical assistance The Strategic Action Plan will include increased technical assistance to meet the demands of the elimination goal (surveil- lance, evaluation, resource tracking and mobilisation and coordination). Technical assistance would also expand initially to include lymphatic filariasis in the 30 co-endemic countries and growing to include all countries where lymphatic filariasis is present. In addition the scenario calls for assistance in the delivery of other PC NTD control measures where there is a clear comparative advantage. This may result in a significant expansion in the anticipated need for technical assistance but there should be cost savings as well. Activities will be coordinated, joint tools and instru- ments developed and synergies identified. The current investment of funds for tech- nical assistance is about USD 10 million per year6. Given the increasing scope, it is to be expected that the amounts of funds required for technical assistance will increase in the early years of the new scenario and decline as elimination is achieved and countries graduate from the need for support from the regional entity and rely increasingly on their own national resources. Funding of operations in countries The revised scenario implies that the new entity will focus on lymphatic filariasis and onchocerciasis in all endemic countries. The operational costs will rise very significantly if all NTDs are to be covered – current esti- mates based on the WHO/AFRO-led evalu- ation of National NTD Master Plans suggest that some $200 million per annum would be required. 6 This estimate is based on figures provided by the APOC Fiscal Agent (represented by the World Bank). 20 A fr ic A n P r o g r A m m e f o r o n c h o c e r c iA s is c o n t r o l (A P o c ) • C O N C E P T N O T E 2 0 1 3 The funding landscape is complex and a large number of partners are involved in mobilising and providing funds for the elimination of NTDs. The contributions from country budgets have increased and are an important component of the neces- sary funding. Historically much of the donor funding for onchocerciasis programmes has been channelled through the World Bank Trust Fund and this has enabled APOC to select priorities on the basis of the needs of the overall effort. To date the Trust Fund has channelled USD 1.25 billion to support onchocerciasis control and elimination efforts. A committed donor group coordi- nate and consult on priorities. Increasingly funds are being granted directly to country ministries of health or to NGDOs as some donors make a clear choice to channel funds directly. In particular, the funds for the elimi- nation of lymphatic filariasis have often gone directly to country programmes. This funding route has tended to consolidate country ownership, but makes coordination of overall regional elimination priorities more difficult. NGDOs continue to make important and regular contributions and often support priorities not supported by other donors. Implications for the transformed APOC Trust Fund Experience shows that while some donors prefer the security of a Trust Fund, others prefer different channels for their support, often with an emphasis on politically more high-profile bilateral arrangements. Given this, the new entity should find other strate- gies and channels for resource mobilization in order to reach the elimination target for onchocerciasis and lymphatic filariasis. One possible approach would be for the Trust Fund to focus primarily on support to the technical roles of the regional entity rather than the operational support to coun- tries. This does not mean that the regional entity would have no operational financing role, since it is clear that some development partners will prefer to route their support through this mechanism. The new entity might primarily target grants for opera- tional financing to support NTD operations in “donor orphan” countries, such as the many francophone and lusophone countries which receive less than their equitable share of development funds at present. In the future, the new entity’s role in providing direct funding to countries for operations would need to be adjusted on the basis of the resource mobilization capability of the partnerships, complemented by direct funding to countries. Conclusion There are historic opportunities for the global health community in the fight against neglected tropical diseases. There is an unprecedented consensus globally, regionally and nationally about aims and the strategies to achieve them. The elimination of onchocerciasis and lymphatic filariasis will be major public health milestones and will strengthen the resilience of some of the poorest communities in Africa. The Strategic Plan for 2016-2025, developed with key part- ners, will demonstrate how to maximize the contribution that partners can make to effec- tive integrated country-led programmes for the elimination of onchocerciasis and lymphatic filariasis and to the broader PC NTD agenda for “an Africa free of NTDs”. 21 A fr ic A n P r o g r A m m e f o r o n c h o c e r c iA s is c o n t r o l (A P o c ) • C O N C E P T N O T E 2 0 1 3 references 1. WHA66.12 Resolution: Neglected Tropical Diseases, Geneva May 2013. 2. Accelerating work to overcome the global impact of neglected tropical diseases: a roadmap for implementation. Geneva, World Health Organization, 2012 (document WHO/HTM/NTD/2012.1). 3. From Promises to Progress. The First Annual Report on the London Declaration on NTDs. www. UnitingToCombat NTDs. org 2013 Jan. 4. Regional Strategic Plan for Neglected Tropical Diseases in the African Region 2014-2020. 5. Traore MO, Sarr MD, Badji A, Bissan Y, Diawara L, Doumbia K, et al. Proof-of- principle of onchocerciasis elimination with ivermectin treatment in endemic foci in Africa: final results of a study in Mali and Senegal. PLoS neglected tropical diseases, 2012 Jan;6(9). 6. Turner HC, Churcher TS, Walker M, Osei- Atweneboana MY, Prichard RK, Basáñez M-G. Uncertainty surrounding projections of the long-term impact of ivermectin treatment on human onchocerciasis. PLoS neglected tropical diseases, 2013 Apr;7(4):e2169. 22 A fr ic A n P r o g r A m m e f o r o n c h o c e r c iA s is c o n t r o l (A P o c ) • C O N C E P T N O T E 2 0 1 3
African Programme for Onchocerciasis Control (APOC) World Health Organization B.P. 549 – Ouagadougou – BURKINA FASO Tel: +226-50 34 29 53 / 50 34 29 59 / 50 34 29 60 Fax: +226-50 34 28 75 / 50 34 26 48 dirapoc@oncho.afro.who.int www.who.int/apoc AFRICAN PROGRAMME FOR ONCHOCERCIASIS CONTROL © AP OC 20 13 – gr ap hi c d es ig n: Li sa sc hw ar b – Ph ot os : A PO C, W HO /T Dr , A nd y C ru m p – W HO /A PO C/ JA F1 9. 7