APOC strategic and exit action plan and budget 2007-2015

African Programme for Onchocerciasis Control (APOC) Programme africain de lutte contre I'onchocercose JOINT ACTION FORUM Office of the Chairman JAF-FAC FORUM D'ACTION COMMUNE Bureau du Pr6sident JOINT ACTION FORUM Twelfth session JAF12.11 ORIGINAL: ENGLISH November 2006Dar-es-Salaam , 5-8 December 2006 Item 1l of the Provisional Agenda APOC STRATEGIC AND EXIT ACTION PLAN AND BUDGET 2007-20t5 APOC Strategic and Exit Action Plan and Budget 2007-2015 Proposal This document was prepared in consultation with many partners. This revised version is being submitted to the Joint Action Forum (JAF) for consideration. If approved by the JAF, the contents will then be incorporated into the current Program Documentfor Phase II and Phasing-out Peri.od I : "{ JAF12.11 Page i Table of content Page INTRODUCTION ..4 ..4 ..4 ..6 OUTCOME & IMPACT: .......... OBSTRUCTIONS TO IMPLEMENTATION PROPOSED YEAR OF APOC EXIT FROM COI]NTRIES APOC ADJUSTMENT STRATEGY (2007-201s)............... .......................7 STJMMARY OF APOC STRATEGIC ACTION PLAN AND BUDGET ................24 JAF12.11 Page 1 APOC Strategic and Exit Action Plan and Budget 2007-2015 EXECUTIVE SUMMARY The African Programme for Onchocerciasis Control (APOC), a long-term pan-African initiative was established in December 1995 to extend the campaign to conquer river blindness in 19 endemic countries in sub-Saharan Africa outside the ambit of the Onchocerciasis Control Programme (OCP) in West Africa. APOC began field operations in endemic countries in mid-1997, almost 10 years ago. Both APOC and its predecessor, OCP are comprehensive, regional programmes with the objective of eliminating the disease as a public-health problem throughout Africa. Operations remain specifically targeted on the world's poorest and most underserved people. Reaching the hitherto unreachable, APOC is today facilitating free and preventive large-scale mass drug administration of ivermectin (Mectizan@), using an innovatory Community-Directed Treatment (ComDT) process. The ten years of donors' support and investments in APOC have yielded enormous benefits. Phase I (1996-2001). The target of APOC for Phase I was to treat 30 million people by 2001 (APOC Programme Document Phase 1). During this period, treatment coverage increased from 1.4 million people treated in 7997 to 25.5 million people in 2001. ln addition to many other accomplishments, APOC put in place a grassroots workforce to strengthen the capacity of the health systems in hard-to-reach areas. By December 2007, 125,000 community ivermectin distributors and 16,000 health workers were trained and 61,000 communities mobilized. APOC total expenditure for this Phase I was US$41,921,000. APOC achieved 857o ofits original target Phase II (2002-2001. The target of APOC for Phase II is to treat 51 million people by December 2007. This decision was based on the results of the REMO exercises undertaken in fragile states. Notwithstanding the unpredictable and serious challenges of recurring conflict in member states, and co-endemicity of loiasis and onchocerciasis causing deaths which APOC partners were faced with, 40 million people were treated with ivermectin in 2005. APOC has achieve d 78y, of its target two years before the end of this phase. The APOC partnership and business models led to an unprecedented rapid and extensive geographic coverage from 61,000 communities in 2001 to 117,000 communities in 2005. The strategy of APOC's Community-Directed Treatment with Ivermectin (CDTI) which enables communities to take charge of drug distribution and ultimately their own health has been instrumental in the rapid increase in treatment coverage from 1.4 million people in 1997 to 40 million people in 2005, helping to avert 500,000 DALYs per year at US$7 per DALY. Also, by 2004 in seven APOC countries, over 18 projects financed by the Programme had combined the delivery of multiple health interventions using APOC's community directed treatment with ivermectin (CDTD structure, prior to the launching of the NTD initiative. This is added value to donor funds spent on projects between 2001 and 2007 (Phase II). The total budget spent during this phase will be known after 31" December 2007. Initial Phasine-out. Extension & Exit Phase (2007 -201$. The target of APOC for this final phase is to reach the Programme's ultimate treatment goal of 67 million people i.e. 65%o of the 102 million people who will be at risk of infection by 2010 and if possible all eligible 90 million persons. If the extension to 2015 is granted, APOC will exceed the treatment coverage of 67 million people by 2010. This target is predicted as quite realistic given that 40 million people were treated in 2005 and about 15 new CDTI projects in post- conflict countries will upscale operations in the coming years. The Programme aims at a more ambitious target of treating 90 million people (all eligible). The forecast total budget for the Initial Phasing out, Extension and Exit Period is US$81,316 million. JAF12.11 PageZ Role of governments and NGDOs. National governments and affected communities will assume the responsibility for the 'final push' towards elimination of onchocerciasis. And the NGDOs are committed to support control activities up to 2015. Because the distribution of ivermectin or a macrofilaricide will continue after the exit of APOC in 2015 it will be incumbent on the governments and the NGDOs to continue supporting thousands of mobilized communities in distribution. Government contribution. The governments of endemic countries are contributing to core activities of onchocerciasis control. Twelve (12) out of 16 counhies receiving APOC Trust Fund supportl contributed US $11,394,234 to ivermectin distribution projects from 2000 when APOC management began gathering information on the contributions of countries. Some countries - Cameroon, Uganda and Ethiopia are providing funding through the debt relief initiative. In Nigeria, more than 50Yo of the 32 states with CDTI projects and the local governments (LGAs) disburse cash for core CDTI activities since 2000 through Primary Health Care (PHC). With the introduction of the Highly Indebted Poor Countries (HIPC) grant, Cameroon increased its financial support to CDTI projects in2004. In addition to paying the salaries ofpersonnel, regional and local governments release cash to support core CDTI field activities including training and IEC. As one such of many examples, the Adamawa State government in Nigeria released N8 million (US$65,000) cash to CDTI project this year (2006) and had released cash annually to the project since 2000. For three years, APOC has provided very negligible financial support to projects in 1 i districts in Uganda and 6 states in Nigeria. The regional, districts and local governments now manage and finance field activities of these projects. The contributions of participating governments as shown above have rapidly increased since 2001 when the APOC monitoring and evaluation of the sustainability of projects began and governments had to develop and adopt CDTI sustainability plans. Detailed information will be provided to JAF12 on this subject. We acknowledge that some of these projects (especially ones in Nigeria) have difficulty maintaining high treatment coverage but APOC partners are persistently devising ways to overcome this challenge. Contribution of NGDOs. The exemplary commitment - technical and financial of the international NGDO Coalition has remained solid since the launching of APOC. Partial data show that US $19,945,0522 was contributed by 9 NGDOs operating in 14 countries between 1999 and2005. The historical Yaounde declaration of the African Ministers of Health underscore the commitment (present and future) of member states to take the responsibility and leadership in the 'final push' to eliminate onchocerciasis. In the declaration, the governments expressed commitment to work together to accelerate the elimination of river blindness as a public health and socio-economic development problem in all countries and to make annual budgetary commitment for onchocerciasis control activities as part of PRSP and in line with MDGs. Considering the recommendations of the Strategic Overview, the 2005 external evaluation of APOC and the Mid-term Review of the Special Intervention Zones, a framework of action and budget has been developed for the period 2007-2015. The focus of APOC during this period as shown in the strategic action matrix will be: to secure complete national government ownership and sustained financing of onchocerciasis control (to help safeguard the huge investments of the ex-OCP countries and their highly- committed donors); ensure that onchocerciasis control remains a key element of national PRSPs and pro-poor disease control setting with national health programmes of endemic countries ' Bangoura O., Onchocerciasis Unit of The World Bank 2 Bangoura O., Onchocerciasis Unit of The World Bank l. ll. JAF12.11 Page 3 strengthen the partnership with NGDOs, Merck & Co.Inc, MDP and TDR; increase visibility of the support of the international NGDOs to ivermectin distribution and to the success of onchocerciasis control. strengthen control activities in post-conflict countries (Liberia, DRC, Burundi, Angola, Chad, CAR, South Sudan), which have received less than eight years of APOC financing or that have had treatment interrupted because of cases of serious adverse events (SAEs) due to the co- endemicicty of onchocerciasis and loiasis (eyeworm); v, re-establish control activities in the few ex-OCP fragile states where conflict has caused the epidemiological indicators to revert to pre-control levels (Sierra Leone, Ivory Coast, Guinea Bissau) and in Ghana, to maintain the achievements of the OCP and safeguard the investments of countries and donors. The OCP countries (Burkina Faso, Guinea, Mali, Niger, Senegal, Togo, Benin) have maintained the success, thus, APOC's role in these countries will unequivocally be to coordinate cross-border collaboration. invest in operational research and maintain its tradition of policy decision-making based on proven research results and new knowledge; build the capacity of nationals of member countries, empowering them with skills and tools to determine where and when to stop ivermectin treatment; gradually decentralize technical and financial management of control activities to the Ministries of Health, WHO country offices and some regional organizations. maintaining a high profile at operational levels in endemic countries; providing APOC's structures, tools and techniques to boost the operations of neglected disease (NTD) control programmes whilst ensuring the onchocerciasis elimination goal is not jeopardized; ensure and proactively advocate that onchocerciasis control - and APOC's products, tools, techniques and systems - play a full role in influencing and driving single- or multi-disease control initiatives or primary health care interventions and innovations, on national, regional and international stages and in all coalitions and development programmes that have a direct impact on control efforts, The additional budget of US$ 39 million (table below) being presented for consideration by the Joint Action Forum the five-year extension (2010 -2015) does not include the contributions of the NGDOs and the governments. The budget has been prepared after careful consideration of APOC Trust Fund spent on a CDTI project in stable and fragile states for 5 years, risk analysis including loss of APOC's investments in Chad, CAR and South Sudan and the cost of managing serious adverse events (SAEs). A risk containment cost of 10% (US$7392) is envisaged to support the adjustment strategy. * Shortfall = additional budget required for the penod 2001 -2015 Total budget US$73 923 plus 10 % Risk containment (73 923 + 7 392) : US$ 81, 315 lll. lv, vl. vii. viii. ix. x. Approved &. forecast Programme budset tl 249 10 500 7 044 5 355 3 795 3 024 2 030 1 100 1 050 1 025 34 923 Shortfall* 3 000 6 606 7 040 6 444 5 957 4 423 3 405 1 160 965 39 000 New Total Programmme Budget 13 500 13 650 12 395 10 239 8 981 6 453 4 505 2210 1 990 73 923 Amount In US$ 2006 2007 2008 2409 2010 201r 2012 2013 20r4 2015 Total 2007-15 JAF12.11 Page 4 TNTRODUCTION: Onchocerciasis control in Africa has reached a critical stage. Some three decades after large-scale vector control began in West Africa under the Onchocerciasis Control Program (OCP) and a decade after efforts began in the rest of Africa under the African Program for Onchocerciasis Control (APOC), we present a strategic plan of the final steps needed to control the disease as a public health problem throughout the continent, sustain that achievement indefinitely, and clearly define the exit strategy of APOC. The OCP attained unprecedented success and countries like Burkina Faso, Mali, Senegal, Guinea and Niger have maintained the achievements. Today, there are no known cases of onchocercal blindness in these countries. However, maintenance of returns on investments in some OCP countries has suffered a setback due to political changes and, in particular, the conflicts which have ravaged or continue to ravage ex-OCP countries like Sierra Leone and Cote d'Ivoire. This setback if unchecked could jeopardize onchocerciasis control across the West Africa region given the long-range flight capability of vector flies and cross-border migration. Building on OCP success, APOC was launched in 1995 with the aim to permanently free the remaining at- risk 150 million people in 30 countries from the threat of onchocerciasis. APOC has broken new ground, learned lessons and developed the highly successful community-directed strategy, useful in revitalizing primary health services and extending multiple health interventions to very remote communities. Efforts are now focused on achieving that goal and on protecting what has already been accomplished in the ten years of its operations. OUTCOME & IMPACT: Operational results so far have been very impressive-more than 100 million people in the former OCP and APOC endemic countries are protected from onchocerciasis each year. In 2005, about 40 million persons were treated in more than 117,000 communities in APOC countries. In West Africa, 600,000 cases of blindness have been prevented and in the APOC area 500,000 DALYs per year have been averted in the period 1996-2005. Recently analyzed impact assessment data from the APOC area showed significant regression of eye and skin diseases as well as improvement in other clinical indicators.The ONCHOSIM modeling of APOC's impact over its first decade will provide additional information. APOC Results (1996-2005) o 40 million people in 16 countries under regular ivermectin treatment. . 500,000 DALYs per year averted o 117,000 communities mobilized. o Workforce of 261,000 community-directed distributors trained and available for other prograrnmes o Economic Rate of Return of ITVo o US $ 7 per DALY averted. OBSTRUCTIONS TO IMPLEMENTATION Item {: Underestimation in target groups Some 22 million more victims than originally forecast have been identified. Despite these tremendously encouraging results, APOC's timeline and resources must be reviewed in light of the scope of the problem it faces-revealed now for the first time. When APOC was planned in 1994195, it was estimated that 85 ivermectin mass distribution projects would be needed in 19 countries and the total population infected was thought to be about 15 million persons. Program staffing, budget and duration were all planned around these figures. Rapid epidemiological mapping of onchocerciasis (REMO) and a decade of APOC operations have now revealed the true scope of the problem. An astonishing 37 million are infected, requiring 111 mass drug distribution and 4 vector elimination projects. A further 7 national onchocerciasis task force headquarter support projects have also been necessary to build capacity of the health systems of participating countries. Thus, there are 22 million or 247Vo more victims than was expected, requiring treatments. Therefore, 44Vo of APOC's projects were unanticipated in the original plan and resource envelope. JAF12.11 Page 5 Item 2= Practical aspects Conflict-recent, continuing and new, as well as problems with co-endemicity of onchocerciasis and loiasis have delayed or intemrpted 43 APOC projects by an average of 7 years (see table below). As a result of the above-both beyond the control of APOC-one-third (43) of the CDTI projects will not be sustainable by the original APOC closure of 2010. If these programs were to lose the support of APOC during the early phases of implementation they would be unlikely to reach the goals of sustainability and control of onchocerciasis. The Strategic Overview concluded that these projects cannot be abandoned: "cessation of support to countries that have made a late start with CDTI would be detrimental and an unethical public health decision." Conflict and./or Loiasis has Delayed Many APOC Projects Country Projects delayed Total:43 Projects launched Year launched Years of Delay* in Implementation Primary Reason Angola 6 I 200s 8 Conflict and loiasis5 Pending 9 Burundi J I 2005 8 Conflict 2 2006 9 Cameroon J J 2005 8 Loiasis CAR I 1 1998 J Interruption (conflict) Congo 2 1 2001 4 Conflict and loiasis1 2004 7 DRC 20 1 2000 J Conflict and loiasis J 2002 5 2 2003 6 8 2004 7 6 Pending 9 Liberia J 1 2000 J Conflict 2 2005 8 Sudan 5 2 2005 8 Conflict and loiasis3 Pendins 8 a Averaqe years lost per proiect 7 *since beginning of APOC operations in 1997 Item 3: Political aspects The context of onchocerciasis control has changed considerably since it was first conceived in the early- 1970s, especially with respect to funding, which has become more difficult as donor priorities have shifted, particularly so in recent years. However, it remains true to its core and overriding aim, that of reducing the impact of disease and of improving the socioeconomic and living conditions for the impoverished subsistence-farming communities upon which interventions are exclusively targeted. To assess the implementation of APOC's activities and the impact of the changing contexts and circumstances, APOC commissioned an external evaluation and an expert review to appraise the future of Onchocerciasis Control in Africa. The group's conclusions represent a consensus on the challenges and opportunities over the next decade. As instructed by the 1lm Joint Action Forum, the group focused on four strategic actions: Extending APOC to enable all projects to be brought to a satisfactory conclusion. The year 2015 was proposed as the new target, considering the time needed for all projects to receive adequate a IAFt2.lt Page 6 support from APOC Trust Fund and also because this is the target for the Millennium Development Goals (MDGs). Strengthening the performance of the Program at all levels to enhance the likelihood that APOC will achieve its objective. Broadening the mandate of APOC to include ex-OCP countries to ensure that the achievements of OCP are maintained and sustained. Integrating onchocerciasis control with other compatible health interventions, especially the "neglected" tropical diseases, with the dual objectives of enhancing the sustainability of CDTI and contributing to the achievement of the MDGs in member countries. In addition, for the future, it is imperative that APOC maintains a position at the forefront of changes that will have a direct or indirect impact on onchocerciasis control and the activities and goals of the programme, either at present or within the expected duration of the programme. This will be essential to help the programme achieve its goals and flexibly adapt to take best advantage of any and all events or circumstances that may develop between now and the intended closure of the prograrnme. We propose therefore that APOC implement a proactive and forwardJooking Adaptation Strategy whereby the programme will, wherever possible, monitor, influence and integrate with activities, developments, projects, tools and techniques - at the national, regional and global levels - all to the best advantage of target communities, onchocerciasis control and the comprehensive socioeconomic and elimination goals of APOC and past onchocerciasis control activities in Africa. Research has shown that, with respect to infectious diseases, overseas aid (ODA) priorities are not based solely on the commonly-used prioritization tool, the burden of disease as measured by Disability Adjusted Life Years (DALYs), but on an unidentified variety of components. Consequently, it is incumbent upon APOC and its partners to ensure that onchocerciasis control is firmly and clearly represented within national health service interventions and budeets. in the medium and long term. as well as in the prioritv-setting mechanism of donors, or of new integrated global disease control initiatives. PROPOSED YEAR OF APOC EXIT FROM COUNTRIES The exit plan of APOC is integrated within the Strategic Action Plan (SAP). An itemized budget estimate, envisaged as necessary to affect the SAP, is attached. It is envisaged that the exit strategy will need to be reviewed and refined at bi-annual internals (2010. 2012 and 2014). 2OO9: APOC Trust Fund support to Ghana, C6te d'Ivoire and Guinea Bissau ceases after 2009. 2O1O:. APOC will start withdrawing financial support to projects in stable countries: Nigeria, Uganda, Cameroon, Ethiopia, Tanzania, Malawi, Eq. Guinea and Congo Brazzaville. (lst Strategic Review in 2O1O) 2012= Withdrawal of support for fragile states begins: Liberia, South Sudan, DRC, Chad, CAR, Burundi, Angola) and Sierra Leone 2012= Cessation of APOC support for Uganda, Nigeria, Cameroon, Ethiopia, Tanzania, Malawi, Equatorial Guinea and Congo Brazzaville (?d Strategic Review in 2O12) 2O14t Cessation of support for Sierra Leone, Liberia, South Sudan, DRC, Chad, CAR, Burundi and Angola. (Final Strategic Review in 2O14) 2015= Closure of APOC a a o JAF12.11 PageT ApoG ADJ USTMENT STRATEGY 12OO7 -2o{ 5) There is a gathering variety and pace of change in matters connected directly and indirectly with onchocerciasis control and the role of APOC, its tools, techniques and targets. As consequence, the prograrnme needs to be proactive and flexible in the way that it interacts with, is influenced by, integrates with and adapts to such changes. It is within APOC's primary mandate to ensure that onchocerciasis control is both effective and sustainably applied to meet interim and elimination goals. APOC member states comprise 500 million people, over half of whom live in extreme poverty, mostly in isolated rural communities. Therefore, it is imperative that APOC maintains its position as the "voice of onchocerciasis", and that the voice is heard in all fora to help protect the health and wellbeing of individuals in the poverty-stricken village households, which exclusively constitute APOC's target group. APOC will need to collaborate with, inform, guide, influence and devise innovatory systems in collaboration with a wide range of agencies, groups, initiatives, products and interventions. Therefore, within the resource limitations of the programme (including human, financial, time and skills inventory), it is proposed that APOC take steps to ensure that it plays a leading role in, and benefits from or is at least represented at, with or in: benefited from direct funding from donors, with modest indirect funding via national health budgets. There is a rapidly increasing trend for donors to provide funds to governments in the form of budgetary support (indirect) rather than fund specific, often disease-specific projects (direct funds), as has been the case in the past. APOC is going to have to adapt to this change of emphasis and engage more directly with recipient governments to ensure that funding for onchocerciasis control is supported and sustained to the necessary level. to be completed by 2008. It is important that onchocerciasis control and ComDT play an important role in the delivery of the multi-disease interventions, meaning that groundwork is set to help ensure that ComDT, as perhaps the most successful mechanism to reach poor isolated rural communities, is adopted as the delivery system of choice, wherever possible in sub-Saharan Africa. combination treatment for diseases to take advantage of economies of scale and integrated multi-disease health interventions, APOC will bring to the NTDs the lessons it has learned and the well-proven techniques and tools that has developed to help drive forward new developments in this area, particularly with regard to the Global Network for Neglected Tropical Disease Control (GNNTDC) and its activities. undertaking their own priority-setting, which will determine the internal allocation of funds as well as attract specific funding from external donors. APOC partners will take steps to ensure that PRSPs include a determinant pro-poor focus, with a specific target for NTDs and onchocerciasis conffol in particular. promoting research to discover a safe, effective and affordable macrofilaricide. The Programme will keep abreast of other potentially significant research, such as the possible use of doxycycline, an affordable and currently available antibiotic and malaria prophylactic, which attacks the Wolbachia symbiont in filarial wonns. countries at operational levels with the Vision 2020 program. JAF12.11 Page 8 STRATEGIG AGTTON PLAN, TtMELtt{E AND BUDGET Reaching all in need OBJEGTIVE {: Establish sustainable national onchocerciasis programmes in all countries where needed. Scope Work under this objective as in the "Strategic Overview" document is to achieve APOC's main objective of establishing sustainable national onchocerciasis programmes in all countries where needed. Scale up APOC activities to reach pre-determined goals for establishing CDTI systems, as set in APOC's core programme of work. Due to a variety of setbacks and obstacles, APOC has not been able to achieve the level of increase of CDTI projects necessary to meet the gradient necessary, as envisaged in core planning. APOC and partners will take proactive and innovatory steps to up scale CDTI programmes to bring the number of treatments to planned targets and timelines. However, to facilitate the rapid implementation and /or up scaling of the remaining CDTI projects particularly in DRC, Angola and South Sudan while maintaining the involvement of governments and NGDOs, the existing contribution s of 7 57o from APOC Trust Fund contribution and 25Vo from governments and NGDOs will be adapted in specific circumstances. lndicators and Targets o The remaining six CDTI projects will be launched in2007 and 2008 with support of our traditional and/ or new NGDOs with resources in countries in conflict and post-conflict situation. In selected projects in post-conflict/fragile countries the APOC Trust fund will finance 80-90% of the CDTI activities. Governments and NGDOs will provide about 20-10% of total cost of project for five years. - Need approval ofJAF' New activities to strengthen and enhance sustainability of projects will be launched by the National Onchocerciasis Task Forces (NOTFs) of Nigeria , Uganda, Tanzania, Cameroon and Ethiopia with the support of APOC partners , particularly NGDOs and APOC management. The aim is to increase and maintain treatment coverage rates of more than 75Yo in all eligible communities. Number of persons treated to reach 55 million in 2008. I Conflict situation in fragile states deteriorates and disrupts community participation and management of ivermectin distribution. o On set of conflictJwar in an APOC stable country where high treatment coverage have been achieved and maintained for years. Because this objective has two components (therapeutic and geographic coverage), the budgets are covered under objectives lb and lc. a Risks c |-] JAF12.11 Page 9 OBJEGTIVE { b: Achieve 65Yo or Higher Therapeutic Coverage in Stable and Post-Conflict Countries that Have Not Attained These Targets (within mandate) Scope I APOC will conduct advocacy visits and facilitate planning, with specific commitments, in countries that are stable or in post-conflict situation and have not yet achieved 65Vo therapeutic coverage. APOC will also facilitate implementation support in the form of visits from counterparts in projects with higher coverage. APOC will strengthen the capacity of communities to increase and maintain high therapeutic coverage and compliance to ivermectin treatment. lndicators and targets I Plans produced and implemented on schedule as shown below. I Therapeutic treatment coverage reaches 65Vo withit three years of plan implementation. 0 Evidence of government support to maintain high levels of treatment coverage in endemic communities to control local problems and prevent cross-border reinvasion of neighboring countries. Risks 0 Conflict and/or instability could delay implementation or decrease coverage. 0 Lack of political will. U Frequent transfer of MoH staff constitutes a serious problem because it prevents staff in key positions from building experience. Timeline Programme current and proposed additional budgets (US$ thousand) 200G2007 2008 2009 20t0 20tt-201s Support to poorlyperforming projects to improve treatment coverage Strengthen advocacy, community mobilization, and health education. Capacity building at community-level to increase CDDs and improve treatment coverage in Congo (Brazzavllle), Equatorial Guinea and Nigeria. Same: Angola, Burundi, Cameroon, Nigeria (some states), Sierra Leone Same: Angola, CAR and Chad. Same: South Sudan and Liberia. Consolidation of achievements and phasing-out. Geographical coverage to reach 1007o in all stable country CDTI projects. 2007-2015 2007-2015 Area Objective Current Programme budget Proposed additional budget 7o in comparison with the total budget (73 923) Achieve 650/o or Higher Therapeutic Coverage in Stable and Post-Confl ict Countries 4000 4000 10.8 JAF12.11 Page 10 OBJEGTIVE { c: Achieve l00oh Geographical Coverage in Stable and Post-Conflict Countries That Have Not Attained These Targets (within mandate) Scope I APOC will conduct advocacy visits and facilitate planning, with specific commitments, in countries that are stable or in post-conflict situation and have not yet achieved I00%o geographical coverage. APOC will also facilitate execution support in the form of visits from national counterparts in countries with high coverage. lndicators and targets 0 Plans produced and implemented on schedule as shown below. I Geographical treatment coverage reaches 1007o within three years of plan implementation Risks I International conflict could undermine cross-border cooperation. I Conflict and/or instability could delay implementation or decrease coverage. Timeline Programme current and proposed additional budgets (US$ thousand) 2006-2007 2008 2009 20to 20tt-2015 High-Level National Advocacy; Facilitated Planning with Specific Output Commitments; Execution Support from Visiting Counterparts from Other Member Countries Advocacy underway, planning and cross- country cooperation facilitated between Equatorial Guinea and Burundi. Planning ongoing in Chad.In 2OO7,high level advocacy visits to Malawi, Nigeria, and possibly CAR. Planning and advocacy visits to Cameroon and Tanzania, plus CAR, Ghana, and Togo if not done in 2007 Attain L00Vo geographical coverage in Angola, Benin, Burundi, DR Congo, and Nigeria. Planning and advocacy visits to Liberia, Southern Sudan. Entomological and epidemiological surveillance in sentinel villages. Planning and advocacy visit to Uganda (small focus sharing border with Sudan). 2007-2015 2007-201s Area Objective Current Programme budget Proposed additional budget 7o in comparison with thC total budget (73923) i To achieve 100% Geographical Coverage and more than 65% Therapeutic Coverage in stable and post-conflict countries concerned 5223 5 000 I 3.8 JAF12.11 Page 11 OBJEGTIVE 2: To strengthen the capacity of APOC Management Scope Work under this objective will focus on strengthening APOC management to enhance output, especially in operational research, to help maintain CDTI project performance and to facilitate government ownership of control strategies in APOC and three former OCP countries (COte d'Ivoire, Ghana and Sierra Leone). Provide adequate onchocerciasis surveillance to countries, in particular, those harbouring refugees from onchocerciasis endemic areas. Provide support to the MDSC through high-level advocacy to become more effective in surveillance. lndicators and targets D Vacant position of Chief, Sustainable Drug Distribution Unit filled in 2006/2007. 0 Epidemiologist/ biostatistician hired by 2008 0 Guidelines and tools for determining where and when to stop ivermectin treatment must be made available by 2011. (See also Objective 3.) Capacity building of nationals on program management should be underway in six of the 16 countries with CDTI projects by 2009. I APOC partners will assist to lobby for new donors to enlisted to support the MDSC. Risks U Difficulties in raising the necessary funds needed to hire new professional staff with competence in the areas described advocacy efforts to be conducted by the Onchocerciasis Coordination Unit of the World Bank by 2008.above. U lnsufficient MDSC financing will increase pressure on APOC's staff and budget and leave countries without long-term surveillance expertise. I Inability to enlist new donors to support MDSC. Timeline Programme current and proposed additional budgets (US$ thousand) 200G2007 2008 2009 2010 20tt-20L5 Strengthen APOC Management Fill all vacant posts, e.g. Chief, Sustainable Drug Distribution Unit, etc. Hire epidemiologisU biostatistician to strengthen the epidemiological unit. Hire epidemiologist IM&EI impact assessment expert. Hire scientist with strong operational research credentials to assist countries in designing and executing studies of particular relevance to their national and local issues- especially research on when and how to stop ivermectin distribution (see Objective 3). Aim is also to foster national operations research capacity and help local scientists compete for international funding such that oncho surveillance and control can continue as needed beyond APOC's closure. Fill position in 2008-9. 2007-2015 2007-20t5 Area objective Current Programme budqet Proposed additional budqet 7o in comparison with the total budget (73923) To sffengthen APOC Management capacrty and advocate for strengthening Onchocerciasis surveillance in particular, in countries harbouring refugees from onchocerciasis endemic areas. 4 200 3 500 10.4 JAF12.11 Page 12 OBJEGTIVE 3: When and How to Stop Ivermectin Distribution Scope Under this objective APOC will focus on accelerating its strategic exit plan by financing field activities studies including further development of ONCHOSIM to determine treatment end points, and by developing capacity at the country level. By the end of 2012, each endemic country will have a pool of national scientists capable of assisting their governments with studies to determine when and where to stop ivermectin treatment. APOC will select sentinel villages in each country for epidemiological evaluation and close monitoring of the impact of ivermectin freatment. Funding to support the achievement of this objective will be sort from The Bill & Belinda Gates Foundation. lndicators I 24Bpidemiologists in 12 APOC countries trained on the tools and instruments of the feasibility study (2 epidemiologists per country) and how to evaluate the cessation of ivermectin treatmentby 2012. 0 Ivermectin treatment safely discontinued in some endemic fociby 2012. I Additional resources mobilized to assist APOC in achieving this objective by end of 2012 in 19 countries (three former OCP countries included). I Evidence-based report submitted to the TCC, CSA, and JAF on status of onchocerciasis following stoppage of treatment in certain areas (as of 2012). I Prevalence and intensity of the disease, including community microfilarial load should be determined and monitored. 0 Changes in ocular and skin lesion indicators assessed and published for use by the international scientific community. Risks I Prolonged conflicts can intemrpted treatment, worsening endemic areas and promoting recrudescence in freed zones. I Lack of resources for capacity development among national scientists would undermine country-led implementation and oversight activities. I Conflict may prevent continuous assessment of the epidemiological indicators in sentinel villages. JAF12.11 Page 13 OBJECTIVE 3: When and How to Stop Ivermectin Distribution (Cont'd) Timeline Programme current and proposed additional budgets (US$ thousand) 2006-|2007 2008 2009 2010 20Lt-2015 ONCHOSIM a) ONCHOSIM model of APOC already commissioned from Rotterdam group. Result expected by March 2007. b) Update of ONCHOSIM model on OCP expected December 2007 Use of on-going study of the feasibility of stopping ivermectin treatment and ONCHOSIM models for high level advocacy and resource mobilization from The Gates Foundation etc. Using new TDR data on-going study of the feasibility of stopping ivermectin treatment to be optimized for more counffies and settings. Strengthen field operations Evidence to stop or continue ivermectin treatment available for some sites. Ivermectin freatment safely discontinued in some endemic foci as of2Ol2. Feasibility studies on when to discontinue ivermectin treatment ongoing in countries. TDR Study on When and where to Stop Ivermectin Distribution Study is now in progress. Funding support provided by the Gates Foundation. TDR results expected. APOC/TDR to seek The Gates Foundation support for application of new tools and results in APOC countries. Further Operational research and field activities on how to evaluate cessation of ivermectin treatment. Further Operational research for policy decision-making. Building Counffy Capacity Special selection process to identify in 6-10 countries Epidemiologists/ Bio- statisticians for training to assist the countries to determine when and where to stop ivermectin ffeatment.. APOC operational research specialist (hired in 2008, see Objective 2) to use new TDR data and updated ONCHOSIM as evidence base with which to help other countries design and execute their own studies on when, where, and how to end ivermectin distribution. Building country capacity using trained epidemiologists will help to ensure that national authorities can formulate and answer their own research questions as more and more situations arise in which it may be possible to end CDTI. Suategic Guidance and Inter-Country Cooperation As experience accumulates, APOC must ensure that counffies have access to the latest data on the cessation of CDTI. This includes strategic guidance on how and when to stop CDTI in a given setting and facilitating information sharing between countries as national staff build research portfolios and maintain surveillance in post-CDTI areas. 2007-2015 2007-201s Area objective Current Programme budset Proposed additional budset 7o in comparison with the total budget (73 923) To determine when and where to stop Ivermectin treatment and build the capacity of the nationals to undertake this activity (new Programme objective) 7 000 9.5 JAFI2,II Page 14 OBJECTIVE 4r To Foster Co-Implementation of Other Interventions via CDTI and Accelerate Integration of Onchocerciasis Control into the National Health Systems Scope Work under this objective will focus primarily in co-funding co-implementation of CDTI and other selected community-based health interventions in countries that have established a formal national policy, made a budgetary commitment and have released counterpart funds to support co-implementation. APOC will help evaluate the impact and cost-effectiveness of co-implementation of CDTI and the control of Neglected Tropical Diseases (NTDs). lndicators and targets I By 2013 in all countries, CDTI fully integrated into the national health systems and funded from government and external sources (e.g. PRSPs). I Number of APOC countries with national policy on integration and co-implementation increased to 60Vo in 2010 and I00Vo in 2014 I By 2012, 70Vo of CDTI projects should be delivering other health interventions through co- implementation. I By 2014, l00%o of stable governments should have national co-implementation policies and fund co- implementation through the normal budgetary process. 0 High level advocacy through regional bodies and international meetings for integration and co- implementation undertaken annually to establish co-implementation via CDTI in all projects by 2014. Risks u Changing priorities in international health may hinder the mobilization of adequate resources for APOC Trust Fund to support co-implementation via CDTI. I Lack of resources for capacity development of nationals for implementation and oversight of administration of multiple interventions. I Acute shortage of district and frontline health facility level health staff to implement the activities. I Inadequate resources by governments to support health systems JAF12.11 Page 15 OBJEGTIVE 4: Co-Implementation and Co-Integration (Cont'd) Timeline Programme current and proposed additional budgets (US $ thousand) 200Gz007 2008 2009 20t0 20tt-2015 National Policies on Co- Implementation Using research evidence, advise countries developing national policies on co-implementation 200'7 -2008 : Ongoing TDR/APOC Study on Community-Directed Interventions (CDI) wilt conclude and results can be used to provide countries with scientific evidence required to develop national policies. Additional evidence on the use of ComDT for integrated control of Neglected Tropical Diseases (NTDs). Co-Funding Co- Implementation Partial result of ongoing TDR/APOC Study on Community- Directed Interventions (CDI) will likely provide the scientific evidence on whether or not other programmes using ivermectin distributors will jeopardize the conffol achievements of APOC. [Pending JAF Approval] Begin co-funding co-implementation where countries have established a formal national policy, made a budgetary commitment, and have released counterpart funds. TOVo of country projects would have been integrated into national health systems by 2010. 60Vo of countries developed plans on co-implementation of CDTI with one or two health interventions by 2008. National coordinators report to JAF on co-implementation to begin in 2008. Facilitate National Meetings on Co- Implementation Strengthen partnerships National meetings on co- implementation have been held already in Nigeria and Tanzania. A similar meeting will be held in DR Congo this year. An early 2007 meeting in Cameroon is planned. Directors of Disease Control meeting on policy and implementation of integrated approaches to be co-financed by APOC and the Neglected Tropical Diseases (Geneva), held in Ouagadougou, March 2007. If the meeting of the Directors of Disease Control is successful, roundtable conferences will be held annually and thereafter replace the single-country consultations (such as those in 2005). These meetings will suggest the most relevant operational research topics, promote within- and between-country cooperation, and help APOC select programs to co-finance (following CSA approval). The meetings also represent an excellent advocacy opportunity and can help countries identify new sources of NTD funding Enlist local NGOs in 40Vo of projects by 2009. Fostering a Horizontal Approach to Promote Integration Oncho activities are not inherently vertical in most minisffies because the National Onchocerciasis Coordinator is often the national coordinator for other disease control programs as well. This is often true at the district and local levels too. However, problems of verticality are introduced because of the oncho-specific (APOC) funds, which has in some cases led to a reduction of government own contributions and caused unnecessary friction between civil servants working on adequately supported control programs and those working with insufficient resources on other diseases. This problem can be overcome through advocacy and new funding strategies. Advocacy: Advocacy for integration must be maintained as a routine APOC activity via regional committee meetings, at the national level and in international fora. Funding Sffategies: This requires further research and discussion. One option is to stipulate that APOC funds be channeled through ministry of health coffers and then disbursed to the NOTFs. This process might reinforce self-fundin g pattern. 2007-2015 2007-201s Area objective Current Programme budget Proposed additional budget 7o in comparison with the total budset (739231 To co-implement multiple health interventions via CDTI; Integration of Onchocerciasis Control into the National Health Systems 3 900 4 000 t0.7 JAFIZ.II Page 16 OBJEGTIVE 5: Broaden APOC mandate to include all Onchocerciasis endemic countries in Africa. [JAF to considerl APOC's mandate should be extended to include all onchocerciasis endemic countries in Africa where the epidemiological situation requires sustainable CDTI. - Strategic overview document. Scope Work under this objective will focus on constant advocacy to governments on adequate funding and to re- establish or strengthen control activities in some fragile states where conflict has disrupted CDTI activities and in some areas caused the epidemiological indicators to revert to pre-control levels (includes some OCP Special Intervention Zones). External support must be secured from regional institutions for onchocerciasis control activities in former OCP and APOC countries. lndicators and Targets 0 Governments with weak projects will establish financing mechanisms and take ownership of control activities to safeguard past investments. I The epidemiological situation in Sierra Leone, which has reverted to the pre-control situation of almost two decades ago, will improve through implementation of planned CDTI activities. Complete (l00%o) geographical and a minimum of 70Vo treatment coverage must be achieved and maintained in all eligible communities in Sierra Leone by 2012. These targets should be reached by 2010 in Benin, C6te d'Ivoire, Ghana, and Togo. I Annual Cross-border meetings between countries sharing transmission zones in West Africa will be in stitutional ized by 20 10. I By 2015, the 14 countries in East and Central Africa should be organizing cross-border meetings. Risks o Lack of political will of governments with poorly performing projects in APOC and Special Interventions Zone (SIZ) countries could translate to inadequate financial commitment and insufficient human resources. I Competing health priorities. I Continuing and/or recurrent conflict in Member States. JAF12.11 Page 17 STRATEGIC OBJECTIVE 5: Broadening APOC's Mandate (Cont'd) Timeline 200G2007 2008 2009 2010 20tt-201s Seek JAF Approval JAF approval requested for extending APOC's geographical mandate, Trust Fund and timeline of operations. Authorization to co-fund co-implementation will also be sought. Pending approval, formal invitations to join APOC will be issued to all non-member endemic countries. [If approved by JAF] Invite OCP-country ministers to JAF. Countries will pay for own participation. Lobby for country leadership and financial sustainability of control activities until elimination is achieved. Invite OcP-country ministers to the JAF to lobby for country leadership and financial sustainability of control activities including surveillance until elimination is achieved. Invite some OCP- country ministers to the JAF. Some OCP- country ministers attending JAF annually. Ministers from former OCP fragile states will be given priority. Former OCP Countries Affected by Conflict or with poor coverage treatment/ performa nce [2007, pending JAF approval] As soon as political situation permits, perform epidemiological assessment of oncho in southem COte d'Ivoire, where treatment by OCP began in 1999 (and was interrupted in 2001). High-level advocacy visit to Ghana and Guinea Bissau where the regressing epidemiological situation must be reversed. 2007-8: Strengthen CDTI in the forest areas of Ghana that were not included in OCP Strongly advocate and support co- implementation of onchocerciasis and LF programs with countries playing a leadership role. Expected by 2009: Improvement in Ghana's epidemiological and entomological indicators; increase in govemment funds released for oncho control. Countries must concentrate on surveillance, and develop own CDTI sustainability plans. APOC/countries will monitor government implementation of sustainability plans and release of funds. Monitoring/ Evaluation of country programs No APOC Trust Fund support to Ghana, C6te d'Ivoire and Guinea Bissau after 2009. Special Interventi on Zones High-level advocacy visits intensified in a]l ex-OCP countries [pending JAF approval] SZ countries will need to sign the APOC MOU by end of 2007 or Jan 2008 after the closure of the SZ. Based on the results of the ONCHOSIM model, work closely with SZ countries to enhance control activities to avoid recrudescence of disease. Carefully monitor epidemiological and entomological findings; intervene as needed. Fully devolve Monitoring & Evaluation responsibilities to countries ; Support the MDSC to take over surveillance activities in SZ countries JAF12,II Page 18 STRATEGIG OBJEGTIVE 5: Broadening APOC's Mandate (Cont'd) Timeline (Gont'd) Programme current and proposed additional budgets (US$ thousand) 200c2007 2008 2009 20L0 2011-2015 Sierra Leone Entomological and epidemiological surveillance in sentinel villages on-going. Study on black fly movement completed. Ivermectin distribution re- launched in 2005. [Pending JAF approvall APOC to take over the oversight of oncho conffol in Sierra Leone; begin co-implementing oncho, LF, vitamin A interventions. Explore support options with World Bank, NGDOs and country-based multi-national companies. Entomological and epidemiological surveillance in sentinel villages. Epidemiological surveillance in sentinel villages. APOC to monitor government leadership and ownership of conffo1. Capacity development of nationals in control & research. l00Vo geographical coverage and >657o teatment coverage in all CDTI villages. Evaluation of CDTI sustainability using sentinel village data. Entomo- epidemiologica I surveillance Develop with country authorities strategy of APOC's exit in 20t2. Strengthen country integrated surveillance system with focus on onchocercias is. No APOC Trust Fund support to Sierra Leone after 2013. Cross-Border Meetings of all West African Endemic Countries. Cross-border meetings of countries sharing transmission zones are essential to maintain gains, prevent recrudescence, and share knowledge and expertise. They have proven invaluable where held thus far: Guinea Conakry-Sierra Leone- Liberia; Benin-Nigeria; Togo-Benin. These must continue with APOC and ministerial support. APOC to ensure that the cross- border meetings will be held annually and are sustainable without external support. Explore possible hosts for future years: WHO country offices, WAHO with support from NEPAD. Cross-border meetings continue as APOC support phases ontby 2012. National Coordinators hold annual review meetings to exchange results and ensure that the prevalence of the disease, even not zero, is at a level that will not lead to disease recrudescence. 2007-2015 2007-2015 Area objective Current Programme budget Proposed additional budget %o in comparison with thc total budget (73923) To broaden the APOC mandate to include all Onchocerciasis endemic countries in Africa. Support to few ex-OCP fragile states. [JAF to consider] 8 000 10.8 JAF12.11 Page 19 STRATEGIG OBJECTIVE 5b: Strengthen Ivermectin Treatment Programs in Fragile States (within current mandate) by Building Alliances With New Partners Scope I APOC will give special support to fragile states in APOC and the former OCP areas, and facilitate the establishment of CDTI in difficult areas in collaboration with new partners. A special request will be made to APOC's traditional NGDOs to support the accomplishments of this objective. Because of constant population migration and the long flight range of the blackfly vector, it is imperative to strengthen ivermectin treatments in fragile states to protect the investments and achievements of countries that have oncho-freed zones. lndicators and targets 0 By the end of 2007, APOC to have facilitated an action plan by each fragile state. 0 By end of 2011, APOC's exit from stable countries should be completed. I By the end of 2013, APOC should have exited from at least two fragile states. Risks U New or continuing conflict may intemrpt operational plans. U Political instability may undermine capacity-building efforts. U New partners may be hard to find and./or unable to reach some areas and if NGDOs are not able to assist. Timeline current and additional thousandP 2006-2007 2008 2009 20L0 20tt-20t5 Plan of Action By the endof 2007, develop new action plan with/ for each fragile state ( South Sudan, Liberia, DRC, Chad, CAR, C6te d'Ivoire. APOC to facilitate each country's effort. Plans will be made to improve performance in difficult areas, e.g., where there is conflict, l. loa, etc. New partners will be sought to increase coverage in these areas, e.g. Medecins Sans Frontieres, UNICEF, refugee NGDOs, etc. Implementation to start: Provide support to DRC, Liberia, and C6te d'Ivoire. Provide support to Chad and South Sudan. Start pulling out of stable countries: Cameroon, Ethiopia, Nigeria, Tatzatia, and Uganda. Complete the exit of APOC in some projects by December 2011. Exit of APOC in all stable countries by December 2012. Exit Sfrategies Identify partners who can help as above, so APOC can build capacity and then devolve responsibilities to permanent institutions, entities and organizations. Develop training packages for new partners and start building capacity with the best candidates- WHO country offices, local NGOs. Continue training new partners. Start pulling out of fragile states to monitor "post- APOC" results in advance, while there is time to take corrective action. Intensive M&E continued by APOC until2013. By others as of 2014. Strengthen fragile state infrastructure where there is co- endemicity of onchocerciasis and Iaiasis. Begin intensive M&E to see how fragile states are performing with these ad hoc methods, new partners and new initiatives. 2007-2015 2007-2015 Area objective Current Programme budget Proposed additional budget 7o in comparison with the total budset (73 9231 To strengthen ivermectin treatment programs in fragile states (within current mandate) by building alliances with new Partners. Advocacy to countries to take ownership and leadership in Oncho control. 7 800 4000 16.0 JAF12.11 Page20 OBJEGTIVE 6: Monitor and Evaluate CDTI Sustainability and the Implementation of Sustainability Plans by Participating Governments; Build Country Capacity for M&E and Ongoing Control Activities Scope For many years, APOC, member countries and partners have worked to ensure the sustainability of CDTI after the end of APOC support. Systematic reviews have evaluated the sustainability of each project and plans have been formulated by governments to ensure long-term sustainability. As usual, APOC will continue to monitor the implementation of these plans by governments, intensifying efforts as APOC support ends in stable and fragile states. lndicators and targets I Onchocerciasis-related blindness and skin disease prevented in countries with unintemrpted annual treatment. (Baseline determined in 2007 ). U 12 countries in the SIZ and APOC areas are freed from onchocerciasis by 2015. I Countries conducting internal evaluation of CDTI projects with resources from MoH increased to 50Vo by 2010. l70Vo of counfries and NGDOs using standardized form to report contributions by 2008. I 757o ofevaluated projects develop sustainability plans by 2007 Risks I Conflict or political instability may render some areas unreachable or weaken health system capacity. I Drug resistance or the above factors could promote disease recrudescence. Timeline Programme current and proposed additional budgets (US$ thousand) 2006-2007 2008 2009 2010 20tt-20t5 Monitoring CDTI Sustainability Plan Implementation By 2Ol0,7O7o of projects with over five years of APOC TF support should maintain the onchocerciasis conffol activities in the District/LcA Comprehensive Health Plans. Also by this date, onchocerciasis control activities should be supported by the normal budgetary process. APOC to completely devolve monitoring implementation of sustainability plans to countries and other partners. Evaluation of project performance. Assessment of health impact of APOC operations. 1007o ofprojects in stable countries and 507o ofthose in fragile states should exceed 65Vo fieatment and 1007o geographic coverage by 2010. Six fragile countries (Angola, Burundi, Chad, Liberia, Sierra Leone and South Sudan) should conduct CDTI projects sustainability evaluations by 2009 , using trained national staff. Number of children spared of the risk of blindness due to onchocerciasis determined in 16 APOC and 11 former OCP countries by 2014. Co-funding for the adaptation of ONCHOSIM and other modeling techniques to assess the health impact of OCP and APOC control operations in 30 onchocerciasis-endemic countries to be completed by APOC it20l3. 2007-2015 2007-2015 Area objective Current Programme budget Proposed additional budget %o in comparison with the total budget (73 923) To monitor and evaluate CDTI Sustainability; assist countries to develop sustainability technical and financial Plans. 4 800 2 500 9.9 JAF12.11 Page2l STRATEGIG OBJECTIVE 7; Financing Scope Financial planning and fundraising for onchocerciasis control. This objective includes APOC's own financing via the APOC Trust Fund and assisting countries to secure sustainable government financing for ongoing onchocerciasis control and/or surveillance. Work will therefore proceed on two fronts. Internationally, the World Bank will continue its regular high level visits to Trust Fund donors. It is essential that the APOC Trust Fund be able to support the additional costs associated with operating in conflict countries with the new mandate if approved. Advocacy visits will be conducted to participating country governments to facilitate investments to maintain the achievements of the OCP and APOC. The NGDOs will be solicited to increase financing to some projects. lndicators and Targets I The World Bank continues to raise funds for onchocerciasis control. Additional funds required to finance control activities in conflict areas in APOC and some OCP countries will be secured on a timeline to be determined by the World Bank. I By 2008, a declaration should be secured from the African Union, stating countries' responsibilities in maintaining the investments and achievements of OCP. 0 By 2010, 50Vo of APOC countries establish national fund to maintain gains and avoid disease recrudescence. I By 2008, L00Vo of countries include oncho in their national health policy andT}Vo in PRSP and PEF. 0 By 2009, 65Vo of APOC countries provide for oncho control activities from the general health budget and debt relief initiatives. Risks I International donors may limit contributions, channel funds through other mechanisms, or leave APOC I Participating country finances may be diverted to other areas. 0 Delays in control activities due to decreased funding I Recrudescence of disease. 200G2007 2008 2009 2010 20tt-2015 World Bank Trust Fund The World Bank will continue its normal fundraising activities as the Fiscal Agent National Coordinator's Meetings The National Coordinator's Meetings (see Objective 3) will help APOC explore opportunities with country teams to dedicate funds to oncho control every year. (i) track government's contributions to onchocerciasis and surveillance activities; (ii) facilitate exchange ofexperience between the participants on technical, financial and managerial matters; (iii) better plan and coordinate it support to countries International Declaration APOC will pursue an international declaration from the European Union and NEPAD (the New Partnership for Africa's Development) calling for the maintenance of onchocerciasis control and the prevention of recrudescence in freed areas. This will aid fundraising, secure country commitments, and help strengthen the MDSC. Country-Level Advocacy Creating Country Trust Funds Advocate for the use of (country-level) basket funds in onchocerciasis control, especially in countries where this mechanism is used but funds are not yet allocated to oncho, as in Ghana (pending JAF approval of mandate extension). Countries will provide funds for oncho activities from health budgets Advocate for basket funds in countries where this mechanism is not yet established, e.g., CAR, Chad, DRC, Liberia, Nigeria. Countries will include oncho into national health policy, PRSP and PEF. Help NOTFs reach out to private partners within their own countries. The extractive industries in particular-petroleum, mining-and the large plantations in rubber, coffee, timber, etc., may be willing to contribute funds for disease control. APOC Management and NOTFs will work to establish country trust funds (TFs) that can hold onchocerciasis control monies for use after 2015. These facilities will hold funds raised by countries themselves. This approach will be pursued where appropriate, and not, for instance in Ethiopia, where CDTI is already fully integrated into the MoH. 2007-8: Establish TFs in Angola, Cameroon, DR Congo and Nigeria. Establish TF in Equatorial Guinea. Establish TF in CAR, Chad, Liberia, and, if needed, in Tanzania. Review of integration of CDTI into health systems in Malawi, Tanzania and Uganda. Monitor and assist as requested to ensure that counffy financing arrangements are functioning smoothly Forecast Extension Costs; Raise Additional Funds Because of exfra costs in conflict areas and the extension, some additional funds may be required. This matter is to be discussed with the World Bank and the CSA. JAFT2.II Page22 STRATEGIC OBJEGTIVE 7: Financing (Cont'd) Timeline Programme current and proposed additional budgets (US$ thousand) 2007-2015 2007-2015 Area objective Current Programme budset Proposed additional budget 7o in comparison with thc total budget (73 923) Financing: Advocacy visits to governments 1 000 1.4 , JAF12.11 Page23 OBJEGTIVE 8: Identify a Drug Effective Against Adult Onchocerca volvulus and a Strategy for Large-Scale Distribution; Build Country Capacity in Operational Research Scope APOC's work under this objective will cover two important areas: (i) continued support for macrofilaricidal drug research and (ii) operational research on incentives and other issues related to sustainability. lndicators and targets I Effectiveness and safety of Moxidectin determined by the end of 2008. I If Moxidectin is appropriate, a distribution strategy should be developed by 2010. 0 If Moxidectin is unsuitable, other promising candidates should be identified by 2010 Risks U Moxidectin may be ineffective and/or unsuitable for mass distribution U Other candidate compounds may also be found unsuitable. Timeline Programme current and proposed additional budgets (US$ thousand) t 200G2007 2008 2009 2010 20tl-2015 MACROFIL Research APOC TrustFund made available to TDR for Phase II clinical trials on Moxidectin and the search for other candidate drugs. Report from TDR on the Moxidectin clinical trials available to TCC, CSA and JAF in 2006 and2007. Moxidectin's safety and macrofilaricidal properties determined by December 2008. If Moxidectin is safe and effective, TDR and countries will be supported to undertake operational research to determine if CDTI or an alternative strategy is the best and quickest way to distribute the new drug to eligible persons. Study to be concluded by 2010. If Moxidectin fails, results of rials on other candidates to be reported by TDR in 2009 and 2010. Study on External Incentives Immunization Programme in Nigeria and APOC co-funded a meeting in July on monetary incentives. Participants identified the major research issues and developed a study protocol. Research results to be used in national policy formation and will be used for high-level advocacy among the major development players in 2008-2010, to promote harmonization and to help eliminate problems created by disparate approaches. Capacity of nationals in 20 countries (APOC and 3 ex-OCP) strengthened to conduct operational research. Results of multi-country studies on the impact of external monetary incentives on CDTI made available to the TCC, CSA and JAF in 2008. 2007-2015 2007-2015 Area objective Current Programme budget Proposed additional budget 7o in comparison with the total budget (73 923) To identifr a drug effective against adlult Onchocerca volvulus and a strategy for large- scale distribution; build country capacity in operational research. 5 000 0 6.8 a JAF12.11 Page24 SUMMARY OF APOC STRATEGIG AGTION PLAN AND BUDGET Programme current and proposed additional budgets by main area objectives (US$ thousand) a SCALING UP OPERATIONS: reacfting all in need 1. Establishing sustainable national onchocerciasis programmes in all countries where needed. 1b+1c. To achieve 100% Geographical Coverage and more than 65%oTherapeutic Coverage in stable and post-confl ict countries concerned. (within mandate) 9 223 9 000 t8 223 24.6 2. To strengthen APOC Management capacity and advocate for strengthening Onchocerciasis surveillance in particular, in countries harbouring refugees from onchocerciasis endemic areas. 4 200 3 500 7 700 10.4 Co-implementation & broadening mandate 3. To determine when and where to stop ivermectin treatment and build the capacity of the nationals to undertake ttris activity (new Programme objective) 7 000 9.5 4. To co-implement multiple health interventions via CDTI; Integration of Onchocerciasis Control into the National llbalth Systems 3 900 4000 7 900 10.7 5. To broaden the APOC mandate to include all Onchocerciasis endemic countries in Africa. Support to few ex-OCP fragile states. [JAF to considerl 8 000 8 000 10.8 5b. To strengthen ivermectin treatment programs in fragile states by building alliances with new Partners. Advocacy to countries to take ownership and leadership in Oncho control. 7 800 4000 11800 r6.0 EXIT: monitoring & evaluation + Finance 6. To monitor and evaluate CDTI Sustainability; assist countries to develop sustainability technical and financial Plans. 4 800 2 500 7 300 7. Financing: Advocacy visits to governments I 000 1000 1.3 TIONAL 8. To identify a drug effective against adult Onchocerca yolvulus and a strategy for large- scale distribution; build country capacity in operational research. 5 000 0 5 000 6.8 TMENT strategy and risk containment costs It is anticipated that resources requirement will increase by at l0 % annually ADruS 7393 Total 34 923 39 000 73 923 100.0 I 2007-2015 Area Objective Current Programme budpet Proposed additional budset Total budget 7o in comparison with the total budset (2007-2015\ 7 000 9.8 IJAF12.11 Page25 Information: If all donors redeem their commitments up to 2010, the additional amount required for extension to 2015 is estimated at US$ 39 - 46,393 million including risk containment cost of US$ 7 393 million. SUMMARY Current Programme budget (2007-2015) : 34 923 Proposed additional budget (2007-2015) = 39 000 Totalbudget (2007-2015) : 73923 Risk containment cost (10% of 73 923 ) = 7 392 Additional amount required for extension to 2015 is estimated at : 39000 to (39 000 + 7 392) = 46 392 Total budget Q007-2015) for extension to 2015 is estimated at : 73 923 to (73 923 + 7 392) = 81 315 I Current Sub-Total 2007-2015 10 500 7 044 5 355 3 795 3 024 2 030 1 100 I 050 1 025 Proposed additional budget (2007-2015) 2008 2009 2010 20tt 2012 2013 2014 2015 Sub-Total 2007-20153000 6606 7040 6444 5957 4423 3405 1 160 965 Total 2008 2009 2010 20tt 2012 2013 2014 2015 Total 2007-201513500 I 3650 12395 10239 898 1 6453 4505 22t0 1990 73923 - 81 316 2014 2015 34 923 2007 39 000 2007