Additional funding request for phase II and phasing out period: plan of action and budget 2012-2015

AFRICAN PROGRAMME FOR ONCHOCERCIASIS CONTROL Additional Funding Request for Phase II and Phasing Out Period Plan of Action and Budget 2012-2015 I 1\ -:. .:) _ ! .r:tF' C E I .r -'!*l I ! .L \ I ..{ $ World Health 0rganization@) JAF I6.I I @ African Programmc for Onchocerciasis Control (WHO/APOC) 2Ot0 All rights reserved. The use of content from this health information product for all non-commercial education, training and information purposes is encouraged. including translation, quotation and reproduction, in any medium, but the content must not be changed and full acknowledgement of the source must be clearly stated. A copy of any resulting product wrth such content should be sent toWHO/APOC No 1473, Avenue Zombre, 0l B 549, Ouagadougou 01, Burkina Faso. The use of any informataon or content whatsoever fiom at for publiclty or advertasang, or for any commercial or income-generatang purpose, is strictly prohrbited. 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Any alterataon to the original content brought about by display or access through different media is not the responsibility of WHO/APOC and WHO/APOC accept no responsibiliry whatsoever for any inaccurate advrce or information that ls provided by sources reached via linkages or references to thr health information product. i Joint Action Forum Office of the Chairman Forum dAction Commune Bureau du Prdsident JAF-FAC: Sixteenth session Abuja, Nigeria, T-9 December 2010 Additional Funding Request for Phase II and Phasing Out Period Plan of Action and Budget 2012-2015 Africa n Prog ra m me for O nchocerciasis Control, World Health Organization (APOCA,VHO) SEPTEMBER 28,2010 AFRICAN PROGRAMME FOR ONCHOCERCIASIS CONTROL 3 \9r Table of contents Executive summary Programme Evolution and Milestones: Rationale for Additional Funding Programme Design lssues, Objectives and Outputs. . . . Background and rationale Objective l: To strengthen core CDTI activities to accelerate elimination of inlection and interruption of transmission of Onchocerciasis.............. Outputl.l: Expanded Core CDTi Activities: Communrty directed rreatmenr with ivermectin (CDTI) Outputl.2: Elimination surveys including capacity burlding for interruption o[ transmissron. Shrinking the Map.. Outputl.3: lmproved Record Keeping at Health Facility Level Outputl ,t' Community Self Monitoring and Stakeholder meetings ........ Outputl.5: Strengthening rhe Scientific and Evidence Base: Establishing an Onchocerciasis Information Memory Objective 2: Co-implementation and gender mainstreaming to strengthen PHC Output 2: Co-implementation and gender equity........... Output 2. l: lnclusion of CDI Approach rn Curriculum of Universities ... .. .... Output 2.2: lntegrated Mapping of Five Neglected Tropical Drseases (NTDs) Output 2.3: Co-implementation and capacity building Output 2.,1: Building Capacity of nationals and increasing rhe output of operational research .6 IO t2 t2 ........... l2 l+ l1 t7 l8 .... l9 ................. 20 ................. 2l .................21 ....... ...22 .. . ............23 21 Objective 3: To transition APOC Programme delivery to complete country management.... 26 Output 3: Enhanced APOC delivery capacity and support to countries.. ..... .....26 Output 3.1. Short Term Measures to Increase Capacity (2012-2015). ..........26 Output 3.2' APOC Programme delivered and transition to complete Country Management ........................ 26 Summary Budget 30 List of acronyms APOC csM FLHF IM JAF LF NGDO cDr CDTi NOTF NTD ocP Afncan Programme for Onchocercusrs Control Communrty Drrected lnterventron Communrty Drrected Treatment wrth lvermectrn Communrty self-Monrtonng Front Lrne Health Facrhty Oncho ln[ormatron Memory Jornt A[ncan Forum Lymphatrc Frlanasrs Non-Govemmental Development Organuatron Natronal Onchocercrass Task Force Neglected Troprcal Drsease Onchocercrasrs Control Programme rn West Alnca Onchocercrasrs Plan o[ Acuon and Budget Preventrve Chemotherapy Pnmary Health Care Raprd Eprdemrologrcal Mapprng of Onchocercrasrs Severe Adverse Events Stakeholders meenng, UNICEF, UNDR world Bank WHO Programme for research and trarnrng rn Troprcal Drsease West Afncan Health Organuatron Oncho PAB PCT PHC REMO SAE SHM TDR WAHO WHO/AFRO wHo 5 World Health Organrzauon u1 0N IN oN uJ I ctlo o z z o U lt o z 4 6 9Elrlc f o r9 z .A o. o z UJ UI - o. G otl. F vt uJ =o tr.l 0c(, z 6 z3lt z o 6-6 6 Executive Summary The long-term commitment and political will of national governments and sustained support from donors and NGDOs to tackle river blindness control is a major, yet unheralded, public health and development success in Africa. This proposal sets out a four year plan 20L2-2015 [or two interrelated goals: first, measures to scale up progress to eliminate Onchocerciasis (river blindness) in[ection in many foci in Africa and transfer full management and control for this to national governments; and second, to utilise the resource and delivery model developed by the Onchocerciasis programme as a platform to strengthen the ability of health infrastructure (primary health care) to tackle Neglected Tropical Diseases (NTDs) and other health challenges. This proposal has been prepared based on the mandate and request of the 14'h and 15'h sessions of the Joint Action Forum QAF) that APOC submit a request and justification [or additional funding for 2OL) - 2015 . At present APOC has $ 1 1.45m in funding available for 2012-2015 for limited core CDTI activities and some technical assistance to post-conflict countries. The total cost o[ the revised plan of action is $60.06m, leaving an unfunded shortfall of $49.5m. Despite many medical breakthroughs in the fight against disease and to improve the quality of life, millions of people in sub-Saharan Africa still do not have access to the available medicines, vaccines and life-saving tools in their communities. Access to these resources would make a significant difference to the social and economic lives of the poor, and remove major barriers to the achievement of the Millennium Development Goals (MDGs). Reducing illness and death caused by @r-M >__i lI e _lil ffi I I .; -1 \'-'"1I ,tt.t 1 t c t' rl i!r- infectious diseases is critical to reducing child mortality due to infectious diseases (MDG 4) and improving the health of mothers, who are disproportionately affected by several tropical diseases (MDG 5). Good health also has a direct impact on productivity and family incomes and thus the achievement of MDGI. The Onchocerciasis Control Programme was highly successful in reducing the incidence of the disease, and also in piloting successful affordable models for community-based health systems. The involvement of the people - the "heart beat" of health systems - has led to significant progress in the control of River Blindness in Africa. For more than a decade, the strategy of community-directed intervention (CDI) has served as an effective platform for the delivery of other health interventions needed by millions of under-served people in 133,000 communities in the sub-region. This record was cited in the conclusion of the first external evaluation of APOC': "ComDT (CDI) has been a timely and innov ativ e str dteg)/ . . . and communities hay e been deeply inyolyed in their ownhealth cdre on a massiye scdle.... ComDT (CDI) is a strdteg)/ which couldbe used as a model in deteloping other community-based programmes and is also a potential entry point in the fght dgdinst other diseases." Many affordable and effective disease control products and interventions have had limited impact on the burden of disease due to inadequate distribution in poor and remote communities. In contrast the CDTI strategy of APOC has been very elfective. lvermectin treatment is popular and I33,000 communities have responded enthusiastically to the concept of 'community directorship' in which they are responsible for its planning and implementation. APOC has successfully used this strategy to provide a cumulative total of over 440 million treatments since its inception, thus protecting 120 million people who are at risk of River blindness disease. The effort has also proved successful in generating efficiencies, and creating significant value for money returns. Engaging and empowering communities is vital to the success o[ river blindness control and enables a treatment cost oI US$0.58 per person treated compared to a cost of US$0.73 in the absence of community engagement. Whilst this per capita cost reduction is small, considering that in 2009 over 67 million people were treated, this represents a saving of more than $ 10m./year. The APOC model works by constantly measuring deliverables, investing in people- centred research, community involvement and ownership, and by strengthening partnership and building the capacity of health workers in the use of health intervention tools. In this way, APOC has developed a cost-effective and workable approach to supporting infrastructure for PHC that provides opportunities for poor and remote communities to access improved quality health care and medicines. The APOC plan 2012-2015 will complete the job of eliminating Onchocerciasis infection and interrupting transmission where feasible !n c(\ IN oN uII ctf6 ct z 2 o U lt o z 4 ciI 0c UJ o. o t, = ra - o, o z uJ ut IA 0c o II ra UJ) o UI G I =oz Dlt z o 66 7 'lndependent External Evaluation of APOC, 2000 i!E!tE' ..^ "d_ ,ss ,$f" ',.. \ ry \ liIIt 890 80 70 8@60o s9s0 o 40 30 2A t0 Figure 1 Percentage of communities with B07o therapeutic coverage 2009-201 5 100 by the time APOC hands over responsibility to countries. All the post-conflict areas would achieve similar rates of improvement with almost all of them reaching the crucial 80o/o therapeutic coverage by the end of 2015. APOC will achieve this through the following activities: mobilization and mop-up treatment rounds, training, monitoring and supervision, advocacy and supporting material. Output Elimination surveys including capacity building for interruption of transmission: Shrinking the Map. The programme will provide technical and financial assistance to countries to carry out epidemiological surveys to assess trends of infection towards elimination endpoints and support for enhanced capacity at national level, and equipping countries with the necessary technical skills, competency and financial and material support. This will accelerate the shift from control to the elimination of onchocerciasis in Africa, and allow national planning around the distribution o[ ivermectin. Progress over 15 years has created the possibility of eliminating onchocerciasis infection and interrupting transmission in Africa. The planned closure of APOC in 2015 requires the presence of enough capacity at country level to take over all onchocerciasis control programmes and./or elimination efforts within countries. OBJECTIVE 2 Co-implementation and gender mainstreaming to strengthen PHC. Output Co-implementation of onchocerciasis control and other health interventions and gender equity Primary health care systems will be strengthened by the introduction of Community Directed Interventions (CDIs) in the curriculum o[ universities (40olo of institutions will teach the CDI curriculum in 20L2,70o/"by 2013,80 o/o by 2014 and the 20r 5 Year by indigenising national management, and also offer a vehicle for scaling up health improvements for some of the poorest African citizens to broaden impacts across a range of neglected tropical diseases. This programme requires increased commitment and resources from countries, additional support of partners (NGDOs) and increased investments by donors. The proposed programme includes a detailed set o[ costed activities with three broad objectives: OBJECTIVE 1 To strengthen core CDTI activities to accelerate elimi nation of infection and interruption of transmission of Onchocerciasis To achieve this objective the programme has two interlinked outputs: achieving new levels of ivermectin coverage and elimination, and a second o[ transferring management of elimination and interruption oI infection to national governments: Output Expanded core community-directed treatment with ivermectin (CDTI): 95o/o ol areas achieve 80o/o threshold for therapeutic coverage with ivermectin by 2015. The percentage of communities achieving 80o/o therapeutic coverage will rise from a baseline of 71.7o/o in 2009 to75o/o in 20I2, 85olo in 2013,90o/" in 2014, ar.d 95o/o by 2015 lr1 oN IN oN lrl(, o Do 6 z z o L' IL o z A ci o 0c UJe f o(, 2 ti Ig 6 z UI rn c G oII rn ut D o lrJ 0c(, z 6 zflt 2 o 66 frnal 50,6 in 2015). This output will support integrated mapping of Neglected Tropical Diseases (NTDs), capacity building initiative for co-implementation o[ other health interventions using CDI and other strategies, gender mainstreaming, buildrng capacity o[ nationals and increasing the output of operational research. OB'ECTIVE 3 To transition APOC Programme delivery to complete Country Management Output Enhanced APOC delivery capacity and supPort to countri$. The capacity of APOC (administrative, personnel services, logistics and infrastructure) over the period 2012 to 2015 will be increased to provide expanded technical support control for ehmrnation, co-implementation, gender mainstreaming and further strengthening of PHC delivery. The current level of staffing especially at the technical and professional levels is inadequate to cope with the new demands being made on APOC. Output APOC Programme delivered and transition to complete Country Management. The main activrties to be undertaken for the complete transition to Country Management include discharging liabilities, documentation and reports, equipments, vehicles, premises, closure of bank accounts, APOC personnel and post closure activities including the electronic archiving of all important documenrs. The overall proposal sets out a Plan of Action and Budget for the period 2012 -2015. The total cost of the programme over 2012-2015 is US $60,959,053 of which US $ I 1,.+59,053 is already secured. This leaves an unfunded shortfall of US $a9,500,000. A detailed budget summary is given in Table 12. o N I a! o a! F UJ\, o l @ o z z 9 F I o z) o- C; o a IT.J o- F f o \, z; I o- o z IT.J I o- cc o I F UJ l o llJ d. \, z o z l I) z o E o o 9 rn oN IN oN rut, cr)6 o z z o L, lt o z G ci o OE ut o. =o Iz ut & 6 z UI t r G olt t, uJ =o UJ 0c I =oz :) l! z o 6 a 10 Programme Evolution and Milestones: Rationale for Additional Funding The African Programme for Onchocerciasis Control (APOC) was launched in December 1995. It succeeded the Onchocerciasis Control Programme (OCP) in West Africa, the activities of which ended in 2002, and had the aim o[ extending the success of Onchocerciasis control in West Africa to 19 African countries. By 2007 , APOC had already made substantial progress: 37 million people prevented from developing debilitating disease; ivermectin was made available to more than 55 million people in i17,000 villages; the prevalence of severe itching and skin lesions was cut by 50ok in 16 countries; and a cumulative total of 3 million DALYs had been saved since the start of the programme. In 2008, there was evidence that many communities are able to interrupt transmission and eliminate the disease from some areas with ivermectin treatment alone, . ,04,-:'' thus paving the way to end the need for treatment. This exciting new development would require longer to achieve than control, and additional support to endemic communities. Thus, the shrinking of the African map o[ river blindness became attainable in the foreseeable future. Interruption oI transmission will also signiflcantly boost agricultural productivity in endemic areas. At the same time, it became evident to the partners that APOC could use its experience and infrastructure especially at community levels in delivering health improvements to marginalized communities through strengthening health systems. The rationale for this proposal document is the decisions by the 14'h and 15'h sessions o[ the Joint Action Forum (JAF) based on the evidence that communities in Mali, Senegal and Kaduna in Nigeria have succeeded in interrupting the transmission of river blindness and eliminating Onchocerca kI ) t I T l-) t1 I It lj+ru d G volvulus infection from some foci with ivermectin treatment alone. In December 2005, the APOC governing body, theJoint Action Forum (JAF) decided that a high level Working Group on the Future o[ Onchocerciasis Control in Africa should review the challenges to control onchocerciasis, its future options and the role of APOC and its partners. This led to: I the September 2006 Yaounde Declaration of Afncan Ministers of Health on Onchocerciasis C ontrol. The Governments expressed commitment to accelerate the elimination oI River blindness as a socio-economic development problem - a truly historical milestone for the commitment o[ the African member States; I the repositioning of APOC by African Health Ministers of participating states and donors in 2007, from a single to a multi-disease programme and support to countries to determine when and where ivermectin treatment could safely be stopped; and I the resolution on onchocerciasis control by the 57'h session of the Regional Committee for Africa (RC57). Based on the above, theJAF decided in 2007 to extend the duration o[ the programme from 2010 to 2015, and also approved support to 4 OCP countries in West Africa (Sierra Leone, Ivory Coast, Guinea Bissau and Ghana) where the epidemiological trend of control had remained unsatisfactory often due to conflicts. The Strategic Plan of Action and Budget prepared to cover the objectives as set up by the Working Group was approved byJAF in 2007. However, partners further decided that APOC Management should also submit an addendum to the Strategic Action Plan and Budget of APOC for 2008-2015 which would include assistance to countries to enable them to take overall management control, and decide when and where to stop ivermectin treatment. This Addendum was approved by donors andJAF in 2008. Based on the very encouraging results, the donors asked APOC management [o review the budget o[ the addendum in December 2008 which was considered modest, and to submit a request and justification for additional funding for 2012 - 2015. A brief presentation of the additional funding was made in December 2009 and this document sets out a proposed PIan ofAction and Budget for 2012-20L5. Lt oN IN oN UI u ol6 o z z o tr\J o z o ci 9 OE uJ o- o I z tl - o. ct z UI t I o. OE o r/'l UJ =o lU 0c I z 6 z z o 6 o 11 t , t I i = , -'t-' De !- L] \ at t'l o N I N o uJ(, oI 00 o z z o l- o z J o. ci 9 OE UJ4 f o t9 z a I G o z uI Ir G o lt r^ ltlf o u,l cc(, =oz J l! z o 6 o 12 Programme Design lssu€s, Objectives and Outputs BACKGROUND AND RATIONALE Onchocerciasis affects the poorest, most marginalized populations in Africa. Minimizing the disease burden enables individuals to continue to work, to attend school, have a social life and provides other socioeconomic benefrts that promote economic growth and diminish the cycle of poverty. The JAF recognized the positive impact on the economies of APOC member countries following onchocerciasis control through CDTi. At its 14'h session held in December 2008 theJAF encouraged APOC countries to work toward achieving and maintaining ivermectin therapeutic coverage of at least 80o/o to replace a minimum target threshold of 650/o. This is required to achieve both morbidity control and reduction in the transmission oI onchocerciasis infection. Although 55 million people had been treated in 2007, theJAF meeting also expressed concern over the negative impact on treatment coveraSe caused by cross- border issues. These include the need for overlapping Rapid Epidemiological Mapping of Onchocerciasis (REMO) at border areas of countries, to enable decisions to be made on whether and when to treat with ivermectin within the respective countries. Treatment by one country in the absence o[ treatment by the other at the border areas negates the gains in the reduction ol transmission. Consequently, APOC Management requested all CDTi projects to adhere to the JAF 14'h session recommendation in order to improve project performance and sustainability. Several CDTi projects in stable countries have achieved therapeutic coverage of close to 80o/o. However, for all projects in post-conflict countries to attain the 80% therapeutic coverage is a formidable challenge that needs special effort and support to overcome. Ivermectin treatment figures reported by CDTi projects in 2009 showed that post-conflict countries achieved an average therapeutic and geographic coverage of 63.9o/o and 81.5% respectively, compared with coverage of 77 .0o/o and 98.2olo respectively for stable countries. The NOTF and APOC management will therefore focus on strengthening communities' ownership and engagement as well as increasing monitoring of CDTi activities. The involvement of community leaders in ivermectin distribution is particularly crucial in the context o[ weak health systems in post-conflict countries. Strengthening this approach has begun through APOC Management and NOTF meetings with community leaders in, for example, two provinces in Angola, in Burundi and in the soulhern part oI Sudan. The programme design draws on the evaluation and reports undertaken over the past three years, and identifres the targets, activities, inputs, and monitoring and evaluation to achieve the overall goals. OBJECTIVE 1 To strengthen core CDTI activities to accelerate elimination of infection and interruption of transmission of Onchocerciasis Activities To respond to the need to help countries to determine when and where ivermectin / 1# I b P treatment can be safely stopped, and raise their therapeutic coverage to 80o/o, APOC will undertake the following activities: I Mobilization and extra treatment rounds Communities will be mobilized to conduct mop-up ivermectin distribution where needed. Provision will be made for them to follow up absentees and/or refusals after the main treatment campaigns, to increase their coverage to 80o/o. I Training Health staff: It will be necessary to train all, or the maximum number o[ health workers at district and health facility levels working in and ouside the onchocerciasis endemic communities. There has been a recurrent problem caused by the high rate of turnover of national and peripheral health staff. This turnover is inevitable, as staff members are transferred out of the onchocerciasis endemic communities to other areas, or move on for career reasons. By targeting a larger pool of staff it is envisaged that the large majority of staff that who are transferred to Onchocerciasis endemic areas would be qualilied to support the control and elimination efforts. This approach will help mitigate the negative impact of the high staff turn-over. I Community Directed Distributors (CDD) - Training of additional Community- Directed Distributors (CDDs) and community supervisors will be undertaken. This is not only required to help them to stay abreast of the increased work-load to move to the high coverage rate but also to minimize the attrition rate of CDDs and its impact on treatment. I Monitoring and Supervision The monitoring and supervision of CDTi implementation by communities and by NOTFs will be intensified to help identify any obstacles to achieving the 80% coverage. There will be annual reporting of the number/proportion of communities with less than 80o/o treatment Figure 2 Average therapeutic and geographic coverage in Stable vs, Post conflict countries 2009 120 I Post conflict 0 stab e100 o C o 80 60 40 20 0 Therapeutic coverage coverage coverage by project(s) and by country (ies). This activity will be intensified and a new monitoring mechanism put in place to detect quickly which communities are falling behind the objective of reaching the 80o/o treatment coverage and enable mitigation strategies. I Advocacy and supporting material Advocacy at regional and district levels will be intensified to bring the health service up to speed with goals o[ elimination of infection. The understanding and support of the administration at these levels will be needed. Additional IEC materials with a focus on elimination issues (e.g. high treatment coverage) will be produced and existing ones updated. I Support to cross-border meetings In view of concern over cross border movements that might compromise treatment in certain areas, support will be provided to all countries flor regular cross- border meetings to assess the prevailing epidemiological and entomological situation and efforts being taken to address the relevant issues. The sub-regional Ministerial meetings will continue each year to assess progress on elimination. It is anticipated that with the measures and activities to be carried out with the support of APOC, each community will obtain the 80o/o therapeutic coverage for ivermectin treatment through their CDDs and under the supervision of health workers. tl oN IN oN ul I of @ 6 z z 9 lJ IL o z c ciI &, UJ o. f o Iz IA Ea o z UJ ra I o. CE o!t ra lrr =o UJ 0c 19 z 6 z3lt z o o- o 13 Table I Budget (in USS) for strengthen ng CDTI core activities rn oN IN oN F uJ lo a D6 o z z o t, lt o z o ci 9 OE UJ o. F =o(, z ut I o. 6 z UJ rn -c G olt F(a ur =o UI G, I =oz3tl z o 6 o 14 2012 20r 3 2014 20r 5Activity Total CDTI core activitles US S 2,400,000 Output 1.1 Expanded Core CDTi Activities: Community directed treatment with ivermectin (CDTI): 90olo of projects achieve 80o/o threshold for therapeutic coverage with ivermectin by 2015 The programme will supplement approved funds by an additional $8.02m, a 690lo increase in support ofcore CDTi activities: advocacy/ sensitization/mobilization, mop-up treatment rounds, elimination surveys - epidemiological and entomological, - training, monitoring and supervision. Special attention will be given to cross-border initiatives to harmonise efforts and avoid inconsistent practices with compromised resuls. Several CDTi projects in the stable countries have already achieved therapeutic coverage close to 80o/o (the new target in 2008 under the elimination paradigm) with the current level of funding. However, there is need for special effort and support to post-conflict countries to attain the 80o/o therapeutic and 100o/o geographical coverage. Through improved technical and financial support, ivermectin treal-ment Iigures as reported by CDTi projects in 2009 showed that post-conflict countries achieved an average therapeutic and geographic coverage of 63.9o/o and 81.5olo respectively, while the figures reported in 2008 were 45.8o/o and 65.4o/o respectively. This is a significant achievemenl-. The additional budget to help undertake the activities in 23 countries (APOC and 4 ex OCP) is estimated to be $8,020,000 as indicated in Table I. Output 1.2 Elimination surveys including capacity building for interruption of transmission: Shrinking the Map Background ond rationale The primary objective of the APOC was to establish, within 12 to 15 years, effective, 2,200,000 1,850,000 1,570,00 8,020 000 self-sustainable, community-directed treatment of onchocerciasis with ivermectin throughout the endemic areas in the geographic scope of the programme. Additionally, the Programme aimed at eliminating the vectors transmitting the parasite in selected circumscribed foci using environmentally safe methods. The attainment of this objective is expected to contribute to the elimination of onchocerciasis as a disease of public health importance throughout Africa, and so contribute significantly to improving the economic and social welfare of the people. APOC has largely achieved the objective to control Onchocerciasis in a number of countries. Recent research findings in Africa (Senegal, Mali, Nigeria, Uganda, Cameroon and Chad) suggest that that long term ivermectin treatment of onchocerciasis can lead to elimination of the disease transmission. If this new important evidence for the elimination oI transmission of onchocerciasis is replicated this opens up the possibility of embarking on elimination of onchocerciasis throughout Africa. For the elimination of onchocerciasis from Africa to be a reality, it will be necessary to include all Ex OCP countries in the epidemiological reassessment exercise to determine in which geographical areas elimination would be feasible. In this respect most of the ex OCP countries that were placed on ivermectin treatment alone, or for some time in conjunction with vector treatment, would qualify for this assessment. The impending closure of APOC by 20L5 requires the transfer o[ capacity to country level to take over the assessment and monitoring of trends and stopping treatment, the management of all onchocerciasis control programmes and/or of elimination within countries. This Plan provides guidance on gradual decentralization and transfer of programme responsibilities to countries, integrates onchocerciasis control and elimination into national policies and processes, accelerates the epidemiological evaluation of all APOC projects and their proS,ress towards elimination, and steps up capacity building efforts to increase local ownership and strengthening of country management systems. Accordingly, the development of sustainability and elimination plans and their evaluation has been stepped up. However, there remarns a lot to be done in building the capacity of countries, to equip them with the necessary technical skills and competency as well as providing them with financial and material support. The l.tth sessionJAF underlined the need for addressing some critical actrvities and for providing an adequate budget additional to the PAB 2008-2015 to enable the execution of these activities. The plan for capacity building for the years 2012 through 2015 takes into consideration a) the transfer of all APOC activities to the participating countries in accordance with agreed country specific assrstance frameworks and b) inserting onchocerciasis control and elimination firmly within national health and surveillance systems. Each ivermectin delivery prqect should be fully sustainable by 2015 and be working towards elimination where feasible. We propose investing more in APOC's ground work of building the capacity of countries, WHO country ofhces and rn country NGDO partners to take over the overall responsibility of running onchocerciasis control programme. Activities I Assisting countries to prepare for elimination where possible. This will also include the ex -OCP countries. Generating evidence on the epidemiological situation in each project area in the 19 APOC countries and the I I ex-OCP countries. I Define areas in which elimination is feasible and target with a clear work plan. dehned end pornts, and monitoring and evaluation plans across the 30 countries. I Delineation o[ transmission zones for each project with technical assisunces of expen entomologrsts and molecular biologrss. ! In partnership with NGDOs and endemic communitres, initiate elimination plans by countnes for oustanding proJects. I Strengthening country capacity for elimination. APOC will create a core of expertise at the national level (as obuins in Nigeria and Uganda) to oversee the implementation of the programme as well as regularly monitor progress. This group will have similar role as the technical consultative committee of APOC. Creation of such expert group and supponing their work needs to be surted in at least 15 countries. APOC will endeavour to: ! Train key in-country resource persons from universities, research institutes, MoHs, NGDO partners on the procedure and their role including: ! Ehmrnation lield activities and on-the-job training. I Epidemiological evaluation and disease monitoring and surveillance cross-sectional surveys involving epidemiology, entomology, derma tology, ophthalmology I assessing health impact of the Programme through the use of the computer simulation model (APOC Onchosim) diagnostics of onchocerciasis using both the classical methods and new methods. Post cqttrol surveillance Post-control surveillance activities will be instituted to help detect any re-emergence of inlection (recrudescence of infection). To undertake these activities countries will be assisted in the selection of sentinel sites based on and using all available pre- control entomologrca! and epidemiological data. Blackfly collection will be undertaken every year using ethical methods and will TA o(\ I r.{ a! F IT.J\, o l co o z z 9 F I o z J o o a L! o- F l o \, = I o- o z ll/ I C d o I F uJ l o UJg. (, z o z l I J z o E o o 15 rn o N I r.{ o r^{ F r!(, o l co o z z 9 F I o z J o- x o a UJ o- F l o \, z; I CL o z IT.J I o- cc o I F uJ l o UJ CE \, =oz l I J z o E o o 't6 Quantity Cost/unit (uss) Des(ription 201 2 20r3 Tola I20]4 20't 5 Table 2 Budget for Ehmrnatron surveys rncludrng capacrty burldrng for rnterruptron of transmrssron Shrrnkrng the Map Asilsthg a //wtcs o gtqrc bt adwehls dkn nffir wlptc ffic A(ceh6ted epdemiologkal elaluton to as:ess progress to^ard5 elimination in allAPOC/ OCP plq,ecs Eraluate c6sa0on of treatment in adunced pqie(ts ard i$iluteppos-cont.ol survalbrre; rntensifred on the- iob raharq d natixral eraluation leam6 nd€seacivfties Documentatnn of epilJemologrcal srtuation in each prq,ect area Defnlon of transmrsron zones fo, each p.oject with technr@l asssurnce of expen entoflrologists Engagement of molecular birlogrss as consultants for delineation of ransmisson zonet Supponrng the p,oducton of gurdehnes for elimmauon and trainrr€ documents (enromology, epidemiology, dognostrcs, etc) lnatiate elimrnaton plans by cotJnlries 2 50000 r 500000 r 0@0q) 2 500000 3ocountries 60@ r80m r80m 3ocounraes 50000 I 10()000 7O0q) | 8@000 5 experts + equpment etc 2m000 2m0(x) 2@0q, 200(m 6m000 30 counrri€s 40@ 1200@ r200m 1200@ t20000 48000 3ocounr,ies 1000 3m0q) 3(x)m 6mm Sterytlwiltq ouary crylty lu c/frnffin frarnangonepi-Ealuaton, 3ocountries nerv end clessical diagnortiG br drs€as€ monito(ing and sunEillance In countrEs. Trarnrng of trairrrson 15 training Epdemblogcal E aluatpn and uorkshops d6ear€ su,\€illance tn countfles E$ablBhing and maintarnng 3 centres Regonal OnchocercEsis diagno$ic and qualty coilrol cenre (\irefl and Central Afrka & Eil and Sorrth Afrlca) T6l be examined for levels of rnfectivity using the DNA probe. Initially this analysis will continue to be undertaken at the molecular biology laboratory at the Multi-Disease Surveillance Centre in Ouagadougou, Burkina Faso and subsequently in other satellite srtes with the appropriate capacity e.g. Noguchi Memorial Institute for Medical Research in Accra Ghana. The resuls from the fly inlecuvity analysis will serve as srgnal for any untoward infection at a particular site. Trained technrcians wrll be visiting each sentinel site once every 3 years for epidemiological surveys in the villages, but sentinel sites will be surveyed annually in rotation 50m0 rmm 5@0q) r 5(x)0(x) 100@0 6500@ 35000 r 500000 500000 6q)0@ r500q) 5(x)m 7$m r 500000 5270000 320000 187000 32000 1065000 National staff will also be trained in the deuiled analysis of, and the interpretation of, the results that are obuined. Criteria for aiding the decision on the presence of recrudescence will be provided to the staff to enable them make the appropriate decisions and undenake necessary measures to contro! any recrudescence. These epidemiologrcal activides are labour-intensive, require special attention, motivation for the suffand will require national suppon. Given that in the posr control era most of the surveys will come back with negative results, lt is essential that motivation to carry out the surveys regularly is sustained, to avoid recrudescence of infection. The budget to undertake the activities under output 1.2 is estimated as US $10,660,000 as set out in table 2. From the approved funds under the Strategic Plan of Action and Budget (PAB) for the period 2008-2015 and the Addendum to the PAB, a balance of US $11,459,053 will remain at the end of 2011. This amount, complemented by US $18,680,000 from the additional funds requested will be used to achieve outputs 1.1 and 1.2 above for core CDTI activities and elimination. Output 1.3 lmproved Record Keeping at Health Facility Level Background and rationole CDTi communities adopt a three part approach to record keeping: I Taking responsibility for the way targeted health interventions are implemented; I keeping records of essential data from their activities; and I forwarding annual summary reports and community registers for annual mass drug administration to the nearest health facility for safe keeping. These records constitute a good repository of important information on the individual and the community as a whole at the health facility level. Monitoring/evaluation of records conducted by APOC revealed inadequate safe-keeping of CDDs records at the FLHE While at community level community registers are usually well kept by CDDs or community Ieaders, evaluation results from 12 countries showed that this is not the case at the under- resourced FLHF levels. Without good record keeping it will be difficult to assess progress made by CDTi projecs towards the elimination o[ onchocerciasis infection and intemrption of transmission. Since 2006, APOC Management has been providing technical and financial support to National Onchocerciasis Task Forces (NOTFs) to establish standard tools (community registers, drug management forms summary forms) for data collection and reporting on CDTi at all levels of the health system and at the community level. This information cannot be made available in a timely manner unless a reliable, systematic and sustainable record-keeping and archiving system is in place. The programme will provide each health facility with a simple, reliable and sustainable filing system for CDTi documentation to support the elimination agenda. The documentation has proved to be a useful source o[ information for Institutions and other Programmes working towards, alleviating the burden of poverty from rural communities. It is envisaged that by 2015, health workers at the front line facility/ health centres in onchocerciasis endemic districts trained on collection of data and documentation and safe-keeping of data for use in elimination ol transmission activities would have increased by 70o/o. Activities I Provision of sustainable filing system at the FLHF Threats to proper storage and easy retrieval oI records include misplacement, loss, water, and lack of sensitization on the importance o[ storage. The filing system should be robust and reliable, for example, strong and waterproof bags; metal lock-up cabines; and reinforcing security of the storage. ut ol\ IN oN UIt, ofo o z z o L., l! o z c 6 9c ulA F) o Iz U! -c o z gI r^ r4 &, o ra ul =o UJ OE \,z a2 =t! z o l- 6 o 17 g6h t Table 3 Budget (rn USS) for provrsron of sustarnable documentatron system ln o I o(\l F UJ\, o l co o z z o F u- o z J o- ci 9 CE UJ CL F l o(, z a I CL o z = u.J I o- c( o I F gJ l o IIJ d. \, =oz f tL J z o E o o 't8 20'r s US5Year 2012 20't 3 20 t4 Amount USS r oil 300 r 0r0000 I Training Target FLHFs willbe identified, following which trarning on basrc fihng and tracking ofrecor& and on the use o[data collected for planning of annual activities and decision-making wil! be underuken. Distribution and handover of matenal to FLHFs and annual inspectron o[ the recording centres will be camed out by district/national personnel. Table 3 sets out the budget for US$3,0,10,100 to undertake this activity. Output 1.4 Community Self Monitoring and Stakeholder meetangs Backgrou nd a nd Ration ol e APOC has encouraged communities that receive ivermectin treatment through the CDTi to adopt Communrty-Self Monitoring (CSM), a novel system for monitoring the communrtres' own performance of the ivermectin distnbution projects. This model is suiuble lor adapution for all PHC seMces within the community with the eligible communities being empowered to set up and to conduct the monrtoring of their own performance. As a community-driven process, CSM provrdes a mechanism for ensuring that the programme is being executed as intended. CSM allows each community to discuss issues that could jeopardize community participation and also to address common problems which weaken delivery e.g. ivermectin shoruge, high rates of absenteeV refusals, and non-treatment of temporary ineligible persons (breastfeeding mothers, @9800 409000 3040 t00 the sick). Furthermore, it enables the community to discuss and review CDDs drop out, lncentives to CDDs and inadequate treatmenl coverage. The outcome of the CSM is reported annually at the Stakeholders meeting (see below), a forum at which rhe communities and health workers have the opportunrty to discuss the aggregate resulrc from the CSM exercises. Between 2007 and 2009 73,000 CSM activrtres have been carned out in 20 projects. Thrs constitutes only 19% for the 108 projecs considered. The current upscaling of the CSM by communities is therefore low, and there is an urgent need lor efforts to encourage uptake to all communities. Expanding CSM in CDTi and for use by other PHC services involves tralnrng health suff at FLHF for facilitation of this exercise at community level. APOC will therefore reinforce communities' involvement and ownership of the entire process of CDTr including extending the use of CSM to 90% of communities by 2015. CSM will be expanded as follows: .10% of total communities in 2012,60oh in 2013, and 80% in 201a. By 2015,90% of communities would be expected to have carried out CSM activities. lt rs APOC's aim to support the communities in achieving a therapeutic coverage of80% rn an effort to accelerate the ehmrnation of the infectron and interruption of transmission in all countries. CSM will be an important component for assessing the performance of the communitres. APOC has encouraged Stakeholders meetings (SHM) in the communities that have embraced Table4 Budget (rn USS) for conductrng CSM and Stakeholder meetrngs SHM A(t ivity 201 32012 20'r 4 20't 5 TOTAL csM SHM Tot l 609 500 2500@ t59500 80940 500000 l3O9/m | 009400 5m000 t 509'l0O r r094q) 5000@ l6Oe 'mO 3537 7N r 750000 s2€,77oo CDTi. At the meetings, the communities report the hndings from CSM activities and other health issues which may need to be addressed through PHC. Such meetings create a forum for the communities to raise health issues they consider imponant for dscussion with other stakeholders, including the health suff. Given the need for an 80% therapeutic coverage, such fora will be critical in ensunng thar communities are consuntly aware o[ the need to include women and minoriry groups and is imporunce for making progress towards elimination of onchocerciasis. Activities I APOC will support countries to sensitize district and sub-district health management teams ro include stakeholder meetings in annual plans of action. Special attention will be given to communities with low ivermectin treatment coverage and other PHC activities requiring improved participation of communities. I Country health services will use SHM as a health system/community platform to improve their performance in all PHC and MDG related health issues. The additional budget for CSM and SHM is US $5,287,700 and is set out in Table 4. Output 1.5 Strengthening the Scaentafic and Evidence Base: Establishing an Onchocerciasis lnformation Memory Bockg rou nd a nd rationole APOC and its partners have established a repository of invaluable information to help wrth the development of self-sustainable systems that are required for the control and elimination of Onchocerciasis and other diseases of poverty. This data collection will continue to constitute a rich source of informatron well beyond the operation of the APOC. It is, however, essential that further plans are made for safe storage, archiving and methods for updating the information and ease of retrieval of the stored data. The change of health staff at all levels and Figure 3 Targets for Communrty Self Monrtonng (CSM) of cDTr 20r 2 r0 2 r 05 Year the normal replacement of CDDs over time means that retaining institutional memory and relevanr knowledge and information could be a challenge if measures for their recording and safekeeping are not established. An Onchocerciasis lnformation Memory (lM) which will be a source of dau and information from previous work as well as for prepanng future storage of data will be essential before APOC closes in 2015. The goal for the onchocerciasis IM is to build a body of knowledge that would be essential for the continuous and effective execution of onchocerciasis control activities now, and after the closure of APOC. This will create an accessible and easily searchable data base on onchocerciasis and related (other NTDs and co-implementation) information that has been generated over 20 years. Such an IM would faciliute availability of information, data, dossiers and rraining materials at all levels when needed, and act as a reference point for all APOC countries to help maintain the standards o[ the methods for the control of onchocerciasis. The inlormation will be used for training and guidance in carrying out onchocerciasis control and elimrnatron activities. lnitially rt would cover 5 APOC countries. The dau and information, to be collected will include expert opinion, studies and evaluations and raw dau on onchocerciasis and its control methods e.g. CDTi, co-implementation and pannerships, epidemiologrcal data, and uaining materials. The dau wil! also include information on guidance on the usage of t00 90 80 ^70ag; 60 9soo .ao 30 20 l0 0 l/t o a! I N o a! F UJ o l co o z z o F I o z) o- o 9 UJ F l o \, z; I o z uJ I o- d, o I F rtt u.J l o UJ E. \, =oz l I J z 9 F o o 't9 TaUe 5 Budget (rn USS) for estabhshrng and marntarnrng Onchocercrasrs lnformatron Memoryo N I r.{ o(\ F \r.J(, o l EO o z z 9 F I o z) o- ci 9 CE LU o- F f o \, = I o- o z UJ I o- o I F uJ l o UJ c( I z o z l I) z o E o o 20 us5Activity 20] 2 2013 20] 4 20] 5 furchasey'lvlaintenance of the portal servec Wki and web sofuare, data collection equiptnent AdvarKed $reb training/ Wshop on marntenance of rnformaton centers DevelopmenL upgrade/distnbute the disk version of the lM, Iotrl USs software programmes, dam and material from peninenr research. Clinrcal dau including chemotherapy, treatment information and dau on Severe Adverse Evens (SAEs) following treatment will also be stored. The format and storage for the information package will b€ accessible through the internet. The lM will initially be accessible by WHO/ AFRO country office libraries, unrversity/ college libraries and some Mintstries of Health library/information centres in 5 countries. The IM should be kept "!ive" wrth appropriate and regular maintenance of the lM web site to keep abreast with the changing health priorities, and adapuble to changing processes and emergrng new ideas. WHO/AFRO or an inter-country faciliry could be best placed to oversee such a maintenance [unction post-APOC. The lM can only be useful and relevant i[ it reaches and is used by the intended recipient. This means that the delivery process should be carefully and well coordinated. The roll out of lM delivery process would be gradual while APOC is still in operation, and measures to monitor iu use instituted. Activities I Knowledge Network APOC wrll revive the current Documenration Centre at its HQ in Ouagadougou and share its body o[ literature with other instttutions. As pan of this process, country libraries and information centres that could be possible holders of APOC information and resources will be rdentrfied, and a Memorandum oI Understanding drawn up with each centre to this effect. The curent APOC website will be enriched and repopulated addrng sections that would make it suitable to host the Information Memory ! Distribution A disk version of the IM will be developed and this will be ready in 2012 for distribution. Additronally, the IM package will be distributed to each of the envisaged centres, starting from 2012, while updates will be sent out each year for the next zl years. I Training and Engagement Workshops to emphasize the importance of maintaining the information centres and persuading the targes to visit them will be spread out in rhe next four years. While keeping records does take time, with commitment from APOC and partners, the savings on trme and effort gained from establishing the IM before APOC closes would help improve luture planning. The budget [or this activity is $112,500 as set out in Table 5. OB.,ECTIVE 2 Co-inrplementation and gender mainstreaming to strengthen PHC. Backg rou nd o nd Rotio n ole For over l2 years, APOC, with the support of the global health community, has been using the (CDl) strategy to fight river blindness in sub-Saharan Afnca. Through this process APOC partners are currently treating close to 70 million people annually with ivermectin (programme UTG is 90 million by 2015), a safe and effecttve drug donated by the pharmaceutical company Merck & Co lnc for the successful control of :he disease. The CDI process has indeed r8000 5 000 0 zr(m 2@0 3 500 25m0 to50 4 000 5m0 20000 29@ 2 000 4m0 24 000 30oo 26000 t7 5@ 690@ ll2500 been a major breakthrough in increasing community involvement and ownership of health care interventions. Additionally, a recent TDR/APOC multi-country study has shown that the CDI strategy is an effective tool for the delivery of muhiple (6ve) health interventions. The expansion of the CDI "know how" to other institutions responsible for health interventions should help equip the current and future health care providers with this tried and successful intervention strategy. APOC, rn collaboration with the West African Health Organization (WAHO) and the Regional Institute for Public Health in the Republic of Benin, has developed a curriculum and training module for CDl, which is suimble for insrruction in higher institutions. This is based on the manual which is currently being used by more than 108 CDTi projects in 23 African countries. The curriculum and training module have been adopted by 35 Universities by November 2010. Twelve of the universities have already submrtted proposals to APOC for the introduction of CDI into the curriculum. The aim of introducing the CDI strategy in the curricula of the Unrversities will broaden knowledge of the CDI methodology, and to improve the ability of health personnel in engaging communities in health care delivery. This wil! contribute to improvement of PHC and help with the attainment of the health related Millennium Development Goals (MDGs). APOC will support Primary Health Care (PHC) delivery through the implementation of onchocerciasis control activities in conjunction with other health interventions with strong emphasis on gender equity. Output 2 Co-implementataon and gender equity This output includes four sub-outputs, including mainstreaming CDI curriculum rn African university training, NTD mapping, capacity building for co-implementatron and enhanced research. The activities leading to these outputs will all emphasise gender equity. Output 2.t lnclusion of CDI Approach in Curriculum of Universities Activities APOC will support the introduction of the CDI curriculum in more than 50 universitieVmedical schools in Africa. ln the next 5 years - by 2015 - 58 universities would be teaching the CDI strategy. The activities to achieve this output will involve the following: I Sensitization seminars and workshops APOC will fund and support sensitization seminars and workshops for faculty staff and the university community. The concept of CDI is a variant of community- based intervention, but a fairly new principle, and in some cases completely unknown to the formal health services. It has not yet been introduced in the institurions that rrain the staff who undertake health interventions. As an essential component of the introduction of the CDI in the institutional curricula, it will be necessary to undertake sensitization seminars and workshops for faculty staff and the university/ institutional community. This is ro ensure adequate understandrng of the philosophy behind the approach, the acceptance of the strategy and to facilitate instruction in the institutions. t New training materials Films, other teaching tools and literature on CDI training manuals particularly suited to the institutions in question will be produced. Additionally, there will be reproduction of existing and new CDI training materials in locaUnational languages for improved dissemination. The CDI curriculum wil! be incorporated into other modules of instruction at the undergraduate level. However, at the post graduate level this will be a "sund alone" module. o ct I d o at F UJ l, of co o z z 9 F I o z J o- ci o IIJ F l o(, z; I o- o z uJ I o- CC o I F lrl l o UJ d \, z o z I J z o E o o 21 Ln or\ I(\ o r.{ F UJ\, ol cEt o z z o F L o z J o- Ci o a IIJ d F l o \, z; I o- o z UJ I o- d. o I F IJJ f o uJ d. \, =oz ftr J z 9 F o 22 I Advocacy "CDl curriculum-for-medical-schools" meetrngs, four in all from 2012-2015, will be organized and funded by APOC. This will bring together Vice- chancellors, deans and senror academics of universitieVmedical schools. Health experts on onchocerciasrs and other control proS,rammes, NDGO partners, personnel from Ministries of Health and Education of countnes and National Universrties Commission or its equivalent in countries will also participate in the meetings, whrch will aim to ensure that more medical schools introduce the CDI process in their curriculum and the roll out follow-up activities. Three advocacy missions wrll be undertaken by APOC in 2012, 2013 and 2015 to help sustain the momentum ln the introducuon of the CDI curriculum and for follow-up actions. I Regional Coordination/Implementation Committee Regional Coordination/lmplementation Commrttees, of selected health experts and senior academics will be set up. The Committees wrll meet each year as from 2012 through 2015 to harmonize the training method in medical, public health and nursing schools, assess progress and measure outcomes against the objective/goal towards institutionaliztng the CDI strategy in the school system. The Committee will also prepare a roadmap for continuity beyond the closure ofAPOC. It is estrmated that a total of US$ I 939 000 will be required to undertake these activities as set out in Table 6. Output 2.2 Integrated Mapping of Five Neglected Tropica! Diseases (NTDs) Backgrou nd a nd rotionol e The Neglected Tropical Diseases (NTDs) are a group of l,t parasitic and bacterial infections that alflrct over 1.4 billion people in the world, mostly affecting the world's poorest people who often live in remote rural areas or urban slums. They strgmatize, disable, and rnhibit indivrduals from being able to care lor themselves or their families, trapping them in a cycle of poverty The seven most common NTDs, lymphatic filariasu (LF), onchocerciasis, schistosomrasis, trachoma, ascariasis, hookworm, and trichunasts, are PCT diseases to be considered by APOC. The la* three are known as Soil-Transmitted Helminthiases (STH). NTDs have hitherto received htde attention and /or funding for therr control. However, cheap, safe to use and cost-effective drugs for the control and/or elimrnatron of many of these diseases are now available. For an oprimum and a cost-effective use of the limited resources for control of the NTDs, an implementation approach wrth proven effectiveness in under-resourced national health sys:ems is requtred The Community- Directed lnterventions approach wrdely used in 15 APOC countries is recognized as one of the appropriate methods lor the control of PCT diseases. lt s a strategy that is readily available in the remotest pars of countries. A recent study conducred by TDR showed that community volunteers when well tratned could be effective rn the co-implementatton of 5 health interventions. Tablc 6 Budget (rn U55) for lnclusron of the CDI approach rn Currrculum of Unrversrtres 20'r 3 20't 420r2Act ivity 20'l 5 Total US5 APOC support for rnedical a,rd nuEing rnstitu- tons rn sub,Saharan Afiica for CO cunrculum and related actvities Mvocacy missions Regional meetrngs on expansion of COI currrcu- lum rn medical instrtutons Coordrnation /lmplementation Commrnee meetings Iotal USI 450000 305500 301 000 2025@ I 259000 30000 r000m 30000 1(x)0q) 30000 r00000 300@ lm0@ r20000 @0m r60m0 r 939000 ,10000 ,()000 ,()000 4()000 620000 a755im a7t000 372500 Table 7 Budget (rn USS) for integrated mapprng of NTDs rn o N I a! o a! F UJ\, ol co o z z o F I o z J o- C; 9 [l o- F f o \, = I o- o z UJ I o- d. o I F UJ l o UJ E. (2 z o z l I) z o E o o 23 Yea r 20'r 2 20t 3 20'14 201 5 uss llappirg io countrl6 Nig€rlaCotedhoale. Guine-llissau Gabon, Ethirpialanzania I Ot20o0 Nlgerialcnya, lleamtiqw Rwarda, Ethiopia t05@o AngrolaSudan AngolaSudan, DRC Alr Tot luss In May 2010, APOC organized a meeting, for resource persons for PCT diseases from l3 African countries to assess the status of mapping o[ these diseases in their respective countries, and to ascertain what gaps need to be filled. The meeting concluded that onchocerciasis is almost fully mapped in the majority of the countries while signifrcant effort has been made in the mapping of lymphatic filanasis. For schistosomiasis, STH and trachoma, a lot of information that was used to produce the maps of the distribution o[ these diseases came from health facilities records or literature review. Activities I Mapping APOC will facilimte the hnahzation of PCT disease mapping in APOC countries where this is appropriate. In this respect APOC will also support NTD VHO/ AFRO to assist countries, in stages, to undertake or complete integrated mapping where needed. The purpose is to obtain accurate starrstics on the burden of major PCT diseases, their overlap and geographical distribution, in regions (usually administrative divisions), initially where a CDTi project is in existence and later in other countries under the scope of APOC operations; I Strategic Action Plans will be developed for integrated control of the major PCT diseases targeted in this proposal: STH (ascariasis, hookworm, and trichuriasis), lymphatic filariasis (LF), onchocercrasis, schistosomiasis, and trachoma. The budget for these actrvities is US$ 3,019,500 as set out in Table 7. 702ym t@oo 3019500 Output2.3 Co-implementataon and capacity building Bockground and Rotionale Since 2008, several of the APOC supported countries have taken the initiative to engage the communities and CDDs in including other health interventions in their usk. This initiative has been largely successful and documented in at least 7 of the countries with over 40 proJects whrch have used their CDDs for the treatment of lymphatic filariasis, STH, Schistosomiasis, trachoma, as well as provision o[Viumin A supplemenution and distribution of lnsecticide Treated mosquito Nes (lTNs), in addition to ivermectin distribution for onchocerciasis conuol. By so doing, many severely underserved onchocerciasis endemic communities have benefited from these and other rnterventions. Co-implementatron o[ multi-drease control activities is a srgnificant health dehvery strategy which helps reduce cosr, and maximizes health impact. Co-implemenation has always been attractive but has been elusive to many health care providers partly because the appropriate or "ideal" strategy for carrying out this had been unavailable. The CDI strategy responds squarely to this need. APOC will suppon NTD/ WHO/AFRO, NGDOs and otherpartners to embark on co- implementation through CDI infrastnrcture already in place in the countries for this strateg'y. ln 2007, theJAF expanded the mandate of the programme to include suppon for co-implemenution of CDTI with other health interventions. However, in order for the CDDs and peripheral health workers to discharge these additronal responsibilities they require further trarning. We also need :o provide additional support to the health TaHc 8 Budget (rn U55) for Capacrty burldrng rn lnstrtutronal strengthenrng and human resource for co-rmplementatton rnterventrons, 201 2-201 5 o I N o N F UJ\, o l EO o z z o F- II o z) o- c; 9 cl LU o- F l o I = I CL o z UJ I o- d o I F l.lJ l o I! G. \, =oz f I J z o E o o 24 ussDescription 2012 201 3 20'r 4 201 5 Training health workers for cormplementaton Training CDDS as awareness ,arsrng agents Monitorang Co{mdementaton wnhCO Tot lUS' 1.550,000 care workers to adequately supervise and monitor the co-implementation activrties. APOC is therefore r€ady to support countries and NTDflVHO/AFRO in strengthening PHC for effective public health interventioru, including those lor PCT diseases, malaria and vitamrn A defrciency, wherever and whenever rhis possible without displacing APOC's primary objecdve of ehminadng onchocerctasis as a public health problem from Africa. APOC will share its experience wirh WHO/AFRO and advocate for use of rs CDI stnrctures. Activities I Support to countries and NTD/ WHO/AFRO for capacity burlding for co-implementation, cost-effective and important public heahh interventions for PHC using the CDI strategy. I Training of tratners for CDDs and peripheral level health workers on plannrng and implementation of co-implementation using CDI strategy. Training CDDs as awareness-raising agents a( the community level to improve, for example, the use of insecticide treated nets by households. I Providing operational funds towards co-implementation of synergistic health commodities and interventrons with ivermectin distribu tion I Monrtoring of co-implementation o[ health interventions Based on these the following major activrties are planned for the period 2012- 2015 to be covered by the additronal request budget of US$ 8,10'+,000. Output 2.4 Building Capacaty of nataonals and increasing the output ofoperational research Background ond rationole The Onchocerciasis Control Programme rn West Africa has benefited enormously from the results and evidence-based data of on-going operatronal research which informed decisions during the course of rs operations. In recognizing the importance and usefulness ofoperational research for such an endeavour, the External Evaluation of APOC in 2005, recommended that APOC strengthen the capaciry of the APOC countries to enable them undenake operational research to support the Programme. ln view of this recommendation, the Technical Consulutive Commirree (TCC) of APOC and APOC Management have made efforts to increase the number as well as to improve the quality of proposals from some APOC countries in the last three years, but with limited success. Beween 2000 and 2008 only 7 countries have had several proposals for operational research accepted. There is need, therefore to identrfy innovative ways to increase the capacity for conducting research, especially in the [rancophone countries, and to facilitate and encourage screntifrc publication within countries. ln view of the increasing importance of rhe CDI approach for co-implementation, operational research needs to be relevant not only to onchocercrasis control projects but to the control of neglected tropical diseases and malaria. APOC will seek to strengthen collaboration and partnershrps with WHO-TDR, other lnstitutes of Troprcal Medicine and Hygrene 400,000 t,250.0@ 400,000 r.250.m0 5m,000 2,300p00 400,0@ t250,000 504,0q) 2,roap00 4(x),m0 t250,000 5m,000 2pt0p00 t,ffi,000 5,m0,000 r,504.000 6,toapoo a and the Liverpool Centre for Neglected Ttopical Diseases among others for building of capacity for operational research. Activities APOC will support the following activities: I Increase in funding level for operational research The funding level for operational research from APOC would be increased by raising the maximum level to US $30,000 per team. This amount should accommodate the perennial fluctuations in the dollar exchange rate /currency situations in the countries concerned. I Training workshops on research methodology /scientifi c writing Training is a basic requirement to improve submission of successful research proposals and their implementation. Short term in-country training is therefore proposed to cover the writing of research proposals and protocols, development of research methodology and preparation o[scientific reports. A regional training workshop on development of research methodology and scientific writing will be held for the Francophone countries of West/Central Africa and a similar one undertaken for the Anglophone countries, which would include Cameroon. I Identification of research requirements A small team of experts will be put together to review APOC activities to identify research requirements. The team will include a member from TDR./WHO plus an independent expert who is experienced in CDTI and research. The team will also be required to visit several countries/projecs to obtain their input on requirements for operational research. I Support for multi country research Multi-country research studies are likely to provide more scientific value and have a higher profile for APOC and the scientific community generally Through a rigorous approach, standardization of methods, large sample sizes involved, and the opportunity to analyze complex and large bodies of data, participants also benefit from the wide variety of research methodologies employed. Such studies will be undertaken every three years and although multi-country multi- site studies tend to be more expensive, they provide value for money as their findings can be extrapolated over a wide area. I Publications APOC will provide support for the publication o[ results in the form o[ assistance in the preparation of manuscripts and assistance with translations o[ documents from English into French and vice versa. The estimated budget proposed for these activities is US$ 2,+40,000. Table 9 Budget (in USS) for lncreasing, capaclty, and output for operational research Lt oN IN oN uJ\, ofo 6 z z o L' t! o z G ci o 0c lllA f o I z ra -c o z lrJ ta I o. E olr. ra UJ :) ot! 0c I z 6 z3t! z o 66 25 2012 201 3 2014 201 5 us5Activity Increase funding fur Operational Research Regional w/shops Research requirements Multi-country research studies Support for publication Total 300,000 250 000 30 000 250 000 45 000 87sm0 300,000 n 0 0 45 000 345 (xro 300,000 250 000 30 000 0 45 000 625 (xro 300,000 0 0 250 000 45 000 595 m0 1,200,0@ 500,000 60 000 s00 000 1 80 000 2'[4O(xro { ra oN IN oN t!(, of6 o z z o TJ lt o z 4 6 9 G UJ G f o I = ut -E a z UIla -G 0c o IL F(a UI =o UJ G, I z 6 z =t! zI ts o o 26 OBJECTIVE 3 To transition APOC delivery to complete Country Management Output 3 Enhanced APOC delivery capacity and support to countries. The planned closure of APOC in 2015 requires an expansion of services to transfer capacity to national authorities, as well as a specific set o[ measures to close the organisation by 2015. Output 3.1 Short Term Measures to lncrease Capacity (2O't2-201s) Background and rationale One of the philosophies of APOC has been to make the participating countries self-reliant in the implementation of a sustainable drug delivery system through the CDTi for the control oI onchocerciasis. ln the process, APOCs Technical, Administrative and Management staff have over the years striven to fully support the countries through the provision of administrative and technical guidance. APOC has also provided managerial input to the countries to help them run their CDTi projects successfully. In this respect APOC has been successful in helping countries establish the CDTi in the delivery o[ other interventions. Some countries still require APOC's support to help them technically and managerially with their control efforts. All the support from APOC hitherto has been provided with a rather small number of staff, which has been stretched to the limit. As APOC transfers management o[ control and elimination to the national level, and supports co-implementation, gender mainstreaming will remain a priority APOC management will require a short term increase in capacity to support this process. These added tasks require more investment in support to managerial, administrative and technical capacity by APOC staff to the countries that will undertake the required activities. It is important for APOC to continue supporting a gender specialist position through to 2015 to strengthen gender equity at country level. Activities I Expert Pool The shortfall in "sitting" technical expertise will be made up by taking on temporary staffand consultants to undertake specific assignments i.e. support to countries (technical, financial and administrative management) and to APOC headquarters in Ouagadougou to a lesser extent. The additional managerial, logistics and administrative support will be needed for the temporary staff and consultants. The annual increase in salaries as well as support for other services will require an additional overall increase in cost as from 2012 through 2015. The total additional for human resource management administration and support services cost ofhuman resource during this period is estimated to be about US $3,922,500 as set out in Table 10. Output 3.2 APOC Programme delivered and transition to complete Country Management. Bockground and Rationale The APOC programme was formally launched in 1995 and its headquarters were Table lO Additional Budget for human resource management administration and support services for 2012-2015 ussActivity Personnel Seruices Professional fixed term staff Temporary staff Administrative support, Logistics and infrastructure Vehicles Office and equipment Total uss 2 632 800 1 137000 152700 3922sOO set up in Ouagadougou in Burkina Faso. This arrangement allowed APOC to benefit from oflfice space, administrative support and finance functions, as well as some initial technical input from the then OCP staff. Over the years the APOC machinery has grown at the Headquarters and APOC has deployed some staff in specific countries. Additionally, the number o[ participants in the Programme has also grown. As APOC prepares to transfer management to countries it will be important to take stock of all these modalities and commence a planned and smooth transition. Activities I APOC Transition Committee A "Ttansition Committee" made up of relevant staff from WHO/AFRO, WHO/HQ and APOC will be set up as from 2012 to oversee the modalities for and to make the appropriate recommendations to APOC, WHO/AFRO and APOC Partners for the closure of APOC. This team will meet early in 2012 to set out the actions to be taken and review the key steps set out below. The group will then meet quarterly at the APOC HQ to assess progress with the plan towards transition. I Personnel of APOC. APOC has two categories of personnel, fixed term staff and temporary. Some of the fixed term staff have continuing emplol'rnent. These face possible redundancy when APOC closes at the end of 2015 unless they frnd other positions within the organization. The contracts o[ the other temporary staff (consultants and short-term professionals) will be prepared in such a way that they come to a natural end with transition to country management The administrative procedures for the termination of the employment will need to be explained carefully and thoroughly to these staff. As was done when the OCP was to close, APOC with guidance from WHO headquarters will provide the necessary information on retirements, rights, possible reassignment opportunities, end of employment benefits and other administrative issues to individuals, as well as on a group basis. Special sessions to be provided by experienced personnel in the WHO will be held for the different categories of staff. It is recognized that some of the staff have spent long parts of their careers with Oncho control and may not have expertise which will allow them to move into other areas. This group of staff will be provided with the opportunity to undertake courses to help them compete in the open market. The staff will also be provided with counselling to prepare them for the impending closure. Possible employment avenues will be discussed with them with the view to encouraging them to consider these positions. APOC has some staff under its responsibility that are located in the WHO country offices in APOC countries. These staff were initially engaged on a temporary basis but some have been converted to frxed term employment basis, but for a limited duration. APOC's responsibility for such individuals will cease with the closure of the Programme. A clear understanding o[ what this means will be communicated to the staff through visits from the administrative staff. I Liabilities APOC administration and management will conduct a detailed assessment of any contingent liabilities that may arise. Advice from the WHO/Legal office and Human Resource Development (HRD) will be sought very early in the preparations for closure. APOC will expect visits from the Legal Office or HRD from the WHO/HQ in Ouagadougou to discuss issues and advise on positions to be adopted by APOC. I Documentation and reports Most APOC documents and reports are in electronic form. Backup copies of these will be made to be placed in the archives and copied to the relevant APOC countries. Material that is not ut oN I(\ oN lu I o =o o z z o U lt o z o ci o 0c u.lG , o Iz t Ie o z lu ah E a. OE olt r^ ur D olrlE Iz a z3]L z o 6 o 27 Table 11 Budget (in USS) for APOC closure activities2012-2015 ln oN IN oN UJI ct36 o z z o U lt o z G ci o E UJc f o (9 =UI !e o z ul rn -G cc o (a llt =o ut ts I z E z =l! z o 6 o 28 USSActivity Closure Committee Personnel Liabilities and legal Premises, land titles and Legal Equipment, inventories, Vehicles, Disposal Bank closures Post- APOC closure team Total USS in electronic form (e.g. egg books and other documents) that were prepared in the early days of APOC will be scanned electronically with the necessary back up for the archives. ln this respect, the proposed Oncho Information Memory will play a key role as from 2012. Material will be shared among the participating countries in both electronic and in hard copies. The process of converting large documents from paper to electronic form could be time consuming, so this process will be stared as early as 2012. I Equipment A full inventory of all equipment presently at the APOC headquarters will be undertaken in 20I2 and updated in 2013. In this regard, the Supplies Unit in APOC began in 2010 to visit all the APOC countries to take inventory of equipment that has been provided by APOC to the NOTE If necessary, agreements with relevantcountries will be drawn up in 2013 for the basis of distribution of any material not kept at the APOC premises. I Vehicles APOC has vehicles which are all in good working condition at the HQ. There are also vehicles that have been purchased by APOC for the projects in the APOC countries. The flnal status of these vehicles will be documented by early 2014 in preparation for their disposal. The disposal of these vehicles will depend on the agreement that is set out with the partners and the recommendations of the Transition Committee. 200,000 1,700,000 230,000 6s0,000 175,000 2955,(x)O I Premises APOC is responsible for and occupies the largest portion of the premises at the APOC HQ in Ouagadougou i.e. the previous OCP building. APOC shares the building with other WHO entities such as the Multi-Disease Surveillance Centre but it is responsible for the land title deeds for plots. APOC will endeavour to complete all the documents and legal agreement and costs pertaining to the buildings and plots before 2014. Depending on whether or not the premises may be taken over by another WHO Programme, the Transition Committee would be charged with recommending the use of the premises. I Disposal of non viable materials, chemical etc. The Supplies Unit in APOC will work with the competent authorities in Burkina Faso to dispose oI all non- viable material including chemical and insecticides. A similar guidance will be given to the various NOTFs for safe disposal of equipment in their countries and records kept. I Closure of Bank accounts Closure of Bank accounts and financial books at APOC headquarters and NOTFs Personal visits will be made by the administration to the relevant countries to undertake these tasks as from early 2015. lt is recognized that full closure of accounts can only occur in 2016. I Legal issues All the legal documents e.g. Memorandum of Understanding with a Governments, Partners, NGDOs etc will be revisited for discussion with the partners with regards to their termination in 2015. All outstanding issues will be addressed as from 2012 with the support from WHO /HQ Iegal department. f Post Transition Arrangements Experience from the closure of the OCP shows that after APOC comes to an end in 2015 it will take at least 9-I2 months to finally wind up all its affairs. A small team consisting of personnel from the management, administration, finance and some ancillary staff will be constituted to undertake this follow up activity through 2016. An estimated amount of US $2,955,000 to undertake the above activities is set out in Table I 1. I ln oN IN oN F UI(, o D6 o z z o \, t! o z c ci 9g uI o. D o 19 z UI -o a z gr ra T o. E olt F an IIJ3I ul OE(, z 6 z Dt! z 9 ts cr o 29 a Summary Budget The total budget for the three year period is $60,959,353 of which $11,459,053 is already approved. The additional funding request is therefore for the amount of $49,500,300 over the four year period. The additional amounts requested for each FY are $I4.60m 2012, $13.72m 2013, $1 1.89m 2014 and $9.22m 2015. The profile of expenditure is shown in Figure 4 and the budget summary is shown in Table 12. Table 12 Budget summary Figure 4 Allocation of New Funding By Area 2012-20'l 5 a Strengthening PHC systems for colmplementat on Transitioning APOC to Closure 1r\ oN IN ol\t ul 1., o =o o z z 9 TJ lt o z G ci 9c uIe =o Iz ut Ie o z uI vt I o- cc olt F ra ul c, IIJc I z a z3 l! z o E o 30 output area TotalYear 2012 Year 2Ol3 Year 2014 Year 2015 Existing approved funding 4,578AN 3,413,500 (Output 1.1) Output 'l Core CDTI octivities ond elimination Output 1.1 2,400,000 2,200,000 Expanded core CDTI Activities Output 1.2 5,170,000 3,250,000 Elimination surveys including capacity building Output 1.3 l,0l 1,300 1.010,000 lmproved Record Keeping HFL Output I .4 859,500 1,309,400 CSM and SHM Programme Output 1.5 23,000 30,500 lnformation Memory (lM) Sub-total 9,463800 7]99,9N Output 2 Co-implementation Output 2.1 620,000 475,500 CDI cuniculum in African Universities Output 2.2 1,01 2,000 1 ,005,000 lntegrated NTD mapping Output 2.3 1,650,000 2,300,000 Co-implementation Output2.4 875,000 345,000 Operational Research Sub-total 4,157,000 4,125,500 Output 3 Enhanced APOCdelivery copocity and supportto co{.tnv'rcs Output 3.1 945,000 1,045,500 Short-term measures to increase capacity Output3.2 298,000 282,000 APOC Closure Sub-total 1,243,000 1,327,5@ 1,706AW 1850,000 2, r 20,000 609,800 1,509,400 29,000 6,r r 8,200 471,N0 702,5N 2,r04,000 625,000 3,902,500 1,026,700 337,s00 13U,2N 1,570,000 1 20,000 409,000 1,609,400 30,000 3,738,4@ 372,5N 300,000 2,050,000 595,000 3,3r 7,500 905,000 2,037,5N 2,%25co 8,020,000 10,660,000 3,040,'t00 5,287,7@ 1 12,500 27,120,3@ 1,939,000 3,0r 9,500 8,104,000 2,m,0N r 5,502,500 3,922,5N 2,955,000 6,877,2W 1,760,753 I 1,459,053 a Additional budget request 14,863,800 13,252,900 11,384,900 9,998,400 49,500,000 Toal Budget 19,U2,2O0 1O6664m 13,091,300 11,759,153 60,959,053 CDT and strengthened tai onal systems

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