Progress report on devolution

Onchocerciasis Control Progranrme in West Africa Programme de Lutte contre l'Onchocercose en Afrique de l'Ouest' JOINT PROGRAMME COMMITTEE Office of the Chairman JOINT PROGRAMIIIE COMMITTEE Seventh sesslon Accra, $-12 December 1986 JPC .CCP COMITE CONJOINT DU PROGRAI\{IVIE Bureau du Prdsident JPC7.5 ORIGINAL: ENGLISH October 1986 I Provisional ACe4Ee ;!!e4 13 PROGRESS REPORT ON DEVOLUTION 1. The concept of devolution within the context of the Onchocerciasis Control Programme in West Africa (0CP) has during the past few years undergone a considerable change. From being perceived as ". . . a progressive process of transfer of activities presentLy carried out by the Programme to the national structures of the countries concerned . . . . " (document NOC 7/4, 1983) implying the setting-up of "mini-OCP" mechanisms in each of the Participating Countries, devolution is today understood to be the assumption by each country of the residual operational responsibili,ty for ensuring that there is no recrudescence of the disease in those areas where it has been brought under effective control, 2. This recent understanding of devolution implies that OCP will remain responsible for vector control and epidemiological evaluation in any given area (OCP Operational Zooe(002)) as long as such actlvi-ties need to be carried out on a routine basis, i.e. until the risk of transmission of the parasite has, for all practical purposes, been eliminated(72-15 years). In the Western Extension area lnvolvement on the lines described above is built into OCP activities from the start of operations. 3. Devolution, as suggested above, amounts therefore to a nationally directed case diagnosis and control of onchocerciasis in areas where OCP no longer operates - although the Progranme continues its vector control activities elsertrhere and remains available for assistance whenever required. Case detection w111 be required 1n areas where sporadic localized transmission of the disease occurs (if ever) so as to a11ow for (ivermectin) treatment of the exposed population in order to prevent a recrudescence of the disease. 4. Consequently, the process of devolution becomes equivalent to the Participating Countries ensuring that their health care systems are suffj-ciently strong to deal effectively with onchocerciasis case detection and, when necessary, ivermectin distribution. The preparation for devolution may therefore be seen as an opportunity for' reinforcement of international and bilateral collaboration in the field of overall hea1t1l development in the countries concerned. This conforms to the desire of the Participati.ng Countries to use devolution for the strengthening of their general entomological and epidemiological surveillance systems, within the context of the development of the health care systems, including Primary Health Care. OCP is collaborating directly with the Participating Countries in drawing up their devolution plans and in identifying resource needs that may attract external assi.stance. 5. The World Health Organization j-s the international lead agency in supporting health development. As devolution and development of health care systems are so closely linked, the role of WH0/AFRO is important in the whole process. { JPCT .6 page 2 6. The three countries which are the first to start devolution, Burkina Faso, Mali andNiger, have prepared detailed plans of action which are attached (documents JPCJ.6(A),6(8) and 6(C) ). The presentation of these plans - at least broadly - follows a commonpattern which has been proposed by the Programme. Other Participating Countries willprepare similar documents as required. Annex 2 sets out the timetable for the implementation of the devolution process; and Annex J provides a map showing thedelineat.ion of the oCP 0perational Zones. Country Plans 7. As will be seen from Annex 1, the preparation for devolution has gone beyond conceptual consideration. The country documents are operational plans of action setting specific, time-situated targets and defining resource-requirements h,ith cost-estimates.Furthermore, the uniformity of presentation witl greatly facilitate future monitoring and evaluation of the implementation at the country tevel. The Participating Countries concerned will submit regular progress reports on devolution within their territories tothe Joint Programme Committee. B. The fotlowing briefly summarizes the strategy and costs presented in the three countryplans. 9. BURKINA FASO: Burkina Faso had initiated in 1985 a devolution Committee bypresldential decree which has already prepared a first devolution plan in 1985. Thepresent plan gives a comprehensive overview of the health system in Burkina, its goaIs,policies and finances. It then gives a very clear and realistic assessment of the present entomological and epidemiological monitoring systems, which the Ministry of Heatth maintains, and infornatj.on on the existing drug distribution mechanisms. The devolutionplan in the narrower sense includes entomological and epidemiological surveillance and selected chemotherapy. The total annual costs for surveillance amount to CFAJB million or an equivalent of US$108,000. Furthermore, some estimates are made for the possible 'rdistribution costs" of ivermectin at CFAI4 per treatment (US$.09). The devolution planfinally places these activities into the context of the five-year health development plan(1986-90). 10. I{ALI: The plan sets out clearly how the Ministry of Health in MaIi hrants to prevent recrudescence of the disease and gives a precise operational description includingdetailed cost estimates. Three main activities are identified: (i) Blackfty monitoring(entomological surveillance); (ii) Epidemiological monitoring, and (iii) Selectlve chemotherapy with the microfilaricide ivermectj.n. The total annual cost (capital and operating) is estimated at about CFA55 million which is equivalent to about US$182,000, exctuding drugs (October 1pB6 exchange rate). The Mali plan also draws attention to the important fact that these activities wil1 haveto be anchored within the institutional framework of the Ministry of Health pubtic health services. Therefore activities will be executed by its Division of Epidemiology andPreventive Medicine which might require additional support. 11. NIGER: The area of Niger in which onchocerciasis is endemic constitutes only onepercent of the total Programme area. Therefore Niger depends to a considerable extent on effective entomological surveillance of the neighbouring countries and devolution activities will naturally be limited. The totat annual costs for entomological and epidemiological surveillance and some chemotherapy (excluding drug costs) are estimated at CFA69 mi11ion, equivalent to US$197,000. The plan gives as well detailed information on other related aspects of the pubtic health system, such as prevention of blindness, EpI, mal-aria control, control of diarrhoeal disease and family planning. t i JPCT .6 page 3 12. As can be seen from the pIans, the initial estimates of the annual cost for entomological and epidemiological surveillance are very moderate. As the devolution prograrme will be implemented, it is expected t.hat the parameters and costs of a focused and llmited chemotherapy component will also gradually become clearer (presently costs and retreatment intervals for ivermectin are not precisely defined). Given the interest expressed by the Donors in devolution at recent sesslons of JPC and their apparent readiness to support the Participating Countrles in their efforts to strengthen their health care systems in order to cope with devolution, it is expected that bilateral and multilateral support will be forthcoming to cover devolution and associated costs. OCP Support for Devolution 73. The Long-Term Strategy foresees the assumption of responsibility by the Participating Countries of residual maintenance activities once the Programme ceases operations in a given Operational Zone. It now appears that there will be limited activities left for the Participating Countries to do once at OOZ has been in the maj.ntenance phase lor four years. This is reflected in the country devolution plans summarized above for Burkina Faso, Mali and Niger. 14. There are, however, i-mportant operational research questions which need to be answered by OCP to support effectively the devolution process. As concluded at a recent meeting on ivermectj-n, the most important ones are connected with the effect and the use of this drug or any new micro or macro filaricide. Shou1d the drug be used for transmission control or only for modbidity control? Can ivermectin reduce disease transmission in the savannah/forest boundary where forest and savannah species overlap? What retreatment schedules would be required to "clean up" very focalized residual transmission in areaslike Pendie? There are similar research issues in the area of ground vector control which need to be researched. 15. OCP gives priority to these research toplcs and the Programme of Operational Research(see Plan of Action and Budget) is taitored towards initiating and conducting the appropriate studies to answer these i.ssues and to provide the Participating Count.ries with cost-effective and easily implemented technologies to prevent a recrudescence of the disease. 16. There wj.1I also be a difference between maintenance (and post-OCP surveiflance) in the present Programme area and in the Extension areas. In the former most of the OCP 0perational Zones have already, for all practical purposes, been in the maintenance phase for !-6 years and will beneflit from OCP support, whenever required, through to the end of the Programme. In that area more than 1! years of 0CP-condrrcted, and subsequent nationally-directed maintenance operations will take the concerned Operational Zones very close to the point where the human parasite reservoir will die out. In the Extension areas, on the other hand, the Programme will cease operations 5 years before the end of the maintenance phase, a situation which, as mentioned above, cal-ls for a study on how best to ensure that post-OCP surveillance is conducted in a manner whereby all necessary safety precautions are taken. 17. A connected lssue i.s that of how best to make use in the public health field of the Programme's technical and managerial experience, and of its infrastructure, as and when OCP operations commence to reduce in intensity and in magnitude in the present core area during Phase III. Although OCP has a legiti.mate role to play in ensuring that optimum use is made of its unique experience in endemic disease control in the Participating Countries, the Programme wiI1, jointly with the World health Organi-zation through its Regional Office for Africa, take the lead and support the countries concerned in regard to the utilization of opportunities offered by devolutj-on for the strengthening of their "public health systems". t JPC7.6 page 4 18. As stressed above, the devolution process will be centred on the integration within national health systems of residual onchocerciasis surveillance activities, rather than building-up a comprehensive control system capable of undertaking all the various operations carried out by OCP. As such, the Programme will continue to provide advice and assistance for the Participating Countries to strengthen these capabilities for endemic disease control and surveillance. To ensure this in the present Plan of Action and Budget, an accelerated training and fel-lowship programme is proposed. I JPCT .6 ANNEX 1 TERMS OF REFERENCE FOR PREPARATION OF DEVOLUTION PLANS I. Reflexions on the formulations of the devolution plan At the time when the country is getting ready to fina1ize its devolution plan, it seems opportune to 1ay special- emphasis on three fundamental points: The devolution plan should be a document leading to concrete, observable and measurable actions. It must be reaslistic in order to get the unqualified support not only of the Donor Countries but also of the Participating Countries. 3 It must be the work of the Participating Country but the 0nchocerciasis Control Programme (OCP) will contribute to it as far as its circumstances permit. 11. Terms of reference of the consultation mission for the formulation of the devolution 1 2 2 plans 1. To describe the methodology and identify the manpower, material and financial resources existing in the fields of entomological and epidemiological surveillance of the common diseases in the countries as well as the resources available for the distribution of drugs to entire populations. To describe the proposed methodology and identify the additional means required for the inclusion of an entomological and epidemiological surveillance in onchocerciasis control. 3. To evaluate the cost of the operations mentioned under 1. above and estimate the cost of the operations under 2. above. To formulate a mode of distribution for j.vermectin integrated into the health services ' sys tem. 5. To estimate the cost of dj.stribution of ivermectin 6 To elaborate a mechanism in the health services system for the follow-up and evaluation of the entomological and epidemiological surveillance of onchocerciasis. Outline of the devolution plan Present situation Health situation in the country: problems, functionlng, means and cost of health services Entomological surveillance - vectors under surveillance - functioning of the surveillance - resources for the surveillance - cost of the surveillance - constraints 4 III. A. 1. 2 I 34 JPCT .6 Annex 1 page 2 Epidemiological surveillance - diseases under surveillance - functioning of the surveillance - resources for the surveillance - cost of the surveillance - constraints Drug distribution - distribution network - means of distribution - constraints B. Onchocerciasis surveillance and control programme 5 Blackfly surveillance - alert, catching, dissection - request to OCP for larviciding - organization and means - estimated cost of the surveillance - collaboration with OCP (support/replacement of OCP entomological surveillance, training, standardization, etc. ) 6. Epidemiological evaluation of onchocerciasis - examinations - diagnosis of individuals who present themselves - frequency of the examinations - organization and means - estimated cost of the evaluation - collaboration with OCP (selection of vilIages, manuals, standardization, analysis of results, training, etc.) Distribution of ivermectin - distribution network and/or teams - organization and means - estimated cost of the distribution Timetable for the implementation of devolution Fo11ow-up and evaluation - methodology - organization (including reporting system) C. Research and Development (R&D) 10. Subjects : - collaboration with OCP - field trial of manuals - use of OCP personnel on return to country (prior training by OCP) - coordination of external aid - public information (for example, preparation for the return of blackflies) - recolonizaLion to a density not permitting transmission of 0. volvulus '7 B 9 I I I JPCT .6 ANNEX 2 Pro cElon for Partlcl t1 Countrles assumln res nslbl 11 t for onc erclasl-s maintenance activltles Dellneatlon of OOZs: see Annex The preparatlon perlod has arbltrarily been set at t 2000t994 / 199 5 L996/ L997 L9981 t999 t986 I 1987 1988 / 1989 L990/ 1991 L992 I 1993Count ry ooZsr in country o9 x-08-x o8 x-O6 rO7-x x-O9-x 06,o7 Benln EZr"tlon2 period Start of devolut. 06,o7r08 09 02 Burktna Faso Preparat lon period Start of devolut. olr02ro8 x-0l-x x-08-x o1 x-02-x 08 x-02-x x-O3,04-x o5 02 o3 04 o5, , C6te dtlvoire Preparatlon perlod Start of devolutlon 02 , 03,04 05 x-02-x o8 02 x-09-x 09 Preparatlon perlod Start of devolut. Ghana 02r08r09 x-08-x x-10.3-x LO.2 10.3 x-10.l-x x-10.2-x 10.1 Guinea Preparat lon period Start of devolut. 10 10.3 x-lO.3-x Guinea Bissau Preparatlon perlod Start of devolut. 10.3 x-10.2-x 10.1 x-10.3-x 10.2 ro.3 01 , 03 ,10 x-Ol-x o1 x-03-x x-lO.l-x 03 Ma11 Fparatlon perlod StarE of devolut. Ntger Preparatlon perlod Start of devolut. o1 x-0l-x 01 x-10.3-x 10. 3 Senegal Preparatlon perlod Start of devolut. 10.3 x-10.2-x x-10.3-x LO.2 10.3 Slerra Leone Preparatlon period Start of devolut. 10 10 , 2 3 x-O9-x 07 o9 Togo Preparat lon period Start of devolut. 07 08 o9, x-08-x I x-07-x o8 years. The above forecasts are indlcatlve only. Note: It ls assumed that 12 years of vector control sufflces. JPC7.6 ANNEX 3 li ii-i' OCP Operational Zones and Corresponding Operational Phases : SITUATION IN 1986 I I I ---__p-- __ _ __ __ __ _ _ __ _i 4 -r- I l 1 06 .-, , ):- M-Th loil -l P 03 I \l , c, \t \I @i tG f, () \i"ii. \ r '-!, 1 l' oII P : Preparatory IOOZ 09, 10.1, 10.2 & 10.3) C : Consolidation (ZOP 02, 03, 04, 05, 06, 07, 08) M : Maintenance (OOZ 01) @)c I I