Responses to questions from the Department For International Development (DFID) of April 30, 2004

AFRICAN PROGRAMME FOR ONCHOCERCIASIS CONTROL (APOC) RESPONSES TO QUESTIONS FROM THE DEPARTMENT FOR INTERNATIONAL DEVELOPMENT (DFrD) of April 30, 2004 4 / ,} &t I$t e, { t. t1 :, J a ; 1 9 may 2004 * nrl: ,*f, -.a.: .; .N' lij - .:r$... !L'- s i1,. ...\. rl|'1 :.i' _) -f '-.+:l :.i{ ,o#T '$eils- s l t t lntroduction The African Programme for Obchocerciasis Control (APOC)was launched in December 1995 based on the successful experience of the Onchocerciasis Control Programme (OCP) in order to get the whole continent of Africa ride of oncho. The objective of the Programme is to establish within a period of 12 to 15 years, effective and sustainable community-directed treatment with ivermectin (CDTI) throughout the endemic areas within the geographic scope of the Programme, and eradicate the vector in 4 selected and isolated foci. The attainment of this objective is expected to contribute towards the elimination of onchocerciasis as a disease of public health importance throughout the CDTI implementation areas. CDTI is the principal strategy for the Programme, and maximum emphasis is placed on ensuring sustainability and community ownership of the Programme. CDTI is implemented in projects areas. Each CDTI project covers a limited geographic area in an endemic country. This approach allows for a phased introduction of CDTI in a country and applying the lessons learned to the rest of the national territory. Each project benefits from APOC financial support for an initial period of 5 years plus a maximum of 3 years of phasing out period to reinforce community appropriation of CDTI and ensure sustainability. A project is co financed up to 75% from the APOC Trust Funds and at least 25% from Government and NGDO partners in cash or in kind. All the donors' contributions go to the APOC Trust Funds managed by the World Bank, the fiscal agent of the Programme. Upon request from the World Health Organization (WHO), the executing agency, the World Bank transfers funds from the Trust Funds to the WHO bank account. As financial needs arise in countries or at APOC fi/anagement level, APOC requests WHO to transfer funds to National Onchocerciasis Task Forces (NOTFs) bank accounts through the WHO offices for CDTI activities. 2 1) What support has APOC provided at the international level - e.g. technical support to advocacy, mobilization of resources or strategic planning - and what data does APOC have on its own effectiveness? Even though the mobilization of funds is not the prerogative of APOC, the Director of the Programme constantly participates in joint missions with the fiscal agent, the World Bank, for advocacy and resource mobilization. Those missions are opportunities to inform donors on the progress of the activities of the Programme and solicit for stronger commitment to APOC. ln addition to targeting onchocerciasis control in Africa, the missions also contribute to advocate for APOC partners (AFRO/[MDSC-, NGDOs) involved also in other health interventions. Some partners who intend to use the network of community-directed ivermectin distributors (CDDs) use APOC maps of onchocerciasis distribution to draw their own plans of intervention. lmpact assessment studies are carried out to determine long-term impact of CDTI on transmission of onchocerciasis, eye disease, skin disease and the socio-economic status of communities. Baseline data are already available. Mid-term evaluation of APOC operations is undenruay and will soon attest the impact of the Programme. N/eanwhile, . 'AFRO/MDSC: WHO Africa regional office /Multi-disease surveillance centre 3 TINANC'IXG C'Ot'NT RY P RO JEC' TS FRO},I A PO C' TRI"'S T TU"\_NS Overvierv of the Financial FIorv-Chart Request Transi'er A Transler Transfer APOC TRUST FUNBS WORLD Wash 1* RequestAPOG Management Ouagadougou a NOTF Bank account National level Project level crrsrltr L.i!a.a*.1U -r'r.'lrr. *a :!E 1 a, If, cD:t-: aD? l",r CDfI.l0 \"*lar.-1 (DiIt.r (J: CO:I.l 'cr1l tl cr;I* I D& g{46 CO:}TJ \oIf:1 DONORS CONTRIBUTION Anbir SFEQSrrd $tales Kitgdon Pahrd ?te BelkW* fl}ossta Gdherkien Fi*hrl (lrit*s Y*rt*rd Cerldl Slrr*da $rifrerhrd I]NDP Irehrd trlPlr &DR AsstrrEr 4 :-r,, 2) What support has APOC provided at the country level - both in terms of technical support and (through the mobilization of resources and disbursement of programme funds) financing of country programmes, and how effective has this been? How effective has APOG's technical capacity building activities been? Through Rapid Epidemiological lVapping of Onchocerciasis (REMO), APOC has enabled the health authorities to assess the endemicity of onchocerciasis (and loiasis in some cases) in the participating countries. lVost APOC countries are well equipped for mapping onchocerciasis, monitoring and evaluating projects, and data management. By the way, many nationals are trained and become resource persons for the other countries. Some countries where loasis is suspected are known to be endemic have benefited from the advice and training of APOC on rapid assessment of loasis (RAPLOA)to assess the endemicity of loasis with always the involvement of nationals for capacity building. Technical support has also been provided in the area of vector elimination, monitoring of projects by the communities themselves, evaluation of project performance, etc. The technical, financial and human resources provided for CDTI are also used for the implementation of other health programs. The areas of capacity building include: medecine (dermatology ophthalmology, public health, community health), economy (health economy, social science (lnformation, Education and Communication, anthropology), programme management, parasitology, data management, finance management, etc. For example in 2002, 103 people were given special training in the above fields to support their governments in the implementation of varied health programmes. During the same year, 13,713 health workers and 107,008 community-directed distributors (CDDs) were trained to implement CDTI. ln addition, more than 60 participants including accountants and NOTF staff members were trained in WHO imprest accounting system and funds management. Financial supporl to country programmes 5 All opportunities of meeting with national authorities either by APOC management or by advisers or all the partners of APOC are used to advocate for need of financial commitment of the countries for CDTI activities. ln some cases, the project implementation levels have taken this responsibility and are now financing the routine/basic activities of CDTI as defined by the second NOTF meeting. Efforts still need to be made in many cases to get the effective commitment of the national structures. 3) What are the mechanisms for working at country level? Are these appropriate, and are there prospects for getting greater stakeholder involvement and country commitment or ownership? APOC activities are launched in a participating country after the set up of the National Onchocerciasis Task Force (NOTF). The NOTF is created and chaired by the IVIOH with representation from the NGDOs and other partners/stakeholders of the Programme in order to strengthen the partnership and create a strong body that has a role of supporting and overseeing the implementation of CDTI projects at the end of APOC. The NOTFs are responsible for developing National Onchocerciasis control plans and specific project proposals which are submitted to APOC for funding. They ensure the availability and timely delivery of ivermectin to the affected communities. A national onchocerciasis coordinator is appointed by the IVIOH to act with his/her team as the Secretariat for the NOTF. APOC strongly encourages the NOTFs and the tVOHs to integrate health programmes at all the levels of the health system. [vlany CDTI activities (planning, supervision, mobilization,...) are fully integrated into the government health system, which reduces the cost of implementing health programmes. Given the encouraging results of CDTI, more and more partners are committed to the programmes, but they tend to put their resources together through basket funding. APOC has put emphasis on advocacy at government and local authority levels to include a budget line for CDTI to ensure sustainability when APOC support comes to an end. 6 Although commitment and ownership is high at the community level, the challenge, in most cases, is to get real and full support of health personnel. 4) What are the defined roles for NGOs involved in the delivery of APOC and what measures are being put into place to sustain activity when the donor funds come to an end in 2007? Will there be transfer of responsibility to government level? Defined roles of NGDOs The NGDOs contribute to the treatment of more than 35 millions people (2003) in 14 APOC countries. a) ereeigitity et tn iee in+rastrueteFe @ The contribution of the NGDOs in the delivery of APOC objectives can be summarised as financial and technical: Financial NGDOs are required to contribute to the 25% (at least) GovernmenUNGDO commitment to each APOC project Some NGDOs benefit from a minor contribution from APOC to their running costs but have to support the majority of those costs from their own resources All NGDOs have independent fundraising mechanisms and collectively contribute approximately $7 million per year to onchocerciasis control 7 NGDOs also encourage others to get involved in onchocerciasis control. Where there are national NGDOs with the necessary potential these may be supported by their international cou nterparts. Technical NGDO Country Office staff work within the NOTF to undertake agreed tasks to ensure effective CDTI and achieve and maintain 100% geographic and at least 65% therapeutic coverage These include participation in preparing national plans; community mobilisation, training and supervision activities, and strengthening of the capacity of health services; ensuring compliance with reporting and ltlectizan control procedures; production of health education materials, and operational research. Transfer of responsibility to Government The objective of the NGDOs is to assist with the integration of CDTI into the Government health structures at national, district, front line health facilities and community level, so that they can function with a minimum of external support. This process is ongoing and the majority of projects which have reached their fifth year of APOC funding are deemed to be "making progress towards sustainability". However, there are concerns about the APOC timeframe to achieve full responsibility by Government for the reasons noted below. Measures to sustain activity The NGDOs, all of whom are active in supporting other health and development activities in the countries in question, aim to reduce their active support to onchocerciasis control wherever this is feasible, without jeopardising the achievements of more than 10 years in preventing blindness and improving the health of some of the poorest people in Africa. However they do not see evidence that they will be able to withdraw their support entirely in the foreseeable future for the following reasons: in numbers of 35 million estimated in APOC Phase I current ultimate treatment goal at 2010 is to treat 86,31 1,328 people Lenqth of time needed to maintain ann al treatment has increased siqnificantlv from 1 2-14 to over 20 years Proiect imolementa tion is done in phases it takes about 3 years to achieve 100o/o geographical and over 65% therapeutic coverage in a pro.lect area there are specific difficulties where Loa loa is co-endemic, eg Cameroon, DRC and Sudan, making optimal coverage harder to achieve. [Vlost endemic countries ranked amono the ooorest of the world Average life expectancy is below 50 tVlost fall at the bottom of the UNDP HDI They have inadequate health budgets and many have weak health structures especially at the periphery 8 This is exacerbated by recent (Sierra Leone, Liberia, Angola), or current (DRC, Sudan and Burundi) conflicts. Difficultv of oriori no onchocerciasis control lVost countries are afflicted with life-threatening diseases such as HIV/AIDS, TB, malaria which are given priority These diseases are also prioritised by international donors, leaving little over for diseases not immediately life-threatening Onchocerciasis control needs to be very long term but the as the symptoms fade compliance is going to be an increasing problem The international community has been supporting onchocerciasis control for many years, but there is still much to be done. Gonclusion The NGDOs are committed to assisting the process of integration of CDTI into health management systems at all levels. The NGDOs are committed to assisting governments to sustain the programmes, but recognise that some external support is likely to be required for the foreseeable future. The NGDOs are committed to providing that support but are having increasing difficulty in raising funds for the reasons stated above. The NGDOs look forward to the studies on the interruption of transmission as a means of determining where onchocerciasis is no longer a public health problem and l/ectizan distribution can be discontinued. The involvement of NGDOs in APOC offers an opportunity to develop a model of how NGDOs can work in partnership with national Ministries of Health and multilateral agencies in other areas of health development. 5) What are the resource requirements to meet the target for elimination of onchocercaasis as a public health problem by 2010 or after? Are current trends in resources sufficient to meet these needs? As stated in the Programme document for Phase ll and the Phasing out period, the objective of the Programme is "fo establish, within a period of 12 to 15 years, effective and se/f-sustainable, community-directed ivermectin treatment throughout the endemic areas within the geographic scope of the Programme, and, if possible, in selected and isolated foci, to eradicate the vector by using environmentally safe methods." The Mectizan@ donation by Merck and co. combined with financial and human resource support from partners will allow the Programme to meet this objective. ln the APOC Programme Document for Phase ll (2002-2007) and the Phasing out period (2008-2010) which was approved by all partners (Donors and Participating countries) during I the 7th session of the Joint Action Forum of the Programme in December 2001, a total amount of seventy nine million one hundred and fifty six thousand (79,156) USD was approved and after pledges were made a gap of 25 million USD was still to be filled. A total population of 51 million was to be treated by the year 2010 to achieve the objective of APOC in the 19 participating countries. To date, with a better mapping of the disease, the population to be treated is now estimated at 90 million. On the other hand, the gap has been reduced to 18 million USD by more donors contributions. Challenqe The main challenge facing the Programme is the mobilization of resources. tMost of the time, officers in the donor countries who have pledged funds on behalf of their countries are replaced by new ones who are not familiar with onchocerciasis and the challenges of the Programme and therefore are reluctant to follow the commitment of their predecessors. Some of the new officers do not even consider onchocerciasis as a priority disease. It is therefore hoped that this neglected disease which is Onchocerciasis will not be overlooked by the donor community for the benefit of the 'big three' (HlV/AlDS, Tuberculosis and Malaria). 6) Examine the Iink between onchocerciasis and other 'neglected diseases' and the case for joint planning or resourcing of these health issues. The so-called "neglected diseases" (e.9. onchocerciasis, schistosomisas, dracunculosis, lymphatic filariasis and sleeping sickness) are largely ancient infectious diseases that have burdened humanity, especially in Africa for centuries. The neglected diseases are concentrated where the poorest of the poor reside and frequently overlap. They share many features that make integrated technical guidance both feasible and advantageous in terms of efficient use of resources, staff, delivery systems, and opportunities for contact with populations. Just as onchocerciasis the other neglected diseases are in the poorest of the poor communities at the end of the road. ln most of the communities in which APOC intervene for onchocerciasis control through ivermectin distribution, the health system is not existent. Even in case it exists it is not equipped with the basic materials. As one of APOC strategies is to integrate onchocerciasis into the public health system at the country, regional, district and community levels, this link exist de facto. ln fact, APOC's CDTI strategy is used as a vehicle to bring to the communities other interventions. 10 The Community-Directed Distributors (CDDs) of ivermectin trained with APOC resources are used by other programmes to address other health problem: vitamin A supplementation, lymphatic filariasis, schistozomiasis, Guinea worm, immunization (polio, measles), cataracts, epilepsy, malaria, water and sanitation, health education (Nigeria, CAR, Cameroon, Chad, Sudan, Uganda, Tanzania, DRC). The strategy of community-directed intervention, pioneered for ivermectin, is being used in other programmes. Challenge While APOC does not pay CDDs, other health programmes come in with incentives to the CDDs, thereby causing attrition among the CDDs in charge of CDTI activities. lt is therefore essential that the programmes harmonise their strategies by empowering the communities. 7) To what extent are plans for onchocerciasis in high burden countries linked to countries own plans for the health sector? What has been the experience of gaining support for onchocerciasis (or other diseases) from broader health instruments such as SWAps or PRS processes? What are the prospects for increasing financial support at country level? Since its inception, APOC has been advocating for onchocerciasis to be integrated into the public health system of the participating countries. lt has become a policy of the Programme to ensure that CDTI project submit sustainability plans in their 3rd or 5th year, fully integrating onchocerciasis into the health sector plans. ln the partnership for the control of river blindness, the APOC programme offers essential experience and expertise in community mobilization, sensitisation and training. Participating countries, donors, and the partnership's governing board have all endorsed the integration of community-directed treatment into existing health systems through other health interventions. ln most of the APOC countries, onchocerciasis has been fully integrated into the PHC systems to ensure the sustainability of its control activities after APOC support comes to an end. Onchocerciasis has become one of the priority diseases in those countries' plans, as it falls into the SWAps and PRS sectors. A typical successful example of gaining support for 11 onchocerciasis control at the country level is the lt/ahenge CDTI Project in Tanzania where common basket funds are used to control priority diseases including onchocerciasis. Challenqe The main challenge is that countries are focussing more attention on the 'big three' (HlV/AlDS, TB and Malaria) where parallel funding mechanisms are more active with the creation of organisations, partnerships within the SWAps and PRS, hence neglecting diseases such as onchocerciasis, lymphatic filariasis, etc. Question 8 What evidence has the partnership been able to produce on the impact of onchocerciasis on the MDGs'l Considering thc Partnership established by APOC, most of the goals contribute to the Millennium Development Goals. In bricf, describing APOC partncrship, we can realize that APOC involves many partners in the program, particularly the pharmaceutical company provide access to affordable essential drugs in developing countries. a a a a The partnerships initiated or strengthened by the P rogramme e mbrace t he M inistry o f health, NGDOs, WHO, donors (including MDP and Merck, Inc.), bodies of experts and civil society. They exist at different levels, from supranational forums to the village, and at each level the different partners interact in different combinations. The establishment of such a quantity and variety of successful partnerships is a major Programme achievement. In the NOTF concept in particular the Programme has further developed a formal model which brings together different stakeholders in onchocerciasis control, in planning and implementing a common plan for a country. This example of a private-public partnership is a significant and strategic achievement in several ways. It provides a flexible forum for non-governmental bodies to have a direct say in the planning and implementation of a national programme; partners have managed to harmonise their methods and strategies; and partners have shared human, material and financial resources in working for a common goal. In most countries a remarkably good relationship has developed between MoH and the NGDOs. This relationship is flexible, with partners accommodating themselves to each other, and exhibits a particular synergy: the NGDOs energise the MoH, while MoH helps the NGDOs to bring their practice into line with accepted norrns. NGDOs also provide forward funding at times, when APOC disbursements arrive late. The establishment and maintenance of the body of donors for the Programme is a significant achievement. It goes without saying that their contribution underpins everything that the Programme has achieved. The same is true of the generous donation of Mectizan@ (ivermectin) by Merck, Inc The main areas of responsibility/contribution are clear, although they vary: 12 a Question 9 How, and to rvhat elTect, has the partnership targeted poor people, and poor women in particular in recipient countries? Health Benefits Due to APOC activities, by 2000, over 20 million people were receiving annual treatment with ivermectin, severely infected individuals were relieved of intolerable itching, and an estimated 20,000 cases of blindness per year were being prevented. Through Phase ll and the Phasing-out Period of APOC, delivery systems will be put in place to provide treatment for 59 million people annually with ivermectin beyond 2010, resulting in cumulative reductions in blindness and itching. The direct involvement in, and assumption of responsibility for, conducting CDTI activities by the communities will result in enhanced health awareness in the field with potential "openings" for instituting similar community-directed approaches for the control of other health problems. CDTI reaches communities at "the end of the road" that have been ignored and have had no, or limited, access to health services. The involvement of peripheral and district health services in supporting the implementation of the Programme will result in a strengthening of health service structures. Also, the direct participation of the national health authorities in the work of the NOTFs has been important in terms of strengthening the collaboration at that level among national and international partners for support to health development beyond onchocerciasis control. Training contributes to capacity building at all levels from the community to the national level. Social benefits The prevention of new cases of onchocerciasis and the control of existing disease convey many social benefits to individuals and communities. The principa! manifestations of the disease are impaired vision, blindness, and skin disease including debilitating itching, all with serious social implications. Onchocercal blindness leads to loss of productivity in affected people, in their most productive years, making them dependent upon their families and the community and reduces life expectancy by more than 12 years. The intolerable itching leads to dermal lesions that often result in social ostracism, especially for women who may find themselves consequently ineligible for marriage. Children in onchocerciasis communities are also at risk. They often drop out of school to care for those who are blind; they themselves may be infected and suffering from 13 the incessant itching. This can lead to socia! ostracism and school dropout, compromising their futures. nomic benefits ln an overview of several studies on the economic benefits of APOC operations, the World Bank concluded that the economic rate of return (ERR) on the investment to the Programme would be in the orderof 17 %, a rate comparing highlyf avourably with ERR's of other investments in development projects regardless of sector. The cost- benefit analyses, however, underestimated the net benefits of APOC, since it only considered the reduction in blindness as the principal benefit accruing from control operations. They did not take into consideration the benefits from such effects of onchocerciasis control as enhanced productivity, increased household welfare and reduced health expenditures resulting from the reduction in skin-related symptoms associated with the disease. Or text from Shanqhai, Paqe 20 . last paraqraph Overall, the economic rate of return (ERR) Phase I was 20%, due to increased labor and the additional arable land made available by the program. Labor was calculated from the 20 years of productive labor per person formerly lost to the disease-8 years of blindness and 12 years of reduced life expectancy. The increased benefits from the land assumed a conservative resettlement rate and the increased agricultural production that would occur in the new lands minus the production foregone in the departed areas. Normally, a 10% rate of return for World Bank projects in the "productive sector" (excluding social projects such as education and health) is considered a success. By 2010, ERR for Phase ll is expected to reach 17%. Question 10 Why were CDTI projects extended from 5 year APOC fundi there evidence that Onchocerciasis will be eliminated in the target countries as intended? no 3'tn to 8 years? ls year in those 1. History Onchocerciasis can be eliminated as a public health problem through annual mass treatment with ivermectin, provided that high treatment coverage can be maintained for a long period of time. It is not yet known how long mass 14 treatment needs to be continued before it can be safely interrupted, but it is expected that at least 15-20 years of treatment will be required. 2. IVlain objective To establish, within a period of 12 to 15 years, effective and self-sustainable, community-directed ivermectin treatment throughout the endemic areas within the geographic scope of the Programme, and, if possible, in selected and isolated foci, to eradicate the vector by using environmentally safe methods. The attainment of this objective is expected to contribute towards the elimination of onchocerciasis as a disease of public health and socio-economic importance throughout Africa and so improve the welfare of its people. 3. External [t/id-term Evaluation conclusion One of the findings of the Mid-term External Evaluation conducted in 2000 was that there needs to be flexibility in determining the duration for APOC support to the CDTI Projects and that additional funding beyond the regular five years may be required in specific situations to ensure sustainability of CDTI. A provision has therefore been made in the current Programme Document for the extension of APOC support, if required, to a maximum of 8 years. This additional support would focus on ful! integration of CDTI into the health services and on related national capacity building. 4. APOC financial support to CDTI projects APOC will monitor progress towards the establishment of sustainable CDTI and determine, on the basis of criteria to be defined by TCC, if and when a project has been successful. The success criteria would cover issues of treatment coverage, community directorship and ownership, health system support and integration of CDTI into the existing health care structures. lt is appreciated that, in spite of best efforts, satisfactory conditions for sustainability cannot always be created within 5 years and that additional support may be needed in certain situations to ensure success. lf required, such additional support would be made available on condition that serious efforts have been made in trying to establish sustainable CDTI within a period of 5 years, and that this is likely to succeed within the near future. Additional support may be provided for a maximum of three years, and would focus on full integration of CDTI into the health seryices and on related national capacity building. Where efforts towards establishing sustainability are not considered adequate, APOC may discontinue its financial support to the concerned project while seeking an alternative solution. 5. Cessation of APOC support 15 IAfter cessation of APOC support (eight years maximum) countries, communities and governments will continue the distribution without support from the APOC Trust Fund, to ensure the elimination of onchocerciasis as a disease of public health importance. Extensions of APOC financial support for projects beyond five years will be based on criteria established by TCC and case-by-case project considerations. 6. Conclusion APOC CDTI projects were extended from 5 external funding years to 8 to establish an efficient and sustainable system in the countries without APOC trust fund. After APOG, activities will continue as long as needed by communities and governments. Question 11 a o If not already covered in the above questions. what were the concerns raised in the APOC mid term report 2000 that are yet to be addressed? The advent of an effective macrofilaricidal drug will be a must for APOG and the communities. So APOC should lend its full support to the current trials for moxydectin drugs (which is now at the human trial stage), and for the teams and centres which are performing this research. APOC should also give serious consideration to implementing a system of monitoring the impact of GDTI on morbidity (through determining disease prevalence and incidence in selected sites), to complement and monitor coverage rates 16