Devolution - situation paper

onchocerciasis control programme in the volta River Basin area Programme de Lutte contre I'onchooercose dans la Rdgion du Bassin de la volta JOINT PROGRAMME COMMITTEE Office of the Chairman JPC. CCP COMITE CONJOINT DU PROGRAMME Bureau du Prdsident JPc5.10(A) (ocP/EAcs .4) ORIGINAL : ENGLISH September 1984( JOINT PROGRA},IME COMMITTEE Fifth session Niamey , 3-6 December 1984 Provisional agenda item 10 DEVOLUTION - SITUATION PAPER Defini tion Devolution, within the context of the Onchocerciasis Control Programte (OCP), may be defined as the process whereby some of the activities of the Progranme will be progressively taken over by the Participating Countries when the health structures of these countries have acquired the technical, organizational and financial capability. Coordination of these activities will initially continue to be the responsibility of OCP but eventually be assumed by an appropriate intercountryfacility which will undertake control Eeasures against the vector as and when necessary so as to ensure that there is no recrudescence of the disease. PAG Mission Report The report of the Preparatory Assistance to Goverrments Mission (PAG) ' presented in 1973, defined the strategy and detailed the plan of action for the launching of OCP and outlined requirements for its designated 20 year lifespan due to expire in 1993. By then it was envisaged that the disease would be under control but not eradicated. The long terltr maintenance and future transfer of OCP to Ehe Participating Countries was not considered. However, it is now recognized that, if no surveillance is carried out and control available when OCP has fulfilled its mandate, Ehere could be a resurgence of the disease in lhe area. Independen t Comission Report This problem was first highlighted in the rePorE of the Independent comnission (1981). In its consideration of the 1on8-term ProsPects of the Prograrnme, the Conmission stressed that, as we1] as extending the area to diminish the impact of reinvasion from outside and developing new drugs to provide a second line of atEack against the disease, ultimate security could only be found in having Ehe surveillance activities maintained by the Pariicipating Countries with coordination of these activities and vector controL, as necessary, being the responsibility of an intercounEry body. The Comission also emphasized that devolution should be implemented gradually and progressively; if carefully planned and successfully accom- iti"n.a,-aevotution would make these countries more self-sufficient, initself an imPortant developmenE achievement' i JPCs . 10 (A) (ocP/EAcs .4) P.age 2 Expert Advisory Cormittee Ihese views were ful1y supported by the Statutory Bodies of the Prograrnme. The Expert Advisory ComiEtee (EAC) in its second session in 1981 underlined the need to strengthen the training prograilne of OCP in prospect of devolution. It considered that vector surveillance activities should be devolved only during the maintenance phase of OCP and be integrated, in the long te::m, into the national health progrrmes. Since then the EAC has continued to address the concept of devolution at each of its sessions. In 1982 the EAC reconmended that OCP undertake studies to determine the type of infrastructure to provide the surveillance and gaintenance scrrrices required, to identify resource needs for such an infrastructure, to establish standards and to develop methods within the Epiderniological Evaluation Unit and Vector Control Unit for an early warning systen. The EAC considered the most efficient infrastructure would be in the form of a multidisease surveillance and control unit. In its fourth session in 1983, the EAC, noting the satisfactory progress being made in planning devolution, reconoended that, in preparation of such pIans, there was a need to consider carefully a nr-mber of factors. These included the following: - the Prograqme elenents which would be devolved, criteria for their selection, the order in which devolution will be implemented and the time frrmes involved; - the need to establish criteria and standards which must be met by national structures of Participating Countries before the activities concerned could be devolved. This was necessary to ensure that the efficiency and/or effectiveness of Progrme activities would not be impeded by devolution; the need to fully involve Participatirg Countries in all aspects of the devolution process, frou planning through implementation; the need to develop and have in place necessary physical infrastructures and menagerial capacity prior to initiation of devolution; - the relationship of devolution to multidisease controL Progrnmes' primary health care and development progrnnrnesl - the role to be played by National Onchocerciasis Comittees, and academic and national research institutes in Participating countries; - the need to train national staff so they would be able to take over responsibility for Progranrme operations. Development and implementation of adequate career structures must also be considered; - the need to recognize that control- action, or lack of it, by a given Participating Country could have profound effects on disease control in others; - the development and maintenance of an intercountry facility which would carry out certain activities after OCP ceases operations; - how to effectiv€ly m:nsge, in ways which would ensure continuance of disease control, the critical t'phase in-phase out" aspect of devolution, when OCP was winding down and Participating Countries gearing up. i I JPC5 .10(A) (ocP/EAC5 .4) Page 3 1 Corrmittee of Sponsoring Agencies In its deliberations the Co'rrmittee of Sponsoring Agencies (CSA) has likewise given due emphasis to devolution. At the beginning of 1983 the CSA underlined devolution as being the most important factor to be con- sidered within the context of the Long-Term Strategy being developed for the Prograuure. It recognized that not all countries would be ready to assume responsibility for all (or many) of the activities at any one time and, although devolution was foreseen by the Independent Conmission to take place around 1990-1993, preparations had to start irnmediately. By the end of 1983, the results of the Progra'rme indicating remarkable progress, the CSA advised the Joint Progrenme Conmittee (JPC) that the Progreme would reach a stage around the middle of the third financial phase, where, in its core area, minimal control operations would be needed although surveillance and other maintenance activities would have to be continued. Accordingly, the possibility for the transfer of appropriate activities Eo the Participating Countries was more inr'rinent than considered heretofore. It recomended that, although devolution would introduce potential incremental costs to the Participating Countries, consideration should be given to analysing how it could become a factor beneficial to the countries within their overatl development progranme. Joint Progranmq Comittee At its second session in 1981 the JPC, while giving support to the idea of devolution as presented by the Independent Conrmission, considered more attention should be given to the possibility of gradual devolution. It recognized the need for external funding to promote devolution and associated activities and for requisite training to be given to health staff at all 1eve1s. In 1982 t.he JPC again stressed the importance of the gradual transfer of responsibilities to the Participating Countries, such devolution being essential to the Long-Term success of the Prograrme and a necessary complement to any extension of operations. It considered devolution should be linked to the primary health care system. National Onchocerciasis Cornmittees At the joint meeting of the National Onchocerciasis Co'r*ittees (NOCs) in 1982 the delegates affi:med that it was up to the Participating Countries to take over the activities of the Prograrme in order to ensure the uainte- nance of results acquired and so ensure the continuation of development projects. However, the countries insisted that they not be handed over a situation which was bEYond their capability to maintain. In this context, technical discussions should be held to prepare a calendar for devolution and the methods to be eruployed, and to identify measures to be taken it-ediately in the field of training and the means necessary to ensure an efficient take-over by the national services. JPC5.10 (A) (ocP/EAC5 .4) Page 4 At its subsequent meeting in 1983, further consideration was given to the implications of devolution for the Participating Countries, the 1evel of activity foreseen in these countries as well as the types of national structures and the form of the intercountry facility. Regarding the latter, it was suggested that such a facility could be a modification of the present OCP rather than the implantation of a completely new organization. The Progranme For its part the Programe has responded to the various concerns and recomendations of the Statutory bodies. The Prograrme Director has had regular consultation with WHO Headquarters, the Regional Office for Africa and with the Participating Countries to determine the most effective courses of action. With the intention of ensuring the fu1I collaboration of the Participating Countries and their involvement in every step of the devolution process each country $ras invited to nominate tr^ro senior officials as focal points. A working group involving one expert frour each Participating Country was held in November L982 to consider the iropLication of devoLution for the countries and prepare recormendations for fol-fow-up. These were as follows: For OCP - to search for an easy and applicabLe technology; - to identify the level of OCP activities in each country; - to define the national structures envisaged, their antici- pated role and requirements; - to study the national mechanisms and the tyPe of support needed; - to study acceptable levels which can be maintained by the countries in case of reinvasion or recolonization; - to estimate the potential for the countries to integrate OCP activities and the risks involved; - to evaluate the prospect of international aid; - to detemine the Ieve1 of epideniological evaluation currently carried out by OCP in each country, and the possible partici- pation of nationals in these surveys; - to set up an evaluation mission to visit each of the Partici- pating Countries with the above as telils of references and to prepare reconmendations acceptable to all parties concerned; - to appoint a working grouP composed of technicians from each of the Participating Countries to study criteria and standards necessary for the transfer of OCP activities to the Partici- pating countries and to prepare terurs of reference of future missions in charge of studying the capability of each country to take over OCP activities. 14 JPC5 . 1 0(A) (ocP/EAC5 .4) Page 5 Ior the Participating Countries - to make a definite political couroitment to devolution and define a clear national policy towards assumption of responsibi I ities; - to select the necessary trained staff and appoint a secretariat; - to create the required national structures; - to identify onchocerciasis as a priority within the national health servicesl - to reorganize and strengthen the NOCs; - to study the possibility of collaboration ,mongst countries within the sarne river basin; - to maintain the OCP methodology after devolution. For WHO (Regional Office for Africa) - to increase training fellowships; - to provide support to national technicians through inter- country projects; - to assist in setting up surveillance structures; - to enable the Special Prograrmre for the Research and Training of Tropical Diseases, Division of Malaria, etc. Eoparticipate in the integration of OCp activities into the National Health systems. Internal meetings involving OCP technical staff have been convened in order to define what should be the standards and criteria to be reachedbefore any particular activity could be devorved. For hydrobiological monitoring, experienced te:rns belonging to national institutes in the countries concerned have already taken over responsibility for carrying out the prescribed schedule of activities and collecting the requisite data, alI being coordinated by OCP. Epidemiological surveillance could be, perhaps,the next activity to be handed over but again there would be the need for central coordination to ensure comparability of data. However, it was emphasized that the detailed study of the evolution of the disease in relationto the vector control operations should continue with OCP meantime. Because of its complexity and the continual demand for information vital to ensuring ProEPt and appropriate action against the vector, the entomological sunreill- ance systeD would be the last activity that could be devolved and then only when the local situation is seen to be secure after several years in the maintenance phase. The format of the inter-country facility (rcF) which will continue a role similar to that of the present OCP in coordinating the activities inthe various countries and providing a control input as necessary is under regular study by the Progranune with the help of a consultant. { JPc6.10(A) (OCP/EAC5.4) Page 6 The Prograrme organized a second working group of national experts which prepared terms of reference for teams to visit the participating Countries to evaluate the potential of each to undertake responsibilityfor different activities, to exr-ine the present structures and to identifypossible shortfalls and training needs. This inrensive R and D study was launched at the beginning of 1984 and 1r being undertaken progressively by a tearn visiting each country in turn. This team is composed of a consultant and a staff member who link up with the two senior officials nominated as focal points in the country visited and joined by one of the focal points from a neighbouring country. when these review visits are completed a rePort will be written and reviewed at a joint meeting of the focal points so providing guidelines to the types of assist.ance these countries will require to build up their national health structures to the Level necessary to continue maintenance activities. Meantime, the Prograrme has recruited another consultant to help draw up a schedule of training and fellowships which should be available through the Progreme to the countries concerned for the period 1984-1993. This will cover a broad range of disciplines e.g. entomology, epidemiology, ophthalmology, hydrobiology, statistics, health economics, sociology and menagement, all of which will be necessary for the countries to assume responsibility at devolution and to respond to development. needs thereafter. The need for an independent group to determine when specific activities should be handed over to the national authorities is a safeguard recognized by the Progreme and the countries concerned. The role of implementing and monitoring the actual transfer of OCP activities to the countries could probably best be undertaken by a group drawn from two of the statutory bodies e.g. the Expert Advisory Conmittee and the Joint Progrn'nme Cornmittee. Future The Long-Term strategy currently being prepared to carry the Prograrme through to the period when its objective will be met leads naturally into devoluEion for the maintenance of activities necessary to prevent a recru- descence of the disease. The timetable for devolution varies substantially from one area to another but from the continuing success of vector control in 9OZ of the control area, and as recorded by the CSA, it could be more inminent than had originally been anticipated. With this in mind, the devolution process must be programned very carefully and coordinated with the absorptive capacity of the countries concerned who must continue to be involved every steP of the way. The Eanner in which it is being pursued, that is by close collaboration among the Programe, the Participating Countries and the Statutory bodies, is sufficiently flexible to accormodate each country according to its particular corrstraints and in relation to its national health Progranme. I I