Report of the external mid-term evaluation of the African Programme for Onchocerciasis Control

AFRICAN PROGRAMME FOR ONCHOCERCIASIS CONTROL RepoRt of the exteRnal mid-teRm evaluation of the afRican pRogRamme foR onchoceRciasis contRol Jaf 16.8 © Copyright African Programme for Onchocerciasis Control (WHO/APOC) All rights reserved. 3RepoRt of the exteRnal mid-teRm evaluation of the afRican pRogRamme foR onchoceRciasis contRol OctOber 2010 Acknowledgements This report was prepared by a team of independent international consultants. It represents the final stage of an intensive process of literature review and consultations to determine progress and make suggestions for the future. We acknowledge the invaluable insight provided by the various persons we interviewed during the process at global, regional and country level. We appreciate the excellent support we received from all the APOC secretarial, administrative and technical staff who facilitated the entire work and made this review more manageable than it will otherwise have been. Special gratitude is being extended to Dr. Uche Veronica Amazigo, Director, for her untiring support throughout this entire exercise. Above all, we are encouraged immeasurably by the vision and zeal of the Regional Director, Dr Luis Gomes Sambo, CSA partners and the countries ministerial leadership whose enthusiasm for seeing the elimination of onchocerciasis become reality in the African region, has lead to the high quality of work that we were privileged to assess. The independent external review team was comprised of: Dr Sam Adjei Chair Prof. Pascale Allotey Mr Paul Derstine Prof. Dik Habbema Dr Ali Mzige Dr Pierre Ongolo-Zogo Ms Eleanor Cozens Dr Anthony Seddoh Limitations to this review document This report is mainly limited by the time allotted for work and our inability to represent in detail all the mass of evidence made available by the secretariat and various countries. In a general sense, the comments and suggestions are limited to the extent that available data and information synthesis permits. However, the direction and emphasis on the future was not lost and we were able to articulate to a high extent, how far the strategic direction has been achieved and what it might take to get countries past the elimination target. We do not in any way suggest in our comments that deliberations on all the issues is finalized. Any recommendations and suggestions made need to be discussed extensively with the APOC management team and its governance stakeholders for consensus. Abbreviations APOC African Programme for Onchocerciasis Control SIZ Special Intervention Zones AIDS Acquired Immune Deficiency Syndrome CDDs Community Directed Distributors CDTI Community Directed Treatment with Ivermectin CDI Community Directed Interventions CSA Committee of Sponsoring Agencies CSA Community Self-Monitoring EPI Expanded Programe of Immunisation GAVI GAVI Alliance GIS Geographical Information Systems GSM Global Management Systems HIV Human Immunodeficiency Virus HSAM Health Education, Sensitisation and Advocacy HLF High Level Forum ITNs Insecticide-treated bed nets IRSP Institut Regional de Santé Publique JAF Joint Action Forum LF Lymphatic Filariasis MDA Mass Drug Administration MDP Mectizan Donation Programme ME Monitoring and Evaluation MDGs Millennium Development Goals NGDOs Non Government Development Organisation NTDs Neglected Tropical Diseases NOTF National Onchocerciasis Task Force OCP Onchocerciasis Control Program PAHO Pan American Health Organisation PHC Primary Health Care RAPLOA Rapid Assessment Procedure of Loa loa REA Rapid Epidemiological Assessment REMO Rapid Epidemiological Mapping of Onchocerciasis SWAp Sector Wide Approach TA Technical Advisers TB Tuberculosis TCC Technical Consultative Committee TRC Technical Review Committee TDR Tropical Disease Research TZ Transmission Zone UNICEF United Nations Children Fund WHO World Health Organization 5table of contents Executive Summary..................................................................................................................... 6 Background................................................................................................................................. 6 Achievements.............................................................................................................................. 6 Challenges.................................................................................................................................. 8 Recommendations........................................................................................................................ 9 Conclusions............................................................................................................................... 11 1. Introduction.......................................................................................................................... 13 1.1 Background....................................................................................................................... 13 1.2 The changing environment for disease and health development................................................ 14 1.3 Phase II and phasing out APOC............................................................................................. 14 1.4 Objectives and terms of reference for the evaluation............................................................... 15 1.5 Methodology..................................................................................................................... 16 2. Progress in coverage and elimination............................................................................... 17 2.1 Progress in therapeutic and geographic coverage.................................................................... 17 2.2 Facilitating guidance to countries for elimination..................................................................... 18 2.3 Issues for further consideration towards elimination. ............................................................... 19 3. CDTI effectiveness and co‑implementation...................................................................... 21 3.1 CDTI and system effectiveness.............................................................................................. 21 3.2 Gender in Program operations.............................................................................................. 24 3.3 CDI and co-Implementation. ................................................................................................ 25 3.3.1 The CDI framework................................................................................................... 25 3.3.2 Progress in co-implementation................................................................................... 26 3.3.3 What has not worked so well..................................................................................... 28 3.3.4 A positive look forward............................................................................................. 29 4. APOC contribution to country led health systems and ensuring sustainability............ 30 4.1 Planning and budgeting...................................................................................................... 30 4.2 Training and Capacity-building.............................................................................................. 31 4.3 Capital equipment: an ongoing commitment.......................................................................... 32 4.4 Drug Procurement and Supply System................................................................................... 32 4.5 Primary Health Care and Community Systems Strengthening..................................................... 34 4.6 Financing of Onchocerciasis.................................................................................................. 34 4.7 Research, monitoring and evaluation..................................................................................... 37 5. APOC Management Arrangement...................................................................................... 38 6. Conclusions and recommendations................................................................................... 41 Annexes...................................................................................................................................... 46 Annex 1: Progress in APOC PAB 2008-2015’s Core Set of Indicators.................................................. 46 Annex 2: APOC organisational chart............................................................................................ 49 Annex 3: List of persons interviewed.......................................................................................... 50 Addendum: Country Case Studies............................................................................................ 52 Case Study: Onchocerciasis control and health systems strengthening in Tanzania............................... 53 Case Study: Onchocerciasis control in the Democratic Republic of Congo, a post-conflict country in transition....................................................................................................................... 57 Case study: Brief on onchocerciasis control in Ghana....................................................................... 63 Onchocerciasis control in Cameroon: illustrating the complexities and challenges of health sector reform processes................................................................................................................ 70 Ex Ec u ti v E su m m a r y — E x tE r n a l m id -t Er m E v a lu a ti o n r Ep o r t 6 executive summary Background 1. In.1995,.the.African.Programme.for. Onchocerciasis.Control.(APOC).was.launched. as.a.follow.up.to.the.highly.successful. Onchocerciasis.Control.Programme.(OCP).. APOC.was.created.to.develop.a.sustainable. community.managed.distribution.of.Ivermectin. for.90.million.people.annually,.protecting.an. at.risk.population.of.120.million..In.2007,. APOC.mandate.was.renewed.leading.to.the. development.of.a.Phase.II.and.Phasing.out. period.and.Addendum.for.the.Plan.of.Action. and.Budget.2008-2015..The.APOC.phasing. out.strategy.was.clear.on.the.need.to.work.with. African.governments.to.help.develop.country- led.feasible,.realistic.end-game.strategies.for. maintaining.the.important.gains.that.have. been.achieved.against.onchocerciasis.in.Africa.. Early.this.year.the.127th.Meeting.of.the.APOC. Committee.of.Sponsoring.Agencies.(CSA).and. the.Joint.Action.Forum.(JAF).decided.that.a. mid-term.evaluation.of.APOC.should.take. place.and.the.report.submitted.to.JAF.16,.in. December.2010. 2. The.objectives.of.the.evaluation.were. provided.as: • To.review.progress.made.by.APOC.towards. establishing.country-led.systems.through. community.empowerment.for.controlling. onchocerciasis.as.a.public.health.problem. in.endemic.Africa.(.2005-2010).and. beyond. • To.review.progress/contributions.made. by.APOC.towards.strengthening.of.health. systems,.in.particular.at.the.community. level. • To.assess.the.capacity.of.APOC.to. co-implement.its.mandate.for.the.control.of. onchocerciasis.with.the.control.of.Neglected. Tropical.Disease.(NTDs).and.other.health. interventions, • To.facilitate.(guidance.to.countries).a. paradigm.shift.from.control.to.elimination. of.onchocerciasis.infection.and.its. transmission.in.specific.areas. 3. This.report.is.a.result.of.the.evaluation.that. took.place.between.July.and.September.2010. and.conducted.by.a.team.of.six.experts..Based. on.extensive.literature.review,.country.visits,. interviews.with.a.wide.range.of.stakeholders,. this.report.reviews.progress.made.by.the. African.Programme.for.Onchocerciasis. Control.(APOC).against.its.revised.2007.goal. “to.have.established,.by.2015,.a.country.led. system.capable.of.eliminating.onchocerciasis. as.a.public.health.problem.in.all.African. countries.endemic.with.onchocerciasis,.both. those.within.the.geographical.area.covered.by. APOC’s.mandate.and.those.in.the.ex-OCP.area. that.are.causing.concern”. 4. The.TOR.required.the.Evaluation.Team.to.not. only.examine.the.progress.of.APOC.but.also. to.be.futuristic.and.comment.on.how.it.sees. APOC.beyond.2015. achievements 5. The.evaluation.team.agrees.that.the.African. Programme.for.Onchocerciasis.Control. (APOC),.an.outstanding.private-public. partnership.for.disease.control,.remains.one. of.the.leading.health.intervention.success. stories.in.Africa..The.APOC.Secretariat.has. performed.creditably.over.the.evaluation. period..After.15.years,.APOC.has.helped.the. disease-endemic.countries.to.successfully. extend.CDTI.coverage.to.a.total.population. of.approximately.68.4.million.people.from. approximately.1.5.million.in.1997,.as. ivermectin.(Mectizan®).reaches.133,000. communities.in.15.countries.across. sub-Saharan.Africa.in.2009. 6. APOC.has.treated.approximately.71%.of.the. eligible.population..This.includes.several. countries.affected.by.security.issues.and. translates.into.a.total.of.133,000.out.of.a. targeted.146,000.communities..The.number. of.projects.with.therapeutic.coverage.under. 65%.in.2009.declined.in.one.year.from.6. to.2.projects.in.stable.countries.and.from. Ex Ec u ti v E su m m a r y — E x tE r n a l m id -t Er m E v a lu a ti o n r Ep o r t 7 29.to.15.projects.in.post-conflict.countries.. The.progress.so.far.means.that.control.of. onchocerciasis.as.a.public.health.problem. has.been.attained.in.a.majority.of.APOC. communities.and.with.accelerated.efforts.to. scale.up.should.move.almost.all.countries. towards.control.targets.by.2015. 7. The.continuing.commitment.of.Merck.to. provide.Mectizan®.for.as.long.as.it.is.needed. is.particularly.pertinent.given.recent.evidence. to.suggest.that.elimination.of.onchocerciasis. is.possible.through.effective.application.of. ivermectin.based.treatment.alone.within. localized.geographical.project.areas..Research. results.from.foci.in.Mali,.Senegal.and.Kaduna. State.in.Nigeria.show.that.after.16-19.years. of.ivermectin.treatment.the.prevalence.of. microfilaria.has.reduced.to.zero..Although.the. data.is.based.on.clearly.defined.small.areas. of.high.transmission.and.not.the.broader. geographical.transmission.zones,.the.signal. that.elimination.of.onchocerciasis.infection.is. possible.adds.a.new.dimension.to.the.work. of.APOC. 8. Onchocerciasis.elimination.presents.a. paradigm.shift.towards.a.positive.new. reality..Elimination.is.defined.as.“the effective application of control activities leading to a sustained interruption in transmission of onchocerciasis to levels that allows treatment to be stopped within a defined transmission zone”..A.transmission.zone.is.defined.as. ‘a geographical area, where transmission of O. volvulus occurs by locally breeding vectors’..The.APOC.Secretariat.has.been. proactive.in.using.the.Krigging.method.to. simulate.elimination.from.project.areas.to. transmission.zones.and.has.been.able.to. demonstrate.a.surprising.level.of.congruence. (97%).between.areas.where.Community. Directed.Treatment.with.Ivermectin. (CDTI).is.implemented.and.the.predictive. Krigging.maps. 9. Information.that.over.time.continued.control. activities.will.ultimately.lead.to.localized. ‘elimination’.has.already.been.communicated. to.countries..It.is.however.important.that.the. operational.definitions.are.understood.and.that. their.implications.are.clearly.communicated.to. countries.and.all.stakeholders..For.clarifying. exactly.what.needs.to.take.place.in.practice.for. moving.from.control.to.localized.elimination. and.stopping.treatment,.a.series.of.steps.has. now.been.established..Each.step.has.specific. manageable.activities.to.be.undertaken.within. a.specified.period..These.are.presented.in. Figure 1.below. 10. The.well.tested.Community.Directed. Treatment.with.Ivermectin.(CDTI).approach,. implemented.by.community-directed. distributors.(CDDs).is.the.core.community. empowerment.model.adopted.by.APOC.. The.CDTI.strategy.has.a.demonstrated. track.record.of.success.in.reaching.rural. Routine surveillance after elimination certication • Resume treatment when results indicate recrudescence Conrmation of low infection and transmission in a post-stopping setting • Entomological and epidemiological survey, 3 years after stopping CDTI • Elimination certi
cation when results of survey satisfy criteria • Resume treatment when results indicate recrudescence Satisfying the criteria for stopping CDTI in the transmission zone • History of CDTI (number of years, coverage) • Surveys (are entomological and epidemiological criteria satisfed?) Delineation and validation of a transmission zone • Krigging REMO map with nodule prevalence • National Consultative meetings (tentative delineation of TZ) • Assessment and validation in surveys Figure 1: Steps towards certifying and maintaining elimination status Table 1: Geographic and therapeutic coverage breakdown by status of countries Geographic coverage (%) therapeutic coverage (%) country 2008 2009 2008 2009 Post-conflict countries 63 82 46 64 Stable countries 97 98 75 77 Ex Ec u ti v E su m m a r y — E x tE r n a l m id -t Er m E v a lu a ti o n r Ep o r t 8 populations.and.ensures.that.a.high. proportion.of.the.population.at.risk.receives. the.drug. 11. Because.CDTI.is.easily.adaptable.and. replicable,.it.has.proved.effective.as. a.platform.for.Community.Directed. Interventions.(CDI).and.has.been.used. in.co-implementation.of.onchocerciasis. control.with.other.health.interventions.such. as.the.distribution.of.bednets.for.malaria. control,.lymphatic.filariasis.treatment,. Vitamin.A.supplementation,.control.of. soil.transmitted.helminths,.primary.eye. care.and.immunization..In.2008,.more. than.11,531,128.persons.benefitted.from. interventions.related.to.malaria.control. (home-based.treatment.of.malaria.and. insecticide.treated.mosquito.nets);.in.total,. 268,718.CDDs.were.able.to.reach.104,974. communities.and.more.than.37,507,494. million.people.were.covered.with.additional. health.interventions..There.is.clear.potential. for.countries.to.increase.their.levels.of. co-implementation.of.onchocerciasis.control. with.that.of.other.NTDs,.especially.where.the. CDTI.approach.is.already.being.implemented. 12. Through.CDTI,.APOC.has.been.supporting. countries.with.community.health.systems. strengthening..APOC.has.recently.taken. this.a.step.further.with.the.development. of.curriculum.and.training.module.for. Community.Directed.Interventions.which.is. being.introduced.to.Universities.and.schools. of.nursing.in.18.countries..In.addition.to.the. provision.of.systematic.supply.of.transport. (vehicles,.motobikes.and.bicycles),.computers. and.generators.to.programme.countries,.APOC. has.recruited.Technical.Assistants.for.five. post-conflict.countries.with.weakened.health. systems.in.order.to.assist.them.with.improving. their.coverage.rates 13. Viewed.from.a.systems.perspective,.CDI.is. a.commendable.example.of.how.a.focused. disease.intervention.can.contribute.to.Primary. Health.Care.systems.strengthening.for. integrated.service.delivery.within.the.context. of.the.Ouagadougou.declaration..The.results. achieved.are.contributing.significantly.to. attaining.the.Millennium.Development.Goals. challenges 14. On.a.risk.benefit.scale,.neither.the.at-risk. populations,.their.national.governments,.nor. any.of.the.development.partners.can.afford.to. allow.onchocerciasis.to.recrudesce,.roll.back. the.impressive.improvements.in.health,.and. reverse.the.spectacular.developmental.and. agricultural.returns.on.the.nearly.$1.1.billion. investment.that.has.been.made.over.the.past. four.decades. 15. The.move.towards.‘elimination’.means.that. Onchocerciasis.control.is.still.an.unfinished. agenda..There.is.a.lot.of.preparatory.work. still.needed.before.many.of.the.elimination- related.surveying,.surveillance.and. certification.activities.can.take.place..The. processes.involved.in.stopping.treatment. will.require.different.surveillance.and. diagnostic.interventions.to.those.used.for. onchocerciasis.control;.this.includes.different. tools.for.epidemiological.and.entomological. surveillance..For.instance,.skin.snip.tests.and. human.baits.for.catching.flies.are.unlikely. to.be.appropriate.or.attractive.surveillance. methods.when.the.physical.disease. manifestations.are.minimal.after.cessation. of.treatment..The.science.for.acceptable. alternatives.is.only.just.emerging. 16. Both.post.OCP.and.APOC.countries.need. to.continue.surveillance.and.MDA.for.some. years.(OCP.countries.in.limited.foci;.APOC. countries.in.larger.areas).to.maintain.the. considerable.investments.and.achievements. of.those.programs..There.is.hard.reality.that. must.now.be.faced:.to.control.onchocerciasis. in.Africa.and.to.attain.the.potential.for. localized.elimination.of.infection.and.stopping. treatment,.continuing.dedicated.external. assistance.is.required..In.proportion.to.what. has.already.been.invested,.this.is.unlikely.to. be.a.substantial.amount..As.external.resources. are.decreasing.rapidly.and.there.is.increasing. competition.with.multiple.global.disease. needs,.a.more.focused.approach.is.needed.to. secure.the.investments.needed. 17. The.evaluation.team.noted.significant.health. systems.weaknesses.in.post-conflict.countries. and.limited.capacity.in.stable.countries.. Ex Ec u ti v E su m m a r y — E x tE r n a l m id -t Er m E v a lu a ti o n r Ep o r t 9 The.Country.Exit.Plans.submitted.to.APOC. by.nine.countries.did.not.take.‘elimination’. into.account.and.are.now.below.necessary. standards.for.ensuring.sustainability..The. cost.per.treatment.is.slowly.creeping.up.and. current.health.expenditure.levels.in.most. countries.are.too.low.to.take.up,.match.or. sustain.the.continued.investment.required.. The.full.cost.implications.for.both.control.and. the.move.to.elimination.are.yet.to.be.properly. ascertained.by.any.country..In.the.Evaluation. Team’s.opinion,.country.health.systems.in. the.short.to.medium.term.remain.weak.for. devolution.of.all.functions.to.governments.at. country.level. 18. With.countries.already.adopting.the.higher. coverage.targets.recommended.for.interrupting. transmission.and.seeking.guidance.on. when.treatment.can.be.stopped.on.the.one. hand,.and.acceptable.epidemiological.and. entomological.tools.not.yet.ready.for.mass. usage,.there.are.clear.challenges.now.facing. APOC.Management..These.are.in.addition. to.the.future.challenge.that.will.be.presented. at.community.level..Communities.are.used. to.being.told.that.it.is.necessary.to.take. ivermectin.even.when.there.are.no.symptoms. and.changing.this.message.to.one.explaining. that.in.some.areas.treatment.can.be.stopped. will.require.great.care.and.skill. 19. At.national.level,.countries.are.increasingly. moving.towards.integrated.NTD.policies. and.planning.and.are.gradually.putting.in. place.adjusted.implementation.structures.. CDDs.are.being.called.on.at.district.and. community.level.to.assist.with.other.health. programs.and.different.intervention.models.. The.reality.of.this.is.that.CDI.is.coming.under. siege.from.those.seeking.rapid.results.and. preferring.to.pay.incentives.for.community. participation.in.the.short-term,.rather.than. investing.in.the.more.lengthy.process.of. community.systems.strengthening.associated. with.the.APOC.model..APOC.has.to.increase. interaction.with.the.other.NTD.programmes. at.international,.regional.and.national.levels,. to.promote.and.facilitate.their.adoption.of. CDI.and.to.advocate.for.consistent.practices. at.community.level..It.is.a.challenge.that.will. need.to.be.resolved.if.countries.are.to.attain. their.vision.of.Primary.Health.Care.articulated. in.the.Ouagadougou.Declaration. 20. Limited.country.capacity.for.moving.to. ‘elimination’.has.been.alluded.to.earlier.and. this.is.also.true.of.the.APOC.Secretariat’s. capacity..It.surprised.the.Evaluation.Team.how. much.has.been.achieved.with.the.low.number. of.technical.staff.and.current.skills.mix..Going. forward,.the.current.staff.strength.will.be. hard.pressed.to.deliver.on.all.the.objectives.of. the.Phase.II.and.Phasing.out.period.and.the. Addendum.for.the.Plan.of.Action.and.Budget. 2008-2015. Recommendations A. Control and elimination programme 21. APOC.should.continue.the.mapping.of.the. state.of.each.transmission.zone..This.will. allow.the.Programme.and.partners.to.be. precise.on.when.and.where.to.stop.ivermectin. distribution.for.each.of.the.countries.in.this. category..This.should.include.entomological. and.additional.epidemiological.studies.to. identify.all.infection.sources.and.verify.level. of.infection.outside.the.core.hyper-endemic. areas.around.a.focus.to.back.up.the.findings. in.human.populations..The.work.should. take.place.ideally.within.the.current.phase. of.APOC.financing.ending.2012..The.results. should.be.disseminated.to.the.scientific. community.and.shared.at.the.WHO.Regional. Committee.for.Africa. 22. Activities.targeting.elimination.should.be. limited.to.localized.project.areas.that.qualify. under.long.lasting.Ivermectin.treatment. with.high.coverage..All.other.project.areas. should.be.supported.to.continue.control. activities.through.country.led.approaches.. While.the.technical.tasks.continue,.it.is. important.APOC.manages.the.expectations. of.countries.and.communities.regarding. the.stopping.treatment.process,.elimination. and.co-implementation..Regular.updates.of. progress.and.explanations.of.what.that.means. for.CDTI.in.practice.will.be.essential..This. must.be.given.due.importance.and.set.within. a.comprehensive.communications.strategy.for. 2015.and.beyond. Ex Ec u ti v E su m m a r y — E x tE r n a l m id -t Er m E v a lu a ti o n r Ep o r t 10 23. Given.our.sense.of.work.to.be.done,. APOC.will.need.a.minimum.of.one. additional.Entomologist.and.two.additional. Epidemiologists.to.undertake.the.work.. Armed.with.knowledge.from.the.mapping. a.multi-disciplinary.team.of.experts.should. be.put.together.to.develop.a.comprehensive. strategic.plan.with.costs.for.the.development. of.capacity.and.resource.needs.for.(i).surveys. for.delineating.transmission.zones.and. stopping.treatment,.(ii).monitoring.and. entomological.and.epidemiological.surveys. once.CDTI.stops,.(iii).define.activities.for. the.3-year.‘.treatment.follow-up.period’. and.(iv).verification,.certification.and.status. maintenance.process..The.national,.regional. and.international.responsibility.areas.on.how. to.implement.these.and.technical.assistance. needs.should.be.clearly.defined.in.the. strategic.plan..These.would.make.a.significant. contribution,.not.only.to.onchocerciasis.but. also.to.the.‘science.of.elimination’.for.diseases. of.poverty. 24. There.is.no.quick.fix.as.control.to.elimination. under.current.scientific.knowledge.is.linked. to.a.fairly.predictable.time.lapse.between. initiation.of.therapeutic.treatment.and. consideration.for.elimination..Merck.has.set. the.example.with.its.commitment;.other.APOC. partners.also.need.to.join.in.and.commit. to.attaining.this.goal.in.the.potential.oncho. elimination.countries. 25. New.memorandum.of.understanding. needs.to.be.developed.and.signed.between. countries.with.the.potential.towards. elimination.and.funding.partners.to. determine.how.resources.may.be.mobilized. and.dispersed.in.support.of.eligible. programmes.in.countries..This.should. ameliorate.donor.dependency.and.encourage. country.ownership.and.commitment B. Contribution of APOC towards systems strengthening and co‑implementation 26. APOC.should.undertake.comprehensive. research.to.explore.the.dynamics.of.existing. CDIs.with.special.focus.on.incentive.and. sustainability.issues.and.options;.this.will. enable.CDI.to.be.better.standardized.and. replicated.as.a.platform.for.Community.Health. Systems.Strengthening.and.for.supporting. co-implementation. 27. Based.on.the.research.findings,.guidelines.for. Community.Health.Systems.strengthening. within.the.framework.of.of.the.Ouagadougou. declaration.should.be.tabled.at.the.next. WHO.Regional.Committee.for.Africa.to.be. adopted.by.all.countries.for.implementation.. This.will.provide.a.firm.support.for.the. introduction.process.of.the.CDI.curricula. developed.with.support.of.APOC.and.for.the. adjustment.and.dissemination.of.the.CDI. range.of.tools. 28. A.funding.window.should.be.considered. under.the.current.Trust.Fund.to.encourage. countries.wanting.to.establish.community. systems.based.on.the.guidelines.for. co-implementation.to.have.access. C. Support transition to countries 29. Health.policy.and.systems.analysts.are.urgently. required.to.support.countries.in.developing. Program.Plans,.Budget.and.Exit.Strategies..In. our.opinion,.a.cost.effective.approach.will.be. for.APOC.to.recruit.personnel.with.expertise. in.Health.Policy.and.Systems.and.Health. Economics.to.work.with.a.network.of.experts. to.assist.countries. 30. Countries.should.be.encouraged.to.take. the.lead.in.developing.a.comprehensive. framework.for.NTDs.drawing.on.their. experience.with.onchocerciasis.control. and.similar.programmes.and.to.situate.or. integrate.onchocerciasis.control.within.this.. A.conscious.effort.should.be.made.to.ensure. that.comprehensiveness.does.not.undermine. the.variability.in.achievements.and.goals. to.be.reached.by.individual.programmes.. WHO-AFRO.should.be.supported.to.provide. Technical.Assistance.to.countries. 31. It.is.suggested.that.APOC.organizes.a. consultative.meeting.with.selected.APOC. countries.to.engage.other.disease.control. entities.in.the.wider.debate.on.health. systems.development,.and.to.focus.on.policy. development,.donor.coordination,.funding. Ex Ec u ti v E su m m a r y — E x tE r n a l m id -t Er m E v a lu a ti o n r Ep o r t 11 and.resource.allocation.and.addressing.human. resource.challenges..Other.control.programs. can.be.invited.to.share.and.discuss.experiences. with.the.aim.of.mainstreaming.onchocerciasis. control.program.experiences.in.country.health. policy.developments. D. Enhancing APOC Secretariat 32. Looking.beyond.2015.a.“transformed- APOC’.that.is.lean.and.efficient.is.advocated. for..This.needs.thorough.consideration.in. the.context.of.the.paradigm.shift.towards. elimination,.the.emerging.NTD.agenda.and. the.potential.for.transition.to.countries.. There.are.many.evolving.variables.that. will.need.to.be.taken.into.account.and.the. scope.of.this.evaluation.was.too.limited.for. giving.a.clear.indication.of.its.exact.form.or. function..A.consultant(s).should.be.recruited. to.assist. 33. Elimination.and.transformation.are.both. concepts.that.can.be.interpreted.in.a.variety. of.ways.and.create.different.expectations. arising.from.the.way.they.have.been. interpreted..It.is.important.that.APOC. avoids.any.miscommunication.and,.above. all.that.communities.understand.the.targets. set.and.any.changes.that.are.made.to. these..A.communications.strategy.should. be.developed.and.implemented.to.convey. the.right.messages.and.to.manage.raised. expectations. 34. APOC.has.succeeded.because.of.the. partnerships.it.has.developed.at.all.levels..The. APOC.partnership.is.likely.to.be.put.under. severe.strain.with.the.emerging.NTD.agenda. and.the.scramble.for.new.funding..APOC. needs.to.be.able.to.engage.with.partners.and. support.them.in.mobilizing.and.accessing. some.of.the.additional.resources.coming. into.the.NTD.area.for.onchocerciasis..APOC. will.need.to.be.proactive.and.to.provide. leadership.to.ensure.that.the.partnership. does.not.unravel.and.that.it.has.the.necessary. capacity.for.participating.in.strategic.planning. and.resource.mobilization.processes.for. NTDs.in.general..This.should.be.taken. into.consideration.when.the.organizational. consultant.is.recruited. conclusion In.conclusion,.the.Evaluation.Team.shares.the. view.that:. “What is so significant (about APOC) is that, by means of a partnership with over 70 partners, we’ve (communities, countries and development partners) been able to join together to achieve a programme which has the prospect of eliminating this disease completely on the continent of Africa.”1 — James Wolfensohn, former President of the World Bank 35. APOC.is.well.managed.with.a.clear.and. ambitious.objective..It.has.performed. successfully.in.treatment.and.prevention.of. onchocerciasis,.has.learned.from.external. evaluations,.works.towards.integration,. generates.and.utilizes.scientific.evidence,.and. demonstrates.commitment.to.sustainability..One. observation.made.is.that.APOC.is.an.evidence- based.success.story.that.very.few.are.aware.of.. The.organization.needs.to.be.more.proactive.in. publicizing.information.about.its.achievements. while.nevertheless.carefully.managing. the.dissemination.of.information.around. elimination..APOC.has.a.core.competency. in.onchocerciasis.control.but.this.does.not. adequately.position.it.to.become.the.lead. agency.for.NTDs..It.is.however.unparalleled.in. establishing.CDI.systems.that.can.be.used.to. assist.countries.strengthen.their.Primary.Health. Care.systems.and.to.support.other.health. interventions.through.co-implementation. 36. Ongoing.support.by.partners.and. strengthening.of.resources.at.the.Secretariat. will.enable.APOC.to.complete.most.of.the. activities.outlined.in.the.new.strategy.and. addendum,.and.to.work.towards.a.strategy. that.ensures.long-term.sustainability.of.APOC’s. achievements.in.countries..The.onchocerciasis. environment.after.years.of.APOC.programme. management.has.changed.and.new.strategies. are.now.required.for.collaboration.in.the. emerging.NTD.environment..The.APOC. partnership.needs.to.provide.leadership.and.to. contribute.its.experiences.to.the.development. of.NTDs.interventions.and.the.management.of. challenges.emerging.in.the.NTD.environment. 1. WHO,.2001,.Empowering.Partnerships.and.Communities,. Geneva.p.10. Ex Ec u ti v E su m m a r y — E x tE r n a l m id -t Er m E v a lu a ti o n r Ep o r t 12 37. APOC.will.continue.to.face.challenges.on.the. journey.towards.elimination.and.transition.to. country.leadership..The.two.objectives.though. initiated.are.far.from.attaining.reasonable. levels.of.preparation.and.implementation..It. is.contradictory.to.expect.APOC.to.exit.the. scene.by.2015.and.yet.to.expect.to.protect. investments.and.attain.the.anticipated.results.. There.will.be.a.continuing.need.for.regional. and.technical.oversight.and.coordination.. This.evaluation.supports.the.need.for.a. ‘transformed-.APOC’.for.the.future.beyond. 2015..Ultimately,.this.is.a.decision.that.lies. within.the.WHO.management.system.and.the. governing.body.of.APOC.but.early.dialogue. with.the.contracting.partners.and.a.sense.of. what.the.direction.may.be.will.be.important.for. helping.shape.partner.financing.strategies.and. for.maintaining.the.focus.and.commitment.of. staff.during.the.period.of.transformation. in tr o d u c ti o n — E x tE r n a l m id -t Er m E v a lu a ti o n r Ep o r t 13 1. introduction 1.1 Background 1. In.West.Africa,.the.highly.successful.30.year- old.Onchocerciasis.Control.Program.(OCP),. which.was.first.based.on.aerial.spraying.in. savannah.areas.of.11.disease-endemic.countries. and.later.added.mass.drug.administration. (MDA).in.savannah.and.forest.areas,.ended. in.December.2002..Launched.in.1974,.the. OCP.has.broken.transmission.in.most.of.its. target.area.and.prevented.more.than.200,000. cases.of.blindness2..The.African.Program.for. Onchocerciasis.Control.(APOC).was.launched. in.1995.to.help.develop.sustainable.annual. MDA.with.Mectizan®,.and.health.education.in. the.remaining.19.affected.countries.in.Africa,. using.a.“community-directed.treatment.with. ivermectin”.(CDTI).approach3. 2. The.APOC.partnership.expects.to.spend. approximately.U.S..$184.million.by.the.time.it. ends.in.2015..After.15.years,.APOC.has.helped. these.disease-endemic.countries.to.successfully. extend.CDTI.coverage.to.a.total.population. of.approximately.68.4.million.people.from. approximately.1.5.million.in.1997,.as. ivermectin.reaches.133,000.communities.in.15. countries.across.sub-Saharan.Africa.in.2009..It. has.treated.approximately.71%.of.the.eligible. population.including.several.countries.affected. by.security.issues..A.number.of.countries.are. on.the.way.to.elimination.while.others.are. securely.on.the.control.chart. 3. Neither.the.at-risk.populations,.their.national. governments,.nor.any.of.the.development. partners.can.afford.to.allow.onchocerciasis. to.recrudesce,.roll.back.the.impressive. improvements.in.health,.and.reverse.the. spectacular.developmental.and.agricultural. returns.on.the.nearly.US.$1.1.billion. 2. World.Health.Organization,.2002.Success.in.Africa:. The.Onchocerciasis.Control.Programme.in.West.Africa,. 1974–2002..World Health Organ Tech Rep Ser.885:.1–72. 3. World.Health.Organization,.1996.Community-Directed. Treatment.with.Ivermectin:.Report.of.a.Multi-Country. Study..Geneva:.World.Health.Organization..TDR/AFR/ RP/96.1. investment.that.has.been.made.over.the.past. four.decades..Both.post.OCP.and.APOC. countries.need.to.continue.surveillance.and. MDA.for.some.years.(OCP.countries.in. limited.foci;.APOC.countries.in.larger.areas). to.maintain.the.considerable.investments.and. achievements.of.those.programs..The.hard. reality.that.must.now.be.faced.is.that.to.control. onchocerciasis.in.Africa,.particularly,.those.in. post-conflict.countries.is.still.largely.dependent. on.external.assistance,.and.yet.the.external. resources.are.now.decreasing.rapidly.and. competing.with.multiple.global.disease.needs. 4. In.2007.the.Technical.Consultative.Committee. of.APOC.TCC.recognized.“the.opportunity.that. exists.to.expand.the.use.of.the.Community- Directed.Intervention.developed.by.APOC. for.onchocerciasis.and.the.existing.CDTI. structures.in.participating.countries.to.support. the.prevention.and.control.of.other.neglected. tropical.diseases”4..The.kind.of.collaboration. anticipated.would.provide.opportunities.to. jointly.address.technical.issues,.such.as.the. 4. Report.of.the.twenty-third.session.of.the.Technical. Consultative.Committee.(TCC).11.–.12.September.2006,. Ouagadougou Onchocerciasis: Microscopic infectious larvae of the filarial worm Onchocerca volvulus enter humans with the bite of tiny Simulium black flies, which breed in fast-flowing rivers. Onchocerciasis (river blindness) is manifest as the larvae mature to adults, gather in nodules, mate, and produce millions of microfilariae that migrate to the skin, where they cause intense itching and are available to be picked up by subsequent black flies and continue the cycle, and to the eye, where they may cause blindness after several years of repeated infections. The itching may prevent victims from working, or concentrating in school, and causes some to disfigure their skin by repeated scratching. Onchocerciasis can be controlled by annual MDA with ivermectin (Mectizan; Merck, Rahway, NJ) at a dose of 150 µg/kg, estimated by height. in tr o d u c ti o n — E x tE r n a l m id -t Er m E v a lu a ti o n r Ep o r t 14 safety.of.co-administration.of.drugs,.and.the. use.of.existing.tools.and.competencies.within. APOC.to.complete.the.mapping.of.the.various. tropical.diseases.in.individual.countries. 5. In.response.to.the.recommendation.from. TCC23,.endorsed.by.JAF12,.and.given.its. growing.recognition.as.a.‘best.practice’.APOC. was.required.to.encourage.countries.integrate. the.CDTI.approach.to.support.national.health. system.strengthening.and.encourage.its.use.to. support.co-implementation.of.onchocerciasis. control.with.Neglected.Tropical.Diseases.and. Malaria. 1.2 the changing environment for disease and health development 6. There.is.a.changing.global.health.architecture. going.forward.with.the.recognition.that.scaling- up.in.health.requires.a.far.more.coherent. approach..This.recognition.takes.many.forms:. a.growing.awareness.that.health.outcome. related.targets.(focusing.on.the.Millennium. Development.Goals,.MDGs5).cannot.be.achieved. without.adequate.investment.in.the.health. systems.that.underpin.health.service.delivery.. Countries.and.their.development.partners.are. seeking.to.make.significant.increases.in.the. level.of.investment.and.activity.in.health.with.a. focus.on.revitalized.Primary.Health.Care..They. recognize.that.unless.they.scale-up.current. efforts.they.are.unlikely.to.achieve.national.or. international.health.related.outcome.goals. 7. The.MDGs.led.to.several.important.initiatives.. This.includes.the.GAVI.Alliance,.the.Global. Fund.for.Malaria,.TB.and.HIV.AIDS.and. the.Global.Network.for.NTDs.an.Alliance. of.international.organizations.working.to. control.and.eliminate.NTDs.by.2020,.the. International.Trachoma.Initiative,.founded.by. Pfizer.and.the.Edna.McConnell.Foundation;. the.Schistosomiasis.Control.Initiative,.started. by.the.Gates.Foundation.and.Imperial.College. of.London;.Liverpool.Associates.in.Tropical. Health,.which.provides.technical.research.on. NTDs;.and.the.WHO.Global.Plan.to.Combat. Neglected.Tropical.Diseases.2008-2015.. 5. The.health.related.MDGs.encompass.MDG1b.(hunger/ malnutrition),.MDG4.(child.mortality),.MDG5.(maternal. health).and.MDG6.(Communicable.diseases). Several.expressions.of.this.consensus.were. reflected.in.the.work.to.follow.up.the.High. Level.Forum.on.the.Health.MDGs.(HLF).the. Paris.Declaration.on.Aid.Effectiveness,.and.the. Accra.Agenda.for.Action. 8. Over.the.period.the.environment.for.addressing. health.priorities.has.changed..The.world.has. witnessed.several.global.health.initiatives. including.safe.motherhood.programs.and. Bamako.Initiative..Since.the.mid.1990s.several. countries.have.undertaken.health.sector.reforms. with.Sector.Wide.Approach.as.the.basis.of.these. reforms..New.and.major.players.on.the.funding. scene.have.included.Foundations.like.Bill.and. Melinda.Gates.Foundation..Currently.there.is.a. global.movement.toward.NTDs.and.funds.are. being.mobilized.for.this. 1.3 phase ii and phasing out apoc 9. In.2007,.the.decision.was.made.to.phase. out.APOC.in.2015.as.the.institution.for. onchocerciasis.control.in.Africa.without. jeopardizing.the.health.of.the.affected. population..APOC.was.requested.to.develop. a.“Phase.II.and.Phasing-Out.Period”.plan. and.budget6..Four.basic.principles.underlie. APOC’s.proposed.strategy.for.the.period. beginning.in.2008.and.ending.with.closure.of. the.program.in.2015. a.. Community.ownership.and.empowerment,. as.embodied.in.the.CDTI.process b.. Sustainability,.as.embodied.in.the. programme’s.drive.to.ensure.that.its. onchocerciasis.control.activities.will.be. progressively.integrated.into.national.health. systems.and,.by.closure.of.the.Programme. in.2015,.implemented.under.the.full. financial.and.administrative.responsibility. of.the.countries.concerned c.. Evidence-based.decision.making,.as. reflected.in.APOC’s.use.of.scientific. research.–.epidemiological,.entomological,. parasitical,.operational.and.sociological.–.to. support.its.decisions d.. Partnership,.as.witnessed.in.the. Programme’s.harnessing.of.the.strengths. and.expertise.of.countries,.NGDOs,.donors,. and.other.international.organizations. 6. WHO,.2006,.APOC.Phase.II.and.phasing-out.period,.Plan. of.action.and.budget.2008.–.2015,.Page.7 in tr o d u c ti o n — E x tE r n a l m id -t Er m E v a lu a ti o n r Ep o r t 15 10. The.APOC.phasing.out.strategy.was.clear.on. the.need.to.work.with.African.governments. to.help.develop.country-led.feasible,.realistic. end-game.strategies.for.maintaining.the. important.gains.that.have.been.achieved. against.onchocerciasis.in.Africa..Though.it.may. never.be.possible.to.eradicate.onchocerciasis. from.Africa;.it.is.possible.to.eliminate.the. infection.and.interrupt.transmission.in.most. of.the.foci..Therefore,.through.these.strategies,. the.countries.with.support.of.partners.should. continue.to.pursue.all.reasonable.avenues.to. discover.potential.ways.to.break.transmission. of.O. volvulus.and.eliminate.onchocerciasis. among.their.affected.populations. 11. The.Technical.Consultative.Committee;. CSA.and.JAF.all.agree.that.“the.opportunity. exists.to.expand.the.use.of.the.Community- Directed.Intervention.developed.by.APOC. for.onchocerciasis.[can.be.used].….to. support.the.prevention.and.control.of.other. neglected.tropical.diseases”7..APOC.has.since. been.mandated.to.explore.the.use.of.the. CDTI.model.a.vehicle.for.the.concomitant. implementation.of.multiple.health. interventions”8.particularly.the.Neglected. Tropical.Diseases.that.use.CDI.approaches.. In.addition,.the.Joint.Action.Forum.(JAF). 7. Report.of.the.twenty-third.session.of.the.Technical. Consultative.Committee.(TCC).11.–.12.September.2006,. Ouagadougou 8. WHO,.2006,.APOC.Phase.II.and.phasing-out.period,.Plan. of.action.and.budget.2008.–.2015,.Page.7 mandated.APOC.“to.have.established,.by. 2015,.a.country-led.system.capable.of. eliminating.onch.ocerciasis.as.a.public.health. problem.in.all.African.countries.endemic. for.onchocerciasis,.both.those.within.the. geographical.area.covered.by.APOC’s.man-. date.and.those.in.the.ex-OCP.area.that.are. causing.concern 1.4 objectives and terms of reference for the evaluation 12. The.15th.Joint.Action.Forum.(JAF).decided. that.a.mid-term.external.evaluation.of.APOC. should.take.place.and.the.report.submitted.to. JAF.16,.in.December.2010..The.objectives.of. the.evaluation.were.provided.as: • To.review.progress.made.by.APOC.towards. establishing.country-led.systems.through. community.empowerment.for.controlling. onchocerciasis.as.a.public.health.problem. in.endemic.Africa.(2008-2015).and.beyond. • To.review.progress/contributions.made. by.APOC.towards.strengthening.of.health. systems,.in.particular.at.the.community.level. • To.assess.the.capacity.of.APOC.to. co-implement.its.mandate.for.the.control.of. onchocerciasis.with.the.control.of.Neglected. Tropical.Disease.(NTDs).and.other.health. interventions, • To.facilitate.(guidance.to.countries).a. paradigm.shift.from.control.to.elimination. of.onchocerciasis.infection.and.its. transmission.in.specific.areas. Box 1: Terms of reference for the evaluation team A. To assess APOC’s capacity in (i) Strengthening community-directed treatment with ivermectin (CDTI) core activities (HSAM), training of ivermectin distributors and supervision at the community level (ii) Building and strengthening national capacity for transition from onchocerciasis control to elimination of infection towards “shrinking the oncho map” of Africa. B. To document (i) capacity building for the co-implementation of onchocerciasis control with four NTDs at the community, district and national levels, (ii) other health interventions under APOC CDTI approaches; (iii) the capacity of APOC to assist countries in mapping of distribution of diseases for integrated control of NTDs; and (iv) the state of RAPLOA and REMO completion in APOC countries C. To evaluate the progress made towards (i) Strengthening health systems in particular, at the community level; (ii) inclusion of the Community-Directed Intervention (CDI) approach in curricula of more than 50 Schools of Public Health and Nursing in Africa D. To assess APOC’s initiation or progress in developing human resources with special reference to gender issues E. To make recommendations on how best to sustain CDTI post 2015 for the elimination of onchocerciasis infection and transmission. in tr o d u c ti o n — E x tE r n a l m id -t Er m E v a lu a ti o n r Ep o r t 16 13. The.guidance.note.from.the.CSA.suggested. that.the.scope.section.should.include.findings,. lessons.learned.and.recommendations.in.the. following.areas: a.. To.what.extent.APOC’s.organizational. structure,.managerial.support.and. coordination.mechanism.supports.national. and.local.CDI.implementation;.APOC’s. potential.to.contribute.to.the.control.of. other.NTDs;.if.the.strategy.of.APOC.will. be.beneficial.to.scaling.up.country-led. NTD.programs b.. So.far,.how.has.the.establishment.of. country-led.systems.been.capable.of. controlling.oncho.through.the.CDI. strategy.has.been.achieved.so.far.and. likelihood.that.the.planned.oncho. result.will.be.achieved,.and.if.not,.what. progress.towards.their.achievement.can. be.expected; 1.5 methodology 14. All.members.of.the.evaluation.team.met.in. Accra.from.8th.to.9th.July.2010..The.purpose.of. the.meeting.was.four.fold: a.. To.discuss.with.APOC.Management.the. APOC.program.since.its.inception.till.now. and.to.receive.any.relevant.documents. that.will.be.needed.for.the.evaluation. b.. To.discuss.amongst.the.evaluation.team,. the.terms.of.reference.and.guidance.notes. prepared.by.CSA.so.as.to.reach.a.common. understanding.of.the.work.before.the. team.and.seek.any.clarification.from.the. APOC.Secretariat.on.this. c.. To.agree.amongst.the.team,.allocation.of. work.and.time.lines d.. To.undertake.field.visit.to.projects.in. Ghana At.the.end.of.the.meeting.a.format.for. collecting.and.drafting.sections.to.be. used.for.each.section.of.the.report.was. developed.and.a.guide.to.the.content.of. the.sections.was.agreed.on.by.the.team.. In.addition.to.two.face.to.face.meetings. in.Accra.and.Ouagadougou,.the.team.had. four.teleconferences.and.exchanged.several. emails..A.special.Google.group.was.set.up. to.facilitate.the.exchange.of.information. amongst.the.evaluation.team. 15. Several.documents.on.the.work.of.APOC.were. made.available.by.the.APOC.Secretariat.for. our.review..These.documents.cover.reports,. published.materials.in.peer.review.journals. and.grey.materials.available.generally..Four. countries.were.selected.in.consultation.with. APOC.Secretariat.with.certain.characteristics. to.support.analysis.namely: a.. Ghana.–.ex.OCP.country,.designated.as.a. Special.Intervention.Zone.with.recent.CDTI b.. Tanzania.–.has.sustainability.plan.and.well- established.decentralization.system.and. APOC.support.for.co-implementation c.. Cameroon.–.where.co-endemicity.with. loiasis.is.occurring. d.. DRC.–.francophone,.post.conflict.and.larger. burden.of.disease 16. In.each.country.extensive.consultation.took. place.at.all.levels.of.the.health.system.with. program.staff,.CDDs.and.policy.makers.as.well. as.NGDOs.and.donors..We.used.the.report. format.and.question.matrix.drafted.at.the.team. briefing.as.guides.for.question.areas..The.time. schedule.did.not.permit.systematic.coverage. of.all.topics.in.each.location,.so.priority.issues. were.selected.that.responds.to.the.objectives.. Interviews.were.conducted.with.a.cross.section. of.persons.from.government.institutions,. donors,.pharmaceutical.agencies,.NGDOs. and.APOC.staff..APOC.Secretariat.generated. the.initial.list.and.a.snow-balling.sampling. technique.was.used.to.get.to.others.mainly.on. a.recommendation.basis. 17. Each.member.of.the.evaluation.team.was.given. a.subsection.to.develop.towards.a.synthesis. report..A.special.section.of.a.subgroup.of.the. team.met.separately.in.the.UK.to.review.and. synthesis.all.materials.that.have.been.produced. by.individual.members.paying.attention.to. evidence,.gaps.and.signaling.to.each.member. further.work.that.is.needed.to.support.the. synthesis..A.new.format.was.developed.for. the.synthesis.in.readiness.for.the.final.report. to.be.developed.by.all.team.members.after. a.zero.draft.was.submitted.to.all..When.the. penultimate.version.was.produced,.a.debriefing. session.was.held.with.senior.APOC.staff.to. discuss.the.report.and.to.validate.information. and.different.sources.that.has.been.used.in. writing.the.report. p r o G r Es s in c o v Er a G E a n d E li m in a ti o n — E x tE r n a l m id -t Er m E v a lu a ti o n r Ep o r t 17 2. progress in coverage and elimination 2.1 progress in therapeutic and geographic coverage 18. At.the.end.of.2009,.APOC.projects. approximate.therapeutic.coverage.was.71%. of.the.total.population.(table 1)..This.is.well. above.the.threshold.of.65%.defining.adequate. therapeutic.coverage.needed.for.controlling. onchocerciasis.as.a.public.health.problem.. Between.2008.and.2009.there.has.been. an.impressive.improvement.in.therapeutic. coverage.from.46%.to.64%.in.countries.in.or. emerging.from.conflict9..The.only.countries. below.the.recommended.threshold.were. Equatorial.Guinea.(47%).and.Liberia.(36%).. In.all.133.000.out.of.146.000.communities. have.been.served. 19. APOC.developed.the.(REMO).tool.for. identifying.communities.likely.to.be.at.high. risk.of.infection..REMO.uses.geographical. information.—.particularly.the.presence.of. river.basins.—.to.identify.likely.foci.of.infection. and.then.assesses.a.small.sample.adults.for.the. presence.of.onchocerciasis.induced.nodules.. The.delineation.of.APOC.projects.has.been. based.on.the.results.of.REMO..In.total,.Rapid. Epidemiological.Mapping.of.Onchocerciasis. (REMO).has.been.done.in.over.11,600. communities.in.19.countries. 20. In.Ghana,.a.survey.was.conducted.in. 2008/2009..The.highest.focus.of.infection. was.observed.in.the.Daka.river.basin.where. Ekumdipe.had.a.prevalence.of.21.9%.with.a. CMFL.of.0.65mf/skin.snip..The.survey.team. observed.worrying.prevalence.rates.found.in. 9. Ref..APOC.Progress.report,.draft.22.sept..2010,.WHO/APOC Table 1: Geographic and therapeutic coverage breakdown by status of countries Geographic coverage (%) therapeutic coverage (%) country 2008 2009 2008 2009 Post-conflict countries 63 82 46 64 Stable countries 97 98 75 77 Box 2: Contribution of APOC to MDGs MDG 1: Reduced morbidity has resulted in healthy lives gained. APOC has contributed significantly to maintain the productivity of artisanal and rural farming families; kept crop production from falling yet further; improved nutrition through de-worming effects of ivermectin and thereby improved overall living standards. MDG 2: Distribution of Ivermectin has led to better eye and skin health allowing children more time in school among the risk population. MDG 4: The distribution of Ivermectin de-worms and helps improve nutrition with benefits for reduced anaemia and a boost to the immune system. Through co-implementation, the CDTI platform has enabled Vitamin A supplementation, bednets and other child interventions to reach millions of children. MDG 5: Approximately 48% of persons receiving ivermectin by end of 2008 were women. Reduced skin disease and severe itching improves overall maternal health and promotes the duration of breastfeeding. MDG 6: As a disease goal onchocerciasis control is probably one of Africa’s leading success stories least told. It is the disease with one of the best systems including HMIS contributing to health systems strengthening. MDG 8: APOC is a successful community- private-public partnership that has successfully transcended frontiers. It holds the credit for an excellent community directed programme partnering with the world’s largest and longest running operational drug (Mectizan®) donation programme provided by Merck & Co. p r o G r Es s in c o v Er a G E a n d E li m in a ti o n — E x tE r n a l m id -t Er m E v a lu a ti o n r Ep o r t 18 2.2 facilitating guidance to countries for elimination 24. At.a.conference.on.eradicating.onchocerciasis. in.Atlanta.in.2002,.it.was.concluded.that. onchocerciasis.is.not.eradicable.worldwide. using.current.tools.due.to.the.major.barriers.in. Africa.(Dadzie.et.al..2003)10..However,.evidence. that.it.is.possible.to.eliminate.the.disease. in.some.settings.in.Africa.with.ivermectin. treatment.alone.has.recently.emerged.from. Senegal.and.Mali.(Diawara.et.al..2009)11,. and.is.supported.by.promising.findings.from. Guinea.Bissau.and.Kaduna.State.in.Nigeria.. The.growing.evidence.led.APOC’s.governing. body,.the.Joint.Action.Forum,.to.approve.an. additional.objective.for.the.programme,.namely. to.develop.the.evidence.base.on.when.and. where.ivermectin.treatment.can.be.stopped,. and.provide.guidance.to.countries.on.how.to. prepare.for.and.evaluate.cessation.of.treatment. where.feasible.(APOC.2008)12. 25. As.one.of.the.first.steps,.a.categorization. of.APOC.projects.was.made.based.on.the. duration.and.coverage.of.CDTI.treatment.in. each.project13..In.theory,.stopping.treatment. can.be.considered.where.projects.have.had. a.minimum.of.10.years.of.annual.treatment,. and.at.least.72%.weighted.therapeutic. coverage.for.the.period..Control.as.a.public. health.problem.may.have.by.then.already. been.reached.a.number.of.years.before.. Using.these.criteria,.it.is.predicted.in.the. report.that.the.projects.are.likely.to.eliminate. infection.and.interupt.transmission.as.follows.. Out.of.the.107.projects,.6.are.predicted. possible.to.declare.elimination.of.infection. and.interuption.of.transmission.before.end. of.2012,.29.by.the.end.of.2012,.33.by.the. end.of.2015.and.39.beyond.2015..Sample. 10. Dadzie.Y,.Neira.M.and.Hopkins.D.(2003).Finalreport.of. the.Conference.on.the.eradicability.of.Onchocerciasis;. Filaria J.2:.2. 11. Diawara.L,.Traore.MO,.Badji.A,.Bissan.Y,.Doumbia.K,. Goita.SF,.Konate.L,.Mounkoro.K,.Sarr.MD,.Seck.AF,. Toe.L,.Toure.S.and.Remme.JHF.(2009).Feasibility.of. onchocerciasis.elimination.with.ivermectin.treatment.in. endemic.foci.in.Africa:.first.evidence.from.studies.in.Mali. and.Senegal..PLoS Neglected Tropical Diseases.3:.e497. 12. APOC.2008.Addendum.for.the.plan.of.action.and.budget. 2008-2015;.Ouagadougou,APOC/WHO 13. APOC.2010.`moving.from.control.to.elimination.where. feasible,.forecasting.and.categorization.of.APOC.projects,. Ouagadougou;.APOC,.June0 the.Pru.river.basin.particularly.at.Dumanafo. 14.4%,.Damongo.9.3%,.Jerusalem.12.4%,. Bita.Akura.11.2%,.and.Akrakuka.3.2%..One. of.the.findings.of.the.Ghana.Onchocerciasis. mapping.is.the.discovery.of.new.Oncho.foci. that.have.no.access.to.Ivermectin..These.are. the.Afram.Plains.district.of.the.Eastern.region,. Ho.municipal.in.the.Volta.region,.and.Amansie. Central.district.in.the.Ashanti.region..These. districts.have.never.been.known.to.be.endemic. for.onchocerciasis,.and.so,.were.not.exposed.to. Ivermectin.tablets. 21. Recently,.the.REMO.data.have.been.re- analysed,.using.a.spatial.statistical.Krigging. analysis,.which.interpolates.REMO.results. over.the.whole.sampled.area.of.Africa..This. is.one.of.the.many.achievements.of.APOC. in.its.preparation.towards.assisting.countries. to.take.responsibility.for.the.programme.. The.resulting.Krigging.maps.were.used.for. identifying.additional.areas.which.require. treatment,.or.the.need.for.further.REMO. surveys..The.maps.were.also.used.as.a.first. step.in.delineating.transmission zones,. the.recently.identified.geographical.unit.for. assessing.onchocerciasis.elimination. 22. The.spatial.statistical.Krigging.analysis. results.produced.predictive.onchocerciasis. transmission.zones..When.the.predictive. map.was.overlaid.with.project.activities.and. CDTI.coverage.area.maps,.it.was.found.that. congruence.between.the.krigging maps and.the CDTI coverage area map was approximately 97%.for.the.areas.for.which. the.modeling.has.been.done..The.explanation. for.this.was.that.projects.through.community. initiatives.extend.their.coverage.to.areas. beyond.the.precise.project.boundaries. 23. The.serious.adverse.events.which.can.occur. in.loa-loa.infected.persons.has.led.to.APOC. undertaking.rapid.assessment.procedure.of. Loa.loa.(RAPLOA).in.areas.where.community- directed.treatment.with.ivermectin.is. indicated..RAPLOA.has.been.conducted.in. 7.APOC.participating.countries..A.total.of. 3429.villages.were.surveyed.in.Angola.(261. villages),.Cameroon.(600),.Congo.(43),.DRC. (2166),.Equatorial.Guinea.(87),.Nigeria.(113). and.Sudan.(159). p r o G r Es s in c o v Er a G E a n d E li m in a ti o n — E x tE r n a l m id -t Er m E v a lu a ti o n r Ep o r t 19 evidence.on.lead.up.to.elimination.is.provided. in.Annex.III..Since.then,.conceptualization. of.the.elimination.process.has.been.evolving.. It.was.realized.that.the.APOC-project.is.not. necessarily.the.appropriate.geographical. unit.for.implementation.of.the.elimination. process..The.appropriate.geographical.unit.of. elimination.has.been.coined.`transmission zone`.(TZ).and.is.defined.as.`a geographical area, where transmission of O. volvulus occurs by locally breeding vectors`..This. zone.can.be.regarded.as.a.natural.ecological. and.epidemiological.unit.for.the.elimination. process14..Cessation.of.treatment.after.2015. may.have.to.be.decided.by.countries.on.results. of.entomological.studies. 26. Information.on.the.possibility.of.stopping. transmission.and.of.APOC’s.support.for. the.move.from.control.to.focussing.on. elimination.has.already.been.communicated.to. Government.partners..Exit.plans.have.however. been.put.on.hold.as.they.cannot.be.realistically. developed.until.after.elimination.plans.have. been.undertaken..It.is.also.understood.that.the. need.to.understand.the.practical.implications. of.elimination.has.delayed.the.final.withdrawal. of.APOC.support.from.a.number.of.projects. 27. On.field.visits,.the.evaluation.team.found.that. health.personnel.at.district.level.were.well. aware.of.the.news.and.most.were.familiar. with.the.revised.targets.of.80%.minimum.for. therapeutic.coverage.and.100%.for.geographic. coverage..Some.health.teams.were.clearly. working.towards.these.targets.and.working. towards.stopping.transmission.and,.ultimately,. treatment..Health.personnel.met.during.the. field.visits.expressed.their.need.for.guidance. on.treatment.issues:.such.as.the.implications. for.duration.of.coverage.in.areas.where.2-3. year.old.children.have.multiple.nodules.but. are.not.yet.eligible.to.start.treatment. 28. The.key.challenge.is.that.while.there.is. evidence.that.transmission.can.be.interrupted,. the.science.for.predicting.this,.and.for.mass. surveillance.which.avoids.painful.skin.snips,. has.not.yet.been.defined..APOC.is.still. learning.by.doing.and.will.not.be.in.a.position. 14. Report.of.the.Informal.Consultation.on.elimination.of. oncho.transmission…shrinking.the.map..2009.. to.answer.many.country-level.questions.until. after.2012..Thinking.in.transmission.zones.is.a. major.paradigm.shift.compared.to.the.previous. thinking.in.administrative.APOC-projects,.as. they.do.not.bear.any.kind.of.relationship.to. project.areas..There.may.be.several.TZ.in.one. project,.TZ.may.cover.parts.of.several.projects,. or.may.even.be.part.of.different.countries,. in.particular.when.rivers.form.the.boundary. between.countries..This.conflicts.with.earlier. recommendations.regarding.the.need.to. realign.projects.with.administrative.boundaries. for.greater.integration. 2.3 issues for further consideration towards elimination 29. When.evaluation.team.members.asked.project. staff.if.the.revised.coverage.targets.would.be. difficult.to.achieve.and.maintain,.there.were. very.similar.responses..It.was.widely.agreed. that.a.lot.more.HSAM.activities,.specific.IEC. materials.and.training.would.be.required;.in. some.districts.with.very.remote.communities,. additional.resources.for.transport..There. are.thus.implications.for.additional.funding. requirements. 30. A.series.of.steps.have.now.been.identified. which.will.need.to.be.undertaken.for. determining.when.treatment.can.be.stopped.. Some.of.these.are.reliant.on.technical.advances. which.have.not.yet.been.finalised.or.proven,. such.as.the.DEC.patch.as.an.alternative.to. skin.snips.for.surveillance.and.the.possibility. of.replacing.human.baits.for.fly.capture.with. pheromone.laced.fly.traps..The.science.is.just. emerging.around.the.paradigm.shift.and.this. brings.with.it.the.need.to.redefine.time.lines.. Admittedly.this.is.a.non.predictive.exercise. 31. There.are.broad.concerns.that.stopping. ivermectin.in.formerly.meso/hyperendemic.or. high.risk.areas.that.border.low.risk.areas.which. have.not.had.CDTI;.recrudescence.could.occur. and.risk.jeopardizing.the.substantial.gains. already.made..Given.that.current.literature. suggests.that.the.duration.of.treatment.may. need.to.be.continued.to.up.to.14.years.and. at.a.high.level.of.coverage,.the.alarm.bells.are. justifiably.ringing..Recent.studies.in.Ghana.have. raised.other.concerns.relating.to.the.possible. p r o G r Es s in c o v Er a G E a n d E li m in a ti o n — E x tE r n a l m id -t Er m E v a lu a ti o n r Ep o r t 20 development.of.resistance.of.the.parasite.to. ivermectin;.these.have.yet.to.be.confirmed. 32. In.view.of.all.the.steps.to.be.taken,.the.road. from.starting.to.define.transmission.zones.to. confirming.that.there.is.no.early.recrudescence. after.cessation.with.treatment.will.probably. take.at.least.4.to.5.years..This.means.that.the. transmission.map.of.oncho.cannot.shrink. much.beyond.current.levels.before.2015,.and. many.of.the.elimination.activities.will.take. place.after.2015..Whereas.the.disease.has. been.controlled.as.a.public.health.problem.in. many.communities.in.countries,.there.is.no. expectation.in.the.evaluation.team’s.view.that. the.levels.of.coverage.of.the.total.population.in. relation.to.transmission.intensity,.prevalence.and. community.micro-filarial.load.will.be.sufficient. to.stop.transmission.within.the.next.five.years. in.all.countries..In.some.countries,.this.will. happen,.as.mentioned.above,.the.evidence.from. Mali.,.Senegal.and.Kaduna.in.Nigeria.show.that. interuption.of.transmission.of.infection.may. have.happened.before.those.studies. 33. Following.the.path.to.‘elimination’,.there.will. need.to.be.an.increasing.shift.in.onchocerciasis. activities.from.CDTI.to.epidemiological. and.entomological.surveys..The.expertise. and.training.required.for.conducting. epidemiological.and.entomological.and. surveys.are.quite.different..Many.countries. will.only.have.limited.survey.expertise.by. 2015,.and.this.will.be.mainly.restricted.to.the. first.phases.of.the.elimination.process..During. the.period.2001-2009,.only.3%.of.capacity. building.of.nationals.and.NGDO.country.staff. concerned.epidemiological.surveillance15.. 15. Update.of.APOC.PAB.2008-2015.Indicators,.WHO/APOC,. version.21Sept2010 34. Where.co-implementation.involves.other. drugs,.there.will.be.a.continued.role. for.health.staff.using.current.training. approaches.in.addition.to.the.need.for. new.survey-related.skills..Guidance.is.also. required.where.ivermectin.treatment.for. onchocerciasis.is.co-implemented.with. lymphatic.filiarisis,.which.is.also.treated. with.ivermectin..Distribution.will.need. to.continue.until.neither.disease.requires. ivermectin.treatment. 35. It.is.the.view.of.the.evaluation.team,. that.there.is.a.potential.communications. challenge.to.be.resolved..This.has.three. dimensions..Firstly,.there.is.general.talk.of. ‘elimination’.rather.than.stopping.treatment. following.the.ending.of.transmission.in. local.areas.–.i.e..localise.elimination..This. needs.clarifying.and.careful.communication. in.order.to.manage.expectations.and.avoid. confusion.Secondly,.the.road.to.elimination. is.not.one.for.which.countries.have.the. necessary.knowledge.and.expertise.and.are. clearly.expecting.continued.APOC.support.. With.APOC’s.original.funding.period.having. already.been.extended,.there.are.expectations. that.APOC.will.now.continue.to.exist.and. to.support.elimination.activities..Third,. communities,.project.and.health.service. personnel.need.to.realise.that.the.science. of.oncho.elimination.has.not.yet.caught.up. with.the.news.that.it.may.be.possible..Clear. guidance.on.the.implications.of.this.will. be.essential.to.avoid.coverage.levels.falling. or.projects.stopping.treatment.based.on. unproved.assumptions..If.effective.control. can.be.achieved.then.communities.would.be. ready.to.stop.treatment.as.soon.as.this.can.be. scientifically.confirmed. Figure 1: Steps towards certifying and maintaining elimination status Routine surveillance after elimination certication • Resume treatment when results indicate recrudescence Conrmation of low infection and transmission in a post-stopping setting • Entomological and epidemiological survey, 3 years after stopping CDTI • Elimination certi
cation when results of survey satisfy criteria • Resume treatment when results indicate recrudescence Satisfying the criteria for stopping CDTI in the transmission zone • History of CDTI (number of years, coverage) • Surveys (are entomological and epidemiological criteria satisfed?) Delineation and validation of a transmission zone • Krigging REMO map with nodule prevalence • National Consultative meetings (tentative delineation of TZ) • Assessment and validation in surveys c d ti E ff Ec ti v En Es s a n d c o -i m p lE m En ta ti o n — E x tE r n a l m id -t Er m E v a lu a ti o n r Ep o r t 21 3. cdti effectiveness and co-implementation need.for.participation.and.ownership.by. communities.in.their.health.and.health.care.. It.has.been.argued.that.this.model.is.essential. for.the.empowerment.of.communities;.a. critical.foundation.for.sustainable.public. health.interventions..Empowerment.is. regarded.as.having.been.achieved.when. communities.can.sustain.implementation.of. existing.interventions,.and.also.expand.into. other.areas.of.perceived.need..“Empowered. communities”.therefore.means.not.only.taking. charge.of.existing.interventions.but.also. taking.initiative.on.new.interventions..There. are.seven.main.features.of.the.APOC.model.of. CDTI.as.shown.in.box 3. 38. With.about.603,000.CDDs.delivering. ivermectin.to.communities.with.a.total.68.4. million.people.in.2009,.the.CDTI.approach. has.effectively.demonstrated.the.potential.of. empowering.communities.in.their.health..The. ultimate.test.is.to.improve.and.sustain.the. coverage.of.the.target.populations.with.the. interventions..The.evaluation.team.analysis.is. presented.in.table 2. 3.1 cdti and system effectiveness 36. The.APOC.‘Phase.II.and.phasing.out.period”. plan.and.budget.defines.sustainability.and. funding.support.beyond.2015.as.“…100%.of. oncho.control.(will.be).borne.by.government. and.NGDOs.….(and).implies.that.in.most. CDTI.areas,.treatment.will.reach.at.least.65%. of.the.population.at.risk.….(and.treatment). will.become.an.integral.part.of.the.national. or.local.health.care.services.of.all.endemic. countries”..A.directive.had.since.gone.out. to.countries.to.present.exit.strategies.and. sustainability.plans..CDTI.is.a.community. directed.approach.in.which.the.distribution. and.administration.of.Ivermectin.to.the. community.is.undertaken.by.the.community. itself..The.community.understands.the.nature. and.importance.of.the.intervention,.and. determines.the.appropriate.time.and.mode.of. distribution.that.will.ensure.accessibility.and. maximum.coverage. 37. The.CDTI.approach.responds.to.one.of.the. central.tenets.of.primary.health.care;.the. Box 3: Main features of APOC Community Directed Treatment with Ivermectin (CDTI) ✔ Community choice of Community Directed Distributors (CDD) is essential. ✔ Community has control of timing of the intervention ✔ CDD is accountable primarily to the community. This provides a good indication of ownership and sustainability. If coverage fall short of the desired therapeutic and geographic levels, the community and their leaders are able to address it appropriately ✔ CDD works to community determined incentives ✔ Communities are able to self monitor based not only on targets determined by health systems but also through self identified targets and indicators. Targets include recognition of best performing individual CDDs in terms of coverage, record keeping etc; as well as best performing communities compared to neighbouring villages. ✔ CDDs maintain a comprehensive census of the population of the community ✔ CDDs are trained and responsible for ongoing record keeping for monitoring of intervention c d ti E ff Ec ti v En Es s a n d c o -i m p lE m En ta ti o n — E x tE r n a l m id -t Er m E v a lu a ti o n r Ep o r t 22 Table 2: Progress in integrating CDTI into country led systems Elements of cdi What is working well What is not working well Community choice of Community Directed Distributors1 (CDD) is essential. The CDDs chosen by the community have the imprimatur of the community leaders and are therefore respected, are willing to work on of terms determined by the community and have a higher level of retention.2,3 It has been possible through this mechanism to introduce gender issues both at the level of compliance to treatment and in human resources in providing women with opportunities to become CDDs4 CDDs selected by the community for CDTI are approached directly by front-line health staff for other interventions without consulting the community. Remuneration offered through by other programmes becomes the main motivating factor for the CDDs and present problems for commitment to less well paid programs and overall sustainability of health interventions that are not well funded. Community has control of timing of the intervention Communities decide on optimal times to enhance coverage taking into consideration issues such as weather, religious and cultural events. There are now (2007) 117,000 communities that have taken responsibility for Ivermectin distribution. APOC has improved on the system for funds release by linking in 2008 fund release to the WHO Global Management System. This has improved the timing of release of logistics and provision of new equipment and replacement of old one to facilitate CDI activities under normally running programs. Community is usually informed about the intervention but timing and logistics are now increasingly being based on the effectiveness of the supply chain management and availability of funds. This is an issue particularly in countries whose funds have been withheld or reduced as a result of failure to submit budgets or reports, fund availability by government and development partners in post- OCP countries and strength of the health system where service provision has been integrated or conflict has resulted in coordinated systems failure In many settings, communities are receiving inte rventions that are actually funded by external donors and the districts are under pressure by programme managers to implement what they are asked for. CDD is accountable primarily to the community. This provides a good indication of ownership and sustainability. If coverage falls short of the desired therapeutic and geographic levels, the community and their leaders are able to address it appropriately Communities have been responsible for obtaining drug supplies, mobilizing members of the community All APOC and country reports show that there is a good coverage for therapeutic and geographic levels. Communities have been known to provide feedback as part of community-self monitoring, in which coverage rates are presented to peers and formal health sector representatives. At the sub national level, the “project management” of Oncho control activities has led to a poor sense of ownership amongst some health professionals viewing it as a “community program”. In many projects, CDI-related activities compete with other “well-resourced” vertical programs with consequences as highlighted in point 2 above. In some settings, community stakeholders such as community based organizations and NGOs are consulted by health professionals solely for planning and in kind or financial support. Lack of communication and transparency has fuelled suspicion around incentives reserved by Government for CDDs. In 2008 and 2009, less than 10% of communities conducted CSM and fewer have hold SHM. Community participation is sometimes tokenistic particularly when the extent of ‘community involvement’ is for social mobilization CDDs are also asked by district officials to implement other public health activities without consulting the community. “The chief of the health centre is our boss” (quote from a CDD) 1. The.term.community.volunteer.is.often.used.in.the.literature.to.highlight.the.fact.that.this.is.an.unpaid.workforce..However.is. has.been.highlighted.(Pers.Comm:.Akogun,.Sept.3.2010).that.‘volunteerism’.implies.self.nomination.and.personal.altruism..The. CDDs.in.this.context.are.nominated.by.their.communities.and.the.recognition.is.an.honour. 2. Katabarwa.et.al.,.“Community-directed.interventions.strategy.enhances.efficient.and.effective.integration.of.health.care.delivery. and.development.activities.in.rural.disadvantaged.communities.of.Uganda.” 3. “Community-directed.interventions.for.priority.health.problems.in.Africa.” 4. Katabarwa.et.al.,.“Involvement.of.women.in.community-directed.treatment.with.ivermectin.for.the.control.of.onchocerciasis.in. Rukungiri.district,.Uganda”;.Katabarwa,.Habomugisha,.and.Agunyo,.“Involvement.and.performance.of.women.in.community- directed.treatment.with.ivermectin.for.onchocerciasis.control.in.Rukungiri.District,.Uganda.” c d ti E ff Ec ti v En Es s a n d c o -i m p lE m En ta ti o n — E x tE r n a l m id -t Er m E v a lu a ti o n r Ep o r t 23 Elements of cdi What is working well What is not working well CDD works to community determined incentives The CDI model is cost effective, financially sustainable and at “a cost the community and country can afford”5 Multi country studies have shown that intrinsic incentives are important to CDDs and although they do express a desire for remuneration, this does not significantly affect their willingness to serve their communities A trend towards globally determined incentives is emerging. Recently funds have been obtained for providing bicycles to CDDs through a donation from Global Network for Neglected Tropical diseases. It has been decided that the bicycles will be given to both male and female CDDs particularly those involved in integrated mass- drug administration of NTD control. It is not clear how this decision came about and its impact on existing community determined incentive systems and choices. In Cameroon, the government pays CDDs a small incentive for each person treated. CDDs are trained and responsible for ongoing record keeping for monitoring of intervention Communities have taken responsibility for conducting community census. APOC is currently in the process of developing a system to digitize the paper based records of CDDs as a valuable health data source at the community level. An outstanding feature of CDI has been the annual training of large numbers of community distributors (CDDs) for enumerating the population, distributing ivermectin, HSAM and record-keeping. The strategy for 2008-2015 aimed to train an additional 550,000 CDDs and to ensure a ratio of 1 CDD trained to every 100 people in the 117,000 communities receiving treatment. The number of CDDs trained and retrained over the last three projects years were 2006/7 (271,113); 2007/8 (345,765) and 2008/9 (420,327). In many of the countries, health information systems are weak and record keeping is ad hoc and erratic. This is because of the low levels of literacy level of many of the CDDs. There are concerns that the CDI model has led to a requirement for vertical reporting and not benefiting from any existing health system information strengths no matter how minimal The target is for 1:100 head of population. Only two countries have attained this ratio. Nigeria has a 1:210 and 1:771 in Equatorial Guinea. Communities are able to self monitor based not only on targets determined by health systems but also through self identified targets and indicators. Targets include recognition of best performing individual CDDs in terms of coverage, record keeping etc; as well as best performing communities compared to neighbouring villages. APOC with assistance of country experts built capacity of CDI implementers in disease mapping; CDI strategy, disease surveillance, report writing, data collection and administration and financing. APOC has developed a tool for community self monitoring to empower communities monitor progress against their own indicators and targets Monitoring is increasingly being based on indicators and targets set by the health services or by funding agencies with no involvement of the communities ‘Opportunity cost’ involved in stakeholder consultations to develop relationships with and support empowerment of both affected communities and across the different levels of the health system, community engagement in the design and implementation, commitment to regular and timely supply of materials and support The opportunity cost is the commitment to establishing sustainable CDTI systems as part of a process of community empowerment and community health systems strengthening as against paying for short term health workers to deliver time-spaced single disease intervention. The model is based on a form of social contract and an implicit social capital where community members are assumed to have a hierarchy of needs which puts long term sustainability over short term incentives. Other programs in co-implementation have expressed concern about the tradeoff between expedience and meeting funding targets and this less tangible process of engaging community when there is not commitment beyond the short term delivery of an intervention. Communities are therefore being disempowered by the advent of interventions wanting quick results and partners are unwilling to invest the time needed for establishing the CDTI model. Direct financial incentives are being provided by partner programmes to CDDs and community members. This can affect trust and generate suspicions between CDTI/CDDs and their front line mainstream health worker. 5. “declaration_almaata.pdf.” c d ti E ff Ec ti v En Es s a n d c o -i m p lE m En ta ti o n — E x tE r n a l m id -t Er m E v a lu a ti o n r Ep o r t 24 3.2 gender in program operations 39. The.non-participation.of.women.as.CDDs. was.identified.as.a.concern.by.APOC.partners. early.in.the.inception.of.the.program16.and. KAP.studies.were.undertaken.to.identify. obstacles.to.their.involvement..Since.then.the. importance.of.gender.has.been.highlighted.in. APOC.operations.and.targets.set.to.achieve. gender.balance.in.the.appointment.of.CDDs. at.the.community.level..In.2008.the.TCC. called.for.disaggregation.of.CDD.data.by.sex. and.information.on.gender.related.attrition.of. CDDs..There.was.also.a.recommendation.to. investigate.whether.increasing.female.CDDs. has.an.impact.on.therapeutic.coverage;.a.field. study.is.to.be.funded.by.APOC. 40. APOC.has.recently.appointed.a.gender. expert.to.undertake.a.number.of.activities.to. address.the.gender.issues.within.communities.. A.gender.mainstreaming.policy.is.being. developed.that.takes.gender.into.account. through.project.planning,.management.and. capacity.building.both.at.the.level.of.APOC. head.quarters,.in.APOC.countries.and.in. affected.communities. 41. It.was.suggested.to.the.Evaluation.Team.that. an.analysis.of.the.gender.issues.has.been. undertaken.for.Cameroon,.Nigeria,.DRC,. Tanzania.and.Uganda.for.data.collected. between.2008.and.2010..Women.currently. represent.24.2%.of.CDDs..Data.from.2009. however.show.that.a.significant.proportion. of.people.treated.(approximately.61%).in. 14.APOC.countries.were.women.although. only.18%.of.CDDs.were.women17..The. Central.African.Republic.reports.0-1.5%. of.women.CDDs..Reasons.for.the.disparity. are.mixed.but.relate.largely.to.cultural.and. religious.barriers..There.remain.areas.where. CDDs.are.still.predominantly.male.where.for. instance.the.community.leaders.have.taken. on.the.responsibility.themselves18.or.where. 16. Katabarwa,.Habomugisha,.and.Agunyo,.“Involvement.and. performance.of.women.in.community-directed.treatment. with.ivermectin.for.onchocerciasis.control.in.Rukungiri. District,.Uganda”;.Katabarwa.et.al.,.“Involvement.of.women. in.community-directed.treatment.with.ivermectin.for.the. control.of.onchocerciasis.in.Rukungiri.district,.Uganda.” 17. Preliminary.data.from.Dr.Diop.(gender.expert) 18. This.was.reported.in.communities.in.Tanga.District.in. Tanzania. it.is.culturally.inappropriate.and.unsafe.for. women.to.take.on.a.role.that.takes.them. unescorted,.door.to.door.to.other.people’s. homes.19.It.has.also.been.suggested.that. insistence.on.gender.balance.runs.counter.to. a.community.directed.intervention;.so.while. APOC.can.encourage.communities.through. highlighting.the.importance.of.the.gender. issues,.it.is.ultimately.up.to.the.communities. to.appoint.those.who.they.deem.most. appropriate.for.the.roles20 42. While.achieving.gender.balance.may. have.its.inherent.advantages,.these.have. not.been.well.researched.and.identified. and.therefore.the.treatment.of.gender.has. been.somewhat.uncritical.and.tokenistic.. There.are.a.plethora.of.gender.issues.in. disease.control.both.from.the.perspective. of.those.experiencing.the.conditions.and. from.the.perspective.of.service.and.care. providers21..There.might.for.instance.be. a.different.dynamic.involved.in.the.non- monetary.incentives.that.apply.to.female. CDDs.that.may.differ.from.their.male. counterparts..It.has.been.reported.from. some.sites.that.CDDs.are.more.likely.to.be. women.where.the.opportunity.costs.are.very. high.and.the.position.therefore.carries.less. status22..However,.these.issues.need.to.be. systematically.investigated. 43. The.improvement.in.the.empowerment.of. communities.as.a.whole.would.have.advantages. for.individuals..The.impact.of.empowerment. on.the.performance.of.and.opportunities.for. CDDs.is.an.important.question..Within.this,. a.gender.based.analysis.could.inform.the. contribution.of.the.gender.balance.strategy.. Furthermore,.there.are.opportunities,.with. co-implementation,.to.assess.the.effects.of. gender.on.uptake.and.compliance.with.single. and.combinations.of.various.interventions.both. from.the.perspective.of.community.members. 19. In.the.conservative.religious.areas.in.Northern.Nigeria,. women.going.out.as.distributors.would.be.unsafe.for.them. (Akogun,.Sept.4.2010.–.Pers.Comm) 20. Katabarwa.et.al.,.“Involvement.of.women.in.community- directed.treatment.with.ivermectin.for.the.control.of. onchocerciasis.in.Rukungiri.district,.Uganda.” 21. Allotey.and.Gyapong,.“TDR.Publications:.The.gender. agenda.in.the.control.of.tropical.diseases:.A.review.of. current.evidence.” 22. Bump,.Akogun c d ti E ff Ec ti v En Es s a n d c o -i m p lE m En ta ti o n — E x tE r n a l m id -t Er m E v a lu a ti o n r Ep o r t 25 and.CDDs..Data.on.these.issues.could.provide. an.important.contribution.to.the.progress.of. MDG3. 3.3 cdi and co-implementation 44. In.2008,.governments.and.international. organizations.significantly.scaled-up.efforts. to.address.NTDs..For.the.first.time,.G8. leaders.put.NTDs.on.the.global.health. agenda.and.called.for.sustained.action.over. the.next.3.to.5.years.to.address.NTDs23..In. addition.to.new.U.S..commitments,.the.UK. announced.a.commitment.of.$80.million. over.5.years.toward.NTD.control.and. elimination..Canada.and.Japan.have.also. provided.some.funding.for.NTD.control24.. The.private.sector.has.also.made.significant. investments..The.pharmaceutical.industry. provides.deeply.discounted.and.donated. drugs.(estimated.$1.billion.since.2006). to.countries.to.treat.NTDs..The.Gates. Foundation.has.provided.new.resources. to.the.field,.including.a.2009.grant.of.$34. million.to.the.Global.Network.for.NTDs. to.establish.regional.strategies.and.funding. mechanisms.and.leverage.new.investments. to.eliminate.some.NTDs.and.reduce.disease. burden.by.202025..Building.on.the.USAID. program,.President.Bush.launched.the. Neglected.Tropical.Diseases.Initiative,.a. 5-year,.$350.million.initiative.to.provide. treatment.to.more.than.300.million.people.in. Africa,.Asia,.and.Latin.America,.and.increase. the.number.of.focus.countries.to.30.by.2013.. USAID.initially.targeted.5.focus.countries.in. 2006.(Burkina.Faso,.Ghana,.Mali,.Niger,.and. Uganda),.and.has.since.expanded.to.include. 7.more.(Haiti,.Sierra.Leone,.the.southern. part.of.Sudan,.Nepal,.Bangladesh,.Tanzania,. and.the.Democratic.Republic.of.Congo). 45. There.is.growing.evidence.that.synergistic. gains.can.be.made.from.linking.the. control.programs.for.onchocerciasis,. lymphatic.filariasis,.Schistosomiasis,.Soil. 23. Global.Network.2008.Leading.the.Fight.Against.Diseases.of. Poverty,.Annual.Review 24. G8.Research.Group.2008.Interim.Compliance.Report,. Health:.Neglected.Tropical.Diseases;.November 25. Global.Network.2009..Global.Network.receives.$34.million. Gates.Foundation.investment.to.scale.up.prevention.and. treatment.efforts.[press.release];.January.30, transmitted.helminthes,.Trachoma.and.other. diseases.in.a.framework.that.allows.for. co-implementation26..Indeed,.combining.other. disease.control.solutions.offers.economies.of. scale,.efficiency.and.cost.saving,.along.with. maximising.benefits.for.recipients.especially. among.poor,.poly-parasitized.populations. enduring.multiple.disease.threats..The.World. Health.Organisation.in.2006.provided.a.guide. on.a.possible.integrated.control.approach27..In. 2007.the.Technical.Consultative.Committee.of. APOC.TCC.recognized.“the.opportunity.that. exists.to.expand.the.use.of.the.Community- Directed.Intervention.(CDI).developed.by. APOC.for.onchocerciasis.and.the.existing. CDI.structures.in.participating.countries.to. support.the.prevention.and.control.of.other. neglected.tropical.diseases”28..The.kind.of. collaboration.anticipated.would.provide. opportunities.to.jointly.address.technical. issues,.such.as.the.safety.of.co-administration. of.drugs,.and.the.use.of.existing.tools.and. competencies.within.APOC.to.complete.the. mapping.of.the.various.tropical.diseases.in. individual.countries. 3.3.1 The CDI framework 46. As.noted.by.the.multi-country.study,. implementation.of.CDI.across.diseases.using. preventive.chemotherapy.involved.addressing. six.major.processes..The.elements.of.APOC. CDI.have.already.been.outlined.in.the.section. on.CDTI.and.community.empowerment..From. our.understanding.of.the.other.diseases.and. CDI.methods.we.conclude.that.a.generic.CDI. system.is.indeed.feasible.to.engage.with.and. adapt.to.deliver.community.directed.services.or. to.achieve.Preventive.Integrated.Chemotherapy. through.co-implementation..The.Evaluation. Team.have.organized.the.elements.identified.in. the.multi-country.study.and.the.APOC.CDTI. framework.in.figure 2.overleaf. 26. Molyneux.DH,.Hotez.PJ,.Fenwick.A,.2005.Rapid-impact. interventions:.how.a.policy.of.integrated.control.for.Africa’s. neglected.tropical.diseases.cold.benefit.the.poor..PLoS Med. 2005:.2:.e.336 27. WHO.2006.Preventive.chemotherapy.in.human. helminthiasis..Coordinated.use.of.antihelminthic.drugs.in. control.interventions:.a.manual.for.health.professionals.and. program.managers..Geneva:.WHO 28. Report.of.the.twenty-third.session.of.the.Technical. Consultative.Committee.(TCC).11.–.12.September.2006,. Ouagadougou c d ti E ff Ec ti v En Es s a n d c o -i m p lE m En ta ti o n — E x tE r n a l m id -t Er m E v a lu a ti o n r Ep o r t 26 47. The.APOC.document,.“Phase.II.and.Phasing- Out.Period”.notes.that.“…the.proven. effectiveness.of.CDTI.has.made.the.strategy. not.only.a.model.for.the.delivery.of.other. health.interventions,.but.also.increasingly,.a. vehicle.for.the.concomitant.distribution.of. multiple.health.interventions”. 3.3.2 Progress in co‑implementation 48. There.is.significant.evidence.that.countries.on. their.own.or.with.APOC.support.are.already. using.the.CDI.model.for.co-implementation.. The.number.of.CDI.projects.co-implementing. other.health.interventions.along.with.ivermectin. treatment.has.increased.from.22.in.2005.to. 73.in.2009..It.is.envisaged.that.all.projects. will.be.co-implementing.by.2015..For.seven. countries.for.which.data.was.made.available,. additional.interventions.were:.distribution.of. Insecticide-treated.bed.nets.(ITNs),.treatments. for.lymphatic.filariasis,.eradication.of.Guinea. Worm,.and.schistosomiasis,.vitamin.A. supplementation,.deworming,.immunization,. and.health.education.on.HIV/AIDS. 49. More.than.11.5.million.persons.benefitted. from.interventions.related.to.control.malaria. (Home-based.treatment.of.malaria.and. insecticide.treated.mosquito.nets)..About. 269,000.CDDs.were.able.to.reach.105,000. communities.and.more.than.37.5.million. people.covered.with.additional.health. commodities..This.is.66.1%.of.the.treated. population.for.CDI.in.2008.(56.7.million. persons)..Distribution.for.seven.countries. available.is.presented.in.figure 3. 50. In.Nigeria,.the.CDTI.structure.has.provided. an.entry.point.for.other.health.interventions. such.as.Vitamin.A.supplementation,. elimination.of.Lymphatic.Filariasis,.control. of.Schistosomiasis.and.distribution.of. Insecticide.Treated.Nets.(ITNs).for.Malaria. and.LF.Control..Co-implementation.with.VAS. using.the.CDTI.structure.was.done.in.Benue,. Taraba,.Cross.River,.Kogi,.Kwara,.Akwa.Ibom,. Adamawa,.Plateau,.Nassarawa.and.Borno,. over.2.million.children.and.women.being. reached..In.Plateau.and.Nassarawa.States.LF. elimination,.schistosomiasis.control,.VAS,. Figure 2: Critical factors in the CDI process of the five targeted diseases for co-implementation Stakeholder processes Similarities in CDI framework of targeted diseases Facilitation and organisation Engaging CDI implementers Engaging and empowering communities Form a base of commitment in the health system, outreach followed in order to engage and mobilise communities to sustain interventions Community and health systems actors become involved in a process of recruitment, support and maintenance of a pool of community volunteers and implementors Strengthening health systems particularly at the frontline needed to engage in specic commitments and tasks related to CDI implementation  Broader health systems changes triggered such that the inherent value of community involvement and empowerment could be internalized by communities and health workers, leading to a more responsive system overall Community awareness eects Community development eects Health worker eects Gender and equity Securing the broad commitment of various stakeholders from national to community level for implementation and stewardship Health system dynamics Broader systems eects c d ti E ff Ec ti v En Es s a n d c o -i m p lE m En ta ti o n — E x tE r n a l m id -t Er m E v a lu a ti o n r Ep o r t 27 ITN.distribution,.are.being.co-implemented.. In.Kaduna.and.Taraba.States,.community. rehabilitation.of.blind.persons.in.few. communities.is.being.undertaken.using.the. CDTI.structure..In.most.Sightsavers’.and.some. CBM–.assisted.States,.efforts.are.on-going. to.integrate.simple.primary.eye.care.(e.g.. screening.for.cataracts).into.CDTI..Funds. accessed.for.LF.and.VAS.have.been.used.to. boost.CDTI..Where.these.have.been.done,. coverage.with.Ivermectin.has.been.boosted.or. sustained.and.individual.compliance.levels.are. increasing. 51. In.Cameroon,.the.National.Onchocerciasis. Control.Program.has.formally.piloted. co-implementation.of.ivermectin.and. Albendazole.in.two.projects.in.the.North. and.far.North.regions.for.oncho.and. lymphatic.filariasis..In.many.districts,. CDDS.are.invited.to.participate.in.public. health.programs.such.as.malaria,.EPI,.polio. immunization,.distribution.of.mebendazole. and.vitamin.A.during.Child.Health. and.Nutrition.Days..This.involvement. is.usually.organized.by.the.District. Health.Management.Team.sometimes. without.referring.back.to.the.community.. Community.supervisors.are.usually.recruited. to.work.for.other.programs.such.as.HIV/ AIDS,.community.based.case.surveillance. of.disease.prone.to.epidemics.or.the.four. diseases.targeted.for.elimination.by.EPI. 52. In.the.Democratic.Republic.of.Congo,.a. National.Policy.for.Neglected.Diseases.2008. has.been.developed.which.adopted.an. integrated.approach.for.the.five.NTDs..This. approach.has.been.further.adopted.in.the. draft.Strategic.Plan.2011.–.2015.for.integrated. fight.against.Neglected.Tropical.Diseases..A. coordination.unit.was.created.in.2009.but. not.yet.fully.operational..When.discussing. co-implementation,.it.became.obvious.to.the. Evaluation.Team.that.the.term.is.used.in.a. variety.of.ways. 53. In.February.2008.APOC.conducted. epidemiological.integrated.mapping.of.the. NTDs,.including.training.of.surveyors.and. health.technicians.in.Equatorial.Guinea.. REMO/REA,.RAPLOA,.ICT,.urine.filtration.and. Kato.techniques.were.used.for.onchocerciasis,. loiasis,.lymphatic.filariasis,.schistosomiasis. and.STH.detection,.respectively..Cross- sectional.surveys.were.conducted.in.90. villages/communities/schools,.selected.all. over.the.country.(10.in.the.Island.and.80.in. the.Mainland)..The.work.was.cofinanced.by. APOC,.the.Sabin.Institute,.Exxon.Mobil.and. Liverpool.Centre.for.NTDs. 54. Ghana.has.a.national.Neglected.Tropical. Disease.Unit..Interestingly,.it.is.only. responsible.for.Lymphatic.Filariasis.and. Onchocerciasis..Schistomiasis.is.under.the. Disease.Control.Division.of.the.Ghana.Health. Figure 3: 37,507,494 persons received multiple interventions in 2008 Primary eye care Diarrhea prevention TB control Deworming Immunization Guinea worm control Schisto control HIV/AIDS prevention LF control Vit A Malaria control 0 2 4 6 Number of persons beneƒtting from interventions in millions 8 10 12 14 c d ti E ff Ec ti v En Es s a n d c o -i m p lE m En ta ti o n — E x tE r n a l m id -t Er m E v a lu a ti o n r Ep o r t 28 Service..It.currently.has.no.national.program. officer.in.the.health.sector..It.is.however. implemented.under.the.Schools.Health. Program.in.the.Ghana.Education.Service.and. co-implemented.with.Vitamin.A.distribution.. Though.not.a.perfect.act,.Ghana.has.attempted. a.number.of.co-implementation.activities. which.has.generally.been.judged.as.the.ideal. way.for.the.future..Through.initiatives.by. District.Directors.of.Health.Services,.there. have.been.joint.programs.around.community- directed.mass.drug.administration.that.have. included.lymphatic.filariasis,.schistosomiasis. and.vitamin.A.distribution. 55. These.take-up.figures.clearly.show.that.APOC. has.the.capacity.to.support.countries.to. develop.the.needed.platform.to.co-implement. health.interventions..The.APOC.CDI.training. manual.for.CDDs.has.been.undergoing. revision.to.include.materials.on.LF.and. schistosomiasis.and.should.be.available.soon.. APOC/WHO/AFRO.have.also.developed.an. integrated.disease.mapping.protocol. 3.3.3 What has not worked so well 56. From.the.country.reports,.a.number.of.issues. have.hindered.attempts.at.co-implementation.. The.most.significant.of.these.have.been. delayed.fund.release.and.late.receipt.of.drugs,. capacity.to.implement.and.concerns.around. service.organization,.control.and.elimination. targets. 57. Malawi.is.another.country.in.which.APOC. is.supporting.oncho.control.activities..This. country.was.visited.by.the.TCC.Chair.in. August.2009..Onchocerciasis.has.been. decentralized.and.integrated.into.existing. health.systems..However.there.are.data. management.problems,.delay.of.MDA.due. to.co-implementation.with.LF.and.delay.of. arrival.of.albendazole..There.are.also.issues. with.human.capacity.at.national.and.district. levels.and.CDD.numbers..It.was.recommended. to.APOC.to.release.capital.equipment.and. support.training.in.data.management.at.all. levels..At.the.MOH;.APOC.was.called.upon.to. support.the.inclusion.of.onchocerciasis.in.the. new.SWAp,.retrain.district.officers.on.CSM. and.encourage.its.implementation. 58. Some.countries.have.moved.towards.a. SWAp.arrangement.to.improve.coordination. of,.multiplicity.of.vertical.programmes. including.NTDs..Success.is.limited.as. the.diversity.of.management.procedures,. delivery.arrangements.and.incentive.policies. continue.to.fragment.the.system..This.makes. co-implementation.of.CDTI.with.other. community.health.interventions.a.very. challenging.endeavour. 59. There.were.some.notable.concerns.in.the. APOC.approach.during.field.visits.by.the. Evaluation.Team..A.stakeholder.in.Tanzania. noted.some.under.performance.of.a.recent. APOC-supported.NTD.pilot.program.in. 5.regions.in.the.country.(including.some. without.onchocerciasis)..The.pilot.which.is.a. year.old,.in.this.particular.individual’s.opinion,. has.resulted.in.a.new.NTD.initiative.now. being.developed.by.the.Ministry.of.Health. with.funding.support.coming.from.USAID. that.will.be.managed.by.an.international.non- governmental.organization. 60. Beyond.service.delivery.Baker.and.others. (2010)29.using.three.interventions.summarized. guidance.provided.for.mapping,.monitoring. and.surveillance..They.noted.a.number. of.similarities.and.differences.in.approach. across.the.diseases..From.the.various. elements.constituting.service.intervention,. the.state.of.control.and.goal.orientations. such.as.elimination,.it.is.clear.that.attempting. to.integrate.NTDs.into.a.single.project. implementation.framework.will.create. significant.problems.at.the.national.level.. However,.coordinating.resource.mobilization. and.delivering.interventions.through.a. Community.Health.System.based.on.the. CDI.model.is.feasible.and.brings.significant. synergistic.benefits. 29. Baker.MC,.Mathieu.E,.Fleming.FM,.Deming.M,.King.JD,. Gariba.A,.Koroma.JB,.Bockarie.M,.Kabore.A,.Sankara.DP. and.Molyneux.DH.2010.Neglected.Tropical.Diseases.. Mapping,.monitoring.and.surveillance.of.neglected.tropical. diseases:.toward.a.policy.framework..Lancet.375.January. 16,.p.231-238 c d ti E ff Ec ti v En Es s a n d c o -i m p lE m En ta ti o n — E x tE r n a l m id -t Er m E v a lu a ti o n r Ep o r t 29 3.3.4 A positive look forward 61. Different.opinions.have.been.expressed. regarding.the.possibility.of.APOC.taking. on.NTDs.and.its.capacity.to.do.so..These. views.bear.more.on.global.prevalence,.targets. for.elimination,.timeframe.for.delivery.of. services.and.established.mechanisms.for. advocacy,.resource.mobilization.and.long. standing.systems.for.programme.management.. Most.of.these.exist.because.of.the.historical. development.of.each.of.the.specific.area. disease.portfolio..The.Evaluation.Team. considers.these.as.valid.observations.and. suggests.that.APOC.does.not.transform.into. an.NTD.Control.organization..Given.the. emphasis.on.elimination,.APOC’s.disease.core. competency.is.in.onchocerciasis..This.is.an. unfinished.business.and.requires.a.lot.of.work. for.which.the.science.is.just.emerging..It.is. prudent.that.the.organization.focuses.on.this. single.disease. 62. The.above.notwithstanding,.APOC.has. developed.adequate.competency.in. establishing.community.based.health. systems..This.is.a.health.system.area.that.is. core.to.Primary.Health.Care.and.requires. dedicated.activities.that.can.be.standardized,. replicated.and.supported.as.a.platform.for. co-implementation..The.process.is.laborious. and.takes.time.to.establish..Not.all.partners.are. prepared.to.wait..As.one.NGDO.representative. stated,.“the.establishment.of.the.CDI.model.is. not.a.quick.fix;.and.USAID.wants.numbers30.”. Consensus.building.and.advocacy.remain.to. be.done.to.assure.different.partners.of.the. significance.of.the.approach..APOC.more. than.any.other.organisation.has.developed. the.technical.competency.for.transferring.this. knowledge.and.the.credibility.to.reassure. any.skeptics.regarding.sustainability..This.is. a.golden.opportunity.to.scale.up.community. empowerment.and.community.health.systems. strengthening.that.should.not.be.missed. 63. Although.the.APOC.CDI.manual.is.being. adjusted.to.take.account.of.lymphatic.filariasis,. the.vast.array.of.other.APOC.tools.and. materials.remain.focused.on.onchocerciasis.. Many.of.these.should.be.adaptable.for.use.by. other.programmes.but.work.needs.to.be.done. to.facilitate.this..There.does.not.seem.to.be. a.systematic.process.in.place.for.doing.this. and.it.is.important.that.the.additional.human. resource.needed.for.this.is.provided.APOC. 30. Quotation.from.a.representative.of.an.APOC.partner.NGDO a p o c c o n tr ib u ti o n t o c o u n tr y l Ed h Ea lt h s y st Em s a n d E n su r in G s u st a in a b il it y — E x tE r n a l m id -t Er m E v a lu a ti o n r Ep o r t 30 4. apoc contribution to country led health systems and ensuring sustainability 4.1 planning and budgeting 66. The.exit.plans.put.understandable.emphasis. on.financial.planning.rather.than.focusing.on. governance.issues..However,.it.is.important. to.consider.the.integration.of.onchocerciasis. control.activities.within.national.health. systems..This.is.one.of.the.PAB.indicators.and. so.far.44.of.111.CDTI.projects.are.considered. to.be.integrated. 67. Participation.and.inclusiveness.in.planning. Oncho.control/.elimination.activities.is. inadequate.as.these.activities.tend.to.be. confined.to.technical.staff.within.directorates. in.charge.of.disease.control.or.preventive. services.without.involving.directorates. of.planning.and.finances..At.the.sub. national.level,.the.“project.management”. of.Oncho.control.activities.has.led.to.a. weak.sense.of.ownership..Some.health. professionals.view.it.as.a.“community. program”..In.many.projects,.CDTI-related. activities.are.competing.with.other.“well- resourced”.vertical.programs..The.leadership. and.ownership.that.should.lead.to.co- management.of.the.CDTI.is.a.significant. challenge.and.usually.dependent.of. individuals.rather.than.on.a.stable.system. 68. Many.countries.are.moving.towards.SWAp. approaches.and.basket.funding..This. facilitates.efficient.planning.and.management. of.resources.at.District.and.National.levels.but. requires.some.flexibility.on.the.part.of.donors.. Currently,.the.only.country.where.APOC.has. been.able.to.adopt.this.approach.is.Ethiopia.. This.is.understandable.given.the.complexity. involved.in.finding.goals.commensurability.. For.instance,.a.SWAp-like.approach.is.not. always.congruent.with.an.elimination.goal. 64. By.2015,.APOC.aimed.to.have.12.of.the.15. countries.fully.responsible.for.the.financing. and.management.of.all.CDTI.projects.in. their.respective.territories.through.effective. integration.of.its.programmes.into.country- led.systems..Integration.is.important.for. ensuring.that.onchocerciasis.activities.are. sustainable.and.that.the.planning.and. budgeting.sit.within.the.national.chains.of. funding.and.accountability.rather.than.outside. them..The.APOC.Phase.II.–.phasing.out. period.Plan.of.Action.and.Budget.2008-2015. is.clear.on.the.need.to.work.with.governments. to.help.develop.country-led.feasible,.realistic. end-game.strategies.for.maintaining.the. important.gains.achieved.so.far.against. Onchocerciasis.in.Africa. 65. A.busy.agenda.of.strategic.approaches.was. set.out..The.specific.activities.identified.for. devolving.to.countries.include.distribution.of. Ivermectin.(HSAM,.ME,.resource.mobilization. and.impact.assessment.of.operations);. integration.of.the.CDTI.process.into.main. stream.healthy.systems.so.the.cost.may. be.borne.by.the.community,.partners.and. government.at.the.country.level,.review. of.technical.reports,.epidemiological.and. entomological.evaluation.and.capacity.to.apply. criteria.to.stop.treatment,.data.management. and.reporting.to.WHO.Country.Offices. Definition of sustainability: CDTI activities in an area are sustainable when they continue to function effectively for the foreseeable future, with high treatment coverage, integrated into the available healthcare service, with strong community ownership, using resources mobilised by the community and the government. a p o c c o n tr ib u ti o n t o c o u n tr y l Ed h Ea lt h s y st Em s a n d E n su r in G s u st a in a b il it y — E x tE r n a l m id -t Er m E v a lu a ti o n r Ep o r t 31 without.technically.adjusting.the.framework.. One.published.paper.states.that.disease. control.programs.“….would.do.well.to.adapt. certain.aspects.of.eradication.programs…. (that.carry.with.them).the.unavoidable. demand.that.eradication.programs.must. operate.with.near-ruthless.focus….(requiring). obsessive.focus,.attention.to.detail.and. accountability.at.all.levels.to.a.degree.that.is. not.true.for.a.control.program.”.31 69. A.further.move.away.from.integration.in. country.systems.has.developed.with.the. APOC’s.move.to.the.WHO.GSM.system. for.financial.payments..With.the.aim.of. improving.project.efficiency,.funds.are.now. transferred.directly.to.projects..This.by-passes. the.usual.in-country.systems.and.sets.APOC. apart.from.other.country-owned.programmes.. This.can.create.frustration.at.the.central. level.because.this.procedure.is.perceived. as.distorting.hierarchy,.accountability.and. answerability.chains. 70. National.Onchocerciasis.Task.Forces.(NOTF). have.been.established.in.some.countries.and. bring.together.international.NGDOs.and. health.officials..The.current.capacity.of.the. NOTFs.and.their.usefulness.in.an.integrated. system.is.not.well.articulated.or.understood.. This.is.going.to.pose.greater.challenges.if. clarity.is.not.established.before.full.integration.. This.difficulty.ties.in.with.the.complexities. identified.in.SWAp.settings 31. Global.Health.Magazine,.Summer,.2009,.Dr..Donald. Hopkins,.The.Allure.of.Eradication,.Page.17 4.2 training and capacity-building 71. Since.its.inception,.APOC.has.aimed.to.train. national.teams.to.undertake.all.activities. taking.place.in-country.and.ultimately.to. learn.to.train.others..APOC’s.commitment. to.capacity.strengthening.is.evident.both. from.the.emphasis.on.formal.training. activities.throughout.the.Plan.of.Action.and. Budget.2008-2015.and.the.Addendum.and. also.from.its.the.participatory.approach. to.implementing.activities..The.skills.and. experience.of.staff.associated.with.oncho. programmes.are.actively.developed.through. opportunities.to.train.and.monitor.the.work. of.others. 72. In.order.for.CDDs.to.deliver.ivermectin.at. community-level,.capacity-building.has. taken.place.from.front-line.health.facility. level.staff,.throughout.districts.and.regions. to.national.level.and.have.covered.a.wide. range.of.topics:.in.technical.skill.areas.and. in.management.and.administration..APOC. Secretariat.has.not.aggregated.the.data.for. this.but.partial.figures.as.in.table 3.give. an.indication.of.people.attending.formal. training.since.2000. 73. A.new.programme.of.Masters.Scholarships.in. public.health,.epidemiology,.entomology.and. community.health.was.introduced.in.2009. with.an.allocation.of.$400,000;.15.candidates. were.put.forward.from.10.countries..The. programme.specifies.gender.balance.and.this. was.achieved.with.the.first.batch.of.awards. made. Table 3: Capacity building in selected technical areas, 2000–2009 (partial data) areas of capacity building of nationals & nGdos country staff number of persons Data management and analysis (statistical or spatial analysis) 277 Collection and management of Data 606 Collection of geographic coordinates and management of Data 201 Disease mapping (REMO/RAPLOA) 883 Integrated mapping of NTDs 33 Entomology 135 Epidemiological surveillance 102 Independent Participatory Monitoring 486 Evaluation of the sustainability of a project 468 Monitoring implementation of sustainability plans 168 Masters in Public health/Epidemiology 15 a p o c c o n tr ib u ti o n t o c o u n tr y l Ed h Ea lt h s y st Em s a n d E n su r in G s u st a in a b il it y — E x tE r n a l m id -t Er m E v a lu a ti o n r Ep o r t 32 74. A.curriculum.for.medical.and.nursing. schools.has.been.developed.as.a.means.of. integrating.the.CDI.strategy.into.health. training;.new.health.personnel.will.graduate. with.an.understanding.of.the.role.of.CDI. and.is.role.in.health.care.delivery..The. curriculum.and.training.module.were. drafted.by.a.small.team.of.experts.and. presented.at.a.meeting.aimed.at.harmonizing. the.programmes.of.different.institutions.in. the.sub-region..A.review.and.repackaging. of.the.curriculum.was.completed.in.2008. and.in.a.high-level.review.meeting.of.vice. chancellors,.Deans.and.senior.academics. convened.in.Abuja.from.June.9-11,.2009.. The.curriculum.and.training.module. were.finalized.with.valuable.inputs.from. participating.universities. 75. Eighteen.(18).universities,.from.11.countries. across.Africa,.adopted.the.curriculum.and. training.module.and.agreed.on.pretesting. and.its.inclusion.in.their.different.university. systems..The.implementation.plans.for.pre- testing.are.to.be.submitted.by.universities. before.the.end.of.February.2010..So.far,.plans. of.action.and.budgets.have.been.received. from.the.Institut.Regional.de.Santé.Publique. (IRSP),.Benin.and.the.University.of.Medical. Sciences.&.Technology,.Khartoum,.Sudan.. Implementation.of.activities.for.these.two. universities.will.be.starting.in.2010.and. APOC.management.has.approved.these.plans. 76. Post-conflict.countries.capacity.is.augmented. with.the.recruitment.of.technical.advisers. (TAs)..These.advisers.live.and.work.as.on- the-ground.experts.in.the.countries.and. receive.salaries.from.the.APOC.Trust.Fund. for.a.maximum.of.3.years32..A.total.of.5.TAs. have.been.recruited.for.CAR,.Chad,.DRC,. Liberia.and.southern.part.of.Sudan.with.the. intention.that.they.will.help.to.build.national. capacity.to.conduct.disease.control.and. surveillance.and.to.apply.criteria.to.phase. out.ivermectin.treatment,.when.such.criteria. become.available..In.addition.AAFs.(finance. assistants.in.WHO.offices).cover.73%.projects. in.6.countries. 32. PAB 77. In.DR.Congo,.the.arrival.of.2.TAs.has. resulted.in.very.noticeable.improvement. in.project.performance.but.may.not.be. developing.the.capacity.of.NOTF.and.NOCP. in.the.way.intended..There.were.challenges. observed.in.the.roles.between.the.TA.and. the.NOTF..The.NOTF.were.concerned.that. their.role.of.undertaking.routine.tasks.was. being.undermined..It.was.suggested.that. the.TA.and.accompanying.office.resources. should.be.located.in.the.NOCP.and.work. alongside.staff. 4.3 capital equipment: an ongoing commitment 78. APOC.continues.to.provide.a.range.of. capital.equipment,.including.vehicles.and. office.equipment..In.2008/9,.APOC.spent. $1,827,544.giving.support.to.60.projects. in.11.countries.with.vehicles,.bicycles,. generators,.computers.and.accessories..This. did.not.include.funding.for.2,500.bicycles. provided.to.5.countries.with.special.funding. from.the.Global.Network.for.NTDs...The. support.is.considered.essential.not.only.for. ensuring.the.efficient.running.of.projects.but. also.for.keeping.health.systems.functioning. in.resource-poor.countries..It.was.reported. by.the.project.visited.in.DR.Congo.that. the.district.health.system.managed.to.keep. operational.during.times.of.conflict.due. to.the.vehicle.and.equipment.provided. by.APOC. 4.4 drug procurement and supply system 79. The.supply.of.ivermectin.is.handled.by.the. Mectizan.Donation.Programme.(MDP),.a.key. partner.in.the.programme.and.one.of.the. members.of.APOC’s.governing.board..While. the.APOC.Secretariat.is.kept.informed.of. any.major.issues.or.delays,.MDP.handles.the. orders.and.there.is.little.direct.involvement. of.APOC.Secretariat.staff..The.drug.supply. system.established.with.MDP.is.simple.and. very.effective..It.works.not.only.in.stable. countries.but.also.in.more.difficult.post- conflict.conditions.with.the.support.of.WHO. offices.where.necessary. a p o c c o n tr ib u ti o n t o c o u n tr y l Ed h Ea lt h s y st Em s a n d E n su r in G s u st a in a b il it y — E x tE r n a l m id -t Er m E v a lu a ti o n r Ep o r t 33 80. Annual.orders.of.the.drug.are.placed.by.the. NOCP,.or.by.projects.in.countries.with.less. experience.in.ordering,.with.the.Mectizan. Donation.Programme..After.checking. consistency.with.the.previous.year.and.any. known.population.fluctuations,.and.after. ensuring.that.tax.exoneration.has.been. obtained,.orders.are.shipped.in.under.month.. Although.tax.exoneration.systems.can.be. complex,.they.generally.do.not.present.a. problem.for.drug.procurement.unless.national. staff.are.unfamiliar.with.them..Drug.collection. usually.does.not.necessitate.additional.funds. since.it.is.collected.when.health.workers.travel. to.the.upper.level.of.the.health.system.for. other.purposes..This.is.one.area.that.APOC. has.shown.the.way.in.facilitating.country. led.systems.for.supply.management.and. collaboration. 81. Indeed,.though.governments.are.increasingly. clearing.ivermectin.shipments.at.the.point.of. entry,.WHO.and.UNICEF.continue.to.provide. support.with.clearance.in.some.countries.. In.DRC,.where.the.transport.system.is.weak,. WHO.organizes.transport.to.its.sub-offices.at. regional.level.where.it.is.collected.by.front.line. health.workers..The.projects.visited.during. were.receiving.timely.supplies.of.Mectizan.in. contrast.with.both.national.essential.medicines. and.the.drugs.required.for.other.vertical. programmes,.notably.for.malaria. 82. Despite.the.simplicity.of.the.system,.delays. in.requesting.Mectizan.were.documented.in. three.of.the.countries.visited;.it.was.generally. attributed.to.poor.planning.or.communication. skills.at.district.level.or.to.changes.in. personnel.and.lack.of.familiarity.with.the. systems..This.had.resulted.in.delayed.drug. distribution,.and.increased.absenteeism.of. persons.expected.to.come.for.treatment..One. area.of.note.is.the.contrast.with.SIZ.countries. which.gives.an.indication.of.what.might. happen.in.the.event.of.total.withdrawal.by. APOC..In.Ghana.where.the.health.system.is. Table 4: APOC equipment support to countries 2000-2009 countries transport computer Generator vehicle motorcycle bicycle desk-top lap-top Angola 8 31 90 8 6 6 Burundi 4 6 78 5 5 3 Cameroon 27 218 208 33 6 0 CAR 4 24 0 2 2 0 Chad 5 48 48 15 4 1 Congo 3 21 0 2 3 2 DRC 29 164 1758 30 28 15 Eq. Guinea 4 10 0 4 3 2 Ethiopia 12 80 0 13 4 13 Gabon 1 0 0 3 0 0 Liberia 3 40 3 3 0 3 Malawi 4 25 185 11 4 2 Nigeria 73 674 3447 68 31 44 Sudan 13 41 516 16 3 5 Tanzania 22 62 298 15 19 0 Uganda 5 50 732 19 1 2 special intervention Zones Côte D’Ivoire 1 0 200 0 0 0 Ghana 0 2 0 0 1 1 Sierra Leone 0 0 0 0 0 0 Total 218 1496 7563 247 120 99 a p o c c o n tr ib u ti o n t o c o u n tr y l Ed h Ea lt h s y st Em s a n d E n su r in G s u st a in a b il it y — E x tE r n a l m id -t Er m E v a lu a ti o n r Ep o r t 34 considered.fairly.strong,.there.were.persistent. shortage.of.drugs.at.the.points.of.delivery. due.entirely.to.weaknesses.in.the.supply. management.system. 4.5 primary health care and community systems strengthening 83. Primary.health.care.is.essential.health.care. based.on.practical,.scientifically.sound.and. socially.acceptable.methods.and.technology. made.universally.accessible.to.individuals.and. families.in.the.community.through.their.full. participation.and.at.a.cost.that.the.community. and.country.can.afford.to.maintain.at.every. stage.of.their.development.in.the.spirit.of. self.reliance.and.self-determination33..The. WHO.Africa.Region.ministers.of.health. Ouagadougou.Declaration.on.Primary.Health. Care34.identifies.community.health.systems. strengthening.as.one.of.the.main.pillars.on. which.to.deliver.primary.health.care. 84. APOC’s.success.highlights.the.continued. relevance.of.one.of.the.central.tenets.of. primary.health.care;.the.need.for.participation. and.ownership.by.communities.in.their.health. and.health.care..It.has.been.argued.that.this. model.is.essential.for.the.empowerment. of.communities;.a.critical.foundation.for. sustainable.public.health.interventions.35. The.majority.of.the.issues.discussed.under. section.2.of.this.report.relates.directly.to. how.APOC.has.contributed.to.community- based.health.systems.strengthening.and. community.empowerment..The.CDI.program. is.evidence.based.and.this.includes.not.only. the.community.based.infrastructure.but.the. development.of.basic.tools.for.determination. (measurement.sticks).of.appropriate.dosages. that.can.be.delivered.by.the.CDDs,.for. enumerating.the.communities.to.be.treated. and.registers.for.collecting.data.at.the. community.level..The.value.of.the.community. enumeration.undertaken.by.CDDs.prior.to. 33. “declaration_almaata.pdf,”.n.d.,.http://www.who.int/hpr/ NPH/docs/declaration_almaata.pdf..(paragraph.VI) 34. WHO/AFRO.2009.Ouagadougou.Declaration.on.Primary. Health.Care.and.Health.Systems.in.Africa:.Achieving. Better.Health.in.Africa.in.the.New.Millennium:.Proposed. Framework.for.implementation;.Brazzaville 35. Mrigesh.Bhatia.and.Susan.Rifkin,.2010.“A.renewed.focus. on.primary.health.care:.revitalize.or.reframe?,”.Globalization and Health.6,.no..1.p.13. ivermectin.distribution.has.proved.to.be.a. particular.asset.which.is.valued.by.frontline. health.staff.for.their.work.more.widely. 85. APOC.has.supported.the.development.of. a.comprehensive.range.tools.and.training. materials.for.all.aspects.of.CDI.training.and. related.project.processes.for.use.at.community. level,.with.frontline.health.staff.and.for.project. staff..Examples.include.Community.Self- Monitoring.and.Independent.Participatory. Monitoring.for.Project.Coordinators..CDTI. was.generally.well.established.with.frontline. health.facility.staff,.although.in.some.countries. where.there.are.zones.not.undertaking.CDTI,. staff.mobility.means.that.there.are.continuing. needs.for.health.staff.training.and.retraining. 86. Ethiopia.and.Nigeria.provide.examples. of.where.management.structures.for.CDI. implementation.are.well.placed.and.operate. within.the.PHC.system..Most.health.workers. involved.in.the.CDI.process.have.other. responsibilities.in.the.primary.health.care. system..Integration.is.much.more.visible. at.the.lower.levels.where.frontline.health. facility.staff.supervising.CDI.activities.are.also. responsible.for.providing.community.care..In. such.instances.supervisory.visits.are.done.in. an.integrated.way..At.higher.levels.integration. is.undertaken.through.joint.use.of.transport,. utilization.of.program’s.training.sections.for. training.in.other.PHC.activities,.and.planning. for.CDI.which.is.done.within.the.PHC.annual. estimates..Ivermectin.delivery.mechanisms. are.partly.integrated,.with.evidence.of.shared. transport.for.transport.of.supplies..Though. delivery.systems.are.not.within.a.national. system.they.work.well.and.function.within.the. government.set.up. 4.6 financing of onchocerciasis 87. The.APOC.partnership.expects.to.spend. approximately.U.S..$184.million.by.the.time. it.ends.in.2015..If.the.paradigm.for.post.2015. points.to.significantly.reduced.funding.support. for.the.historical.APOC.program,.then.APOC. needs.to.be.in.a.very.good.position.to.now.be. actively.seeking.to.leverage.whatever.funding. support.that.may.still.be.available.from.current. donor.partners.and.governments..Currently.it. a p o c c o n tr ib u ti o n t o c o u n tr y l Ed h Ea lt h s y st Em s a n d E n su r in G s u st a in a b il it y — E x tE r n a l m id -t Er m E v a lu a ti o n r Ep o r t 35 is.refreshing.to.note.that.APOC.management. is.devoting.significant.time.and.energy.to. helping.countries.to.put.in.place.plans.for.the. sustainability.of.CDTI.activities.and.the.exit.of. APOC.trust.fund. 88. Many.of.the.projects.have.achieved.reasonable. coverage.of.eligible.populations.using.the. CDTI.strategy,.but.adequate.financial.support. by.donors,.national.and.local.governments. can.be.a.major.obstacle.to.achieving. sustainability36..To.assess.progress.in.countries. increasing.their.responsibility.for.funding. and.ensuring.sustainability.after.the.phase. out.period,.the.level.of.country.financial. contributions.has.been.compiled.from. self-declarations.by.countries.during.NOTF. annual.meetings..Establishing.a.clear.idea.of. both.government.and.NGDO.contributions. can.be.difficult.as.both.can.be.reluctant.to. share.financial.information..The.information. therefore.should.be.interpreted.with.caution. 89. Couuntries.are.showing.good.will.towards. budgeting.and.spending.funds.in.support. of.onchocerciasis.control..Data.available. suggests.that.the.percentage.of.approved.and. disbursed.funds.has.improved.in.recent.years. hitting.82%.in.2009.(see.table 5)..In.2007,. 12.countries.disbursed.about.US$1.million. for.CDTI.core.activities.while.9.countries. disbursed.$1.1.million.in.2008..In.2008,.the. countries.gave.almost.equal.attention.to.the. 36. Amazigo.U,.Okeibunor.J,.Matovu.V,.Zoure.H,.Bump. J,.Seketeli.A.Performance.of.predictors:.evaluating. sustainability.in.community-directed.treatment.projects.of. the.African.programme.for.onchocerciashs.control..Soc Sci Med.2007.64.p.2070-82 four.CDTI.core.activities.with.disbursement. of.funds.ranging.from.22%.to.30%..District,. regional.and.national.governments.provided. 36%,.15%.and.49%.respectively. 90. The.compiled.information.indicate.that.many. projects.face.difficulties.in.accessing.funds,. spending.and.accounting.for.the.funds.they. receive.both.from.APOC.and.from.their.own. government.budgets..Within.APOC.there. are.significant.concerns.that.programmes. are.not.submitting.timely.reports.with.some. financial.reports.being.six.months.overdue.. This.impedes.the.timely.release.of.subsequent. funds.in.line.with.the.new.GSM.arrangements. that.establish.performance.based.management. of.funds.as.a.principle. 91. Conteh.and.others.(2010)37.in.their.analytical. work.noted.that.the.list.of.donated.medicines. is.remarkable,.and.pharmaceutical.companies. providing.these.drugs.are.committed.to.their. long-term.donation..The.evaluation.team. observed.that.the.cost.of.donated.drugs,. extremely.important,.is.not.usually.reported. in.the.delivery.of.services.and.thus.was.unable. to.estimate.total.cost.of.projects..We.note. this.enormous.support.and.commitment.by. organizations.such.as.Merck.in.the.table 6. overleaf. 92. The.international.drug.price.estimates. suggest.that.the.market.price.used.to. treat.more.than.15.types.of.helminthic. and.parasitic.infections.is.US$.0.02.per. 37. Conteh.L,.Engels.T,.Molyneux.DH.2010.Neglected.Tropical. Diseases.4:.Socioeconomic.aspects.of.neglected.tropical. diseases..I.375.p.239-247 Table 5: Government financial contributions (Thousands US$) items 2006 2007 2008 2009 Amount budgeted 11,029 11,645 14,750 10,267 Amount disbursed 4,285 4,876 11,032 8,379 Disbursed as % of budget 38.9 41.9 74.8 81.6 Salaries budgeted 6,450 5,985 4,937 2,397 Salaries disbursed 1,240 1,043 1,617 1,277 Disbursed as % of budget 61.4 71.9 79.5 80.6 Equipment budgeted 1,469 2,053 697 586 Equipment disbursed 267 303 404 344 Disbursed as % of budget 6.2 6.2 3.7 4.1 a p o c c o n tr ib u ti o n t o c o u n tr y l Ed h Ea lt h s y st Em s a n d E n su r in G s u st a in a b il it y — E x tE r n a l m id -t Er m E v a lu a ti o n r Ep o r t 36 tablet.(albendazole,.diethylcarbamazine. and.mebendazole..These.are.generally.the. drugs.donated..The.market.price.of.a.6mg. ivermectin.tablet.is.US$0.5238..From.this. perspective,.and.for.sustainability.analysis,. it.is.more.important.to.evaluate.the.cost.of. the.program.from.money.spent.on.activities. perspective.rather.than.a.drug.perspective. given.that.drugs.are.generally.already. donated.anyway. 93. Some.evidence.already.exists..In.a.study. of.the.costs.of.the.African.Program.for. Onchocerciasis.Control,.the.mean.financial. cost.was.US$0.58.per.treatment.with. ivermectin,.which.was.provided.free.by. Merck,.and.volunteer.time.was.excluded.. The.economic.cost.doubled.to.US$.1.26. per.treatment.once.the.volunteer.time.and. donated.ivermectin.cost.was.included39.. Under.certain.circumstances,.cost.per. treatment.is.going.up.in.some.countries..For. instance.in.Congo.DR,.cost.per.person.treated. has.gone.up.to.US.$1.81.in.2008.compared. with.$0.02.in.2007. 38. The.donated.ivermectin.tablets.for.onchocerciasis.and. lymphatic.filariasis.programs.are.3mg.tablets..Merck.quotes. US.1.5.cents.per.treatment 39. Goldman.AS,.Guisinger.VH,.Aikens.M.and.others.2007. National.mass.drug.administration.costs.for.lymphatic. filariasis.elimination..PLoS Negl Trop Dis.1;.e67 94. In.a.cost.evaluation.of.CDTI.in.Cameroon,. Nigeria.and.Uganda,.the.breakdown.of.costs. showed.(excluding.the.cost.of.donated.drugs). that.endemic.countries.covered.about.half.of. the.cost.of.the.programme,.and.the.donors. and.NGDOs.cover.the.rest..The.2009.APOC. progress.report.noted.that.in.2008,.nine. governments.invested.US$1.1.million.to.fund. core.CDTI.activities,.slightly.more.than.have. been.invested.in.2007.by.12.countries..While. this.is.encouraging,.it.must.also.be.noted.that. in.Fiscal.Year.2009,.APOC.invested.US$.15.5. million,.pointing.to.a.gap.that.still.needs.to.be. closed.beyond.2015. 95. Given.the.fact.that.most.neglected.diseases. are.not.on.the.minimum.benefit.package.of. countries.with.National.Health.Insurance. Schemes.such.as.Ghana,.cost.sharing.based. on.out.of.pocket.may.be.an.option.and.a.real. challenge.to.be.confronted.in.a.phase.out. strategy.Willingness.to.pay.for.the.prevention. and.treatment.of.neglected.tropical.diseases. is.probable.options.which.in.recent.studies. have.shown.mixed.results40..A.study.in.Haiti. showed.that.although.most.of.the.community. placed.positive.value.on.both.prevention. and.treatment.of.lymphatic.filariasis,.7%.and. 40. See.Kirigia.JM,.Sambo.LG,.Kainyu.LH.2000..Willingness-to- pay.for.schistosomiasis-related.health.outcomes.in.Kenya.. Afr.J.Health.Sci.7.p.55.-.67 Table 6: Drug donor organizations and their commitments treatment drugs donor and commitment Albendazole & Ivermectin GSK donates Albendazole to WHO directly for the global elimination of LF. Merck and Co donates through Mectizan Donation program which is housed in the Taskforce for Global Health in Atlanta for the elimination of LF in Africa Ivermectin Merck and Co donates through Mectizan Donation program which is housed in the Taskforce for Global Health in Atlanta for the elimination of LF in Africa Praziquantel Merck Serono SA currently donates 200 million to WHO ending 2017. It also recently made an offer to supply 100 million tablets per year at production cost. Talks are ongoing with German to finance this initiative. This could be channeled through WHO. GSK is considering donating 300 million tablets towards STH Albendazole/ Mebendazole Merck and Co donates through Mectizan Donation program which is housed in the Taskforce for Global Health in Atlanta for the elimination of LF in Africa GSK committed donation of Albendazole and to continue. It is likely to be extended to STH (for a total of 600 million treatment a year) through WHO Johnson and Johnson donate 50 million tablets of Mebendazole per year for treatment in children and committed to scale this donation up to 100 million tablets per year Azythromycin Pfizer donates135 million tablets for trachoma treatment through Task Force for Global Health in Atlanta Compiled by Authors a p o c c o n tr ib u ti o n t o c o u n tr y l Ed h Ea lt h s y st Em s a n d E n su r in G s u st a in a b il it y — E x tE r n a l m id -t Er m E v a lu a ti o n r Ep o r t 37 39%.of.households.were.not.willing.to.pay. for.prevention.and.treatment.respectively41.. In.lower.economic.quintiles,.this.result.will. show.an.almost.100%.inability.particularly. because.of.the.debilitating.effect.of.particular. neglected.diseases.under.consideration.. Any.cost.recovery.policy.would.be.likely.to. result.in.inadequate.participation.and.limited. sustainability. 4.7 Research, monitoring and evaluation 96. Progress.on.the.core.set.of.indicators.based.on. what.APOC.set.out.to.do.as.articulated.in.the. APOC.Phase.II.–.phasing.out.period.Plan.of. Action.and.Budget.2008-2015.is.attached.as. Annex 1. 97. In.the.15.years.of.its.existence,.the.APOC. Programme.has.developed.a.pan-African. network.that.has.developed.a.very.significant. core.competency.to.encourage.and.support.a. massive.amount.of.evidence-based.research.. The.foot-notes.to.this.report.provide.one.“snap. shot”.of.the.valuable.“library”.of.research. projects.that.the.Programme.has.generated,. some.by.staff,.some.managed.by.the.WHO. TDR.office.and.some.managed.through.a. broad.network.of.scientists.and.research. institutions.linked.to.partners..Information. contained.in.the.most.recent.report.from.the. TCC.and.the.WHO/APOC.“2009.Progress. Report”.provides.another.“snap.shot”.of.the. kind.of.research.that.has.been.facilitated.by.the. Programme,.such.as: • “Assessment.of.interruption.of.Onchocerca. volvulus.transmission.in.Community- Directed.Treatment.with.Ivermectin…”.[in. three.countries] • “Epidemiological.and.REMO/RAPLOA.risk. assessment…”.[carried.out.in.225.villages]. 41. Rheingans.R,.Haddix.A,.Messonnier.M,.Meltzer.M,.Mayard. G,.Addiss.D.2004.Willingness.to.pay.for.prevention.and. treatment.of.lymphatic.filariasis.in.Leogane,.Haiti.Filaria J.3.2 • “Epidemiological.Evaluations.of.Progress. toward.Elimination.Endpoints.….” • Various.reports.related.to.the.ongoing. for.the.development.of.‘Moxidectin’.as.a. possible.macrofilaricide.for.the.control.of. onchocerciasis • “Assessment.of.the.Social.Benefits.of. CDTI…”.[in.four.countries] 98. Epidemiological.research.was.recently. concluded.in.Ghana..Mention.has.also.been. made.in.the.earlier.section.of.this.report.on. the.innovative.approaches.towards.establishing. predictive.transmission.zones..There.are. proposals.being.developed.towards.the.testing. of.innovations.for.diagnostics.and.black.fly. sample.collection. 99. The.APOC.Secretariat.recognizes.that.far. too.often,.it.does.not.adequately.“market”. the.accomplishments.that.it.is.facilitating.. Certainly,.as.noted.earlier.in.this.report,. the.vastness.and.richness.of.the.“research. library”.may.be.one.of.the.most.overlooked. accomplishments.by.the.APOC.Programme. to-date. 100. National.Technical.Review.Committees.have. been.established.with.financial.support. from.APOC.in.Cameroon,.Ethiopia,.Nigeria. and.Uganda;.they.now.review.project. technical.reports.and.advise.the.NOTF.on. operational.research.proposals..There.are. early.indications.that.this.is.working.well.. This.is.an.important.step.forward.given.the. major.role.played.by.the.APOC.Technical. Consultative.Committee,.both.formally. and.informally,.in.project.oversight.and.the. provision.of.technical.advice. 101. Though.fully.appreciated.and.APOC.should. duly.be.recognised.for.being.the.lead.agency. in.Onchocerciasis.research,.NGDOs.in.oncho. research.feel.their.research.findings,.though. published.in.peer.review.journals.are.not.given. the.full.recognition.they.deserve. a p o c m a n a G Em En t a r r a n G Em En t — E x tE r n a l m id -t Er m E v a lu a ti o n r Ep o r t 38 5. apoc management arrangement “What is so significant (about APOC) is that, by means of a partnership with over 70 partners, we’ve been able to join together to achieve a programme which has the prospect of eliminating this disease completely on the continent of Africa.” 42 JAmeS WOLfenSOhn, fOrmer PreSident Of the WOrLd BAnk 102. The.APOC.governance.and.dialogue.structure. is.the.strength.of.the.onchocerciasis.control. partnership..Though.different.agencies.these. work.as.components.of.a.single.framework.. The.participation.is.representative.and.the. entire.programme.is.reasonably.country- led..Figure 4.and.table 7.provides.the. management.partnership.and.functions. 103. The.various.management.bodies.have.clearly. articulated.roles.and.responsibilities.which. are.pertinent.to.the.smooth.running.of.APOC.. Particularly.during.this.period.of.transition,. these.agencies.will.need.to.consult.regularly.. There.were.concerns.during.interviews.that.too. many.meetings.are.being.held.and.that.probably. 42. WHO,.2001,.Empowering.Partnerships.and.Communities,. Page.10. the.number.of.the.bodies.should.be.reduced.. Having.examined.the.various.functions. carefully;.the.Evaluation.Team.is.of.the.opinion. that.the.various.bodies.are.still.needed. 104. What.may.be.adjusted.are.functions.and. internal.agreements.to.review.the.number. of.meetings..This.cannot.be.legislated.and. is.best.left.to.their.discretion..However,.we. offer.some.suggestions..The.CSA.for.instance. may.focus.more.on.resource.mobilization. and.accountability.issues..Other.functions. may.be.reorganized.and.delegated.to.a.TCC. sub-committee.that.has.representatives.of.all. the.parties.working.in.collaboration.with.the. APOC.Secretariat..This.may.meet.once.a.year.. Decisions.between.TCC.meetings.may.be. delegated.to.the.TCC.chair. 105. The.National.Onchocerciasis.Task.Forces. (NOTF).bring.together.international.NGDOs. and.health.officials..The.current.capacities. of.NOTFs.are.not.well.understood..This. is.because.the.National.Onchocerciasis. Coordinator.(NOC).is.the.Executive.Secretary. of.the.NOTF.and.it.is.only.when.there.are. evident.weaknesses.or.issues.with.the.NOC. that.the.strengths.or.weaknesses.of.the.NOTF. will.be.really.apparent. Representatives of UNDP, WHO and WB A representative of NGDO Coordination Group A representative of the Mectizan Donation Program (MDP) One representative of donor of ivermectin A representative of the African Development Bank Representatives of 15 NGDOs with a focus on Onchoceriasis control activities A representative of each Contibuting Party i.e. donors, Ministers of 159 APOC countries; Ministers of 11 ex-OCP countries; Co-sponsoring agencies; 11 representatives of NGDOs private sector donor(s) of ivermectin 11 experts appointed by the Executing agency (WHO), upon recommendation of the CSA (3 of which are proposed by the NGDO Coordination Group) 1 representative of a non-proŒt ivermectin donation organisa- tion (who is not eligible to become Chairperson) Committee of Sponsoring Agencies Joint Action Forum NGDO Coordination Group Technical Consultative Committee figure 4: Working management partnership a p o c m a n a G Em En t a r r a n G Em En t — E x tE r n a l m id -t Er m E v a lu a ti o n r Ep o r t 39 106. The.roles.and.responsibilities.of.each.body. are.clearly.defined.in.the.Memorandum. of.Understanding.that.is.signed.by.each.of. the.multi.and.bilateral.governments.and. foundations.that.contribute.to.the.APOC.Trust. Fund.and.governments.of.African.countries. with.endemic.onchocerciasis...A.notable. feature.is.the.clear.allocation.of.country-level. programme.governance.to.Ministries.of.Health. and.of.the.supporting.roles.of.collaborating. partners.(Merck.and.NGDOs)..This. framework,.which.ensures.that.all.partners. understand.their.allocated.responsibilities,.was. identified.by.Secretariat.senior.management. as.a.key.reason.for.the.smooth.and.productive. functioning.of.the.APOC.partnership..The. other.two.key.contributing.factors.identified. by.the.evaluation.team.are.the.shared.goal.of. combating.onchocerciasis.and.the.availability. of.the.necessary.funding.for.the.both.the. programmes.and.the.functioning.of.the. partnership. 107. Led.by.a.strong.Programme.Director,.the. APOC.Secretariat.serves.as.the.nexus.for. operating.the.APOC.partnership.and.has. performed.creditably..APOC.Secretariat. core.programme.competencies.are.in.CDTI,. mapping,.training.and.capacity-building.from. CDD.to.technical.experts,.evidence-based. research.and.maintaining.the.institutional. framework.for.onchocerciasis..It.has.developed. remarkable.skills.in.coordinating.and. supporting.the.bi-annual.meetings.of.all.the. different.APOC.structures..These.meetings. have.been.key.to.the.development.of.the. Table 7: Functions of management bodies and meetings management body functions no of annual meetings Joint Action Forum • Reviews and approves proposed APOC Action Plans and budgets • Assesses financial requirements • Decides on countries included (on recommendation of CSA) • Considers and decides changes in APOC’s geographic scope and other matters relating to the programme that are raised by any member Once or twice as determined by JAF. Participants cover all expenses Committee of sponsoring Agencies • Reviews Action Plans and budgets • Examines reports submitted to it by any of the statutory bodies and transmits them, together with observations, to JAF, in timely fashion • Approves amendments to Action Plans and Budgets, upon the recommendation of the Programme Director and according to available funds • Acts on behalf of JAF when JAF is not in section (all decisions subject to JAF’s ratification) Twice and once by video conferencing. Participants cover all expenses Technical Consultative Committee • Advise the Programme Director on: • Criteria for eligibility and phasing of implementation of CDTI projects, as well as components of such projects involving other disease control • Parameters which applications for funding by APOC should address; • Acceptability of new project proposals for funding by APOC; • Technical and operational research matters related to APOC; • Review applications for funds for new CDTI projects, based on technical justification and financial feasibility, and make recommendations to the Programme Director on their acceptability for APOC funding; review overall progress towards sustainability and integration of CDTI into the health system and make recommendations on any appropriate action; and review new national plans. Twice (March and September) on convocation of Programme Director. APOC Trust Fund Covers all expenses NGDO Coordination Group Members, working with the Ministries of Health, are involved in the management, financing and training aspects of ivermectin distribution projects. They assist Ministries of Health of the Participating Countries in the establishment of National Onchocerciasis Task Forces (NOTFs). Meets Twice. Participants cover all expenses a p o c m a n a G Em En t a r r a n G Em En t — E x tE r n a l m id -t Er m E v a lu a ti o n r Ep o r t 40 close-knit.network.of.APOC.implementers.and. technical.experts. 108. The.staff.numbers.and.the.current. organisational.structure.(see.organisational. chart.in.annex.2).represent,.however,.a. major.constraint.for.shifting.the.paradigm. to.elimination..With.only.nine.professional. staff.members.including.the.Director,.it.takes. a.stretch.of.imagination.to.comprehend. the.enormous.amount.of.work.done.so. far..During.this.evaluation.and.time.spent. with.the.Secretariat,.we.noted.an.unending. around.the.clock.work.schedule.that.needs. to.be.corrected..Additional.staff.numbers. are.required.even.if.this.sounds.counter.to. an.organizational.downsizing.strategy..It.is. however.important.that.the.aspirations.of. a.lean.operation.are.not.confused.with.the. enormous.amount.of.work.that.needs.done. 109. There.is.an.observable.reduction.of.APOC. funding.and.increasing.funding.for.NTDs.. Ministries.of.Health.are.free.to.respond.to. new.disease.control.opportunities.outside. APOC.and.both.Ministries.and.NGDOs.are. seeking.new.sources.of.funding.beyond. APOC..Generally,.this.is.encouraging.but.will. also.introduce.competitive.bidding.among. the.different.disease.components..A.focused. agency.like.the.APOC.Secretariat.and.NGDOs. will.be.essential.for.leveraging.financing.for. onchocerciasis.control.and.elimination.to. protect.the.large.investments.made. 110. The.APOC.Secretariat.has.worked.well.. However.like.any.good.work.there.is.always. room.for.improvement.and.added.benefits. if.the.concerns.identified.can.be.addressed.. In.this.regard.some.NGDO.partners.have. expressed.a.sense.of.being.increasingly.isolated. from.the.APOC.Secretariat..This.is.attributed. to.a.mix.of.the.Responsible.Officer.for.NGDO. Coordinationin.Geneva.not.being.adequately. informed.on.country.level.activities.to.NGDOs. not.being.valued.for.their.research.work.at. community.level..TDR.appears.to.be.more. visible.in.research.because.of.its.pioneering. work.in.onchocerciasis.in.Africa..It.is. important.that.the.APOC.Secretariat.provides. the.needed.leadership.to.address.these.issues. by.actively.encouraging.others.to.engage. c o n c lu si o n s a n d r Ec o m m En d a ti o n s — E x tE r n a l m id -t Er m E v a lu a ti o n r Ep o r t 41 Conclusion 1: Contribution of APOC towards systems strengthening and co‑implementation 111. Since.its.introduction.in.1997,.the.CDTI. approach.has.been.extended.to.more.than. 67.million.Africans.and.the.success.of. onchocerciasis.control.as.a.public.health. problem.can.be.attributed.to.its.effective. implementation..Currently.the.CDTI. program.reaches.approximately.one.sixth. of.the.population.of.sub-Saharan.Africa.. Barring.logistic.difficulties,.it.has.enabled. communities.to.take.control.for.planning. and.implementing.interventions.relating.to. onchocerciasis. 112. Within.the.general.framework.of.the. Ouagadougou.Declaration.on.Primary.Health. Care.and.Health.Systems.Strengthening,.it. appears.that.a.template.for.community.health. systems.management.has.emerged.based.on. the.CDTI.and.its.modified.versions.approach.. The.framework.is.well.researched.and.the. systems.are.beginning.to.be.standardized.for. formal,.informal.and.practical.knowledge. transfer..A.curriculum.for.medical.and.nursing. schools.has.been.developed.as.a.means.of. integrating.the.CDI.strategy.into.health. training;.new.health.personnel.will.graduate. with.an.understanding.of.the.role.of.CDI.and. is.role.in.health.care.delivery..This.aspect. of.APOC.work.and.the.core.competency. developed.has.been.poorly.disseminated.. Though.curriculum.and.manual.has.been. developed.and.introduced.to.schools,.the.CDI. framework.has.not.been.formally.adopted. for.use.in.Community.Health.Systems. Strengthening.by.countries. 113. The.success.of.the.CDTI.framework.has. naturally.attracted.the.attention.of.other. disease.control.programs,.stimulating. various.attempts.to.adapt.and.duplicate. its.principles.particularly.for.interventions. that.involve.preventive.chemotherapy..Due. to.similarities.in.the.fundamental.design.of. different.CDI.approaches,.a.fair.number.of. CDDs.are.already.involved.in.other.health. and.development.activities.as.a.result.of. their.involvement.with.the.CDTI.system.. The.recently-published,.three-year,.multi- country.study.has.demonstrated.that.in. remote.African.communities,.community. delivery.of.underutilized.health.interventions. in.an.integrated.manner.can.dramatically. improve.access.to.vital.drugs.and.preventive. treatments..The.interventions.include.malaria. prevention.and.treatment,.and.vitamin.A. supplementation..As.a.fore.runner.with. consistent.implementation.of.the.CDI. framework,.APOC.has.built.the.platform. for.service.delivery.but.will.be.hard.pressed. to.take.on.the.additional.responsibility.of. actually.delivering.on.the.other.NTDs.as.a. primary.responsibility.without.transforming. into.a.full-fledged.disease.control. organization. Recommendations 114. Undertake.comprehensive.research.to.explore. the.dynamics.of.existing.CDIs.including. incentive.and.sustainability.options.so.it.may. be.better.standardized.and.replicated.for. Community.Health.Systems.Strengthening.in. countries.to.support.co-implementation. 115. Based.on.the.research.findings,.guidelines.for. Community.Health.Systems.strengthening. within.the.framework.of.as.part.of.the. implementation.of.the.Ouagadougou. declaration.should.be.tabled.at.the.next.WHO. Regional.Committee.for.Africa.to.be.adopted. by.all.countries.for.implementation..This.will. provide.a.firm.support.for.the.introduction. of.curricula.developed.with.support.of.APOC. already.going.on.in.countries. 6. conclusions and recommendations c o n c lu si o n s a n d r Ec o m m En d a ti o n s — E x tE r n a l m id -t Er m E v a lu a ti o n r Ep o r t 42 116. A.funding.window.should.be.considered. under.the.current.Trust.Fund.to.encourage. countries.wanting.to.establish.community. systems.based.on.the.guidelines.for. co-implementation.to.have.access. Conclusion 2: APOC activities and capacity to facilitate guidance to countries for elimination 117. There.is.now.evidence.from.foci.in.Senegal,. Mali.and.Guinea.Bissau.that.elimination.is. possible.within.defined.geographical.areas.. There.is.also.promising.data.from.six.foci. in.Kaduna.and.Ebonyi.States.in.Nigeria.and. Bebidja.and.Danamadji.in.Chad.after.14-19. years.of.ivermectin.treatment.the.prevalence. of.mf.has.reduced.to.zero..The.evaluation. team.found.that.the.APOC.management.had. already.been.proactive.in.the.move.from. control.to.elimination.and.are.grasping.what. needs.to.be.done.to.secure.that.paradigm.shift. in.countries..It.is.however.our.opinion.that. ‘elimination’.needs.to.be.precisely.defined.and. better.communicated.because.the.term.in.its. generic.form.even.within.WHO.is.not.entirely. applicable.in.the.onchocerciasis.elimination. language. 118. For.our.purpose.and.taking.a.cue.from.the. work.done.so.far.by.APOC.and.PAHO;. ‘elimination.of.infection.and.interruption.of. transmission.is.feasible’.means:.‘Onchocerciasis. can.be.eliminated.in.project.areas.that.have. sustained.consistent.application.of.CDTI.of. above.65%.population.and.therapeutic.coverage. for.at.least.10.years.excepting.any.political. and.economic.uncertainties’..It.is.increasingly. evident.that.elimination.is.better.seen.as.a. ‘continuum in sustainable results’.rather. than.a.new.phase..The.97%.congruence.found. between.the.modeled.predictive.transmission. zones.and.the.CDTI.coverage.areas.partly. attests.to.this.and.is.a.highly.commendable. and.positive.outcome..The.actual.elimination. management.science.–.DEC-patch,.GIS,.fly. trap.technology,.scale-up,.end-point.strategies. and.alternative.intervention.strategy.etc-.is.only. now.emerging..Current.capacity.with.the.APOC. Secretariat.is.thin.[short.of.saying.the.current. staff.working.at.breakpoint.limit]..With.the.help. of.consultants.preparatory.work.has.started.but. the.bulk.of.the.verification;.certification.and. management.work.is.likely.to.take.place.after. 2015..Both.internal.capacity.strengthening.and. external.technical.assistance.is.required.to.get. the.work.done. Recommendations In.view.of.the.evidence.available.and.the.stated. objective,.we.recommend.that.for.the.years. leading.to.2015: 119. APOC.should.continue.the.mapping.of.the. state.of.each.transmission.zone..This.will.allow. the.Programme.and.partners.to.be.precise.on. when.and.where.to.stop.ivermectin.distribution. for.each.of.the.countries.in.this.category..This. should.include.entomological.and.additional. epidemiological.studies.to.identify.all.infection. sources.and.verify.level.of.infection.outside. the.core.hyper-endemic.areas.around.a.focus. to.back.up.the.findings.in.human.populations.. The.work.should.take.place.ideally.within.the. current.phase.of.APOC.financing.ending.2012.. The.results.should.be.disseminated.to.the. scientific.community.and.shared.at.the.WHO. Regional.Committee.for.Africa. 120. Activities.targeting.elimination.should.be. limited.to.localized.project.areas.that.qualify. under.long.lasting.Ivermectin.treatment. withhigh.coverage..All.other.project.areas. should.be.supported.to.continue.control. activities.through.country.led.approaches.. While.the.technical.tasks.continue,.it.is. important.APOC.manages.the.expectations. of.countries.and.communities.regarding. the.stopping.treatment.process,.elimination. and.co-implementation..Regular.updates.of. progress.and.explanations.of.what.that.means. for.CDTI.in.practice.will.be.essential..Given. the.2015.horizon,.this.must.be.given.due. importance.and.set.within.a.comprehensive. communications.strategy.for.2015.and. beyond. 121. Armed.with.knowledge.from.the.mapping. pointing.to.potential.elimination.areas,.a. multi-disciplinary.team.of.experts.should. be.put.together.to.develop.a.comprehensive. strategic.plan.with.full.normal.costing. and.a.risk.scenario.for.the.development.of. c o n c lu si o n s a n d r Ec o m m En d a ti o n s — E x tE r n a l m id -t Er m E v a lu a ti o n r Ep o r t 43 resource.needs.for.(i).surveys.for.delineating. transmission.zones.and.stopping.treatment,. (ii).monitoring.and.entomological.and. epidemiological.surveys.once.CDTI.ceases.and. for.(iii).verification,.certification.and.status. maintenance.process..The.national,.regional. and.international.responsibility.areas.and. technical.assistance.needs.should.be.clearly. defined.in.the.strategic.plan 122. There.is.no.quick.fix.as.control.to.elimination. under.current.scientific.knowledge.is.linked. to.a.fairly.predictable.time.lapse.between. initiation.of.therapeutic.treatment.and. consideration.for.elimination..The.Mectizan. Donation.Programme.has.set.the.example.with. its.commitment..APOC.partners.need.to.join. in.and.commit.to.attaining.this.goal.in.the. potential.oncho.elimination.countries. 123. Given.our.sense.of.work.to.be.done,. APOC.will.need.a.minimum.of.one. additional.Entomologist.and.two.additional. Epidemiologists.to.undertake.the.work..Armed. with.knowledge.from.the.mapping.a.multi- disciplinary.team.of.experts.should.be.put. together.to.develop.a.comprehensive.strategic. plan.with.costs.for.the.development.of. capacity.and.resource.needs.for.(i).surveys.for. delineating.transmission.zones.and.stopping. treatment,.(ii).monitoring.and.entomological. and.epidemiological.surveys.once.CDTI.stops,. (iii).define.activities.for.the.3-year.‘.treatment. follow-up.period’.and.(iv).verification,. certification.and.status.maintenance.process.. The.national,.regional.and.international. responsibility.areas.on.how.to.implement. these.and.technical.assistance.needs.should. be.clearly.defined.in.the.strategic.plan..These. would.make.a.significant.contribution,.not. only.to.onchocerciasis.but.also.to.the.‘science. of.elimination’.of.infectious.diseases.of.poverty. 124. New.memoranda.of.understanding.needs.to.be. developed.and.signed.between.countries.with. the.potential.for.moving.towards.elimination. and.funding.partners.to.determine.how. resources.may.be.mobilized.and.dispersed.in. support.of.eligible.programmes.in.countries.. This.should.ameliorate.donor.dependency. and.encourage.country.ownership.and. commitment Conclusion 3: Progress made with transition to countries 125. The.APOC.Secretariat.is.engaging.with. countries.in.a.manner.that.minimize.its. direct.role.and.presence.in.country.level. implementation..The.role.of.APOC.in.the. procurement.and.distribution.of.ivermectin. is.now.less.prominent;.this.is.a.good.sign.for. sustainability..In.some.countries,.although. governments.are.increasingly.clearing. ivermectin.shipments.at.the.point.of.entry. WHO.and.UNICEF.continue.to.provide. support.with.clearance.in.some.countries.. In.DRC.there.is.a.continuing.systems.failure. but.this.is.ameliorated.by.WHO’s.ability.to. organize.transport.to.its.sub-offices.where. drugs.and.logistics.are.collected.by.frontline. health.workers. 126. Further.down.the.supply.chain,.ivermectin. delivery.to.rural.communities.is.generally. good,.even.where.APOC.funding.has.been. terminated.in.countries..Drug.collection. usually.does.not.necessitate.additional.funds. since.it.is.collected.when.health.workers. travel.to.the.upper.level.of.the.health.system. for.other.purposes..It.is.not.all.smooth. sailing.as.delays.in.requesting.Mectizan.were. documented.in.three.of.the.four.countries. visited.during.this.evaluation..This.was. generally.attributed.to.poor.planning.or. communication.at.district.level..A.major. achievement.is.the.curriculum.development. for.nursing.training.schools.on.CDI..There. is.a.positive.scale.up.in.the.number.of.CDDs. trained.but.the.anticipated.CDD.to.population. ratio.of.1:100.has.not.yet.been.attained.except. for.two.countries..Though.Technical.Assistants. have.been.posted,.there.is.mixed.reaction.over. purpose.and.clarity.of.roles. 127. Countries.have.been.requested.to.submit. exit.strategies.but.the.contents.are.far. below.minimum.expectation.to.make.them. meaningful..This.attests.to.poor.capacity.to. analyze.the.situation,.articulate.scenarios,. plan.and.budget.to.implement.the.programme. either.as.a.standalone.or.integrated. intervention..This.situation.is.simply.a. reflection.of.existing.weaknesses.in.country. health.systems..Though.traditionally.classified. c o n c lu si o n s a n d r Ec o m m En d a ti o n s — E x tE r n a l m id -t Er m E v a lu a ti o n r Ep o r t 44 by.the.programme.in.the.past.as.stable. countries.and.countries.in.or.emerging.from. conflict,.there.is.now.clear.evidence.that.APOC. will.need.to.take.account.of.complications.of. internal.systems.in.relation.to.organization.of. services.and.management.systems..The.donor. coordination.mechanisms.are.also.complex. depending.on.the.goal.orientation.and.funding. mechanisms.available..Even.within.generalized. concepts.such.as.Sector-Wide.Approaches. and.decentralization,.there.are.sub-system. frameworks.that.need.to.be.understood. and.traditional.partnerships.that.need.to.be. reconstructed. 128. Existing.cost.evaluations.of.CDTI.point.to. endemic.countries.covering.about.half.of. the.cost.of.the.programme,.and.the.donors. and.NGDOs.cover.the.rest.and.the.nominal. value.has.increased..Particular.mention.is. made.of.Merck.&.Co..Inc..who.have.shown. an.unprecedented.example.of.commitment. to.disease.control.and.elimination.under. the.onchocerciasis.program..While.this.is. encouraging,.we.noted.that.in.Fiscal.Year. 2009,.APOC.invested.US$.15.5.million,. pointing.to.a.gap.that.should.not.exist.beyond. 2015..The.evaluation.team.also.observed.with. concern.that.when.personnel.time.(including. volunteers).is.fully.costed.in.addition.to. treatment,.the.economic.cost.doubles.and.by. trend,.the.cost.per.person.treated.has.gone.up. in.countries.such.as.Congo.DR.from.US$.0.02. in.2007.to.US$.1.81.in.2008. Recommendations 129. After.years.of.doing.the.same.thing,.there.is. need.for.a.consultant.to.be.recruited.to.do. a.proper.interventions.analysis.and.costing. scenarios.organization.of.services.and.in.view. of.the.acceleration.towards.elimination 130. Health.policy.and.systems.analysts.are.urgently. required.to.support.countries.in.developing. Program.Plans,.Budget.and.Exist.Strategies..In. our.opinion,.a.cost.effective.approach.will.be. to.recruit.personnel.with.expertise.in.Health Policy and Systems and.Health Economics to.work.with.a.network.of.experts. 131. Countries.should.be.encouraged.to.take. the.lead.in.developing.a.comprehensive. framework.for.NTDs.drawing.on.their. experience.with.onchocerciasis.control. and.similar.programmes.and.to.situate.or. integrate.onchocerciasis.control.within.this.. A.conscious.effort.should.be.made.to.ensure. that.comprehensiveness.does.not.undermine. the.variability.in.achievements.and.goals. to.be.reached.by.individual.programmes.. WHO-AFRO.should.be.supported.to.provide. Technical.Assistance.to.countries. 132. It.is.suggested.that.APOC.organizes.a. consultative.meeting.with.selected.APOC. countries.to.engage.other.disease.control. entities.in.the.wider.debate.on.health. systems.development,.and.to.focus.on. policy.development,.donor.coordination,. funding.and.resource.allocation.and. addressing.human.resource.challenges.. Other.control.programs.can.be.invited.to. share.and.discuss.experiences.with.the.aim. of.mainstreaming.onchocerciasis.control. program.experiences.in.country.health. policy.developments. Transforming APOC Governance arrangement including APOC Secretariat: now and beyond 2015 133. APOC.is.a.well.managed.organisation. with.a.clear.and.ambitious.objective..It. has.performed.successfully.in.treatment. and.prevention.of.onchocerciasis,.learned. from.external.evaluations,.works.towards. integration,.generates.and.utilises.scientific. evidence,.and.demonstrates.commitment. to.sustainability..It.has.encountered. difficulties.in.achieving.its.objectives.due. to.co-endemicity.and.civil.unrest,.and. adjusted.its.strategy.accordingly..It.is.going. to.be.challenged.on.the.journey.towards. elimination..Ongoing.support.by.partners.will. enable.them.complete.most.of.the.activities. outlined.in.the.new.strategy.and.addendum,. and.to.work.towards.an.exit.strategy.that. ensures.long-term.sustainability.of.APOC’s. achievements.in.countries. c o n c lu si o n s a n d r Ec o m m En d a ti o n s — E x tE r n a l m id -t Er m E v a lu a ti o n r Ep o r t 45 134. Looking.beyond.2015.was.like.gazing.into.a. crystal.ball..From.the.evidence.and.context,. the.evaluation.team.looked.at.the.probable. chance.of.transforming.APOC.as.a.whole..A. “transformed.and.focused.APOC”.that.is.lean. and.efficient.is.advocated.for..This.would. need.thorough.thinking.in.the.context.of.the. paradigm.shift.towards.elimination.and.the. consolidation.and.knowledge.transfer.around. community.health.systems.strengthening. in.the.context.of.Primary.Health.Care.and. the.emerging.co-implementation.agenda.of. NTDs.as.well.as.its.funding.arrangements.. The.Evaluation.Team.acknowledged.that. there.are.complexities.and.opinions.vary.as. to.how.this.may.be.addressed..Ultimately,. this.is.a.decision.that.naturally.lies.within.the. WHO.management.system.and.the.governing. board.of.APOC..An.early.engagement.in. dialogue.with.the.contracting.partners.and. a.sense.of.what.the.direction.may.be.will. help.shape.partner.financing.strategies.and. build.commitment.of.staff.during.these. transformation.years. Recommendation 135. The.governing.body.of.APOC.should.consider. engaging.the.expertise.of.a.consultant.(or. a.health.systems.management.consulting. firm).with.experience.in.in.organizational. restructuring.to.study.this.closely.and.make. recommendation.for.its.consideration.taking. into.account.the.functions.stated.earlier. 136. APOC.has.succeeded.because.of.the. partnerships.it.has.developed.at.all.levels..This. partnership.is.likely.to.be.put.under.severe. strain.under.the.emerging.NTD.agenda.and. the.scramble.for.new.funding..There.should.be. nothing.barring.APOC.from.engaging.partners. and.mobilizing.some.of.this.additional. resources.coming.into.the.NTD.area.for. onchocerciasis..APOC.however.has.to.provide. leadership.to.ensure.that.the.partnership.does. not.unravel.and.that.the.resource.mobilization. capacity.is.available..This.should.be.taken. into.consideration.when.the.organizational. consultant.is.recruited. a n n Ex Es — E x tE r n a l m id -t Er m E v a lu a ti o n r Ep o r t 46 annexes annex 1: progress in apoc paB 2008-2015’s core set of indicators Objective 1 target 2005 2008 2009 2015 Target 1 Geographical ivermectin coverage rate of total APOC area 58% 82% 91%* 100% Target 2 Therapeutic ivermectin coverage rate of total population at high risk of onchocerciasis in the APOC area 43% > 70% 71%* 80% Target 3 No. of conflict-affected APOC countries with areas in which RAPLOA surveys have been completed in order to confirm suspected onchocerciasis-loasis co-endemicity 2 3 3‡ 5 Target 4 No. of APOC countries with a national onchocerciasis integration policy 0 5 6 All 16 Target 5 No. of CDTI projects integrated into national health systems 44 44 111 Target 6 No. of sustainability-evaluated CDTI projects that have developed sustainability plans enabling them to secure long-term government funding 39 64 70 All 111 Target 7 No. of APOC countries in which capacity building has ensured that monitoring and evaluation of CDTI projects are under the responsibility of governments 3 5 5 All 16 Target 8 No. of onchocerciasis-endemic communities in the APOC operational zone that are included in the community information database 0 49,000 50,374 125,000 *See Table A on p.48 for geographic and therapeutic coverage detailed breakdown. ‡RAPLOA has also been expanded to 5 stable countries. Objective 3 target 2005 2008 2009 2015 Target 1 Onchocerciasis-endemic areas for which epidemiological criteria for stopping ivermectin treatment are available NA Only savannah areas 9 foci in 4 countries All 16 Target 2 No. of countries with at least 2 epidemiologists trained in the application of criteria for deciding where and when to stop ivermectin treatment NA 0 3 All 16 Target 3 No. of APOC countries that have applied criteria for stopping ivermectin treatment NA 0 0* 12 *(i)Criteria have been reviewed by country representatives and TCC. (ii) Criteria to be finalized at a consultative meeting in Cameroon in October 2010 and made available to countries. Objective 2 target 2005 2008 2009 2015 Target 1 No. of APOC countries that have national co-implementation policies and that have allocated regular budget funds for co-implementation NA 5 6 All 16 Target 2 No. of CDTI projects co-implementing other health interventions along with ivermectin treatment 22 61 73 All 111 NA = Not applicable. a n n Ex Es — E x tE r n a l m id -t Er m E v a lu a ti o n r Ep o r t 47 Objective 6 target 2005 2008 2009 2015 Target 1 No. of countries fully responsible for the financing and management of all CDTI projects in their respective territories NA 0 0 12 Target 2 Regional entities supporting African countries’ onchocerciasis control activities WHO/ AFRO WHO/ AFRO 2 (AFRO + WHO country offices) WHO/ AFRO, OOAS, OCEAC Target 3 No. of APOC countries with surveillance systems covering onchocerciasis and integrated into the national health system 0 0 0 12 Objective 5 target 2005 2008 2009 2015 Target 1 No. of APOC countries that have submitted to APOC an action agenda setting out how they aim to prepare for APOC’s cessation of all financial, technical and operational support for onchocerciasis control NA 4 8 All 16 Target 2 Proportion of APOC expenditure on onchocerciasis control activities defrayed by government and NGDO contributions • Stable countries >25% • Post-conflict countries: <10% >= 25% • Stable countries >35% • Post-conflict countries: <15% 100% Target 3 No. of APOC countries using regular budget funds to finance onchocerciasis control activities 6 6 9 15 Target 4 No. of countries receiving financial, technical, and operational support from APOC 15 19 15 APOC countries + 4 ex-OCP countries 4 Objective 4 target 2005 2008 2009 2015 Target 1 No. of high-risk ex-OCP countries in which CDTI has been re-launched NA 2 4 All 4 Target 2 Geographical ivermectin coverage rate in the area covered by high risk ex-OCP countries NA 80 88 100% Target 3 Therapeutic ivermectin coverage rate of the total population at high risk of onchocerciasis infection in ex-OCP countries NA 78 66* 85% NA = Not applicable. * In 2009, Côte d’Ivoire that has re- launched CDTI in 2008 was in the process of up scaling gradually and did not cover the whole country. a n n Ex Es — E x tE r n a l m id -t Er m E v a lu a ti o n r Ep o r t 48 Table A: Geographic and therapeutic coverage breakdown by status of countries Geographic coverage (%) therapeutic coverage (%) country 2008 2009 2008 2009 Post-conflict 62.6 81.5 46.2 63.9 Stable 97.1 98.2 75.3 77.0 Table B: Monitoring and evaluation of CDTI projects number of projects evaluated for sustainability 78 Number of sustainability plans received 70 Number of projects monitored for implementation of their sustainability plans 28 Number of projects monitored in an independent participatory manner 81 Table C: Capacity building in selected technical areas, 2001 – 2009 (partial data) areas of capacity building of nationals & nGdos country staff number of persons Data management and analysis (statistical or spatial analysis) 277 Collection and management of Data 606 Collection of geographic coordinates and management of Data 201 Disease mapping (REMO/RAPLOA) 883 Integrated mapping of NTDs 33 Entomology 135 Epidemiological surveillance 102 Independent Participatory Monitoring 486 Evaluation of the sustainability of a project 468 Monitoring implementation of sustainability plans 168 Masters in Public health/Epidemiology 15 TOTAL 3374 NB: These are partial figures. A more comprehensive database that includes names of individuals trained is being developed. Table D: Population per CDD ratio, 2009 country total population number of cdds population /cdd Angola 843,375 3,980 212 Burundi 1,406,983 8,828 159 Cameroon 6,373,612 40,437 158 CAR 1,399,294 4,398 318 Chad 1,871,174 13,602 138 Congo 760,793 1,682 452 DRC 27,036,661 115,059 235 Eq. Guinea 80,206 104 771 Ethiopia 5,756,141 66,681 86 Liberia 2,176,273 7,721 282 Malawi 1,978,306 14,147 140 Nigeria 33,352,380 193,408 172 Sudan 5,605,726 11,790 475 Tanzania 2,207,132 12,579 175 Uganda 2,947,581 101,505 29 Grand Total 100,347,007 602,959 166 NB: Data to be validated during NOTFs meeting 27-29 September 2010 in Ouagadougou, Burkina Faso. a n n Ex Es — E x tE r n a l m id -t Er m E v a lu a ti o n r Ep o r t 49 annex 2: apoc organisational chart H EA LT H SY ST EM SP EC IA LI ST (H SO ) SC IE N TI ST - O PE RA TI O N A L RE SE A RC H (S O R) CH IE F, S U ST A IN A BL E D RU G D IS TR IB U TI O N U N IT (C SD ) A dm in . A ss is t./ Se c Se cr et ar y Se cr et ar y Se cr et ar y Se cr et ar y Se cr et ar y Se c. /b il. TE CH N IC A L A D VI SO RS (7 P O SI TI O N S) CO M M U N IT Y O W N ER SH IP & PA RT N ER SH IP O FF IC ER (C O P) A D VO CA CY & CO M M U N IC A TI O N O FF IC ER (A CO ) Cl er k/ D riv er D IR A D M IN IS TR A TI O N O FF IC ER (A O ) TE CH N IC A L A D VI SO R (V EC TO R CO N TR O L) Se ni or A dm . A ss is t M ee tin g A dm . A ss is t./ Se c A dm . A ss is t/ Se c A ss is t. M ai nt . M ai nt en an ce te ch ni ci an A dm . A ss is t./ Se c Cl er k / Pe rs Cl er k D riv er D riv er D riv er Se ni or A dm . A ss is t P er so nn el Se ni or A dm . A ss is t T ra ve l Se ni or A dm . A ss is t S up . & S er v. St or e ke ep er Cl er k Bl d. & S er v. Eq . O p. (fa x, te le x) Cl er k Te le ph Se cr et ar y/ Cl er k A ss is t. A cc ou nt s & B ud ge t (2 P O SI TI O N S) A ss is t. A cc ou nt an t (4 P O SI TI O N S) Se ni or A ss is t. Fi na nc e Co un tr y Im pr es t Se ni or A ss is t. Fi na nc e Se cr et ar y (2 P O SI TI O N S) A ss is t. A dm in . F in an ce (8 P O SI TI O N S) A ng ol a Ca m er oo n D RC Et hi op ia N ig er ia Su da n Ta nz an ia U ga nd a FI N A N CE O FF IC ER (F O ) (2 P O SI TI O N S) BU D G ET & F IN A N CE O FF IC ER (B FO ) A dm in . A ss is t./ Se c D at a en tr y cl er k D at a en tr y cl er k A ss is t. D at a m an ag em en t A ss is t. D at a en tr y & m an ag em en t Se ni or A ss is t. D at a en tr y & m an ag em en t BI O ST A TI ST IC S & M A PP IN G O FF IC ER (B IM ) Se cr et ar y Se cr et ar y Se cr et ar y EP ID EM IO LO G IS T (E PI -A ) EP ID EM IO LO G IS T (E PI -B ) Eq ui p. & O pe ra tio ns Te ch ni ci an Se ni or M ed . A ss is t. A dm . A ss is t./ Se c IN FO RM A TI O N SY ST EM O FF IC ER (IS O ) IN FO RM A TI O N TE CH N O LO G Y O FF IC ER (IT O ) C H IE F, E PI D EM IO LO G Y & V EC TO R EL IM IN A TI O N (C EV ) Se cr et ar y/ D IR A dm in . L ia is on O – ce r ( A LO ) M es se ng er M es se ng er A dm in . A ss is t./ Se c CO O RD IN N A TO R O FF IC E O F D IR EC TO R (C O O RD ) D IR EC TO R, A PO C D EP U TY CO O RD IN N A TO R (D CO ) PR O G RA M M E O FF IC ER M EE TI N G (P RO ) TR A N SL A TO R (T RA D ) a n n Ex Es — E x tE r n a l m id -t Er m E v a lu a ti o n r Ep o r t 50 annex 3: list of persons interviewed COUNTRY LEVEL ACTORS Cameroon 28..HE.Dr..André.Mama.Fouda,.Minister.of.Health 29..Prof..Fru.III.Angwafo,.Secretary.General,.MoH 30..Mrs.C..Balanos,.Coordinator.NGDOs. Coalition,.LCIF,.Sight.First 31..Mrs.J.Essama,.Lymphatic.Filariasis.focal. person.at.NOP 32..Dr.Eyamba,.Carter.Centre,.Country.Director 33..Dr.C..Faty-Ndiaye,.WHO,.Country. Representative 34..Mr.Georges.Mbenda.Beyalal,.Director,. Perspective 35..Mr.J.Ndjoh,.Programme.Officer,.Perspective 36..Dr.M.Ntep,.National.Onchocerciasis. Coordinator 37..Prof..G..Ondovo.Andze,.Director,.Directorate. for.Disease.Control,.Chair.of.the.NOTF,.Focal. point.for.NTDs; 38..Drs.J..Oye,.Country.Director,.Sightsavers.with. colleagues.Cyrille.Evini,.Andrew.Atabe, 39..Mrs.Mary.Tanya,.Finance/Administration. Manager,.Perspective 40..Prof..L.A..Tchuem.Tchuente,.National. Coordinator.Schisto.and.STH.Control. Program,.member.of.APOC.TCC 41..Dr.Kingsley.Shu,.Regional.Oncho.Coordinator. North.West.Region.and.staff.members 42..Regional.Oncho.Coordinator, 43..Mr.E.L..Florent,.District.Medical.Officer.and. staff,.Ngambe.District,.Littoral.II.Region 44..DMO.and.staff,.Littoral.1.Region,.Melong Democratic Republic of Congo 45..HE.Victor.Makwenge,.Minister.of.Health 46..Dr.Pierre.Lokadi.Secretary.General,.Ministry. of.Health 47..Dr.Issiaka.Compaore,.WHO.Country. Representative 48..Dr.Alexandre.Tiendrebeogo,.Central.Africa. Advisor,.WHO 49..Dr.Nouhou.K.Diallo,.Technical.Advisor,.APOC 50..Dr.Serge.Akongo,.Technical.Advisor,.APOC 51..Ms.Aimerance.Kabena,.Country.Representative. HKI 52..Mr.Augustin.Kamenda.Bishimini,.Head.of. Micronutrients.division.at.National.Nutrition. Programme DONORS 1..Prof..Donald.Bundy,.World.Bank., 2..Ms.Brenda.Colatrella,.Merck.&.Co 3..Dr.John.Gibb,.Policy.and.Programme.Manager,. Polio.and.Neglected.Tropical.Diseases,.Human. Development.Department,.DFID 4..Mr.Ken.Gustavsen,.Merck.&.Co TECHNICAL AGENCIES 5..Dr..Anarfi.Asamoa-Baah,.WHO.HQ,.Geneva,. Switzerland 6..Dr..D.Engels,.WHO.HQ,.Geneva,.Switzerland 7..Dr..Tony.Ukety,.NGDO.Group.Coordinator,. WHO.HQ ACADEMIC INSTITUTIONS 8..Prof.Oladele.Akogun,.Yola.University.of. Technology,.Nigeria 9..Dr..M.Boussinesq,.Institut.de.Récherche.pour. le.Développement(IDR),.Montpellier,.France 10..Dr.Jesse.Bump,.Takemi.Fellow.in.International. Health,.Harvard.School.of.Public.Health;.and. Consultant,.26385.Consulting 11..Dr..Pat.Lammie,.CDC 12..Prof.D.Molyneux,.Liverpool.School.of.Tropical. Medicine,.UK 13..Dr..Frank.Richards,.Emory.University 14..Dr..W.Stolk,.Dept..of.Public.Health,.Erasmus. University,.Rotterdam,.The.Netherlands 15..Prof..G.Weil,.Washington.University,.St.Louis,. USA 16..Prof..Mamadou.Souncalo.Traoré,.TCC.Member NGDOs 17..Mr.Peter.Ackland,.CEO.of.IAPB 18..Dr..Sarla.Chand.IMA.World.Health 19..Mr.Dominic.Haslam,.Head.of.Government. Relations.&.Policy,.Sightsavers 20..Dr..Adrian.Hopkins,.MDP.Director 21..Ms.Mary.Linehan,.RTI.International 22..Mr.Chad.MacArthur,.Helen.Keller.International 23..Dr.Kisito.Ogoussan,.Associate.Director.MDP CONSULTANTS 24..Dr.Boakye.Boatin,.Former.Director.APOC;. WHO/TDR.retired 25.. J.H.F.Remme,.consultant,.France 26..Prof..Soungalo.Traoré,.TCC.Member 27..Dr.André.Yebakima,.TCC.Member a n n Ex Es — E x tE r n a l m id -t Er m E v a lu a ti o n r Ep o r t 51 53..Dr.Koffi.Tsogbe,.WHO.Focal.Point.for.EPI/ Polio 54.. In.one/two.meetings: 55..Dr.Lomanga.Nsaga,.NOTF.Member 56..Dr.Tshitoka.F.Ntumba,.NOCP 57..Dr.Marcel.Bakajika,.President.of.NGDO. Coalition 58..Dr.Kalimba.Buhendwa,.NOCP.Supervisor 59..Dr.Watinga.Mukunda,.National.Coordinator. for.NTDs 60..Dr.Joseph.Linguba,.Director,.National. Programme.for.LF 61..Dr.Encendjo 62..Dr.Mukiar.Temor,.Assistant.Coordinator.NTDs 63..Dr.Jean.Tankwey,.NOCP 64..Mr.Kinswara.Nalo,.Accountant,.NOCP 65..Mrs.I.Manzila,.Supervisor,.NOCP 66..Mr.Mbaya.Kamuranya,.supervisor,.NOCP 67..Ms.E.Agwatukalusu,.CDAF,.NTDs 68..Dr.Kalongo.Mutebe,.SAE.Manager,.NOCP 69..Mr.T.Luntadila,.AAF,.APOC 70..Dr.Jean.Njemba,.Directorate.of.Disease. Control 71..Dr.Adrian.Loka,.Sankuru.Project.Coordinator. and.19.zonal.staff:.doctors.and.supervisors 72..Territorial.Administrator,.Lodja 73..Dr.Gabriel.Osango,.Vangakete.Zone.and.health. team.staff 74..Dr.Marten.Kombo.Koaba,.Ototo.Zone.and. health.team.staff 75..Dr.Marcel.Okito,.Tshudi.District.and.and. health.team.staff 76..Dr.A.Luthongo.Paluku,.WHO.Lodja Tanzania 77..Dr..Deo.Mtasiwa,.Chief.Medical.Officer 78..Dr..Neema.Rusibamayila,.Ag..Director. Preventive.Services.(position.at.MOHSW. Assistant.Director.Reproductive.and.Child. Health) 79..Dr..Bernadette.Shilio,.Ag..National. Coordinator.for.Onchocerciasis 80..Dr..Edward.Kirumbi,. Programme.Officer. Onchocerciasis.and.Eye.Care 81..Mr..Oscar.Kaitaba,.Programme.Officer.Eye. Care 82..Dr..Upendo.Mwingira,.National.Coordinator. NTD 83..Dr..Theodore.Tigahwa.Focal.person.from. Health.Education.and.Health.promotion 84..Medical.Stores.Department 85..Mr..Beatus.Msoma.,.Programme.Manager. Vertical.Programme 86..Dr..Ibrahim.Kabole.,.Country.Director.Sight. Saver.International.Chair.NGDO 87..Dr..Margaret.Kasiko,.Regional.Quality.Manager. SSI.(Nairobi).Kenya 88..Dr..Martins,.Ag..WR.Tanzania 89..Dr..Grace.Saguti,.WHO.Officer 90..Dr..Alphoncina.Nanai,.National.Programme. Officer.NTD 91..Dr..Mtatifikolo,.Ag..Regional.Medical.Officer 92..Dr..Maggid.Rehmah,.Regional.Coordinator. NTD 93..Dr..Tom.Kimweri.Mtoi,.District.Medical. Officer 94..Mr..Abdul.Amir.Daffa,.District.NTD. Coordinator Ghana 95..Dr.Robert.Mettle.Nunoo,.Deputy.Minister.for. Health 96..Dr.George.Amofa;.Deputy.Director.General,. Ghana.Health.Service 97..Dr.Sylvester.Anemena;.Chief.Director,.Ministry. of.Health 98..Dr.Frank.Nyonator,.Director,.Ghana.Health. Service 99..Dr.Nana.Biritwum,.Program.Manager,.NTDs 100..Dr.Edmund.Kaitoo,.District.Director.of.Health. Services,.East.Akim.District 101..Dr.Erasmus.Agongo,.Regional.Director.of. Health.Services,.Eastern.Region 102..Prof..Dr..Johnny.Gyapong;.Director,.Health. Research.Unit,.GHS 103..All.members.of.the.East.Akim.DHMT.(12. persons) 104..All.members.of.the.Regional.Directorate,. Eastern.Region.(15.persons) a d d En d u m : c o u n tr y c a sE s tu d iE s — E x tE r n a l m id -t Er m E v a lu a ti o n r Ep o r t 52 addendum: countRY case studies a d d En d u m : c o u n tr y c a sE s tu d iE s — E x tE r n a l m id -t Er m E v a lu a ti o n r Ep o r t 53 case study: onchocerciasis control and health systems strengthening in tanzania to.the.relevant.government.departments.and. WHO.country.office.in.Dar.es.Salaam. Burden of disease 2. Onchocerciasis.is.present.in.5.regions.and.19. districts.of.Tanzania.(Rapid.Epidemiological. Mapping.of.Onchocerciasis.(REMO).2006). with.approximately.4.million.people.at. risk..Current.data.are.based.on.the.REMO. conducted.in.2008.(see.figure A)1..Prevalence. of.up.to.63.9%.has.been.recorded.in.some. focal.endemic.areas.and.pathologies.reported. are.dermatologic,.lymphatic,.ophthalmologic. and.systemic2 3. All.five.preventive.chemotherapy.targeted. neglected.tropical.diseases.(schistosomiasis,. soil.transmitted.helminths,.lymphatic. filariasis,.onchocerciasis.and.trachoma).are. endemic.in.Tanzania.reflecting.the.low.socio- economic.status,.particularly.of. rural.populations..Other.endemic. diseases.include.HAT,.rabies,. echinococcosis,.cysticercosis,. brucellosis.and.plague..Most. of.the.population.is.at.risk.of. co-infection.with.two.or.more. of.these.diseases..A.baseline. survey.conducted.in.2004-6.in. 50.districts.found.that.active. trachoma.is.endemic.in.43. districts,.(prevalence.>.10%. among.1-9.year.olds).many.of. which.were.also.onchocerciasis. focal.areas..There.is.also.LF. overlap.in.all.the.Onchocerciasis- endemic.regions. 1. Tanzania.Country.Profile..APOC.2009 2. Ministry.of.Health.and.Social.Welfare.. 2009..The.United.Republic.of.Tanzania. Neglected.Tropical.Diseases.Country.Plan. 2009-2014 overview 1. Tanzania.has.one.of.the.longest.running,. community.directed.Ivermectin.programs. for.Onchocerciasis.control.in.Africa..The. APOC.program.was.officially.launched.in. 1998.and.currently.funds.9.projects.covering. 17.districts.and.just.under.2.million.people.. Tanzania,.like.most.African.countries,. faces.many.of.the.challenges.highlighted. in.the.report.with.regard.to.resource. mobilization,.capacity,.fragmentation,.logistics. and.persistent.poverty..Nonetheless,.an. examination,.particularly.of.the.CDI,.health. system.and.human.resources.infrastructure. and.strategies.highlights.some.important. lessons.that.can.be.considered.in.APOC’s. support.for.country.led.systems.for.disease. control..Site.visits.were.made.to.the.regional. health.offices.in.Tanga.and.to.communities.in. Luandai.Soni.and.Korogwe.Lushoto.as.well.as. 40°E 38°E36°E34°E32°E30°E28°E 40°E 38°E36°E34°E32°E30°E28°E 2°S 4°S 6°S 8°S 10°S 12°S 2°S 4°S 6°S 8°S 10°S 12°S Lindi Arusha Tabora Rukwa Iringa Mbeya Ruvuma Morogoro Singida Kigoma Mara Kagera Pwani Dodoma Shinyanga Tanga Mwanza Mtwara Kilimanjaro Dar es salaam Kusini Unguja Kusini Pemba Kaskazini Pemba Kaskazini Unguja 0 100 200 300 km APOC/Mgt/January 2008 Tanzania REMO map Denite CDTI areas To be rened No CDTI areas Excluded zones Regions boundaries Communities and population at high risk, 2008 Number of communities in meso/hyper endemic (red) areas 5,553 Total population living in meso/hyper endemic (red) areas 2,073,824 Figure A: REMO map with CDTI areas a d d En d u m : c o u n tr y c a sE s tu d iE s — E x tE r n a l m id -t Er m E v a lu a ti o n r Ep o r t 54 health system 4. There.is.a.strong.rural.basis.to.health.care. delivery.in.Tanzania..It.is.important.to.note. however.that.although.the.distribution.of. facilities.was.planned.to.take.account.of. population.coverage,.over.time,.the.ratio. has.been.overtaken.by.high.population. growth.rates3..The.general.model.conforms. to.a.primary.health.care.approach,.with. two.trained.health.workers.chosen.by.the. community.to.operate.at.the.level.village. health.services..Dispensaries.provide. secondary.care.catering.for.up.to.10,000.head. of.population.followed.by.health.centres.at. the.ward.level.to.accommodate.approximately. 50,000.people..The.district.level.supports. a.Council.Health.Management.Team.which. has.the.authority.to.determine.priorities.and. plan.and.implement.programs.for.the.district.. District.hospitals.also.provide.tertiary.level. hospitals.with.periodic.specialist.services.from. hospitals.at.the.regional.level..There.are.a. limited.number.of.consultant.hospitals.across. the.country.(4.government.and.4.private)). 5. There.remain.problems.with.access.to. services;.approximately.two.thirds.of. the.total.population.are.not.able.to.raise. the.costs.for.treatment.or.to.travel.the. distance.to.receive.treatment..Geographical. accessibility.is.reported.at.about.90%.of.the. population.living.within.5km.of.a.health. service,.however.where.this.is.not.the.case,. distances.may.be.up.to.10km..Furthermore,. the.quality.of.existing.even.where.proximity. is.not.an.issue.is.variable,.compromising. equity..Recent.human.resource.figures.suggest. a.ratio.of.2.doctors.to.100,000.population. with.the.total.workforce.running.at.less. than.32%.of.requirements4..Given.this. problem.with.human.resources.for.health,. the.CDTI.approach.has.been.critical.to.the. achievement.of.current.levels.of.coverage.of. the.onchocerciasis.control.program. 3. Ministry.of.Health.and.Social.Welfare..2009..The.United. Republic.of.Tanzania.Neglected.Tropical.Diseases.Country. Plan.2009-2014. 4. The.United.Republic.of.Tanzania,.Ministry.of.Health. and.Social.Welfare..2007.PRIMARY.HEALTH.SERVICES. DEVELOPMENT.PROGRAMME.(PHSDP).2007–2017. “FINAL.MMAM.26.11.2007.pdf,”.n.d.,.http://www.moh. go.tz/documents/FINAL%20MMAM%2026.11.2007.pdf. the onchocerciasis control program and cdi 6. There.is.very.strong.commitment.by.the. political.leadership.for.NTD.control.in.general. and.Onchocerciasis.control.in.particular.. Political.commitment.is.demonstrated.for. instance.by.the.involvement.of.politicians.in. mass.drug.administration.campaigns.and.the. public.taking.of.tablets.to.allay.fears.of.and. rumors.about.surreptitious.administration.of. mass.sterilization..The.risk.however.is.that. commitment.is.only.as.strong.as.the.particular. elected.government. 7. At.the.national.level,.the.National. Onchocerciasis.Control.Program.(NOCP).is. coordinated.by.National.Eye.Care.Program.of. the.Ministry.of.Health.and.Social.Welfare..The. NOCP.was.supported.by.Non-governmental. Development.Organization.(NGDO).partners. Helen.Keller.International.(HKI),.IMA.World. Health,.Sightsavers.International.and.Rotary. International. 8. CDTI.projects.in.several.of.the.districts.in. Tanzania.are.supported.by.a.strong.partnership. model.between.the.Ministry.of.Health,.NGDOs,. regional.authorities.and.district.councils..The. ministry.provides.technical.support.for.the. implementation.of.several.activities,.some. funding,.supervises.and.monitors.CDTI. activities.implemented.in.the.project..The. region.supports.supervision.and.fuel.for. vehicles.during.advocacy.and.mobilization. activities..The.NGDO.partner.provides.funds. for.training.of.front.line.health.staff.especially. in.eye.care,.logistics.(transport).and.technical. advice.on.how.to.execute.integration.of.CDTI. activities.with.other.programme..District. councils.provide.salaries.to.front.line.health.staff. and.support.HSAM,.supervision,.planning.and. training.of.CDDs..Planning.and.implementation. of.interventions.is.coordinated.through.the. districts.with.some.supervision.from.the. regional.programme..Staffs.at.both.district. and.the.regional.levels.are.actively.involved.in. both.implementation.and.supervision..Formal. resources.have.been.developed.and.translated. into.Swahili.for.the.support.and.supervision.of. CDDs..Community.mobilization.is.undertaken. as.a.joint.activity.with.the.districts..In.Tanga,. a d d En d u m : c o u n tr y c a sE s tu d iE s — E x tE r n a l m id -t Er m E v a lu a ti o n r Ep o r t 55 local.radio.stations.donate.airtime.to.providing. communities.with.appropriate.information.. This.information.is.combined.with.the.use. of.megaphones.across.the.communities..The. Community.mobilization.and.sensitization. process.also.includes.education. 9. The.community.is.responsible.for.the. collection.of.Mectizan.from.the.nearest.Health. Post.and.the.distribution.to.community. members.on.an.annual.basis.with.the. understanding.of.a.15.year.commitment. 10. Therapeutic.coverage.with.Ivermectin. (donated.by.Merck).reached.80%.in.2002. and.has.remained.consistent..Ivermectin. distribution.is.done.once.a.year,.covering.ages. 5.years.and.above.in.all.communities.with. disease.prevalence.of.20%..The.prevalence.is. ascertained.through.nodule.rate.surveys. 11. CDI.has.served.as.a.distribution.model. for.other.PC.NTD.programs..In.addition,. three.of.the.CDI.projects.are.successfully. co-implementing.the.control.of.Lymphatic. Filariasis.in.endemic.communities.by. providing.Albendazole.(donated.by.GSK).and. bed.nets..CDDs.also.deliver.interventions. such.as.eye.care,.schistosomiasis.control.and. soil.transmitted.helminthes.(STH)..Where.the. coordination.had.fallen.short,.the.challenges. included.resource.mobilization,.problems.in. harmonization.across.NTD.interventions,.lack. of.predictability.over.the.procurement.of.drugs. and.the.potential.for.fragmentation.by.different. models.of.incentives.to.CDDs.and.different. levels.of.engaging.with.communities. 12. At.the.district.level,.the.problems.with. coordination.are.being.addressed.through.an. integrated.team.approach.to.NTD.control.. The.team.is.represented.by.staff.from.a.range. of.divisions.including.MCH,.HIV/AIDS,.Cold. Chain,.Malaria,.IMCI,.TB.and.Leprosy.as. well.as.School.Health.and.Onchocerciasis. control..Operational.research.to.explore.the. experience.of.this.coordinated.approach.would. provide.valuable.information.about.how.to. overcome.these.problems..A.similar.approach. has.been.adopted.at.the.national.level.with. a.recommendation.to.include.representation. from.the.procurement.and.medical.stores. departments.so.that.there.is.a.better. understanding.of.the.need.for.coordination.of. drug.supplies.as.well. 13. The.Primary.Health.Care.Plan.recognizes.the. need.for.genuine.participation.of.communities. and.has.proposed.community.participation. in.the.management.of.health.facilities.at.the. Council.level.through.Council.Health.Services. Boards,.Hospital.Governing.Committees.and. Health.Facility.Committees.of.the.Health. Centres.and.Dispensaries5 14. Resource.mobilization.is.an.important. issue.to.overcome,.particularly.to.ensure. sustainability.of.the.programs..There.has.been. some.advocacy.to.obtain.greater.support.from. local.councils.but.this.is.an.ongoing.effort.. Their.engagement.would.present.alternative. forms.of.funding.and.governance.once.there. is.no.longer.formal.support.from.programs. such.as.APOC..Some.communities.expressed. the.importance.of.at.least.having.their. contributions.acknowledged.by.their.local. politicians.even.if.they.were.not.remunerated. 15. Community.incentives.to.CDDs.include. exemption.from.community.labour.activities. and.other.community.members.volunteer. to.cover.their.daily.responsibilities.such. as.farming,.which.would.not.otherwise. be.covered.while.they.undertake.drug. distribution.activities..CDD.quote: “We are not asking to be paid for this job. When we accepted this job we knew that there is no payment, we are happy to help our brothers, sisters, and neighbors who otherwise would not have had the opportunity to have this drug. But if there is any kind of incentive that the program can give us we shall be very grateful. Raincoats for instance would be very good to prevent the record books and drug packets from getting wet. Boots will help to get through the mud in the rain. It would also be good to have T-shirts or badges to identify us as CDDs. We are going to continue to do this job for as long as it takes.” CDD 5. The.United.Republic.of.Tanzania,.Ministry.of.Health. and.Social.Welfare..2007.PRIMARY.HEALTH.SERVICES. DEVELOPMENT.PROGRAMME.(PHSDP).2007–2017. “FINAL.MMAM.26.11.2007.pdf,”.n.d.,.http://www.moh. go.tz/documents/FINAL%20MMAM%2026.11.2007.pdf. a d d En d u m : c o u n tr y c a sE s tu d iE s — E x tE r n a l m id -t Er m E v a lu a ti o n r Ep o r t 56 Others.were.keen.on.the.opportunity.for. training.across.a.range.of.health.issues..A. number.expressed.their.disappointment.in. the.restrictions.they.faced.in.being.involved. with.some.of.the.interventions.as.a.result. of.limited.literacy..Their.commitment. notwithstanding,.there.was.a.recognition. that.some.interventions.were.associated.with. remuneration.while.others.were.not..Their. suggestions.were.for.these.resources.to.be. pooled.across.programs.as.a.fairer.way.of. working. 16. At.the.national.level.the.issue.of.coordination. would.also.need.to.involve.advocacy.and. lobbying.of.external.donors.to.support. integration.with.other.programs.determined. at.the.national.and.regional.levels..This.would. require.donors.to.be.more.flexible.in.their. reporting.requirements.recognizing.the.need. for.streamlining.of.vertical.programs. capacity building 17. Staff.from.the.MOHSW.acknowledged.the. support.and.training.at.various.levels.received. through.the.APOC.secretariat,.WHO.AFRO. and.the.WHO.country.office..Capacity.in.this. context.covered.a.range.of.areas.including. disease.control,.CDI,.resource.mobilization,. advocacy,.community.sensitization,.health. education,.monitoring.and.evaluation,. accountability.and.financial.reporting..Similar. capacity.has.been.developed.over.the.duration. of.the.programme.at.the.regional,.district.and. provincial.levels. 18. The.CDI.strategy.fits.well.with.Tanzanian. broader.plans.for.health.workforce. development6..Interviews.with.staff.at.the. national.ministry.level.highlighted.discussions. of.a.range.of.proposed.training.programs. for.community.based.workers..The.general. approach.would.the.establishment.of.more. training.facilities.to.cover.a.diversity.of.levels. of.training..Community.workers.(at.the. equivalent.level.of.CDDs).will.be.recruited. 6. The.United.Republic.of.Tanzania,.Ministry.of.Health. and.Social.Welfare..2007.PRIMARY.HEALTH.SERVICES. DEVELOPMENT.PROGRAMME.(PHSDP).2007–2017. “FINAL.MMAM.26.11.2007.pdf,”.n.d.,.http://www.moh. go.tz/documents/FINAL%20MMAM%2026.11.2007.pdf. and.trained.over.a.6.month.period..This. training.will.be.open.to.those.with.basic. literacy.skills,.able.to.keep.some.records.. The.strategy.is.to.build.a.‘reserve’.workforce. who.can.be.called.upon.on.an.ad.hoc.basis. rather.than.on.permanent.‘retainer’..They. would.have.the.added.advantage.of.being. selected.by.the.community.and.therefore. with.a.high.level.of.community.acceptance. for.population.wide.interventions.and. increased.access.and.coverage..Workers. at.this.level.could.be.recruited.for.a.wide. range.of.projects.including.community. development,.social.welfare,.agriculture.and. health..It.could.offer.a.pathway.to.certificate. and.diploma.and.would.improve.options.for. employment.and.education..This.recognizes. the.evidence.of.how.much.CDDs.at.this.level. have.contributed.to.the.public.health.effort.. The.quality.of.the.records.for.instance.for. the.population.census.and.monitoring.drug. distribution.was.high..One.of.the.CDDs. interviewed.said: “Now that we are doing other health work we would like to be trained so that we can continue to help our community. There are other diseases that disturb our community like diarrhoeal diseases, leprosy, TB. It would also be very good to visit other towns and districts to exchange ideas with CDDs”. 19. Community.health.workers.would.be.the. next.level.with.a.more.formalized.training. program.that.would.be.a.potential.career. pathway.into.the.health.sector..Workers.at. this.level.would.supervise.CDDs.and.have. a.more.structured.role.within.community. health.services. 20. Other.levels.of.training.will.focus.on.in- service.training.and.continuing.professional. development.for.existing.staff..These.all. present.opportunities.for.the.resources. developed.by.APOC.for.health.systems. strengthening.at.the.community.and.other. levels.to.be.trialed.further.developed.and. adapted.and.used.to.support.the.promotion. of.primary.health.care..The.need.for.an. increased.voice.of.community.in.training.is. acknowledged.within.the.primary.health.care. development.plan. a d d En d u m : c o u n tr y c a sE s tu d iE s — E x tE r n a l m id -t Er m E v a lu a ti o n r Ep o r t 57 conclusion and ongoing challenge 21. The.APOC.programme.has.made.a.significant. contribution.to.the.health.system.in. Tanzania.through.the.CDI.approach.and. the.integration.of.CDDs.in.many.of.the. public.health.program.plans..This.has.been. facilitated.in.part.by.an.approach.that.has. been.strongly.country.led..The.approach. has.supported.strong.advocacy.for.inclusion. of.CDTI.and.co-implementation.into. comprehensive.health.plans.at.the.regional. and.district.levels. 22. There.is.a.risk.that.in.integration,.the.rigour. that.has.to.date.been.applied.to.onchocerciasis. control.will.be.compromised..It.is.therefore. critical.for.ongoing.implementation.research. be.undertaken.to.develop.evidence.for. best.practice.and.to.monitor.the.progress. of.onchocerciasis.control.within.a.larger. integrated.NTDs.program. case study: onchocerciasis control in the democratic Republic of congo, a post-conflict country in transition overview 23. The.Democratic.Republic.of.Congo.(DRC).has. a.population.of.64million7.living.in.an.area. of.2,345,000.km2.and.sharing.9,165.km.of. frontiers.with.nine.neighbouring.countries..Ten. years.of.conflict.during.the.1990s,.combined. with.poor.governance.and.the.withdrawal.of. most.foreign.aid,.inflicted.severe.damage.on. the.population.and.on.the.country’s.social. and.economic.infrastructure..Transport.and. communications.infrastructure.are.very.poor. and.an.estimated.71%.of.the.population.is. living.below.the.poverty.line.8.DRC.is.ranked. by.UN.Human.Development.Index.in.176th. position.out.of.182.countries.in.2009.9.DRC. reached.the.Heavily.Indebted.Poor.Countries. Initiative.Completion.Point.in.June.2010.and. will.now.benefit.from.$12.3.billion.support. in.debt.relief10;.this.has.generated.optimism. for.future.funding.at.the.Ministry.of.Health. level..Although.there.are.still.some.areas.of. 7. National.Health.Development.Plan.2011-2015 8. NHDP 9. UNDP.Human.Development.Report.2009 10. International.Monetary.Fund.Press.Release.No.10/274,.July. 1.2010 instability,.especially.in.the.East.of.the.country,. the.GENERAL.situation.is.now.considered.one. of.transition.to.a.development.phase. 24. CDTI.was.launched.in.DRC.in.2000.but.the. programme.has.suffered.from.disruptions,. notably.due.to.episodes.of.conflict.and.the. effects.of.co-endemicity.with.loa-loa.causing. a.number.of.severe.adverse.events.and.deaths. in.2005..Onchocerciaisis.is.present.in.all. 11.provinces.and.there.are.now.20.projects. covering.230.districts;.four.projects.only. became.operational.in.the.last.3.years..The. projects.reflect.previous.provincial.and.district. boundaries.and.often.straddle.several.districts. and.more.than.one.province;.some.were. reported.to.be.difficult.to.manage.because.of. these.administrative.complexities.and.the.vast. areas.covered. Burden of disease 25. It.is.estimated.that.26.million.Congolese.in.all. the.11.provinces.are.living.in.Oncho.meso/ hyper-endemic.areas,.while.14.million.are. infected. a d d En d u m : c o u n tr y c a sE s tu d iE s — E x tE r n a l m id -t Er m E v a lu a ti o n r Ep o r t 58 26. There.are.zones.with.Loaisis.co-endemicity.in. 14.out.of.20.projects..The.occurrence.of.Severe. Adverse.Events.(SAEs).and.associated.deaths. when.these.zones.were.first.treated,.led.to.a.halt. in.ivermectin.distribution.in.2005.while.the. prevalence.of.Loaisis.was.mapped..A.national. unit.for.managing.SAEs.was.established.and. is.closely.involved.in.supervising.the.gradual. inclusion.of.these.zones.although.it.has.not. prevented.the.occurrence.of.some.SAEs. 27. Most.of.the.13.Neglected.Tropical.Diseases. (NTDs).are.present.in.DRC,.including. lymphatic.filariasis.(LF),.schistosomiasis. (Schisto),.and.soil.transmitted.helminths. (STH);.some.mapping.has.been.undertaken,. but.it.has.not.yet.been.completed. health system 28. During.the.conflict.period,.the.stewardship.role. of.the.Ministry.of.Health.was.greatly.diminished. and.many.other.well-resourced.actors.entered. the.sector,.from.both.the.humanitarian.and. private.sectors..As.a.result,.health.system. structures,.such.as.those.for.procurement,. health.information.management,.have.become. fragmented.with.multiple-decision. making.centres.at.national.and. provincial.level..There.are.52.vertical. programmes.and.the.districts.and. zones.are.coping.with.a.variety.of. uncoordinated.approaches. 29. The.focus.of.the.health.system. is.currently.on.preventive.care.. Patients.pay.for.consultations.at.the. primary.level;.this.practice.began.in. 1990s.when.the.health.centres.had. no.other.source.of.revenue..Fees.still. support.essential.running.costs.and. contribute.70%.of.zonal.operating. costs11.but.are.not.controlled.or. managed..There.are.little.or.no. essential.medicines.available.due. to.supply.chain.failures,.even.with. externally.funded.projects..“The drugs we ordered in September 2009 from AXxes Project are still awaited”. a.District.Medical.Officer.(August. 11. WHO.Cooperation.Strategy. 2010)..Even.for.these.projects,.patients.have. to.take.prescriptions.to.the.burgeoning.but. unregulated.private.“pharmacies”. 30. There.are.continuing.frustrations.with.salaries,. which.are.low.and.often.paid.in.arrears,.at. all.levels.of.the.system..District.health.staffs. were.not.receiving.their.salaries.regularly. and.there.were.reports.that.some.staff.lacked. professional.competency.owing.to.irregular. peer-recruitment.procedures..It.was.also. reported.that.the.routine.functioning.of.the. health.dialogue.structures,.from.the.village. to.district.levels,.relies.heavily.on.external. support.received.for.holding.monitoring.and. evaluation.meetings..Without.this.support,.the. committees.are.said.to.stop.functioning. 31. With.the.recent.adoption.of.the.National.Plan. for.Health.Development.2011-2015.which. operationalises.the.National.Health.Policy. of.2001,.the.Ministry.of.Health.now.has.a. framework.that.promotes.decentralisation. and.integration.for.reforming.the.health. structure..An.institutional.audit.has.been. conducted.and.corrective.measures.that. clearly.delineate.responsibilities.and.reporting. Figure B: REMO map with CDTI areas Communities and population at high risk, 2009 (partial data) Number of communities in meso/hyper endemic (red) areas 40,529 Total population living in meso/hyper endemic (red) areas 26,562,354 Oriental Katanga Equateur Bandundu Maniema Kasai Oriental  Kasai Occidental Sud Kivu Nord Kivu Bas-Congo Kinshasa  Legend CDTI priority areas No CDTI areas Areas to rene REMO pending areas Parks 0 440 660 880220 Km a d d En d u m : c o u n tr y c a sE s tu d iE s — E x tE r n a l m id -t Er m E v a lu a ti o n r Ep o r t 59 lines.from.district.to.the.provincial.and.the. national.levels.are.expected..The.new.structure. allows.the.central.levels.to.concentrate.on. strategic.thinking.and.regulation.and.delegates. regulatory.powers.to.the.provincial.level;. this.was.said.to.be.a.source.of.frustration. for.some.individuals.at.national.level..With. the.transfer.of.the.support.and.supervision. roles.to.the.provinces,.the.provincial.steering. committees.have.been.specifically.identified. for.strengthening.but.not.the.health.district. and.zone.dialogue.structures. the onchocerciasis control program and cdi 32. Leadership.and.coordination.at.national. level.has.been.weak.within.the.National. Onchocerciasis.Control.Programme.for.several. years.and.this.has.recently.been.the.subject.of. APOC.advocacy.at.the.highest.levels..There. are.problems.with.the.structure,.management. capacity,.levels.of.understanding.and. communications..There.was.also.evidence.of. internal.dissension.and.lack.of.motivation.owing. to.poor.central.level.resourcing.and.to.APOC. funding.now.going.directly.to.projects..There.are. no.clear.strategies.for.resource.mobilisation.and. advocacy.to.support.oncho.control.activities.but. rather.a.poor.sense.of.accountability.at.different. levels,.poor.communications.and.suspicion.. Recognising.the.failures.of.the.current.structure. and.management.capacity,.the.Ministry.of.Health. is.said.to.be.reviewing.the.NOCP.structure. 33. The.weakness.of.the.NOCP.and.the.poor. progress.in.achieving.the.coverage.rates. needed.to.control.onchocerciasis.led.to. APOC’s.decision.to.support.two.Technical. Advisor.posts.in.DRC..Since.their.arrival. there.has.been.a.very.marked.improvement. in.coverage.rates.but.the.relationship.between. the.APOC.Technical.Advisor.based.at.WHO. country.office.and.the.secretariat.of.the. NOCP.is.difficult.and.is.characterised.by.poor. communications.and.distrust..The.WHO. Representative.commented.that.there.is.lack.of. understanding.of.the.range.of.WHO.resources. that.support.such.posts..Other.Ministry. personnel.were.said.to.be.supportive.of.the. posts.and.NOTF.recognised.the.progress. achieved.since.these.posts.were.filled. 34. National.therapeutic.coverage.rates.have. increased.markedly.in.the.last.couple.of.years:. from.40%.in.200812.to.65%.in.2009,.while.the. geographic.coverage.rate.improved.from.60%.to. 87%.during.the.same.period..Nevertheless,.this. average.masks.variable.project.performance;. the.therapeutic.coverage.target.of.65%.was.only. attained.by.5.projects.in.2008.and.by.7.projects. in.200913.with.a.few.well-performing.projects. having.increased.the.overall.averages..It.is. reported.that.in.many.projects,.treatment.does. not.continuously.cover.the.same.communities:. different.areas.or.zones.may.be.covered.in. different.years..The.35%.eligible.population.not. covered.was.attributed.to.absences.-.particularly. people.away.in.mines.–.and.to.refusals.due. to.fear.of.secondary.effects.or.illness/alcohol. consumption.or.some.religious.beliefs. 35. Co-endemicity.with.loaisis.continues.to.slow. progress.in.covering.all.districts..In.2008. there.were.105.SAEs.and.6.deaths.and.137. SAEs.and.12.deaths.in.2009..Training.in.the. management.of.SAEs.has.been.conducted.but. treatment.has.still.not.yet.begun.in.some.zones. with.co-endemicity. 36. While.the.coverage.figures.are.encouraging,. general.concerns.were.expressed.about.levels. of.monitoring,.evaluation,.data-collection. and.supervision..Members.of.the.National. Onchocerchiasis.Task.Force.(NOTF).only.visited. 3.projects.in.2008.and.recognise.the.need. to.increase.supervision.levels..Likewise.they. expressed.concern.that.APOC.has.only.organised. sustainability.evaluations.for.6.of.the.20.projects.. Although.it.was.subsequently.explained.that. these.were.prevented.by.safety.reasons.2003- 2007,.security.has.since.greatly.improved.in. many.areas..The.situation.of.of.projects.with. delayed.sustainability.evaluations.should.now. be.reviewed.and.the.evaluations.undertaken. where.feasible..Data.collection.at.the.community. level.is.a.worrying.issue.with.large.numbers. of.missing.reports.(14,361.villages).and.some. villages.in.one.project.were.considering.refusing. to.send.data..Project.reports.are.routinely. criticised.by.the.APOC.Technical.Consultative. Committee.for.gaps.in.data,.internal. inconsistencies.and.inadequate.explanations. 12. NHDP 13. APOC.Summary.Data a d d En d u m : c o u n tr y c a sE s tu d iE s — E x tE r n a l m id -t Er m E v a lu a ti o n r Ep o r t 60 37. Communications.about.budgeting.and.financial. matters.have.been.problematic.between.APOC. and.many.projects;.on.one.hand.the.projects. are.convinced.their.submitted.budgets.are. realistic,.if.not.conservative,.on.the.other. hand.APOC.is.reducing.the.proposed.budgets. without.explanations.thus.obliging.projects.to. cut.activities.and.re-plan..The.effects.of.reduced. budget.allocations.should.be.accurately.assessed. so.that.budgets.sent.are.easier.to.defend. 38. Logistics The.logistics.of.Ivermectin. procurement.and.supply.to.frontline. health.facilities.present.several.challenges,. including.complex.customs.clearance.and.tax. exoneration.procedures..The.WHO.network.of. sub-bureaus.is.used.for.delivering.Ivermectin. supplies.to.the.provincial.level.because.of. the.poorly.performing.local.clearance.and. transport.systems;.it.is.expensive.as.Ivermectin. supplies.have.to.travel.by.air.to.the.provinces.. Many.shortages.in.supply.were.reported.in. 2009,.but.the.reasons.were.unclear.as.no. one.actually.analyses.these.supply.chain. difficulties;.it.is.likely.that.poor.planning.skills. will.have.played.a.role. 39. The.lack.of.reliable.banks.in.some.project. areas.has.led.to.APOC.funds.being.sent. directly.to.projects.via.the.WHO.sub- bureaus.in.line.with.the.requirements.of. the.GSM.mechanism.and.the.necessity.for. accountability..This.presents.a.challenge.for. future.project.integration.as.this.routing.is.not. aligned.with.current.national.processes.nor. with.the.new.decentralised.structure.whereby. funding.will.flow.to.the.Provincial.Ministries. for.disbursement.to.projects. sankuru project succeeding despite the challenges 40. The.evaluation.team.visited.the.Sankuru Project.in.Kasai.oriental.province..Despite. the.issues.experienced.in.other.projects.in. DRC,.this.project.shows.that.a.high.level. of.performance.can.be.achieved.despite.the. challenges.of.a.broken.health.system..This.is. largely.attributed.to.the.skills.and.motivation. of.the.personnel.involved..The.Coordinator. originates.from.the.region.and.has.a.Masters. in.Public.Health.(funded.by.APOC);.his. leadership,.the.commitment.of.the.health. staff.in.the.project.area.and.the.engagment.of. communities.has.all.led.to.this.success. 41. Sankuru.Project.is.one.of.only.two.to.have. consistently.achieved.coverage.targets.for.the. last.three.years.and.to.have.reached.the.80%. therapeutic.coverage.rate.and.100%.geographic. coverage.required.for.moving.to.elimination.. Two.health.zones.have.foci.of.co-endemicity. with.a.very.low.prevalence.of.Loaisis;.there. were.concerns.with.SAEs.when.treatment.first. started.but.none.have.occurred.recently.as. they.are.proceeding.carefully;.some.remote. communities.(difficult.to.reach.without.a.boat). have.not.yet.reached.targeted.coverage.rates. 42. The.CDTI.approach.is.generally.working.well. in.Sankuru.although.there.is.scope.for.further. improvement..The.communities.are.aware. of.Ivermectin.and.recognise.the.benefits.of. taking.it.for.their.skin.and.eyesight..However,. persistent.fear.of.“minor”.secondary.effects. such.as.swelling.and.aches.is.still.leading.to. repeat.refusals.of.Ivermectin.treatment..The. CDDs.encountered.by.the.evaluation.team.had. clearly.not.got.the.knowledge.or.confidence. needed.for.counteracting.these.fears..The. communities.visited.requested.medicines.for. counteracting.the.secondary.effects;.these. were.provided.when.distribution.first.started. and.it.was.not.clear.if.they.are.still.meant. to.be.provided..There.is.suspicion.amongst. the.communities.that.drugs.provided.for.the. management.of.side.effects.are.used.for.other. purposes. 43. To.address.these.issues,.the.project.has. developed.some.IEC.materials.but.long. awaited.image.books.being.developed.by.the. NOCP.have.still.not.materialised.and.there. was.clearly.a.need.for.more..Increased.training. and.awareness-raising.are.required.but.budgets. and.materials.for.current.HSAM.activities.are. already.insufficient. 44. The.gender.ratio.amongst.CDDs.is.currently. 3M:.1F..The.project.trains.2-3.times.the. number.of.CDDs.that.it.requires.because. of.the.high.dropout.rate;.many.people.are. said.to.volunteer.thinking.that.they.will. eventually.receive.incentives.of.some.kind.. a d d En d u m : c o u n tr y c a sE s tu d iE s — E x tE r n a l m id -t Er m E v a lu a ti o n r Ep o r t 61 Other.programmes.calling.on.community. volunteers.(community.relays.and/or.the. CDDs).give.varying.levels.of.incentives.to. individuals.and.also.give.support.for.meetings. of.community.structures.for.planning. monitoring.and.evaluation..There.were.varying. levels.of.community.support.for.the.CDDs,. some.were.not.getting.anything.as.it.had.not. been.understood.they.were.not.receiving.any. external.incentives. 45. Project.staff.recognised.that.Community.Self- Monitoring.is.a.useful.tool.that.could.be.used. independently.and.also.by.DMOs;.it.was.not. being.used.because.it.is.found.a.cumbersome. process.and.there.are.no.resources.for. supporting.the.community.meetings..It.is. worth.noting.that.CSM.was.perceived.more.as. a.tool.for.health.staff.than.a.tool.for.community. empowerment..The.evaluation.team.question. whether.some.difficulties.stem.from.the.need. to.form.a.group.in.the.community.whose.role. may.involve.criticising.their.peers.and.the. health.personnel.they.work.with..The.role.of. health.personnel.in.this.needs.examining.as.it. may.be.preferable.for.an.existing.group.or.CSO. in.the.community.to.undertake.this. 46. Project.data.was.being.collected.and.collated. and.the.project.has.been.praised.by.the.TCC. for.the.quality.of.its.reports..Health.data.was. being.collated.and.publicly.displayed.at.the. offices.visited.by.the.evaluation.team.but. it.was.not.being.analysed.and.utilised.for. decision-making.purposes. 47. Problems.experienced.with.organising. Ivermectin.supply,.data-collection.and. reporting.difficulties.reported.elsewhere.were. not.affecting.Sankuru.Project..The.Coordinator. explained.that.if.one.understands.the.system. and.plans.well.in.advance.the.system.can.be. made.to.work. 48. The.Project.staff.and.health.staff.were.aware.of. their.coverage.levels.and.of.APOC’s.refocusing. on.elimination but.they.were.not.actively. integrating.elimination.in.their.objectives.. They.thought.that.elimination.would.be. feasible.but.would.require.a.doubling.of. investment.in.HSAM,.with.the.provision.of. materials,.further.assistance.with.transport. and.some.incentives.for.both.CDDs.and. community-monitoring.(as.this.is.what.other. programmes.do)..Issues.and.queries.were. raised.regarding.elimination:.how.long.will. 80%.therapeutic.coverage.rate.be.required. if.65%.has.previously.maintained.for.a. while.–.when.is.the.start.point?.What.are. the.implications.for.elimination.strategies.of. children.aged.2.with.lots.of.nodules.who.have. not.yet.reached.treatment.age? co-implementation and integration 49. The.concept.of.co-implementation.is.already. widely.accepted.as.logical.both.by.district. health.staff.and.by.communities.and.has. been.happening.for.some.time..In.2005,. pilots.were.conducted.combining.Ivermectin. distribution.with.Vitamin.A.and.Mebendazole;. these.were.supported.by.APOC.and.involved. other.government.and.NGDO.partners..These. have.been.followed.by.APOC.agreement. with.NOCP.to.support.co-implementation.of. Vitamin.A.+.Mebendazole.in.three.projects.. According.to.the.NOTF.reports,.this.worked. well.the.first.year,.but.numbers.of.people. treated.have.reduced.owing.to.difficulty.in. coordinating.supplies;.Vitamin.A.distribution. did.not.take.place.in.2008.due.to.lack.of. funding.and.difficulties.were.experienced.in. ordering.Albendazole.until.LF.mapping.has. been.completed. 50. Co-implementation.is.already.happening. with.other.interventions.such.as.vaccinations,. distribution.of.Vitamin.A,.Mebendazole. and.bednets.during.national.Mother.and. Child.Health.and.Nutrition.week..For.health. personnel,.Vitamin.A.and.de-worming.were. obvious.interventions.for.co-implementation,. while.for.the.communities,.malaria.was.the.key. priority..Health.personnel.at.central.and.district. levels.are.clearly.aware.of.the.Ministry.of.Health’s. key.policy.of.integration.and.are.anticipating. further.changes.in.their.ways.of.working. 51. The.2008.National.Policy.for.Neglected. Diseases.and.the.draft.Strategic.Plan.2011- 2015.for.integrated.control.of.NTDs.have. adopted.the.CDI.as.the.strategy.for.tackling. onchocerciasis,.LF,.schisto.and.STHs..A.clear. distinction.is.made.between.this.group.of. a d d En d u m : c o u n tr y c a sE s tu d iE s — E x tE r n a l m id -t Er m E v a lu a ti o n r Ep o r t 62 NTDs.controlled.by.integrated.preventive. chemotherapy.and.the.remainder.which.are. controlled.by.appropriate.case.management.. The.draft.plan.aims.to.establish.the.endemicity. of.NTDs,.reduce.morbidity.and.mortality. linked.with.NTDs.and;.by.2014,.eliminate. Leprosy.in.all.health.areas..The.total.budget. for.5.years.is.estimated.at.US$.9,205,630.with. APOC.as.the.largest.funder.and.expected.to. contribute.46%.of.the.total.budget..In.2009,. a.Ministerial.order.created.the.NTDs.control. coordinating.mechanism.for.organizing.the. integration.of.the.control.activities.between. the.existing.national.programmes.to.combat. NTDs.such.as.Oncho,.LF,.Schisto.and.STHs.. It.is.unclear.how.the.new.integrated.structure. will.be.achieved:.the.current.range.of.vertical. programmes,.each.with.their.own.interests. and.ways.of.working,.is.hindering.joined.up. working..It.clearly.has.implications.for.the. future.roles.of.the.NOTF.and.NOCP.staff,.but. their.views.on.this.aspect.of.the.plan.were. not.clear. 52. The.key.challenge.for.progressing.with.co- implementation.of.NTDs.is.the.completion. of.mapping.the.other.NTDs..Stakeholders. at.national.and.district.levels.agreed.that.the. quickest.way.to.kick.start.the.integrated.NTD. control.program.would.be.to.train.the.Oncho. teams.to.complete.the.NTD.mapping.(for. LF.+.STHs.+.Schisto).drawing.on.APOC.for. support.with.the.survey.protocols;.preventive. chemotherapy.could.then.be.implemented. building.on.the.Oncho.control.infrastructure.. Acknowledged.challenges.for.successful. co-implementation.are.the.integration.of. planning,.monitoring.and.evaluation.processes. at.all.levels,.the.coordination.of.drugs.supply. and.the.provision.of.training.in.all.diseases.to. the.supervisors.and,.motivation.of.health.staff. capacity-building 53. The.emphasis.of.APOC’s.capacity.building. support.continues.at.community.level;.large. numbers.of.new.CDDs.and.existing.CDDs. and.health.assistants.are.trained.and.retrained. each.year..An.extensive.range.of.training. has.been.provided.for.both.project.staff.and. NOTF.secretariat.in.programme.management,. management.of.SAEs,.CSM,.data.collection,. analysis.and.report-writing,.operational. research,.advocacy.and.M&E..Capacity. development.at.the.national.level.is.critical. for.ensuring.adequate.availability.of.HSAM. materials,.appropriate.advocacy.to.decision- makers.and.donors,.and.timely.Ivermectin. ordering..Despite.this,.the.NOTF.identified.a. continuing.need.for.training.in.a.wide.range. of.topics.at.district,.provincial.and.national. levels;.this.included.new.areas.such.training. in.fulfilling.their.new.mandates.and.advocacy.. At.district.level,.high.staff.turnover.rates. require.the.continuation.of.training.in.essential. routine.topics.such.as.supply.management,. accountability.and.financial.reporting. 54. In.addition.to.the.expressed.needs,.the.health. dialogue.structures.at.all.levels.will.need. strengthening.so.that.they.understand.not.only. their.own.role.and.responsibilities.but.those.of. associated.structures;.this.will.promote.good. governance,.leadership.and.accountability..At. all.levels,.there.is.a.major.need.for.improved. internal.communications.and.HSAM. conveying.clear.and.simple.messages.and.to. avoid.misunderstandings.and.confusion. 55. The.2.APOC.Technical.Advisors.(TAs).have. clearly.made.a.valuable.contribution.but. the.NOCP.and.NOTF.expressed.discontent. that.they.are.doing.routine.work.rather.than. providing.expert.advice.and.evaluation.skills;. the.TAs.are.thought.to.be.undermining.national. leadership..It.was.suggested.that.they.should. be.located.in.the.NOCP.office.so.that.NOCP. staff.can.benefit.from.more.frequent.interface. and.the.resources.attached.to.the.post. conclusions and ongoing challenges 56. Levels.of.community.ownership.are.variable:. in.some.communities,.members.were.more. involved.and.playing.a.larger.role,.while. in.others,.CDTI.had.more.guidance.and. ownership.from.the.health.system..Low.levels.of. community.support.were.generally.attributable. to.poor.communication.of.the.fact.that.CDDs. do.not.receive.external.incentives.and.that. these.are.for.the.community.to.provide..The. incentives.given.by.other.programmes.add. to.the.impression.that.incentives.may.exist. somewhere.in.the.system.and.also.lead.to. a d d En d u m : c o u n tr y c a sE s tu d iE s — E x tE r n a l m id -t Er m E v a lu a ti o n r Ep o r t 63 expectations.of.support.when.participating.in. activities.such.as.CSM.meetings. 57. There.are.clear.resourcing.implications.for. improving.coverage.rates,.(especially.for. reducing.fear.of.secondary.effects).and.for. moving.to.elimination.and.co-implementation.. In.particular,.HSAM.will.need.considerable. strengthening;.if.the.budget.requires.doubling. in.a.project.such.as.Sankuru,.the.needs.will.be. much.greater.in.other.projects..It.will.also.be. important.to.build.capacity.in.analysis.and.the. use.of.data.for.decision-making 58. There.is.a.clear.commitment.to.integrated. programming.for.NTDs.but.there.are.a. number.of.key.steps.required:.formal. adoption.of.the.NTDs.strategic.plan,. restructuring.at.national.level.and.the. completion.of.mapping.processes.for.NTDs.. It.will.be.useful.for.APOC.to.support.the. mapping.since,.until.this.happens,.it.will.be. difficult.for.additional.donor.funding.to.be. mobilised.for.NTDs.-.and.this.may.leave.the. oncho.programme.bearing.the.weight.of.the. other.NTDs..The.quickest.way.would.be.for. NTDs.to.‘piggy-back’.on.CDTI,.especially.for. the.mapping;.this.could.be.quickly.completed. if.training.is.given.to.project.staff. 59. Despite.reassurances.to.the.contrary,.the. consistent.absence.of.a.high-level.DRC. representative.at.the.JAF.meeting.and. the.continued.vacancy.of.the.position.of. NOCP.coordinator,.both.point.to.a.lack.of. engagement.and.ownership..With.the.current. infrastructure.and.ongoing.decentralisation. process,.the.transition.to.national.ownership. in.DRC.is.likely.to.take.some.time.in.order. to.clarify.roles.and.responsibilities.within. the.decentralised.structures,.to.appoint. competent.and.skilled.personnel,.to.improve. resource.mobilisation,.to.reconstruct.a. reliable.drugs.supply.and.management. chain.and.to.rebuild.a.trustworthy.financial. infrastructure. case study: Brief on onchocerciasis control in ghana Background 60. The.Onchocerciasis.Control.Program.(OCP). was.created.in.1974.with.a.mandate.to. eliminate.onchocerciasis.in.7.countries.in.the. Volta.River.Basin.–.Benin,.Burkina.Faso,.Cote. d’Ivoire,.Ghana,.Mali,.Niger.and.Togo..The. main.intervention.then.was.aerial.larviciding.. The.program.was.extended.to.southern.Ghana. in.1988.when.O. Volvulus.was.discovered. in.those.areas..By.1995,.vermectin.was. considered.efficacious.and.was.made.freely. available.to.countries..OCP.started.transferring. the.responsibility.of.residual.control. and.surveillance.to.national.authorities.. Coordination.of.the.control.program.was.then. placed.within.the.Ministry.of.Finance.with. technical.implementation.provided.by.the. Ministry.of.Health. 61. The.Onchocerciasis.Control.Programme.(OCP). effectively.controlled.the.disease.in.Ghana. for.26.years..The.activity.of.OCP.completely. ceased.by.the.end.of.the.year.2002.and.was. later.replaced.by.the.Special.Intervention. Zones.(SIZ).Programme.which.ran.from.2002. to.2007. 62. Ghana.did.not.fall.within.the.APOC.program. framework.and.had.government.take.over.the. program..However,.there.were.four.countries. classified.as.Special.Intervention.Zones.(SIZ). where.the.entomo-epidemiological.situation. has.on.the.whole.remained.unsatisfactory.. Ghana’s.Special.Interventions.Zone.areas. included.the.Pru.river.basin.covering.a. population.of.85000.population,.a.prevalence. of.7.8%.and.CMFL.of.almost.0mf/skin.snip. in.2001..However,.the.Oti.river.basin,.and.its. a d d En d u m : c o u n tr y c a sE s tu d iE s — E x tE r n a l m id -t Er m E v a lu a ti o n r Ep o r t 64 tributaries.in.Togo.covering.a.population.of. 185,000,.a.prevalence.of.21.7%.and.CMFL.of. 0.90.mf/skin.snip.in.2001,.and.other.known. onchocerciasis.endemic.areas,.continued. to.receive.annual.treatments.under.the. program..Since.the.devolution.of.the.former. Onchocerciasis.Control.Program.(OCP).and.the. inception.of.the.SIZ.Program,.the.country.has. focused.its.package.of.interventions.in.areas. identified.as.Ochocerciasis.transmission.hot. zones..These.are.mainly.in.the.Pra,.Pru,.Black. Volta,.the.Oti.and.Asukawkaw.river.basins. Burden of disease 63. Current.standard.prevalence.rate.for.O. volvulus. in.the.93.sentinel.sites.is.above.5%..Crude. prevalence.rate.ranged.between.0.–.55%.. So.far,.O. volvulus.is.the.only.parasite.found. in.Ghana..The.highest.focus.of.infection.is. observed.in.the.Bui-Black.Volta.basin.where. 66.7%.of.communities.surveyed.in.2008. had.prevalence.of.over.5%.with.indication.of. an.increasing.trend.since.1997.while.that.of. areas.such.as.the.Pru.river.basin.are.showing. a.declining.trend..The.trends.in.microfilarial. infectivity.rates.from.the.Bui-Black.Volta.river. basins.and.the.Pru.river.basins.are.shown.in. figure C.below. 64. Results.from.on-site.black.fly.dissection.from. the.Bui-Black.Volta,.Tain.and.Densu.river. basins.in.2007.show.a.monthly.biting.rate. of.27..In.all.29.L3.larval.forms.were.found. thereby.confirming.infectivity.of.black.flies. in.the.river.basins..The.focus.of.activities.in. the.Tain.district.was.as.result.of.the.decision. to.make.the.entomological.study.part.of. the.health.impact.assessment.following. government’s.desire.to.construct.a.hydro- electric.dam.on.the.Black.Volta.River. package of interventions 65. Surveillance:.Surveillance.activities.are.based. on.annual.longitudinal.tracking.of.control. activities.both.to.monitor.recrudescence.in. the.black.fly.and.the.impact.of.Ivermectin. administration.within.human.populations..Fly. capture.for.DNA.pool.screening.at.the.MSDC. and.on-site.blackfly.dissection.are.part.of.the. program. 66. Recent.trends.show.a.downward.trend.in. communities.participating.in.skin.snipping. processes.with.an.overall.participatory.rate.of. 56.5%.compared.to.above.70%.in.year.leading. to.2006..The.reasons.have.been.attributed. to.repeat.sampling.of.subjects.in.same. communities,.the.discomfort.associated.with. repeated.snips.and.reversed.benefits.of.high. awareness.of.HIV.infection.control.measures.. It.has.also.been.observed.that.macrofilaricide. field.trials.by.research.institutions.without. coordination.and.synchronization.with. existing.programs.have.increased.oncho. related.activities.resulting.in.community. fatigue.in.involvement.with.the.program. 60 50 40 30 20 10 0 1987 1994 1997 2001 2007 % C ov er ag e 100 80 60 40 20 90 70 50 30 10 0 1987 1989 1991 1994 1997 20071988 1990 1992 2004 % P re va le nc e Baour Akura Bui Dam Site Agbelekame Asubende Fawomang Hiampe Bui-Black Volta Basin, 1987–2007 Pru river basin, 1987–2007 Source: Ghana Health Service Annual report of the Ghana Onchocerciasis Control Program 2008 figure c: Trends of Oncho prevalence in Bui-Black Volta and Pru river basins a d d En d u m : c o u n tr y c a sE s tu d iE s — E x tE r n a l m id -t Er m E v a lu a ti o n r Ep o r t 65 67. Treatment:.Ivermectin.remains.the.principal. drug.of.use.under.the.oncho.control. program.in.Ghana..The.delivery.approach. remains.Community.Directed.Treatment. with.Ivermectin.(CDTI)..Treatment.coverage. averaged.72%.nationally.though.there.are. variations.in.coverage.from.one.district.to.the. other..Observations.of.CDDs’.registers.showed. some.gaps.in.treatment.data.which.suggested. a.declining.treatment.uptake..However,.overall. there.has.been.a.marked.improvement.both. geographic.and.therapeutic.coverage.for. the.Ghana.National.Onchocerciasis.Control. Program.since.2006.to.date.(table F). 68. Community mobilization:.Intensive. community.mobilization.and.education. sessions.are.part.of.the.intervention.strategy. in.endemic.communities..It.includes.census- taking.as.part.of.updating.community.registers. and.public.sensitization..The.focus.of.activities. was.on.community.meetings.and.durbars. where.the.cooperation.and.participation.of. individuals.for.a.successful.treatment.campaign. were.solicited..The.regions.also.conducted. media.briefings.and.radio.discussion,.especially. in.areas.endowed.with.radio.facilities.. Traditional.communication.channels.such.as. gong-gong.beating,.roof-top.announcements,. and.church.and.mosque.announcements.were. also.employed..Although.there.were.periods. of.political.activities.that.affected.community. focus,.these.sensitization.activities.continued. 69. Other.community.based.interventions.include. (i).conducting.extensive.mapping.of.all. satellite.communities,.farm.huts.and.fishing. village;.(ii).establishment.of.systems.to.capture. migrant.farmers,.nomads,.sand.winners,. traders,.etc.during.the.period.of.Ivermectin. treatment;.and.(iii).encouraging.communities. to.nominate.their.own.representative.for. training.as.CDDs. 70. Human resource:.The.Oncho.control.program. can.be.said.to.have.developed.a.network.of. health.practitioners.without.compromising.the. health.system.in.Ghana..There.are.548.staff. trained.on.the.CDTI.Strategy.who.are.part. of.the.Ghana.Health.Service..These.include. District.Directors.of.Health.Services,.Public. Health.Nurses.and.Disease.Control.Officers.. In.addition,.there.are.several.other.community. based.volunteers. 71. Program.management:.The.Onchocerciasis. program.in.Ghana.is.currently.managed.by. a.Program.manager.in.charge.of.Neglected. Tropical.Diseases.in.Ghana..He.is.assisted. by.three.technical.officers.housed.in.a.single. office. co-implementation with other programs in ghana 72. Though.not.a.perfect.act.for.several.reasons,. the.National.Onchocerciasis.Control.Program. has.attempted.a.number.of.co-implementation. activities;.this.has.generally.been.judged.to.be. the.ideal.way.for.the.future..There.have.been. joint.programs.around.community-directed. mass.drug.administration.that.have.included. lymphatic.filariasis,.schistosomiasis.and. vitamin.A.distribution..In.2007,.the.Neglected. Tropical.Diseases.Control.Program.took. delivery.of.over.25.5.million.Ivermectin.tablets. and.over.8.million.tablets.of.Albendazole.for. distribution.to.endemic.regions.of.the.country.. These.drugs.were.targeted.at.treating.at.risk. populations.for.both.Lymphatic.Filariasis.and. Onchocerciasis.including.areas.that.are.co- endemic.for.both.diseases..It.has.been.found. that.using.this.approach.has.brought.about. synergies.in.supporting.resource.constrained. programs..A.preliminary.assessment.indicates. that.community.drug.distributors.who.were. trained.under.the.Oncho.program.can.be. Table F: CDTI data for Ghana National Onchocerciasis Control Program since 2006 year treatments coverage (%) persons communities therapeutic Geographic 2006 1,269,341 1,963 65.4 88.9 2007 1,544,155 1,851 72.8 82.8 2008 1,835,162 3,244 71.8 97.9 2009 (1st round) 544,959 1,280 75.8 93.7 a d d En d u m : c o u n tr y c a sE s tu d iE s — E x tE r n a l m id -t Er m E v a lu a ti o n r Ep o r t 66 and.are.already.involved.in.other.health.and. development.activities.(distribution.of.vitamin. A,.malaria.treatment,.polio.immunization,. guinea.worm.eradication,.nutrition,.and.water. protection),.and.serving.as.community.health. workers. What has worked well? 73. In.the.project.areas.disease.surveillance.was. undertaken.through.a.multiple.layer.approach:. (i).recruiting.staff.with.recognized.public. health.qualifications.as.team.leaders.for.the. district;.(ii).sensitizing.community.leaders. across.the.social.profile.of.the.community. and.the.geographical.target.area.to.identify. the.disease.and.the.vectors.and.report.these;. (iii).train.community.volunteers.on.basic.case. observation.and.recording.based.on.a.standard. format.that.is.easily.memorized. 74. The.Onchocerciasis.control.program.clearly. blazed.the.trail.for.community.directed. treatment.and.CDD..Inter-sector.collaboration. with.Agricultural.Extension.Officers,. Educationists.(teachers).and.the.District. Assemblies.generated.partnerships.that.assisted. in.providing.opportunities.for.mapping.;. breaking.group.specific.socio-economic. barriers.requiring.social.sensitive.strategies;. providing.population.specific.information.and. developing.adequately.“gendered”.approaches. to.meet.special.needs.of.the.community... There.is.a.clear.demonstration.that.with. the.appropriate.incentives,.it.is.possible.to. maintain.CDD.for.long.periods.of.time.(see. box A)..Admittedly,.there.has.been.attrition. albeit.not.significant.in.CDDs.on.the.program. currently. 75. The.regular.consultations.with.representatives. from.the.communities.allowed.the.program. to.benefit.from.cultural.compatibility,.ensure. social.mobilization.and.cooperation,.local. involvement.and.awareness.generation,. information.collection.in.coordination.with. health.system.staff.and.community.based. monitoring.and.evaluation..Rumor.registers. were.maintained.as.part.of.a.legitimate.source. of.possible.disease.up-break.or.escalation. 76. A.study.initiative.with.APOC.found.that. awareness.of.Oncho.and.the.‘white.tablets’.was. very.high;.there.was.integration.of.CDTI.with. other.programmes.such.as.vitamin.A,.guinea. worm,.NID/EPI,.malaria.and.TB.and.a.general. willingness.of.many.communities.to.continue. with.Ivermectin.treatment What has not worked well? 77. Surveillance.activities.were.temporarily.halted. in.2008.mainly.because.the.Multi-Disease. Surveillance.Centre.stopped.collecting. black.flies.for.analysis.for.almost.two.years.. Specialist.skills.such.as.epidemiologists.were. not.readily.available..As.a.result,.the.amount. of.data.generated.from.the.93.sentinel.sites.in. 2007.was.not.being.adequately.analyzed.to. inform.strategic.planning..Antecedent.to.this. were.the.frustrations.that.while.new.Oncho. foci.were.being.discovered,.it.was.unlikely.that. the.program.will.extend.its.reach.to.address. the.situation.creating.a.level.of.disillusion. among.project.officers. 78. Sporadic.resource.availability.has.become.a. major.issue..Under.the.then.OCP.program,. the.Black.Volta.basin.was.adequately. resourced.until.the.program.was.passed.on. to.the.Ghana.government.in.December.2002.. Box A: CDD as Oncho worker Mr Ansah is a farmer and catechist and currently the only CDD in the community after the transfer of another CDD who was a teacher. He is clearly committed to the community and has been working as a health volunteer for 18 years and CDD for 10 years. The community leaders find him very devoted and cooperative and use him for all such initiatives. Oncho was the first program he has been involved with for drug distribution. He has since added on the distribution of drugs for Lymphatic Filariasis, polio and bed nets. Mr Ansah notes that the community is happy with the treatment and would report any adverse reactions to him. He says he has a good relationship with the local health personnel and he works with Traditional Birth Attendants and child welfare clinics. He is not paid an allowance but is excused from communal labour duties because of his contribution as a CDD. a d d En d u m : c o u n tr y c a sE s tu d iE s — E x tE r n a l m id -t Er m E v a lu a ti o n r Ep o r t 67 Between.2002.and.2005.the.Bui-Black.Volta. Basin.had.experienced.gaps.in.Ivermectin. distribution..When.treatment.resumed. in.2005.supply.remained.sporadic.with. persisting.drug.shortage.and.poor.supervision.. Across.the.endemic.areas,.the.preparation. of.measuring.poles.over.the.period.is.no. longer.standardized.across.the.endemic. region..As.funds.become.limited,.District. Managers.willing.to.continue.the.programs. have.attempted.to.replace.or.introduce.new. poles.without.the.proper.guidance.and. standardization.information. 79. .Osei.and.others.published.an.article.in. the.Lancet.that.suggested.the.possibility.of. resistance.emerging.in.the.adult.Onchocerca volvulus.female.worms.as.a.result.of.rapid. population.of.microfilaria.in.some.subjects. in.20.study.communities.in.Ghana..Their. publication.suggested.that.the.repopulation. was.the.failure.of.Ivermectin.to.suppress. release.of.intra-uterine.microfilaria.by.the. adult.worm..Fortunately,.the.publication. concluded.the.Ivermectin.is.still.effective. against.the.microfilaria..This.evidence.and. other.hypotheses.as.espoused.in.box B.have. precursor.triggers.for.probable.cause.and. consequence.emanating.from.the.systemic. failures. 80. Community.members.absent.during. ivermectin.distribution.days.do.not.appear. to.have.opportunities.to.receive.the.drug.on. other.days..Concerns.have.been.raised.about. requirements.for.unused.drugs.during.the. distribution.window.period.to.be.returned. rather.than.retained.for.those.who.missed. coverage..Planning.for.distribution.has.not. taken.into.consideration.issues.of.students. going.away.to.boarding.schools.leading.to. several.missed.treatments.for.consecutive. years. 81. There.was.enough.evidence.from.the. field.visit.to.suggest.that.community.drug. distributors.were.willing.to.continue.with. the.service.the.inadequate.and.late.arrival. of.drugs,.short.duration.of.treatment.and. inadequate.social.support.as.key.challenges. confronting.them. 82. The.evaluation.team.also.noted.the.following. challenges.that.militate.against.the.Ghana. Oncho.control.programme:.(i).bad.roads. linking.communities.to.hamlets;.(ii).need.for. improved.incentives.for.CDDs;.(iii).migration. of.settler.farmers.to.more.fertile.and.oncho. free.areas;.(iv).difficulty.in.planning.treatment. periods.as.these.are.dictated.by.availability.of. funds.and.logistics;.(v).inadequate.integration. of.Oncho.program.in.main.health.sector. planning.and.budgetary.framework.(vi).biting. nuisance.of.the.black.flies.in.certain.river. basins.especially.within.the.Black.Volta.Basin. some systemic observations causing neglect of disease Program management 83. The.Onchocerciasis.program.because.of.its. historical.development.as.a.vertical.program,. though.transferred.to.government.has.still. not.been.integrated.in.the.true.sense.into. main.stream.health.sector.management.. Responsibilities.have.not.been.fully.transferred. to.Regional.and.District.Directors..Though. a.National.Onchocerciasis.Control.Program. office.exists,.there.is.no.program.emphasis.for. control.leading.to.elimination.in.the.priority. activities. 84. Political.and.health.sector.leadership. commitment.towards.the.disease.appears.to. have.waned.considerably..None.of.the.aide. memoires.signed.between.the.government. Box B: Hypothetical evidence on resistance The persistent significant microfiladerma (PSM) could be attributable to the non-response of the adult female worms to ivermectin with the possibility of resistance emerging naturally in these adult female worms (Awadzi and others 2004; Osei-Atweneboana and others 2007) The observations of resistance could be related to the issues of geographical treatment coverage, therapeutic coverage and compliance to the treatment (Hotez 2007) a d d En d u m : c o u n tr y c a sE s tu d iE s — E x tE r n a l m id -t Er m E v a lu a ti o n r Ep o r t 68 and.health.development.partners.since.1997. mentioned.Onchocerciasis.as.a.program.of. public.health.significance..The.disease.was. mentioned.only.once.in.the.annual.review. program.and.this.was.in.2000..It.however. did.not.feature.in.the.subsequent.programs.of. work.developed..Another.disease.that.suffers.a. similar.fate.is.schistosomiasis. 85. It.should.come.as.no.surprise.to.find.that. the.only.program.the.oncho.program.has. had.continuing.tagging.to.is.Lymphatic. Filariasis..In.Ghana,.the.Lymphatic.Filariasis. Elimination.Programme.was.merged.with.the. Onchocerciasis.Control.Program.in.2004..An. observation.made.is.that.Lymphatic.Filariasis. and.Guinea.worm.have.suffered.similar.levels. of.neglect.and.only.gain.import.under.project. approaches..Each.of.these.have.different. program.managers.and.the.level.of.resource. mobilized.is.entirely.dependent.on.the. individual.program.manager’s.ability.to.attract. particular.donor.interest..Co-implementation. even.among.these.programs.has.remained. difficult.because.the.varying.levels.of. availability.of.inputs. Program financing 86. Financing.of.the.program.is.inadequate.and. cannot.sustain.the.level.of.interventions. required.to.control.the.diseases..The.table. below.shows.the.amount.of.money.available.to. the.program.in.2007. 87. Compared.to.total.government.allocation.to. the.affected.regions,.the.level.of.financing.may. be.considered.significant.in.proportion.to.total. government.non-wage.recurrent.expenditure. for.a.single.disease..Approximately.97%.of.all. government.resources.in.2007.was.spent.on. personnel.emoluments..The.sector.is.therefore. heavily.reliant.on.external.aid.for.non-wage. recurrent.expenditure. 88. Country-based.donor.financing.of. onchocerciasis.has.not.fared.any.better.after. the.OCP.years.for.two.reasons..First,.the. sector-wide.approach.provided.a.platform.for. negotiating.priorities.that.could.be.funded. through.the.main.‘common.basket’.financing. arrangement..For.a.program.to.count.as. priority,.it.must.have.strong.advocates.or. Program.Managers.with.Directors.of.Public. Health.that.see.it.as.priority..This.level.of. top.level.champions.was.observed.to.be. generally.weak.over.the.years..Recent.reviews. show.that.with.the.advent.of.Sector Budget Support (SBS).and.Multi-donor Budget Support.(MDBS).Ghana.now.has.health. sector.financing.arrangement.that.may.now.be. termed.a.‘fragmented sector-wide approach’.. The.actual.dialogue.has.moved.out.of.the. sector.lead.by.the.Ministry.of.Health.while. the.oncho.control.program.sits.in.the.Ghana. Health.Service..Within.SBS,.the.funds.are. already.earmarked.to.the.contributing.partner. preferences.whiles.the.MDBS.has.encouraged. the.choosing.of.less.difficult.or.low.hanging. Table G: Financing of Onchocerciasis 2007 region number of districts (oncho/lf) amount allocated by GoG (Gh¢) contribution by partners (Gh¢) remarks ssi apoc lfsc‡ usaid Eastern 10 (3) 51,220 34,420 - 16,800 - Western 7 (10) 210,109 16,560* - - 193,549 Ashanti 20 33,987 17,200 - 16,787 - Brong Ahafo 11 (2) 53,100 - 39,900 13,200 - Volta 8 16,020 16,020 - - National - 24,027 2,495 8,400 - 13,132 For country-wide monitoring and surveillance activities Total 56 (15) 388,463 86,695 48,300 46,787 206,681 *Tullow oil, sent funds directly through SSI to Western Region, and so, were not part of the GH¢70,135 transferred to the national level. ‡Liverpool LF Support Centre Donated GH¢90,000 for MDA implementation in Ghana a d d En d u m : c o u n tr y c a sE s tu d iE s — E x tE r n a l m id -t Er m E v a lu a ti o n r Ep o r t 69 fruits.as.triggers,.causing.policy.responsible. persons.to.shy.away.from.programs.requiring. sustained.efforts..Onchocerciasis.control.not. featuring.‘loudly’.invariably.falls.through.the. cracks. 89. Experience.from.the.above.points.to.the. probability.that.for.programs.to.receive. adequate.attention.and.be.taken.to.scale,. it.may.be.necessary.to.isolate.them.from. the.comprehensive.and.general.integrated. approach..Programs.such.as.HIV,.TB,. Malaria,.maternal.and.child.health.after. the.collapse.of.the.‘common.basket’.have. now.got.resources.because.there.are.direct. international.and.national.advocacy.to. ensure.that.there.is.financial,.human.and. logistic.resources.available.to.scale.up. these.interventions..This.comes.against.the. backdrop.that.the.benefit.package.covered. under.recently.introduced.National.Health. Insurance.Scheme.in.2004.is.unlikely.to. address.public.health.conditions.whose.onset. lie.in.factors.that.depend.heavily.on.socio- economic.determinants.of.health. 90. District.level.program.implementers.have. raised.concerns.that.the.withdrawal.of. targeted.funding.of.the.oncho.program.will. be.challenging.as.this.will.mean.requesting. the.District.Assemblies.to.fund.the.program. which.will.be.impossible..They.note.that. though.CDDs.are.not.paid,.they.manage.to. keep.part.of.the.oncho.targeted.funds.allocated. for.training.and.give.them.allowances.for.food. when.they.come.for.their.annual.refresher. training. Drug supply and information management 91. Whereas.it.may.be.possible.to.tag.aspects.of. NTD.programs.on.well.resourced.programs. such.as.insecticide.treated.nets,.TB.drug. distribution.and.social.mobilization.programs. associated.with.these.and.HIV,.the.fundamentals. of.drug.availability.and.program.specific. interventions.need.to.be.strong.in.the.first.place. to.ensure.predictable.co-implementation..Given. the.current.level.of.inconsistent.flow.of.program. funds.and.drug.availability,.co-implementation. is.unlikely.to.be.an.effective.strategy. 92. There.is.a.high.level.of.Ivermectin.refusal. rate.in.some.communities.(New Longoro, Kyingakrom and Begbemdo) due.to.previous. experience.with.adverse.drug.reactions..As. noted.earlier,.drug.supply.chain.management. had.suffered.from.inefficiency.and.this.has. translated.into.erratic.Ivermectin.distribution. and.ineffective.management.at.the.community. and.district.level..Hamlets.linked.to.main. communities.are.often.partially.or.not.treated. 93. Health.information.management.capacity. is.noted.as.weak.at.all.levels.of.the.system.. Treatment.records.are.incomplete.at.regional,. district,.sub-district.and.community.levels.. Records.are.poorly.managed;.most.of.them.are. stored.manually.thereby.making.calculating. coverage.for.most.communities.a.problem.. This.problem.is.generally.systemic.because. onchocerciasis.is.not.part.of.routinely.collected. health.sector.information.and.does.not.feature. in.the.core.health.sector.indicator.set.and. managed.data. Communities.visited:.Potrase,.Amanfrom,. Odumase a d d En d u m : c o u n tr y c a sE s tu d iE s — E x tE r n a l m id -t Er m E v a lu a ti o n r Ep o r t 70 Background 94. Cameroon,.often.referred.to.as.“Africa.in. miniature”,.is.located.in.Central.Africa. bordering.the.Gulf.of.Guinea.and.offering. a.very.diverse.landscape.covering.475,650. sq.km.from.the.Northern.savannahs.to.the. Southern.Equatorial.rain.forests..Home.to. almost.19.million.inhabitants.(2005.census). with.a.growth.rate.of.2.87%,.the.average.age. of.its.population.is.22.years.with.almost.46%. aged.-.<15.years,.while.senior.citizens.above. 65.years.account.for.an.estimated.3.2%.. The.urban.population.reached.51%.in.2003. and.life.expectancy.at.birth.was.50.years.in. 2006.14.There.are.more.than.230.tribes.living. in.Cameroon,.clustered.in.five.ethnic.groups:. Sudanese,.Hamits,.Semits,.Bantu.and.Pygmies,. and.more.than.200.national.languages;. French.and.English.are.the.official.languages.. Administratively,.Cameroon.is.divided.in. 10.regions.each.under.the.authority.of.a. Governor,.with.58.divisions.and.355.urban. and.rural.councils. 95. Legislation.to.establish.decentralization.was. voted.in.2004.with.the.aim.of.enhancing. local.government.authorities.in.matters. related.to.health,.education,.sanitation,.and. environment..The.decentralization.process.is. being.implemented.progressively.with.Health. and.Education.as.the.pilot.sectors..The health sector organization in the post structural adjustment era (2001 to the present) is.in.line. with.the.reorientation.of.primary.health.care. framework.and.the.district.health.system. approach..The.prevailing.philosophy.is.the. 14. National.Institute.for.Statistics,.Statistics.Book.2007 Bamako.Initiative.grounded.on.community. participation.and.health.financing.through. user.fees.for.care.(predominantly.out-of- pocket.expenses),.promotion.of.the.use.of. affordable.essential.health.technologies,. community-based.management.of.health. services.through.local.health.boards,.and. strong.partnership.between.the.state.and.other. stakeholders..Health.services.are.organized. in.three.levels:.central:.in.charge.of.design,. coordination,.supervision.and.regulation;. regional:.for.support.and.peripheral:.the. operational.level. 96. A revised health sector strategy15 has.been. adopted.within.a.conceptual.framework. of.primary.healthcare..A.new.2001-2015. strategy.will.be.implemented.under.a.SWAp framework.with.district.development.being. the.main.pillar:.the.objective.is.to.enable. health.districts.to.provide.sustainable,. affordable.high.quality.healthcare.and.health. services..A.viable.district.is.one.that.is. technically,.administratively.and.financially. autonomous..In.practice,.technical.autonomy. means.that.the.district.is.able.to.produce. and.deliver.high.quality.health.care.that.is. responsive.to.staff.and.population.needs.and. expectations..Financial.autonomy.means.that. the.district.is.able.to.cover.costs.generated. through.local.incomes.or.external.support,. while.institutional.autonomy.concerns. the.ability.of.stakeholders.to.manage.the. district.with.everyone.playing.his/her.own. role.fully..Equity.and.social.justice.are.the. grounding.values.of.the.district.development. 15. Ministry.of.Public.Health,.The.revised.health.sector.strategy. 2001-2015 onchocerciasis control in cameroon: illustrating the complexities and challenges of health sector reform processes a d d En d u m : c o u n tr y c a sE s tu d iE s — E x tE r n a l m id -t Er m E v a lu a ti o n r Ep o r t 71 process.and.particular.attention.should.be. paid.to.the.most.vulnerable.populations.. Community.participation.and.the.building. of.sound.partnerships.are.considered.the.key. components.in.reducing.costs. 97. The implementation of this revised strategy is.guided.by.the.values.of.the.Paris.Declaration. on.the.effectiveness.of.development.aid16:. the.Cameroon.Government.has.invited.its. technical.and.financial.partners.to.join.its. efforts.in.a.common.program.under.a.SWAp. framework.led.by.the.Ministry.of.Health.. Planning.and.coordination.mechanisms.are. being.progressively.strengthened:.districts. were.asked.to.conduct.a.situation.analysis. using.the.Systemic.Quality.Improvement.tool. developed.by.GTZ.during.the.year.2007-8.and. to.conduct.participative.development.planning. for.the.period.2009-2012..These.development. plans.have.now.been.revised,.consolidated. and.validated.by.the.Technical.Secretariat. of.the.Steering.committee.in.charge.of.the. follow-up.of.the.Implementation.of.the.Health. Sector.Strategy..A.Medium.Term.Expenditure. Framework.(MTEF).has.been.elaborated..It. is.planned.that.the.decentralization.process. will.be.based.on.Regional.Special.Funds.made. available.to.secure.drugs.and.supplies. 98. The.principle.of.contracting.with.district. health.management.teams.based.on.their. performance.has.been.agreed..Resources.will. be.provided.directly.to.districts.in.line.with. their.validated.plans.of.action.and.non-profit. private.providers.will.also.receive.funds. through.contracts..As.part.of.developing. sustainable.demand,.community.based. health.insurance.schemes.will.be.promoted. in.all.districts,.while.the.Government.and.its. partners.will.pay.for.some.categories.of.users. and.maternal.and.infant.care.and.services. The. sector.is.suffering.from.a.chronic.shortage.of. skilled.human.resources.particularly.in.remote. rural.areas.and.it.is.planned.to.develop.a.range. of.relevant.strategies.for.addressing.this. 99. The.National.Onchocerciasis.Control. Programme (NOCP),.established.in. 16. OECD.(2003).Paris.Declaration.on.Aid.Effectiveness.. http://www.oecd.org/document/18/0,3343, en_2649_3236398_35401554_1_1_1_1,00.html Cameroon.since.1987,.is.one.of.a.dozen. vertical.public.health.programs.operating. nationwide,.including.a.Schisto.and.STH. control.programme..There.are.16.projects:.a. support.project.for.the.NOTF.Secretariat.and. 15.projects.in.almost.all.the.10.regions.and. many.of.their.districts..The.NGDO.coalition. includes.the.following.partners:.Sight.Savers. International,.International.Eye.Foundation,. Carter.Centre,.Helen.Keller.International,.Sight. First.and.Lions.Club.International.Foundation. and.Perspective. Burden of disease 100. More.than.10.million.people.are.at.risk,.c.6. million.are.infected,.approximately.90,000.are. blind.and.more.than.1,500,000.suffer.from. skin.lesions..There.are.10,253 communities. with.a.total.population.of.6,321,398. inhabitants.in.areas.that.are.classified.as.meso. and.hyper-endemic.for.Onchocerciasis..There. are.foci.of.Loaisis.co-endemicity.in.13.out.of. the.15.projects. package of interventions 101. CDTI:.Ivermectin.remains.the.principal. drug.of.use.by.the.Oncho.control.program. although.some.research.testing.Community. Directed.Doxycyclin.Treatment.has.been. undertaken.in.28.co-endemic.communities. in.the.Littoral.1.project..Treatment.coverage. has.been.constantly.improving.and.reached.a. national.average.of.75.9%.[63.3.–.84.6%].in. 2009,.while.the.geographic.coverage.reached. 98.8%.nationally..District.and.Regional.Health. Personnel.are.aware.of.their.coverage.levels. and.the.refocus.on.elimination.-.80%.TCR. target-.and.have.clearly.incorporated.this.into. their.thinking..In.many.projects,.CDTI.is.being. used.in.hypo.endemic.areas.to.satisfy.insistent. community.demands.for.CDTI.made.through. their.health.committees;.coverage.therefore. extends.beyond.transmission.areas. 102. The.CDDs.use.different.delivery.strategies.to. suit.local.needs;.these.include.door-to-door. delivery,.at.schools.and.in.gatherings.at.the. compounds.of.the.traditional.rulers..The. Government.has.committed.itself.to.providing. financial.incentives.to.the.CDDs:.25FCFA. a d d En d u m : c o u n tr y c a sE s tu d iE s — E x tE r n a l m id -t Er m E v a lu a ti o n r Ep o r t 72 ($5cents).per.patient.treated.to.be.paid.the. year.after.the.actual.campaign;.in.practice. the.payments.are.often.delayed.and.this.was. observed.to.be.causing.some.discontent.and. suspicion..This.suspicion.was.in.turn.affecting. collaboration:.in.some.districts,.CDDs.have. refused.to.render.their.registers.for.data. analysis.to.the.health.facility.because.they. were.convinced.their.incentives.had.been. siphoned.off. 103. Ivermectin.distribution.is.integrated.in.annual. district.implementation.plans.but.the.ability. of.districts.to.actually.implement.these.plans. is.negatively.affected.by.central.demands.of. other.programs.for.their.activities.such.as. vaccination.campaigns.and/or.by.delays.in. supplies. 104. According.to.REMO.and.RAPLOA,.co- endemicity with Loaisis.is.present.in.13.out. of.15.projects.and.had.contributed.to.several. SAEs.in.the.earlier.years.of.the.program;.this. led.to.treatment.being.halted.in.co-endemic. districts.while.the.situation.was.researched. and.SAE.management.systems.established..A. progressive.approach.to.rolling.out.CDTI.in. these.districts.is.now.being.undertaken.and,. in.a.few.of.them.it.has.only.begun.in.last.1-2. years..Rumours.of.SAE.are.clearly.affect.levels. of.community.acceptance.but.with.awareness- raising.activities.the.effects.can.be.overcome.. In.2008,.25.SAEs.including.one.death.were. registered.and.in.2009,.12.SAEs.including.2. deaths.were.registered. 105. In.specific.foci,.vector control.activities. have.been.conducted.by.industries.(hydro- electric.dam.authorities.and.sugar.plants). under.the.leadership.of.the.Yaoundé.Initiative. Foundation..Recently,.a.national.task.force. was.created.to.advise.the.Ministry.of.Health. on.vector.control.as.the.country.is.planning.to. build.new.dams.and.some.stakeholders.such. as.the.Carter.Center.are.pushing.for.additional. interventions.to.accelerate.elimination. 106. Community mobilization takes.place. during.sensitization.meetings.before.the. drug.distribution.campaigns.and.often. involves.the.elected.members.of.the.health. dialogue.structures.(health.committees.and. management.boards)..The.targeted.groups. are.administrative.authorities,.traditional. and.religious.leaders,.some.local.political. authorities.and.elites..Once.the.date.is.agreed. for.distribution,.community.supervisors.and. CDDs.then.start.updating.their.population. data.using.the.community.registers.. Sensitization.is.happening.in.churches,. mosques,.markets,.and.family.or.village. meetings..In.some.districts.where.community. radios.exist,.they.are.requested.to.broadcast. sensitization.and.information.messages..In. other.areas,.community.mobilization.also. includes.resource.mobilization.for.logistics. support.to.CDDs..Depending.on.the.region,. CDDs.are.elected.by.community.members.or. designated.by.traditional.leaders. 107. Human resources:.in.2009,.approximately. 41.6%.of.health.personnel.working.in.the. districts.implementing.CDTI.were.involved. in.the.process..At.the.district.health.services. level,.the.district.medical.officer.and.the.head. of.the.health.bureau.are.coordinating.the.CDTI. activities,.while.heads.of.health.centres.are. interacting.directly.with.the.communities.to. ensure.the.smooth.organization.of.distribution. campaigns..In.2009,.40,001.CDDs.were. trained.or.retrained.and.the.mean.CDD:. population.ratio.was.1:123.[1:86.–.1:300].. The.NOTF.Secretariat.gives.a.briefing.on.the. CDTI.strategy.to.newly.graduated.doctors. prior.to.their.postings.and.also.to.medical. students.in.year.4.before.their.community. posting..Transfers.of.medical.personnel.from. non-Oncho.areas.to.Oncho.areas.mean.that. new.staff.may.lack.basic.training.in.CDTI;. refresher.training.is.provided.every.year.but.it. is.not.always.sufficient.for.staff.who.have.not. had.the.basic.training.in.CDTI. 108. The CDDs.are.trained.annually;.the.attrition. rate.is.said.to.be.low.by.the.health.authorities. (1-6%).although.meetings.with.CDDs. gave.the.impression.of.a.higher.drop-out. rate.especially.over.time..Incentives.were. perceived.to.be.the.key.reason.for.drop-out. although.at.each.site.a.motivated.core.was. continuing..Key.training.needs.perceived.at. district.and.community.level.are.HASM.and. CSM..Health.dialogue.structures.–.COSA,. COSADI.etc.–.do.not.seem.to.be.recognised. a d d En d u m : c o u n tr y c a sE s tu d iE s — E x tE r n a l m id -t Er m E v a lu a ti o n r Ep o r t 73 as.specific.targets.for.capacity-building/. training.as.members.are.frequently.recruited. as.CDDs..The.sex.ratio.amongst.CDDs.was. usually.c..3.or.2.male:.1.female. 109. Program management:.the.NOCP.is. managed.at.the.central.level.by.the.Secretariat. of.the.NOTF;.the.15.projects.are.under.the. Regional.Delegate.for.Public.Health.who. is.assisted.by.a.Regional.Onchocerciasis. Coordinator.(ROC)..The.national.secretariat. comprises.a.team.of.seven.people.including. the.LF.focal.person..They.operate.under.the. Directorate.of.Disease.Control.in.the.Ministry. of.Health..The.Director.of.Disease.Control.is. the.Chair.of.the.NOTF.and.the.focal.point.for. NTD.control..Control.of.NTDs.in.Cameroon. is.managed.by.four.vertical.programs:.Oncho. and.LF;.Schisto.and.STH;.Trachoma.under. Blindness.control.program;.Buruli.Ulcer,.HAT. and.Leprosy. co-implementation with other programmes in cameroon 110. The.NOCP.has.formally.piloted.co- implementation.of.Ivermectin.+.Albendazole. in.two.projects.in.the.North.and.far.North. regions.for.LF..Meanwhile,.in.many.districts,. CDDs.are.involved.in.other.public.health. interventions.such.as.ITN.distribution,.social. mobilization.for.the.EPI.campaigns,.Polio. vaccination,.distribution.of.Mebendazole.and. Vitamin.A.during.Mother.and.Child.Health. and.Nutrition.Days,.Home.Management. of.Malaria,.distribution.of.condoms,.HIV. prevention.etc..Community.supervisors.are. most.frequently.recruited.to.work.for.other. programs.such.as.HIV/Aids,.community- based.case.surveillance.of.disease.prone.to. epidemics.or.the.four.diseases.targeted.for. elimination.by.the.EPI. 111. Co-implementation.is.already.happening. at.community.level.at.initiative of the district health managers.and.is.going. beyond.NTDs,.with.CDDs.involved. in.malaria,.vaccination.and.MCH&N. programmes..There.is.no.sense.that.the. Oncho.programme.should.be.undertaking/ managing.co-implementation.as.the.other. programmes.want.to.maintain.their.own. roles..Co.implementation.is.accepted.by. CDDs.as.well.as.communities.but.creates. sense.of.competition.when.different.levels. of.incentives.are.provided..TDR.research. on.co-implementation.involved.2.sites.in. Cameroon.in.Littoral.and.West.projects. and.the.main.challenges.were.relative. to.procurement.of.commodities.(ITN,. Antimalarials,.Condoms). 112. A.national.consultation.was.organized.in. September.2010.by.the.Directorate.of.Disease. Control,.with.the.financial.support.from. APOC,.to.harmonize.approaches.towards. community.health.workers.and.to.look.for. potential.synergies.for.co.implementation.and. sharing.responsibilities.with.municipalities. in.delivering.by.public.health.interventions.. The.diversity.of.community.health.actors.and. their.motivation.schemes.are.jeopardizing. efforts.to.foster.community.participation. as.the.monetary.incentives.have.generated. competition.between.programs. 113. With.respect.to NTD mapping, REMO.has. been.done.almost.everywhere.but.there.is.a. clear.need.for.updating..A.national.mapping. exercise.is.ongoing.for.LF;.STH.have.been. mapped.nationwide.but.Schisto.has.only.been. partially.mapped..In.2009-2010,.RTI.funded. an.updating.of.the.Schisto.map.in.three.of.the. seven.regions.needed.and.a.trachoma.mapping. is.underway.in.the.Far.North.region..Buruli. Ulcer,.Leprosy,.HAT.have.also.been.mapped.. There.is.no.integrated.mapping.at.either.the. national.or.sub.national.levels;.the.existing. maps.are.not.used.at.District/Regional.levels. for.guiding.decision-making. strengthening health systems 114. The.health.system.in.Cameroon.is.structured. in.line.with.the.health.district.framework. promoted.in.the.African.Region.to.implement. the.primary.healthcare.framework..With. the.1996.Constitution,.municipalities.are. responsible.for.Public.Health;.the.State. decentralization.law.was.adopted.in.2004. and.has.started.being.implemented.in.this. fiscal.year..However,.in.the.health.sector. decentralization.began.to.be.operationalised. much.earlier.in.the1990s.as.it.is.one.of.the. a d d En d u m : c o u n tr y c a sE s tu d iE s — E x tE r n a l m id -t Er m E v a lu a ti o n r Ep o r t 74 two.pilot.sectors..Health.districts.are.allowed. to.determine.and.collect.user.fees.and.budget. their.locally.generated.incomes.for.their. running.costs. 115. A.health.SWAp.was.signed.in.July.2010.after. c..5.years.preparation.and.the.Government. hopes.to.add.further.donor.signatures.. Districts.want.basket-funding.so.that.they. can.manage.their.resources.more.efficiently;. they.are.currently.combining.resources. informally.where.this.is.possible..The.timely. implementation.of.district-level.plans.is. difficult.because.national.level.demands.of. districts.and.responses.to.district.needs.do.not. take.district.planning.into.account17. 116. Different.dialogue.structures.are.established. as.governing.bodies.and.operate.at.district. and.community.levels;.the.health.committee. (COSADI).and.the.district.management. board.(COGEDI).oversee.health.district. activities.whereas.the.district.hospital.is. under.a.management.board.(COGEH).and. health.centres.are.under.a.local.area.health. committee.(COSA). 117. The.CDDs.are.coordinated.by.front-line./. district.health.personnel.and.provide.data. to.them..The.attitudes.of.District.and.FLHF. staff.towards.CDDs.were.observed.by.the. evaluation.team.to.be.paternalistic.and.also. utilitarian..Health.staff.talked.of.‘using’.CDDs. for.implementation.and.were.going.directly. to.them.for.help.with.other.initiatives.rather. than.via.community.leaders.as.with.oncho.. The.CDDs.met.were.in.turn.reporting.to. health.staff.rather.than.the.community:.“the head of the health office is our boss“..In.one. community,.however,.the.CDDs.had.formed. a.formal.association.(a.CBO).that.was.actively. participating.in.discussion.and.planning.of. community.health.activities.with.health.staff.. See.box C. 118. The.CDDs.visited.were.not.analysing.their. data.or.aware.of.results.at.community.level.but. responded.to.the.evaluation.team’s.questions. with.their.impressions..Community.Self- Monitoring.is.new.and.weak.as.although. 17. Ministry.of.Public.Health,.Midterm.Evaluation.Report.of.the. Health.Sector.Strategy.2007 training.has.been.conducted,.there.are. no.funds.for.rolling.out..APOC.thought. communities.should.be.doing.this.without. support;.although.it.has.now.been.agreed.to. provide.some.support,.this.is.still.considered. inefficient..Health.system.staff.are.also.doing. own.validating.and.checking.and.have. ownership.of.the.data. 119. Poor.communications.between.health.staff. and.CDDs.were.observed.to.be.leading. to.friction;.there.was.no.evidence.of.a. communications.strategy.or.of.much.in.the. way.of.IEC.materials..HSAM.and.CSM.are. seen.as.Oncho.activities.with.little.sense.of. relevance.to.other.programmes. What has been working well 120. Community.acceptance.is.high.and.there.are. demands.for.“our.Mectizan”.even.beyond.the. meso.and.hyper.endemic.communities. 121. The.great.majority.of.health.personnel.are. committed.to.the.Oncho.program.although. Box C: CDDs in Ngambe The CDDs in Ngambe urban health area, which is beside the District Hospital in Ngambe District but has no frontline health facility, have formed themselves into a formally registered community- based association. Members are actively participating in discussion and planning of community-based and directed health activities with health staff but also hold their own meetings where they have solidarity and equity savings known as “Nangui”. When a community health activity is planned that requires community actors, the association provides the names and receives the associated financial incentives; these funds go to the “Nangui”. This approach is proving a successful mechanism for managing the varying levels of incentives received and for avoiding issues of competition, distrust and suspicion amongst community health actors. The health staff are keen to support the idea and to promote it in other communities but none have yet taken up the idea; likewise the association has done some limited sharing of the idea but it does not have the resources for being proactive in this. a d d En d u m : c o u n tr y c a sE s tu d iE s — E x tE r n a l m id -t Er m E v a lu a ti o n r Ep o r t 75 some.do.postpone.CDTI.when.a.well- resourced.program.plans.its.activity.at.the. same.time..District.and.Regional.Health. Personnel.are.aware.of.their.coverage.levels. and.the.refocus.on.elimination.-.80%.TCR. target-.and.have.clearly.incorporated.into.their. thinking..SAEs.are.properly.managed.in.almost. all.the.districts. 122. Many.communities.have.developed.ways.of. motivating.CDDs.irrespectively.from.the.State. funds.for.CDDs.incentives. What has been working less well 123. Mobilizing.State.resources.for.CDDs’. incentives.has.been.a.yearly.challenge.and.is. a.threat.for.CDTI.with.CDDs.in.some.areas. suspecting.health.professionals.of.siphoning. off.their.incentives..These.suspicions.were. leading.to.distrust.and.affecting.collaboration.. Political.commitment.expressed.for.oncho. control.and.elimination.does.not.usually. translate.into.resource.allocation.for.CDDs. 124. Although.an.extraordinary.meeting.of.the. General.Assembly.recently.took.place,.the. annual.review.meetings.involving.other. stakeholders.are.no.longer.taking.place. regularly..Without.this.forum.for.sharing. experiences.and.discussing.challenges,.there. is.a.lack.of.communication.and.coordination. between.the.projects..Possibly.because.of.this,. advocacy.beyond.the.traditional.partners.has. not.been.organised.for.involving.new.national. NGDOs.or.CSOs.able.to.support.Oncho. Control.activities. 125. Health.information.management.capacity. was.ranked.as.very.weak.and.fragmented.at. all.levels.of.the.system.during.the.midterm. evaluation.of.the.health.sector.strategy.in. 2006/2007..Community.data.bases.at.the. national,.regional,.district,.sub-district.and. community.levels.are.inexistent..Records. by.CDDs.are.poorly.managed.by.already. isolated.and.overloaded.health.professionals. in.first.line.health.facilities..Research.results. and.mapping.data.are.not.consolidated. at.the.central.level.and.are.rarely.shared. amongst.stakeholders.notably.those.fighting. against.NTDs. conclusions and recommendations 126. The.evaluation.team.noted.the.following. challenges.facing.oncho.elimination.in. Cameroon:.(i).devolution,.elimination.and. co-implementation.are.not.well.understood. in.a.context.where.vertical.programmes.are. competing.to.attract.health.personnel.and. community.actors;.(ii).the.rampant.poverty. exacerbated.the.search.for.extra.incomes.by. almost.all.the.implementers.including.health. professionals.and.CDDs;.(iii).the.tensions.around. the.need.for.additional.tools.while.moving. towards.elimination.such.as.vector.control,.bi. annual.distribution.of.Ivermectin,.more.frequent. impact.assessment.studies;.(iv).competing. interests.between.NTD.control.programs;.and. (v).inadequate.involvement.of.national.civil. society.organizations.and.associations.in.the. fight.against.Oncho.and.(vi).the.pervasive. commercialisation.of.the.health.sector. 127. At.project.level,.the.key.practical.challenges. are:.(i).absence.of.improvement.in.levels.of. absentees.and.Ivermectin.refusal.rate.due. to.alcohol.consumption,.rumours.and.fears. of.SAE.and,.human.mobility;.(ii).Poor.road. infrastructure;.(iii).late.arrival.of.drugs,. short.duration.of.drug.distribution.and.(iii). inappropriate.community.support. 128. The.evaluation.team.observations.of.an. apparent.lack.of.accountability.of.CDDs.to. the.community.and.of.utilitarian.approaches. by.the.health.system.staff.should.be.explored. further.as.they.run.counter.to.the.philosophy. of.community.ownership.and.empowerment. 129. Because.co-implementation.is.already. happening.in.uncoordinated.and.unregulated. way,.there.is.a.need.to.consider.a.formal. Community.Health.Actor.cadre.for.eliminating. the.current.sense.of.competition.and.creating. room.for.municipalities.to.take.over.preventive. health.interventions.such.as.sanitation.and. mass.drug.administration. 130. Implementation.should.be.more.district- centered.with.greater.central.flexibility.and. responsiveness.to.district.planning.processes.as. the.district.constitutes.the.machinery.for.health. interventions;.currently.there.were.reports.that. a d d En d u m : c o u n tr y c a sE s tu d iE s — E x tE r n a l m id -t Er m E v a lu a ti o n r Ep o r t 76 central.processes.hinder.the.implementation. of.their.plans..This.would.facilitate.SWAp. implementation.and.the.districts.would.be. more.able.to.determine.their.targets,.their. interventions.and.the.timing.of.activities..For. this.to.happen,.capacity-building.in.the.use.of. mapping.and.community.data-bases.will.be. needed.to.enable.districts.to.take.full.advantage. of.these.in.their.planning.and.monitoring. activities..They.will.need.to.understand.the. “Oncho.map”.as.it.changes.–.transmission,. parasitology.and.entomology.–.and.have.access. to.an.integrated.and.consolidated.NTD.map. 131. There.is.still.a.need.to.align.the.NOCP. structure.and.governance.with.the. decentralised.system..Because.of.its.historical. development.as.a.vertical.program,.the. national.secretariat.and.the.regional.Oncho. coordinator.are.still.too.powerful.for.health. districts.to.take.over.their.responsibilities.. Ways.of.increasing.integration.at.district.level. need.identifying,.particularly.for.facilitating.a. smooth.transfer.of.responsibilities.to.the.local. municipal.administration. 132. Capacity-building.activities.seem.to.be. motivated.more.by.programme.performance. and.targets.than.health.system-strengthening.. There.is.a.need.to.change.focus.of.training. from.programme.of.disease.control/elimination. to.system.focus.whereby.health.professionals. and.community.actors.are.trained.in.a. way.that.fosters.partnership.–.where.each. understands.their.own.role.and.responsibilities. and.those.of.others. 133. The.overall.financing.of.the.program.is. inadequate.for.sustaining.the.activities. needed.for.oncho.elimination.and.for.co. implementation.for.NTDs..Since.moving. towards.elimination.will.require.additional. resources,.this.was.perceived.to.be.in. contradiction.with.APOC’s.phasing.out. dynamics..As.some.projects.are.over.ten. years.old,.the.support.needs.identified.for. achieving.elimination.included.resources. for.training.(basic.and.refresher),.enhancing. HSAM,.implementing.CSM,.supervision.and. surveillance;.organizing.vector.control.and. impact.assessments. 77 Brief biographies of the Evaluation Team Dr Sam Adjei, formerly Deputy Director General, Ghana Health Service. Currently Chief Executive, Centre for Health and Social Services (CHeSS), Accra, Ghana. Prof. Pascale Allotey, Professor of Public Health & Associate Director Malaysia, Monash Global Health, JC School of Medicine and Health Sciences, Monash University Sunway Campus. Paul Derstine, Retired President/CEO of IMA World Health, New Windsor, Maryland (USA). Independent consultant. Prof. Dik Habbema, until June 2010 Professor Medical Decision Sciences, Erasmus MC, University Medical Center Rotterdam, the Netherlands Dr Ali A. Mzige, Public Health Consultant, Director International Medical Technological University Hospital, Dar es Salaam Tanzania. Former Director Preventive Services Ministry of Health Tanzania. Dr Pierre Ongolo-Zogo, Director of the Centre for Development of Best Practices in Health, Yaoundé Central Hospital and consultant radiologist. Former Director Health Operations Research Ministry of Public Health Cameroon. Eleanor Cozens, Independent Consultant in international development sector, working with and for INGDOs. Dr Anthony Seddoh, Director, Operations, Center for Health and Social Services and a Health Policy Specialist.

r Ep o r t o f th E Ex tE r n a l m id -t Er m E v a lu a ti o n o f th E a fr ic a n p r o G r a m m E fo r o n c h o c Er c ia si s c o n tr o l