African Programme for Onchocerciasis Control (APOC) Programme Africain de lutte contre l'Onchocercose National Onchocerciasis Task Force (NOTFs) of Nigeria Second meeting of the National Onchocerciasis Task Forces (NoTFs) Representatives, Abuja, 17-22 June 2002 BACKGROUND DOCUMENT ON SELF.SUSTAINABILITY DrR/APOC 06t06t02 ,Page I' 0., Focal vector eradication activities No new vector eradication activities will be undertaken during Phase II and the phasing-out period. Existingactivities will be critically reviewed early in Phase II, to ditermine the cost benefiI of each pr":*il""a whether the project should be completed. Ground larviciding using the already t"o*., environmentally safeinsecticides will remain the vector iontrol method of choice. 5 SUSTANABILITY OF CDTI 5.1 The importance of sustainable CDTI onchocerciasis can be eliminated as a public health problem through annual mass treatment with ivermectin,provided that high trcatment coverage can be maintiined for a long period of time. It is not yet known howlong mass treatment needs to be continued before it can be safely iniemrpted, but it is expected that at leastl5-20 years of treatment will be required. The effectiv"r"r, urd.ustainaUitity of the treatment prograrnme are therefore essential for the success of onchocerciasis control. Experience to date has shown that CDTI isan effective drug delivery mechanism that achieves freatrnent coverage rates of more than 70% ofthe totalpopulation (over 85% of eligibles), a level that is considered adequate for the elimination of the disease as apublic health problem. Operational research has shown that CnTt has important characteristics, such ascommunity ownership of the drug delivery process, that greatly enhance its potential for sustainabiu'*.--- ln view of the above, the objective of APOC is "to establish effective and self-sustainable, community-directed ivermectin treatment throughout the endemic areas in the.geograprri" ..op" oi,h; p;;;;#;;'ir;" section 3-'1)' During phase I, signilicant progress has been made ii eslabiishing "rr""tiu. CDTI in endemicareas.' The main emphasis in phase II will bi on assessing and strengthening the sustainability of CDTI. Asconcluded by the Mid Term External Evaluation Team, "sistainabilit! is ttreiey issul for phase 2 of ApoC,and the major challenge for the future of onchocerciasis control". 5.2 CDTI proiects and sustainabilitv The establishment of CDTI is done through projects. Each CDTI project covers a limited geographic area inan endemic country, such as a number of adjacent health districts.-This project upp.ouch allows for a phasedintroduction of CDTI in a country, focusing support to the early phases or -cDtI development with the viewof applying the lessons leamed to the rest oi tt " "orrt y The aim of each project is to establish effective and self-sustainable CDTI within a period of about 5 years, rnd to prepare the conditions that will ensure sustained commitment and support to Cort after the cessationof APOC support. An important element of this preparatory work is the inLgration of CDTI into the healthsystem and to strengthen the capacity of the healtL system to provide the .rece"ssary rrppoa in the long term. It is recognised that the status and viability of the health system vary significantly from country to countryand from district to district within the same country. Therefore the pace and effectiveness of integration would differ from place to place. 5.3 Alo9 will monitor progress towards the establishment of sustainable CDTI and determine, on the basis ofcriteria to be defined by TCC, if and when a project has been successful. The success criteria would coverissues of treatment coverage, community airectorstrip and ownership, health ,y.t"- support and integrationof CDTI into the existing health care structures. It is appreciated that, in spite of best efforts, satisfactory conditions for sustainability cannot always becreated within 5 years and that additional support may be needed in certain situations to ensure success. Ifrequired, such additional support would be made avaiiable on condition that serious efforts have been madein trying to establish sustainable GDTI within a period of 5 years, and that this is likelf to succeed within thenear fufure' Additional support may be provided for a maximum of three years, arid would focus on full { Page2 integration of CDTI into the health services and on related national capacity building. Where efforts towards establishing sustainability are not considered adequate, APOC may discontinue itJfinancial support to the concemed project while seeking an altemative solution. 5.4 Generatins an d sustainins commitment to at all levels 5.4.1 National level Continued commitment towards CDTI at the national level is essential for the success of onchocerciasis control. Indicators of such national commitment include: i adequacy of budgetary provision and timely unencumbered release of funds for the administrative and field operations of CDTI including meetings of NOTFs; ii the facilitation of procurement including tax free importation and community access to ivermectin in accordance with the terms of the Programme Memorandum related to the importation and clearance of Mectizan at the national port of entry of the drug; lll the provision of suitable, secure and adequate storage and transport facilities for the distribution of the drug to the DistricUstate level. APOC supported advocacy towards ensuring continued commitment towards CDTI will be directed at decision and policy makers with the use of appropriate Programme-generated data and effective mode of communication. 5.4.2 District level Operational research undertaken during the first phase of APOC has indicated that an indispensable key to the ultimate sustainability of CDTI is the perfonnance at the District level. District gealih Management Teams have the crucial role of ensuring that their staff who manage the frontline health facilitles are adequately oriented towards CDTI, appropriately motivated and provided with the means of discharging their diverse responsibilities. These responsibilities include: i ensuring that target endemic communities have timely and adequate access to ivermectin; ii carrying out the training and supervision of Community-Directed Distributors (CDDs); iii monitoring and providing for the managerrent of severe adverse events; iv generally ensuring that CDTI operations run smoothly at the peripheral level. The capacity to execute these responsibilities will not always be available and APOC may need to assist with capacity building through the relevant CDTI projects. Indicators for successful integration of CDTI into the health system include evidence that CDTI activities feature as part and parcel of the process of planning, execution and evaluation ofthe health service at all level. 5.4.3 Community level Most of the communities have shown in several ways strong commitment to CDTI and willingness to assuming its ownership. The benefits of this commitment are reflected in enhanced community partfuipation in the process and an overall increase in treatment coverage. There remain, however, a few areai of concern for sustainability at the community level that would be vigorously tackled during Phase II. Notable among these are the inter-related problems of CDD attrition over time and the need for providing appropriate community-level incentives by way of inducement, compensation or reward, or a combinatlon bf in"r". NOTFs would be encouraged to seek and provide appropriate local (community-specific) answers, through ,Page 3 properly devised and executed operational research projects and through the holding, as regularly aspossible' of stakeholders' meetings which appear to'have the potentiai of enhancing the prospects ofsustainability of CDTI at the periphiry. 5.5 Additionalconsiderationsforsustainability one of the cardinal features of GDTI is its potential value as an entry point for other community-based healthprogrammes' Inadequacy of human, material and financial resources has often been given as reason forfailure to implement or extend a number of health p.og.urrn.. io .nuny end-of-the-road communities such asthose whcrc onchocerciasis is endemic. The window 6f opportunity. piovided uy cbil for introducing otherhealth programmes inthese.and similarly deprived communities,is-increasir4i.;;rised. For example, aninter-agency meeting held in May 200i in uganda recommended "the "ppiilii".""f community directedinterventions for the prevention ind control of other diseases of public rrlrrrn ,igrficance e.g. Iymphaticfilariasis' schistosomiasis etc." The feasibility of using cDTias an entry point for-a variety of other healthprogrammes needs to be further investigated. This could be aone irom _rnany-perspectives includingassessing, with the conculrence of the communities concerned, the ability of cD;; to assume responsibilityfor other health related activities in the community. The extension of the CDTI concept courd considerablybroaden the scope of community-based health piogrurn-", introduced in the wake of cDTI during thesecond phase of APOC, and imprlve the sustainatitit-y of onchocerciasis conhol. 5.5.2 Role of women in CDTI activities Reports on the first phase of APoc have indicated that increased participation of women in the decisionmaking process of GDTI is associated with better perfo.-un.". parameters of effectiveness, such astreatment coverage' and an assortment of indicators of sustainability, ;; ;; public awareness andcommunity participation are frequently better when women voluntariry unJ actively participate in thedecision-making processes and urrung"rn"nts for the distribution of ivermectin. It would be valuable toidentify how the traditional roles of wJmen in the various facets of the life of endemic communities could besuccessfully adapted to include their more active involvement in cDTI. It is intended th"."fore in the secondphase of APoc to encourage NorFs to enhance the role of women in GDTI, in a manner compatible withsocietal norrns, and acceptable to all sections of the community. 5.5.1 5.5.3 Cost recovery and cost sharing 7.4.2 of be A few APoc countries have adopted the policy of cost recovery as a_national primary health care policy.The policy of cost recovery is consonant withihe APoc principle of sustainability of 6DTI, but severalcaveats must be noted' First, since ivermectin is donated free of charge uy rvr"."t ato, Ir"., cost recoverymust not include trrllosj of the drug. second, cost recovery shoJd operate in-a ,.ranrer that does notcompromise the APoc Programme goal of treatment "ou".1ug" and_ sustainability of GDTI. No personshould be denied treatment with ivermectin in the GDTI str"ategy because of inability to pay. Third,communities should be involved in the management of fundJ collecteJ ,frr"rgf, the cost recoverymechanism' Such funds may well be used in payirig for community expenses in".r.."f,in the GDTI strategy,e'g' transport for collection of drugs. while cost recovery holds promise as a tool for sustainability, it mayimpact negatively on treatment coverage. rn" ir.u" ;;;'il, warrants further attention in the Apocoperations research agenda in order toirnderstand the effect of both positive and negative incentives forindividuals, communities, CDDs and health workers. IIon During Phase II and thePhasing-out Period,APoc will support 2Z.newcDTI projects, and continue supportfor 63 projects initiated in Phase I. A total of_85 GDTI pro.lects *itt u. successfully under the dircction of thecommunities by the end of Phas e rr (2007). However, as mentioned above, a certain number of projects may aPage 4 still need financial support from APOC during the Phasing-out Period (2008-2010) to achieve satisfactory indices for sustainability. Figure 6 shows the number of CDTI projecrs supported by ApOC by y; J;;i;L the course of Phase I, Phase II and the Phasing-out Period. Programme financiai support to each CDTIproject will decrease gradually to ensure that governments have developed the capacity in key prog.*." activities like data management, monitoring, community-self-monitoring, integration of COtl irio tl"r" pHC and strengthening of peripheral health services to provide the necessary support to communities. Actual field work in ivermectin delivery will continue to be carried out by National Onchocerciasis Task Forces (NOTFs). These will include, planning drug procurement and timely delivery to collection points, mobilization and sensitisation of communities, training communiry directed distributois (CDDs), .rp"iui.i,rg the treatment, monitoring and evaluation of operations, reporting and treatment of SAEs, ad6erence to th!timelines on sustainability, and establishment and maintenance of optimal coverage. To increase and strengthen community participation and ownership, programs will involve, whenever possible, community based organizations (CBos) and national NGos as partnlrs. Experience from APOC Phase I Period has shown that to establish sustainable ivermectin treatment it is cruc.ial to enhance political commitment, in particular, the long term support of health authorities inparticipating countries. There will be strong emphasis on securing long-lasting commitment of participatint governments to the community directed strategy. To that effect, project self-sufficiency after fiue yeais ,uiii be determined at the beginning of Phase II for ten projects which will be completing their fifth y.u.if afOC support by the end of 2002: Nigeria (4), Uganda - Phase I projects in four districts, Malawi (liand Tanzania(l). These projects will be carefully evatuated as they will provide the first evidence on self-sufficiencv after 5_J1lo of APOC support, feasibility of integration into the health system and the likely susrainabiiiry ofCDTI. In supporting ivermectin distribution, the spirit of partnership will prevail. NGDOs and local NGOs u,ill provide technical, administrative support and continue to follow the guidelines of the prograrnrne. Figure 6: Numbcr of CDTI projects supported by ApOC by year 90 t0 o 70 P soA E50 o A10 Qoo. 30 l0 0 s" $$ Ss's S'S S*3ss *ss'*" -s 0 73 l0 I
African Programme for Onchocerciasis Control (APOC) Programme Africain de lutte contre l'Onchocercose National Onchocerciasis Task Force (NOTFs) of Nigeria Second meeting of the National Onchocerciasis Task Forces (NoTFs) Representatives, Abuja, 17-22 June 2002 BACKGROUND DOCUMENT ON SELF.SUSTAINABILITY DrR/APOC 06t06t02 ,Page I' 0., Focal vector eradication activities No new vector eradication activities will be undertaken during Phase II and the phasing-out period. Existingactivities will be critically reviewed early in Phase II, to ditermine the cost benefiI of each pr":*il""a whether the project should be completed. Ground larviciding using the already t"o*., environmentally safeinsecticides will remain the vector iontrol method of choice. 5 SUSTANABILITY OF CDTI 5.1 The importance of sustainable CDTI onchocerciasis can be eliminated as a public health problem through annual mass treatment with ivermectin,provided that high trcatment coverage can be maintiined for a long period of time. It is not yet known howlong mass treatment needs to be continued before it can be safely iniemrpted, but it is expected that at leastl5-20 years of treatment will be required. The effectiv"r"r, urd.ustainaUitity of the treatment prograrnme are therefore essential for the success of onchocerciasis control. Experience to date has shown that CDTI isan effective drug delivery mechanism that achieves freatrnent coverage rates of more than 70% ofthe totalpopulation (over 85% of eligibles), a level that is considered adequate for the elimination of the disease as apublic health problem. Operational research has shown that CnTt has important characteristics, such ascommunity ownership of the drug delivery process, that greatly enhance its potential for sustainabiu'*.--- ln view of the above, the objective of APOC is "to establish effective and self-sustainable, community-directed ivermectin treatment throughout the endemic areas in the.geograprri" ..op" oi,h; p;;;;#;;'ir;" section 3-'1)' During phase I, signilicant progress has been made ii eslabiishing "rr""tiu. CDTI in endemicareas.' The main emphasis in phase II will bi on assessing and strengthening the sustainability of CDTI. Asconcluded by the Mid Term External Evaluation Team, "sistainabilit! is ttreiey issul for phase 2 of ApoC,and the major challenge for the future of onchocerciasis control". 5.2 CDTI proiects and sustainabilitv The establishment of CDTI is done through projects. Each CDTI project covers a limited geographic area inan endemic country, such as a number of adjacent health districts.-This project upp.ouch allows for a phasedintroduction of CDTI in a country, focusing support to the early phases or -cDtI development with the viewof applying the lessons leamed to the rest oi tt " "orrt y The aim of each project is to establish effective and self-sustainable CDTI within a period of about 5 years, rnd to prepare the conditions that will ensure sustained commitment and support to Cort after the cessationof APOC support. An important element of this preparatory work is the inLgration of CDTI into the healthsystem and to strengthen the capacity of the healtL system to provide the .rece"ssary rrppoa in the long term. It is recognised that the status and viability of the health system vary significantly from country to countryand from district to district within the same country. Therefore the pace and effectiveness of integration would differ from place to place. 5.3 Alo9 will monitor progress towards the establishment of sustainable CDTI and determine, on the basis ofcriteria to be defined by TCC, if and when a project has been successful. The success criteria would coverissues of treatment coverage, community airectorstrip and ownership, health ,y.t"- support and integrationof CDTI into the existing health care structures. It is appreciated that, in spite of best efforts, satisfactory conditions for sustainability cannot always becreated within 5 years and that additional support may be needed in certain situations to ensure success. Ifrequired, such additional support would be made avaiiable on condition that serious efforts have been madein trying to establish sustainable GDTI within a period of 5 years, and that this is likelf to succeed within thenear fufure' Additional support may be provided for a maximum of three years, arid would focus on full { Page2 integration of CDTI into the health services and on related national capacity building. Where efforts towards establishing sustainability are not considered adequate, APOC may discontinue itJfinancial support to the concemed project while seeking an altemative solution. 5.4 Generatins an d sustainins commitment to at all levels 5.4.1 National level Continued commitment towards CDTI at the national level is essential for the success of onchocerciasis control. Indicators of such national commitment include: i adequacy of budgetary provision and timely unencumbered release of funds for the administrative and field operations of CDTI including meetings of NOTFs; ii the facilitation of procurement including tax free importation and community access to ivermectin in accordance with the terms of the Programme Memorandum related to the importation and clearance of Mectizan at the national port of entry of the drug; lll the provision of suitable, secure and adequate storage and transport facilities for the distribution of the drug to the DistricUstate level. APOC supported advocacy towards ensuring continued commitment towards CDTI will be directed at decision and policy makers with the use of appropriate Programme-generated data and effective mode of communication. 5.4.2 District level Operational research undertaken during the first phase of APOC has indicated that an indispensable key to the ultimate sustainability of CDTI is the perfonnance at the District level. District gealih Management Teams have the crucial role of ensuring that their staff who manage the frontline health facilitles are adequately oriented towards CDTI, appropriately motivated and provided with the means of discharging their diverse responsibilities. These responsibilities include: i ensuring that target endemic communities have timely and adequate access to ivermectin; ii carrying out the training and supervision of Community-Directed Distributors (CDDs); iii monitoring and providing for the managerrent of severe adverse events; iv generally ensuring that CDTI operations run smoothly at the peripheral level. The capacity to execute these responsibilities will not always be available and APOC may need to assist with capacity building through the relevant CDTI projects. Indicators for successful integration of CDTI into the health system include evidence that CDTI activities feature as part and parcel of the process of planning, execution and evaluation ofthe health service at all level. 5.4.3 Community level Most of the communities have shown in several ways strong commitment to CDTI and willingness to assuming its ownership. The benefits of this commitment are reflected in enhanced community partfuipation in the process and an overall increase in treatment coverage. There remain, however, a few areai of concern for sustainability at the community level that would be vigorously tackled during Phase II. Notable among these are the inter-related problems of CDD attrition over time and the need for providing appropriate community-level incentives by way of inducement, compensation or reward, or a combinatlon bf in"r". NOTFs would be encouraged to seek and provide appropriate local (community-specific) answers, through ,Page 3 properly devised and executed operational research projects and through the holding, as regularly aspossible' of stakeholders' meetings which appear to'have the potentiai of enhancing the prospects ofsustainability of CDTI at the periphiry. 5.5 Additionalconsiderationsforsustainability one of the cardinal features of GDTI is its potential value as an entry point for other community-based healthprogrammes' Inadequacy of human, material and financial resources has often been given as reason forfailure to implement or extend a number of health p.og.urrn.. io .nuny end-of-the-road communities such asthose whcrc onchocerciasis is endemic. The window 6f opportunity. piovided uy cbil for introducing otherhealth programmes inthese.and similarly deprived communities,is-increasir4i.;;rised. For example, aninter-agency meeting held in May 200i in uganda recommended "the "ppiilii".""f community directedinterventions for the prevention ind control of other diseases of public rrlrrrn ,igrficance e.g. Iymphaticfilariasis' schistosomiasis etc." The feasibility of using cDTias an entry point for-a variety of other healthprogrammes needs to be further investigated. This could be aone irom _rnany-perspectives includingassessing, with the conculrence of the communities concerned, the ability of cD;; to assume responsibilityfor other health related activities in the community. The extension of the CDTI concept courd considerablybroaden the scope of community-based health piogrurn-", introduced in the wake of cDTI during thesecond phase of APOC, and imprlve the sustainatitit-y of onchocerciasis conhol. 5.5.2 Role of women in CDTI activities Reports on the first phase of APoc have indicated that increased participation of women in the decisionmaking process of GDTI is associated with better perfo.-un.". parameters of effectiveness, such astreatment coverage' and an assortment of indicators of sustainability, ;; ;; public awareness andcommunity participation are frequently better when women voluntariry unJ actively participate in thedecision-making processes and urrung"rn"nts for the distribution of ivermectin. It would be valuable toidentify how the traditional roles of wJmen in the various facets of the life of endemic communities could besuccessfully adapted to include their more active involvement in cDTI. It is intended th"."fore in the secondphase of APoc to encourage NorFs to enhance the role of women in GDTI, in a manner compatible withsocietal norrns, and acceptable to all sections of the community. 5.5.1 5.5.3 Cost recovery and cost sharing 7.4.2 of be A few APoc countries have adopted the policy of cost recovery as a_national primary health care policy.The policy of cost recovery is consonant withihe APoc principle of sustainability of 6DTI, but severalcaveats must be noted' First, since ivermectin is donated free of charge uy rvr"."t ato, Ir"., cost recoverymust not include trrllosj of the drug. second, cost recovery shoJd operate in-a ,.ranrer that does notcompromise the APoc Programme goal of treatment "ou".1ug" and_ sustainability of GDTI. No personshould be denied treatment with ivermectin in the GDTI str"ategy because of inability to pay. Third,communities should be involved in the management of fundJ collecteJ ,frr"rgf, the cost recoverymechanism' Such funds may well be used in payirig for community expenses in".r.."f,in the GDTI strategy,e'g' transport for collection of drugs. while cost recovery holds promise as a tool for sustainability, it mayimpact negatively on treatment coverage. rn" ir.u" ;;;'il, warrants further attention in the Apocoperations research agenda in order toirnderstand the effect of both positive and negative incentives forindividuals, communities, CDDs and health workers. IIon During Phase II and thePhasing-out Period,APoc will support 2Z.newcDTI projects, and continue supportfor 63 projects initiated in Phase I. A total of_85 GDTI pro.lects *itt u. successfully under the dircction of thecommunities by the end of Phas e rr (2007). However, as mentioned above, a certain number of projects may aPage 4 still need financial support from APOC during the Phasing-out Period (2008-2010) to achieve satisfactory indices for sustainability. Figure 6 shows the number of CDTI projecrs supported by ApOC by y; J;;i;L the course of Phase I, Phase II and the Phasing-out Period. Programme financiai support to each CDTIproject will decrease gradually to ensure that governments have developed the capacity in key prog.*." activities like data management, monitoring, community-self-monitoring, integration of COtl irio tl"r" pHC and strengthening of peripheral health services to provide the necessary support to communities. Actual field work in ivermectin delivery will continue to be carried out by National Onchocerciasis Task Forces (NOTFs). These will include, planning drug procurement and timely delivery to collection points, mobilization and sensitisation of communities, training communiry directed distributois (CDDs), .rp"iui.i,rg the treatment, monitoring and evaluation of operations, reporting and treatment of SAEs, ad6erence to th!timelines on sustainability, and establishment and maintenance of optimal coverage. To increase and strengthen community participation and ownership, programs will involve, whenever possible, community based organizations (CBos) and national NGos as partnlrs. Experience from APOC Phase I Period has shown that to establish sustainable ivermectin treatment it is cruc.ial to enhance political commitment, in particular, the long term support of health authorities inparticipating countries. There will be strong emphasis on securing long-lasting commitment of participatint governments to the community directed strategy. To that effect, project self-sufficiency after fiue yeais ,uiii be determined at the beginning of Phase II for ten projects which will be completing their fifth y.u.if afOC support by the end of 2002: Nigeria (4), Uganda - Phase I projects in four districts, Malawi (liand Tanzania(l). These projects will be carefully evatuated as they will provide the first evidence on self-sufficiencv after 5_J1lo of APOC support, feasibility of integration into the health system and the likely susrainabiiiry ofCDTI. In supporting ivermectin distribution, the spirit of partnership will prevail. NGDOs and local NGOs u,ill provide technical, administrative support and continue to follow the guidelines of the prograrnrne. Figure 6: Numbcr of CDTI projects supported by ApOC by year 90 t0 o 70 P soA E50 o A10 Qoo. 30 l0 0 s" $$ Ss's S'S S*3ss *ss'*" -s 0 73 l0 I