Report on final evaluation of the Special Intervention Zones(SIZ)

African Programme for Onchocerciasis Control (APOC) Programme africain de lutte conhe I'onchocercose JAF-FAC I l" JOINT ACTION FORTJM Office of the Chairman JOINT ACTTON FORUM Fourteenth session Kampala- Uganda 8-11 December 2008 FORUM D'ACTION COMMTINE Bureau du Prdsident JAFI4/INF/DOC.I ORIGINAL: ENGLISH September 2008 REPORT ON FINAL EVALUATION OF THE SPECIAL INTERVENTION ZONES (SIZ) Report of the final external evaluation of the Special lntervention Zones (SlZs) September 2008 World Health Organization Evaluation team Catherine Hodgkin (Chair) Richard Biritwum (Vice Chair) Marc Karam Fatu Yumkella Peter Enyong Hannah Brown (Secretary) 2Table of contents Table of contents................. List of annexes, tables, and figures. Acronyms and abbreviations Acknowledgements...... Executive summary.... A. Introduction ............. l. The Special lntervention Zones 2. Country-specific background B. The evaluation process.. 1. krtroduction to the evaluation 2. Objectives.............. 3. Methodology .......... C. Findings 1. Achievements of S2...... l-I Geographical and therapeutic coverage 1-II. Achievement of OCP target epidemiological parameters........ 2. Programme Management .............. 2-I Financial resources.. 2-II Adequacy of human resources for SZ 2-III. Relationships and effectiveness of coordination between SIT and national coordinators ..27 2-[v. Post-SZ devolution of responsibilities from sIT to county programmes..............28 3. Implementation of CDTI.......... 29 .,6 ..9 ..9 l1 T4 t4 t4 l7 t7 t7 20 .23 .23 .26 3-I. Ivermectin distribution.............. 3-tr. Population and communities................. 3-trI. Sensitisation, training, supervisiorg and reporting ..... 3-IV. Findings related to community directed distributors.. 4. Vector conhol activities 4-I. Management of aerial operations........ D. Perspectives for the future....... I . County progress towards sustainability ...... l-I. Government and other parhrer support including funding.... I -IL lntegration and co-implementation ........ I -trI. Unintemrpted fl ow of ivermectin ........... 1-IV. Community ownership and commiftnent 1 -V. Regular epidemiological and entomological surveillance....... 2. Lessons learnt and best practices from the SZ experience.. D. Conclusions and recommendations l. Concluding remarks E. References......................... Annex [: Terms of Reference .....................30 .......34 4-trI. Effects of larviciding on fly populations ..40 4-IV. Intensity of transmission ...................40 4-V. Correlation of entomological and epidemiological parameters .41 4-VI. Summary of vector control experience ...........4I 4-VII. Role of the Multi-Disease Surveillance Cenfre. ......,.....,.......,,42 ..........44 ..........44 ..........44 ..........46 46 46 .47 .47 50 ..50 ..54 ..57 ..61Annex II: SZ management organizational chart JList of annexes, tables, and figures Table of contents............ ....................2 List of annexes, tables, and figures. ......................3 Acronyms and abbreviations ............4 Acknowledgements...... .....................5 Executive summary..... .......................6 Table 1: Numbers of villages comprising SIZs in each country and geographical coverage rates for the 5 years ofthe project................. ....................18 Table 2: The total population comprising SIZs in each counfiy with therapeutic coverage rates over the duration ofthe project .............19 Table 3: Trends in prevalence of microfilaria and changes in community microfilarial loads (CMfL) since the start of SIZ activities................. ......................22 Table 4: APOC/SZ financial contributions to SZ countries 2003-2007 ...................24 Table 5: APOCISIZ financial contributions to non-SIZ countries 2006-2007 ............24 Table 6: Financial contributions by partners other than APOC/SIZ to onchocerciasis control activities in the SZ countries 2003-2007* ..............25 Box 1: The many uses of census data....... .........32 Box 2: The Mano River Union .......33 Box 3: lncentives---an ongoing challenge ........37 Box 4: The crucial role of NGDOs.............. ......45 Figure 1: Map showing former OCP area and SIZ ...............62 Figure 2: Graphs showing the effects of larviciding on annual transmission potential and biting rates............ ......63 I 4Acronyms and abbreviations AFRO APOC ATP CDD CDT CMfL CDTI CVCT EHI HKI IEC LF MDSC NGO NGDO NOCP NOBCP NTDs OPC OCP PNLO PNLOC REMO SAC SIT SV SSI TDR WHO Regional Office for Africa African Programme of Onchocerciasis Control Annual transmission potential Community directed distributor Community directed treatment Community microfi larial load Community directed treatment with ivermectin Central vector control team Evergreen Helicopters, lnc Helen Keller lnternational lnformation Education and Communication Lymphatic filariasis Multi-Disease Surveillance Centre Non-governmental organization Non-governmental development organization National onchocerciasis control programme National onchocerciasis and blindness control programme Neglected tropical diseases Organisation pour la Prdvention de Ia C6cit6 Onchocerciasis control programme in West Africa French hanslation of NOCP French translation NOBCP Rapid epidemiological mapping of onchocerciasis Special Advisory Committee Special lntervention Team Special Intervention Zone Sight Savers lnternational Special Programme for Research and Training in Tropical Diseases World Health Organization a wHo 5Acknowledgements Throughout the process of this exercise, the Evaluation Team has been extremely grateful for the unstinting support and kindness offered by all from whom advice, information, and help was sought. In particular, we would like to thank everyone actively involved in the implementation of the Special Intervention Zone (SIZ) programme and onchocerciasis control in Benin, Ghana, Guinea, Sierra Leone, and Togo, including: o In each country visited, the Ministers of Health, the communities participating in community-directed treatment with ivermectin, the national coordinators and the national onchocerciasis control programme teams, and the staff of national, district and local-level health services o Management staff at the African Programme for Onchocerciasis Control (APOC) and SIZ Headquarters in Ouagadougou, in particular Dr Uche Arnazigo, Director of APOC and Dr Laurent Yameogo, who is SIZ Team Leader in addition to his senior responsibilities in APOC; the secretaries at APOC/SZ headquarters in Ouagadougou who helped the team with administrative support; and numerous other resoruce people o Staff at the Multi-Disease Surveillance Centre (MDSC), based in Ouagadougou, who helped with compiling the tables of entomological data o WHO representatives and country office staff of the countries visited . The members of the non-govemmental development organisations involved in onchocerciasis control in countries of the former Onchocerciasis Control Programme (OCP) area, namely Helen Keller International (HKI), Organisation pour la Pr6vention de la C6cit6 (OPC), Sight Savers Intemational (SSD, and Lion's Club lnternational o The members of the Committee of Sponsoring Agencies (CSA) of APOC for their feedback during the planning process of the evaluation Special thanks are due to Bernard Philippon who, in his position as Expert Advisor to the evaluation, has been unfailing in his provision of advice, information, and support. He has guided team discussions of crucial issues throughout the evaluation process, drawing on his extremely valuable experience in vector control and contributing country- specific knowledge for information- gathering miss ions. 6Executive summa The Special Intervention Zones (SIZs) are areas of five West African countries--- Benin, Ghana, Guinea, Sierra Leone, and Togo---in which, despite several years of combined vector control and ivermectin treatment, the epidemiological and entomological situation with regard to onchocerciasis remained unsatisfactory in some sites at the end of 2002. This date marked the planned closure of the Onchocerciasis Control Programme in West Africa (OCP), Iaunched in 1974 to eliminate onchocerciasis as a public health and socio-economic development problem in westem Africa. Although the programme broadly achieved its objectives, there remained a few areas within four of the countries plus the entire territory of Sierra Leone (where the decade-long civil war interrupted onchocerciasis control efforts) in which epidemiological and entomological parameters did not meet the prograrnme's targets. So, rather than withdraw activities completely in these areas, the OCP Joint Programme Committee decided to extend support for onchocerciasis control for five subsequent years in a prograrnme of special intervention, to be implemented under the auspices of the African Programme for Onchocerciasis Control (APOC). The regions now known as the SIZs encompass the Pru basin in Ghana, the tributaries of the Upper Oti basin in Benin and Togo, the adjacent Upper Oueme river basin in Benin, and the basins of Mafou (including upper Niger) and Tinkisso in Guinea, in addition to the whole of Sierra Leone. Beginning on January 1,2003, and expected to run until December 31,2007, the SIZ project's general objective was to bring and keep down the entomo-epidemiological parameters in target regions to levels corresponding to the OCP standards, which could easily be maintained by participating countries. Specific goals were to reduce the adjusted prevalence of microfilaria in the population to less than 5%o regularly for some time and to reduce the mean microfilarial load in the population to a level of 0.5 mf/s. All the activities under the auspices of the SIZ project were implemented by teams from the national onchocerciasis control programme with the support of a Special Intervention Team (SIT), appointed by WHO AFRO and located at APOC headquarters in Ouagadougou. It was projected to cost US$ 12 098 732, a sum to be covered by undisbursed funds remaining from phase V of the OCP (1998-2002). The principal method of disease control in all SIZ was agreed as Community- Directed Treatment with Ivermectin (CDTI), a strategy initially implemented in OCP countries in 1998 and consisting of use of community volunteers to treat village members with once yearly doses of a microfilaricide. Modifying the initial strategy, the SIZs were set "reinforced" CDTI targets of 100% geographical coverage and 80-85% therapeutic coverage (although in Sierra Leone the therapeutic target was set lower, at 65%o, to reflect the scale of progress needed there) with the aim of bringing onchocerciasis in these regions to target levels within the 5 year time frame of the project. In the tributaries of the Upper Oti and the adjacent Upper Oueme, CDTI was complemented with vector control using the same insecticide treatment strategy that had been in place for the duration of the OCP. The specific indicators chosen to monitor progress in onchocerciasis control were the parameters used in the OCP, which included trends in prevalence and community microfilarial loads. I 7The pre-specified time allocated for the SIZ activities---the 5 years between 2003 and2007---is now complete and the achievements and challenges of this period are under scrutiny in the present report. This evaluation was commissioned to review and assess the achievements of SIZ programme against its stated objectives and mandate. Specific additional objectives include assessing the level of incorporation of SIZ activities into routine country health activities and assessing the prospects for sustainability of activities related to onchocerciasis control. Team members conducted site visits to national onchocerciasis control programme offices; regional, district, and community health centres; and communities in both high and low coverage areas to interview key individuals involved in onchocerciasis control and to collect data from existing records. Findings from these missions were subsequently synthesised into a final evaluation report, put together during a team writing workshop in Ouagadougou. Conclusions from this evaluation process describe the most significant lessons learned from the implementation of operations undertaken in SIZ areas and a series of l3 recommendations cover key issues for improvement including: funding, incentives for community distributors, gender issues, training for technical support staff, annual meetings of onchocerciasis control staff, support for surveillance and entomological evaluation, operational research, and validation of national data on CDTI. The SIZ programme enabled continuous support to be given for five years to five zones in the ex-OCP region to enable them to reach a situation in which the entomo- epidemiological situation was satisfactory. At the end of the five-year period, it is important to note that this original objective has been substantially, if not entirely, achieved. Three countries have reached and maintained targets of geographical and therapeutic coverage, Sierra Leone is already reaching the lower target set for it to reach and the trends in Ghana are positive although problems remain. If the OCP defined the situation in which onchocerciasis would be eliminated as a socio-economic and public health problem, then three countries have achieved this and there are prospects for doing that in the other two countries. However, averages hide pockets of poor control where the parameters are not met and these could always be the source of recrudescence. Despite recognising the substantial achievements of the prografirme and its staff, the Evaluation Team concluded that there is an urgent need to consolidate these achievements and to secure the future of onchocerciasis control. While onchocerciasis has been enormously reduced as a current socio-economic and public health tlreat, experience has shown that recrudescence can occur quickly, particularly during times of conflict or social unrest, and this requires country and regional action and vigilance. Among the aims of the phasing out strategy of the APOC programme, which is due to come to an end in20l5, specific mention is given to the need to support cross-border activities, to prevent recrudescence, and to secure onchocerciasis control for all countries where it is needed. So, although the SIZs are over, there are opportunities for APOC to consolidate results and to continue support to countries where it is really needed. After 2015, APOC will no longer play this role and other actors must take on responsibility for essential tasks. The Evaluation Team found that while the vector-control activities were carried out efficiently and according to plan by a dedicated team, it is not possible to indicate the separate impact of these activities on the entomological situation, because the reduction in transmission potential is also influenced by the successful implementation of CDTI and the subsequent reduction in the human reservoir of parasite. However, due to expense and 8the persistent risk of reinvasion by black flies from non-vector-controlled areas, it is inadvisable for this strategy to be considered as a sustainable method for onchocerciasis control in future. Nevertheless, a clear conclusion of this evaluation is that CDTI is having a real and significant effect on reducing the human reservoir of the parasite responsible for onchocerciasis, underlining the effectiveness of this method as a strategy for the eventual elimination of onchocerciasis as a disease of public health importance. For this to happen, however, the CDTI model needs to be sustained because onchocerciasis elimination requires mass drug administration of ivermectin up to the end of the natural life span of the macrofilaria---aroturd 12-15 years. It is the firm belief of APOC that achieving this step requires integration of the community-directed treatment approach into current health-system structures and the Evaluation Team noted examples where integration of disease control strategies has increased efficiency of service delivery for the health system and improved the effectiveness of health spending. But to facilitate integration and maintain the network of community drug distributors---whose commitment is what underpins the programme's successes to date--- altemative sources of funding, training, and support must be found to replace the SIZ funds. If the health systems of SIZ countries step in to fill the programme's shoes, as they have pledged to do, there should be added benefits to health in the country as a whole, not just safeguarding achievements in onchocerciasis control. 9A. Introduction 1. The Special Intervention Zones The Special Intervention Zones (SIZs), which form the subject of this evaluation, are areas of five West African countries---Benin, Ghana, Guinea, Sierra Leone, and Togo- --in which, despite several years of combined vector control and ivermectin treatment, the epidemiological and entomological situation with regard to onchocerciasis remained unsatisfactory in some sites at the end of 2002. This date marked the planned closure of the Onchocerciasis Control Programme (OCP), launched in 1974 by the World Health Organisation (WHO) as the executing agency, in collaboration with three other United Nations agencies: the World Bank (as the fiscal agent), the United Nations Development Programme, and the Food and Agriculture Organization. Stretching over I 300 000 km'z in 1l countries, the OCP became one of the most successful public-health programmes in Africa, after broadly reaching its objective of eliminating onchocerciasis (river blindness) as a disease of public-health importance in target countries. This achievement has prevented an estimated 600 000 cases of blindness and enabled 25 million hectares of land to become safe for use for cultivation and settlements. By December 2002, virtually all onchocerciasis transmission had been halted in 10 out of the 1 1 OCP countries. However, there remained a few areas within four of the 10 countries plus the entire territory of Sierra Leone (where the decade-long civil war intemrpted onchocerciasis control efforts) in which epidemiological and entomological parameters did not meet the programme's targets. So, rather than withdraw activities completely in these areas, the OCP Joint Prograrnme Committee decided to extend support for onchocerciasis control for five subsequent years in a prograrnme of special intervention, to be implemented under the auspices of the African Programme for Onchocerciasis Control (APOC). The regions now known as the SIZs encompass part of the Pru basin in Ghana, the tributaries of the Upper Oti basin in Benin and Togo, the adjacent Upper Oueme river basin in Benin, and the basins of Mafou and Tinkisso (including upper Niger) in Guinea, in addition to the whole of Sierra Leone. Indicating the extent of the problem in these areas, in the Oti basin recorded prevalence rates of onchocerciasis of up to 21 .lYo atthe end of the OCP programme, against a target of less than 5Yo, and with annual transmission potentials greater than 100 in savannah areas (the threshold beyond which visual sequaele may occur in the general population). In Siena Leone, prevalence rates in some areas were above 70Yo, displaying little apparent evidence of the 5 or so years of combined larviciding and ivermectin distribution that had been successfully undertaken before the war. Other common factors in the SIZ regions were the presence of significant seasonal migratory movements, compromised census data as a result of widely dispersed and isolated settlements, and the emergence or disappearance of villages---all of which hindered efforts to ensure comprehensive disease control. Beginning on January I,2003, and expected to run until December 31,2007,the SIZ project's general objective was to bring and keep down the entomo-epidemiological parameters in target regions to levels corresponding to the OCP standards, which could easily be maintained by participating countries. Specific goals were to reduce the adjusted prevalence of microfilaria in the population to less than 5%o, maintain this level, and to reduce the mean microfilarial load in the population to a level of 0.5 mf/s. 10 All the activities under the auspices of the SIZ project were implemented by teams from the national onchocerciasis control programme with the support of a Special Intervention Team (SIT), appointed by WHO AFRO and located at APOC headquarters in Ouagadougou. It was projected to cost US$ 12 098 732, a sum to be covered by undisbursed funds remaining from phase V of the OCP (1998-2002). During the early years of OCP, onchocerciasis control activities were exclusively based on control of the disease's vector, Simulum damnosum s./. (the black fly) by use of aircraft-distributed insecticides applied weekly over breeding sites to kill larvae. However, in 1987, Merck & Co Inc agreed to donate the anti-onchocerciasis drug ivermectin (Mectizan) for as long as needed to facilitate disease control efforts, which changed the programme's focus from exclusively vector control to a combination of drug treatment and larviciding or, in some areas, ivermectin alone. The Joint Programme Committee of the OCP in December 2002 recommended that the principal method of disease control in all SIZ should be Community Directed Treatment with Ivermectin (CDTI), initially implemented in OCP countries in 1998, and the primary strategy for onchocerciasis control in the 19 sub-Saharan APOC countries. By contrast with APOC countries, however, the SIZs were set "reinforced" CDTI targets of 100% geographical coverage and 80-85% therapeutic coverage (although in Sierra Leone the therapeutic target was set lower, at 650/o, to reflect the scale of progress needed there) with the aim of bringing onchocerciasis infection in these regions to target levels within the 5 year time frame of the project. Achieving 100% therapeutic coverage is implausible because in any community, individuals who are sick, pregnant, or younger than 5 years old are excluded from treatment. Ivermectin treatment was to be given annually in Ghana and Sierra Leone and semi-annually in the remaining three countries. In the tributaries of the Upper Oti and the adjacent Upper Oueme, CDTI was complemented with vector control using the same insecticide treatment strategy that had been in place for the duration of the OCP. This basic strategy also incorporated capacity building (including inter-country assistance), targeted operational research (finalising studies on black fly migratory movements, identification of parasite, and qualitative studies of knowledge, attitudes, and perceptions, etc), epidemiological and entomological surveillance, and hydrobiological oversight in areas of vector control. The specific indicators chosen to monitor progress in onchocerciasis control were the parameters used in the OCP, which included trends in prevalence and community microfilarial loads. For the whole SIZ period, WHO was the executing agency of the prograrnme, with administrative headquarters based at APOC headquarters in Ouagadougou, and an operational base at Kara, Togo. Support was provided to country teams by a Special Intervention Team (SIT) in Ouagadougou, whose head was appointed by WHO-AFRO and also held the post of programme manager of APOC in the office of the Programme Director of APOC. SIZ administrative matters, including the budget, human resources, and logistics, were managed by APOC, with Ouagadougou staff also providing necessary technical advice and support as needed. Funds for SIZ were sent from the World Bank to WHO headquarters in Geneva and replenished by APOC from there. The overall management of the budget and finance of SIZ was done by APOC. Most staff from the SIZ programme were nationals of the participating countries, with just a few international staff with WHO status recruited from the OCP, who were working mainly in Ouagadougou at APOC headquarters and at Kara in Togo. Various activities, including monitoring, training, financing, expertise, and evaluation, were 11 conducted in collaboration with other partners including Sight Savers International, in Benin, Togo, Ghana, Sierra Leone, and Guinea. Helen Keller International and Organisation for the Prevention of Blindness (OPC) were also involved in Guinea. After the end of the SIZ period, it was planned that countries should continue the activities---particularly reinforced CDTI until 2012---without further f,rnancial or management support from the SIT and SIZ management, who were due to end their involvement with the prograrnme at the end of 2007 . A mid-term evaluation of progress of the SIZ activities was done in 2005. This report is the final evaluation of the project's achievements (See Terms of Reference, Annex I, for fulI objectives). 2. C o untry-sp e ciJic b ac k gr o und At the beginning of the evaluation exercise, during an initial planning meeting in Ouagadougou, February 2008, oral presentations from representatives of each of the SIZ countries were given to the Evaluation Team to provide background information on the specific successes and challenges in each nation. This information is summarised below, incorporating additional background information from country mission reports (See Annex II a-e). Benin In Benin, the endemic onchocerciasis zone covers an area of about 81 000 km'z extending from the north to the south about 40 km before the sea, and affecting 51 cofirmunes out of the 77 which make up the country. The OCP started operating in Benin in 1977 on the Niger and Oti tributaries; it was extended to all the Atlantic basins in 1998, and at the end of OCP in 2002 onchocerciasis endemicity had been reduced to a point that it did not pose a public health problem, with the exception of few pockets in the northern part of the country where epidemiological and entomological data were considered unsatisfactory. The area designated for special intervention consisted of communities in 11 communes. Reinforced CDTI implementation for this area started in 2003 and drug distribution is done twice a year in all SZ areas. Vector control activities, as a protection against contamination by reinvasion of the Upper Oti basin, continued in the Oti and Ou6m6 basins at the same level during the SIZ period as during the OCP, but without the aid of paid fly collectors. Ghana In Ghana, nine of the 10 regions have onchocerciasis endemic areas with an estimated 3204 communities affected and a total at-risk population of about 3 million. Onchocerciasis activities started in 1974, focused on larviciding as in other OCP countries at the time. Ivermectin distribution started in 1987 using mobile teams and later switching to CDTI in 1998 as the primary distribution method, as in other countries. Vector control was halted in the Volta basin and its tributaries in 1993-94 but continued up to 2002 in the Pru basin where, at 740, the annual transmission potential (ATP), a measure indicating the number of infected human parasites a person sitting at a catching point would have received during a year from the bites of the black fly population, still remained higher than the target of 100. The special intervention zone on the mid and lower Pru river, created in 2002 and launched in 2003, served as the focus of reinforced CDTI activities. This area now covers 247 communities in seven districts, after a re- demarcation of the SIZ area in 2005. t2 In2003, the onchocerciasis and lymphatic filariasis programmes were merged and, although this development has helped improve coverage, it has also caused reporting issues because it is now difficult to isolate information on onchocerciasis-endemic communities. Since 2007, the programme has been implemented as part of an integrated programme against trachoma, onchocerciasis, lymphatic filiarisis, schistosomiasis, and soil transmitted helminths with different mechanisms of distribution and support across the country. Guinea Onchocerciasis occupies most of the area of Guinea with 2 million people exposed to the disease and 20 000 already blind as a result of infection. Disease-control preparatory activities date back to 1986 but the main national control programme was established in 1989-90, when ivermectin distribution and larviciding were set up in the majority of the country. From 1990-93, ivermectin was distributed using mobile teams, but this method was subsequently replaced by CDTI in 1997 as in other countries. Once this change occurred, the mobile teams instead took on roles in evaluation surveillance, entomological surveillance, and monitoring and supervision. [n most of Guinea, larviciding for vector control was gradually stopped when reductions in ATP showed that virtually all transmission had stopped. But there remained three basins---the Haut Niger, Mafou, and Tinkisso, all of which are tributaries of the Niger river---where ATPs were rising again in 2000-2002, despite remaining lower than 100. Investigation of this trend led to agreement of a special intervention zone comprising 6 districts, 2412 vlllages, 872954 villagers, and 440 community-directed distributors (CDDs). CDTI was then reinforced in this area, by adoption of twice yearly rather than once yearly distributions of ivermectin and intensified coverage. The SIZ was expanded in 2005, at the initiative of the national coordinator, to include three extra districts along the border with Siena Leone bringing the final total SIZ region to 3215 villages and over one million people. Sierra Leone An estimated 60Yo of Sierra Leone lies in the onchocerciasis belt of West Africa and is drained by a network of several large rivers with numerous breeding sites for black flies. From 1990, the beginning of disease control operations in the country, both aerial larviciding and distribution of ivermectin were used to reduce disease prevalence. These activities continued in the country until around 1994, with fairly good results; however, because of the war ravaging the country between 1991 and 2002, onchocerciasis activities had to be stopped. There was a brief resumption of vector control in 1997 , but this ended after five weeks due to continued insecurity. In 2003, the programme was essentially started from scratch, with the entire territory considered a SIZ using CDTI as the only disease control method. This strategy is applied in all of the 12 districts of the country, but it has only been effectively implemented for the past two years. Because of the severity of the situation, and the low level of control activities, at the inception of the SIZ prograrnme, Sierra Leone was assigned a lower therapeutic coverage target (65%) than the other SIZ countries. Togo Onchocerciasis has been highly prevalent in Togo, and is present in all but two southern districts. Vector control under the OCP began in Togo in 1977 and was limited to the Upper Oti river basin and White Volta tributaries. However, in 1987 this area was extended to the east and south to cover all the onchocerciasis foci. The first large scale 13 treatment with ivermectin took place in 1987 and was followed by a programme of distribution by mobile teams. CDTI was adopted in 1997. The SIZ area in Togo is in the north of the country covering 21 000 km2 in 1l out of 30 districts, and, as in the other countries, includes populations that were partly or episodically left out of onchocerciasis control efforts in the past, so represented a true reservoir of microfilaria. About 1060 villages with 870 000 inhabitants comprise this region and they are serviced by 3000 CDDs. Distributions of ivermectin are carried out twice yearly in the SIZ regions, compared with just one annual treatment in non-SIZ areas. Togo also housed the operational headquarters of the SIZ programme, which was based in Kara. t4 B. The evaluation process I. Introduction to the evaluation The pre-specified time allocated for the SIZ activities---the 5 years between 2003 and2007---is now complete and the achievements and challenges of this period are under scrutiny in the present report. This evaluation was commissioned to review and assess the achievements of SIZ against its stated objectives and mandate. Specific additional objectives include assessing the level of incorporation of SIZ activities into routine country health system activities and assessing the prospects for sustainability of activities related to onchocerciasis control. Conclusions from this evaluation process describe the most significant lessons leamed from the implementation of operations undertaken in SIZ areas. Findings presented here build on the work of a mid-term evaluation of the SIZ countries, undertaken in 2005. At that time, onchocerciasis was clearly a health priority in participating countries, integration was showing good prospects, and it was noted that despite growing requests for incentives, CDDs' dedication to the task of ivermectin remained strong and the paucity of incentives, although an often-mentioned issue, was not adversely affecting coverage rates. However, the mid-term review also underlined the fact that there was an imperative need for continuation of CDTI in SIZ and non-SIZ areas, and of adequate monitoring and surveillance for an undetermined number of years after cessation of SIZ activities at the end of 2007. The review of progress and achievements at both the mid-term and final points of the SIZ was initially recommended by the Expert Advisory Committee of the OCP, in addition to a recommendation for annual monitoring of SIZ activities by an oversight committee. In this report, in accordance with the Terms of Reference, the Evaluation Team presents its assessment of the achievements of the SIZ activities in the five intervention zones, as measured against the specific objectives. Also presented are lessons leamt, conclusions, and recofirmendations for follow up action needed. 2. Objectives 2-I General objectives o To assess the achievements of SIZ against its stated objectives and mandate o To assess the level of incorporation of essential post-SIZ activities in national plan of countries and their routine health activities o To assess the prospects for sustainability in all countries including adequacy of surveillance systems, national policy on integration, co-implementation with NTD and other diseases as well as financial provision for continuing residual activities related to onchocerciasis control o To describe the most significant lessons learned from the success or failure of the operations undertaken in SIZ areas relevant to the elimination of onchocerciasis or other disease control activities o To formulate conclusions and recommendations of the evaluation for each stakeholder involved (Countries, WHO, donor community, NGDOs, etc.) which might be useful for APOC or other similar international public health partnership pro gramme. 15 2 -I I S p e ciJic o bj ectiv es To review and assess the SIZ management arrangements at all levels (headquarters, Kara, and country levels), taking into account the support received from APOC To review and evaluate the processes and performance of CDTI, vector control including aquatic monitoring and surveillance in the SIZ against stated objectives and indicators To assess the adequacy of the support given by the APOC/Special Intervention Team to SIZ countries and those outside the Special Intervention Zones To review and evaluate the performance of epidemiological and entomological surveillance in the former SIZ countries, including SIZ achievements, taking into account whether the surveillance systems in these former SIZ countries are effective enough to maintain OCP achievement To assess prospects of sustainability of onchocerciasis control in former SIZ areas beyond2007, taking into account government commitment, availability of key inputs, stakeholders participation, partnerships and external support and integration into national health systems To assess the needs of the former SIZ for further support from APOC post 2007 To assess the level of integration of onchocerciasis control activities in the health systems of the former SIZ countries To examine the need for and possible role and modality which would enable inter-country coordination of former SIZ countries in 2008 and beyond. o a a a a a a 3. Methodology The evaluation team had a preliminary meeting in Ouagadougou in February 2008. During the first part of this meeting, the team was able to talk with key people including each of the national coordinators or a representative from the national SIZ team. After these discussions, the team met and refined the Terms of Reference, designed an evaluation framework, developed the methodology and tools (see Annex III), and drafted a preliminary work plan with time-lines agreed. The evaluation builds, where possible, on the work carried out during the mid-term review and also examines the extent to which the recommendations of this review have been followed up and implemented. Data to inform the evaluation was gathered in a number of ways. Staff and stakeholders involved in the SIZs (at all levels) have been interviewed and documents made available for an extensive review. Five country visits were made by the evaluation team and during these visits interviews were held at national, regional, district and community level. The results of these interviews enabled the team to "cross reference" and "triangulate" the data collected. A debriefing was given at country level at the end of the five visits. Reports of these country visits were used by the evaluation team in a "write shop" where results, key findings, and recommendations were developed. The quantitative data that is used in this report has been extracted from the regular reports to the SIT with additional data provided by the national coordinators and staff based at APOC headquarters in Ouagadougou. a t6 The evaluation team consisted of six members and one expert advisor who contributed his expertise and long-standing knowledge of OCP and SIZ throughout the evaluation. The team has received support and much information from those involved in the implementation of the SIZ programme but the conclusions are solely those of the team, and have been independently arrived at. The recorlmendations are the result of the joint deliberations of the team. Every effort has been made to ensure the accuracy and the reliability of the report and the results will be discussed by APOC with key stakeholders. 3-1. Limitations of the methodologlt The sites visited during country missions were chosen in consultation with the relevant national coordinators, who were asked to suggest contrasting sites to give an idea of the varying levels of progress and challenges within each country. The sites are not necessarily representative but, rather, illustrative. The quantitative data has been provided by the national onchocerciasis control programmes Q.{OCPs) and by the SIT, and has not been validated as there was neither the time nor the budget available to do this. The team has suggested that sampled validation of the data be considered and APOC has indicated that it is likely that funds will be made available in future to complete this task. The entire evaluation was carried out to a tight time-schedule---a common limitation in evaluation exercises such as this---with a week available for each of the country visits; these restrictions meant that assessment of country progress depended largely on information collected through field and central level interviews, and summary review of document records provided by SIT and the NOCPs. Detailed review of Ministry of Health work plans to assess the level of incorporation of onchocerciasis activities in national plans was not possible. t7 C. Findings In presenting the results of this final assessment of the SIZ programme, the evaluation team has chosen to highlight the overall outcomes of SIZ strategies in terms of coverage rates and changes in OCP parameters before moving on to consider how each aspect of the prograrnme may have impacted on these final results. The team took as an initial assumption the notion that if all SZ procedures were implemented as planned, we would expect to see by the end of SIZ that all countries would have achieved 100% geographical coverage and 80-85% therapeutic coverage with corresponding reductions in prevalence and clinical symptoms. These results are presented below under the broad heading Achievements of SIZ. From this basis, and in accordance with the Terms of Reference, we subsequently analysed the three key programme components---management, CDTI, and vector control---to ascertain the extent to which good or poor perforrnance may have impacted on the overall outcomes recorded by the end of the SIZ programme. Findings related to the extent to which onchocerciasis control has been incorporated into future work plans in SIZ countries are discussed in the section on sustainability. l. Achievements of SIZ l-I Geographical and therapeutic coverage Geographical coverage The regions now known as the SIZs encompass the Pru basin in Ghana, the tributaries of the Upper Oti basin in Benin and Togo, the adjacent Upper Oueme river basin in Benin, and the basins of Mafou and Tinkisso (including upper Niger) in Guinea, in addition to the whole of Sierra Leone. From the initiation of the project, the SIZ regions were set stringent targets for geographical and therapeutic coverage with the aim of bringing onchocerciasis under control in compliance with prograrnme targets within 5 years. The number of villages in each country that made up these special intervention zones was agreed between the national onchocerciasis prograrnmes of each country and the SIT based on the results of the review of OCP progress at the end of 2002 and taking particular account of areas in which onchocerciasis control had been missed, delayed, or inadequately implemented. In Ghana and Guinea, the SIZ regions were both re- demarcated some way during the SIZ project for different reasons. In Ghana, there was a reduction of SIZ village numbers in response to queries from APOC about variable population numbers. And in Guinea, the national coordinator noticed additional problem areas in three districts along the border with Sierra Leone that had not been included in the 2002 review and added these to the SIZs in consultation with SIZ management. Although all SIZs shared the common characteristics of significant seasonal migratory movements, compromised census data as a result of widely dispersed and isolated settlements, ffid the emergence or disappearance of villages, in Benin, there was a particularly marked steady increase in the number of hamlets and villages covered by the SlZs---around 100 year-on-year---as new settlements were identified. This reflects a major effort to improve coverage. There was a similar increase in Togo, although at a lesser extent. 18 Benin, Guinea, and Togo have maintained a high geographical coverage over the five years of the SIZ period. However, the large numbers of new settlements found each year in Benin were so high that the coverage rate in 2003 should be interpreted with caution, in light of the fact that many settlements had not yet been recorded. In the case of Sierra Leone, geographical coverage of close to 100% was achieved only in 2006 and 2007 after a difficult start to CDTI in 2003104, and then intemrption of treatments in 2005. However, the epidemiological mapping of onchocerciasis is not yet completed so more endemic but untreated populations may yet be identified, which implies careful interpretation of the 100% coverage. The situation in Ghana has been erratic. In 2003, geographical coverage was 100% but declined to 86.8% in2004, and in 2005 there was virtually no treatment. In 2007, the geographical coverage was 78.5%. Table 1: Numbers of villages comprising SIZs in each country and geographical coverage rates for the 5 years ofthe project Therapeutic coverage The target for therapeutic coverage was set at 80-85%o for all SIZs except for Sierra Leone where, as mentioned earlier, the war had reversed almost all previous achievements in onchocerciasis control so a 65%o level was seen as more realistic. Even with these high targets, Togo and Benin were able to achieve their goals throughout the 5 years of treatment. In Guinea, the target coverage was achieved in 2006 and 2007. However, in Ghana, therapeutic coverage rates remained slightly below target at around 70Yo for most of the SIZ period although in 2005 there was a significant drop in coverage when only 9%o of the total population was treated, due to issues related to funding of onchocerciasis control efforts. Despite these summary data, however, reviews of records from the field visits in all the countries conducted by the evaluation team showed wide Country 2003 2004 2005 2006 2007 Benin Villages t470 t575 r 615 r862 I 903 % 99.7 89.6 9s.8 94.0 98.7 Ghana Villages 477 477 247 247 247 % 100.0 86.8 t5.4 90.7 78.5 Guinea Villages 24t2 24t2 24r7 24t6 3220 % 99.6 99.8 99.9 100.0 100.0 Sierra Leone Villages 845 1 84s 1 845 1 845 1 845 1 % 28.3 22.2 0 98.0 100.0 Togo Villages na r025 r042 1050 1054 % 100.0 98.0 100 99.0 99.5 19 variation in coverage in the communities ranging from 40Yo to as high as 9lo/o. The use of the average coverage rates therefore hides information on poorly treated communities, and the evaluation team found evidence that follow up for particularly poor performing villages was variable across the SIZs. This discrepancy must be addressed, perhaps by encouraging systematic reporting of proportions of villages falling below coverage targets. Table 2: The total population comprising SIZs in each country with therapeutic coverage rates over the duration of the project Conclusion: At the end of the SIZ period, the geogrophical objectives seem to have been achieved in Benin, Guinea, and Togo and partially achieved in Ghana and Sierua Leone, where the trends qre encouraging. The data also indicate that the target of 80-85% of therapeutic coverage rates is attainable---an observation that can be considered in the planning of other onchocerciasis control programmes. Recommendation 1: Due to the finding that average coverqge rates hide information on poorly treated communities which are sometimes not followed up, the evaluation team encourages systematic reporting of proportions of villages falling below coverage targets and urges national systems to keep up surveillance of local problems in coverage and react quickly to address issues. Checking the validity of 100% geographical coverage rates is a priority. It also recommends that support be given to Sierua Leone and Ghona to complete the mapping of the disease. Country 2003 2004 2005 2006 2007 Benin Population 533738 621680 66064r 692996 76983r % 80.9 80.7 82.0 8t.2 83.0 Ghana Population 248,082 274,219 172,685 199,227 204,208 % 74.0 70.0 9.0 77.7 75.3 Guinea Population 893,221 893,221 897,715 876,599 1,122,553 % 78.0 78.0 79.3 80.1 81.0 Sierra Leone Population 2,023,022 2,023,022 2,023,022 2,440,992 2,352,586 % 35.0 28.0 0 54.0 75.0 Togo Population N/A 751,514 776,706 829,230 866807 % 86.0 85.0 84.0 85.0 83.7 20 1-II. Achievement of OCP target epidemiological parameters One of the main measures of success of the SIZ is the assessment of epidemiological indices, an exercise that was pre-planned to be carried out at three-yearly intervals. The specific measures chosen for analysis were the same as those used in the OCP: adjusted prevalence of microfilaria in the population and community microfilarial toad (CMfL). The former is a measure of the proportion of individuals within a population who are carrying the onchocerciasis parasite and the latter indicates the average burden of infection. Both are measured in the population by use of calibrated skin biopsies (skin snips), which require trained technicians, well-maintained equipment (sclerotomy punches), and willing volunteers because the operation can be quite painful if the instruments used are blunt. Target values for these two indices, the levels at which it was concluded that the public health problem of onchocerciasis had been brought under control, were set at 5oh prevalence and the CMfL was less than 0.5 microfilaria/skin snip. Compared to the number of villages under treatment, most progralnmes used very few villages for the epidemiological evaluation. And by the end of 2007, when the project wound down, most of the countries had conducted only one round of evaluation. In places where two rounds were done, the same villages were not always used, hindering the comparability of the two sets of figures. To obtain the data, each country was divided into epidemiological units comprising one or more sentinel villages. Each sentinel village was to be visited every 3 years but every epidemiological unit was to be visited every year. It was apparent from the evaluation team's findings that the national prograrnmes in SIZ countries could not follow fully the specified programme for many reasons to do with limited resources, logistics, and other constraints. Encouragingly, the results in three countries Benin, Togo, and Guinea indicate low prevalences of microfilaria which were below the pre-determined target limits. In Togo, there is a steady decrease in the prevalence of microfilaria, most likely to be the direct result of success of the control activities. However, Ghana and Siera Leone still have a high proportion of villages surveyed with prevalences of microfilaria above the 5o/o threshold and the Evaluation Team found evidence that, particularly in Ghana, there seem to be populations outside the boundaries of the SIZs in which prevalences are as high as 50%. All national coordinators placed significant emphasis on the necessity for continued epidemiological evaluation in the detailed plans of operations and budget for the 2008- 2012 period, prepared on request from SIT and the Special Advisory Committee (SAC). However, because the mechanism for epidemiological evaluation has been organized as a sentinel network of villages, and its contribution depends largely on keeping to the scheme of work as planned, a major concern about the future of this work is funding. For the duration of the SIZ, this activity was largely supported by SIZ and NGDO budgets, which brings into question the sustainability of activities. A proposal has been put forward that onchocerciasis surveillance might be coordinated at an inter-country level to help facilitate raising of extemal funds. However, such an initiative would require all participant countries to agree on the general principles and protocols and their implementation at the country level, including whether or not current approaches and techniques be revised. 2t To facilitate expanded epidemiological evaluation, it is suggested that the DEC patch-test, which has been experimentally studied for many years by OCP, APOC, and the Special Programme for Research and Training in Tropical Diseases (TDR- MACROFIL project) be further considered as a tool for epidemiological evaluation eventually replacing the skin snip test if there is sufficient scientific evidence to support the substitution and consensus behind such a move. Furthermore, countries should be encouraged to identifu national institutions which could provide support for epidemiological and entomological evaluation including support with data analysis and operational research. For example, the Noguchi Memorial Institute for Medical Research in Ghana and other similar institutions in other countries could perform this function. 22 Table 3: Trends in prevalence of microfilaria and changes in community microfilarial loads (CMfL) since the start of SIZ activities Country Year Villages evaluated (Total) Prevalence of microfilaria CMfL Mf :0 >0 -< 50h > 5"h 0-0.4 >= 0.5 Benin 2003 NrL (1470) 2004 le (l s7s) t2 (63.2\ 6 (31.6) t (s.2) t9 (100.0) 0 2005 t2 (t6ts) 6 (s0.0) s (41.7) 1 (8.3) t2 000.0) 0 2006 NrL (1892) 2007 l3 (1e03) 8 (61.s) s (3 8.s) 0 l3 (100.0) 0 Ghana 2003 NrL (477) 2004 t4 (477) I r)(7 3 (21.4) l0 (71.4',) l2 (8s.7) 2 (14.3) 2005 e (247) 2 (22.2\ 3 (33.3) 4 (44.4) 8 (88.e) 1 r)(11 2006 12 (247) 7 (58.3) 2 (16.7) J (2s.0) t2 (100.0) 0 2007 NrL (247) Guinea 2003 NrL (2412) 2004 s2 (2412) 2 (3.8) 43 (82.7) 7 ( l3.s) 5 .1 1 )(e8 I ( 1.e) 2005 3s (2417) l5 (42.9\ 1e (s4.3) I (2.8) 35 (100.0) 0 2006 t3 (2416\ 7 (s3.8) 6 (46.2) 0 13 (100.0) 0 2007 20 (3220) 1e (es.0) l (s.0) 20 (100.0) 0 Sierra Leone 2003 43 (84s1) 0 0 42 (100) 1 (2.3) 42 (e7.7) 2004 43 (8461) 0 0 43 (100.) 0 43 (1oo) 2005 3s (84s1) 0 I (2.e) 34 (e7.r) 8 (22.9\ 27 (77.1) 2006 NrL (84s1) 2007 NrL (84s1) Togo 2003 20 (1026) 5 (2s.0\ 2 (10.0) l3 (6s.0) 20 (100.0) 0 2004 10 (1026) 2 (20.0) s (s0.0) 3 (30.0) l0 (100.0) 0 2005 22 (t042) 2 (e.1) l3 (s9.1) 7 (31.8) 22 (100.0) 0 2006 27 (r0s0) 8 (29.6\ e (33.3) 10 (37.0\ 27 (100.0) 0 2007 2s (r0s4) l3 (s2.0) 11 (44.0) 1 (4.0) 25 (100.0) 0 Conclusion: Four countries have done very well in achieving the epidemiological aims of SIZ and there are encouraging trends in Ghana. 23 Recommendation 2: Continued monitoring and evaluation of epidemiological parameters in SIZs is essential to ensure that the SIZ project target of bringing down and keeping down these measures is seen to be met after the closure of the programme. There should be inter-country discussions with APOC management and WHO-AFRO to develop a strategt to ensure this work can continue. Recommendation 3: Few operational research studies have been done during the SIZ period, even though this was one of the objectives of SIZ. National research capacity in SIZ countries should be developed and associated with the continuing research agenda of TDR. 2. Programme Management 2-I Financial resources The budget of SIZ was drawn from the OCP trust fund reserve amounting to US $ 12 098 732 at the end of 2002. The funds were managed by the finance department of APOC, in accordance with WHO established procedures. This section discusses the management and disbursement of the central funds. Additional funds are mobilized at country level, from both govemment and NGDOs, and these are analysed and discussed in more detail in the section in this evaluation report on sustainability (section 6). Table 4 gives an overview of the main disbursements made through APOC for SIZ activities. No separate auditing of SIZ funds was planned or carried out; however, the overall APOC funds are audited by WHO internal auditors and by the external auditors of WHO. The approved auditors' reports were presented to the evaluation team. Disbursement to country level National onchocerciasis control programme teams presented a yearly proposed plan of action and budget to SIT. After approval, Letters of Agreement describing the activities and the matching budget were signed between SIT and the Ministries of Health. Funds sent to countries in installments in accordance with the work plans and in accordance with the letters of agreement. The first installments of the funds were generally transferred to the countries in January, or no later than early February, so that they were made available in time for the work to be carried out by field teams. Senior management of APOC informed the evaluation team that there had never been a shortage of funds or a delay in receiving funds from Ouagadougou, when national programmes complied with the WHO financial rules and regulations. However, it was clear from the Evaluation Team's research that some countries, particularly Ghana, had considerable trouble meeting the necessary requirements for fund disbursement. Issues of concern During their country visits, the Evaluation Team heard of several cases where the planned work was delayed or not carried out because the necessary funds had not been disbursed. It would seem that there were two main reasons for these delays. On the one hand countries reported difficulties in complying with the complex financial rules and regulations and reported that minor administrative errors could result in long delays. On the other hand, countries reported problems in pre-financing implementation plans in the 24 way that was required by the method of payment in installments. In some countries this resulted in delays, others were able to solve the problem internally. The mid-term evaluation made a recommendation that national control programmes, in implementing Letters of Agreement, must ensure full compliance with WHO rules, including punctual and accurate submission of monthly returns, while SIZ management must continue to exercise control and provide targeted training to overcome the difficulties encountered. The evaluation team learnt that all SIZ countries have implemented Letters of Agreement in compliance with WHO rules and regulations with the exception of one country. SIZ management informed the evaluation team that this country has been lagging in submitting financial returns through the lifespan of SIZ. Table 4: APOC/SIZ financial contributions to SIZ countries 2003-2007 Table 5 : APOC/SIZ financial contributions to non- SIZ countrie s 2006 -2007 Countries 2003 2004-200s 2006-2007 TOTAL o//o Benin $434 s40 $907 670 $614 stz $r 956 722 15.0" Togo $967 7t4 $1 990 040 $t 892 617 $4 850 371 37.3'/o Ghana $26,395 $2t,936 $138,1 15 $186 446 1.40 Guinea $24,2T4 $40,055 $85,815 $150 084 l.2o/" Sierra Leone $t26 299 s29s 320 $950 ss9 sl 372 178 10.50h Fellowships, grants, and other contributions $0 $136 930 $r7 92t $154 851 1.20 Temporary assistance for the 5 countries $34s 8s3 $r 57t 643 $1 s26 088 $3 443 s84 26.5"/o Research $8s5s $1t,377 $55,000 s74,932 0.60h General operating expenses for the 5 countries $134 329 9244 772 $265 844 $644 945 5.0"/o TOTAL s2 067 899 s5219 743 s5 s46 471 $12 834 113 98.60/0 Countries 2003 2004- 2005 2006-2007 TOTAL Senegal $t6 273 st6 273 0.lo Burkina Faso $r22s6 st2256 0.lo/" Mali $31 61s $31 615 0.20h C6te d'Ivoire $76 9ss $76 955 0.60/0 Guin6e Bissau $4s 669 $4s 669 0.40h TOTAL $182 768 $182 768 L.4o/" i,.t' I .i ii, 25 Table 6: Financial contributions by partners other than APOC/SZ to onchocerciasis control activities in the SIZ countries 2003-2007* Togo(FCFA) Benin (FCFA) Sierra Leone (US$) Ghana (Cedi) Guinea (GF) * In general there is not a distinction made between the funds for the special intervention zones and national activities so these fund" represent contribution for onchocerciasis control activities and not just for the SIZ programme. PARTNERS 2003 2004-2005 2006-2007 TOTAL MOH 5 000 000 37 500 000 42 500 000 SSI 42 094 s49 85 624 04s 64 720 844 r92 439 438 AFRO 2 062 328 2 026 440 4 088 768 TOTAL 42 094 549 92 686373 104 247 284 239 028206 PARTNERS 2003 2004-2005 2006-2007 TOTAL MOH 40 000 000 200 000 000 380 000 000 620 000 000 SSI 0 2 000 000 90 000 000 92 000 000 AFRO 0 4084 0 4084 COMMUNITY r426 64t6 0 1842 TOTAL 40 001 426 202 010 499 470 000 000 712 ott 925 PARTNERS 2003 2004-2005 2006-2007 TOTAL MOH N/A ttz 476 2t5 230 327 706 SSI N/A 4s 000 84 000 r29 000 HKI N/A 7500 9000 16 500 World Bank N/A r78 57r I 43s 760 I 6t4 331 TOTAL N/A 405 666 2 694 986 2 087 537 PARTNERS 2003 2004-2005 2006-2007 TOTAL MOH 0 2t2 400 53 340 265 740 SSI 18 782 43 174 2r2 689 274 645 HKI 0 0 0 0 World Bank 0 0 0 0 TOTAL t8 782 43 174 2t2 689 540 38s PARTNERS 2003 2004-200s 2006-2007 TOTAL MOH 29 76r 108 400 53 000 191 161 SSI 31 860 162 472 250 000 444 332 HKI 0 175 475 11 085 186 560 OPC 45 761 329 612 85 000 460 373 AFRO 0 20 48r I 10 000 130 481 TOTAL 140 955 882 868 79s 456 1 412 907 26 2-II Adequacy of human resources for SIZ The organigram (Annex IV) shows organisation structure of SIZ management and how it was embedded in APOC. It also shows the planned positions in terms of human resources. According to planning, 13 people would work with SIZ as WHO Staff members. In general, staff members were recruited on time without real difficulty (both at APOC headquarters and in Kara and Parakou) since most employees came from the pool of former OCP staff and had the appropriate knowledge for the job. Problems were experienced in recruiting and retaining the person responsible for drug distribution and training (CDDT). This post was vacant from April up to October 2003 and again from 2005. All positions in Kara and Parakou were in the WHO contract category of Short Term Staff (professional and general services). According to WHO's rules and regulations, staff in this category cannot be employed beyond a maximum of 4 years. In view of the fact that this rule was likely to cause a major disruption to the SIZ activities through discontinuity in staffing, the mid-term evaluation recommended that a solution should be found to ensure the continuity of the prograrnme. A special exception to the 4- year limit was subsequently granted to make staff available until the closure of the SIZ. Job descriptions were available for all positions and staff appraisals were carried out according to the Performance Management and Development System (PMDS) used by WHO. A plan of work was prepared by each staff member at the beginning of the year and progress regularly reviewed. In addition to the WHO staff recruited by SIZ, national staff participated in the work of SIZ. These were government employees seconded to SIZ in Kara and Parakou under Letters of Agreement betweenslZ and the governments of Togo and Benin. The National Onchocerciasis Control Programme of Togo also liaised with SIZ staff in Kara for a coordinated effort. Human resource issues All the planned positions were filled (although not necessarily for the whole of the period) and human resources were managed in accordance with agreed procedures. However, the SIZ management recognised in retrospect that in spite of this apparently positive picture there were problems in relation to the adequacy of human resources, because the planned number of staff was not sufficient to do all the work. In some cases a post was filled by someone who also had other senior management responsibilities. In particular the Team Leader of SIT was also the Programme Manager of APOC, which meant that he was faced with a double work load and extremely demanding expectations that were sometimes impossible to meet. Although the Evaluation Team also note that this burden may not have been so much of a problem had there been consistent support for the whole SIZ period from an appropriate Assistant Team Leader. Furthermore, the lack of continuity in the position of CDDT had implications for support to countries (see section below) and the retirement and late replacement of the SIT Assistant Team Leader in 2006 meant that the work load at the already overstretched headquarters increased. 27 Conclusion: The shortage of staff at headquarters impacted on the support SIT was able to give to nationol coordinators and in their capocity to do in-depth analysis of country- level data and support opportunities for operational research. Lessons from this exercise should be used to inform staff planningforfuture onchocerciasis control activities. 2-III. Relationships and effectiveness of coordination between SIT and national coordinators The structure of the SIZ is field-oriented with only a minimum staff based in Ouagadougou. These members of the SIT facilitate the coordination and funding of SIZ activities and liaise with in-country onchocerciasis personnel. An annual review and planning meeting took place in November in Ouagadougou to which all countries including OCP non-SIZ countries sent representatives to discuss points of common interest. There was a specific emphasis on cross-border issues at these meetings. All national coordinators participated and presented their annual activity report as well as the plan of action for the subsequent year. Members of the Special Advisory Committee (SAC) and non-governmental partners of national onchocerciasis control programmes also participated in these meetings. During the meeting, data regarding the implementation of CDTI, geographic and therapeutic coverages, epidemiological evaluation, drug stocks management and entomological evaluation of each SIZ were reviewed. Plans for future activities were then submitted to, and reviewed by, SIT. The final report of the annual planning meeting is submitted to the SAC. Evaluators noted that these annual meetings were greatly valued by SIZ countries and it may be beneficial if they continue in some form even after the closure of SIZ. The mid term evaluation recommended that "SIZ management's contribution to data analysis, and provision of operational advice as well as scientific and technical guidance to national progrqmmes should be strengthened without delay, if necessary with the support of temporary consultants, in an attempt to increase the likelihood of achieving SIZ objectives during the remaining two yeors of SIZ activities, while seektng all possible solutions to improve the entomo-epidemiological results. " However, the evaluation team found that while SIZ management has certainly contributed to the area of data management, data analysis, and guidance in its dealings with national programmes, there were still considerable gaps in the effectiveness of coordination. No consultants were hired for this purpose; resources were drawn solely from APOC staff. Sierra Leone reported that they had received considerable support in data aur,allysis and operational research while other countries reported insufficient support and input in these areas, describing contact with SIT as limited. SIT staff seldom visited and the main contact was through e-mail, letters, the annual planning meetings and the SAC. It is important to note however, that visits to countries by SAC members, perceived by SIT as part of SIZ support, were not always understood as such by countries---a fact that may have contributed to an underestimation of SIT support by NOCPs. Evidence from country visits showed that expectations of SIT, and its role in support of national coordinators, were not clear right from the start of the SIZ period. Although one country certainly benefited greatly from SIT attention, others felt there was little input from SIT outside the regular meetings. Closer monitoring of problem areas by SIT could have helped national coordinators better tackle their specific challenges; 28 however, it should also be noted that suggestions by SIZ management to visit for fact- hnding and support activities were rejected by one country. Conclusion: While efforts had been made throughout the SIZ period to improve coordination between SIT and national onchocerciqsis control programmes, the recommendation of the mid-term review has not been fully addressed. Opportunities have been missed to strengthen the evidence base from the experience of SIZ countries and to give targeted technical support to country coordinators. Recommendation 4: Given the value placed on the SIZ annual meetings by countries, APOC should consider ways that these could continue in some form after the closure of SZ. 2-IV. Post-SIZ devolution of responsibilities from SIT to country programmes SIT has facilitated the discussions between national control programmes, WHO country offices, and NGDOs to define the role played by each stakeholder/partner in onchocerciasis control in the post-SIZ era. The evaluation team collected information on the progress of these discussions. Staff Several SIZ staff were employed at the Kara base in Togo which is now part of the WHO office in Togo. Following this move, a few staff members will be maintained in their positions under conditions indicated in a Letter of Agreement between the WHO Country office and the Government of Togo to support activities related to ivermectin distribution and epidemiological evaluation. At the closure of SIZ, the chief of the vector control team was recruited by APOC. Other staff at Kara were retained to participate in the SIZ closing activities (particularly to organise the archives) until the end of April. The contract of the other staff will be terminated in accordance with WHO rules and regulations. During country visits, some Evaluation Team members noted that not all people working for the SIZ programme at national level were demobilised in an orderly way. Buildings and equipment The Kara base has a number of buildings (offices, laboratories, garages, and stores) and a huge hangar near a local airstrip which was used for the helicopters contracted by OCP. All are the property of WHO. At the time of the evaluation team visit, discussions were ongoing to hand over the hangar to the World Food Prografilme and the Togo government, but no final decision had been made. Other premises were reassigned to the WHO country office and were being refurbished into offices, laboratories and archives to serve as a local base for WHO activities. Equipment including laboratory materials, vehicles, and insecticides, will remain in Kara to be used by the local WHO staff or sent to Ouagadougou. Organisation of archives Among the staff members mentioned above, one person was retained to organise the archives of Kara which will be available for consultation by anyone interested (a number of students and the hydrological services of the country have been already using the relevant OCP archives). The entomological and epidemiological data collected by OCP 29 are being digitalized and will be available in an electronic format in Ouagadougou and in Kara. Conclusion: The evaluation team concluded that the devolution and "winding down" processes appeared to have been planned and implemented in an orderly way with an eye for sustainability and future ne eds. 3. Implementation of CDTI Because sustained drug delivery over decades of the type required for control of onchocerciasis is diff,rcult to achieve by use of the regular health services alone, a system of community-led drug distribution has been adopted as the principle strategy for combating this disease. The vision behind CDTI is that community members in endemic communities, who are appointed and directed by their peers, should work in close collaboration with primary health care services to ensure the mass distribution of ivermectin on a yearly basis. The system relies on a cascade of training from national programme coordinators right down to communities, with each level of the health system involved in onchocerciasis related planning, and all relevant staff members received refresher training courses regularly. At the community level, front line health workers are the ones to approach communities and explain the concept of CDTI, giving the village leaders time after this initial discussion to select individuals they want to put forward for training as distributors (CDDs). Training and re-training of CDDs was carried out annually in all SIZs, although distributions were either once or twice yearly according to plans. Once trained, the CDDs were instructed to collect drugs for the annual distribution from local health centres and conduct censuses of their communities, in addition to distributing drugs and educating their communities about onchocerciasis. Drug distributions were done within a strict time limit of around 5 days and records of population changes and drug administrations are kept in a notebook, which is retumed to the local health centre soon after distributions have taken place. The philosophy of CDTI requires that the community as a whole decides on the month and specific dates of ivermectin distribution, which the CDD communicates to their contact health worker/facilitation team. CDDs also monitor adverse reactions and treat cases of minor reactions where possible. Any difficult or severe cases are referred to the nearest health facility. The last Joint Prograrnme Committee of the OCP, in 2002, endorsed the objective of strengthening CDTI in the SIZ to achieve 100% geographical coverage and 80-85% therapeutic coverage, with the exception of Sierra Leone, whose target was set lower at 65%. This section reviews the implementation of CDTI in the five SIZs with particular attention to the flow of ivermectin, training at all levels, and retention of CDDs. The evaluation team has identified successes, challenges, and issues of concern, and makes some specific recommendations for implementation of CDTI in future. 30 3-1. Ivermectin distribution Frequency of ivermectin distribution As decided by the OCP Joint Programme Committee, on the basis of simulations using the ONCHOSIM model, the timing and frequency of ivermectin distribution varied in the five SIZs. In Togo, Benin, and Guinea ivermectin is currently distributed twice a year at times decided on by the villages. In Togo, these distributions are in June and September-December, at the beginning and end of the dry season. In Guinea, twice yearly treatment has been implemented since 2005. In Benin, one of the treatment rounds is exclusively for onchocerciasis and the other is carried out simultaneously with the treatment for lymphatic filariasis. In Ghana, treatment is done once a year and the timing of distribution is determined locally by the district health team as part of the decentralised planning for health system. In Sierra Leone, which re-established CDTI fully in 2005, once yearly treatment is timed to coincide with the dry season. Conclusion: Frequency of distributions of ivermectin was consistent with SIZ planning although the reasoning behind the choice of once or twice yearly administrations does not seem to be well understood. The mid-term review of SIZ suggested that the assumptions of the ONCHOSIM model, on which this and other planning decisions were based, should be verffied. Recommendation 5: ONCHOSIM simulation with data collected in the SIZ should be continued to give o more accurate prediction tool. This, in combination with other operational research, will enable predictions to be made as to if and when CDTI might be phased out in the future. Ivermectin procurement, availability, and delivery All countries have systems in place to ensure that ivermectin is procured and supplied for use at community level. In Benin, Togo, Ghana, and Guinea ivermectin goes through the same channels as other essential medicines; in Sierra Leone, WHO facilitates the procurement for tax reasons. There have been occasional problems relating to estimating the requirements for ivermectin; most notably in Ghana where variations in census figures led to fluctuations in need and where overstocks from a previous year were assumed to be available whereas they were approaching expiry date thus no longer suitable for distribution. Some tablets are lost in all countries but the proportion lost is small and considered acceptable (eg, in Togo and estimated 8 or 9 tablets per village) and there is no evidence of "lost" drugs being resold or misused. Systems are in place for excess tablets to be returned. Record cards showing distribution were seen by the evaluation team in allhealth centres visited and it was only in Sierra Leone that the record cards seen were not fully maintained in a way that could indicate stocks received and available. Distribution was only exceptionally hampered by delays in procurement of tablets; in Benin the application of taxes on ivermectin by the mayor of Cotonou meant that the national onchocerciasis control programme were obliged to obtain its annual donation of ivermectin through Togo. Conclusion: Ivermectin procurement systems workwell in general in all countries. There are some losses, but these are usually considered acceptable in terms of quantity. In most countries, ivermectin flow and records are functioning well, but there are some minor issues related to record keeping and tracking ofleft over drugs for later use that need to 31 be resolved by local and national teams. Apart from minor logistical hiccoughs there were few problems in supply chain. 3-II. Population and communities The effectiveness of CDTI for keeping track of community members and ensuring high coverage for drug distributions is influenced by shifting communities that move, for instance, to respond to mining or seasonal farming opportunities, making the reliability of CDD-collected data difficult to ascertain. Problems maintaining accurate census figures, partly as a result of various forms of economic migration both in and out of country, and cross-border issues, are common to all the SIZs. Census development One of the positive spin-offs of CDTI has been the establishment and maintenance of census registers at community level, nonetheless it is a constant challenge to keep the censuses updated and accurate. Although CDTI helps to support censuses in general, because the populations change so rapidly, particularly in mining areas, and not all settlements are known at the initiation of drug distribution activities, it is common for population and village numbers to change over times. Most SIZ countries do censuses directly before starting rounds of ivermectin treatment and few problems were reported during the field visits. However, the fact that Benin reports the "identification" of around 100 new villages or hamlets each year is indicative of a situation in which there is still a lot to be done to document and update information about where people live. In Ghana, the population data have fluctuated substantially during the SIZ period and this pattern has posed problems in estimating medicines requirements or calculating left-over stocks. In 2005, SIZ HQ questioned apparently inconsistent data from the Ghana census and this led to the re-demarcation of SIZ. Ghana is the only country that updates the census at the time of distribution rather than ahead of distribution so drug requirements are based on estimates that are one year old. During the evaluation in Sierra Leone, it seemed that the population movements so evident in the aftermath of war had settled down and that CDTI had helped re-establish reliable information about where people are living. This was a positive finding since Sierra Leone has faced major challenges in re-establishing the census data needed for CDTI as during the civil war villages were destroyed and many populations fled from their home communities. Conclusion: Censuses were generally well done and these activities have contributed to the establishment of CDTI in countries. Now, census data generated by CDTI is being used by other progrommes. )/. Box 1: The many uses of census data Migrant populations and cross border issues Considerable efforts have been made over the past few years to track down hard-to- reach communities and seasonal migrant workers and to accommodate nomadic populations (although this last group does not contribute substantially to transmission). The mid-term review recorrmended that SIZ and national management teams should pay special attention to these groups and to their effect on transmission and on the reliability of coverage data. In general, the recommendations from the mid-term review have been implemented. Social scientists have been recruited to advise on hard-to-reach communities and some surveillance flights have been made by helicopters to seek out new settlements. In Benin and Togo, widely scattered communities are difficult for CDDs to reach with illegal loggers posing specific problems. During the last 2 years, prospection of new villages was assisted with helicopters using pre-paid flights originally planned for larviciding. Both in Guinea and Togo, efforts, by CDDs themselves in some areas, have been made to identify new villages and treat migrant populations. In all of the countries new CDDs were appointed when hamlets were identified. Togo has a special register devoted to migrant populations. The Fulani people who migrate between Nigeria and Ghana have a special treatment card indicating the time and date of treatment. Some countries have regular meetings to discuss cross-border issues. An example of this kind of meeting is the Mano River Union, between Guinea, Sierra Leone, Liberia, and Cote D'Ivoire, which offers a forum for these countries to discuss onchocerciasis control among other matters. In Ghana, in the sites visited during the field visits it was stressed As the commrlrity volunteers on which onchocerciasis control depends travel from door to door in their villages spreading infonnation and distibuting dnrgs, they are also performing an accounting task that has many uses beyond the simple hacking of treatnents for which it was designed. Before, or sometimes during, each treafrnent round, the CDDs orcheshate the annual task of collecting census data by taki-ng note of each of the rosidents in each household, listing them by age, height (a necessary mezrsure to determine the appropriate drug doses), along with the date and quantity of treafrnents. Incorporating notes for people who are sick or absent for reasons of employment, mariage, or temporary voyages in many cases these records constitutp the fust written deseription of rural populations in SZ counkies. Such unique and valuable information has helped onchocerciasis control by enabling accurate ordering of drug stocks, tracking of treated and untreated individuals, and provided a mechanism for follow up of those who were pregnant, under the age of 5, or otherwise ineligible for treahent at a given distribution time. But the most broadly beneficial effect of this information is the value it has to other programmes. During field visits conducted for'this evaluation, the Team encountered nurnerous reports of non-onchocerciasis related NGDOs seeking out census records generated by CDTI to help in their planning of looal projects; thorOby helping to expand access for communities to other forms of help and development support. JJ that flexibility about treatment timing was lacking and that this was critical as migrant workers were often way during the time that treatment was carried out. Box 2: The Mano River Union Conclusion: Mid-term evaluation recommendations have been followed up. A lot has been done to extend outreach, but this is not always evident in geographical coverage rates. A positive observation is that CDDs are taking the initiative to track down and treat people in newly identffied settlements themselves. and Leone set the goals states and strengthening 2004 :4 Cross border co-operation is wgstern the example of the Mano 34 3 -I I I. S e ns itis atio n, training, s up e rvis ion, and rep orting Sensitisation In general, prior to every CDTI round, an annual session for advocacy and sensitization is organized at all levels in the SIZs. After training, CDDs return to their communities and share what they have learnt, sometimes in a formal village meeting, about the disease and about the mechanisms for drug distribution. Some national control progralnmes take advantage of community radios to air messages about the relevance of taking ivermectin every year and to alert communities about dates earmarked for treatment. In Sierra Leone, billboards promoting ivermectin treatment were observed by evaluators. These systems, although heterogenous, seem to work effectively and reliably in all SIZs. Training Generally training is done in cascade fashion in all countries. Training activities are timed to occur before ivermectin distribution, so that prograrnme participants will have up-to-date knowledge about the rationale for treatment, the processes and expectations. The capacity building process begins with national teams providing updates for district Ievel staff, and district staff then transfer this knowledge to nurses at health centre level staff. The nurses, in turn, have the responsibility of providing refresher training for CDDs who have done the job before and to train newly appointed CDDs. The training curriculum for CDDs covers the method of ivermectin distribution, how to complete treatment registers, and how to prepare reports after the treatment round. The cascade process worked well for some countries while others encountered difficulties. Togo and Guinea were able to meet training targets over the last three years and are well resourced with training and IEC materials. Benin was not able to carry out refresher training for CDDs in 2007 for lack of funds. In the case of Ghana, there was not much central oversight of training activities going on at district level, and IEC materials (pamphlets and posters) were notably absent at facility level. This situation prompted questions about the quality of the training more specifically the training of CDDs. Still, CDDs interacted with in Ghana during the course of the evaluation demonstrated sound knowledge about the rationale for ivermectin treatment and the required processes involved in carrying out treatment. There was team-work among CDDs where literacy is at different levels. Supervision Supervision is also in cascade form from the periphery to higher level centres, but the intensity of supervision is not the same all year round. In Ghana, the health centre team provide adequate supportive supervision during distribution but liftle at other times. CDD supervisors operate in some villages in Guinea and are CDDs jointly selected by communities and the health centre chief to assist the CDDs in clusters of several villages for filling forms and transmitting reports to the health centre. 35 Reporting After every treatment round, CDDs are expected to compile their reports and are given a short deadline to turn in their reports to the focal health centre. One good practice observed in Ghana was organisation of a meeting of CDDs after the reports had been submitted to give feedback and address any problems with record completion. After CDD reports are collected, the health centre is responsible for collating all the data received from CDDs and forwarding these figures to the district level. Districts create the comprehensive district level report and make these available to the central level, to inform the official national report. The process seems to be working well for most SIZ countries. For Ghana, there was one flaw in the process. There does not seem to be any urgency on the part of district level staff about updating data or getting reports to central areas. For example, two distributions were carried out in one district to meet 2007 targets, yet only the coverage rate of the first distribution had been incorporated into official reports. This had an impact on coverage estimates reported to the SIZ secretariat. Furthermore, report writing may be hampered by the level of litteracy of CDDs. In some areas of northern Benin and Togo, evaluators found that it is sometimes difficult to recruit and replace literate CDDs. Conclusion: Sensitisation, training, supervision, and reporting ore governed by well- functioning procedures that for the most part leave CDDs and health staff members with adequate lcnowledge for their tasl{s and the necessary follow up. However, there are variations in the way these procedures are applied across regions, districts, and health facilities, which can sometimes couse problems further up the national onchocerciasis control chain. Recommendation 6: Even though the procedures for training, sensitisation, and supervision are largely decentralised in the SIZs, the Evaluation Team noted that some central oversight---perhaps in the form of occasional spot checl<s---could help maintain quality standards and ensure that the aims of the programme continue to be met. 3-IV. Findings related to community directed distributors In each of the countries the evaluation team met highly motivated, well trained, and committed CDDs with high levels of knowledge. Attrition rates were generally low and most CDDS were selected by the communities they serve. In countries that reported that there were two CDDs per village, it appeared that often only one was actually active. In most countries IEC materials were available with posters prominently displayed. However, in spite of a generally positive impression, there are a number of common challenges faced by countries relating to CDDs. In all countries, the question of incentives is a concern particularly given the incentives offered by other disease control programmes to people in communities who take on a specific role. Varying strategies have been adopted at country level and this reality is reflected in the report of the mid-term evaluation of the SIZ. The evaluation recommended that countries take their own decisions regarding the compensation of CDDs and that communities should work out the mechanism for providing suitable incentive packages so as to maintain community ownership. The mid-term evaluation also encouraged countries to develop and implement a consistent policy and discuss the implications and potential impact on sustainability of different programmes adopting different approaches. 36 Benin gives a token of 2000 CFA to CDDs as an incentive for each treatment round, paid out of the health centre revolving fund. However, according to some CDDs, this amount has not been paid for some time and threats have been issued by some CDDs to withhold the reports and refuse further cooperation with the programme. This is what one CDD commented: "The work is dfficult. I have requestedfor a bicycle but did not get it. I send reports and do not get a feedback so this time I hove not handed my report and I have decided not to treat when the time comes because there are no incentives. It is rumored that the nurse in charge is withholding our money destinedforus." In Guinea and Togo, pledges from the community to provide in-kind incentives to CDD are rarely honoured according to the CDDs. In the case of Sierra Leone, Helen Keller Intemational donates t-shirts to CDDs as a form of incentive. Other incentive ideas used in SIZ countries in the past included: flags for CDDs houses, identity cards, and certificates. Some communities do provide in-kind incentives such as transport, food, etc but the contribution is often not documented or recognized as incentives. For example, one community leader in Offinso district, Ghana, provides funds to the CDD towards transportation costs to attend training and also provides food for CDDs during distribution. Villages in Techiman district in Ghana have had meetings to identify additional incentives for CDDs. What emerged is that the health teams in Ghana are not aware of these efforts, and seem to believe that communities are not supporting CDDs. To compensate CDDs, health staff include a modest line item in the training budget to cover costs towards food and transportation costs. Added to this, many communities tend to nominate the same CDD for other progranunes, as was the case in Togo. Distributers in Togo also take part in rapid diagnostic tests for malaria and this co-implementation arrangement offers some solutions for the incentive issue, since the CDD is remunerated by other programmes so may not specifically demand extra incentives for his/her onchocerciasis work. Few and far between are the people prepared to do work for free. This truism seems to be a constant issue of contention in communities where volunteers are working every year to ensure the accurate distribution of drugs and information for onchocerciaisis control. The task requires work, for which the volunteer receives little or no recompense. And no matter how valuable a role he is playing in protecting the community's health, after a while, it is almost inevitable that he will request some sort of financial reimbursement for the tasks performed. An issue encountered again and again by Evaluation Team members was the fact that other disease control programmes---perhaps shorter term, with defined endpoints and large budgets--- approach the same communities to do health-related tasks and offer money, gifts, or other badges of recognition. Seeing these things on offer, commurity volunteers rightly query why there is no such enticement for their year-in-year-out onchocerciasis work. Some health facilities solve this problem by paying their CDDs. But this decision in itself brings problems. If the money is slow to arrive, CDDs become agitated, even in some cases refusing to carry out treatments or hand in reports. Entering into this kind of employer-employee relationship is neither effective nor sustainable for the national health services, especially because over time it is inevitable that there will be requests for inJlationary increases in compensation. Paradoxically, this issue could be an ultimate threat to sustainability of onchocerciasis control as more frequent co-implementation of programmes at community level (which will hopefully occur as onchocerciasis is better integrated into national health system planning) creates larger burdens for volunteers, and greater opportunities to see the enticements on offer from moneyed progftrrnmes. While it is certainly up to countries take their own decisions regarding the compensation of CDDs, the Evaluation Team found there was an unmet need to help communities decide on suitable incentive packages they could formulate themselves to maintain the motivation of their volunteers. According to interviews, what community volunteers most want are T-shirts, badges, or other such markers to identifu them as onchocerciasis control people within their communities and act as recognition for the work they have done. Time and time again, we heard the same message: volunteers are committed to the work, and will do it as long as necessary, but they feel their effons lack recognition. But it is important to remember that there remains no evidence that this dissatisfaction will have -term benefits for sustainability 5t Box 3: Incentives---an ongoing challenge Conclusions: It seems as though the true voluntary systemfor CDTI does not really exist. But the issue should be does this inJluence coverage. Mostly, CDDs will continue despite agitatingfor more incentives. Many CDDs take pride in being selected as a CDD and see this as an incentive in itself. Recommendation 7: It is helpful if countries develop a policy on incentives, to eliminate the risk of competition between programmes and limit the extent to which these are health-system dependent. Instances where good-performing communities have come up with incentives for their CDDs that don't involve money should be documented and best practices shared. 38 Participation of women in community distribution Recurrent advocacy by some stakeholders emphasises the importance of improving the gender balance of CDDs by encouraging more women to be involved in drug distribution. The evaluation team noted that there are very few female CDDs in SIZ countries but when the reasons for this gender imbalance were investigated by evaluators, there seemed to be a variety of reasons why it persists. In Benin, for example, women are not considered for the role primarily because of cultural norrns which make it difficult for them to make the necessary house-to-house visits. Communities in Sierra Leone perceive the tasks of CDDs as labour intensive and are of the view that women will not be able to fulfil the expectations of the role. Respondents in Ghana dismissed the idea of recruiting women as CDDs on the grounds that women are very active economically and will not be interested or have the time to perform the CDD role effectively. These findings'run counter to observations from other countries in Africa, so may be useful for informing planning of other onchocerciasis control proj ects. Recommendation 8: The participation of women in CDTI is low but effirts to change this situation should take account of the cultural context and not work from a pre-conceived idea about ideal gender balance. Issues relating to the gender balance of CDDs vary from country to country. In some countries women qre very active economically and have little time to take on this work and in others the tasl<s of CDDs conJlict with cultural norms. 4. Vector control activities Vector-control activities, although concerning a small overall area of the SIZ located in just two countries, consumed the major proportion of the budget and therefore warrant discussion. The objective of vector control is to intemrpt transmission of the parasite for a sufficiently long time to allow the human reservoir of the disease to die out. In the context of onchocerciasis, this aim was met during the initial period of the OCP with aerial larviciding, which started in March 1977 and was limited to the K6ran-Kara- Mo river basins in Togo and the Niger tributaries in Benin. In 1988, the larviciding area was extended to cover the entire river basin network in Togo and B6nin. These activities ceased by 2002. The basic OCP larviciding strategy was to apply appropriately formulated insecticides on a weekly basis to all productive Simulium damnosum breeding sites in doses that would prevent vector reproduction without causing irreversible damage to the aquatic environment. Ground larviciding was sometimes used in areas and at times when aerial larviciding was not feasible or was not cost-effective. On the basis of 2000-2002 predictions about the post-OCP evolution of entomo- epidemiological parameters, it was concluded that, in northern Togo, vector control should continue during the SIZ period in addition to reinforced CDTI to enable the programme to meet its objectives. This strategy was extended to the Upper Ou6m6 river basin in Benin as a protective measure against black flies migrating from there to repopulate the upper-Oti river basin. The SIZ vector control area consisted of 22 O0O km2. In Togo, the insecticide treatment area covered the Koumongou, K6ran, Kara, and Mo river systems; and in Benin the origins of these rivers, along with the Upper Ou6m6 system, were targeted. 39 The basic principles of OCP larviciding strategy were applied over the 2003-2007 period (except on the upper Ou6md river basin where larviciding was intemrpted by 2006), and this work required a continuation of OCP use of helicopters, weekly measurement of river discharges, and hydrobiological surveillance of fish and invertebrate populations. 4-1. Management of aerial operations The aerial larviciding operation (including entomological evaluation of the effects) was staffed by 30 people all of whom were experienced, having previously worked with OCP. As reported in the mid-term SIZ review, Evergreen Helicopters, Inc (EHD, accepted a renewed contract negotiated by WHO in Geneva for the 2003-2005 period, in which one helicopter was to be kept operational at any time of the season of treatments, with 636 annual flight hours prepaid by WHO at a cost of 1225 US$/hour. Of particular benefit to the SIZ operation, the company retained two of its most experienced pilots, who were familiar with the OCP area and aerial onchocerciasis control, together with a team of mechanics. Preparations for renewed negotiations for a second 2-year contract (2006-2007) were initiated by SIT and APOC, but WHO and EHI did not come to an agreement on a new rate for flight hours before the end of 2007. However, despite these issues, aerial operations were not discontinued before the SIZ programme closure. Payment for the flown hours is still under discussion but payment at the initial cost was regularly made. The number of total flight hours for the SIZ was 3180, 98.7% of which were used for aerial larviciding and 1.3 o/o for aerial prospections to identiff new villages, following on from the mid-term review recommendation that aerial larviciding should be intemrpted. Apart from occasional minor issues, stock management of larvicides was good with needs calculated by the CVCT and orders made by WHO. The CVCT was also responsible for kerosene estimates, orders, transportation from Lom6, storage, and distribution. The main stocks were installed in Kara; caches combining insecticides and kerosene were distributed in the field in several villages and regularly checked and supplied. Detailed records of consumption of each insecticide per week and river basin are kept in Ouagadougou. 4-II. Imp lementation of larviciding Aerial larviciding was done during the rainy season (usually May-June to November- December) with planned temporary suspensions during the time of river floods and subsidence when these activities would have been ineffective. During the whole prograrnme, non-planned intemrptions of larviciding occurred only twice: during a 2003 insecticide shortage resulting from civil unrest in C6te d'Ivoire and for a few weeks at the beginning of 2005 because of civil unrest in Togo. Rainy season ground treatments were also done in a few sites in northern B6nin during the flood period, and were performed by the Parakou operational base team. This procedure had proven its efficiency for decades in OCP and was continuously scrupulously respected in the two SIZ by the same team in charge of the operations during the OCP time. 40 4-III. Effects of larviciding onJly populations The immediate effects of larviciding, which were laid out in the mid-term review, were assessed through intensive weekly checks of key breeding sites (Figure 2). Biting fly population control was monitored according to the OCP protocol of standardized catches- identifications-dissections of biting Simulium damnosum female flies. Evaluation measured the combined impact of CDTI and vector control. Persistently high annual biting rates on rivers treated through vector control---as were observed throughout the SIZ period---indicate either the persistence of local productive breeding sites or the presence of migrant flies coming from outside. In the two SIZ maximum biting occurred in rainy season. Very heavy rainfalls rn2003, which affected the whole region, increased the size and duration of maximum blackfly production in all the water systems leading to a general rise in annual biting rates. This was compounded by the fact that all other OCP vector control operations had ceased, permitting contamination of SIZ areas by outside vectors. Because biting densities are dependant on many extemal factors (hydrography, hydrology and riverbeds topography, climatology, meteorology, anthropic influence) which influence breeding and fly movements, this measurement has to be complemented with information on fly identity and age. Complete sets of rough and analyzed entomological data (as well as detailed aerial operations, larval checks and fly infections data) were compiled on the different standardized OCP forms and kept in Kara and in Ouagadougou. 4-IV. Intens ity of transmiss ion At the OCP closure, crude annual transmission potentials (ATPs) were generally satisfactory on most of the catching sites, except on one site on the mid-K6ran (the only site which was considered for Onchosim predictions in the Togo-Bdnin SIZ), the lower Mo, and the Ou6m6 river. A marked increase was recorded in 2003 in all the river basins except on the Kara (where it was deferred onto 2004 and attenuated). Although corrected transmission potentials, which reflect only the human-infecting strain of the parasite, stayed at lower levels markedly lower than crude ones, they were also affected by the same overall increase. On the upper Oti tributaries, a general decrease began in2004 (only one site, on the K6ran river, showed crude ATP>I00, the threshold for observation of visual problems in the general population) and, by 2005, ATPs were below the 100 threshold everywhere until the end of the SIZ. Corrected ATPs followed the same regression movement, although, as to be expected, always with lower figures. In two major sites in the upper Ou6m6 basin crude ATPs increased to 500 and 700 in 2002, which may correspond to patterns of onchocerciasis meso-endemicity. Until 2005, trends in corrected ATPs followed the crude ATPs climbing curve, but in 2006- 2007 they were nil in all sites despite the continued increase of crude ATPs. This discrepancy is most likely explained by the fact that, by 2006, humans, on whom migrant biting flies were feeding, were no longer infected, possibly as a result of improved CDTI coverage consecutive to aerial mapping of human settlements. Maintenance of proper 4l CDTI coverage in areas adjacent to SIZ and in all the oncho foci of the country consequently appears to be a condition for maintaining low transmission rates in the SIZ river basins. 4-V. Correlation of entomological and epidemiological parameters Entomological results, especially ATPs, have to be considered in correlation with epidemiological ones, although it should be recognized that the latter reflect the impact of ATPs on transmission with several years delay. With this in mind, ATPs may offer a somewhat predictive tool of later epidemiological trends in areas---for example, West African savannahs---where a rough correlation has been made between graduated levels of ATPs measurements and the severity of clinical symptoms (especially ophthalmological ones). At SIZ closure, CMfLs were far below 0.5 in the whole SIZ area and, as a whole, the evolution of epidemiological parameters was quite synchronous with that of adjusted ATPs on all the basins except on the lower Mo, where the absence of a catching point meant the persistence of high prevalence could not be matched with ATP. Whether the 2003 peak in entomological parameters will have an impact on the parasito-epidemiological pattern in coming years remains to be seen. However, this is a strong reason to recommend an accurate entomo-epidemiological surveillance after the SIZ programme closure, since entomological evaluations carried out in the past on a large scale will no longer be done. Pool screening, apolymerase chain reaction-based assay for detecting single infected flies from large numbers of flies, has replaced fly dissection. Issue of concern An issue of concern in this respect is the fact that there were substantial problems carrying out pool screening during the SIZ period. Mid-term recommendations to improve the mechanism for this type of surveillance---including implementation of a realistic network of collection sites to be operated in connection with the epidemiological evaluation network---have not been fully followed up and, until this year, no real attempt has been made to look for new approaches. Since 2005, there have been requests for a meeting with external experts, and while this event finally happened in January 2008, it was not as large or productive as expected. The pool-screening system has obviously not been fully operational in the SIZ in Togo and B6nin, and the opportunity of matching it systematically against the ATP calculations has been missed. Recommendation 9: Pool screening has to be rapidly upscaled and improved to become the main entomological tool to complement the epidemiological evaluation network during the post-SIZ period. 4-W. Summary of vector control experience Owing to the quality, professional experience, and field knowledge of the SIZ and EHI teams, vector control and entomological evaluation were conducted in the most effrcient manner over the 5 years. Consequently, the control of locally-bred fly populations was consistently optimal without intemrption at OCP closure. 42 Despite various physical and epidemiological conditions, the combination of vector and therapeutic control strategies succeeded in bringing crude and adjusted ATPs below tolerable levels all over the SIZ areas, although it should be noted that it is impossible to distinguish the independent effects of CDTI and vector control. The peaks of crude and corrected ATPs in2003-2004 matched changes in biting rates and rainfalls. On the upper Oti tributaries, the progressive decline of ATPs by 2005 demonstrated that in conditions of reduced rainfall and low contamination by outside flies accurate vector control and reinforced CDTI can result in excellent control of O. volvulus transmission. 4-WI. Role of the Multi-Disease Surveillance Centre The Multi Disease Surveillance Centre (MDSC) was established at the closure of OCP on the OCP/APOC premises in Ouagadougou. The role envisaged for MDSC, as its name suggests, was that it would develop into a facility that would support not just onchocerciasis surveillance but also surveillance for other diseases. At present the MDSC has four permanent staff members: the Director, a microbiologist, an epidemiologist and a data manager. In addition there is one person in charge of field epidemiology and another staff member responsible for laboratory training programs. There is also an epidemiologist from the US Centers for Disease Prevention and Control working on vaccine introduction. The previous onchocerciasis staff members are currently being employed on a short term basis since the closure of SIZ in December 2007. The MDSC has faced persistent challenges in funding and this has limited the extent to which it has been able to take on the role envisaged. The evaluation team examined the role and input of MDSC in supporting the SIZ activities. Entomological surveillance for all programmes should rely on the technique of fly collection and infectivity analysis through pool-screening. For economic reasons linked to devolution of control, this strategy must replace dissection techniques used in OCP partway through the SIZ period. Presently, only the MDSC laboratory carries out this DNA technique, so it is therefore indispensable in terms of future onchocerciasis surveillance and control unless alternatives are found. The activities MDSC says were undertaken to support SIZ included: . Development of a network for the collection of black flies . Determination of infectivity rates (including identification of infective larvae) in Benin and Togo . Some entomological evaluation and entomological surveillance (although the SIZs also had their own resources for these activities) Staff members from the unit have visited Togo, Benin, Guinea and Guinea Bissau provide entomological support and training in methods of collection and preservation of biological samples. In addition training on entomological techniques was provided to onchocerciasis personnel after the cessation of war in Sierra Leone. During the SIZ period, nearly 500 000 flies have been received by MDSC for pool screening from all the former OCP countries. About 1717 slides of infected flies have been received (mostly from Sierra Leone) and processed. The results of the analyses are 43 passed to the director of the unit for transmission to the various countries. In addition the results are often provided during scientihc or technical meetings of the programme. The target time for response to country requests is two months but in fact delays are experienced because of staff and funding problems. During the country visits the problems in response time were confirmed. Issue of concern Although the MDSC has invaluable expertise and has tried to maintain entomological surveillance techniques to the best of its abilities, it has faced persistent funding problems. The report of the second meeting of the WHO-MDSC Scientific Committee held in Ouagadougou at the end of January 2008 recognised that MDSC is now in a state of financial crisis with a real risk of losing its staff and failing to meet its obligations to partners. The Scientific Committee concluded that a restructuring of the Centre is required and that a new governance and financial structure was needed to attract resources. Conclusion: The evaluation team notes that this long-standing problem is still not addressed and that there is no clear plan of action to secure the essential scientific support for onchocerciasis surveillance. If these issues remain unresolved, they mayjeopardize the sustainability (in terms of surveillance of the ffict) of onchocerciasis control activities. Recommendation 10: There is an urgent need for a clear plan of action to secure the essential scientific support for onchocerciasis surveillance in the Multi-Disease Surveillance Centre laboratory. Given the importance of surveillance if these issues remain unresolved, they may jeopardize the sustainability of onchocerciasis control activities. 44 D. Perspectives for the future 1. Country progress towards sustainability A critical question to the five SIZ participating countries after several years of onchocerciasis control under OCP and an additional 5 years under the SIZ is whether countries now have the capacity to sustain onchocerciasis control activities. At the end of SIZ, the expectation was that countries should continue the activities---particularly reinforced CDTI wi1l20l2---without relying on financial or management support from APOC. However, the necessity for further assistance in two countries, Ghana and Sierra Leone, at the end of the SIZ period has altered this initial plan. Several parameters will influence whether countries are able to carry on activities after SIZ. For this evaluation, questions were asked about the status of standard parameters known to influence CDTI sustainability: government and partnership support including funding, integration of CDTI activities into health systems, community ownership and commitment, etc. Evaluators also talked to stakeholders at all levels to get their perspectives about what is currently in place and still needs to be done to maintain onchocerciasis control with CDTI activities for the future. l-1. Government and other partner support includingfunding The long-terrn commitment of governments to provide funding for onchocerciasis control and steady partnerships with NGDOs have been key to the success of control activities in SIZ countries. Although few countries were able to provide specific quantitative information about future commitments to onchocerciasis activities, all of them asserted that partners remained committed and governments still considered the disease a priority. In Benin, for example, the ministry of health was very positive about taking over the staff of the former Parakou base and had already set aside a proportion of the budget for vector control, in line with their national plan recommended to be drawn up by allSlZ countries. For the whole SIZ project, three NGDOs and two multilateral partners have contributed significantly to onchocerciasis control. These are Sight Savers International (SSI), Helen Keller International (HKI), Organisation pour la Prevention de la Cecit6 (OPC), the World Health Organization (WHO), and the World Bank. NGDOs are working closely with the government through the NOCPs and contribute substantially to control activities in SIZ countries. Support from NGDOs goes beyond funding. The evaluation team saw many positive examples of the major contributions of NGDOs to sensitization, production of IEC materials, and capacity building. For example, Helen Keller has been instrumental in setting up the CDTI process in Sierra Leone, while SSI and OPC working in Guinea have made available opthalmological equipment for the field and hospital surgery, and built a system for early detection and treatment of individuals with visual impairment. The growing intemational emphasis on the group of neglected tropical diseases is a potential source of new funding and is focusing country attention on developing and implementing strategies for the integrated management of these diseases. Partnerships with, among others, WHO, the EU and USAID, particularly through its Neglected Tropical Diseases Program, are emerging as potentially positive elements to future success of onchocerciasis control programmes; however, the effects of these prograrnmes on existing structures and available resources remain to be seen. Guinea, 45 Sierra Leone, and Ghana are on track to receive additional funding to tackle a mixture of diseases, and the CDTI strategy is the approved strategy for drug delivery. Box 4: The crucial role of NGDOs Issues ofconcern Although several NGDOs have been long term and consistent partners in onchocerciasis control, there is no guarantee that this support will continue. In Guinea, Helen Keller Intemational has already said they will not commit further funds, although will continue to act as a liaison with other partners; Sight Savers has pledged to continue. Furthermore, the budgeted sums from government are not always available or released on time, which causes substantial problems for the national teams charged with implementing onchocerciasis control activities. Lapses in funding compromise the timely implementation of CDTI strategy and the evaluation team were concerned that these issues have persisted throughout the SIZ period. Providing funding, equipment, sensitization materials, along with capacity building support and intemational advocacy, non-governmental development organisations (NGDOs) are crucial to all onchocerciasis control activities, but particularly so in the SIS regions. In the SIZ countries three NGDOs ---Sight Savers lnternationa] (SSD, Helen Keller Intemational (HKI), and Organisation pour la Prevention de la Cecit6 (OPC)--have been crucial, working closely with governments and multilateral partners to contribute to onchocerciasis control efforts. (Although the funds have not been specifically for the SZ programme). In some areas of Ghana, NGDO support was the only deciding factor for treatment to be able to be carried out in 2005. In areas where that support was lacking, no treatment occurred. The contribution is a long-standing one. These organisations were at the forefront of efforts to implement the first large-scale distribution of Mectizan. And, after forming a coordination group in the early 1990s to uniff efforts for onchocerciasis control, helped to promote world-wide interest and support for this drug. NGDOs now have a crucial role as part of the APOC partnership and are represented on tlre governing bodies and technical consultative committee of this organisation. They report their activities to a Geneva-based focal person in the form of standardised semi-arurual reports, The networks these organisations have helped established for onchocerciasis have now been suooessfully used to introduce other disease-control initiatives---sueh as lymphatic filarias-is elimination, trachoma and schistosomiasis control, vitamin A distribution, cataract case-findi,irg and rehabilitation training of community members who have suffered irreversible blindness-- in numerous countries. It is clear that onchocerciasis control, and particularly the ilqplementation of CDTI, would be many years behind in progress---and perhaps even a complete failure- --without this unstinting support. 46 I -II. Integration and co-implementation There was strong evidence from the field that countries have made good progress in integrating onchocerciasis control into national health systems. At the central level there is a funded national plan for onchocerciasis control in all SIZ countries. With the exception of Togo, where the national coordinator is also the director of health for the entire northern region, national coordinators oversee onchocerciasis control as well as at least one other communicable disease. Some coordinators are also responsible for lymphatic filariasis (Ghana, Benin, Sierra Leone), or blindness prevention (Guinea). It is clear that integration is quite active at the district level. Evaluators were shown integrated work plans and reports for preventive health prograrnmes. Some countries designate one district health management team member as an onchocerciasis focal person, although this individual also has other responsibilities. At the frontline, where human resources are scarce, onchocerciasis control activities are planned for and implemented using pooled human, financial, and material resources. Health centre staff members are responsible for carrying out sensitization, mobilising communities for mass campaigns, and training, monitoring, and supervising all community workers, including the CDDs who distribute ivermectin. At the grass-roots level, integration is also taking place. Some community distributors also carry out health-related activities for other diseases. Many are involved in, for example, distribution of albendozole, vitamin A, and bednets for malaria control. 1 -III. Uninteruupted Jlow of ivermectin When voicing perspectives about prerequisites for sustainability of onchocerciasis control, many key actors in countries placed the continued availability of ivermectin on the top of the list. Merck's continued donation of the drug free of charge for as long as necessary to control onchocerciasis as a public health problem is seen as key. At the same time, stakeholders put the onus on countries to procure the ivermectin in good time, and ensure that the tablets move from the quay to stores to service delivery points and to communities on time. SIZ countries have not experienced any serious bottlenecks with the availability of ivermectin or with the flow. The district records assessed show adequate amounts of ivermectin in stock each year to treat targeted population. L-IV. Community ownership and commitment The ultimate success of the delivery of ivermectin through the CDTI process relies on community empowerment to fulfil some critical expectations. Communities need to: select at least two individuals who are energetic and willing to commit time every year to distribute ivermectin; come up with their own compensation strategies for CDDs as a sign of appreciation for the work CDDs do; and, most importantly, be keen and enthusiastic to take the drug every year. The therapeutic coverage rate over time is a good marker to assess the success of sensitization activities in sustaining community eagerness to take ivermectin. In Togo, Benin and Guinea over 80oZ of the population were available at the time of treatment and took the drug. Intense advocacy and sensitization in Sierra Leone saw a gradual climb in coverage rates reaching 70%o of its at risk population and the prospects for reaching the 80% target seems good. Section C makes the point that even though communities and health staff cite the issue of incentives or lack thereof as a challenge, CDDs taking part in onchocerciasis control remain committed to the job, demonstrated by high retention rate across all SIZ countries. Low attrition rates, high 47 coverage rates, and high community demand for the drug all hold promise for future sustainability. Long term, more effective control of onchocerciasis may lead to a reduction of community support for the prograrnme as symptoms are no longer seen and memories of blindness fade. Continued awareness-raising will be crucial to maintaining community support and dedication. 1 -V. Reg ular epidemiological and entomolo gical s urveillance Central to monitoring efforts for onchocerciasis control is the availability of up-to- date and accurate information about the epidemiological and entomological situation. Regular and reliabl e data are necessary for timely detection and action to resolve any signs of recrudescence. Inter-country activities will be particularly important for maintaining onchocerciasis control in future because of the risk of cross-border disease spread in SIZ areas. A sufficient number of trained individuals, in terms of in-country technicians and laboratory scientists, is cruciaI. However, there is evidence to suggest that maintaining a pool of qualified technicians is a challenge in all countries. Long-serving individuals who are approaching retirement age may be difficult to replace if additional frrnds for training a new cadre of technicians is not committed by governments or partners. Conclusion: In general the stakeholders interviewed by evaluators were unanimous in their conviction that, as long as the drug is available, CDDs are willing to distribute the drug, and communities demand treatment, then CDTI is sustainable. However, these three elements depend on consistent financial support for training/re-training, sensitisation, and incentives, which seem to be key to CDD dedication- Recommendation 10: Many of the curuent cadre of onchocerciasis-related technicians qre qpproaching retirement age, so there is qn urgent need for funds to train technicians in epidemiology, entomologt, and statistical analysis. Recommendation 11: There is a needfor continued periodic support for epidemiological and entomological surveillance and statistical analysis to be provided to all the countries. Mechanisms through which this could be provided should be considered and developed to ens ur e sus tainability. 2. Lessons learnt and best practicesfrom the SIZ experience A clear conclusion of the Evaluation Team from observations in the SIZ countries is that the strategy of CDTI is having a real and significant effect on reducing the human reservoir of the parasite responsible for onchocerciasis, underlining the effectiveness of this method as a strategy for the eventual elimination of onchocerciasis as a disease of public health importance. However, because there is always the risk of reinvasion from areas where infected flies remain the risk of resurgence exists. The threshold below which a residual reservoir of parasite would not be significant for a resurgence of the disease is not known; studies are underway to answer this question. Evidence from other countries adopting the CDTI strategy as the main method of control of onchocerciasis is that as active cases get fewer, then community demand for the drug may wane as they are less and less aware of the dangers posed by the disease, thereby threatening the sustainability of CDTI due to decreasing commitment of volunteers. However, the focused and time- 48 limited efforts of the SIZ project have generated the opportunity to identiff notable lessons---whether these were challenges surmounted, or planning errors that caused subsequent problems---with potential positive benefits not only for the SIZ countries but others implementing onchocerciasis control activities with the eventual aim of eliminating the public-health burden of this disease. Chief among the lessons of the SIZ experience is that a target of 85Yo therapeutic coverage---which is higher than the target set for APOC countries---is certainly achievable, even in areas of shifting populations and high endemicity. The evaluation team noted the fact that three countries achieved this target within the SIZ period, and the other two were showing positive trends, was an encouraging sign that other onchocerciasis control programmes could leam from. A much talked-about spin off effect of CDTI is the impact the process has on census data. During this evaluation, team members found specific examples of cases where population records generated for the purposes of CDTI are being used by other prograrnmes to help plan their activities. This development is important to document because it shows that CDTI is indeed contributing to strengthening the base for other prograrnmes particularly in remote areas. Issues of human resources and leadership have been significant in the success of this programme, and are often at the root of problems where they have arisen. At country level, the appointment of good country prograrnmes managers has been key to the success of the prograrnme. Making the right appointments and supporting the capacity development of staff is crucial. A key finding from interviews with national staff was that the process of bringing prograrnme managers together at annual review meetings, and sending them to other countries to learn best practices, is extremely beneficial for professionalisation of in-country staff and capacity building in national programmes. Furthermore, the exchange of knowledge throughout the SIZ seems to have increased awareness about onchocerciasis among national staff at all levels, which is a pleasing finding. At headquarters level, initial underestimates of the numbers of staff necessary to manage the SIZ project meant that a committed and hard-working team were over- stretched. Therefore, an instructive conclusion to be carried over to other programme is that expectations and work loads must be matched by sufficient numbers of staff with time to meet them for programmes like the SIZ to be successful. In addition to these general issues, the evaluation team identified a number of best practices that could be followed up or transferred to other settings: Management Inter-country annual review meetings, which were greatly valued by all SIZ countries, contributed to capacity building and could be transferred to other multinational disease control settings. Nigeria, Benin, Sierra Leone are all holding meetings to discuss cross-border issues a o 49 Ivermectin records Migrant populations CDDs a Benin and Guinea have implemented effective systems using ivermectin stock cards to track left over drugs. a Cards for nomadic populations that show when and where they were treated were found useful for tracking ivermectin distribution and covering previously missed populations. Use of mobile phones is enabling better coordination between health services and communities in some places CDDs in Guinea are being trained to supervise other newer CDDs, fuither reducing the burden of work on the health system In some countries, CDDs are taking the initiative to track down and treat people in newly identified settlements themselves One good practice observed in Ghana was organisation of a meeting of CDDs after the reports had been submitted to give feedback and address any problems with record completion. Community leaders in Ghana provide funds for CDDs transportation costs to attend training and food during distribution Some villages have had meetings to identify additional incentives for CDDs that could replace health-system-derived payments a a a o a a 50 D. Conclusions and recommendations l. Concluding remarks The SIZ programme enabled continuous support to be given for five years to five zones in the ex-OCP region to enable them to reach a situation in which the entomo- epidemiological situation was satisfactory. At the end of the five-year period, it is important to note that this original objective has been substantially, if not entirely, achieved. Three countries have reached and maintained targets of geographical and therapeutic coverage, Sierra Leone is already reaching the lower target set for it to reach and the trends in Ghana are positive although problems remain. If the OCP defined the situation in which onchocerciasis would be eliminated as a socioeconcomic and public health problem, then three countries have achieved this and there are prospects for doing that in the other two countries. However, averages hide pockets of poor control where the parameters are not met and these could always be the source of recrudescence. Nevertheless, the achievements of the programme and its staff are substantial and deserve recognition: at SIZ headquarters, at Kara and Parakou, and in the countries themselves dedicated teams have worked hard and consistently to achieve these results. However, there is an urgent need to consolidate these achievements and to secure the future of onchocerciasis control, which will be in jeopardy without sustained efforts at country level and international and regional support and coordination. While onchocerciasis has been enormously reduced as a cuffent socio-economic and public health threat, experience has shown that recrudescence can occur quickly, particularly during times of conflict or social unrest, and this requires country and regional action and vigilance. Among the aims of the phasing out strategy of the APOC programme, which is due to come to an end in2015, specific mention is given to the need to support cross-border activities, to prevent recrudescence, and to secure onchocerciasis control for all countries where it is needed. So, although the SIZ is over, there are opportunities for APOC to consolidate results and to continue support to countries where it is really needed. After 2015, APOC will no longer play this role and other actors must take on responsibility for essential tasks. The evaluation team found that while the vector control activities were carried out efficiently and according to plan by a dedicated team, it is not possible to indicate the separate impact of these activities on the entomological situation, because the reduction in transmission potential is also influenced by the successful implementation of CDTI and the subsequent reduction in the human reservoir of parasite. However, due to expense and the persistent risk of reinvasion by black flies from non-vector-controlled areas, it is inadvisable for this strategy to be considered as a sustainable method of controlling onchocerciasis control in future. Nevertheless, the observations of sharp declines in adjusted transmission potentials in areas where crude transmission potentials were high or climbing shows that CDTI is having a real and significant effect on reducing the human reservoir of the parasite responsible for onchocerciasis, underlining the effectiveness of this method as a strategy for the eventual elimination of onchocerciasis as a disease of public health importance. For this to happen, however, the CDTI model needs to be sustained because 51 onchocerciasis elimination requires mass drug administration of ivermectin up to the end of the natural life span of the macrofilaria---around12-15 years. It is the firm belief of APOC that achieving this step requires integration of the community-directed treatment approach into current health-system structures and the evaluation team noted examples where integration of disease control strategies has increased efficiency of service delivery for the health system and improved the effectiveness of health spending. But to facilitate integration and maintain the network of community drug distributors---whose commitment is what underpins the programme's successes to date--- alternative sources of funding, training, and support must be found to replace the SIZ funds. If the heatth systems of SIZ countries step in to fill the programme's shoes, as they have pledged to do, there should be added benefits to health in the country as a whole, not just safeguarding achievements in onchocerciasis control. One final issue is the fact that although CDDs undertake to do their work as a community service, it should be acknowledged that the reality on the ground is that CDDs increasingly demand some sort of recompense for their services, whether that be financial or in-kind. The evaluation team observed several examples where communities were taking the initiative to discuss ways of supporting their CDDs that do not depend on direct health system support or financial remuneration. These examples should be documented and shared between countries to help encourage health-system-independent incentive systems that can contribute to the efforts to make CDTI sustainable long-term. It is clear that although the APOC management of SIZ has come to an end, this milestone is not so much of a landmark for the national control teams who continue to work on onchocerciasis control and will do so far into the future. The experience of SIZ has contributed to the professionalisation of the efforts, and supported capacity development in countries. It is the hope of the evaluation team that some particularly valued aspects of the support provided by SIT during this time might still be continued in some form to help countries through the transition to sustainability of onchocerciasis control. 2. Recommendations While acknowledging that the specific period of the SIZ is over, the evaluation team felt it was important to formulate recommendations from their findings that could help facilitate the sustainability of onchocerciasis control in the five countries, or help support disease control efforts elsewhere. The following recommendations are annotated with a specific target group and ordered according to the sequence of issues discussed in the main report text. D In spite of the commitments of governments, onchocerciasis control is still funded to a large extent from external sources at the moment. ln the interests of sustaining the achievements made by the SIZ programme, there is an urgent need for governments to take the initiative to make multi-year commitments to onchocerciasis control and to proactively look for partners who will do the same. [Countries, NGDOs] D It is helpful if countries develop a policy on incentives, to eliminate the risk of competition between prograrnmes and limit the extent to which these are health-system dependent. lnstances where good-performing commurities have 52 come up with incentives for their CDDs that don't involve money should be documented and best practices shared. [Countries, NGDOs] ru) The participation of women in CDTI is low but efforts to change this should work from the cultural context and not from a pre-conceived norm about gender balance. Issues relating to the gender balance of CDDs vary from country to country. In some countries women are very active economically and have little time to take on this work, and in others the tasks of CDDs conflict with cultural norms. [APOC, donors] IV) Many of the current cadre of onchocerciasis-related technicians are approaching retirement age, so there is an urgent need for funds to train technicians in epidemiology, entomology, and statistical analysis. [Countries, APOC, WHO AFRO, donorsl V) Given the value placed on the SIZ arurual meetings by countries, APOC should consider ways that these could continue in some form after the closure of SIZ. [APOC, Countries]. VD Even though the procedures for training, sensitisation, and supervision are largely decentralised in the SIZs, the Evaluation Team noted that some central oversight---perhaps in the form of occasional spot checks---could help maintain quality standards and ensure that the aims of the programme continue to be met. VII) There is an urgent need for a clear plan of action to secure the essential scientific support for onchocerciasis surveillance in the Multi-Disease Surveillance Centre laboratory. If these issues remain unresolved, they may jeopardize the sustainability of onchocerciasis control activities. IWHO AFRO, APOC] VIII) Pool screening has to be upscaled and improved to become the main entomological tool to complement the epidemiological evaluation network during the post-SIZ period. [WHO] IX) Due to the finding that average coverage rates hide information on poorly treated communities which are sometimes not followed up, the evaluation team encourages reporting of proportions of villages falling below coverage targets and urges national systems to keep up surveillance of local problems in coverage and react quickly to address issues. [Countries] X) There is a need for continued periodic support for epidemiological and entomological surveillance and statistical analysis to be provided to all the countries along with a mechanism for making sure that scientific best practices are maintained. Strategies through which this could be provided should be considered and developed to ensure sustainability. [APOC, WHO AFRO] XD ONCHOSIM simulation with data collected in the SIZ should be continued to give a more accurate prediction tool. This, in combination with other operational research, will enable countries to have some idea of whether CDTI may be phased out in the future. [WHO] 53 XII) Few operational research studies have been done during the SIZ period, even though this was one of the objectives of SIZ. National research capacity in SIZ countries should be developed and associated with the continuing research agenda of TDR. [Countries, APOC] XIII) Validation of collected data were outside the scope of this evaluation. Particularly in the two countries that are to become part of APOC, this process, and additional research on sustainability, would be beneficial for future planning. 54 E. References Anonymous. Report on an EAC Task Force, Geneva, 1-2 October 2001 . Doc. EAC/OCP. Anonymous. Summary of the report of the 0CP/TDR meeting on ivermectin impact on onchocerciasis transmission, Rotterdam, 3-5 October 2001. Doc. EAC.AD-2. Anonymous. Onchocerciasis Control Programme. External Evaluation 2002. Report. Doc. JPC/2 3.9, October 2002. Anonymous. Report of the 23rd session of the Expert Advisory Committee, Ouagadougou, September 2002. Doc. JPC 23.3. Anonymous. Report of the meetings of national coordinators on country specific problems. Doc. ZAC 2j. j, Ouagadougou, September 2002. Anonymous. Lutte contre I'onchocercose en Guin6e. Progreds accomplis et perspectives post-OCP. Doc. EAC/OCP, September 2002. Anonymous. Specif,rc questions about onchocerciasis control in OCP countries. Doc JPC. 2 3/INF/DOC. 1, December 2002. Anonymous. Onchocerciasis control in sepcial intervention zones including Sierra Leone in the OCP area. Doc. JPC.2j.4 (a), December 2002 Anonymous. Report of the 23rd session of the Expert Advisory Committee, Ouagadougou, September 2002. Doc. JPC 23.3. Anonymous. Report of the meetings of national coordinators on country specific problems. Doc. ZAC 2j.j, Ouagadougou, September 2002. Anonymous. Lutte contre I'onchocercose en Guin6e. Progrds accomplis et perspectives post-OCP. Doc. EAC/OCP, September 2002. Anonymous. Specific questions about onchocerciasis control in OCP countries. Doc JPC. 23/INF/DOC. l, December 2002. Anonymous. Onchocerciasis control in sepcial intervention zones including Sierra Leone in the OCP area. Doc. JPC.2 j.4 (a), December 2002 Anonymous. Workshop on the reinforcement of onchocerciasis control in the special intervention zones (SIZ). Ouagadougou l9-21 May 2003. Report. Doc. APOC/SIZ, June 2003. Anonymous. Report of the mid-term review of the activities in the Special Intervention Zones (SIZ) and Effectiveness of Onchocerciasis Surveillance Systems of the ex-OCP Countries. Doc. JAFI I/INF/DOC.2, December 2005. 55 Anonymous. Interview guidelines, CDTI progress, achievements, challenges and prospects for sustainability, Mid-term review of the activities in the 512,2005. Anonymous. Interview guidelines, CDTI progress, achievements, challenges and prospects for sustainability, Mid-term review of the activities in the 5I2,2005. Anonymous. Report of the mid-term review of the activities in the Special Intervention Zones (SIZ) and Effectiveness of Onchocerciasis Surveillance Systems of the ex-OCP Countries. Doc. JAFI I/INF/DOC.2, December 2005. Anonymous. Report on a meeting for the reinforcement of active surveillance of onchocerciasis, Ouagadougou 15-17 June 2007. Doc. MDSC. Anonymous. Reports of the annual SAC/SZ meetings (Ouagadougou December 2003 and June 2004 to June 2007 + ad hoc meeting, September 2007). Yearly SIZ/APOC doc., December 2003 to December 2007). Anonymous. Terms of Reference for the final evaluation of the Special Intervention Zones (SIZ). SAC/SZ, November 2007, amended SIZ/ET 23 February 2008. Anonyme. Recommandations formul6es par les Coordonnateurs Nationaux des pays de I'ex-OCP lors de la r6union tenue d Ouagadougou, 06-10 novembre 2007. Doc SIZ pour FAC.I3. Anonymous. Onchocerciasis control in Special Intervention Zones in the OCP area. Work-plan, institutional and financial arrangements. Doc APOC/SIT, SIZfinal evaluation planning meeting, Ouagadougou, 20-23 February 2008. Anonymous. Reports of the annual review and planning meetings in SIZ (Ouagadougou, November 2003 to November 2007). Yearly SIZ APOC doc., early 2004 to early 2008. Diallo, N.K. Rapport d'activit6s du Programme National de Lutte contre l'Onchocercose 2003. Doc. Ministdre de la Santd Publique de Guinde, ddcembre 2003. Diallo, N.K. Rapport d'activite 2004. Programme National de Lutte contre I'Onchocercose et la C6cite (PNLOC). Doc. MinistDre de la Santd de Guinde, d,icembre 2004. Diallo, N.K. Rapport d'activit6s pour I'ann6e 2005. PNLOC. Doc. Ministdre de la Santd Publique, Conalvy, ddcembre 2005. Diallo, N.K. Rapport d'activit6s pour I'ann6e 2005. PNLOC. Doc. Ministdre de la Santd Publique, Conalcry, ddcembre 2 00 5. Diallo, N.K. Rapport d'activit6s du PNLOC. Doc. Ministbre de la Santd Publique, Conalvy, janvier 2007. Diallo, N.K. Rapport d'activit6s annuel 2007 du PNLOC. Doc. MinistDre de la Santd Publique, Conalvy, janvier 2008. 56 Diallo, N.K. Pr6sentation des SIZ de la Guinde. Rdunion de planification de l'dvaluation finale des SIZ, Ouagadougou, 20-23 February 2008. Diallo, N.K. Difficult6s de mise en oeuvre op6rationnelle des outils de la surveillance de I'onchocercose. Rdunion sur les outils de la surveillance de l'onchocercose, Ouagadougou 30-31 January 2008. Diallo, N.K. Technical annual reports to SAC/SIZ, Jvrre 2003,2004,2005,2006,2007. Doc. PNLOC/SZ. Diallo, N.K. Presentations to the annual SIZ Review and Planning Meetings, November 2003, 2004, 2005, 2006, 2007 . Doc. PNLOC/SZ. Diallo, N.K. Rapport d'6valuation 6pid6miologique simple des villages dans les zones hors SIZ de la Guin6e, mai 2007. Doc. PNLOV/ Guinde, 06/06/2007. L6vdque C and Philippon B. Report on a visit in Guinea 28 August-3 September 2005 Mid-term review of the activities in the SIZ. Philippon B. Contribution d I'analyse des donndes d'6valuation 6pid6miologique de la Guin6e-Conakry. Situation en novembre2007. Doc. APOC/SIZ, novembre 2007. 5l Annex [: Terms of Reference Terms of Reference for the final evaluation of the Special Intervention Zones (SIZ) 1. Introduction and background 1.1 With the cessation of OCP operations in December 2002 the Programme had met its objective i.e. to eliminate onchocerciasis as a disease of public health importance and as an obstacle to socioeconomic development throughout practically all of the Programme area. 1.2 However, in four limited and defined areas the entomo-epidemiological situation remained unsatisfactory after several years of combined vector control and ivermectin treatment. These areas therefore qualified for "special Intervention" and were referred to as "special Intervention Zones (SIZs)". They included the basin of the Pru (Volta Lake) in Ghana, the basin of the Oti and its tributaries in Togo, the adjacent Upper Oueme river basin in Benin, and the basins of Mafou and Tinkisso (Upper Niger) in Guinea. In addition to these limited areas, the whole of Sierra Leone where onchocerciasis control activities were suspended after a maximum of f,rve consecutive years of combined larviciding and ivermectin distribution was included as a fifth SIZ. 1.3 It was therefore decided by the last session of the Joint Prograrlme Committee in December 2002 that for all five zones ivermectin distribution should be reinforced to achieve 100% geographical and at least S5Yotherapeutic coverage (650/o in Sierra Leone), ivermectin treatment to be given annually in the Pru basin and Sierra Leone and semi- annually in the remaining three basins, all up to 2012 (beyond 2012 in Sierra Leone where treatment was just being established), while aerial larviciding would be continued during five years after December 2002 in the Upper Oti and the Upper Oueme river basins. 1.4 The principal method of control in the SIZs was ivermectin treatment under community direction [Community-directed Treatment with Ivermectin (CDTI)]. Aerial larviciding, combined with CDTI was applied in the Upper Oti and Oueme river basins. Furthermore, an important element was capacity building and mobilization and sensitization. 1.5 The cost of operations in the five SIZs was estimated as US $ 12,098,732 covering activities until the end of the project in2007. 1.6 The general objective of operations in the five SIZs was to bring the entomo- epidemiological parameters to levels which correspond to the OCP standards and which can easily be maintained by the Participating Countries. 1.7 The period allocated for SIZ activities was 5 years after which countries would continue the activities. The SIZ activities have been implemented over the 5 year period 2003 to 2007 according to JPC 23 approval and are now being evaluated. 58 2. General obiective oflhe evalualiaa 2,1 To assess the achievements of SIZ against its stated objectives and mandate 2.2 To assess the level of incorporation of essential post-SIZ activities in national plan of countries and their routine health activities. 2.3 To assess the prospects for sustainability in all countries including adequacy of surveillance systems, national policy on integration, co-implementation with NTD and other diseases as well as financial provision for continuing residual activities related to onchocerciasis control. 2.4. To describe the most significant lessons learned from the success or failure of the operations undertaken in SIZ areas relevant to the elimination of onchocerciasis or other disease control activities 2.5 To formulate conclusions and recommendations of the evaluation for each stakeholder involved (Countries, WHO, donor community, NGDOs, etc.) which might be useful for APOC or other similar international public health partnership program. 3. Specific obiectives of the evaluation 3.1 To review and assess the SIZ management arrangements at all levels (headquarters, Kara, and country levels), taking into account the support received from APOC. 3.2 To review and evaluate the processes and performance of CDTI, Vector control including aquatic monitoring and surveillance in the SIZ against stated objectives and indicators. 3.3 To assess the adequacy of the support given by the APOC/Special Intervention Team to SIZ countries and those outside the Special Intervention Zones. 3.4 To review and evaluate the performance of epidemiological and entomological surveillance in the former SIZ countries, including SIZ achievements, taking into account whether the surveillance systems in these former SIZ countries are effective enough to maintain OCP achievement. 3.5 To assess prospects of sustainability of onchocerciasis control in former SIZ areas beyond 2007, taking into account government commitment, availability of key inputs, stakeholders participation, partnerships and external support and integration into national health systems. 3.6 To assess the needs of the former SIZ for fuither support from APOC post 2007. 3.7 To assess the level of integration of onchocerciasis control activities in the health systems of the former SIZ countries. 3.8 To examine the need for and possible role and modality which would enable intercountry coordination of former SIZ countries in 2008 and beyond 59 4. Terms of reference 4.1 Programme Management 4.1.1 To review and assess the administrative and technical arrangements at the headquarters of SIZs operations in Ouagadougou and Kara, taking into account the support received from APOC. 4.1,2 To examine the financial management at the headquarters of operations in the SIZs and in the f,reld. (Suggest drop or do review of auditor's reports). 4.1.3 To examine the national onchocerciasis programme management (at the various levels: central, regional, district and community) and adequacy of resources in SIZ countries. 4.1.4 Assess the extent to which recommendations from the mid-term review have been acknowledged and acted upon. 4.2 Programme implementation, financing and its impact 4.2.1 To review the activities carried out and evaluate performance and effectiveness in the five SIZs. 4.2.2 To review the process of CDTI implementation across all SZ countries and in particular evaluate the overall geographical and therapeutic coverages attained. 4.2.3 To review and evaluate the performance and impact of the vector control activity. 4.2.4 To assess countries' progress towards sustainability of onchocerciaisis control taking into account community empowerment, health systems support, including integration, partner support (WHO country offices, NGDOs) and the adequacy of disease surveillance and monitoring system. 4.2.5 To review and assess the role and input of the MDSC in supporting the SIZ activities. 4.2.6 To assess the support provided by the Special Intervention Team to SIZs. 4.2.7 To discuss the prospects for the elimination of onchocerciasis as public health and socio economic problem in West Africa. 4.2.8 To discuss useful lessons generated and to what extent the approaches can be replicated in other onchocerciasis endemic areas, or disease control programmes or sectors (including the following dimensions: development/strengthening of relevant countries' health systems and institutions, mobilisation of other resources, knowledge exchange, policy/prograrnme implementation, replicable best practices - eg skin snips, treatment timing and treatment coverage, new forms of cooperation with other development institutions or NGDOs, etc). 4.2.9 Assess needs for further support to the SIZs from APOC post-2007 5.1 5.2 60 5. Orsanizational aspects 5.3 Field visits to the former SIZ countries will be arranged as required. The evaluation will take place in the first quarter of 2008, the draft report will be presented to the CSA in July 2008 and the final report will be completed and presented to the Executing Agency of the SIZ (WHO) and the Fiscal Agent (The World Bank) in the context of the APOC CSA by the end of October 2008. The Headquarters of the operations in the SIZ and the Management of APOC will provide support for the evaluation. ooc oN c o coto s 66oao oc cE 3 o od E oo ot,Ef oE o B o E o E Eo o o 0,c E E co Eo e o o o oJ oEc a oc o = .! Foo c oG GooL EBOQE-l6P EB 6 h6 9E "t= o06ErE EF oE o E EF Bco EO^ =5 EfRE6-6 o a o g E o 0d E>ao6* " €E5o-E- EE ,l ., iaa o-9 o:ll s!ETtgG EEou oL € E>la u€s 83d EEoL E^6<E=oo -a-sor: Esii o'6 E{ .9ttrE F6 o oo at oEE E.E o L:o cto- oo ={(!t: EG !:ooo .go EooF d UJ o *6{ 6Eotr860G o{ =8S90.E o JFI oEIo 'i6;s;o oF lo oo EE1E!GGO-J €8 EX OG cQ. Ei1eOGjq. 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E o) a 6t!l2 c)L 00 fr C.l\o ousf,lE {-N o5 e t uJ co) 63 Figure 2: Graphs showing the effects of larviciding on annual transmission potential and biting rates ANNUAL BITING RATE IN OTI AND UPPER OUEME BASIN 60000 u o 30000 20000 10000 0 TITlRA TAPOUNDE KOUPORGOU LANDA POZANOA BAGAN ALEHERIDE BETEROU WARI MARO 82002 tr 2003 fi2004 tr 200s a2006 82007 Oti basin (Keran,Kara,M6) Upper Oueme CORRECTED ANNUAL TRANSMISSION POTENTIALS IN OTI AND UPPER OUEME BASIN 812002 tr 2003 fi2004 0 2005 a2006 82007 350 300 o-F t,o oo o(,) 0 Upper OuemeOti basin (Keran,Kara,M6) IE ll {rh IIlf, ffim dll,ll' f,l€ . fl Jl Hh Elr TITIRA TAPOUNOE Kd,,PORGOU LANDA POZANDA BAGAN ALEHERIDE BETEROU WARIMARO a) t'