ONCHOCERCIASIS CONTROL

AFRICAN PROGRAMME

FOR

ONCHOCERCIASIS CONTROL

Additional Funding Request for

Phase II and Phasing Out Period

Plan of Action and Budget 2012-2015

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@ African Programmc for Onchocerciasis Control (WHO/APOC) 2Ot0 All rights reserved.

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i

Joint Action Forum Office of the Chairman

Forum dAction Commune Bureau du Prdsident

JAF-FAC:

Sixteenth

session

Abuja, Nigeria,

T-9

December 2010

Additional Funding Request for

Phase II and Phasing Out Period

Plan of Action and Budget 2012-2015

Africa n Prog ra m me for ^O nchocerciasis Control, World Health Organization (APOCA,VHO)

SEPTEMBER 28,2010

AFRICAN PROGRAMME

FOR

ONCHOCERCIASIS CONTROL

\9r

Table of contents

Executive

summary

Programme Evolution and Milestones:

Rationale

for Additional Funding Programme

Design lssues,

Objectives

and

Outputs.

. . ^.

Background and rationale

Objective l:

To strengthen core

CDTI activities

to accelerate

elimination of inlection

and

interruption of

transmission of Onchocerciasis...

Outputl.l:

Expanded Core CDTi Activities: Communrty directed rreatmenr

with

ivermectin

(CDTI)

Outputl.2: Elimination

surveys

including

capacity

burlding

for

interruption

o[ transmissron.

Shrinking

the Map..

Outputl.3:

lmproved Record Keeping at Health

Facility

Level

Outputl ,t' Community

Self

Monitoring

and Stakeholder meetings ...

Outputl.5:

Strengthening rhe Scientific and Evidence Base: Establishing an Onchocerciasis

Information

Memory

Objective 2: Co-implementation and gender mainstreaming to strengthen PHC

Output

2: Co-implementation and gender equity...

Output

2.

l: ^lnclusion

of CDI Approach rn

Curriculum

of Universities ... .. ....

Output

2.2: lntegrated Mapping of Five Neglected Tropical Drseases (NTDs)

Output

2.3: Co-implementation and capacity

building

Output

2.,1:

Building

Capacity of nationals and increasing rhe

output of

operational research

.6

IO

t2 t2

...

l2 l+

l1 t7 l8

....

l9

... 20 ...

2l

...21

... ...22

.. . ...23 21 Objective 3: To

transition

APOC Programme

delivery

to complete

country

management.... 26

Output

3: Enhanced APOC delivery capacity and support to

countries..

^...

^...26

Output

3.1. Short Term Measures to Increase Capacity

(2012-2015).

...26

Output

3.2' APOC Programme delivered and

transition

to complete

Country Management

... 26

Summary Budget

30

List of acronyms

APOC

csM

FLHF IM JAF

LF NGDO

cDr

CDTi

NOTF NTD

ocP

Afncan Programme for Onchocercusrs Control

Communrty Drrected lnterventron Communrty Drrected Treatment wrth lvermectrn

Communrty self-Monrtonng Front Lrne Health Facrhty Oncho ln[ormatron Memory Jornt A[ncan Forum

Lymphatrc Frlanasrs Non-Govemmental Development Organuatron Natronal Onchocercrass Task Force Neglected Troprcal Drsease Onchocercrasrs Control Programme rn West Alnca

Onchocercrasrs

Plan o[ Acuon and Budget Preventrve Chemotherapy Pnmary Health Care

Raprd Eprdemrologrcal Mapprng of Onchocercrasrs

Severe Adverse Events Stakeholders meenng,

UNICEF, UNDR world Bank WHO Programme for research and trarnrng rn Troprcal Drsease

West Afncan Health Organuatron Oncho

PAB PCT PHC REMO

SAE SHM TDR

WAHO WHO/AFRO

wHo

World Health Organrzauon

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Executive Summary

The

long-term commitment

and

political will

of

national

governments and sustained

support from

donors and NGDOs

to

tackle

river

blindness

control

is a major, yet unheralded,

public health

and development success

in

Africa.

This

proposal sets

out

a

four

year plan 20L2-2015

[or two interrelated

goals:

first,

measures to scale up progress

to eliminate

Onchocerciasis

(river blindness) in[ection in

many

foci in Africa

and transfer

full

management and

control for this

^to

national

governments; and second,

to utilise

the resource and

delivery model

developed

by

the Onchocerciasis programme as a

platform

to strengthen the

ability

of health

infrastructure (primary health

care) to tackle Neglected

Tropical

Diseases (NTDs) and

other health

challenges.

This

proposal has been prepared based on the mandate and request

of the

14'h and

15'h sessions

of

the

Joint Action Forum QAF)

that APOC

submit

a request and

justification [or additional funding for

2OL)

-

2015 .

At

present APOC has $ 1 1.45m

in funding

available

for

2012-2015

for limited

core

CDTI activities

and some technical assistance to

post-conflict

countries. The

total

cost o[ the revised

plan

of

action

is

$60.06m, leaving an

unfunded shortfall

of $49.5m.

Despite many medical breakthroughs

in

the

fight

against disease and to

improve

the

quality

of

life, millions

of people

in

sub-Saharan

Africa still

^do

not

have access

to

the available medicines, vaccines and life-saving

tools in their

communities.

Access

to

these resources

would

make a

significant

difference

to

the social and economic lives

of

the poor, and remove

major

barriers

to

the achievement of the

Millennium

Development Goals (MDGs).

Reducing illness and death caused by

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infectious

diseases

is critical

to reducing

child mortality

due

to infectious

diseases

(MDG 4)

and

improving

the

health of

mothers,

who

are

disproportionately

affected by several

tropical

diseases

(MDG 5).

Good

health

also has a

direct impact

on

productivity

and

family

incomes and

thus

the achievement of

MDGI.

The Onchocerciasis

Control

Programme was

highly

successful

in reducing

the incidence

of

the disease, and also

in piloting

successful affordable models

for

community-based health systems. The

involvement of

the people

- the

"heart beat"

of

health systems - has

led

to

significant

progress

in

the

control of

River Blindness

in Africa. For

more than a decade, the strategy

of community-directed intervention (CDI)

has served as an effective

platform for

the

delivery

of

other health interventions

needed

by millions

of under-served people

in

133,000

communities in

the sub-region.

This

record was cited

in

the

conclusion of

the

first external evaluation

of APOC':

"ComDT

(CDI)

_{has been a timely and} innov ativ e str dteg)/ . . . and communities hay e

been deeply inyolyed

in their ownhealth

cdre on a massiye scdle.... ComDT (CDI) is a strdteg)/ which couldbe used as a model

in

deteloping other community-based programmes and is also a potential entry

point in

the

fght

^{dgdinst other} diseases."

Many affordable

and

effective

disease

control products

and

interventions

have had

limited impact on

the

burden of

disease due

to

inadequate

distribution in poor

and

remote communities. In contrast the CDTI strategy

of APOC has been

very elfective. lvermectin treatment

is

popular and I33,000 communities

have responded

enthusiastically to

the concept

of 'community directorship' in which they

are responsible

for its planning

and

implementation.

APOC has successfully used

this

strategy

to provide

a

cumulative total of

over 440

million

treatments since

its inception, thus protecting

120

million

people

who

are at

risk of

River

blindness

disease.

The

effort

has also proved successful

in

generating efficiencies, and creating

significant

value

for

money returns.

Engaging and empowering

communities

is

vital to

the success o[

river

blindness

control

and enables a treatment cost

oI

US$0.58 per person treated compared to a cost of US$0.73

in

the absence

of community

engagement.

Whilst this

per capita cost

reduction

is

small,

considering

that in

2009 over 67

million

people were treated,

this

represents a saving of more

than

$ 10m./year.

The APOC model

works

by

constantly

measuring deliverables,

investing in

people- centred research,

community involvement

and

ownership,

and by

strengthening partnership

and

building

the capacity

of

health

workers in

the use of

health intervention tools. In

this way, APOC has developed a cost-effective and

workable

approach to

supporting infrastructure for

PHC that provides

opportunities for poor

and remote

communities

to access

improved quality health

care and medicines.

The APOC

plan

2012-2015

will

complete the

job

of

eliminating

Onchocerciasis

infection

and

interrupting

transmission where feasible

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Figure 1 Percentage of communities with

B07o therapeutic coverage 2009-201 5 100

by the time APOC hands over

responsibility

to countries.

All

^the

post-conflict

areas

would

achieve

similar

rates of improvement

with

almost

all

of them reaching the crucial

80o/o therapeutic coverage by the end

of

2015. APOC

will

achieve

this

through the

following

activities:

mobilization

and

mop-up

treatment rounds,

training, monitoring

and supervision, advocacy and supporting material.

Output

Elimination

surveys

including

capacity

building for interruption

of transmission:

Shrinking

the

Map.

The programme

will

provide technical and financial assistance to countries to carry out epidemiological surveys to assess trends

of infection

towards

elimination

endpoints and support for enhanced capacity at national level, and equipping countries

with

the necessary technical

skills,

competency and financial and material support. This

will

accelerate the

shift

from

control

to the

elimination

of onchocerciasis

in

Africa, and allow national planning around the

distribution

o[ ivermectin. Progress over 15 years has created the

possibility of

eliminating onchocerciasis

infection

and

interrupting

transmission

in

Africa. The planned closure of APOC

in

2015 requires the presence of enough capacity at

country

level to take over all onchocerciasis

control

programmes and./or

elimination

efforts

within

countries.

OBJECTIVE 2

Co-implementation

and

gender mainstreaming to strengthen

^PHC.

Output

Co-implementation

of onchocerciasis

control

and

other health interventions

and gender

equity

Primary health care systems

will

be strengthened by the

introduction of Community

Directed Interventions (CDIs)

in

the

curriculum

o[ universities ^(40olo

of institutions will

teach the CDI

curriculum in

20L2,70o/"by 2013,80 ^o/o by 2014 and the

20r 5 Year

by indigenising national management, and also offer a vehicle

for

scaling up health improvements

for

some of the poorest

African

citizens to broaden impacts across a range of neglected

tropical

diseases. This programme requires increased

commitment

and resources

from

countries,

additional

support of partners (NGDOs) and increased investments by donors.

The proposed programme includes a

detailed set o[ costed

activities with

three broad objectives:

OBJECTIVE ¹

To

strengthen

core CDTI

activities to

accelerate elimi

nation

of

infection

and

interruption

of transmission

of

Onchocerciasis

To achieve

this

objective the programme has

two interlinked outputs:

achieving new levels of

ivermectin

coverage and

elimination,

and a second

o[

transferring

management

of elimination

and

interruption

oI

infection

to

national

governments:

Output

Expanded core

community-directed treatment with ivermectin

^(CDTI): 95o/o

ol

areas achieve 80o/o

threshold

for

therapeutic

coverage

with ivermectin

by 2015.

The percentage of communities achieving

80o/o therapeutic coverage

will

^rise

from

a

baseline of 71.7o/o

in

2009 to75o/o

in 20I2,

85olo

in

2013,90o/"

in

2014, ar.d 95o/o by 2015

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in

2015). This

output will

support integrated mapping of Neglected Tropical Diseases (NTDs), _capacity

building initiative

for co-implementation o[ other health interventions using CDI and other strategies, gender mainstreaming,

buildrng

capacity o[ nationals and increasing the

output of

operational research.

OB'ECTIVE 3

To

transition

APOC Programme

delivery

to

complete Country Management Output

Enhanced APOC

delivery

capacity

and

supPort to

countri$.

The capacity of APOC (administrative, personnel services, logistics and

infrastructure)

over the period 2012 to 2015

will

be increased to provide expanded technical support

control

for ehmrnation, co-implementation, gender mainstreaming and

further

strengthening of PHC delivery.

The current level of staffing especially at

the technical and professional levels is inadequate to cope

with

the new demands being made on APOC.

Output

APOC Programme

delivered

and

transition to complete Country Management.

The

main

activrties to be undertaken

for

the complete

transition

to

Country

Management

include

discharging

liabilities, documentation

and reports, equipments, vehicles, premises, closure

of bank

accounts, APOC personnel and post closure

activities including

the

electronic archiving

of

all important

documenrs.

The

overall

proposal sets

out

a Plan

of Action

and Budget

for

the

period

2012 -2015. The

total

cost

of

the programme over 2012-2015 is US $60,959,053 of

which

US

$ I 1,.+59,053 is already secured.

This

leaves an

unfunded shortfall of

US $a9,500,000.

A detailed budget summary is given

in

Table 12.

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Programme Evolution and Milestones: Rationale for Additional ^Funding

The African Programme for Onchocerciasis

Control

^(APOC) was launched

in

December 1995.

It

succeeded the Onchocerciasis Control Programme (OCP)

in

West Africa, the activities of which ended

in

2002, and had the aim o[ extending the success

of

Onchocerciasis control

in

West Africa to 19 African countries.

By 2007 _, APOC had already made substantial progress: 37

million

people prevented from developing debilitating disease; ivermectin was made available to more than 55

million

people

in

^i17,000 villages; the prevalence

of

severe itching and skin lesions was cut by 50ok

in

16 countries; and a cumulative total of 3

million

DALYs had been saved since the start of the programme.

In

2008, there was evidence that many communities are able to

interrupt

transmission and eliminate the disease from some areas

with

ivermectin treatment alone,

. ,04,-:''

thus paving the way to end the need

for

treatment. This exciting new development

would

require longer to achieve than control, and additional support to endemic communities. Thus, the

shrinking

of the African map o[ river blindness became attainable

in

the foreseeable future.

Interruption

oI transmission

will

^also signiflcantly boost agricultural

productivity in

endemic areas.

At

the same time,

it

became evident to the partners that APOC could use its experience and infrastructure especially at community levels

in

delivering health improvements to marginalized communities through strengthening health systems.

The

rationale for this

proposal document is the decisions

by the

14'h

and

15'h sessions

o[

the

Joint Action Forum

^(JAF) based on the evidence

that communities in Mali,

Senegal and Kaduna

in Nigeria

have succeeded

in interrupting

the transmission of

river

blindness and

eliminating

Onchocerca

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volvulus

infection from

some

foci with ivermectin

treatment alone.

In

December 2005, the APOC governing body,

theJoint Action Forum

^(JAF) decided that a

high

level

Working

Group on the Future o[ Onchocerciasis

Control in

Africa should review the challenges to

control

onchocerciasis,

its future

options and the role of APOC and its partners.

This

led to:

I

the September 2006 ^Yaounde Declaration

of

Afncan Ministers of Health on Onchocerciasis

C ontrol. The Governments expressed commitment to accelerate the elimination oI River blindness as a socio-economic development problem

-

^a

^truly

^historical

milestone for the commitment o[ the African member States;

I

the repositioning of APOC by African Health Ministers of participating states and donors

in

2007, from a single to a multi-disease programme and support to countries to determine when and where ivermectin treatment could safely be stopped; and

I

the resolution on onchocerciasis control by the 57'h session of the Regional Committee for Africa (RC57).

Based on the above, theJAF decided

in

2007 to extend the duration o[ the programme from 2010 to 2015, and also approved support to 4 OCP countries in West Africa (Sierra Leone, Ivory Coast, Guinea Bissau and Ghana) where the epidemiological trend of control had remained unsatisfactory often due to conflicts.

The Strategic Plan of Action and Budget prepared to cover the objectives as set up by the Working Group was approved byJAF

in

2007. However, partners further decided that APOC Management should also submit an addendum to the Strategic Action Plan and Budget of APOC for 2008-2015 which

would

include assistance to countries to enable them to take overall management control, and decide when and where to stop ivermectin treatment. This Addendum was approved by donors andJAF

in

2008.

Based on the very encouraging results, the donors asked APOC management [o review the budget o[ the addendum

in

December 2008 which was considered modest, and to submit a request and

justification for

additional funding for 2012 - 2015. A

brief

presentation of the additional funding was made

in

December 2009 and this document sets out a proposed PIan

ofAction

and Budget for 2012-20L5.

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Programme Design ^lssu€s, Objectives and Outputs

BACKGROUND AND RATIONALE Onchocerciasis affects the poorest, most marginalized populations

in

Africa.

Minimizing

the disease burden enables

individuals

to continue to

work,

to attend school, have a social

life

and provides other socioeconomic benefrts that promote economic growth and

diminish

the cycle of poverty.

The JAF recognized the positive impact on the economies of APOC member countries

following

onchocerciasis

control

through CDTi.

At its

14'h session held

in

December 2008 theJAF encouraged APOC countries to

work

toward achieving and maintaining ivermectin therapeutic coverage of at least 80o/o to replace a

minimum

target threshold of 650/o. This is required to achieve both

morbidity control

and reduction

in

the transmission oI onchocerciasis infection.

Although

55

million

people had been treated

in

2007, theJAF meeting also expressed concern over the negative impact on treatment coveraSe caused by cross- border issues. These

include

the need for overlapping Rapid Epidemiological Mapping of Onchocerciasis (REMO) _at border areas

of

countries, to enable decisions to be made on whether and when to treat

with

ivermectin

within

the respective countries. Treatment by one

country in

the absence o[ treatment by the other at the border areas negates the gains

in

the reduction

ol

transmission.

Consequently, APOC Management requested

all

CDTi projects to adhere to the JAF ^14'h session recommendation

in

order to improve project performance and sustainability.

Several CDTi projects

in

stable countries have achieved therapeutic coverage

of

close to 80o/o. However, for all projects

in post-conflict

countries to attain the 80% therapeutic coverage is a formidable challenge that needs special effort and support to overcome.

Ivermectin

treatment figures reported

by

CDTi projects

in

2009 showed that

post-conflict

countries achieved an average therapeutic and geographic coverage

of

63.9o/o and 81.5% respectively, compared

with

coverage of 77 .0o/o and 98.2olo respectively

for

stable countries. The NOTF and APOC management

will

therefore focus on strengthening communities' ownership and engagement ^as

well

as

increasing

monitoring

of CDTi activities.

The involvement of

community

leaders

in

ivermectin

distribution

is

particularly

crucial

in

the context o[ weak health systems

in post-conflict

countries. Strengthening this approach has begun through APOC Management and NOTF meetings

with community

leaders

in, for

example, two provinces

in

Angola,

in Burundi

and

in

the soulhern part oI Sudan.

The programme design draws on the evaluation and reports undertaken over the past three years, and identifres the targets, activities, inputs, and

monitoring

and evaluation to achieve the overall goals.

OBJECTIVE ¹

To

strengthen

core CDTI

activities to

accelerate

elimination

of

infection

and

interruption

of transmission

of

Onchocerciasis

Activities

To respond to the need to help countries to determine when and where ivermectin

/ #

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b

P

treatment can be safely stopped, and raise

their

therapeutic coverage to 80o/o, APOC

will

undertake the

following

activities:

I Mobilization

and extra treatment rounds Communities

will

be mobilized to conduct mop-up ivermectin

distribution

where needed. Provision

will

be made for them to

follow

up absentees and/or refusals after the main treatment campaigns, to increase

their

coverage to 80o/o.

I Training

Health staff:

It will

be necessary to

train all, or

the

maximum

number

o[

health workers at

district

and health

facility

levels

working in

and

ouside

the onchocerciasis endemic communities.

There has been a recurrent problem caused by the

high

rate of

turnover of

national and peripheral health staff. This turnover is inevitable, as staff members are transferred

out

of the onchocerciasis endemic communities to other areas, or move on

for

career reasons. By targeting a larger

pool

of staff

it

is envisaged that the large

majority

of staff that

who

are transferred to Onchocerciasis endemic areas

would

be

qualilied

to support the

control

and

elimination

efforts. This approach

will

^help

^mitigate

the negative impact of the

high

staff turn-over.

I Community Directed Distributors (CDD)

-

Training

of

additional Community- Directed Distributors (CDDs)

and

community

supervisors

will

be undertaken.

This is

not

only required to help them to stay abreast of the increased

work-load

to move to the

high

coverage rate

but

also to

minimize

the

attrition

rate of CDDs and its impact on treatment.

I Monitoring

and Supervision The

monitoring

and supervision

of

CDTi implementation by communities and by NOTFs

will

be intensified to help

identify

any obstacles to achieving the 80% coverage. There

will

be annual reporting of the

number/proportion of

communities

with

less than 80o/o treatment

Figure 2 Average therapeutic and geographic coverage in Stable vs, Post conflict countries 2009

120

I ^{Post conflict}

0

^{stab e}

100

o

C

o 80

60

40

20

0

Therapeutic coverage coverage

coverage by

project(s)

and by

country

(ies). This

activity will

be intensified and a new

monitoring

mechanism

put in

place to detect

quickly which

communities are falling behind the objective of reaching the 80o/o treatment coverage and enable

mitigation

strategies.

I

Advocacy and

supporting material

Advocacy at regional and

district

levels

will

be intensified to

bring

the health service up to speed

with

goals o[

elimination of

infection. The understanding and support of the administration at these levels

will

be needed.

Additional

IEC materials

with

a focus on

elimination

issues (e.g.

high

treatment coverage)

will

be produced and existing ones updated.

I

Support to cross-border meetings In view of concern over cross border movements that

might

compromise treatment

in

certain areas, support

will

be provided to

all

countries flor regular cross- border meetings to assess the prevailing epidemiological and entomological situation and efforts being taken to address the relevant issues. The sub-regional

Ministerial

meetings

will

^{continue each}

year to assess progress on elimination.

It

is anticipated that

with

the measures and activities to be carried out

with

the support of APOC, each community

will

obtain the 80o/o therapeutic coverage

for

ivermectin treatment through

their

CDDs and under the supervision of health workers.

tl

o

N NI

o

N ul

I

o f

@

6 z z 9

lJ IL

o z c

ci I

&, UJo.

f o I z

IA

E a o z

UJra

I

o.

CE

o

!t ralrr

= o

UJ 0c 19

z 6 z 3

lt

z o

o-

o

Table

I

Budget (in USS) for strengthen ng CDTI core activities rn

o

N NI

o N F

uJ

lo

a

D 6 o z z o

t,

o lt

z o

ci

9

OE UJo.

F

= o (, z

ut

I

o.

6 z

UJrn

- c

G

o

lt F

(a ur

= o

UI G,

I

= o 3 z

tl

z o

6 o

2012 20r 3 2014 20r 5

Activity Total

CDTI core activitles US S 2,400,000

Output

1.1

Expanded Core CDTi Activities: Community directed treatment

with

ivermectin ^(CDTI):

90olo of projects achieve 80o/o threshold

for

therapeutic coverage

with

ivermectin by 2015 The programme

will

supplement approved funds by an additional _$8.02m, a 690lo increase

in

support

ofcore

CDTi activities: advocacy/

sensitization/mobilization, mop-up treatment rounds, elimination surveys

-

epidemiological and entomological,

-

^training,

^monitoring

and supervision. Special attention

will

be given to cross-border initiatives to harmonise efforts and avoid inconsistent practices

with

compromised resuls.

Several CDTi projects

in

the stable countries have already achieved therapeutic coverage close to 80o/o (the new target

in

2008 under the elimination paradigm)

with

the current level of funding. However, there is need for special effort and support to post-conflict countries to attain the 80o/o therapeutic and 100o/o

geographical coverage. Through improved technical and financial support, ivermectin treal-ment Iigures as reported by CDTi projects

in

2009 showed that post-conflict countries achieved an average therapeutic and geographic coverage

of

63.9o/o and 81.5olo respectively, while the figures reported

in

2008 were 45.8o/o and 65.4o/o respectively. This is a

significant achievemenl-.

The additional budget to help undertake the activities

in

23 countries (APOC and 4 ex OCP) is estimated to be $8,020,000 as

indicated

in

Table

I.

Output

1.2

Elimination surveys including capacity

building

for

interruption

of transmission:

Shrinking the Map

Background ond rationale

The primary objective of the APOC was to establish,

within

12 to 15 years, effective,

2,200,000

1,850,000 1,570,00

8,020 000

self-sustainable, community-directed treatment of onchocerciasis

with

ivermectin throughout the endemic areas

in

the geographic scope of the programme. Additionally, the Programme aimed at eliminating the vectors transmitting the parasite

in

selected circumscribed foci using environmentally safe methods. The attainment of this objective is expected to contribute to the elimination of onchocerciasis as a disease of public health importance throughout Africa, and so contribute significantly to improving the economic and social welfare of the people.

APOC has largely achieved the objective

to control

Onchocerciasis

in

a number

of

countries. Recent research

findings in

Africa (Senegal,

Mali,

Nigeria, Uganda, Cameroon and Chad) suggest

that

that

long

term

ivermectin

treatment of onchocerciasis can lead to

elimination

of the disease transmission.

If this

new

important

evidence

for

the

elimination

oI transmission

of

onchocerciasis is replicated

this

opens up the

possibility

of embarking on

elimination

of onchocerciasis

throughout

Africa.

For the

elimination

of onchocerciasis

from Africa

to be a reality,

it will

be necessary to

include all

Ex OCP countries

in

the epidemiological reassessment exercise to determine

in which

geographical areas

elimination would

be feasible.

In this

respect most of the ex OCP countries that were placed on

ivermectin

treatment alone,

or

for some

time in conjunction with

vector treatment,

would qualify for this

assessment. The

impending

closure of APOC

by

20L5 requires the transfer

o[

capacity to

country

level

to

take over the assessment and

monitoring

of trends and stopping treatment, the management of

all

onchocerciasis

control

programmes and/or of

elimination within

countries.

This

Plan provides guidance on gradual

decentralization

and transfer of programme

responsibilities

to

countries,

integrates onchocerciasis

control

and

elimination into national policies

and processes, accelerates the

epidemiological evaluation of all

APOC projects

and their

^proS,ress towards

elimination,

and steps up capacity

building efforts

to increase local

ownership

and

strengthening of country

^management

systems.

Accordingly,

the development

of sustainability

and

elimination

^plans and

their evaluation

has been stepped up.

However, there remarns a

lot

to be done

in building

the capacity

of countries,

to

equip

them

with

the necessary

technical skills

and competency as

well

as

providing

them

with financial

and

material support.

The

l.tth

sessionJAF

underlined

the need

for

addressing some

critical actrvities

and

for providing

an adequate budget

additional

to

the

PAB 2008-2015

to

enable the

execution of

these

activities.

The

plan for

capacity

building for

the years 2012

through

2015 takes

into consideration a)

the transfer

of all

APOC

activities

to the

participating countries in

accordance

with

agreed

country

specific assrstance

frameworks

and

b) inserting

onchocerciasis

control

and

elimination firmly within national health

and

surveillance

systems.

Each

ivermectin delivery prqect should

be

fully

sustainable

by

2015 and be

working

towards

elimination where

feasible. We propose

investing

more

in

APOC's

ground work of building

the capacity

of countries, WHO country

ofhces and rn

country NGDO partners to

take

over

the

overall responsibility of running

onchocerciasis

control

programme.

Activities

I

^Assisting

countries

to prepare

for elimination

where possible.

This will

also

include

the ex -OCP

countries. Generating evidence

on

the epidemiological

situation in

each

project

area

in the

19 APOC countries and

the

I

I

ex-OCP countries.

I

^Define areas

in which elimination

is feasible and target

with

a clear

work plan.

dehned end pornts, and

monitoring

and

evaluation

plans across the 30

countries.

I

Delineation o[ transmission zones for each project

with

technical assisunces of expen entomologrsts and molecular biologrss.

!

^In partnership

with

NGDOs and endemic communitres, initiate elimination plans by countnes for oustanding proJects.

I

Strengthening

country

capacity for

elimination.

APOC

will

create a core

of

expertise at the national level ^(as

obuins in

Nigeria and Uganda) to oversee the implementation of the programme as

well

as regularly

monitor

progress. This group

will

have

similar

role as the technical consultative committee of APOC. Creation of such expert group and

supponing their work

needs to be

surted in

at least 15 countries. APOC

will

endeavour to:

!

Train key

in-country

resource persons from universities, research institutes, MoHs, NGDO partners on the procedure and

their

role

including:

!

Ehmrnation lield activities and on-the-job training.

I

Epidemiological evaluation and disease monitoring and surveillance cross-sectional surveys involving epidemiology, entomology, derma tology, ophthalmology

I

^assessing health impact of the Programme through the use of the computer simulation model (APOC Onchosim) diagnostics

of

onchocerciasis using both the classical methods and new methods.

Post

cqttrol

surveillance

Post-control surveillance activities

will

be instituted to help detect any re-emergence of inlection (recrudescence of infection).

To undertake these activities countries

will

be assisted

in

the selection of sentinel sites based on and using all available pre- control entomologrca! and epidemiological data. Blackfly collection

will

be undertaken every year using ethical methods and

will

TA

o (\

I

r.{

a!

F

\,

IT.J

o

l

co

o z z 9

F

o

I

z

J

o o a

L!

o- F

o

l

\,

=

I

o-

o z

ll/

IC d

o

I F

uJ

l

o

UJg.

(, z o z

l

I J

z o

E

o

o

rn

o

N

I

r.{

o

r^{

Fr!

(, o

l

co

o z z 9

F

o

I

z

J o-

x o a

UJ

o-

Fl

o \, z ;

I

CL

o z

IT.J

I

o- cc

o

I

F

uJl

o

UJ CE

\,

= o z

l

I J

z o

E

o o

Quantity Cost/unit (uss)

Des(ription 201 2 20r3 20]4 20't 5 Tola I

Table

2

Budget for Ehmrnatron surveys rncludrng capacrty burldrng for rnterruptron of transmrssron Shrrnkrng the Map

Asilsthg

a

//wtcs o gtqrc bt

adwehls

dkn

nffir

wlptc

ffic

A(ceh6ted epdemiologkal elaluton to as:ess progress to^ard5 elimination in allAPOC/

OCP plq,ecs Eraluate c6sa0on of treatment in adunced pqie(ts ard i$iluteppos-cont.ol survalbrre; rntensifred on the- iob raharq d natixral eraluation leam6 nd€seacivfties Documentatnn of

epilJemologrcal srtuation in each prq,ect area Defnlon of transmrsron zones fo, each p.oject with technr@l asssurnce of expen entoflrologists

Engagement of molecular birlogrss as consultants for delineation of ransmisson zonet

Supponrng the p,oducton of gurdehnes for elimmauon and trainrr€ documents (enromology, epidemiology, dognostrcs, etc)

lnatiate elimrnaton plans by cotJnlries

2

50000

r

500000

r 0@0q) 2 500000

3ocountries

^60@

r80m r80m

3ocounraes 50000

I

10()000

7O0q) | 8@000

5 experts + equpment etc

2m000

2m0(x) 2@0q, 200(m

^6m000

30

counrri€s 40@ 1200@ r200m

1200@

t20000

⁴⁸⁰⁰⁰

3ocounr,ies 1000

^{3m0q) 3(x)m}

6mm

Sterytlwiltq ouary

crylty

lu

c/frnffin frarnangonepi-Ealuaton,

3ocountries nerv end clessical diagnortiG

br drs€as€ monito(ing and sunEillance In countrEs.

Trarnrng of

trairrrson

^{15 training}

Epdemblogcal E aluatpn

and

^uorkshops

d6ear€ su,\€illance tn countfles

E$ablBhing and

maintarnng

^{3 centres}

Regonal OnchocercEsis diagno$ic and qualty coilrol cenre (\irefl and Central Afrka

& Eil and Sorrth Afrlca)

T6l

be examined for levels of rnfectivity using the DNA probe.

Initially

this analysis

will

continue to be undertaken at the molecular biology laboratory at the Multi-Disease Surveillance Centre

in

Ouagadougou, Burkina Faso and subsequently

in

other satellite srtes

with

the appropriate capacity e.g. Noguchi Memorial Institute for Medical Research in Accra Ghana. The resuls from the

fly

inlecuvity analysis

will

serve as srgnal for any untoward infection at a particular site. Trained technrcians

wrll

be visiting each sentinel site once every 3 years for epidemiological surveys

in

the villages, but sentinel sites

will

be surveyed annually

in

rotation

50m0 rmm

5@0q) r 5(x)0(x)

100@0 6500@

35000 r 500000

500000 6q)0@

^r500q)

5(x)m

7$m

r 500000

5270000 320000 187000 32000

1065000

National staff

will

also be trained

in

the deuiled analysis of, and the interpretation of, the results that are obuined. Criteria for aiding the decision on the presence

of

recrudescence

will

be provided to the staff to enable them make the appropriate decisions and undenake necessary measures to contro!

any recrudescence. These epidemiologrcal activides are labour-intensive, require special attention, motivation for the

suffand will

require national

suppon.

Given that

in

the posr control era most of the surveys

will

come back

with

negative results,

lt

is essential that motivation to carry out the surveys regularly is sustained, to avoid recrudescence of infection.

The budget to undertake the activities under

output

1.2 is estimated as US $10,660,000 as set out

in

table 2.

From the approved funds under the Strategic Plan of

Action

and Budget (PAB)

for

the period 2008-2015 and the Addendum to the PAB, a balance of US $11,459,053

will

remain at the end of 2011.

This

amount, complemented by US $18,680,000

from

the

additional

funds requested

will

be used to achieve

outputs

1.1 and 1.2 above

for

core

CDTI

activities and

elimination.

Output

1.3

lmproved

Record Keeping at Health Facility Level

Background and rationole

CDTi communities adopt a three part approach to record keeping:

I

^Taking responsibility for the way targeted health interventions are implemented;

I

keeping records of essential data from their activities; and

I

forwarding annual summary reports and community registers for annual mass drug administration to the nearest health

facility

for safe keeping.

These records constitute a good repository of important

information

on the

individual

and the community as a whole at the health

facility

level.

Monitoring/evaluation of records conducted by APOC revealed inadequate safe-keeping of CDDs records at the FLHE

While

at community level community registers are usually well kept by CDDs or community Ieaders, evaluation results from 12 countries showed that this is not the case at the under- resourced FLHF levels.

Without

good record keeping

it will

be

difficult

to assess progress made by CDTi projecs towards the elimination o[ onchocerciasis infection and

intemrption of

transmission. Since 2006, APOC Management has been providing technical and financial support to National Onchocerciasis Task

Forces (NOTFs) to establish standard tools (community registers, drug management forms summary forms) for data collection and reporting on CDTi at all levels of the health system and at the community level.

This information cannot be made available

in

a timely manner unless a reliable, systematic and sustainable record-keeping and archiving system is in place.

The programme

will

^{provide each health} facility

with

a simple, reliable and sustainable

filing

system for CDTi documentation to support the elimination agenda. The documentation has proved to be a useful source o[

information for Institutions

and other Programmes

working

towards, alleviating the burden of poverty from

rural

communities.

It

is envisaged that by 2015, health workers at the front

line facility/

health centres

in

onchocerciasis endemic districts trained on collection of data and documentation and safe-keeping of data

for

use

in elimination ol

transmission activities

would

have increased by 70o/o.

Activities

I ^Provision

of sustainable

filing

system at the FLHF

Threats to proper storage and easy retrieval oI records

include

misplacement, loss, water, and lack of sensitization on the importance o[ storage. The

filing

system should be robust and reliable,

for

example, strong and waterproof bags;

metal

lock-up cabines;

and

reinforcing

security of the storage.

ut

o

l\

NI

o N

t,

UI

o f

o o z o z

L., l!

o z c 6 9 c

A

ul

F )

o I z

U!

c -

o z

r^gI

4 r

&,

o

raul

= o

UJ OE

\, z a 2

=

t!

z o

l-

6 o

h g6

t

Table 3 Budget ^(rn USS) for provrsron of sustarnable documentatron system ln

o

I

o

(\l F

UJ

\, o

l

co

o z z o

F

u-

o z

J o- ci

9

CE UJ CL

Fl

o (, z a I

CL

o z

=

u.J

o-I

c(

o

I

F

gJ

l

o

IIJ d.

\,

= o z

f

tL J

z o E o o

20'r s US5

Year 2012 20't 3 20 t4

Amount USS r

oil

^{300 r 0r0000}

I

^Training

Target FLHFs

willbe

identified,

following

which trarning on basrc fihng and tracking

ofrecor&

and on the use o[data collected for planning of annual activities and decision-making

wil!

be underuken.

Distribution and handover of matenal to FLHFs and annual inspectron o[ the recording centres

will

be camed out by district/national personnel.

Table 3 sets out the budget for US$3,0,10,100 to undertake this activity.

Output

1.4

Community

Self

Monitoring and

Stakeholder meetangs

Backgrou nd a

nd

Ration ol e

APOC has encouraged communities that receive ivermectin treatment through the CDTi to adopt Communrty-Self Monitoring ^(CSM), a novel system for monitoring the communrtres' own performance of the ivermectin

distnbution projects. This model is suiuble lor adapution for all PHC seMces

within

the community

with

the eligible communities being empowered to set up and to conduct the monrtoring of their own performance.

As a

community-driven

process, CSM provrdes a mechanism for ensuring that the programme is being executed as intended.

CSM allows each

community

to discuss issues that could jeopardize

community

participation and also to address common problems

which

weaken delivery e.g.

ivermectin shoruge, high rates of absenteeV refusals, and non-treatment of temporary ineligible persons (breastfeeding mothers,

@9800

409000

3040 t00

the

sick).

Furthermore,

it

enables the

community

to discuss and review CDDs drop out, lncentives to CDDs and inadequate treatmenl coverage.

The outcome of the CSM is reported annually at the Stakeholders meeting ^(see below), a forum at

which

rhe communities and health workers have the

opportunrty

to discuss the aggregate resulrc

from

the CSM exercises. Between 2007 and 2009 73,000 CSM activrtres have been carned out

in

20 projects. Thrs constitutes

only

19%

for

the 108

projecs

considered. The current upscaling of the CSM by communities is therefore low, and there is an urgent need

lor

efforts to encourage uptake to

all

communities. Expanding CSM

in

CDTi and

for

use by other PHC services involves tralnrng health

suff

at FLHF

for facilitation

of this exercise at

community

level.

APOC

will

therefore reinforce communities' involvement and ownership of the entire process of CDTr

including

extending the use of CSM to 90% of communities

by

2015.

CSM

will

be expanded as

follows:

^.10%

of

total communities

in

2012,60oh

in

2013, and 80%

in

201a. By 2015,90% of communities

would

be expected to have carried

out

CSM activities.

lt

rs APOC's aim to

support

the communities

in

achieving a therapeutic coverage

of80%

rn an

effort

to accelerate the ehmrnation

of

the infectron and

interruption of

transmission

in all

countries. CSM

will

be an

important

component for assessing the performance

of

the communitres.

APOC has encouraged Stakeholders meetings (SHM)

in

the communities that have embraced

Table4 Budget (rn USS) for conductrng CSM and Stakeholder meetrngs SHM

A(t ivity 2012 201 3 20'r 4 20't 5 TOTAL

csM SHM

Tot l

609 500 2500@

t59500

80940 500000

l3O9/m

| 009400 5m000 t 509'l0O

r r094q) 5000@

l6Oe 'mO

3537 7N r 750000 s2€,77oo

CDTi. At the meetings, the communities report the hndings from CSM activities and other health issues which may need to be addressed through PHC. Such meetings create a forum for the communities to raise health issues they consider imponant for dscussion

with

other stakeholders, including the health

suff.

Given the need for an 80% therapeutic coverage, such fora

will

be critical

in

ensunng thar communities are consuntly aware o[ the need to include women and minoriry groups and

is

imporunce for making progress towards elimination of onchocerciasis.

Activities

I

^APOC

will support countries

to sensitize

district

and

sub-district health

management teams ro

include

stakeholder meetings

in

annual plans of

action.

Special

attention will

be

given

to

communities with low ivermectin

treatment coverage and

other

PHC

activities requiring improved participation

of

communities.

I Country health

services

will

use SHM as a health

system/community platform

to

improve their

performance

in all

PHC and

MDG

related

health

issues.

The

additional

budget

for

CSM and SHM is US $5,287,700 and is set

out in

Table 4.

Output

1.5

Strengthening the

Scaentafic and Evidence Base: Establishing an Onchocerciasis

lnformation Memory

Bockg rou nd a

nd rationole

APOC and its partners have established a

repository of invaluable

information

to help

wrth

the development of self-sustainable systems that are required

for

the

control

and

elimination

of Onchocerciasis and other diseases of poverty. This data

collection will continue

to constitute a

rich

source

of

informatron

well

beyond the operation

of

the APOC.

It

is, however, essential that

further

plans are made for safe storage, archiving and methods

for updating

the

information

and ease of retrieval of the stored data.

The change of health staff at

all

levels and

Figure 3 Targets for Communrty Self Monrtonng ^(CSM) of cDTr 20r 2 r0 2 r 05

Year

the normal replacement of CDDs over time means that retaining

institutional

memory and relevanr knowledge and

information

could be a challenge

if

measures

for their

recording and safekeeping are not established. An Onchocerciasis

lnformation

Memory

(lM) which will

be a source of

dau

and

information

from previous

work

as

well

as for prepanng future storage of data

will

be essential before APOC closes

in

2015.

The goal

for

the onchocerciasis

IM

is to

build

a body of knowledge that

would

be essential

for

the continuous and effective execution of onchocerciasis

control

activities now, and after the closure of APOC. This

will

create an accessible and easily searchable data base on onchocerciasis and related

(other

NTDs and

co-implementation) information

that has been generated over 20 years.

Such an

IM would faciliute availability of information,

data, dossiers and

rraining

materials at

all

levels when needed, and act as a reference

point

for

all

APOC countries to help

maintain

the standards

o[

the methods

for

the

control

of onchocerciasis.

The

inlormation will

be used

for training

and guidance

in

carrying

out

onchocerciasis

control

and elimrnatron

activities. lnitially

rt

would

cover 5 APOC countries.

The dau and information, to be collected

will

include expert opinion, studies and evaluations and raw

dau

on onchocerciasis and its control methods e.g. CDTi, co-implementation and pannerships, epidemiologrcal data, and uaining materials. The dau

wil!

also include information on guidance on the usage

of

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