APOC: at the Vanguard of the neglected tropical

(9}

APOC: at the Vanguard of the neglected tropical

diseases policy in Africa: Action ^{plan 2006-2010}

APOC Management, 20 June 2006

APOC: at the vanguard of neglected tropical diseases policy in Africa: Action ^{plan 2006-2010}

Introduction and Rationale

l.

^APOC

^(African

^Programme

^for

Onchocerciasis Control) has, and

will

continue, to facilitate effective and sustainable control of onchocerciasis throughout the endemic areas

in the

19 participating countries

in Africa by

Community Directed Treatment with Ivermectin (Mectizan@) (CDTI). The four ^localised vector-elimination projects ^{have been} scheduled to be completed by December 2008.

2.

^{The number of} persons treated yearly in participating countries ^{has increased:}

o

1997:14.58 million

o

2000: 22.00 million

o

2AQ2:28.45 million

o

2005:40.00 million.

3.

Therapeutic coverage (the number

of

people treated each year as

a

percentage

of

a

country's population) ^{has increased}

r

AveragingT}%o for five countries (2004).

In addition to the ^cases of blindness prevented (43,000 annually duringthe current life

of

the programme (1996-2010)), the alleviation

of

unbearable itching and elimination

of unsightly skin

diseases

APOC (like OCP before it) has

enabled socioeconomic development

in

some of the poorest regions of the world and brought the poorest of the poor within the remit

of

self-determined strategies for healthcare, helping to make these people active partners in their own health viz.

.

261,000 Community-Directed Distributors (CDDs) (2005)

Sustainability demands

that for the future of

onchocerciasis

control

individual communitieJ

in

each country are empowered

to

continue

to

^{seek CDTI}

ⁱⁿ

a politically meaningful

way,

helping

to

ensure governments

in the

participating countries are

."rporrire

^{and have the political}

^will

to provide ^and administer an adequate budget for the

CDTI

programmes

in their

countries, maintaining the previous prioritization and ^over US$1.5 billion investment (to date) in onchocerciasis-control.

Sustainability

will

also be achieved

by

maintaining the solidarity demonstrated by ^the donors

and further

evidenced

by the work of

APOC's other partners

who

remain responsive to the future ^needs of the ^{programme as} they have done in the past. APOC's strength lies in its diverse partnership including:

o

I17,000 disease-affectedcommunities

o

20 donors

.

19 African national governments

. I

multinational pharmaceutical firm

o l6

national and international NGDOs

Health, development and economic experts now ^agree that Close-to-Client Community- Directed Treatment (ComDT) ^pioneered by CDTI for onchocerciasis control represents a

proficient ^and highly cost-effective mechanism. Quantifiable ^measures for CDTI:

o

Economic rate of retum ^l7%o

.

$0.58 ^per treatment 4.

5.

6.

7.

APOC Management, 20 June 2006

8.

9.

t0.

11.

. _$7

per Disability Adjusted

Life

Year

(DALY)

averted (thanks

to

Merck

&

Co's donation of Mectizan@)

APOC's infrastructure ^provides a proven mechanism and best value for introducing ^health interventions against other neglected tropical diseases

(NTDs) in Africa:

ascariasis, trichuriasis, hookworm, schistosomiasis, lymphatic filariasis and trachoma. In addition to the health and poverty burden of onchocerciasis and these other woffn infections specific indicators

for the

benefits

of

deworming are documented

for the

control

of

malaria morbidity.

Supporting APOC and

its

continued activities (including potential leadership

in

^the

Neglected Tropical Diseases Coalition and Malaria Quick ^Impact Initiative) is thus an

investment in social empowerrnent, improved health ^and poverty alleviation amongst ^the world's most deprived ^people.

APOC's enforced experience in continuing some delivery

of

health care in conflict ^and post-conflict situations demonstrates that

it

is ^possible to cope in such circumstances ^and represents a body of knowledge that can be transferred to others facing similar difficulties.

Aware

of the

responsibility represented

by

APOC's path-breaking

role in

neglected tropical ^diseases policy in Africa and working to maximize the current ^programme (with thJ goal

of

sustainability at the fore) APOC commissioned the 2005 External Evaluation Report. This provided the opportunity for an assessment of the current status of APOC ^and how best to iake the programme forward.

It

has informed this strategic Action Plan and where appropriate the Expected Outcomes. The heading dates are

initiation

dates only, not completion ^dates.

o APOC: at

the vanguard

of

neglected

tropical

^diseases

policy in Africa,

Action Plan 2006 to 2010.

APOC Management, 20 June 2006

Action plan currently in progress and to continue: APOC ^and Partners l.

APOC is advocating for and supporting the training of key CDTI staff, particularly district

coordinators and project managers, on methodologies and other key aspects ofoperational research.

2.

APOC is intensiffing communication with project staff ^at various levels and with ^partners e.g. enhancing field visits to promote ^shared understanding of problems encountered and their possible solutions.

3.

^{NOTFs are} intensiffing sensitization ^and mobilization to

o

Encourage communities to select more CDDs.

o l,, ffi:l'.:iJlf8r;i:fi'",Ti3l .",,",

'

^a decreasing workload for individual CDDs

I

an improved level of ^coverage.

.

Increase communities'selection of ^Women CDDs.

r ^Remindi'

[iHtdf#:::;..

'

^{the Public}

.

_political leaders

about the basics of CDTI, particularly ^{the need} to continue ivermectin ^treatment for many years after symptoms disappear and the progress of the disease has been halted.

Expected Outcomes:

for

.

onchocerciasiscontrol

r

other neglected tropical diseases' the participating countries.

.

Data collection

'

CDTI implementation.

.

_{increased CDDs} per population ratio of for ivermectin distribution

.

increased treatment coverage

.

reduced demand for incentives' onchocerciasis comPonent.

APOC Management, 20 June 2006

Action plan for 2006: APOC and partners

l.

^APOC

^will

synthesize

the

monitoring and evaluation experiences

of CDTI

projects appraised to date

(in

10 countries) to identifu ^lessons that could benefit individual projects.

Expected Outcome:

2.

APOC

will

convene an ad hoc meeting of experts on the criteria for certification of vector elimination

in all

the Vector Elimination Projects (VEPs) and consider the ^best way to report on and publicise the success of the vector elimination ^at Itwara, Uganda.

Expected Outcomes:

Itwara focus represents for APOC and the health of Africa's poor.

3.

APOC

will

prepare an analytical position paper

for

review and decisions by Technical Consultative Committee (TCC) ^and Committee

of

Sponsoring Agencies (CSA) on issues

related

to the NOTFs'

responsibility

for

^providing

25% of a

^project's ivermectin- distribution ^costs.

r

The _PaPer

will:

o

^Ensure that efforts in monitoring contributions by participating governments and NGDOs

(in

compliance with their obligations under the APOC Agreement) ^are enhanced;

o

And ^{lead to:}

o

Development

and

implementation

(with NOTFs) of a

mechanism ^whereby planned and actual contributions by local partners can be better examined.

o

^{A mechanism} to trigger corrective action by NOTFs and, if needed, by APOC, e.g' targeted advocacy ^measures within or outside the country.

Expected Outcome:

F ^The

development

of a

position paper

on

participating governments' and NGDOs' contributions to ivermentin distribution ^costs.

4.

^APOC

will

collaborate with WHO headquarters to find a responsive solution for retaining STPs whose contracts cannot be converted into fixed-term status, including ways ^that permit APOC management to continue to employ essential professional staff.

Expected Outcome:

5.

^NOTFs

^will

formulate a plan

to

provide

for

the budget needed

to

sustain and enhance capacity building. APOC and partners ^can then ensure adequate funds are available, ^as n"Ld"d, for projects that have completed their fifth year. The plan should incorporate:

.

Needs for training ^and retraining of ^health workers and CDDs,

.

Review ^and revision of Information, Education, Communication (IEC) ^materials.

Expected Outcome:

F

Country NOTFs

will

^{produce new} and revised IEC materials

to

lead the ^programme forward at the local human level and allow appropriate funding allocation.

APOC Management, 20 June 2006

6.

^APOC

^will

ensure that the system (developed

by

MEC/TCC)

for

dealing

with

^Severe Adverse Events (SAEs) is rapidly made available

to

countries

with

a high risk

of

SAE.

The system

will

be further updated when validated new information are provided through Rapid Assessment of Loaisis (RAPLOA).

Expected Outcomes:

onchocerciasis and Loaloa.

7.

^APOC

^will

^{develop a plan for the transfer of} functions to the participating countries with the goal of sustainability. ^{The plan}

will

o

Define areas of activity to be transferred

. Speci&

participants' roles e.g. NOCPA{OTFs,

WHO

country offtces (APOC expects WHO support to be provided on a Country-by-Country ^basis tailored to local needs), NDGOs.

o

Delineate workable timeframes for achieving an effective transfer before APOC closes.

Expected Outcome:

F

Action Plan (with timeframe) for decentralization of APOC HQ functions (Ouagadougou) concerned with managing the APOC Trust Fund to the participating countries ^and WHO country offices.

8.

^APOC's

^will

^{ensure that} optimal technical assistance is provided to the Tukuyu ^(Tanzania)

VEP

project,

both for

treatments and

for

entomological evaluation.

By the

end

of

operations, the procedure should ^be similar to that in Bioko (Equatorial ^Guinea).

g.

APOC's VEP at Mpamba-Nkusi (Uganda): ^one more annual larvicide treatment round ^is expected to be performed, and intensive entomological monitoring continued.

At

the end

of 2005 this VEP was ^deemed likely to ^repeat the ^{success at} Itwara (Uganda). Itwara ^and Mpamba-Nkusi could ^{serve as} pilots for future elimination of ^{S. neavei} foci in ^East Africa.

ApOC

has

given the

projects

all the

support needed

for a

successful conclusion, notwithstanding the 2005 deadline for completion of larviciding.

Expected Outcome:

.

Mpamba-Nkusi(Uganda)

.

Bioko Island (Equatorial ^Guinea)

.

_Tukuyu (Tanzania).

10. Be alert to and immediately investigate reports

of

'leakages'

of

ivermectin, and promptly take corrective action.

Expected Outcome:

APOC Management, 20 June 2006

Action plan for 20072 APOC and partners

l.

^APOC

will

^initiate

^a

detailed review

(with

help from WHO headquarters staff and/or outside consultants as necessary)

on staff

adequacy

for

implementation

of the

²⁰⁰⁵

External

Evaluation

Report

recommendations

and take follow-up

^{actions, where}

appropriate.

Expected Outcome:

2.

^NOTFs

^to

organize special meetings

to

deliberate and ^reassess

the

current status

of

'incentives': without ^these CDTI ^{may be} unsustainable' Expected Outcomes:

'

^Regional

'

CountDr-specific

3.

ApOC

will

enhance Learning-by-Doing through a meeting

of

national and local project coordinators involved in projJcts in their ^{3'd year} of phasing-out to

o

Pool experiences

o

Draw lessons

o

Share results.

Expected Outcomes:

Evaluation

Report's

recommendations ^and sustainability.

and utilization ofshared ^results, lessons and experiences.

4.

ApOC

will

^{analyze the process} of developing ^and implementing sustainability ^plans, with

a view to determining ^standards for CDTI ^budgets.

Expected Outcomes:

)

Guidelines for CDTI ^budgets for implementing ^and sustaining these projects' practice in

cDTI

sustainability

will

^{serve as an example for others.}

5.

^ApOC

^will

^document experiences and lessons on

CDTI in

conflict situations and offer greater help in conflict/post-conflict situations ^so that regardless of the number of years a

[roject

^{has been}

in

eiistence,

CDTI will be

considered

to be in its initial

^phases,

reniembering that ^most work cannot be done until ^peace is restored. ^Such experience could lead

to

guicLlines useful

for

countries that might move

into conflict

situations

in

^the

future.

Expected Outcomes:

CDTI.

World

i"pt,t

^on beit ^practices in drug delivery for Neglected Tropical ^Diseases.

countries

to

implement the 2005 ^External issues related

to CDTI

incentives ^and

APOC Management, 20 June 2006

6.

APOC remains aware that effective partnership

will

be essential

for

sustainability

of

CDTI, and in view of the phasing-out and eventual closure

will

o

Formulate

plans

(collaborating

with WHO where

required)

for

^increased

involvement of WHO country offices in CDTI activities (December 2007).

o

Formulate similar plans

with

any other organisation, such as UNICEF, which could make a substantive contribution to the sustainability of CDTI.

o

Define clearly and

in

good time the role, contribution, and willingness

of

other partners

-

^{current as well as those yet to}

^join

^the partnership

-

^within the overall

obj ectives of post-APOC activities.

Expected Outcomes:

7.

APOC vector elimination at Bioko

will

maintain entomological monitoring over ^another two-year period.

If

the biting

fly

reappears during this period, a protocol

will

^{be worked}

out for a national project.

Expected Outcomes:

D

Development of nationals' ^capacity to conduct vector elimination monitoring activities.

surveillance operations.

8.

^APOC

will

introduce the impact assessment protocols for monitoring human infection ^(as already carried

out on a

national basis

by

some APOC-countries)

to all

participating countries. ln countries with only one sentinel site the number of sites

will

be increased.

Expected Outcomes:

F New

sentinel sites established

in all

participating countries

for

impact assessment

of

human infections.

r

Fact sheets

.

Publications

.

Advocacy Reports

APOC Management, 20 June 2006

Action plan for 2008: APOC and partners

1.

APOC

will

advocate

with

governments asking them

to

examine

their role at

^each

administrative level in ^the country, and identiff programme-related areas for strengthening in preparation for transferring functions to individual country governments.

2.

APOC

will

develop a plan for the transfer

of

its functions to the participating ^countries with the goal of sustainability. ^{The plan}

will

o

Incorporate a Learning-by-Doing ^approach that begins

by

intensiffing support

to

a

small number of countries whose experience

will

serve to inspire ^and provide ^practical help to others.

3.

^APOC

will give

greater

priority to

operational research

and

enable active APOC participation in scientific discussions at national and international meetings.

Expected Outcomes:

F

^Ensure the inclusion of onchocerciasis control on major regional political agendas and at high profile conferences.

evaluation of ^good practice in decentralization ^and plans for the exit of APOC ^{can be} demonstrated.

key research needs.

4.

^APOC

^will

^{work with programme financial and} administrative assistants stationed in WHO offices ^(whose responsibilities ^are clearly defined), to ^ensure they are able to

.

Play a role conducive to decentralizing ^certain APOC functions

o

Alleviate the administrative ^{burden on} APOC headquarters in these matters.

o

Expand the responsibilities ^and authority of ^such officers, among other things to

o

Screel and recommend approval

or

otherwise

of

project expenditure statements

o

^Advise on oPerational budgets

o

^Take part in operational ^{audits and} reviews

o

Provide training.

Expected Outcomes:

F

^Establish guidelines for WHO country offtces' responsibilities.

APOC Management, 20 June 2006

Action plan for 2009: APOC and partners 1.

APOC

will

encourage NOTFs to

o

Ensure that all projects ^go to ^scale with community self-monitoring.

o

Ensure adequate investment

is

made

in

follow-up REMO studies: the ^programme urgently ^{needs updated} information on onchocerciasis endemicity in ^selected areas.

o

Enhance information sharing among

all

stakeholders and strengthen communication among partners by establishing APOC-funded country-onchocerciasis-websites.

Expected Outcomes:

countries

diseases (NTDs)

will

^{be produced.}

Country-by-country case studies on Rapid Epidemiological Mapping

for

Onchocerciasis (REMO) for disability estimates on onchocerciasis ^and other NTDs

will

be produced.

Technical support

will

^be provided to countries enabling them to implement health impact assessment.

Country-by-Country ^websites for APOC activities. APOC's ^{example as the} path-finder for neglected tropical diseases, appropriate financing mechanisms, research priorities ^and surveillance ^can by publicised and shared.

2.

^{APOC requests that the} Ministries of Health in the participating countries and

their

partners:

o Work to

ensure

that CDTI is fully

integrated

into the

health systems

of all

^the

participating countries in Africa, with ^levels of therapeutic coverage to be kept as high

as possible and at least at 65+oh.

o

Strengthen their collaboration with other partners (including donor agencies), to find ways

of

enhancing integration

of

health services and developing

an

appropriate strategy and plan.

Expected outcomes:

through collaboration with regional organization ^{such as} WAHO' other NTDs.

3.

^{APOC requests that} the International NDGOs:

o Actively

take part

in

future

joint

planning exercises dealing

with

the longer-term future

of

CDTI, because their past experience in APOC's development represents a resource for the future.

o

Envisage strengthening their support even further, as required by current and emerging projects.

o

Jointly

with

NOTFs, identifu local NGDOs

with

the potential

to

act effectively ^on their own after training ^{and capacity} building.

Expected Outcomes:

NGDO Coalition.

the

participating neglected tropical

APOC Management,20 June 2006

4.

^{APOC requests that our} Comrttittee of Sponsoring Agencies/.lAF ^partners:

o

Arrange for an expert review of the stratery and research on MACROFIL.

.

Ensure there is active support to find and prompt use of new drugs and technologies, particularly macrofilaricides and alternative drugs to Mectizan @.

o

Extend APOC Trust Fund support, on a decreasing scale, to 2015 to

o

Compensate for the delays that a number of CDTI projects ^have experienced

o

Ensure

that the

remaining projects

-

^some

^{of which will}

^{operate under}

difficult post-conflict environments

-

^are brought to satisfactory conclusion.

o

Enhance effectiveness and quality

of its

deliberations on sustainability

by

inviting resource persons, possibly country representatives on a rotation basis, to participate in deliberations on relevant agenda items.

o Alleviate the

heavy workload

on

Programme management

by

rationalizing and reducing statutory ^and other meetings.

Expected Outcomes:

conflict situation.

10 APOC Management, 20 Jurre 2006

ACRONYMS

APOC

^{African Programme for} Onchocerciasis Control

CDD

Community Directed Distributor of Ivermectin

CDTI

Community Directed ^Treatment with Ivermectin

ComDT

Community-Directed ^Treatment

CSA

^{Committee of} Sponsoring Agencies

DALY

Disability Adjusted Life Year

IEC

Information, Education, Communication

NGO

Non-Governmental Organization

NOCP

National Onchocerciasis Control Programme

NOTF

^National Onchocerciasis Task Force

NTD

Neglected TroPical ^Diseases

OCP

Onchocerciasis Control Programme

REMO

Rapid Epidemiological Mapping of Onchocerciasis

SAE

^Severe Adverse Effect

STP

Short-term Personnel

TCC

Technical Consultative ^Committee (of APOC)

VEP

Vector Elimination Project WAHO West African Health Organization

WHO

World Health Organization

11 APOC Management, 20 June 2006