Introduction
Due to the socioeconomic impact of human onchocerciasis (commonly referred to as river
blindness) in West Africa, the Onchocerciasis Control Programme in the Volta River
Basin (OCP) was instituted [1]. This initial programme started in 1975 and covered
seven West African countries: Benin, Burkina Faso, Cote d’Ivoire, Ghana, Mali, Niger,
and Togo. However, later evidence indicated that endemic areas outside the initial
area posed a threat to the achievement of the OCP and, hence, the Programme was extended
southward and westward to include four additional countries, bringing the total number
of countries covered by OCP to eleven. The formal name was then changed to the Onchocerciasis
Control Programme in West Africa, retaining the acronym OCP.
OCP used aerial larviciding as its principle strategy to control the vectors of human
onchocerciasis, members of the Simulium damnosum complex, in the absence of a safe
drug for mass treatment against the parasites [2]. Efforts to control onchocerciasis
evolved in 1987 when ivermectin was donated to kill the juvenile worms that cause
the various symptoms associated with the disease. As a result of the donation, OCP
instituted a new strategy of chemotherapy in combination with vector control. In the
11 countries covered by OCP, this two-prong approach led to the virtual elimination
of onchocerciasis as a public health problem and as an obstacle to socioeconomic development.
The availability of a donated drug effective against the parasite and safe for mass
drug administration, coupled with evidence that other pathological effects of onchocerciasis
were equally important socioeconomic threats, led to the decision that onchocerciasis
should be controlled in all endemic countries in Africa (Fig 1).
10.1371/journal.pntd.0003542.g001
Fig 1
Onchocerciasis-endemic countries in Africa, showing countries covered by the OCP and
initially by APOC.
Map from 2010. Note that South Sudan gained independence in 2011, becoming the 20th
APOC country.
The African Programme for Onchocerciasis Control (APOC) was launched in December 1995.
In order to reach its objective of onchocerciasis control in all endemic countries
in sub-Saharan Africa, the Programme used Rapid Epidemiological Mapping of Onchocerciasis
(REMO) [3] to delineate areas of mesoendemicity and hyperendemicity and to estimate
the population at high risk of contracting onchocerciasis. Countries included in the
APOC program were: Angola, Burundi, Cameroon, Central African Republic, Chad, Congo,
Democratic Republic of Congo, Equatorial Guinea, Ethiopia, Gabon, Kenya, Liberia,
Malawi, Mozambique, Nigeria, Rwanda, South Sudan, Sudan, Uganda, and Tanzania. The
exercise revealed that 102 million people in the Programme area were at risk and needed
ivermectin treatment, while an estimated 37 million people were already infected with
the disease [4]. In 1997, APOC adopted community-directed treatment with ivermectin
(CDTi) as its core strategy [5–7]. Following CDTi introduction and implementation,
coverage and compliance with ivermectin steadily improved—the number of persons benefiting
from ivermectin treatment increased from 1.5 million in 1997 to 75.8 million in 2010
and to 100.79 million in 2013. CDTi ensured a sustainable method to deliver ivermectin
and also strengthened health systems.
Long-term impact assessments of APOC operations revealed a decrease in the number
of persons infected from 37.9 million in 1995 to 15.1 million in 2011. An estimated
9.5 million cases of severe itching were prevented, 400,000 persons were protected
from low vision, and 200,000 persons were protected from blindness. In most advanced
APOC projects, the prevalence of infection is already close to zero. The operations
of APOC prevented 8.9 million disability-adjusted life years (DALYs) from 2005–2010,
with another estimated 10.1 million averted from 2011–2015 [8]. Through co-implementation
activities, APOC has also averted an additional 1 million DALYs for other targeted
diseases such as ascariasis, trichuriasis, hookworm, lymphatic filariasis, strongyloidiasis,
and epidermal parasitic skin diseases over the duration of the Programme [9].
Research now shows that ivermectin treatment can not only control, but in many areas
(Mali, Senegal, Uganda, and Nigeria), eliminate river blindness infection and interrupt
transmission [10–12]. In 2009, taking into account the feasibility of the elimination
of onchocerciasis infection and interruption of its transmission with ivermectin mass
treatment alone [10], the Joint Action Forum (JAF), the governing body of APOC (described
below), directed the Programme to shift from control to elimination of onchocerciasis.
In 2010, the third midterm evaluation of APOC advised the JAF that it would be premature
to close the Programme in 2015 given the perspective of onchocerciasis elimination.
Thus, in 2011, JAF reaffirmed its endorsement for the Programme to pursue the elimination
of onchocerciasis in Africa as well as co-implementation of preventive chemotherapy
interventions for other selected neglected tropical diseases (NTDs) in the context
of increased support to community-level health systems strengthening. The other preventable
NTDs susceptible to mass drug administration include lymphatic filariasis (elephantiasis),
trachoma, schistosomiasis (bilharzia), and soil-transmitted helminths, which include
roundworm (ascariasis), whipworm (trichuris), and hookworm.
Participative Governance
The Programme is a unique partnership between the affected communities, governments,
bilateral and multilateral agencies, foundations, non-governmental development organizations
(NGDOs), the scientific community, and the private sector. The partnership is built
on a legal agreement called the “Memorandum of the African Programme for Onchocerciasis
Control” [13]. The APOC Secretariat is responsible for initiating the budget process,
taking the lead in preparing a multi-year plan of action for APOC and using this to
develop an indicative budget to implement the multi-year plan. APOC is governed by
the JAF, consisting of representatives of (a) the participating countries; (b) the
contributing development partners; (c) the sponsoring agencies; (d) members of the
NGDO Coordination Group; (e) Merck & Co., Inc. representing the private sector as
the donor of ivermectin; (f) intergovernmental regional or sub-regional organizations;
and (g) other invited entities. The JAF decides on the overall policy and strategy
of APOC, assesses progress review, approves the APOC Plan of Action and Budget, and
assesses global financing requirements of the Programme. The JAF meets annually and
is usually hosted alternatively by a participating country and a donor country.
The Committee of Sponsoring Agencies (CSA), comprising representatives from sponsoring
agencies, NGDO Coordination Group, Merck & Co., Inc., and the Mectizan Donation Program
(MDP), works closely with the APOC Secretariat. CSA makes interim decisions on behalf
of JAF when required, follows closely the financial situation of APOC, and scrutinizes
documentation for the JAF. WHO is the executing agency within this partnership and
the World Bank is the fiscal agent of the Programme [13]. The World Bank mobilizes
donor contributions into the APOC Trust Fund and provides funds for APOC’s operations.
Although APOC provides some contribution to the NGDO Coordination group through the
Trust Fund, most of the funds from the NGDO group to countries are raised by the individual
members of the group.
Programme Management
APOC is one of the few programs that the WHO Regional Office for Africa implements
directly. The WHO Regional Director for Africa ensures the overall guidance of APOC
Secretariat, which is headed by the APOC Director. WHO Headquarters provides administrative
and technical as well as operational research support. APOC maintains close collaboration
with WHO offices of all participating countries and with National Onchocerciasis Task
Forces (described below) in the implementation and monitoring of CDTi projects.
The Secretariat of the Programme is based in Ouagadougou, Burkina Faso, and runs two
technical units: Sustainable Drug Distribution Unit and Epidemiology and Vector Elimination
Unit. Administrative support is provided through the Director’s Office Coordination
Unit. APOC currently supports onchocerciasis control and elimination activities in
31 African countries, including the 19 original signatories of the Memorandum, South
Sudan, and the 11 ex-OCP participating countries. These countries included: Angola,
Benin, Burkina Faso, Burundi, Cameroon, Central African Republic, Chad, Congo, Côte
d’Ivoire, Democratic Republic of Congo, Equatorial Guinea, Ethiopia, Gabon, Ghana,
Guinea, Guinea Bissau, Kenya, Liberia, Malawi, Mali, Mozambique, Niger, Nigeria, Rwanda,
Senegal, Sierra Leone, South Sudan, Sudan, Tanzania, Togo, and Uganda. The main activities
implemented by the Secretariat include the design, execution, monitoring, and evaluation
of community-directed ivermectin distribution projects, as well as mapping of the
disease, capacity building for countries, and provision of technical guidance in efforts
to control and eliminate river blindness in Africa.
Sustaining Partnership
APOC’s broad partnership includes the poor in programmatic decision-making. This partnership
involves over 146,000 local communities, African endemic countries, donor countries
and institutions, over 16 NGDOs, Merck & Co. Inc., research institutions, and programs
such as the WHO Special Programme for Research and Training in Tropical Diseases (TDR),
as well as research institutions within onchocerciasis-endemic countries.
Engaging Communities
The CDTi strategy is built on a participation paradigm in which communities play an
important role for planning, leading, and managing interventions that benefit their
own health. In the CDTi context, a community is the lowest autonomous unit whose members
are linked to one traditional or political head and share resources in common. CDTi
focuses on empowering communities to take responsibility for ivermectin delivery by
deciding how, when, and by whom the ivermectin treatment should be administered. This
strategy seeks to empower the people who are the most affected to take specific roles,
responsibilities, and critical decisions for interventions that address their needs.
CDTi, using a bottom-up approach, is a well-tested and highly cost-effective strategy
that has extended the reach of essential interventions to those at the end of the
road at a reasonably low cost. The success of CDTi, especially in remote areas of
countries affected by conflict and war, has opened the doors to a number of other
health care interventions that lend themselves to the community-directed intervention
approach (CDI) [4,14]. There is evidence that at least four to five interventions
could effectively be implemented through CDI with a boost in ivermectin coverage by
10% [15,16].
Empowered communities have contributed to improving the prevailing therapeutic coverage
with ivermectin from 62.2% to at least 65% and geographical coverage to 100% [17].
CDTi/CDI is undertaken at the community level under the direction of the community
itself. The health services and NGDOs introduce the concept of community ownership
and role, whereby the community takes charge of the process.
Without community engagement in planning, designing, implementing, and monitoring,
it is difficult for an external agent to identify the various social factors that
will influence intervention implementation and service absorption within the village
and to reach expected results. Using trained community-directed distributors (CDDs)
selected by the community, APOC has been able to scale up treatment with ivermectin
from 1.5 million in 1995 to over 75 million people in 2010. Engaging communities has
yielded multiple health gains to remote communities, providing additional health interventions
and commodities such as medicines for the control of other preventable NTDs, insecticide-treated
bed nets for malaria control, and vitamin A supplementation.
Engaging Governments and Other Stakeholders
All of the APOC participating countries have established a National Onchocerciasis
Task Force (NOTF) composed of Ministry of Health (MoH) staff from relevant divisions,
representatives of implementing NGDO partners, research institutions and representatives
from other related Ministries (e.g., Ministry of Education). The National Onchocerciasis
Control Programme (NOCP) serves as the Secretariat of the NOTF.
The NOTF has the responsibility of overseeing implementation of the onchocerciasis
control efforts at the national level. The MoH has the critical role to create a favorable
environment for all partners and enabling policies for community-directed interventions
for the control and elimination of onchocerciasis and other NTDs targeted by preventive
chemotherapy (PC-NTDs); ensuring entry of ivermectin and other NTD medicines in the
country without imposing duty, tax, or other charges; as well as chairing and expanding
the NOTF to include coordination of control and elimination of onchocerciasis and
other PC-NTDs. The MoH also advocates for and mobilizes national financial contributions.
Between 2010 and 2011, governments of 15 countries disbursed US$16,937,214 for CDTi-related
equipment and salaries of health personnel of various CDTi implementation units. Those
countries included: Angola, Burundi, Cameroun, Central African Republic, Chad, Congo,
Democratic Republic of the Congo, Equatorial Guinea, Ethiopia, Liberia, Malawi, Sudan,
Nigeria, Uganda and United Republic of Tanzania. These governments also disbursed
US$3,012,750 to core CDTi activities alone [18]. However, in order to ensure elimination
of onchocerciasis, the governments of participating countries need to increase financial
and human resources for the following core CDTi activities: health education, sensitization
advocacy and mobilization, training, distribution of ivermectin, supervision, monitoring,
and reporting.
Ensuring Medicine Availability
In 1987, Merck committed to donate Mectizan (ivermectin, MSD) for the treatment of
onchocerciasis to all countries that need it for as long as necessary. In 1998, the
donation was expanded to the treatment of lymphatic filariasis in the African countries
where onchocerciasis and lymphatic filariasis are co-endemic. Medicine donation programs
are critical as they cover a major technical and financial component of the control
and elimination of onchocerciasis and other PC-NTDs. Sustaining the action of such
programs is a key determinant for success in the fight against onchocerciasis and
other NTDs. Between 1997 and 2011, the Mectizan Donation Programme (MDP) supplied
2,168,732,700 tablets to APOC participant countries. In 2011 alone, 352,594,500 (77%)
tablets were distributed to APOC participant countries and 107,939,500 (23%) tablets
were distributed to ex-OCP member countries for onchocerciasis or for integrated lymphatic
filariasis and onchocerciasis control [19].
Coordinating NGDO Actions
The WHO Programme for the Prevention of Blindness created the NGDO Coordination Group
for Ivermectin Distribution in partnership with seven NGDOs in 1991, which later became
known as the NGDO Coordination Group for Onchocerciasis Control at the launch of APOC
in 1995. The membership of the Group increased to 12 NGDOs in order to address the
need of expansion of the Programme in Cameroon, Nigeria, and Uganda. Since 2005, additional
NGDOs have joined the Group as the result of increased momentum towards controlling
NTDs. To date, the Group comprises 14 full members and three associate members. The
full members include: Charitable Society for Social Welfare (CSSW), Christoffel-Blindenmission
(CBM), Helen Keller International (HKI), IMA World Health, Lions Club International
Foundation (SightFirst Program), Malaria Consortium, Mectizan Donation Program (MDP),
Mission to Save the Helpless (MITOSATH), Organisation pour la Prévention de la Cécité
(OPC), Schistosomiasis Control Initiative (SCI), SightSavers International, The Carter
Center, United Front Against River Blindness (UFAR), and US Fund for UNICEF. The three
associate members include: International Agency for the Prevention of Blindness (IAPB),
Liverpool Centre for Neglected Tropical Diseases (CNTD), and Merck & Co, Inc. The
NGDO Coordination Group for Onchocerciasis Control provides managerial, technical,
and financial support to more than 80% of CDTi projects in participating countries.
NGDOs also get involved in operational research activities. During the last few years,
intra-country collaboration among members of the Group has allowed addressing the
financial constraints faced by some of their members in order to sustain support to
CDTi projects.
CDTi Projects for Field Operations
APOC has delineated CDTi project areas using data obtained through REMO. Each CDTi
project covers a delineated geographic area of an endemic country. The CDTi project
approach allows for a phased introduction of CDTi in a country and focuses support
on the early phases of CDTi development with the view of applying the lessons learned
to the rest of the country. In 2010, treatment activities in 16 APOC participating
countries covered 138,448 out of 144,837 (96%) endemic communities [19]. In total,
75.8 million people were treated with an average therapeutic coverage of 79.0% in
countries with a stable security situation and 71.4% in post-conflict countries [19].
APOC presently supports 122 CDTi projects in 20 APOC participant countries and four
ex-OCP member countries, Cote d’Ivoire, Ghana, Guinea Bissau, and Sierra Leone.
Technical Oversight and Evaluation
The APOC Technical Consultative Committee (TCC) ensures the technical oversight of
APOC operations. Its main function is to review new CDTi projects plans and budget,
annual technical reports from CDTi projects and operational research proposals. TCC
thus contributes to establishing a research agenda for APOC. Its recommendations are
addressed to the Programme Director or, if required, to the CSA. The TCC members meet
twice a year. The TCC comprises 12 members which are selected through various mechanisms.
One of the 12 TCC members is a representative from MDP and is appointed by Merck &
Co. Inc. Eleven members are scientists/experts appointed by the WHO Director-General
based upon the recommendation of the CSA. Among those, three members are proposed
by the NGDO Coordination Group for the consideration of the CSA. The other eight members
are suggested by APOC management to the CSA for their consideration. TCC members appointed
by the Executing Agency hold membership for three years renewable for a maximum of
another three years, on a staggered basis. However, since MDP oversees the donation
of the drug ivermectin, the MDP representative has permanent tenure on the TCC.
The review function of TCC has been partly devolved to some countries, including Cameroon,
Nigeria, and Uganda, where Technical Review Committees (TRC) have been established
to review annual technical reports of mature projects (defined as distributing ivermectin
to endemic communities for seven or more years) on behalf of the TCC, and to support
in-country operational research agenda in relation with CDTi implementation. An external
evaluation system was established since the inception of the Programme. Evaluations
are undertaken every five years, supported financially by the donor community and
organized by the CSA. The evaluation teams are composed of scientists with a relevant
background in public health. Three mid-term external evaluations have been undertaken
in 2000, 2005, and 2010. They have made recommendations that allowed the JAF to make
decisions on the mandate and future of APOC [20–22]. The next evaluation is planned
for 2015.
The Way Forward
The structure and management framework of APOC was determined based on the OCP experience.
This mechanism has demonstrated efficacy in achieving APOC’s initial goal of establishing
sustainable community-directed systems for ivermectin distribution that effectively
controls onchocerciasis as a public health problem. In addition, the CTDi and CDI
strategies have significantly contributed to scaling up other health interventions,
such as control of lymphatic filariasis, distribution of insecticide-treated bed nets,
and vitamin A supplementation, among others [20]. The success of APOC has prompted
the JAF to extend the Programme beyond 2015, support countries in achieving elimination
of onchocerciasis, use acquired expertise to benefit other targeted NTDs amenable
to the PC strategy, and strengthen health systems at the community level across Africa.
The evolution of APOC after 2015 is captured in the development and adoption of a
concept note document and indicative budget to transform APOC into a new regional
entity, provisionally named Programme for the Elimination of Neglected Diseases in
Africa (PENDA) [23,24]. This new entity will have a mandate for “the coordination
of the implementation of the elimination of onchocerciasis and lymphatic filariasis,
and support interventions for other PC-NTDs in Africa” [24].
The global momentum and commitment for the elimination of targeted NTDs [25,26] requires
putting in place adequate collaboration mechanisms and structures at all levels to
ensure effectiveness, efficiency, and synergy of interventions. In this environment,
APOC structures and management framework may evolve towards complementarity with other
NTDs programs in PENDA. When APOC mechanisms have a competitive advantage, they should
be extended to serve other NTDs in PENDA, for example, with the APOC Trust Fund and
the JAF. At the same time, PENDA should also benefit from the added value of proven
approaches for particular situations such as conflict, post conflict, urban settings,
and problematic areas. With respect to global and regional governance and management
structures, due attention should be given to the structure and management of NTD control
and elimination programs at the national level, in accordance with country NTD master
plans. Thus, the NOTF should be extended to cover other NTDs. Fig 2 depicts a possible
evolution of APOC structures and mechanisms. Such an evolution would require the revision
of the Memorandum of APOC [9]. The APOC Secretariat will support the transition of
APOC from a single disease entity to a regional NTD elimination program and help ensure
that future generations in Africa live free from the threat of debilitating and preventable
diseases.
10.1371/journal.pntd.0003542.g002
Fig 2
Possible evolution of APOC structures and mechanisms.