Research Article: Investing in Onchocerciasis Control: Financial Management of the African Programme for Onchocerciasis Control (APOC)

Date Published: May 14, 2015

Publisher: Public Library of Science

Author(s): Donald A. P. Bundy, Bilkiss Dhomun, Xavier Daney, Linda B. Schultz, Andy Tembon, Moses J Bockarie.

Abstract: None

Partial Text: The African Programme for Onchocerciasis Control (APOC) has been described as one of the most successful public-private partnerships for health in Africa [1]. The Programme helps the governments of 20 onchocerciasis-endemic countries to develop sustainable delivery of ivermectin treatment in order to control and eliminate river blindness [2]. APOC is one of a very few programs that the WHO implements directly, in this case through the Regional Office for Africa (AFRO) and the APOC Secretariat established in Ouagadougou, Burkina Faso. As the Executing Agency of APOC, WHO is responsible for the development of procedures for implementing community-directed treatment with ivermectin (CDTi), approving funding to countries, maintaining surveillance, and ensuring monitoring and evaluation [3]. The Executing Agency supports governments directly in this role, aided by a group of 15 Non-Governmental Development Organizations (NGDOs), operating nationally, regionally, and globally [4]. The 15 NGDOs include Charitable Society for Social Welfare, Christoffel-Blindenmission (CBM), Helen Keller International (HKI), Light the World, Mectizan Donation Program (MDP), Mission to Save the Helpless (MITOSATH), Organisation pour la Prévention de la Cécité (OPC), Sightsavers International, United Front Against Riverblindness (UFAR), Interchurch Medical Assistance (IMA) World Health, Lions Clubs International Foundation, Malaria Consortium, Schistosomiasis Control Initiative, The Carter Center, and The United States Fund for UNICEF. The funding for national onchocerciasis control comes from the countries and civil society, with additional funding from APOC through contributions from more than 30 development partners to a Trust Fund that the World Bank manages in its role as Fiscal Agent.

The origins of financial support for onchocerciasis control can be traced back to those of World Bank’s support for health in general. The International Bank for Reconstruction and Development (IBRD)—the first institution of what was later to become the World Bank Group (WBG)—was founded in 1944 with the primary aim of supporting post—World War II reconstruction and economic development. In the 1960s, the World Bank extended its remit to specific support for low-income countries by the provision of concessional credits and grants through the International Development Association (IDA).

In 1974, OCP used vector control with larvicides to control river blindness in 11 countries in West Africa. The 11 countries included Benin, Burkina Faso, Cote d’Ivoire, Ghana, Guinea, Guinea Bissau, Mali, Niger, Senegal, Sierra Leone, and Togo. The Executing Agency was WHO, with the World Bank working with other development agencies as Fiscal Agent, essentially under the same division of labor as exists today with APOC. OCP was very successful in controlling the disease, freeing 18 million children from the risk of blindness and reclaiming some 25 million hectares of abandoned arable land—enough to feed about 17 million people [10]. But expansion of OCP to the other 20 onchocerciasis-endemic countries in Africa was not feasible, as costs for the OCP countries alone had spiraled to nearly a billion US dollars (Fig 1) and the riverine vector control methods for the savannah onchocerciasis in the OCP area were not applicable to the forest onchocerciasis found in other regions. These countries included Angola, Burundi, Cameroon, Central African Republic, Chad, Congo, Democratic Republic of the Congo, Equatorial Guinea, Ethiopia, Gabon, Kenya, Liberia, Malawi, Mozambique, Nigeria, Rwanda, Sudan, Tanzania, Uganda, and South Sudan (which became the 20th participating country as of 2011).

The key financial instrument for managing APOC finances is its Trust Fund, a mechanism through which several donors can co-finance international development projects. The first World Bank trust fund was established in 1960 to finance the Indus Basin Project in Pakistan, providing US$90 million over 15 years. Trust fund management today plays a major role in World Bank support for development, with fund flows totaling US$29.1 billion in 2011 [12]. Some of the largest of these funds support health investments, such as the US$2.45 billion Global Fund to Fight Aids, Tuberculosis and Malaria (GFATM); the US$211 million International Finance Facility for Immunization (IFFIm); and the US$137 million Pilot Advance Market Commitment for Vaccines against Pneumococcal Diseases (AMC) [13]. The trust fund established in 1974 to help control onchocerciasis, covering both the OCP and the APOC period, has accumulated receipts to date of over US$1.2 billion (Fig 1).

APOC has strong representative governance. The ultimate decision-maker is the Joint Action Forum (JAF), which is comprised of the 20 governments of the participating countries represented at the level of Ministers of Health, as well as representatives of more than 30 contributing development partners, co-sponsoring agencies, and 15 NGDOs (that also formed into the NGDO Coordination Group for Onchocerciasis Control) that help implement and support the program [15]. The annual meeting of JAF makes the main policy decisions, in particular, the approval of plans of action and budgets, in accordance with legal proceedings overseen by the WHO Secretariat. There have been 19 meetings of the JAF up to the end of 2013.

The primary role of the World Bank is as the fiscal agent for APOC. The World Bank is represented on different organs of APOC governance, but does not define or approve WHO requests for funding. In particular, the World Bank does not prepare or approve the PAB (Fig 3), although it is part of the oversight and scrutiny of the process. There is therefore a clear separation (within the APOC organizational framework) between the fiscal and implementing roles.

The APOC Trust Fund is supported entirely through voluntary contributions from development partners that have been formally admitted as contributors to the Program. The Trust Fund was established in 1995 and is expected to have managed approximately US$258 million by 2015. Fig 6 shows the annual receipts since 1996, averaging US$13.0 million per annum. Together, the OCP and APOC trust funds have managed more than US$1.2 billion in support of river blindness control over the last 30 years (Fig 1).

The primary focus of support for national health systems in a given country is the national budget. In the case of onchocerciasis, three main channels through which development assistance is provided to support national health efforts to achieve onchocerciasis control can be identified: first, through bilateral aid to government health budgets (e.g., from bilateral, intergovernmental, and multilateral development agencies); second, through the regional trust fund created by APOC, receiving funding from multiple sources within and beyond the region; and third, indirect support from technical and civil society organizations (NGDOs), such as members of the NGDO Coordinating Group and technical assistance organizations, which themselves are supported by bilateral and multilateral development partners, private sector organizations, and their own fundraising efforts.

The APOC Trust Fund serves a useful role as a central funding mechanism for the various contributors and in particular for those who place a high premium on fiscal accountability. It presents a secure mechanism for obligating funds.

In January 2012, a high-level meeting in London, “Uniting to Combat Neglected Tropical Diseases,” announced a new public-private partnership to eliminate or control the seven preventable NTDs. The meeting, co-chaired by Bill Gates, from the Bill & Melinda Gates Foundation, and Sir Andrew Witty, CEO of GlaxoSmithKline, brought together 13 pharmaceutical companies as part of the continuing Gates-CEO Roundtable to enhance private sector investment in public health challenges in low-income countries. The meeting led to the “London Declaration on NTDs.” Among other pledges, the pharmaceutical companies collectively committed to donate most of the drugs necessary to control and eliminate all seven preventable NTDs in low-income countries.