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The African Programme for Onchocerciasis Control (APOC)

Note: the review below was completed in 2009. Our current review of APOC is available here.
APOC did not meet our criteria for further evaluation (see below).


More information:


In a nutshell

  • What do they do? APOC supports mass drug administration to control onchocerciasis (river blindness) through direct funding, advising and assistance, and monitoring and reporting on projects implemented by local governments.
  • Does it work? We believe there's a reasonable case that mass drug administration to control onchocerciasis (river blindness) is highly effective when implemented well, and can result in significant reductions in the skin disease and vision problems associated with river blindness. However, we have serious questions about how - and whether - APOC is holding the governments it funds accountable.
  • What do you get for your dollar? When implemented effectively, 10-50 years of debilitation from onchocerciasis (skin disease, poor vision/blindness) can be prevented for $100. However, because of concerns about effectiveness, we aren't confident that this figure applies to donations to APOC.
  • Bottom line: We have emailed APOC multiple times in order to answer our remaining questions but APOC has not responded. Until we answer these questions, were unable to confidently recommend APOC.

Programs

APOC focuses on mass drug administration to control onchocerciasis (river blindness), which can result in significant reductions in the skin disease and vision problems associated with river blindness. Its primary aim is "The establishment of sustainable national onchocerciasis control programmes in all African countries where such programmes are needed."1

Activities

APOC's focus is on mass drug administration of onchocerciasis programs. APOC lists its primary activities as:
  • Directly funding local projects2
  • Monitoring project implementation and treatment coverage3
  • Monitoring project progress towards sustainability (i.e., ability to continue to exist without APOC funding)4
  • Identifying obstacles to coverage and implementing an improved approach5
  • Reporting on the worldwide status of onchocerciasis programs6
  • Providing funding for researching into new approaches for onchocerciasis control7
  • Visiting local projects to train and advise implementers and coordinate resources within a country8
We do not have all the necessary information to determine how APOC's funds break down across these activities. It does provide a chart of its 2007 expenses, but they are broken down by different (and not entirely clear) categories. The chart is reproduced below.9 This chart implies that the majority of APOC expenses directly fund local projects. However, we do not know specifically how local projects utilize these funds. We also do not know how to match the expenses provided by APOC here to their activities listed above. We discuss this further below.

Does it work?

APOC's primary aim is "Establishing sustainable community-directed treatment with ivermectin in all African countries, where such programmes are needed."10 We believe that this program - when implemented well - is likely effective against onchocerciasis, though evidence of an effect on debilitating outcomes is not conclusive. For more, see our full report on this program. However, we are not convinced that APOC is effectively translating funding into implementation of this program. Most of its funding is provided to developing-world governments, raising a question of whether they spend it as intended. APOC does perform some monitoring of its grant recipients, but we are concerned that it does not sufficiently hold them accountable.

APOC's monitoring

APOC mentions (a) monitoring reports focused on whether projects are implemented according to requirements and (b) evaluations of financial documents submitted to APOC by funded projects. Based on the information below, we believe that the monitoring reports identify significant, potential problems with project implementation and financial reporting, but we don't see evidence that these findings lead to significant action by APOC towards non-performing projects. We are therefore concerned about APOC's willingness and ability to hold funding recipients accountable. Project implementation APOC reports that "All CDTI projects go through M&E [monitoring and evaluation]. To date, a total of 64 projects had undergone independent participatory monitoring.... Independent participatory monitoring is conducted by a team, consisting of 2 external and 4 monitors and takes place in the second year of a CDTI project."11 It appears that only a relatively small proportion of APOC's total projects have undergone evaluation: its statements about financial returns imply at least 1200 completed or ongoing projects,12 a number that dwarfs the 64 that have been monitored/evaluated to date. We have relatively little information on the specifics of monitoring and evaluation. The 2007 Progress report states that "two projects in Tanzania (Tunduru and Morogoro) were monitored during the period under review,"13 and gives the following findings:14
  • "CDTI strategy is well understood and the process followed; the Tunduru CDTI project needs to improve the process of selection of CDDs and decision-making by communities;"
  • "Funds are being disbursed from the Morogoro District Council funds for CDTI activities;"
  • "Reporting of supervisory activities need to be improved (no checklist was available);"
It is not clear to us specifically how these conclusions were reached, or whether there were any consequences for the insufficient reporting of supervisory activities. Reporting requirements APOC also reviews individual country reports, assessing whether they meet reporting requirements. These reports do not seem to assess whether projects have been implemented appropriately.15 In 2007, APOC rejected a number of reports including a project in the Congo,16 multiple projects in Malawi,17 and multiple projects in Uganda.18 However, it is not clear to us whether rejection of these reports was accompanied by any consequences related to funding. Financials APOC receives and reviews financial returns from projects they support. However, in 2007-08, APOC only received 60% of the returns that were due.19 In addition, a significant number of projects were more than four months late in submitting financial returns, a delay APOC considers particularly egregious.20 In response, APOC stated that "all concerned partners should find ways of improving the situation."21

What do you get for your dollar?

APOC only funds a portion of project expenses - the remainder are contributed by governments and partner NGOs - so the APOC expense figures we have do not provide a reasonable estimate of total program costs. Independent estimates imply that the type of program APOC focuses on is highly cost-effective: $7-$40 per disability-adjusted life-year (DALY) averted , or $100 to avert a total of 10-50 years of serious debilitation (blindness, low vision, or irritating skin disease). Details on cost-effectiveness here; more on the DALY metric here. Because of our concerns about APOC's implementation (see above), we don't have confidence that it can be expected to reliably achieve this level of cost-effectiveness, and have little with which to construct a more realistic estimate.

Room for more funding?

We have not seen any expansion plan, "funding gap" analysis, or list of strong but underfunded proposals from APOC. We also do not have basic financial data for the organization. As such, we have little sense of whether it can productively use more funding.

Financials/other

In 2007, APOC had a budget of $13.5 million.22 We do not have financial data for previous years. Revenue and expense growth (about this metric): We do not have the information necessary to make this assessment. Assets-to-expenses ratio (about this metric): We do not have the information necessary to make this assessment. Expenses by program area (about this metric): The chart above provides this information. 55% of APOC's expenses are used to fund countries' MDA projects. Expenses by IRS-reported category (about this metric): We do not have the information necessary to make this assessment.

Unanswered questions

  • What exactly do APOC monitors evaluate? What specifically do countries report? We've seen summaries of reports provided by monitors, but these don't provide specifics on what monitors check or how they determine that a program is implemented properly.
  • Sample reports. APOC publishes summaries of monitoring outcomes, but we haven't seen individual reports, along the lines of those provided by other, transparent organizations (see, for example, GAVI). Are these available?
  • Matching financials to activities. We have a relatively clear picture of APOC's activities but we aren't able to cleanly match these activities to reported expenses. This makes it difficult for us to determine which APOC activities account for much of their expenses. Is this information available?
  • Consequences for non-performance. APOC-funded projects frequently non-perform in (a) reporting requirements or (b) submitting financial documents. In addition, as discussed above, APOC countries have weaknesses in program implementation. We have found little evidence that countries suffer any material consequences for non-performance. Are there consequences for non-performance?
  • APOC's financial situation. We were able to access relatively little information about APOC's financial situation (see above). Is more financial information available?

Sources

  • 1. "The establishment of sustainable national onchocerciasis control programmes in all African countries where such programmes are needed remains the key preoccupation of APOC. The mapping of the endemicity of onchocerciasis has now been completed in 12 of the 19 countries and efforts are being made in collaboration with Lancaster University in UK for a better delineation of the areas co-endemic for onchocerciaisis and loiasis to guide safe ivermectin (Mectizan®) mass distribution in all countries." APOC, "Progress Report (2007)," Pg vi. "Establishing sustainable community-directed treatment with ivermectin in all African countries, where such programmes are needed, is the key preoccupation of APOC. There are three main aspects to attaining this objective: establishing a sustainable system for disease mapping, maintaining high coverage of ivermectin distribution and managing severe adverse events; creating adequate capacity to sustain control programmes; and ensuring effective programme management and partnerships to enhance the sustainability of control programmes." APOC, "Progress Report (2007)," Pg 2.
  • 2. "One hundred and seven CDTI projects were funded. This includes five new CDTI projects launched in 2007 in DRC (3) and Angola (2), as well as six NOTF Secretariat- support projects. Two projects in North Sudan (Northern Sector CDTI project and NOTF Secretariat) were not funded because the project did not present a plan of action and budget. All projects that complied with WHO/APOC financial rules and procedures received funds from the Trust Fund for their activities. 55% of the approved budget was allocated to national projects." APOC, "Progress Report (2007)," Pg 21. APOC also funds vector elimination activities, though these appear to be a very small part of what it does. "APOC's mandate in this area is limited to four foci: Itwara and Mpamba-Nkusi (Uganda), Bioko Island (Equatorial Guinea) and Tukuyu focus (Tanzania), and restricted to ground larviciding except in Bioko Island where combined ground and aerial spraying was undertaken." APOC, "Progress Report (2007)," Pg 20.
  • 3. "183. APOC conducts three activities globally in all APOC countries. The first activity is the independent participatory monitoring, which is conducted in year two of the project with two objectives. Firstly, to determine whether the process of Community-Directed approach is being put in place in the communities as a way to empower the communities; and secondly to look at the treatment coverage." WHO, "African Programme for Onchocerciasis Control," Pg 46.
  • 4. "184. The second activity is an evaluation, which is conducted after three years of project implementation. The main objective of the evaluation is to find out if the project is moving towards sustainability. Following the evaluation, the evaluation team remains in the country to assist the project develop sustainability plans, which clearly indicate the financial contribution of the Ministry of Health and partners. At this stage of the process, APOC financial support is decreased, and support is limited to logistics (vehicles and office equipment). 185. The third activity is the monitoring of the implementation of the sustainability plan. This activity is funded by APOC and conducted by a team of six people, two of whom are external and appointed by APOC, one NGDO partner and three local people selected by the country. From that year on, the country becomes responsible for carrying out independent monitoring, and it could select one external person to join the local team for the activity." WHO, "African Programme for Onchocerciasis Control," Pg 46.
  • 5. Examples:
    • Identifying a problem and implementing a study: "The uncontrolled movement of black flies and intensified migration of human populations within the region carries with them the risk of transmission. APOC, thus actively promotes cross border collaboration between affected countries to coordinate operational research and control activities. The fly movement study combined with the infectivity rates evaluation being undertaken between Benin and Nigeria and between Sierra Leone, Guinea and Mali is part of this cross border collaboration effort. This collaboration is also useful for advocacy to maintain political motivation and for resource allocation." APOC, "Progress Report (2007)," Pg 17.
    • Identifying a problem and implementing a solution:"Given the workload of CDDs particularly in dispersed populations and the resultant implications of this on treatment coverage, the TCC recommended that projects should train more CDDs in order to reduce their workloads, improve therapeutic coverage and enhance the quality of implementation. Consequently, in the period under review, a “special country initiative”, was launched by APOC Management aimed at increasing the CDD: population ratio of each project to a maximum of 1:100. This initiative is on-going in Burundi, Uganda and Nigeria and is being implemented by the NOTFs. It is expected that by December 2007 the three projects in Burundi, one project in Uganda and ten in Nigeria would have trained and/or retrained additional 117,631 Community-Directed Distributors (CDDs), 13,243 health workers and 63,240 community Supervisors in the CDTI strategy. (Table 5)." APOC, "Progress Report (2007)," Pg 13.
  • 6. The 2007 Progress Report provides data on:
    • The total number of people treated annually in APOC countries during 1997-2006 (Pg 5)
    • The number of APOC-supported projects that were approved, implemented and reported results (Pg 6)
    • The number of communities and people targeted for treatment and those that received treatment (Pg 6)
    • The number of health workers or community-directed distributors trained in each country and the number of projects they cover (Pg 15)
    • The number of projects which simultaneously implement additional health interventions, like vitamin A supplementation, ITN distribution, or deworming drugs (Pg 28)
    The 2008 Technical Consultative Committee Report provides APOC's decision on whether the country has complied with its requirements, along with brief blurbs on each country's program, and suggestions for improvements to the program (Pgs 14-46).
  • 7. One example is the Macrofil program: "The WHO/TDR -APOC Macrofil programme has made remarkable advances in the search for a potential macrofilaricide for Onchocerciasis elimination/eradication." APOC, "Progress Report (2007)," Pg 19.
  • 8. The APOC management undertook several missions to 14 APOC countries, in collaboration with the Technical Consultative Committee (TCC) members, the Non-Governmental Development Organizations (NGDOs) Coordination Group members, and other external experts during the period under review. These were for technical advice on collaboration with other programmes; advice on integration and co-implementation with malaria plus initiative; meetings with policy and decision-makers to improve CDTI through integrated approach; review of the onchocerciasis control situation; and clarification of the role and contribution of different partners. The missions reviewed and advised on administrative and financial operations of CDTI projects; re-launching CDTI activities in some countries, facilitated training workshops on APOC philosophy and the CDTI strategy for project managers; trained accountants in the WHO accounting system and collection of CDTI data." APOC, "Progress Report (2007)," Pg 22.
  • 9. APOC, "Progress Report (2007)," Pg 22.
  • 10. APOC, "Progress Report (2007)," Pg 2.
  • 11. APOC, "Progress Report (2007)," Pgs 10-11.
  • 12. "Out of the 1209 financial returns to be received for 2007-2008, 724 were received (equivalent to 60%) and 626 (86% of the received returns) were analysed by the AAF at the country level and APOC HQ." WHO, "African Programme for Onchocerciasis Control," Pg 13.
  • 13. APOC, "Progress Report (2007)," Pgs 10-11.
  • 14. APOC, "Progress Report (2007)," Pg 11.
  • 15. WHO, "African Programme for Onchocerciasis Control," Pgs 14-46.
  • 16. WHO, "African Programme for Onchocerciasis Control," Pg 31.
  • 17. WHO, "African Programme for Onchocerciasis Control," Pgs 36-39.
  • 18. WHO, "African Programme for Onchocerciasis Control," Pg 45.
  • 19. "Out of the 1209 financial returns to be received for 2007-2008, 724 were received (equivalent to 60%) and 626 (86% of the received returns) were analysed by the AAF at the country level and APOC HQ. At the end of February 2008, 99 returns are to be analysed by APOC Headquarters." WHO, "African Programme for Onchocerciasis Control," Pg 13.
  • 20. "As of 29 February 2008, 51 projects had red cards meaning they are more than four months late in submitting financial returns. The release of funds to these projects has been suspended until they submit the 403 returns concerned." WHO, "African Programme for Onchocerciasis Control," Pg 13.
  • 21. WHO, "African Programme for Onchocerciasis Control," Pg 13.
  • 22. APOC, "Progress Report (2007)," Pg 21.