SUMMARY OF THE MID-TERM REVIEW OF TRACHOMA ELIMINATION

PROGRAMMES IN AFRICA

Review conducted by Tropical Health LLP on behalf of The Queen Elizabeth Diamond Jubilee Trust and the UK Department for International Development

Submitted November 2016

AN INDEPENDENT REVIEW OF TRA-CHOMA ELIMINATION PROGRAMMES SUPPORTED BY THE UK DEPARTMENT FOR INTERNATIONAL DEVELOPMENT (DFID) AND THE QUEEN ELIZABETH DIAMOND JUBILEE TRUST

AN INDEPENDENT REVIEW OF TRACHOMA ELIMINATION PROGRAMMES SUPPORTED BY THE UK DEPARTMENT FOR INTERNATIONAL DEVELOPMENT (DFID) AND THE QUEEN

ELIZABETH DIAMOND JUBILEE TRUST (THE TRUST) HAS SHOWN THAT BOTH PROGRAMMES ARE ACHIEVING SIGNIFICANT RESULTS ON AN UNPRECEDENTED SCALE.

Trachoma is the world’s leading infectious cause of blindness, responsible for the visual impairment of about 2.2 million people, of whom 1.2 million are irreversibly blind. It is most commonly found in poor, rural communities where people have limited access to clean water and healthcare. The World Health Organization recommends implementing the SAFE strategy for eliminating blinding trachoma:

S

A

F

E

SURGERY TO CORRECT THE POSITION OF IN-TURNED EYELASHES

ANTIBIOTICS DISTRIBUTION TO TREAT INFECTION

FACIAL CLEANLINESS PROMOTION

ENVIRONMENTAL IMPROVEMENTS TO REDUCE REINFECTION AND TO PREVENT TRANSMISSION

KEY FINDING: THE TRACHOMA INITIATIVES HAVE RECORDED SUCCESSES IN AREAS

WHERE THE TRACHOMA COMMUNITY FACED MAJOR CHALLENGES TO DATE

IN 2014, THE TRUST AND DFID INITIATED TWO ALIGNED AND

AMBITIOUS FIVE YEAR (2014-2019) PROGRAMMES FOR THE ADOPTION

AND SCALE-UP OF THE SAFE STRATEGY ACROSS NINE COUNTRIES IN AFRICA, WITH A TOTAL BUDGET

OF £80.5 MILLION.

The goal of The Trust’s Trachoma Initiative is to eliminate blinding trachoma in Malawi, Kenya and Uganda and make significant advances towards elimination in Mozambique, Nigeria (Katsina State) and Tanzania. The goal of DFID’s programme is to effectively deliver the SAFE strategy for trachoma elimination in Chad, Ethiopia, Tanzania and Zambia. Both programmes

are being delivered by the International Coalition for Trachoma Control (ICTC), with Sightsavers acting as grant manager.

A mid-term review of both programmes was commissioned in 2016 to assess progress against targets and to provide recommendations for any actions that need to be taken to ensure success.

SIGHT-SAVING

132,000

PEOPLEhave�eceived

SURGERYBLINDING TRACHOMA

32 MILLONPEOPLE

have�eceived

TREATMENTto end

BLINDING TRACHOMA

TANZANIA

DFID SUPPORTED COUNTIRES

TRUST SUPPORTED COUNTIRES

KEY

AREAS OF TRACHOMA WORK BY DFID AND THE TRUST IN AFRICA

MALAWI

ZAMBIA

NIGERIA

CHAD

ETHIOPIA

MOZAMBIQUE

KENYAUGANDA

TANZANIA

OF THE TOTAL ESTIMATED NUMBER OF PEOPLE WHO REQUIRE SURGERY HAVE ALREADY RECEIVED IT.

Both programmes have implemented a large scale-up of activities to provide surgery to all people who need it. In the first two years of the programmes, 131,708 surgery cases were managed. This means that 41% of the total estimated number of people who require surgery, in the programme locations, have already received it. At the time of this review, this is ahead of schedule.

All countries, except for Katsina State in Nigeria, are on track to achieve their surgery goals by 2019. New data has predominantly shown that there are fewer people in need of surgery than initially expected.

41%

SURGERY

SURGERY RESULTS AFTER TWO YEARS

Country

Number of People with

Surgery Cases Managed

Percentage Reduction in Surgery Backlog

Measure of Performance

Relative to Targets

Target For First Two Years

Achieved in First Two Years

Chad 14,131 19% 40% 211%

Kenya 30,881 54% 56% 104%

Ethiopia 39,589 33% 33% 100%

Malawi 2,670 53% 40% 75%

Mozambique 1,179 36% 46% 128%

Nigeria:Katsina State 1,628 45% 8% 18%

Tanzania (DFID) 2,792 20% 11% 55%

Tanzania (Trust) 1,510 17% 55% 324%

Uganda 35,439 73% 85% 116%

Zambia 1,889 36% 38% 106%

TOTAL 131,708 36% 41% 114%

KEY FINDING: THE TRACHOMA PROGRAMMES HAVE PROVIDED UNPRECEDENTED

TRACHOMA SURGICAL SERVICES

A lack of accurate data caused some initial challenges for the programmes. The

DFID-funded Global Trachoma Mapping Project - a groundbreaking three-year

disease-mapping project completed in early 2016 – provided more accurate data

on the number of patients requiring surgery. Using this data has enabled the

programmes to be more targeted and cost-efficient.

Using a combination of fixed health centres, mobile teams and surgery outreach

camps has enabled a huge scale-up in surgical activities to provide treatment

where it is needed.

As fewer people require surgery, the costs of locating cases increases and

creative strategies are required to find the last few patients who are in more

remote locations.

Training ophthalmic nurses and eye care workers as trachoma surgeons is building

the long-term capacity of government health systems to provide treatment.

FINDINGS

The programmes are focusing on providing high quality surgery by supporting

surgeons, strengthening further supporting supervision, increasing the number

of follow-up appointments with patients 3–6 months after the operations, and

improving data gathering on success rates.

Security concerns, the Ebola crisis, and a lack of mobile surgery camps have

contributed to slow progress in Nigeria. On behalf of the Trust and the ICTC,

Sightsavers is developing an action plan to reach surgery targets that will be

owned by the state Ministry of Health.

NEXT STEPS

MASS DISTRIBUTION OF ANTIBIOTICS IS SUPPORTED BY THESE PROGRAMMES IN CHAD, ETHIOPIA, KENYA, MALAWI AND ZAMBIA.

DISTRIBUTION OF ANTIBIOTICS IN THE OTHER COUNTRIES IS ALREADY SUPPORTED BY OTHER ORGANISATIONS.

FINDINGS• Using existing community volunteers

has been an effective way of mobilising communities for mass distribution of antibiotics.

• Good planning, and coordination with local partners, combined with post-distribution surveys and review meetings are resulting in effective implementation.

• Using the mass drug administrations as an opportunity to identify surgery cases has been successful in Malawi, especially in areas where there are few cases left.

NEXT STEPS• The programmes will build on these

successes by using lessons from each round of mass drug distribution to plan the next round.

• Countries will ensure that plans are in place to conduct disease surveillance activities once targets for elimination have been achieved.

ANTIBIOTICS

KEY FINDING: ALL COUNTRIES ACHIEVED OVER 80% COVERAGE IN THE ENDEMIC DISTRICTS...

WITH A TOTAL OF 31.85 MILLION PEOPLE BEING REACHED THROUGH ANTIBIOTIC

DISTRIBUTION TO DATE

© Zul Mukhida / Sightsavers

YEAR 1 YEAR 2

NUMBER OF PEOPLE TREATED WITH ANTIBIOTICS EACH YEAR

MASS DRUG ADMINISTRATION RESULTS AFTER TWO YEARS

CountryNumber of Doses

of Antibiotics Distributed

Percentage of districts Achieving

80%+ Coverage

Chad 3,787,449 100%

Ethiopia 13,671,301 100%

Kenya 3,837,236 100%

Malawi 8,625,793 100%

Zambia 1,936,004 100%

TOTAL 31,857,783 100%

EFFECTIVE FACIAL CLEANLINESS AND ENVIRONMENTAL IMPROVEMENT ACTIVITIES ARE CRITICAL FOR ACHIEVING AND SUSTAINING THE ELIMINATION OF TRACHOMA TRANSMISSION.

ACTIVITIES ARE BEING SUPPORTED BY DFID AND THE TRUST IN FIVE COUNTRIES: CHAD, KENYA, MALAWI, UGANDA AND ZAMBIA. IN KENYA, MORE THAN 17,000 SCHOOLCHILDREN HAVE BEEN TAUGHT THE IMPORTANCE OF FACE WASHING TO REDUCE REINFECTION AND

PREVENT TRANSMISSION OF TRACHOMA.

FINDINGS• The Trust and DFID trachoma

programmes have been instrumental in increasing engagement with organisations focusing on water and sanitation at the global and national levels.

• The trachoma programmes are developing useful insights that would help engage the water and sanitation sector in the fight against other neglected tropical diseases.

NEXT STEPS• More work is still required to secure

further buy-in from the water and sanitation sector to support trachoma elimination work.

FACIAL CLEANLINESS AND ENVIRONMENTAL IMPROVEMENT

KEY FINDING: THESE TWO TRACHOMA INITIATIVES ARE MAKING SIGNIFICANT CONTRIBUTIONS TO THE ATTAINMENT

AND SUSTAINMENT OF GLOBAL TRACHOMA ELIMINATION GOALS

© Karel Prinsloo / Sightsavers

AN INDEPENDENT REVIEW OF TRA-CHOMA ELIMINATION PROGRAMMES SUPPORTED BY THE UK DEPARTMENT FOR INTERNATIONAL DEVELOPMENT (DFID) AND THE QUEEN ELIZABETH DIAMOND JUBILEE TRUST

A major strength of the programme has been its commitment to ensuring that national governments play a strong role. High-level support is crucial to ensure that the achievements of the programmes are sustainable.

Both programmes need to maintain their momentum over the next three years to ensure that blinding trachoma is eliminated.

The focus now begins to shift from implementing the programmes at scale, to tracking down the last few patients in need of surgery and enabling countries to prepare the necessary information required

to declare themselves trachoma free. The findings from this review will be shared with the wider trachoma and neglected tropical diseases communities. This will contribute to the work of the ICTC and the ‘WHO Alliance for the Global Elimination of Trachoma by the year 2020’ (GET2020).

These trachoma programmes will continue to improve the quality of data, which can now be used to support advocacy and attract resources to tackle trachoma, and other neglected tropical diseases, at both the national and global level.

KEY FINDING: THE ALIGNMENT OF TWO MAJOR TRACHOMA INITIATIVES THROUGH

COMMON OBJECTIVES, MANAGEMENT STRUCTURE AND EXCELLENT COORDINATION

BETWEEN THEM RESULTS IN THE PROGRAMMES BEING ABLE TO PROMOTE

AND IMPLEMENT THE SAFE STRATEGY AT AN UNPRECEDENTED SCALE.

This summary document has been prepared by DFID, the ICTC, Sightsavers and the Trust.