This week a new learning paper, ‘Trachoma Elimination in Africa, Lessons from Two Multi-Country Initiatives’ was launched, showcasing 10 lessons from two ICTC partnership initiatives, The Queen Elizabeth Diamond Jubilee Trust’s Trachoma Initiative and the UK Department for International Development (DFID) SAFE Program. Established in 2014, these two programs have brought together 82 stakeholders including two international donors, government ministries, ICTC members, local NGO partners and international bodies to further support these countries to achieve the elimination of trachoma as a public health problem.
With a total budget of £80 million over five years, these programs have supported scale up of the WHO-endorsed SAFE strategy (surgery, antibiotics, facial cleanliness, environmental improvements) at unprecedented levels across ten countries in Africa. Most significantly, the investment has supported over 213,000 surgeries to treat trachomatous trichiasis the late blinding stage of trachoma, the delivery of 75.7 million antibiotic treatments to people living in endemic areas and implemented facial cleanliness and environmental improvement interventions to reduce transmission in 153 districts.
As the programs draw to an end in 2019, the evaluative learning exercise and learning paper provide important lessons to guide future elimination programs for trachoma and other neglected tropical diseases. Some keys lessons include:
The significance of partnership in the two programs cannot be overstated. Employing a unique and complex model, the programs were implemented by ICTC members who also worked as country coordinators in collaboration with health ministries. This work was led by Sightsavers as the ICTC nominated grant manager and supported by an ICTC programme advisory committee who provided technical and programmatic quality assurance guidance.
By avoiding competition and working collaboratively towards common goals, the diverse experience of ICTC members could be used strategically.
By avoiding competition and working collaboratively towards common goals, the diverse experience of ICTC members could be used strategically. Partners routinely shared robust data and work plans so that work was not duplicated and resources were used efficiently.
The diversity of stakeholders within the partnership, including endemic countries, donors, research and NGO implementers, supported cross-sectoral collaboration between health, education and WASH stakeholders. This was particularly important for integrating trachoma messaging into national school and sanitation guidelines so that the results of programs are sustained after the programs end. By developing strong relationships with established organisations, community trust in the programs was strengthened, which further increased the uptake of interventions and improved health outcomes.
The learning exercise also highlighted the importance of community consensus on agreed, standardized evidence-based approaches for the implementation of interventions. ICTC’s preferred practices and toolkits were widely recognised for improving quality and consistency of care throughout the partnership initiatives. Preferred practices were particularly effective when adopted into national trachoma guidelines, which improved the uptake of the tools provided.
Going forward, health ministries should be supported to ensure preferred practices are integrated with national plans, particularly when ministries have limited capacity or engagement with the programs. This is particularly true for ICTC’s latest series of preferred practice about transitioning interventions into routine services after elimination has been achieved. This will be critical to ensure that people can still access the services they require as elimination programs end.
Achieving the elimination of trachoma as a public health problem requires a focus on equity, which was well understood by both partnership initiatives. National programs were required to monitor equity objectives, including gender, socio-economic factors, access to clean water, sanitation and hygiene and the provision of interventions for hard to reach populations.
An example of this includes Tanzania’s work to improve women’s eye health in the Masai community. The national trachoma program trained well-respected women from local microfinance groups to identify trichiasis cases and counsel women with trichiasis to seek surgery, recognising that women often lack access to services compared to men. Women who received surgery also became ‘trachoma ambassadors’ to encourage other women to make use of available services.
Achieving elimination cannot happen without an explicit strategy to access to isolated populations living in endemic areas. By tailoring programs to address hard-to-reach populations, the trachoma community can ensure no one is left behind, a key tenant of the sustainable development goals, and a critical objective to achieve SDG3.3 on better health and well-being.
Room for improvement: Sustainability
Planning for post-elimination is essential to sustain trachoma elimination. Several challenges to sustainability were raised including late delivery of F&E activities due to a lack of technical WASH capacity. Developing cross-sectoral partnerships at the beginning of programs so that F&E components are planned alongside surgery and MDA campaigns is critical to ensure the gains made are sustained.
Programs must also ensure that each country has the capacity to manage any cases after programs finish. Although the programs trained over 300 surgeons and mobilised more than 68,000 case finders, the majority of health system strengthening efforts focused heavily on surgical services. Future programs would benefit from planning transition before program implementation so that trachoma interventions are appropriately integrated into the broader eye health sector. Lessons from the programs have also been incorporated into newly published ICTC toolkit on transition planning across the SAFE strategy to support future programs.
In partnership with national health ministries, The Queen Elizabeth Diamond Jubilee Trust, UK Department for International Development and partners in the trachoma community have helped accelerate progress to eliminate trachoma as a public health problem by 2020.
Lessons from the programs are numerous and should be carefully examined so that donor investments and partnership models continue to benefit the trachoma, NTD and global health communities to implement future programs more efficiently and effectively. As these programs come to an end in 2019, ICTC extends its deep appreciation and thanks to The Queen Elizabeth Diamond Jubilee Trust and the UK Department for International Development for their commitment to partnership and working in a coordinated and collaborative approach with ICTC members to significantly scale up the full SAFE strategy across these two partnership initiatives. ICTC also thanks Sightsavers as the ICTC nominated grant manager, ICTC members and partners across the programs for their tireless efforts to work together in order to achieve our common goal. Although there is still work to do, the Trachoma Initiative and DFID SAFE Program demonstrate that by working together, the end of trachoma is within reach.
ICTC members involved in The Queen Elizabeth Diamond Jubilee Trust Trachoma Initiative and Department for International Development (DFID) SAFE Program include Amref, BICO, CBM, Helen Keller International, IMA World Health, Johns Hopkins University, Kilimanjaro Centre for Community Ophthalmology, Light for the World, Orbis, Organisation pour la Prévention de la Cécité, RTI International, Sightsavers, The Carter Center, The Fred Hollows Foundation, Wateraid and World Vision.