**4. Challenges**

The control of schistosomiasis and STHs is a long-term undertaking, which involves several challenges. The first challenge is to mobilize the funds required for successful actions. Unlike some of the stigmatising NTDs with 'visible' morbidity such as onchocerciasis and LF which have successfully raised funding for the implementation of control activities, little funding are globally available for the implementation of schistosomiasis and STH control alone. Therefore, for their schistosomiasis and STH control programmes, endemic countries should take advantage of the opportunities resulting from the global growing financial resources generated by the new partnerships and impetus for NTD control. The recent changes in the international agenda and the increasing funding opportunities provide leverage for the control of schistosomiasis and STHs. The piggyback and integrated control approaches – based on a complementary co-administration of relevant drugs – are the basis for cost-effectiveness and streamlined efficiency. However, pigging back on other interventions or integration with other health programmes requires the setting up of clear efficient coordination mechanisms in order to optimize the use of resources mobilized from various partners. Among other challenges, the most important are the co-ordination at various levels, the country ownership and leadership, the scale up of control, the sustainability of control programmes, the strengthening of partnerships and institutional capacities, the implementation of operational research, monitoring and evaluation, and the development of new diagnostic tools.

#### **4.1 Co-ordination**

The NTD control programmes involve many partners and stakeholders, different diseases, several funding sources, and multiform resources. The main challenge is to set up clear efficient coordination mechanisms in order to optimize the resources mobilised from all partners. To ensure transparency in all processes, there is a need for a coordination mechanism for funding, drug supplies and integrated control of NTDs to enable all stakeholders to share information. The coordination mechanism should be at global, regional and country levels. The precise form of this co-ordination mechanism needs to be explored and agreed amongst stakeholders. At national level, the Ministry of Health should play the central role in this co-ordination.

#### **4.2 Country ownership and leadership**

In order to ensure the sustainability and the success of NTD control programmes, country leadership in the coordination of activities is essential. Each partner may have its own vision and own interest, and the ones who bring the money also sometimes decide what to do.

prevalence and intensities in all three regions, with an overall decline of prevalence from 90.06% (95% CI: 89.45-90.63%) to 24.11% (95% CI: 23.37-24.86%). Based on the prevalence data, the continuation of annual or bi-annual MDA for STH was recommended, as well as an extension of PZQ treatment in identified moderate and high risk communities for schistosomiasis (Tchuem Tchuenté et al., 2012). These results show the positive impact of annual deworming campaigns, and illustrate the progressive success of the national programme for the control of schistosomiasis and STH in Cameroon. This is illustrated in Figure 2. Parasitological surveys are in progress in the remaining regions of Cameroon for

The control of schistosomiasis and STHs is a long-term undertaking, which involves several challenges. The first challenge is to mobilize the funds required for successful actions. Unlike some of the stigmatising NTDs with 'visible' morbidity such as onchocerciasis and LF which have successfully raised funding for the implementation of control activities, little funding are globally available for the implementation of schistosomiasis and STH control alone. Therefore, for their schistosomiasis and STH control programmes, endemic countries should take advantage of the opportunities resulting from the global growing financial resources generated by the new partnerships and impetus for NTD control. The recent changes in the international agenda and the increasing funding opportunities provide leverage for the control of schistosomiasis and STHs. The piggyback and integrated control approaches – based on a complementary co-administration of relevant drugs – are the basis for cost-effectiveness and streamlined efficiency. However, pigging back on other interventions or integration with other health programmes requires the setting up of clear efficient coordination mechanisms in order to optimize the use of resources mobilized from various partners. Among other challenges, the most important are the co-ordination at various levels, the country ownership and leadership, the scale up of control, the sustainability of control programmes, the strengthening of partnerships and institutional capacities, the implementation of operational research, monitoring and evaluation, and the

The NTD control programmes involve many partners and stakeholders, different diseases, several funding sources, and multiform resources. The main challenge is to set up clear efficient coordination mechanisms in order to optimize the resources mobilised from all partners. To ensure transparency in all processes, there is a need for a coordination mechanism for funding, drug supplies and integrated control of NTDs to enable all stakeholders to share information. The coordination mechanism should be at global, regional and country levels. The precise form of this co-ordination mechanism needs to be explored and agreed amongst stakeholders. At national level, the Ministry of Health should

In order to ensure the sustainability and the success of NTD control programmes, country leadership in the coordination of activities is essential. Each partner may have its own vision and own interest, and the ones who bring the money also sometimes decide what to do.

the update mapping.

development of new diagnostic tools.

play the central role in this co-ordination.

**4.2 Country ownership and leadership** 

**4.1 Co-ordination** 

**4. Challenges** 

Fig. 2. Comparative maps of the overall soil-transmitted helminthiasis prevalence between the years 1985-1987 (A) and 2010 (B) in the Centre, East and West regions of Cameroon.

Sometimes, many people in a country are working for the same thing, but with different targets because there are different donors. Country ownership brings many gains, including development of local capacity and expertise. There should be a strong political commitment to tackle NTDs in endemic countries. Indeed, examples of success stories are from those countries (e.g. Japan, Morocco and China) that had clear ambitious goal, with high government and national commitment, funding mobilization and leadership. For example, in early 1963 STH occurred in Okinawa, Japan at high prevalence up to 40% in adult population. Through the development of an ambitious 'zero parasites' campaign a successful control was conducted and within a period less than 10 years STHs and other

Control of Schistosomiasis and Soil-Transmitted

**4.6 Strengthening of institutional capacities** 

**4.5 Strengthening of partnership** 

and the community ownership.

resistance, is of vital importance.

**4.8 Monitoring and evaluation** 

**4.9 Better diagnostic tools** 

integrated preventive chemotherapy interventions.

**4.7 Operational research** 

Helminthiasis in Sub-Saharan Africa: Challenges and Prospects 369

An efficient control requires multisector collaboration and multilateral funding. No single organization can hope to achieve this goal alone. School-aged children are the target group for schistosomiasis and STH, so the collaboration between the Ministry of Health and the Ministry of Education should be reinforced. The target group for the different filarial infections is the entire population and the control strategy is based on community-directed interventions, which requires ownership by the communities and strong partnership with NGOs. Overall, partnership with other government departments and NGOs concerned with water supply, sanitation and development projects should be developed and reinforced.

The integration of control activities within the health services is fundamental for the sustainability of the programme. However, most of the existing structures do not have the capacity to ensure the implementation of these activities, leading to programme failure. Therefore, the strengthening of the health system is a requirement for the long-term viability of the control programme. Furthermore, an efficient participation of schools and communities in the disease control requires a reinforcement of capacity of the school system

It is important to support operational research to fulfill gaps and improve the implementations of the control. For example, the understanding of some key issues, such as baseline epidemiology, morbidity assessment, drug efficacy testing and monitoring of drug

Regular monitoring and evaluation are necessary to ensure that programmes are efficiently implemented and that the beneficiaries gain the maximum benefit. This is particularly challenging given the diversity of tools and indicators. Substantial progress has been made towards the development of standardized tools for monitoring and evaluating NTD control programmes. WHO is currently developing guidelines based on the experience to date with

Because of its simplicity and relatively low-cost, the Kato–Katz technique (Katz et al., 1972) is widely used for epidemiological field surveys and is recommended by the WHO for surveillance and monitoring of schistosomiasis and STH control programmes (WHO, 1991; Montresor et al., 1998). Though the specificity is very high, the sensitivity of Kato–Katz in single stool sample examination is limited by day-to-day variation in egg excretion leading to measurement error in estimating the presence of infection. This is particularly accentuated in areas with high proportions of light intensity infections (Hall, 1981; Booth et al., 2003; Tarafder et al., 2009). In the current era of preventive chemotherapy, the intensification of large-scale interventions and repeated mass deworming will significantly reduce the prevalence and intensities of schistosomiasis and STH infections (Savioli et al., 2004; Kabatereine et al., 2007). As consequence of the increase of low-intensity infections, more light infections will be often missed if single stool samples are examined by Kato–Katz method, resulting in high underestimation rates. Therefore, there is a need to develop and

parasites were eradicated in Okinawa. In contrary, lack of ambitious control is remarkable in Sub-Saharan Africa where many countries have passive attitude, waiting for partners to decide and to tell them what to do. African governments should develop more positive and ambitious approach for the control of NTDs, and donors and agencies beyond disease endemic countries—the agents of aid to developing countries—will need to accept that countries must have ownership of their health systems and total control over decisions about the health of their people.

#### **4.3 Scale up of control**

In order reach the target set by WHA for the different NTDs, there is a need to accelerate the extent of treatment. The extension of regular deworming coverage as a public health intervention to reach all individuals at risk remains a challenge. There is also a challenge to tackle the big countries such as Nigeria, Democratic Republic of Congo, Ethiopia and Tanzania which count for 60% of at risk population not covered by preventive chemotherapy yet. In the context of multi-disease integrated control, the current tendency in sub-Saharan Africa is to integrate helminth control within the community-directed interventions, taking advantages of the long experience and gains of onchocerciasis and LF control programmes through the establishment of community-directed treatment with ivermectin (CDTI) in all countries supported by the African Programme for Onchocerciasis Control – APOC (Sékétéli et al., 2002; Amazigo et al., 2002). Yet, in the majority of countries, STHs are more widely distributed than both onchocerciasis and LF. Therefore, the challenge will be to extend MDA coverage in those areas where CDTI does not exist. Countries should thus act cautiously and anticipate to avoid to neglect STH and schistosomiasis control in those endemic areas. School-based deworming is probably the simple, cost-effective and best sustainable way to expand coverage of children. With more schools than clinics, and more teachers than health workers, the existing and extensive education infrastructure provides the most efficient way to reach the highest number of school-age children and to reach the WHO target of covering at least 75% of all school-aged children in need. The recent increases of donated anthelminthic medicines by Merck KGaA (praziquantel), Johnson & Johnson (mebendazole) and GlaxoSmithKline (albendazole) constitute a real boost towards the achievement of this goal.

#### **4.4 Sustainability**

To roll back the NTDs, it is necessary to continue and maintain the implementation of control activities during very long period. The programme should be long-term, and financial and implementation plans should be made accordingly. This would avoid one of the major errors of the past where most of the programmes were supported by short-term external funds and stopped immediately when funds ceased. To ensure sustainability, countries should, from the beginning, envisage strategies to: (1) keep the momentum, interest and enthusiasm for the control of the diseases; (2) organize and finance in a sustained way the distribution of drugs to those who need them; (3) mobilize funding for operational costs for drug distribution, health education materials, baseline data collection, monitoring and evaluation, etc.; (4) ensure the availability and affordability of the drugs at community level in endemic areas; (5) integrate programme activities within the existing health structures and networks; and (6) strengthen the health system and national capacity at all levels, especially in the peripheral and remote areas which manage the greater number of communities and infected persons. One of the key questions is how to guarantee the continuation of control after the decline or interruption of external funds.
