Transforming lives: Ascend West and Central Africa
Celebrating success 2019-2020
In 2019 the UK Government launched Ascend, its flagship programme for the sustainable control and elimination of neglected tropical diseases (NTDs).
Working in partnership with communities, national governments, ministries of health and partners including the World Health Organization (WHO), Ascend West and Central Africa will protect millions of people by making major progress towards the control or elimination of five painful and poverty trapping NTDs: intestinal worms, lymphatic filariasis, river blindness, schistosomiasis and trachoma.
Introducing Ascend
Ascend is one programme, but functions as two geographic entities:
- Ascend West and Central Africa is managed by a consortium including Sightsavers, the Liverpool School of Tropical Medicine, Mott MacDonald and Unlimit Health.
- Ascend East Africa and South Asia is managed by a consortium led by Crown Agents.
This is the story of the first year of implementation of Ascend West and Central Africa (hereafter 'Ascend'), which has already made significant progress in its first twelve months.
The programme began in April 2019, and was officially launched by Baroness Sugg at the 2019 Neglected Tropical Disease NGDO Network Conference. The programme was later showcased to MPs at an all-parliamentary group event in October 2019.
Focus on drug treatment
Treatment for the five programme NTDs is with preventive oral medicines, donated free of charge by the pharmaceutical companies Merck and Co., Merck Serono, Pfizer, GlaxoSmithKline and Johnson & Johnson.
Donated medicines are distributed through mass drug administration (MDA) campaigns, meaning that all eligible people receive the treatment they need, regardless of whether or not they are infected. Led by ministries of health, these recurring campaigns will continue until the national government determines that each endemic community can stop treatment following an impact survey.
MDA campaigns are delivered by thousands of volunteer community directed distributors (CDDs) and teachers. These volunteers are vital to the success of Ascend. They distribute and record treatments across vast areas, and raise awareness within their communities about NTDs and the importance of good hygiene to prevent infection.
Focus on surgery and patient care
Further to treatments, Ascend supports life-changing surgeries and patient care activities to alleviate the painful and debilitating conditions associated with lymphatic filariasis and trachoma.
For lymphatic filariasis, the programme performs hydrocele surgeries to drain fluid build-up in the scrotum, and trains people with swollen limbs (lymphedema) in self-care and symptom management.
Sight-restoring trichiasis surgeries are provided to treat advanced trachoma, the world’s leading infectious cause of blindness.
Other areas of Ascend support
The Ascend programme approach is to not only support countries to reach national treatment targets, but to also strengthen national health systems. Which is done by both building capacity, and by integrating targeted NTD interventions into wider country plans and activities.
Ascend also champions efforts to promote good practice in water, sanitation and hygiene (WASH), through collaborations between the WASH, NTD and education sectors, and deliver behaviour change campaigns to target the behaviours that facilitate disease spread.
Finally, to encourage innovation, the Ascend learning and innovation fund with Accenture Development Partnerships is providing grants in Ascend countries to test out new ideas, generate new evidence and enhance learning.
Where we work
This map illustrates some of the key activities supported by Ascend in its first year.
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MDA overview
MDA campaigns are integrated where possible, meaning that, if necessary, an individual can receive treatment for more than one disease at a time.
In its first programme year, Ascend successfully supported the delivery of treatments to over 1,050 endemic districts across seven countries. This was achieved despite significant logistical challenges of getting donated drugs first into countries and then out to endemic districts, insecurity, and the outbreak of COVID-19.
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Victor's story: The vital work of CDDs and teachers
When drugs do arrive at the many thousands of hospitals and rural village centres in endemic districts, they are collected by CDDs or teachers for distribution.
Victor Scott is a CDD in Gbarpolu, Liberia. He has been volunteering as a CDD since 2016, and is seen here giving treatment for river blindness to Fatta Barclay. Victor carries a wooden dose pole to measure each person and determine the correct does of medication. During an MDA campaign, Victor will deliver drugs house-to-house to over 3,000 community members.
Victor enjoys his role as a CDD, but it comes with its own set of challenges. For example, if a community member refuses treatment, Victor then has to rely on his training to explain the importance of taking the drugs for the health of the individual, and the wider community:
"I love my people and I love my community. To save lives, that’s why I do this work".
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Schistosomiasis treatment in Cote d'Ivoire
In order for an MDA campaign to be considered effective, a certain percentage of people in each endemic area must take the treatment. This is a WHO-defined population treatment threshold and varies by disease.
Schistosomiasis MDA campaigns specifically target school-age children and adults expected to be at a higher risk of infection. To be effective, at least 75% of the total population of school-age children must be treated in each endemic district.
In Cote d'Ivoire, Ascend supported the treatment of over 1.7 million school-age children across 28 endemic districts in its first year. The MDA campaign was effective in all but one district in Agnéby-Tiassa region where the programme was unable to complete treatment.
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River blindness treatment in Nigeria
River blindness MDA campaigns target all individuals over five years of age. To be effective, at least 65% of the total population of each endemic district must be treated.
In Nigeria, Ascend supported the treatment of over 18 million people for river blindness across 116 endemic districts in its first year, and was effective in all treated districts.
The national government had planned treatment with Ascend support in 15 further districts. This was unfortunately not possible due to insecurity and restrictions associated with COVID-19 in Adamawa, Borno and Niger states.
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Miko's story: Mobilising communities to receive drug treatment
Miko Garba is a farmer in Sokoto, Nigeria. When an MDA campaign was held in Miko's community, the local leader and CDD were responsible for mobilising everyone to ensure that no person was left behind. Miko has received drugs to prevent lymphatic filariasis for many years, and fully supports this vital ongoing work:
"We have so far seen how diseases affect people’s lives and render them helpless, so we try as much as we can to always take our medication to avoid diseases".
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Surgery overview
To identify individuals in need of hydrocele and trichiasis surgery, or lymphedema support, Ascend supports government backed awareness raising campaigns in affected communities with the help of a network of case-finders. These volunteers sweep entire communities, moving house-to-house to screen and refer those in need of support to the relevant services.
The programme supports ministries of health to conduct detailed assessments of all medical facilities before the implementation of surgeries or lymphedema support services. This is to ensure that areas of weakness can be strengthened, and mitigates any potential risk to patients.
In its first programme year, Ascend supported ministries of health to perform hydrocele or trichiasis surgeries in nearly 200 endemic districts across six countries.
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Hydrocele surgery in Nigeria
Building off the work of UK aid's previous river blindness and lymphatic filariasis programme , which helped identify the need for hydrocele surgeries, an extensive scale-up in effort was undertaken to find, treat and support people living with painful and debilitating symptoms caused by lymphatic filariasis.
Working in close collaboration with the federal ministry of health of Nigeria to coordinate activities across a vast project area, over 2,700 hydrocele patients were operated on - more than double the number expected. This was in spite of insecurity, and significant bureaucratic challenges at local hospitals as hydrocele surgeries must be delivered in clinical settings.
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Usman's story: The life changing impact of hydrocele surgery
Usman Jatau is a cobbler and farmer in Kebbi, Nigeria. He has been living with hydrocele for more than 20 years. This meant he often struggled to walk and work on his farm. Usman's wife helped him with his symptoms until she passed away seven years ago.
Two years ago he found love again, but due to his hydrocele he was unable to marry.
Following the advice of his community leader, Usman was screened, diagnosed and referred for hydrocele surgery. Free of this debilitating condition, he is now busy planning his wedding!
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Trichiasis surgery in Chad
In Chad, access to basic health services is extremely limited and the health system struggles with chronic shortages of trained health workers, medicines and equipment.
Building from the foundations of the prior UK aid funded SAFE programme , a critical first step for Ascend was to train and equip a network of case finders, facilitating the delivery of over 1,300 trichiasis surgeries in Ascend's first programme year.
It is estimated that there are 6,000 further cases of trichiasis in Chad. Ascend will continue to support efforts to reach these patients over the next two years.
Progress to disease control and elimination
Pictured here are blood samples collected for a river blindness impact survey in Sierra Leone. Impact surveys such as this one are done to confirm whether disease prevalence levels have decreased to or below the WHO threshold, meaning that MDA is no longer needed. It is a significant achievement to stop treatment in a formerly endemic community, but ongoing surveillance is required to ensure the reduction in endemicity is maintained.
In its first year, impact surveys supported by Ascend provided evidence of significant progress towards national elimination goals:
- In Nigeria, it was confirmed that lymphatic filariasis MDA could be stopped for over two million people living in Kebbi and Sokoto states.
- Provisional approval was also granted by the national programme of Nigeria to stop river blindness MDA in Kebbi and Zamfara states. This follows an earlier decision to stop river blindness MDA in Kaduna state.
- In Chad, impact surveys confirmed that trachoma MDA could be stopped in seven health districts.
- In Ghana, following an impact survey in the Greater Accra Region, the sustained interruption of lymphatic filariasis transmission was confirmed. This is an important step forward for Ghana's national elimination programme.
Response to COVID-19
On 1st April 2020, the WHO issued guidance for national NTD programmes, recommending that MDA campaigns, surgical case-finding activities and surveys be postponed.
In response, Ascend designed a series of targeted COVID-19 responses in collaboration with national NTD programmes. This was possible thanks to the flexibility of UK aid, which has enabled the programme to repurpose just under £7m of the second-year programme budget to directly support the COVID-19 response and prevent health systems from being overwhelmed. The activities supported are illustrated in this map.
Consortium partner M&C Saatchi World Services has been instrumental in supporting the mass media communications components of this response, providing strategic advice on message development and adaptation based on local operating contexts.
When to re-start activities safely in each Ascend country will be determined following an assessment using a set of consortium-developed Risk Assessment and Mitigation Action (RAMA) tools.
Key challenges and lessons learned
- Mitigating drug delivery delays: Late arrival of drugs in-country can have a severe impact on the timeliness of MDA campaigns. However, this can be mitigated by using monitoring systems that enable the programme to track the status of inbound donated drug shipments ahead of MDA campaigns, and take appropriate action if there is a likelihood of delay.
- Raising awareness: NTDs are called ‘neglected' for a reason as they affect the poorest populations - people living in remote, rural areas, urban slums and conflict zones. Raising awareness and supporting grassroots advocacy in the countries where Ascend works is therefore crucial for NTD elimination goals to be met. For example, in Ghana, more than 250 people took to the streets of the capital, Accra, for a Health Walk on 30 January 2020 as part of celebrations to mark the first-ever World NTD Day .
- Defining what it means to Leave No One Behind: Ensuring that everyone in need of support receives it is often challenging due to social and political barriers. Ascend is addressing this in partnership with ministries of health through the development of country specific leave no one behind strategies, supplemented by capacity building and training to ensure there is a common understanding on what this means in practice.
The significant progress in year one would not have been possible without strong collaboration between communities, national ministries of health, the Ascend consortium, and partners including the WHO, the Expanded Special Project for the Elimination of NTDs (ESPEN), and the UK government.
As the programme enters its second year of implementation, the consortium will continue working together to ensure that NTD activities can re-start and operate safely during the ongoing COVID-19 pandemic.
We remain optimistic that we will soon be able to resume activities, and continue our work supporting national governments to enhance the health, quality of life, and future well-being of people affected by these painful, poverty-trapping diseases.
Hawa Barclay from Gbarpolu, Liberia pictured here with the drug Mectizan® to treat river blindness.
