ITI Strategic Program Plan and Review Meeting - Final Report2

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					                                                                                  ITI SPPR Meeting Report  
           Strategic Program Plan and Review for the International Trachoma Initiative
                             The Task Force for Child Survival and Development
                                                Atlanta, USA
                                             9-10 March 2009

                                            TABLE OF CONTENTS

  I.          Introduction and Background
 II.          Meeting Outcome
              1   New ITI Strategic Framework – Questions and Comments
              2   Scale Up – Presentation by IHI and Group Discussion
              3   CARE – Comments by J. Moore on behalf of CARE
              4   Strategic and Operational Opportunities and Priorities – Comments from the group
              5   Task Force Next Steps – Comments by M. Rosenberg, Executive Director, and T.
                  Rosenberger, Chief Operating Officer, the Task Force for Child Survival & Development
Annex 1           Agenda
Annex 2           List of Participants
Annex 3           Working Groups Session 1 – SAFE Strategy Components – Report from the Working
                  Groups with Comments
Annex 4           Working Groups Session 2 – Key Issues in Scaling Up Trachoma Elimination Programs –
                  Report from the Working Groups with Comments


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                                            MEETING REPORT

    I.    Introduction and Background
          1.    At the end of 2008, the International Trachoma Initiative (ITI) and the Task Force for Child
                Survival and Development initiated steps to merge ITI into the Task Force.
          2.    In order to establish a strategic program plan to guide the future direction for ITI, a two-step
                plan was devised:
                 a. First, to assemble a small group of experts to identify options for ITI’s role in scaling up
                      the SAFE strategy to reach the GET 2020 objectives (February 9-10, 2009); and
                 b. Second, to present these options to a larger group of stakeholders for consideration and
                      input at a subsequent meeting to be hosted by the Task Force (March 9-10, 2009).
           3.   The present meeting was the second step in the two-step plan. The majority of participants
                who attended the February technical meeting joined the larger group for this meeting.
           4.   Participants were provided with the following background documents in advance of the
                 a. Report from the technical advisory group meeting held in February; and
                 b. Planning for Scale: A Guide for Designing Large Scale Improvement Initiatives,
                      Institute for Healthcare Improvement
           5.   Al Sommer, Meeting Chair and Mark Rosenberg, opened the meeting by outlining the goals
                of the meeting:
                 a. To present ITI’s plans for a new strategic framework and get feedback from key partners
                 b. To mark the beginning of the new “scale-up” phase of ITI by understanding how the
                      collective experience and insights of key partners can help the Task Force shape the
                      scale-up of trachoma elimination programs
           6.   Specific areas of focus included new and innovative ways to scale up globally, ways to
                integrate work on the NTD’s and the full SAFE strategy, and opportunities for collaboration
                in resource mobilization, knowledge management and advocacy.

    II.   Meeting Outcome

          1.    The new strategic framework comments and questions
                 a. Summary of key outcomes from February 2009 technical advisory meeting by chair:
                     ITI seeks to partner with countries and other organizations to achieve the goals of GET
                     2020; the nature of that relationship will vary by country and partner. In the context of
                     existing resources, three key roles were identified for ITI.
                      • Supply chain management of Zithromax donation
                      • Advocate at global, regional, and country level for the elimination of blinding
                      • Key partner in trachoma knowledge management.

                 b. Comments and questions from the group about the strategic framework:
                      i.   In order to achieve rapid scale-up, the ITI board thought it was necessary to have a
                           lead partner that had a field structure, how has this been addressed? (R. Mallett)


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           The need for a field-based lead partner in scale-up was raised and discussed at
           length; there is a lot that needs to be considered in terms of scale-up, how it’s done
           and the best approaches to achieving that goal. In different scenarios, a field-
           based lead partner may play a larger or lesser role, and different organizations
           might take on the relevant task(s). All approaches will ultimately be based on the
           core concept of networking. The technical advisory group that met in February
           felt it was premature at this time to adopt a single approach. (M. Rosenberg)

     ii.   Will countries be prioritized or will ITI work across all countries? (J. Feczko)
           Countries will be prioritized, recognizing that countries with adequate internal
           resources to address trachoma elimination should do so without the need for
           significant ITI support. The new ITI framework emphasizes partnerships within
           the larger context of the goal to create and strengthen a global movement to
           eliminate blinding trachoma; how each country participates in that global
           movement and accomplishes the goals that it needs to accomplish can vary
           dramatically. Engaging relevant country ministries and ensuring government
           ownership of the program are essential steps. (A. Sommer)

    iii.   Was there any discussion in the February meeting on mobilizing resources for this
             work? (K. Spahn)
           We recognize there is a tremendous need for resources. The question is how to go
           about doing that. The previous meeting was focused on ITI’s role: ITI will work
           with all the partners and countries to craft relevant requests for resources that meet
           the needs of the global mission and the emerging partnerships. Hopefully this will
           prove particularly attractive to donors, and efficient in best meeting at least some
           of the needs of the partnerships for additional resources. ITI is committed to
           working with the other NGO’s and with governments to try and help find those
           resources. This meeting is an opportunity to explore whether the partners and
           other NGO’s think this is an appropriate global approach. (A. Sommer)
           A “principal partner approach” was discussed, without conclusion. “High priority
           countries” would be identified through country prioritization. A principal partner
           would be identified who might provide principal support to each national program
           and through which the outside support is channeled. (P. Emerson)
           SSI in Kenya is an example of this type of partnership. SSI Kenya heads a
           consortium of NGO’s raising funds and assisting with government planning. (I.
           We had a trachoma summit last week and it was a real step forward, getting the
           water and sanitation actors involved. UNICEF was there with their country wash
           program and they even identified trachoma as a line item or program. It is a good
           way to communicate what trachoma is to other main line development partners.
           Coming from the two vantage points of ophthalmology and development partners
           towards trachoma; I think there’s a lot of potential for this type of partnership on
           the country level. We had a lot of good participation by the Ministries of Water
           and Environment. It requires a lot of networking and communication. (N.


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              iv.      What role could trachoma have in NTD integration? (R. Mallett)
                       This is an ongoing and central issue in the strategic planning process that will be
                       evaluated for fit with each of the three roles identified for ITI - Zithromax supply
                       chain management, advocate for the elimination of blinding trachoma, and key
                       partner in knowledge management. The world of NTD integration is evolving and
                       the value and opportunities remain unresolved, developments will be monitored
                       closely for appropriate opportunities for more fully engaging trachoma activities.
                       (M. Rosenberg)
                       In the February meeting report it says that “ITI will facilitate training and
                       disseminate operational research findings”. This is a real turning point that ITI has
                       this opportunity to facilitate integration and to work with the other programs that
                       the Task Force already has to gather data and to work with the programs that
                       Gates is already supporting. I know Sheila West was here for the first meeting
                       and Dan Colley is heading up the schisto work to try to put together data so we
                       know from operational research how to best do integration. It is an optimal time.
                       (J. Cook)
                       Looking towards integration and how it will happen, the context of integration
                       will be essential to the success of the program. There’s a two-fold piece in which
                       ITI plays a unique role. It is a very disease-specific and targeted goal that you are
                       trying to help accomplish; making sure that goal is reached is essential. Then you
                       have the other piece of working within the context of integrated diseases and
                       integrated disease control. In bringing those two worlds together and sharing
                       knowledge, ITI should not lose sight of the disease-specific targets in the context
                       of the overall integration. (J. Jacobson)
                       Our mandate is to fund co-implementation of NTD’s. The discussion on how
                       trachoma will become a part of the integrated world is a very important one. At
                       both global and country levels, trachoma has been the hard one to get data on, to
                       figure out who’s on the ground; trachoma has been the hard one to co-implement.
                       That is really important to us. In terms of resource mobilization, we are not the
                       only ones who have moved to this co-implementation framework. DFID is also
                       talking about integrated service delivery; the G-8 that made a commitment to
                       NTD’s was talking about NTD’s in the co-implementation framework. Resource
                       mobilization for trachoma alone may not get you very far in the current funding
                       environment, so integration is key for funding as well as providing new delivery
                       options. (C. Hanson)

    2.   Scale-up presentation by J. McCannon, Institute for Healthcare Improvement with
         questions and comments from the group
         In developing targeted strategies for scaling up programs and spreading a framework of
         change, the Institute for Healthcare Improvement draws from lessons learned in settings as
         varied and diverse as military operations, agricultural production and auto manufacturing.
         Joe McCannon, Vice President of IHI, shared some of what’s been learned and the ways it
         might be applied to scaling up trachoma control in the future.

         a. Questions for further consideration directed to the group by J. McCannon:
             •      In looking at the SAFE strategy, what can be spread at scale because it is self-
                    explanatory and what requires something more?

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        •    What is the degree of leadership engagement on trachoma reduction vs. tackling
             NTD’s more generally?
        •    Where are we in the story of trachoma elimination? How much of a foundation is in
        •    What is the most aggressive possible goal? Can we put a number on it?
        •    Which elements of the SAFE strategy can be decoupled? Which could naturally
             piggyback on other efforts?
        •    Which elements, simple vs. complex, lend themselves to particular dissemination
        •    How might the dissemination method vary based upon geography and resources?

    b. Discussion points (Comments and questions from the group with responses by J.
        i.   What is the biggest caution in planning for scaling up?
             When it comes to the intervention itself we should not think of SAFE as monolithic,
             i.e. always applied the same way in different settings. Uncoupling interventions and
             pairing with other programs will be more important. If possible, it is important to be
             explicit about ownership or aim in an area, to have people pledge to carry specific
       ii.   How do we do trachoma elimination with other NTD’s?
             There might be lessons in how IHI “bundled” various interventions in its campaign to
             reduce hospital deaths. Similarly we could pull out elements of the SAFE strategy
             and bundle them with other NTD’s using kits or packages of interventions.

              • Having participated in the IHI hospital improvement program, [I can share my
                impressions] from a participants’ perspective. The real strengths of the [IHI]
                program are hands-on technical expertise, peer-to-peer teaching and learning, and
                the simplicity of the interventions. (S. Kassim-Lakha)
              • WHO and WHA can create a mechanism for people to come together to advance
                the idea; how many extension agents can we create in the IAPB to put pressure to
                put SAFE in place? It will be the eye nurses and the people on the ground that
                will bring SAFE strategy to the attention of the people who can make decisions in
                the ministry. (J. Cook)
              • [The notion of working in a] plan, do, study, act cycle [(PDSA) is a powerful idea
                that we should apply to trachoma]. We can do this with the convening power of
                WHO and the supporting power of ITI. WHO can set norms and standards; ITI
                can support WHO in convening the annual global meeting and regional and sub-
                regional meetings where country programs have the opportunity to present
                successes within the framework. (P. Emerson)
              • Key challenges of scale-up are supply and demand and they apply differently to
                various parts of the SAFE strategy. For S&A, even when there is adequate
                supply, we need to generate demand. The challenge with F and E is mobilizing
                sufficient supply in Africa. (N. Thuo)


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    3.   CARE
         Jennifer Moore, speaking on behalf of CARE, outlined CARE’s interest in trachoma,
         synergies that existing CARE programs have with trachoma control, assets CARE could
         contribute and needs that CARE would have to fulfill in joining the trachoma control effort.
         CARE’s interest in exploring partnership, with the Task Force/ITI in trachoma control,
         centers on trachoma’s application to the MDG’s benefiting water and sanitation; additional
         overlap of programmatic priorities exist in addressing an underlying cause of poverty and the
         inequitable disease burden on women.
         In initial discussions internally and with the Task Force, CARE views entering trachoma
         control as an important partnership going forward. Although CARE has no clear history in
         trachoma control, both the SAFE strategy and advocacy efforts are viewed as an entry point
         for CARE. With 150 programs in 40 countries in water and sanitation, the easiest and
         clearest fit is in addressing the F and E components of SAFE. The comprehensive approach
         of the SAFE strategy further matches CARE’s programmatic approach.
         CARE has regional units and country offices; the best opportunity for CARE to contribute is
         at the country and regional levels through both country offices and regional networks. Most,
         if not all of the country offices, are located in trachoma-endemic countries. CARE is well-
         positioned for country-level advocacy and community education in water and sanitation. The
         in-country networks of local governments, NGO’s and international NGO’s are active on
         community, district and regional levels and could be mobilized to expand F and E into other
         programs and to work on demonstration or pilot projects that could be taken on by a different
         partner and expanded. CARE has developed a manual on safe water systems in Kenya on
         point-of-use water treatment that includes a school-based hand washing program; very easy
         to add face washing to existing projects and to expand the model to additional areas.
         CARE’s needs were identified as a coordinator at CARE, achieving country office buy-in and
         ensuring that the activities that are implemented have implications.
    4.   Strategic and Operational Opportunities and Priorities
         The group was asked to consider a 3-6 month horizon and identify the key strategic and
         operational opportunities and priorities that they recommend the Task Force address or
         pursue. The group’s responses overwhelmingly centered on the importance of effective
         partnership – defining a formal coalition to seek funding and carry out a coordinated strategy,
         fostering regional networks, and collaboration and communication with country offices. The
         group also emphasized the importance of defining a strategic plan with a multi-year budget,
         naming a strong director and Technical Expert Committee (TEC) members, and reporting on
         this meeting’s outcomes to the broader trachoma community with a policy statement on the
         new ITI. They also stressed the importance of transparency and frequent communications
         between organizational headquarters and teams in the field. Additional comments included a
         recommendation to change the brand through the logo or name.


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    5.   Task Force Next Steps
         Mark Rosenberg, Executive Director, Task Force acknowledged the group’s endorsement of
         the strategic framework and the need for transparency. He highlighted the ITI merger with
         the Task Force as a unique opportunity to work on NTD integration within the Task Force
         and to advance this work globally in partnership with WHO, USAID and the other groups
         represented at the meeting.
         Mark Rosenberg and Tom Rosenberger, Task Force Chief Operating Officer, outlined the
         Task Force’s next steps.
               1) Director
                  Will identify and announce a strong director within two weeks.
               2) Technical Expert Committee
                  Will establish a committee of experts and liaison members that builds on their
                  individual and collective strengths; please submit recommendations for
                  consideration. We hope to hold the first committee meeting in the fall.
               3) GET 2020 Alliance – July 2009
                  Need to work closely with Silvio Mariotti at WHO Prevention of Blindness, with
                  Chad MacArthur on ICTC and all partners to build a global alliance.
               4) Strategic Plan
                  Strategic framework is a good starting point; the plan will take a little time to
                  evolve; commitment to involve partners in that evolution.
               5) WHO NTD Conference – December 2009
                  Working with WHO NTD Director to build a strong inclusive alliance of all NTD
               6) Committed to maintaining these relationships
               7) Communication with the country office staff
               8) Developing the scale-up strategy
                  Working with the TEC it is important to begin to know what this will look like;
                  may be developing a pilot multi-year, multi-country plan


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    1.    Welcome                                            (A. Sommer/D. Cavanaugh)
    2.    Burden of the Disease and the Challenges Ahead                  (S. Mariotti)
    3.    Review of the Strategic Framework from Technical                (A. Sommer)
          Advisors Meeting - February 9-10, 2009
    4.    Institute for Healthcare Improvement(IHI)                     (J. McCannon)
          Briefing on Scale-Up
    5.    Working Group Sessions
          1. SAFE Strategy Components
          2. Key Issues in Scaling Up Trachoma Elimination
    6.    Key Insights
    7.    Summary of Major Options
    8.    Framing Next Steps
    9.    Closing


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                                    LIST OF PARTICIPANTS

Dr. Agatha Aboe, MD, Country Representative, International Trachoma Initiative, 10th Floor Premier
Towers, Opposite Pension House, PMB, Ministries, Accra, GHANA [Tel. +288 21 689231, Email:]
Mr. Phillip Albano, Manager LCIF Sight Programs Dept., Lions Club International Foundation, 300 W.
22nd Street, Oak Brook, IL 60523-8842, USA [Tel. +1(630) 468-6895, Email:]
Mr. Michael A. Bailin (International Trachoma Initiative Board Member), CEO and President, Edna
McConnell Clark Foundation (retired), 441 Lexington Avenue, Suite 1101, New York, NY 10017-3910
USA [Email:]
Mr. Nat Bascom, Country Director, Christian Blind Mission, CBM Africa Regional, Office East 1, 58004
Ring Road Westlands, 00200 Nairobi, KENYA [Tel. +254 (20) 375 1654, Email: natbascom@cbmi-]
Ms. Denise Cavanaugh (Meeting Facilitator), Partner, Cavanaugh, Hagan & Pierson, 1990 M Street NW,
Suite 480, Washington, DC 20036, USA [Tel. +1(202) 331-8925, Email:]
Dr. Joseph A. Cook, MD, MPH, Former Executive Director, International Trachoma Initiative,
University of North Carolina Chapel Hill, School of Public Health, Chapel Hill, NC, USA [ Email:]
Dr. Paul Courtright, MD, Co-Director, Kilimanjaro Centre for Community Ophthamology, Tumaini
University, PO Box 2254, Moshi, TANZANIA [Tel. +255 27 275354, Email:]
Dr. Walter Dowdle, MD, Director, Polio Eradication Program, TheTask Force for Child Survival &
Development, 325 Swanton Way, Decatur, GA 30030, USA [Tel. +1+1(404) 687-5608, Email:]
Ms. Christina Dykstra Mead, Chief Administrative Officer, International Trachoma Initiative, 441
Lexington Avenue, Suite 1101, New York, NY 10017-3910 USA [Tel. +1(212) 490-6460, Email:]
Dr. Paul Emerson, PhD, Director, Trachoma Control Program, The Carter Center, 1149 Ponce de Leon
Avenue, Atlanta, Georgia 30306, USA [Tel. +1(404) 420-3854, Email:]
Dr. Joseph M. Feczko, MD (International Trachoma Initiative Board Member), Sr. Vice President and
Chief Medical Officer, Pfizer, Inc., 235 East 4(2 Street, New York 10017, USA [Tel. +1(212) 733-2323,
Ms. Kim Frawley, Sr. Manager, U.S. Philanthropy, Pfizer Foundation, 235 East 42 Street, New York
10017, USA [Email:]
Dr. Danny Haddad, MD, Director, Children Without Worms, The Task Force for Child Survival &
Development, 325 Swanton Way, Decatur, GA 30030, USA [Tel. +1(404) 687-5623, Email:,]


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Ms. Christy Hanson, PhD, MPH, Sr. Public Health Advisor, USAID, 1300 Pennsylvania Ave., NW
Office 3.7.23, Washington, DC 20523, USA [Tel. +1(202) 712-5429, Email:]
Dr. Adrian Hopkins, MD, Director, Mectizan Donation Program, The Task Force for Child Survival &
Development, 325 Swanton Way, Decatur, GA 30030, USA [Tel. +1(404) 687-5616, Email:]
Mr. Ibrahim Jabr, President, International Trachoma Initiative, 441 Lexington Avenue, Suite 1101, New
York, NY 10017-3910 USA [Tel. +1(212) 490-6460, Email:]
Dr. Julie Jacobson, MD, Sr. Program Officer, Infectious Diseases, Global Health Program, Bill and
Melinda Gates Foundation, 1551 Eastlake Ave. East, Seattle, WA 98102, USA [Email:]
Dr. Shaheen Kassim-Lakha, MD, PhD, Sr. Program Officer, Conrad N. Hilton Foundation, 10100 Santa
Monica Blvd., Ste. 1000, Los Angeles, CA 90067, USA [Email:]
Ms. Samantha Kluglein (Rapporteur), Sr. Program Associate, The Task Force For Child Survival &
Development, 325 Swanton Way, Decatur, GA 30030, USA, [Tel. +1(404) 592-1444, Email:]
Mr. Geoffrey Knox, President, Geoffrey Knox & Associates, 48 West 21st Street, 12th Floor, New York,
NY 10010, USA [Tel. (212) 229-0540, Email:]
Dr. Mary Linehan, MD, Acting Director, NTD Control Program, RTI International, 701 13th Street NW,
Washington, DC 20005, USA [Tel. +1(202) 728-1964, Email:]
Mr. Peter Lochery, Director of Water, CARE USA, 151 Ellis Street, NE, Atlanta, GA 30303, USA [Tel.
+1(404) 681-2552, Email:]
Mr. Chad MacArthur (Chair, International Coalition for Trachoma Control (ICTC)), Director of
Training and Community Education, Director Neglected Tropical Diseases, Helen Keller International,
352 Park Avenue South, 12th Floor, New York, NY 10010, USA [Tel. +1(212) 532-0544, Email:]
Mr. Robert Mallett (International Trachoma Initiative Board Chair) Sr. VP Worldwide Public Affairs
and Policy, Pfizer, Inc., 235 East 42 Street, New York 10017, USA [Tel. +1(212) 733-0922, Email:]
Dr. Silvio Mariotti, MD, Senior Medical Officer, Prevention of Blindness and Deafness, World Health
Organization, 20 Avenue Appia, CH-1211, Geneva 27, SWITZERLAND [Tel. 41 (22) 791-3491, Email:]
Mr. Joe McCannon, Vice President, Institute for Healthcare Improvement, 20 University Road, 7th Floor,
Cambridge, MA 02138 USA [Tel. +1(617) 301-4836, Email:]
Mr. Jennifer Moore, Technical Advisor, CARE-CDC Health Initiative, CARE USA, 151 Ellis Street, NE,
Atlanta, GA 30303, USA [Email: ]
Dr. Eric Ottesen, MD, Director, Lymphatic Filariasis Support Center, The Task Force for Child Survival
& Development, 325 Swanton Way, Decatur, GA 30030, USA [Tel. +1(404) 687-5604, Email:]
Dr. Muhammad Babar Qureshi, MD, Director Trachoma Programme, Pakistan Institute of Community
Ophthalmolgy (PICO), Hayatabad Medical Complex, P.O.Box 125 G.P.O. Peshawar, PAKISTAN [Tel.
0092-91-9217377-80, Email:]


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Dr. Mark Rosenberg, MD, MPH, Executive Director, The Task Force For Child Survival &
Development, 325 Swanton Way, Decatur, GA 30030, USA [Tel. +1(404) 687-5635, Email:]
Mr. Tom Rosenberger, Chief Operating Officer, The Task Force for Child Survival & Development, 325
Swanton Way, Decatur, GA 30030, USA [Tel. +1(404) 592-1430, Email:]
Dr. Lorenzo Savioli, MD, Director, Dept. of Neglected Tropical Diseases, World Health Organization, 20
Avenue Appia, CH-1211, Geneva 27, SWITZERLAND [Tel. 41 (22) 791 2664, Email:]
Ms. Vivian Singletary, Logistics Manager, ITI Program, The Task Force for Child Survival &
Development, 325 Swanton Way, Decatur, GA 30030, USA [Tel. +1(404) 592-1419, Email:]
Dr. Alfred Sommer, MD, PhD (International Trachoma Initiative Board Member), Dean Emeritus, Johns
Hopkins University, Bloomberg School of Public Health, 615 N. Wolfe Street, Room 1041- Hygiene,
Baltimore, MD 21205-2179, USA [Tel. +1(410) 502-4167, Email:]
Ms. Kathy Spahn, President and CEO, Helen Keller International, 352 Park Avenue South, 12th Floor,
New York, NY 10010, USA [Tel. +1(212) 532-0544, Email:]


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                       Working Group Session 1 – SAFE Strategy Components

Working groups were asked to develop a clear understanding of ITI’s role in the SAFE strategy. Groups
were asked to discuss topic-specific questions, while all four groups were also asked to address the
    •   How do we apply the SAFE strategy to the new ITI with respect to each component?
    •   What should be the role of our partners for each approach?

a. Surgery
    (Participants: P. Albano, N. Bascom, P. Courtright (chair), D. Haddad, K. Spahn, A. Sommer, A.
    Charge to the group: Discuss methods for setting targets and measuring impact.
    The group first identified issues in implementation of the “S” component:
        •   low surgical rates
        •   inadequate quality of surgery
        •   need for improved techniques
        •   attrition of trained personnel

    ITI’s Role
    •   Ensuring that S is in the plans submitted, using the donation of Zithromax as an incentive to
        encourage countries to provide surgical services. ITI can serve as a broker in getting S in place,
        leverage the Zithromax donation to get surgery in place, work with partners to get training and
        strategies in place
    •   Provide Zithromax post-surgery to comply with WHO technical guidelines
    •   Identify possible funding under partnership; without acting as a conduit or implementer.
    •   Serve as repository for dissemination of information but not responsible for generating
    •   Advocate to include S into national and district VISION 2020 plans
    •   Advocate as a convener, not to replace existing networks with a new partnership, but to bring
        together experts to assist with setting standards (WHO)
    •   Advocate for targets at national and district levels that include annual monitoring and reporting,
        without responsibility to set goals and targets for surgery
    •   Consider having a data bank of technical experts or certified trainers to be available to countries
        and others


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    Partner Roles
    WHO provides technical policy; other partners will fulfill roles identified above as being outside the
    responsibilities and capabilities of ITI. Roles that ITI will not take on include:
          •     Generating evidence and research
          •     Providing training and strategy
          •     Determining surgical goals and targets

b. Antibiotics
    (Participants: J. Cook, P. Emerson (chair), J. Feczko, K. Frawley, C. Hanson, M. Linehan, R. Mallett,
    S. Mariotti, M. Rosenberg, V. Singletary)
    Charge to the group: Discuss the limiting steps in scaling up distribution of Zithromax, lessons learned
    in leveraging the distribution, and how to measure impact and conduct M&E.

    Limiting steps
    • Zithromax availability
      Pfizer’s continued donations are not in doubt. Pfizer is expected to continue to respond positively to
      requests from countries made through the Technical Expert Committee (TEC). Donated Zithromax
      is to be used in the context of the SAFE strategy.
    • Distribution costs
      Majority of cost falls on the endemic countries through a combination of financial and opportunity
      costs; supporting organizations may supplement financial costs.
      Lessons in leveraging
      •       Mobilize ministries, countries and communities to trachoma control
      •       Facilitate national planning by ensuring countries have an adequate plan for trachoma control
      •       Facilitate a ‘green light committee’ to assist endemic countries that require assistance in
      •       Advocate for co-administration where appropriate, provide technical input to, and support
              operational research on co-administration of drug combinations.
      ITI’s Role
      As steward of the Pfizer donation, ITI is responsible for accurate forecasting and delivering the right
      quantities of Zithromax, to the right place, at the right time. The group further defined this role as
      the “rational use of the allocated antibiotic refereed by Trachoma Expert Committee (TEC)” and
      noted that allocations may not be limited to one dose per person per year.
      Additionally ITI should maintain data on antibiotic coverage and other process indicators, support
      and facilitate impact assessments of trachoma control programs, and provide support for periodic
      Zithromax coverage surveys.


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         Partner Roles
         Although not explicitly reported by the working group, there was consensus in the larger group that
         partner roles should include technical and other support for in-country distribution, survey
         implementation, and operational research.

     c. Facial Cleanliness
         (Participants : W. Dowdle, A. Hopkins, I. Jabr, C. MacArthur (chair), B. Qureshi)
         Charge to the group: Discuss whether face washing can be separated from the provision of clean
         water and which educational approaches are appropriate in terms of ability to deliver and assess

         ITI Role
         ITI has an opportunity to integrate with NTD’s and other platforms in promoting hygiene and to get
         facial cleanliness included in other agendas; e.g. water and sanitation and the NTD’s. Possible roles
         include building a network with partners with expertise in behavior change and mapping;
         maintaining a knowledge base of best practices in behavior change; and collaborating with ministries
         of health and education on a health development curriculum that includes hygiene information.
         Partner Roles
         Although not explicitly reported by the working group, there was consensus in the larger group on
         the need to integrate with development partners and the water and sanitation sector.
    d.   Environmental improvement
         (Participants: A. Aboe, M. Bailin, S. Kassim-Lakha (chair), G. Knox, T. Mead, J. Moore, T.
         Rosenberger, N. Thuo)
         Charge to the group: Discuss programmatic strategies and strategies to link trachoma control with
         the water sector.

         Identified strategies:
         The group identified two key programmatic strategies to scale-up the environmental component:
             • Add face washing to existing education strategies
             • Assign a monetary value to the Zithromax donation and use this to mobilize matching
                 contributions in the S, F, and E components.
         Recognizing that E is expensive, it may be difficult to mobilize sufficient resources for the E
         component just using trachoma control measures or trachoma control as the rationale. It would be
         more effective to link with the existing platforms and partner organizations that are working on
         water and sanitation; this provides the greatest opportunity to ensure robust inclusion of this
         component. Identified linkages included: MDG’s focused on water, sanitation, and NTD’s; all face
         washing activities; NTD’s for water; e.g. LF and oncho; local governments, and the ministries of
         health, water, and rural development.


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           ITI Role
           The group endorsed the new ITI framework that recognizes country ownership while working in
           partnership with national and international NGO’s. Specific roles for ITI in the environmental
           improvement component include: leverage of the Zithromax donation, supporting data and education
           advocacy, and planning country level E strategies as part of SAFE with other national and
           international partners.
           Partner Roles
           The group highlighted the need for water and sanitation partners to expand water, sanitation and
           hygiene (WASH) into endemic areas and suggested providing data as a strategy to engage these
           partners. Possible partners identified by the group included: World Bank, CARE, UNICEF Water
           Aid, NGO’s, other international NGO’s, and countries. Countries have the responsibility to identify
           a lead organization and assign a coordinator to spearhead the effort.

     e. Large Group Discussion on SAFE – Key Points
           The entire group commented on the four working groups’ recommendations. The larger group’s
           comments centered in three key areas: the value of the Zithromax donation, working through
           partnerships, and the importance of integrating trachoma control with other global platforms and

          i. Zithromax
                ITI’s primary role is focused on supply chain management of Zithromax with a secondary focus
                on leveraging the Zithromax donation to encourage implementation of other elements of the
                SAFE strategy.
                • Do countries need to have full SAFE strategy in place to receive Zithromax donations?
                      The group suggested that recipient countries must either have full SAFE strategy in place or
                      demonstrate an active plan to include SAFE strategy elements. The national plan would need
                      to include all SAFE elements and provide timetables to implement SAFE components not
                      currently in place. The group further recommended that ITI establish acceptable timetables for
                      implementation. F and E elements could possibly be addressed through advocacy for general
                      hygiene; e.g. could have included face washing messages in UNICEF’s hand washing
                • How do you monetize1 the leveraging power of Zithromax?
                      The donation should be monetized at an appropriate value for the name brand drug; it should
                      not be valued at the cost of the generic drug which is valued at 25 cents per dose. Partner
                      contributions in resources, labor, etc. should also be given appropriate monetary values to
                      facilitate measuring the leveraging impact of in-kind resource donations.

    Assigning a monetary value to in-kind contributions.


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     ii.     Partnerships
             There is a clear need to inventory existing partners, networks and partnerships and their
             capacities and to develop a database of everything that everyone could bring to the table. It is
             important to determine who has lead expertise, who will be “boots on the ground” and to
             determine the rules of engagement.
           • Should the Technical Expert Committee (TEC) that ITI is forming as outlined in the new ITI
             strategic framework, coexist with the International Coalition for Trachoma Control (ICTC) as
             two separate entities?
             It is recommended that after the Trachoma Expert Committee (TEC) is formed the TEC meet
             with ICTC and WHO to discuss common goals and ways to reach those goals more efficiently
             and quickly. ICTC will meet following the GET 2020 meeting 20-22 July 2009 in Geneva.
             The TEC will try to have liaison representatives from critical trachoma control organizations.
    iii.     Integrating trachoma control across other NTD’s and with water and sanitation
             There is a strong need for technical assistance and participation by the water and sanitation
             organizations. To address these gaps with the existing level of resources will require much
             better integration. Additionally, integration will provide good opportunities for funding.
           • Without a commitment to SAFE, we run the risk of being outpaced by mass drug
             administration; we can’t talk about trachoma control without SAFE. How will the new ITI
             focus on the other elements of SAFE?
             In integration efforts with NTD programs, trachoma control contributes the benefit of the
             comprehensive SAFE strategy to existing NTD program implementation efforts. ITI will
             focus on support for the other components through partner organizations.


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    ANNEX 4

    Working Group Session 2 – Key Issues in Scaling Up Trachoma Elimination Program
    Working groups discussed key issues in scale-up through a series of topic specific questions each
    group was asked to address. The working groups reported their conclusions to the meeting
    participants who then commented. The working group reports and the larger group’s questions and
    comments are summarized below.
    1. Prioritizing Countries
       (Participants: N. Bascom, C. MacArthur, S. Mariotti (chair), B. Qureshi, T. Rosenberger, V.
        Charge to the group: Discuss criteria for prioritizing countries and to what extent should
        government commitment to SAFE impact evaluation of country applications.
        The group segmented criteria for mass distribution into “population at risk,” (see below),
        government commitment, country capacity, and additional predictors of “quick gains”. The
        “population at risk” criteria included: high burden with defined parameters through district-based
        prevalence surveys, high population density (risk of extensive spread), and suspected trachoma
        zones (limited district surveys). Government commitment criteria focused on planning (national
        plan with target date) and review (agreement for periodic review), and evidence of a
        comprehensive funded approach (multi-sectoral task force and full SAFE plan with budget).
        Criteria demonstrating country capacity included evidence of ministry and development partner
        commitment (letter of intent), a partnership base to provide monitoring and evaluation (M&E)
        capacity, or the presence of an active and successful NTD program. Countries with low
        prevalence numbers were identified as an opportunity for quick gains.
        Additionally, the group thought some of these criteria could also be applied to evaluating countries
        to receive support in conducting surveys.

    2. Scaling up and NTD Integration
       (Participants: J. Cook, W. Dowdle, J. Feczko, I. Jabr, S. Kassim-Lakha, R. Mallett, K. Spahn
        Charge to the group: Discuss possible roles for ITI in scale-up on both country and global levels
        and the role that NTD integration could play in taking trachoma elimination to scale.
        Zithromax supply management and advocacy were identified as the key roles for ITI on both
        global and country levels. Although ITI’s specific functions in advocacy varied between the
        levels, ITI’s role as manager of the Zithromax supply chain provides a unique opportunity for ITI
        to serve as a strong advocate in both arenas. Further, NTD integration is a significant opportunity
        for trachoma, for ITI and the Task Force; we need to take advantage of the visibility, the
        momentum and the available funding.
        Global advocacy focus
            •   Policy – ITI has significant opportunity to impact public health policy through advocacy
                intervention in national planning and brokering through NGO’s on the ground
            •   Partnerships – convene and work with partners to link appropriate sectors to trachoma
                control and to link trachoma to other agendas; e.g. water and sanitation, NTD’s; and to
                facilitate joint fund raising for scale-up activities.

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           •   Ensure trachoma is included in the Global Network for Neglected Tropical Diseases
               Control (GNNTDC) mapping process

       Country advocacy focus
           •   Knowledge base – serve as global repository of information resources available to both
               global and country partners for all activities around the SAFE initiative
           •   Partnerships – convene appropriate government departments and NGO’s

       Comments from the large group:
       The country advocacy functions, listed by the working group, appeared to contradict elements of
       ITI’s framework that stress government program ownership and implementation through a lead
       country partner. The larger group discussed and agreed that ITI may serve as an information
       resource to country partners or may lay the groundwork for another partner to step in.
       The concept of partner organizations serving in a lead role raised the question of how to ensure
       accountability. The working group identified standardized routine data reporting of process and
       output controls as a key strategy to evaluate accountability and success metrics.
       Members of the larger group suggested that trachoma control has the capacity to lead the NTD’s
       based on the strength of trachoma’s current knowledge base; existing strategies and monitoring
       programs. More information is currently available on the geography and scale of trachoma than
       any of the other NTD’s. The SAFE strategy is more comprehensive than NTD strategies.
       The group suggested mapping support was an important role for ITI that would allow countries to
       clear significant technical and financial hurdles.

    3. Mobilizing Resources
       (Participants: P. Albano, M. Bailin, K. Frawley, C. Hanson (chair), T. Mead, A. Sommer)
       Charge to the group: Identify strategies ITI could use to mobilize financial and non-financial
       resources, as an organization and in partnership with other organizations.
       The group considered both short and long-term funding needs and strategies and compared the
       relative benefits of fundraising just for trachoma versus fundraising with an “integrated NTD”
       Financial Resources:
       In the short term, ITI funding will be limited to supply chain, advocacy and knowledge
       development. In the long term, the group envisioned funding available to more fully support the
       SAFE strategy. The group looked at ways to facilitate horizontal or integrated fundraising within
       the Task Force across its NTD programs and recommended two possible strategies: hiring a
       designated “NTD czar” and additional senior fund raiser, and conducting gap analysis on each of
       the programs to determine shared and individual strengths and deficits.
       In the global context of NTD integration, the group identified the following potential strategies:
       establishing a celebrity trachoma ambassador, seeking funding for big ticket items such as water
       and sanitation projects and using a country cluster or priority country approach.
       Powerful brand recognition and accountability were the main advantages of “silo” fundraising; the
       integrated perspective yields significant synergies in addition to funder support of this approach.
       The group concluded that both approaches were necessary and suggested different approaches to
       different funders: trachoma specific (Lions Club International) and integrated NTDs (USAID).


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       Non-Financial Resources:
       Additionally, the group identified some strategic non-financial resources that would be useful to
       mobilize: human resources such as Pfizer fellows and similar service contribution programs,
       senior corps and private sector consultants to volunteer business planning expertise to country
       programs, medical supply in-kind contributions (e.g. surgical kits), data systems, physical and
       human resource assets.
       Comments from the large group:
           •   Need to further define: In the context of Vision 2020, what is short-term and what is long-
           •   Need for partnership approach to funding to avoid duplication of efforts and infringing on
               another organization’s donors; should also explore regional development approaches.
           •   Need to consider: concept of “coopetition” where we will cooperate to seek funding and
               where we will compete for funding.
           •   Need for transparency and to examine which funds should be pursued and accepted.
           •   Given the programs already present within the Task Force, there is an opportunity here to
               bring together the technical expertise for pulling together the NTD’s.

    4. Advocacy
       (Participants: A. Aboe, D. Haddad, A. Hopkins (chair), G. Knox, J. Moore, M. Rosenberg)
       Charge to the group: Discuss ITI’s potential role in building coalitions on both country and global
       levels and in advocating for trachoma control with donors.
       Building country level coalitions
           •   Goal: Build support for programs in the field
           •   Identify partners at every level beginning with the community level
           •   Pull the partners together while understanding the primary responsibility rests with the
               government; ITI can stimulate the government to look at ways to build coalitions.
           •   Advocate for national, district, and community task forces; possible multiple task forces
               for different NTD’s within a single country that could be linked, for example, through eye
               care or the water and sanitation agenda
           •   Leverage the Zithromax donation to advance programmatic goals
       Building global coalitions
       The Task Force’s history in building coalitions was viewed by the working group as a distinct
       advantage in mobilizing a global effort in trachoma control. The group identified two clear
       opportunities to build global level coalitions. 



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           •   A combined advocacy effort through a National Trachoma Task Force provides a larger
               and more comprehensive story line with the potential for greater impact. The Trachoma
               Task Force will be centered around the Ministry of Health and will be a working
               collaboration of government, NGO’s, the International Association for the Prevention of
               Blindness (IAPB), the International Coalition for Trachoma Control (ICTC), the
               International Association of Health Educators, and water and sanitation associations.
           •   Establish a NTD coordinator who is jointly shared by the Task Force and CARE

       Possible advocacy strategies directed to donors
           •   Build and use the Task Force “voice” – connected to the 700 million impacted by its
           •   Hire a communications development specialist
           •   Combine advocacy messages with CARE for greater impact and visibility
           •   Enter the “world of development”, stressing the socioeconomic and gender impact of

       Comments from the large group:
       The comments of the larger group focused on two linkages: the development agenda and NTD
       integration. The group endorsed linking to the development agenda and discussed the relative
       advantages of NTD integration. Dr. Mariotti outlined the relative advantages of the way trachoma
       is housed at WHO. Within WHO, trachoma is under the Prevention of Blindness Department
       (PBD) (chronic disease) not NTD (infectious disease). A WHO internal memorandum of
       understanding provides for trachoma to fall under chronic disease but to function operationally
       under NTD’s. There have been discussions within WHO about moving trachoma administratively
       to the NTD’s but there are significant advantages to the existing organizational structure. PBD
       provides the connection to the surgery and water and sanitation components. If the program were
       moved to NTD’s, some of these connections may be lost. Trachoma was not included in the NTD
       booklet that focused on preventative chemotherapy only. Trachoma has a complete strategy in
       SAFE. In the future, NTD’s may evolve to a more comprehensive strategy that is “SAFE-like”.

       It is important to note that Dr. Lorenzo Savioli, Director of Neglected Tropical Diseases at WHO
       ran a full-day of last year’s Global Alliance agenda and will be involved again this year. How
       WHO administratively organizes this should not be confused with how it is operationalized.
       Trachoma should be operationalized in a number of ways – through NTD’s, through eye care,
       through whatever structure(s) is most useful. The 2010 World Health Assembly provides a great
       opportunity to raise the profile of trachoma globally, and coincides with the date when the
       trachoma program is scheduled to report on its accomplishments to date.

       Additional comments focused on the need to distinguish between the global and country-level
       advocacy activities and goals and affirmed the importance of including country-level advocacy to
       empower trachoma control at the community-level.

    5. Framing the knowledge management opportunities and priorities
       (Participants: P. Courtright, P. Emerson, M. Linehan (chair), N. Thuo, A. Zayan)
       Charge to the group: Discuss ITI’s potential role in knowledge management and in developing a
       data-driven approach to the elimination of blinding trachoma.
       The group identified data as a cornerstone to scale-up - “without evidence, you have no proof”.
       ITI’s role in data and knowledge management was defined by the functional roles of data in scale-

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    up, monitoring, advocacy, and knowledge management. The group defined data as process and
    output indicators (number of Zithromax doses distributed, surgeons trained, surgeries conducted),
    measured on a monthly or quarterly basis. ITI’s possible contributions through data and
    knowledge management in each of these areas is outlined below
        • Provide information for evidence-based decision-making
        • Demonstrate program effectiveness for fundraising
        • Demonstrate effectiveness for spread of successful interventions
        • Recognition of successes to accelerate scale-up and spread
      • Mapping and surveys – provide technical support
      • Targets – assist countries in setting targets
      • Antibiotics – routine monitoring of process and output indicators
      • Normative standards – support WHO in convening technical meetings and setting
       • Advocate for full SAFE strategy – provide routine process and output indicators to ensure
          consistencies in S, F, and E
       • NTD integration and integration with neglected other infectious diseases (NOIDs)
       • Integration with development agenda
       • Trachoma control as a model for other disease control efforts
       • Recognition of successes to promote country-level advocacy
    Knowledge Management
       • Operational research – Technical Expert Committee (TEC) identifies and make
          recommendations for priority areas; match to institutions and provide basis for protocol
          development and fundraising
       • Inform country programs – disseminate findings and recommendations through regional
    Comments from the large group:
    The large group commented on the roles of the Task Force and the TEC in data, the costs of data
    collection and management, and managing adverse events.
    Data collection is a function of the implementation level; the TEC is viewed as a data repository.
    Further, the group viewed the Task Force as a facilitator of data not a funder or a creator. There
    were conflicting viewpoints on roles in data analysis; one participant suggested that analysis may
    be a role for the Task Force; the Public Health Informatics Institute (PHII), a program of the Task
    Force ensures data uniformity through design of the data collection process and developing
    analysis guidelines. Another participant reminded the group that this responsibility lies with WHO
    and that the countries have no incentive to respond to the Task Force in this role.