NTDs affect more than 1.5 billion people in the most impoverished, marginalized, remote communities. Yet, in 2016 alone, more than 1 billion people were reached with treatment for at least one NTD. The scope and access of NTD programmes to some of the world’s poorest communities can provide a gateway to universal health coverage (UHC).
The NTD delivery platform can support ministries of health in ensuring broader, equitable access to care and services. Training health workers to provide high-quality treatment, conducting novel disease surveillance, and encouraging referral to the local health facility help to strengthen health systems in countries.
Equity: NTD programmes reaching the unreached
In 2016 alone, interventions against NTDs were delivered in over 130 countries around the world. From the nomadic tribes in the deserts of Niger to the Yanomami tribe in the rainforests and mountains of northern Brazil and southern Venezuela, community health workers covered vast distances, on foot and by boat, by camel and by bicycle, to reach those who needed treatment.
Where there is poverty, NTDs are commonly an accepted part of life. But this is not inevitable. Togo, ranked 166 of 188 countries on the human development index, recently became the first sub-Saharan African country to eliminate LF. Similarly, Burkina Faso, which is ranked 185 of 188 countries, with nearly 12.5 million individuals at risk of five NTDs that can be treated by preventive chemotherapy (PC NTDs), achieved nearly 90% overall coverage in 2016.
Combating NTDs and reaching poor rural communities can put countries on the pathway to achieving UHC and, in turn, shared prosperity.
Case study: Expanding the reach of services in Niger
Against all odds, community drug distributors in Niger are providing NTD treatment to populations at risk. Niger is a vast West African country in the Sahel, of which two thirds (1,267,000 km2) is mostly desert.
Battling temperatures up to 45 °C, violent sandstorms, sudden drastic changes in weather, security risks and long distances on foot, community drug distributors are making a sacrifice for their communities and their country and are to be celebrated.
Villages are very far apart, especially in the northern part of the country. Even within the same village, homesteads may be up to 5 km apart. At times, the drug distributors travel distances of up to 170 km on sand and stone, making it difficult even by motorcycle.
The central zones are populated primarily by nomadic groups, who may change their location weekly or sometimes daily, however, the drug distributors working in the NTD programme keep up with their movements in order to maintain high treatment coverage.
In spite of all the challenges, in 2016 alone, nearly 9 million people were treated for one or more NTD, with funding from the United States Agency for International Development (USAID).
Population coverage: protecting the last billion
The average global target of up to 80% coverage for all NTD programmes by 2020 is aligned with the UHC target for quality essential services by 2030. As shown in Figure 1, NTD programmes are approaching that goal.
Figure 1: Comparison of 2016 coverage for PC NTDs with the WHO NTD target and the UHC coverage target (over 1 billion people reached with PC in 2016)
Before the London Declaration, in 2011, average coverage of PC NTDs was 37%. Thus, out of the 1.9 billion people requiring treatment for at least one PC NTD in 2011, 1.2 billion were not treated. With a strong partnership, coverage had increased to 63% of those in need by 2016.
The NTD programme has now become one of the largest health programmes in the world, covering nearly every region at risk and protecting over 1 billion people worldwide.
As the NTD programme is community-based, ministries of health are not only ensuring coverage of marginalized populations but evidence shows that they are also reaching men and women equitably with treatment through mass drug administration (MDA).
In some settings, the NTD programme represents the first access of communities to preventive services. This is well documented for the Yanomami population, for whom the onchocerciasis elimination programme led to more comprehensive provision of primary health services.
Additionally, coverage is increasing for NTDs that require innovative and intensified diseases management and cannot be prevented through MDA. Diagnostic tools that can be used by community workers in remote areas to diagnose NTDs quickly and effectively are key to this progress. Deploying these tools, the numbers of cases have fallen substantially. For example, the numbers of cases of human African trypanosomiasis (HAT) and VL were reduced by 68% and 60% respectively, from 6,747 and 53,727 in 2011 to 2,184 and 21,646 cases in 2016. Again, through the NTD platform, ministries of health are extending their capacity to diagnose and to treat impacted communities beyond their health facility walls.
As we move closer to global targets, strong national health systems will be critical to ensure that progress towards NTD control and elimination not only accelerates but is sustainable – recognizing that these targets can be met only with health systems that can successfully prevent, detect and treat NTDs.
Case study: Novel techniques in diagnosis increase the capacity of community health workers
In Ghana and Malawi, a trial was conducted to examine the use of mobile technology to record morbidity in patients with lymphoedema and hydrocoele simply and accurately. Both are chronic conditions caused by LF. Local community health workers were trained to recognize the conditions and to use SMS mobile devices to report cases.
The data were mapped to help the ministries of health establish the prevalence of the diseases in a given area, in order to provide services to those affected by prioritizing, planning and starting treatment and care programmes. In Malawi, about 1850 cases of hydrocoele and 650 cases of lymphoedema were identified. The Ministry of Health, with the support of the Liverpool School of Tropical Medicine and funding from UK aid, is now providing an essential minimum care package. Hydrocoele surgery camps and training in lymphoedema treatment at home were started within months of completion of mapping in the two most endemic districts.
Primary health care: an army of community health workers powering the NTD programme
The scale of the NTD programme is incredible. Through this platform, millions of health workers have been trained, from community drug distributors to nurses, surgeons and ministry of health programme staff.
USAID alone trained over 1 million health workers in 2016, 900,000 of whom were drug distributors. Training strengthens health systems so that they can provide prevention and services for people affected by NTDs through the primary health system. For example, through this training, in 2016, a record 260,000 operations for trichiasis were performed, primarily in Ethiopia, where the highest burden of trichiasis is recorded.
In many communities affected by NTDs, drug distributors may be the only health workers they see. These workers are often volunteers from the endemic communities being treated. Their local knowledge is invaluable in establishing and strengthening trust between community members and the health system. Their community access and trust can also encourage patient referral from these hard-to-reach communities to local health facilities, as seen during the outbreak of Ebola virus in Liberia and Sierra Leone, where community drug distributors were a critical part of the response to the crisis.
Frequently, drug distributors are called upon to extend their role in community health care by delivering items such as long-lasting insecticide-treated nets, family planning tools and vitamin A supplements. The potential of this group of workers has yet to be fully tapped and should be explored by endemic counties.
Financial protection: generous drug donation reduces out-of-pocket health expenditure
Through the London Declaration and the Uniting partnership, industry partners have committed medicines worth over US$ 17 billion for the fight against NTDs from 2012 to 2020. In 2016 alone, over 2.9 billion tablets for over 1.8 billion treatments were provided to the world’s poorest populations.
In large part due to these donations, NTD interventions have been described as one of the most cost-effective in public health. In addition, they allow NTD programmes to give endemic communities access to health services without out-of-pocket payment, which is a known barrier to accessing health care, thus reducing the risk of catastrophic financial loss.
Even with free treatment, indirect costs such as transport, food and accommodation must be considered when discussing the cost of health care. The delivery platforms used in NTD programmes, which are embedded in the community, ensure that these costs are minimized for affected individuals.
Case study: Bringing treatment closer to home
Human African trypanosomiasis (HAT) must be quickly diagnosed by specialized, skilled staff in health facilities so that this fatal disease can be treated. The distance a patient must travel impacts whether or not they are able to get to treatment.
Throughout affected areas of Africa, new tools have allowed diagnosis in rural communities with poor access to electricity, allowing patients who previously had to travel an average of 25 km to access services nearer to their homes.
Over 80% have to travel over 3 hours to a treatment centre and 92% over 5 hours. By 2014, there were a 1,000 operating treatment centres in 23 endemic countries.
Return on investment: NTD programmes are a best buy in global health
The end of NTDs offers a net benefit to affected individuals of about US$ 25 for every dollar invested by funders.
The effects of meeting the WHO 2020 targets and the end of NTDs by 2030 have been calculated for nine NTDs de Vlas SJ, Stolk WA, le Rutte EA, Hontelez JAC, Bakker R, Blok DJ et al. Concerted efforts to control or eliminate neglected tropical diseases: how much health will be gained? PloS Negl Trop Dis. 2016;10:e0004386.. Between 2011 and 2030, 600 million disability-adjusted life-years (DALYs) would be averted, corresponding to an average of 30 million DALYs per year. The health gains would include averting about 150 million manifestations of irreversible disease (such as blindness) and 5 million deaths. For PC NTDs, 96% of the health gains would be averting disability, and for the NTDs that require innovative and intensified disease management, 95% of the impact would be due to averted deaths.
According to the World Bank Holmes KK, Bertozzi S, Bloom BR Jha P. Disease Control Priorities, third edition. Vol 6. Major infectious diseases. Washington DC: World Bank; 2017., the estimated benefit in averted out-of-pocket health expenditure and lost productivity for affected individuals would exceed US$ 342 billion during the period 2011–2030. The end of NTDs would offer a net benefit to affected individuals of about US$ 25 for every dollar invested by funders, and elimination could offer a 31% annualized compound rate of return overall: a fair, efficient investment in UHC and social protection for the poorest.
The cost of the NTD programme is a much smaller investment than that required for many other health initiatives. A paper published recently in The Lancet estimated that an additional US$ 274 billion would be needed per year by 2030 to make progress towards the SDG 3 targets Stenberg K, Hanssen O, Tan-Torres Edejer T, Bertram M, Brindley C, Meshreky A et al. Financing transformative health systems towards achievement of the health Sustainable Development Goals: a model for projected resource needs in 67 low-income and middle-income countries. Lancet Global Health. 2017;5:e875–87.. The WHO estimates the costs of health sector interventions to end most NTDs to be US$ 750 million per year until 2020 and US$ 300 million per year from 2020 to 2030. Additional resources for environmental interventions, including water, sanitation and hygiene (WASH), vector control and veterinary public health, are also critical for the sustained elimination of multiple NTDs and UHC. Even so, NTD elimination efforts represent a fraction of the resources required to achieve the SDGs and yield a high rate of return.
The unequalled reach of NTD programmes can provide a gateway to UHC, with over one billion people treated in a single year, millions of health workers and community volunteers trained and services provided to people who are frequently far from a health facility. Eliminating the burden of NTDs could give individuals the chance to no longer be at risk for infection and be free to lead productive and fulfilling lives and can strengthen economies. The programme is implementable, the investment is achievable, and ending these diseases of poverty is within reach.
Case study: Domestic resource mobilization in Burkina Faso
Burkina Faso provides a good example of the power of domestic support. In a 10-year period (2004–2014), Burkina Faso’s government provided US$ 300,000–400,000 per year to support their NTD programme costs. In 2016, the programme was assisted with a World Bank loan, to cover per diems and other expenses for community mobilization, monitoring and evaluation. Today, Burkina Faso, with the support of USAID and UK aid, has achieved nearly 90% coverage of its population at risk with MDA.
|UHC principle||Description||The NTD programme|
|UHC principle Equity||Description Everyone has access to quality essential health care regardless of geographical location, sex, ethnicity or economic or social status.||The NTD programme NTDs affect 1.5 billion of the poorest, most marginalized people, living in the most remote areas. In 2016, over one billion people were reached with treatment for at least one NTD. NTD programmes reach populations in the hardest to reach geographical settings; at the end of the road, track or river. Where people live, NTD programmes reach. In addition to ensuring coverage of marginalized populations, community programmes reach both men and women equitably through MDA.|
|UHC principle Population coverage||Description WHO and the World Bank have agreed on a UHC target of at least 80% population coverage with quality essential health services by 2030.||The NTD programme The NTD programme has a global population coverage target of 80%, which is aligned with that of UHC. In 2016, over one billion people – one in seven of the world’s population – were treated for NTDs. This accounted for 63% of the population in need, closing in on the 80% target.|
|UHC principle Primary health care||Description The cornerstone of health system strengthening is primary health care, the interface between health systems and people.||The NTD programme The NTD programme has trained millions of health workers throughout the health spectrum. In 2016 alone, USAID trained over one million health workers, including community drug distributors, surgeons, nurses and government health officials. This helped in 2016 to achieve a record-breaking number of operations for trichiasis, the leading infectious cause of blindness.|
|UHC principle Financial protection||Description Countries should strive for 100% financial protection from both catastrophic and impoverishing health payments, helping to reduce out-of-pocket payment.||The NTD programme Generous drug donations from pharmaceutical companies and investments from donors to NTD programmes give poor people access to treatment without the risk of catastrophic financial loss. Through the London Declaration on NTDs, industry partners have committed to donate drugs worth over US$ 17 billion to NTDs (2012-2020), and donors, to funding NTD programmes. In 2016 alone, donors invested close to US$ 300 million that helped deliver over 1.8 billion donated treatments to the world’s poorest populations.|