Considerations for a sustainability framework for neglected tropical diseases programming.

Addressing neglected tropical diseases (NTDs) is critical to achieving universal healthcare and the Sustainable Development Goals. Significant strides are being made to expand NTD programs, but these programs still need to be fully incorporated into national governance, financing, planning and service delivery structures. The World Health Organization has developed a sustainability framework that calls for governments to create a vision and a multisector plan to achieving sustainability. Several critical factors need to be considered to avoid undermining progress toward disease elimination and control targets, while merging program components into national systems.

Introduction

In 2012, the World Health Organization (WHO) launched a road map for neglected tropical diseases (NTDs) that laid out implementation approaches and established control, elimination and eradication targets for 17 diseases.[1] In the subsequent years, the reach of NTD programs significantly expanded through an extraordinary global partnership encompassing countries, the WHO, pharmaceutical companies, donors, researchers and non-governmental organizations. The programmatic and public health gains achieved in that time have exceeded expectations with >1.7 billion treatments provided in 2019 and 40 countries eliminating at least one NTD.[2,3]

These efforts have created a foundation for NTD programs to advance progress towards achieving disease-specific targets and the 2030 Sustainable Development Goals (SDGs) adopted by United Nations member states in 2015. Capitalizing on this progress will require further programmatic expansion and systematic integration into national systems to ensure long-term sustainability of services and the respective goals. To accomplish this, the WHO has developed a sustainability framework (SF) as a companion document to a new NTD road map that outlines updated disease targets and program approaches through 2030.[3] The road map SF calls for strong country leadership to ensure NTD programs are an essential component of primary healthcare that provides effective prevention, referral and treatment services for all relevant diseases. Cross-sector collaboration will be essential to guarantee the broad reach and long-term sustainability of programmatic gains, the success of which depends on an understanding of the critical assumption inherent in the SF.

The case for an SF

To ensure NTD programs continue to contribute to broader health and development objectives an SF is needed that moves beyond strengthening disease-specific programs to supporting national ownership by facilitating efforts to systematically incorporate NTDs into national governance, policy, planning, financing and delivery systems. There is a strong case for a framework that places NTD programs more centrally in national health policies, as NTD programs contribute to:

Achieving the SDGs: Erasing lifelong debilitating NTDs overcomes poverty (SDG1) and hunger (SDG2), ensure healthy lives and promote well-being for all at all ages (SDG3), improve education (SDG4) and economic growth (SDG8) and serve as tracers for equity and universal access.[4,5]

Achieving universal health coverage (UHC): NTD programs reach the poorest and most disenfranchised. Ensuring NTD services are included in essential benefits packages supports the overall reach and value of primary healthcare by providing a visible and effective service for underserved people, subsequently harnessing public support for UHC.

Ensuring prosperity and well-being by generating billions in economic benefits: Addressing leprosy, visceral leishmaniasis, Chagas disease and human African trypanosomiasis alone has an estimated benefit of up to US$16.6 billion for the 2021–2030 period globally. This represents a US$10.4 billion reduction of out-of-pocket expenses.[6]

Furthering high-quality health systems: NTD prevention and care requires quality service delivery from communities to facilities, robust and functioning supply chain systems, laboratory networks and health management information systems to ensure control and elimination targets are on track. Building comprehensive, integrated NTD programs can therefore improve the overall performance of health systems.

The need for a paradigm shift

Over the past 30 y, pharmaceutical donation programs have created an unprecedented opportunity to expand national NTD programs, attracting investors and allowing programs to reach national scale for select diseases. The 2012 road map coalesced stakeholders around achieving disease-specific objectives. In response, the development community focused on strengthening capacities in NTD programs to access drug donation programs and support respective delivery platforms. While effective, this approach has not systematically strengthened all diseases within national NTD programs, reinforced national leadership or ensured NTD programs are appropriately integrated into national governance, policy, financing, planning and delivery structures.

Addressing sustainability calls for a paradigm shift—a pivot from approaches grounded in principles of humanitarian assistance to one that places NTD control within country health systems overseen and managed by national governments. This supports ongoing efforts to rethink the effectiveness of health systems to achieve UHC. It requires national leadership to define and implement a vision for long-term sustainability that articulates clear health and development outcomes that NTD programs would advance and around which current and future stakeholders can focus resources to promote high-coverage, effective services.

The SF will help map out where NTD program components need to reside across national systems and identify gaps in policies, coordination and decision-making bodies, as well as how financing, human resources and services can be optimized. From the SF, countries can develop sustainability plans, establishing priorities and sequencing based on the contextual environment, disease burden and system capacity. The success of such an approach requires that the underlying assumptions of the SF be acknowledged and addressed.

Critical assumptions of an NTD SF

Increasing program sustainability is a long-term objective requiring careful and well-timed modifications that avoid undermining current progress towards control and elimination targets. For NTDs, such a framework needs to take into consideration and ensure that critical actions are being addressed. These include the assumptions that:

Governments lead the development and implementation of the SF. Engaging with countries will ensure their needs are foundational to the process, align with their expectations, address all relevant diseases and increase ownership and accountability of the process.

Increased domestic investment includes both funding and optimizing existing systems and resources. Sustainability needs to both increase domestic financing for NTD programs and leverage existing human resources, regulatory systems, service delivery and monitoring platforms. With a view to achieving UHC and the revision of essential packages of care, opportunities exist to better design, utilize and strengthen existing systems to provide NTD and other services. NTD elimination should be viewed as a return on investment and not merely an investment need.

Clear goals and objectives for cross-sector coordination/collaboration are needed. Multisector approaches involving a vast array of ministries are essential to obtaining the maximum impact of NTD programs and promote prevention, primary healthcare and development more broadly. This requires political commitment, clearly defined objectives and a better understanding of how different sectors contribute to respective goals, roles and responsibilities. The WHO Region of the Americas’ Elimination Initiative targets >30 diseases and conditions, including NTDs, with the aim to consolidate and coordinate individual approaches to foster sectoral and intersectoral synergies.[7]

Community ownership remains a focus. Active engagement of affected communities is a key component for program design and sustainability. Understanding their culture and traditions as well as making them part of the solution is critical for success. Civil society leadership in the decision-making process is crucial to adaptation to the community context and strengthened governance.

A clear transition plan for drug donation programs where time frames exist. Transitioning national programs from drug donations requires that quality, safe and effective drugs are available on the open market at competitive prices and accessible to the health system. Subsequently, national programs need to be ‘system ready’ to forecast, procure and distribute pharmaceuticals.

Donor support and technical assistance continues. Incorporating NTD programs into country planning and financing cycles may take several years to achieve. Rethinking delivery systems to ensure quality services that include NTDs and maximize programmatic synergies will require policy changes, careful planning and retraining. Withdrawing donor support prematurely can disrupt services and current progress towards elimination goals.

Research and development remain active. Critical gaps regarding diagnostics, guidelines, interventions and surveillance need resolution to clarify service delivery approaches and cost implications. Implementation science will document why and how redesigned NTD programs succeed or fail.

Conclusion

Optimizing the benefit of sustainable NTD programs over the next decade calls for thoughtful incorporation of NTD programs into national health systems. In response to the new WHO 2030 road map and SF, the needed revision of national master plans creates an opportunity for country-led consultation and collaboration across all sectors with affected populations and key stakeholders to translate into policy and greater country ownership. Collectively addressing the critical assumptions will ensure that the systemic processes and structures that underlie the SF are in place to support the recommendations within the WHO NTD road map. National programs that are able to implement the proposed activities in the SF will maximize their contributions and progress towards long-term global control, elimination and eradication of NTDs.