Conditional cash transfers for neglected tropical diseases.

An Article and a Comment published in The Lancet Global Health discussed conditional cash transfers (CCTs) as a potential tool to control neglected tropical diseases (NTDs). It is in my opinion that both of these pieces fail to discuss the controversial implications of this approach in NTDs.

During the past two decades, some governments (eg, Mexico, Philippines, and Zambia) have introduced programmes that transfer money to low-income households on a set of requirements, including attendance for health care. In short, CCTs are used to pay people who receive low incomes to take care of themselves.

CCTs have been associated with various pitfalls, including low coverage and limited potential in improving service access. In addition, CCTs have been considered to be stigmatising by somehow labelling people as guilty for their diseases due to their behaviour and poverty.

Furthermore, CCTs introduce elements of financial transaction in a domain that should be regarded as a human right (in which health care alleviates suffering) or a civic duty (in which complying with a public health measure results in a public benefit). Paying implies acknowledging the incapacitation of the individuals who receive low incomes to take care of themselves and relegating them to a perpetual minority of age. In fact, many of these problems were part of the review undertaken by WHO towards the development of the concept of NTDs as diseases of neglected populations, which resulted in the establishment of the NTD department in 2005.

None of these considerations were taken into account by Engels and Elphick-Pooley, who described CCTs as an “interesting opportunity” for improving NTDs outcomes. The Comment does not provide any insight into the risk of a possible shift from the active role of public health services of endemic countries to that of individual households. Additionally, the authoritative role of the two authors currently or in the past might imply a consensus of WHO on the proposal made in the Comment.

The implications of such a theoretical shift from the original vision of the NTD roadmap in controlling, eliminating, and eradicating NTDs to large-scale preventive chemotherapy and intensified disease management, delivered free of charge together with other cross-cutting and disease-specific services, are not negligible. Such shift entails a refocus from a proactive, well coordinated role of the public health infrastructure towards a model that views the health system, possibly including the private sector as a service provider, relegated to a passive referral role with key responsibilities taken over by individual households. The key question, which is not discussed in the Comment, is whether behavioural conditionality itself has any added value for reaching WHO's 2030 targets for NTDs now that most NTD programmes have shifted from control to elimination, including those of the Article, leprosy, schistosomiasis, and soil-transmitted helminthiasis.1, 2, 6

For leprosy, this approach should be weighed against the additional stigmatising effect produced by CCTs, which would add to stigma-related discrimination and prejudices that represent powerful barriers to ending leprosy. Preventive chemotherapy programmes (eg, schistosomiasis and soil-transmitted helminthiasis), which were designed to proactively treat the highest number of individuals in a coordinated manner in the shortest amount of time, has had an impact on transmission beyond morbidity, building a sustainable strategy for people who receive low incomes.

As mentioned by WHO's director-general in 2020, since 2012 there has been exemplary country leadership and the continued support of industry and global partners that have allowed considerable reduction in the prevalence and transmission of many of these diseases, bringing some close to elimination and eradication. The countdown to 2030 has begun with a clear second roadmap by WHO, relying on proven interventions based on the previous roadmap of 2012. We should continue to focus forward on strategically proven approaches.

I declare no competing interests.