How has the Ascend programme contributed to strengthening health systems for sustainable country-driven neglected tropical disease programming?

The Ascend West and Central Africa programme, a UK aid-funded programme, was implemented across 12 countries. The programme focused on strengthening national health systems for sustainable neglected tropical disease (NTD) control and elimination. This commentary presents how Ascend's approach contributed to developing country-driven sustainable systems for NTDs and offers learnings to inform future sustainable NTD programming.

A major objective of the Ascend West and Central Africa programme (hereafter called ‘Ascend’)—a UK aid-funded programme—was to deliver a range of key interventions for the control and elimination of neglected tropical diseases (NTDs) while ensuring a strong health systems strengthening (HSS) approach was applied. Ascend strengthened relevant building blocks of national health systems to support countries to provide the prevention, detection, treatment and surveillance activities necessary to maintain the reduced disease burden in the longer term, and to prevent disease resurgence.

The WHO states that ‘a well-functioning health system working in harmony is built on having trained and motivated health workers, a well-maintained infrastructure and a reliable supply of medicines and technologies, backed by adequate funding, strong health plans and evidence-based policies’.[1] HSS comprises strategies and activities designed to sustainably improve country health system performance. Evidence shows the impact of HSS interventions is associated with improvements in service utilisation, financial protection and quality service provision, all important outcomes on the pathway to improved health.[2]

The Ascend programme focused on strengthening relevant WHO building blocks of national health systems, which are required for sustainable NTD control and elimination. A key principle of the Ascend approach was the prioritisation of context-specific activities across the six HSS building blocks (Table 1). Prioritisation was critical in order to select activities that would have the most impact for NTD control and elimination, and which would contribute to overall HSS while recognising the limitations of the programme's ability to initiate full health systems reform.

Table 1.

NTD sustainability dimensions/HSS building blocks

NTD sustainability dimensions defined by Dalberg Tool	HSS building blocks (WHO)
Policy and leadership	Health governance and leadership
Budget	Health financing
Delivery system	Service delivery and access to medicines
Organisation capacity	Human resources for health
Partnerships	Health governance and leadership
Evaluation and adaptation	Health information systems

The values and vision of Ascend's HSS approach are directly aligned with the WHO's Ending the neglect to attain the Sustainable Development Goals: a road map for neglected tropical diseases 2021–2030[3] and Sustainability Framework for Action 2021–2030.[4] Both are grounded in embedding NTDs in universal health coverage and moving away from a siloed disease approach towards the integration and mainstreaming of NTDs into the wider health system.[5]

We can take several lessons away from how Ascend's approach contributed to developing country-driven sustainable systems for NTDs. One such learning is the value of the process undertaken through a strong dialogue with the Ministries of Health (MOHs) to design priority interventions that have the most impact on NTD control and elimination. Jointly designing systems-change interventions with MOHs supports countries with their journey to self-reliance. These interventions will contribute to the sustainability of NTD programming and also to systems strengthening in its entirety. For example, to strengthen the building block of health information systems, Ascend supported the NTD programme in Kwara, Nigeria, to implement electronic-based reporting of NTD treatment data, through the real-time mass drug administration reporting tool set up with support by the Accelerate Programme. This system has been used to monitor and report on NTD treatment and drug stock indicators at community level. Using district health information system, community-level summary forms are collected and entered in local government areas. A command centre is set up to monitor data entries for potential errors, low coverage, drug supply challenges and comments. The Nigerian MOH has observed that the tool reduces data-management issues (delays in data collation, errors and inconsistences). The Nigerian MOH is planning a national scale-up of this system to report on treatments distributed in other states.

In addition, the systematic consultations with MOHs demonstrated a means to better understand the wider blockages for the integration of NTDs. For instance, findings from a Human Resources for health building block mapping exercise[6] on the integration of NTD community health workers (CHWs) and community drug distributors (CDDs) are useful for the wider health sector. The findings show there are opportunities to reduce the barriers between CHWs and CDDs and preserve their roles, for example, through combined training programmes and harmonised incentive models. Further integration of CHWs and CDDs into the larger health infrastructure can provide appropriate capacity and resources for the detection and treatment of any remaining NTD cases, particularly as the postelimination stages are reached.

We developed a structured and systematic methodology to determine a country-driven prioritisation of HSS interventions for each Ascend country. HSS assessments were undertaken to identify the existing systems, understand national priorities and identify gaps where improvement and support was needed. The HSS assessments applied a set of tools to assess the maturity of the health systems and to measure the sustainability of the NTD programmes through the level of government ownership of NTD programming and availability of domestic resources. Bespoke tools were developed for political and economy, and public expenditure analyses, combined with the existing NTD Sustainability Assessment Tool developed by Dalberg,[7] which defines sustainability as the level of government ownership of NTD programming measured across six sustainability dimensions. This was mapped against the WHO building blocks for HSS during our analysis (Table 1). The service delivery and access to medicines building blocks are incorporated under a single dimension of Delivery System in the Dalberg tool, demonstrating the important pharmaceutical element of NTD service delivery. The HSS assessments allow governments and partners to see where support is needed and serve as a basis for future dialogue.

A guiding principle that we applied during implementation was for all interventions to be tailored to each country to acknowledge variations in the national health systems, the status of the national NTD programmes and unique disease-elimination targets. To drive the government ownership of the Ascend investment for HSS, country-level workshops and meetings with NTD programme teams and stakeholders beyond the health sector were held to validate the findings of the HSS assessments and prioritise activities that address the specific needs of each country. Other major drivers supporting the design of activities included coordination and collaboration with NTD stakeholders; this coordination sought to minimise duplications and achieve harmonisation with other ongoing initiatives and support the countries to address other weaknesses to fully transition to integrated NTD programmes in the future.

The contribution to NTD master plan development using the new WHO Guidelines is a central pillar of the Ascend HSS investment. On a global level, through collaboration with the WHO NTD department and expanded special project for elimination of neglected tropical diseases, we contributed to the drafting of the new WHO Country NTD Master Plan 2021–2025 Guidelines and Framework for Development[8] and the WHO Sustainability Framework for Action against NTDs.[9] At country level, master plan development is a MOH-led process and we have integrated our resources according to the expressed needs from MOHs. We have also supported the coordination and codependencies with other partners and agencies to plan the development of master plans and the related sustainability framework companion documents such as investment cases. The need to increase NTD funding was demonstrated in the Ghana investment Case for NTDs that we supported the Ghana Health Service to develop. The Ghana Health Service is transitioning into a new health sector medium-term plan and the investment case opens discussions on increasing domestic financing for NTDs, highlighting the work that needs to be done to ensure NTD masterplans can deliver against their targets. Indeed, COVID-19 has shown that it is possible to mobilise additional domestic resources for health.

Key reflections identified across the Ascend HSS mainstreaming process include: (i) the need for greater political will on NTDs and the implementation of policies that benefit long-term elimination strategies; (ii) the need for data integration into national health information systems to raise the profile of NTDs and garner more attention from government; (iii) the need to elevate domestic partnerships to source new funding; and (iv) the need to review how best to support and preserve CHWs and CDDs as part of the larger health infrastructure.

Finally, through the engagement with MOHs and the coordination with key NTD stakeholders, we have been able to support the countries with the transition for the early exit of Ascend by looking at what has been achieved and what gaps remain as we close the programme. The transition support process captures the short and longer term needs in one document for funding discussions. This thereby ensures all data and information are handed over to MOHs and potential donors to make use of the results, which will hopefully sustain the gains made in the control and elimination of NTDs and to inform future sustainable NTD programming.

In conclusion, despite the early exit taking place as key HSS interventions were underway, Ascend has achieved important progress contributing to the development of sustainable systems for NTDs delivery.