WORKING PAPER DIRK ENGELS AND CHRISTIAN FRANZ - INTEGRATING NTDS: OVERLAPPING THEMES AND PROJECTS IN THE GERMAN DEVELOPMENT COOPERATION PORTFOLIO ...

 
WORKING PAPER DIRK ENGELS AND CHRISTIAN FRANZ - INTEGRATING NTDS: OVERLAPPING THEMES AND PROJECTS IN THE GERMAN DEVELOPMENT COOPERATION PORTFOLIO ...
WORKING PAPER
DIRK ENGELS AND CHRISTIAN FRANZ
INTEGRATING NTDS: OVERLAPPING THEMES
AND PROJECTS IN THE GERMAN
DEVELOPMENT COOPERATION PORTFOLIO
on behalf of the
German Network against Neglected Tropical Diseases (DNTDs)
WORKING PAPER DIRK ENGELS AND CHRISTIAN FRANZ - INTEGRATING NTDS: OVERLAPPING THEMES AND PROJECTS IN THE GERMAN DEVELOPMENT COOPERATION PORTFOLIO ...
The German Network against Neglected
Tropical Diseases (DNTDs) e. V.
is a national platform that cooperates with
international partners to fight more strongly against
poverty-related and neglected infectious diseases
(NTDs, Neglected Tropical Diseases). The German
network is committed to the London Declaration on
NTDs, and aims to support the World Health Organisation
(WHO) as well as programs in the affected countries in
controlling, eliminating or eradicating at least ten of
the altogether 20 NTDs by the end of the decade.

Imprint
Oktober 2018

Publisher:
German Network
against Neglected Tropical
Diseases (DNTDs)
www.dntds.de

We thank all our
discussion partners who took
part in the study.

Layout:
www.zumweissenroessl.de
Cover photo:
Riccardo Lennart Niels Mayer – getty
OUTLINE
1 Abstract .........................................5                    4 Overlap of NTD-programs and
                                                                           selected projects funded by
                                                                           Germany ......................................23
2 Introduction ..................................6                       4.1 Co-morbidity between HIV and schistosomiasis .... 23

2.1 Diseases of neglect and progress                                     4.2 WASH and NTD-projects .................................... 26
    in combatting them ...........................................6
                                                                         4.3 Nutrition and NTD-projects.................................. 29
2.2 NTDs in the Global Health Transition
    towards 2030 ....................................................8   4.4 German support of an NTD-program in the
                                                                             CEMAC-region................................................... 31
2.3 About the working paper .....................................9

                                                                         5 Health systems strengthening,
3 Mapping the assets of NTD
                                                                           NTDs & prioritization of the most
  interventions ................................10
                                                                           vulnerable ...................................34
3.1 Operational assets for cross-sectorial projects....... 10

3.2 Strategic assets that can help in policy-making..... 20

                                                                         6 Way forward .................................36

                                                                         7    Abbreviations................................................... 37

                                                                         8    References and Endnotes ................................... 38

                                                                                                                          Integrating NTDs 3
1

    4 Integrating NTDs
ABSTRACT

                                                                                                                                FOREWORD
Neglected Tropical Diseases (NTDs)        development, and the bridges that can     portfolio. These case studies can serve
are intimately related to poverty and     be built between so-called vertical       as support for future analyses helping
poor living conditions. Often the dis-    and horizontal health programs, i.e.      to build integrated development pro-
abling consequences of NTDs become        programs that address single diseases     jects that embed the cross-sectorial
apparent and are unrecognised in          vs. those that address health systems     and pro-poor focus of the sustainable
other health areas (co-morbidities).      as a whole. For that purpose, the au-     development goals (SDGs).
Yet, those consequences are largely       thors identify and outline operation-
preventable by large scale treatment      al and strategic ‘assets’ of programs
                                                                                    Berlin, October 2018
starting early in life, as well as by     against neglected tropical diseases
some of the most basic development        (NTDs), i.e. processes, platforms, and
infrastructure and interventions.         characteristics of NTDs and the respec-
                                          tive projects.
The occurrence of NTDs, as a tracer
of poverty and inequity, provides an      By integrating NTD programs and NTD
opportunity to monitor the capacity       program components into other health
of health systems to achieve Uni-         programs and cross-sectoral programs
versal Health Coverage (UHC) and          (e.g. WASH (water, sanitation and hy-
implement large-scale preventive ac-      giene) and nutrition) these assets can
tion to eliminate disabling infectious    be put to work for a more effective
diseases in populations that are left     and/or efficient achievement of com-
furthest behind. This working paper       mon goals between formerly separate
aims at exploring the integration of      programs. The authors illustrate those
NTD interventions in primary health       assets by analysing selected ongoing
care health services and multi-sectoral   projects in the German development

                                                                                                           Integrating NTDs 5
2 INTRODUCTION

      2.1 Diseases of neglect and progress in combatting them

      Since the beginning of the current        diseases – after HIV/AIDS, TB, and                  Lived with Disability (YLD), unlike the
      millennium, Neglected Tropical Dis-       malaria.3                                           Years of Life Lost (YLL), remains three
      eases (NTDs) have emerged as a                                                                times as high as for priority commu-
      group of poverty-related diseases of      Yet, even though a few NTDs cause                   nicable diseases such as malaria.4
      global significance in the interna-       high mortality (see figure 1 page 7)
      tional health and development agen-       most of them cause important chron-                 Thus, NTDs are disabling diseases that
      da. NTDs occur predominantly in trop-     ic morbidity, e.g. through permanent                represent medical poverty traps that
      ical or sub-tropical environments.        disablement. As a result, the current               affect more than 1.5 billion people
      They were previously looked at in         residual burden in terms of Years                   globally in more than 100 countries,
      isolation as high-burden (but rather
      localized) health problems of which
      the public health relevance was rap-
      idly diluted when priorities needed to    Table 1: Prevalence of NTDs and changes since the beginning of
      be set at national, regional or glob-     the 1990’s
      al level. This neglects that there are
      more than two billion prevalent cases
                                                 Disease                       Prevalent cases                  Change since 1990
      of NTDs worldwide – with intestinal
                                                                               (millions), 2013                 (in %)
      worm infections representing about
      75 percent of all NTD-infections (see      Ascariasis                                804.4                            -25.50
      table 1 below).1 At the turn of the        Trichuriasis                              477.4                            -11.60
      21st Century, their collective burden      Hookworm                                  471.8                             -5.10
      of disease, calculated as DALYs, was
                                                 Schistosomiasis                           290.6                             30.90
      Tuberculosis (TB).2 Even though there
      has been major progress in the fight       Trematodes                                  80.2                            51.10
      against Neglected Tropical Diseases        Dengue*                                     58.4                          610.90
      over the last 15 years, their numbers
                                                 Lymphatic filariasis                        43.9                           -32.10
      continue to remain impressive. This
      burden is represented in the concept       Onchocerciasis                                17                           -31.20
      of DALYs (Disability Adjusted Life         Chagas disease                               9.4                            22.40
      Years) which accounts for premature        Other NTDs                                68.74
      deaths due to those diseases as well
      as their debilitating and disabling
      effects. According to this indicator      * Represent incident cases in 2013 rather than prevalent cases.
                                                Source: Herricks, J. R., Hotez, P. J. et al (2017). The global burden of disease study 2013: What
      NTDs still account for the fourth larg-   does it mean for the NTDs? PLOS Neglected Tropical Diseases, 11(8), e0005424. Original data:
      est burden of disease from infectious     Global Burden of Disease 2013.

 6 Integrating NTDs
Figure 1: Disease burden by mortality (YLL) and morbidity (YLDs)

Malaria
NTDs

                                                                                                                                                         CHAPTER 2
Trachoma
Onchocerciasis
Lymphatic filariasis
Hookworm disease
Trichuriasis
Leprosy
Ascariasis
Schistosomiasis
Chagas disease
Leishmaniasis
Dengue
Trypanosomiasis
Rabies

                            %            10%        20%         30%         40%         50%         60%         70%         80%          90%      100%

                                  YLDs           YLL

Note: The numbers of leprosy were inverted in the original dataset.
Source: Fitzpatrick C et al. (2017). An Investment Case for Ending Neglected Tropical Diseases. In: Disease Control Priorities (third edition):
Volume 6, chapter 16. Underlying data: WHO, 2012.

primarily the poorest sections of pop-              Deutsche Gesellschaft für Technische                tion in the global public health agen-
ulations in the developing world.                   Zusammenarbeit (GTZ) GmbH, German                   da, large scale donations of medi-
NTDs can be considered as an indi-                  ministries, the World Health Organi-                cines by the pharmaceutical sector,
cator of poverty, neglect, poor living              zation (WHO) and partners.8 These                   enhanced R&D mostly by public-
conditions, lack of access to health                workshops have led to the definition                private Product Development Partner-
services, and ensuing consequenc-                   of a comprehensive strategy to com-                 ships (PDPs), financial engagement
es such as malnutrition, inability to               bat a group of very diverse diseases,9              by international donors such as the
make a living, stigma and exclusion.5               in turn leading to a global program-                US, UK and the Bill and Melinda Gates
As such they affect not just the Sus-               matic response to what is currently                 Foundation, and commitment by af-
tainable Development Goal (SDG) 3                   known under the umbrella term ‘Ne-                  fected countries and a large network
(health), but also poverty reduction                glected Tropical Diseases’ (NTDs).                  of global health actors and develop-
(SDG 1), fight against hunger (SDG2),                                                                   ment partners. More recently, Germa-
education (SDG4), gender equality                   This type of global programmatic re-                ny has started to play an increasingly
(SDG5), clean water and sanitation                  sponse, often referred to as “verti-                important role in the support of R&D
(SDG6), sustainable cities (SDG11),                 cal” like the one adopted for HIV/                  for neglected and poverty-related
and climate action (SDG13).6,7                      AIDS, tuberculosis, malaria, and Na-                diseases, too. The focus on individual
                                                    tional Immunization Days (NIDs) as                  diseases has also allowed substantial
The current approach to combat-                     well as polio eradication, has ena-                 progress in controlling NTDs in are-
ting tropical diseases has originat-                bled the mobilisation of unprece-                   as where poverty prevails, and health
ed from a series of workshops in Ber-               dented resources for the fight against              care infrastructure is usually weakly
lin in 2003 and 2005, with the then                 NTDs. These include increased atten-                developed. The World Health Organ-

                                                                                                                                   Integrating NTDs 7
ization has played an important role       volunteers for intervention delivery,      eases. For example, political commit-
     in mainstreaming this comprehensive        providing a new impulse to the well-       ment is visible not only on a national
     strategic approach, as well as in mo-      known primary health care concept of       level (14 priority countries in sub-Sa-
     bilizing increased resources and co-       community-based outreach. In 2016,         haran Africa have now national work
     ordinating action among very diverse       more than 1 billion people, equalling      plans for NTDs that are annually up-
     partners.                                  62.3 percent estimated to be a risk        dated)12 and on a regional level (the
                                                globally, benefitted from this inter-      African Leaders Malaria Alliance – AL-
     Progress in intervention delivery has      vention.10                                 MA – embedded NTDs as indicators to
     been most visible for large scale pre-                                                be reviewed biannually by heads of
     ventive treatment, one of the strate-      Substantial progress has also been         states alongside with other infectious
     gies to combat NTDs whereby entire         made with improving treatments             disease indicators).13
     populations or high-risk groups (such      and control tools for complex NTDs,
     as school age children or women of         adapting their use to resource-poor
     childbearing age) are treated with         areas and as such providing access in
     single-dose medicines* at a frequen-       remote areas to prevention, early di-
     cy determined by the endemicity lev-       agnosis and prompt treatment for dis-
     el. As the medicines are safe and no       eases such as African sleeping sick-
     individual diagnosis is required, the      ness, Buruli ulcer, Chagas disease,
     intervention is easy to deliver and        leprosy, rabies, and visceral leishma-
     guarantees in principle that all in-       niasis.11 This progress is a direct con-
     fected people could be reached. Suc-       sequence of the renewed ambition of
     cess has largely been determined by        endemic countries to organize an in-
     the engagement of community-based          tensified management of those dis-

     2.2 NTDs in the Global Health Transition towards 2030
     The adoption of the Sustainable De-        Moreover, the goal of “ending the ep-      of most NTDs, to an extent that na-
     velopment Goals (SDGs) in 2015 has         idemics of AIDS, TB, malaria and ne-       tional systems and services will be
     introduced a paradigm shift for global     glected tropical diseases” by 2030 (SDG    able to deal with the residual burden
     health programs. At the core of this       Goal #3, target 3.3) calls for stepping    as part of their routine services. While
     shift lies the principle of Univer-        up preventive measures. For NTDs this      continuing to further expand cover-
     sal Health Coverage: the provision         relates to addressing their underlying     age with quality care and preventive
     of health services when and where          socio-economic determinants – pover-       treatment services, this will require a
     people need them, without facing           ty, inadequate sanitation, proximity to    strong focus on mainstreaming NTD
     financial hardship (SDG Goal #3, tar-      domestic animals, livestock and infec-     interventions into national health
     get 3.8). It shifts the emphasis from      tious vectors of disease – and acting      systems and developing collaboration
     global health priorities to all-inclu-     jointly with other sectors and devel-      with other sectors.
     sive health care tailored to local situ-   opment programs. Such integrated ac-
     ations and communities. At the same        tion across sectors will need involve-
     time, the principle of “leaving no one     ment of a multitude of actors, ranging
     behind” calls for special attention to     from education, water and sanitation,
     ensuring equitable access to care for      agriculture and animal husbandry, to
     the specific health problems of the        environment, housing, and rural and
     poorest, such as NTDs. This goes hand      urban development.
     in hand with the need to enhance in-
     tegration of NTD interventions into        Meeting the specific NTD indicators to
     national health systems and peripher-      achieve SDG Goal #3 will logically lead    * Mostly donated by the pharmaceutical in-
     al health care.                            to elimination or near-elimination         dustry

8 Integrating NTDs
2.3 About this working paper
Against this background, this working       the ‘not-knowing’ of the potential op-     The disabling consequences of NTDs –
paper aims at understanding the po-         erational benefits of integrated pro-      most of which become visible in oth-
tential of integrating NTD-programs         grams in achieving individual goals.       er health areas (co-morbidities) – are

                                                                                                                                  CHAPTER 2
with other health programs and/or           Second, the structure of development       preventable by large scale treatment
programs in other relevant sectors.         cooperation is usually not designed        starting early in life, as well as by
We identify processes, platforms, and       for cross-sectorial cooperation. Units     some of the most basic development
characteristics of NTDs and their pro-      within governments, implementing           infrastructure and interventions. We
grams that could be utilized more gen-      NGOs, and advocacy have – often            hope that this working paper can
erally (for which we will use the term      with good reason – emphasised expert       contribute to the discussion about
‘assets’).                                  knowledge in a specific area. Moreo-       potential synergies between develop-
                                            ver, cross-sectorial projects raise con-   ment programs. NTDs are just one –
Two motivations have been most cru-         cerns about budget allocations within      but as we outline an important angle
cial for this analysis: First, the global   organizations. Structurally, the fight     to look at multisectoral collaboration
health community still struggles to         between ‘value for money’ and ‘long-       and implementation.
find concrete pathways for synchro-         term sustainability’ has made the di-
nizing efforts to achieve UHC (e.g.         viding lines even more pronounced, as
through health systems strengthen-          monitoring and showing evidence for
ing) and efforts to fight major debil-      cross-sectorial or long-term projects’
itating or killing diseases. We believe     effectiveness is deemed to be much
that part of the explanation lies in        more difficult than for narrow projects.

                                                                                                             Integrating NTDs 9
3 MAPPING  THE ASSETS
  OF NTD INTERVENTIONS
      After more than a decade of steady
      progress, in big part due to a strong          Box 1
      global programmatic focus that has
      helped to enhance access to essential          The Merck praziquantel donation program can supply up to 250 million
      NTD medicines and to rationalize case          tablets per year for the treatment of schistosomiasis in school-age chil-
      management of complex NTDs, there              dren in sub-Saharan Africa. This potential quantity is currently not com-
      needs to be a strong focus on mak-             pletely used. The praziquantel needs are currently based on the estima-
      ing NTD interventions part of national         tion of school-age populations in districts confirmed to be endemic by
      health services. Even though interven-         a regional mapping exercise. As schistosomiasis is a very focal disease,
      tion delivery has always involved na-          building district level capacity for decision analysis and monitoring would
      tional and peripheral health services,         enable to tailor the needs to the sub-district endemicity, optimize the use
      health systems capacity for monitor-           of praziquantel and enable to cover more children in real need in Africa.
      ing, evaluation and deciding on local          Merck KGaA is currently working on a new formulation of praziquantel that
      intervention strategies merits to be           can be administered to young children – the current tablets being only
      enhanced. This is expected to lead to          suitable for children older than six.
      a better integration into already ongo-
      ing (and funded) health programs and
      optimization of resources by better
      planning according to local data and      tors can provide opportunities to en-      projects that can be utilized by oth-
      situations (illustration box 1).          hance delivery of NTD interventions        er sectors. Secondly, we wish to draw
                                                in a very cost-effective manner, by        attention to several ‘strategic assets’
      Intervention delivery for NTDs can        adding them on to already existing         that describe more general aspects
      provide assets to enhance delivery        activities. The following sections will    about the fight against NTDs and
      of additional health care activities      first outline ‘operational assets’, i.e.   that can help policy makers to iden-
      (or benefits) into remote communi-        processes, platforms, and charac-          tify overlaps in the goals of different
      ties. Inversely, health and other sec-    teristics of NTDs and the respective       sector strategies.

      3.1 Operational assets for cross-sectorial projects
      3.1.1 NTD assets for                      the NTDs on some non-communicable          tosomiasis) disease has since long
                                                diseases such as anaemia (hookworm         been known (see a more comprehen-
      Health Systems
                                                and schistosomiasis), cardiac disease      sive list in table 2).
                                                (Chagas disease), cancer (urinary
      3.1.1.1 Co-morbidities
                                                schistosomiasis, opisthorchiasis and
      Neglected Tropical Diseases cause         clonorchiasis), and chronic liver (in-
      important co-morbidities in other         testinal schistosomiasis and echino-
      health areas. The impact of some of       coccosis) and kidney (urinary schis-

 10 Integrating NTDs
Table 2: NTDs as causes for chronic non-communicable diseases, 2008

  Chronic Condition                           NTDs as Etiologies               Approximate Number of Major Geographic
                                                                               Cases of Each Infection Distribution

                                                                                                                                                      CHAPTER 3
  Cardiovascular disease

  Cardiomyopathy                              Chagas disease                              8–9 million            Latin America

  Endomyocardial fibrosis                     Loiasis (and other                            13 million           sub-Saharan Africa
                                              helminthiases)

  Cancer

  Bladder cancer; squamous cell               Urinary schistosomiasis                     119 million            Africa
  carcinoma                                   (S. haematobium
                                              infection)

  Bile duct carcinoma                         Opisthorchiasis and                        6–44 million            Southeast Asia and China
                                              clonorchiasis

  Gastrointestinal and liver disease

  Inflammatory bowel disease                  Trichuriasis                                604 million            Developing countries

  Megacolon and megaesophagus                 Chagas disease                               8-9 million           Latin America

  Intestinal and liver fibrosis               Schistosomiasis                               68 million           Africa, Brazil,
                                              (S. mansoni infection and                                          and East Asia
                                              S.japonicum infection

  Liver cyst                                  Amebiasis                                             N/A          India, Latin America
                                              Echinococcosis                                        N/A          Developing countries

  Chronic renal disease

  Hydronephrosis and renal failure            Urinary schistosomiasis                     119 million            Africa

  Blood dyscrasias

  Anemia                                      Hookworm infection                          576 million            Developing countries
                                              Schistosomiasis                             207 million            Developing countries

  Pancytopenia                                Leishmaniasis                                 12 million           India, Africa, Brazil

  Chronic respiratory conditions

  Hemoptysis                                  Paragonimiasis                                21 million           East Asia

  Asthma                                      Ascariasis                                  807 million            Developing countries
                                              Toxocariasis                                         ND            Worldwide

Note: Inconsistencies in the cases for per infection (column 3) and table 1 are due to different observations in time. We decided to report the
original figures reported in the source. See more information on the data in the original source: Hotez, P. J., & Daar, A. S. (2008). The CNCDs and
the NTDs: Blurring the lines dividing non-communicable and communicable chronic diseases. PLoS Neglected Tropical Diseases, 2(10), 1–3. https://
doi.org/10.1371/journal.pntd.0000312.

                                                                                                                              Integrating NTDs 11
Table 3: Health threats to women resulting from neglected tropical diseases

       Health Condition                                                     Neglected Tropical Disease

       Sexually Transmitted Infections

       HIV/AIDS                                                             Urogenital schistosomiasis

       Trichomoniasis                                                       Trichomoniasis

       Social Exclusion and Stigma

       Limb, breast, skin, and genital deformities                          Lymphatic filariasis, Buruli ulcer, Onchocerca skin
                                                                            disease, leprosy, leishmaniasis

       Facial disfigurement                                                 Leishmaniasis, leprosy

       Reproductive Health

       Infertility                                                          Urogenital schistosomiasis, hookworm

       Severe anaemia of pregnancy/lactation and                            Hookworm (major), schistosomiasis (minor)
       high maternal morbidity and mortality

       Anaemia associated with menstruation and                             Hookworm
       amenorrhea

       Congenital infection                                                 Chagas disease, leishmaniasis, strongyloidiasis,
                                                                            hookworm

       Low birthweight and/or premature birth from                          Hookworm and other soil-transmitted helminth
       placental inflammation and maternal anaemia                          infections, schistosomiasis

       Exacerbation of disease during pregnancy                             Leprosy, schistosomiasis

     Source: Hotez, P. J. (2009). Empowering Women and Improving Female Reproductive Health through Control of Neglected Tropical Diseases, 3(11),
     e559. Original evidence see publication. Translation by the authors.

     But not only are NTDs important                 it because of biological reasons or              for a great mutual programmatic im-
     causes for non-communicable diseas-             because of social and cultural norms/            pact for other areas.
     es that affect hundreds of millions of          role models.
     people. Those parasitic, bacterial,
     and viral diseases are also adverse-            In the following sections we will an-            HIV/AIDS and NTDs
     ly affecting reproductive health of             alyse in further detail some of these
     women, increasing the likelihood of             co-morbidities that represent not only           The relationship between NTDs and
     sexually transmitted diseases, and              a considerable burden of disease, but            HIV/AIDS – as schematically repre-
     lead to social stigma and exclusion.            also offer some striking overlaps in             sented in figure 2 – is an interesting
     Table 3 gives an overview of the                intervention programs. These overlaps            one as it runs in both directions: On
     co-morbidities of NTDs and condi-               represent a vast and increasing range            the one hand side, people who have
     tions in these three areas. In most             of opportunities where NTD interven-             HIV/AIDS are known to develop more
     of these co-morbidities women and               tions can relieve morbidity in other             often the parasitic NTDs Chagas dis-
     girls are clearly disadvantaged – be            health areas and have the potential              ease and Visceral leishmaniasis (VL).

12 Integrating NTDs
Figure 2: Pathogenesis: The bi-directional relationship between NTDs and HIV/AIDS

                                                                  Increases viral loads
      NTDs
      Intestinal helminths                                        Decreases CD4 counts

                                                                                                                                                      CHAPTER 3
      Schistosomiasis                                             Causes anemia
      Lymphatic filarisis                                         Increases horizontal transfer
                                                                  Increases mother-child transmission

                                                                                                                                HIV/AIDS

      NTDs (opportunistic                                         Increases pathogen
      infections)                                                 reproduction
      Chagas disease                                              Increases
      Visceral leishmaniasis                                      immunosuppression

Source: Adapted from Noblick, J., Skolnik, R., & Hotez, P. J. (2011). Linking global hiv/aids treatments with national programs for the control and
elimination of the neglected tropical diseases. PLoS Neglected Tropical Diseases, 5(7), 1–4. Translated by the authors.

HIV/AIDS is not only leading to an                FGS below). Helminth co-infection                  illustrates schematically how differ-
increased reproduction of living path-            is associated with increased risk for              ent programs directed at population
ogens in the body, but also increases             mother-to-child-transmission (MCTC)                groups could work together. For ex-
the immunosuppression. Especially                 of HIV, possibly by a mechanism in                 ample, clinics that provide treatment
VL has emerged as an important op-                which parasite antigens activates                  against HIV/AIDS as well as TB and
portunistic infection associated with             lymphocytes in utero.15 A recent pro-              other co-infection could be stacked
HIV. In areas endemic for VL, many                spective study in Tanzania has even                with NTD-medications based on re-
people have asymptomatic infections.              documented a significantly increased               gional NTD-prevalence. Vice versa,
A concomitant HIV infection increas-              risk of acquiring HIV for lymphatic fil-           NTD-programs that reach into the
es the risk of developing active VL by            ariasis-infected individuals.16                    most rural and remote areas could
between 100 and 2320 times.14 The                                                                    provide expanded HIV testing and
two diseases are mutually reinforcing:            Similar relationships between other                care. Thus the programs could help
HIV-infected people are particularly              NTDs, HIV and other viral co-infec-                decreasing HIV unawareness in these
vulnerable to VL, while VL accelerates            tions such as hepatitis may exist.                 areas. Another example builds on the
HIV replication and progression to                As an example, recent evidence has                 community health worker programs
AIDS.                                             been brought up that HIV or hepa-                  within HIV/AIDS programs (e.g. of
                                                  titis (B and C) co-infections may be               PEPFAR) to reach vulnerable and or-
On the other hand, some NTDs are                  associated with many unfavourable                  phan children. Given the ease of
likely to increase the likelihood of              outcomes in leprosy patients, from a               treatment of many NTDs with medi-
either transmission and/or devel-                 higher number of inflammatory com-                 cines, these community health work-
opment of HIV/AIDS. For example,                  plications and nerve damage to an in-              ers can be trained to spot and treat
an intestinal helminths infection                 creased relapse rate.17                            possible NTD-coinfections with HIV/
can reduce the CD4-count and/or                                                                      AIDS or refer them to a nearby health
increase the viral load and can also              These links between HIV/AIDS and                   centre. This integration would help
cause anaemia. Suffering from schis-              different NTDs call for a closer look              alleviate a major weakness of school-
tosomiasis infection increases the                at the respective intervention pro-                based programs that often unable
likelihood of horizontal transmission             grams and whether there are/should                 to reach those children who stay (or
between individuals (see section on               be an integrated approach. Figure 3                have to stay) at home.18

                                                                                                                               Integrating NTDs 13
Figure 3: Operative links for integrated control of NTDs and HIV/AIDS

            NTD                                                                                                                       HIV/AIDS
           Control                                                                                                                     Control
                              School and community-
                              based drug distribution                                       Treatment Clinics, Community
                                                                      Children              Health Workers outreach to
                                                                                            Orphan and Vulnerable Children

       Scale up of
       Mass Drug              Antenatal Clinic and
                              community-based drug                                                                                    Anti-
       Administra-
                              distribution                                                  Antenatal Clinics                         retroviral
       tion through                                                   Pregnant
                                                                       Women                                                          Therapy
       Rapid Impact
       Packages

                                                                                            Treatment Clinics
                              Comminuty based drug
                              distribution                                                  Community Health Workers
                                                                  Non-pregnant              outreach in the home-based
                                                                     adults                 care setting

     Source: Noblick, J., Skolnik, R., & Hotez, P. J. (2011). Linking global hiv/aids treatments with national programs for the control and elimination of
     the neglected tropical diseases. PLoS Neglected Tropical Diseases, 5(7), 1–4. Translated by the authors.

     HIV/AIDS and Female                                entifically document a causal asso-                as the researcher Peter Hotez put it
     Genital Schistosomiasis                            ciation,28,29,30,31 to the extent that             2013 – “possibly […] one of the most
                                                        WHO produced a visual pocket atlas                 common gynaecologic condition in
     (FGS)                                              for clinical health care professionals             sub-Saharan Africa”.35
     Even though gynaecological schisto-                to recognize FGS,32 and for WHO and
     somiasis has long been known by cli-               UNAIDS to issue a joint technical
     nicians, and described in the medical              document presenting state-of-the art
     literature as early as the 1940s,19,20 it          evidence for its association with HIV/
     was in the early 1970s that the syn-               AIDS and advocating for large scale
     drome was described close to what to-              prevention.33
     day is known as FGS.21,22 The term Fe-
     male Genital Schistosomiasis was first             The need to consider FGS as a seri-
     used in the mid-1990s,23 and suspect-              ous threat to the health of women in
     ed as a risk-factor for the transmission           Africa stems from the terrible conse-
     of HIV on the basis of epidemiologic,              quences of the illness (see box 2) and
     immunologic, and pathophysiologic                  the dramatic estimates that indicate
     data.24,25 Even at that time the need              up to 150 million women and girls in
     for a specific gender perspective was              sub-Saharan Africa could be affected
     already highlighted,26 but one had to              by FGS.34 The estimate is based on the
     wait until 2006 before an association              evidence that between one third and
     between FGS and HIV was first alleged              75 percent of women and girls who
     on the basis of field data.27 From there           are infected by schistosomiasis also
     it took over a decade to further sci-              have FGS. This number makes it –

14 Integrating NTDs
The connection between FGS and an
HIV infection is based on three ob-
servations: First, cross-sectional stud-        Box 2
ies in several African countries have
found that adult women with uro-                “FGS causes lesions and scarring in the female genital and repro-
                                                ductive tract. These lesions provide easy entry points for the HIV

                                                                                                                               CHAPTER 3
genital schistosomiasis had 3-4-fold
higher odds of having HIV. Second,              virus and can triple women’s risk of contracting HIV/AIDS. Women
among adolescent girls with FGS a               who have FGS also frequently have reproductive organ damage which
higher proportion of HIV receptors on           can lead to sexual and reproductive health problems such as pain-
their genital tissue cells were found           ful intercourse, infertility, ectopic pregnancy, spontaneous abortion,
compared with girls that did not have           premature birth and low birth weight. Women and even young (and
FGS. Third, there is a striking geo-            still sexually inactive) girls with FGS are often misdiagnosed with
graphical overlap between HIV inci-             having a sexually transmitted infection (STI) which leads to stigma
dence and FGS prevalence.36                     and discrimination; they often suffer from psychological problems
                                                and depression.”
Those findings lend themselves to
the conclusion that preventing young            In the ‘normal’ scenario of schistosomiasis, the parasites are
girls from getting infected with Schis-         present in the small blood vessels in intestines and bladder. The
tosomiasis will help reducing HIV in-           eggs that are produced continuously by the adult parasite try to
fections later in life. Women who have          penetrate the inside of those organs. From there they exit the body
been treated against schistosomiasis            through urine or stool. As the sanitary situation in many countries
with praziquantel at least once in their        of sub-Sahara Africa is insufficient, open defecation – often next
life, have developed 50 percent less            to a freshwater reservoir – remains quite common and the water
FGS later on in life.37 And treatment of        is used as a means of cleaning. These freshwater resources then
schistosomiasis has been suggested to           become the living environment for the intermediate snail host that
decrease the number of HIV infections           gets infected with the larvae hatching from the schistosome eggs,
by up to 16-20 percent.38                       and multiplies and transforms them into a new form of larvae that
                                                can penetrate the human skin. Whenever humans then come in
These findings indicate that inte-              touch with the water there is a risk that these larvae penetrate the
grating the treatment of populations            skin and become new adult parasites.
at risk of FGS into the traditional
HIV-programs might prove to be not              It is this aspect of the transmission cycle that makes women
only cost-efficient but might also              much more vulnerable to schistosomiasis. They get water from the
help to target poor communities first.          reservoirs, wash their children, and do their laundry. Moreover, for
Importantly, they address an impor-             women it is not only intestines and bladder that are affected, but
tant gender bias in HIV infections by           also genitals. Due to the specificities of the blood vessels in the
focussing on girls and young women.             female pelvis eggs can penetrate into the uterus and the vagina.

Prevention of FGS, and therefore a de-
crease in risk of transmission of HIV/
AIDS, is indeed possible by regular
treatment with praziquantel,39 as long
as it is given early in life in order to
prevent chronic damage of the genital      for NTDs could indeed be added to
tract that occurs already in adoles-       the package of combined preventive
cent girls in areas where schistosomi-     action in girls, adolescent girls and
asis prevails.40 Hence the suggestion,     young women and constitute an in-
already in 2009, that large scale pre-     novative way to contribute to the tar-
ventive treatment with praziquantel        get of “accelerating HIV prevention to
in children could constitute “Africa’s     reduce new infections by 75 percent”,
32 Cents Solution for HIV/AIDS”.41,42      as stated in the HIV Prevention 2020
Inexpensive, large scale treatment         Road Map.43

                                                                                                         Integrating NTDs 15
Anaemia and NTDs
                                                     Box 3
     Anaemia in low- and middle-income
     countries is usually a result of mul-
     tiple etiological factors – nutrition-          UNAIDS’ HIV Prevention 2020 Road Map – ‘Accelerating HIV prevention
     al, infectious and genetic. Regarding           to reduce new infections by 75 percent’
     infectious (and thus preventable)
     causes of anaemia, hookworm infec-              Despite a significant reduction in new infections over the last 15 years,
     tion and schistosomiasis are among              around 1,8 million new HIV infections still occur annually. Globally, ado-
     the most widely encountered, to-                lescent girls and young women (15-24 years), account for approximate-
     gether with malaria and HIV/AIDS.               ly 6,900 new HIV infections every week, and out of these 5,500 were
     Childhood anaemia is therefore very             among young women (15-24) in sub-Saharan Africa.
     common in poor communities, further
     amplified by poor nutritional status,           As part of global efforts to end AIDS as a public health threat, UNAIDS,
     and disproportionately affects wom-             UNFPA and partners launched a roadmap to reduce new HIV infections by
     en of child-bearing age later in life.46        75 percent. This road map intends to enhance country-led movements
     Hence the recent reminder by WHO                to scale up HIV prevention programs – combining primary prevention
     that every girl and every woman has             with the preventive effects of treatment – to meet global and national
     the right to be regularly dewormed 47           targets to end AIDS as a public health threat by 2030. The Road Map
     and that the fight against NTDs should          is relevant for all low and middle-income countries but focuses on 25
     be linked with gender programs.                 countries with the highest numbers of new infections in 2016, 18 of
                                                     which are in sub-Saharan Africa.*
     Mental health and NTDs                          As part of the implementation of combined primary prevention packag-
                                                     es, UNAIDS has recently promoted the integration of reproductive health
     The burden of mental health condi-              interventions in order to leverage synergies and improve women’s lives.
     tions are predicted to become one of            As such, HPV vaccination to prevent cervical cancer and early schistoso-
     the leading contributors to the global          miasis treatment to prevent Female Genital Schistosomiasis,44,45,33 were
     burden of diseases by 2030.48 Co-mor-           recommended to be part of primary HIV prevention programs among
     bidities between mental health and              school age children and girls. Adolescent girls and young women should
     NTDs are as old as these ancient dis-           further have access to regular screening and early clinical care for both
     eases themselves. One just needs to             conditions as part of Sexual and Reproductive Health and Rights (SRHR)
     think about the historical treatment of         programs, such as HIV screening, family planning, and mother-and-child
     leprosy (social exclusion) to see what          health programs. In this way, combined innovative prevention programs
     disfigurement can mean for people.              are likely to have an enhanced and comprehensive impact, while sat-
                                                     isfying the specific public health needs of adolescent girls and young
     There are different ways how NTDs               women in the poorest settings.
     can affect mental health: Some NTDs
     directly affect the central nervous sys-
     tem. Neurocysticercosis (caused by the
     pork tapeworm) manifests itself most-
     ly in the form of (late onset) epilepsy.   However, the more common link be-
     The same is true for onchocerciasis as-    tween NTDs and mental health is
     sociated epilepsy (OAE) or more com-       through the cycle of depression,
     monly called “Nodding Syndrome”. The       stigma and discrimination, exclusion
     clinical picture of second stage African   from participating fully in society,
                                                                                          * Angola, Brazil, Cameroon, China, Côte d’Ivo-
     trypanosomisis (sleeping sickness)         lack of educational opportunities and     ire, Democratic Republic of the Congo, Ethi-
     includes psychiatric manifestations        exclusion from income-generation          opia, Ghana, India, Indonesia, Kenya, Leso-
     and coma. And ectopic localisations        and employment opportunities. This        tho, Malawi, Mexico, Mozambique, Namibia,
                                                                                          Nigeria, Pakistan, South Africa, Swaziland,
     of schistosomiasis eggs in the brain       particularly affects NTDs that result
                                                                                          Uganda, Ukraine, United Republic of Tanza-
     or spinal cord can cause epilepsy, and     in infertility, such as schistosomiasis   nia, Zambia and Zimbabwe. Bold = BMZ partner
     hemi- or para-paresis or -paralysis.       and hookworm, and in disability if        countries with health priority.

16 Integrating NTDs
Table 4: Estimated numbers of existing cases of selected NTDs
which cause stigma and disablement

  Specific NTD                                   Disabilities resulting                            Number of cases/yr or with

                                                                                                                                                        CHAPTER 2
                                                 from disease                                      permanent chronic symptoms
  Buruli ulcer                                   Disfigurement                                     5000/yr
  Cutaneous/mucocutaneous                        Disfigurement                                     1.5 million/yr
  leishmaniasis
  Onchocerciasis                                 Blindness, severe itching                         265 000 existing cases
  Lymphatic filariasis                           Lymphoedema                                       15 million existing cases
  Trachoma                                       Trichiasis                                        8.2 million
  Yaws                                           Disfigurement                                     2.5 million (global prevalence
                                                                                                   estimate 1995)
  Leprosy                                        Disfigurement                                     213 000/yr
  African trypanosomiasis                        Neuropsychiatric disorders                        Circa 10 000 new cases/yr

Source: Litt, E., Baker, M. C., & Molyneux, D. (2012). Neglected tropical diseases and mental health: a perspective on comorbidity. Trends in Parasi-
tology, 28(5), 195–201.

untreated, such as buruli ulcer, cu-               mass treatment with azithromycin for               health system. As delivery is large-
taneous leishmaniasis, leprosy, lym-               trachoma has shown a wide-ranging                  ly carried out by resident communi-
phatic filariasis, and onchocerciasis.49           impact on other illnesses. Recent                  ty-based volunteers, this platform can
Women and girls invariably suffer                  studies have established this positive             be capitalized on to bring additional,
more from mental consequences and                  effect particularly when it comes to               simple interventions to these commu-
disorders related to NTDs.                         child mortality. In 2009, a study of               nities, to carry out screening for spe-
                                                   effects of anti-trachoma interventions             cific health problems and to help with
Table 4 gives an overview of some                  in Ethiopia has shown that child mor-              surveillance of emerging diseases. Em-
of the most important links between                tality decreased in areas where mass               powering communities to assist with
NTDs and their disabling effects. Giv-             treatment for trachoma had been                    the delivery of a simple package of in-
en the fact that mental conditions are             practised.50 This impact was further               terventions will contribute to building
often kept hidden or are not made                  investigated in a cluster-randomized               community resilience and achieving
a subject of discussion, an accurate               trial in Niger, Malawi and Tanzania.               UHC.
estimation of the global prevalence                The result was that particularly chil-
is challenging. The case numbers in-               dren in the age group of one to five
dicated in column three of table 4                 months had the greatest effect from                3.1.1.3 NTD supply chains
nevertheless give an indication of the             the treatment (in the order of 25 per-             and health systems
extent of NTD-mental health co-mor-                cent reduction in child mortality).51
bidities.                                                                                             Intervention delivery of NTDs is asso-
                                                                                                      ciated with a massive, but well-func-
Child mortality and NTDs                           3.1.1.2 Regular annual                             tioning logistics and supply chain sys-
                                                   community health contact                           tem on which the health system 52 can
NTD interventions delivered to remote                                                                 build to improve this often-under-val-
communities that have limited access               The periodic, community-based deliv-               ued aspect of health systems strength-
to health services can also provide                ery of NTD interventions provides at               ening. The network of pharmaceutical
unexpected collateral health benefits.             least one annual contact of remote                 firms, WHO, partner countries, and NG-
For example, the effects of preventive             communities with the local/national                DOs has scaled the supply chain from

                                                                                                                                Integrating NTDs 17
more than 700 million tablets in the       er example of improvement is the re-      to those, supply chains requiring fre-
     year 2009 to more than 1.5 billion         duction in unreported or mis-reported     quent re-supply of commodities – e.g
     tablets in 2016 and 2017. This supply      stockpiles of medicines in receiving      essential medicines supply chains –
     chain involves all steps from the first    countries. A joint mission of WHO vis-    follow usually different processes.55
     mile (application for drug donations,*     ited 6 priority countries in 2016 and     Better collaboration among the cam-
     production, shipment, and transport        found around 180 million tablets sup-     paigns could theoretically range from
     to Central Medical Stores in the coun-     plied to the country between 2012 and     complete ‘managerial integration’ to
     tries)53 to the last mile (distributing    2015, that had been unreported for. The   ‘sharing infrastructure’. One of the
     the necessary drugs to the communi-        mission was able to find information      central overlaps seems to be the dis-
     ties and the respective places where       on 73 percent of the unreported tab-      tribution network and assets. For ex-
     preventive medical treatment in at-risk    lets. These missions show clearly that    ample, one of the NTD control program
     areas is delivered).                       the substantial amounts of unreported     managers of the NTD control program
                                                medicines are neither lost nor expired    in Malawi has an agreement with the
     Managing those supply chains has           but reveal the information gaps in the    Director of the Expanded Program on
     proven to be a challenging task. Yet,      Supply Chain Management of medicine       Immunization (EPI) to borrow EPI
     progress has been encouraging. For         that exist in endemic countries**         vehicles when they are not otherwise
     example, in 2015 only 20 percent of                                                  being used – and in turn covers the
     medicines for preventive chemotherapy      In an analysis of NTD-supply chains,      operating costs of the vehicles.56
     were delivered on time, i.e. two months    the largest potential was seen in syn-
     before date for the preventive mass        chronizing NTDs with bednet cam-          While the previous example highlights
     treatment in the country. By 2017, this    paigns, nutrition campaigns, and          options for collaboration for the last
     share had reached 60 percent.54 Anoth-     immunization campaigns. In contrast       mile, there have been initiatives to

     Figure 4: Presence of neglected tropical diseases

         No NTDs
         1-2
         3-4
         5-6
         7-8

     Sources: The Carter Center for Guinea
     Worm Disease, STH, Trachoma,
     Schistosomiasis, Onchocerciasis,
     Lymphatic Filariasis. WHO for Chagas
     disease, dengue fever and leishmaniasis.
     Note: Years of last observations vary
     between 2013 and 2016. Analysis and
     illustration CPC Analaytics.

18 Integrating NTDs
streamline the first mile supply chain,    ly visible only at a late stage and often   And even, while the impact on growth,
too: A public-private consortium es-       in other medical/health areas (see sec-     nutrition, educational performance and
tablished the NTD Supply Chain Forum       tion on co-morbidities above). Before       worker productivity has been well de-
(NTDSCF) that created a dedicated          that, they cause substantial hidden or      scribed for soil-transmitted helminths
‘control tower’ that works to centralize   ‘subtle’ morbidity, that seriously affect   and schistosomiasis, the cumulative

                                                                                                                                            CHAPTER 3
management and visibility in tracking      children’s educational performance and      burden of infection with multiple NTDs
orders and shipments. The NTDSCF col-      adult productivity. Therefore, beyond       has so far been poorly documented,60
laborates with the international logis-    the health sector, NTD interventions        and therefore the effect of controlling
tics company DHL, that also contrib-       have the potential to enhance the im-       multiple NTDs on human health, well-
utes to the effort in kind.57              pact of various initiatives such as food    being and life course opportunities is
                                           security and nutritional programs, an-      likely to be much more significant.
                                           ti-hunger campaigns, and social safety
                                           initiatives to enhance educational im-
3.1.2 The underestimated                                                               3.1.3 Poverty
                                           pact and employment opportunities.
‘subtle’ burden of NTDs                    To underpin the latter, one could cite      identification
and its broad, socio-                      the documentation of long term eco-
economic impact on life                    nomic consequences of the successful        The geographical occurrence of NTDs,
                                           eradication of hookworm disease from        as a proxy for poverty and neglect, can
NTDs tend to cluster in the same poor      the American South, which started           direct local authorities to areas where
populations, who are affected by multi-    circa 1910,58 as well as the long-run       water supply, sanitation infrastructure
ple diseases as a rule rather than as an   impacts of investments in school-based      and environmental improvements are
exception. Many NTDs, become clinical-     deworming in Kenya.59                       most needed and will also have most
                                                                                       impact. This is true both in rural and
                                                                                       peri-urban areas. Because of ever in-
                                                                                       creasing urbanization and internation-
                                                                                       al travel, cities are indeed becoming
                                                                                       important hubs for the transmission
                                                                                       of infectious diseases,61 as shown by
                                                                                       recent vector-borne disease outbreaks.

                                                                                       * A country’s application for drugs involves
                                                                                       more than just ordering tablets, but also “in-
                                                                                       formation on disease burden, number of people
                                                                                       targeted for treatment, date of scheduled MDAs,
                                                                                       and mechanisms for distributing donated med-
                                                                                       icines. The applications also include strategies
                                                                                       for monitoring and evaluation, providing appro-
                                                                                       priate training and supervision to teachers and
                                                                                       health workers responsible for distributing med-
                                                                                       icine, and preventing reinfection (i.e., provision
                                                                                       of health education, water, and sanitation).”
                                                                                       ** The mission identified three major reasons
                                                                                       for these discrepancies: a) information on the
                                                                                       amount of stocks of PC medicines available at
                                                                                       subnational and/or national level was obtain-
                                                                                       able at country level but was not accurately
                                                                                       reported to WHO; b) some of the treatments
                                                                                       delivered to individuals during MDA campaigns
                                                                                       were not reported to WHO; and c) information
                                                                                       communication gap between the programs han-
                                                                                       dling the PC-medicine supplies and NTD pro-
                                                                                       gram manager on the amount supplied, utilized
                                                                                       and available balance.

                                                                                                                  Integrating NTDs 19
3.1.4 Assets of Health                     laboratories),62 as well as strengthen-   management of all the NTDs. In 2015,
                                                ing health information systems, would     WHO has launched a global strategy
     Systems and other sectors
                                                greatly help enhancing national di-       to strengthen efforts on water, sani-
     to support NTD programs                    agnostic and care capacities, as well     tation and hygiene to accelerate pro-
                                                as capacity for monitoring and evalu-     gress against NTDs.63 This strategy
     Preventive or promotional programs in      ation, including of potential drug re-    calls for closer coordination of WASH
     the health or other sectors can be used    sistance (e.g. AMR).                      and NTD programs, through joint plan-
     to deliver NTD interventions. Examples                                               ning, delivery and evaluation of pro-
     of such programs – well-known, but         Similarly, mainstreaming NTDs in          grams, strengthening of evidence, and
     still largely under-used – are school      training and capacity strengthening       making better use of endemicity data
     health programs, immunization and          initiatives of (public and private)       to target WASH services to the most
     mother-and-child health programs, as       health workforce will greatly contrib-    vulnerable, underserved populations.
     well as promotional programs for ado-      ute to building national implementa-      Inversely, adding a (modest) NTD im-
     lescents, such as in sexual and repro-     tion capacities for NTDs.                 plementation component – including
     ductive health. The logic can further be                                             vector containment and control - to
     extended to other sectors where there      National initiatives in health finance    much more substantial investments in
     are opportunities to reach specific risk   and governance can greatly contrib-       water and sanitation infrastructure is
     groups during their life course, such      ute to achieving UHC without finan-       a cost-effective way to expand NTD
     as through professional groups and         cial hardship, increasing the imple-      interventions. Many WASH and NTD
     cooperatives, agricultural support in-     mentation capacity for NTDs and           actors have started to work together
     itiatives, nutritional programs, etc…)     lessening the dependence on external      on planning and implementation and
                                                donor funding in the long term.           have started to document their expe-
     Making sure that NTD requirements are                                                riences and lessons learnt.64
     met in building, renovating and equip-     Water, sanitation and hygiene (WASH)
     ping health infrastructure (including      are critical in the prevention and

     3.2 Strategic assets that can help in policy-making

     3.2.1 Poverty focus                        pact of river blindness control in Af-    ance of suffering and disability,68 but
                                                rica.67 Not only do people not become     also in terms of return on investment
     NTDs are intimately related to pov-        blind or suffer from severe skin dis-     in the long term, both for individ-
     erty and keep on anchoring affected        ease anymore, but they have been          ual diseases 69,70,71 as for NTDs as a
     people in poverty because of their         able to return to cultivate the best      whole.72,73 The level of cost-effective-
     impact on education, performance,          fertile land near rivers they had left    ness of NTD interventions is driven,
     productivity and earning a livelihood,     because of fear of infection with the     among other factors, by the commit-
     as well as de facto out-of-the pock-       parasitic disease. River blindness in-    ment of pharmaceutical companies to
     et expenses that are related to their      vestments have thus made 25 million       provide free medicines, the number of
     treatment and care in most health          hectares of arable land safe to culti-    people affected and scale of potential
     systems in the developing world.65,66,     vate, with the potential to feed 17       health and socio-economic benefits,
     Wide access to NTD interventions –         million people.                           the opportunities for economies of
     free of charge to the end user – have                                                scale by integrating and synergizing
     a clear potential to break this vicious                                              delivery modes, and the substantial
     cycle and contribute to poverty re-        3.2.2 Investment case                     volunteer contributions by commu-
     duction. In the long term NTD inter-       and efficient spending                    nities and teachers.74 These econom-
     ventions could therefore contribute                                                  ic effects are most likely an under-
     to a livelihood approach to poverty        NTD interventions are known to be         estimation of the actual gain from
     and migration. A good example of           some of the most cost-effective pub-      NTD-interventions, because they do
     such improvements in both health           lic health interventions, not only in     not include wider social effects of in-
     and wealth are provided by the im-         the short term with regard to avoid-      fections (e.g. productivity effect).

20 Integrating NTDs
3.2.3 A vast and diversi-
fied international part-                        Box 4
ner network, including
                                                Key Messages from: An Investment Case for
the private sector, that is
                                                Ending Neglected Tropical Diseases:75
highly committed

                                                                                                                                CHAPTER 3
                                                   Neglected tropical diseases (NTDs) together account for a
Drawing inspiration from the World                 significant and inequitably distributed global disease burden,
Health Organization (WHO) “NTD                     similar in order of magnitude to those of tuberculosis or malaria
Roadmap for Implementation” 76,                    at approximately 22 million disability-adjusted life-years (DALYs)
which outlines bold targets for the                in 2012
control, elimination or eradication                Cost-effective interventions to end NTDs are available for as little
of NTDs by 2020, leaders of several                as US$3 per DALY averted; these interventions reach the poorest
prominent global health and devel-                 and most marginalized populations and provide an integrated
opment organizations, together with                approach to treat multiple diseases
industry partners, met in London in
2012 and pledged to unite in their                 Ambitious eradication, elimination, and control targets for
efforts to support the achievement                 individual diseases emerged with the launch of the World
of the WHO 2020 goals in respect to                Health Organization’s NTD roadmap in 2012; the Sustainable
10 neglected tropical diseases. These              Development Goals target “the end of NTDs” by 2030
collective promises of support were                Interventions to end NTDs are affordable globally; estimated
formalized into the London Declara-                treatment costs are US$750 million per year for 2015 to 2020
tion on NTDs,77 and it is around this              and US$300 million per year for 2020 to 2030
declaration that a broad coalition                 Interventions to end NTDs are affordable for the governments of
of partners has emerged. This coali-               most endemic countries
tion of NTD partners, called Uniting
                                                   Treatment and vector control combined require less than 0.1
to Combat NTDs,78 is composed of bi-
                                                   percent of domestic health spending. Domestic value for money is
lateral and multilateral donors, the
                                                   enhanced by the unprecedented scale of the London Declaration
private sector, philanthropic foun-
                                                   donation of medicines for nine of the most prevalent NTDs
dations, endemic countries, NGDOs,
and academia. These partners have                  Reaching those targets could avert an estimated 519 million
been working alongside WHO and na-                 DALYs from 2015 to 2030, compared to 1990 and the beginning
tional programs to address the ne-                 of concerted efforts to control NTDs
glected disease burden in some of                  The benefit to affected individuals in terms of averted out-of-
the world’s hardest to reach areas,                pocket health expenditures and lost productivity exceeds US$342
tracking their progress towards the                billion over the same period
2020 goals annually. The NTD index by              The net benefit to affected individuals is about US$25 for every
Uniting to Combat provides an over-                dollar to be invested by public and philanthropic funders between
view of a country’s progress in reach-             1990 and 2030—a 30 percent annualized rate of return
ing people in need of NTD treatment.79
                                                   The end of NTDs represents a fair and efficient transfer toward
                                                   universal health coverage and social protection for those who are
This alliance can also provide collabo-
                                                   least well-off
rative links with a vast network of very
diverse international partners, and op-
portunities to leverage investments by
individual donors or donor agencies,
not only in taking field implementa-       The strict accountability approach in     ion summit in January 2018. By doing
tion to scale, but also to support mul-    terms of monitoring progress has led      so, African leaders are making a pub-
tilateral research, translating research   the African Leaders Malaria Alliance      lic commitment to hold themselves
findings into practice, and swiftly in-    (ALMA) to add neglected tropical dis-     accountable for progress on NTDs,
troducing novel products into imple-       eases to its annual scorecard on dis-     as the ALMA scorecard is personally
mentation.                                 ease progress at the 30th African Un-     reviewed by African heads of state

                                                                                                          Integrating NTDs 21
Table 5: Drug donation overview by disease in 2017

       Disease                                  Drug                 Form                 Company           Shipped
                                                                                                            treatments
       Lymphatic Filariasis                     DEC                  Tablet               Esai                143.587.200
                                                Albendazole          Tablet               GSK                 770.419.000
                                                Ivermectin           Tablet               MSD                 113.441.437
       Trachoma                                 Azithromycin         Tablet               Pfizer                81.381.274
       Soil-transmitted helminths               Albendazole          Tablet               GSK                 123.690.000
                                                Mebendazole          Tablet               J&J                   29.200.800
       Onchocerciasis                           Ivermectin           Tablet               MSD                   97.324.187
                                                Ivermectin           Tablet               MSD                   89.210.080
       Schistosomiasis                          Praziquantel         Tablet               Merck                 60.343.200
       Leprosy                                  PB/MB                Tablets and          Novartis               2.242.428
                                                                     Blister packs
       Visceral Leishmaniasis                   AmBisome             Vials                Gilead                     62.600
       Chagas                                   Nifurtimox           Tablets and          Bayer                  1.500.000
                                                                     Blister packs
       Human African trypanosomiasis            Nifurtimox           Tablets              Bayer                    300.000
                                                Eflornithine         Tablets              Sanofi                       3.200
                                                Pentamidine          Tablets              Sanofi                       1.130

     * Represent number of tablets/vials shipped.

     Note: Total tablet donations amount to almost 1,7 billion tablets (representing c. 1.5 billion treatments).
     Source: 2017 drug donation data overwiew, Uniting to combat NTDs.

     every year, putting NTDs alongside        they merely require a stand-alone,        in poor communities. High occurrence
     malaria and maternal and child health     vertical approach. There are many         of NTD co-morbidities in such com-
     as top health priorities for the conti-   links (co-morbidities) with other         munities should trigger the search
     nent. Moreover, there are discussions     priority public health areas such as      and preventive action for NTDs, both
     to also institute a nutritional score-    non-communicable diseases (NCDs),         in terms of preventive treatment and
     card for Africa which should also en-     female reproductive health, mental        care as well as fundamentally preven-
     tail an NTD-component.                    health and others. Moreover, most of      tive interventions in other sectors.
                                               the NTD consequences that become          Only in this way will countries be
                                               visible in other health areas – such as   able to strengthen their health ser-
     3.2.4 NTDs as an                          female infertility, chronic anemia and    vices according to local priorities, tai-
                                               increased HIV transmission, high inci-    lor their UHC package to the needs of
     opportunity to make
                                               dence of late-onset epilepsy, liver and   their poorest communities, and direct
     poor people fully                         kidney disease due to schistosomiasis     development to where it is most ur-
     benefit from Universal                    or chronic heart disease due to Cha-      gently needed and will yield the high-
     Health Coverage and                       gas disease - are preventable by large    est impact.
     integrated development                    scale action against NTDs starting
                                               early in life. Therefore, NTDs should
     NTDs are not an isolated group of dis-    become an integral part of the UHC
     eases and it is wrong to think that       essential benefit package especially

22 Integrating NTDs
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