The Sustainability Continuum for Neglected Tropical Diseases Programs

December 29th, 2017

The Neglected Tropical Diseases Program (NTDP) Sustainability Continuum measures a national NTDP’s progress toward achieving long-term sustainability. Consisting of four stages that begin with ‘stand-alone NTDPs’ and advance toward full integration with the broader health system, the Sustainability Continuum seeks to help countries achieve their goals of NTD elimination and post-elimination care.

The NTDPs in several END in Africa countries have already made considerable progress along the sustainability continuum, advancing beyond the first two stages and moving well into the third. Stage 3 signifies that the countries’ NTDPs have succeeded in integrating NTD activities with other health programs and in garnering support from all necessary decision makers.

Moving from stage 3 to stage 4 poses many challenges, however, causing some NTDPs to ask: How do we move towards more integration in health programs? And what should integration look like? Finding answers to these questions is a high priority for reasons, including the anticipated achievement of elimination of several NTDs—namely, trachoma and lymphatic filariasis—in multiple END in Africa countries, and the expected decrease in NTD funding from donors such as the U.S. Agency for International Development (USAID) after 2023. The expected funding decrease is a particularly pressing issue, as prevention and treatment efforts to combat various END in Africa project NTDs—including onchocerciasis, schistosomiasis (SCH), and soil transmitted helminthiasis (STH)—are expected to require continued attention, funding, and support post-2023. Effective integration strategies may help countries achieve global NTD control and elimination benchmarks; indeed, available evidence has already shown an association with increased coverage and reduced costs.

While the answer to the question of how NTDPs should operate in the future is still unclear and will be unique in each country, Deloitte is working with Cote d’Ivoire and Ghana to begin the conversation around a future state for NTD programs. Given funding uncertainties and changing but continued demands for NTD support, considering several key questions can help national NTDPs identify areas where increased coordination within ministries of health and with other ministries could increase program coverage, reduce costs, and move countries closer to stage 3.

What are the NTDP’s coordination and integration objectives? Initially, it’s helpful for NTDPs to begin identifying areas of potential collaboration and coordination. These coordination points may be in other divisions of the Ministry of Health or with outside ministries. We recommend using evidence and best practices to put together a detailed plan for how this coordination activity will be implemented and articulate what the return will look like, both programmatically and financially. For example, how much value did the country of Rwanda derive from integrating deworming campaigns into the mother and child health weeks, which served to improve STH and SCH outcomes? By how much did program changes related to the links between helminth coinfections and increased susceptibility to/worsening progression of HIV/AIDS, reduce financial and other costs for Tanzania? Ascertaining the answers to such questions can help countries to create realistic financial and operational plans for integrating NTDP functions, or even entire NTDP operations, into other programs over the long term.

What formal protocol needs to be followed and how can the NTDP influence decision-makers? Using evidence and best practices to identify areas of collaboration that cut across vertical programs is only the first step. The next step is determining the protocol in place within each government entity to create support and buy-in from decision makers. This process will depend on the type of activity and level of required coordination. For example, the protocol and process necessary to incorporate NTDP activities into local health service delivery provision will differ from those needed to insert NTDP activities into national policies, strategies, or guidelines. While these conversations should be led by the NTDP, it may be helpful to include civil society organizations, community leaders, or public/private sector groups to provide support and to strengthen advocacy efforts with the necessary people.

What is the best message for your audience? Once there is a vision for carrying out this work and an understanding of the key decision makers, the next step is similar to any advocacy activity: outlining the best way to reach your target audience and crafting messages that will most resonate. Before crafting a message, NTDPs should identify and fully understand the alignment between the NTDP’s interests and those of each stakeholder. Many decision makers will want to understand the impact of the proposed change on both health outcomes and budgets. Articulating the value of the proposal using the most effective communication media will improve the NTDPs’ chances of being able to move forward with necessary support. Note that while moving through the decision-making process and communicating with different officials, NTDPs will likely need to change their messages and communication media according to what these individuals need to hear, as determined through prior due diligence.

How best to prepare for the future and set realistic expectations? With progress being made towards disease elimination and a changing funding landscape, countries will need to create strategies to guide their future neglected tropical disease response efforts. As countries think through the efficiencies that can be gained through improved coordination of any scale or at any level of the health system, they may need to make course corrections. Consistent monitoring and evaluation will also be important.

There is no single answer or one size fits all approach, but thinking about patient care and improving health outcomes in a holistic and comprehensive way can lead to efficient and sustainable changes to prevention and treatment of neglected tropical diseases. There is likely not a perfect marriage of activities, but ongoing communication with other programs will in the long-term benefits citizens and will reduce the burden on budgets.

The END in Africa project is currently exploring these points of coordination in Ghana and Cote d’Ivoire. These efforts are not to replace the work of NTDPs, but to fully explore what the future of NTDs will look like in the respective countries and how countries can respond.


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