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How to create an enabling environment to tackle NTDs long term /

Since the framing of the NTD ‘sector’ some 30 years ago, development partners have shouldered much of the responsibility for NTD service delivery owing to significant limitations in governments’ resources and capacity. These efforts have advanced surveillance, diagnosis and treatment for these complex diseases, improving societal behaviours and successfully reduced the disease burden. Notably, much is also owed to the NTD drug donation programmes of pharmaceutical companies, with advancements in socioeconomic development in endemic countries also playing a role.

Such focus on donated drugs and delivery has resulted in huge progress in preventive treatments and towards elimination goals. However, it ‘has not systematically strengthened all diseases within national NTD programs, reinforced national leadership or ensured NTD programs are appropriately integrated into national governance, policy, financing, planning and delivery structures’. Espinal, Kruk Mohamed and Wainwright, Royal Society for Tropical Medicine and Hygiene, 2021

Aligning to government ambitions for more resilient health systems, independent of external support, major NTD funders such as USAID, FCDO, BMGF, the End Fund/ELMA and CIFF have increasingly committed to improving national health systems and transitioning NTD programmes to national ownership.

The ARISE programme consortium – Crown Agents, Oriole Global Health, Abt Associates – has a global portfolio of health systems support for Ministries, many with specific NTD experience. Our work on ARISE and the FCDO Ascend programme over the past 3 years confirms that the development of resilient and nationally-owned NTD programmes needs to be structured and supported through a clear multi-year transitional strategy with associated system strengthening interventions. Lessons from the Ascend and ARISE programmes about what it takes to secure an enabling environment for government ownership include the following 4 key areas:

1. NTD Programmes along the entire delivery system; from frontline volunteer health workers to global donation platforms; are susceptible to external shocks. The stop-start nature of external funding impacts national health programming and time utilisation of health workforces. Drug pipeline disruption is inevitable as lead times of 6 months on drug supply are resourced on only 12-24 month commitments. Donors (including drug donation programmes) could signal a carefully managed end to funding with an exit framework and timeframe that is shared with partner governments to allow time for corrective measures. Incentives such as match-funding might be useful for this, whereby the more a government contributes from domestic resources, the more donor funding will be provided over a specified timeframe.

2. There is often limited capacity in MOHs to take over management of NTD programmes. Suppliers, implementing partners, need to evidence effective and sustainable capacity building and skills transfer, and funders should incentivise them to demonstrate this kind of impact, not just hard results such as MDA treatments. By linking NTD funding to governments investing in the quality and tenure of their programme staff, and evidence of national ownership of NTD data, transitioning to national ownership can become incentivised.

3. Sustained investment in basic systems infrastructure – such as DHIS2, LMIS, evidence-based policy making, and public financial management systems. This could include support for MEL, embedded TA for data management, supply chain management, training in costing and budgeting and NTD master-planning.

4. As most of the systems support mentioned are needed for all health care, not just NTDs, the integration of NTDs into mainstream public health services will be key to sustained success: such as including NTDs within other communicable diseases programming and basic primary health messaging. This implies an end to disease-specific, or silo-ed funding and a commitment to look at NTD funding through a systems lens.

The Ascend programme, followed by ARISE, made some headway building up health systems that respond to the skills and systems issues above. Below we highlight examples of the learning we developed across the WHO Health systems pillars: Health systems financing; Health information systems; Leadership and governance; Health workforce; and Access to essential medicines.

Health Systems Financing

We ran training for Ministries in Public Financial Management and worked closely with Ministries to help them interrogate cost drivers in NTD activities. This helped secure value for money in contracting implementation partners, and also helped the government to build a baseline of financial information for costing their plans including the overarching NTD Masterplans.

Health Information Systems

NTD data is the lifeblood of programme management. We worked with Ministry staff to improve their usage of DHIS2, and create improved modules linking NTD data to other national health systems. We also created a mobile app for Bangladesh to better understand the distribution of VL cases.

Leadership and Governance

Our embedded technical assistance staff and secondees within the Ministries of Health support developing of NTD Masterplans, a VL strategy for Kenya, and developed standard operating procedures for safe delivery of MDAs during Covid-19. We established useful guidance tools such as a practical introduction to NTD supply chains including the JRSM ordering process, customs and storage practices.

Health Workforce

Through structured review of the each ministry tailored and specific training was provided to build the capacity of the MoH. We summarise the challenges and opportunities of involving seconded staff in implementation of NTD programmes in the learning brief. We also conducted research on the changing role of CHWs during the Covid-19 pandemic.

Access to essential Medicines

Ascend worked closely across supply chains to improve understanding of the particular challenges of NTD drugs and commodities. We trained Customs and Central Medical Stores personnel, and worked with the pharmaceutical industry on a successful pilot of NTDeliver, a tool for improving the visibility of drugs at the last mile.