By Matilda Nash and Paul Smithson
World NTD Day is an opportunity to reflect on what we’ve learnt from different approaches to health service integration, such as the mainstreaming of NTD services into government owned and managed health systems, and how these lessons can help us overcome challenges as we push towards targets to prevent, control, eliminate or eradicate neglected tropical diseases (NTDs) in the decade ahead.
The global NTD community recognises the benefits of integration, including greater national ownership, opportunities for economies of scale, and improved cooperation between stakeholders. It is also a core tenet of the World Health Organization’s (WHO) NTD road map for 2021–2030.
Multi-country, multi-disease initiatives like the UKAid-funded Accelerating Sustainable Control and Elimination of Neglected Tropical Diseases programme (Ascend) have seen success through three particular types of integration:
- Integration of control measures for multiple NTDs;
- Cross-sectoral collaboration, notably with the water, sanitation and hygiene (WASH) sector;
- Integration between NTD control and the government health system.
In regard to the first type, Ascend Lot 1, which works in countries in East and Southern Africa as well as Asia, has combined services for multiple NTDs. For example, the programme has carried out joint mass drug administrations (MDAs) for lymphatic filariasis (LF) and schistosomiasis in Mozambique and Zanzibar, and delivered community sensitisation and advocacy for LF, visceral leishmaniasis (VL) and now Covid-19 in Nepal.
As for the second type of integration, the programme is integrating NTDs and WASH through various activities. These include combining WASH with LF mapping in Bangladesh and schistosomiasis mapping in Kenya; integrating NTDs into national WASH behaviour change communication strategies in numerous countries; supporting the formation of coordination committees at national and regional level in Uganda to promote collaboration between WASH and NTD stakeholders; and supporting the development of national NTD-WASH frameworks in seven countries.
But the third type of integration shows the greatest potential for lasting change – mainstreaming NTD services into government health systems – as this improves country ownership, resilience, and sustainability.
A need for national ownership
The economic crises caused by Covid-19 have accelerated the need for increased national ownership as traditional donors struggle to balance domestic fiscal pressures with overseas development assistance commitments.
But the reality of integrating parallel delivery systems into fragile national health systems is not without challenges. Strengthening health systems, including addressing institutional barriers (such as women’s representation in decision-making), requires a conscious and multi-stakeholder effort that may not yield results for decades. Partners often default to establishing dedicated systems to meet delivery commitments within a funding cycle.
To date, NTD supply chains, data management systems, and financing have typically been established and/or managed by external partners, but these are essential elements of health systems that should be integrated to ensure long-term sustainability of national NTD services.
This is the approach adopted by Ascend Lot 1.
Opportunities for integration
The programme is enabling integration in multiple ways.
Firstly, it is providing training and policy support to strengthen national supply chain management systems, as well as helping to integrate the importation, storage and transportation of vital drugs and equipment into nationally managed hubs wherever possible.
In Mozambique, this has involved addressing high administrative charges on importing essential NTD drugs. In Kenya, Ascend Lot 1 is supporting the national NTD programme to renegotiate fees that previously prevented the Ministry of Health from using the national Central Medical Stores to warehouse donated NTD commodities. If successful, these changes will make it easier and more affordable to channel NTD commodities through national supply chain systems.
Secondly, Ascend is supporting the strengthening of Health Management Information Systems (HMIS) in a number of countries. In Bangladesh and Uganda, teams are providing technical assistance to Ministries of Health to integrate NTD surveillance into the national HMIS. The Programme is also supporting governments to move from vertical surveillance systems to integrated ones that span department, such as the widely used District Health Information Software (DHIS2) and the WHO Integrated NTD database (CIND).
Thirdly, Ascend Lot 1 is also providing training on health financing, budget cycles and public financial management processes to national NTD teams. The training aims to equip national NTD stakeholders with the knowledge and competence to bid for financial resources through their domestic budget systems – improving the prospects for sustainability. The training has recently been piloted in Kenya and will be rolled out in additional countries this year.
Lastly, capacity is also being built at the district level where service delivery takes place. In Zambia, Ascend plans to work directly with local health authorities to deliver MDAs for schistosomiasis instead of channelling funds through external International NGOs. The programme is providing technical assistance to build the public financial management capacity of local health authorities to manage future MDAs.
By working with national governments to deliver NTD services, Ascend Lot 1 has identified a number of opportunities to strengthen NTD mainstreaming at all levels: logistics and supply chain, information systems, governance and financing, and service delivery.
Important work has started in these areas, but it will need to continue beyond the lifetime of Ascend in order to meet the sustainability goals envisioned in the 2021-2030 NTD Roadmap. These long-term goals are most likely to be feasible and become sustainable when national Ministries of Health are empowered to lead an integrated approach to NTD service delivery.