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Neglected Tropical Disease financing – lessons from Ascend /

Neglected tropical diseases (NTDs) are a group of preventable and treatable parasitic, viral and bacterial diseases that affect more than one billion people globally.[1] These diseases are ‘neglected’ as they have been given less priority, funding and attention relative to more high-profile diseases such as AIDS, malaria, and TB. The Accelerating the Sustainable Control and Elimination of Neglected Tropical Diseases (Ascend) programme is a UK-aid funded effort to combat 5 of these diseases[2] in 11 countries[3]. across Asia and Africa and is the UK’s contribution to a global effort to eliminate these debilitating diseases.

This note was born out of an effort to identify how much domestic governments and development partners are spending to combat 5 neglected tropical diseases in Ascend’s countries of operation. Our main aims in undertaking this work were to:

  • Understand the level, sources and focus of NTD financing
  • Provide an evidence base for advocacy for additional resources for NTDs
  • Establish a baseline against which changes in domestic government and external development partner (EDP) funding could be assessed.

We hoped that the findings could contribute towards answering other important questions as well, for example:

  • Does the current distribution of funding align with medical need?
  • Who should provide the additional funding required to meet World Health Organisation goals on elimination and control of NTDs?

Data was obtained for all countries. However, it quickly became apparent that there are significant obstacles to tracking funding for NTDs in a manner that is objectively comparable across countries and years. The purpose of this note is to share what we learned in the process, which we believe will be relevant and useful for others working on NTDs. In the sections that follow, we identify the 3 key barriers that prevented us from achieving our aims and a potential response to them. The note concludes with 4 headline learnings we have drawn from this exercise.

The 3 key barriers to understanding how NTD programmes are financed

  1. Public financial management arrangements don’t facilitate tracking of programme expenditure

The most fundamental obstacle to identifying the levels of funding available for combatting NTDs is that many governments simply don’t have systems for tracking budget allocations and expenditure on NTDs in a clear way.

In some Ascend countries, budget classifications and charts of accounts do not enable tracking of NTD programme budgets at all. In these cases, the centre or department responsible for dealing with NTDs has an overall budget for dealing with a broader set of responsibilities, and there are no clear allocations for NTD programmes specifically.

In another group of countries, there are budgets allocated to NTDs as a broad category but not to specific diseases. Typically, these budgets cover some or all the Ascend NTDs in addition to others, such as leprosy, trypanosomiasis, and soil transmitted helminthiasis (STH). While these figures give an indication of government financing for NTDs overall, they do not enable identification of funding levels for the Ascend NTDs or other specific diseases.

In a third group of countries, systems for disease-specific budgeting and accounting are in place, enabling at least partial identification of government financing levels for the Ascend NTDs. However, even in these countries, not all relevant resources are necessarily captured. For instance, a health ministry or disease control centre might allocate some funding for their NTD prevention programmes or activities and track spending accordingly. But funds disbursed to hospitals and other health entities involved in providing treatment are typically not included, meaning that only a proportion of the total financial resources allocated to combatting NTDs by government is captured. For a truly comprehensive picture of government financing, including both prevention activities and treatment, one would have to identify the proportion of hospital and other health entity funding allocated to NTDs as well.

Further complications arise in federal systems, where health ministries don’t always have oversight of budgeting and spending at subnational level. The challenge here is that collecting data from subnational governments – of which there may be hundreds in a single country – is a potentially huge undertaking. And there is in any case no guarantee that the subnational governments would have systems in place for tracking their spending on NTDs.

  1. Limited available information on NTD financing by EDPs at country level

Although many EDPs make significant efforts to publish data on how their funds are spent (e.g. through the International Aid Transparency Initiative), it proved surprisingly difficult to identify reliable information on NTD financing at a country level.

In Bangladesh, the health ministry produces an annual report containing budget and expenditure data for NTD programmes, with government and EDP contributions clearly delineated. Similarly, the health ministries in Mozambique and Tanzania both collate details of EDP funding for NTDs in annual reports, though these reports don’t contain any information on the government contribution. All these reports were a valuable resource for our research. However, we were unable to identify evidence of similar practices in other Ascend countries.

In these cases, we requested funding information from EDPs directly. However, many declined to share what they viewed as sensitive information on their funding of NTD programmes. Others were unresponsive. While we approached the exercise with good intentions, we clearly lacked the authority and mandate needed to secure access to the information required.

  1. Valuation of drug donations is not straightforward

The findings of our data collection effort suggest that in-kind donations of drugs by private pharmaceutical companies account for most of the funding for combatting NTDs. In £ terms, the donations appear to greatly exceed the funding provided by more traditional development partners. However, these donations are often tax deductible at source and pharmaceutical companies value their donations in accordance with the relevant conventions on tax treatment of charitable giving in their countries of operation. Our findings suggest that the unit prices on which these valuations are based sometimes significantly exceed established market rates in the recipient countries, and exceed the wholesale cost of generic alternatives by an even greater margin. The appropriate £ value to assign to drug donations for an exercise of this kind is therefore debateable.

How these barriers might (eventually) be overcome 

A positive and very achievable first step forward would be to replicate the coordinated annual reporting of EDP budgets and expenditure data seen in Bangladesh, Mozambique and Tanzania in additional countries. Health ministry leadership would be needed to convene all the relevant partners in each country and ensure that the practice is sustained over time. But an established, well-placed EDP programme focused on NTDs could support implementation of such an initiative.

Where possible, details of domestic government budgets and expenditure should also be included in these reports. However, many domestic governments lack the systems needed to generate reliable data on their financing of NTD programmes. The problem is not unique to NTDs; it is similarly challenging to obtain reliable information on other areas of health spending (eg. HIV/AIDS, malaria, maternal and child health). Sector wide rollout of programme-based budgeting and accounting systems is the only remedy. This can take years to achieve and may be resisted by the very government bureaucracies that would need to implement the reform. However, international experience demonstrates that it is possible. The central government agencies with overall responsibility for PFM would ideally lead in this area, possibly with support from an EDP-funded PFM technical assistance programme. A multilateral commitment to report NTD spending to WHO could help create the impetus for such reforms.

With regards to the valuation of drug donations, we propose that estimating their replacement cost (ie. the wholesale cost of generic alternatives) as the best approach. This would yield the most relevant figure for planning and sustainability, and it is relatively straightforward to obtain the needed costings from large generic suppliers.

Headline learnings drawn from this exercise

1. It is not at all simple to measure or track disease or programme level expenditure across time or countries in an objective manner. The same has been found in attempts to track spending on other programmes.

2. It is a relevant and worthwhile undertaking – for purposes of advocacy and accountability – to try and track government commitments to NTDs. However, this requires international mandate – and would best be undertaken as a multilateral commitment to report NTD spending to WHO.

3. External support for NTDs is also difficult to track. The largest element is the drug donations – and the relevant valuation to attach to these for planning and sustainability purposes is “market generic replacement cost” rather than invoice value declared by supplier.

4. Surprisingly little information available about other external funding for NTDs. This is vital for countries to plan and to coordinate resources strategically. Domestic government NTD units should require EDPs to provide detailed annual data on their support for NTD programmes.

 

[1] https://www.cdc.gov/globalhealth/ntd/resources/ntd_factsheet_2021.pdf

[1] Schistosomiasis, trachoma, lymphatic filariasis, onchocerciasis and visceral leishmaniasis

[1] Bangladesh, Ethiopia, Kenya, Malawi, Mozambique, Nepal, Sudan, South Sudan, Tanzania, Uganda and Zambia