Professor Sir Roy Anderson FRS is Chairman of Oriole Global Health, part of the Crown Agents-led consortium managing the UK-Aid funded Ascend (Accelerating the sustainable control and elimination of Neglected Tropical Diseases) Lot 1 programme. He is also Professor of Infectious Disease Epidemiology at Imperial College London and Director of the London Centre for Neglected Tropical Disease (NTD) Research.
Roy has been working in the field of NTDs for more than 40 years and discusses how NTD control has improved, what is needed to further achieve global control and how Ascend Lot 1 is working to ensure their long-term management through strengthened health systems.
How would you describe achievements in NTD control to date?
The term NTD was coined in the 1970s and about 20 years ago the World Health Organization (WHO) set up a science and technology advisory group (STAG) to identify research needs for improving NTD control, which I had the privilege of chairing in its early years post establishment. Since then, many generous funders, including the Gates Foundation and national aid budgets, have provided a lot of money to help countries with endemic infections devise effective control programs. This was supported by a number of major pharmaceutical companies donating millions and millions of drugs to treat certain neglected infections such as intestinal nematode worms
The WHO then devised 10-year roadmaps for NTD control, which were ambitious but successful, and we are now building on the success of the last one (2010-2020), which saw excellent progress in reducing the prevalence of many infections, and in particular controlling the morbidity induced by these infections.
The challenge for the 2020–2030 programme is that it is often easier to make progress in the beginning when infection prevalence is high. It is typically more difficult to sustain good progress once prevalence is low due to past control activity. For example, to deal effectively with low prevalence settings it is important to manage prevalence village by village, such that resources are effectively targeted at the remain pockets of infection. So, going the ‘last mile’ is the challenge for the coming decade – made even more challenging by the Covid-19 pandemic, which has of course inhibited the implementation of mass drug administration programmes and surgeries in hospitals.
How can we assist in the pandemic response while maintaining NTD activities?
The pandemic of Covid-19, which has caused so much suffering and mortality world-wide is the top public health priority in the nearer term. The Covax programmes aimed at providing Covid-19 vaccines to resource poor countries should be the primary aim for most ministries of health in the coming two years.
But there are opportunities here where the Ascend programme can help countries design and implement their Covid vaccination programmes. This is because vaccination programmes are typically aimed at children, to deliver vaccines such as those that protect against polio and measles viruses, while many NTD programmes are aimed at communities encompassing all ages, with treatment based on community wide distribution of drugs for diseases like schistosomiasis and onchocerciasis. This scaffold for community–wide treatment could be used to support vaccine distribution across all age groups.
The point is that this is not simply about NTDs, it’s about trying to build infrastructure in resource poor settings that can improve health and reduce the morbidity and mortality caused by infections, whether NTDs or novel pandemics of newly emerged viruses and bacteria.
Is this goal of building infrastructure a key part of Ascend?
The prime objective is to build capacity in resource poor settings to create and service an effective health care infrastructure. As you get more and more successful in controlling infections, making the case to go the last mile becomes more difficult because there are other priorities in healthcare.
One of the key aims of Ascend Lot 1 and the UK Aid programme is to slowly transfer the responsibility and capabilities to country health ministries to continue these programmes in future decades. That requires further building on local capacity to run these programmes and transferring skill sets on how best to use limited resources to treat people and to accurately record data on the prevalence of these infections to inform policymakers and civil servants. All these aspects are critical to the Ascend Lot 1 programme.
There are today many not for profit organizations that implement drug delivery to communities in regions of endemic NTD infections and conduct surgeries in the case of Trachoma control,. This is hugely beneficial. But it is also desirable to build the capability within ministries of health in the countries where infections are endemic so eventually, they can take it over the role of the NGOs and other external organizations to deliver effective NTD control.
Is this what Ascend Lot 1’s delivery model aims to achieve?
There are many facets to the effective delivery of NTD control. By way of illustration of these I list just five.
First, you need to get hold of the drugs and get them into the country and to the ministry of health. Then they need to be distributed to the communities you wish to reach. The experience of Crown Agents is very important in this aspect given its great experience in constructing and improving supply chains to make sure there is always a supply of drugs locally.
Second, you need competitive tendering for the implementation part of delivering treatments. In some countries there can be but one dominant player who has been there for a long time. What we have attempted to do in Ascend Lot 1 is insert a competitive tendering process, where we ask a number of implementers if they feel capable to deliver pills to communities or surgeries to hospitals, for example. By asking a number of organizations we try by competition to reduce the cost of the implementation of NTD control, eventually bringing it down to a level where countries feel they can afford to do it themselves from local Ministry of Health budgets. But competitive tendering takes time and it takes effort. You also need to make sure you identify organisations or implementers who can effectively do the job. Because of this, Ascend Lot 1 took a little while to get up to speed, but the benefits are coming in strongly now in terms of reducing costs and delivering treatments and surgeries.
Thirdly, we encourage countries to improve the acquisition of data to inform policy formulation and to address questions such as how best to distribute drugs to areas that most need them, through monitoring and evaluation (M&E). We are trying to build further capacity for this within countries, to help them acquire data that identifies where pockets of infection are, where cases are left and where drugs should be distributed. They can then present this in a way to policymakers so they know which areas to focus on and help refocus efforts towards remaining pockets of infection.
The cost of implementing M&E programmes at a fine spatial scale has often been a major impediment to date. For example, if you have a budget for a public health programme and are told 10-15% needs to be spent on collecting data to evaluate how well you’re doing, this is a difficult argument to make, as most might wish to spend this on delivering pills to people. But unless you know exactly what you’re doing and what you’re achieving then you’re not totally sure if the money is being well spent. You need to gently demonstrate why it’s important to collect that information as good M&E saves money in the long run. As prevalence reduces, it becomes more important as you need to find the pockets left to eradicate in the difficult to reach pockets of infection in remote areas. Ironically, it becomes more and more important as you become more successful.
Fourthly, you need to provide broader aspects of training, including how to build and sustain effective supply chains for drugs and diagnostics, data management, and how to conduct competitive tendering programmes for implementing treatment and surgeries. Countries are invariably very enthusiastic to receive information and training on how to do things better.
Lastly, we need to ask critical questions on whether we can combine programmes to save on the costs of delivering treatments for prevalent infections. For example, countries have malaria, HIV, TB and childhood vaccination programmes. Now they have Covid-19 vaccines to deliver to communities. But you can combine community NTD activities with Covid vaccinations and other disease control programmes, saving money and, in turn, strengthening health systems in a more generic manner. This is also the case for water and sanitation services (WASH). It may seem obvious to all of us that washing hands is important for the control of so many common infections, but it is one of the most difficult things to do. Clean water and hand washing in schools in very expensive as it requires infrastructure such as clean water supplies and good sanitation— but it has enormous benefits. You also need budgets to maintain facilities that have been put in, either by governments or NGOs. Keeping them clean and functioning is a critical part of WASH. It requires both improving infrastructure and maintaining the improvements.
Can Ascend achieve these goals?
Like all programmes which are short in duration you have high expectations and achievement goals. Really good progress has been made over the past 18 months, in particular in countries that are often difficult to operate in, such as South Sudan and Sudan. The challenge is to sustain this progress and further build local capacity to further enhance local NTD control programmes
The challenge is to sustain interest as new governments come in, in helping countries to develop and maintain NTD programmes. You also need to find other funders to ensure sustainable goals by ministries of health and to continue transferring skills so we don’t just end this programme.
That is going to be a challenge, but I am optimistic that a variety of donors, both national governments and philanthropic organizations, will continue to help with NTD control in countries with endemic NTD infections. I also very much hope the UK government continues its generous support of NTD control in Africa and parts of Asia.