Neglected tropical diseases: Funding the next stage of the fight

The recent NTDs Summit in Geneva, Switzerland, highlighted the massive strides that have been made against neglected tropical diseases over the past five years with relatively small sums of money. Sixty percent of those in need have now been treated for at least one NTD — a group of 18 potentially debilitating poverty-related infectious diseases — with some, including lymphatic filariasis and Guinea worm disease, appearing to move in the direction of elimination.

Foreign aid for NTDs amounted to about $200 million to $300 million a year between 2012 and 2014, according to a report from the World Health Organization. “A relatively small amount of financing is needed to have big impact on NTDs,” Christopher Fitzpatrick, a health economist for the WHO, said at the summit.

Yet delegates also highlighted that while NTDs are considered one of the best buys in public health, they continue to be underfunded, and remain largely dependent on donors.

More of the much-needed resources for the next stage of the fight — which in 2015 the WHO estimated at $750 million a year up to 2020, and $460 million a year thereafter — must come from national governments and innovative financing, they said.

Foreign funding

The issue is not only about the availability of finance, but also how it flows, where it is deployed and the resulting impact.

As the fight against NTDs continues to evolve, the latest WHO report, released ahead of the summit, predicts that by 2030, high levels of coverage of essential NTD medicines would “not only result in a decrease of about 90 percent in the number of people requiring treatment but also in the elimination of some NTDs.” Globally, however, “new investments are expected to decrease year-on-year after 2020.”

Last month, traditional donors who have supported the fight against NTDs, including the United Kingdom government and the Bill & Melinda Gates Foundation, made a range of commitments yielding more than half a billion dollars of new investment.

But while experts gathered at the NTDs Summit said that some governments — notably the U.K. and the United States — have made significant investments to date, others could do more. Emeritus Professor David Molyneux of the Liverpool School of Tropical Medicine told Devex: “I am disappointed that Germany, France and Switzerland are not investing in NTDs.”

Further, the WHO report cautions that current levels of official development assistance for NTDs could come under pressure in the future. “Increased competition for scarce resources to fund Sustainable Development Goal-related initiatives could put pressure on a worldwide NTD response that is already underfunded,” it says.

That is a concern, because NTD programs are disproportionately dependent on foreign funding. Citing data from low-income African countries, the report shows that NTDs account for a lower share of financing from domestic governments where the diseases are endemic, compared to other infectious diseases.

‘One of the best buys in public health’

While more than $150 billion will be needed to achieve the Sustainable Development Agenda in low-income countries, new investments of $150 million annually until 2020 will be enough to cover populations in sub-Saharan Africa, which account for more than half of those who have not yet been treated for NTDs, according to the WHO.

Large donations from the pharmaceutical industry have also helped to make NTDs one of the best buys in public health. In the five years since the 2012 London Declaration — when key stakeholders agreed to collaborate in the fight against NTDs — 10 pharmaceutical companies have donated over 7 billion treatments. According to a recent report by the International Federation of Pharmaceutical Manufacturers and Associations, “by 2020 as much as $18 billion worth of medicines will have been distributed in the largest medicine donation the world has ever seen.”

The U.S. Agency for International Development, one of two key bilateral donors supporting the fight against NTDs, suggests that “every $1 invested by USAID in NTDs leverages $26 in pharmaceutical donations for mass treatment campaigns, which has reduced treatment costs to 63 cents per person.”

However, while NTD medicines are largely donated, they need to be delivered to those suffering from these diseases, often in remote areas among the poorest and most vulnerable populations. The WHO estimates that the costs of active case-finding can range from $2 per capita in sparsely populated and remote areas of Africa, to less than $0.20 per capita in densely populated regions of South Asia.

Professor Molyneux told Devex that the cost of delivery typically amounts to 1 to 3 percent of government health expenditure.

The WHO report stresses the importance of increased domestic investment. “Because the amounts invested in NTDs by domestic government are so small, modest increases can have a big impact, allowing even low-income countries to take ownership of an important global health programme,” the report says, pointing to Congo, Sudan, Egypt and Tanzania as among those that have made moves to increase domestic financing.

Dr Osagie E Ehanire, a minister of health for Nigeria, told his audience at the NTD Summit that “ministries of health must take ownership of these programs and decide on how funding must flow, in order to avoid duplication of efforts and ensure equitable distribution of resources within a country.”

Dr Anarfi Asamoa-Baah, deputy director-general of the WHO and former director of medical services for Ghana, agreed: “Endemic countries should be central in this fight and must own this,” he said, adding that there is a limit to the impact that external funders can have.

More integrated financing

Since NTDs are considered a sound investment when it comes to public health, philanthropy has also been a key source of financing to date. Stakeholders told Devex that this can have an impact on how the money is used.

“One of the key challenges at the moment is how to break the infection cycle; to not just manage but eliminate these diseases,” Alan McCormick, a partner at Legatum, the private investment firm behind the END Fund, told Devex. “Private investors often have a much higher risk appetite for experimentation and identifying new solutions, whereas larger institutions can be less nimble, so private capital is an important element in eliminating these diseases.”

He added that: “Given the scale of the challenge, it is going to take all sorts of capital to accomplish this goal.”

Founded in 2012, the END Fund — a vehicle that brings together private donors to fund work against the NTDs — has so far mobilised $75 million to fight the five most common neglected diseases, which account for nearly 90 percent of the NTD burden.

Apart from increased advocacy around NTDs and knowledge to improve treatments, McCormick emphasised the importance of targeted goals in attracting private finance.

“Investors understand returns and NTDs are easily the best buy in global health — given the donated drugs and support, it’s hard to spend a global health dollar in a more impactful way,” he said. “However, we need to articulate clear, bold goals to inspire new investors to join this movement and to see the benefits of allocating capital in this area.”

Others at the summit also discussed the need to explore alternative models of financing.

Katey Owen, NTDs director of the Bill & Melinda Gates Foundation, pointed out that NTD programs are typically run in silos, using vertical funding mechanisms. The efficiency of this model is increasingly being questioned, but while bilateral funders are interested in alternative financing mechanisms, she said, “the alternatives are not yet clear.”

“It is sometimes difficult to find out what kind of investments will have the fastest impact. We are not tied to traditional methods; we are open to creative ideas from the communities and grantees,” she said, emphasizing the importance of measuring and incentivizing good results through financing.

Emily Wainwright, division chief for NTDs at USAID, argued in Geneva that mainstreaming NTDs into routine health care will improve efficiencies. It was an overarching theme at the summit that the next stage of the fight against NTDs will increasingly require movement on broader health goals such as nutrition and water, sanitation and hygiene.

In its report, the WHO also discourages the ring-fencing of funds, citing evidence to show that earmarking funds for specific diseases “may actually limit rather than empower countries.”

Mainstreaming NTDs “will help to ensure that the domestic share of funding for NTDs is no less than that for the interventions of the health sector as a whole,” it says. That, in turn, could help endemic countries to take ownership of the fight.

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