Universal Health Coverage & NTD programmes – who are we missing and how do we reach them?

10 Dec 2021

Great progress has been made to control and eliminate Neglected Tropical Diseases. On Universal Health Coverage Day we ask ourselves: How much more could we achieve if we really Leave No One Behind in our NTD programmes? 

In this blog, Anouk Gouvras from the Global Schistosomiasis Alliance, Christine Makia Masong from the Catholic University of Central Africa and Leshawn Benedict from iCHORDS Community of Practice look at how NTDs are linked to the SDG target on Universal Health Coverage, and how the “Leave No One Behind” principle is essential for NTD programmes.

Universal Health Coverage and Neglected Tropical Diseases

People affected by Neglected Tropical Diseases (NTDs) are often missed by public services, such as healthcare and/or water and waste management. These diseases thrive on inequalities and poverty, hampering human and economic development, reducing productivity, causing harm and disability, and perpetuating the cycle of poverty and ill-health. 

At the UN Summit in 2015, world leaders adopted a 2030 Agenda for Sustainable Development, comprising 17 Sustainable Development Goals (SDGs), targeting intricately linked aspects of economic, social and environmental development and focusing on people, planet, prosperity, peace and partnership. These goals mobilize countries to step up efforts to end all forms of poverty, fight inequalities and tackle climate change, while ensuring that no one is left behind. SDG 3, the health goal to “Ensure healthy lives and promote well-being for all ages”, has nine targets, two of which are particularly linked to NTDs: 

  • SDG3 Target 3.3  “End the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and combat hepatitis, water-borne diseases and other communicable diseases”.
  • SDG3 Target 3.8 “ Achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all”. 

Achieving Universal Health Coverage for all by 2030 is a strategic priority for the World Health Organization and all member states. In the current climate we understand, perhaps better than ever, that resilient and robust health systems, built on primary care that is accessible to all, including the most marginalized and disadvantaged populations, benefits everyone. Addressing NTDs is essential to break the cycle of poverty,  build long-term economic development and to achieve UHC and the SDG targets, for a safer, fairer and more prosperous world.   

Great progress has been made in addressing NTDs through national public health programmes. For example, a study commissioned by the WHO found that preventive chemotherapy (PC) of school-aged children in areas at risk of schistosomiasis has resulted in a 60% reduction in prevalence from 2000 to 2019. However, whilst there is a lot to celebrate here, we know that barriers to schistosomiasis and NTDs treatment and prevention still exist. These barriers are preventing equitable access to health services, affecting marginalized communities and putting the hard-earned gains of NTD control and elimination at risk - barriers and challenges that have been compounded by the COVID-19 pandemic.

For Universal Health Coverage Day we ask ourselves: How much more could we achieve if we really “Leave No One Behind” in our NTD programmes?

Leave No One Behind – we need to know who we are missing

For NTDs controlled by preventive chemotherapy through Mass Drug Administration (MDA) programmes, increasing focus has been put on reaching missed populations with universal health coverage targets,  especially as these population groups make up the majority of missed groups in primary health care interventions. Indeed ‘NTDs are a litmus test for Universal health Coverage’ (Dean et al., 2019).  

In a recent paper “Achieving equity in UHC interventions: who is left behind by neglected tropical disease programmes in Cameroon?” the authors highlight specific groups of populations consistently (or regularly) left behind by MDAs for preventive chemotherapy interventions. Population sub-groups such as women of reproductive age, migrant farming populations, indigenous farming communities, and out-of-school children (including children with disabilities) have been identified as the most left out, predominantly for cultural and socio-economic reasons, as well as program implementation challenges.

Identifying these groups offers a strong opportunity in closing the gap to 2030 elimination goals for schistosomiasis and other NTDs. This complements the up-take in preventive chemotherapy coverage efforts for schistosomiasis, as recently documented in school-aged children in sub-Saharan Africa. To achieve schistosomiasis elimination as a public health problem, preventive chemotherapy for schistosomiasis needs to be accessible to all at-risk groups. Accordingly, we need to approach our NTD programmes with an equity lens, looking at who is being missed and why, then adapt and tailor interventions to reach marginalized groups. 

Moving from a “one-size-fits-all” to a “people-centred, inclusive, participatory and responsive to differing contexts and specificities” NTD intervention strategy will promote trust in public health services, and build resilience in communities. We can in fact design effective NTD intervention deliveries for all groups and subgroups in our communities.  

Finding solutions and building trust through participatory approaches

In a podcast by iCHORDS, a community of practice on social and behavioural science research for NTDs, Dr. Akinola Oluwole and Dr. Kim Ozano, from the COUNTDOWN consortium, describe how the use of participatory research approaches and methods engages communities and ensures that the interests, viewpoints and realities of people affected by diseases or illnesses are heard and better understood throughout research studies. Such an approach works to build trust and partnerships with communities, and reach all stakeholders with solutions that work for, and are owned by, them.

An example of one of the methods within participatory research is the use of transect walks which explore environmental and social resources, conditions, and systems by listening, asking, observing and creating a transect diagram alongside the community. As Dr. Akinola Oluwole notes, transect walks allow us to understand where people meet and how people are interacting with different structures within the community so we can better understand processes such as sensitization and the distribution of drugs.

When asked about how participatory approaches contributed to the Last Mile of NTD elimination and control Dr. Oluwole says:

“It has been able to increase therapeutic and geographical coverage where the project has been implemented and it has increased acceptability of the program. There is now more increased awareness of neglected tropical diseases in Enugu State (Nigeria) and of persons who have been neglected... that means moving towards leaving no one behind”

Participatory research builds on community strengths, promotes capacity building and co-learning, and emphasizes collaborative partnerships. However, participatory research requires time and resources in order to build trust and meaningful relationships.

As Dr. Ozono states, “It is really important to have these personal relationships because it builds trust, and with trust, you have better exchange of knowledge and information”.

The Universal Health Coverage target states that everyone should have access to essential quality health services, and access to safe, effective, quality and affordable essential medicines and vaccines, without incurring large financial costs or financial hardship. PC NTD medicines are on the WHO essential medicines list, and due to the very nature of NTDs, NTD programmes aim to reach communities who are underserved by public services. Whilst there have been huge strides made through national NTD programmes, population groups & subgroups are missed by these vertical, large-scale programmes and a shift in our approach is needed as highlighted by the WHO Road map for NTDs 2021-2030 

“The road map, developed through an extensive global consultation, encourages a fundamental shift in approach from vertical disease programmes to cross-cutting approaches based on the needs of patients and communities.”

Identifying who is being missed by our programmes, and using participatory research tools such as transect walks will help us design and integrate NTD delivery services that meet the needs of all groups and subgroups in communities, so that health services are equitable and accessible for all, and no one gets left behind. 

Find out more about Universal Health Coverage Day