A nice blog on lessons learnt in global health. Advice? Let poor countries run their own programmes and take a systems perspective ...
This blog was originally published here on the Guardian website.
Lessons in global health: let poor countries run their own programmes
In 2008, Square Mkwanda found himself in a quandary: international pharmaceutical companies had just donated millions of dollars worth of drugs to treat Neglected Tropical Diseases (NTDs) in his native
Malawi but the civil servant had no money to distribute them and they were stockpiling in the ministry of health’s warehouses. “I thought, what am I going to tell pharmaceutical companies? That I let billions of kwachas’ [Malawi’s currency] worth of drugs expire because we couldn’t spend just a few millions to distribute them?”
So he talked to his minister of health and they managed to free up enough funds to distribute the drugs in eight districts. By 2009, the distribution programme had reached all 26 districts and was entirely funded by Malawi. Seven years on, Mkwanda, who is the lymphatic filariasis (LF) and NTD coordinator at Malawi’s ministry of health, proudly announced that Malawi has
interrupted transmission of LF (pdf), the second country in Africa to do so.
Leadership like that demonstrated by Malawi was one of the key themes in the
third progress report of the London declaration on NTDs, produced by the consortium Uniting to Combat NTDs and released at the end of June. The report said: “Endemic countries are demonstrating strong ownership and leadership, in variable financial, political and environmental circumstances, to ensure their NTD programs are successful in meeting 2020 targets. Countries are achieving elimination goals, more people are being reached, and the drug donation program for NTDs, the largest public health drug donation program in the world, continues to grow.”
In the wake of the Ebola crisis and in preparation for the sustainable development goals, these success stories are important best practice examples for the global health community as it rethinks how to effectively deliver sustainable programmes. Recognising the opportunities for lessons learned, the World Health Organisation called the elimination and control of NTDs a “
litmus test for universal health coverage (UHC)” – one of the targets of the new development agenda.
Other countries are joining Malawi to take charge of their public health initiatives. Bangladesh, the Philippines and India are now financing 85%, 94% and 100% of their NTD programmes respectively. Motivated by growing evidence of the impact of NTDs on child development and productivity (and as a result on economic growth) 26 endemic countries met in December 2014 to sign the
Addis Ababa NTD Commitment, in which they agreed to increase domestic investment for NTD programme implementation. The Addis commitment was an initiative of Ethiopia’s minister of health Kesetebirhan Admasu. Explaining why more governments are showing interest in this work, Admasu said: “NTDs are not only a health agenda, but a development agenda too, for which the poor pay the highest price.”
These country-owned programmes come in different guises but at the heart of every successful one is an integrated, multi-sectoral approach. Ethiopia for instance requires that every partner working on trachoma implement the full
SAFE strategy – Surgery, Antibiotics, Facial Hygiene, Environmental Improvements – and not just the ‘S’ or ‘A’, on which development programmes tend to focus.
Brazil decided to include NTDs in its national poverty reduction programme, which has other development targets such as education, water and sanitation. Municipalities, who implement the programme, are given free rein to tailor interventions to best suit their circumstances (a peri-urban municipality would have different issues from an Amazonian location for instance).
Other countries used the single funded programme they had – onchocerciasis in Burundi’s case – as the building block to a fully integrated, multi-disease programme. There the ministry of health put in place a dedicated NTD team and worked with national and international partners to build a national programme that has been immensely successful. By end of the programme in 2011,
national prevalence of schistosomiasis had been
reduced from 12% to 1.4%.
Country ownership doesn’t just encourage policymakers to come up with strategies to reach their entire populations with health interventions but it also enables them to practice good resource management. Mkwanda says that NTDs brought good discipline at the ministry of health. “As with NTDs, we sit and budget. And we do not segregate diseases – integration isn’t just for NTDs, it’s for the whole essential care package.”
The story gets even better as countries in the global south, such as Brazil and Nigeria, are not just coming up with their own programmes but also funding others’. Marcia de Souza Lima, deputy director of the
Global Network for Neglected Tropical Diseases says the new funding streams will guarantee that NTD programmes outlive traditional support (a large proportion from philanthropic foundations) but she concedes it also makes them susceptible to leadership change – although recent elections in Brazil and Nigeria suggest this hasn’t been the case.
