Uniting to Combat Neglected Tropical Diseases
International Development Committee: Call for evidence opened on impact of UK aid cuts
About Uniting to Combat Neglected Tropical Diseases
Uniting to Combat NTDs was established in 2012, following the signing of the London Declaration on NTDs. Her Majesty’s Government (HMG) spearheaded the London Declaration where governments, industry, donors and civil society pledged their commitment to tackle neglected tropical diseases (NTDs). They committed amongst others, to enable adequate funding to endemic countries to implement NTD programmes. Industry partners on the other hand, committed to ensure the necessary supply of drugs and other interventions to help control, eliminate and eradicate 10 neglected tropical diseases.
The momentum from the London Declaration helped grow the global NTD effort into one of the largest public private health initiatives in history, reaching one billion people annually with better tools and at lower costs. Because of the progress made, 600 million people are no longer at risk of NTDs, and 33 countries, including many of strategic importance to the UK have eliminated at least one NTD.
The UK has been a global leader in the fight against NTDs for well over a decade - harnessing the power of British scientists, NGOs, private sector and philanthropists and leveraging drug donations worth some $17 billion from pharmaceutical companies including GlaxoSmithKline (GSK).
In April 2017 the UK announced new support of £205 million to NTDs. These new investments were used to launch the “Accelerating the Sustainable Control and Elimination of Neglected Tropical Diseases” (ASCEND) programme, its flagship programme working to fight six NTDs in 24 countries across Africa and Asia and protecting 200 million people worldwide from debilitating diseases.
In April 2021, the partnership found out - as part of the UKs aid cuts - that the UK had decided to completely exit from supporting ASCEND and other NTD programmes, and that all activities had to stop by end of August 2021.
Following is our response to how this exit has been communicated, the impact this will have on those affected by these diseases of poverty and on the partnership to end neglected tropical diseases, to which the UK is a signatory.
Response to ‘Strategy’
At present the UK lacks a transparent overseas development aid (ODA) strategy and is yet to publish its global health strategy. Therefore, we have to rely on FCDO’s statements on what its priorities are. Even with published statements, it is still unclear how priorities have been translated into funding decisions.
For example, The Secretary of State Dominic Raab in his written statement to parliament on 21 April, stated that his department had “strived to ensure that every penny of the FCDO’s ODA spend brings maximum strategic coherence, impact and value for taxpayers’ money”.
With this criterion, it is hard to see why some programmes, such as those that support the elimination of neglected tropical diseases and proven to deliver both impact and value for money have been completely withdrawn.
The UK Government has stated that it will return to its commitment of 0.7% of gross national income to ODA when the fiscal situation allows. The Government has been pressed multiple times, including by MPs, to outline what those fiscal conditions that would allow a return to 0.7% are, and the timetable for doing so. To date, it has not been able to make this information public.
The decision to permanently exit from programme to fight NTDs is incongruous with this narrative of this being a temporary cut. The Government could have kept the programme running, albeit at a reduced level, as it has done for other programmes, with a view to returning to the full programme when the fiscal situation allows. This is especially true for NTDs as they are infectious diseases targeted for elimination, where tremendous progress is being made, and with many countries close to reaching this milestone. Exiting the programme abruptly, risks disease re-emergence and undoing years of taxpayer investments. 12 FCDO supported countries are on the cusp of achieving elimination.
The UK Government has stated its commitment to leaving no one behind, delivering on the SDGs and in tackling infectious preventable diseases. SDG 3 is focused on ending the epidemics of HIV/AIDS/TB/Malaria and NTDs, yet NTDs and the poorest members of society impacted by them are once again being left behind.
Finally, Lord Ahmad, Minister of State for South Asia and the Commonwealth, speaking at The APPG on the UN Global Goals for Sustainable Development on 12th May, stated that one of the Governments’ top priorities was forging stronger links with the private sector. The NTD programme is the best example in global health of what a strong private, public partnership looks like, with 13 major pharmaceutical companies, including GSK, committing US$17 billion of free medicines to treat nine neglected tropical diseases. On January 30, 2021, the Prime Minister Boris Johnson celebrated GSK’s 10 billionth treatment to fight intestinal worms and lymphatic filariasis. These donations have helped treat 923 million people in 92 countries and contributed to the elimination of lymphatic filariasis - a leading cause of disability - in 17 countries so far. Exiting from this strong partnership is not consistent with a desire to build stronger relationships with the private sector. Private funding and resources are at risk with the UK pulling out from supporting NTD programmes. The UK needs to stay at the table to keep partners invested. For example, how can we get industry to engage in other areas of global health when the UK lets them down on NTDs?
Value for money
NTD programmes are cost effective interventions, and with the added benefit of drug donations by pharmaceutical companies, the value for money and returns on investment are very favourable.
The United States Agency for International Development estimated that, for every US$ 1 spent on NTD programmes, US$ 26 in donated medicines are leveraged through partnerships with pharmaceutical companies (WHO NTD roadmap 2021-2030).
These NTD programmes support many of FCDO’s global challenges, as evidenced
Global Health Security:
NTD programmes were flexed to help the UK’s global response to the COVID-19 pandemic. The delivery platforms that had been set up to reach rural ‘last mile’ communities with NTD treatment quickly flexed to deliver COVID safe messaging. Furthermore, these platforms are so successful at reaching these communities that they have been proposed as the route to deliver COVID vaccines.
Global health security requires disease surveillance and data sharing, especially at the community level. NTD programmes help to strengthen the primary health care system and community-based health care structures that are leveraged for data surveillance beyond NTDs, as was seen during the Ebola crisis where NTD programmes contributed significantly to the response in Guinea, Liberia and Sierra Leone.
The Government has said that it will focus where the need is greatest in Africa, yet the withdrawal from NTD programmes that affect 600 million Africans, many of them amongst the poorest people on the planet, is not consistent with this narrative.
The of Secretary State, Dominic Raab, in his statement on 21st April, stated that one of the seven priority areas is “getting more girls into school” and yet the government appears to have deprioritised services that address the key barriers to girls attending school such as deworming and nutrition.
Among children, intestinal worm infections interrupt education and cause malnutrition, impairing intellectual and cognitive development and stunting growth. And by interfering with education and employment, NTDs keep young girls trapped in poverty.
Deworming in children (against two NTDs: intestinal worms and schistosomiasis) has been shown to considerably reduce school absences - increase attainment - while raising wages in adulthood by as much as 20% (World Bank Group: Human Capital Project), and leads to 14% higher spending on consumption goods (Twenty Year Economic Impacts of Deworming). All with pills that are freely donated by pharmaceutical companies and costs less than 50p to deliver. Making this one of the best buys in development.
The World Bank also notes that the knock-on impact of deworming one girl reduces the risk of others getting worms, indirectly improving their ability to learn in school and attain higher wages later in life (World Bank Group: Human Capital Project).
This deworming initiative can also protect women and girls from HIV. Bilharzia (also known as schistosomiasis) is a parasitic worm that if left untreated causes female genital schistosomiasis, which triples the risk of women getting HIV (UNAIDS: No more neglect).
If the government's priority is girls' education, then it should also address the key barriers to attendance, learning, concentration and attainment at school.
Economic development and trade:
Trade and economic development are heavily reliant on human capital. Without investments in healthy populations, many of whom work in industries that are a priority for the UK’s trade investments, such as in agriculture, productivity within these sectors will be limited.
If NTDs are eliminated as per SDG 3, then benefits to the global economy exceeding US$342 billion up to 2030, in terms of averted out-of-pocket health expenditures and lost productivity for affected individuals will be realised (Disease Control Priorities).
A Twenty Year Economic Impacts of Deworming report found a conservative estimated annualized social internal rate of return of 37%. A high return by any standard.
The Economist Intelligence Unit recently showed that by eliminating the devastating effects of just two NTDs (soil-transmitted helminths and schistosomiasis - both prioritised by the UK) in just four countries (Ethiopia, Kenya, Rwanda and Zimbabwe) would boost these countries GDPs by $5.1bn (purchasing power parity) by 2040. Ethiopia and Kenya would see the biggest gains - $3.2bn and $1.3bn respectively. Their funding for NTDs has just been cut.
What we feel is missing from the global challenges:
The Queen’s speech outlined that a key aim for this government was reducing poverty and alleviating human suffering, yet the recent cuts and the programmes that have been targeted for an exit do not align with this. The current focus does not seem to prioritise the poorest or the most vulnerable members of society. Poverty alleviation, prioritizing communities in poor resource settings and ensuring we don't leave anyone behind, or the Sustainable Development Goals are not mentioned in the seven global challenges.
Currently the world, and the African continent more specifically is facing a huge challenge with vaccine acceptability. Vaccine availability is one part of the problem. A bigger hurdle is building the confidence and trust of individuals to accept the vaccine.
The NTD programme, which has been successfully reaching 1 billion people, five years in a row, has over the years, built the structures, the platforms and the trust of communities and community leaders to accept prevention and treatment against neglected tropical diseases year in year out. There is simply no programme like it, in global health, operating at such a scale and reaching hardest to reach communities on the planet, across ethnic, religious, cultural and gender backgrounds.
These very platforms, that are community led, community driven, and community owned, can be utilised now for the COVID-19 vaccine distribution. The NTD delivery platform which has proven to be a trusted lifeline for hard-to-reach communities during the COVID-19 crisis is deeply rooted within primary health care.
Finally, it would be good to see the Government maximising the gains that have been made so far to protect the investments that taxpayers have made to date. A risk analysis of the impact of exiting programmes at this stage and the implication of that decision would be welcome.
Response to ‘Process’
At the time of writing this submission, the UK Government has not yet fully published the list of programmes that it will continue to fund, the levels of funding it will be providing and the list of programmes the UK Government is exiting from. A lack of transparency in the process has been deeply concerning as the UK Government is a signatory to international protocols on aid transparency.
In response to the cuts, the UK Government has stated that it is spending more on Global Health than other programmes. On the surface, this may appear to be the case but including contributions to COVAX and COVID-19 support to countries, at the expense of other global health programmes, does not appear to be strengthening global health and strengthening health systems. In fact, it weakens it. As millions of communities that were benefitting from treatments to chronic health problems, at a community level, will now be putting pressure on already overstretched health systems.
Other G7 countries such as Canada and Germany are funding their COVAX contributions out of emergency and crisis funds.
Whilst the Secretary of State has published that FCDO will spend £1,305m on global health, “through its commitments to COVAX, GAVI and WHO, and through bilateral spend where the need is greatest in Africa”, it is not clear how this commitment is broken down. A complete breakdown would be welcome.
On NTDs specifically, the UK is a founding member and a signatory to the London Declaration on NTDs, which is a partnership that includes pharmaceutical companies, donors and non-government organisations.
The UK was the main funder of the Queen Elizabeth Diamond Jubilee Trust, which spearheaded the trachoma elimination in the Commonwealth. This project was intended to provide a lasting legacy for Her Majesty the Queen to celebrate her diamond jubilee. This was followed by a commitment in the London Commonwealth Heads of Government Meetings (CHOGM) communique that the UK hosted in 2018 along with further funding for trachoma through the Commonwealth Summit Fund. This was then followed up by the Ascend NTD programme in 2019 which included trachoma. Recently, the Countess of Wessex, joined the Vice President of The Gambia to celebrate the elimination of blinding trachoma in the Commonwealth. Trachoma elimination has also been added by member states in the draft communique for the rescheduled CHOGM as a priority. The UK, whilst Chair in Office, of CHOGM, has now reneged on this formal commitment risking the legacy of the Queen.
Communication with stakeholders, including some pharmaceutical companies that have manufactured and delivered billions of drugs to countries ready for distribution has been poor, and very delayed. In 2020 alone, during a global crisis, pharmaceutical companies, including Eisai, GSK, Merck KGaA, MSD, Pfizer, Gilead, Johnson and Johnson, Sanofi, to name but just a few, most of whom have been busy with the production of the COVID-19 vaccine, have met their commitment to these diseases of poverty, donating and delivering over a billion treatments in 2020 alone to countries. This has meant for some companies, millions of drugs donated and shipped to countries worth billions of dollars risk being wasted, as these companies were not forewarned those programmes would be cut.
Countries, and recipients of this aid were also not given ample warning of these cuts meaning that in some circumstances it is too late to find alternative funding to deliver treatments as the weather window for delivery is very tight.
Response to ‘Impact of Changes’
This decision to withdraw support will leave more than 200 million people vulnerable to NTDs at a time when we are also fighting a global health pandemic.
The UK Government had committed this financial year (to the end of March 2022) to support at-risk communities in 26 countries via its ASCEND and Guinea Worm Eradication programmes. This would have delivered over 250 million treatments, leveraging over 770 million donated medicines (worth roughly US$ 1.2 billion), and supported 180,000 disability-preventing surgeries, whilst strengthening health systems.
As part of its exit plan and communication to partners, the UK Government has stated that it will fund a limited number of activities, but these will need to have ceased by the end of August 2021.
This arbitrary timing means tens of thousands of people that were expecting life changing surgery to prevent blindness and disability will not receive it.
Typically, the majority of mass treatments in countries occurs between November - March, which would have been part of this programme year. Ceasing activities by the end of August means millions of treatments that were planned this year will not take place and some of the corresponding drugs already delivered to the countries may be wasted.
This abrupt exit threatens elimination goals in 12 countries that were on the cusp of reaching this milestone, and we may see possible disease resurgence in areas once free of these devastating diseases:
50% of the global burden of visceral leishmaniasis (VL) - a fatal disease, is in East Africa. The ASCEND programme has been a major provider of life saving medicines to those at risk, supporting the procurement of medicines and diagnostic tests for populations at risk. Exiting from the ASCEND means that individuals that were due to receive lifesaving treatment may no longer receive it. It means a disruption to the global manufacture and supply of essential diagnostics and medicines for VL, due to the loss of a major provider of funding and will cost lives.
Loss of funding to the Guinea worm eradication programme comes at a critical time in the global campaign. Slowing the pace could cause unnecessary setbacks and have devastating impacts on the poorest communities in the world. As Guinea worm is poised to be the second human disease to be eradicated, after smallpox, endgame efforts are focused on stopping transmission in the handful of remaining countries. In 1986, the debilitating disease afflicted an estimated 3.5 million people annually in 21 countries in Africa and Asia. The final cases of any eradication campaign are the most challenging. As a result of strong partnerships, led by the countries themselves, the incidence of Guinea worm disease has been reduced by more than 99.99% to 27 human cases in 2020.