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26 THIRD WHO REPORT ON NEGLECTED TROPICAL DISEASES *** Beyond 2020 If the Roadmap’s targets are met for eliminating and controlling five of the NTDs, investment in delivery of medicines for preventive chemotherapy can be scaled down over time, from US$ 390 million in 2015 to US$ 74 million by 2030. The period 2021– 2030 should see re-investment of these savings into other interventions within the NTD portfolio. US$ 17 billion is targeted for the 10-year period, decreasing from US$ 3.0 billion in 2020 to US$ 1.3 billion by 2030 (panel A). This investment will include finishing off the broader preventive chemotherapy agenda, namely surveillance after the intervention has been stopped to prevent recrudescence (panel G). Estimates of the backlog of cases requiring surgery for hydrocele and trichiasis are uncertain, but millions are known to be suffering, and investment targets for morbidity management and disability prevention are significant – US$ 3.1 billion over the period 2015–2030 (panel H). An investment target for passive infectious disease surveillance has not been included here, but is discussed in Chapter 4 in the investment case for human African trypanosomiasis. As targets for preventive chemotherapy are met and transmission of at least three NTDs is interrupted, vector control for Chagas disease, dengue and visceral leishmaniasis will assume an increasingly important share within the NTD portfolio – about US$ 1.2 billion per year or 73% of the total investment targeted for the period 2021–2030 (panel I). Although targets imply an ambitious scale up from current levels of coverage, the investment targets are lower than the costs that would be incurred by health systems in the absence of vector control. The economic cost of illness due to vector-borne NTDs is already estimated in billions of dollars each year (29–32). Investments in vector control for Chagas disease may decrease after an initial programme attack phase in 2015–2020, as countries move to a surveillance phase. Investments in vector control for dengue, on the other hand, may continue to increase until 2030, in the context of a changing climate. These investments will contribute also to the control of other arbovirusrelated diseases transmitted by the same vectors. Innovative vector control methods under development will hopefully help decrease cost while extending coverage. In any case, investments in vector control for dengue are expected to be complementary to the eventual introduction of a vaccine against dengue. Although it may be possible to rebalance the investment portfolio – from vector control towards immunization – the cost–effectiveness of any such rebalancing needs to be evaluated. Immunization may be constrained by manufacturing capacity and the lack of vaccines for diseases transmitted by the same vectors. As a result, vector control will continue to play a pivotal role in reducing vector densities and managing outbreaks. Given the scale of the investment targeted well beyond 2020, universal coverage against NTDs requires a serious investment strategy.
*** INVESTING TOWARDS UNIVERSAL COVERAGE AGAINST NTDS − CHAPTER 2 27 Beyond charity Excluding medicines, the investment target for universal coverage against NTDs averages US$ 2.1 billion per year over the period 2015–2030. This target approaches the US$ 2.5 billion that was spent on malaria control in 2012, but is less than the US$ 5.1 billion that the malaria control community has estimated is required on average each year (33,10). It is aimed at reducing a global burden of disease equivalent to about one half of that for malaria (6,7). Investments in universal coverage against NTDs will not be trivial – neither in their scale nor in their impact. The role of foreign donors and community volunteers in the progress made in NTD control to 2015 is highlighted later in this chapter. However, NTD control needs to become an integral part of national health plans and budgets and rely less on charity if it is to achieve universal coverage. Reliance on foreign donors and community volunteers becomes problematic when it results in fragmented NTD projects that fail to deliver the high levels of sustained coverage that are required to interrupt transmission. The investment target for universal coverage against NTDs is about 10 times the US$ 200–300 million disbursed or committed by foreign donors during 2012–2014 (34). It is unlikely that an increase of this order of magnitude can be achieved in the current global health financing climate. Studies of the cost of preventive chemotherapy reviewed for this chapter indicate that unpaid volunteers were used in about 80% of sites. In studies in which the opportunity cost of their time was estimated, it comprises 8–60% of the total. The role of community health workers will continue to play a role in universal coverage against NTDs; but fully-scaled NTD control programmes covering over a billion people cannot expect to recruit and retain sufficient numbers of volunteers if other major disease programmes are offering incentives. 2.4.3 Investment targets for low- and middle-income countries Where do most of the investments in universal coverage against neglect need to be made? In this section, investment targets are broken down by groups of low- and middle-income countries. Middle-income countries include both lower-middle-income and upper-middleincome countries. Fig. 2.5 combines investment targets for preventive chemotherapy excluding medicines, surveillance after preventive chemotherapy, yaws eradication and vector control under the heading of “prevention”. The investment target for prevention during 2015–2030 is US$ 30 billion. Most of the investment in prevention is required in lower-middle-income countries – US$ 11 billion including vector control or US$ 3.0 billion excluding it. Investment targets decrease as diseases are eradicated, eliminated or controlled such that the frequency of interventions can be scaled down. In upper-middle-income countries, targets for prevention are made up almost entirely of investments in vector control.
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*** ANNEXES 179 ANNEXES
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*** ANNEXES 185 WHA66.12 3. REQUEST
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*** ANNEXES 189 Annex 5. Medicines
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*** ANNEXES 191 WHO REGIONAL OFFICE
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