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INVESTING TOWARDS UNIVERSAL COVERAGE AGAINST NTDS − CHAPTER 2
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With this report, WHO will begin to publish updated cost−effectiveness estimates for NTD
interventions at the global or regional level that can be included in priority setting exercises
for UHC. This work continues with the third edition of the Disease Control Priorities
Project. Country-specific results will be developed with countries upon request, to facilitate
country-level priority-setting.
2.5.2 Towards an investment case including equity
WHO’s Guidance for Priority Setting in Health Care, or GPS-Health, initiative offers a
checklist of equity criteria relevant to the categorization of “priority classes” that should
be considered in addition to cost−effectiveness analysis (37). These include: criteria related
to the disease or condition targeted (severity of disease, capacity to benefit and past health
loss); characteristics of social groups (socioeconomic status, area of living, gender, etc.); and
non-health consequences of an intervention (financial protection, economic productivity
and care for others). Multi-criteria approaches to priority-setting have already been applied
in health and are beginning to emerge within the NTD space (38). How prepared is the
NTD community to provide and use socioeconomic and other non-health evidence to
inform the priority-setting process?
A review of the evidence on within-country inequality in the distribution of 10 selected
NTDs reveals that most, but not all, evidence points to a higher risk of infection among low
socioeconomic groups – the so-called social gradient. Evidence is scarce for some NTDs
but more readily available for others and, among the evidence that does exist, the slope of
the gradient varies across diseases and countries. In general, however, the prevalence of
infection is several times higher in lower compared with higher socioeconomic groups,
leading to a high concentration of the burden among the poorest. 1 For example, in Bihar,
India, 83% of households in communities with high attack rates of visceral leishmaniasis
belonged to the two lowest quintiles (the poorest 40%) of the wealth distribution (39).
Dengue may be a notable exception within the NTD portfolio, with conflicting evidence
on whether risk is associated with socioeconomic status (40,41). Nevertheless, the absence
of a gradient in the risk of infection does not mean that the economic cost is not heaviest
among the poor.
Studies of catastrophic health expenditure 1 or the related concept of indebtedness aim
to capture some of the economic cost of disease. Such studies are still relatively few for the
NTDs. Catastrophic expenditure and indebtedness have, nonetheless, been documented for
treatment and care of Buruli ulcer (42), dengue (43,44) and human African trypanosomiasis
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1
See Abstract 67 of the 63rd annual meeting of the American Society of Tropical Medicine and Hygiene (New Orleans (LA),
USA, 2–6 November 2014): Kulik MC, Houweling TA, Karim-Kos HE, Stolk W, Richardus JH, de Vlas S. Socioeconomic
inequalities in the burden of neglected tropical diseases (http://www.astmh.org/AM/Template.cfm?Section=Abstracts_
and_Education1&Template=/CM/ContentDisplay.cfm&ContentID=6128; accessed January 2015).
2
Out-of-pocket payments exceeding 10% of annual household spending or, alternatively, 40% of non-subsistence spending.