Lancet Series. Neglected Diseases Complete

Editorial
2 www.thelancet.com Vol 375 January 2, 2010

Drug development for neglected diseases: pharmas inuence
The pharmaceutical industrys latest attempt to sabotage
the work of the WHO Intergovernmental Working
Group on Public Health, Innovation and Intellectual
Propertycommonly referred to as IGWGreached
a new low last week when the non-governmental
organisation, Intellectual Property Watch, noticed two
privileged IGWG draft documents and an analysis of the
drafts by the International Federation of Pharmaceutical
Manufacturers and Associations (IFPMA) on Wikileaks,
a website that anonymously publishes sensitive infor-
mation. This unfortunate situation is a double blow
to the member states, public health advocates, and to
non-governmental organisations that have strived to
make research and development for neglected diseases
a feasible reality. Not only has the IFPMA blatantly
served its own interests by examining and discussing
docu ments that, according to WHO, it was not supposed
to have, but also the draft report falls pathetically short
of the strong, decisive plan necessaryironically, mostly
thanks to the inuence of the pharmaceutical industry.
The leaked draft report lists the innovative ideas for
drug research and development least likely and most
likely to work. Those ghting to prevent deaths from
neglected diseases will be disappointed. Several of
the much supported proposals, such as prize funds
and an R&D Treaty, have been deemed ineective.
Unsurprisingly, the IFPMA thinks that the draft report
is fair to industrys concerns, but appears wary of
UNITAIDs proposed patent pool, a drug-purchasing
mechanism currently supported by an international
campaign.
The drug industry should no longer be allowed to
hold the poor people of the world to ransom. After
this latest incident, perhaps it is time for another
global public out cry (just like in 2001 when 39 drug
companies took the South African Government to
court over its use of generic drugs) to protest at the
tactics used by the pharma ceu tical industry. History
has not yet drawn a line under inno vative research
and development for neglected dis eases. There is still
time to put the health needs of poor people rst in
upcoming meetings to discuss the draft IGWG pro-
posals. But a bold WHO and UNITAID are essen tial.
Buckling under pressure is not an option. The Lancet
For more on the leaked
documents see http://www.ip-
watch.org/weblog/2009/12/09/
condential-documents-
released-from-who-rd-nance-
group-pharmaceutical-industry/
For more on the drug industrys
inuence on the IGWG process
see Editorial Lancet 2007;
370: 1666
For more on the UNITAID
patent pool proposal see
Editorial Lancet 2009; 374: 266
For more on the patent pool
campaign see http://www.
msfaccess.org/main/access-
patents/make-it-happen-
campaign/
For more on WHOs list of
neglected tropical diseases see
http://www.who.int/neglected_
diseases/diseases/en/
For more on snake bite see
http://www.who.int/neglected_
diseases/integrated_media_
snakebite/en/index.html
Snake bite: time to stop the neglect
A Series about neglected tropical diseases, for which
David Molyneux provided advice and helped to co-
ordinate, starts in The Lancet today. These diseases aect
people in the bottom billion, the poorest in the world.
Additionally, snake bite, which was added to WHOs list of
neglected tropical diseases in April, 2009, is discussed by
David Warrell in a Seminar and by David Williams, from
the perspective of the Global Snake Bite Initiative, in a
Viewpoint. Like the other diseases on WHOs list, snake bite
aects mainly the poorest people in the world; however,
unlike the others, it is a non-communicable disease.
About half of venomous snake bites result in
envenoming. So far, estimates of the number of deaths
worldwide resulting from such bites are not supported
by data from adequately done community-based epi-
demiological studies, and dier greatly from 20 000 to
125 000. This di culty could be ameliorated if snake
bite was made a notiable disease and recorded with the
International Classication of Diseases code T63.0 (toxic
eect of contact with snake venom) in death certication,
and deaths outside hospitals were accounted for properly.
People most likely to be bitten by snakes live in rural
areas in Africa, Asia, and Latin America, and work mostly
in agriculture; therefore, snake bite also aects food
prod uction in these communities. Education of commu-
nitieseg, about avoiding snakes through improved
understanding of their behaviour, wearing protective
boots when out in paddy elds, and not sleeping on the
groundwould reduce the likelihood of being bitten,
and is inexpensive. Treatment of victims with antivenom
is often eective but, in some cases, needs to be supple-
mented with support for respiratory or renal failure. Use of
antivenom needs regulation and further research, which
is made di cult because placebo-controlled studies are
generally regarded as unethical. Hopefully, recognition
of snake bite as a neglected tropical disease will promote
funding for assistance and investigation of its many dier-
ent aspects for which information is lacking. The Lancet
See Comment page 3
See Perspectives page 21
See Series page 67
See Seminar page 77
See Viewpoint page 89
Published Online
December 15, 2009
DOI:10.1016/S0140-
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The printed
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an image merely
for illustration
Comment
www.thelancet.com Vol 375 January 2, 2010 3
Neglected tropical diseasesbeyond the tipping point?
A Series starting in The Lancet today
1
is a tipping point
to ensure that some of the most prevalent infections
of the worlds poorest people gain recognition. These
diseases and the billion people that they a ict are
worthy of a fairer share of global health assistance than
previously committed, and of increased attention from
the research community in view of their prevalence and
burden of disease (panel).
Only 06% of overseas development assistance for
health is allocated to neglected tropical diseases, despite
such diseases aecting at least 1 billion people.
2,3
Since
2004, the case for recognising these diseases as the
most prevalent, disabling, and stigmatising infections
of the worlds poorest people has been consistently
articulated.
46
Neglected tropical diseases are the low-
hanging fruit interventions because success has been
achieved in their control with strategies that are cost
eective, deliverable, eective, and which provide
beyond disease-specic benets.
3,4
The idea that one drug can combat more than one
disease, and conversely, that an intervention can be used
to distribute more than a single drug inspired WHO to
launch a global strategy against helmintic diseases.
7
The
unit costs of delivering the drugs against these infections
is often less than US$050 per person per year, while
the provision of donated drugs by several major drug
companies is crucial.
3,5,7
The core interventions for laria-
sis, onchocerciasis, schistosomiasis, and soil-transmitted
helmin thiasis are among the most cost eective in terms
of disability-adjusted life-years averted.
8
These diseases
can be tackled through co-implementation, to give savings
of up 47%,
9
which suggests that preventive chemotherapy
interventions are among the best buys in public health.
10
Community-directed interventions can serve as a
platform for interventions against both malaria
11
and
HIV
12
where formal services are limited, while schools also
provide an eective entry point to deliver commodities
to children and communities.
The Series on neglected tropical diseases reviews these
diseases from perspectives of partnership, governance,
and policy; in terms of the need for integration into
existing health-care systems; and how the needs for
mapping, monitoring, and evaluation and surveillance
can be built into programmes to provide metrics. Finally
the crucial inuence of the social and economic eects
of these diseases is summarised, showing the inuence
on the worlds poorest people but emphasising the low
costs and add on benets.
10
The Series focuses on the core neglected tropical
dis eases:
3,5
those most prevalent, with the highest
burden, and with demonstrable success in proven
strategies and scaling-up. Arguments remain as to
what constitutes a neglected tropical disease. Many
diseases vie for inclu sion as the marginalised infections
of poor populations and deservedly require attention:
the neglected zoonotic infections; snakebite as a non-
communicable but neglected problem that a icts the
poorest people with least access to health facilities;
13

and the respiratory and diarrhoeal diseases that are
neglected in terms of research resources compared
with the burden of mortality.
1
Millennium Development Goal 6 refers to other
diseases, which fuelled the desire to recognise these
other diseases and created advocacy constituencies
that emphasise the need for recognition of diseases
beyond HIV, tuberculosis, and malaria.
6
The fraction of
the planet infected with HIV (about 40 million of the
bottom billion) raises issues of equity in view of the
burden of diseases on the 960 million without HIV or
those who have survived malaria but are now exposed
to other debilitating infections of poverty.
Going beyond the tipping point now means new
resources must be mobilised within a challenging
Panel: Neglected tropical diseasesthe context and key points
At least the bottom billion of the poorest people a icted
Burden at least equivalent to tuberculosis and malaria
<1% of overseas development aid for health devoted to control
Major drug companies provide good-quality e cacious products as long-term donations
Proven successes as a platform; dened strategies, country commitment, and rapid
scaling-up possible
Broad-spectrum eect of some donated products, including educational benets and
possible prevention of HIV infection
Community-based and school-based treatment provides platform for other
interventions (insecticide-treated bednets, vitamin A, HIV prevention)
Freedom from neglected diseases as human-right equity; e cacy, equality,
eectiveness, and elimination/eradication
Research needs well-dened drugs and diagnostics (including surveillance tools)
Regional approaches to nancing, intervention strategies, epidemiology, and regional
elimination of targeted diseases
Units costs per annum as low as US$050; DALYs averted among lowest cost
interventions; economic rates of return among the highest in health
See Editorial page 2
See Series page 67
Comment
nancial landscape. The Bill & Melinda Gates Foundation
announced a new catalytic investment to build regional
funding to support integrated control and elimination
strategies for neglected tropical diseases worldwide, and
to leverage additional investments in support of a global
campaign, called End the Neglect 2020,
14
in partnership
with WHO. Decentralisation into regional strategies
will harmonise eorts and empower governments,
donors, and international organisations to address the
epidemiological and health-system settings in which the
diseases exist.
The rst regional fund was established at the Inter-
American Development Bank with the Pan American
Health Organization to support regional elimination
strategies and increase access to deworming drugs for
children.
15
Pooled investments will aggregate demand
and provide an incentive for endemic countries to
establish plans. Such models are designed to show that
resources can be eectively mobilised across a range of
development priorities, such as water, sanitation, and
education, maximising the impact of those investments
in the poorest communities at the lowest cost.
If the global health community, which purportedly
is seeking to serve the poorest, cannot deliver donated
drugs of proven e cacy that can eliminate disease and
provide multiple benets at the annual cost of cents
rather than dollars, it is di cult to see that community
rising to the greater and costlier challenges. This is a tip-
ping point for the diseases of the poorest people. There
are challengesto nd the resources to deliver available
interventions and to increase research and development
for diseases that are tool decient. Such new tools
must be nanced, delivered, and sustained in the most
resource-constrained health systems. However, much can
be done now to address existing fundamental inequity.
David H Molyneux
Centre for Neglected Tropical Diseases, Liverpool School of
Tropical Medicine, Liverpool L3 5QA, UK
david.molyneux@liv.ac.uk
I am the executive secretary of the Global Alliance to Eliminate Lymphatic Filariasis.
I have received grants from the UK Department for International Development,
including a 25% contribution from GlaxoSmithKline to the Liverpool School of
Tropical Medicine. I attend meetings of the Mectizan Donation Program, and am
supported by GlaxoSmithKline and Merck to provide independent scientic advice.
1 Liese B, Rosenberg M, Schratz A. Programmes, partnerships, and governance
for elimination and control of neglected tropical diseases. Lancet 2010;
375: 6776.
2 Liese B, Schubert L. O cial development assistance for healthhow
neglected are neglected tropical diseases? An analysis of health nancing.
Internat Health 2009; 1: 14147.
3 Hotez PJ, Fenwick AS, Savioli L, Molyneux DH. Rescuing the bottom billion
through control of neglected tropical diseases. Lancet 2009; 373: 157075.
4 Molyneux DH. Neglected diseases but unrecognised successeschallenges
and opportunities for infectious disease control. Lancet 2004; 364: 38083.
5 Hotez PJ, Molyneux DH, Fenwick A, et al. Control of neglected tropical
diseases. N Engl J Med 2007; 357: 101827.
6 Molyneux DH. Combating the other diseases of MDG 6: changing the
paradigm to achieve equity and poverty reduction? Trans R Soc Trop Med Hyg
2008; 102: 50919.
7 WHO. Preventive chemotherapy in human helminthiasis. Coordinated use of
anthelminthic drugs in control interventions: a manual for health
professionals and programme managers. 2006. http://www.who.int/
neglected_diseases/preventive_chemotherapy/pct_manual/en/index.html
(accessed Oct 29, 2009).
8 Laxminarayan R, Mills A, Breman JG, et al. Advancement of global health: key
messages from the Disease Control Priorities Project. Lancet 2006;
367: 1193208.
9 Brady MA, Hooper PJ, Ottesen EA. Projected benets from integrating NTD
programs in sub-Saharan Africa. Trends Parasitol 2006; 22: 28591.
10 Conteh L, Engels T, Molyneux DH. Socioeconomic aspects of neglected
tropical diseases. Lancet (in press).
11 Molyneux DH, Hotez PJ, Fenwick A, Newman RD, Greenwood B, Sachs J.
Neglected tropical diseases and the Global Fund. Lancet 2009; 373: 29697.
12 Stoever K, Molyneux DH, Hotez P, Fenwick A. HIV/AIDS schistosomiasis and
girls. Lancet 2009; 373: 202526.
13 Kasturiratne A, Wickremasinghe AR, de Silva N, et al. The global burden of
snakebite: a literature analysis and modelling based on regional estimates of
envenoming and deaths. PLoS Med 2008; 5: e218.
14 Global Network for Neglected Tropical Diseases. Special announcement:
Global Network for Neglected Tropical Diseases receives $34 million grant
from Gates Foundation. Jan 20, 2009. http://gnntdc.sabin.org/feature/
gates-announcement (accessed Oct 13, 2009).
15 Global Network for Neglected Tropical Diseases. Global Network for
Neglected Tropical Diseases partners with IDB, PAHO to help control,
eliminate neglected tropical diseases. Sept 8, 2009. http://www.global
network.org/press/2009/9/8/global-network-neglected-tropical-diseases-
partners-idb-and-paho-help-control-and-eli (accessed Oct 13, 2009).
Preventing ventricular tachycardia with catheter ablation
Sustained ventricular tachycardia late after myocardial
infarction often leads to cardiac arrest and sudden
death. However, in some patients the tachycardia is
haemodynamically stable, presenting as a wide QRS
tachycardia. Regions of myocardial brosis are the
anatomical substrate for these arrhythmias, inter-
spersed with poorly coupled surviving myocytes, and
slow conduction that promotes re-entry. This substrate
is usually stable over years and does not depend on
episodes of myocardial ischaemia.
1
Observational
series suggest a low risk of sudden death (24% in one
series mana ged largely with anti arrhythmic drugs and
cathe ter ablation
2
), for patients with stable ventricular
tachy cardia, a group largely excluded from random-
ised trials of implantable cardio verter debrillators.
Several considerations, however, support use of such
See Articles page 31
Perspectives
Prole
David Molyneux: raising the prole of neglected tropical diseases
With more than a third of the worlds population exposed
to neglected tropical diseases (NTDs), and around 1 billion
people infected at any time, its hard to understand how the
word neglected can possibly be part of the terminology.
Onchocerciasis, lymphatic lariasis, schistosomiasis, soil-
transmitted helminthiasis, and trachoma are the ve
most common NTDs, and there are many more. Aected
individuals often have multiple NTDs, which leads to
a vicious cycle of poverty and illness and also results in
about half a million deaths each year. David Molyneux, of
the Liverpool School of Tropical Medicine, has dedicated
his 40-year career to ghting these diseases.
Molyneux, who coordinated The Lancets series on NTDs
that begins this week, has had a long association with the
Liverpool School of Tropical Medicine, where he took his
rst position as a lecturer after degrees in zoology and
parasitology from Cambridge University. Between 1970
and 1972, he worked in Africa at the Nigerian Institute of
Trypanosomiasis Research, where he gained invaluable rst-
hand experience of many NTDs. After returning to Liverpool,
Molyneux worked on leishmania parasites and then, in
1975, was recruited by WHO to run a project in what is now
Burkina Faso, developing diagnostic techniques for African
trypanosomiasis and new approaches to spraying insecti-
cides on the tsetse ies that spread the disease. This project
eventually extended across Africa. It was quite a complex,
challenging project, Molyneux recalls. As an English person
in a Franco-African environment, it was di cult arranging
helicopters, insecticides, and ying experts in and out.
In 1977, Molyneux settled back in the UK with his young
family, and became Chair of Biological Sciences, and later Dean
of the Faculty of Science, at the University of Salford. But his
interest in tropical medicine continued to ourish, especially
in WHO and partners onchocerciasis programme. When he
returned to the Liverpool School of Tropical Medicine as its
Director, in 1991, he says that funding was scarce: At that
time, there was no Gates Foundation, and the Department
for International Development (DFID) was reorganising
previous core support to the School. However, in 1997,
DFID approached Molyneux to develop a partnership with
GlaxoSmithKline to eliminate lariasis. DFID would provide
1 million per year while GlaxoSmithKline would supply
albendazole free until 2020. And from this collaboration the
Global Alliance for the Elimination of Filariasis was formed.
Molyneux only stepped down as Director of the Liverpool
School of Tropical Medicine in 2000, after DFID assured him
that support for lariasis would be for at least 5 years. The
programme now treats half a billion people in 51 countries
each year. David Molyneux is one of the most original and
innovative minds I have come across and a mentor for
many of us in WHO with his extensive experience in the
control and elimination of several tropical diseases, says
Lorenzo Savioli, Director of WHOs Department of Control
of Neglected Tropical Diseases.
Advocacy on NTDs began to accelerate with the estab-
lishment of WHOs NTD Department in 2005. Although
there is no support from the Global Fund to Fight AIDS,
Tuberculosis and Malaria, the Bill & Melinda Gates Founda-
tion began to show an interest and the US and UK
Governments have both recently stepped up funding in this
area. Funding is a critical issue: funds for NTDs represent
just 06% of total international development assistance,
compared with 37% for HIV/AIDS. It is a gap Molyneux
has never understood, especially when there are drugs for
many of these diseases available at low cost or donated free
from pharmaceutical companies. If we cant deliver free
drugs to poor people which actually have multiple impacts,
I dont think there is much else we can do in international
health, he says. Molyneux has been criticised by the HIV
and malaria communities for his comments on funding
distribution. Taking Ethiopia as an example, Molyneux says
he cannot understand why HIV, which aects less than 2%
of the population, receives US$135 million, and the rest of
the Ethiopian health system receives $35 million. If this
situation arose in the UK, there would be riots, he asserts.
The Gates Foundation has given its support to publicise
NTDs, but more must be done and Molyneux says there
are encouraging signs from DFID, USAID, and G8 countries
that NTDs are moving up the agenda. My position has
always been that if you are going to do anything about the
MDGs which have the overall objective of taking people out
of poverty then you had better to do something about the
diseases which aect the most people rather than those
that aect the minority, he says. Molyneux believes the
best solution would be incorporation of NTDs into the
Global Fund portfolio and that attention must be given
to sustainable interventions that reach beyond health
systems. He points out that many communities aected
by onchocerciasis are at least 20 km from the nearest
health facility, yet they receive treatment. We need to pick
the low-hanging fruitthat is, do what we can do now
with what we have nowwe cant simply wait for health
systems to develop in countries. Molyneux adds that: The
voiceless poor are disenfranchised. People at policy level
believe only malaria, tuberculosis, and HIV exist. The other
diseases of MDG 6 are totally ignored, but cause as large a
burden as malaria and tuberculosis.
Tony Kirby
tony.kirby@lancet.com
To listen to an audio interview
with David Molyneux see
http://www.thelancet.com/audio
See Comment page 3
See Series page 67
Series
Neglected Tropical Diseases 1
Programmes, partnerships, and governance for elimination
and control of neglected tropical diseases
Bernhard Liese, Mark Rosenberg, Alexander Schratz
Neglected tropical diseases represent one of the most serious burdens to public health. Many can be treated
cost-eectively, yet they have been largely ignored on the global health policy agenda until recently. In this rst paper
in the Series we review the fragmented structure of elimination and control programmes for these diseases, starting
with the ambiguous denition of a neglected tropical disease. We describe selected international control initiatives
and present their eect, governance arrangements, and nancing mechanisms, including substantial drug-donation
programmes. We also discuss eorts to exploit shared features of these diseases by integration of selected control
activities within countries, thus creating economies of scope. Finally we address the challenges, resulting from the
diversity of disease control approaches and governance structuresboth nationally and internationallyand provide
some suggestions for the way forward.
Introduction
Neglected tropical diseases represent the most common
diseases for the 27 billion people living on less than
US$2 per day.
1
Despite their substantial disease burden,
they have been largely ignored in the global health policy
debate until recently. These diseases hinder economic
development, cause chronic life-long disability, and
impair childhood development in poor and dis en fran-
chised communities in which they are most prevalent.
24

Some advocates suggest that control of neglected tropical
diseases might be an e cient way to ght poverty,
5
since
some of these diseases can be treated very cost-
eectively.
68
Measured in disability-adjusted life-years
(DALYs) lost, the group of diseases represents one of the
most serious burdens in global public health, ranking
higher than malaria and tuberculosis in some
assessments (table 1).
9
Social stigma, prejudice, marginalisation, extreme
poverty of a icted populations, and low mortality are
several factors contributing to the neglect of these
diseases. Their prevalence in specic geographical and
environmental conditions outside the developed world
and their insignicant market share for pharmaceutical
business further reduces these diseases prominence in
the global health debate.
11
Neglect is also evident in
monetary terms, since these diseases receive a very
small proportion of o cial development assistance for
health. Of the total o cial development assistance for
health from 2003 to 2007, the average share of control
projects for HIV/AIDS was 366%, for malaria 36%,
and for tuberculosis 22%; by contrast, the average
share for control of neglected tropical diseases was
06%.
12
In research and development, the share for the
so-called big three diseases is even larger, at 80% of
total spending.
13
Neglected tropical disease is an umbrella term for a
large group of diseases. Although more high-level
attention and advocacy has recently been given towards
such diseases,
14
there is also a proliferation of programmes
and partnerships that are engaged in their control.
Renewed interest in neglected tropical diseases
One of the rst internationally coordinated initiatives
addressing a neglected tropical disease was the
Onchocerciasis Control Programme (OCP), which was
conceived as early as in 1968, and launched in 1974, with
co-sponsorship by WHO, the World Bank, UNDP, and
the Food and Agriculture Organization.
15
The UN
co-sponsorship was typical of initiatives started during
that period. Its primary objectives at inception were dual,
emphasising both the public health and economic
dimensionto eliminate the blinding disease and by
doing so opening up large areas of prime agricultural
land for settlement.
16
But in the late 1970s and 1980s,
resources and the political momentum for control of
tropical diseases dwindled, partly because of the failure of
the malaria eradication programme and a shift of focus to
the social and equitable dimensions of health in the form
of primary health care.
17
By the late 1980s, another public
health issue gained prominence, which increasingly
dominated and continues to dominate the discourse in
popular culture, academia, and even the security and
intelligence communitythe HIV/AIDS pandemic.
18,19

An exclusive innovative nancing mech anism was set up
for HIV/AIDS, malaria, and tuberculosis in the form of
the Global Fund, while funding for neglected tropical
diseases remained limited to a few donors. Although
funding for HIV/AIDS is often regarded as additional to
the historical o cial development assistance ows to
health, many believe that it has forced out other public
health resources.
20
Yet, this trend shows that resource
mobilisation through innovative mech anisms can be
successful when the need is eectively communicated to
a broad coalition of stakeholders.
Against this backdrop, two workshops in Berlin,
co-hosted by the German Agency for Technical
Lancet 2010; 375: 6776
See Comment page 3
This is the rst in a Series of
four papers about neglected
tropical diseases
Department of International
Health, Georgetown
University, Washington, DC,
USA (B Liese MD, A Schratz MA);
and Task Force for Global
Health, Decatur, GA, USA
(M Rosenberg MD)
Correspondence to:
Dr Bernhard Liese, Department
of International Health,
Georgetown University, SNHS,
3700 Reservoir Road, NW,
Washington, DC 20007, USA
bhl6@georgetown.edu
Series
Cooperation and WHO in 2003 and 2005, refocused
attention towards so-called neglected diseases. In the
rst workshop, participants called for an integrated
approach towards these diseases both for e ciency and
advocacy reasons.
21
The second workshop concluded that
the burden of disease shared by all the neglected tropical
diseases justied an increased share of resources, that
low-cost and cost-eective interventions were widely
available, and that some integration or co-implementation
was possible.
22
Terminology
Nonetheless, there is still some ambiguity about the
term neglected tropical diseases, which is shown in a
study by the UK Department for International
Development stating in 2003 that There is no standard
global denition of neglected diseases,
23
a nding that
still holds nowadays. Rather than having a widely
accepted and endorsed denition, we nd two
approaches to dening neglected tropical diseases,
which have resulted in many similar, yet dierent,
denitions that contain co-existing and changing lists
of diseases (panel 1). The rst approach emphasises
neglect as the dening characteristic, whereas the
second concentrates on the diseases shared features
and their eects on poverty and development. Although
initially neglect was emphasised as the dening
characteristic, recent denitions draw attention to the
diseases shared features and their eects on poverty
and development.
The 2003 International Workshop on Intensied
Control of Neglected Diseases in Berlin constituted the
rst systematic approach to redirect international
attention and to dene neglected diseases. Its report
specically identies the three levels of neglect that are
common to all the targeted diseasesneglect locally,
nationally, and internationally.
21
Subsequently, publications and the overall discourse
placed more emphasis on other shared features that
had also been noted in the 2003 report. In particular,
the diseases link to poverty and development has been
singled out as their key characteristic. The phrase most
commonly used by WHO is that neglected tropical
diseases persist in conditions of poverty, where
they cluster and frequently overlap.
28
This trend
towards the term diseases of poverty is apparent in
academia and policy alike.
1,5,29
Yet neglect is still
emphasised when these diseases are analysed under a
human-rights paradigm.
30
Recently, there has been a tendency to broaden the
geographic scope of neglected tropical diseases beyond
the tropics. Attempts are made to connect the neglected
diseases in the developing world to those of dis-
enfranchised minorities in the developed world.
31
Thus it
seems as if neglected tropical diseases in all its variations
serves as a rather vague umbrella term that is used to
promote several slightly dierent agendas.
International control initiatives
Despite early calls for integration and the apparent
similarities of neglected tropical diseases, their control
initiatives are heterogeneous. They dier in terms of
origins, geographic coverage, epidemiological goal,
stakeholders involved, funding, and governance structure.
Table 2 presents an overview of initiatives that we have
selected to show key dierentiating organisational and
Disability-adjusted
life-years (million)
Deaths Approximate global
prevalence (million)
Approaches to control
High-prevalence diseases
Hookworm infection 18221 300065 000 600 MDA with rapid eect package or albendazole
Ascariasis 12105 300060 000 800 MDA with rapid eect package or albendazole or mebendazole
Trichuriasis 1664 300010 000 600 MDA with rapid eect package or albendazole or mebendazole
Lymphatic lariasis 58 <500 120 MDA with rapid eect package or diethylcarbamazine+
albendazole or ivermectin+albendazole
Schistosomiasis 1745 15 000280 000 200 MDA with rapid eect package or praziquantel
Trachoma 23 <500 84 SAFE strategy with azithromycin
Onchocerciasis 05 <500 37 MDA with rapid eect package or ivermectin
Leprosy 02 132 000 02 MDA with dapsone, rifampicin, or clofazmine
Vector-borne protozoan and viral diseases
Dengue fever 07 19 000 50 Integrated vector management
Leishmaniasis 21 51 000 12 Case detection and management, and integrated vector
management
Chagas disease 07 14 000 89 Integrated vector management
Human African trypanosomiasis 15 48 000 <01 Case detection and management, and tsetse control
Table reproduced from reference 5, with permission from authors and publisher. Data from Hotez and colleagues,
5
WHO, and Jamison and colleagues.
10
MDA=mass drug
adminstration. SAFE=Surgery, Antibiotics, Face cleanliness, and Environmental improvement. Rapid eect package of four drugs=albendazole or mebendazole, and
praziquantel, ivermectin or diethylcarbamazine, and azithromycin.
Table 1: High-prevalence and other vector-borne neglected tropical diseases
Series
control features. There are, of course, many more
initiatives that are no less important.
Onchocerciasis control remains one of the longest
continuous international disease control eorts. Initially
based on larvicide spraying by helicopter to control the
larvae of Simulium (blacky) vectors in the rivers of
11 west African countries in 1987, it moved to include a
mass drug administration component when the
pharmaceutical company Merck provided its drug
ivermectin (Mectizan) free of charge as long as needed.
32,33

OCP was concluded in 2002, resulting in the elimination
of onchocerciasis from large parts of west Africa and
freeing up 250 000 km of arable land.
The African Programme for Onchocerciasis Control
(APOC) follows the collaborative structure of OCP. Its
primary objective is control of the disease. In 1995,
APOC expanded the area of onchocerciasis control to
the remaining 19 endemic countries throughout Africa.
The programme relies entirely on mass drug
administration and an extensive network of community
drug distributors to reach marginalised communities
that are outside the reach of the regular health system.
34

A crucial element to this strategy is the contribution
from non-governmental development organisations,
which organised themselves in a coordination group as
early as 1992. The groups orchestrated advocacy
facilitated and accelerated the launch of APOC,
particularly the component of community-directed
treatment with ivermectin.
3537
APOC, similar to its
predecessor OCP, is governed through a chartera
memorandum of understandingwhich explicitly
outlines the roles and responsibilities of all entities
comprising the programme.
Established in 1991, the Onchocerciasis Elimination
Programme for the Americas is a multinational,
multiagency coalition between national governments,
Merck, the Pan American Health Organization (PAHO),
the US Centers for Disease Control and Prevention
(CDC), the Carter Center, the Bill & Melinda Gates
Foundation, Lions Club International, and others. The
programme also deploys a community-based dis-
tribution strategy of ivermectin, but with the goal to
eliminate the disease in the Americas. A programme
coordinating committee provides programmatic and
technical review, whereas the main responsibility for
implementation lies with national control programmes
of the participating countries.
38,39
Unlike the onchocerciasis control programmes, the
Guinea Worm Eradication Programme is a fully-edged
eradication programme with the aim to interrupt the
diseases transmission. It relies not on drugs but on
provision of health education, safe drinking water, and
vector control.
40,41
Started in 1980 by the CDC, the
programme is spearheaded by the Carter Center
since 1986, as a global publicprivate partnership
including CDC, WHO, UNICEF, Bill & Melinda
Gates Foundation, and other stakeholders at all levels
of governance.
42
The principal leadership of a few
stakeholders is widely recognised, and each takes
the lead in respective countries. Jointly, they periodic-
ally liaise to sustain global funding and coordinate
strategies.
Panel 1: Denitions of neglected tropical diseases
WHO
Denition
...Chronically endemic and epidemic-prone tropical diseases, which have a very
signicant negative impact on the lives of poor populations [and] remain critically
neglected in the global public health agenda.
24
Diseases
Focus diseases: blinding trachoma, Buruli ulcer, Chagas disease, dengue, dracunculiasis,
human African trypanosomiasis, Japanese encephalitis, leishmaniases, leprosy,
lymphatic lariasis, onchocerciasis, schistosomiases, soil-transmitted helminthiasis,
yaws; other diseases: anthrax, anthroponotic leishmaniasis, brucellosis, cysticercosis,
echinococcosis, rabies.
Global Network for Neglected Tropical Diseases
Denition
The neglected tropical diseases are a group of 13 parasitic and bacterial infections that
aect over 14 billion people, most of whom live on less than $125 per day.
25
Diseases
Ascariasis, Buruli ulcer, dengue, dracunculiasis, human African trypanosomiasis,
hookworm, leishmaniasis, leprosy, lymphatic lariasis, onchoceriasis, schistosomiasis,
trachoma, trichuriasis.
Public Library of Sciences Neglected Tropical Diseases
Denition
The [neglected tropical diseases] are dened as a group of poverty-promoting chronic
infectious diseases, which primarily occur in rural areas and poor urban areas of
low-income and middle-income countries. They are poverty-promoting because of their
impact on child health and development, pregnancy, and worker productivity, as well as
their stigmatizing features.
26
Diseases
Amoebiasis, balantidiasis, Chagas disease, giardiasis, human African trypanosomiasis,
leishmaniasis, taeniasis-cysticercosis, dracunculiasis, echinococcosis, food-borne
trematodiases, loiasis, lymphatic lariasis, onchocerciasis, schistosomiasis,
soil-transmitted helminthiasis, toxocariasis and other larva migrans, dengue, Japanese
encephalitis, jungle yellow fever, other arboviral infections, rabies, Rift Valley fever, viral
haemorrhagic fevers, bartonella, bovine tuberculosis in human beings, Buruli ulcer,
cholera, enteric pathogens, leprosy, leptospirosis, relapsing fever, trachoma,
treponematoses, mycetoma, paracoccidiomycosis, scabies, myiasis.
Neglected Tropical Disease Program (USAID)
Denition
These diseases disproportionately impact the poor and rural populations, who lack
access to safe water, sanitation, and essential medicines. They cause sickness and
disability, compromise childrens mental and physical development, and result in
blindness and severe disgurement.
27
Diseases
Targeted diseases: lymphatic lariasis, schistosomiasis, trachoma, onchocerciasis,
soil-transmitted helminthiasis.
USAID=US Agency for International Development.
Series
Chagas disease (caused by Trypanosoma cruzi and
transmitted by triatomine bugs) in the Americas is
tackled by another type of programme. Aected countries
initiated regional programmes, such as the Southern
Cone Initiative to Control/Eliminate Chagas Disease
(INCOSUR). Founded in 1991, INCOSUR is a key
example of regional coordination. On the one hand,
countries retain full responsibility for nancing,
designing, and implementation of their own national
programmes. On the other hand, there is a common
commitment and a yearly exchange of strategies, goals,
and results.
43
Such regional cooperation was fostered by
the simultaneous development of a common market and
the historic links between countries in this region.
Moreover, technical assistance is provided by an
international technical secretariat based at PAHO, which
catalysed cooperation.
44
Similar initiatives in the PAHO
region are undertaken in Amazonian, Latin American,
and Andean countries.
Another approach is to focus on advocacy, com-
munication, and technical assistance to support a WHO
global programme. This approach was taken by the
Global Alliance for the Elimination of Lymphatic
Filariasis in supporting WHOs Global Programme to
Eliminate Lymphatic Filariasis. Organised as a
partnership of WHO, World Bank, pharmaceutical
companies, non-gover nmental development organ-
isations, and country representatives, the Global Alliance
for the Elimination of Lymphatic Filariasis retains a
light governance structure that facilitates exibility in
addressing specic needs at regional and national
levels.
45
All partners of the alliance elect a representa-
tive contact group, which reects their dierent
expertise and perspectives. However, manage ment and
strategic planning is undertaken by a smaller bodythe
executive group.
The International Trachoma Initiative (ITI) is a
publicprivate partnership created by the Edna
McConnell Clark Foundation and Pzer in 1998, to
promote the WHO-endorsed SAFE strategy (Surgery,
Antibiotics, Facial cleanliness, and Environmental
improvements) and coordinate the distribution of the
antibiotic azithromycin (Zithromax), donated by Pzer,
in selected countries.
4648
This initiative is a partner of
WHOs Alliance for Global Elimination of Trachoma by
2020, established with the goal to eliminate blinding
trachoma and a governance structure similar to other
WHO-driven initiatives described in this paper.
49,50
In
2009, ITI merged with the Task Force for Global Health.
Its governance has been changed by dissolving the
previous ITI board of direc tors and expanding the
authority and decision- making responsibilities of the
trachoma expert committee, which consists of indepen-
dent technical experts together with liaison representa-
tives from inter national organisations, development
agencies, and Pzer. The trachoma expert committee
obtains input from na tion al governments of endemic
countries through repre sen tation by and a close working
Focus disease Duration Relation to
WHO
Regional
distribution
Membership Types of activities Epidemiological
goal
Stated objectives
APOC Onchocerciasis 19952010 Formal (internal)
partner
19 countries in
Africa
Countries, international
organisations, NGOs,
private sector
Advocacy, nancing,
technical assistance
Control Eliminate onchocerciasis in Africa
through community-based
ivermectin treatment
OEPA Onchocerciasis 19912007 Formal (internal)
partner
6 countries in
Americas
private sector
Technical assistance Elimination Eliminate onchocerciasis in Americas
through ivermectin distribution in
endemic communities
GWEP Dracunculiasis 1991present Formal (internal)
partner
6 countries in
Africa
private sector
Advocacy, nancing,
programming, technical
assistance
Eradication Complete eradication of
dracunculiasis
INCOSUR Chagas disease 1991present Formal (internal)
partner
7 countries in
South America
organisations
Technical assistance Control/
eradication
Elimination of Triatoma infestans and
reduction of Chagas disease
GAELF Lymphatic
lariasis
200020 Formal (external)
partner
83 countries in
global tropics
private sector
Advocacy, technical
assistance
Elimination Elimination of lymphatic lariasis by
2020; alleviate hardships for
individals with disability induced by
lymphatic lariasis
ITI Trachoma 19982020 Formal (external)
partner
17 countries in
Africa+Vietnam
private sector
Advocacy, nancing,
assistance
Elimination Achieve global elimination of
blinding trachoma by 2020 through
the SAFE strategy
ILEP Leprosy 1975present No formal
relation
14 developing
countries
NGOs Advocacy, technical
assistance
Control Support leprosy programmes by
providing technical assistance
SCI Schistosomiases 2002present No formal
relation
Sub-Saharan
Africa
NGOs, private sector Advocacy,
assistance
Control Reduce the global disease burden of
neglected tropical diseases in
sub-Saharan Africa by 2015
APOC=African Programme for Onchocerciasis Control. OEPA=Onchocerciasis Elimination Programme for the Americas. GWEP=Guinea Worm Eradication Programme. INCOSUR=Southern Cone Initiative to
Control/Eliminate Chagas Disease. GAELF=Global Alliance for the Elimination of Lymphatic Filariasis. ITI=International Trachoma Initiative. ILEP=International Federation of Anti-Leprosy Associations.
SCI=Schistosomiasis Control Initiative. NGO=non-governmental organisation. SAFE=Surgery, Antibiotics, Face cleanliness, and Environmental improvement.
Table 2: Selected initiatives for control of neglected tropical diseases
Series
relationship with the Alliance for Global Elimination of
Trachoma by 2020.
51
In addition to publicprivate partnerships, there are
also alliances by various private or non-governmental
organisations working on shared goals. In 1966, major
antileprosy associations organised themselves into an
umbrella organisation, which became the International
Federation of Anti-Leprosy Associations (ILEP) in 1975.
ILEP partners coordinate their policies by regularly
sharing information and frequently collaborating on
priority projects. Moreover, they assign one lead
association to every endemic country or state within large
countries. Although there have been recurrent attempts
to forge an alliance between ILEP and WHOs Leprosy
Elimination Programme, that partnership was not always
harmonious.
52,53
The debate about whether elimination or
control should be the goal of the alliance clearly shows
the need for having a congruent mission, strategy, and
values in a successful partnership.
54
Nonetheless, the
alliance was re-established in 2004, and the partners from
both sides are optimistic.
55
The Schistosomiasis Control Initiative was established
in 2002 at Imperial College London through a grant
from the Bill & Melinda Gates Foundation, partnering
with WHO and the Danish Bilharzia Laboratory. Its goal
was to establish sustainable national schistosomiasis
and intestinal helminth control programmes in
sub-Saharan Africa, focusing on treatment of school-
aged children and other high-risk groups.
56,57
Eight
countries were selected, and the initiative focused on
operational research and in-country training through a
project-based approach. In 2006, its mission was
broadened with another grant from the Bill & Melinda
Gates Foundation to include other prevalent neglected
tropical diseases, because co-infections were the norm
rather than the exception in the target countries.
58

Consequently, pro gramme managers in the eld have
now started to explore integrated approaches for drug
delivery, moni toring, and assessment.
59
Drug donations
No other public health initiative has beneted from the
availability of donated drugs to such an extent as have
neglected tropical diseases. Key enabling factors for these
donations are the preventive public health nature of the
programmes; their large scale; the pre-existence of
structured multidonor, international control eorts; and
clearly delineated accountability and evaluation
mechanisms.
60
These factors seem to facilitate both the
willingness of the pharmaceutical industry to provide
such charitable donations and their eective use. Such
cooperation between the industry and programmes for
neglected tropical diseases is a good example of a
publicprivate partnership. Table 3 provides an overview
of selected drug-donation programmes.
One of the oldest and largest examples of a
privatepublic partnership is Mercks Mectizan Donation
Programme, which was launched in 1987. Merck
committed to donate as much Mectizan (ivermectin) as
was needed for the treatment of onchocerciasis and for
as long as necessary. In 1998, the programme expanded
the donation to include ivermectin for the elimination of
lymphatic lariasis wherever onchocerciasis and
lymphatic lariasis are co-endemic.
73
By 2007, Merck had
donated more than 27 billion ivermectin tablets for
these diseases.
61,62,74
Another privatepublic partnership
to eliminate lymphatic lariasis was formed in 1998,
when GlaxoSmithKline pledged to provide albendazole
free of charge in support of a global eort to eliminate
this disease by 2020.
63
To combat trachoma, Pzer has
Donated drug Donor company Duration of programme Amount of drugs donated by 2008
Onchocerciasis
61
Ivermectin Merck 1987open-ended 21 billion tablets by 2007
Lymphatic lariasis
62
Ivermectin Merck 19982020 648 million tablets by 2007*
Lymphatic lariasis
63
Albendazole GlaxoSmithKline 19982020 1 billion tablets
Trachoma
64
Azithromycin Pzer 1998open-ended 551 million tablets
Leprosy
65,66
Multidrug therapy Novartis 200010 NA
Human African
trypanosomiasis
67
Pentamidine isetionate,
melarsoprol, eornithine
Sano-Aventis 200111 NA (total of 940 000 vials in 200106)
Human African
trypanosomiasis
68
Suramin Bayer Healthcare 200212 NA
Schistosomiasis
58
Praziquantel MedPharm NA NA (14 million tablets in 2004)
Chagas disease
68,69
Nifurtimox Bayer Healthcare 200412 NA (500 000 tablets in 200405; 25 million
tablets pledged in 200712 )
Soil-transmitted
helminthiasis
70
Mebendazole Johnson & Johnson 2006open-ended NA (30 million tablets in 2006; 50 million
tablets per year pledged)
Fascioliasis
71
Triclabendazole Novartis 200709 NA (600 000 tablets pledged in 200709)
Schistosomiasis
72
Praziquantel Merck KGaA 200817 NA (200 million tablets pledged in 200817)
NA=data not available. *216 million treatments, three tablets per treatment. 145 million treatments, 38 tablets per treatment.
Table 3: Overview of selected drug-donation programmes for neglected tropical diseases
Series
donated its antibiotic Zithromax (azithromycin) across
18 countries through ITI since 1998.
64
One of the most recent privatepublic partnerships is
called Children Without Worms, which was launched in
2006 by the Task Force for Child Survival and Development
and Johnson & Johnson, with Johnson & Johnson
committing mebendazole to treat school-aged children.
70
In 2007, German Merck KGaA launched another
drug-donation programme in partnership with WHO to
combat schistosomiasis. The company pledged to supply
praziquantel for 10 years, allowing the treatment of
roughly 27 million schoolchildren in Africa.
72
Integration of national activities
Shared features and integration of activities for control
and prevention of neglected tropical diseases has
attracted some attention, as shown through a series of
grants by the Bill & Melinda Gates Foundation. Its
proponents emphasise the organisational and nancial
synergies and economies of scope by co-implementation
of preventive chemotherapy, mapping, and community
involvement.
21
Suggestions range from combining
several drugs into rapid impact interventions and
development of common delivery mechanisms to link
neglected tropical diseases with other diseases.
6,9

Theoretically, there would be a wide range of gradual
measures to exploit or create synergies.
75
Yet, in view of
the multiplicity of programmes, dierences in nancing
mechanisms, and diverse governance structures, the
co-implementation and harmonisation of activities for
neglected tropical diseases remain challenging. Further-
more, government interest and funding are scarce since
these diseases largely aect communities with little
political power.
Most attention in integration of activities so far has
focused on technical challengeseg, compatibility of
drug combinations, preventive chemotherapy, joint
mapping, monitoring and surveillance, and exploring
economies of scale through community-directed treat-
ment.
22
In particular, the preventive chemotherapy and
transmission control approach articulated by WHO,
which is widely accepted and increasingly used, advocates
the joint and synergistic implementation of large-scale
drug treatment inter ventions for several helminthic
infections: lymphatic lariasis, onchocerciasis, schisto-
somiasis, and soil-transmitted helminthiases.
76
Since 2007, several pilot programmesmostly in
Africaare underway to test not only preventive chemo-
therapy and transmission control but also the premise of
integrated control for neglected tropical diseases.
77
Two
examples from Nigeria show particularly promising
results. In the rst case, two operational tasks (mass
anthelminthic drug administration and vector control)
were successfully combined.
78
The second case lends
supports to the claim that community-directed approaches
could be used as entry-point for the delivery of other drugs
and micronutrients.
79
Sceptical assessments are voiced in
view of the experiences in Uganda, where challenges
encountered include the overburdening of community
drug distributors, inability to harmonise health
information and education, and the risk of setting up an
extensive health-care system that is parallel to the existing
one.
80
However, a recent multicountry study by the Special
Programme for Research and Training in Tropical
Diseases on community-directed health inter ventions in
Africa showed that communities managed integrated
interventions successfully.
81
On the basis of such studies,
major donors, academics, and senior professionals force-
fully promote integration of activities.
22
In-country implementation of integrated activities by
government agencies, however, is still at an initial stage.
Although geographical areas where the diseases overlap
and co-endemicity occurs could benet from an inte-
grated approach,
77
there are still substantial challenges to
overcome in practice by integration of activities that have
dierent epidemiological goals, dierent control methods,
and dierent local and international constituencies. The
key operational challenges for countries (panel 2) range
from integration of such disease control eorts into the
countrys overall health-delivery system, to dierences in
key institutional contributors implementing controleg,
school-based mass drug administration programmes
within the portfolio of the Ministry of Education and
community-based programmes through district health
services under the Ministry of Healthand intra-
ministerial coordination of disease control units.
Panel 2: Example of challenges of integration in Tanzania
82,83
Tanzanias national Government initiated discussions to
integrate control of neglected tropical diseases through
preventive chemotherapy as early as 2004. Moreover, these
diseases have represented a separate item in the countrys
medium-term expenditure framework since the nancial year
200708. However, Tanzania also showcases the
organisational challenges in harmonising fragmented
governance structures for preventive chemotherapy and
transmission control. For example, the control of
soil-transmitted helminths in most regions is undertaken
under the auspices of the National Schistosomiasis and
Soil-transmitted Helminths Control Programme. That
programme is placed within the National School Health
Programme and conceived as a joint partnership of the
ministries of health and education. Programming and
operations are closely coordinated with the Schistosomiasis
Control Initiative. However, deworming in selected other
regions will be managed under the auspices of the new
nationally integrated neglected tropical disease programme,
which was developed by a consortium of several international
non-governmental development organisations, the Ministry
of Health and Social Welfare, the National Institute for Medical
Research, and all four national vertical neglected tropical
disease programmes.
Series
Harmonisation of a fragmented governance
structure
Before addressing governance structures for control of
neglected tropical diseases (table 4), the tested governance
system established for HIV/AIDS, malaria, and tuber-
culosis can serve as a point of reference. Exclusively
dedicated to the ght against HIV/AIDS, the Joint UN
Programme on HIV/AIDS (UNAIDS) brings together
ten UN organisations, representatives from national
governments and non-governmental organisations, and
associations of people living with HIV/AIDS. Its structure
and operations are governed by resolutions of the UN
Economic and Social Council, and its director is
responsible to the UN Secretary-General.
8486
Similarly,
the programmes Roll Back Malaria and Stop TB
Partnership are sophisticated global partnerships
involving a multiplicity of stakeholders with structured,
constituency-based boards, hosted by WHO.
87,88
Such a level of organisation and governance is unlikely
to be reached for many neglected tropical diseases, the
exception being the long running African onchocerciasis
programmes and, to an extent, the Guinea Worm
Eradication Programme. Major eorts have focused not
on governance and coordination, but on advocacy, both to
establish neglected tropical diseases rmly on the map of
international health priorities and to access more nancial
resources. Yet, even in the area of advocacy, the eort is
more complex than it is when dealing with a single
disease such as HIV/AIDS, malaria, or tuberculosis,
because delivery of a disease-related message is di cult.
Therefore, advocacy has focused on neglect, poverty, and
economies of scopeie, the possibility of inte grating
control. A combination of several political and academic
contributors has been particularly eective in advocacy,
leading to two sub stantial US Government grants for
integrated control of neglected tropical diseases.
89
A major
driving force in these advocacy eorts has been the Global
Network for Neglected Tropical Diseasesan alliance of
mostly USA-based or UK-based organisations working to
control these diseases by 2020, with support from two
grants from the Bill & Melinda Gates Foundation.
90
Although harmonisation eorts so far have thus con cen-
trated on advocacy and technical challenges, almost no
attention has yet been given to national governance and
sustainability challenges. Financing is largely o-budget
for many recently established programmes for neglected
tropical diseases, almost all in Africa, and special
semi-autonomous implementation arrangements are
common. Such arrangements result in a high amount of
donor dependence, high transaction costs, and di culties
with sustainability.
91
By contrast, the large multilaterally
nanced single-disease program messuch as APOC or
WHOs Global Programme to Eliminate Lymphatic
Filariasiswork fully within the recipient countries
institutional and budgetary framework. In the eort
towards securing additional resources for integrated
control of neglected tropical diseases and establishment of
pilot programmes, these issues have been neglected and
remain to be adequately addressed.
To harmonise activities of the multiplicity of partners
and programmes globally, WHO called a rst meeting
for neglected tropical disease partners in 2007.
92
Although
this action has facilitated the working relation between
ongoing programmes, particularly those using preventive
chemotherapy, an attempt to forge a more formal
umbrella or a coalition for these diverse programmes has
not yet been undertaken. Towards the same end, WHO
created a special neglected tropical diseases department
in 2006 that coordinates eorts to control these diseases.
However, even within WHO, integration of control still
Hosted or independent Board Charter Membership Activities (primary/secondary)
APOC Hosted by World Bank/
WHO/UNDP
Constituency-based Yes (MOU with World
Bank and WHO)
organisations, NGOs, private sector
Financing/technical assistance
OEPA Hosted by NGO None No Countries, international
Financing/technical assistance
ILEP Independent Constituency-based Yes (constitution) NGOs Coordination/advocacy
GWEP Hosted by NGO None* No Countries, international
Financing/advocacy
INCOSUR Hosted by PAHO None No Countries, international
organisations
Coordination
ITI Independent Competency-based No Countries, international
Financing/advocacy
GAELF Hosted by academia Constituency-based No Countries, international
academia
Advocacy/technical assistance
SCI Hosted by academia Competency-based No NGOs, private sector academia Financing/technical assistance
APOC=African Programme for Onchocerciasis Control. OEPA=Onchocerciasis Elimination Programme for the Americas. ILEP=International Federation of Anti-Leprosy
Associations. GWEP=Guinea Worm Eradication Programme. INCOSUR=Southern Cone Initiative to Control/Eliminate Chagas Disease. ITI=International Trachoma Initiative.
GAELF=Global Alliance for the Elimination of Lymphatic Filariasis. SCI=Schistosomiasis Control Initiative. NGO=non-governmental organisation. PAHO=Pan American Health
Organization. MOU=memorandum of understanding. *Eradication certied by WHO-appointed commission.
Table 4: Governance of selected programmes
Series
presents challenges since the department is within the
infectious disease cluster, which does not cover on-
chocerciasis and trachoma. Furthermore, regional WHO
o ces have created their own structures or focal points
and developed lists of regionally relevant neglected
tropical diseases.
24,93
The way ahead
Globally, some coordination of the fragmented structure
seems desirable. Since the prole of neglected tropical
diseases has recently been greatly raised, such coordination
has become urgent. There are models such as the Stop TB
Partnership, which have been eective in harmonising
activities of several diverse partners through a so-called
partners forum, navigating the complicated link between
WHOs institutional support, normative functions,
country responsibility, and partner authority.
94
An
exploratory meeting of crucial stakeholdersmodelled
after the well regarded Rockefeller Foundation Bellagio
meetingsto identify shared goals and the areas in which
collaboration could improve outcomes, as well as exploring
strategy, structure, membership of a larger alliance, could
be important next steps to ensure momentum and
sustainability of the present advocacy for these diseases.
Such a meeting could also attempt an agreement about
what constitutes a neglected tropical disease. Although
some exibility seems inevitable and necessary in this
very dynamic eld, the present proliferation of dierent
denitions and interpretations of the term needs some
clarication. This denition could lead to the development
of criteria for inclusion of a diseaseie, disease burden,
eect on the poorest and most vulnerable populations,
and suitability for integration. Furthermore, identication
of categories of neglected tropical diseases that are
suitable for integration, taking into consideration
regional epidemiological patterns and the institutional
settings, would operationalise the discussion and be
helpful for funders.
However, immediate coordination of governance
arrangements is needed between the supporting
international contributors of neglected tropical diseases
for national programmes that are based on preventive
chemotherapy and transmission control. Such pro-
grammes have been forcefully supported by the Bill &
Melinda Gates Foundation and recently by the US Agency
for International Development, sometimes including
complex trachoma control, yet they are organisationally
diverse and their governance arrangements are strongly
aected by funding source and donor requirements. The
identication of best practices for preventive chemo-
therapy and transmission control and the development
of harmonised processes between the global programmes
and partnerships would decrease the burden on national
health systems that have to work with many partners
under dierent frameworks of cooperation and with
diverse requirements for mapping, data reporting, and
monitoring and evaluation.
Another governance issue is the emerging pattern of
allying control of neglected tropical diseases with other
programmes, such as programmes for malaria, HIV, or
tuberculosis and those for micronutrients distribution,
particularly vitamin A. Co-implementation of mass drug
administration with home-based management of
malaria and distribution of longlasting bednets, or
combination of mass drug administration with inter-
mittent preventive treatment, has shown remarkable
interactions. The next step will be to scale up from
operational research or pilot projects to large-scale
co-implementation nationally or subnationally, and thus
forging administrative mech anisms to allow such
co-implementation to occur routinely. Yet, to establish
and, importantly, maintain cooperation between well
resourced programmes such as malaria and marginal
initiatives for neglected tropical diseases will be no
trivial challenge. If successful, it could have a substantial
public health eect. But most importantly, the present
momentum in putting neglected tropical diseases on
the global health agenda needs to be maintained, which
includes not only increased advocacy and funding but
also the establishment of consensus across stakeholders
on denitions, objectives, and strategies.
Contributors
All authors contributed to the conceptualisation of the report and have
approved the nal version. BL and AS conceptualised, drafted, and
revised the report.
Conicts of interest
We declare that we have no conicts of interest.
Acknowledgments
We thank the reviewers for their suggestions and comments.
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Series
Integration of control of neglected tropical diseases into
health-care systems: challenges and opportunities
John O Gyapong, Margaret Gyapong, Nathaniel Yellu, Kwadwo Anakwah, George Amofah, Moses Bockarie, Sam Adjei
Although progress has been made in the ght against neglected tropical diseases, current nancial resources and
global political commitments are insu cient to reach the World Health Assemblys ambitious goals. Increased
eorts are needed to expand global coverage. These eorts will involve national and international harmonisation
and coordination of the activities of partnerships devoted to control or elimination of these diseases. Rational
planning and integration into regular health systems is essential to scale up these interventions to achieve complete
eradication of these diseases. Programmes with similar delivery strategies and interventionssuch as those
for onchocerciasis, lymphatic lariasis, and soil-transmitted helminthiasiscould be managed on the same
platform and together. Furthermore, better-resourced programmessuch as those for malaria, HIV/AIDS, and
tuberculosiscould work closely with those for neglected tropical diseases to their mutual benet and the benet
of the entire health system.
Introduction
Neglected tropical diseases are still a major public
health concern for most developing countries. The
ve most common neglected diseases are lymphatic
lariasis, onchocerciasis, soil-transmitted helmin-
thiasis, schisto somiasis, and trachoma.
13
How ever,
with the development of more eective treatments in
the past 20 years, several implementation strategies
have attempted to control, eliminate, and even eradicate
these diseases with varying degrees of success.
1
Key
determinants of success have been how eectively
these treatments and strategies have been integrated
into health systems of endemic countries, and the
existence, reach, and quality of health systems.
1,2
The
traditional debate of vertical versus horizontal
programmes has continued.
48
Programmes are called
vertical because they are directed, supervised, and
executed, either wholly or to a great extent, by a
specialised service with dedicated health workers.
Horizontal programmes seek to tackle health problems
on a wide front and on a long-term basis through the
creation of a system of permanent institutions
commonly referred to as general health services.
4,5

However, such debates should look at how best disease
control programmes (especially those targeted for
elimination) could leverage the health system and vice
versa, to strengthen and improve health-care delivery
in general.
Challenges of health-care delivery
Over the years, health-care systems in developing
countries have attempted to improve health status with
public health interventions (eg, vaccinations, health
education, vector control, and drug treatment pro-
grammes) for diseases that cause the greatest burden of
ill health.
6
Basic health service focused on clinical care
through the development of a network of clinics to treat
the most common conditions.
5,6
Primary health-care
programmes in the late 1970s recognised that this
network was inadequate to improve health service.
4,9

Primary health care targets underlying factors such as
education and environmental health, and promotes
intersectoral collaboration and a team approach in the
delivery of care.
4,5,9
Despite many years of health-care
delivery based on this strategy, health status has not
improved as much as was hoped. The strengthening of
district health systems initiative was an attempt to deal
with some of the underlying issues, such as manage-
ment, which aected health-care delivery.
10
This
initiative was followed by restructuring and reorganising
the health-care system to address ine ciencies that
lead to persis tent vertical structures at all levels,
especially nationally.
In the past 10 years, many countries have made
attempts to restructure and improve their health
delivery system through strategic documents,
implementation of the sector-wide approach, and
strengthening district health systems.
5,6,10
Furthermore,
stewardship role, policy debate, and relevant research
have all improved.
10,11
However, most health systems in
disease-endemic countries continue to face many
challenges. At best, they function at national and district
levels but, beyond that, service provision is rudimentary.
9

Most rural health centres in Africa have at most a
midwife, a public health nurse, and some auxiliary sta
with a catchment population of about 30 000.
Consequently, they tend to focus on static service
provision with limited commit ment to, or time for,
community interventions.
Although health programmes (including those for
neglected tropical diseases) often have high political
priority, the system for implementation varies in quality
and resources.
11
Disparity exists between expenditure
and needs, and between resource allocation and
Lancet 2010; 375: 16065
This is the second in a Series of
tropical diseases
Research and Development
Division, Ghana Health Service,
Accra, Ghana
(Prof J O Gyapong MD,
M Gyapong PhD, N Yellu MA,
K Anakwah BSc); Ghana Health
Service, Accra, Ghana
(G Amofah MD); Liverpool
School of Tropical Medicine,
Liverpool, UK
(Prof M Bockarie PhD);
and Public Health Consultant,
Accra, Ghana (S Adjei MD)
Correspondence to:
Prof John O Gyapong, Research
and Development Division,
Ghana Health Service,
PO Box MB-190, Accra, Ghana
gyapong@4u.com.gh
Series
population distribution, partly resulting from high
population growth rate and slow growth of the health
sector. With a per head expenditure for health in most
endemic countries of less than US$10 per year, health-
care delivery cannot address equity issues.
12
Much of
this meagre resource goes into secondary and tertiary
care to the detriment of primary health-care activities.
Strengthening of primary health-care activities is
essential if neglected tropical disease control is to be
integrated into the general health service.
Disease elimination and eradication through
health systems
Elimination and eradication of human disease has been
pursued for more than a century. However, with the
exception of smallpox, no disease has been eradicated,
although there are encouraging signs for polio and
guinea worm.
13
Malaria, yellow fever, and yaws
eradication programmes had been unsuccessful;
nevertheless, they substantially contributed to an
improved understanding of the complexities of
achieving disease control.
13
In 1997, the World Health
Assembly passed a resolution for the elimination of
lymphatic lariasis as a public health problem.
14
WHO
has also listed leprosy,
15
onchocerciasis,
16
and Chagas
disease
17
as being candidates for elimination as public
health problems within 10 years. Strategies for the
implemen tation of elimination programmes can be
described as vertical at least at the beginning of the
programme. This approach is usually based on a mass
campaign strategy and calls for solution of a given
health problem by single-purpose machinery (ie, a
system of activities focused on eliminating only the
disease of concern). Although control measures depend
on routine services being instituted and maintained in
a long-term perspective, elimination activities are time
limited, often intensive, targeted, and organised in
circumscribed programmes with campaign elements as
prominent features.
Elimination programmes have therefore been charac-
terised by unsustainable activities that might bypass or,
even worse, compromise the development of the health
system, especially in the poorest developing coun-
tries.
4,18
Favourable attributes and potential benets of
elimination programmes are a well dened scope with
a clear objective and endpoint, substantial donor
support, and short duration. General health services
have the advantage of being comprehensive, exible in
adjusting to changing disease patterns, permanent, and
embedded in community life. Furthermore, mass
campaigns can deal eectively with diseases that are
widespread, have a high prevalence and incidence, and
aect a high proportion of the population, thereby
hindering social and economic development of the
country.
18,19
Although the two approaches are strategically
dierent, they could be combined and coordinated with
the long-term goal of being within a unied scheme of
general health services. The design, content, and
management of health systems translate into dierences
in a range of socially valued outcomes, such as health
responsiveness and equity. The key elements that
should come together in any control eort that seeks
to integrate eectively into the health system are
the strategies for delivery of the interventions,
human resource development, logistics and infra-
structural develop ment, information systems including
information and communication technology, govern-
ance issues, and nancing.
6,18,19
Although implementation of disease-specic pro-
grammes, such as those for lymphatic lariasis and
onchocerciasis, without recourse to the general health-
care delivery systems might be benecial, integration of
such programmes into mainstream health systems can
result in greater e ciency, place the elimination priority
in the context of other services, and have more
sustainable political and community support.
6,7
For
many donors and political establishments, vertical
programmes are attractive because they give quick
results and are easier to manage than are horizontal
programmes. However, most policy makers in
developing countries see vertical programmes as
diverting human and nancial resources from already
resource-constrained systems and as detrimental to
overall health systems development.
20
Therefore,
vertical programmes create islands of excellence in an
under-funded sector
12
and place pressure on the general
health delivery system. For example, the polio
eradication campaign has negative eects, such as
diverting resources from other health activities, creating
extra costs for health services, community fatigue from
several visits, high volunteer drop-out rate, lack of
exibility in adapting to local situations, and risk of
falsication of data because of pressure to achieve
coverage.
21
However, such eradication programmes
strengthen disease surveillance systems, increase the
prestige of the health sector, boost the motivation of
health workers, establish the political will to tackle
other major health problems, increase community
involvement, and engage countries as core to the
eectiveness of privatepublic partnerships.
18,19,22
Integration of neglected tropical disease control
into health-delivery systems
Integrationthe process by which disease control
activities are functionally merged or tightly coordinated
within the context of multifunctional health-care
deliverymight be more di cult to achieve than co-
implementation of some key activities
23,24
because it
increases accessibility and equity of services.
25,26

Experiences with integration processes in several
countries show that successful integration requires
thorough preparation and planning, and several hurdles
need addressing, many of which are specic to the local
context. Strong leadership, team work, and a shared
Series
vision are also important.
2326
For neglected tropical
disease control programmes to be sustainable,
integration into the general health system is needed.
The success or failure of the integration process
depends on the ability of the health system to deliver
the required service promptly and adequately.
2729
For
integration of neglected tropical diseases to be eective,
the health system needs to develop beyond the health
centre, interventions should be co-implemented, and
nancial resources should be coordinated through
eective plans and budgets at national and district
levels. Because of the goal of no global incidence,
neglected tropical disease control or elimination have
usually been initiated as vertical programmes
(eg, guinea worm,
30
trachoma,
31
onchocerciasis,
32
and
lymphatic lariasis
33,34
).
Most neglected tropical disease interventions use
community-directed mass drug administration as a
strategy where formal health systems are weak or
absent. Delivery of health care (including interventions)
beyond the health centre would require revisiting the
basic tenet of primary health care, which has remained
elusive in most endemic countries.
9
The community-
directed treatment approach for drug delivery, which
has been eective for onchocerciasis control, provides
evidence of what is feasible.
35,36
Indeed, the success story
of community-directed treatment was extended to other
mass drug-distribution programmes, such as lymphatic
lariasis
37
and schistosomiasis, and shown to be
eective.
38
Community-directed treatment has therefore
become the main strategy in several endemic countries,
especially in sub-Saharan Africa, where health services
do not reach many communities. The condence in,
and competence of, community drug distributors has
resulted in their use for other health interventions. A
preliminary assessment indicates that community drug
distributors can be and are already involved in other
health and development activities (eg, distribution of
vitamin A, malaria treatment, polio immunisation,
guinea worm eradication, nutrition, and water protec-
tion), serving as community health workers, among
others.
3942
However, in India, community-directed
treatment did not work well because it was di cult for
people who live in the same community and yet belong
to dierent caste systems to come together for mass
drug administration.
43
Drug distribution under the leadership of health
services, with the active involvement of community
members, might be the most eective option to achieve
high coverage of the target population. However,
community involvement must be undertaken in ways
that are consistent with local norms, systems, and
structures acceptable to the community. Strategies that
do not conform to local cultures are likely to be opposed
or not sustained for the number of treatment rounds
required. If community norms are adhered to in the
development of drug distribution strategies, the interest
of community drug distributors is more likely to
continue for the entire duration of the programme.
3942

One key challenge is that the health system and its
partners need to look for more innovative ways of
incentivising community drug distributors. Community-
directed treatment cannot be entirely executed without
full cooperation, and overarching supervision and
surveil lance, by the usual health systems. The success
of this integrated approach can provide a robust
structure for the delivery of other health interventions,
as is already in place in some endemic countries, and
ensure that health services are delivered to remote and
hard-to-reach communities with no or inadequate
health facilities.
41,43
The rationale for the integration of neglected tropical
diseases that use a preventive chemotherapy strategy is
based on the observation that extensive geographic
overlap and co-endemicity exist for these diseases.
2,44

The coordinated control or elimination of the ve most
common neglected tropical diseases (lymphatic
lariasis, onchocerciasis, soil-transmitted helminthiasis,
schistoso miasis, and trachoma) represents an inexpen-
sive but cost-eective intervention, which is a priority
investment in human capital and a reduction in
poverty.
45
On the basis of the substantial reduction of
morbidity when cutting down polyparasitism, a
comprehensive strategy that benets poor people has
been proposed to integrate programmes for either
control or elimination of these ve neglected diseases
with use of existing drugs. Such integration eorts are
especially relevant to sub-Saharan Africa because
neglected diseases in this region have a high degree of
geographic overlap.
46

Financing of neglected tropical disease
programmes in an integrated health system
Another challenge to the eective integration of control
of neglected tropical diseases into the health system is
the nancing mechanisms that currently exist for these
programmes. Because many of these programmes are
established through international resolutions, various
attempts have been made to mobilise resources from
the international community. Many disease-endemic
countries have, therefore, not systematically captured
such programme activities in their health budgets
nationally and regionally. Consequently, when inter-
national resources begin to decline, they are unable to
sustain programme implementation. If health managers
do rational planning, they will logically allocate
resources to address priority issues according to the
results of a rational planning process. One would expect
that, if neglected tropical diseases are a priority in a
specic area, managers will allocate corresponding
resources for control. Unfortunately, overwhelming
evidence over the years indicates that managers do not
plan rationally or allocate funds rationally, and therefore
dened priorities invariably suer, unless dedicated
Series
funding exists for such priority programmes, at least at
the initiation and scaling-up phases. Because
elimination-programme budgets can be so huge that
they might distort the countrys health budget, countries
must provide some minimum contribution from their
regular budget. The Dominican Republic was able to
sustain the lymphatic lariasis programme in spite of
reduced external funding, and to strengthen the
development of the mainstream health delivery system.
This result was possible because integration was part of
the initial planning process.
47

New ways of doing things are needed if Millennium
Development Goal 6 (ie, control of HIV/AIDS, malaria,
tuberculosis, and other tropical diseases) is to be
achieved. This goal requires control programmes to
work closely together and have an equitable distribution
of funding.
4851
Indeed, integration into the national
health planning process presents an opportunity for
resources from special initiatives to be coordinated in a
more e cient way to yield maximum results for
the entire health sector. Programmes with similar
delivery strategies and intervention methodssuch as
those for onchocerciasis, lymphatic lariasis, and soil-
transmitted helminthiasiscould be delivered on the
same platform and managed by the same people as
is now happening in many countries. Programmes
that do not have the same resources might have the
opportunity to work together, when the formal
health system is absent, through the community-
directed treatment approach, thus leveraging available
resources.
2729
There is no reason why community drug
dis tributors for lymphatic lariasis, onchocerciasis, and
soil-transmitted helmin thiasis could not work closely
with people involved in the malaria programme in the
distribution of bednets.
50

The next level of integration requires leveraging
resources of the better-funded initiatives, such as the
Global Fund to Fight AIDS, Tuberculosis and Malaria.
The modest costs of including neglected tropical
disease control eorts into programmes for malaria,
HIV/AIDS, and tuberculosis provide opportunities and
collateral benets, such as reductions in anaemia,
worm burdens, and susceptibility to HIV/AIDS,
tuberculosis, and malaria morbidity.
44
Bilateral donors
and partnerships for malaria, HIV/AIDS, and
tuberculosis should expand their portfolios to
incorporate deworming, lymphatic lariasis and
onchocerciasis elimination, and other neglected disease
control initiatives as a cost-eective means to reduce
morbidity and mortality of people with HIV/AIDS,
tuberculosis, or malaria. Such interventions are
inexpensive, eective, and fully compatible with the
Millennium Development Goals, and the recom-
mendations of the report of the Commission for Africa
(UN Millennium Project).
2,50,51
The ght against
neglected tropical diseases is a quick win in terms of
reducing disease burden.
2,46,48,51
Additional opportunities
exist to bundle the control of neglected tropical
diseases with that of malaria and HIV/AIDS.
44
Such
measures could exploit the geographic overlap of these
diseases as well as potential synergies in public health
control, resulting in cost savings. For example, a study
has shown that administration of drugs for neglected
tropical diseases by community distributors led to a
nine-fold increase in the distribution of antimalaria
bednets.
29
Also, the sandy patches of female genital
schisto som ia sis seem to increase susceptibility to
HIV/AIDS,
52,53
thus anti-schistosomal treatment could
be an innovative HIV/AIDS prevention strategy.
54

Conclusions
Neglected tropical diseases are possibly the worst
diseases in terms of their destructive eects and their
association with political instability and civil strife. They
are the most common infections of the poorest billion
people, causing chronic, debilitating, disabling, and
disguring eects. These diseases tend not only to occur
in poor settings but also to exacerbate poverty and to
destabilise communities.
55,56
Their integration into the
health system makes programmes sustainable, improves
on coverage, and reduces cost.
57
However, vertical
programmes ensure quick results and are easier to
manage. The process of integration and co-implemen-
tation needs careful planning. Published reports indicate
that careful planning and preparation need to precede
implementation of the integration process. This stage
should include a realistic situation analysis, commitment
building, formulation of clear plans for integration,
training of health workers, and provision of adequate
and timely information to the public.
Because of the human resource challenges of the
health- care system, development of the health system
beyond the traditional health centre is needed. The
community-directed treatment approach provides
opportunities for health services to work closely with the
community to deliver interventions. Community
volunteers are capable, motivated, and reliable. However,
such volunteers should be incentivised to provide the
essential service that bridges the link between health
centre and community.
A more prudent nancing mechanism needs to be
developed. Neglected tropical diseases need to pool
resources together for co-implementation of their
activities; however, the resources currently available are
woefully inadequate to achieve the elimination goals of
these diseases. A more eective resource-mobilisation
planincluding leveraging resources for the health
sector to control malaria, tuberculosis, and HIV/AIDS
should be pursued. We need to address the social
structures in which neglected tropical diseases ourish,
and invest in research and development for new
diagnostics and drugs. Developed countries must provide
access to medicines and innovations for the elimination
or control of these diseases.
49,58
Series
Contributors
JOG, MG, GA, MB, and SA developed the framework for the review.
NY and KA did most of the literature search, reviewed the reports, and
summarised the key issues under the dierent subheadings. JOG
prepared the initial draft of the report, and all other authors added
their contributions and comments.
Conicts of interest
We declare that we have no conicts of interest.
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Series
Mapping, monitoring, and surveillance of neglected tropical
diseases: towards a policy framework
M C Baker, E Mathieu, F M Fleming, M Deming, J D King, A Garba, J B Koroma, M Bockarie, A Kabore, D P Sankara, D H Molyneux
As national programmes respond to the new opportunities presented for scaling up preventive chemotherapy
programmes for the coadministration of drugs to target lymphatic lariasis, onchocerciasis, schistosomiasis,
soil-transmitted helminthiasis, and trachoma, possible synergies between existing disease-specic policies and
protocols need to be examined. In this report we compare present policies for mapping, monitoring, and surveillance
for these diseases, drawing attention to both the challenges and opportunities for integration. Although full integration
of all elements of mapping, monitoring, and surveillance strategies might not be feasible for the diseases targeted
through the preventive chemotherapy approach, there are opportunities for integration, and we present examples of
integrated strategies. Finally, if advantage is to be taken of scaled up interventions to address neglected tropical
diseases, eorts to develop rapid, inexpensive, and easy-to-use methods, whether disease-specic or integrated, should
be increased. We present a framework for development of an integrated monitoring and evaluation system that
combines both integrated and disease-specic strategies.
Introduction
Recent policy papers have emphasised the rationale for
linking control programmes for lymphatic lariasis,
onchocerciasis, schistosomiasis, trachoma, and soil-
transmitted helminthiasis, in co-implemented packages
that have rapid eect.
13
These diseases aect the poorest
communities that are supported by the weakest health
infrastructures. In 2006, WHO published a strategy for
preventive chemotherapy in human helminthiasis
2
to
guide countries in the implementation of this integrated
approach to control neglected tropical diseases. This
preventive chemotherapy strategy needs the wide-scale
delivery of drugs, either alone or as a package, at regular
intervals. Since 2007, the US Government, the UK
Government, and the Bill & Melinda Gates Foundation
have pledged new funding to lend support to the
implementation of preventive chemotherapy pro gram-
mes, and the pharmaceutical companies Merck,
GlaxoSmithKline, Pzer, Johnson & Johnson, and
MedPharm have also committed to continued large
donations of drugs.
4
As national programmes respond to
these opportunities and to the challenges posed by
co-implementation of preventive chemotherapy control
strategies, many tactical issues arise that need to be
addressed.
5
These issues include identication of the
most cost-eective ways to rapidly map areas at high risk
of neglected tropical diseases, establishment of the most
appropriate monitoring systems, and development of
postintervention surveillance strategies as the pro-
grammes for lymphatic lariasis, onchocerciasis, and
trachoma reach the elimination phase. This report
compares the present disease-specic protocols for
mapping, monitoring, and surveillance for the diseases
targeted by the preventive chemotherapy approach. It
draws attention to the challenges and opportunities of
integration, outlines innovative solutions being proposed
to meet these challenges, and oers a conceptual
framework to address these issues.
Successes, challenges, and opportunities posed
by integration
The neglected diseases being targeted with large-scale
preventive chemotherapy are caused by diverse infective
agents (helminthic parasites and bacteria) with very
dierent epidemiological characteristics. Although the
aim of programmes for soil-transmitted helminthiasis
and schistosomiasis is disease control, lymphatic
lariasis, onchocerciasis, and trachoma are being
targeted for elimination. Additionally, interventions to
eliminate trachoma involve more than preventive
chemotherapy. Programmes targeting these infections
have up until now usually worked separately, and
therefore have evolved their specic methods and
instruments to achieve their goals.
As new nancing opportunities allow disease-control
programmes to scale up rapidly, a review of the methods
and instruments available for mapping, monitoring,
and surveillance is needed, together with a discussion
about if, how, and when these methods can be
integrated to achieve increased cost-eectiveness. The
table provides an overview of the mapping, monitoring,
and surveillance methods developed for each
disease-control programme, and we will outline the
opportunities and challenges posed by integration and
possible solutions.
Mapping
Mapping of disease prevalence and distributions is
crucial for any control eorts. Although the geographic
distribution of the targeted neglected diseases is widely
known,
3438
detailed mapping information is needed to
allow planning for implementation.
Lancet 2010; 375: 23138
This is the third in a Series of
tropical diseases
RTI International, Washington,
DC, USA (M C Baker PhD,
D P Sankara MD); Parasitic
Diseases Branch, Division of
Parasitic Diseases, Centers for
Disease Control and
Prevention, Atlanta, GA, USA
(E Mathieu MD, M Deming MD);
Schistosomiasis Control
Initiative, Imperial College,
London, UK (F M Fleming MSc);
The Carter Center, Atlanta, GA,
USA (J D King MPH); NTD
Control Program, RISEAL,
Niamey, Niger (A Garba MD);
National Onchocerciasis
Neglected Tropical Diseases
Control Program, Ministry of
Health and Sanitation,
Freetown, Sierra Leone
(J B Koroma MD); Liverpool
Liverpool, UK
(Prof M Bockarie PhD,
Prof D H Molyneux DSc); and
Liverpool Associates of Health,
Liverpool, UK (A Kabore MD)
Correspondence to:
Dr M Baker, RTI International,
Center for International Health,
805 15th Street NW, Suite 601,
Washington, DC 20005-2207,
USA
mcb93@georgetown.edu
Series
The creation of easy-to-use methods for the lymphatic
lariasis and onchocerciasis elimination programmes has
enabled their rapid expansion.
39
To identify priority areas
for mass distribution of ivermectin, the African
Programme for Onchocerciasis Control
40
developed the
rapid epi demiological mapping of onchocerciasis (REMO)
risk assessment instrument,

on the basis of the proximity
of probable Simulium breeding sites.
1416
A subsample of
communities in areas identied as high risk by REMO are
subsequently screened with the rapid epidemiological
assessment (REA) method
17
to estimate onchocercal
nodule prevalencea surrogate for the more invasive
skin-snip methods. Mapping of loaisis, caused by the
larial parasite Loa loa, became increasingly important
with the discovery that serious adverse events can develop
in heavily infected individuals after treatment with
ivermectin (Mectizan; Merck, Whitehouse Station, NJ,
USA) for onchocerciasis.
41
To identify areas at high risk of
loaiasis, approaches were developed on the basis of remote
sensing images to dene high-risk areas,
42
and a
non-invasive method, rapid assess ment procedures for
loaisis (RAPLOA), was implemented that uses a survey
questionnaire asking for the patients history of eye
worm.
43
The lymphatic lariasis programme has used
immunochromatographic card tests
44
to replace the need
for microscopy of night-time blood specimens to detect
infection. These test cards, which can be used at any time
of the day, together with the develop ment of standardised
cost-eective sampling strategies (with lot quality
assurance sampling and spatial sampling grids) have
enabled the rapid mapping of lymphatic lariasis.
610

The table summarises guidelines for mapping schisto-
somiasis and soil-transmitted helminthiasis. Whereas the
simple questionnaire designed to ask schoolchildren about
the presence of blood in urine has been proposed as a
quick, inexpensive, and reliable method for identication
of schools at high risk for Schistosoma haematobium
infection,
4547
the logistics needed in getting a stool sample
from children when using the Kato-Katz technique for the
diagnosis of Schistosoma mansoni and soil-transmitted
helminthiasis makes this method less rapid. Brooker and
colleagues
48
have proposed alternative methods for
schistosomiasis mapping. Although these alternatives
need validation, they could well prove to be valuable to
assist the planning of mass distributions of praziquantel.
The rst uses the lot quality assurance sampling technique,
which reduces the number of stool samples needed to
identify the prevalence of S mansoni infection in a school
and is thus a cheap and quick approach.
48,49
The second
method is for the rapid diagnosis of S mansoni through the
detection of circulating cathodic antigens (CCA) in the
urine with a CCA-based dipstick that is both highly
Mapping Monitoring Postintervention surveillance
Lymphatic lariasis Survey in children older than 15 years and adults with
antigen detection card test to establish whether
implementation unit is greater than 1% infection
prevalence.
610
Administrative unit varies, but usually done
within districts
10
Reported coverage.
10
Validate reported coverage with
household surveys.
10
Sentinel and spot-check sites (night
bleeds and clinical examinations) every 2 years.
10
LQAS
cluster ICT survey in schoolchildren after ve to six rounds
of MDA.
10
Entomological studies
11
China and Korea instituted surveillance to conrm
elimination. Surveillance in Suriname, Costa Rica,
Trinidad and Tobago, and Solomon Islands to
conrm transmission has ceased.
12,13
Post-MDA and
postelimination surveillance being developed in
countries completing ve to seven rounds of MDA
12,13
Onchocerciasis For APOC in 19 African countries, mapped at village level by
REMO
1416
then REA
17
to establish onchocercal nodule
prevalence. APOC projects undertake CDTI in hyperendemic
or mesoendemic communities dened by nodule prevalence
>20% (hypoendemic areas not treated).
15
In the Americas,
OEPA identies endemic foci in all endemic countries by
parasitological studiesall endemic foci treated
18
Reported coverage.
19
Various methods for measuring
coverage through household visits.
20,21
Sentinel sites every
45 years (eect on transmission [skin snips], eect on eye
and skin lesions, clinical examinations, entomological
studies at MDSC).
22,23
Sustainability of drug delivery after
withdrawal of APOC funding
24
Surveillance in OCP areas to assess recrudescence-
DNA testing of parous ies.
25
In Americas (OEPA),
3 years after intervention surveillance before
certication of elimination and the continued
surveillance
26
Schistosomiasis Mapped within villages and communities by school-based
cluster or prevalence survey.
27,28
Stool and urine samples or
questionnaire on blood in urine.
28
Communities classied as
high, medium, or low prevalence to establish frequency of
treatment and age groups to be targeted
29
Reported coverage in schoolchildren.
28,30
Prevalence and
intensity surveys of egg counts in urine and stool samples;
prevalence of blood in urine.
29,30
Ultrasound to measure
pathological changes in bladder and liver
31
Soil-transmitted
helminthiasis
Mapped within villages and communities by school-based
prevalence survey.
28
Stool samples.
28
Communities classied
by prevalence and intensity of infection to establish
frequency of treatment and age groups to be targeted
29
Treatment coverage in schools.
28,30
Prevalence and
intensity surveys of egg counts in stools; morbidity
(severe anaemia, stunted growth, school attendance)
29,30
Trachoma A cluster-sample household survey determines whether

the prevalence of TF is high enough for the entire district
population to be treated. If prevalence is somewhat lower,
each community is assessed separately.
32
Determine
intervention strategy (SAFE) on the basis of prevalence of
disease based on clinical examination: TF in children and
TT in adults
32
Reported antibiotic coverage; progress towards ultimate
intervention goals; reported number of TT cases receiving
surgery; number of communities receiving health
promotion and proportion of households with
sanitation.
32
Reassess prevalence of clinical signs after at
least 3 years of SAFE interventions
32
Periodic surveys to establish whether prevalence
remains below target threshold.
32,33
Postelimination
surveillance guidelines being developed
LQAS=lot quality assurance sampling. ICT=immunochromatographic card test. MDA=mass drug administration. APOC=African Programme for Onchocerciasis Control. REMO=rapid epidemiological mapping of
onchocerciasis. REA=rapid epidemiological assessment. CDTI=community-directed treatment with ivermectin. OEPA=Onchocerciasis Elimination Programme for the Americas. MDSC=multidisease surveillance
centre. OCP=Onchocerciasis Control Programme. TF=trachomatous inammation follicular. SAFE=surgery, antibiotics, facial hygiene promotion, and environmental improvements. TT=trachomatous trichiasis.
Table: Summary of mapping, monitoring, impact assessment, and surveillance methods developed, by disease
Series
sensitive and specic but costly in identication of at-risk
communities in high-trans mission settings.
50,51

The simplied trachoma-grading system that is used to
identify clinical signs of trachoma and is recommended
for mapping and monitoring has inherent, although
acceptable, disadvantages related to the reliability of the
examiners ndings.
32,52,53
Additionally, clinical indicators
of trachoma do not always correlate well with the presence
of ocular chlamydia.
53,54
So far, no additional guidelines
have been published for the programmatic use of various
laboratory assays to verify clinical ndings, and further
assessment is needed to review the usefulness and role
of a rapid point-of-care assay to detect Chlamydia
trachomatis during surveillance activities.
55
The existing disease-specic mapping protocols (table)
are all designed to acquire essential information needed
for programme implementationie, the mapping
protocols are designed to produce so-called actionable
maps that can identify populations that should be targeted
for intervention. These protocols, however, vary in terms
of the sampling strategy used, the amount of classication
needed, the implementation unit, and the diagnostic
methods used. For example, mapping protocols for
lymphatic lariasis and trachoma are designed to initially
identify districts in which the whole population is
treated.
10,32
Once a district is above the specied prevalence
threshold, then all people in the district are dened as
being at risk of infection and are targeted for intervention.
However, these two programmes dier since WHO
guidelines for trachoma control recommend further
assessment of communities within districts that are
initially identied as being at low risk.
32
Additionally,
trachoma indicators are based on two age groups: children
aged 19 years, and children older than 14 years and
adults. The mapping methods for onchocerciasis, schisto-
somiasis, and soil-transmitted helminthiasis are more
detailed than are those for lymphatic lariasis and
trachoma, since treatment decisions are made separately
for each village or community, and further stratication
of communities by prevalence is needed to identify what
age groups should be targeted for treatment and the
frequency of treatment.
In addition to these alternatives, rapid-mapping
procedures, with remote sensing, geo-statistics, and
climate-based risk models have been developed that might
be useful to guide control eorts nationally by excluding
areas in which little or no transmission occurs.
56
So far,
remote sensing has been eectively used to identify areas
at risk of serious adverse events from loasis where
onchocerciasis programmes are being implemented, and
in development of risk maps for schistosomiasis
endemicity. The potential for increased use of geographical
information systems and remote-sensing techniques in
mapping the distribution of neglected tropical diseases
remains to be fully exploited. Integrated approaches,
particularly those linking knowledge of co-endemicity to
allow more eective and e cient programme planning
and integration, will be crucial. Ideally this information
should be accessible to all via an internet-based portal,
incorporating not only data for prevalence but also progress
in control activities.
Although opportunities for integrated mapping are
limited by the geographical overlap of the infections and
by the maturity of the disease-control programmes,
innovative approaches to integrated mapping have been
undertaken in several countries. In Cameroon, rapid
assessment procedures for loaisis and rapid epi-
demiological assessment surveys for onchocerciasis were
co-implemented.
57
The investigators noted that this
approach was helped by the fact that the two surveys have
many similarities in their methodological approaches
(they target the same population, and sample sizes are
not conicting). They showed that one examiner could
execute both the interview for rapid assessment
procedures for loaisis and nodule palpation for rapid
epidemiological assessment with great e ciency, and
reported both cost and time savings. Similar e ciencies
are reported from integrated surveys of neglected tropical
diseases undertaken in Togo, Equitorial Guinea, and
southern Sudan (unpublished data). In Nigeria, addition
of trachoma mapping to school surveys for schistosomiasis
had the important advantage, compared with the usual
district-wide cluster sample survey, of identifying villages
needing intervention in districts in which prevalence of
trachomatous inammation follicular was less than 10%
in children.
58
In Ethiopia, combined malaria and
trachoma surveys
59
have shown that prevalence estimates,
indicators, and risk factors for both diseases could be
obtained for the cost of undertaking one disease survey.
However, the investigators noted that the integrated
survey needed much more planning and coordination
than did only one disease survey. Conversely, Richards
and colleagues
60
reported that combined mapping for
schistosomiasis and lymphatic lariasis in Nigeria was
di cult, resulting in fewer states being mapped and
subsequently treated for schistosomiasis.
We conclude that if advantage is to be taken of
opportunities to treat these neglected tropical diseases,
eorts to develop rapid, inexpensive, and easy-to-use
mapping methods should be stepped up, and the
feasibility of integrated mapping should be assessed for
dierent scenarios.
Monitoring
Once target populations have been identied through
mapping, intervention programmes should be imple-
mented. Monitoring should then aim to assess
programme progress. For this report we have used the
term monitoring to encompass both routine monitoring
of indicators and periodic or one-time evaluations.
Treatment coverage has been used as a key indicator
across disease-control programmes (table) to monitor
programme results. However, the information sources
for denominators (programme registers or census bureau
Series
data) and denitions of denominators (including eligible
population, target population, total population, and
ultimate treatment goal) are not uniform. Such challenges
to integration are compounded by dierent donor
requirements, disease programme reporting forms, and
reporting channels. Progress towards integration,
therefore, must lie in standardisation of denitions of
coverage and creation of agreed common reporting forms
that will enable comparability of data across countries
and diseases. Thus, WHO has developed a useful online
interactive databank providing results for lymphatic
lariasis, schistosomiasis, and soil-transmitted hel-
minthiasis, along with endemic country proles.
Since donors also need to report the overall progress of
integrated programmes for neglected tropical diseases,
new indicators need to be created and dened that will
sum numbers across the disease programmeseg, the
total number of treatments delivered through the
preventive chemotherapy approach and the percentage of
people at risk of these diseases reached would be useful
for advocacy purposes. Programme managers would also
benet from a range of resources that enable them to
monitor programme inputs and processes.
In addition to routine measurement of treatment
coverage based on data contained in drug distributor
registers, a survey done after mass drug distribution can
be used to validate reported coverage rates.
10,61
Such survey
approaches can be used to track sex inequities, access of
school-aged children to treatment, eectiveness of social
mobilisation, drug distributor adherence to guidelines,
and co-implemented drug-delivery logistics. A cluster
survey designed to validate reported coverage rate for the
four drugs (ivermectin, albendazole, praziquantel, and
azithromycin) distributed by preventive chemotherapy
programmes has been created and implemented in
several countries.
62
Challenges in development of
aordable integrated survey instruments include
establishment of a sampling framework which recognises
that the diseases do not overlap completely within
countries or even districts, and balancing the need for a
sample size large enough to give the required precision
against having a cheap and easy-to-use instrument.
Furthermore, because people are asked to dierentiate
between dierent treatments that they received, the issue
of recall after the intervention should be addressed.
Infection, morbidity, and nutritional indicators have
been used by individual disease-control programmes to
show the impact that programmes are achieving.
6366

These indicators also draw attention to areas in which
treatment strategies need to be modied. Challenges to
integration of the monitoring of programme impact are
similar to those encountered with mappingeg, in
having indicators that are often measured in dierent
populations (communities vs schools), in use of dierent
sampling strategies, and with little overlap in the
diagnostic methods or procedures used (table).
In addressing these challenges, one strategy is to focus
on potential cross-cutting indicators such as anaemia,
disability, and blindness, although none of these indicators
is associated with all diseases targeted with a preventive
chemotherapy approach. An alternative approach is to
draw on the existing disease-specic indicators of impact
to develop a small set of indicatorsselected for their
acceptability, ease of collection, and costwhich could be
used in dierent combinations depending on the
overlapping disease endemicity. With this approach, the
logistics of data collection can be integrated; one technical
team (either a group representing the dierent disciplines
or a specially trained multiskilled sta) gathers data from
surveys in schools or communities, or both, sampling the
same individuals for several diseases when appropriate.
Sites are then followed up at dened time intervals
dependent on the indicator requirements of the
For more about the WHO
preventive chemotherapy
databank see http://www.who.
int/neglected_diseases/
preventive_chemotherapy/
databank/en/index.html
Panel: Summary of dierent stakeholder requirements for
information
Policy makers, both within endemic countries and
internationally, need information for setting priorities.
They need to assess the burden of disease and the
cost-eectiveness of interventions for neglected tropical
diseases compared with other health programmes to
allocate scarce resources and advocate for additional
funding. They should also be able to position control
programmes for these diseases in the context of the
countrys health system and to monitor progress in
developing national plans and establishing budget lines.
National programme managers need information for
programme planning to enable them to make informed
decisions about use of resources. Thus they need
knowledge of the geographical distribution of the diseases
to plan drug distribution; assessment of drug coverage;
identication of areas needing strengthened social
mobilisation and strategies for information, education,
and communication; and in some cases the identication
of areas requiring focal retreatment or enhanced
operations for mass drug administration. Furthermore,
the programmes have to work within the dened goals of
WHO disease-control and elimination policy and in
accordance with the relevant World Health Assembly
resolutions. The challenge, therefore, is to establish
information and reporting systems responsive enough to
serve both national and global requirements now and for
future implementation of postintervention surveillance.
Donor community need information that will show
achievements and lend support to advocacy for continued
funding. Information will relate to audits and
accountability to ensure value for money and leveraging
of additional resources with a view to sustainability. For
drug donors in particular, detailed information is needed
for forecasting drug needs (and production) to scale up
programmes, to report to regulatory authorities,
41,67,75,76

and to monitor for changes in drug eectiveness.
68,77,78
Series
disease-specic programmes that were integrated. This
approach to measure the eect of co-implemented
programmes has been used in Uganda, Burkina Faso,
and Niger, and the results will be important for shaping
policy development.
In programmes that are treating populations at scale
with donated products, pharmacovigilance from the
community distributors to the formal health system is
needed to ensure that the statutary reporting by
manufacturers to regulatory authorities can be instigated
in the event of serious adverse events. The reporting of
such events has been tested in areas of central Africa,
where loasis and onchocerciasis are co-endemic and
serious adverse events have occurred.
41
Additionally, since
cost savings in drug distribution are attempted through
co-administration of the combination of praziquantel,
albendazole, and ivermectin, or in trachoma-endemic
areas co-endemic for helminth diseases amenable to
control through the preventive chemotherapy approach,
combination of azithromycin with anthelminthic drugs
will need to be assessed, as was done in Zanzibar.
67
Drug
eectiveness throughout preventive chemotherapy
programmes will also need to be assessed as part of
routine monitoring, in view of reports of reduced e cacy
and possible resistance.
68
Research into the necessary
instruments is a priority, and the need to precisely dene
drug eectiveness and drug resistance is paramount.
Surveillance
Surveillance is dened as surveillance after intervention
activities end and is therefore a key component of the
elimination programmes for lymphatic lariasis,
onchocerciasis, and trachoma. For lymphatic lariasis
programmes, the immunochromatographic card test is
the recommended instrument for assessment of progress
towards elimination endpoints, especially when used to
assess cohorts of children born since the intervention
began.
10
This approach has been used in Egypt,
69
and will
be widely implemented as other countries seek to stop
their mass drug administration and move towards
surveillance. Alternative approaches to endpoint assess-
ment and surveillance that are being studied include
exposure antibodies in children
70
and PCR methods for
xeno-monitoring larial parasites in mosquitoes.
12,63

In countries included in the Onchocerciasis Control
Programme in west Africa, a surveillance system has
been established in onchocerciasis-freed areas on the
basis of the molecular detection of Onchocerca volvulus
infection in blackies with PCR technology.
65
The
Onchocerciasis Elimination Programme for the
Americas, which has the objective of regional elimination
of onchocerciasis, has reported interruption of
transmission in four foci in three countries (Guatemala,
26

Mexico,
71
and Colombia
71
) with criteria established by
WHO.
71
Treatment with ivermectin has been stopped in
these foci, and they have entered a 3-year post-treatment
surveillance phase to monitor for transmission
recrudescence. If no evidence is available after 3 years of
continued transmission, a certicate of elimination can
be issued; however, long-term surveillance should
continue. The need for suitably sensitive, specic, rapid,
and easy-to-use diagnostic methods to detect
recrudescence remains urgent.
25
Instruments now being
explored to replace skin snips and simulium dissection
Figure: Logic framework for programmes for control of neglected tropical diseases targeted with preventive chemotherapy
Inputs Activities Outputs Outcomes Impact
Increased support for
programmes for neglected
tropical diseases
Cost-eciencies
achieved through
integrated approach
Advocacy and
resource mobilisation
Sentinel site
monitoring
Monitoring and
evaluation
Data collection
and management
Procurement of
drugs and supplies
Training and
supervision
Drug distribution
Health education
Mapping
Planning
Policy and
environmental
setting
Drugs
Human resources
Financial resources
Political will
Diseases mapped
People treated
People received surgery
Environmental
improvements made
Reduced morbidity
caused by lymphatic
lariasis, onchocerciasis,
schistosomiasis,
soil-transmitted helminthiasis,
and trachoma
Elimination or control
of individual diseases
Improved nutritional
status in children and
women; reduced disability;
reduced blindness
Reduced poverty; improved
access to health care;
improved school attendance
and number of work days;
increased sex equity;
improved education status;
and strengthening of health
systems
Series
are the Ov16 antibody test
72
(in either a point-of-care test
format or a laboratory-based ELISA) and the diethyl-
carbamazine patch test
73
(based on diethylcarbamazine in
Nivea cream that would detect skin microlariae within
24 h of application). In countries included in the African
Programme for Onchocerciasis Control, a high amount
of control through sustainable community-directed
treatment with ivermectin, rather than elimination, is
the target; therefore these countries are unlikely to
need post-implementation surveillance instruments.
18

However, in Mali and Senegal (countries previously part
of the Onchocerciasis Control Programme) where
ivermectin has been used for 1518 years twice yearly,
Diawara and colleagues
74
have reported the complete
cessation of transmission. This result has provoked a
reassessment of the possibility of elimination of
onchocerciasis, and thus future approaches to monitoring
and surveillance might change further.
Endpoints for elimination of blinding trachoma are
based on maintaining a rate of clinical disease at lower
than target thresholds for at least 3 years after
interventions have ended.
33
Surveillance guidelines are
being developed to ensure the sustainability of
elimination of chronic, blinding trachoma.
The need for a monitoring and assessment
system and framework
Substantial progress has been made in development of
monitoring and assessment systems for the individual
disease-control programmes. Although full integration
of all elements of mapping, monitoring, and surveillance
strategies for the diseases targeted through the preventive
chemotherapy approach is not feasible, there could be
many opportunities for integrated strategies when
integration is the best option. As momentum for pro-
grammes for neglected tropical diseases increases, the
number of national and international stakeholders
expands, and eorts have to be made to reduce duplication
and streamline information needs of the wide range of
stakeholders that often have dierent, yet overlapping,
monitoring and evaluation requirements (panel).
The development of an integrated strategy for
monitoring and evaluation would dene priorities and
include an agreed set of indicators (integrated and disease-
specic) that will enable programme managers to gather
a standard set of data that will allow comparison of
information across time, geographical regions, and
diseases.
The gure presents a basic framework that can be used
by policy makers to develop a strategy for monitoring and
evaluation for programmes for neglected tropical diseases
that are based on preventive chemotherapy. It concept-
ualises the sequence of essential programme elements
from inputs, to activities, outputs, outcomes, and
impacts. Many inputs, including nancial and human
resources, are needed to implement a range of activities.
The intended output of these activities is to identify areas
for treatment and to obtain high treatment coverage.
Ultimately the goal is to achieve programme impactie,
reduction and elimination of infection and morbidity,
improvement of the health of the population,
improvement of health systems, and having a positive
eect on the broader development challenges embodied
in the Millennium Development Goals. With reference to
such a framework, specic programme indicators can be
createdeg, input indicators measuring the number of
drugs and human resources used; process indicators
used to count activities such as the number of districts
mapped by disease, the number of people trained, and
the number and quality of health education activities
implemented; output indicators such as treatment
coverage; outcome indicators that measure cost-
eectiveness and the increased priority and prole of
neglected tropical diseases; and impact indicators
measuring both the direct eect of the programme on
infection and disease and indirect contributions of the
programme towards achieving the Millennium
Development Goals.
The development of a monitoring and assessment
strategy for neglected tropical diseases should embrace
existing disease-specic methods and indicators, and
develop new approaches. Additionally, although the
national health information systems within which
control programmes for such diseases function are
often weak, opportunities might exist for mutually
benecial linkages.
79,80
For example, intervention
coverage questions and impact assessments could be
linked to large scale, externally funded surveys with
high visibility, such as the Demographic and Health
Survey
81
and the Multiple-Indicator Cluster Survey.
82

Results from monitoring and assessment are not only
important in establishing, determining, and modifying
strategies and reporting public health successes, but
are also key for the advocacy for continued support both
nationally and internationally.
Contributors
MCB took the lead role in writing the report and coordinating input from
co-authors. DHM, EM, FMF, MD, and JDK participated in developing the
concepts, writing, and editing the report, and undertook research into the
data and references. AG and JBK reviewed the report and participated in
providing information about the way national neglected tropical disease
control programmes have used mapping, monitoring, and surveillance as
a management instrument for decision making. MB participated in
developing the concepts, provided references, and reviewed the report.
AK and DPS participated in the review of the report and provided input
and comments on various drafts.
Conicts of interest
MCB is employed by the NTD Control Program, which is funded by
USAID. AG has received research funding in 2006 from the European
Union for project Contrast. DHM is the Executive Secretary of the
Global Alliance to Eliminate Filariasis. Since 2000, he has received
research grants from the UK Department for International
Development, which includes a 25% contribution from GlaxoSmithKline
to the Liverpool School of Tropical Medicine. He attends meetings of the
Mectizan Donation Program and is supported by GlaxoSmithKline and
Merck to provide independent scientic advice to programmes. EM, FM,
MD, JDK, AG, JBK, MB, AK, and DPS declare that they have no conicts
of interest.
Series
Acknowledgments
We thank Annie Bandjord for her administrative supporting in preparing
this report. The views of the authors are their own and do not necessarily
represent those of the US Centers for Disease Control and Prevention.
This study is made possible by the generous support of the American
people through USAID. The contents are the responsibility of the authors
and do not necessarily reect the views of USAID or the US Government.
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47 Clements ACA, Brooker S, Nyandindi U, Fenwick A, Blair L.
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48 Brooker S, Kabatereine NB, Gyapong JO, Stothard JR, Utzinger J.
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50 Stothard JR, Kabatereine NB, Tukahebwe EM, et al. Use of
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51 Legesse M, Erko B. Field-based evaluation of a reagent strip test for
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52 Thylefors B, Dawson CR, Jones BR, West SK, Taylor HR. A simple
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53 Miller K, Schmidt G, Melese M, et al. How reliable is the clinical
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54 Mabey D, Solomon A, Foster A. Trachoma. Lancet 2003;
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55 Michel CE, Soloman AW, Magbanua JP, et al. Field evaluation of a
rapid point-of-care assay for targeting antibiotic treatment for
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57 Wanji S, Tendongfor N, Esum M, et al. Combined utilisation of rapid
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58 King JD, Eigege A, Richards F, et al. Integrating NTD mapping
protocols. Can surveys for trachoma and urinary schistosomiasis be
done simultaneously? Am J Trop Med Hyg 2009; in press.
59 Emerson PM, Ngondi J, Biru E, et al. Integrating an NTD with one
of the big three: combined Malaria and trachoma survey in
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60 Richards FO, Eigege A, Miri S, Jinadu MY, Hopkins DR. Integration
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Series
Socioeconomic aspects of neglected tropical diseases
Lesong Conteh, Thomas Engels, David H Molyneux
Although many examples of highly cost-eective interventions to control neglected tropical diseases exist, our
understanding of the full economic eect that these diseases have on individuals, households, and nations needs to
be improved to target interventions more eectively and equitably. We review data for the eect of neglected tropical
diseases on a populations health and economy. We also present evidence on the costs, cost-eectiveness, and
nancing of strategies to monitor, control, or reduce morbidity and mortality associated with these diseases. We
explore the potential for economies of scale and scope in terms of the costs and benets of successfully delivering
large-scale and integrated interventions. The low cost of neglected tropical disease control is driven by four factors:
the commitment of pharmaceutical companies to provide free drugs; the scale of programmes; the opportunities for
synergising delivery modes; and the often non-remunerated volunteer contribution of communities and teachers in
drug distribution. Finally, we make suggestions for future economic research.
Introduction
The 13 parasitic and bacterial infections known as
neglected tropical diseases include three soil-transmitted
helminth infections (ascariasis, hookworm infection, and
trichuriasis), lymphatic lariasis, onchocerciasis, dracun-
culiasis, schistosomiasis, Chagas disease, human African
trypanosomiasis, leishmaniasis, Buruli ulcer, leprosy,
and trachoma.
1
These diseases have a substantial health
and economic burden on poor populations in Africa,
Asia, and Latin America,
1,2
causing about 534 000 deaths
every year, and sharing a similar burden of disease to
either malaria or tuberculosis.
1
An estimated 57 million
disability-adjusted life-years (DALYs) are lost every year to
neglected tropical diseases; however, recent recalculations
of the morbidity and mortality caused by these diseases
suggest that the DALY burden might be higher than that
reported.
3
The economic eect
4
of these diseases, together
with their social and psychological burden,
59
is extensive
and global.
Here, we draw on selective publications to provide
examples of the economic eect, costs, and cost-
eectiveness associated with various neglected tropical
diseases. For consistency, all costs in text and tables are
reported in US dollars as of 2008. The US consumer
price index was used to inate US dollar costs, as
reported in the original reports, to their US dollar 2008
equivalent with a constant dollar rate.
10
Ideally, tradable
goods should be inated with US dollar ination rates,
and non-tradable goods and services with the local
ination rate; however, the costs reviewed were not
always disaggregated to reect tradable and non-tradable
components.
11
Eect of neglected tropical diseases on health
The overall burden of disease is assessed with DALYs.
DALYs averted are calculated by combining burden of
disease averted from less morbidity (as a function of
incidence, length of disease, and eect on quality of life)
and less mortality (as a function of incidence, case fatality
rate, and average life expectancy). DALY calculations are
mainly driven by mortality rates. Many neglected tropical
diseases do not have high mortality rates, but are
characterised by lengthy periods of suering and often a
lifetime of disablement (blindness, total incapacity, or
partial disability). DALYs do not adequately illustrate such
chronic diseases.
A detailed analysis of the individual and collective
disease burden (DALYs) and cognitive disabilities
associated with neglected tropical diseases is outside the
remit of this report.
12
However, many DALY burdens
currently attributed to individual neglected tropical
diseases are disputed as too low.
1316
The misrepresentation
of DALYs is important from an economic perspective as
it will underestimate the incremental cost-eectiveness
ratio of any economic evaluation. If the DALY used for
schistosomiasis is underestimated, the incremental
cost-eectiveness ratio will seem less cost eective
because the costs (the numerator) would be divided by a
smaller benet in the form of an underestimated DALY
(the denominator). A study suggested that the average
disability burden attributed to schistosomiasis infection
could be 215% instead of 0506% estimated by WHO
in 1990.
15,17
Similarly, a recent epidemiological assessment
of the burden caused by onchocerciasis showed a loss of
15 million DALYs every year, which is signicantly
higher than the estimated 048 million DALYs estimated
in 2002.
18

DALYs might not adequately indicate the severity of
many neglected tropical diseases and the eect on an
individuals quality of life and subsequent DALY
scores.
7,19,20
In addition to serious potential under-
estimation of DALY burdens, numbers of individuals
infected by certain neglected tropical diseases are
underestimated.
20
For example, the African Programme
for Onchocerciasis Control treats only hyperendemic
and mesoendemic communities; hence, the number of
infected individuals in hypoendemic communities (ie,
<40% prevalence of Onchocerca volvulus infection) is not
Lancet 2010; 375: 23947
This is the fourth in a Series of
tropical diseases
London School of Hygiene and
Tropical Medicine, London, UK
(L Conteh PhD); IBF
International Consulting,
Brussels, Belgium
(T Engels MA); and Liverpool
Liverpool, UK
(Prof D H Molyneux DSc)
Correspondence to:
Dr Lesong Conteh, London
School of Hygiene and Tropical
Medicine, Keppel Street, London
WC1E 7HT, UK
lesong.conteh@lshtm.ac.uk
Series
known, and therefore the burden of skin and eye disease
is not included in any calculation of burden outside
hyperendemic and mesoendemic areas.
21
Many popula-
tions in the poorest areas are also polyparasitiseda
phenomenon not previously assessed in terms of
disease-burden calculations.
22
Economic eect of neglected tropical diseases
Understanding the eect of neglected tropical diseases
on the economy is crucial if we want to better estimate
the benet of their control on economic growth in
endemic countries.
23,24
The economic burden of these
diseases can be assessed by adding the direct costs of
expenditure on prevention and treatment with the
indirect costs of productive labour time lost because of
morbidity and mortality. Costs can be assessed at the
microlevel to provide insight into the eect on individual
households and businesses, and at the macrolevel, to
show the eect on the economic performance of a
nation.
Financial and economic costs of treatment and control
of neglected tropical diseases are often considered from
the perspective of the health-care provider, most notably
the costs faced by government-funded health facilities.
Individuals and families have heavy out-of-pocket (direct)
costs when seeking care for treatment for these diseases.
In Ghana, the cost of care per patient with Buruli ulcer in
a household in the poorest earning quartile was reported
as 242% (193315%) of their annual earnings, which can
be regarded as catastrophic.
25
By contrast, in a household
in the richest earning quartile the cost per patient was
reported as 94% (89105%) of their annual earnings.
Although the economic eect on both income groups is
catastrophic, this dierence indicates inequity, since
treatment costs disproportionally aect the incomes of
the lowest-income households.
26
A study in Sri Lanka
27

reported how the poorest patients with lymphatic
lariasis were driven into the medical poverty trap, and
how they delayed accessing the health-care system,
thereby allowing the symptoms to progress and making
treatment di cult or impossible. Studies in Thailand
and south Vietnam found that an average family pays
US$74 and $67, respectively, to treat a child with dengue
haemorrhagic fever, which was more than an average
monthly salary at the time the studies were done.
28,29
The indirect costs to people aected by neglected
tropical diseases and their carers, and the economic
eect on a household, further compound the costs.
30

Neglected tropical diseases aect worker productivity.
31

In Bangladesh, the labour of tea pluckers showed
Setting Reported productivity loss*
Chagas disease Latin America
35
Estimated 752 000 working days per year lost because of premature deaths.
US$12 billion per year in lost productivity in seven southernmost American countries.
Brazilian absenteeism of workers aected by Chagas disease represented an estimated minimum loss of $56 million per year.
Cysticercosis India, Honduras,
the Eastern Cape
Province
36
The societal monetary cost of Taenia solium cysticercosis was estimated at $1527million (95% CI $5162990 million) in India, $283 million
($71429 million) in Honduras, and $166 million ($83228 million) in the Eastern Cape Province.
Dengue fever India
37
The average total economic burden was estimated at $293 million ($275311 million).
Costs in the private heath sector were estimated to be almost four times the public sector expenditures.
Echinococcosis Jordan;
34
Province in Tibet,
China
38
Total losses to the Jordanian economy is a median of $49 million ($3381 million). Furthermore, because of the low purchasing power parity in
Jordan, these losses would be the equivalent of $21 million in the USA.
Evaluation of human losses associated with treatment costs and loss of income due to morbidity and mortality, in addition to production losses in
livestock due to Echinococcus granulosus infection.
Annual combined human and animal losses were estimated to reach $249 240 ($216 386282 516) if only liver-related losses in sheep, goats, and yaks
are taken into account. This equates to about $396347 per person per year. However, total annual losses can be almost $14 million, if additional
livestock production losses are assumed.
Lymphatic
lariasis
Various countries
39
Annual economic burden of lymphatic lariasis measured in lost productivity reported in 1998 was about $17 billion in 2008, taking into account
ination in APOC countries. ERRs are 25% at the end of investment period 2019 and 28% over 30 years. Programme breaks even in tenth year.
Economies of scope with onchocerciasis.
Lymphatic lariasis causes almost $13 billion a year in lost productivity.
Onchocerciasis Various countries
40
Economic evaluations of the OCP in west Africa have calculated a net present value (equivalent discounted benets minus discounted costs) of
$919 million for the programme over 39 years, using a conservative 10% rate to discount future health and productivity gains. The net present value for
APOC is calculated at $121 million over 21 years, also using a 10% discount rate. However, the economic success of ivermectin distribution is sensitive to
the fact that the drug itself has been donated free of charge. The market value of Mercks donations to the APOC for just 1 year considerably outweighs
the benets calculated for both the OCP and the APOC over the duration of these projects.
Soil-transmitted
helminthiasis
Kenya
41
On the basis of the estimated rate of return to education in Kenya, deworming is likely to increase the net present value of wages by over $40 per
treated person. Benet-to-cost ratio of 100. Deworming can increase adult income by 40%.
Schistosomiasis Philippines
42
After a series of computations, of which the disability rate was regarded as the most important, a total of 454 days lost per infected person per year
was obtained.
Trachoma Various countries
43
The average cost of untreated trichiasis, or the net present value of life-time lost economic productivity, was $118.
APOC=African Programme for Onchocerciasis Control. ERR=economic rate of return. OCP=Onchocerciasis Control Programme. *All costs and losses are inated from their original year of calculation and
converted to their US dollar 2008 equivalent with constant dollar rate Bureau of Labour Statistics.
10
Base year of costs not given, so costs remain in original form.
Table 1: Economic costs of selected neglected tropical diseases
Series
a negative association with three worm infections
(Ascaris lumbricoides, Trichuris trichiura, and hookworms)
between the intensity of helminth infections (eggs and
faeces) and worker productivity.
32
In Egypt, workers with
schistosomiasis beneted from improved quality of life
and increase productivity if they could access early
detection and treatment.
33
If individual cases of lost
productivity are scaled up, the eect on productivity at a
national and international level is substantial.
34
Table 1
provides examples from published reports on the
economic eect of selected neglected tropical diseases.
Households and rms adapt their productive activities
in response to the burden of neglected tropical diseases.
These coping strategies can lead to low savings and
investment, lost capital and purchasing power, and
ine cient labour substitution.
44,45
The macroeconomic
impact of other diseases has been widely reported to
strengthen the argument for increased funding and to
promote development.
46,47
The rates of return of inter-
ventions to control neglected tropical diseases (estimated
at 1530%)
48
are not adequately captured in cost -eective-
ness analyses because these typically focus only on the
economic eect on the health-care sector, with only a few
including the eect on the patient or their house hold.
23,24

Canning
23
argues that interventions to control neglected
tropical diseases promise large economic pay-os outside
the health sector in agricultural productivity and
educational benet, and hence are investments in human
capital and poverty reduction.
Infections of children with soil-transmitted helminths
and schistosomes are associated with reduced education
and school performance and attendance, and adverse
eects on future earnings and productivity.
5,41,49
Perhaps
one of the most compelling examples of the eect of
control of a neglected tropical disease is the analysis of
hookworm control in the southern states of the USA,
where a substantial income gain and a substantial rise
in literacy resulted from the reduction in hookworm
infection.
50
Costs and cost-eectiveness of control and
treatment of neglected tropical diseases
Five continuing major control or elimination programmes
for lymphatic lariasis, onchocerciasis, schistosomiasis,
soil-transmitted helminthiasis, and trachoma use pre-
ventive chemotherapy as a key approach. These pro-
grammes, with support of governments, donors, technical
agencies, and non-governmental development organ-
isations, achieved high levels of coverage and cost-
eectiveness. For example, a recent study in Laos showed
that a school deworming campaign reached a national
coverage rate of 95% at a cost of $013 per year per child
for two rounds of deworming with mebendazole, almost
completely eliminating high and moderate intensity
infections.
51
Costs included training, health education,
drug procurement and distribution, media campaigns,
supervision, and monitoring. The largest cost was training
teachers in primary schools. This high coverage and low
delivery costs have also been reported in Cambodia
52
and
Vietnam.
53
A seven-country study assessing costs of mass
drug administration to eliminate lymphatic lariasis
estimated a nancial cost per person treated between
$007 and $267. Economic costs varied between $048
and $697. Coverage rates varied between 53% and 91%.
54
Costs of treating neglected tropical diseases are small
compared with those of combating HIV/AIDS, tuber-
culosis, and malaria. Having taken into account the long-
term donations of ivermectin for onchocerciasis and
lymphatic lariasis, albendazole for lymphatic lariasis,
and azithromycin for trachoma, the total cost of treatment
of all those infected is about $046 per person treated,
55

equivalent to the bulk cost of about 12 condoms
56
or less
than half the annualised cost of a longlasting insecticidal
bednet to combat malaria.
57
These low costs for neglected
tropical disease control are driven by four factors: the
commitment of pharmaceutical companies to provide
free drugs; the scale of the programmes; the potential for
synergising delivery modes to increase e cien cy and
reduce costs; and the often non-remunerated volunteer
contribution of communities and teachers in drug
distribution.
Cost-eectiveness studies (in terms of cost per health
gain achieved) for neglected tropical disease control are
scarce. Table 2 shows the cost-eectiveness of combating
various neglected tropical diseases, alone or in
combination.
5860
The costs per DALY averted associated
with many neglected tropical diseases are among the
lowest. For example, to reach elimination of lymphatic
lariasis in areas of high prevalence, annual mass drug
administration to treat the entire population at risk costs
$510 per DALY averted. Treatment of schistosomiasis
and intestinal worms through schools with (non-donated)
drugs costs $211 per DALY averted for intestinal worms
alone, $410844 per DALY averted for schistosomiasis
alone, and $1023 for intestinal worms and schisto-
somiasis combined. Therefore, cost savings are possible
by combining these two interventions compared with the
costs of delivering the two interventions separately.
61
This
result suggests the possibility to further increase cost-
eectiveness by packaged delivery of drugs as is currently
recommended by WHO.
62
More expensive control and treatment estimates are
associated with disease for which case management and
environmental control are the main interventions. Case
nding and treatment of African trypanosomiasis and
leishmaniasis cost less than $1224 and $1122 per DALY
averted, respectively, mainly because of private-sector
contributions for donated or preferentially priced drugs.
With regard to dengue fever, (supportive) case manage-
ment costs $7161757 per DALY averted, whereas
(preventive) environmental control requires more than
$2440 per DALY averted. Interventions to control
neglected tropical diseases cost in many instances less
than $427610 per DALY averted associated with anti-
Series
retroviral treatment for HIV/AIDS in areas of low treat-
ment costs and high adherence, and about $643 per
DALY averted for tuberculosis with directly observed
therapy and $621 per DALY averted for insecticide-treated
bednets.
63

When an intervention becomes cost eective remains
debatable, and the selection of cost-eectiveness
thresholds in published reports varies.
64
Recent studies
have used a multiple of gross national income (GNI) and
gross domestic product (GDP) per head to decide cost-
eectiveness thresholds.
56,6567
WHO states that an
intervention is highly cost eective if it is less than one
GDP per head.
56
The average GDP per head, in 2008 for
Africa, was $2328;
68
therefore, almost all measures for
neglected tropical disease control are well within the
highly cost-eective range. However, low costs and high
cost-eectiveness do not guarantee that an intervention
is aordable and can be readily adopted as a national
strategy. Because of scarce resources and competing
interventions, countries might recognise the advantages
of having measures to control neglected tropical diseases
but struggle to secure the funds.
Financing of neglected tropical disease control
Sustainability is an important aspect in the nancing of
national and multinational programmes.
69
Goldman and
colleagues
54
compared costs in seven countries doing
nationwide lymphatic lariasis mass drug administration
programmes. In addition to the total programme costs
and average treatment costs, the study assessed con-
tributions of endemic countries and external partners. In
general (excluding the costs of donated medicines),
governments of endemic countries contributed 6090%
of recurrent costs.
54,70
In a cost evaluation of community-
directed treatment with ivermectin for onchocerciasis
control in Cameroon, Nigeria, and Uganda, the break-
down of costs showed (excluding the cost of donated
medicines) that endemic countries covered about half
the cost of the programme, and the donors and non-
governmental development organisa tions the rest.
71,72

Commitment by governments and communities is
essential for sustainability.
73
The list of donated medicines is remarkable, and
pharmaceutical companies providing these drugs are
committed to their long-term donation.
74
Costs of donated
drugs are not always reported in the delivery costs of
treatment of neglected tropical diseases, mainly because
donated drugs place no cost on programme of delivery or
end user. Therefore, the cost of the programme is, from a
nancial perspective, the money spent to do the
programmes activities.
The importance of drug donation programmes for
neglected tropical disease control should not be
underestimated.
55,75
From an economic perspective,
however, even donated drugs have a cost, more accurately
an opportunity cost. International drug price estimates
76

suggest that the market price of many key drugs used to
treat more than 15 types of helminthic and parasitic
infections,
77
donations aside, is as low as $002 per tablet
(eg, albendazole, diethylcarbamazine, and mebendazole).
Praziquantel is on average $006 per 600 mg tablet. The
market price of a 6 mg ivermectin tablet is $052 (the
donated ivermectin tablets for onchocerciasis and
lymphatic lariasis programmes are 3 mg tablets).
In a study of the costs of the African Programme for
Onchocerciasis Control, the mean nancial cost was
$058 per treatment with ivermectin, which was provided
free by Merck, and volunteer time was excluded.
71
The
economic cost doubles to $126 per treatment once the
cost of the volunteer time (an additional $016) and the
donated ivermectin tablets are included. The dierence
between economic and nancial costs shows the
importance of identifying the type of cost and the huge
cost savings that programmes for neglected tropical
diseases derive from donated drugs and volunteer
time.
54

Intervention* Cost per DALY
averted (US$)
Chagas disease Vector control 317
Lymphatic lariasis In implementation units (districts) where prevalence is higher than
1%, annual mass drug administration to treat the entire population
at risk for 57 years: ivermectin and albendazole in Africa and
diethylcarbamazine and albendazole in onchocerciasis-free
countries:
to interrupt transmission and achieve elimination of public
health problem
to initiate morbidity control, surgery, and lymphoedema
management
Fortied salt with diethylcarbamazine (China)
Vector control
510
35
14
59370
Schistosomiasis Mass school-based treatment with praziquantel and albendazole
to combine with schistosomiasis treatment
Mass school-based treatment with praziquantel alone
1023
410844
Trachoma Surgery to repair eyelids, trachoma control based on SAFE strategy:
Surgery, Antibiotic treatment, Face washing, and Environmental
control
5100
Onchocerciasis Community-directed treatment programmes with ivermectin 9
Soil-transmitted
helminthiasis
(hookworm,
roundworm, and
whipworm)
Mass school-based treatment with albendazole or mebendazole 211
Leprosy Case detection and treatment with multidrug therapy with
donated drugs
Prevention of disability
46
1122
Dengue fever Case management
Environmental control
7161757
>2440
Leishmaniasis Case nding and treatment 1122
African
trypanosomiasis
Case nding and treatment:
with melarsoprol
with eornithine
<12
<24
The table is an adaptation of references 58 and 59 based on the work of reference 60. Adjusted from original US dollars
in 2001 to US dollars in 2008 with constant dollar rate Bureau of Labour Statistics.
10
*Donated drugs are ivermectin
for onchocerciasis and lymphatic lariasis; albendazole for lymphatic lariasis; mebendazole for soil-transmitted
helminthiasis (proportion of need); azithromycin for trachoma; melarsoprol, eornithine, and suramin multidrug
therapy for leprosy; pentamidine for African trypanosomiasis; and praziquantel for schistosomiasis (proportion of need).
Table 2: Cost-eectiveness of neglected tropical disease control
Series
Studies into household willingness to pay for the
prevention and treatment of neglected tropical diseases
have shown mixed results. Willingness to pay provides
useful insight into how people value an intervention and,
if cost recovery strategies were to be introduced, how this
might aect various subgroups in a community.
78
A study
investigating willingness to pay for prevention and
treatment of lymphatic lariasis in Haiti showed that,
although most of the community placed a positive value
on both prevention and treatment of lymphatic lariasis,
7% and 39% of households were not willing to pay for
prevention and treatment, respectively; therefore, any
cost recovery policy would be likely to result in inadequate
participation and limited sustainability.
79
Economies of scale
Economies of scale in neglected tropical disease
interventions indicate that increasing the size of a
programme, up to a certain point, reduces the average
cost per unit. There comes a point, however, when a
programme reaches full capacity and resources are
overstretched and no longer used e ciently; this can
increase the average cost per unit and is known as
diseconomies of scale.
80
The scale of many programmes
designed to combat neglected tropical diseases has been
key to their success. By tackling the diseases with an
orchestrated, national or multinational approach, costs of
reaching populations has been reduced and benets have
been substantial. Detailed evidence on the economies of
scale of multinational neglected tropical disease initiatives
is important but scarce. However, transaction costs might
be kept to a minimum and duplication of resources
might be reduced if large-scale, cross-country, coordinated
eorts to control neglected tropical diseases are made by
public and private stakeholders.
81

At which point do cross-country initiatives become too
big and coordination ine cient? Successful control
eorts of programmes to eliminate lymphatic lariasis,
onchocerciasis, Chagas disease, leprosy, dracunculiasis,
and schistosomiasis have all operated at a multicounty
level, reaching hundreds of millions of vulnerable
people.
75
For example, the African Programme for
Onchocerciasis Control, together with national health
services and non-governmental development organi sa-
tions, have ensured the distribution of ivermectin
(donated by Merck) in 19 African countries, using a
network of more than 261 000 community-directed
distributors spanning over 217 000 communities. This
coverage (40 million treatments in 2005) enabled not
only those living near health facilities to benet from the
treatment but also the populations most vulnerable and
di cult to reach (in terms of remoteness and conict) to
receive treatment regularly.
82,83
Evidence suggests that
these networks are sustainable.
84

Over the past 10 years, the Global Programme to
Eliminate Lymphatic Filariasis has had activities in
48 countries and distributed almost 2 billion treatments.
85

On this scale, and with donated albendazole and
ivermectin, costs of treatment have been reported as low
as $007 (or $706 per DALY averted) in some African
settings and even lower in parts of Asia.
54
$706 per DALY
averted might be an overestimation because the benets
from anaemia reduction, nutrition, cognitive function,
and a reduction of itching associated with lice, scabies,
and onchocerciasis, were not included in this DALY
estimate.
85

Reduction of costs per unit associated with scaling up a
national school-based helminth control programme
(schistosomiasis and intestinal worms) and the
commonly overlooked issue of intracountry variation of
costs per unit have been described

in Uganda.
61
In that
setting, the cost per child treated was $060 (range
$045100), and per anaemia case averted was $352
($1871048). These ranges show the importance of
variation and their implications on budget planning in
dierent regions, and warn against the assumption of
constant returns to scale because, with most interventions,
the average cost per recipient is likely to change
depending on the level of output.
61,86
When comparing
across countries, the costs of seven national lymphatic
lariasis programmes varied mainly because of the
duration of the programme (inuence of start-up
investments and costs), the use of volunteers, the mode
of drug delivery, and the size of the population.
54
Hence,
the changing nature of average costs at dierent stages of
control eorts is an important issue. Neglected tropical
disease programmes need to be able to forecast the
changing costs of starting up,
70,72
and ultimately moving
towards the endpoint of elimination (either cessation of
transmission or the absence of a public health
problem).
75

Economies of scope: integration of strategies
To achieve additional benets from the treatment of
neglected tropical diseases, a debate exists about how
current successful strategies can be associated e ciently
with other health interventions aimed at the same
populations.
87,88
Economies of scope are evident among
the synergies of controlling several neglected tropical
diseases at once
56
and alongside the benets that might
derive from control of malaria and HIV/AIDS.
88,89
Costs per DALY averted associated with one specic
neglected tropical disease or a combination of several
(schistosomiasis and intestinal worms) are in the range
of what are regarded as the most cost-eective public
health interventions.
58
Yet, additional positive externalities
associated with such control eorts exist.
12,41,90
Positive
externalities are the benets of control and treatment of
neglected tropical diseases that are not explicitly costed
in the economic analysis. The lymphatic lariasis
elimination programme is a clear example where, in an
attempt to combat one disease, other diseases or
infections/infestations (intestinal worms, onchocerciasis,
and ectoparasites), anaemia, cognitive outcomes, and
Series
school attendance are aected, yet rarely explicitly
included in economic evaluations. These other eects
are also positive externalities of schistosomiasis and
intestinal worm control.
91

A comprehensive strategy to benet poor people has
been suggested for the elimination of seven neglected
diseases: ascariasis, trichuriasis, hookworm, lymphatic
lariasis, onchocerciasis, schistomiasis, and trachoma.
55

In Africathe continent with the highest burden caused
by neglected tropical diseasesthis strategy could be
achieved with four existing drugs: ivermectin,
albendazole, azithromycin, and praziquantel. The rst
three are donated by Merck, GlaxoSmithKline, and
Pzer, respectively, and the last is about $023 per child.
56

For an annual cost of $228 million in 2008, 500 million
African people could be treated with these four-drug
integrated packages for $046090 per patient. Cost
savings of between 26% and 47% are estimated as a
result of coordination and partnership, since costs
associated with, for example, delivery and community
sensitisation could be shared if separate programmes
worked together.
55,92
Scaling up such a package for Africa
would give $228 million on top of the $3 billion already
spent on malaria control
93
and yield considerable
potential benet for malaria control.
88
The rationale of allying neglected tropical disease
control with programmes for HIV/AIDS, tuberculosis,
and malaria might oer untapped opportunities.
12,88

These diseases are co-endemic and can aect patients
concurrently. Combining these programmes can reduce
costs of delivery and, importantly, increase coverage
for all interventions. A multisite study in Nigeria,
Cameroon, and Uganda
94
showed that in districts where
home management of malaria was integrated with
oncho cerciasis-related community-directed intervention
(a dose of ivermectin per year), many more children
received antimalarial treatment than they did in areas
with home-based management alone. Furthermore, the
use of insecticide-treated or longlasting nets was
increased two-fold in districts with the community-
directed intervention than in those without.
94

In Nigeria, a nine-fold increase in households with
children younger than 5 years and pregnant women
owning an insecticide-treated bednet was reported after
insecticide-treated bednet distribution was coupled with
lymphatic lariasis and onchoceriasis mass drug
administration.
95

Recent evidence on intermittent preventive treatment
against malaria might also oer new opportunities for
combining neglected tropical disease treatment. Inter-
mittent preventive treatment programmes for pregnant
women might benet by the inclusion of anthelmintic
drugs.
96
A recent intermittent preventive treatment pro-
gramme in schoolchildren has shown reduction of
anaemia and improvement of cognitive abilities;
97
the
next step could be to combine this strategy with
deworming.
98,99
Women with urogenital schisto somiasis
have a three-fold increased risk of horizontal trans mission
of HIV/AIDS.
100
Those working in both HIV/AIDS and
schistosomiasis communities might benet from
investigating how they can better exploit the strengths of
both their prevention and treatment strategies.
89,100,101

Future agenda
Neglected tropical diseases place health, social, and
nancial burdens on household and national economies.
Success in the control of these diseases has been the
result of concerted and focused eorts to adopt strategies
that are some of the most cost-eective public health inter-
ventions, even when DALYs, which are disputed at present
as too low, are used. Future benets in cost-eective ness
are to be expected by packaged delivery and inte gration
with other interventions, as currently advocated by WHO
and the international neglected tropical disease com-
munity. Scaling up integrated control measures will need
to be documented and researched further.
To date, control of neglected tropical diseases has been
mainly vertical. Further research into what is meant by
integration in the neglected tropical disease community
and how this relates to interpretations of integration
among those working in the primary health-care setting
is needed. Economic analysis can forecast nancial and
economic implications of any change in implementation
strategy, drugs, and technological developments. Further-
more, the analysis of feasible levels of funding to ensure
high coverage of neglected tropical disease control
interventions is important for individual countries and
international organisations to ensure sustainability,
especially in a time of global economic crisis when
commitments to spending on health are uncertain.
102

Further work is needed to document the benets
derived from the economies of scope and scale. For
example, research is needed to explore the point at
which programmes grow too large and start to have
diseconomies. Threshold analysis can help to inform
decision makers when it is cost eective to switch
interventions, delivery strategies, or rst-line drugs
amid increasingly reduced e cacy or proven drug
resistance, to step up vector control measures, or to
target subgroups instead of the general population.
Equity analysis must ensure that interven tions are
reaching the most vulnerable groups and target those
with the greatest need. With implementation pro-
grammes operating on a large scale and a growing
interest in integrated strategies, economic studies
should adopt common core protocols and strong
cross-country collaborations to generate methodologically
comparable data within and across countries.
Several highly cost-eective interventions exist to
control various neglected tropical diseases. It is now
important to investigate how additional e ciency gains
can be achieved by exploiting economies of scope and
conrming neglected tropical disease control as some of
the best value-for-money health interventions.
Series
Contributors
LC participated in the literature search and writing of the report.
TE participated in the literature search and commented on the nal
draft. DHM initiated the report, coordinated the authors, participated
in the preparation of various drafts, and assisted in the nal edits before
submission.
Conicts of interest
DHM is the executive secretary of the Global Alliance to Eliminate
Lymphatic Filariasis. Since 2000, he has received grants from the UK
Department for International Development, which includes a 25%
contribution from GlaxoSmithKline to the Liverpool School of Tropical
Medicine. He attends meetings of the Mectizan Donation Program and
is supported by GlaxoSmithKline and Merck to provide independent
scientic advice to programmes. The other authors declare that they
have no conicts of interest.
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Trachoma A cluster-sample household survey determines whether

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