5 lessons in mobilizing domestic financing for NTDs
By Maria Francisco, Jose Luis Gonzalez, Alemu Chekole
Neglected tropical diseases (NTDs) are a group of disabling and debilitating conditions that affect over 1 billion people every year — primarily the world’s poorest and most marginalized communities.
Investment in NTDs is considered one of the “best buys” in public health. Cost effective interventions exist for preventing, treating, and, in some cases, eliminating disease. And these interventions have the potential to return significant health and economic benefits — thus breaking the cycle of poverty and disease for those affected by NTDs.
Enormous progress has been made to expand access to these NTD interventions through effective global cooperation and unparalleled public-private partnerships with the pharmaceutical sector to donate treatment.
However, NTD programs remain largely underfunded in many countries and are highly dependent on external donor funding. As health ministries coordinate and prioritize the use of limited resources across competing health needs, ongoing health threats — such as COVID-19 — pose additional risks to the long-term sustainability of NTD programs.
We’re sharing learnings we have drawn from our work in Uganda, Tanzania, Ethiopia, and Nigeria under the USAID’s Act to End Neglected Tropical Diseases | East program (Act | East). We also share some key lessons from Colombia, Guatemala and the Philippines — three countries that have achieved notable success in self-financing their NTD response. The Act | East program aims to support countries moving to transition from donor support to more sustainable domestic financing for NTD interventions.
The information presented below comes from a series of Act | East country briefs for Colombia, Guatemala and the Philippines, where we examine the key factors that have contributed to enhancing domestic financing for NTDs.
So, what have we learned so far?
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The ways and means of mobilizing adequate domestic funding for ‘neglected’ diseases varies by health system and program context.
In many countries, NTD programs remain largely dependent on donor funding and, in most cases, operate in siloes outside national health systems. As the landscape for donor financing of NTDs is changing, it is uncertain whether government funding for NTDs will increase in the near term, making these successful programs vulnerable to shifts in donor priorities and support at a time when programs need to shift resources to different components. Government commitments to fund NTD control and elimination have been more clearly observed at the federal/national level; subnational governments have demonstrated minimal budget space or flexibility, and health spending is generally dominated by the “big” infectious diseases of malaria, HIV, and tuberculosis.
In Colombia and the Philippines, NTD programs are decentralized and more integrated into broader health financing mechanisms. These countries achieved some success in self-financing the NTD response and reaching elimination milestones, utilizing a mix of financing instruments at national and decentralized levels to fund both population-based interventions and more individual-based higher level care, including through pooled universal health coverage (UHC) or primary health care (PHC) financing mechanisms, earmarking funds for NTDs, and in some instances, included requirements for matching funds and/or performance incentives.
Although these countries are largely self-reliant in implementing their NTD programming, external donors also provided supplemental resources in the form of technical and advocacy support, strategic guidance and donation of drugs and diagnostics that helped to support and elevate the response locally.
2. A multisector, multi-level, and multi-donor NTD response requires good governance and coordinated effort to monitor and account for all NTD resources.
In some NTD endemic countries, a significant portion of external financing to the health sector is directed through off-budget channels. Consequently, expenditure data play little role in the government’s annual planning for NTDs and governments rarely estimate NTD-related resource needs and funding gaps or do so with considerable technical assistance. Instead, discussions are driven by donor priorities and budgets. NTD resources are generally not well quantified and are spread across many budget holders, while expenditures are not routinely tracked.
In Colombia, Guatemala, and the Philippines, strong governance plays a key role in ensuring that NTDs remain a focus of health investment particularly as diseases are nearing elimination status and the health threat perceived to no longer be a problem. Health ministries from the three countries have effectively coordinated NTD financial and programmatic efforts at national and subnational levels of government, while also incorporating and managing external donor and multi-stakeholder contributions.
This coordination has allowed governments to make annual health financing decisions, allocate funding to meet specific programs’ resource needs, and ensure donor contributions complement the domestic budget for NTD activities. Moreover, this coordination ensures international health partners’ investment aligns with national policies and programs guidelines.
3. NTD programs are more likely to be financed when program goals are prioritized in national and sub-national health plans and strategies.
In Colombia, Guatemala, and the Philippines, NTD programs are recognized as a national priority in relevant health policy documents and strategies that set priorities during the health sector budget allocation process.
For instance, in Colombia, NTD targets and goals were included in the Colombia National Health Plan 2011–2021, and this increased their visibility in public health resource allocation at national and sub-national levels. Given that the National Health Plan defines public health investment lines for the health sector, the health ministry and local health authorities establish their annual budgets following the strategies and programs prioritized in the national plan and, consequently, in the territorial health plans, including the control and elimination of NTDs.
Similarly, in the Philippines, NTD control and elimination targets are embedded in national and local health objectives, promoting budget prioritization. In Guatemala, the alignment of NTDs with the SDG goals has become a key driver to enable programs to maintain their annual budget allocation, even though other health and disease programs are also pursuing sustainability planning — all competing for resources and prioritization.
4. Domestic funding for NTDs, as a marker for equity, is more sustainable when integrated within broader financing reforms and essential health service delivery under UHC.
As countries progress toward UHC goals, NTD services can benefit if they are part of essential services and, therefore, linked to a new health financing scheme for UHC.
In Colombia and the Philippines, health ministries were able to situate NTDs within the broader political narrative and reforms that were being undertaken to strengthen the overall health system, including those devoted to the advancement of UHC and its objectives for ensuring equitable access and financial protection.
For instance, in Colombia, the integration of NTDs with national funding streams for UHC has mobilized additional resources. NTD health services have been progressively incorporated into the national health insurance plan. This inclusion has enabled subnational governments to focus the public health budget on funding NTD population-based interventions.
In the Philippines, as progress is made toward UHC, all individual-based services were scheduled to be incorporated into an outpatient/primary care package paid by PhilHealth by 2021. Consequently, the progressive inclusion of NTD-related services into clinical care services covered by PhilHealth is expected to reduce household out-of-pocket expenditure in the coming years.
5. Generation and use of NTD program and financial data is crucial for advocacy and decision-making at all levels of the health system.
Generation and use of NTD program and financial data have helped Colombia and the Philippines inform prioritization and decision-making for the use of limited health resources amidst competing priorities and health system challenges. NTD program staff have been able to utilize data to identify needs and engage within health ministries and with local governments to understand how best to finance those needs (whether bundled in service packages paid through integrated financing pools or through earmarked funds or special initiatives for NTDs to reach “last mile” communities). In the two countries, the generation and use of data to drive decision making has been crucial to secure funding for NTDs.
Looking ahead
As Act | East continues to support countries in their efforts for sustainable NTD programming, R4D plan to assist government officials at the subnational levels in generating and using financial data to strengthen local capacity for planning, budgeting and resource mobilization. This will include assisting NTD programs in Uganda, Tanzania, Ethiopia, and the Philippines in developing methods for improving tracking of NTD expenditures, coaching local health authorities to prepare and negotiate health budgets, and implementing evidence-driven advocacy strategies. We hope that lessons learned from Act | East countries can help inform policy and practice in other countries who face similar challenges and opportunities.