Neglected Tropical Diseases as a ‘litmus test’ for Universal Health Coverage? Understanding who is left behind and why in Mass Drug Administration: Lessons from four country contexts

Abstract

IntroductionIndividuals and communities affected by NTDs are often the poorest and most marginalised; ensuring a gender and equity lens is centre stage will be critical for the NTD community to reach elimination goals and inform Universal Health Coverage (UHC). NTDs amenable to preventive chemotherapy have been described as a ‘litmus test’ for UHC due to the high mass drug administration (MDA) coverage rates needed to be effective and their model of community engagement. However, until now highly aggregated coverage data may have masked inequities in availability, accessibility and acceptability of medicines, slowing down the equitable achievement of elimination goals.MethodsWe conducted qualitative programmatic analysis across different country contexts through the novel application of the Tanahashi Coverage Framework enhanced by gendered intersectional theory to interrogate different components of programme coverage: availability, accessibility, acceptability, contact and effective. Drawing on communities and health implementers perspectives (using focus groups, interviews, and participatory methods) from varying levels of the health system, across four African country contexts (Cameroon, Ghana, Liberia and Nigeria), we show who is left behind and provide recommendations for programmes to respond.FindingsWe have unmasked inequities in programme delivery that repeatedly leave vulnerable populations underserved in relation to the prevention and treatment of PC NTDs across all components of coverage explored within the Tanahashi framework. Inequities are influenced by health systems challenges and limitations, due to lack of consideration of gender, power and equity issues. Effective treatment for individuals and communities is shaped by individual identities and the intersecting axes of inequity that converge to shape these positions including gender, age, disability, and geography. Health systems are inherently social and gendered thus they become mediators in managing the impact that social and structural processes have on individual health outcomes.SignificanceTo our knowledge this is the only paper which has combined a comprehensive equity framework with intersectional feminist theory, to establish a fuller understanding of who is left behind and why in MDA across countries and contexts. Ensuring the most vulnerable have continued access to future treatment options will contribute to the progressive realisation of UHC, allowing the NTD community to continue to support their vision of being a true ‘litmus test’.

Community-directed distributors—The “foot soldiers” in the fight to control and eliminate neglected tropical diseases

“…Another important challenge of the CDD model and co-implementation of NTD interventions recently highlighted by Dean and colleagues [ 59 ] and others [ 60 , 61 ] is the gender barrier in MDAs. Reasons for the disparity and treatment coverage being significantly higher in areas where women are included as CDDs may relate largely to cultural and religious barriers.…”

Ethical dimensions of neglected tropical disease programming

“… 27 Power imbalances between international donors, implementing partners and national programmes, which are a common feature in global health programmes, can limit the autonomy of national and local actors to respond to needs within their own context. 28 …”

“…To better understand these inequities, data on gender, age, wealth and disability should be collected with routine monitoring of drug coverage, supplemented by qualitative research on underlying social and power dynamics. 28 Such information can be used to develop strategies that ensure access to underserved and marginalized groups.…”

“…Decades of research on stigma has led to effective, comprehensive approaches that have been adapted for NTD programmes, 44 and qualitative research has provided guidance for more effective community engagement. 28 , 45 …”

The SARS-CoV-2 crisis and its impact on neglected tropical diseases: Threat or opportunity?

“…Delays and interruptions to treatment cycles are not unknown to the NTD space, due to setbacks in the supply chain, unseasonal rains, conflicts, political campaigning, or even reduced funding. NTD programs are remarkably adept at making the necessary accommodations to adjust for such delays [4]. Regardless, many countries may need to "catch up" with intermediate rounds of MDAs to mitigate the effect of the enforced pause on infection rates in communities.…”