Reflecting on the power dynamics between researchers and vulnerable communities: A Ghana case scenario

Pamela Selormey blog

By Pamela Selormey (Research Technologist and a Research Ethicist at Council for Scientific & Industrial Research – CSIR)

Schistosomiasis and soil-transmitted helminthiasis (STH), two neglected tropical diseases (NTDs) that are stubbornly prevalent in Ghana, are contracted through exposure to contaminated water and soil where parasites are present. The WHO fact sheets on these diseases call schistosomiasis an “acute and chronic disease … causing immune reactions and progressive damage to organs”, and describe that children infected with STH become physically and intellectually impaired. It is no coincidence that poor communities, lacking infrastructure and weighed down by unstable and seasonal livelihoods, suffer disproportionately from schistosomiasis and STH.

The COUNTDOWN project seeks to develop and improve upon current strategies to fight these diseases, with the hope of eliminating them completely. As part of the COUNTDOWN research team, I participated in fieldwork in communities that suffer from high incidence and prevalence of these “neglected” diseases. This prompted me to explore the challenges of working with extremely vulnerable communities, and the obligations we, as researchers, have towards them.

Researching Community-Wide Expanded Treatment

School-aged children are routinely treated with preventive medicine during annual campaigns called mass drug administration (MDA). During MDA, teachers and volunteers give medicine to pupils. However, pre-school-aged children and adults are also at risk, particularly in areas that lack adequate sources of clean water and latrines or other sanitation infrastructure. COUNTDOWN tested community-wide expanded access to treatment, providing praziquantel and albendazole treatment for most people in the community, from toddlers to elders. Our study assessed infection prevalence of schistosomiasis and STH, and environmental risk factors. Fieldwork took place in four communities in Ga-South municipality of Greater Accra region in Ghana (Manheam, Tomefa, Torga-kope and Ada-kope). Participants provided stool and urine samples for parasitological and molecular diagnosis of parasites to determine the prevalence of infections in all four communities before and after treatment.

Community Vulnerability

When our research team arrived, I saw that the common livelihoods of people were fishing for men, selling fish (fresh, fried, smoked or salted) for most women, and some petty trading or small-scale farming. The average educational background was senior high school with a very high number of out-of-school children, mostly due to lack of money. The main source of water for these communities for cooking, washing, bathing and drinking, is the Weija Dam reservoir. Both animals and people depend on the reservoir for water. Waste disposal and latrines in households and schools are inadequate; one latrine can be shared by three or four households. Others do resort to the bush and the Weija Dam reservoir for such purposes.  Sanitation is a major problem.

In this study, we provided a biscuit (or cookie) to participants when they presented their stool and urine samples. This small incentive was a token of appreciation for their willingness to participate. I observed that after providing their own sample, some children were giving us their mom or dad’s sample container. “Can I have another biscuit?” they would ask, beaming up at us. Of course, we gladly gave them biscuits, but the data quality team had to take great care that these samples were from the correct participant. This scenario was repeated in all four communities we studied.

In hindsight, I am not surprised that these sweet little kids wanted more treats. Still, the scenario raised several questions in my mind: Was the incentive we gave in line with established ethical guidelines? Should we be thinking differently about research incentives where children are concerned? Above all, how can we protect the quality and integrity of research while also protecting and caring for the communities that are generously participating in it for the greater good?

Conducting Research with Respect and Integrity

Let’s consider the question about the biscuit incentive. A review of the various ethical guidelines reveals no prescribed standards for differentiating between ‘due’ and ‘undue’ incentives. There are, however, some common elements of undue inducement, including:

  • Undermining voluntariness
  • An offer that one cannot reasonably refuse
  • Leads to a decision against one’s better judgment
  • Assumes substantial risk that compromises one’s welfare
  • Causes participants to lie or conceal information that would exclude them from participating

When applying the elements above in vulnerable communities and with children, serious care must be taken. In the case presented above, household food insecurity likely played a role in the children’s behaviour and how they viewed the biscuit. I would like to sound a word of caution to researchers and Institutional Review Boards (IRBs) to consider the local context of any proposed research. In highly vulnerable communities, this might need to extend beyond a consideration of the item’s value in terms of currency. I am sure other researchers can very much relate to this scenario. A case-by-case compilation of similar scenarios and how they were handled could also help sharpen policy.

What can researchers do to acknowledge and appropriately address the power imbalance that exists between them and local communities where they conduct fieldwork?

Working with vulnerable communities in low-income countries means asking for their trust and pledging to be worthy of it. Based on the lessons I learnt on the COUNTDOWN project, I offer the following recommendations that can be adapted and applied to other contexts:

– First, awareness of the economic power of the local area should guide research design and the selection of incentives.

– Second, scientists should think through how and when they give incentives.

– Third, community leaders should be consulted about the procedures of community-based research, including incentives and their distribution.

If you have experience working in highly vulnerable communities, what challenges did you encounter? Share with us on Twitter: @ntdghcountdown and @NTDCOUNTDOWN.

(Edits by Tori Lebrun)

From ‘shiny hospitals’ to equitable access to NTD Services and the road to Universal Health Coverage

APPG Sept 10th 2019 Blog 1

By Shahreen Chowdhury and Kelly Smyth

On 10th September 2019 the All-Party Parliamentary Group on Malaria & Neglected Tropical Diseases (NTDs) held a meeting at the House of Commons, Westminster to discuss ‘Achieving Health for All: How UK action on NTDs is delivering Universal Health Coverage (UHC)’. Jeremy Lefroy MP(link is external), chair of the meeting opened by celebrating the UK’s contributions and commitment to UHC. He named DFID as the 2nd largest supporter in eliminating five key diseases in 25 countries.

How do successful NTD programmes support UHC? We are all in agreement that we need to be working with governments to increase healthcare access for the poor and vulnerable. But huge numbers of people are being left behind in diagnosis and treatment of NTDs. It is important that efforts should be directed towards reaching the most poor and vulnerable.

Mass Drug Administration (MDA) programmes can be very successful in their own right, but as with most approaches they do not come without challenges. MDA focuses on prevention but even if NTDs are eliminated, there are millions still affected by NTD-related morbidity and disability. If we are serious about ‘leaving no one behind’, we must focus our efforts on increasing equitable access to healthcare.

As disease prevention increases, mass treatment will cease to be cost-effective in some areas. We will need new and more collaborative techniques to direct funding towards delivering healthcare to those who are being missed. It is not enough to implement vertical programmes as we need to consider how NTD programmes can benefit from complementary approaches such as vector ecology, veterinary ecology and behaviour change psychology.

Perhaps the answers lie in an intersectoral approach? It is undeniably shocking that in data published by WaterAid earlier this year it is estimated that over 1.5 billion people globally have no sanitation service at their healthcare facility, and that 1 in every healthcare facilities have no place for people to wash their hands.

APPG Sept 10th 2019 Blog 2

The need for intersectoral collaboration was highlighted by Yael Velleman (SCI) and Helen Hamilton (WaterAid). There is a significant link between Water, sanitation & Hygiene (WASH) and NTDs. Stagnant water and poor access to sanitation increases the risk of contracting diseases such as schistosomiasis, lymphatic filariasis, trachoma and soil-transmitted helminthiases. Access to clean water is also crucial in the management and treatment of NTDs as water is needed not only to wash wounds, but to also take the medication during MDA. We cannot reach the target of eliminating NTDs by 2020 with MDA alone.

A promising step in implementing collaboration with WASH has been the toolkit recently published with the World Health Organization (WHO) stamp of approval WASH and Health Working Together(link is external). This toolkit provides step-by-step guidance to empower NTD programme managers and partners on how to work with the WASH community and reach out to services, thereby improving delivery of WASH services to marginalised populations affected by NTDs.

But lack of long-termism in programmes is a big issue. Once the programme has ended and the last of the funding has been spent- what now? Jeremy Lefroy MP proposed investing in financial protection and integrating services into primary care, rather than investing in ‘shiny hospitals that poor, vulnerable people cannot access’. Christian Rassi, the Seasonal Malaria Chemoprevention (SMC) Programme Director from the Malaria Consortium also made a strong case for the transition from ‘vertical’ NTD programmes to integrating the detection and management of NTDs within primary healthcare (PHC).

It is all well and good talking about policies, targets and figures. What about the realities faced by people? There is a need to think beyond MDA and focus on a more people-centred approach through PHC. However, Mr Rassi mentioned that this requires health systems to have adequate financing, human resources and infrastructure. Community health workers are at the forefront of the NTD Programmes – but they are chronically under-funded and under-resourced (as outlined in outgoing COUNTDOWN  research).

As WHO worked on the new roadmap on NTDs for a post-2020 world, we hope that governments take the opportunity to focus on disability inclusion and develop new measures of programme success, such as community accountability mechanisms and intersectoral collaboration.

A key message from the meeting was that strong political commitment is vital in implementing UHC and primary health care. As researchers, we tend to present research and statistics well but ultimately, we have a responsibility to advocate in a way that is accessible and attractive for politicians to invest in sustainable change.

APPG Sept 10th 2019 Blog 3

DFID and the UK have contributed greatly to the progress on eliminating NTDs, but how can we do better? We will need to take a step back and look at the bigger picture.

Health for all at Universal Health Coverage 2030

UNHC2030 Blog by RT

#HealthforAll @UHC2030 

By Dr Rachael Thomson

 

In preparation for the UN General Assembly high-level meeting (UN HLM) on universal health coverage, taking place on 23rd September 2019, the President of the General Assembly, with the support of the World Health Organization and UHC2030, convened an interactive multi-stakeholder hearing on 29th April 2019 at the United Nations in New York. The overall theme of the meeting later this year is: Universal Health Coverage (UHC): Moving Together to Build a Healthier World.

The one-day hearing focused on core themes around UHC, noting that UHC is a catalyst for social-economic development and a key contributor to equity, social justice and inclusive economic growth. Investing in health systems for UHC drives progress on all health-related targets as well as across several Sustainable Development Goals beyond the health sector, including Goal 1 -no poverty, Goal 2 -food security, nutrition and sustainable agriculture, Goal 4 -quality education, Goal 5 -gender equality, Goal 6 -clean water and sanitation, Goal 8 -decent work and economic growth and Goal 16 -inclusive societies.

Prior to this consultation meeting, 6 Key Asks on UHC for Political Commitment from the UNHLM September meeting have been prepared:

  1. Ensure political leadership beyond health
  2. Leave no one behind
  3. Regulate and legislate
  4. Uphold quality of care
  5. Invest more, invest better
  6. Move together

To develop these Key Asks, the UHC2030 committee conducted three-month consultations with all actors of the UHC movement – parliamentarians, civil society, the private sector, agencies, networks and academia. The UHC Key Asks will feed into the UHC Political Declaration and are the foundation for coordinated advocacy efforts that all partners can promote together throughout the preparation of the UN HLM, the Financing for Development Forum and the SDG Summit as well as other regional or economic fora in 2019.

The stakeholder hearing opened with powerful keynote speeches highlighting coverage acceleration, focus on health coverage as a driver for development and prosperity, equitable health systems and finally, increasing & enhancing multisectoral action. The speakers all called for action. The Director-General of the World Health OrganisationTedros Ghebreyesus, participating via video link from the Democratic Republic of Congo, emphasised response from all of society was needed to achieve success and ‘move from surviving to thriving’. “Half of the world population do not have access to quality services: 800 million people spend more than 10% of their household expenditure on health care – catastrophic costs. UHC provides financial protection”, he added.

AMREF Health’s CEO and Co-Chair of UHC 2030, Dr Githinji Gitahi asked governments to commit at least 5% Gross Domestic Product on public health spending as UHC is not a technical problem but a social and ethical one. ‘Make your power count today!’ he advocated. Dr Alaa Murabit, a Sustainable Development Goals Global Advocate explained that UHC is not just medical treatment or medical provision but is a definition of human security – environmental, safe clean workplaces, equal opportunity, recognising social political and historical forces. She added that UHC breaks cycles of poverty, ill-health and child marriage.

The structure of the meeting was three panel discussions interspersed with certain organisations asked to present their two-minute statements on UHC. There was an interactive ‘pigeon hole’ app where the audience could submit and vote on questions for the panel.

Panel 1: Session 1: UHC as a driver for inclusive development and prosperity

The focus of this panel was discussion of health as a human right. Amanda Glassman highlighted the Disease Control Priority project(link is external) which compared cost effective interventions, with a quarter of all economic growth coming from investments in health. Professor Srinath Reddy of Public Health Foundation of India explained that investing in strong primary care is necessary to ensure health systems deliver the services that people need. He called on governments to increase investments in public health care with key emphasis on primary health workers such as nurses and community health workers. He asked that they be administratively empowered and technically enabled, to deliver essential primary care services.

Panel 2: Session 2. Leave No One Behind – UHC as a commitment to equity

The panel discussed social accountability and UHC as a commitment to equity. It was highlighted that we need to move from commitment to action. The question was asked: ‘How do we ensure that one billion more people have access to health care’?

In response to the 18 million shortage of health workers to reach UHC, it was suggested that youth be empowered and involved in this process. Women and girls should no longer be considered as a marginalised group because when women are empowered, so is the community. Making sure that UHC works for communities means everyone’s involvement and there is the need to promote the right to health and citizen participation. It was highlighted that 15% of the world’s population who live with disabilities are unable to access the health care they need. UHC needs to be built on inclusive health systems. There was also a call for progressive universalism which prioritises the most vulnerable.

Session 3. Multi-sectoral and Multi-stakeholder Action and investments for UHC

This panel focused on how much progress has been made in certain areas such as through increased funding via the Global Fund and its use of multisectoral partners at all levels. It highlighted the need for inclusion of different groups during all stages of decision-making.

Key Observations from the Audience:

DFID expressed a need for better prioritisation using an integrated approach to UHC and quality of patient safety.

There are 18 million jobs needed to achieve UHC and a strong call, led by Women in Global Health and others, suggested that women can fill these especially as gender equality and women’s rights are drivers of health.  There was a strong call for a 7th ‘Ask’ on gender equity and reproductive rights addressing the following:

  • Prioritise the health needs of the most marginalised women and girls.
  • Address the gender determinants of health that drive risk and ill health for all genders
  • Ensure that UHC programmes and policies are inclusive of sexual and reproductive health interventions
  • Acknowledge the role of women as 70% of the health workforce and ensure decent work
  • Integrate the unpaid health and social care work done by women into the formal labour marker
  • Enable women from diverse groups to be represented in equal numbers to men in UHC

While there was no discussion on NTDs from any of the panel discussion members, audience member, Thoko Pooley of Uniting to Combat NTDs, highlighted that NTDs are diseases of poverty and NTD interventions are a marker for equity in health care. She expressed that progress towards UHC should promote equity, reach the least well-off and by virtue be pro-NTD elimination’.

Reflections for LSTM and COUNTDOWN

For me, adding this 7th Ask seems vitally important. There has been a lot of social media action especially on Twitter calling for this to be added. The authors of the consultation document have listened and plan to include it, which is a huge progress.

The concept of progressive universalism is very powerful and while there was little discussion on how to do this, it seems that this is an area that LSTM and COUNTDOWN can support in order for equitable access for all to be achieved.

Few academic groups attended this meeting and were not represented on the panels or keynotes. Of the 31 groups called upon to read out their messages, none were from an academic institution. There was a strong sense that implementers and policy makers know what they need to do. However, little or no discussion was had on how to do it. Whether or not implementers do have the required knowledge, tools and information to make this happen remains uncertain, especially in relation to challenging contexts. Therefore, to be heard in the UHC discourse, implementers, policy makers and academics need to shift the focus from proof of concept studies examining ‘what’, to implementation research studies discovering ‘how’.

Societal Influences on NTD Programme Success: Reflections of a Four-Country Panel

Societal influence blog

L-R: Dr Michèle Ndonou, Vida Kukula, Dr Theobald Nji, Noela Gwani, Professor Sally Theobald, Alice Perkins, Karsor Kollie

By Dr Theresa Hoke

The COUNTDOWN Consortium recently convened in Monrovia, Liberia for our Annual Partners Meeting.  One highlight of the meeting was a panel discussion moderated by Karsor Kollie, Country Director for COUNTDOWN, Liberia and Director of Liberia’s National NTD Programme.  Research colleagues from the COUNTDOWN teams in Cameroon, Ghana, Nigeria, Liberia, and Liverpool served as panel participants. The aim was to examine the relevance of key findings produced by COUNTDOWN Liberia’s social science research portfolio to NTD programmes in other COUNTDOWN countries.

 

Below are some key take-aways from panellists’ remarks.

Q. Liberia has found traditional beliefs can impact low acceptability and therefore low awareness which has led to challenges for delivery of services.  What are the similarities and difference in your own countries?

Dr Theobald Nji, Social Scientist with COUNTDOWN Cameroon, confirmed that traditional beliefs influence the success of NTD programming in his country. For example, it’s not uncommon for people to believe that NTDs are caused by people being “bewitched”. It follows that traditional medicines are sometimes used to treat NTDs. Traditional beliefs about the causes of ill-health and the effectiveness of health services strongly influence how communities respond to NTD services.

Alice Siakeh, COUNTDOWN Liberia, raised the point that NTDs have the greatest impact on the poorest communities, which often implies those with the least education. The social science research team identified how communication was a major gap in NTD programming. To combat limited awareness of NTDs and the drug distribution programme, COUNTDOWN findings show the need for communications using multiple methods, including interpersonal communication, large-scale community meetings, the use of town criers and engagement of town chiefs and elders.

Q. Since CDDs are a key actor in delivering services, we need to look for ways to support and enable them to function effectively.  How have you done this in your own countries?

Noela Gwani, Social Scientist, COUNTDOWN/Nigeria, confirmed this is a priority concern in her country. Programme managers are seeking the best solutions for providing incentives, either financial or non-financial.  In some cases, a certificate of recognition is a strong source of motivation for CDDs.

Vida Kukula, Social Scientist, COUNTDOWN Ghana, described a notable development in her country. CDD training has recently doubled from 2 days to 4 days in response to a request from CDDs themselves for more extensive instruction.  Another interesting finding emerging from COUNTDOWN’s social science research in Ghana is CDDs’ desire “to belong”.  Specifically, CDDs have made it clear that they want to be identified as part of the health care system. One practical solution suggested by study participants is to have an identification card or badge that affiliates CDDs with the Ministry of Health.

Another opportunity to recognize CDDs’ contributions is during training. It is worth recalling that CDDs belong to the communities where they distribute drugs.  When national programme leaders come to trainings held at the periphery, their presence brings prestige and attention to the work of CDDs. This, in turn, increases CDDs’ ability to mobilise communities and encourage participation in MDA.

Q. Where, when, and how drugs are distributed has shown to be a key factor in willingness to take them, Delivery models include fixed point and house-to-house. How are different options used in your countries, and what lessons can be learnt from these options?

Panellist Dr Michèle Ndonou, Health Economist, COUNTDOWN Cameroon, explained that the most important lesson is that delivery models must be shaped by community needs and preferences. In some communities, people prefer house-to-house distribution, so they don’t have to spend money on transportation to access MDA. Fixed-point distribution may not work in rural areas where communities are too far apart, requiring people to travel long distances to access drugs.  By contrast, in urban areas house-to-house distribution may not work if many people spend substantial amounts of time away from their homes.  A more effective solution for urban areas may be to rely on places where large number of people convene, like churches and mosques.

Vida Kukula reflected on how delivery models have been adapted to situations in Ghana.  MDA is not nation-wide, but rather focused on districts that are hotspots for NTDs. Substantial effort is focused on reaching hard-to-reach communities. In areas where hamlets are widely dispersed, programme managers have found that it is best to have set distribution points.

The panel turned to the topic of resource mobilisation for programming. Reflecting on the example of Liberia’s National Communications Strategy, its development was a major step forward, but implementation of that strategy is what really matters now.  Essential to success is investment of resources that flow all the way down to the periphery. Two factors threaten adequate resource allocation, however.  First, as one panellist put it, “Those who manage budgets don’t live with NTDs.”  Stated another way, NTDs are diseases of poverty, and the communities most impacted by NTDs typically lack the power and influence to ensure that NTDs receive adequate attention. A second threat to adequate funding is the way NTD programming is heavily donor-driven. Programmes are dependent on donors prioritizing NTDs and allocating enough resources for roll-out.  One panellist commented, “We have the tools.  It’s implementation that’s the problem.”

Professor Sally Theobald from COUNTDOWN LSTM shared some closing remarks.  She noted Liberia’s great achievement in developing the Communications Strategy, success that can be attributed to formation of an effective partnership across Ministry of Health departments.  She also noted how well-substantiated accounts of how people are affected by NTDs bring into sharp focus why we must get MDA right.  Prof Theobald reminded us how WHO has referred to NTDs serving as a “litmus test” for the Sustainable Development Goals. This means that progress in eliminating NTDs is an important indicator of how essential health services are being extended to the poorest, most vulnerable communities.

A clear conclusion drawn from the panel is that all four countries face similar challenges, and some of the strongest influences on programme success are social rather than technical. The COUNTDOWN Consortium has come to appreciate the invaluable contributions of a multi-disciplinary team. Whilst the technical expertise of parasitologists and epidemiologists is important, social scientists have emerged as an essential partner on the research team. They gather evidence to help tailor NTD services to local contexts, and they serve as a liaison to implementers and community members to ensure their voices is represented in programme design and implementation. Partners in all four COUNTDOWN countries have learned and benefitted from multidisciplinary collaboration.

Religious practices and Neglected Tropical Diseases: What is the connection?

Baptism Weija

By Dr Samuel Armoo

 

On a warm and humid Sunday afternoon during a COUNTDOWN field trip on schistosomiasis related to our implementation research on expanding the mass drug administration treatment against schistosomiasis and soil-transmitted helminthiasis,  I observed 20 individuals performing the Christian practice of baptism by full-water-immersion in Manheam – a community along the Weija dam where schistosomiasis remains highly endemic.

My interaction and discussions with the people revealed that participants were not local to the community but had travelled from afar to baptise or be baptised in the dam. I also found out that this was a common practise among many churches in Accra, as Weija dam was within easy commute. So how could I ignore this observation as my COUNTDOWN team had revealed active on-going transmission of schistosomiasis, a parasitic disease also known as bilharzia, being highly endemic in the local community. This meant that many of these unsuspecting individuals, living in areas further away with no risk of infection, could now be exposed to a disease in the process of practising this religious act. The Weija dam is within a day’s trip to millions of Ghanaian Christians, so the significance of this observation should not be overlooked. Moreover, Ghana is a deeply religious country, with about 70% of the population being Christians.

Infection occurs when the larval forms of the parasite are deposited by freshwater snails which can penetrate the skin when it comes into contact with the infested water. The parasitic worms that cause schistosomiasis can live up to 40 years within the system of an infected individual if left untreated. As a result of a single water baptism in an infested water source, this can lead to contracting this disease, with unfortunate life changing experiences.

S Armoo Blog

Figure 1: Several activities at Manheam that bring people in contact with schistosomiasis- infected water.

The World Health Organisation estimates that over 200 million people around the world are infected with the Schistosoma parasites, with most of the burden of prevalence in sub-Saharan Africa. Ghana is one of the top five countries (Nigeria, Tanzania, Ghana, the Democratic Republic of Congo, Mozambique) on the continent with high prevalence rates of schistosomiasis.

In sub-Saharan Africa the disease presents in two forms: intestinal schistosomiasis, which is caused by S. mansoni, and urinary schistosomiasis, which is caused by S. haematobium. Urinary schistosomiasis known as urogenital schistosomiasis also affects women’s reproductive health leading to infertility, social stigma and an increased rate of abortion. The lesions associated with retained S. haematobium eggs in the female urogenital tract have been associated with an increased risk of HIV infection. For male genital schistosomiasis, the most common symptoms include blood in semen, inflammation of one or both testicles, and prostate inflammation. Both intestinal and urinary schistosomiasis results in anaemia and impaired childhood development, with the risk of reduced intellectual function.

The current control strategies for schistosomiasis is mainly based in identified endemic communities, who usually have close proximity to dams, lakes and other still water bodies. Despite the many successes against the disease in Ghana, it still remains a public health threat. Many areas in Accra are not within the control radar for the national control programme with regards to schistosomiasis. The frequent water baptism in the infested Weija dam area could mean a large cohort of infected individuals living outside the targeted intervention communities. And the most concerning issue is that many of these individuals may not be aware of their infection status and may relate the symptoms of schistosomiasis to other diseases, and wrongly treat them. This calls for an urgent need to inform, communicate and ultimately educate those largely oblivious to the risks of schistosomiasis, in a professional manner allowing them to seek better alternatives.

My suggested way forward is for the churches to create safer places for water baptism, without losing its religious significance and connection or to educate about the risks of infected water sources. The national or district disease control programmes could help advise and collaborate with churches to set up safer ponds with treated water, since people should not be prevented from exercising their Christian faith. Environmental control of schistosomiasis has a long history of local water engineering schemes but is sadly often forgotten. Despite the dangers of drowning in the lake during baptism activities – like was reported a few weeks after my observation, the risks of contracting schistosomiasis during baptism needs to be mitigated and addressed as part of the national NTD control programme.

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Dr Samuel Armoo is the Head of the Biomedical and Public Health Research Unit at the Council for Scientific and Industrial Research – Water Research Institute (CSIR-WRI) in Accra, Ghana. You can reach him via his email: Samuel.k.armoo@gmail.com

Research to Practice: COUNTDOWN Findings lead to improved Community Awareness for Neglected Tropical Diseases in Nigeria

Ogun Sensitisation - radio interview

Discussants after a radio programme on NTDs in a local radio station in Abeokuta, Ogun State.  
From Left to Right: Mr. Ayo Ayowojolu (Coordinator FUNAAB radio), Ms. Chienye Egwuonwu (Programme anchor/ presenter), Prof. Sammy Sam- Wobo (Chairman, State Advisory Committee on NTDs- SACON), Dr. Soneye Islamiat (Ogun State NTDs Programme Coordinator), Prof. Uwem Ekpo (A professor of parasitology and epidemiology, from Federal University of Agriculture, Abeokuta) and Dr. Olabanji Surakat (Ph.D Parasitology).Photo credit: Ogun NTD Programme

By James Nuphi Yashiyi (Social Scientist, COUNTDOWN Ogun State), Victoria Lebrun, COUNTDOWN Consortium

 

COUNTDOWN research conducted in Ogun State, Nigeria indicates that understanding in relation to Neglected Tropical Diseases (NTDs) and associated awareness campaigns is limited in some areas. Consequently, the NTDs programme unit in the state recently organized an NTD awareness creation campaign across the 20 Local Government Areas (LGAs) of the State. The goal of such campaigns is to increase participation in the distribution of medicines to control diseases like onchocerciasis, schistosomiasis, and lymphatic filariasis and help people manage side effects if they encounter any after taking the medicine. Ogun State is one of two states in Nigeria where COUNTDOWN has been working to understand how the NTD programme is functioning and how to accelerate progress against NTDs.

In the state capital – Abeokuta, staff of the NTD Control Unit and other public servants from the Ministry of Health and the Ministry of Information walked through the streets, calling out messages, distributing handbills, and holding illustrative posters that explained the drugs used in the mass administration of medicines (MAM).

Ogun sensitisation

A poster in the local Yoruba language displaying the four NTDs prevalent in the state and their treatment  Photo credit: James Yashiyi (Social scientist, COUNTDOWN Nigeria)

As part of the awareness creation, the NTDs Control Unit staff were joined by parasitology experts from the University on a FUNAAB Radio show (89.5FM) based at the Federal University of Agriculture, Abeokuta in Ogun State. They shared with the public the signs and symptoms of several NTDs and explained how to prevent them. They also debunked the myth that preventive chemotherapy (PC) drugs can be harmful and encouraged parents to set a good example of hygiene for their children like regular washing of hands and keeping their environments clean.

This campaign featured evidence-based approaches informed by COUNTDOWN’s situational analysis and ongoing research. Here are a few ways that this campaign reflects the findings of COUNTDOWN research.

  1. Getting to the heart of End-user Needs

The project’s situational analysis brought attention to the perspectives and needs of communities. In the development of the awareness campaign, COUNTDOWN’s Participatory Action Research(link is external) approach brought all health system actors together whilst focusing on the community perspective. To learn about the programme COUNTDOWN used qualitative methods such as interviews, participatory workshops, and focus groups. The volunteer community directed distributors (CDDs) and school teachers, who carry out the essential task of giving people PC drugs, were engaged in mock trainings using existing information, education, and communication materials. Feedback sessions from teachers, children, community members and CDDs revealed opportunities to improve these materials, which were updated to use the local language and have clearer, more appealing visual aids. COUNTDOWN held regional and national dissemination meetings, which informed the decision of the Ogun State NTD programme to make raising public awareness a priority.

2. Use of Strategic Points in Awareness Creation

One of the activities completed during COUNTDOWN’s participatory action research cycle were several transect walks in various study communities, including those in urban and rural areas. This involved community leaders walking through their communities with researchers and pointing out strategic places where people gather, such as to do business, socialize, or worship. Discussions with female and male community members also revealed important locations and communication channels where men and women can get information. To maximize the impact of the campaign, the NTD programme used research findings to select popular communication channels, like the radio, and strategic locations to distribute PC drugs, such as the large Kuto Market in the state capital, Abeokuta.

3. Adapting to changes over time

A key theme highlighted in the situational analysis is that new challenges have emerged over time. MAM’s success has reduced morbidity due to NTDs, leading some to think that taking PC drugs is not necessary. Volunteers and school teachers reported having to address rumours that PC is harmful. The radio show addressed these issues head on: it explained the need to take the medicine over several years and as a preventive measure and advised against believing “fake news” about the medicines killing children or the government having ulterior motives. Engaging influential community members and leaders such as members of the Parents Teachers Association (PTA), religious leaders etc. was critical to supporting the programme to address rumours about the need for the medicines and their side effects. COUNTDOWN’s community mapping activities supported the programme to identify which individuals could be targeted to support programme delivery in this way.

The global health community is always looking for ways in which the move from evidence to practice can be accelerated and made smoother. It is exciting to see how COUNTDOWN’s holistic approach to research uptake is helping the NTD programme in Ogun, Nigeria. We can see how participatory methods in research allow for the voices of communities to be heard by programme leads, facilitating better community ownership which in turn leads to greater acceptance of medicines.

Highlighting New Paradigms for fighting Neglected Tropical Diseases

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Several COUNTDOWN members attended the Coalition for Operational Research on Neglected Tropical Diseases (COR-NTD) meeting in October 2018. COR-NTD is an alliance of researchers, programme implementers, donors, and advocates with the shared goal of optimizing NTD control and elimination. The meeting highlighted many urgent topics related to how and when to shift strategies to tackle NTDs with more precision and better treatment/intervention coverage, despite implementation challenges.

In Africa, several national NTD programmes are achieving scale-up of preventive chemotherapy (PC) with better access to medications and annual treatment coverage. However, progress against each NTD can be uneven. For example, certain populations remain vulnerable, overlooked, and left behind. Part of COUNTDOWN’s mission is to find out why this is happening, how to ensure better access to treatment, through making the most of limited resources. To improve programme implementation and turn the tide against NTDs in some of the remaining strongholds of NTDs, COUNTDOWN researchers presented new evidence from ongoing research.

Embedding social science methods into a national NTD programme

The first step in improving NTD programme coverage is to ask, ‘who is being left behind, and why?’ For example, mass drug administration (MDA) with a combination of deworming medications, aims to kill the parasites that cause schistosomiasis, onchocerciasis, lymphatic filariasis, and soil-transmitted helminthiasis. The delivery of effective medications is a pro-poor intervention often linked to the third Global Goal, universal health coverage. Laura Dean delivered a presentation in the session, “Aligning NTD programmes with Universal Health Coverage: lessons from research” on the problem of increasing coverage of an intervention already at scale to reach non-covered individuals and populations.

Critical analysis

Critical analysis of programme areas. Image courtesy of Laura Dean   

NTD programmes need to make the focus on equity explicit and plan their activities with the goal of reaching the most marginalized. Participatory Action Research (PAR) cycles are an approach COUNTDOWN used in Liberia and Nigeria to leverage community knowledge to find out who is missing MDA and how to be more inclusive. Getting community members to help tailor programme delivery according to local needs and desires can overcome contextual disadvantages like working with a hard-to-reach population. The approach is particularly well suited for devising strategies for overcoming misconceptions and fears about MDA. If this approach is sustained, the NTD programme will become increasingly agile and adaptable. Researchers are working to establish champions of the method who will ensure it is included in MDA planning and activities.

Send out letters to the LGA Chairman, community leaders, religious leaders like the Pastors and Imams, and influential people like youth leaders. Letters indicate date and time of advocacy visits.
Advocacy visit to these leaders on schistosomiasis and STH.
Sensitising owners/operators/leads and placing posters in worship centres, football viewing centres, boreholes, schools, motor parks, suya and waina joints, bus stops, and grinding mills.
Road shows and practical mobilisation of the communities before and during mobilisation using the IEC materials, radio jingles and television adverts.

Examples of activities using the PAR approach.

Re-thinking who needs PC treatment

Even with revised international guidelines being promoted by WHO from recently conducted randomised controlled trials, millions of women in Africa continue to be excluded from praziquantel treatment such that the burden of female genital schistosomiasis (FGS) goes unchecked. Reasons for this are multifaceted: from shortages in praziquantel supplies to exposing knowledge gaps in the peripheral health system. These latter include insufficient medical education and training of primary health care providers who remain oblivious to FGS etiology as well as confusion within afflicted communities. For example, many mistakenly interpret blood in urine, a cardinal sign of FGS, with that of sexually transmitted diseases. Detailed discussions and exploratory solutions to tackle FGS were guided by Professor Russell Stothard and Dr Jutta Reinhard-Rupp within the session organized by Dr Goylette Chami delving into better behavioral interventions against NTDs. Recent COUNTDOWN research in Ghana has shown that adolescent girls with FGS are being unduly stigmatised for promiscuity.

New mapping technique helps identify where to focus intensive efforts

Professor Louis-Albert Tchuem Tchuenté chaired the session “Shrinking the map for Schistosomiasis.” Geospatial mapping has long been employed to conduct surveillance and plan NTD programme activities. However, schistosomiasis control through treating school-aged children with PC is usually planned by surveying a limited number of schools in a region or district and then either treating, or not treating, all the schools in that geographic area. New evidence from COUNTDOWN demonstrates that mapping NTD prevalence at a more granular level would result in more efficient resource allocation by targeting only schools and/or communities that have an infection prevalence in the 10% threshold. This methodology is called precision mapping.

Precision map

Precision mapping of schistosomiasis gives high-resolution information at the local level and allows for a better and rational utilization of praziquantel and available resources

In a recent study in Cameroon (pictured above), this method would reduce the overall number of treatments even if more ambitious targets for schistosomiasis elimination are adopted. In the session, participants discussed the need for new evidence-based guidance and the need for further operational research to develop it.

Fluid contexts call for partnerships with communities and experts in other disciplines

COUNTDOWN’s Dr  Rachael Thomson and Dr Sunday Isiyaku led a panel on community engagement in emergent contexts such as border regions, urban areas, and conflict zones, where NTD programmes must rely even more on the goodwill and participation of communities to conduct MDA successfully. Dr Theresa Hoke explained how a research uptake strategy can engage communities from start to finish so they experience increased ownership in the NTD programme.

Communities are a unique stakeholder in NTD research because some community members are involved at every stage of the research process, including using the research findings. Luret Lar M.D. of COUNTDOWN’s Nigeria team spoke more about how this philosophy was applied in Nigeria. Following a situational analysis that uncovered specific needs related to community engagement, several participatory methods were employed during PAR cycles, including transect walks and community mapping, a discrete choice experiment with community drug distributors, mock training cascades. Participatory approaches like this group exercise are helping communities identify solutions to sustain participation with the NTD programme. Another approach COUNTDOWN has used is to learn from other disciplines. Anthony Bettee, from COUNTDOWN Liberia, shared how they used research to develop a new communications strategy, leveraging the expertise of the National Health Promotion Department.

In conclusion, reaching programmatic targets often means extra effort in finding those who need treatment, and more precise identification of at-risk populations and geographic locations. Then, programmes must go to those communities that are most in need and work with them, using fit-for-purpose research methods. Increasing equity in NTD control means considering other paradigms besides the current methodologies for carrying out treatment and prevention activities.  A key challenge at COR-NTD arises in being a broad forum bringing together researchers and implementors spanning the major strategies for NTD control.  The meeting has done an outstanding job highlighting common issues and questions that may be answered with further research applying techniques and perspectives from a range of disciplines. The diverse COUNTDOWN Consortium is playing an important role in discussions that will guide this progression towards more equitable and sustainable control of NTDs in Africa.

Albendazole for lymphatic filariasis… direct hit or misfire? (Reposted from ‘BugBitten’)

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For two decades albendazole has been donated for lymphatic filariasis mass treatment programs. An updated Cochrane Review investigates the effectiveness of albendazole for lymphatic filariasis.

Lymphatic filariasis

Lymphatic filariasis, a disease common in tropical and subtropical areas, is spread by mosquitoes and caused by infection with parasitic filarial worms. Once infected, larval worms grow into adult worms and mate to produce microfilariae (mf). The mf are then collected by mosquitoes during a blood meal, and the infection can be spread to another person.

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Life cycle of parasitic worms causing lymphatic filariasis.
CDC

Infection can be diagnosed using tests for circulating mf (microfilaremia) or parasite antigens (antigenemia), or by ultrasound imaging to detect live adult worms.

The World Health Organization (WHO) recommends annual mass treatment of entire populations for at least five years. The main treatment is a two-drug combination of albendazole and a microfilaricidal (antifilarial) drug, either diethylcarbamazine (DEC) or ivermectin.

Albendazole alone, given biannually, is recommended for areas co-endemic for loiasis, where DEC or ivermectin should not be used due to the risk of serious adverse events.

Albendazole for lymphatic filariasis

Both ivermectin and DEC rapidly clear mf infections and can suppress their reappearance. However, mf production will resume due to the limited effects on adult worms. Albendazole was considered for lymphatic filariasis after a study reported that high doses given over several weeks caused serious adverse reactions suggestive of adult worm death.

WHO informal consultation report then proposed that albendazole has a killing or sterilizing activity on adult worms. In 2000, GlaxoSmithKline began donating albendazole for lymphatic filariasis treatment programs.

Elephantiasis-300x207

Elephantiasis of leg due to filariasis.
Wikimedia Commons

Randomized clinical trials (RCTs) investigated the effectiveness and safety of albendazole alone or in combination with ivermectin or DEC. Several systematic reviews of RCT and observational data followed, but it was unclear whether albendazole was of any benefit for lymphatic filariasis.

In light of this, a Cochrane Review published in 2005 has been updated to assess the effects of albendazole in people and communities with lymphatic filariasis.

The Cochrane Review update

Cochrane Reviews are systematic reviews that aim to identify, appraise and synthesize all the empirical evidence that meets pre-specified criteria to answer a research question. Cochrane Reviews are also updated when new evidence becomes available.

Cochrane methods minimize bias in the review process. This includes using tools to assess the risks of bias in individual trials and GRADE the certainty (or quality) of evidence for each outcome.

GRADE-768x578

Use of GRADE for synthesizing evidence and developing recommendations. The upper half describes steps common to Cochrane systematic reviews.
GRADE handbook

The updated Cochrane Review, ‘albendazole alone or in combination with microfilaricidal drugs for lymphatic filariasis’, was published in January 2019 by the Cochrane Infectious Diseases Group and COUNTDOWN consortium.

The Review sought RCTs that assessed:

1) albendazole vs placebo;

2) albendazole plus DEC vs DEC; and

3) albendazole plus ivermectin vs ivermectin

Outcomes of interest included measures of transmission potential (mf prevalence and density), markers of adult worm infection (antigenemia prevalence and density, and adult worms detected by ultrasound) and adverse events.

Using electronic searches, the authors attempted to identify all relevant trials up to January 2018 regardless of language or publication status. Two authors independently assessed studies for inclusion, assessed the risks of bias, and extracted trial data.

What the research says

The Review included 13 trials with 8713 participants. To measure treatment effects, meta-analyses were used for parasite prevalence and adverse event outcomes. Tables were prepared to analyse parasite density outcomes, as poor reporting meant the data could not be pooled.

The authors found that albendazole alone or added to a microfilaricidal drug makes little or no difference to mf prevalence over two weeks to 12 months after treatment (high-certainty evidence).

They do not know if there is an effect on mf density between one to six months (very low-certainty evidence) or at 12 months (very low-certainty evidence).

Treatment with albendazole alone or added to a microfilaricidal drug makes little or no difference to antigenemia prevalence between six to 12 months (high-certainty evidence).

risk-of-bias

‘Risk of bias’ summary: authors’ judgments about each risk of bias item for each trial.
Albendazole alone or in combination with microfilaricidal drugs for lymphatic filariasis.

The authors do not know if there is an effect on antigen density over six to 12 months (very low-certainty evidence). Albendazole added to a microfilaricidal drug may make little or no difference to adult worm prevalence detected by ultrasound at 12 months (low-certainty evidence).

When given alone or as a combination, albendazole makes little or no difference to the number of people reporting an adverse event (high-certainty evidence).

Implications for practice

The Review found good evidence that albendazole alone or in combination with microfilaricidal drugs has little or no effect on completely clearing the mf or adult worms up to 12 months after treatment.

There was no convincing data across studies of an effect on mf density or adult worm viability.

Given that the drug is part of mainstream policy, and the W

HO now also recommend a triple‐drug regimen, it seems unlikely researchers will continue to evaluate albendazole in combination with DEC or ivermectin.

However, albendazole alone is recommended in areas endemic for loiasis. Therefore, this remains a priority for research to know whether the drug is effective in these communities.

A macrofilaricidal drug with a short treatment regimen could make a significant impact on filariasis elimination programs. One such drug is currently undergoing preclinical development, and has been covered in a recent BugBitten blog.

Towards LF Elimination: Are drugs all that is needed?

Towards LF Elimination - Are drugs all that is needed

Irene Honam Tsey, Dodowa Health Research Centre, Ghana

During my last trip to the field in the latter part of 2018, I spent time observing people receiving drugs to control lymphatic filariasis. This fieldwork was part of the COUNTDOWN study which is exploring community health volunteers’ experiences of working with neglected tropical disease programmes to deliver drugs at the community level. My observations made me realise how challenging implementing this programme can be and raised questions about whether simply delivering drugs is sufficient.

 

We visited two villages in the Western region of Ghana considered very hard to reach due to their geographical location. The villages are forest settlements with cocoa farms and cottages and one of these is only accessible by boat or canoe.

Boat MDA Ghana by Irene Tsey

The other was accessible by car along an untarred and poorly maintained road. People living here had migrated from the northern part of Ghana and were working on farms with their families. Due to the nature of these settlements which are scattered and in the rain forest, house to house distribution of the drugs was very difficult and there was no community drug distributor present in the community. We decided to visit this community because in selecting the participants for the study we wanted as much as possible to include a range of communities to understand the scope of experiences and how may vary in different contexts. In trying to enquire about volunteers from hard to reach communities, we were informed by the Neglected Tropical Diseases (NTDs) focal person that Mass Drug Administration (MDA) had stopped taking place in such communities because they had no community health volunteer. The focal person informed the sub – district focal person who is also a community health nurse and she agreed to go with us so she could organise an outreach program for mothers and their children under five years as well administer the drugs to the community members. Prior to our visit, one of the community leaders representing these communities was informed.

In this community, the administration of drugs had not happened for more than 5 years since the community health volunteer passed away and no other community resident felt able to volunteer – perhaps reflecting the challenging conditions they would have to negotiate to distribute drugs. In both communities, from the central meeting point to the closest hut or cottage took about 45 minutes by foot.  

Walking in water to reach community by Irene Tsey

With a team made up of us two researchers, the district NTD focal person and a community health nurse) arriving at the central point where community members had gathered and were ready to administer the drugs through DOT; it came to light that there was no drinking water available. Whilst deliberating on what to do about the situation, most of the community members were talking about the distance to their cottages and their hesitance to walk such a distance and back. Interestingly, the central meeting place was just along the River Pra which has been destroyed due to Galamsey (small scale illegal mining) activities. A young mother quickly removed her baby strapped at her back, gave the baby to another woman and sped off. Unknown to us and to our surprise she had decided to go get a gallon of drinking water from her cottage. Unfortunately, her baby kept crying for the whole period the mother was away. However, after a long wait, she returned with a gallon of water on her head.

In the other hard to reach community visited by the team, the road was terrible and not accessible in the rainy season. However, the team was able to make the trip because the research team came with a land cruiser. Upon arriving at the community after a bumpy ride of 30 minutes to the main central meeting point, we were informed by the community members that the Galamsey (small scale illegal mining) activities had destroyed their main source of drinking water and for some time they have not been able to draw water. They added that they need to wait for the water (which was at the time muddy) to settle – usually by the evening – for them to be able to fetch the water and take the drugs. The team therefore drove back to the closest town to buy some bags of sachet drinking water for the MDA to take place.

These experiences speak to the complex challenges faced during mass drug administration, the realities within rural hard to reach contexts and the challenges faced by both communities and community health volunteers. Moreover, this adds to the existing discussion on MDA success and poses the question whether it is enough to just provide drugs for distribution?

Inclusion, Integration and sustainability: Towards the Endgame of Neglected Tropical Diseases

Inclusion, Integration and sustainability - Towards the Endgame of Neglected Tropical Diseases

By  Laura Dean, Sharon Ngang & Pamela Bongkiyung

The COUNTDOWN project during its Annual Partners Meeting in March 2018 held a panel discussion that focused on finding solutions that were inclusive and integrated for a sustained control of neglected tropical diseases (NTDs). The panel which was made up of multidisciplinary experts from Liberia, Nigeria, Ghana, Cameroon and the UK discussed outcomes from our research informing action towards a successful endgame for NTD control.

In considering leaving no one behind, the first item of business was maximising inclusion in NTD delivery, not just for mass drug administrations but in dealing with morbidity management within wider health system frameworks. The Tanahashi framework was applied by the social science team in our analysis and discussions to identify the population that are lost at certain levels of the service delivery and why. The Tanahashi framework identifies five elements of service provision which should help identify the bottlenecks or areas where people are lost on the pathway to achieving effective intervention coverage.  These include: i) Availability of resources such as manpower, facilities and drugs required to provide service; ii) How accessible this service is to the people who need it (how close is the service to its recipients); iii) Acceptability (has the population accepted the service) iv) Actual contact between the service provider and user to establish contact coverage and v) Service performance appraisal as ‘contact between the service provider and the user does not always guarantee a successful intervention related to the user’s health problem or an effective service.’ (Tanahashi, 1978: pg297)[1]

Accessibility and acceptability issues presented as constituting a major challenge to successful MDA campaigns across all partner countries. Factors identified included migrants and border groups, hard to reach areas both socially and geographically, time constraints and difficulty in reaching certain target groups such as out-of-school-children. In terms of acceptability, fear of side effects or perception of links with family planning are hindering factors which led to refusals though incentives such as food provision before drug ingestion increased willingness to receive treatment. In some cases, difficulties in access to highlighted barriers to mass drug administration (MDA) to include timing of MDA, work overload as community drug distributors are few, lack of knowledge about treatment, lack of supervision and monitoring of adverse side-effects. Most important in working towards the control and elimination of NTDs, discussions pointed to a need for context relevant solutions, particularly in hotspot and highly endemic areas where transmission persists.

COUNTDOWN’s research is using a multidisciplinary approach to unpack the influence of socio-economic and demographic factors on participation in and adherence of communities to MDAs in some partner countries. Krentel, Gyapong et al (2018)[2] advance that ‘we must acknowledge the systematic noncompliers as the potential reservoirs of infection but we have done little to understand who these people are, why they have been left out, and what we need to do to reach them. Ignoring these kinds of implementation challenges risks maintaining them in perpetuity. We need the skill and creativity of many disciplines to respond to these challenges.’

During the panel discussion, the issue of rapid results expectations from donors was presented as a major barrier to the sustainability of NTD programmes. There was a call for donors to be more flexible in funding distribution to allow for effective integration of NTD programmes. This is because it is important that finances are directed to areas where they are most needed and the countries are best placed to know that. However, it was added that more effective supervision will be required at all levels to ensure activities are being carried out effectively with the appropriate funds and available resources; reducing supervision costs ensuring more direct cost to the activities. The panel acknowledged that sometimes identifying what is needed for proper integration to occur can be a challenge. This led to a proposal for adapting solutions to the settings as no one size fits all and countries presented varying needs for health infrastructures, sometimes making integration not necessarily the right fit for some. Integration is possible and has great potential for sustainability and inclusivity of NTD programmes, but this can only be possible if the countries take the lead.

Sharing experiences and knowledge was encouraged as knowledge gaps in some cases lead to misdiagnosis of NTDs as has been the experience with Female Genital Schistosomiasis (FGS) whose symptoms are mistaken for that of a sexually-transmitted illness (STI). In Ghana, COUNTDOWN’s research is informing the training materials of professionals and cross-sector collaboration such as getting the educational institutions to understand the issue of FGS and in so doing, avoid issues around FGS such as stigmatisation of young girls. Issues of NTDs go beyond the health sector, so there is a need for a mix of different partners from various sectors to come together to deal with NTDs which should be seen more as a governmental issue rather than simply a health issue.

Discussions highlighted the five key points needed to build long-term sustainability in this area: strengthen country leadership by building local expertise; reinforce country ownership and strengthen structures of health systems. Sustained capacity building at all levels was seen as vital, just as much as getting internal and external funding for needed activities. With all these in place, then we can ensure an inclusive and integrated programme which can be sustained in the long-term for the control and elimination of NTDs.

[1]Bulletin of the World Health Organization, 56 (2): 295-303 (1978)

[2]Krentel A, Gyapong M, Ogundahunsi O, Amuyunzu-Nyamongo M, McFarland DA (2018) Ensuring no one is left behind: Urgent action required to address implementation challenges for NTD control and elimination. PLoS Negl Trop Dis 12(6)