A CALL TO SUPPORT FRANCOPHONE AFRICAN COUNTRIES TO END THE TREMENDOUS SUFFERING FROM NTDs

Francophone African countries (FPACs) carry the greatest share of the NTDs burden in SSA. In 2016, NTDs and malaria accounted for 14% of the total burden of disease (Figure 1), and 22% of communicable diseases (Figure 2). • Eighteen Neglected Tropical Diseases (NTDs) and Malaria account together for 22% of the total burden of communicable diseases in 25 Francophone African Countries (FPACs). • The cumulative impact of NTDs decreases the quality of life of households, slows economic growth and results in millions of dollars in lost economic productivity annually. For example, the World Bank (WB) estimates annual losses of US$33 million in Cameroon, US$13 million in Chad and US$9 million in Madagascar. • Of the 18 NTDs, 5 can be controlled by preventive chemotherapy (PC) through safe Mass Drug Administration (MDA). • In 2017, the WB launched the Deworming Africa Initiative (DAI), with the purpose of raising the profile of NTDs control and elimination efforts among endemic Sub-Saharan African (SSA) countries to eliminate NTDs as a public health threat. • DAI’s strategy seeks to reduce the burden of NTDs in 3 key population groups that mostly impact on human capital: young children (12-23 months), pregnant women, and school-age children (SAC) (5-14 years of age). To achieve this objective in a sustainable way, DAI supports Country efforts to strengthen the coordinated engagement of the health, education, water, sanitation and hygiene (WASH) and economic sectors with a national prevention and control strategy. • The WB's total annual investments in NTDs control have increased from US$3.3 million in 2013 to US$13.9 million in 2018. The objective is to reach US$25 million annual investments by 2030 to contribute to the achievement of the global universal deworming coverage target (75%). • Multisectoral collaboration between Ministries of economy, health, education, and WASH is a promising approach to maximize national resources towards the long-term sanitary and financial objectives of reducing NTDs in SSA. KEY MESSAGES: P ub lic D is cl os ur e A ut ho riz ed

• Eighteen Neglected Tropical Diseases (NTDs) and Malaria account together for 22% of the total burden of communicable diseases in 25 Francophone African Countries (FPACs).• The cumulative impact of NTDs decreases the quality of life of households, slows economic growth and results in millions of dollars in lost economic productivity annually.For example, the World Bank (WB) estimates annual losses of US$33 million in Cameroon, US$13 million in Chad and US$9 million in Madagascar.• Of the 18 NTDs, 5 can be controlled by preventive chemotherapy (PC) through safe Mass Drug Administration (MDA).
• In 2017, the WB launched the Deworming Africa Initiative (DAI), with the purpose of raising the profile of NTDs control and elimination efforts among endemic Sub-Saharan African (SSA) countries to eliminate NTDs as a public health threat.• DAI's strategy seeks to reduce the burden of NTDs in 3 key population groups that mostly impact on human capital: young children (12-23 months), pregnant women, and school-age children (SAC) (5-14 years of age).To achieve this objective in a sustainable way, DAI supports Country efforts to strengthen the coordinated engagement of the health, education, water, sanitation and hygiene (WASH) and economic sectors with a national prevention and control strategy.The Democratic Republic of Congo (DRC) carries the second largest burden of leprosy in the continent and reported 84% of all Human African Trypanosomiasis (HAT) cases in the world (2012).Trachoma is endemic in every single FPAC, with women being the most affected, accounting for 75% of trachoma-related blindness.Chad and Mali continue to report cases of Guinea-Worm, despite regional eradication efforts.In 2016, an estimate of 37 million SAC were at risk of soil transmitted helminths (STH) infection and required treatment for deworming.Coverage in FPACs for STH deworming is still far from the recommended goal of 75%.

ECONOMIC IMPACT OF NTDs
The economic consequences of NTDs at a household level are stifling and lead to low economic productivity, catastrophic health expenditures and a low quality of life.
According to studies conducted by the NTDs WB team, the accumulated impact of NTD infections at a macroeconomic level reduces economic growth.Madagascar for example, loses an estimated US$9 million annually in economic productivity due to NTDs, equivalent to 0.29% of its annual GDP.Similar impacts are observed in Cameroon (US$33 million), Central African Republic (US$16 million), Chad (US$13 million), Senegal (US$8 million) and Burundi (US$3 million).
A failure of FPACs to assume a leading role in curbing the burden and impact of NTDs in the region will have grave consequences for human capital development, economic growth, and the achievement of the Sustainable Development Goals (SDGs).

NTDs: AN ANCIENT « PUBLIC BAD »
Despite the existence of an important number of people treated with effective MDA in Africa, NTDs are still considered a "public bad" because of: (i) the large number of people affected in the region (half of the population), (ii) the resistance of being eliminated as a public health threat, and (iii) its high level of transmissibility.The latter is due to (a) vectors (mainly mosquitoes) and worms, (b) large internal migration flows that expand worm's infestation, and (c) poor WASH infrastructure and resources in the region.These factors convert NTDs into a chronic and endemic structural problem.
Raising the profile of NTDs control as a regional public health good is certainly a key public policy to address this ancient problem.NTDs control should include: (i) raising awareness among decision makers and affected communities; (ii) increasing knowledge including new technologies for surveillance, (iii) developing coordinated multisectoral policy and regulatory frameworks, (iv) integrating NTD control within health systems through the Universal Health Coverage (UHC) as a service of the basic health package and (v) prioritizing selected programs such as deworming in key populations.

THE WB DEWORMING AFRICA INITIATIVE (DAI) FOR REACHING UNIVERSAL DEWORMING COVERAGE
In 2017, the WB launched DAI, with the objective of raising the profile of NTDs control and elimination efforts among endemic SSA countries to eliminate NTDs as a public health threat.DAI supports Country efforts to strengthen the coordinated engagement of the health, education, WASH and economic sectors with a national prevention and control strategy.
Specific goals of DAI include (i) supporting countries to prevent and control, and where possible, eliminate the five PC-NTDs, as public health threats using MDA; (ii) achieving universal deworming coverage of 75% in endemic countries to control STH and schistosomiasis -the current gap being 5.8 million in SAC (Figure 3) and (iii) supporting countries to increase financing and multisectoral activities for deworming, to reduce its morbidity, economic and social burden, particularly among young children, pregnant women, and SAC.

GOVERNMENTAL INITIATIVES FOR NTD CONTROL AND ELIMINATION IN FPACs
The investments and actions needed to eliminate NTDs as a public health threat in FPACs, are feasible, but require a strong commitment of governments, which includes: i.
A commitment to develop and implement a multisectoral national strategy that includes performance agreements and joint actions between the health, education, WASH, and financing sectors.To achieve the broader aim of poverty alleviation linked to NTDs, actions should urgently be directed towards the improvement of service delivery in the above-mentioned sectors.The SDGs represent an entry point to integrate NTDs into national budgets through health sector reform and greater collaboration between relevant ministries to reach the target population.By reducing the NTD burden, FPACs can improve their human capital and progress towards the realization of SDGs.ii.
A commitment to scale up a national comprehensive strategy in the health sector for NTD prevention, control and surveillance activities, particularly those focusing on the PC-NTDs that can be controlled through MDA.As FPACs move rapidly towards UHC), governments should commit to the sustainable control of NTDs in the long-term through the mainstreaming of prevention and control services for NTDs into the UHC guaranteed benefit package of services and in the universal school health package, provided at the community and primary care level of the health system. iii.
A commitment to increase domestic investment towards NTD prevention and control activities and consider NTD-specific health, education and WASH expenditures as a cost-benefit public policy investment.For example, the WB estimates that a combined additional investment of US$ 97.1 million in the health sectors of the 25 endemic FPAC, including CAR, Chad, DRC, Madagascar, among others, is required to reach the WHO 75% deworming coverage target among at-risk young children, school-age children, and pregnant women by 2020.On the other hand, if the WHO 2020 NTD roadmap targets are achieved, countries such as the DRC will save an estimated US$ 610 million and avert 8.7 million disability-adjusted life years (DALYs) by 2030.It is very clear that a focus on NTDs is beneficial for both health and economic returns.

DYNAMIC AND GOVERNMENTAL AGREEMENTS
Francophone Africa is moving swiftly towards these commitments.In December 2014, 14 FPACs were among On October 11, 2018, the heads of State and Governments of FPACs met in Yerevan, Armenia for the 17th Summit of La Francophonie.This was an opportunity to reaffirm their commitment to the fight against NTDs

THE WB COLLABORATION TO FIGHT AGAINST NTDs
Looking ahead, the three above-mentioned commitments will increase the sustainability of national NTD programs and enable financial partners, like the WB, to leverage domestic investments.Multisector collaboration between health, education, and WASH sectors is a promising approach to pool and maximize limited domestic resources.Some FPACs in the region, such as Burkina Faso, Madagascar, Mali, and Niger are currently implementing WB financing instruments to increase domestic financing for NTD control activities.
The WB will continue to support SSA countries to incentivize the "graduation" of countries in both, their capacity to control NTDs in a multi-sectoral way, and their capacity to mobilize local resources and reward the achievement of targets to ensure that those affected by NTDs can lead healthier and more productive lives.
In 2012, WHO, the WB, other development partners, pharmaceutical companies, and endemic country Governments committed to sustain, expand and extend programs to ensure the necessary supply of drugs to help eradicate guinea worm, and eliminate leprosy, LF, trachoma and trypanosomiasis by 2020.
Partners additionally pledged to control Chagas, leishmaniasis, onchocerciasis, schistosomiasis and STH globally.
To achieve this ambitious vision, thirteen pharmaceutical companies committed to donate medicines free of charge for 10 of the most prevalent NTDs through 2020, including the five PC-NTDs.
In addition, the WB invested US$ 4.8 million in 2015 and in 2018 this investment almost tripled to US$ 13.9 million (Figure 4).The WB aims to increase this annual investment to US$ 15 million in 2020, and to US$ 25 million in 2030.

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Figure 1: Evolution of the NTDs as a proportion of total burden of disease (DALYs) in FPACs (1990-2016)

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Source: ESPEN-WHO including soil-transmitted helminths (STH), schistosomiasis, lymphatic filariasis (LF), onchocerciasis and trachoma can be controlled through MDA of PC.This strategy is only effective, if the MDA´s threshold coverage is sustained annually for at least three to five years or longer.If the threshold coverage is met, countries can reduce the frequency of MDA, and shift resources to integrated disease surveillance and other public health priorities.While the 5 PC-NTDs can effectively be managed through MDA in the short term, WASH service delivery is the key strategy to control PC-NTDs in the long term.Both require a long term financial strategy to have a sustainable impact.

Figure 3 :
Figure 3: Population gap for reaching the regional universal deworming target among SAC (2016) of the Addis Ababa NTDs Commitment.By signing this commitment, Ministers of Health from endemic countries outlined five priority actions to achieve the WHO Roadmap targets for 2020, including to "increase domestic financing for the implementation of NTD programs, through the expansion of government, community, and private sector financing."Additional countries are encouraged to join this commitment and strengthen the momentum around country ownership of NTD programs.