Global health policy and neglected tropical diseases: Then, now, and in the years to come

1 Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Basel, Switzerland, 2 University of Basel, Basel, Switzerland, 3 School of Public Health, Imperial College London, London, United Kingdom, 4 Independent consultant, Basel, Switzerland, 5 Swiss Centre for International Health, Swiss Tropical and Public Health Institute, Basel, Switzerland, 6 Department of Control of Neglected Tropical Diseases, World Health Organization, Geneva, Switzerland

Declaration on NTDs was written and endorsed by a number of public and private organisations, institutions, and pharmaceutical companies that formed the Uniting to Combat NTDs coalition in the same year [10]. The coalition committed to support the eradication of dracunculiasis, the elimination of lymphatic filariasis, leprosy, human African trypanosomiasis, and blinding trachoma, and the control of schistosomiasis, soil-transmitted helminthiasis, chagas, visceral leishmaniasis, and onchocerciasis by 2020 [10]. In recognition of the progress and to urge continued efforts, the key strategies and targets were enshrined in the first ever WHA resolution (66.12) on all NTDs in 2013 [11]. Uniting to Combat NTDs started to produce annual scorecards to provide status updates [10], and WHO published its Second (2013), Third (2015), and-very recently-Fourth Report on NTDs (2017) [12][13][14].
During this journey, public-private partnership approaches proved successful in developing innovative tools against NTDs and in helping to secure unprecedented resources. Main bilateral donors such as USAID and the Department for International Development (DfID) of the United Kingdom, international organisations such as WHO and the World Bank, philanthropic foundations such as the Bill & Melinda Gates Foundation, nongovernmental development organisations, academia, the endemic countries themselves, and pharmaceutical companies were critical in gaining and sustaining momentum. For instance, the support of the latter started in 1987 with ivermectin donations from Merck & Co., Inc., for onchocerciasis control, gained increasing traction over the years, and now comprises donations of 14 different drugs from 10 companies with an estimated worth of US$2-$3 billion annually [2,5,[8][9][10][11][12][13].
In September 2015, the Sustainable Development Goals (SDGs) were adopted as a successor of the MDGs until 2030. The NTDs are now explicitly mentioned under target 3.3 of the health-related SDG3, and progress is measured against the specific indicator 3.3.5, "Number of people requiring interventions against NTDs" [15]. With this highest policy level breakthrough and the successful public-private partnership approach, which has also been branded as a "rags-to-riches story" by WHO Director-General Margaret Chan [16], what else needs to be done in terms of health policy?
It is important to note that being considered in the vast SDGs agenda will not automatically ensure or even further raise the profile of NTDs. Furthermore, MDG-related structures, longer-term commitments, and connections will not automatically be adjusted to the SDG goals. As with the MDGs, the cross-cutting linkages of NTDs with various SDGs should be continuously stressed and cross-sectoral and transdisciplinary collaborations sought. Besides the wellknown, mutually beneficial links-for instance, with efforts to "end poverty in all its forms everywhere" (SDG1) or with strains to "ensure availability and sustainable management of water and sanitation for all" (SDG6)-new allies may emerge [17]. One potentially very powerful tie from within the health sector could be with the paradigm of universal health coverage (UHC; SDG target 3.8) [14,15]. UHC is likely to be one of the leading health policy paradigms in the years to come and is defined by the 3 dimensions that (i) all people in need (ii) can use promotive, preventive, curative, rehabilitative, and palliative health services of sufficient quality (iii) without suffering from financial hardship [18]. Evidently, UHC can only be achieved if people affected by or at risk of NTD infections also receive appropriate health services. Hence, UHC offers a strong leverage to insist on interventions against NTDs to all in need, and at the same time, as NTDs are often most prevalent in the most neglected and poorest populations, the NTDs can serve as a "litmus test" for UHC [13,14].
Unfortunately, so far, UHC and NTD policies have been developed separately and are often disconnected. Little guidance is available on which specific NTD-related activities within the 5 key strategies should be prioritized for inclusion in UHC benefit packages. For instance, most strikingly, the key strategy "intensified case management" may include a large variety of activities-potentially ranging from simple antibacterial treatment to surgery-and to social inclusion programmes, depending also on the country-specific endemicity of the different NTDs. Concerns have been raised that UHC policies could lead to an increasing focus on health facility-based care rather than prevention, giving lower priority to more communitybased treatment and often also cross-sectoral, NTD-relevant interventions such as vector control, veterinary public health, and WASH, even though the latter activities are also of greatest benefit to the least well off. This currently still unclear situation is further complicated by the Table 1. Populations requiring interventions against neglected tropical diseases (NTDs) and living in poverty. To predict the percentage and the total number of people requiring interventions against NTDs and living below US$3.10 purchasing power parity (PPP) per day and person, 2 extreme scenarios were considered. The "optimistic" scenario assumes that the percentage of people living in severe poverty is the same among those who do and those who do not require NTD interventions. However, the proportion of people living in severe poverty is likely to be higher in those requiring NTD interventions than the national average as NTDs are usually most prevalent among the poor. The "pessimistic" scenario assumes that those who require NTD interventions are first of all those who live in severe poverty.  fact that the current effective coverage of various NTD-relevant health services is insufficiently documented in many endemic countries. As another challenge, the Third WHO Report on NTDs estimated investment targets for universal coverage against NTDs and concluded that a large part of funding is unlikely to come from foreign donors [13]. At the same time, simple combination of estimates about people requiring interventions against NTDs with estimates about people living below the severe poverty threshold suggests that, overall, between 54% and 89% of those requiring NTD interventions in the 21 countries with the highest NTD burdens live in severe poverty (Table 1). Apparently, country-specific differences exist, but a considerable number of people requiring interventions against NTDs will be unable to substantially contribute to financing these interventions. Consequently, the UHC paradigm will necessitate (and should also be harnessed for) the redesigning of policies for the collection, pooling, and reallocation of investments and revenues in endemic countries and to identify additional inland financing strategies for NTD interventions over the next years.

Country
Obviously, much has been achieved in the fight against NTDs over the past years with regards to (global) health policy and financing, but major challenges are still ahead (Box 1). In order to address these challenges and sustain the momentum also when NTD prevalences and morbidities dwindle, it may be advisable to complement the original rallying cry about the "neglect" of the respective tropical diseases. Major achievements and particularly historic opportunities for success in the control, elimination, and-in the cases of dracunculiasis and Box 1. Highlights.
• The omission of the NTDs in the MDGs was a call to arms for the respective stakeholders and a stimulus to join forces to gain critical mass.
• Since then, the NTD brand has been forcefully developed, and advocacy led to the establishment of new organisations and collaborations and recognition by national and international institutions.
• Public-private partnerships have proven highly successful in securing unprecedented resources and also developing tools and strategies to support the fight against NTDs.
• In the SDGs, the NTDs are explicitly mentioned under target 3.3 ("By 2030, end the epidemics of AIDS, tuberculosis, malaria, and neglected tropical diseases, and combat hepatitis, water-borne diseases, and other communicable diseases").
• To sustainably support and strengthen the fight against NTDs, opportunities for crosscutting linkages and cross-sectoral and transdisciplinary collaborations in the SDG agenda should be actively sought.
• The paradigm of UHC (SDG target 3.8) should become a natural ally-the UHC movement can help to highlight the still substantial coverage and investment gaps in the fight against NTDs, and the NTDs can serve as a "litmus test" for UHC.
• Historic opportunities for success in the fight against NTDs should be strongly emphasised in the years to come and complement the original branding about the neglect of the respective tropical diseases-this may help to ensure the continued support by old and new partners and also when NTD prevalences and morbidities dwindle.
yaws-even eradication of NTDs should be strongly emphasised to ensure a continued buy-in from existing partners and to mobilise additional stakeholders.