Resourcing schistosomiasis elimination – changing the rules of the game

Last month, the new WHO guidelines on control and elimination of human schistosomiasis were launched. This guidance represents the first crucial step in reaching elimination of schistosomiasis by 2030 as outlined in the WHO NTD road map.

It is increasingly clear, based on the new guidance as well as recent modelling, that existing strategies of preventative chemotherapy targeting only school-aged children will not lead to the elimination of schistosomiasis. The new guidance represents a strategic shift from disease control strategies that require continuous rounds of preventative chemotherapy indefinitely into the future to multi-sectoral interventions that tackle the transmission of  parasites. These new guidelines aim for a permanent removal of the burden posed by schistosomiasis on populations at risk.

Such a significant shift in approach will require considerable changes across the whole deworming sector, not just in terms of how programmes are designed and implemented, but also the way in which they are funded.

A changing funding landscape for NTD programmes

Organisations like ours, that work with ministries of health in endemic countries, will need to align our ways of working with this ambition. This means placing impact, cross-cutting approaches, and country ownership at the heart of everything we do. These paradigm shifts require a complete overhaul of the funding model for schistosomiasis and other NTD programmes.

As a community, we face significant funding challenges to reaching the global targets, requiring new and innovative funding models:

• Cost-effectiveness – a major driver of investment in deworming – naturally reduces as elimination approaches, since fewer people require treatment across the same population, and people at-risk are likely to be harder, and more costly, to reach. Many funders focus primarily on the cost-effectiveness of deworming when making funding decisions, an approach that fails to recognise the cost-benefit of elimination and its significant positive impacts on health systems.
• The overall number of donors investing in deworming initiatives has also reduced significantly over the last few years, and the major deworming funding channels are not currently aligned with the elimination agenda and associated guidance set by the WHO. This lack of alignment and the insistence on a narrow view of cost-effectiveness undermines country ownership of programmes and hampers countries’ elimination ambitions.
• Mobilising sustainable resources to support cross-sectoral comprehensive interventions is often challenging due to siloed funding streams, the lack of very easily understood metrics, and a lack of awareness of or interest in the resources needed for – and benefits gained from – effective coordination between sectors.
• Investing in generating data that allows for effective utilisation of the finite drug supplies donated to support elimination programmes is not prioritised by some current donors. This undermines the effective targeting of donated drugs to the populations that need them, and the ability to expand treatment to underserved groups in order to reach elimination.

Changing the rules to achieve schistosomiasis elimination sustainably

The launch of the new guidance in the year that the SCI Foundation celebrates its 20th anniversary strengthens our commitment to build on the foundations we have helped lay towards elimination of this preventable disease. This year, we will roll out our new strategy and operational model with a particular focus on innovative financing models for comprehensive, cross-sectoral disease elimination efforts, working to embed deworming within sustainable routine healthcare service delivery.

To respond to the changes required to achieve elimination and to threats of reduced funding, we must strengthen our resolve to champion in-country ownership of deworming programmes, and of NTD programmes more broadly. This requires:

• Partnership: building trust, valuing diverse perspectives, and investing in local health systems
• Alignment: Being agile and avoiding parallel structures in-country that undermine country ownership, infrastructure, and decision making
• Building expertise: Lending technical expertise to enable rapid progress in-country

These may seem like general and simple statements of intent, but in practice, they mean creating a new normal among organisations within our disease community in which we hold ourselves accountable to elimination and purposefully ‘work ourselves out of a job’, avoiding dependency and putting the sustainability of country efforts ahead of our own.

As elimination comes within sight for several countries after decades of investment, this ambition is endangered by decisions made by those who are removed from their impact. A change in the rules of the game is needed now to keep elimination within reach, and to place decision making power back where it belongs.