Analysis of Neglected Tropical Diseases Advocacy Landscape Key Findings 2013

Context and Purpose This presentation was commissioned by the Global Policy and Advocacy Group of the Bill & Melinda Gates Foundation (BMGF). BMGF seeks to identify advocacy gaps within the Neglected Tropical Disease (NTD) sector that the NTD community must bridge in order to meet the London Declaration’s goals for NTD control. The Foundation engaged Dalberg Global Development Advisors, a development-focused consulting and advisory firm, to assess the scope of current advocacy activities in the NTD sector and propose how advocacy can best support the scale-up of NTD control and treatment programs in endemic countries. With an eye to understanding the landscape and identifying gaps, this study sought to answer three questions: (1) what are the most critical requirements for meeting the London Declaration’s 2020 targets?, (2) where is advocacy needed to support these requirements?, and, given the current NTD advocacy landscape, (3) where can new or existing organizations play a role to address these advocacy needs? The conclusions and recommendations stated here are representative of the current NTD landscape, and they should be applied in the future as appropriate within the evolving global health and political context. Overall, the NTD community expressed strong consensus on several high-priority advocacy needs for the next few years, and there are many potential roles for advocacy organizations to play to address those needs. This presentation represents summary findings from this study, conducted from May – August 2013. For more information, please contact Alexandra Farnum, Global Policy & Advocacy Group, Bill & Melinda Gates Foundation ([email protected]); Vicky Hausman, Partner, Dalberg Global Development Advisors ([email protected]); or Matthew Frazier, Associate Partner, Dalberg Global Development Advisors ([email protected]).

2

Methodology Stakeholder Group

Current perspectives

No. interviews

Donor governments Endemic country governments Foundations NTD advocacy or implementing NGOs Multilaterals Pharmaceuticals Advocacy experts Other (academics, HNWIs, etc.)

7 5 17 33 10 6 7 9

Existing and historical literature

Review of dozens of existing documents: • Neglected tropical disease research and literature • WHO documentation • NTD country plans

New quantitative analysis

• Quantitative analysis of global NTD burden and estimated costs and funding gaps • Newly created models utilizing current health spending, historical patters of NTD engagement, and additional analysis 3

Executive Summary (1/3) Over one billion people currently suffer from Neglected Tropical Diseases (NTDs), a group of tropical infections that trap vulnerable communities in a cycle of poverty and are responsible for 15 – 30% of lost productivity in the world’s poorest regions. Based on interviews with dozens of NTD experts, the most pressing needs in the eyes of the NTD community are: A. Engaging NTD-endemic country governments in scaling up prevention and treatment programs B. Mobilizing adequate donor funding to support endemic countries C. Improving collaboration and coordination between NTD organizations at the national and international levels In order to meet the London Declaration’s ambitious NTD control, elimination, and eradication goals by 2020, treatment programs need to scale dramatically. The greatest challenge in achieving this goal will be bridging an estimated current annual funding gap of $300 million. • Currently, NTD treatment programs in endemic countries rely heavily on funding from two bilateral anchor donors—the US and UK—which together have pledged to provide $168 million of the estimated $600 million needed annually • Endemic country spending and cash contributions from other bilateral and private donors account for an estimated additional $130 million, leaving a funding shortfall of approximately $300 million. However, endemic country spending on health dwarfs Official Development Assistance (ODA) for health, in a ratio of nearly 40:1 • Assumption of greater responsibility by endemic countries for domestic NTD programs and contributions by new bilateral donors will be essential in mobilizing new sources for needed funding to finance global NTD treatment and surveillance annually. To achieve these advocacy outcomes, the NTD community will need to collaborate more closely on advocacy targets and tactics 4

Executive Summary (2/3) Many highly endemic countries have the ability to fund their own NTD programs – over 70% of the global NTD burden (in terms of DALYs) exist in middle income countries • Specifically, regional leaders such as India, Brazil, Nigeria, and other smaller highly endemic countries with sufficient health resources – such as the Philippines – make attractive advocacy targets. Each has interest in addressing NTDs, but the gap between current and needed NTD spending remains large • Together, these four countries could address 41% of the global NTD burden and close an estimated $200 million of the annual funding gap if they were to fund their own internal NTD needs. • NTD advocacy and implementation organizations have established operations in these countries, but greater coordination on tailored messaging and outreach to adjacent local advocacy groups would strengthen government advocacy Though the US and the UK have been the major sources of NTD implementation and research funding, additional funding will have to come from new bilateral donors. • Bilateral donors are the most attractive source of new funding for NTDs because they 1) command the largest share of global health donor resources, 2) provide sustainable funding via large grants over time, 3) can support integration of NTD programs into parallel development and health systems strengthening initiatives, 4) are already in contact with NTD advocacy and implementation organizations operating in donor countries • The NTD community ought to focus on large donors with growing ODA, existing interest in NTDs or related sectors, and an openness to engage with the NTD community. While there are a number of donors that meet these needs, some of the more attractive donors include Germany, Australia, and France • Although a number of NTD-focused organizations exist in these countries, they could increase their advocacy effectiveness by better aligning messages and activities directed at specific donors • Through coordinated targeting of new donors, the NTD community could potentially bridge the remaining third of the annual funding gap through bilateral donations 5

Executive Summary (3/3) In order to support successful implementation of these activities, cooperation among the host of global NTD advocacy actors must improve. By better coordinating efforts through, for example, a global NTD advocacy working group, the NTD community could: • Align advocacy around high-value targets • Coordinate messaging and global “success stories” to use in communications • Contribute to the creation of compelling NTD narratives tailored to the interests of parallel health and development sectors, such as WASH

6

Contents NTD Landscape Introduction

Engaging Endemic Countries

Mobilizing Donor Resources

Improving Collaboration and Coordination

7

The London Declaration on NTDs identified several requirements in order to achieve the WHO goals by 2020 • Governments, multilaterals, NGOs, and pharmaceutical companies met in January 2012 and committed to supporting WHO goals to eradicate, eliminate, and control the ten most common NTDs by 2020: – Eradicate: Guinea worm disease – Eliminate: Lymphatic filariasis, leprosy, human African trypanosomiasis, blinding trachoma – Control: Schistosomiasis, soil-transmitted helminthes, Chagas disease, visceral leishmaniasis, river blindness (onchocerciasis) • Participants identified a number of requirements in the NTD sector in order to accomplish these goals: – Advance R&D through partnerships and provision of funding to find next generation treatments and interventions for neglected diseases. – Enhance collaboration and coordination on NTDs at national and international levels through public and private multilateral organizations to work more efficiently and effectively together. – Enable adequate funding to implement NTD programs necessary to achieve these goals, supported by strong and committed health systems at the national level. – Provide technical support, tools and resources to support NTD-endemic countries to evaluate and monitor NTD programs. – Provide regular updates on the progress in reaching the 2020 goals and identify remaining gaps. • Today, progress has been made on some of these activities, but others lag behind, resulting in a pressing need for NTD advocacy

8

According to interviews with 60 NTD experts, advocacy can play a major role in addressing three of six needs identified by the NTD community Requirement

2. Donor resource mobilization

3. Collaboration

4. Endemic country capacity-building

5. Research and new tools

6. Drug supply

5

5

6

6

6

6

5

6

5

4

2

2

2

4 1 5

3 1 3 2 2 2 13

5

Description

2 36

6

5

4

5

3 35

2 31

• Engage NTD-endemic country governments to dedicate financial and human resources • Mobilize adequate funding to support program scale-up in endemic countries

• Enhance collaboration between NTD actors • Coordinate with parallel sectors • Communicate progress succinctly

Advocacy Priorities

1. Endemic country engagement

Importance to reach LD Goals1

• Direct resources toward technical support and training at the government and community levels

Respondent:

12

1 1 1

6

• Advance R&D to find nextgeneration treatments

Academic Advocacy NGO BMGF Donor Organization

• Sustain, expand, and extend programs to ensure necessary supply of drugs

Endemic Government Implementing NGO Multilateral Pharmaceutical

N = 60

Question: What is the most important requirement needed to meet the goals of the London Declaration by 2020? How can advocacy play a role? Note: Most interviewees specified more than one requirement as most important for NTD control. Source: Expert interviews, May – July 2013

9

Advocacy organizations should set specific objectives to assist the NTD community in meeting these needs 1 Endemic country engagement

2 Donor resource mobilization

3 Collaboration

High priority advocacy objectives

Secondary advocacy objectives

• Increase government financial support • Increase political support; improve HR and health systems

• Public education within endemic countries

• Maintain support from existing anchor donors (US and UK) • Secure new funding from bilateral/ multilateral donors

• Engage HNWIs and Foundations • Secure private sector contributions • Public fundraising

• Prioritize advocacy targets • Coordinate on messaging, data and presenting success stories • Collaborate to present tailored and consistent narratives to parallel development initiatives (e.g., WASH)

• Coordination among implementers to integrate with other health programs and with health system strengthening

10

Sources: Literature review; Expert interviews, May – July 2013

Contents NTD Landscape Introduction

1

Engaging Endemic Countries

2

Mobilizing Donor Resources

3

Improving Collaboration and Coordination

11

The most critical advocacy need is mobilizing an additional $3 billion by 2020 to finance implementation of NTD control and treatment programs Estimated Total Cost of NTD Program Implementation, 2012 - 2020 Billions USD

• Estimated cost of extending prevention & treatment to achieve NTD control by 2020 is $5 billion

2.9

Foundations Pharma Funding Domestic Resources Bilateral Funding

5.2

2.2 0.1 0.1 0.8

• This equates to an annual funding gap of $300 million, which is estimated to decrease slightly with time as success is achieved

1.2

Expected Funding

• Future donor and endemic country spending is projected to only account for $2-3 billion, leaving a total funding shortfall of $2-3 billion

Gap

Total Need

12

Sources: Abt Associates “Preliminary NTD Funding Gap Analysis,” 2012; Expert interviews, May – July 2013

Endemic countries represent large and rapidly growing sources of global health funding and should be top priority targets for advocacy Endemic country health spending

Health ODA

Total government health expenditure (billion USD)

Gross disbursements of health ODA by donor (billion USD)

All Other Mexico 500 450

486

Brazil

24%

China

321

300

12% 10%

250 200 150

257 13% 11%

Other Foundations

Canada

BMGF 20

UK US 0.6%

15 12.7

12.5

26%

26%

25%

11%

5% 5% 12% 12%

5% 12%

58%

57%

12.3

26%

26%

15 13.0

10

26% 5%

28%

10 12%1

24% 54% 54%

100 50

9%

Grants from US independent foundations (billion USD)

All Other

8%

12%

350

20

11% 393

400

Philanthropy, global health

52%

5

50%

5 57%

57%

0

0

2009

2010

2011

2012E

0 2009

2010

2011

2012E

2.1 21% 79% 2009

1.7 21%

3.8 13%

4.2 13%

87%

87%

2011

2012E

79% 2010

Developing economies are rapidly increasing national health spending, representing a total resource base far larger than any potential donor sources Note: 1) Philanthropy CAGR represents 2005-11, recent year-on-year growth volatile. Sources: ONE “2013 Data Report;” OECD QWIDS Database; WHO Health Expenditure Database; Foundation Center; Dalberg research

13

Over 70% of the global NTD burden is borne by middle income countries with the capacity to deploy health resources against NTDs Disease Burden by Country, Top 14 Endemic Countries

Annual Health Budget Increase, Top 14 Endemic Countries2

Million DALYs lost to NTDs

Current billions USD, based on past health spending trends

4,500,000

1,500,000

1,000,000

500,000

1,443,709

72%

465,858 4,462,992

60%

43%

Chagas disease Leishmaniasis1 African trypanosomiasis Schistosomiasis

565,806

Lymphatic filariasis

459,964

Onchocerciasis Soil-transmitted helminthes

Philippines

94%

Vietnam

249,044

Trachoma

777,970

37%

287,866

Middle income countries account for over 70% of global DALYs attributed to NTDs

48%

1.6

1.8

2+

1.01

Sudan

0.69 0.36

N/A 0.08

Bangladesh

55%

1.4

4.8

87%

53%

1.2

5.7

Nigeria

67%

1.0

India

Indonesia

42%

0.8

27.9

58%

565,061

0.6

Brazil

237,878

375,448

0.4

52.6

Mexico

410,822

0.2

China

50%

55%

All Other

0.0

259,623

1,287,608

Leprosy

0

Ethiopia Mozambique

Middle income countries

0.15 0.08 0.05

DRC

0.01

Tanzania

0.00

In the next year, high-burden middle income countries will spend an additional $93.2 billion on health

Notes: 1) Leishmaniasis burden includes visceral, cutaneous, and mucocutaneous strains. 2) Budget increase represents projected growth from most recent spending figures available. Sources: IHME Global Burden of Disease, 2010; WHO Global Health Expenditure Database, 2011

14

Endemic country targets can be identified by mapping their potential impact on disease burden and openness to engagement

Importance to Public Health (y-axis): Absolute national NTD disease burden in DALYs

“Size of the Prize” (bubble size & color): Current health budget (PPP) and recent health budget growth trends

Openness to Engagement (x-axis): Opportunity for NTD advocacy organizations to influence government decisions, based on existing commitments to NTD control, level of NTD NGO activity in country, openness of decision-making and resource allocation to advocacy, and political stability 15

Source: Dalberg analysis

Several endemic countries– including India, Brazil, Nigeria, and the Philippines – emerge as high-potential NTD advocacy targets Endemic countries by openness to engagement, disease burden, health budget 1 2012 or most recent data 4,600

Health Budget Real Growth 2009-11 (PPP)

4,500

Strong growth (+15%)

Attractive targets are countries with a high portion of the global disease burden and high openness to engagement

India

Nigeria

Steady growth (7-15%)

1,200

Slow growth (0-7%)

NTD Disease Burden (‘000 DALYs)

1,100

India and Nigeria have among the world’s highest disease burdens; their engagement will be essential to global NTD control

Declining (