The devastating impact of HIV/AIDS, tuberculosis (TB) and malaria on the world's poor is well documented. Until recently, however, little mention has been made of NTDs, a group of infectious diseases that inflicts suffering and chronic disability on one billion of the world’s most impoverished...

Can we win the war against NTDs?

The devastating impact of HIV/AIDS, tuberculosis (TB) and malaria on the world's poor is well documented. Until recently, however, little mention has been made of NTDs, a group of infectious diseases that inflicts suffering and chronic disability on one billion of the world’s most impoverished and marginalised people, making it even more difficult for them to rise out of poverty.

This three-year, US $8.2 million Initiative aimed to enable two small African countries, Rwanda and Burundi, to address the prevalence of seven NTDs – schistosomiasis, the three soil transmitted helminths (STHs), onchocerciasis, trachoma and lymphatic filariasis – to below public health hazard levels through the biannual distribution of drugs and the continuous delivery of prevention education.


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Strategic Initiative

SECTOR

Health

TOTAL INVESTMENT

US$ 8,207,056

LOCATION

Burundi & Rwanda

LIVES CHANGED

9,700,108

SOCIAL IMPACT INDEX

66.7 (out of 100)

AVERAGE COST PER LIFE

US$ 0.85

Expand All

SI Breakdown:

Key Achievements

  • Millions of people treated for NTDs – Three years, five MDAs and 8.5 million people treated later, the two countries have achieved major milestones by public health standards. The prevalence rates of schistosomiasis, in some areas, have dropped below the World Health Organization (WHO) threshold of 10 percent. Trachoma is considered hypoendemic.
  • Disease mapping and baselines – the completion of nationwide mapping and baseline studies of six of the seven NTDs provided important information on the status of these diseases in Rwanda and Burundi. These exercises provided information that allowed the teams to monitor the impact of the drug administrations and target the most at-risk populations for treatment.
  • National health systems reinforced – Both countries have built and strengthened their capacity to diagnose, treat and control the spread of NTDs through training health workers, community members and teachers; equipping health facilities with diagnostic equipment; and developing a national health information system that captures NTD prevalence throughout the country.

The Problem

The devastating impact of HIV/AIDS, TB, and malaria on the world's poor is well documented. Until recently, however, little mention has been made of NTDs, a group of infectious diseases that inflict suffering and chronic disability on one billion of the world’s most impoverished and marginalised people, making it even more difficult for them to rise out of poverty. A vast majority of those infected live in sub-Saharan Africa, where unsafe water, poor sanitation and strained health care systems allow these diseases to thrive. NTDs cause severe pain, long-term illness and even death for the millions infected. In children, infection also leads to malnutrition, developmental problems, stunted growth and school absence. In adults, the ill effects of disease lead to social stigma, low self-esteem and a loss of productivity. In 2007, NTDs were wreaking havoc upon millions of Rwandese and Burundian children. Unknowingly infected, they were suffering from stomach ailments and missing school or performing poorly because of frequent illness.

Solution

This three-year, US$ 8.2 million initiative aimed to enable two small African countries, Rwanda and Burundi, to reduce the prevalence of seven NTDs – schistosomiasis, the three soil transmitted helminths (STHs), onchocerciasis, trachoma and lymphatic filariasis – to below public health hazard levels through the biannual distribution of drugs and the continuous delivery of prevention education. The initial programmes were designed so the Legatum Foundation would work with an experienced organisation to provide the technical expertise and oversight needed to implement a programme of this scale in both countries. The Schistosomiasis Control Initiative (SCI), a department of the Imperial College London, was designated as the principal technical advisor to design the programmes with the Rwandan and Burundian partners. The approach included an initial assessment of the geographic burden of each disease, since after years of conflict, most of the country data was unavailable or outdated. Based on the mapping exercises, mass drug administration would be conducted.

Critical Analysis

By the end of three years, 8.5 million people had received treatment for STHs and schistosomiasis, and many were also treated for onchocerciasis and trachoma. (Lymphatic filariasis was not detected in either country, and therefore no treatments were administered.) Additionally, more than 90 percent of school children received NTD prevention education. The third-year reports from our partners indicate that the prevalence of schistosomiasis decreased from 6.4 percent to 3.6 percent, and prevalence of STHs decreased from 25.5 percent to 13.7 percent in the seven schistosomiasis-endemic provinces of Burundi. In Rwanda, the prevalence of schistosomiasis decreased by 90 percent, and STH infections decreased by 15 percent in three pilot districts. 

Our partners in both countries formed beneficial partnerships with other organisations that deliver health care goods and services in Rwanda and Burundi. This led to a leveraging of finances and a building of in-country cooperation. Though the goal of reducing NTDs to below public health hazard levels has not been fully realised – largely due to the high re-infection rates of STHs – we are hopeful that these partnerships and the respective governments’ commitments to control NTDs will sustain the progress made, eventually leading to the achievement of the goal. 

MDAs, held in conjunction with the biannual Mother and Child Weeks in both countries, have further confirmed the efficiency of an integrated health delivery model. Though we remain concerned by the STH re-infections, we are convinced that both countries have laid a strong foundation for the continued control of NTDs as a result of funding provided through this Initiative.

Lessons Learned

Successes:

  • No-cost extension and leveraged funding – An estimated US $3.1 million in in-kind and cash-leveraged funding was received by both NTD programmes, significantly contributing to savings for the Legatum Foundation grants and leading to a fourth year of programme implementation in each country under a no-cost extension period. This allowed for the continued treatment of millions of people and enabled both countries to strengthen their health systems and health workforce capacity, an important foundation for the continuity of these programmes by their governments.
  • Strategic partnerships – By partnering with other organisations that are delivering public health goods and services, the NTD programme and its partner organisations were able to efficiently use their resources, save on logistical costs, and reach a higher number of the target population.
  • Importance of monitoring and evaluation (M&E) – Annual M&E exercises measure the prevalence rates of NTDs after MDAs and compare them to the baseline rates. The resulting data shows progress against diseases and indicates which treatments are still needed and where. 

Challenges:

  • Lack of clean water and sanitation facilities – An important challenge the programme faces in decreasing the burden of NTDs remains the lack of access to clean water and sanitation infrastructure throughout Burundi and Rwanda. Limited access contributes to re-infection and makes it difficult for the population to implement the prevention strategies recommended by the NTD programmes. This key problem needs to be addressed in tandem with NTD interventions.
  • Re-infections – In 2009, both countries noted an increase in the prevalence rates of STHs since 2008, signalling re-infections. Possible explanations for this increase include a lack of water and sanitation facilities; potential drug resistance; and/or faulty data. 
  • Use of funds – The Rwanda team has consistently expended over 90 percent of their annual allocated budget, with close to 50 percent of the expenses incurred in personnel costs. This is largely due to the fact that the Rwanda programme was run by an NGO, whereas in Burundi it was managed in partnership with the government, whose contribution, in terms of personnel and offices to run the programme, had a positive impact on total costs.

Rwanda and Burundi Tropical Disease Control: Featured Projects

SII ScoreProject NameGrantLives ChangedCost Per LifeSector
72.20 Burundi NTDC Program$1,965,3825,378,628$0.37
61.20 Rwanda NTDC Program$3,158,3984,321,480$0.73
Note: The Social Impact Index Score reflects the relative social impact of a given development project. The lowest possible score is 20; the highest possible score is 100.

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