Incentivizing disease elimination through debt relief - an article by Ken Gustavsen

We're pleased to share the following article written by Ken Gustavsen, Merck & Co., Inc., Kenilworth, NJ, USA

The original article can be found here: https://www.linkedin.com/pulse/incentivizing-disease-elimination-through-debt-relief-gustavsen/  

Linking debt relief in Africa to progress in control and elimination of neglected tropical diseases (NTDs) to improve health and economic outcomes.

Background

Neglected tropical diseases (NTDs) are a set of communicable diseases that affect more than one billion people globally, primarily in resource-constrained settings with inadequate healthcare systems.  These debilitating diseases create tremendous burdens on individuals and populations, putting a brake on health, economic and social advancement. Programs to address NTDs have been active for decades through a combination of effective, if somewhat vertical and independent, philanthropic initiatives, government programs, and international coalitions. A major step forward came in 2012 when a group of international public and private partners coalesced to endorse the London Declaration on NTDs. Through the London Declaration and its supporting structure, Uniting to Combat NTDs, members pledged to sustain, expand, and coordinate efforts to control and eliminate NTDs. The disease-specific, time-bound goals of the partnership are linked to the World Health Organization’s (WHO) Roadmap on NTDs

Making progress, but not fast enough

Since 2013, annual updates from WHO and other stakeholders showcase the significant accomplishments towards achieving the global NTD goals. At the community, national and regional levels, millions of people are being freed from the burden of NTDs. In 2018, a new tool was added to track the progress against 5 NTDs in Africa: lymphatic filariasis, onchocerciasis, soil-transmitted helminths, schistosomiasis, and trachoma. Future performance at the national level to control and eliminate these diseases will be added to the scorecard of the African Leaders Malaria Alliance (ALMA). This is a welcome addition to the transparency and accountability of country-led efforts to combat NTDs.

Unfortunately, even with these various partnership and tracking mechanisms, the rate of progress is not sufficient to achieve the current disease control and elimination goals. People continue to suffer from infection, disease transmission continues, and subsequently, economic progress at the individual and country level is thwarted. While existing frameworks like the WHO Roadmap, the London Declaration and the ALMA scorecard provide the vision to achieve the NTD control and elimination goals, what is lacking is an innovative financial incentive mechanism – a “prize” – that would galvanize and accelerate country-led efforts.

 The best buy in public health

NTDs programs are often characterized as “best buys in public health” due to the significant long-term return from relatively moderate investments. Unfortunately, while the promise of avoiding future health costs – the “NTD dividend” – is attractive, the tangible value of future reduced spending is often hard to quantify and difficult for policy makers to appreciate. Faced with a range of legitimate competing issues, national budgets may not prioritize investments into NTD programs. As a result, significant health and economic outcomes are delayed. Is there a way to leverage the “NTD dividend” to deliver direct financial return to a country’s balance sheet while also creating an incentive to prioritize NTD programs?

 Addressing debt and development…

The fight against NTDs in Africa is taking place against a backdrop of increasing national indebtedness. Over the past several years, countries have been taking on more and more debt. As a result, necessary spending on national priorities like health is under pressure. One tool to address this debt is the Heavily Indebted Poor Countries (HPIC) program of the International Monetary Fund (IMF), a “comprehensive approach to debt reduction is designed to ensure that no poor country faces a debt burden it cannot manage.” Eligible countries can apply for debt relief by making structural changes – initial and over time – that demonstrate a commitment to meaningful reforms. Increasing levels of debt relief are awarded to applicants with a track record of performance against their plans. 

 …and disease?

The potential to control and eliminate NTDs coupled with the need to address runaway debt creates a perfect opportunity for mutually-reinforcing advances in health and economic development in Africa. NTD frameworks lack incentive structures, while indebted countries need tools to generate economic value. These needs are complementary, not competing: Adding metrics on NTD progress to debt reduction criteria would have a mutually reinforcing benefit.  Therefore, by working with the IMF to expand the HIPC program to include NTD program performance captured in the annual ALMA scorecard, countries would have a material incentive to advance on health programs that might otherwise receive a lower priority. In turn, success on those “best buy” health programs would serve as fuel for economic growth.

From theory to practice

Several things are needed to move this model of a debt-relief financial “prize” for progress against NTDs from theory to practice. The WHO can work with the IMF to further explore this linkage and examine the case for program integration. At the country level, national budgets are the purview of ministers of finance, while health programs fall to the health ministry; greater dialog is needed on the mutually beneficial opportunities created by linking NTD activities to the HIPC and ALMA programs. Additionally, more work is needed by the international NTD community to quantify the economic impact of control and elimination programs, such as an updated NTD return on investment tool

Conclusion

NTDs create a health and social burden for more than a billion people, and hinder social and economic progress in countries already constrained by development challenges. The global push to combat NTDs, while making progress, would benefit from innovative financing incentives to motivate policy makers to keep NTDs high on the list of priorities. The creation of a financial “prize”, by linking national NTD performance as represented in the ALMA scorecard to debt forgiveness achieved through the IMF’s HIPC program, could contribute to a self-reinforcing cycle of health and economic progress.