Neglected tropical diseases: draft road map for neglected tropical diseases 2021–2030: report by the Director-General

SEVENTY-THIRD WORLD HEALTH ASSEMBLY A73/8 Provisional agenda item 11.8 6 May 2020 Neglected tropical diseases Draft road map for neglected tropical diseases 2021–2030 Report by the Director-General 1. In decision EB146(9) (2020), the Executive Board at its 146th session, having considered the report on neglected tropical diseases1 and recalling resolution WHA66.12 (2013) on neglected tropical diseases, WHO’s road map for accelerating work to overcome the global impact of neglected tropical diseases (2012–2020) and Member States’ commitment to target 3.3 of Sustainable Development Goal 3, requested the Director-General to develop, in consultation with Member States and in collaboration with relevant stakeholders, the road map for neglected tropical diseases 2021–2030, aligning it with Sustainable Development Goal targets for 2030, in order to maintain the momentum and sustain the gains achieved in addressing neglected tropical diseases, as well as applying lessons learned from implementing the road map for 2012–2020, and to submit it for consideration by the Seventy-third World Health Assembly. 2. Since 2018, under the guidance of the WHO Strategic and Technical Advisory Group for Neglected Tropical Diseases, the Secretariat has undertaken a global consultative process to gather input on the development of the draft road map from Member States and stakeholders, including organizations of the United Nations system, scientific and research groups, nongovernmental organizations, implementing partners, donors and private sector organizations. Six workshops were held in 2019, at which more than 70 Member States were represented. Concurrently, more than 100 stakeholders were consulted through bilateral interviews. Additionally, the Secretariat hosted two rounds of online public consultations between April and August 2019, gathering more than 300 responses which were compiled into a first draft of the road map. 3. During its annual meeting in April 2019, the Strategic and Technical Advisory Group for Neglected Tropical Diseases reviewed a first draft of the road map and convened an extraordinary meeting in September 2019, which endorsed a revised version of the draft road map that reflected the input from the global consultative process.2 The Secretariat resolved that the draft road map endorsed by the Strategic and Technical Advisory Group would be made available through the WHO website for further review. 1 Document EB146/14. 2 See the report of the 12th meeting of the Strategic and Technical Advisory Group for neglected tropical diseases. Available at https://www.who.int/neglected_diseases/events/twelfth_stag/en/ (accessed 7 April 2020). A73/8 2 4. Pursuant to decision EB146(9), the Secretariat also initiated further consultations on drafting the new road map with Member States and stakeholders. The draft document was made available on WHO’s website on 19 February 2020. An informal consultation was held with Member States on 9 March 2020. All comments received from Member States and stakeholders have been reviewed and their suggested changes incorporated into a revised draft document that is accessible on the WHO website.1 CURRENT SITUATION 5. Neglected tropical diseases are a diverse set of 20 diseases and disease groups that disproportionately affect populations living in poverty, predominantly in tropical and subtropical areas. They impose a devastating human, social and economic burden on more than one billion people worldwide. More than 200 000 people die each year from snakebite envenoming, rabies and dengue alone. Lack of timely access to treatment and care for other neglected tropical diseases2 leaves hundreds of millions more severely disabled, disfigured or debilitated. Neglected tropical diseases cost developing economies the equivalent of billions of United States dollars each year in direct health costs, lost productivity and reduced socioeconomic and educational attainment.3 6. Interventions against neglected tropical diseases support the vision of universal health coverage. Neglected tropical disease programmes adopt grassroot approaches that enable them to gain access to some of the world’s poorest, hard-to reach communities and people affected by complex emergencies. In doing so, they ensure equitable access to health care and services. Success in overcoming neglected tropical diseases can serve as a litmus test of progress towards the achievement of universal health coverage, which can only be attained if people affected by or at risk of these diseases are adequately reached by health services. 7. A critical juncture has been reached on the road towards elimination of NTDs, providing both an opportunity and an urgent need to accelerate progress. Important advances have been made since the adoption in 2012 of the road map for accelerating work to overcome the global impact of neglected tropical diseases (2012–2020). Today, 500 million fewer people than in 2010 require interventions against neglected tropical diseases. Furthermore, 40 countries, territories and areas have eliminated at least one neglected tropical disease. Dracunculiasis is close to eradication, with 54 human cases reported in four countries in 2019; lymphatic filariasis and trachoma have been eliminated as a public health problem in 16 and nine countries, respectively; onchocerciasis has been eliminated in four countries in the Region of the Americas; the annual number of reported cases of human African trypanosomiasis has fallen from more than 7000 in 2012 to fewer than 1000 in 2018, eclipsing the original target of 2000 cases by 2020; and the number of new leprosy cases reported globally has continued to decline since 2010 at on average of 1% per year after most endemic countries achieved elimination as a public health problem, defined as less than one case on treatment per 10 000 population. 8. Interventions against neglected tropical diseases have been recognized as one of the best buys in development, given their contribution to human and economic well-being. Public–private partnerships have facilitated progress. Pharmaceutical companies donate an average of nearly three billion tablets or 1 Available at: https://www.who.int/neglected_diseases/WHONTD-roadmap-2030/en/ (accessed 28 April 2020). 2 Notably, Buruli ulcer, cutaneous leishmaniasis, leprosy, lymphatic filariasis, mycetoma, onchocerciasis and trachoma. 3 Redekop WK, Lenk EJ, Luyendijk M, Fitzpatrick C, Niessen L, Stolk WA, et al. The socioeconomic benefit to individuals of achieving the 2020 targets for five preventive chemotherapy neglected tropical diseases. PLoS Neglected Tropical Diseases. 2017; 11(1):e0005289 (https://edoc.unibas.ch/54396/1/journal.pntd.0005289.pdf, accessed 7 April 2020). A73/8 3 other formulations of safe, quality-assured medicines annually, worth hundreds of millions of United States dollars, to support control and elimination efforts in countries where neglected tropical diseases are endemic. 9. Although substantive progress has been made since 2012, it is evident that not all of the 2020 targets will be met. The draft road map for neglected tropical diseases 2021–2030 identifies the main gaps as well as the actions required to reach the targets for 2030 (see Annex 1). Experience gained over the past decade shows that further multisectoral action is required across the full scope of 20 diseases and disease groups and in particular areas, such as diagnostics, monitoring and evaluation, access to and logistics for medicines and medical products, advocacy and funding. DRAFT ROAD MAP FOR NEGLECTED TROPICAL DISEASES 2021–20301 10. The draft road map for neglected tropical diseases 2021–2030 seeks to encourage a fundamental shift in focus from disease-specific programmes that may be reliant on external partners to integrated approaches based on common delivery platforms centred on the needs of patients and communities in the context of universal health coverage. It also aims to foster stronger multisectoral coordination, greater ownership by national and local governments, and measurable impact based on outcomes that matter to affected populations. The revised draft road map for consideration by the Health Assembly is available on the WHO website. Annex 2 sets out the proposed global targets for 2030, with milestones for measuring impact by 2023 and 2025, as well as cross-cutting targets aligned with the strategic priorities of WHO’s Thirteenth General Programme of Work, 2019–2023 and the Sustainable Development Goals. Neglected tropical diseases have the greatest relevance for the achievement of Sustainable Development Goal 3 (Ensure healthy lives and promote well-being for all at all ages), but they also affect and are affected by many of the other areas covered under the 2030 Agenda for Sustainable Development. For Goal 1 (End poverty in all its forms everywhere), neglected tropical disease programmes can play an important role in reducing the financial burden of health care costs. Similar cross-cutting areas of alignment are apparent for Goal 2 (End hunger, achieve food security and improved nutrition and promote sustainable agriculture), Goal 4 (Ensure inclusive and equitable quality education and promote lifelong learning opportunities for all), Goal 6 (Ensure availability and sustainable management of water and sanitation for all), Goal 11 (Make cities and human settlements inclusive, safe, resilient and sustainable) and Goal 17 (Strengthen the means of implementation and revitalize the global partnership for sustainable development). Less obvious but equally compelling connections link neglected tropical diseases to the other 10 Goals. The draft road map describes the integrated approaches needed to achieve these targets through cross-cutting activities that intersect multiple diseases. It is built on three pillars that will support global efforts to control, eliminate and eradicate neglected tropical diseases. 11. Pillar 1. Accelerate programmatic action. Action is required to advance scientific understanding, develop new tools, improve strategies, strengthen service delivery and boost enablers. Ongoing research and innovation are essential to drive progress and take mitigating action against risks such as antimicrobial resistance, climate change, complex emergencies and political instability. Strong health systems and a global enabling environment are essential to achieve and sustain the targets for neglected tropical diseases. Although overall strengthening of health systems is a long-term goal, building capacity in specific technical areas will be especially beneficial. Critical gaps and areas have 1 See https://www.who.int/neglected_diseases/WHONTD-roadmap-2030/en/ (accessed 7 April 2020). A73/8 4 been identified for action across multiple diseases, including diagnostics, monitoring and evaluation, access and logistics, advocacy and funding (see Annex 1). 12. Pillar 2. Intensify cross-cutting approaches. Given the breadth and diversity of the portfolio of neglected tropical diseases, an approach focused on individual diseases alone will not be sufficient to achieve the 2030 targets. Cross-cutting approaches are therefore needed; these embrace integrating approaches across diseases, mainstreaming delivery platforms within national health systems, and coordinating efforts across sectors. 13. Pillar 3. Change operating models and culture to facilitate country ownership. Delivering on the targets, once they are adopted, will require pragmatic shifts in organizational structures and new ways of working between and across health programmes, including noncommunicable diseases initiatives. The draft road map will be implemented to accommodate changes in current practice and facilitate compliance with its strategic pillars and guiding principles. THE ROLE OF MEMBER STATES, STAKEHOLDERS AND THE SECRETARIAT 14. Role of Member States. Countries are both the drivers and the beneficiaries of progress towards the 2030 targets for neglected tropical diseases. Where countries lead, stronger country ownership and accountability will follow. A proactive approach is thus necessary from national and local governments to define and deliver action plans financed partly or fully through domestic funds. The draft road map provides guidance on how countries can update or prepare national plans that are aligned with the targets set out in the draft road map and the Sustainable Development Goals. It offers recommendations on how to achieve greater integration of approaches and multisectoral coordination and to sharpen the focus on the gaps that should be filled as a priority. 15. Role of stakeholders. The support of stakeholders has been important in enabling the advances of the past decade and their sustained commitment will be essential to achieving the targets for 2030. Stakeholders should align their support by making their funding streams and reporting structures more flexible and harmonized. At the regional and global levels, stakeholders should provide strategic support to WHO by promoting research that generates evidence to inform guidance to countries, as outlined in the draft road map. 16. Role of the Secretariat. In line with its core roles, the Secretariat will continue to set, communicate and disseminate normative guidance, policy advice and implementation guidance to support country action. To support implementation of the draft road map, the Secretariat will also develop an investment case, a sustainability framework, a monitoring and evaluation framework, a research portfolio and an updated global strategy on water, sanitation and hygiene and neglected tropical diseases. At the global, regional and country levels, the Secretariat will provide support to Member States in implementing the draft road map and in reviewing and updating national plans, where appropriate. 17. The Secretariat will ensure that its policy-setting process responds to the evolving public health context of neglected tropical diseases and that its global technical guidance is regularly updated by incorporating innovative tools and strategies that have proven to be effective. In addition, it will strengthen its own capacities at the global, regional and country levels so that it is better positioned to lead coordinated global efforts to meet the cross-cutting and disease-specific targets and to ensure implementation of all the recommendations contained in the draft road map. The Secretariat will promote the research and knowledge required to fill the gaps specified in the draft road map and to ensure sustainable progress towards disease control, elimination and eradication. The Secretariat will A73/8 5 continue to engage with the pharmaceutical industry to secure donated medicines and products, and to advocate for increased commitments from partners, donors and academic institutions. 18. The Secretariat will monitor implementation of the draft road map and regularly evaluate progress towards the milestones set for 2023 and 2025 and the targets for 2030 using the proposed monitoring and evaluation framework. It is proposed that the Secretariat should report on progress to the Health Assembly the year after the milestone and target years (in 2024, 2026 and 2031) as well as in 2029, the year after WHO’s fourteenth general programme of work will conclude. The draft road map (including its milestones and targets) will be updated, when indicated, to ensure its alignment with the latest global policy recommendations and to reflect the evolving contexts of neglected tropical diseases. ACTION BY THE HEALTH ASSEMBLY 19. The Health Assembly is invited to consider the draft road map for neglected tropical diseases 2021–2030 and to provide further guidance on the following questions: • What changes to current operating models and culture will Member States need to make in order to facilitate country ownership and ensure the sustainability of national programmes on neglected tropical diseases? • What commitments should stakeholders put forward to preserve the achievements made in implementing the previous road map (Accelerating work to overcome the global impact of neglected tropical diseases – a road map for implementation 2012–2020) and to align their future support with the new draft road map (Ending the neglect to attain the Sustainable Development Goals: a road map for neglected tropical diseases 2021–2030)? • What contributions will the draft road map for 2021–2030 make towards demonstrable improvements in global public health? A 7 3 /8 6 ANNEX 1 GAP ASSESSMENT FOR EACH NEGLECTED TROPICAL DISEASE Source: https://www.who.int/neglected_diseases/WHONTD-roadmap-2030/en/. Technical progress Enablers Strategy and service delivery Diagnostics 3 4 1 3 2 Access and logistics 2 3 2 2 3 2 Planning, governance and programme management 3 2 2 3 3 Collaboration and multisectoral action 2 2 3 3 2 3 2 2 3 2 Health care infrastructure and workforce Operational and normative guidance 2 2 3 2 3 2 3 3 3 3 1 2 Scientific understanding Effective intervention 2 3 2 2 3 1 Monitoring and Evaluation 3 3 3 4 3 2 2 3 3 2 3 1 Capacity- and awareness-building Advocacy and funding 3 3 3 4 3 3 3 3 3 2 2 3 3 3 3 3 1 2 3 4 2 2 2 3 3 4 4 3 Elimination (interruption of transmission) Elimination as a public health problem Eradication 3 3 3 2 2 4 4 3 2 3 2 4 3 2 1 2 3 2 2 4 3 3 3 2 2 3 4 3 4 3 3 3 1 2 3 3 3 3 4 3 3 3 3 2 2 2 4 3 2 3 3 1 2 3 2 2 4 2 2 1 2 1 3 2 2 4 2 2 2 3 2 1 3 3 2 1 1 4 3 3 3 4 3 2 2 4 4 3 3 4 3 4 4 2 2 4 4 2 1 3 4 3 3 3 4 3 4 4 3 4 4 3 3 1 4 4 4 4 3 4 4 4 4 4 3 1 4 4 3 3 2 1 3 3 3 3 2 3 3 3 3 4 4 3 2 2 3 3 2 2 2 2 4 3 2 4 3 1 4 4 4 4 4 4 3 4 3 3 3 3 4 4 4 2 4 4 Control 3 2 3 2 A73/8 7 ANNEX 2 PROPOSED ROAD MAP TARGETS, MILESTONES AND INDICATORS Overarching global targets Indicator 2030 Percentage reduction in people requiring interventions against neglected tropical diseases 90% Number of countries having eliminated at least one neglected tropical disease 100 Number of neglected tropical diseases eradicated 2 Percentage reduction in disability-adjusted life years related to neglected tropical disease 75% Cross-cutting targets Indicator 2030 INTEGRATED APPROACHES Integrated treatment coverage index for preventive chemotherapy 75% Number of countries that adopt and implement integrated skin neglected tropical disease strategies 40% Percentage reduction in number of deaths from vector-borne neglected tropical diseases (relative to 2016) – to achieve WHO’s global vector control response goal 75% MULTISECTORAL COORDINATION Access to at least basic water supply, sanitation and hygiene in areas endemic for neglected tropical diseases – to achieve targets 6.1 and 6.2 of Sustainable Development Goal 6 90% Share of the population at risk protected against catastrophic out-of-pocket health expenditure due to neglected tropical diseases – to achieve target 3.8 of Sustainable Development Goal 3 90% Share of countries with neglected tropical diseases integrated in national health strategies/plans 90% UNIVERSAL HEALTH COVERAGE Share of countries including neglected tropical disease interventions in their package of essential services and budgeting for them 90% Share of countries with guidelines for management of neglected tropical disease-related disabilities within national health systems 90% COUNTRY OWNERSHIP Share of countries reporting on all relevant endemic neglected tropical diseases 90% Share of countries collecting and reporting data on neglected tropical diseases disaggregated by gender 90% Impact of integrated approaches on disease-specific targets Disease Indicator 2020 2023 2025 2030 TARGETED FOR ERADICATION Dracunculiasis Number of countries certified free of transmission 187 (96%) 189 (97%) 191 (98%) 194 (100%) Yaws Number of countries certified free of transmission 1 (1%) 97 (50%) 136 (70%) 194 (100%) TARGETED FOR ELIMINATION (INTERRUPTION OF TRANSMISSION) Human African trypanosomiasis (gambiense) Number of countries verified for interruption of transmission 0 0 5 (21%) 15 (62%) Leprosy Number of countries with zero new autochthonous leprosy cases 50 (26%) 75 (39%) 95 (49%) 120 (62%) Onchocerciasis Number of countries verified for interruption of transmission 4 (12%) 5 (13%) 8 (21%) 12 (31%) TARGETED FOR ELIMINATION AS A PUBLIC HEALTH PROBLEM Chagas disease Number of countries achieving interruption of transmission through the four transmission routes (vectoral, transfusion, transplantation and congenital), with 75% antiparasitic treatment coverage of the target population 0 4 (10%) 10 (24%) 15 (37%) Human African trypanosomiasis (rhodesiense) Number of countries validated for elimination as a public health problem (defined as <1 case/10 000 people/year, in each health district of the country averaged over the previous five-year period) 0 2 (15%) 4 (31%) 8 (61%) Leishmaniasis (visceral) Number of countries validated for elimination as a public health problem (defined as <1% case fatality rate due to primary visceral leishmaniasis) 0 32 (43%) 56 (75%) 64 (85%) A73/8 Annex 2 8 Lymphatic filariasis Number of countries validated for elimination as a public health problem (defined as infection sustained below transmission assessment survey thresholds for at least four years after stopping mass drug administration; availability of essential package of care in all areas of known patients) 19 (26%) 23 (32%) 34 (47%) 58 (81%) Rabies Number of countries having achieved zero human deaths from rabies 80 (47%) 89 (53%) 113 (67%) 155 (92%) Schistosomiasis Number of countries validated for elimination as a public health problem (currently defined as <1% proportion of heavy intensity schistosomiasis infections) 26 (33%) 49 (63%) 69 (88%) 78 (100%) Soil-transmitted helminthiases Number of countries validated for elimination as a public health problem (defined as <2% proportion of soil-transmitted helminth infections of moderate and heavy intensity due to Ascaris lumbricoides, Trichuris trichuria, Necator americanus and Ancylostoma duodenale) 7 (7%) 60 (60%) 70 (70%) 96 (96%) Trachoma Number of countries validated for elimination as a public health problem (defined as (i) a prevalence of trachomatous trichiasis “unknown to the health system” of <0.2% in ≥15-year-olds in each formerly endemic district; (ii) a prevalence of trachomatous inflammation – follicular in children aged 1–9 years of <5% in each formerly endemic district; and (iii) written evidence that the health system is able to identify and manage incident cases of trachomatous trichiasis, using defined strategies, with evidence of appropriate financial resources to implement those strategies) 9 (14%) 28 (44%) 43 (68%) 64 (100%) TARGETED FOR CONTROL Buruli ulcer Proportion of cases in category III (late stage) at diagnosis 30% <22% <18% <10% Dengue Case fatality rate due to dengue 0.80% 0.50% 0.50% 0% Echinococcosis Number of countries with intensified control for cystic echinococcosis in hyperendemic areas 1 4 9 17 Foodborne trematodiases Number of countries with intensified control in hyperendemic areas N/A 3 (3%) 6 (7%) 11 (12%) Leishmaniasis (cutaneous) Number of countries in which 85% of all cases are detected and reported, and 95% of reported cases are treated N/A 44 (51%) 66 (76%) 87 (100%) Mycetoma, chromo- blastomycosis and other deep mycoses Number of countries in which mycetoma, chromoblastomycosis, sporotrichosis and/or paracoccidioidomycosis are included in national control programmes and surveillance systems 1 4 8 15 Scabies and other ectoparasitoses Number of countries having incorporated scabies management in the universal health coverage package of care 0 25 (13%) 50 (26%) 194 (100%) Snakebite envenoming Number of countries with incidence of snakebite achieving reduction of mortality by 50% N/A 39 (30%) 61 (46%) 132 (100%) Taeniasis/cysticercosis Number of countries with intensified control in hyperendemic areas 2 (3%) 4 (6%) 9 (14%) 17 (27%) Source: https://www.who.int/neglected_diseases/WHONTD-roadmap-2030/en/. = = =