Neglected tropical diseases (NTDs) are a diverse set of 20 debilitating infectious diseases which affect more than 1 billion people worldwide. The most affected communities are the most impoverished, marginalised and rural communities in countries where the diseases are endemic. According to WHO, NTDs contribute to nearly 19 million disability-adjusted life years. It is estimated that more than 1.7 billion people require treatment for at least one NTD, every year. Over one third of people affected by NTDs live in Africa.
The control and elimination of NTDs has been identified as a public health priority, with the capacity to greatly reduce health inequalities and accelerate progress towards Universal Health Coverage (UHC). Global commitment to the control, elimination and eventual eradication of NTDs was first strongly expressed in the 2012 London Declaration on NTDs. This commitment was followed by the development of the 2012 WHO NTD roadmap “accelerating work to overcome the global impact of Neglected Tropical diseases: a roadmap for implementation.” A subsequent roadmap: “ending the neglect to attain the Sustainable Development Goals” was developed for the period 2021-2030. The 2021 to 2030 roadmap, which was endorsed by Member States at the 73rd World Health Assembly in 2020, defines ambitious 2030 targets and milestones towards ending NTDs globally. The roadmap pushes for stronger accountability, intensified cross-cutting approaches and a change in operating model and culture – including stronger country ownership.
Development of national scorecard management tools to enhance accountability in the fight against NTDs
The scorecard accountability and action mechanism has been adapted for country level and for various disease and health priorities.
Country scorecards are country-owned management tools implemented at national, subnational and community levels to:
- track national and sub-national health performance
- identify bottlenecks or gaps
- increase accountability
- enhance decision-making to drive action
Between 2013 and 2020, ALMA has supported the development and strengthening of 40 malaria, 29 RMNCAH, 3 nutrition and 4 community scorecards, across Africa.
Over the last few years, as endemic countries have prioritized NTD programmes and defined their strategic plans, the demand for strengthened monitoring, evaluation and accountability to support achievement of programmatic targets has increased. Following the inclusion of an NTD indicator in the ALMA Scorecard for Accountability and Action, countries started to develop country-owned and country-managed tool to track progress on the implementation of their NTD programmes.
Between 2018 and 2021, at the request of the countries, ALMA supported the development of eight NTD scorecards:
Additionally, in 2020, Rwanda introduced NTD indicators into its existing Malaria Control and Elimination Scorecard.
How it works
National NTD scorecards are country-owned tools which use existing data to track the performance of priority indicators, selected based on country NTD strategic plans, disease burden and availability of reliable data sources providing routinely updated data.
Scorecards are updated quarterly or biannually, integrated into country review and accountability mechanisms and discussed by key stakeholders led by NTD programmes.
During scorecard discussions, bottlenecks to progress are identified and corrective actions agreed upon and implemented. This accountability cycle draws from the successful implementation of other (malaria, RMNCAH, nutrition, community) national scorecards.
How NTD scorecards are developed
The development of NTD scorecards is a consultative process at country level usually led by NTD programmes and including other MOH programmes and sections such as HMIS/Planning M&E and National Public Health. Research institutions and health partners are also involved in the process. (including WHO, Speak Up Africa, UNICEF, RTI, World Vision, Helen Keller International, Jeunesse Secours, Uniting To Combat NTDs, KOICA, Carter Center, Organisation pour la Prevention de la Cécité (OPC), Sightsavers, WaterAid).
The process of development of scorecards includes:
- agreement of overall purpose of the tool
- selection of priority indicators to be tracked
- identification of key stakeholders who will use the tool
- review mechanisms where the scorecard will be discussed (national and sub-national levels) and and agreement of roles and responsibilities for its continuous use.
- periodicity of update and review of the scorecard. Most country NTD scorecards are updated twice a year but the Namibia, Rwanda and Sudan NTD scorecards are updated quarterly.
The rollout of the scorecard also involves training stakeholders in the use of the Scorecard Web Platform (where the scorecard is hosted). Senior stakeholders are also oriented on the use of the tool.
The development of a national scorecard is concluded with population of the first scorecard.
NTD scorecard Indicators
Indicator selection is a major part of the establishment and continued strengthening of the scorecards. Countries select priority indicators to be tracked by the scorecard using three major criteria:
- high priority (based on country’s targets and goals, disease burden, programmatic strategic priority)
- ability to drive action
- availability of and access to routinely updated data (updated at least annually).
Scorecard indicators include disease-specific, cross-cutting and programme management indicators and performance is tracked at the national and subnational levels.
Currently, the diseases under focus in country scorecards range from two to 11, based on the endemic and priority NTDs in the country, commonly including:
- soil transmitted helminthiasis
- lymphatic filariasis
- buruli ulcer
- human African trypanosomiasis
- guinea worm
- snake bites
Diseases included reflect high prevalence, diseases targeted for elimination and data availability and indicators are used to monitor disease burden, geographic coverage, therapeutic coverage, morbidity management and disability prevention (MMDP), case management, vector control, surveillance, drug management and behaviour change communication (BCC).
Indicators that are not specific to diseases include those measuring access to water sanitation and hygiene facilities, monitoring and evaluation, advocacy, finance and programme management indicators.
Notably, unlike indicators in more established disease and health programmes such as malaria and RMNCAH programmes, data for NTD scorecard indicators are predominantly sourced from programme reports and not the national DHIS.
Integration of scorecard tools in routine accountability mechanisms
Review of country NTD scorecards is integrated in existing accountability mechanisms, both at national, regional and district levels. Some countries are planning to expand dissemination and discussion of thier scorecards including during parliamentary meetings as well as key national and international meetings to galvanize support from senior decision makers and partners.
NTD scorecards have been used by countries to mobilise resources from the government and partners.
In Congo, the NTD programme used the scorecard to advocate for funding. Using the scorecard to present gaps identified during its analysis, the NTD programme was able to mobilise an additional 100,000 million CFA francs (almost US$ 170,000) to support the four NTD programmes in 2020. The country also mobilised additional funds for mass drug administration targeting schistosomiasis and soil-transmitted helminthiasis as well as to map these diseases in 2021.The scorecard is integrated into the Ministry of Health semi-annual and annual reports, and the NTD programme shares it regularly with the ministry, departments, districts stakeholders and partners. The scorecard has also been incorporated into an NTD annual report, which is shared with government institutions and partners.
Use of the scorecard to enhance partner support
In Niger, the scorecard was used to highlight the identified gaps and request for and provision of WHO technical assistance for the mapping of onchocerciasis elimination.
In Zambia, the scorecard has been used to help identify which priority areas to focus on to ensure that the financial resources are channelled towards interventions that will have the most impact. Using the scorecard as an advocacy tool, the country then secured financial and technical assistance to train community health workers in home-based care and to train health workers in management of lymphoedema and hydrocele in 85 districts of Zambia. Partners also committed to assisting the country to secure support for the mapping of Onchocerciasis, and to support mass drug administration for Schistosomiasis MDA in all the districts where the disease is a public health problem. Lastly, they committed to support WASH activities in the three lowest performing provinces.
Use in planning
In Malawi, the use of the scorecard led to the enhanced coordination between the different NTD programmes. Used during the NTD Partners Advocacy meeting, it led to actions such as ordering the adequate quantity of deworming medicines based on the targeted population, and the country is working to ensure that all targeted populations for mass drug administration (MDA) are reached. In addition, the scorecard has guided the schistosomiasis programme to maintain community-based MDA in some regions of the country, when the programme was initially considering only school-based MDAs.
Wide implementation of country scorecards for accountability and action across Africa has enabled country NTD programmes to successfully establish NTD scorecards to strengthen programme management and support acceleration towards control and elimination. Early experiences in the deployment of NTD scorecards has highlighted common bottlenecks faced across countries such as lack of data or issue of data quality, limited resources allocated to NTDs, lack of funds to organize MDA or mapping activities.
The scorecards have enabled timely corrective action associated with improvement of indicators, such as steady increases of both geographic and therapeutic coverages, as well as improvement in data quality.
The scorecards have been used to advocate for support from national governments and partners and have led to significant financial commitments.
Lastly, the establishment of NTD scorecards has highlighted the need for support to countries to strengthen data systems to enable wider collection of relevant data and fast-track integration into DHIS2. This is necessary to improve real-time access of data for decision-making at all levels. As more countries implement NTD Scorecard tools, this will be a critical step to achieving the bold targets of the WHO Roadmap.