Business Case

Summary Sheet

Title: Accelerating the Control and Elimination of Neglected Tropical Diseases (ASCEND)

Programme Summary: To provide a comprehensive package of interventions to reduce the disability, disfigurement, stigma, deaths, lost livelihoods and poverty which occur as a result of NTDs.

Programme Value: (REDACTED) Country/ Region: Africa and Asia regions

Programme Code: 205249

Start Date: December 2018

End Date: March 2022

Overall programme risk rating:

Moderate

Vault Number:

1

ContentsIntervention Summary...................................................................................4Abbreviations................................................................................................7A. Strategic Case.....................................................................................8

Global Context..........................................................................................8NTDs are diseases of neglected people...................................................9Link to UK aid strategy, SDP, Human Development Department business plan, Sustainable Development Goals and other relevant global targets 10Interventions to tackle NTDs...................................................................12Integrated approaches for sustainable NTD control and elimination.......17International context and funding............................................................22Domestic commitment to NTD control.....................................................24What is DFID already doing to tackle NTDs?..........................................25Impact and outcome that we expect to achieve......................................28Gender Equality......................................................................................33Conflict and Fragility................................................................................34Disability inclusion...................................................................................35Climate and the environment..................................................................35Counter terrorist financing.......................................................................36Risk.........................................................................................................37

B. Appraisal Case..................................................................................37A. Appraisal of disease integration options.............................................38B. Appraisal of delivery route options......................................................38Economic appraisal and value for money...............................................44Theory of Change for the Preferred Option.............................................52Measures of value for money..................................................................56

C. Commercial Case..............................................................................56Programme structure...............................................................................57Assurance about organisation’s capability and capacity to deliver..........60Ensuring value for money........................................................................63

D. Financial Case.......................................................................................64Cost profile..............................................................................................64Payment of funds....................................................................................66Tax costs.................................................................................................67

2

Asset Management.................................................................................67How will expenditure be monitored, reported, and accounted for?.........67Assessment of financial risk and fraud....................................................68

E. Management Case.................................................................................69Management arrangements for the implementation of ASCEND............69Performance management......................................................................71Risk management...................................................................................72Partnership principles..............................................................................72Monitoring and evaluation.......................................................................72

F. Appendices.............................................................................................75Annex 1. Further information on the identified diseases.........................75Annex 2. Current focus of DFID’s NTD programmes, and potential activities for ASCEND scale-up...............................................................77Annex 3. Multi-Criteria Decision Analysis process and results from the appraisal of delivery route options...........................................................78Annex 4. Overall programme risk matrix.................................................80

3

Intervention Summary

Summary of why UK support needed, what the funds will be spent on, where, over what period of time, via whom and what they will deliver. Neglected Topical Diseases (NTDs) are a group of infectious diseases that thrive in poor and often rural settings. They affect 1.6 billion of the world’s poorest people causing disability, disfigurement, stigma and mortality. Investing in combating NTDs is highly cost-effective, and considered a development “best buy”.

The UK will invest up to xxxx from 2018/2019 to 2021/2022 to support the control and elimination of NTDs in approximately 20 high burden countries. ASCEND will focus on five NTDs: lymphatic filariasis; onchocerciasis; schistosomiasis; visceral leishmaniasis and trachoma. Other NTDs included in the London Declaration on NTDs1 may be included where activities can be efficiently integrated with interventions for our identified diseases based on geographical overlap, and where there is justification of need in terms of disease burden and lack of other funding. This adds to existing commitments, and (pending approval), new Guinea Worm and trachoma programmes.

ASCEND will support the elimination of visceral leishmaniasis in Asia and at least one of trachoma, lymphatic filariasis or onchocerciasis in several DFID supported countries, as well as significant progress towards the sustainable control and elimination of our identified NTDs. The majority of the programme will be delivered by Non-Governmental Organisations (NGOs), academic partners and/or private sector companies, acting individually or in consortia, selected through competitive tenders covering: (1) implementation activities; and (2) independent monitoring and verification activities.

Does the programme fit with DFID’s strategic architecture: the UK Aid Strategy, Single Departmental Plan, International Development Act and the department’s Business Plan? Yes. The programme will contribute to UK Aid Strategy and Single Departmental Plan (SDP) objectives 2 and 4: strengthening resilience and response to crisis; and tackling extreme poverty and helping the world’s most vulnerable. This programme meets the provisions of the International Development Act: ASCEND furthers the sustainable development and welfare of developing countries and will contribute to poverty reduction.

What percentage of DFID’s Single Departmental Plan results target does this programme represent? Could the programme be adjusted in scope or scale to deliver SDP results? The programme will not contribute to SDP results targets.

Is the programme coherent with the wider international community and partner government response? Has the programme set out a sustainable exit strategy? The programme contributes to Sustainable Development Goal (SDG) targets 3.3 (end the epidemics of AIDS, tuberculosis, malaria and NTDs) and 3.8 (achieve universal health coverage, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all). ASCEND also responds to the aims of the 2012 London Declaration on NTDs, and integrates

1 Leprosy, sleeping sickness, soil transmitted helminths and Chagas disease (note that Chagas disease does not occur within the ASCEND geographical scope).

4

water, sanitation and hygiene (WASH), consistent with WHO’s strategy. The programme has been designed with input from other major actors in NTD control.

The programme will support countries to build national capacity, in line with the Addis Ababa NTD Commitment (2014) by African health ministers to “work to increase our domestic contribution to the implementation of NTD programs”. Over the programme timeframe we expect countries to progress at different rates, depending on the current status of NTD control and elimination activities, the disease burden and other contextual factors within each country. Based on this context, ASCEND will work across the spectrum of activities, from supporting scale-up of interventions with less mature NTD programmes, to strengthening the ability of the health system to effectively monitor trends post-elimination and provide the services needed for residual morbidity. Suppliers will be required to keep an up to date sustainable exit plan, agreed with both DFID and each country in which they operate.

Has the programme considered working with HMG Departments and accessing cross-HMG funds? No other HMG Department supports programmes to tackle NTDs. ASCEND will not access cross-HMG funds.

How does the programme relate to other UK aid within the specific sector, including multilateral, bilateral and centrally managed programmes? ASCEND has particular synergies with DFID supported NTD research (product development; operational research), health system strengthening activities, and WASH programmes, and the UK’s support to WHO.

Is there sufficient flexibility to learn and adjust to changes in the context? What level of flexibility is there to shift this and future commitments? Robust monitoring, in combination with collaboration with country governments and other partners, will ensure the programme can adapt as required. The programme will have the flexibility to scale up or down, move resources between countries or activities, or stop if needed, responding to country requirements, other donor activities, UK priorities, and performance. A “policy and strategic investment fund” will provide flexible funding to respond to new opportunities or rapidly changing contexts.

Does the proposed level of risk to be taken fit with DFID’s risk appetite for this portfolio? ASCEND has been assessed as ‘moderate’ risk (Annex 4), within Human Development Department’s risk appetite.

Is there a clear communications strategy to reinforce our objectives? Will the programme be branded with the UK aid logo and recognise UK Government funding – and, if not, why not? A detailed communication strategy will be developed in consultation with the DFID Communications Team. The UK aid logo will be used by delivery partners in line with current branding guidelines.

Has the programme been quality assured? How confident are we that the skills, capability, resources and political will exist to deliver the programme? This programme builds on learning and experience from current NTD programmes, and has been reviewed by technical experts across DFID, and the DFID Quality Assurance Unit (QAU). An Early Market Engagement (EME) event contributed to assessment of the skills, capability and resources of potential suppliers. The results of the EME and

5

experience with existing NTD programmes gives confidence that there is capability, resources and political will for successful programme delivery.

Does the SRO and team have the capability and resources to deliver this programme? Yes. Resources have been prioritised to support ASCEND, with a Senior SRO, close engagement from the hub and team leaders, and dedicated performance manager and deputy programme manager. Technical support will be provided by a senior health advisor and further advisory input.

6

Abbreviations

ADG Assistant Director GeneralAPOC African Programme for Onchocerciasis ControlBCC Behaviour Change CommunicationBMGF Bill and Melinda Gates FoundationCDD Community Drug DistributorDALY Disability Adjusted Life YearDFID Department for International DevelopmentEME Early Market EngagementESPEN Expanded Special Project for Elimination of Neglected Tropical DiseasesFCAS Fragile and Conflict Affected StateHMG Her Majesty’s GovernmentHST Health Services TeamIDM Innovative and Intensified Disease managementIEC Information Education CommunicationKPI Key Performance IndicatorLLIN Long lasting insecticidal netMoU Memorandum of UnderstandingM&E Monitoring and EvaluationMDA Mass Drug AdministrationNGO Non-Government OrganisationNTDs Neglected Tropical DiseasesODA Overseas Development Assistance ODF Open Defaecation FreeOJEU Official Journal of the European UnionPbR Payment by ResultsPCT Prevention Chemotherapy and Transmission ControlPSIF Policy and strategic investment fundSAFE Surgery, Antibiotics, Facial Cleanliness and Environmental InterventionsSDG Sustainable Development GoalSRO Senior Responsible OwnerTAS Transmission Assessment SurveyToR Terms of ReferenceUHC Universal Health CoverageUSAID United States Agency for International DevelopmentVfM Value for MoneyWASH Water, Sanitation and HygieneWHO World Health OrganizationWHO AFRO World Health Organization Regional Office Africa

7

A. Strategic Case

Global Context1. Neglected Tropical Diseases (NTDs) are a group of diseases (categorised by the

World Health Organization [WHO]) that affect the world's poorest and most marginalised people. NTDs predominantly affect remote and hard-to-reach communities that frequently lack access to basic health services and safe water, sanitation and hygiene (WASH) services; both critical components for NTD prevention, treatment and care. The 20 NTDs listed by WHO have varying geographical distributions, epidemiological patterns, health impacts, and intervention strategies.

2. The NTDs can cause severe pain, long-term disability, chronic illness, irreversible blindness, disfiguration and death. These outcomes also result in further socio-economic impacts, such as significant out-of-pocket health expenditures, lost livelihoods, stigma and social exclusion. NTDs inhibit children from learning and developing to their full potential, prevent adults from working to support their families economically, and trap the poor in a cycle of poverty and disease.

3. Regionally, Africa and South East Asia bear the largest burden of NTDs: over 40% of disability adjusted life years (DALYs) lost associated with NTDs occur in Africa, and 31% occur in South East Asia2. More than 1.6 billion people, including 850 million children, are at risk from these diseases and require intervention (see Figure 1)2, and individuals are often affected by more than one NTD. NTDs cause approximately 170,000 deaths every year worldwide, and a considerably larger burden of ill health and disability (in 2015 they are estimated to have resulted in over 20 million DALYs)3,4.

4. DFID’s support to NTD control and elimination focusses on trachoma, onchocerciasis, lymphatic filariasis, schistosomiasis and visceral leishmaniasis (and Guinea Worm, which is not considered within this business case). These are the NTDs targeted by DFID programmes since the London Declaration on NTDs5 in 2012. Our decision to focus on these diseases was based on a detailed examination of which would be best tackled by our support. This analysis focused on whether the NTD affected regions and countries were already supported by DFID, the burden of the disease, availability of effective treatment and estimated cost effectiveness of treatment and preventive interventions. As a result, we

2 World Health Organization (2017). Integrating neglected tropical diseases into global health and development: fourth WHO report on neglected tropical diseases.3 World Health Organization (2016). Cause specific mortality and disease burden estimates for 2015: http://www.who.int/healthinfo/global_burden_disease/estimates/en/index1.html 4 DALYs are a standardised measure of overall disease burden, used to quantify and compare the impact on health of a particular disease. DALYs combine in a single value both (a) years lived with disability (YLD) and (b) years of life lost (YLL) due to early death, where DALY = YLD + YLL. DALYs tend to underestimate the burden of NTDs due to data gaps in low- and middle-income countries (LMICs), and underestimation of disability weights for chronic diseases such as the NTDs.5 https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/67443/NTD_20Event_20-_20London_20Declaration_20on_20NTDs.pdf

8

focused on the NTDs, listed above, that lacked international funding and where significant gains could be made through effective support.

Figure 1: Number of people requiring interventions against NTDs, 20152.

NTDs are diseases of neglected people5. NTDs predominantly affect disadvantaged populations and can be considered

diseases of poverty. Low- and lower middle-income countries account for over 80% of the burden of NTDs, and many low-income countries are affected by at least five NTDs, amplifying their burden.

6. Substantial evidence indicates that within countries those in the lowest socio-economic categories, and those with lower levels of education, have a substantially increased risk of NTDs6. Conditions of poverty, such as inadequate access to safe WASH, poor housing and lack of education and access to information contribute to persistence of NTDs within communities. In addition, affected populations generally have little political voice, and so are unable to effectively advocate for additional resources.

7. The effects of NTDs can act to perpetuate poverty in affected countries through different routes. For example, out of pocket expenditures associated with seeking appropriate health care can be substantial. Disability and disfiguration can result in the inability to work, or social exclusion, impacting on individual economic productivity.

8. Recent scale-up of NTD control has had significant positive impacts. However, reductions in the burden of NTDs since 1990 have been greater in upper middle-

6 Houweling TAJ, Karim-Kos HE, Kulik MC, Stolk WA, Haagsma JA, Lenk EJ, et al. (2016). Socioeconomic Inequalities in Neglected Tropical Diseases: A Systematic Review. PLoS Negl Trop Dis 10(5): e0004546. 

9

income countries, with less progress made in the poorest countries7. This is likely to be related to slower scale-up of recommended control strategies in the lowest-income countries due to limited human and financial resources, weak health systems, conflict and social unrest. In addition, the specific NTDs present vary between income groups (e.g. upper-middle income countries accounted for the greatest burden due to soil transmitted helminths in 1990, but have seen a significant reduction in burden in this NTD subsequently).

Link to UK aid strategy, SDP, Human Development Department business plan, Sustainable Development Goals and other relevant global targets9. The programme will contribute to UK aid Strategy and annual Single

Departmental Plan (SDP) objectives 2 (strengthening resilience and response to crisis) and 4, (tackling extreme poverty and helping the world’s most vulnerable).

10. As outlined above, NTDs are considered diseases of poverty. ASCEND will reduce the need for out-of-pocket expenditures on health care and remove the physical and social impacts of NTDs which can prevent economic activity. This positively impacts on individual productivity, with aggregate effects, including increased economic productivity, at national and regional scales. Thus, NTD control activities can form a major pillar in poverty reduction activities. Concerted efforts to tackle NTDs will result in elimination or control to such a level that these programmes become more manageable for national governments, contributing to countries’ long-term economic prosperity far beyond the scope of ASCEND. NTD control efforts also work to strengthen and build resilience in national health systems, helping them to better respond to the health needs of the population.

11. The Human Development Department’s business plan includes an objective focussed on the control and elimination of infectious diseases, including NTDs (particularly visceral leishmaniasis, trachoma, lymphatic filariasis, schistosomiasis, onchocerciasis, Guinea worm – see Annex 1 for further information on each of these NTDs), which this programme will feed directly into. The programme will also support the development of resilient and responsive country health systems; for example, through targeted activities to strengthen supply chains, train health workers and develop increased capacity for data management and use, where necessary to ensure sustainable progress on NTDs.

12. At the heart of the Sustainable Development Goals (SDGs) is a commitment to ‘leave no-one behind’, ensuring everyone has a fair opportunity in life no matter who or where they are and that people who are furthest behind, who have least opportunity and who are the most excluded are prioritised. Programmes to address NTDs, and which integrate health and WASH interventions in line with best practice, respond to this ambition.

7 Stolk WA, Kulik MC, le Rutte EA, Jacobson J, Richardus JH, de Vlas SJ, et al. (2016). Between-Country Inequalities in the Neglected Tropical Disease Burden in 1990 and 2010, with Projections for 2020. PLoS Negl Trop Dis 10(5): e0004560.

10

13. SDG 3, “Ensure healthy lives and promote wellbeing for all at all ages”, covers a range of health issues. Of the 13 targets, one (target 3.3) covers NTDs specifically: “By 2030, end the epidemics of AIDS, TB, malaria and NTDs and combat hepatitis, water-borne diseases and other communicable diseases”.

14. Aside from SDG target 3.3, several other targets are relevant to NTD control activities, particularly target 3.8 on Universal Health Coverage (UHC). This is a commitment to “achieve universal health coverage (UHC), including financial risk protection, access to quality essential health care services, and access to safe, effective, quality, and affordable essential medicines and vaccines for all”.

15. As NTDs predominantly affect marginalised populations, NTD control activities can be considered a gateway to UHC8, although there is a need to strengthen the linkages between the NTDs (and other communicable diseases) and UHC to ensure that efforts are harmonised and integrated where possible:

i. The community based approach used in NTD control activities help to ensure that the communities most in need can be reached.

ii. Drug donation programmes and community based drug distribution help to avoid financial hardship associated with NTDs.

iii. NTD programmes include health system strengthening activities within national health systems, which can support improved primary health care.

iv. Improving access to free diagnostics and treatment for NTDs can help to avoid catastrophic health expenditures related to treatment seeking for affected families.

16. In addition to SDG targets, implementation targets for the control, elimination, or eradication9 of a range of NTDs by 2020 were set out in the 2012 World Health Organization NTD Roadmap. See Table 1 for an overview of targets of relevance to ASCEND, and recent progress towards them10. Many of these targets are considered aspirational, but provide a clear pathway for progress against each of the relevant NTDs.

Table 1: WHO NTD roadmap targets and recent progress, for ASCEND identified diseases.

Disease Health impacts Target Progress to 20172

Lymphatic filariasis

Abnormal enlargement of

Global elimination as a

Over 499 million people no longer need preventive

8 Uniting to Combat NTDs (2017). Ending Neglected Tropical Diseases: A gateway to Universal Health Coverage, Fifth progress report on the London Declaration on NTDs.9 Control is defined as a reduction of disease incidence, prevalence, morbidity, and/or mortality to a locally acceptable level as a result of deliberate efforts, where ongoing interventions are likely to be required to maintain this level; Elimination as a public health problem is achieved when specific targets on the disease incidence, prevalence, morbidity, and/or mortality have been met; Elimination of transmission is defined as the reduction to zero of the incidence of infection caused by a specific pathogen in a defined geographical area, with minimal risk of reintroduction, as a result of deliberate efforts; Eradication is defined as the complete and permanent worldwide reduction of new cases of an infectious disease to zero, through deliberate efforts.10 World Health Organization. (2012). Accelerating Work to Overcome the Global Impact of Neglected Tropical Diseases: A Roadmap for Implementation.

11

lower limbs and genitalia, resulting in pain, disability and social stigma.

public health problem by 2020.

interventions and 18 countries have reached elimination; 45 countries have begun mass drug administration (MDA11), although scale up is required in 20; projected 45/72 endemic countries will reach national elimination by 2020.

Trachoma Eye pain and discomfort, scarring of the eyelid and cornea, causing eventual irreversible blindness.

Global elimination of blinding trachoma by 2020.

Three countries have eliminated; six countries are undergoing validation of elimination; good progress but unlikely to meet this target.

Schistosomiasis

Can cause liver damage, kidney failure or bladder cancer.

75% intervention coverage in school-aged children by 2020; elimination of transmission in selected countries.

Coverage of 53.7% in school-aged children in 2016; very unlikely that target will be met in all countries without additional efforts to expand coverage.

Visceral leishmaniasis

Fever, weight loss, anaemia, and swelling of the liver and spleen. Untreated cases usually result in death.

Elimination as a public health problem in Asia by 2020.

Feasible if efforts are sustained in Indian Subcontinent

Onchocerciasis Severe itching, disfiguring skin conditions and irreversible blindness.

Scale-up control ; elimination of transmission in selected countries by 2020.

12-13 countries may have reached elimination by 2020. Support for onchocerciasis control likely to be required post 2025

Interventions to tackle NTDs17. The WHO recommends five intervention types to tackle NTDs:

11 Mass Drug Administration (MDA) is the administration of curative drugs to entire populations, regardless of their infection status.

12

i. preventive chemotherapy and transmission control (PCT); ii. innovative and intensified disease management (IDM);

iii. vector ecology and management; iv. veterinary public health services; and v. safe water, sanitation and hygiene.

18. ASCEND will deliver activities covering all these interventions, except veterinary public health services. For the identified diseases (schistosomiasis, onchocerciasis, lymphatic filariasis, visceral leishmaniasis and trachoma) and geographical focus of this business case, veterinary public health services are not part of the WHO recommended intervention strategy.

19. NTD control and elimination efforts address four main purposes, as outlined in Table 2, below: prevention of new infections; curative treatment of those infected; care for those with irreversible complications; and building systems for sustainability of efforts.

Table 2: Purposes of NTD control and elimination efforts.Prevention of new infection

Preventing new infections will reduce the overall burden of disease. Prevention of infection is carried out using (1) Mass Drug Administration (MDA12) or case detection and treatment to reduce prevalence of infection and, therefore, onwards transmission; (2) targeted sanitation and hygiene promotion interventions to reduce ongoing transmission of NTDs where poor WASH contributes to transmission; and (3) where relevant, vector control and behaviour change activities.

Curative treatment of those infected

Both MDA and case detection and treatment for IDM-diseases will generally provide effective curative treatment for those infected, to prevent development of complications. Surgery can also be used to reduce further complications (e.g. eye surgery to prevent blindness as a consequence of trachoma).

Care for those with irreversible complications

In some cases, infection will already have resulted in complications, in which case interventions can be provided to support morbidity management and self-care (e.g. of swelling of the lower limbs, caused by lymphatic filariasis).

Systems and sustainability of control

By strengthening national leadership and coordination, and embedding aspects of NTD prevention and care within national and sub-national health strategies and systems, greater sustainability can be developed. Supporting greater coordination between the health and WASH sectors will also facilitate sustainable control and elimination.

20. Effectively addressing NTDs also requires adequate monitoring, evaluation and surveillance. Strong health information systems, integrating NTD relevant data alongside data relating to other aspects of health, provide detailed and dynamic

12 The administration of curative drugs to whole populations, regardless of their infection status.

13

understanding of the disease burden and its distribution across a country and between different population groups, enabling more effective and efficient targeting of interventions. Robust data are also vital to track progress and understand the impact of interventions.

21. There is also an ongoing agenda to progress towards Universal Health Coverage (UHC). This is embedded within the SDGs and is a key priority for WHO and many national governments. As discussed in paragraph 15, there is a strong inherent link between NTD control and elimination efforts, and progress towards UHC. The financial protection of all individuals seeking treatment or care for NTDs is also a prerequisite for reaching the UHC target of 100% financial protection by 203013. Moving forward, there is a requirement to consider how countries can accelerate progress towards UHC; and how actions to drive forward on UHC ambitions and activities to progress towards the sustainable control and elimination of NTDs can act in a synergistic way to support and strengthen both agendas.

22. NTD control and elimination efforts are supported by a unique and highly valued public-private partnership, with several pharmaceutical companies donating the drugs required for control and elimination efforts. The scale of this donation programme is substantial (it represents the largest public-private partnership in the health sector), with drugs valued at US$17.8 billion pledged from 2014 to 2020, and 1.3 billion tablets having been donated globally in 2016. In 2017, drug donations for NTD programmes were awarded the Guinness book of records for the largest medication donation in 24 hours. The use of donor resources to leverage the positive outcomes of these donation programmes enhances the value for money (VfM) of NTD programming, and allows partner countries to more rapidly progress towards NTD targets.

23. The education sector is also important for NTD control and elimination efforts: the delivery of MDA for schistosomiasis is often conducted via schools, as the main target population is school-aged children.

Preventative chemotherapy and transmission control (PCT)24. PCT is a strategy of providing drug treatment to populations at risk to (a) reduce

morbidity and (b) prevent onward transmission. Over time, PCT can effectively control or locally eliminate some target diseases. The approach focuses on diseases for which safe and effective drugs are available, as well as the necessary tools and strategy to implement. Large-scale preventive chemotherapy for PCT-diseases is usually implemented via mass drug administration (MDA)14, using trained community drug distributors (CDDs) or teachers to deliver scheduled rounds of treatment to entire populations at risk.

13 World Health Organization (2015). Investing to overcome the global impact of neglected tropical diseases. Third WHO report on neglected tropical diseases.14 PCT is used to refer to an overall strategy for NTD control and elimination, PCT-diseases is used to refer to the NTDs for which PCT is the recommended strategy, and MDA is used to refer to a specific activity which forms part of this strategy (administration of curative drugs to whole populations, regardless of their infection status).

14

25. WHO recommends PCT to control several NTDs including lymphatic filariasis, onchocerciasis, schistosomiasis and trachoma.

Innovative and intensified disease management (IDM)26. The IDM approach aims to improve access to existing diagnostics and treatments

for individual patients (as opposed to treating an entire population at risk, as in PCT, described above)15. This is supplemented by encouraging rapid development and implementation of improved tools and advocating for improved health services in affected areas, an approach which is beneficial for both PCT and IDM diseases.

27. WHO recommends that these diseases should be managed within the primary health-care system and the strategies to address the diseases should focus on increasing access to early diagnosis and prompt treatment, and improving surveillance that is integrated into health-services.

28. The IDM approach is relevant for several NTDs, including visceral leishmaniasis.

Vector control29. Many NTDs are vector-borne diseases, including visceral leishmaniasis

(transmitted by sandflies), lymphatic filariasis (mosquitoes), onchocerciasis (blackflies) and schistosomiasis (water snails play a role in the transmission cycle). Reducing the size of vector populations can reduce or interrupt transmission of disease, contributing to reductions in their burden, and vector control is a recommended strategy for the control of NTDs in some contexts.

30. Insecticide spray for use within homes, use of insecticide–treated bed nets (e.g. long-lasting insecticidal nets (LLINs), which are widely used in malaria control), environmental management and personal protection can be effective measures that protect humans from the bites of disease vectors. Onchocerciasis control can also be supported by the use of larvicides in identified breeding sites within some settings (treatment of fast-flowing water, where the blackfly vector breed, to kill the insect larvae), although this is not appropriate in all endemic countries.

31. There are some synergies between vector control for other insect-borne diseases and NTD control: for example, the delivery of LLINs for the purposes of reducing the burden of malaria can have positive impacts on the control of lymphatic filariasis. However, significant differences in the epidemiology of diseases and the ecology of different vector species need to be accounted for (e.g. malaria control requires higher LLIN coverage than lymphatic filariasis control, but over a shorter timescale)16.

15 http://www.who.int/neglected_diseases/disease_management/Innovative_Intensified_Disease_Management/en/ 16 Stone CM, Lindsay SW, Chitnis N (2014). How Effective is Integrated Vector Management Against Malaria and Lymphatic Filariasis Where the Diseases Are Transmitted by the Same Vector? PLoS Negl Trop Dis 8(12): e3393.

15

32. Note that ASCEND will not directly support vector control (e.g. insecticide use, or LLIN distribution), but will coordinate with existing vector control programmes, and integrate BCC activities to encourage uptake of vector control interventions provided through other programmes, to support the aims of ASCEND.

Safe water, sanitation and hygiene33. Ensuring people have access to, and use, safe WASH is a critical component of

effective and sustainable control, treatment and care of some NTDs. i. Sanitation and the establishment of open defaecation free (ODF) communities

reduce the amount of human excreta in the environment, which is critical to reduce the transmission of some NTDs, including schistosomiasis and trachoma.

ii. Good hygiene practices and facial cleanliness protects against trachoma.iii. The use of protected water supplies reduces the risk of some NTD infections;

for example, by reducing contact with surface water inhabited by aquatic snails infected by the parasite that causes schistosomiasis.

iv. Access to WASH facilities both at home and in schools and health centres is also critical for effective treatment and care of some NTDs. For example, WASH in health care facilities is essential for safe surgical procedures to address morbidity caused by lymphatic filariasis and trachoma, and for patient care.

34. There have been several recent systematic reviews examining the relationships between WASH interventions and the control of NTDs and the key evidence is summarised below. It should be noted that as with most public health interventions, conducting trials similar to those deployed in clinical medicine is difficult, but the evidence base summarised below is considered to be strong.

i. Access to safe water and adequate sanitation is associated with reduced prevalence of schistosomiasis17.

ii. Improved hygiene in children and access to sanitation are associated with reduced prevalence of trachoma18.

iii. Improved access to WASH, particularly sanitation, and improved practices such as hand washing are also associated with reductions in the prevalence of other NTDs, such as soil-transmitted helminths19.

35. In 2015, WHO launched a global strategy and action plan to integrate WASH with other public health interventions to tackle NTDs20. This recognises that an integrated approach addressing the underlying causes of NTDs is likely to be

17 Grimes JET, Croll D, Harrison WE, Utzinger J, Freeman MC, et al. (2014). The Relationship between Water, Sanitation and Schistosomiasis: A Systematic Review and Meta-analysis. PLoS Negl Trop Dis 8(12): e3296.18 Stocks ME, Ogden S, Haddad D, Addiss DG, McGuire C, et al. (2014) Effect of Water, Sanitation, and Hygiene on the Prevention of Trachoma: A Systematic Review and Meta-Analysis. PLoS Med 11(2): e1001605.19 Strunz EC, Addiss DG, Stocks ME, Ogden S, Utzinger J, et al. (2014) Water, Sanitation, Hygiene, and Soil-Transmitted Helminth Infection: A Systematic Review and Meta-Analysis. PLoS Med 11(3): e1001620.20 World Health Organization (2015). Water sanitation and hygiene for accelerating and sustaining progress on neglected tropical diseases: A global strategy 2015-2020.

16

more cost effective and sustainable and ensures that investments in WASH reach those most in need. This approach is employed in ASCEND.

Integrated approaches for sustainable NTD control and elimination36. Taking an integrated approach to NTD control and elimination efforts makes

logical sense due to the significant geographical overlap between different NTDs, the fact that individuals are commonly affected by more than one NTD, the use of similar intervention approaches for several NTDs and common delivery channels21. Within our current NTD programme footprint, all but two countries (India and Bangladesh, for which focus is required to achieve elimination of visceral leishmaniasis in Asia) are endemic for at least three of our identified NTDs (see Figure 2). Integration also raises the potential to improve cost-efficiency within NTD programmes, better coordinate efforts to strengthen relevant components of the health system, generate evidence on delivery of communicable disease programmes, and accelerate progress towards global targets. There has been considerable recent progress in integrated NTD programming, which will be extended and strengthened through ASCEND.

Figu re 2. Number of DFID targeted NTDs present, by country (excluding Guinea Worm).

37. There are several meanings of integration with regards to NTD programmes22,23,24. The ASCEND programme will be delivered in adherence with four major

21 Watts C (2017). Neglected tropical diseases: A DFID perspective. PLoS Negl Trop Dis 11(4): e0005492.22 Marchal B, Van Dormael M, Pirard M, Cavalli A, Kegels G, Polman K (2011). Neglected tropical disease (NTD) control in health systems: The interface between programmes and general health services. Acta Tropica, Volume 120, Supplement 1, S177-S185.23 Grépin KA, Reich MR (2008). Conceptualizing Integration: A Framework for Analysis Applied to Neglected Tropical Disease Control Partnerships. PLoS Negl Trop Dis 2(4): e174.24 Means AR, Jacobson J, Mosher AW, Walson JL (2016). Integrated Healthcare Delivery: AQualitative Research Approach to Identifying and Harmonizing Perspectives of Integrated Neglected Tropical Disease Programs. PLoS Negl Trop Dis 10(10): e0005085.

17

approaches to integration to ensure cost-effectiveness, benefits for wider health systems, and optimal impact. These are set out below, along with key lessons and evidence on the related benefits and challenges.

National level leadership and coordination38. Integration efforts should be led by national Governments to ensure their

priorities are addressed and implementation aligns with overall health system development25. Clear coordination, implementation and reporting structures should be in place. The development of a national strategy will support these crucial elements. However, integrating components of control strategies for different diseases is technically, logistically and managerially challenging26, and may not always result in significant cost savings for implementation efforts (although longer term savings may be realised in relation to improved sustainability).

Integrated delivery39. Integrating delivery of multiple health interventions can reduce costs and expand

intervention coverage26. Due to the geographical overlap of NTDs, and commonalities in several intervention types, integrated delivery of MDA is encouraged for onchocerciasis, lymphatic filariasis, schistosomiasis, trachoma and soil transmitted helminths (i.e. PCT-diseases)27. However, due to concerns over the side effects of some of the drugs, it is not always possible or appropriate to give all treatments at the same time.

40. USAID has been implementing integrated delivery of NTD activities, based on these recommendations, for over ten years. DFID’s current programme “Nigeria: Tackling Neglected Tropical Diseases through an Integrated Approach” has also applied this approach since 2012. These examples (both focussed on PCT-diseases) demonstrate the feasibility of national-scale delivery of integrated control28.

41. Published evidence indicates that integrated delivery of MDA could be achieved for as little as $0.40-0.79 per person per year in sub-Saharan Africa (or $0.19 per treatment, per person in Niger)27,29, representing cost savings of 16-47% in

25 Dembele M, Bamani S, Dembele R, Traore MO, Goita S, et al. (2012). Implementing Preventive Chemotherapy through an Integrated National Neglected Tropical Disease Control Program in Mali. PLoS Negl Trop Dis 6(3): e1574. doi:10.1371/journal.pntd.000157426 Kabatereine NB, Malecela M, Lado M, Zaramba S, Amiel O, Kolaczinski JH (2010). How to (or Not to) Integrate Vertical Programmes for the Control of Major Neglected Tropical Diseases in Sub-Saharan Africa. PLoS Negl Trop Dis 4(6): e755.27 Hotez PJ, Molyneux DH, Fenwick A, Kumaresan J, Ehrlich Sachs S, Sachs JD, Savioli L (2007). Control of Neglected Tropical Diseases. New England Journal of Medicine 357:1018-102728 Linehan M, Hanson C, Weaver A, Baker M, Kabore A, Zoerhoff KL, et al. (2011). Integrated Implementation of Programs Targeting Neglected Tropical Diseases Through Preventive Chemotherapy: Proving the Feasibility at National-Scale. In: Institute of Medicine (US) Forum on Microbial Threats. The Causes and Impacts of Neglected Tropical and Zoonotic Diseases: Opportunities for Integrated Intervention Strategies.29 Leslie J, Garba A, Boubacar K, Yayé Y, Sebongou H, Barkire H, et al. (2013). Neglected tropical diseases: comparison of the costs of integrated and vertical preventive chemotherapy treatment in Niger. International Health, 5(1) 78–84.

18

comparison with non-integrated programmes30,29. Evidence also suggests that integration of MDA does not negatively impact on coverage rates31.

42. In comparison with PCT-diseases, there is limited experience or evidence regarding integrated delivery of interventions for IDM-diseases32. Much of the emphasis of large-scale NTD control and elimination programmes to date has focussed on the PCT-diseases, which partly explains this lack of evidence. However, there is growing interest in the integration of specific activities or interventions, such as disease burden assessments, training activities, active case finding, or self-care support groups, where appropriate33,34.

43. In spite of the logic to integration and evidence of reduced costs, there are challenges to the integrated delivery of NTD control and elimination efforts. Although many countries are affected by multiple NTDs, their distributions will not coincide completely, necessitating a detailed prior understanding of disease distributions and areas of co-endemicity, and a geographically stratified MDA strategy35,32. There are also differences in the target population and treatment schedules between NTDs which need to be considered in planning. Evidence suggests that while unit costs for integrated MDA are lower, there are additional costs associated with the required coordination36. Many NTD control activities also rely on delivery of interventions by volunteer CDDs: integrated approaches are likely to place increasing burdens on CDDs, which may result in attrition32, but should also maximize cost-effectiveness of CDD training and deployment.

Embedding NTD prevention and care within health systems44. NTDs affect the poorest and most marginalised communities, with weak health

systems, and poor and inequitable access to health services contributing to the problem. There is also evidence that weak health systems prevent progress towards disease-specific targets.

45. “Vertical” programmes (which focus on specific health conditions, rather than more general health services) can provide rapid progress towards disease-

30 Brady MA, Hooper PJ, Ottesen EA (2006). Projected benefits from integrating NTD programs in sub-Saharan Africa. Trends Parasitol 22: 285-29131 Ndyomugyenyi R, Kabatereine N (2003). Integrated community-directed treatment for the control of onchocerciasis, schistosomiasis and intestinal helminths infections in Uganda: advantages and disadvantages. Trop. Med. Int. Health, 8: 997-1004.32 Kolaczinski JH, Kabatereine NB, Onapa AW, Ndyomugyenyi R, Kakembo ASL, Brooker S (2007). Neglected tropical diseases in Uganda: the prospect and challenge of integrated control.Trends in Parasitology 23(10): 485-493.33 Mitjà O, Marks M, Bertran L, Kollie K, Argaw D, Fahal AH, et al. (2017). Integrated Control and Management of Neglected Tropical Skin Diseases. PLoS Negl Trop Dis 11(1): e0005136.34 Pryce H, Mableson HE, Choudhary R, Dev Pandey B, Aley D, Betts H, et al. (2018). Assessing the feasibility of integration of self-care for filarial lymphoedema into existing community leprosy self-help groups in Nepal. BMJ Public Health: 18, 201.35 Finn TP, Stewart BT, Reid HL, Petty N, Sabasio A, Oguttu D, et al. (2012). Integrated Rapid Mapping of Neglected Tropical Diseases in Three States of South Sudan: Survey Findings and Treatment Needs. PLoS ONE 7(12): e52789.36 Fitzpatrick C, Fleming FM, Madin Warburton M, Schneider T, Meheus F, Asiedu K, et al. (2016). Benchmarking the Cost per Person of Mass Treatment for Selected Neglected Tropical Diseases: An Approach Based on Literature Review and Meta-regression with Web-Based Software Application. PLoS Negl Trop Dis 10(12): e0005037

19

specific targets, but are less sustainable than services embedded within health systems. They can also undermine already fragile health systems via fragmentation (e.g. setting up separate supply-chains), diversion of resources (such as human resources) from general health services, and inefficiencies37.

46. Embedding NTD services within health systems has a dual benefit:i. NTD programmes can contribute to health system strengthening. NTD

programmes must be aware of national systems, making use of them and embedding activities within existing national health systems where appropriate, and ensuring activities do not act to weaken national systems. Targeted support for components of the overall health system which are directly relevant to the delivery of NTD control activities, where system weaknesses have been identified, should also be provided to ensure that the embedding of NTD activities is not undermined by weak systems. This includes working through national Ministries and sub-national administrations to support the development and application of health strategies; developing workforce capacity in NTD control and elimination activities; strengthening the management and security of supply-chains used for NTD drugs and other commodities; building robust monitoring, surveillance and evaluation systems; and developing laboratory capacity.

ii. By providing targeted support to health system strengthening, and ensuring NTD prevention and care activities are integrated within well-functioning health systems, sustainable NTD control and elimination can be achieved. A fully integrated approach within a strong and resilient health system will ensure that NTDs can be effectively prevented, detected and treated38.

47. Integration within overarching health systems, coordinated by national Ministries of Health, is vital for sustainable control of NTDs: this includes both those diseases for which PCT and IDM are the primary strategy. For visceral leishmaniasis in particular, the primary focus of intervention is building the capacity and capability of the health system to provide effective and efficient case detection, treatment, and timely outbreak detection and response. Community awareness and behaviour change is also important. Not all NTD programme activities (e.g. MDA) are appropriate for integration within routine health services, although linkages can be made, and lessons shared. For example, MDA related activities for NTDs can link with broader community health approaches, potentially enabling resource-sharing and development of improved community health approaches more generally, including reaching the most vulnerable people and sharing best practice to reach remote and disadvantaged communities. However, when countries or districts within countries meet disease specific targets, allowing MDA to be discontinued, routine health services

37 Gyapong JO, Gyapong M, Yellu N, Anakwah K, Amofah G, Bockarie M, Adjei S (2010), Integration of control of neglected tropical diseases into health-care systems: challenges and opportunities, The Lancet 375 (9709): 160-165,38 Nonvignon J, Mensah E, Vroom FBC, Adjei S, Gyapong JO (2016). The Role of Health Systems in the Control of Neglected Tropical Diseases in Sub-Saharan Africa. In: Gyapong J, Boatin B. (eds) Neglected Tropical Diseases - Sub-Saharan Africa. Neglected Tropical Diseases. Springer, Cham.

20

need to have the appropriate capacity and resources for the detection and treatment of any remaining emerging cases of disease.

48. In some settings, there may also be scope to generate further health system efficiencies by coordination with non-NTD related health campaigns such as immunisation days; or by coordinating with vector-control activities which may impact on NTDs and other vector-borne diseases such as malaria. Some of this coordination is already happening, highlighting the potential benefits. This approach may also improve overall programme effectiveness by helping to alleviate problems associated with a lack of capacity at community levels: for example where MDA implementation needs to be delayed due to other health campaigns requiring scarce CDD or health worker resource.

49. It is important to bear in mind that health systems vary considerably in their structure, financing, level of provision from public vs private providers, accountability and strength of governance. Due to this, approaches need to be carefully adapted to the specific country context. Where specific components of health systems required for NTD control and elimination efforts are weak, NTD activities should seek to strengthen and build capacity to ensure that efforts to embed NTD services are not undermined.

50. The scope of health systems strengthening activities will depend on the specific country context. In some countries (for example those experiencing conflict and severe instability), the approach to delivering NTD programmes may focus more on delivery of NTD services, and less on health systems aspects. Nevertheless, NTD control and elimination efforts can be successful in fragile and conflict affected states (FCAS): for example, South Sudan recently reported that they had detected no cases of Guinea Worm during the 15 months to February 2018, setting it on the path towards elimination

Cross-sectoral collaboration51. Cross-sectoral collaboration is vital to address underlying determinants of NTDs

and to improve treatment and care. Integration of WASH activities, and coordination between the health and WASH sectors at national, sub-national and local levels is a key consideration due to the importance of WASH in reducing the transmission of several NTDs, and improving treatment and care, as discussed in paragraph 3320. In particular, the strategy used to control trachoma relies heavily on WASH: the SAFE strategy (Surgery; Antibiotics; Facial cleanliness and Environmental improvements) requires collaboration between the health and the WASH sectors. Previous studies have shown WASH strategies to be highly effective in reducing trachoma (infection and clinical outcomes)18.

52. Cross-sectoral collaboration with (and investment in) education systems and a focus on teaching is also important to influence health related behaviours, such as the avoidance of open-defaecation and the importance of good hygiene. Schools are also widely used for the delivery of MDA for schistosomiasis (where school aged children are a target group, along with high-risk adults).

21

53. The sustainability of control and elimination efforts will depend on successful coordination and collaboration to both directly and indirectly reduce disease transmission. Key areas identified for collaboration between the WASH and NTD sectors include advocacy, policy and communications; capacity building; mapping, data collection and monitoring; and research39. In some cases where responsibilities for hygiene and sanitation lie within Health Ministries, integration is easier to achieve, compared to cases where other Ministries are involved. Cross sectoral planning and coordination at local levels (e.g. districts) will be prioritised to ensure that local governments can plan and deliver the required interventions in a coordinated way.

International context and funding54. In January 2012, DFID joined with the World Bank, WHO, USAID, the Bill and

Melinda Gates Foundation (BMGF), leading pharmaceutical companies and NGOs in committing to “a new, coordinated push to accelerate progress toward eliminating or controlling ten NTDs by 2020” (London Declaration on Neglected Tropical Diseases)5. This declaration pledged to focus efforts on five diseases addressed via PCT (lymphatic filariasis, onchocerciasis, schistosomiasis, soil transmitted helminths, trachoma), and five diseases addressed via IDM (Chagas disease, Guinea worm disease, human African trypanosomiasis, leprosy and visceral leishmaniasis). These NTDs were included based on the feasibility for effective control or elimination using existing strategies.

55. The 2017 NTD summit in Geneva celebrated achievements made during the first 5 years following the London Declaration on NTDs, and planned for the future. At this summit, DFID pledged an additional £205 million for NTD control and elimination efforts, giving a total investment of £360 million over the period 2017/2018 to 2021/2022, more than doubling our average annual investment in tackling NTDs40.

56. The Uniting to Combat NTDs partnership (of which DFID is a member) plays a key role in coordination related to the London Declaration on NTDs and increasing the global profile of NTDs. They are also responsible for reporting on annual progress since the London Declaration. Uniting to Combat NTDs have recently developed an NTD indicator, in collaboration with WHO, which has been included in the African Leaders Malaria Alliance score card for Accountability and Action, raising awareness of country progress on NTDs with Heads of State41.

57. The UK is proud to be a global leader on NTDs. The UK and the US are the two largest bilateral donors supporting the implementation of NTD programmes.

39 Freeman MC, Ogden S, Jacobson J, Abbott D, Addiss DG, Amnie AG, et al. (2013). Integration of Water, Sanitation, and Hygiene for the Prevention and Control of Neglected Tropical Diseases: A Rationale for Inter-Sectoral Collaboration. PLoS Negl Trop Dis 7(9): e2439.40 Neglected Tropical Diseases Summit 2017, UK Pledge (2017). https://www.gov.uk/government/news/neglected-tropical-diseases-summit-2017-uk-pledge 41 African heads of state endorse new measurement of progress on neglected tropical diseases (2018). http://unitingtocombatntds.org/news/alma-ntds-2018/

22

USAID are currently procuring a large NTD programme: the UK and US collaborate closely on NTD control and coordinate activities at the country level where appropriate, and we will continue to work closely during the planning and implementation of our new programmes.

58. Other major donors to NTD control include: BMGF, who provide substantial support focussed on research and product development, with some support for implementation (particularly Guinea worm disease and visceral leishmaniasis); and the END Fund, a platform to engage private philanthropists for the control of NTDs. Further donors providing varying levels of funding to NTD control include the World Bank, Germany, Belgium, Kuwait, Canada, South Korea, Good Ventures, Children’s Investment Fund Foundation, Conrad Hilton Foundation, Dubai Cares, Legatum and the Lion Club International Foundation.

59. Several pharmaceutical companies (Bayer, Eisai, Gilead Sciences Inc., GlaxoSmithKline, Johnson & Johnson, Merck, Merck Sharp and Dohme, Novartis, Pfizer and Sanofi) play a key role in supporting NTD control activities, via the donation of essential medicines required for NTD control and elimination. Increasing volumes of pharmaceutical donations has supported scale-up of interventions, increasing access to high-quality medicines free of charge for hundreds of millions of people worldwide.

60. Overall, NTD control remains underfunded by international donors. Some NTDs and countries in particular suffer under-investment. For example, aside from BMGF support to vector control in India and the activities of several NGOs, there is no other significant donor support (aside from DFID) for visceral leishmaniasis control. Several countries in Africa, such as South Sudan and Guinea Bissau, have a significant burden of NTDs, but receive little external support.

61. Global technical leadership for NTD control and elimination efforts is provided by WHO: their role covers the production of normative guidance and supporting countries to adapt these for their needs; coordination of activities; setting of targets and tracking progress towards them; setting strategic direction for NTD control efforts; and management of the drug donation programme which is critical for NTD activities globally. WHO also acts as an important advocate for NTDs, playing a key role in the explicit inclusion of NTDs in the SDGs, and also making the case for additional attention to NTDs at the national level through country representatives.

62. WHO-AFRO hosts the Expanded Special Project for the Elimination of NTDs (ESPEN; a five year project). ESPEN is a public-private partnership, which works with national NTD programmes in Africa to ensure they have the required training, expertise, tools, and resources to scale-up intervention coverage and to achieve elimination of PCT NTDs. ESPEN also works to improve the capacity of countries to collect, analyse, share and use data on NTDs effectively; supports NTD programmes to identify investment targets required, and to secure funding

23

to achieve their goals; and works to improve the efficient utilisation of donated medicines through strengthened supply chain management.

Domestic commitment to NTD control63. ASCEND will deliver accelerated progress towards NTD targets within our

programme countries, significantly reducing the prevalence of disease and associated health burden. Alongside this, ASCEND will work to strengthen relevant components of national health systems, supporting countries to provide the prevention, detection, treatment and surveillance activities necessary to maintain the reduced disease burden in the longer term, and to prevent disease resurgence.

64. Embedding NTD control and elimination efforts within national plans and systems is essential for sustainability, and it is important to ensure that NTD control is not disproportionately dependent on donor support relative to other health programmes. To achieve this, increased domestic resources for NTD control and increased commitment to inter-sectoral collaboration (e.g. between health and WASH) are vital. WHO recommended target investment levels for NTDs are affordable, and would represent less than 0.1% of domestic health expenditure in low and middle income countries over the period 2015 to 203013.

65. In 2014, ministers from 26 African countries committed to increase domestic investment in NTD control, strengthen NTD programme goals and inter-sectoral collaboration, work towards global NTD targets and leverage NTD activities to strengthen overall health systems (the Addis Ababa NTD commitment)42. Working towards the inclusion of NTD activities within national essential packages of health services and national investment plans may provide a route to increase domestic support for NTDs.

66. Detailed health accounts data relating to NTD financing are not widely available, although WHO is working to improve the availability of this information. Despite this limitation, there are specific examples of good progress in domestic commitments to NTD control. In the Democratic Republic of the Congo, the proportion of NTD financing coming from Government resources increased from 0% in 2011 to 25% (US$2 million) in 2013. The Government of Tanzania funded approximately 40% of total NTD financing (approximately US$7 million) in 20122. While there is still significant progress to be made in domestic support for NTD control and elimination activities, these examples highlight good practice and the opportunity that exists. It is important that donor-funded programmes, including ASCEND, support countries to mobilise and manage domestic resources for investment in the health of their people.

67. ESPEN complements donor activities by providing advocacy support to encourage increasing domestic funding for NTD activities, supporting countries to take greater leadership. In addition, WHO has initiated in-country financing

42 Available from: http://unitingtocombatntds.org/wp-content/uploads/2017/11/addis_ababa_ntd_commitment.pdf

24

dialogues as a key strategy to advance both the domestic financing and integration agendas. These will look at budgetary allocations, and private as well as public expenditure on NTDs and have significant potential for driving domestic funding and sustainability, but remain unproven as yet.

What is DFID already doing to tackle NTDs?68. At the London Declaration in 2012 the UK committed an additional £195 million

towards NTDs. The UK currently supports a range of high performing programmes on NTD implementation and research, largely channelled through: the Liverpool School of Tropical Medicine; the Schistosomiasis Control Initiative at Imperial College; the London School of Hygiene and Tropical Medicine; Sightsavers; and Mott MacDonald. Other non-UK partners include the Carter Center and the WHO.

69. The UK focuses its support on the following NTDs, selected from the London Declaration’s focal diseases: lymphatic filariasis; onchocerciasis; schistosomiasis; trachoma; visceral leishmaniasis; and Guinea Worm. Control of soil transmitted helminths is also provided in some of our current programmes, in integration alongside activities to control schistosomiasis. This selection of diseases was informed by an analysis carried out in 2008 and extended in 2011, as discussed in paragraph 4. This selection of NTDs remains relevant for DFID support through ASCEND: discontinuation of existing NTD programmes at the current time risks a loss of progress made towards control or elimination, resulting in reduced VfM from previous investments.

70. Geographically, the UK currently supports NTD control in 19 countries in Africa, three in Asia and four in the Pacific Islands (see Appendix 2 and Figure 3). Future support to the Pacific Islands will be via a separate programme (“Contributing Towards Eliminating Blinding Trachoma in the Commonwealth”): this region is not considered in ASCEND.

25

Figure 3. Number of NTDs currently targeted by UK programmes, by country (excluding support for Guinea Worm Eradication, and the Pacific Islands).

71. The UK also currently provides support to the WHO NTD Department and ESPEN. i. Our current support to the WHO NTD Department supports three posts. This

includes an economist (who has been critical for the development of a strong investment case for NTDs and has driven the production of a large volume of evidence around the cost-effectiveness and VfM of NTD control activities); and two staff members who manage the majority of the global drug donation programme (this is critical for the efficient management of very large volumes [and values] of pharmaceutical drugs which are donated for use in NTD control and elimination efforts every year, ensuring that NTD programmes can have access to the drugs they require, at the appropriate time). In addition we have supported some visceral leishmaniasis specific activities via WHO.

ii. ESPEN complements NTD control and elimination efforts funded by donor organisations by focussing on: scaling-up intervention coverage in countries which cannot easily be supported by other donors; supporting supply chain strengthening activities to ensure effective and efficient delivery, management and use of donated drugs; and strengthening NTD data and information systems to inform timely planning and coordination.

72. Future support to Guinea worm eradication will not be included in the ASCEND programme but will be supported by a new programme (subject to approval). As current activities are directed towards the eradication of the disease, the strategy required is very different from that used for our other identified NTDs, and there is only one delivery partner for the required activities.

73. The Tanzania country office are also in the process of preparing a business case amendment for a WASH programme (subject to approval), aiming to integrate activities which are specifically targeted towards the control of NTDs. ASCEND will coordinate activities with this programmes to ensure synergy.

74. Our current NTD implementation programming (£30m in 2016) supported:i. Scale-up of preventive interventions (predominantly MDA, but also sanitation

and hygiene activities in some cases) for lymphatic filariasis, schistosomiasis, onchocerciasis and trachoma. In 2016, DFID reached over 95 million beneficiaries with preventive interventions, delivering over 150 million treatments.

ii. Improved case detection, diagnosis and treatment for visceral leishmaniasis, which will prevent people suffering and dying due to this disease. In 2016, DFID reached over 11,000 beneficiaries with curative treatments, in addition to supporting national authorities to tackle outbreaks promptly.

iii. Morbidity management interventions (including surgery and self-care education) for trachoma and lymphatic filariasis patients, which can prevent the development of blindness or alleviate disability. In 2016 DFID reached over 72,000 beneficiaries with morbidity management interventions.

26

iv. Training of health workers, teachers and health volunteers in a range of activities relevant to NTD control, including delivery of MDA, provision of surgery and the identification of patients who may require care. In 2016, DFID supported the training of over 250,000 health workers, teachers and health volunteers.

75. In addition to support for NTD implementation programmes, the UK funds a number of research programmes which cover: the development of new drugs and diagnostics for NTDs; implementation research studies for NTDs to improve the cost-effectiveness of interventions; and operational research to improve the equitable coverage of MDA and to enable integration of NTD programmes within health systems.

76. In January 2016, the Ross Fund Portfolio was announced. This is a £1 billion programme, which brings together UK Government investments to tackle the world’s deadliest infectious diseases by developing, testing and delivering a range of new products (including vaccines, drugs and diagnostics). This included £100 million to specifically support NTD control and elimination, although other investments through the Ross Fund are likely to indirectly support NTD control and elimination.

77. In April 2017 the UK announced an additional £205 million on programmes to tackle NTDs between 2017/18-2021/22. This is in addition to planned spending over 2017/18-2018/19, presented above, that completes the UK’s 2012 commitment to NTDs. Including the implementation funding of £100m from the Ross Fund, the UK will invest, in total, £360 million in implementing programmes from 2017/18-2021/22.

Impact and outcome that we expect to achieve78. The impact and outcome that will be achieved by ASCEND will be specified during

the procurement phase, and is dependent on the final combination of programme countries, and the specific activities for each NTD to be undertaken in each country. The specific results will not be pre-determined as the data available on intervention coverage has a reporting lag of approximately two years, and the situation within each country can change rapidly due to other donor’s ongoing and planned activities. The most effective means to ensure coordination with other activities is by suppliers working with individual country governments to assess gaps and priorities. However, we will use available data to assess the likely scale of results per country, as a basis for assessing tenders, and to ensure that there are no major gaps in terms of our priority countries and diseases.

79. Several factors influence the level of the results which can be achieved, including: the level of start-up costs required in each country; where more focus is required to strengthen relevant components of the health system or WASH aspects, costs may be higher; the number of NTDs present per country (and the number of NTDs that ASCEND will target per country, given that other donors may be

27

supporting interventions for some), and the extent to which they geographically overlap; costs tend to be higher in the most hard-to-reach areas, or those affected by conflict. However, based on current NTD programme budgets and results, we provide below an indicative estimate of the expected results. Within all countries, progress towards the 2020 NTD roadmap targets will be expected for the targeted diseases, although the rate of progress will vary depending on the current status of activities within each country, and the scale of intervention required.

80. The impact of the project will be a reduction in the number of people requiring interventions against NTDs (aligned with the SDG indicator for NTDs). ASCEND will contribute a reduction of the morbidity, mortality and disability, and their social and economic costs, which occur as a result of NTDs in programme countries. ASCEND will also support the elimination of visceral leishmaniasis in Asia and improved control in Africa; and the elimination of at least one of trachoma, lymphatic filariasis or onchocerciasis in 8 to 15 countries.

81. The project outcome will be to reduce the prevalence of NTDs and associated morbidity and disability, and to establish sustainable integrated NTD programmes in targeted countries. ASCEND will support:

i. The protection of 180 million to 260 million people from pain, disability, disfigurement and death due to NTDs;

ii. Reduction of morbidity and disability in 40,000 to 70,000 people with lymphatic filariasis (via management of hydrocele and lymphedema);

iii. Provide surgeries to prevent between 350,000 and 450,000 cases of blindness due to trachoma;

iv. Improve control of schistosomiasis, resulting in reduced illness and deaths in the future;

v. Increase the integration of aspects of NTD programmes within domestic health systems in all programme countries;

vi. Integration of health and WASH focusing on NTD prevention, treatment and care within all programme countries, covering joint planning, monitoring and review;

vii. Increased domestic allocation of NTD funding aligned to national NTD strategy.

82. The project’s outputs will include:i. Delivery of over 800 million treatments (worth over £3 billion; the majority of

which represents leveraged pharmaceutical donations) over 3 years;ii. Evidence of NTDs being embedded within national (or sub-national, where

appropriate) health strategies or UHC costed plans and reported against in national reviews;

iii. Agreement on the methodology used to calculate DALYs averted (or another relevant measure of programme impact) for each of the identified NTDs.

iv. Facial cleanliness promoted as an integrated component of Trachoma control in all related programmes, and positive behaviour change achieved;

28

v. Additional outputs covering: people reached by morbidity management (such as surgery); supply chain strengthening activities; and better data availability and utilisation following improved surveillance and disease mapping activities.

83. ASCEND is a significant scale up in relation to our current level of support for NTD control and elimination, approximately doubling our annual investment. While our current NTD portfolio includes more than seven separate programmes (most focussing on a single NTD), ASCEND aims to create efficiencies and drive accelerated progress towards elimination targets by incorporating these strands of work into a single, integrated programme. In addition, ASCEND will take a more ambitious approach to aspects of health systems strengthening, integration, and cross-sectoral collaboration.

84. The level of progress towards sustainable control and elimination of our identified NTDs during the programme timeframe will vary by country, and disease. We set out three potential scenarios below:

i. In countries where elimination is anticipated (e.g. Bangladesh, Nepal, India), the programme will include activities to ensure national governments have the capacity and systems in place to effectively monitor trends post-elimination, and to detect and respond to increases in transmission.

ii. Where NTD programmes are mature (i.e. operating at full geographical coverage), but elimination is not anticipated within the programme timescale (e.g. Mozambique, Tanzania), programme activities will include implementation of interventions, strengthening government capacity and supporting supplementary requirements for elimination. In these countries, we anticipate our support will have significantly reduced the burden of disease (both transmission of disease and the morbidity caused), to such a level that ongoing programmatic activities would be more feasible for national ministries to fund themselves in the future.

iii. In settings where NTD control activities have not yet scaled up, or where there are specific challenges to implementation such as weak national capacity, or conflict (e.g. South Sudan, Guinea Bissau), ASCEND will focus on scaling-up interventions to reach full geographical coverage, developing national capacity, and strengthening local systems. In these settings it is likely that ongoing support will be required beyond the programme timeframe.

85. There will be a substantial learning agenda during the ASCEND programme timeframe for DFID and other providers of external support to NTD programmes. As an increasing number of countries reach the point that MDA can be discontinued, or where elimination is declared, ASCEND will seek to identify the most effective means to transition away from donor support and ensure that partner countries have the capacity, systems and financing in place to maintain the level of control achieved. This learning, and the progress achieved over the timeframe of ASCEND, will feed into the planning of future support for NTD control and elimination by DFID.

29

86. In addition to the specific outputs listed above, as a result of the programme, we expect to see a more effective, integrated, efficient and evidence based approach to integrated NTD control, which can be expanded across and beyond targeted countries. Precise programme results and log-frames will be confirmed during the competitive tendering process. The programme will have a number of key areas of activity:a) Mapping: Mapping of NTDs is necessary to enable targeting of resources to

areas most in need and provide the information required for drug requests and to prioritise WASH interventions. Mapping for most of our targeted NTDs has been largely completed, but important gaps remain. ASCEND will ensure completion of coordinated mapping of NTDs and WASH data for all project countries.

b) MDA: Distributing donated drugs once or twice a year to prevent the targeted PCT-disease, via integrated MDA as appropriate. Scale-up of MDA activities in target countries towards 100% geographical coverage, while also meeting population coverage targets within each endemic district, in collaboration with other partner’s programmes.

c) Morbidity management: Provide case finding, capacity building and training to prevent disability. This includes eyelid surgeries to people who are at high-risk for visual impairment and blindness from trachoma, and hydrocele surgeries to treat the manifestations of lymphatic filariasis.

d) Diagnosis and referral capacity developed: Build up diagnostic and treatment capacity as part of the normal health services to ensure appropriate visceral leishmaniasis response.

e) Surveillance: Support improved disease surveillance systems and carry out surveys to monitor progress, detect emerging outbreaks, and support validation of elimination in targeted countries, as appropriate. Cooperate with others, such as WHO, to monitor for the emergence of drug resistance, where appropriate.

f) Behaviour change communication: Promotion of behavioural practices that will protect people from NTDs and communication to help people understand the reasons for MDA. In areas affected by trachoma, focus on the importance of facial hygiene as part of a broader SAFE strategy. It is important to ensure communication is integrated with other relevant programmes (health, education, WASH) to exploit synergies and maximise efficiency. ASCEND will also support BCC activities to increase community understanding, acceptance and uptake of vector control options, (in relation to vector control activities supported by other donors/programmes, not by ASCEND).

g) Supply chain management: Support countries to order and import required donated drugs and to manage drug and other supplies, including appropriate storage, transportation and tracking via inventory systems. Procurement of other commodities (including some drug procurement which are not covered by donations, and procurement of equipment and laboratory reagents). Collaborate with other ongoing supply chain improvement work to ensure shared learning and integration, where appropriate.

h) Advocacy, and transition and sustainability planning: Advocacy efforts should encourage national Ministries to embed NTD control and elimination

30

activities within their plans, including increasing access to WASH. Programme activities should also ensure transition and sustainability plans are considered throughout the programme lifecycle.

i) Impact assessment and validation of elimination: Conduct impact assessments43 to determine effectiveness of activities. Where target countries have reached the criteria for elimination, support the development of required evidence for validation/verification of elimination.

j) Health systems strengthening: Endemic countries’ Ministries of Health should take on leadership of the response against NTDs, to maximise sustainability of this programme, although we recognise that in some contexts of conflict or extreme instability this may not be possible. The programme will provide technical assistance to the endemic country governments, supporting specific areas of most relevance to the delivery of NTD control and elimination programmes within the national context: this includes supply chain management; strategy and policy development; coordination and leadership of activities; and health workforce development. Suppliers will be expected to assess the appropriate extent and type of support to health systems strengthening for each country they will be operating in. DFID will retain responsibility for approval of the proposed activities, with the support of the monitoring agent as needed.

k) Sanitation and hygiene: Provision of hygiene behaviour change communication activities, particularly to support trachoma control. Identification of NTD hotspots, based on sanitation and water supply coverage information and NTD prevalence data within programme countries, where WASH support could have maximum impact. Coordination between WASH and health sectors, ensuring that relevant WASH programmes consider NTDs in planning. Influence Government and other WASH programmes to prioritise NTD hotspots for the provision of water access and sanitation. The potential to expand ASCEND’s WASH activities will be explored during the development of programme Terms of Reference (ToR), ensuring that any included WASH activities have a primary focus on the control and elimination of NTDs. See Table 3 for a breakdown of WASH interventions which will and will not be provided as part of ASCEND.

l) Coordination with other sectors (see table below): Ensure coordination with existing DFID programmes, non-DFID funded programmes and national activities in targeted countries, including health systems strengthening, malaria, TB, service delivery, WASH, vector-control and education, especially at district level.

Included ActivitiesYes Facial cleanliness promoted as an integrated component of Trachoma

control in all related programmesYes Identify local WASH plans and partners: where these exist, ensure WASH-

health coordination occurs Yes Compare sanitation and water supply coverage information with NTD

43 Impact assessments are used to determine whether interventions can be discontinued for a specific NTD within a specific geographical area.

31

prevalence data within programme countries to identify areas where WASH interventions could have maximum impact

Yes Where possible, integration will be achieved by influencing governments and their development partners to refocus existing WASH plans and activities

Yes Integration of health and WASH focusing on NTD prevention, treatment and care within all programme countries, covering joint planning, monitoring and review

Yes Completion of coordinated mapping of NTDs with WASH data for all project countries

TBC Where limited WASH activities exist and gaps in WASH are a critical barrier to NTD prevention and/or treatment, plan and implement appropriate WASH interventions in collaboration with national government, working towards sustained Open Defeacation Free (ODF) communities with handwashing also being promoted

TBC Improved access to WASH in health facilities supporting NTD related procedures and care

Table 3: Scope of WASH activities within the ASCEND programme.

Gender Equality 87. The proposed project is compliant with the Gender Equality Act (2014). DFID will

ensure that any activity supported considers the impact on gender equality, including disaggregation of data by gender and the inclusion of gender-based targets in results measurement.

88. Gender roles and relations can shape peoples’ vulnerability to and experience of NTDs, how they experience poverty, and their ability to access care and treatment44. Efforts to control and eliminate NTDs must consider how gender impacts on men's and women’s ability to access and benefit from NTD control and elimination interventions. Women are more susceptible to some NTDs whilst men are more at risk of others. However, NTDs disproportionately affect women and girls for the following reasons.

i. Increased vulnerability e.g. pregnancy causes females with chronic helminth-infections to be more vulnerable to severe anaemia45.

ii. Socio-cultural factors can increase the risk of NTDs e.g. water-based domestic activities increases risk of diseases such as schistosomiasis; women are two to four times more likely than men to develop trichiasis that can lead to blindness because they are more likely to provide child-care46. Conversely, young men who migrate for agricultural work in Ethiopia are most at risk of visceral leishmaniasis.

44 Theobald S, MacPherson EE, Dean L, Jacobson J, Ducker C, Gyapong M et al. (2017). 20 years of gender mainstreaming in health: lessons and reflections for the neglected tropical diseases community. BMJ Glob Health 2017;2:e000512. 45Neglected Tropical Diseases: Women and Girls in Focus, Summary report of meeting held on July 27–28, 2016. http://unitingtocombatntds.org/sites/default/files/document/women_and_girls_in_focus_english.pdf 46 Courtright P, West SK (2004). Contribution of sex-linked biology and gender roles to disparities with trachoma. Emerg Infect Dis. Nov;10(11):2012-6.

32

iii. NTDs that cause disfigurement and disability can potentially lead to stigmatisation and social exclusion. For women, disability and disfigurement resulting from infection limits their employment and marriageability, impacting their social and economic wellbeing45. For example, men are susceptible to developing lymphatic filariasis hydrocele (scrotal swelling) while lymphedema (severe swelling in arms or legs) can affect both men and women.

iv. NTDs can disproportionately affect women and girls as caregivers, even women and girls who are not infected with NTDs may suffer social and economic consequences through time away from education or work47.

89. The role of women in programme implementation is also critical and can improve the effectiveness of NTD implementation48, including equal or greater coverage, less participant attrition and higher job performance of drug distributors. There is also some evidence that NTD programmes can be strengthened with participation of female community health workers. Participation of women as CDDs may improve the social status of women49 but can also put additional burdens on women in countries where social norms mean women are generally the main care-givers50. Consideration of the gender balance in the training of health workers can also strengthen female representation in key roles within Ministries of Health, including leadership roles: this aspect will be addressed within ASCEND’s activities.

90. In summary, the programme is expected to have a net positive effect for women and so contribute to improved gender equality.

Conflict and Fragility91. ASCEND activities will cover several FCAS, or parts of FCAS. Reducing the

prevalence of NTDs and the health and social impacts that they cause will contribute to the reduction of fragility due to increases in economic productivity. Activities which support the strengthening of health systems will also contribute to increased resilience of health services.

92. Conflict and security is not a major priority for ASCEND, and Conflict Security and Stability Fund resources would not be appropriate.

93. As noted in paragraph 49, the implementation approach may need to be adapted within FCAS, prioritising the delivery of NTD services over other aspects of the programme. Careful consideration of country contexts is required to adapt the implementation approach to specific settings.

47 Allotey P, Gyapong M ‘The gender agenda’. http://www.who.int/tdr/publications/tdr-research-publications/gender-agenda-controltropical-diseases/en/48 Various studies noted in Neglected Tropical Diseases: Women and Girls in Focus 49 Mutalemwa P, Kisinza WN, Kisoka WJ, Kilima S, Njau J, Tenu F, et al. (2009). Community directed approach beyond ivermectin in Tanzania: a promising mechanism for the delivery of complex health interventions. Tanzan J Health Res. Jul;11(3):116-25.50 Katabarwa MN, Habomugisha P, Ndyomugyenyi R, Agunyo S (2001). Involvement of women in community-directed treatment with ivermectin for the control of onchocerciasis in Rukungiri district, Uganda: a knowledge, attitude and practice study. Ann Trop Med Parasitol. Jul;95(5):485-94.

33

Disability inclusion94. DFID will ensure the programme promotes equitable access to services

regardless of ethnicity, religion, gender, disability and social status – with particular focus on ensuring that vulnerable populations are able to benefit from DFID-funded activities.

95. Many NTDs cause significant disability, including disabling lymphedema, massive hydrocele, disfigurement, and blindness. The management of disease complications (also called morbidity) and disability prevention are critical components of NTD programmes. If people with disabilities are not included in all aspects of the NTD response, elimination targets will not be met.

96. ASCEND will apply strategies to ensure that interventions reach all appropriate members of target communities, including those with disabilities. For example, conducting activities door to door will help to ensure that no one is excluded. Ongoing research supported by DFID (countdown) is specifically focussing on this aspect of NTD control, identifying tools and approaches to assess the equity of NTD programme coverage, and to identify barriers and challenges to access. Where intervention coverage data is collected (e.g. coverage of MDA), this will be disaggregated by a range of characteristics, including disability status. For specific activities, identifying those with disabilities will be an essential component (for example, identifying individuals with lymphedema caused by lymphatic filariasis will be essential to allow morbidity management, including training in self-care practices).

97. The programme will comply with the Public Sector Equality Duty by ensuring that: 1) harassment and discrimination are not tolerated and 2) promoting equal opportunity between people who share protected characteristics with those who do not.

Climate and the environment98. The programme will not count against climate finance. All appraisal options

proposed have similar climate and environmental considerations.

99. The programme will have some climate and environment opportunities. Support to improve sanitation and hygiene will have a positive impact on the environment via the prevention of faecal contamination of the environment. Where water supply interventions are proposed, there is an important opportunity to promote effective water resources management. Where the programme is only advocating for improved WASH interventions, it is important that this includes advocacy for better water management and the effective disposal and isolation of faeces.

100. The disposal of waste generated through programme activities (e.g. medical equipment used in surgeries, pharmaceutical packaging) will need to be carefully managed by suppliers, including the appropriate handling of sharps, other medical wastes and expired drugs. We will ensure that successful suppliers have

34

in place the appropriate procedures to appropriately manage any waste produced, to avoid the contamination of the environment. We will ask suppliers to share with us their waste management protocols and standard operating procedures so that we can check these are adequate. Where they are not considered adequate we will ask for improvements to be made.

101. ASCEND will not be using insecticides for vector control. Our vector control activities will focus on advocacy, behaviour change communication and coordination with other activities. Advocacy will include material related to safe storage and handling of insecticides and to promote selection of the least environmentally damaging insecticides. It is important that insecticides used are subject to regulation as commonly used substances include pyrethroids and DDT, both of which cause environmental damage, particularly in aquatic environments. Pyrethroids are toxic to humans and exposure must be carefully controlled. Whilst there is evidence that metabolites of pyrethroids may be found in aquatic systems and food, at present the evidence is inconclusive about the risk these pose to health.

Counter terrorist financing102. There are no foreseen risks relating to terrorism from this programme.

103. DFID will carry out due diligence assessments of the selected suppliers, who in turn will carry out due diligence assessments of all downstream partners in line with DFID requirements. As part of the due diligence a delivery chain mapping exercise will be completed that identifies and captures the names of all partners involved in delivering the programme, down to the end beneficiary. This will be updated and reported throughout implementation. The due diligence assessment will include checks to ensure their systems and procedures provide adequate protection against the risk of terrorist financing.

104. DFID will jointly agree the potential risks and mitigation measures with the implementing partners at the outset and will follow-up throughout implementation.

Risk105. Taking into account the current risks identified and applying mitigation

strategies (Annex 4), the programme is classified overall as ‘Moderate’ risk. See the Management Case for further information on risk management.

B. Appraisal Case

106. The purpose of this intervention is to accelerate progress towards the control and elimination of onchocerciasis, lymphatic filariasis, trachoma, schistosomiasis and visceral leishmaniasis, in order to reduce the morbidity and mortality caused by these diseases, particularly for the poor and vulnerable.

35

107. As a minimum, this programme will support NTD implementation covering the diseases currently supported by DFID, within the countries that DFID’s current NTD programmes are active. However, ASCEND will significantly increase UK funding to NTD implementation and the appraisal of options will also consider the ability to increase the reach and scope of UK support to deliver in additional geographical areas (within existing countries or additional countries). ASCEND may also support additional activities to tackle other NTDs included in the London Declaration, where there is a strong case that these can be integrated based on geographical overlap with our identified diseases, and a clear justification of need based on disease burden and a lack of other financial support. These additional activities must be delivered within the ASCEND programme timeframe, be cost effective and be delivered in conjunction with activities targeting our identified diseases. See Annex 2 for a summary of current support for NTD implementation activities, by country, with suggested areas for expansion of activities. Expansion into additional countries may also be considered. Note that programme activities will be geographically targeted within programme countries to cover only areas endemic for the specific NTDs addressed. In addition, full geographic coverage will not necessarily be reached for identified NTDs in ASCEND’s programme countries due, for example, to requirements for additional capacity development, access constraints, or the timescale required to scale-up to all endemic areas. The specific WASH activities (e.g. proportion of the budget to support improved WASH, and the extent to which water supply within health centres or communities will be addressed) will be confirmed during development of ToRs. This will be agreed by the head of the Human Development Department, and the costs and benefits of different scenarios will be presented.

108. The scenario of ‘do nothing’ was considered but rejected as the ASCEND programme is critical to delivering the UK commitment on NTDs announced in April 201751, and to achieving the global targets outlined in WHO’s NTD roadmap10. The ASCEND programme is also critical to protecting the investments that the UK has already made in the project countries (approximately £170 million from 2010-2017), avoiding any public health impacts of existing DFID projects ending and treatments stopping before elimination as a public health problem is reached, such as potential disease resurgence, and ensuring the UK supports partner countries to make faster progress to elimination targets. Given limited other funders for NTD control and elimination efforts, an option of ‘do nothing’ would have significant adverse impacts on the coverage of NTD interventions, and the current trajectory for our targeted NTDs.

109. This section appraises:A. Disease integration options (separate components for PCT and IDM diseases;

integrated implementation across all focus NTDs); andB. Delivery route options (existing suppliers; multilateral organisation(s); open

competition; direct support to national NTD strategies).

51 https://www.gov.uk/government/news/uk-to-protect-200-million-people-from-tropical-diseases

36

A. Appraisal of disease integration options110. The following disease integration options have been considered to manage

the ASCEND programme:i. Integrated implementation across the focus NTDs; and

ii. Separate components focussing on (a) integrated implementation across the focus PCT diseases and (b) integrated implementation across the focus IDM diseases.

111. Based on the evidence presented in the “Integrated approaches forsustainable NTD control and elimination” section, the preferred option is Ai: integrated implementation across the focus NTDs. The activities covered in ASCEND will be those listed in paragraph 30. ASCEND will:

i. Bring together activities to address onchocerciasis, lymphatic filariasis, trachoma, schistosomiasis, visceral leishmaniasis (and potentially other London Declaration NTDs, as noted in paragraph 107);

ii. Focus on embedding NTD control and elimination within country health systems, and strengthening specific components where weaknesses may undermine these efforts; and

iii. Enhance cross-sectoral coordination, advocacy and linkages, in particular with the WASH sector.

112. There is a scarcity of evidence regarding the integration of activities for PCT and IDM diseases. However, strong health systems with embedded NTD prevention and care services are a core requirement for sustainable control and elimination of both PCT and IDM diseases. For this reason, activities for both PCT and IDM diseases should be delivered by the same suppliers within ASCEND. This approach will ensure the programme will support a coherent approach to NTDs within each programme country, strengthening key components of the national health system, and effectively working towards sustainable national ownership of NTD control and elimination efforts.

113. ASCEND’s primary focus is the implementation of NTD control and elimination activities. However, there will be scope to strategically fund supporting activities, innovative approaches or research. For example, operational research may be conducted to fill strategic evidence gaps or answer specific programmatic questions through a policy and strategic investment fund (PSIF; see paragraph 147). This would complement other ongoing DFID funded NTD research, and would focus specifically on questions related to the approach taken in ASCEND, as outlined in paragraph 131.

114. In summary, the selected options are:i. Integration across all focus NTDsii. Delivery via supplier(s) selected via competitive tender

iii. Without the inclusion of a challenge fund

115. The design of the tender is considered in the commercial case.

37

Economic appraisal and value for money116. The economic appraisal aims to address the following issues. It firstly

presents the evidence on the economic impact of NTDs. Secondly it presents evidence on the cost-effectiveness of the programme and its constituent parts. Thirdly it considers key cost drivers that will influence the tender design and the prospective winning bid.

117. The exact selection of countries, and the prioritisation of activities and allocation of resources between them, will be established through the tender process, based on the latest epidemiological data and evidence of what other existing partners are funding. These decisions will influence the final scope of the programme.

118. The calculation of DALYs for NTDs is difficult, with some controversy around different methods. Some approaches exclude subtle morbidities such as impaired cognitive development, or mental health problems related to stigma, which can contribute significant burdens of those affected. This may underestimate the total burden of NTDs53. Therefore, comparison between different estimates of DALYs and cost-effectiveness should be made with care.

Economic impact of NTDs119. The majority of the economic impact of NTDs results from lost productivity

(inability to work, lost earnings, and in some cases the inability to use agricultural land due to risk of infection). For example, blindness caused by trachoma or onchocerciasis has been found to result in a productivity loss of between 60 and 100%. A summary of the estimated lost productivity due to different NTDs is presented in Table 4, highlighting the potential for large impacts on household incomes52. Globally, accounting for productivity losses alone, the cost of lymphatic filariasis is estimated at $1.3 billion per year, and trachoma is estimated at between $2.9 billion and $8 billion per year53. Global economic impact estimates are not available for all NTDs.

Table 4: Economic burden through lost productivity of selected NTDsNTD Sequela Annualised loss in

productive input (%)

Lymphatic filariasis HydroceleLymphedema

14-192-23

Onchocerciasis Visual impairmentBlindness

14-3879-100

Schistosomiasis General 1-23

52 Fitzpatrick C, Nwankwo U, Lenk E, de Vlas SJ, Bundy DAP (2017). An Investment Case for Ending Neglected Tropical Diseases, Chapter 17 in Holmes KK, Bertozzi S, Bloom B, Jha P editors. Major Infectious Diseases. Disease Control Priorities, third edition, volume 6. Washington, DC: World Bank. doi:10.1596/978-1-4648-0524-0.53 World Health Organization (2010). First WHO report on neglected tropical diseases: working to overcome the global impact of neglected tropical diseases.

38

Trachoma Visual impairmentBlindness

2560-100

Visceral leishmaniasis General (treated) 6-30

120. The costs for prevention, diagnosis, medical treatment and other associated expenses also add to the economic burden of NTDs. Even where appropriate diagnostics and medicines are provided free of charge, direct out of pocket expenses can be considerable due to other costs such as transportation or accommodation. For example, in India, Bangladesh and Nepal, up to 75% of households affected by visceral leishmaniasis are estimated to experience catastrophic health expenditures to access diagnosis and treatment, even though these are provided free of charge36.

121. Meeting the London Declaration targets by 2020 (as summarised in Table 1) within DFID’s current NTD programming footprint (i.e. for the specific NTDs that we currently focus on, in the specific countries that we currently support) would result in an estimated 167 million DALYs averted, and $40.8 billion of costs averted (accounting for costs to the individual, excluding wider costs, such as health service costs) between 2011 and 203054. This represents the potential gains as a result of collective contributions from DFID-funded programmes, other donor programmes, and the utilisation of domestic resources for NTD control efforts. While these figures demonstrate the significant potential benefits that come from the control and elimination of NTDs, progress towards the London Declaration targets is off-track: thus, these are likely to be over-estimates of the actual benefits of the collective investment for the time-period considered. If the targets are achieved later than 2020, this scale of benefit may be anticipated over a longer time period.

122. Under the same assumption (the London Declaration targets are met by 2020), the projected return on investment is $27 for every $1 spent on NTD control during 1990-2020, and $42 for every $1 invested during 1990-203055. There is a limited availability of return on investment estimates in other scenarios (i.e. return on investment if the London Declaration targets are not met). For lymphatic filariasis control, each $1 of investment is estimated to result in a return of $20-$3056, and for onchocerciasis control there is an estimated 17% economic rate of return (this excludes the financial value of drugs which are donated by pharmaceutical companies from the estimated costs)57.

54 Dekker M, Santegoets F, Bakker R (2016). Health and economic impact of achieving the WHO targets for control and elimination of London Declaration NTDs (interactive dataset). https://erasmusmcmgz.shinyapps.io/dissemination/55 Redekop WK, Lenk EJ, Luyendijk M, Fitzpatrick C, Niessen L, Stolk WA, et al. (2017). The Socioeconomic Benefit to Individuals of Achieving the 2020 Targets for Five Preventive Chemotherapy Neglected Tropical Diseases. PLoS Negl Trop Dis 11(1): e0005289.56 Chu BK, Hooper PJ, Bradley MH, McFarland DA, Ottesen EA (2010). The Economic Benefits Resulting from the First 8 Years of the Global Programme to Eliminate Lymphatic Filariasis (2000–2007). PLoS Negl Trop Dis 4(6): e708.57 Amazigo U (2008). The African Programme for Onchocerciasis Control (APOC). Annals of Tropical Medicine & Parasitology Vol. 102, Iss. sup1.

39

123. Based on the evidence, there are strong grounds to expect a large return on our investment (in terms of health and economic benefits) from ASCEND, although we are unable to quantify them using currently available methodologies. In addition to the averted DALYs and averted costs outlined above, the successful and sustained control and elimination of our identified NTDs will generate broader financial savings to the health sector.

Cost-effectiveness of NTD interventions124. Cost-effectiveness for health interventions is commonly measured as the cost

per DALY averted: this is used to compare the VfM of different interventions. A range of thresholds have been used to judge whether or not a given cost per DALY averted represents a cost-effective intervention. A recent publication suggests that interventions costing less than US$200 per DALY averted could be considered cost-effective enough to be included in UHC packages in low-income countries (and US$200-$500 for lower-middle income countries) – so setting a benchmark for the acceptable costs for countries in different economic situations58.

125. The Lancet Commission on Investing in Health (an independent group of 25 leading economists and global health experts from around the world) concluded that the control and elimination of the London Declaration NTDs constitutes good VfM. This is due to the low per-capita costs of intervention (which utilises significant volumes of donated pharmaceuticals) and previous experience indicating that significant reductions in the transmission and overall burden of the focal diseases can be achieved using available tools59.

126. NTD interventions are cost-effective, at as little as US$3 per DALY averted53. Table 5 presents cost per DALY estimates for the main NTD interventions included in the ASCEND programme, all of which fall well below the threshold presented in paragraph 124. There are no available cost-effectiveness estimates for other aspects of the ASCEND programme (e.g. facial cleanliness and environmental aspects of trachoma control, surgery for hydrocele)60.

127. The cost-effectiveness of PCT versus IDM strategies is generally comparable, despite lower unit costs for MDA-based control and elimination (see Table 6, below). This is due to disease severity: some IDM diseases have more serious clinical outcomes than PCT-diseases. Therefore, a higher unit cost to detect and treat a single case of an IDM disease will avert a greater number of DALYs than providing MDA to an individual to treat or prevent a PCT-disease60.

58 Horton S, Gelband H, Jamison D, Levin C, Nugent R, Watkins D (2017). Ranking 93 health interventions for low- and middle-income countries by cost-effectiveness. PLoS ONE 12(8): e0182951.59 Seddoh A, Onyeze A, Gyapong JO, Holt J, Bundy D (2013). Towards an investment case for neglected tropical diseases. Commission on Investing in Health Working Paper.60 For comparison, treatment of children with severe malaria using parenteral artesunate is estimated as $5 per DALY; provision of insecticide treated bed-nets to prevent malaria as $61–$94 per DALY; management of acute childhood diarrhoea with oral rehydration salts at $153 per DALY; and

40

128. Available evidence suggests that an integrated approach to NTD control is likely to improve cost-effectiveness for the factors described in paragraphs 36 to 41. In Uganda, stand-alone NTD programmes (covering the PCT-diseases) were estimated to cost US$17.9 per DALY averted, in comparison to US$10.2 per DALY averted for an integrated programme63. However, beyond the integration of intervention delivery for MDA activities, there is little evidence of the costs, impact or cost-effectiveness of integrated approaches (for example coordination of IDM activities and PCT activities; integration of WASH for NTD control39).

129. In spite of the highly cost-effective nature of NTD control and elimination, and significant progress in recent years, progress is insufficient to meet the goals set out at the London Declaration in 2012. The main challenges limiting progress are a lack of financial and human resources to enable the significant scale-up of activities required, including to remote areas which lack even the most basic services8. There has been limited adoption of NTDs as a priority public health intervention in domestic health resourcing (see paragraphs 63 to 66): thus, it is important for donors to ensure the continuity of NTD programmes to bank previous gains, support scale up activities, and work to facilitate country ownership and increased domestic financing. Explicit inclusion of NTDs in the SDGs incentivises additional resource mobilisation to address NTDs and data suggests that although domestic spending on NTDs per capita is low, increases have been seen2.

Theory of Change for the Preferred Option

130. The theory of change for the preferred option is presented in Figure 4 below. The key assumptions underpinning this are (see also Appendix 4 for the full risk matrix):

i. Continued donation of required drugs by pharmaceutical companies, and effective management of drug donations via WHO;

ii. Continued support from, and close collaboration with, other key donors, particularly for countries in which multiple donor activities are contributing to NTD control and elimination efforts;

iii. Country-level political commitment, and increasing national level capacity, with increasing domestic resources available to support national NTD strategies;

iv. High level of community uptake for interventions (e.g. for MDA activities), to ensure adequate intervention coverage to effectively reduce NTD transmission; and

v. Political stability and low level of conflict events allow implementation activities to occur within focus countries. However, there are examples of successful NTD programmes even in conflict situations (e.g. the Guinea worm eradication programme in South Sudan).

41

131. The evidence to support this theory of change, as outlined in the Strategic and Appraisal cases is strong. There is clear evidence that the implementation at scale, of the activities outlined within ASCEND, can effectively reduce overall disease burden, reduce transmission of disease, and in time can result in the local control or elimination of specific NTDs within discrete geographical areas. This programme builds on over 10 years of experience in NTD programming, including annual review findings, external evaluations, and a significant body of published research from international organisations and academic experts. There are some areas where the evidence is weaker, and filling these evidence gaps will be a priority for the ASCEND programme:

i. Opportunities and challenges for the integration of PCT and IDM disease activities;

ii. The added-value of integrated versus disease specific NTD programmes, in terms of health outcomes, health systems strengthening, and cost effectiveness;

iii. Approaches to build sustainable country ownership of NTD programmes;iv. Degree of trade-off between strengthening national health systems and

delivering expanded NTD activities at scale;v. Effective strategies to maximize health system gain from NTD programmes;

vi. Successful management of hard-to-reach and nomadic populations;vii. Measurement of the quality of NTD implementation programmes, not just the

quantity and reach of treatment.

132. Suppliers bidding for the programme will be required to set out how they will address these specific areas. Un-earmarked policy and strategic investment funds will also be used to support further small-scale, discrete, activities or operational research which may help to fill these evidence gaps. Suppliers will also be required to produce a country-specific Theory of Change for each country in which they are working, accounting for the specific mix of activities required within each particular country context.

Figure 4: Theory of Change for ASCEND programme (next page).

42

43

Measures of value for money133. The ASCEND programme will have a VfM strategy and appropriate

monitoring tools to ensure VfM is embedded across all activities and is regularly reported to DFID.

134. Value-for-money in ASCEND will be tracked using the following key measures of cost-effectiveness, disaggregated by country and NTD (as noted above, there are varying opinions on the calculation of DALYs for NTDs: we will encourage our suppliers to develop a coherent approach across each of the NTDs for these calculations):

i. Cost per DALY avertedii. Cost per case of disability averted

iii. Cost per case managed (surgery or other management of disease symptoms)iv. Cost per surgery completed

135. In addition, the following measures of operational efficiency and VfM will be tracked across the programme lifespan, disaggregated by country and NTD:

i. Cost of baseline, coverage or impact survey conducted, per evaluation unit (and per population of evaluation unit)

ii. Cost per person treated with MDA iii. Cost per case of visceral leishmaniasis detected and treated in Africa (this

indicator is not appropriate in Asia due to reduced case numbers)iv. Cost per community drug distributor/health worker/surgeon trainedv. Cost per surgery

vi. Cost of sanitation and hygiene promotion per open defaecation free community

C. Commercial Case

136. The Commercial Case outlines the commercial arrangements for our selected delivery route (option Biii: Supplier(s) through a competitive tender, open to one or more consortia bids). This assessment has considered inputs from the Procurement and Commercial Department, Annual Reviews and mid-term evaluations of existing NTD implementation programmes, the DFID Commercial Health Strategy document and a range of team members. See also the appraisal case for key commercial considerations for each of the appraisal options.

137. An early market engagement (EME) event was held in November 2017 to engage the interested supplier community and to invite comments from the market on the design of ASCEND. 43 individuals attended from a mixture of private sector companies, research organisations (including UK universities) and NGOs. This explored ways to ensure effective delivery to increase the scale and scope of UK support to NTD implementation, gathered feedback on the different potential delivery models, identified key challenges and highlighted areas where

44

further assessment would be required in shaping an efficient and effective programme. (REDACTED)

138. (REDACTED)

Programme structure139. As part of the commercial case, we have considered three options for

programme structure, based on geographical coverage of tenders:i. (REDACTED)

140. The addition of a separate contract for independent monitoring and evaluation, and the inclusion of a separate policy and strategic investment fund to provide small amounts of flexible funding to cover strategic issues, are also considered in this commercial case (see paragraphs 145 and 147 respectively).

141. REDACTED142. REDACTED

i.

143. REDACTED144. The decision of tendering for one main contract or multiple contracts

addressing individually specific regions or components (i.e ‘lotting’) will be made during development of the sourcing strategy.

145. In addition, a separate contract will be used for independent monitoring, verification and evaluation activities. This contract will prioritise the monitoring of progress, quality assurance of programme delivery and verification of results. It will also manage the implementation of a programme evaluation. This option allows greater accountability of the supplier(s) and delivery chain to DFID, enabling a greater level of oversight of programme activities. The appropriateness of The Global Evaluation Framework Agreement (GEFA) for these activities will be assessed initially. A competitive tender will be used in case the framework is not suitable for the requirements of the ASCEND programme, acknowledging that GEFA was designed for evaluation purposes rather than independent monitoring.

146. Based on the performance of programme supplier(s) during implementation, the programme team will consider whether one or more regional DFID advisers may be required to ensure an appropriate level of DFID engagement with the programme, programme staff, and national governments within programme countries. In this case, an additional component will be added to ASCEND to cover funding for these posts

147. Within the implementation component, a ‘Policy and strategic investment fund (PSIF)’ will be managed by the supplier(s), which will be up to 5% of the contract value. The PSIF will be an un-earmarked fund that allows for strategic investments to be made, to support new innovative ideas, fill critical gaps in treatment coverage and to deliver an enhanced learning agenda, for example via

45

operation research related to programmatic activities. Governance arrangements for the PSIF will ensure that DFID officials have final approval on any expenditure proposed by the supplier(s). This will ensure that PSIF funds are not used to deliver activities which are included as part of the implementation contracts.

148. REDACTED

Assurance about organisation’s capability and capacity to deliver149. The supplier(s) for the ASCEND implementation and independent monitoring

and evaluation components will be selected through competitive tender processes. Due diligence and supplier chain mapping will be carried out for the preferred bidder(s) prior to final award of the contracts to ensure they have the required capability and capacity to deliver.

150. Following the approval of the business case, the sourcing strategy will determine the preferred form of competitive process (e.g. open procedure, restricted procedure, competitive procedure with negotiation, or competitive dialogue) that would be appropriate following the analysis stated within the appraisal case above. The findings from the EME and experience with current and previous NTD programmes will help to inform the ToR, which will set out the core requirements for ASCEND: a well-defined ToR will be critical to ensure a high quality programme which meets the overall objectives within the programme timeframe. This will include an overview of essential, high priority and lower priority activities for the programme by country, along with a summary of other external support to NTD implementation and DFID funded WASH and health systems programmes in each country (as illustrated in Annex 2). This information will assist suppliers to identify key programme activities in each country and the results that can be delivered in the timeframe. Suppliers will be expected to demonstrate their value and comparative advantage against the different elements of the programme, including determining what they will deliver, where, within the specific parameters set out in the ToR. The ToR for the independent monitoring and evaluation contract may be delayed until full details of the implementation activities by country are available, in which case this contract will begin approximately six months after the implementation contract(s).

151. All tender activity will be over the EU threshold and therefore subject to EU regulations. Past supplier performance, capacity, capability and experience in delivering NTD implementation in the priority regions/countries will be important criteria for the appraisal of bids received for the two regional implementation contracts. DFID will also consider key supplier management reviews and commercial expertise reviews of NGOs, and due diligence where appropriate.

152. The ASCEND programme will support national NTD programmes. Engagement with government partners is a core requirement to build and strengthen sustainable NTD implementation and progress towards elimination

46

targets. Supplier(s) competing for the implementation tender(s) will be assessed on the strength of their proposed approach to engage with and build national capacity for sustained provision of NTD prevention and treatment services. A single lead implementing organisation should be identified for each programme country, and it will also be expected that country representatives for the supplier(s) participate in key national NTD meetings, particularly for the countries in which the majority of programme activities will be taking place (e.g. Nigeria, Ethiopia and DRC). In-country staff should be further supported be strong specialist technical support across all of the targeted NTDs.

153. The separate tender for an independent monitoring, verification and evaluation agent will assess the capacity of potential suppliers in terms of ability to provide robust monitoring and oversight, including accurate data collection, strengthening of national data reporting systems and programme evaluation activities.

154. Contract ToR will be flexible to ensure the programme can effectively scale up, scale back or modify activity in specific countries, as required: for example to ensure activities address national priorities, or to ensure efficient coordination of NTD implementation activities with other DFID funded programmes61 and activities funded by other donors. In addition, the timescale for the programme contracts will be three years and four months (may be shorter for the independent monitoring and evaluation contract), with the option of extension (cost or no-cost) to extend the full programme by up to 50% in value and time. This will be further discussed during development of the sourcing strategy. Extension(s) may be required rather than a new procurement in specific contexts, such as where there is a risk of a scheduled MDA not occurring (e.g. due to other donors withdrawing funding within specific areas, or delays to drug delivery), which may jeopardise broader achievements. Any cost or no-cost extensions will be contingent on satisfactory supplier performance. The contracts will be subject to break points after 6 months and 18 months. Continuation of the services after these periods will be based on agreement of deliverables and on satisfactory performance and the progress of the Supplier against the specified outputs.

155. DFID’s Procurement and Commercial Division will conduct due diligence checks on winning NGO/private sector bidders and check on their processes for procurement and sub-contracting, before entering into any contract. This will include a thorough review of organisations’ safeguarding procedures, ensuring that strong processes and procedures are in place to ensure that allegations of sexual harassment, exploitation or abuse are appropriately dealt with, and reported to DFID as well as the appropriate authorities.

156. All supplier(s) contracted through competitive tender will be required to manage visibility of DFID money using open-book accounting, due diligence of

61 This includes a proposed new programme “Contributing Towards Eliminating Blinding Trachoma in the Commonwealth”, and a proposed amendment to an existing WASH programme in Tanzania to incorporate NTD targeted activities, both of which are pending approval.

47

sub-contracted partners and lines of accountability throughout the delivery chain. Contract and supplier performance will be managed through the life of the programme via regular contractual performance and logframe reviews, annual reviews, reporting from the third party monitoring and verification agent, strong and relevant Key Performance Indicators and Service Level Agreements where necessary. Risk and reporting of savings and efficiencies will be embedded into the contractual review meetings as business as usual on a quarterly basis. A fraud risk matrix that sets out the specific risks and maps the key controls for each will be developed early in implementation.

Ensuring value for money157. The main cost drivers for the programme were set out in the appraisal case

we anticipate the major drivers to be personnel/per-diems and transportation costs. It is important to note that costs per person reached or per DALY prevented are expected to increase as countries progress towards elimination and the focus of intervention shifts from prevention and treatment to post-elimination surveillance. This is due to a range of factors, such as the higher costs associated with reaching the most marginalised, remote and potentially conflict affected areas to ensure that everyone requiring treatment has been reached, and a reduced ability to achieve economies of scale when the population requiring treatment is smaller. The ToR for the tender will include cost drivers and benchmarking as major bid evaluation criteria, including up-front assessment of costs informed by context, including fragility and progress towards elimination. An in-depth appraisal of the bids will be undertaken by DFID to evaluate their ability and capacity to manage finances and risk efficiently and effectively, and the overall VfM offered by each supplier.

158. A robust VfM strategy will be required as part of each bid provided. The successful bidder will have to demonstrate significant competence and capability in ensuring VfM and also in managing all downstream partners.

159. A range of approaches will be used to drive cost-effectiveness in the ASCEND programme. Regular contract management meetings will be used to track programme progress and opportunities for improved economy and efficiency within the programme. Payment milestones will be scheduled, and payments will be made in arrears and will be contingent on performance against KPIs, supported by the independent monitoring.

D. Financial Case

Cost profile160. The programme will run for 3 years and four months with an option to

extend for up to 50% in value and time (contracts awarded will also have the potential for extension, subject to satisfactory supplier performance). The programme will be managed and funded by the Health Services Teams (HST), Human Development Department, DFID.

48

161. See Table 7 for a provisional spending profile by programme component. This investment will contribute towards our £360 million spending commitment (2017/18 to 2021/22), and will come from programme budget. The budget profile reflects an anticipated inception period and time required for scale-up of the programme.

49

Payment of funds162. The funds will be disbursed via procurement contracts (separately for

implementation activities, and for monitoring and verification). The disbursement mechanism will defined during development of the sourcing strategy for the contracts. Where payment in advance is requested by partners, strong written justification will be required: this will be heavily scrutinised by the programme team, with authorisation required from the SRO. In no circumstances will payment in advance of need covering a period of greater than six months be allowed. Performance management aspects, including the use of PbR or similar mechanisms, will be defined during development of the sourcing strategy. The programme spend type will be RDEL and all funding will be ODA eligible. Funding to 2019/20 has been factored into current resource allocations. In line with DFID’s Smart Rules, we will seek HMT approval for funding beyond the current spending review period.

163. Payments related to the contracts will be made to the lead supplier for each contract: the lead supplier will then be responsible for the transfer of funds to downstream partners, as appropriate. The lead supplier will provide and update delivery chain information, covering all downstream partners and the value of funds flows. These payments will be linked to key activity-based payment milestones, as set out in the contract. Payments related to the MoU will be made to WHO-HQ communicable diseases cluster.

164. See Table 8 below for an overview of funding types and input sectors, by component.

Table 8: Funding types and input sector codes allocated by componentImplementation contract (205249-101)Funding type: Procurement of Services (104)

Input sector Input sector code Percentage allocation1 Infectious

Disease Control12250 70%

2 Basic Health Care 12220 30%Independent monitoring & evaluation of NTD implementation activities contract (205249-102)Funding type: Procurement of Services (104)

Input sector Input sector code Percentage allocation1 Infectious

Disease Control12250 70%

2 Basic Health Care 12220 30%WHO-HQ communicable diseases cluster MoU (205249-103)Funding type: Multilateral Organisation (109)

Input sector Input sector code Percentage allocation1 Infectious

Disease Control12250 70%

50

2 Basic Health Care 12220 30%

Tax costs165. All ASCEND contributions fall outside the scope of UK VAT. The beneficiaries

of ASCEND will be people in low- and middle-income countries at risk of, or suffering from, NTDs.

Asset Management166. Any assets purchased by the programme will be properly recorded and

remain under the ownership of DFID. Suppliers will set out how they will maintain, control and report on assets purchased with DFID funds, mitigating against theft, damage or loss. DFID will then determine how the assets are disposed of at the end of the programme as part of the closure strategy. Any funds not spent by the programme will be returned to DFID at the end of the programme. All assets will be disposed of in a way that represents best VfM with a clear record of decision making, including approval by Head of Department or delegate.

167. Suppliers will also be required to set out a robust plan for the management and security of assets on which programme delivery is dependent (in particular including donated pharmaceuticals, but also including procured drugs, diagnostics and other equipment). This should cover their processes for procurement, logistics, inventory management and supply chain security from the regional, to the national and local levels.

How will expenditure be monitored, reported, and accounted for?168. Suppliers will be required to provide monthly forecasts and actual

expenditure figures to DFID. Quarterly financial reports will also be required (alongside progress reports), including disbursements to downstream suppliers. Forecasts should be realistic and free of optimism bias, with suppliers informing DFID of potential slippage or overspends as soon as they are identified. Suppliers will be required to provide a final forecast for the upcoming month before the end of the previous month, at the latest. Contracts will outline how disbursement of funds will take place, agreed beforehand with the suppliers. Open book accounting will also be required, in line with the supplier review, to ensure full transparency of supplier finances, including any profit margins associated with the programme.

169. The audit provisions will be set out in all formal exchanges and Suppliers will record evidence of the use of funds through the receipt of annual audited accounts. These will be signed-off by the Finance Managers on behalf of the implementing partners and certified by their auditors in order to separately identify DFID funds, associated disbursements and unspent funds.

51

Assessment of financial risk and fraud

170. ASCEND will be operating in multiple countries, including fragile and conflict affected states. The programme will be reaching remote and marginalised communities. Based on this context, the risk of aid diversion is judged to be major. DFID will take the following measures to mitigate against financial risk and fraud:

i. Monthly financial forecasts and expenditure reports; quarterly financial reports; and monthly meetings with our lead-partners for each of the three contracts will mitigate the risk of large over or under spending within ASCEND.

ii. The lead suppliers associated with the contracts will be required to set out their fraud mitigation strategies including internal risk management systems and reporting systems.

iii. The independent monitoring and evaluation supplier will mitigate against major fraud committed by the implementation suppliers, for example charging DFID for services that have not been provided, exaggerating the number of beneficiaries. The independent monitoring and evaluation supplier will also be required to set out how it will mitigate the risk of fraud in its own services, e.g. collusion with the implementation contract suppliers.

iv. Annual financial audits will be requested to include spot checks of high risk areas of programme activity. Should this highlight any potential concerns, the right will be reserved to conduct a full forensic audit.

v. The risk of fraud through downstream suppliers or with partners in country will be partly mitigated through the lead supplier’s due diligence of downstream suppliers, ensuring acceptable levels of financial control and reporting before granting funds. It will also be partly mitigated through the third party monitoring supplier.

171. The lead suppliers will be required to set out how they will monitor the performance and financial management of downstream suppliers and national partners supported through the programme.

172. If fraud is detected, DFID will require full remedial action including repayment in full if the fraud involves diversion of UK funds. Continued disbursement of funds will be contingent on adequate financial oversight mechanisms.

173. In some countries, programme funds may be used to support specific activities of national and local governments, where appropriate and to ensure use rather than duplication of national systems. Due diligence and fiduciary risk assessments will be carried out by the main supplier(s). The contract tendering stage will ensure thorough consideration of suppliers’ abilities, capacity and systems to perform these assessments. We would also expect the supplier(s) to help strengthen financial capacity where necessary, and conduct periodic financial checks.

52

E. Management Case

Management arrangements for the implementation of ASCEND174. The programme will be managed by the Health Services Team (HST), Human

Development Department, DFID, with the following roles and responsibilities:i. The Diseases of Poverty hub lead (A1) will be the Senior Responsible Officer

(SRO) with overall responsibility for the programme. ii. Day to day management of the programme and our key partners will be the

responsibility of an A2 Performance Manager in HST (0.5 FTE). iii. The technical lead for the programme will be an A1 Senior Health Adviser (0.3

FTE).iv. Support on additional technical aspects (e.g. M&E, health systems) will be

provided by an A2 statistics adviser and an A2 health adviser as required (0.1 FTE each).

v. Additional programme management support will be provided by B1/B2 (0.3 FTE each) members of the programme management hub within HST.

vi. Commercial support will also be provided via Human Development Department’s commercial adviser.

vii. Based on programme performance and the level of oversight available, the programme team may decide to add an additional component to the programme which would fund one or more regional DFID advisers to provide a greater level of DFID engagement with the programme and national governments within programme countries.

175. Together, the team will ensure rigorous forecasting, monitoring and accounting of expenditure using DFID financial management systems. The Programme Manager will profile the project budget and forecasts on a monthly basis with updated forecasts from the suppliers. Any budget changes or realignments of more than +/- 5% of the budget lines will require approval from the SRO.

176. The lead supplier(s) will assume the full responsibility for delivering the areas of work under their contract – intervention delivery, capacity building, and contribution to global public goods (lesson learning). They will sub-contract other partners with the correct specialist skills and geographic presence as needed, and they will set out the responsibilities and required standards. Overall the service delivery contractor/lead providers will:

i. Manage the relationship with DFID core management team to report on progress, emerging issues and opportunities;

ii. Ensure strong relationships with local actors including government at central and sub-national levels and beneficiaries;

iii. Effectively co-ordinate activities undertaken by sub-contracted partners/consortium members so there is coherence within and between programme countries; and

iv. Provide reports and access to information, systems and programme activities as required to allow the independent third party monitor to undertake the responsibilities outlined below.

53

177. DFID will commission an independent third party monitor to provide independent monitoring and quality assurance of programme delivery, documentation of lessons, robust tracking of results and programme evaluation. Findings from the independent monitor will be reported to DFID on a quarterly basis, and a separate logframe will be used to monitor this component. The third party monitor will:

i. Verify clinical standards through a regular inspection regime and unannounced visits;

ii. Verify results through sampling and spot checks of records and client interviews;

iii. Provide qualitative assessment of programme performance including alignment with and strengthening of health systems;

iv. Support DFID in assessing the scope of support to strengthening of health systems and cross-sector support.

v. Assess programme performance and make recommendations for improvement to suppliers and DFID, including providing supporting assessments for annual reviews;

vi. Quality assure the methodologies for supplementary surveys carried out by the lead suppliers;

vii. Identify strengths and weaknesses in national and programme data reporting systems, and support the strengthening of these systems, where necessary;

viii. Check on fraud and fiduciary risk through regular inspections, data verification and interviews with staff and clients;

ix. Assess data trends and emerging issues needing policy attention; andx. Evaluate programme performance.

Performance management178. Performance will be managed throughout the lifecycle of the programme:

this will be led by the A2 performance manager, but other team members will also contribute.

179. Monthly progress meetings will be held with the implementation supplier(s) to oversee overall progress. This will comprise the core DFID programme team, representatives from DFID country offices/regional programmes if appropriate, and the contractor/consortium. These meetings will review progress towards delivery of outputs, the budget forecast and actual expenditure, results achieved and risk mitigation. Separate meetings will also be held on at least a quarterly basis with the supplier responsible for independent monitoring and evaluation, to seek an external view of the progress of the programme, the results being achieved and the strength of national and supplier data reporting systems.

180. Quarterly cross-partner meetings (to include implementation suppliers and the independent monitoring and evaluation supplier) will also be held to discuss programme activities and progress, and to facilitate cross-programme learning.

54

181. The supplier(s) will provide quarterly progress reports and an annual report to DFID. DFID will undertake mandatory annual reviews which will measure progress against annual milestones, Key Performance Indicators and VfM metrics: reports from implementation suppliers and information provided by the monitoring and evaluation supplier will be used in this process. Annual reviews will also look at budget execution and all aspects of implementation arrangements. The annual review process will provide recommendations to enhance delivery and achievement of outcomes.

182. The logframe will be the main monitoring tool for the ASCEND programme. It will be revised following the commercial tender process, as the content of the logframe will be dependent on their proposed approach (including which specific activities will be prioritised in which countries). The suppliers will also be requested to develop individual country logframes (nested logframes) for each country that they are working in, to underpin the overall programme logframe.

183. Understanding of the political economy, risks and opportunities within each country will be essential. The implementation supplier(s) (or consortia of supplier(s)) will be required to develop a country engagement strategy within the overall programme: this will then be used to support the tracking of programme progress. The third party monitoring supplier will engage and seek advice from specialists based in those countries where DFID has a presence before and during implementation, and may commission separate analysis for any target countries where DFID does not have an office.

Risk management184. See Annex 4 for a summary of the main risks to the overall programme. This

will be further developed and maintained during the programme lifecycle. The successful suppliers will also be requested to develop and maintain detailed risk matrices, including mitigation strategies, for each country in which they will be operating prior to commencing activities.

185. The overall risk rating for the programme is judged as major, and after mitigation is judged as moderate. This risk rating reflects the complex nature of the programme, working across a range of challenging environments. Overall, based on the performance of our current NTD programmes and the level of ambition in this programme, there is a moderate risk that the programme will not be able to deliver against expectations within the programme timeframe. This mostly relates to the relatively short three year timescale for the programme (although the option to extend the programme has been included), and the possibility that the pace of activity scale-up in some countries will be slower than required.

Partnership principles186. Programme delivery within countries will be carried out in partnership with

national governments, and where possible will make use of national systems. The main suppliers will determine their specific activities within each programme

55

country in coordination with national governments and other donors supporting NTD control and elimination efforts, to ensure that national priorities are met whilst avoiding duplicative activities.

187. The independent monitoring and evaluation supplier will provide oversight of adherence to the partnership principles within programme countries. In case of any concerns, the DFID programme team will communicate directly with suppliers to ensure that programme activities remain aligned with national priorities as well as meeting DFID’s requirements.

Monitoring and evaluation188. Programme monitoring will be carried out predominantly by the main

implementing supplier(s), using (and strengthening, where appropriate) national data reporting systems. The independent monitoring and evaluation supplier will take a higher level oversight of the programme, monitoring quality, conducting spot-checks and independent verification, identifying strengths and weaknesses in the existing monitoring systems, and using both quantitative and qualitative approaches to assess programme performance. Where appropriate, they will provide recommendations for the implementation supplier(s) to support the further strengthening of monitoring systems and to supplement monitoring with surveys where this would help to provide disaggregated data on beneficiaries, or help to assess the success of the programme in achieving outcomes. More detailed monitoring arrangements will be determined during the development of ToR for contracts.

189. ASCEND’s monitoring approach will encompass routine programme monitoring data, national health information, independent intervention coverage surveys and impact assessments. ASCEND’s programme monitoring will prioritise the strengthening and utilisation of national reporting systems, and will not create parallel reporting streams. We will request that data provided should be disaggregated by gender, disability, age group, sub-national geography, socio-economic status and whether children are in schooling or not, where appropriate (e.g. independent coverage surveys and impact assessments should collect additional information on respondents to enable disaggregation by all of these characteristics). Monitoring data related to ASCEND will also feed (via national reporting systems) directly into national and international reporting (for example the NTD data portal, developed by ESPEN, the WHO PCT NTD databank and the WHO Global Health Observatory): covering, for example, data on the number of people requiring interventions against NTDs, coverage of NTD interventions and data from impact assessments.

190. An evaluation of the programme will be carried out during programme implementation: this is likely to encompass aspects of both process and performance. A process evaluation would aim to better understand the quality of programme implementation and the added benefit of an integrated approach over disease-specific approaches, covering all programme countries. This will build on evaluations of DFID’s current NTD programming, in particular of our

56

integrated NTD programme in Nigeria, and will specifically look at aspects listed in paragraph 191. A performance evaluation would examine how well the programme is performing within a sub-set of programme countries, including the contribution of the programme towards outcomes and impact. The exact evaluation approach will be clarified following programme approval with the assistance of an evaluability assessment (via the EQUALS service). This will look at the feasibility of conducting an evaluation, recommend what type of evaluation would be most appropriate to answer our priority questions, and help to clarify the exact approach to evaluation. The evaluability assessment will also assess independent monitoring plans to ensure the evaluation approach is linked to, and uses data from, programme monitoring.

191. The responsibility for the evaluation will lie with the independent monitoring, verification and evaluation supplier, with technical input and direction from the ASCEND programme team. We anticipate that the evaluation will focus on the following important evidence gaps in NTD programming, which will support global efforts towards the control and elimination of NTDs:

i. Added benefit of an integrated approach to NTD programming (including across both PCT and IDM diseases), covering national level coordination and planning, integrated delivery and cross-sectoral coordination and advocacy efforts (e.g. coordination between WASH and health sectors), and recommendations for how this can be strengthened;

ii. Cross-programme learning across programme countries, and between different technical aspects; and

iii. Contribution to building government ownership, embedding NTD activities within health systems, health system strengthening and the route taken towards sustainable domestic provision of NTD activities.

F. Appendices

Annex 1. Further information on the identified diseases

Lymphatic Filariasis62

192. The disease is caused by infection with threadlike worms called nematodes. Mosquitoes spread the infection when feeding, and the worms lodge in the human lymphatic system. Infection can cause a variety of health outcomes, including lymphedema (abnormal swelling) of the limbs, genital disease (such as swelling of the scrotum and penis) and recurrent acute attacks, which are extremely painful and are accompanied by fever. The vast majority of infected people do not show symptoms, but virtually all of them have some lymphatic damage and as many as 40% have kidney damage.

193. Currently, 856 million people in 52 countries are living in areas that require treatment to stop the spread of infection. An estimated 120 million people are infected with lymphatic filariasis; of these, almost 25 million men have genital

62 World Health Organization Factsheet. (2017). http://www.who.int/mediacentre/factsheets/fs102/en/

57

disease and almost 15 million, mostly women, have lymphedema or elephantiasis of the leg.

194. The physical manifestations caused by chronic LF can cause serious stigmatisation, with affected individuals unable to work. India loses $1bn a year, and 15% of an individual’s income is lost due to chronic LF in India63

Onchocerciasis64

195. Onchocerciasis, commonly known as river blindness, is caused by filarial worms that are transmitted from person to person by the bite of the black fly. These black flies breed in fast-flowing rivers and streams, mostly in remote villages located near fertile land where people rely on agriculture. Adult worms produce larvae (microfilariae) that move to the skin, eyes and other organs.

196. The death of microfilariae produces serious inflammatory reactions, resulting in skin and eye symptoms, including rashes, severe itching and skin lesions and irreversible blindness.

197. More than 99% of infected people live in 31 countries in sub-Saharan Africa. Of those infected with the disease, over 6.5 million suffer from severe itching or dermatitis and 270 000 are blind.

198. There has been a concerted effort to target onchocerciasis through the African Programme for Onchocerciasis Control (APOC) 1995-2015 and the Onchocerciasis Control Programme (OCP) prior to APOC.

Schistosomiasis65

199. Schistosomiasis, also known as bilharzia, is a disease caused by an infection that is acquired when people come into contact with fresh water infested with the larval forms of parasitic blood flukes, known as schistosomes. The microscopic adult worms live in the veins around the urinary tract and intestines. When the worms release eggs they often get trapped in the tissues and the body’s reaction to them can cause organ damage.

200. Several million people all over the world suffer from severe ill health due to schistosomiasis. Chronic schistosomiasis reduces the capacity of those infected to work and in some cases can result in death. Schistosomiasis affects almost 240 million people worldwide, and more than 700 million people live in endemic areas. The infection is prevalent in poor communities without access to safe drinking water and adequate sanitation.

Trachoma66

63 Ramaiah KD, Das PK, Michael E, Guyatt H (2000). The Economic Burden of Lymphatic Filariasis in India. Parasitology Today 16 (6); 251-253.64 World Health Organization Factsheet. (nd). http://www.who.int/mediacentre/factsheets/fs095/en/65 World Health Organization Factsheet. (2017). http://www.who.int/mediacentre/factsheets/fs115/en/66 World Health Organization Factsheet. (2017). http://www.who.int/mediacentre/factsheets/fs382/en/

58

201. Trachoma is the leading infectious cause of blindness worldwide. It is a disease of the eye caused by infection with the bacterium Chlamydia trachomatis. The infection is transmitted through contact with eye and nose discharge of infected people, particularly young children who harbour the principal reservoir of infection. It is also spread by flies which have been in contact with the eyes and noses of infected people. Over time, repeated eye infections cause scarring of the eyelid, causing the eyelashes to turn inwards and scratch the eyeball, eventually resulting in scarring of the cornea and blindness.

202. It is known to be a public health problem in 41 countries, and is responsible for the blindness or visual impairment of about 1.9 million people. In 2016, 190.2 million people lived in trachoma endemic areas and were at risk of trachoma blindness.

Visceral leishmaniasis67

203. Visceral leishmaniasis, also known as kala-azar, is fatal if left untreated in virtually all cases. It is caused by a parasite that is transmitted to humans by the bite of infected female sandflies. It can cause irregular bouts of fever, weight loss, enlargement of the spleen and liver, and anaemia.

204. It is highly endemic in the Indian subcontinent and in East Africa. An estimated 50,000 to 90,000 new cases of VL occur worldwide each year. In 2015, more than 90% of new cases reported to WHO occurred in 7 countries: Brazil, Ethiopia, India, Kenya, Somalia, South Sudan and Sudan. Asia is likely to meet the target of elimination of VL as a public health problem by 2020. Elimination is not possible in Africa with current tools.

67 World Health Organization Factsheet. (2017) http://www.who.int/mediacentre/factsheets/fs375/en/

59

Annex 2. Current focus of DFID’s NTD programmes, and potential activities for ASCEND scale-up (excluding support for Guinea Worm Eradication and the Pacific Islands, which are not covered in ASCEND). *Note that soil transmitted helminth MDA should be provided in integration with schistosomiasis MDA where appropriate.

Lym

phati

c Fi

laria

sis

Onc

hoce

rcia

sis

Schi

stos

omia

sis

Soil

tran

smitt

ed

helm

inth

s*

Trac

hom

a

Visc

eral

Le

ishm

ania

sis

Bangladesh x xEthiopia scale up scale up scale up scale upIndia xKenya scale up ++Malawi x c X Mozambique

c c C

Nepal x xSouth Sudan ++ ++ ++ scale upSudan ++ ++ + scale upTanzania x + c X Uganda h c X +Zambia c scale up scale up Burkina Faso

h

Chad + ++ scale up Cote d'Ivoire + c + (s) DRC scale up c scale up + Ghana h Guinea c + (s) Guinea Bissau

++ x ++ + (s)

Liberia c c Niger c Nigeria scale up c scale up scale up CAR + + + Benin + (s) Sierra Leone + (s) X Support country to reach and sustain elimination

++ Priority extension of activities to cover this NTD (limited other donor support)

+ Potential extension of activities to cover this NTD(s) Potential extension to cover surgeryscale up Scale-up current activities towards full geographical coverageC Ensure continuity of current programme activitiesH Coordinate possible hand-over of activities to other donor programmes Current DFID implementation activities

60

Annex 4. Overall programme risk matrix.

Risks Manifestation Probability Impact

Mitigation Residual risk

External ContextLack of partner government buy in / support

Lack of motivation and leadership within national Government may hinder progress

Possible Severe

Geographical spread and programme flexibility will ensure that programme can achieve results where possible. Suppliers engage with national ministries of health prior to commencing work to ensure adequate national support is in place. Coordination with other donors and international / regional bodies (e.g. ESPEN) to ensure government capacity and leadership is strengthened.

Major

External Context: Fragility and conflict

Partners may be unable to access some areas to deliver programme activities

Likely Severe

Geographical spread and programme flexibility will ensure that programme can achieve results where possible. Suppliers will develop detailed risk appraisals with mitigating actions for each country in which they will operate prior to commencing work. The duty of care will be applied. Suppliers will monitor the security situation within programme countries on an ongoing basis. Programme staff should be composed mainly of

Major

61

country nationals, rather than international staff.

External Context: Insufficient technical capacity

Services cannot be efficiently delivered via government systems; or supplier organisations reach saturation of available technical capacity

Likely Major

Activities may be delivered in coordination with national governments where capacity is weakest. Suppliers will also provide TA for national capacity development to ensure domestic capacity is sufficient to support programme activities, ensure sustainability and prevent capacity gaps in other areas (e.g. if a lot of human resources are being used to support the NTD activities). Consortia approach (or sub-contracting) for contracts may be used to facilitate engagement of additional technical capacity from a range of organisations.

Major

External Context: Disease outbreaks

Large-scale disease outbreaks may disrupt delivery of interventions, for example due to prioritisation of health worker deployment to deal with a disease outbreak, or via major disruption of health services Possible Major

Geographical spread and programme flexibility will ensure that programme can achieve results where possible. Suppliers will develop detailed risk appraisals with mitigating actions for each country in which they will operate prior to commencing work. Suppliers will monitor the security situation within programme countries on an ongoing basis.

Moderate

62

Delivery: Drug donation delays or shortfalls

Country requirements for donated pharmaceuticals are unable to be fulfilled in a timely manner

Possible Major

Suppliers will ensure coordination across countries and donors to prioritise drug requirements. Moderate

Delivery: Break down of relationship between lead supplier and other partners; or delivery partner faces crisis and unable to deliver.

Ineffective management of full delivery chain, jeopardising delivery of programme.

Unlikely Severe

Evaluation of tenders will assess the capacity of organisations to manage programme delivery. The programme implementation activities will be tendered in two separate contracts, sharing risk across a range of partners.

Moderate

Delivery: Timescale not sufficient to meet programme ambition

Scale-up of programme occurs at a pace insufficient to reach overall programme results within the timescale; rapid pace of scale-up may prioritise quantity of results over quality, undermining the overall quality of the programme.

Likely Severe

Evaluation of tenders will assess the capacity of organisations to manage programme delivery, including their in-country presence and ability to scale-up rapidly. Flexible approach will enable programme to adapt to scale-up challenges: programme management will also have oversight of balance between quantity and quality of results, ensuring programme flexibility is utilised to ensure an overall high quality programme. Contracts have the possibility for extension to ensure that sufficient scale-up in challenging environments can still be realised. Contracts also outline balance between quality of programming and quantity of results.

Severe

63

Delivery: Insufficient technical capacity within DFID to manage high value contracts

Insufficient oversight of programme activities, potential for inefficient programme delivery

Possible Major

Dedicated Performance Manager role, with additional strong programme management support will provide strong overall management of the contracts. The use of independent monitoring and evaluation will help to support overall oversight of programme activities, and provide greater confidence in programme results.

Moderate

Fiduciary risk: Lead suppliers or downstream partner(s) do not use DFID funding for the intended purposes

Poor financial reporting, allegations of fraud, loss, theft or damage of assets

Likely Major

Evaluation of tenders and due diligence assessment will examine the capacity of organisations and their systems and controls for managing and reporting on different aspects of the programme (e.g. financial management and reporting processes). Audited financial reports will be required on an annual basis. Independent monitoring supplier will conduct random spot-checks to ensure appropriate use of resources and to verify results reported by the programme.

Moderate

Financial riskMajor slippage of programme spending

Implications for overall DFID spending

Likely Major

Detailed monitoring of programme results, including independent verification, allows progress to be tracked regularly. Flexible approach enables

Moderate

64

coordination across programme countries, with the potential to negate slippages in one country based on increased activity in another country.

Operational/ reputational: Insufficient embedding of activities within national health systems

Vertical programme delivery creates parallel systems and weakens overall health system functioning, reducing programme sustainability

Possible Major

Terms of reference for implementation contracts will explicitly cover ways of working and requirements to integrate with, rather than duplicate, existing health system structures. Evaluation of tenders will assess suppliers’ capacity and track-record in working with national health systems. Independent monitoring and evaluation activities will have a particular focus on health systems strengthening aspects of the programme.

Major

Operational: Programme does not reach the priority beneficiaries

Low or inequitable coverage of interventions (e.g. low coverage of MDA in children who are not in school), which may jeopardise programme outcomes and impact

Possible Major

Independent monitoring and evaluation supplier will have a particular focus on equity of intervention coverage, to ensure that the programme is reaching the most marginalised and vulnerable population groups.

Moderate

Operational: Lack of programme sustainability

Lack of domestic resourcing for NTDs by partner governments; ongoing lack of national technical capacity

Likely Severe

Main implementing partners will be required to work closely with national governments, building local capacity, supporting the development of national NTD

Severe

65

strategies and advocating for domestic resources. Coordination with other donors supporting NTD control and elimination will ensure cross-donor messaging in terms of country ownership and sustainability of programming.

Operational: Sub-optimal planning of programme activities due to inaccurate data on needs

Programme activities missing geographical regions in need of intervention; programme activities occurring in areas with low burden of NTDs; requirements for new data collection activities prior to intervention to ensure activities are targeted appropriately.

Unlikely Severe

Programme planning will triangulate between available data sources, and will consider the quality of available data. Activities will be prioritised accordingly, with NTD surveys used to assess disease burden in areas where data is missing or of low quality.

Moderate

Operational/reputational: Level of funding displaces potential domestic (or other donor) support

Other funding sources (including domestic funding) may be discouraged from supporting planned NTD programmes, if ASCEND proposes activities within the same remit of other planned activities (this may occur where we are unaware of the plans of other funders, particularly domestic funding)

Possible Major

Suppliers will be required to coordinate activities with other donors and national Ministries of Health to ensure priority is given to areas which lack other support. Technical assistance may be provided to support domestic provision of NTD activities. Programme will also support advocacy to encourage increased domestic provision of NTD interventions.

Major

Operational/reputational: Over-reliance on supplier reporting systems for monitoring of programme results

Reputational risk if results’ reporting relies on implementing partner systems, without external verification; potential for

Likely Major

A separate independent monitoring, verification and evaluation supplier will be contracted to ensure robust and

Minor

66

insufficient accuracy in results reporting or insufficient oversight of programme achievements.

accurate results reporting.

67