NTD Program: Use of data and modelling to inform program decision making.

 • “A healthy and productive nation free from NTDs”, is the vision of the MOH – NTD program. NTDs, a diverse group of conditions of bacterial, viral, parasitic, fungal, and noncommunicable in origin. PC- NTDs; NTDs amenable by WASH and preventive chemotherapy and contribute to the highest burden and are targeted for control and elimination by 2027. CM – NTDs; managed at the health facilities and targeted for control.

• Morbidity for NTDs; detectable, measurable clinical consequences of infections and disease that adversely affect the health of individuals. o Measured in DALY’s – Disability Adjusted Life Years; This is a measurement of the gap healthy life lost, between an “ideal” healthy population and the reality caused by a specific disease in terms of premature mortality and disability in a particular society.

 Summary of Disease burden (detailed burden on the problem statement)

Estimating the burden of Neglected Tropical Diseases (NTDs) in Kenya poses a significant challenge due to weak surveillance structures and a resultant scarcity of data. Despite that, more than 25 million Kenyans are believed to be affected by at least one NTD, resulting in a loss of 3-5 million years due to disability and premature death1. In 2019, the economic impact of NTDs was substantial, with the estimated value of healthy life years lost reaching around $900 million2. Although death may not result from NTDs, their adverse effects on individuals’ productivity throughout their lives underscore the necessity of investments from both the global community and governments in controlling NTDs.

Service delivery gaps

• In NTDs context these are preventive chemotherapy/MDA, environmental and behavioural improvement, management (surgeries and inpatient treatment)

• MDAs/campaigns

With safe donated medicines, it costs approximately $1.00 to treat a child per year. However, after many years of supporting deworming, donor fatigue is evident and it’s imperative to accelerate progress to achieving elimination of these PC NTDs. Therefore, ensuring positive outcomes in each campaign round i.e.Targeted risk groups/populations are reached (no one is left behind) is vital in achieving elimination targets and timelines.

• Treatment and management

At the different levels of health care, there is a limitation in capacity for clinical/laboratory diagnosis and management of infections and associated morbidities due to a low index of suspicion among health workforce,Ex. of vaginal lesions due schistosomiasis, low awareness of the community to seek care and a preference for consulting traditional healers resulting in poor outcomes e.g. SBE, trachoma.

• Environmental and behavioural improvements.

Improvement in access to safe water and proper sanitation facilities – SDG 6 has been linked to better NTD outcomes particularly for PCs. However, national coverageon these indicators is still wanting; 59%have access to safewater and29%to sanitation facilities3. WASH department and NTD program sit under different directorates within MOH and weak coordination between these programs limits the positive synergy that WASH investments would have in driving down NTD burden.

 • 2023 focus: improving campaign planning and implementation decisions by access to information on MDA performance through the development and use of the NTD Integrated database (NTD IDB) to report and visualize performance at sub county level. This allowed the supervisors to monitor areas experiencing challenges and come up with solutions.

 • 2024 focus: In addition to the 2023 approach, focus will include generating evidence that the routine health system can be used for NTD surveillance for public health action. Linkages with CHAI programs will be vital in demonstrating this concept. Monitoring and evaluation of case management for trachoma and LF surgeries using the NTD IDB.

Supply chain gaps

• An overreliance on donations to treat and manage PC-NTDs

 • Last mile supply chain challenges for PC-NTDs have resulted in accountability issues in stock use reporting. Last year, according to WHO (donations come through them), Kenya had a balance of ~11M donated tabs of Albendazole unaccounted for and therefore the country’s 2024 request for medicines was blocked delaying MDAs for Q4 2023 for Schiso and STH. These campaign delays put the country at risk of not achieving elimination targets on time.

 • Weak inventory management for NTDs outside of KEMSA structures. For example, for Schistosomiasis and STHs, medicines (Praziquantel and mebendazole) upon arrival into the country are not stored at KEMSA. Or in the case of Trachoma (azithromax and tetracycline eye ointment), upon arrival into the country, distribution from KEMSA is done by partners. The same is observed for other commodities like kalaazar medicines which is a CM NTD

 • In Kenya and the larger East African region, effective treatment for SBE is generally scarce with most antivenoms proving to be ineffective and unavailable in most facilities (antivenoms are specific to regions). Kenya gets most of its antivenom from South Africa and India and this is distributed to health facilities.

 • High cost of medication for NTDs limits access to treatment and lifesaving medications. An example of rabies where the direct medical cost associated with a complete regime of PEP (post-exposure prophylaxis) is estimated at $85 per person2. For SBE, one polyvalent antivenom vial costs an average of $50 USD per vial, and many snake bite patients require upwards of 10+ vials. Poor households face difficulties paying fortheselifesaving medications. Shortages of thesemedications are also common, furtherincreasing the costs as victims are forced to travel to far flung centres to obtain treatment.

 • 2023 focus: Resolved the issue of drugs accountability. Developed a supply chain functionality within the NTD IDB to strengthen stock use and reporting at multiple levels. Supported reverse logistics of medicines after Schisto and STH MDA in compliance of supply chain guidelines.

 • 2024 focus: In addition to 2023 approach, we intend to with SBE actors (K-SRIC) to improve access to locally produced antivenom to meet the demand in the country. Strengthen the F&Q processes for NTDs to reduce

 Data & data use/measurement

Gaps

Data access is a major gap at both national and subanational levels. Data from MDAs, surveys, facility cases is reported and stored on different platforms and this fragmentation of NTD data and systems limits the opportunities for the NTD program to capitalize on multiple data streams to monitor trends and assess the impact of the interventions, and in this digital age, leverage the strengths of analytical solutions justifying the need for an robust NTD data system.

• Lack of robust data systems routinely reporting timely, complete, and quality data is a major challenge for NTDs. Reliance of point surveys to monitor health trends instead of continuous/routine data has a high likelihood of missing changes in health event trends like an upsurge of cases like on 20th November 2023, when an NTV news broadcast reported of an outbreak of bilharzia, “The Bleeding Village” in Tana River (a county endemic for Schisto), however monthly data reported on MOH 706B, actually showed that Tana River was reporting the highest cases from July!

• On MOH registers, some NTDs are either missing from the Health facility registers or incorrectly/inadequately captured. This deters the routine surveillance of key NTDs like Elephantiasis, masking the true burden of diseases.

• Given the observed challenges in the data collection and reporting systems, the data used for decision making is likely to have quality challenges negatively impacting use of data. Campaign data has multiple aggregation stages given the mostly paper-based nature of the reporting system from the CHP up to the Subcounty level, therefore it made sense to conduct a data quality assessment exercise to verify the coverage. This was done after Q1 MDAs conducted in Coast region from sampled sub counties and the findings highlighted huge differences in total number of people treated across the 2 data sources (register vs google sheets-digitization level of MDAs), an example of one ward in the sampled subcounty.

(Fig: Variance in the data reported from 2 data sources during campaigns).

This ward reported a coverage of 135% (reported data) while register data coverage was 142.6%. In addition to the discordance displayed, population denominators are a challenge especially in lower administrative levels (>100% coverages

2023: Work so far

Data collection and reporting:

• Developed an NTD Integrated database to serve as a repository and generate disease dashboards with robust data. In addition, MOH and Partners (LF and Trachoma

programs) have requested that newly developed NTD data collection forms for case management be included into IDB for reporting on surgeries done.

• Initiated engagements with HIS and NTD stakeholders to map existing and new NTD indicators and developed an integrated NTD reporting tool for inclusion in KHIS.

Data analysis

• Conducted a campaign data review for Q1 2023 at subnational level to assess their performance by risk groups and admin unit to help in course correcting during implementation

 Data use:

• To improve service delivery, areas that were identified as having achieved low coverage will be prioritized in the next cycle for MDA.

•2024 focus:

Engagement with Digital Health unit to Migrate the IDB into MoH servers to legitimize its government ownership status. Iintegrate the system with MoH platforms like echis that will be collecting and reporting data at the lowest level. Generate analytical outputs that explore different questions to inform decisions on implementation and evaluation of interventions. Champion routine review of data at different levels to inform public health actions

Under health financing

• Management morbidity for NTDs: There is need to cost NTD services (diagnosis, treatment and management) so that they can be included in the NHIF benefits package. The cost of treating patients affected by NTDs has generally not been well defined in the national health insurance package, with the cost of several components being procured outside the national supply chain system (e.g antivenom, drugs for VL). This is compounded by health facilities not being able to claim for services rendered while treating for NTDs due to a lack of accurate diagnosis for the particular disease.

• For LF, surgeries to correct hydroceles (type of scrotal swelling) are required for approximately 8,000 men across 6 Coastal counties as of 2022. Hydrocele surgeries are covered within the NHIF package. However, KDHS 2022 data shows that in rural areas, only 17.5% males had any health insurance, and we can estimate that approx. only 1,500 of those affected can access the surgeries at a lower cost. However, there’s need to verify who are the clients that require hydrocele management by county and their NHIF status.

• Despite a few counties including NTDs in their county development plans, the same is not replicated in the annual budgets submitted to county assemblies for ratification. This reduces the resources available for NTD prevention and control activities