A Comprehensive Sustainability Framework for a Neglected Tropical Disease Elimination Program: A Multiple Case Study of the Lymphatic Filariasis Elimination Program in Kenya Open Access
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Background: Elimination of a disease is the holy grail in global health. The pathology of several neglected tropical diseases (NTDs), and the treatments available make elimination feasible. Achieving elimination requires that NTD programs be sustainable; the disease the program must be able to confirm elimination and ensure that it does not return. Many countries are utilizing the World Health Organization (WHO) guidelines to design, implement, and plan for the sustainability of NTD elimination programs to attain this goal. These guidelines typically focus on technical factors, such as drug choice and the epidemiological indicators to confirm elimination. Comprehensive guidance that includes programmatic and contextual factors that can influence sustainability planning are lacking. This study aimed to develop a comprehensive sustainability framework to identify all factors influencing sustainability of NTD elimination programs. Methods: This research applied a two-step qualitative methodology process. The first step was a literature review of existing NTD and sustainability literature to develop a draft NTD sustainability framework. The literature review identified 29 NTD-related articles and 15 sustainability frameworks. These, along with the researcher’s existing professional expertise with NTDs, were analyzed and overlaid to produce a draft NTD sustainability framework. The second step in the methodology was to test this draft NTD sustainability framework using a multiple case study methodology. The Kenya National Program for Elimination of Lymphatic Filariasis was selected. Within this program three counties, each with an active lymphatic filariasis (LF) elimination program, were selected. The researcher developed an interview guide that was informed by the draft sustainability framework and subsequently conducted 24 semi-structured in-depth interviews with key informants. Three of the interviewees were from the malaria sector. Additional data sources included 11 program documents, and participant observations of four meetings. All interviews, documents and observations were selected to ensure either a global, regional, national, or county-level representation. Interviews were transcribed, and together with the documents and observation notes, entered into NVivo Pro 11 and coded. Within-case data analysis was conducted on all NTD-specific data sources to identify key themes. A cross-case data analysis was done to compare themes between NTD and malaria specific programs. Results: NTD elimination programs have three phases. In the first phase, the program distributes medicine and scales up to reach all targeted individuals. In the second phase, the program must maintain treatment for the target population for at least five years. In the third and final phase, assessments are conducted to confirm that the disease has been eliminated and surveillance systems are established. Three categories of factors were found to influence sustainability of NTD programs: (a) technical factors, or factors related to the actual intervention; (b) programmatic factors, those related to the implementation of the program; and (c) contextual factors, or factors related to the environment in which the program is being implemented. Contextual factors were found more relevant to NTD sustainability than programmatic factors. More specifically, reliable funding and a decentralized governance system were found to be most relevant to sustainability planning. Decentralization was a factor not previously identified as relevant to NTD sustainability. The programmatic factor that was found to have most influence on NTD sustainability was the integration of the lymphatic filariasis program into other existing health programs. The role of the community in sustainability planning, although not highly influential, was also identified as an important programmatic factor in this research.Conclusion: This research concluded that contextual factors were more relevant to sustainability than programmatic factors. Among contextual factors, reliable funding and governance systems were most relevant. More specifically, a decentralized governance system was found to have a significant influence on NTD sustainability research. Among programmatic factors, integration of aspects of the lymphatic filariasis program into the broader health system—and not just into the malaria program—was identified as a key factor influencing sustainability. A new finding within the programmatic factors was the role of the community. The community drug distributers and the beliefs held by the beneficiaries were found to influence sustainability. This research also found that the ideal time to plan for sustainability is before phase one actually starts—during the design phase. Based on these findings, this research presented an NTD specific Sustainability Framework and confirms that appropriate and sufficient consideration of contextual and programmatic factors is crucial to sustainability planning.