Are NTD Programs “Pro-Poor?” Insights from the Demographic and Health Surveys

Health equity is one of the core values – and goals – of global health. The World Health Organization (WHO) states that addressing health equity entails more than focusing on health determinants, as differences in health status infringe upon our ability to flourish and enjoy overall wellbeing.1 Nowhere is the claim of equity more important than in efforts to control and eliminate neglected tropical diseases (NTDs), which perpetuate a vicious cycle of infection and poverty.2-4  NTD programs target these diseases, and we consider NTD programs to be “pro-poor”.2 But are we actually reaching those who are most economically and socially disadvantaged?

A paper just published by Nathan Lo and colleagues, with co-authors from FACE, examined this question.5 Using data from demographic and health surveys (DHS) from 50 countries between 2003 and 2017, we assessed whether children in families with the lowest incomes were more likely to receive treatment for intestinal worm infections (i.e., in a “pro-poor” or equitable manner). In 90% of these countries, we found just the opposite – deworming was more common in children from wealthy families! Overall, 27.5% of children in the lowest wealth quintile received deworming medicine during the previous 6 months (as reported by mothers), compared to 38.3% in the highest wealth quintile. We also observed considerable geographic inequity within these countries.

Without evidence to document equitable coverage and access, we cannot assume that our NTD programs are actually reaching those at greatest risk. Consequently, our programs may not always be “pro-poor,” despite our best intentions. As an NTD community, we can do better. FACE is continuing to work with Dr. Lo and colleagues at the WHO, UC San Francisco, and Stanford University to explore opportunities for routine monitoring of equity in national deworming programs. Such monitoring is essential for ensuring that NTD control and elimination programs do all they can to achieve the goal of health equity.6



  1. World Health Organization. Published online June 8, 2011. Accessed October 8, 2019.
  2. Hotez P, Raff S, Fenwick A, Richards F, Molyneux DH. Recent progress in integrated neglected tropical disease control. Trends in Parasitology, 2007; 23(11): 511-514.
  3. Hotez P, Fenwick A, Savioli L, Molyneux D. Rescuing the bottom billion through control of neglected tropical diseases. Lancet 2009; 373(9674), 1570-1575.
  4. Bailey TC, Merritt MW, Tediosi F. Investing in justice: Ethics, evidence, and the eradication investment cases for lymphatic filariasis and onchocerciasis. Am J Public Health 2015; 105:629–636.
  5. Lo NC, Heft-Neal S, Coulibaly JT, Leonard L, Bendavid E, Addiss DG. State of deworming coverage and equity in low-income and middle-income countries using household health surveys: a spatiotemporal cross-sectional study. Lancet Global Health 2019; Published online September 23, 2019.
  6. Constitution of the World Health Organization”, American Journal of Public Health 36, no. 11 (Nov. 1, 1946): 1315-1323.

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