Author: Diana Weil is a Sr. Health Specialist and TB focal point at the World Bank. She is seconded from the World Health Organization's Stop TB Department. She trained in development studies and health policy analysis, and has 14 years of experience in TB control technical assistance and systems analysis. Diana has collaborated with many partners in the development of the Stop TB Partnership, its Global TB Drug Facility, and the scale up of efforts to meet the Millennium Development Goal # 6 - the reversal of communicable disease epidemics.
Partnership and results
March 24 is World TB Day and it will be commemorated in many countries affected by this global epidemic. The Indian Government will host the Second Stop TB Partners' Forum with Ministerial Delegations from the 22 countries with the greatest burdens of TB control. India and China alone carry over 40% of the global burden of TB. Some countries in Sub-Saharan African have seen a trebling of TB incidence rates and find up to 80% of TB patients are HIV-positive. The experience of the former Soviet Republics in the 1990s, as well as that of the U.S. more than a decade ago, show that formerly strong disease control systems can break down quickly and incidence and mortality can increase. Still, many countries are showing that the TB epidemic can be reversed, but often at too slow a pace.
The Forum in India will bring leaders in health and finance together with donors, technical agencies, academics, civil society organizations and businesses to discuss how far the global community has come towards TB control targets set for 2005: detection of 70% of infectious cases and 85% treatment success of detected cases. These targets provide a challenging, but feasible, interim benchmark in the move towards 2015 targets to more than halve mortality and prevalence and reverse TB incidence trends. The meeting will also take stock of progress in implementing the Global Plan to Stop TB which was launched in 2001. The Plan is pathfinding in that it demonstrated broad consensus among diverse stakeholders on various streams of action that need to proceed simultaneously, including strategy development, service delivery, social mobilization and research and development.
India has shown how rapidly DOTS services can be scaled up within existing infrastructure given: political support, increased financing, coherent standards, logistics management, monitoring, operational research, and adaptation of delivery schemes. More than 100,000 new patients are put on treatment each month in India today. Over 70% of districts are engaged. and treatment outcomes are published quarterly on a national website. Millions of patients have been treated successfully since the revised program was launched in 1997.
Yet, India also demonstrates that it is no simple task to reach and cure those ill -- a huge country, vast differences among communities and patients at risk, a complex cascade of government public health services and a dominant private sector in health service provision. Yet, surprising to many, the scale up of TB control has progressed. Public services have shown they can attract more patients with quality services, as well as initiate collaboration with private providers and NGOs. Still, maintaining and deepening the penetration of services may be as, or more challenging, as scaling up.
The World Bank's World Development Report 1993 provided a major boost for TB control efforts. It provided the first major publication of evidence of the relative cost-effectiveness of ambulatory short-course chemotherapy (6-8 months of treatment) for TB using national-level data from several Sub-Saharan African countries. That report also noted the recent launch of the same TB control approach in China. This approach moved beyond clinical orientations to packaging core public health functions & systems required for large-scale diagnosis and treatment programs. That approach is now known as DOTS (the Directly-observed Treatment, Short-course Strategy). By 2000, counties in 12 provinces of China were engaged. A TB prevalence survey demonstrated that where DOTS was launched, TB prevalence fell by 36% from 1990-2000, vs. only a 3% drop in areas not covered.
In the last ten years, operational research and cost-effectiveness analysis have continued to add tremendous value to those seeking guidance on what adaptations of the core elements of DOTS might be most appropriate to reach different populations and address distinct facets of the epidemic, given limited resources. This analysis has also been critical for the development of interventions against new threats, namely HIV-associated TB and multi-drug resistant TB.
Strengthening systems - within TB and beyond TB
This is a period of actions that are both "horizontal" or "vertical" in nature: Sector-wide Approaches in health, budgetary support, PRSPs as well as the Global Fund and major partnerships against disease threats. It is hard to think of a country, low or high income, that has done a good job in communicable disease control without intensive effort to ramp up the oversight and support functions in disease control, as well as strengthen service systems. Getting the vertical/horizontal balance right is no picnic, but working proactively in this direction is progress. In huge and decentralizing countries, such as the Philippines, Brazil and Pakistan, DOTS scale-up strategies are aided by explicit inclusion in sub-national health system development plans. In Sub-Saharan Africa, having defined financing for TB control within nationally-financed sector programs is a major step forward.
In 1999, WHO assembled an "ad hoc" group of experts to examine means to overcome major obstacles in TB control. The majority of recommendations of that group have been addressed. Responses include: important recent increases in global financing of TB control via traditional donors, increased national commitments in a few notable cases, and the creation of the Global Fund to Fight AIDs, TB and Malaria. It also includes responding to the dangerous problems of timely & efficient drug procurement and supply systems. With the creation of a Global TB Drug Facility, that has changed. Over 40 countries are using the mechanism already, and others are finding new assistance for drug supply strengthening.
"Scaling out" with new partners
Despite rapid improvement with DOTS of cure rates and program adoption, case detection has not speeded up sufficiently in most countries where DOTS has been adopted. We are still only half way to the 70% infectious case detection target. This last year, the Stop TB Partnership called on a second "ad hoc committee on the TB epidemic" to look at "what next" to reach more cases. Its conclusions are noted in the attached reading and a more complete backgrounder is included in the references. The recommendations are relatively general, but address far more health systems challenges than previous TB analyses. The report also builds on two years of increased dialogue and documentation on barriers to TB care of the poor. The Partners' Forum provides a time to devise immediate steps to act on these recommendations in 2004-2005.
One take-away message from this report is that we need to draw in more partners to continue to scale-up core DOTS efforts. Also, these partners can help reach out to new populations and patients. This signifies "scaling out" or diversifying delivery strategies and using different providers and new messengers, especially to serve those most likely to be missed. The report repeats the universal appeal to address the health workforce crisis. New incentives for public service staff recruitment and retention will benefit TB control and all the health MDGs. Numerous studies on community-based care and public program collaboration with private providers show that these strategies can improve efficiency as well as some already show coverage benefits. Countries that are broadening their DOTS delivery base, such as India, are doing very well.
More health systems need levers to formalize and facilitate local partnerships. Where pursued, poverty reduction strategies should help link system strengthening to broader development strategies. The committee recommended joining with those far more advanced in social mobilization and networking. It also addressed the still daunting agenda to better link TB and HIV control efforts without which TB will not be controlled in Africa. Increased global attention to HIV treatment, and its health systems underpinnings, represents a major new opportunity.
TB R&D may see a renaissance of sorts, due in large part to major contributions from the Gates Foundation and others. They are supporting innovative public-private partnerships that engage industry, quantify the demand for new products, and link up partners in high burden countries for future field trials. New diagnostics are needed to make TB detection faster and less messy. New drugs are needed to diminish the risks of drug resistance and to deliver a cure faster. New vaccines could open up the possibility to prevent disease given infection or perhaps prevent infection altogether.
Two major new studies provide new health delivery frameworks that mirror or complement these TB "scaling-out" strategies: The World Development Report 2004 and the Bank's new work on strategies to progress rapidly towards the health-related Millennium Development Goals (MDGs). Both highlight the tremendous obstacles that still stand in the way of reaching those most at risk, but also offer guidance on scaling up and "out", including examples from child health, disease control, nutrition and maternal health.
Decades with little global attention, resources or new tools at their command, led many teams dedicated to TB control to be isolated or to isolate themselves. That situation has radically shifted with more attention, more demands and far more potential to collaborate "beyond TB" today. When partners meet in India, they have a challenge in looking at a glass both half empty and half full, and using both vantage points to motivate a much-broadened partnership to do more.
A future viewpoint will address developments in economics and financing of TB control.