Global Leadership, Collaboration Aligned in the Fight Against Tuberculosis

Tuberculosis preys on the urban poor. ​​In the photo, the family of Rehmat Shek deals with the disease in Rafik Nagar slum in India. Global leaders in the fight against TB hope to end the epidemic by 2035. David Rochkind / WHO

With approval of the post-2015 global tuberculosis strategy by the World Health Assembly, the global community stands united as we work toward ambitious new targets for 2025 and 2035 to end the global TB epidemic. As we look to the future, it is important to evaluate the current global response to the epidemic so we may develop an effective and coordinated approach going forward. Major investments in TB by high-burden countries, the U.S. Government, the Global Fund (GF), the World Health Organization (WHO) and others have led to impressive progress and shown the potential for future impact. Promising new tools are now finally available, with others in the pipeline, and governments, donors and partners are allied around a new strategy with refocused resources.

Where are we succeeding?

TB kills three people a minute, is a security threat to the world, and puts health care personnel and poor and marginalized populations at risk around the globe. Yet, TB treatment is one of the best buys in global health – the disease is almost always curable (unless resistant to major drugs) with inexpensive medications and low-cost delivery approaches, and has been considered in various assessments as one of the most cost-effective public health interventions. New and cheaper models to diagnose and treat multidrug-resistant TB are being scaled up in many high-burden countries and the cost of second line drug treatment regimens to cure TB have decreased by 32 percent, thanks to efforts by the Global Drug Facility (GDF).

In the space of 17 years since the implementation of a new standard approach to control TB, 56 million people across the globe have been successfully diagnosed, treated and cared for, and WHO estimates that 22 million lives have been saved by using comprehensive and proven approaches to TB care[U1] , compared to what would have occurred if previous standards continued. These milestones reflect the ongoing commitment of governments and the global community to transform the fight against TB and work toward elimination of this major public health problem and global threat. Since 1990, TB deaths have declined by 45 percent and TB prevalence has declined by 37 percent globally. The world is now on track to meet the MDG target of 50 percent reduction in mortality by 2015.

Key ingredients to success and readiness to face challenges:

1.  Proven strategies, collaboration and leadership. Coordination and harmonization of efforts were the key to high effectiveness and success. The national programs take the lead in establishing policies aligned with international best practice and ensuring their implementation within primary care services. A clearly budgeted national strategic plan is fundamental to optimizing the use of resources and identifying gaps. Technical partners and financiers support the plan in a uniform manner. Supporting this model, the U.S. Government is the largest bilateral donor for TB and USAID serves as the lead agency for international TB control. Without this current systematic response, we will miss out on opportunities with endemic country partners and governments. Most importantly, progress in saving lives will be slowed.

 2.  Boots on the ground.  The U.S. bilateral program works directly with local governments and ministries of health to develop country-owned approaches and build national capacity so countries can successfully implement their TB care and treatment programs. This close collaboration with ministries of health has resulted in faster detection and treatment of TB; scaled-up prevention and treatment of multi-drug resistant TB (MDR-TB); expanded coverage for interventions for TB/HIV; and improvements in the health system. This approach also improves the strategic use of GF and domestic resources as well as the quality of TB programs.

3.  Resource Allocation and Realignment. The Global Fund and the United States both recently realigned their resources to further strengthen the next phase of TB response and focus where the need is greatest to sustain value and resolve outstanding challenges. Among the concerns faced by countries are ability to match external financing, coverage of services, and the MDR-TB and TB/HIV burdens. Since 2009, the U.S. Government has allocated almost $3.3 billion towards implementation of TB programs in high-burden countries with over $600 million in FY13 (see table below). The U.S. bilateral program, led by USAID, is focused on countries with the greatest TB burden and need. The current 27 USAID-supported countries carry almost 70 percent of the world’s annual TB cases, not including China. Through its new funding model, the GF has also redefined support for TB.  Twenty-four of the eligible countries account for 79 percent of the world’s annual TB cases (not including China) and have been allocated almost 60 percent of the total of TB funds. The GF has increased TB resources from 16 percent to 18 percent of all funds for 2014-2017.

*Assumed flat-line budget numbers based on the public FY12 figures.

**This represents 1/3 of the total TB allocations to countries in each year. It is the actually disbursement of TB funds for in this year. Note, the increase in 2013 is due to a large increase in distribution of funds for India.

 4.  Research and Innovation. After decades of using outdated tools that limited achievements, the TB community now has newer rapid molecular diagnostics, modernized approaches and new medicines already available for the treatment of MDR-TB. With the introduction of an innovative diagnostic test, Xpert, countries can implement faster and better detection of TB and drug resistant TB.  Further, the price buy-down of this new technology by the U.S. Government, the Bill & Melinda Gates Foundation and UNITAID has ensured rapid adoption and implementation of Xpert by over 100 low- and middle-income countries. In addition, new TB treatment regimens that use novel drugs and will bring renewed hope for TB patients are under study, including the expanded STREAM study (a 9 month MDR-TB regimen with a new drug) and the PaMZ study that is evaluating the efficacy, safety and tolerability of a treatment regimen for both drug susceptible and drug-resistant TB. Lastly, the work of the Global Drug Facility, supported by the U.S. Government, has ensured that quality, affordable second line drugs are available as countries scale-up MDR-TB treatment. USAID has collaborated with the Global Drug Facility and other partners to support over 40 manufacturers to improve the quality and availability of second-line drugs and make MDR-TB treatment more affordable.

A doctor visits a patient at the Group of TB Hospitals in Mumbai during the daily rounds. / David Rochkind, WHO

Future Strategic direction: 

The post-2015 Global TB Strategy approved at the World Health Assembly in May 2014 focuses on three pillars including: patient centered care and prevention; bold policies and supportive systems; and intensified research and innovation. The U.S. Government  is developing a new long-term strategy that will align with the recently approved WHO post-2015 strategy to Reach, Cure, and Prevent.  The U.S. Government commits to Reach every person with TB, Cure those in need of treatment and Prevent new infections and spread of the disease. To reach these goals, the different U.S. agencies involved in TB treatment and control will need to leverage their collective strengths and continue to collaborate through existing processes such as a common strategy and joint projects, defined roles, joint reporting and regular coordination.

Filling the Funding Gap – Despite recent wins and progress against TB, the current funding gap of $2 billion per year remains a fundamental challenge to face. The availability of this funding would result in major benefits for a huge number of people. As mentioned in the recent February Lancet commentary, domestic resources should continue to be mobilized for long-term and effective TB care and treatment. The international community must continue to bolster national efforts as well as support the development of global, common goods such as research, affordable and quality TB commodities, and support for innovations and new research. Global partners should help mobilize resources to fill gaps in TB care, including crowding in partner country financing and identifying new partners.

Building a multi-sectoral response – Tuberculosis provides a perfect example of how health security is intimately linked to social and economic development. Ending extreme poverty is critical to global progress on TB as are overarching efforts to achieve universal health coverage. A person’s health status is intimately entwined with underlying poverty, political and social stability, economic growth, food security, education and gender equality.  Development agencies such as USAID, along with U.N. agencies, NGOs and civil society, need to play their part in building cross-sectoral links. Together, we must work in harmony to reduce the social determinants of TB and to reach and serve the poorest and most vulnerable.

Research – The post-2015 goals will be difficult to achieve without a more robust research pipeline. This will require additional funding for research to ensure that the top priorities for innovation are a point-of-care diagnostic, better and shorter regimens and a new vaccine.  New tools for improving approaches at the country level will be necessary to optimize results.

The global fight against TB remains fragile, given resource constraints. Yet, promising new tools are now available, with others in the pipeline, and donors and partners are allied around a new strategy with refocused resources. We are now at a crossroads between ending the TB epidemic by 2035 and witnessing millions more TB deaths. But with continued consultation, coordination and leadership, we believe we will end the epidemic.

[1] USAID CBJ budget figures for each year

[2]  PEPFAR FY13 CBJ: http://www.pepfar.gov/documents/organization/222642.pdf

[3] GF website: http://portfolio.theglobalfund.org/en/Home/Index

[U1]Footnote that this is WHO data.