The freeze on U.S. aid and the announced withdrawal of the U.S. from the WHO have significant repercussions on the global health system. How do these decisions specifically impact the fight against tuberculosis, particularly in Africa?

I want to make it clear from the outset that while we have ended a partnership, we remain deeply engaged and committed to the well-being of people with TB and to what is happening at the country level. The U.S. review of its aid policies, including those related to health, and its new focus on health assistance have significant implications, not only for global institutions in Geneva and other capitals, but especially at the national level.

The withdrawal of US funding from WHO is deeply worrying. However, the most serious impact will be felt at the national level, particularly for people with TB, HIV and malaria who have relied heavily on U.S. support for treatment and diagnostics. This withdrawal poses a significant challenge for countries that have relied directly on U.S. funding for the procurement of medicines and diagnostics. As a result, these countries may face severe shortages, creating a major gap in health services.

Beyond the issue of medical commodities, there is also a significant impact on health care providers and support systems. Many service providers, including those who diagnose and follow up on treatment, as well as civil society organizations and community groups that support people living with TB, HIV, and malaria, have been funded by U.S. aid. This funding cut has disrupted vital supply chains in several African countries where health workers relied on U.S. salaries to maintain their services.

In some cases, these disruptions have led to the complete cessation of diagnostic and treatment services in certain regions. While no entire country's TB program is known to have been completely crippled, there are parts of countries - sometimes significant parts - where the freeze in U.S. funding has essentially halted services.

As a result of this disruption, hard-won progress against these diseases is being rolled back. This setback threatens our ability to achieve the global goal of ending TB by 2030, as well as related Sustainable Development Goal (SDG) targets. Ensuring that these gaps are quickly addressed is critical to maintaining momentum in our fight against these epidemics.

The preparation for the eighth replenishment of the Global Fund comes at a critical time. What are STOPTB's priorities in this process, and how do you plan to mobilize resources given the general trend of declining international aid?

This is an important issue and it's crucial for the Global Fund to explain how it plans to mobilize resources and what its strategy is for engaging partners in this process.

We have expressed our full willingness and desire to support them in their efforts. But so far, we have not been involved in any way, and our support has not been requested.

My response is that I am waiting to see what the Global Fund team intends to do and where they may need our help. Once they identify specific areas where our support is needed, we will help in any way we can. For now, I have not received any specific requests for engagement, commitment, or action.

Development agencies from Western countries seem to be reducing their support for global health. As the Executive Director of STOPTB, how do you envision maintaining the effectiveness of tuberculosis programs in Africa despite this reduction in funding?

We must all recognize an important reality: the era of relying on donor funding to sustain the TB response, as well as other health responses in countries, is ending. This has become especially evident following the recent situation with the U.S. For many years, U.S. funding was the most significant and dependable source of financial support for TB programs—both directly and through contributions to the Global Fund, WHO, research institutions, and other organizations. The U.S. was the largest, most reliable, and most predictable donor. Now, that support is no longer available.

Countries are learning the hard way that they cannot rely on external donors to finance essential parts of their health programs. For some nations, like Nigeria and South Africa, this transition may be somewhat easier thanks to the proactive leadership of their impressive ministers of health. While there are other remarkable health leaders, these two countries stand out for their efforts to ensure that the funding gap left by the withdrawal of U.S. support is filled through domestic or alternative donor resources.

What is urgently needed now is strong national leadership and innovative thinking. Relying on external funding for critical elements such as drugs and diagnostics is no longer sustainable. Countries must find ways to secure these essential resources independently.

In addition to ensuring the availability of drugs and diagnostics, addressing workforce shortages is crucial. Since no country, particularly in Africa, has enough healthcare workers, empowering communities to play a greater role could help fill this gap. Rather than working within isolated disease-specific programs, integrating services can improve efficiency and outcomes.

Historically, donors often encouraged vertical programs that addressed individual diseases in isolation. However, many countries have been advocating for more integrated approaches. The current situation presents an opportunity to shift towards more comprehensive health delivery models at both national and sub-national levels. This shift must ultimately be a national decision led by ministers of health, aiming to create broader systems that effectively address various health concerns.

Focusing on TB remains critical. Countries must keep TB on their health agendas. However, integration is key—for instance, diagnostics for TB can often be combined with screening for other diseases. Similarly, campaigns for bed nets or other preventive measures can simultaneously promote TB and HIV prevention.

Empowering communities is essential. With primary healthcare systems already under-resourced, communities can become key contributors in supporting TB, HIV, malaria, and other health needs. By adopting such integrated approaches, countries can navigate these challenges effectively and sustainably.

In Africa, tuberculosis is a leading cause of mortality, and health systems are often fragile. What specific challenges do you face in managing tuberculosis due to these funding crises, and what innovative solutions might emerge in this context?

Effective TB control requires innovative approaches. As I mentioned in my previous response, we need to be realistic about the situation in several high-burden countries in Africa and other low-income regions. These countries have fragile health systems and will continue to need donor support. They are unlikely to be able to reorganize their health systems and secure resources on their own in the short time available. Continued support is therefore essential.

However, this support should not come exclusively from traditional donors. Countries from the same continent and from the Global South should also play an important role. There is great potential for transformative progress if countries in the Global South work together to reduce dependence on large producers. While this will not be easy and will take time, with strong will and regional cooperation, Africa could demonstrate how collective efforts can align priorities and drive progress.

Innovative approaches can further strengthen TB control. For example, TB is an airborne disease, and miniaturized diagnostic tools are now available that are portable and highly effective. Portable X-ray machines, enhanced with artificial intelligence, can analyze images without a doctor present and provide detailed insights. These tools can diagnose TB, but they can also detect other conditions. For example, they can show that a patient's lungs are clear, but his or her heart is enlarged (indicating cardiomegaly), or that there are potential problems with the spine or bones that warrant further investigation. This multipurpose use of diagnostic tools allows for the most efficient use of healthcare resources.

Similarly, integrating prevention strategies across multiple diseases is critical. For TB prevention in Africa, we already focus on people living with HIV, children, and people who have contact with TB patients. By working with families affected by TB, health care providers can provide broader prevention and intervention services during the same visit.

Many of these solutions have been discussed for years, but have yet to be widely implemented. This delay is not solely the fault of individual countries; donors have historically promoted a siloed, disease-specific approach through separate funding allocations. Going forward, we must adopt a more integrated approach, especially in light of the current financial environment and global challenges. Adopting innovative, collaborative strategies is essential to improve health outcomes and ensure sustainable progress in TB control.

Africa, with its unique challenges, remains at the heart of the fight against tuberculosis. What is your vision for the future of the fight against this disease in the region, especially in the face of uncertainties and reductions in international aid? What priority strategies should be implemented to strengthen local capacities?

I think we already have the policies and guidelines on how to deal with TB. I would be very unhappy if we reopened discussions about how to diagnose or treat TB, or what interventions are needed to end TB. What I think is needed, especially in the African region, is a very practical conversation.

What concerns me is that in order to have such a conversation, decision-makers need to be at the table - ministers in particular - but not in a setting where they feel obliged to sit on a panel, read a statement and leave. Instead, there should be concrete discussions, without written statements, involving ministers of health and technical experts.

These discussions should take place first at the national level, and then countries should come together regionally. For example, there was a recent meeting in Addis Ababa in early February - possibly around Valentine's Day. It was a good meeting, but it consisted largely of general statements and lacked concrete outcomes.

Concrete discussions could address issues such as We need better TB diagnosis. Current methods such as GeneXpert are expensive. There's an Indian alternative that's a little cheaper, but it's still expensive. Are there other options? If so, can any country help produce these alternatives for Africa? If not, how soon can such production take place? What do we do in the meantime? How do we secure financing for these solutions? Can African countries combine their procurement plans to leverage bulk purchasing and reduce costs?

In terms of drugs, what types are needed? How can we make them affordable? Similar conversations should take place about diagnostics, learning from past experiences. There should also be discussions about health insurance.

South Africa, for example, is making significant efforts to promote national health insurance. While this raises policy questions, particularly about private sector involvement, it's important to explore ways to align public and private sector efforts without compromising their distinct responsibilities.

In terms of financing, some propose the use of "sin taxes" and similar mechanisms. In the past, particularly in Africa where HIV/AIDS was a major concern, the response to HIV became a priority for prime ministers and presidents. Given the current impact on HIV, malaria and TB programs, this could serve as an entry point for high-level conversations about how to collectively manage communicable diseases at the national level.

Without changing the way business is done - or perhaps by changing the "business model" - we must emphasize country leadership. Countries must take responsibility for the health of their citizens. The hard lesson we've learned, both at the country level and as global institutions, is that over-reliance on a single donor, especially in health, leaves countries extremely vulnerable.

Governments need to set a threshold or red line - ensuring that essential medicines and diagnostics are funded from domestic resources. Beyond that, additional support can be sought. This difficult but necessary discussion needs to take place.

Is there anything else you would like to add?

Well, the only thing I would like to add is that my biggest concern is for our friends from the TB survivor communities, as well as those from HIV and malaria communities, and civil society groups — they will be the most impacted.

This is particularly concerning because, if countries are facing such a dramatic situation, especially in Africa, in terms of finding resources to even cover the costs of drugs and diagnostics, allocating funds to civil society and community networks will be extremely challenging.

I'm very worried because, at least in the TB response — and probably in others as well — we've built these community and civil society networks with tremendous effort. We've reached a stage where they are extremely strong, powerful, and visible. They still are, but I’m not sure they will be able to continue without sufficient funding.