One of the major themes in the Executive Director’s Report is that multi-drug resistant TB is creating a real threat to global health security and now is the time for a rapid and urgent response on TB. The disease has become a public health crisis as more people die from drug-resistant TB than any other antimicrobial resistant agent. The Report of the Executive Director to the Global Fund Board meeting in Montreux on 16-17stated that if the global community is going to tackle antimicrobial resistance and global health security, it must tackle drug resistant TB. Aidspan recently published an article on ways in which the Fund could improve efforts in the fight against TB here.
Figures from the WHO show that TB is now the leading cause of death from an infectious agent, killing 5000 people a day. Investment in the fight against TB fall far short of the targets set in the Global Plan to End TB 2016-2020, the End TB Strategy milestones and the 2030 SDG target of ending TB.
TB often results from the inadequate care of people with drug-susceptible TB, resulting in the development of drug resistance, as well as ongoing person-to-person transmission. TB infection therefore becomes a vicious circle of transmission due to the fact that so many missed cases of drug-resistant TB occur. MDR TB is simply a symptom of not investing enough resources to prevent, find and treat people from a curable disease fast enough to make the necessary progress.
According to the report, among Global Fund eligible countries, India, Indonesia, Nigeria and Ukraine have the largest number of estimated cases of MDR-TB. The Eastern European region has been highly affected by MDR-TB. In fact, the region has some of the highest rates of drug-resistant TB in the world. In Belarus, for example, about half of individuals diagnosed with TB have the drug resistant form.
Tactics and tools
In order to more effectively fight TB and MDR TB, the Executive Director’s report presents some strategies the Fund intends to employ such as:
In the report the Fund identifies the need to use scientific advances to defeat tuberculosis in its ordinary and resistant forms:
New drugs: Bedaquiline and Delamanid–the development of Bedaquiline and Delamanid show great potential.
New regimens: The WHO recently endorsed a shorter treatment regimen for MDR-TB cases, including pediatric patients. This shorter treatment regimen is cheaper and has better treatment outcomes.
Lab tools: GeneXpert technology has significantly influenced he way the disease is diagnosed among drug resistant cases of tuberculosis and the Fund is investing heavily in expansion of this technology.
Expand testing for resistance to second line medications. This is important in helping identify patients with drug resistant TB who are eligible for short treatment regimens so they can be can put on quicker and more efficient treatment, saving more lives and resources.
The report states that the amount of MDR-TB funding facilitated by the Fund is growing, and has more than tripled over the last 6 years through reprogramming of existing grants. However, funding has fallen far short and more is needed. According to the Global Tuberculosis Report 2016, US$6.6 billion was available for TB care and prevention in low and middle-income countries in 2015, of which 84 percent was from domestic sources.
National TB programs in low-income countries continue to rely on international support for almost 90% of financing. Investments in low and middle-income countries are almost US$2 billion short of the US$8.3 billion needed in 2016 for the basic response package and far below the Global Plan’s budget to accelerate the response to end TB. It is critical for the Global Fund to support countries in order to strategically address their epidemics before transitioning out of the countries.
Focus on partnerships
The Fund is the minority investor in some high burden TB countries but has an opportunity to partner with them in different ways. The greatest burden of disease, in part due to population size, is in areas with more limited investment – 50% of the TB burden is in Brazil, Russia, India China and South Africa. In light of this, the Fund should consider innovative approaches to partnerships with these countries in order to play an even greater and more effective role in driving greater domestic investments and impact.
In its report, the Fund reiterates it must continue to invest strongly in community health systems in order to address issues of patients lost by inadequate health systems. Progress against the disease has been far too slow and calls for radical expansion. TB and MDR- TB will be key priorities for the Fund’s catalytic investments (for more on catalytic investments see the article on it in this issue here) over the 2017 – 2019 allocation period. TB remains one of the best ‘value for money’ interventions in global development. Every dollar spent on TB results in an economic benefit of US$43. TB treatment coverage is a proxy measure of Universal Health Coverage.
The Executive Director’s report states it is critically important to find the 4.3 million people with TB who remain “missing” – undetected and untreated or not reported to national programs - every year. These missing people with TB constitute a major global health challenge and an important reason for the slow decline in TB incidence. Partners continue to work to find the missing people using innovative tools and approaches such as Stop TB Partnership’s TB REACH initiative.
Reaching these missing people is a key priority for the Fund and its technical partners and has guided the investment priorities identified for catalytic funding, including:
- Systematic screening for active TB/Active case finding
- Engaging private sector health care providers to improve notification and treatment
- Accelerating investments to address TB-HIV co-infections
- Active case-finding among high-risk and under-served groups
- Strengthening country and regional capacity in DR-TB care delivery
- Building resilient and sustainable systems for health, essential for an effective and efficient response to drug-resistant TB
The Executive Director’s Report Board Document GF-B36-10, should be available shortly at www.theglobalfund.org/en/board/meetings/36.