What do we want from the High-Level Meeting on TB?
Article Number: 2
A critical meeting for the global TB community
On 22 September 2023, the United Nations will host a High-Level Meeting on Tuberculosis. In this article we look at the opportunity this meeting presents globally and for Africa in particular, why countries must ensure that they are represented at the highest level and what the TB community wants to get out of this meeting. We discuss the Political Declaration and look at how organizations like the African Union could play a significant role in leveraging this meeting to bring about concrete changes in TB programming that will help countries to achieve the 2030 targets.
On 22 September, Heads of State and Government and representatives of States and Governments will assemble at the United Nations in New York to reaffirm their commitment to end the tuberculosis (TB) epidemic by 2030, and review progress achieved in realizing the 2018 political declaration of the High-Level Meeting (HLM) of the General Assembly on the fight against TB.
The HLM on TB is a real opportunity both globally and especially for Africa
According to the World Health Organization (WHO) Global Tuberculosis Report 2022, TB is the second leading infectious killer after COVID-19 and the 13th leading cause of death worldwide. TB is also the leading killer of people with HIV (PLHIV) and drug-resistant TB (DR-TB) is responsible for one in three deaths related to antimicrobial resistance (AMR). And the stark reality is that TB in Africa kills more people than HIV and malaria combined. Accelerating TB elimination progress is crucial.
It is estimated that 10.6 million people became ill with TB in 2021 (according to the Global Tuberculosis Report 2022), an increase of 4.5% compared with 2020. There was also an estimated 1.6 million TB related deaths in 2021, up from 1.4 million in 2020.
In 2021, an estimated 10.6 million (95% confidence interval 9.9-11 million) people fell ill with TB worldwide, of which 6.0 million were men, 3.4 million were women and 1.2 million were children. PLHIV accounted for 6.7% of the total.
The TB incidence rate (new cases per 100,000 population per year) rose by 3.6% between 2020 and 2021, reversing declines of about 2% per year for most of the past two decades.
Globally, the estimated number of deaths from TB increased between 2019 and 2021, reversing years of decline between 2005 and 2019. In 2021, 1.6 million people died from TB, including 187,000 PLHIV.
Eight countries accounted for more than two thirds of the global total: India, Indonesia, China, the Philippines, Pakistan, Nigeria, Bangladesh and the Democratic Republic of the Congo.
The End TB Strategy post-2015 calls for countries to reduce TB deaths by 75% and cases by 50% by 2025 compared with the 2015 levels. To cross the 2025 milestone, the annual pace of reduction should reach 10% per year. The Stop TB Partnership’s The Global Plan to End TB 2023-2030 outlines the priority actions and estimated financial resources needed to end TB as a global health threat by 2030.
Between 2023 and 2030, the Global Plan calls for the mobilization of $249.98 billion, diversifying the sources of financing from domestic budgets of governments, external donors, development banks, social health insurance, philanthropy, the private sector, and innovative sources of financing. Of this, $157.2 billion is for TB prevention and care, $52.6 billion for vaccination once new vaccines are available, and an additional $40.18 billion to accelerate the development of new TB medicines, treatment regimens and diagnostics. The funding needs detailed in the Global Plan are essential to recapture lost progress due to COVID-19 and accelerate progress towards ending TB.
According to the WHO Africa Region, the region is recording about a 4% annual decline rate in TB cases. Yet despite the slowing pace towards the 2025 target, the African region has made progress in recent years. For example, TB deaths in the region fell by 26% between 2015 and 2021, with high-burden TB countries surpassing initial targets to lower TB cases. Yet in 2021, 40% of people falling ill with TB (about 1 million) did not access care. So, although the rate is double of that globally, the region risks missing major milestones and targets to end the disease if efforts are not rapidly scaled up.
The HLM on TB provides member countries with a real chance to commit to putting mechanisms in place at the national level that will support national TB programs in their efforts to meet those ambitious targets. Indeed, more and better funding is among the “key asks” of this HLM, given that in 2021 44% of the African national TB budgets ($595.5 million) were unfunded (Global TB Report, 2021). It is important therefore that countries ensure that they are represented at the highest level, especially from Africa and Asia – the regions most affected by TB.
Is the Political Declaration fit for purpose?
The draft Political Declaration (PD) of 8 August notes the signatories’ deep concern that some of the global targets set at the UN high-level meeting might not be reached; it outlines their alarm concerning the adverse impact of the COVID-19 pandemic on access to diagnosis and treatment for people affected by TB which has resulted in increased illness and deaths, and the persistent crisis of drug-resistant and multidrug-resistant TB (DR/MDR-TB).
Representatives want to “seize the opportunity that the mid-term review of progress on the Agenda for Sustainable Development presents to intensify leadership and action for a comprehensive and urgent response against the disease, its determinants and consequences at the national, regional and global levels, in order to scale-up investments for the TB response, research and innovation to reduce the number of people falling ill and dying and incurring catastrophic costs from TB, including by incorporating lessons learnt from the response to the COVID-19 pandemic, and achieve the targets agreed in the 2030 Agenda for Sustainable Development and in the End TB Strategy set at the UN high-level meeting”. This is followed by 83 paragraphs reaffirming commitment and noting continued and future actions to combat TB.
The Political Declaration is the result of a lengthy process of consultations and discussions with stakeholders, spearheaded by co-facilitators from the New York missions of Poland and Uzbekistan with the support of the Stop TB Partnership and WHO. Six months of negotiations have resulted in a set of aspirational asks but, some say, somewhat watered down from what stakeholders originally discussed. Several areas on the Political Declaration are weaker than the TB community would like, for example, concerning research and development, vaccines, vague language concerning funding commitments, and the failure to credit the past five years of strenuous efforts in advancing community, rights and gender concerns. There is also scant recognition of the communities’ role in holding their governments accountable for national TB responses.
However, stakeholders have been hard at work to strengthen the PD. Since the 8 August version, a new draft was issued on 25 August; the PD has now entered the next phase before approval, the three-day “silence procedure”. This will last until 2200 on 28 August. To help everyone easily see and understand changes between the 8 and 25 August versions, the TB 2023 HLM Affected Communities and Civil Society Coordination Hub has embedded all changes in its PD reading companion (see areas highlighted in yellow from page 16 onwards). A summary of changes against G77 reasons for breaking silence is also available here. Note that some minor language change requests from the G77 were secured (although not all), and one new paragraph (see para 63) was added. Overall, says the Hub, its analysis (see page 2 – 15) and key takeaways from the 8 August version still hold for this later version. Nonetheless, there has been some progress and it is hoped that no further amendments will be proposed, allowing the PD to make it through to 28 August without further changes.
The Declaration is required to have full consensus among UN member states in order for it to be formally adopted on 22 September. However, it has still not been finalized. Even if it could be a stronger statement of intent, it is nonetheless important to have it finalized by 22 September as a symbol of high-level political commitment to ending TB.
UN HLM “Key Asks” from stakeholders
While consensus-building for the PD is important, it is unfortunate but generally true that having to accommodate the views of multiple stakeholders usually results in weaker language. Accordingly, the Stop TB Partnership has published a set of six “Key Asks” for the HLM on TB. Funding is critically important but in itself is not enough without political support at the highest level; and these six Asks provide a simple framework for governments to commit to.
Key Ask 1
|Reach all people affected by tuberculosis (TB) with prevention, diagnosis, treatment, and care by implementing evidence-based and quality interventions and tools as per the latest international guidelines
Key Ask 2
|Ensure all national TB responses are equitable, inclusive, gender-sensitive, rights-based and people-centered
Key Ask 3
|Accelerate the research, development, roll-out, and access to new TB vaccines, diagnostics, drugs, and other essential new tools, including digital health technologies geared to the needs of the most neglected, key and vulnerable populations
Key Ask 4
|Invest the funds necessary to End TB
Key Ask 5
|Prioritize TB across systems for health:
Key Ask 6
|Ensure decisive and accountable global, regional and national leadership, including regular UN reporting and Review
We need to challenge countries to select someone to take the lead
Since the commitments of the 2018 HLM on TB have not been met for various reasons, including member states reaching less than half of their commitments to increase global TB funding to $13 billion per year, how can we ensure that the resolutions of the HLM on TB are leveraged for the best results? There needs to be a common position statement on post-HLM implementation, perhaps led by the African Union (AU), translating the commitments made into concrete action, and following this up with a post-HLM on TB resolution on the next steps including who will follow up, how this will be done and how progress will be monitored and measured.
Translating the 2023 Political Declaration’s global targets into national targets will be critical for monitoring progress, encouraging increased financial resources, and holding governments accountable, since it is challenging to assign accountability and responsibility for global targets. The Stop TB Partnership led the process to develop national level targets in 2018 (here). The Partnership is again leading this process for the 2023 Political Declaration.
There is a clear role for civil society watchdogs to hold their governments responsible for honouring the commitments to be made on 22 September. But unless we have these national targets, CSOs can’t really hold their governments accountable for global ones.