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Fourth Technical Advisory Group Meeting (TAG) to Stop TB in the Western Pacific Region, Manila, Philippines, 17-19 November 2003

December 31, 2003 World Health Organization

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Fourth Technical Advisory Group (TAG) Meeting - - -

Manlll, Philippines 17-19 November2003

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Fourth Technical Advisory Group (TAG) Meeting in the Western Pacific Region

to Stop TB

Manila, Philippines 17 - 19 November 2003

WORLD HEALTH ORGANIZATION Regional Office for the Western Pacific

© World Health Organization 2004 All rights reserved. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. The World Health Organization does not warrant that the information contained in this publication is complete and correct and shall not be liable for any damages incurred as a result of its use. Publications of the World Health Organization can be obtained from Marketing and Dissemination, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel: +41 22 791 2476; fax: +41 22 791 4857; email: bookorders@who.int). Requests for permission to reproduce WHO publications, in part or in whole, or to translate them – whether for sale or for noncommercial distribution – should be addressed to Publications, at the above address (fax: +41 22 791 4806; email: permissions@who.int). For WHO Western Pacific Regional Publications, request for permission to reproduce should be addressed to Publications Office, World Health Organization, Regional Office for the Western Pacific, P.O. Box 2932, 1000, Manila, Philippines, Fax. No. (632) 521-1036, email: publications@wpro.who.int

TABLE Summary

CONTENTS v 1 6 7 8 8 8 11 11 13 13 14 15 15 17 17 19 19 20 22 22 24 24 24 24 25 25 28 29 30 31 33 34

Conclusions and key recommendations of the TAG Conclusions and recommendations of the ICC 1. Introduction 1.1 Objectives 1.2 Organization 1.3 Opening ceremony 2. Proceedings 2.1 Global DOTS expansion and Stop TB partnership 2.2 Regional Stop TB Special Project Progress Report 2.2.1 Progress and status of the Stop TB Special Project 2.2.2 External thematic evaluation 2.2.3 Addressing special issues 2.2.4 Financial and human resources 2.3 Progress in countries with a high burden of tuberculosis 2.3.1 Current status of tuberculosis control 2.3.2 Issues and challenges 2.3.3 Responding to issues 2.4.1 Case finding 2.4.2 Programme evaluation 2.4.3 Human capacity building 2.5 Tuberculosis control in countries with an intermediate Burden 2.5.1 Progress of tuberculosis control 2.5.2 Applying DOTS 2.5.3 Technical issues 2.6 Tuberculosis/HIV co-infection 2.7 Public-private mix DOTS 2.8 Western Pacific Regional Office Strategic Plan (2004 – 2005) 2.9 Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) 2.10 Quality assurance 2.11 Tuberculosis and poverty 2.12 Regional Interagency Coordinating Committee Session 2.13 National tuberculosis programme managers’ meeting

2.4 Accelerating DOTS in countries with a high burden of tuberculosis 20

3. Conclusions and recommendations of the meeting 3.1 TAG conclusions and recommendations 3.2 Regional ICC conclusions and recommendations

37 37 47

Annex 1: Fourth Stop TB Technical Advisory Group Meeting for the Western Pacific Region - Timetable. Manila, Philippines, 17-19 November 2003 50 Annex 2: List of Technical Advisory Group Members, Participants, Consultants, Resource Persons, Representatives of Partner Agencies and secretariat 51 Annex 3: Opening Remarks of the Regional Director at the Fourth Technical Advisory Group (TAG) Meeting,17-19 November, 2003, Manila, Philippines Annex 4: Country presentations: Countries with a high burden of tuberculosis Annex 5: Country presentations: Countries with an intermediate burden of tuberculosis 59 61 79

LIST

OF ACRONYMS

ARV CCM CDC CIDA DFID DOTS EQA GDF GFATM ICC MDG MDR-TB NAP NCTB N-ICC NTP PhilCAT PhilHealth PhilTIPS PPMD PR SARS TAG TB TRP TWG UNAIDS USAID

Antiretroviral Country coordinating mechanism Centers for Disease Control and Prevention Canadian International Development Agency Department for International Development (United Kingdom) Directly observed therapy, short-course External quality assessment Global Drug Facility Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) Interagency Coordination Committee Millennium Development Goal Multidrug-resistant tuberculosis National AIDS programme National Center for Tuberculosis Control and Prevention (China) National Interagency Coordination Committee National tuberculosis control programme Philippine Coalition Against Tuberculosis Philippine Health Insurance Corporation Philippine Tuberculosis Initiatives for the Private Sector Public-private mix DOTS Principal Recipient Severe acute respiratory syndrome Technical Advisory Group Tuberculosis Technical Review Panel Technical Working Group Joint United Nations Programme on HIV/AIDS United States Agency for International Development

SUMMARY Following the declaration of a tuberculosis crisis in the Western Pacific Region in September 1999, the Regional Committee (WHO’s governing body in the Region) endorsed the establishment of a Special Project to Stop TB. As a first step, a Stop TB Technical Advisory Group (TAG) was formed, as a means of monitoring progress and status of the project. At its first meeting in February 2000, the TAG approved the five-year “Regional Strategic Plan to Stop TB in the Western Pacific”, with the main objective to halve the burden of tuberculosis in the Region by 2010. The seven countries with the highest burden of tuberculosis were the main focus of the second TAG meeting, which was convened in June 2001. The TAG members acknowledged the five-year national action plans of these countries as technically sound and recommended them for full implementation. At the third TAG meeting, in February 2002, progress of the action plans in the countries with a high burden of tuberculosis was followed up, with the focus extended to include the seven countries with an intermediate burden of tuberculosis. Main recommendations were to step up DOTS implementation in the countries with a high burden and to undertake a further analysis of factors to address the decline in tuberculosis stagnation rate in the countries with an intermediate burden. At the fourth TAG meeting, held in Manila, the Philippines from 17 to 19 November 2003, countries with a high burden of tuberculosis presented their two-year country acceleration plans, which were approved for implementation by the TAG. The Regional Interagency Coordination Committee (ICC) participated in the plenary sessions of the TAG meeting and conducted a parallel meeting on the second day. The objectives of the fourth TAG meeting were: 1. to review the progress and analyse the current status of DOTS expansion in the seven countries with a high burden of tuberculosis, with reference to their five-year action plans; 2. to review the current status of the control programme and further discuss the strategy for increased expansion of DOTS in countries with an intermediate burden; 3. to recommend steps, including two-year acceleration country plans, to achieve the target for the seven countries with a high burden; 4. to provide recommendations on the future direction of the regional Stop TB Special Project; and 5. to further strengthen the regional partnership and facilitate coordination among partners.

The meeting was attended by 72 participants and observers, including eight TAG members; 24 national tuberculosis programme (NTP) managers and staff from 15 countries in the Region; 22 representatives from international, governmental and nongovernmental organizations; two resource persons; and 16 WHO staff representing Headquarters, the Western Pacific Regional Office and its country offices.

CONCLUSIONS AND KEY RECOMMENDATIONS OF THE TAG (SEE SECTION 3.1 FOR FULL DETAILS) CONCLUSIONS TAG WHO,

AND RECOMMENDATIONS BY 1

COUNTRIES AND PARTNERS

TAG congratulates Mongolia for achieving the regional targets of 85% cure and 70% case detection through the application of high-quality and sustainable 100% DOTS coverage.

GLOBAL

TUBERCULOSIS SITUATION AND PARTNERSHIP RESPONSE

CONCLUSIONS: Due to the significant progress made in the Region, through the development of strong partnerships at regional and national levels, it is clearly possible for the Stop TB programme to reach the 2005 targets without delay. Severe acute respiratory syndrome (SARS) has had a positive impact on the TB programme, strengthening commitment for enhancing pubic health organization and surveillance systems. RECOMMENDATIONS FOR THE WESTERN PACIFIC REGIONAL OFFICE: 1. The Western Pacific Region should capitalize on the opportunities of the Millennium Development Goals (MDG) and SARS to strengthen the awareness and the role of tuberculosis control strategies in the horizontal organization of public health functions.

TUBERCULOSIS CONCLUSIONS:

AND POVERTY

The Western Pacific Regional Office is well positioned to identify and incorporate pro-poor initiatives into the DOTS strategy. This would make a substantial contribution towards accelerating DOTS coverage and reaching the case detection target.

RECOMMENDATIONS FOR THE WESTERN PACIFIC REGIONAL OFFICE: 1. The Western Pacific Regional Office should further develop and finalize the regional framework to promote pro-poor approaches in tuberculosis control.

WESTERN PACIFIC REGIONAL OFFICE STRATEGIC PLAN CONCLUSIONS: The TAG supports the Western Pacific Regional Office strategic plan as an overall framework within which to prioritize the specific issues of case detection and human resources for all countries with a high burden. Significant and prompt progress towards DOTS expansion and case detection in China is essential to achieve the objectives of the Stop TB Special Project. RECOMMENDATIONS FOR THE WESTERN PACIFIC REGIONAL OFFICE: 1. The Western Pacific Regional Office should recognize that while the existing plan represents a comprehensive approach to improving tuberculosis control in the Region, a stronger focus and priority on human resource capacity and accelerating DOTS expansion is essential over the next two years (2004–2005), if the 2005 targets are to be met. 2. The Western Pacific Regional Office should adopt a special approach in selected priority provinces in China, which will increase case detection by addressing the epidemiological burden in the country.

TWO-YEAR

ACTION PLAN IN THE SEVEN COUNTRIES WITH A HIGH

BURDEN OF TUBERCULOSIS

CONCLUSIONS: The two-year DOTS acceleration plans are well developed and have been acknowledged by the TAG as technically sound. The TAG notes with concern the slow progress made in DOTS expansion in China and Papua New Guinea. RECOMMENDATIONS FOR THE WESTERN PACIFIC REGIONAL OFFICE: 1. The Western Pacific Regional Office should urgently invite China to host a special TAG meeting in 2004 to review and address the acceleration of DOTS coverage and case detection in the country, with an emphasis on province-specific progress.

RECOMMENDATIONS FOR COUNTRIES: 1. Countries with a high burden of tuberculosis should urgently implement the two-year country acceleration plans.

CASE

DETECTION

CONCLUSIONS: The Western Pacific Regional Office’s analysis outlining the distribution and location of missing cases is useful and TAG considers the use of the “onion model” a practical conceptual framework. RECOMMENDATIONS FOR THE WESTERN PACIFIC REGIONAL OFFICE: 1. The Western Pacific Regional Office should assist countries to develop country-specific strategies to increase case finding. RECOMMENDATIONS FOR COUNTRIES: 1. Countries should analyse case detection using the “onion model” to determine the distribution and location of the missing cases.

HUMAN

RESOURCE CAPACITY DEVELOPMENT

CONCLUSIONS: The current level of human resource capacity is insufficient for the Region to achieve the targets set by its Special Project. RECOMMENDATIONS FOR THE WESTERN PACIFIC REGIONAL OFFICE: 1. The Western Pacific Regional Office should provide all the necessary technical assistance to support country efforts to strengthen human capacity, in particular in the three countries that have not yet reached the 100% DOTS coverage target (China, the Lao People’s Democratic Republic, Papua New Guinea). RECOMMENDATIONS FOR PARTNERS: 1. Partners should strengthen their support in the Western Pacific Region to significantly increase quantity and quality of human resources, in order to reach the 2005 targets.

PUBLIC-PRIVATE CONCLUSIONS:

MIX

DOTS

Scaling up public-private mix DOTS (PPMD) may have a significant impact on increasing case detection. RECOMMENDATIONS FOR THE WESTERN PACIFIC REGIONAL OFFICE: 1. The Western Pacific Regional Office should further develop and share the framework of PPMD with countries, as part of the strategy to increase DOTS expansion and case detection, including its application to hospital networks.

TUBERCULOSIS/HIV CONCLUSIONS: TAG commends the Western Pacific Regional Office on finalizing the regional framework, in line with the recommendation from the third TAG meeting. The “3 by 5” Initiative is an important opportunity to further strengthen tuberculosis control in the Region; the Western Pacific Regional Office has a strong collaborative approach with the regional HIV/AIDS programme. RECOMMENDATIONS FOR THE WESTERN PACIFIC REGIONAL OFFICE: 1. The Western Pacific Regional Office should encourage and support the collaborative activities of NTPs with national HIV/AIDS programmes and partners. RECOMMENDATIONS FOR COUNTRIES: 1. Countries should proactively approach and collaborate with national HIV/AIDS programmes and partnerships, while addressing joint strategy development for “3 by 5” implementation.

JOINT

PROGRAMME EVALUATION

CONCLUSIONS: Programme evaluations are an effective means of highlighting key constraints and challenges to further guide the direction of NTPs.

RECOMMENDATIONS FOR COUNTRIES: 1. Countries should conduct a joint national programme review, at least every two years, which includes the participation of all partners, including Global Fund representation.

GLOBAL FUND CONCLUSIONS: Technical Working Groups, which consist of technical agencies such as WHO to advise and guide the Principal Recipient (PR), are critical in providing technical assistance as required. RECOMMENDATIONS FOR THE WESTERN PACIFIC REGIONAL OFFICE: 1. The Western Pacific Regional Office should provide technical support to countries, in close collaboration with the Global Fund Secretariat and country coordination mechanisms.

COUNTRIES

WITH AN INTERMEDIATE BURDEN OF TUBERCULOSIS

CONCLUSIONS: It is important to adopt cohort analysis at every level of the health service (including the private sector), wherever tuberculosis patients are provided with care. RECOMMENDATIONS FOR COUNTRIES: 1. Countries should expand the use of tuberculosis case management using the Expanded Framework, including the application of DOT. 2. Countries should implement a comprehensive cohort analysis of tuberculosis cases.

QUALITY ASSURANCE CONCLUSIONS: External Quality Assessment (EQA) is critical to ensure high-quality passive diagnosis by sputum smear microscopy and increase the case detection rate.

RECOMMENDATIONS FOR THE WESTERN PACIFIC REGIONAL OFFICE: 1. The Western Pacific Regional Office should provide all the technical support required to countries to adopt and implement the Regional Guidelines on Quality Assurance.

CONCLUSIONS (SEE SECTION

AND RECOMMENDATIONS OF THE

ICC

3.2

FOR FULL DETAILS)

CONCLUSIONS: Close collaboration among tuberculosis partners at the country, regional and global levels is essential for meeting the 2005 targets. At the country level, all tuberculosis-related efforts should support the action plan of the NTP. RECOMMENDATIONS TO THE WESTERN PACIFIC REGIONAL OFFICE: 1. The Western Pacific Regional Office should facilitate information exchange among countries, regional partners, and global partners. RECOMMENDATIONS FOR COUNTRIES: • NTPs should strengthen collaboration among partners in order to assist in the implementation of their two-year national acceleration plans and so meet the 2005 targets.

1. INTRODUCTION Following the declaration of a tuberculosis crisis in the Western Pacific Region in September 1999, the Regional Committee (WHO’s governing body in the Region) endorsed the establishment of a Special Project to Stop TB. As a first step, a Stop TB Technical Advisory Group (TAG) was formed, as a means of monitoring progress and status of the project. At its first meeting in February 2000, the TAG approved the five-year “Regional Strategic Plan to Stop TB in the Western Pacific”, with the main objective to halve the burden of tuberculosis in the Region by 2010. The seven countries with the highest burden of tuberculosis were the main focus of the second TAG meeting, which was convened in June 2001. The TAG members acknowledged the five-year national action plans of these countries as technically sound and recommended them for full implementation. At the third TAG meeting, in February 2002, progress of the action plans in the countries with a high burden of tuberculosis was followed up, with the focus extended to include the seven countries with an intermediate burden of tuberculosis. Main recommendations were to step up DOTS implementation in the countries with a high burden and to undertake a further analysis of factors to address the decline in tuberculosis stagnation rate in the countries with an intermediate burden. At the fourth TAG meeting, held in Manila, the Philippines from 17 to 19 November 2003, countries with a high burden presented their two-year country acceleration plans, which the TAG determined to be technically sound. The Regional Interagency Coordination Committee (ICC) participated in the plenary sessions of the TAG meeting and conducted a parallel meeting on the second day. In preparation for the meeting, the Western Pacific Regional Office worked closely with countries with a high burden of tuberculosis (Cambodia, China, the Lao People’s Democratic Republic, Mongolia, Papua New Guinea, the Philippines and Viet Nam) to develop their twoyear national DOTS acceleration plans, based on the five-year plans which were endorsed at the second TAG meeting. Progress and key constraints towards meeting the 2005 regional targets were discussed, including DOTS expansion, the case detection rate and human capacitybuilding. For the seven countries with an intermediate burden of tuberculosis (Brunei Darussalam, Hong Kong [China], Japan, the Republic of Korea, Macao [China], Malaysia and Singapore), the technical discussions during the meeting focused on the importance of cohort analysis, the standardization of short-course chemotherapy treatment and enhanced information systems to improve the efficiency of the reporting system. In addition, the TAG considered the Western Pacific Regional Office’s achievements and future plans in the context of an appropriate response to country needs. Through the Regional ICC session, regional and national partnerships for DOTS expansion were further strengthened.

1.1 OBJECTIVES The objectives of the fourth TAG meeting were: 1. to review the progress and analyse the current status of DOTS expansion in the seven countries with a high burden of tuberculosis, with reference to their five-year action plans; 2. to review the current status of control programme and further discuss the strategy for increased expansion of DOTS in countries with an intermediate burden; 3. to recommend steps, including two-year acceleration country plans, to achieve the target for the seven countries with a high burden; 4. to provide recommendations on the future direction of the regional Stop TB Special Project; and 5. to further strengthen the regional partnership and facilitate coordination among partners.

1.2 ORGANIZATION The meeting was attended by 72 participants and observers, including eight TAG members; 24 NTP managers and staff from 15 countries in the Region; 22 representatives from international, governmental and nongovernmental organizations; two resource persons and 16 WHO staff representing Headquarters, the Western Pacific Regional Office and its country offices. Annex 1 shows the timetable of the meeting and Annex 2 contains the list of participants.

1.3 OPENING

CEREMONY

Dr Richard Nesbit, Director of Programme Management for the Western Pacific Regional Office, on behalf of Dr Shigeru Omi, WHO Regional Director for the Western Pacific, officially opened the Fourth Technical Advisory Group Meeting (TAG) to Stop TB in the Western Pacific Region. In order to reach the 2010 goal of reducing the tuberculosis burden by half from 1999 levels, the Stop TB Special Project has committed itself to achieving a set of intermediate targets by 2005, including regionwide DOTS coverage. Dr Nesbit congratulated two countries with a high burden of tuberculosis, the Philippines and Viet Nam, for their outstanding progress towards reaching these targets. Dr Nesbit expressed WHO’s appreciation for continued support from Stop TB partners, leading to a dramatic reduction in the funding gap, from 40% in 2001, to the current level of 10%. With now only two years left to reach the 2005 targets, he stressed that the remaining challenge lies with countries to expand the DOTS strategy, through the effective and timely implementation of their two-year national acceleration plans.

He explained that this strategy would lead, in turn, to increasing the case detection rate, which currently falls far below the 70% target. Dr Nesbit requested that the TAG also give due attention to countries with an intermediate burden of tuberculosis and provide guidance on how to improve the implementation and monitoring of their tuberculosis control activities. Dr Nesbit concluded by acknowledging the major commitment made by TAG members, as well as all partners, towards fighting the tuberculosis problem in the Western Pacific Region. The following is a list of TAG members, indicating office-bearers appointed for the meeting (for full details, see Annex 2: List of participants): Dr Jaap Broekmans (Vice-Chairperson) Dr Donald Enarson Dr Michael Iademarco (Rapporteur) Dr Sang Jae Kim Dr Toru Mori (Chairperson) Prof Ian Riley Dr Alberto G. Romualdez Jr. (Vice-Chairperson) Dr Mitsuhiro Ushio

2. PROCEEDINGS 2.1 GLOBAL DOTS EXPANSION AND

STOP TB

PARTNERSHIP

Dr Léopold Blanc, Medical Officer in Tuberculosis Strategy and Operations, WHO Headquarters, provided an overview of the global tuberculosis situation, focusing in particular on progress of tuberculosis control in the Western Pacific Region. Dr Marcos Espinal, Executive Secretary for the Stop TB Partnership, WHO Headquarters, presented the Stop TB partnership response to the global tuberculosis problem. Dr Blanc presented the regional tuberculosis status in comparison to the global situation. Globally, there are more than eight million new tuberculosis cases, of which around half are smear-positive. Due to the prevalence of HIV, the number of deaths related to TB/HIV has increased to around two million. There has been a rise in tuberculosis cases over the 1995–2000 period, largely due to an improvement in reporting standards. Tuberculosis cases have dramatically increased in Africa, a high HIV-prevalent continent. In the Western Pacific Region, there has been a small rise in the number of tuberculosis cases notified over the last five years, but generally the rate has remained relatively stable. To understand the rationale behind this phenomenon, further epidemiological analysis is required. Overall, the Region is very well placed; rates are low, in terms of deaths, failure cases and unknown outcomes. Through the development of strong partnerships at regional and national levels, national tuberculosis programmes are functioning well, as indicated by the increase in rates of both DOTS detection and overall case detection. Although there remain a large proportion of cases not detected under DOTS programmes, the Western Pacific Region fares well compared to other Regions. The prevalence survey in China has proven a very effective tool in pointing out where the “missing cases” lie. However, it should be noted that despite this, China, which represents over half the Region’s tuberculosis burden, still lags far behind the case detection target. This may impede the Region’s progress towards achieving the 2005 targets. Dr Blanc stressed that the major challenges faced by the Western Pacific Region are how to increase DOTS expansion and case detection. Various causes lie behind these constraints: • • • • poor health care infrastructure/systems reform financial barriers weak laboratory services and networks lack of involvement of private sector

• • •

health “workforce crisis” weak political commitment increase of TB/HIV co-infection

The “3 by 5” Initiative was launched by WHO, in collaboration with the Joint United Nations Programme on HIV/AIDS (UNAIDS), two weeks after the TAG meeting. This is a call for NTPs to improve joint TB/HIV activities, including better care for people living with HIV/AIDS and tuberculosis patients, in order to contribute to the goal of tuberculosis prevention. NTPs should support this cause by drawing on the experience of the tuberculosis community, who are familiar with the delivery of long-term treatment, including daily supervision, through their experiences in implementing the DOTS strategy. The second ad hoc committee on the tuberculosis epidemic in Montreux in September 2003 revisited recommendations made at the first ad hoc committee in 1989. The issue now is how to improve tuberculosis control programmes. The key elements to accelerate tuberculosis control globally are: • • • • • proper management, engaging partners at all levels, strengthening public-private collaboration, mobilizing the community to engage in tuberculosis care, and improving health education.

The presentation on the Stop TB Partnership described the remarkable progress that has been made in the short time since it was established three years ago. A notable achievement is the Global Drug Facility (GDF), which has committed free drugs for over 2.5 million patients. A recent milestone for the Stop TB Coordinating Board is the establishment of a Memorandum of Understanding with the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM), to improve the use of mechanisms such as the GDF. In a recent Stop TB Evaluation, conducted by the Institute of Health and Social Development in the United Kingdom, it was recognized that the Partnership has made significant achievements and “adds value”. A key challenge is to work towards the 2005 targets and beyond. In the discussions that followed the presentations, TAG member and Vice-Chairperson, Dr Jaap Broekmans, observed that the Millennium Development Goal (MDG) set for tuberculosis, i.e. “to have halted by 2015, and begun to reverse the incidence of tuberculosis”, marks an unprecedented opportunity to anchor overall public health activities in the higher domain of political commitment. He noted that the national

level should be placed within this frame of global health, so that national plans may also have access to MDGs. Furthermore, Dr Broekmans remarked that the severe acute respiratory syndrome (SARS) epidemic revealed certain weaknesses of public health systems in developing and industrialized countries. As a result, this led to strengthening leadership in governments and improving quality delivery of infection control services. The TAG recommended that NTPs utilize this key opportunity to build on huge reinvestment in the public health sector.

2.2 REGIONAL STOP TB SPECIAL PROJECT PROGRESS REPORT Dr Dongil Ahn, Regional Adviser for the Stop TB Unit, WHO Western Pacific Regional Office, and Responsible Officer for this TAG meeting, presented the progress of the Stop TB Special Project, referring specifically to progress on recommendations from the third TAG meeting. Most recommendations have either been or are being implemented. The main issues and challenges that need to be addressed in the next two years, in order to reach the 2005 targets, formed the second part of Dr Ahn’s presentation. 2.2.1 PROGRESS AND STATUS OF THE STOP TB SPECIAL PROJECT TUBERCULOSIS CONTROL TARGETS

Dr Ahn explained the different sets of targets in place for tuberculosis control. The global Stop TB targets are: to achieve a 70% case detection rate and an 85% cure rate by 2005. Regional targets, endorsed by the Regional Committee in 1999, consist of three process targets and one impact target. The three process targets include reaching the two global targets, as well as attaining 100% DOTS coverage by 2005. The impact target, endorsed at the first TAG meeting in 2000, is to achieve a 50% reduction of prevalence and mortality by 2010. Another target, which has been set by the Millennium Development Goals, is to have halted and begun to reverse the incidence of tuberculosis by 2015. COUNTRIES WITH A HIGH BURDEN OF TUBERCULOSIS

The cure rate already exceeds the 85% target. For DOTS coverage, 65% of the population had access to DOTS in 2001, which increased by over 10%, to reach 77% in 2002. The case detection rate remains the main challenge, with the current rate at 44%, falling well short of the 70% target rate. Dr Ahn mentioned that the reason why more than 20% of the population still has no access to DOTS is largely attributable to

China, where DOTS coverage has remained less than 70% since 1996. He also highlighted the fact that the case detection rate in DOTS areas (53%) is much higher than that in non-DOTS areas (28%), as a justification for the rapid expansion of DOTS (see Figure 1). Figure 1: Progress on DOTS implementation (2001-2002) Indicators Population accessible DOTS (among total population) DOTS enrolment rate (among detected cases) Case detection rate (among estimated cases) Cure rate in DOTS areas 2001 65% 2002 77% (Target: 100%) 84% (Target: 100%) 44% (Target: 100%) >85% (Target: 85%)

78% 41% >85%

COUNTRIES

WITH AN INTERMEDIATE BURDEN OF TUBERCULOSIS

Of the seven countries with an intermediate burden of tuberculosis, five have achieved 100% DOTS coverage and six have attained a 70% case detection rate. The treatment success rate has reached 78%. The main challenges faced by these countries are how to apply the definition of DOTS in a flexible manner and how to ensure good treatment outcomes, by improving treatment results through cohort analysis and enhanced information systems. 2.2.2 EXTERNAL THEMATIC EVALUATION As part of the response to a request from WHO’s Executive Board to the Director-General, all Regions of WHO are required to undertake a thematic evaluation each biennium, as a means of assessing how effectively WHO works with its Member States. In line with a greater global emphasis on programmatic evaluation, and because of its public health importance, the Regional Director selected the Stop TB Special Project to be evaluated by an independent team. The external evaluation of the Special Project was led by four experts in tuberculosis or public health. One of the key recommendations of the evaluation team was that the Western Pacific Regional Office continues its technical support to countries in order to reach the 2005 targets, through increased collaboration with partners, including the Global Fund.

2.2.3 ADDRESSING SPECIAL ISSUES TB/HIV CO-INFECTION

In line with the recommendation from the third TAG Meeting, the Regional Framework on surveillance, prevention and control of TB/HIV in the Western Pacific has been finalized. Pilot TB/HIV activities are ongoing in Cambodia, supported by Centers for Disease Control and Prevention (CDC), United States Agency for International Development (USAID) and WHO. Four countries have been included in the “3 by 5” Initiative, which will be an important opportunity for the national tuberculosis and HIV/AIDS programmes to identify areas of collaboration. PUBLIC-PRIVATE MIX-DOTS (PPMD)

The outline of a national strategy for large-scale implementation of PPMD in the Philippines has been developed in collaboration with Department of Health Philippines; GFATM; the Philippine Coalition Against Tuberculosis (PHILCAT); the Philippine Health Insurance Corporation (PhilHealth), the national insurance system; Philippine Tuberculosis Initiatives for the Private Sector (Philippine TIPS), a USAIDassisted project; and WHO. Regional Guidelines on PPMD are being developed, based on the experiences in the Philippines. MULTIDRUG RESISTANT

(MDR)-TB

AND

DOTS-PLUS

Drug resistance surveillance is being expanded in China and the Philippines. WHO Western Pacific Regional Office is providing technical input for a DOTS-plus pilot project in the Makati Medical Center, Manila, the Philippines, which has succeeded in receiving support from the Global Fund for second-line anti-tuberculosis drugs. 2.2.4 FINANCIAL AND HUMAN RESOURCES FINANCIAL RESOURCES

The funding shortfall for the 2001–2005 period in the seven countries with a high burden of tuberculosis has been dramatically reduced from 40% in 2001 to approximately 10% in early 2003 (see Figure 2). This is largely attributable to commitments by major partners in the Region, including the joint loan of US$ 104 million to China from the World Bank and the Department for International Development of the United Kingdom (DFID).

Figure 2: Reduced funding gap in countries with a high burden of tuberculosis (Total requirement US$ 665 M)

Loan 0.2%

3.8% External Assistance

Loan 16%

External Assistance 17%

56% National Budget

40% Gap

57% National Budget

10% Gap

2001 Due to World Bank, DIFD, GFATM, etc.

2003

Support from a new partner, GFATM, has also been critical in reducing the funding gap. Six countries with a high burden of tuberculosis submitted proposals to GFTAM. All of them secured financial support. In addition, an intercountry proposal submitted by 10 Pacific island countries was also approved. This brings the total commitment by the Global Fund for tuberculosis control in the Region in 2003–2004 to US$ 37.7 million. HUMAN RESOURCES

The most crucial challenge for the Special Project now lies in strengthening human capacity-building, particularly in China, the Lao People’s Democratic Republic and Papua New Guinea, which are still expanding DOTS. Although the number of country posts has significantly increased since the third TAG meeting was convened in February 2002, additional resources are still required (see Figure 3). Many activities focusing on human capacity-building were cancelled during the SARS outbreak, particularly in China, where monitoring and supervisory visits were frozen at both central and provincial levels. However, the positive impact of SARS has subsequently been felt in China, particularly through the increased support for the national surveillance system. During the discussion, TAG member Professor Ian Riley, highlighted the importance of improving the health structures and functionality of peripheral health services, as part of the solution to the issue of human capacity-building. The Stop TB Unit agreed and responded that a regional TB and Poverty Framework will be developed to address the issue of improving accessibility to tuberculosis control services for poor and marginalized groups living in remote areas.

Figure 3. Capacity-building: WHO

• Currently 12 staff/posts including 7 at country level - 2 China - 1 Cambodia - 1 Viet Nam (Subregional) - 1 Philippines - 1 Papua New Guinea - 1 Pacific • Total requirement: 7 RO + 9 CO = 16 (esp GFATM)

7 6 5 4 3 2 1 0 -1990 2000 2001 2002 2003

Regional Office (RO) Country Office (CO)

2.3 PROGRESS

IN COUNTRIES WITH A HIGH BURDEN OF

TUBERCULOSIS

WHO Western Pacific Regional Office has worked closely with the seven countries with a high burden of tuberculosis in the Region (Cambodia, China, the Lao People’s Democratic Republic, Mongolia, Papua New Guinea, the Philippines and Viet Nam) to develop two-year national action plans based on the five-year Stop TB plans endorsed at the Beijing TAG meeting held in 2001. These plans aim to facilitate regionwide access to DOTS by 2005. 2.3.1 CURRENT STATUS OF TUBERCULOSIS CONTROL DOTS coverage is over 75% in all countries except Papua New Guinea. Only two countries (Mongolia and Viet Nam) have reached the 70% case detection rate. Low case detection is a particular concern in China (34%), the Lao People’s Democratic Republic (48%) and Papua New Guinea (16%). Each of the seven countries presented the main components of their two-year national acceleration plans, focusing on progress and key issues. Cambodia: Eighty-five per cent of the health centres are covered by DOTS and partners are providing regular support, with the aim to implement DOTS in the remaining health centres by 2005. This is reflected in the increase in the tuberculosis case detection rate, from 45% in 2001 to 52% in 2002. In order to address the growing problem of TB/HIV, joint pilot projects have been set up in four provinces. The national ICC (N-ICC) has been active in mobilizing resources and addressing emerging issues including those related to quality assurance

(QA) in the laboratory network, human resources development and uninterrupted supply of anti-tuberculosis drugs. The issue of weak managerial capacity persists at central and provincial levels and is being targeted in the action plan. China: Implementation of the DOTS strategy is expanding in China, supported by various new tuberculosis projects and coordinated by the Ministry of Health, in collaboration with WHO. The new National Center for Tuberculosis Control and Prevention (NCTB), established within the China CDC, has increased its number of human resources. The main priority is now to strengthen its capacity through recruiting experienced staff. Drug resistance surveillance studies were expanded to four additional provinces in 2003. A joint programme review was conducted in November 2003, following this TAG meeting. Due to the recent SARS outbreak, a dramatic change was observed in political commitment to fight tuberculosis, which is an asset in terms of reaching the tuberculosis control targets. The TAG noted with concern that despite commitment and plans from the NTP, no apparent progress has been made in improving the case detection rate. Further efforts are needed to involve the general hospital to a greater extent and bring known cases under proper treatment through improved case management. Given the weight of the tuberculosis situation in China for the status of tuberculosis control in the Region, it was observed that specific recommendations are needed from the TAG to address the tuberculosis problem in China. The Lao People’s Democratic Republic: Slow but steady progress has been made by the NTP. DOTS coverage progressed during the last two years, reaching 85% of the population (by October 2003) in 17 provinces and 106 districts. Case detection rate of new smear-positive cases has also increased from 37% to 47% in the space of a year. All planned activities aim at improving services, expanding DOTS coverage, increasing the tuberculosis case detection rate and improving the management of the national tuberculosis programme. Major issues are human capacity-building, management and training, and development of technical guidelines. Mongolia: In 2002, Mongolia reached the regional 2005 targets for tuberculosis control. In general, the NTP is performing well and is well equipped for addressing major issues. Global Fund project activities started in March 2003 and the anti-tuberculosis drug supply has been secured until mid-2005. The action plan, among other issues, will consider how to address vulnerable groups in prisons (with high MDR) and how to strengthen laboratory services. Papua New Guinea: Introduction of the DOTS programme has been initiated in half of the country’s provinces, with additional advocacy being performed in other areas. In response to the growing problem of TB/HIV co-infection, collaborative activities are under discussion

between the NTP and the National AIDS Programme. Treatment success and case detection rates are very low and the role of the tuberculosis laboratory network remains weak. The action plan is oriented towards DOTS expansion. The Philippines: Significant progress has been accomplished, with 100% DOTS coverage attained in 2003. Drug resistance surveillance has been carried out, a DOTS–plus pilot project established, and PPMD projects developed with support from various partners and WHO. Human resource development and drug management are among the main issues addressed in the action plan. The plan will adopt the PPMD strategy as an approach for improving case detection, but the TAG noted that problems specific to hard-to-reach communities (due to geography, economic conditions) and prisons should also be addressed. Viet Nam: In September 2002, WHO Western Pacific Regional Office established a new post for a Medical Officer to provide technical assistance to NTPs in three countries: Cambodia, the Lao People’s Democratic Republic and Viet Nam. A joint programme review was conducted in August 2003, covering a wide range of issues, including implementing the DOTS strategy, TB/HIV co-infection, human capacitybuilding and health systems development. The review concluded that the NTP has been very effective in reaching full DOTS coverage and is achieving the WHO targets through a highly organized programme, which provides easy access to the population. The action plan addresses the issues raised by the review. 2.3.2 ISSUES AND CHALLENGES It was clear from the presentation of the two-year national acceleration plans that one of the main challenges facing countries is how to step up DOTS efficiently. Expanding DOTS is vital in order to increase case detection. This is proving a constraint in many countries due to weak human capacity-building, based on a combination of issues such as quantity, quality and distribution of staff. Weak managerial capacity at central level was identified as a particular concern, notably in China. In some countries, the problem of poor supervision of laboratory and DOTS activities was highlighted, such as in Cambodia and Mongolia. Countries with an increasing rate of TB/HIV noted this as an area of concern in their action plans. The positive outcomes of the recent outbreak of SARS were noted for tuberculosis control activities. For example, strengthened surveillance systems and political commitment in China, and increased awareness for the need to implement preventive measures in Cambodia.

2.3.3 RESPONDING TO ISSUES There is a need to increase case detection while maintaining high standards in DOTS and case management. It was suggested that innovative initiatives for increasing case detection should be explored, such as decentralization of DOTS, social mobilization and PPMD. Strengthening human capacity is a key constraint faced by most countries with a high burden of tuberculosis, and the TAG emphasized that managerial capacity should be improved through increased training and retraining of tuberculosis staff. In countries where laboratory services require strengthening, there should be a focus on developing enhanced laboratory network systems and expanding quality assurance. To address the concern of the growing rates of TB/HIV, there is a need to build better knowledge of the current situation, such as by including tuberculosis patients in the HIV surveillance system and promoting voluntary testing. Joint strategies and guidelines for combining treatment of TB and HIV should also be developed and cross-border strategies for combating TB/HIV investigated.

2.4 ACCELERATING DOTS OF TUBERCULOSIS

IN COUNTRIES WITH A HIGH BURDEN

2.4.1 CASE FINDING Dr Pieter van Maaren, Medical Officer for the Stop TB Unit, Western Pacific Regional Office and a Responsible Officer for this TAG meeting, discussed the concept of the “onion model”, based on the WHO Headquarters model, as a strategy to locate missing tuberculosis cases and to identify corresponding interventions to increase case detection. Dr van Maaren contended that the thickness of the seven onion layers or rings vary. In the Western Pacific Region, the major reasons for low case detection rates lie in rings 1–4 (see Figure 4), which were summarized as low DOTS coverage in the public sector, limited PPMD and restricted access to tuberculosis control services. Dr van Maaren further identified the four barriers to increasing case detection, those being, weak system responsiveness, physical constraints, economic costs and lack of knowledge. The increase in case detection by each intervention was also estimated. He concluded that to reach the 2005 target of 70% case detection in the Region, it is necessary to fully implement high- quality DOTS. He suggested that each country should determine the thickness of the rings, in order to help them develop specific strategies to increase case detection. Dr Daniel Chin, Medical Officer of the WHO office in China, demonstrated how this conceptual model is operating in China, using the data collected during the 2000 national prevalence survey and other

Figure 4. Detecting the missing cases

Where are the cases a) Estimated TB cases b) All true TB cases c) Cases presenting to health facilities d) Cases presenting to public health facilities e) Cases presenting to DOTS facilities f) Cases correctly diagnosed by DOTS facilities g) Diagnosed cases reported by DOTS facilities

What are the approaches 1. 2. 3. 4. 5. 6. 7.

1. Epidemiological analysis 2. Access to TB control 3. Public Private Mix DOTS 4. DOTS in public sector 5. Quality of laboratory services 6. Quality of recording & reporting 7. Quality of case holding

local studies. Two major concerns that surfaced are (1) delay in diagnosis due to lack of awareness and financial constraints of patients, and (2) around 40% of unreported tuberculosis cases are in the county and township hospitals. Thus, the following strategies to increase case detection in China were suggested to reach the 70% target: (1) full expansion of high-quality DOTS; (2) targeted efforts towards poorly performing counties; (3) increasing the number of referred cases from hospitals to tuberculosis dispensaries; and (4) strengthening health promotion activities. A discussion followed on the issue of whether it would be feasible for the hospitals in China to implement DOTS. Ultimately, it was agreed that this would prove very difficult and instead it was recommended that China should work on strengthening referral of tuberculosis cases from hospitals. It was further agreed that provincial analysis would prove useful in China. The TAG suggested investigating how health sector reform initiatives affect case finding activities, especially in resourcepoor areas. TAG members and participants viewed the analytical method of the “onion model” as a practical and useful means of helping to prioritize strategies to increase case detection. It was suggested that countries should undertake this type of analysis by carefully reviewing their own data, specifically the results of the national prevalence survey. It was further recommended that resource requirements should be included for each of the strategies.

2.4.2 PROGRAMME EVALUATION In this session, three countries, China, the Philippines and Viet Nam, presented their experiences of conducting NTP joint reviews. During their presentations, the rationale behind conducting such reviews was highlighted, including increasing political support from the government for the NTP, strengthening commitment from donors and improving technical support at country level. All partners at country level were involved in the review process with the aim of identifying constraints and challenges, in order to further guide the direction of the NTP. In China, the main constraints highlighted were the lack of both human and financial resources. Increased efforts are required to bring about changes in planning and procedures. The review emphasized that priority should be given to expansion of DOTS and high-quality services. In the Philippines, partners agreed to jointly monitor the areas that were identified for strengthening, including advocacy, human resources and the drug supply system. In Viet Nam, the main areas identified for prioritization included restructuring of the heath system, countrywide DOTS expansion and improvement and organization of the reporting system in remote areas. Following the success of the joint programme reviews in these countries, it is planned to conduct a second review in China in November 2003, while Cambodia will conduct its first review in the first quarter of 2004. The TAG indicated their strong support for conducting joint programme reviews. Professor Ian Riley outlined the stages that the review process should follow. A detailed preparation of the review was indicated as the first and most important step, while taking into consideration anticipated outcomes. The need for active engagement by all parties involved was stressed, as well as the responsibility of the service undergoing review, to use the process as a means and opportunity to improve programme performance. 2.4.3 HUMAN CAPACITY- BUILDING Ms Priya Goyal, Technical Officer for the Stop TB Unit, WHO Western Pacific Regional Office, presented the issue of human capacity-building, one of the key challenges raised during the meeting. She emphasized that strengthening human capacity remained the single key constraint facing the Stop TB Special Project in reaching its targets. It was highlighted that increased efforts need to be made particularly in China, the Lao People’s Democratic Republic, and Papua New Guinea, if the 100% DOTS coverage target is to be achieved by 2005.

Various solutions leading to improved human capacity were outlined, such as increasing the numbers of skilled staff, improving management capacity (particularly at central level) and reducing administrative barriers. Ms Goyal presented an effective management solution, based on the current “pyramid” structure, with staff at all levels functioning according to a specific role (see Figure 5). Figure 5. Management Structure

TE AM

PLANNING POLICY

CENTRAL

BU ILD

COORDINATION/ TECHNICAL SUPPORT

G IN

PROVINCIAL

ROUTINE ACTIVITY

PERIPHERAL

One of the main points raised during the discussion by Dr Alberto Romualdez, Vice-Chairperson, was that the human resource strategy should be considered in terms of health-sector reform. However, the risk of diluting efforts for tuberculosis control activities was raised, in the context of integration and a multi-skilled workforce. Dr Broekmans recognized that technical assistance is required in order for an effective human resource development plan to be constructed. Furthermore, it was acknowledged that the current level of staffing at regional level is insufficient in order to deal with increasing country requests for technical support, such as for Global Fund activities. The need for assessment of the workforce was also emphasized, to determine the number and type of staff functioning at the various levels of the “pyramid”, and of staff training, in order to better evaluate the quantity and quality required. The TAG was requested to focus on human resource development as priority in their recommendations to both the Regional Office and countries. Dr Broekmans commented that this was very timely, in view of the increasing importance of human resource development for health service delivery and programme management.

2.5 TUBERCULOSIS INTERMEDIATE

CONTROL IN COUNTRIES WITH AN

BURDEN

2.5.1 PROGRESS OF TUBERCULOSIS CONTROL Countries with an intermediate burden of tuberculosis were divided into two groups for this session. Each country presented a poster outlining progress made since the third TAG meeting, including main issues and constraints. DOTS is available to the public sector in all these countries, but is not fully implemented in all of them. For example, in Hong Kong (China), although DOTS is accessible to 100% of the population, enrolment under DOTS is only 80%. In general, the five elements of the DOTS strategy are observed in all the countries. Research has been undertaken in some countries to explain the lack of decline in case notification. This phenomenon has been largely attributed to the ageing of the population. However, in Brunei Darussalam, where the tuberculosis notification rate stagnated after 1974, and in Macao (China), where the notification trend has remained stable since 1996, it was suggested that migration was a factor leading to this stagnation. Currently, cohort analysis is only for some of the tuberculosis cases. In the conclusion of the meeting, it was recognized that cohort analysis of treatment outcome is an essential component of the DOTS strategy that can effectively monitor the performance of NTPs in the countries with an intermediate burden of tuberculosis. 2.5.2 APPLYING DOTS Dr Léopold Blanc presented the definition of DOTS as it is in the WHO publication, “An Expanded Framework for Effective Tuberculosis Control” (Geneva 2002). He also presented an example of one province in France where a retrospective study of reporting shows that the standard compulsory notification report only 60% to 70% of cases and cohort analysis is highlighting a high defaulter rate. This example showed the importance of assessing the performance of a reporting system and the critical role of cohort analysis. Dr Michael Iademarco, presented an American perspective on DOTS. He contended that direct observation of treatment is an essential tool in improving adherence to treatment and highlighted the value of process indicators in monitoring the effectiveness of the NTP.

2.5.3 TECHNICAL ISSUES A session was devoted to discussing various technical issues related to DOTS implementation in the countries with an intermediate burden of tuberculosis. The key issues raised were the importance of the standardization of short-course chemotherapy treatment under proper case management conditions (including DOT) and an efficient recording and reporting system with assessment of treatment results. Web-based reporting is being implemented in the Republic of Korea. Enhanced information systems in these countries are improving reporting of tuberculosis cases and treatment outcomes; however, they should be subject to periodic assessment in order to ensure the accuracy of the system. There is a critical need for cohort reporting and analysis of all tuberculosis cases by health care providers. Other suggestions raised during this discussion were the inclusion of TB/HIV data in the information system, routine monitoring of contact investigation, and completion of preventive therapy.

2.6 TUBERCULOSIS/HIV

CO-INFECTION

Dr Pieter van Maaren reported on progress made since the third TAG meeting in Osaka, including presenting the finalized Regional Framework to address the issue of TB/HIV co-infection, one of the key recommendations of the TAG. He noted that though in comparison with the African Region, the problem of HIV in the Western Pacific Region is relatively small. In some countries, notably Cambodia and Papua New Guinea, HIV prevalence in the general population has reached alarmingly high levels. For example, in Cambodia, a national HIV prevalence survey of tuberculosis patients was conducted in 2002, showing that 30% of tuberculosis patients in Phnom Penh are HIVpositive. Therefore, the epidemic in the Western Pacific Region is characterized by serious localized HIV epidemics, showing a clear increase over the past 10 years. This phenomenon poses a considerable threat to tuberculosis control in a number of countries. Dr van Maaren reported on activities that had been conducted at the national level, including a TB/HIV survey in Cambodia and meetings between the national TB and AIDS programmes in four countries with a high burden of tuberculosis: Cambodia, China, Papua New Guinea and Viet Nam. Following such initiatives in Cambodia, joint TB/HIV pilot projects have been launched in selected provinces. In view of the size and the urgency of the TB/HIV problem, the Region is organizing a subregional TB/HIV meeting for the Mekong region for Cambodia, China, Myanmar, the Lao People’s Democratic Republic, Thailand and Viet Nam, to be held in Viet Nam in the first half of 2004.

Dr van Maaren then presented the Regional Framework. This Framework responds to the specific characteristics of the TB/HIV epidemic in the Region, taking into account the varying degrees of HIV prevalence in countries and defined areas within countries, the strong commitment to tuberculosis of governments, as well as the fact that AIDS partnerships and programmes are still developing. The Region promotes active collaboration with AIDS programmes, rather than integration between the two programmes. The final Framework has expanded chapters and annexes on HIV surveillance, intensified case finding, treatment and care and includes criteria for commencing collaborative TB/HIV activities. The recommended level of collaboration (see Figure 6) would be decided on reviewing the severity of the problem, categorizing countries in one of three groups, depending on the national adult HIV prevalence rate, the level of HIV prevalence in distinct administrative areas and the national HIV prevalence among tuberculosis patients. Figure 6. Level of collaborative activities

LEVEL AIDS Programme

Policy/ Strategy

TB Programme

Prevention and Care

Management/ Coordination

DOTS Strategy

Service Delivery

Proposed next steps include the introduction of the Regional Framework at the country level, and the establishment and expansion of collaborative TB/HIV pilot projects, which would include anti-retroviral (ARV) treatment as part of the comprehensive care package. WHO Western Pacific Regional Office would provide support and technical assistance to countries in establishing the pilot projects and also provide guidance to countries on the role and input of tuberculosis programmes for the “3 by 5” Initiative of WHO.

Dr Bernard Fabre-Teste, HIV/AIDS Regional Adviser, WHO Western Pacific Regional Office, then briefed the members about the regional strategy for implementing the new “3 by 5” Initiative of WHO. The main goal of the initiative is to provide ARV treatment to 3 million people with HIV by the year 2005. The key elements of the “3 by 5” Initiative are global advocacy, establishment of emergency response country teams, establishment of a Global AIDS Drug and Diagnostic Facility, development of simplified ARV regimens, scaling-up of ARV treatment, development of monitoring and evaluation tools, and capacity-building of staff and communities. In the Western Pacific Region, the initiative will focus on Cambodia, China, Viet Nam and Papua New Guinea, with the objective of treating 80 000 HIV-infected people by the end of 2005. The “3 by 5” Initiative would provide opportunities for tuberculosis control by expanding DOTS, preventing tuberculosis and providing comprehensive care to HIV-positive tuberculosis patients. Questions raised in the discussion focused on a number of practical issues such as drug management and distribution, development of guidelines, human resource development and the prevention of ARV resistance. In view of the recent development of the “3 by 5” Initiative, it was not possible to provide detailed information. Dr Broekmans commented that the TAG members appreciated that the “3 by 5” Initiative had been launched and recognized its importance for tuberculosis control activities.

2.7 PUBLIC-PRIVATE

MIX

DOTS

Dr Michael Voniatis, Medical Officer of the WHO office in the Philippines, presented PPMD from both a global and regional perspective. He highlighted the rationale behind PPMD, i.e. to increase the case detection rate and improve treatment outcome. He described the experience gained not only from pilot projects globally, but also at regional level, in particular in the Philippines. Reference to the costeffectiveness of PPMD was presented by quoting outcomes of recent operational research. The PPMD models and framework developed at regional level were outlined. It was indicated that there was a need to further develop regional guidelines on PPMD, as this would be beneficial for a number of countries in the Region. Dr Rosalind Vianzon, NTP Manager, Department of Health, the Philippines, presented the aspects and experience of public-initiated PPMD in the Philippines. Dr Charles Yu, Chairman of PHILCAT, outlined the experience and implementation of private-initiated PPMD in the Philippines. During the discussion, it was pointed out that NTPs should not concentrate all their efforts in PPMD in trying to increase case detection rate, but rather use this approach as a supplementary method. It was

also mentioned that in some countries, such as China, a third approach, public-public mix DOTS, might be needed, in order to increase case detection and improve treatment outcome. All these approaches were very much related to analysing each country’s case detection “onion rings”, in the context of DOTS expansion and increased case detection and how to introduce the most appropriate approach. Dr Blanc suggested that WHO Western Pacific Regional Office should share the development of a PPMD Framework with other countries in the Region where public-private initiatives are an issue, including the application to hospital networks, as part of the overall strategy to increase DOTS expansion and case detection in the Region.

2.8 WESTERN PACIFIC REGIONAL OFFICE STRATEGIC PLAN (2004–2005) Dr Dongil Ahn, presented the WHO Western Pacific Regional Office strategic plan (2004 – 2005), entitled, “Towards 2005 targets”. The presentation was based on reaching the 2005 targets in the Region, focusing in particular on increasing case detection. The regional strategy for beyond 2005 was also considered, outlining potential activities for 2006 – 2010. REACHING 2005 TARGETS The 85% cure rate has already been achieved. With a current DOTS coverage rate of 77%, the Stop TB Special Project is likely to reach the 100% target by 2005. Case detection remains the main challenge with the current rate at 44%. Strategic approaches to improve case detection have been initiated, based on the concept of the “onion rings” developed by WHO Headquarters. This model was further analysed in the session on case finding (see section 2.4.1). Dr Ahn explained that the main priority is to step up DOTS in order to increase case detection. Enhancing human capacity-building at both country and regional levels and developing country-specific strategic plans are critical if the targets of 100% DOTS coverage and 70% case detection are to be achieved by 2005. WHO Western Pacific Regional Office has initiated a Regional Framework to improve case detection among the poor. Dr Ahn also stressed that the four countries where the “3 by 5” Initiative has been introduced should coordinate with national AIDS programmes, in order to strengthen political commitment for tuberculosis control.

REGIONAL STRATEGIC PLAN FOR 2006–2010 Dr Ahn explained that the Stop TB Unit aims to fully develop this plan by the end of 2004 for review by the TAG in 2005. This strategy is important in order to sustain the achievements made in 2004–2005 and to ensure that the 2010 impact target is met, which in turn represents an important step towards reaching the 2015 MDG for tuberculosis. The possible components of this plan were outlined, focusing on: (1) expanding and sustaining high-quality DOTS; (2) surveillance; (3) tuberculosis and poverty; (4) continuing to address the issues of TB/HIV, PPMD and MDR-TB; and (5) sustainability, including health systems development. It was pointed out that the Stop TB Unit would require more funding than is presently available in order to successfully implement this plan. During the discussion, Dr Broekmans encouraged the Stop TB Unit to further develop systematic approaches to human resource development. TAG members, Dr Iademarco and Dr Enarson, recognized that in view of the short time remaining until the 2005 targets, TAG recommendations should focus on priority tasks and countries, in particular China.

2.9 GLOBAL FUND TO FIGHT AIDS, TUBERCULOSIS MALARIA (GFATM)

AND

Stéphane Rousseau, Regional Coordinator for GFATM issues, presented an “Overview and Operational Issues” of the Global Fund. Globally, US$ 2.1 billion over three years has been committed to countries by the GFATM Board. In the Western Pacific Region, 26% of the Global Fund share is allocated to tuberculosis. Only 40% of the funds committed to the Region for STB have been disbursed to date (see Figure 7).

Figure 7. Global fund in the Westen Pacific Region

Total grants by disease Tuberculosis 26% $ 37 677 180 $ 65 347 804 $ 40 848 646

HIV/AIDS 46%

Malaria 28%

The Global Fund has introduced a number of country operating mechanisms in order to facilitate the effective and efficient management of the Fund. In particular, the Technical Working Group (TWG), which comprises of a committee of technical experts, including WHO representatives, plays an important role in guiding the Principal Recipient (PR) and advising the Country Coordinating Mechanism (CCM) on the direction of its projects. During the discussion, it was evident that countries had established variations of the TWGs, with different members and differing mandates. It was recommended that each project should have a TWG to support the Global Fund process, by playing an advisory role to the PR. Mr Rousseau announced that the call for proposals for the fourth round of the Global Fund will be issued with updated guidelines on 10 January 2004 and completed applications must be submitted by 5 April 2004. The Technical Review Panel (TRP) will meet in May to review the technical merits of the proposals; the Board will meet from 28 to 30 June 2004 to decide on the funding. Mr Peter King, head of the Procurement Unit in the Western Pacific Regional Office, gave a presentation on key procurement issues related to the Global Fund. He explained that the PR is the overall responsible agency for project procurement, with the assistance of a TWG. Mr King stressed that WHO will not undertake local procurement. However, for international purchase, where the recipient has been assessed as having limited capacity, WHO can offer its purchasing service through the Reimbursable Procurement Scheme. This scheme enables the purchase of supplies and equipment using WHO purchasing services, which can greatly assist the country in terms of cost and convenience. Questions that followed included the relationship between the Procurement Unit and the Global Drug Facility (GDF). Mr King replied that the Western Pacific Regional Office does not have a direct relationship with GDF. However, WHO Headquarters in Geneva collaborates directly with GDF. Large drug purchases are handled through the Purchasing Unit of WHO Headquarters. Finally, Dr Michael Voniatis delivered a short presentation on the monitoring and evaluation (M&E) plan of the PR in the Philippines, outlining a model for undertaking the technical and programmatic aspects of this plan. The process of monitoring and evaluation, including the important role of the TWG in this activity, was described. During the discussion, it was agreed that the TWG should be the major player in the implementation of the M&E plan.

2.10 QUALITY

ASSURANCE

Dr Sumana Barua, focal point for tuberculosis laboratory services in the Western Pacific Regional Office, gave an update on the progress of work in the Region, which geared towards ensuring the high quality of tuberculosis laboratory services. He reiterated the importance of the

laboratory in the NTP, since it guarantees correct diagnosis, guides the selection of treatment regimen, monitors response and helps in conducting tuberculosis surveillance. Activities conducted since the last TAG meeting include: the first meeting of NTP and laboratory managers from countries with a high burden of tuberculosis, which was held in Cebu, the Philippines, in December 2002; and the finalization of the regional Guidelines for Quality Assurance in April 2003 and the Quality Assurance Guidelines for the Pacific Island Countries in July 2003. Dr Barua explained that unlike the global guidelines that focus mainly on external quality assessment (EQA), the regional version has been expanded to cover different aspects of quality assurance, including quality control, EQA and quality improvement. China, Cambodia, the Philippines and Viet Nam have started developing their national guidelines based on the regional guidelines. Dr Barua concluded that by 2005, all countries with the assistance of the Western Pacific Regional Office are expected to develop and implement national guidelines on quality assurance of smear examination.

2.11 TUBERCULOSIS

AND POVERTY

Ms. Anjana Bhushan, Poverty and Gender Focal Point, Health Systems Unit, presented an overview of the advocacy paper on tuberculosis and Poverty, entitled “Reaching the poor: Challenges for TB programmes in the Western Pacific”. This paper was produced jointly by the Stop TB and Health Systems Units, in response to the recommendation of the external thematic evaluation of the Stop TB Special Project, to integrate a greater focus on poverty and tuberculosis into the Region’s tuberculosis control strategies and advocacy. Ms Bhushan explained how poverty is a multidimensional phenomenon. Evidence shows that poverty is associated with a higher burden of tuberculosis, and that tuberculosis leads to greater poverty. Since tuberculosis causes greater poverty, DOTS can indirectly reduce poverty by curing tuberculosis patients and cutting the transmission (see Figure 8). However, health-related research from beyond the tuberculosis community offers many reasons to suspect that, even with free diagnosis and treatment, DOTS may not be reaching the poor. The little evidence we have from within the tuberculosis community is beginning to reveal a similar trend. Based on the framework presented in A Systematic Analysis of TB and Poverty (Geneva, Stop TB Partnership, WHO, 2003), the health-seeking behaviour of tuberculosis patients along the pathway to cure was analysed, to identify why DOTS may be missing the poor. The poor may be denied access to DOTS because of: (1) physical access; (2) economic costs; (3) low knowledge and stigma; and (4) lack of system responsiveness, in both the private and public sectors. To overcome these constraints and ensure that targets are met, the tuberculosis programme can ensure that poverty is integrated into tuberculosis

Figure 8. Poverty and Tuberculosis cycle

The poor are at greater risk of ill-health Tuberculosis may lead to: • loss of 20-30% of annual wages among poor • global economic costs: $12 billion annually

Poverty

Tuberculosis

Poverty may lead to: • increased risk of infection and disease • delayed access to DOTS

control. Ms. Bhushan presented various strategies for increasing the accessibility of DOTS to the poor, which will be further elaborated upon in the forthcoming Regional Framework on TB and Poverty. Several participants congratulated the Secretariat on WHO’s work in the area of tuberculosis and poverty and for highlighting the key issues and concerns in the presentation. Dr Romualdez observed that poverty plays a significant role in the areas of major concerns identified during the TAG meeting, namely, slow progress in China and in general, human resource challenges in countries with a high burden of tuberculosis. In China, poverty is strongly correlated to the major reasons for why tuberculosis symptomatics fail to present to health services—financial barriers and lack of concern about symptoms. In addition, it was suggested that tuberculosis staff in poorer areas should receive training, in order to become more responsive to patients from low-income households. Dr Enarson pointed out that more rigorous analysis is needed to establish conclusively whether DOTS is or is not a pro-poor strategy. In particular, such analysis and assessment should compare DOTS with its alternatives, such as non-DOTS or an improved version of DOTS. Furthermore, the relative impact of alternative methods of adjusting DOTS should be systematically analysed, in order to better meet the needs of poorer populations. It was recognized that the Western Pacific Regional Office is well placed to carefully carry forward this process analysis and assessment. Finally, Dr Enarson urged all concerned to critique the FIDELIS project and provide feedback on how to address tuberculosis and poverty concerns through this fund, which was

expressly designed to address the needs of those with limited access to health care. In this light, Professor Riley pointed out that tuberculosis programmes provide an opportunity to redistribute resources towards the poor, helping to reduce the burden of tuberculosis among such marginalized groups.

2.12 REGIONAL INTERAGENCY COORDINATING COMMITTEE SESSION Dr Dongil Ahn opened the session by nominating Dr Andrew Clements of USAID as Chairperson and Ms Myrna Jarillas of the Canadian International Development Agency (CIDA) as Rapporteur for the session. The nominations were unanimously approved. Dr Ahn presented an overview of the regional and national partnerships for Stop TB. He noted that funding for Stop TB at country level has dramatically improved, although a funding gap still remains, in particular, for new or accelerated efforts to support countries. In addition, while not sufficient, funding for WHO at regional level has dramatically increased in comparison with the situation three years ago. Dr Ahn stressed that strong support from partners for tuberculosis control, including the Global Fund, is critical for programme success, especially now that the focus has shifted from the global and regional levels to national level. Finally, he mentioned that all recommendations from the ICC meeting at the third TAG are being addressed or have been completed. Dr Marcos Espinal followed with a presentation on the Global Stop TB Partnership. He focused on future activities of the Stop TB partnership and possible areas for collaboration between global, regional and national partnerships. In particular, the Stop TB Partnership plans to enhance efforts at the country level by supporting the creation of national Stop TB partnerships, in order to reach and sustain the tuberculosis control targets. This will broaden the network of organizations involved in fighting tuberculosis, allowing for more innovative advocacy strategies to be introduced. The participants observed that the N-ICCs appear to be functioning well and offer an important means of reaching complementarity and synergy among partners, as well as mobilizing resources and technical inputs. The strength of the N-ICCs in China and the Philippines are illustrated by the joint programme reviews that the NTPS have undertaken in these countries. Although there appears to be good coordination among partners at country level, concern was expressed over the piecemeal approach to funding. It was observed that the key to establishing a good partnership is: (1) to have a clearly developed plan in place, in order to allow NTPs to identify and “fill in” the gaps; (2) to have the support of the Ministry of Health;

and (3) to have a strong secretariat. In most countries, the Country Coordinating Mechanism (CCM), set up through the Global Fund, ensures that a sound plan is in place and facilitates the establishment of effective partnerships. Building on further on the experience of N-ICCs, the Stop TB partnership plans to support the creation of Stop TB partnerships at country level. Using the Stop TB partnership “brand”, the aim is to create an effective advocacy network that can mobilize political commitment and implement advocacy campaigns. Examples of countries with expanded partnerships include Cambodia and the Philippines; other countries have strengthened their ICCs through collaboration on Global Fund projects. The Regional ICC currently provides a means to update partners on progress in the Region. As many issues are effectively resourced at the country level, it is difficult to expand the objectives of the Regional ICC, although there may be scope to consider cross-border issues, such as TB/HIV co-infection. The challenge of sharing information, including planning and results, within agencies and between the national, regional and global levels, was discussed. Tools for information sharing include the WHO Global Plan, the WHO Global TB report and the Stop TB Partnership list-serve. The Western Pacific Regional Office plans to launch a quarterly e-newsletter in 2004, which will include updates and information on planned activities.

2.13 NATIONAL

TUBERCULOSIS PROGRAMME MANAGERS’ MEETING

The subject of this discussion was “Addressing TB/HIV”, in view of the increasing importance of this issue in the Region. The session was attended by NTP Managers from the countries with a high burden of tuberculosis and facilitated by Dr Maarten Bosman, Medical Officer of the WHO office in Viet Nam. The objectives of the session were: (1) to discuss operational issues related to the three key components of the Regional TB/HIV Framework, i.e. surveillance, referral mechanisms, and treatment and care; and (2) to identify next steps for introducing and/or implementing relevant components of the Framework. The NTP in two countries, Cambodia and Viet Nam, where TB/HIV coinfection is rapidly increasing, shared their experiences of tackling this issue. In Viet Nam, the HIV epidemic is concentrated among intravenous drug users and commercial sex workers, whereas in Cambodia the epidemic is more generalized, occurring through heterosexual transmission. Initiatives have mainly been from the NTP side, in terms of responding to the growing TB/HIV epidemic. The NTP

has organized TB/HIV meetings and proposed a joint committee, but as yet no national strategy has been established. In Cambodia, through close collaboration with the national HIV/AIDS and tuberculosis programmes, a TB/HIV subcommittee was set up in 1999, followed by the development of a Framework for TB/HIV control in 2002. Since 2003, pilot projects have been established in four provinces, funded by local partnerships and supported by WHO. During the open forum, one of the main issues discussed was the stigmatization of HIV patients. The NTP in Cambodia explained how improved information and education activities and strengthened political commitment, has lead to improving the situation in the country. Another point discussed was the mortality rate in HIV-positive tuberculosis patients and how this is not due to MDR-TB, but rather to other opportunistic infections. Countries were interested to understand how to address organizational issues, in order to establish close collaboration between their NTP and national AIDS programme (NAP). The NTPs in Cambodia and Viet Nam admitted that attempts so far have been a one-way process from the side of the NTP, but acknowledged that the “3 by 5” Initiative could make a difference, encouraging the two programmes to communicate and work together effectively. Dr Bosman discussed some elements of the TB/HIV Framework in detail, such as surveillance methods. Highlighted examples included: (1) the national TB/HIV prevalence survey conducted in Cambodia; (2) the sentinel surveillance of the NAPs undertaken in China, the Philippines and Viet Nam; and (3) routine testing of tuberculosis patients in some of the countries with an intermediate burden of tuberculosis, as well as in selected areas of the Lao People’s Democratic Republic and Papua New Guinea. Putting countries into specific categories according to the Framework was also discussed and it was observed that only Cambodia fits the Category I criteria. The outcomes of the discussion included suggestions for countries to adopt the Regional Framework, create TB/HIV committees, establish close collaboration between their NTP and NAP and set up pilot projects for joint activities. Specifically, the NTPs of Cambodia, China, Papua

New Guinea and Viet Nam, where the problem of TB/HIV infection is growing, were urged to actively engage in “3 by 5” task forces.

3. CONCLUSIONS AND RECOMMENDATIONS OF THE MEETING 3.1 TAG CONCLUSIONS AND RECOMMENDATIONS

TAG congratulates Mongolia for achieving the regional targets of 85% cure and 70% case detection through the application of high-quality, sustainable 100% DOTS coverage. 3.1.1. GLOBAL TUBERCULOSIS SITUATION AND PARTNERSHIP RESPONSE CONCLUSIONS:

1. Due to the significant progress made in the Region, through the development of strong partnerships at regional and national levels, the Stop TB programme is very well placed to reach the 2005 targets without delay. 2. The MDG is important to sustain political commitment and progress achieved, in order to further reduce the global TB burden. 3. The “3 by 5” Initiative offers an important opportunity for tuberculosis control programmes to improve joint TB/HIV activities and provide better care for HIV and tuberculosis patients. 4. SARS has had a positive impact on the tuberculosis programme, strengthening commitment for enhancing pubic health organization and surveillance systems. RECOMMENDATIONS FOR THE

WESTERN PACIFIC REGIONAL OFFICE:

1. The Western Pacific Regional Office should identify further areas for close collaboration at global, regional, and country levels in order to achieve the 2005 regional targets. 2. The Western Pacific Regional Office should capitalize on the opportunities of the MDG and SARS to strengthen the awareness

and the role of tuberculosis control strategies in the horizontal organization of public health functions. RECOMMENDATIONS FOR PARTNERS:

1. Partners should dramatically strengthen their support to Western Pacific Region, in light of the tuberculosis burden in the Region, in order to significantly increase human and financial resources to reach the 2005 targets. 3.1.2. TUBERCULOSIS AND POVERTY CONCLUSIONS:

1. Poverty reduction and tuberculosis control are integral to the MDGs, which WHO is committed to supporting. 2. The Western Pacific Regional Office is well positioned to identify ways of delivering a more effective pro-poor DOTS strategy. This would make a substantial contribution towards accelerating DOTS coverage and reaching the case detection target. RECOMMENDATIONS FOR THE

WESTERN PACIFIC REGIONAL OFFICE:

1. The Western Pacific Regional Office should further develop and finalize the regional framework to promote pro-poor approaches in tuberculosis control. 2. The Western Pacific Regional Office should pursue collaboration with partners at regional and national levels, to ensure that tuberculosis is put on the poverty agenda. RECOMMENDATIONS FOR COUNTRIES:

1. Countries should widely use the regional tuberculosis and poverty advocacy publication, Reaching the poor: challenges for TB programmes in the Western Pacific, in order to increase awareness among NTP staff and to mobilize political support for addressing tuberculosis and poverty issues. 2. In collaboration with the Western Pacific Regional Office, countries should put poverty on the tuberculosis agenda and implement and evaluate projects with a pro-poor focus. 3.1.3. WESTERN PACIFIC REGIONAL OFFICE STRATEGIC PLAN CONCLUSIONS:

1. The TAG supports the Western Pacific Regional Office strategic plan as an overall framework within which to prioritize the

specific issues of case detection and human resources for all countries with a high burden of tuberculosis. 2. Commendable progress has been made in most countries towards reaching the Western Pacific Region’s objectives. 3. Significant and prompt progress towards DOTS expansion and case detection in China is essential to achieve the objectives of the Stop TB Special Project. 4. There are insufficient human resources to implement the Western Pacific Regional Office’s strategic plan for 2004–2005. 5. The plan acknowledges the important role of training and capacity-building, as demonstrated by the success of the tuberculosis programme in Viet Nam. RECOMMENDATIONS FOR THE

WESTERN PACIFIC REGIONAL OFFICE:

1. The Western Pacific Regional Office should recognize that while the existing plan represents a comprehensive approach to improving tuberculosis control in the Region, a stronger focus and priority on human resource capacity and accelerating DOTS expansion is essential over the next two years (2004 – 2005), if the 2005 targets are to be met. 2. The Western Pacific Regional Office should adopt a special approach in selected priority provinces in China, which will increase case detection by addressing the epidemiological burden in the country. 3. The Western Pacific Regional Office should develop the second phase of the Special Project to Stop TB, which will focus on achieving the 2010 target of reducing the tuberculosis burden in the Region by half. 4. The Western Pacific Regional Office should develop a plan for monitoring the progress toward set impact targets, including conducting prevalence surveys. 3.1.4. TWO-YEAR ACTION PLAN IN THE SEVEN COUNTRIES WITH A HIGH BURDEN OF TUBERCULOSIS CONCLUSIONS:

1. The two-year DOTS acceleration plans are well developed and acknowledged by the TAG as technically sound. 2. Provision of free diagnosis and treatment throughout general health services for the care of tuberculosis patients is an essential component of DOTS. 3. The TAG notes with concern the slow progress made in DOTS expansion in China and Papua New Guinea.

4. Because of China’s population size, disease-burden and programme performance, innovative approaches are required, focusing on selected provinces to increase the case detection RECOMMENDATIONS FOR THE

WESTERN PACIFIC REGIONAL OFFICE:

1. The Western Pacific Regional Office should assist countries to urgently implement their two-year country action plans. 2. The Western Pacific Regional Office should significantly increase human resources to implement, monitor and maintain DOTS. 3. The Western Pacific Regional Office should urgently invite China to host a special TAG meeting in 2004 to review and address the acceleration of DOTS coverage and case detection in the country, with an emphasis on province-specific progress. 4. The Western Pacific Regional Office should hold a high-level meeting with China’s Ministry of Health to facilitate bridging the barriers between curative health services (i.e. the hospital sector) and public health programmes. RECOMMENDATIONS FOR COUNTRIES:

1. Countries with a high burden of tuberculosis should urgently implement the two-year country action plans. 2. China should significantly increase human resource capacity, especially at central and provincial levels, directed at strengthening the management of the NTP at provincial and lower levels and increasing the DOTS case detection rate. 3. China’s Ministry of Health should outline a plan to link up the hospital sector (under the department of Medical Administration) and the CDC (under the department of Disease Control) to ensure that hospitals fully participate in the NTP and adopt the DOTS strategy in the care of their tuberculosis patients. 4. China should host a special TAG meeting in 2004 to review and address the acceleration of DOTS coverage and case detection, with an emphasis on province-specific progress. 5. Papua New Guinea should urgently step up efforts to increase DOTS expansion. 3.1.5. CASE DETECTION CONCLUSIONS:

1. The Western Pacific Regional Office’s analysis outlining the distribution and location of missing cases is useful and TAG considers the use of the “onion model” a practical conceptual framework.

2. The TAG acknowledges the practical application of this model to analyse the distribution and location of missing cases in China, offering important evidence on how to further guide DOTS expansion and case finding in China. 3. The TAG acknowledges the importance of linking public health DOTS with wider curative services in support of increasing the case detection rate. 4. Although the provision of a free supply of drugs for sputum smear-negative patients with tuberculosis disease, which is being considered by China, can be part of a comprehensive tuberculosis control programme, there is insufficient evidence to conclude that this will have a significant impact on increasing case detection. 5. Further analysis of the connection between tuberculosis and poverty and PPMD, is a means of increasing the case detection rate. RECOMMENDATIONS FOR THE

WESTERN PACIFIC REGIONAL OFFICE:

1. The Western Pacific Regional Office should develop a system of population-based geopolitical units of analysis to harmonize reporting, in order to better identify priority areas for increasing case detection. 2. The Western Pacific Regional Office should develop and finalize the regional framework for analysing strategies to increase case detection. 3. The Western Pacific Regional Office should assist countries in conducting national analysis to determine the distribution and location of missing cases. 4. The Western Pacific Regional Office should assist countries to develop country-specific strategies to increase case finding. 5. The Western Pacific Regional Office should share its framework with WHO Headquarters in order to disseminate to other Regions where case detection is lagging. RECOMMENDATIONS FOR COUNTRIES:

1. Countries should analyse case detection using the “onion model” to determine the distribution and location of the missing cases. 2. Countries should develop specific strategies to increase case detection.

3.1.6. HUMAN RESOURCE CAPACITY DEVELOPMENT CONCLUSIONS:

1. Human capacity-building is a critical challenge faced by the Stop TB Special Project 2. The current level of human resource capacity is insufficient for the Region to achieve the targets set by its Special Project. 3. Special efforts in human capacity-building are needed to reach DOTS expansion targets in three countries with a high burden of tuberculosis (China, the Lao People’s Democratic Republic, Papua New Guinea). RECOMMENDATIONS FOR THE

WESTERN PACIFIC REGIONAL OFFICE:

1. The Western Pacific Regional Office should work with governments and partners to place human capacity-building as a high priority on their agenda. 2. The Western Pacific Regional Office should provide all the necessary technical assistance to support country efforts to strengthen human capacity-building, in particular in the three countries that have not yet reached the 100% DOTS coverage target (China, the Lao People’s Democratic Republic, Papua New Guinea). 3. The Western Pacific Regional Office should develop and pilot the application of a systematic set of quantitative and qualitative indicators of human resource development, in order to refine workforce planning and development. 4. The Western Pacific Regional Office should reinforce its Stop TB team by strengthening human capacity-building. RECOMMENDATIONS FOR COUNTRIES:

1. Countries should strengthen human capacity-building in China, the Lao People’s Democratic Republic and Papua New Guinea, which have not yet reached the 100% DOTS coverage target. RECOMMENDATIONS FOR PARTNERS:

1. Partners should strengthen their support to the Western Pacific Region to significantly increase quantity and quality of human resources, in order to reach the 2005 targets.

3.1.7. PPMD CONCLUSIONS:

1. TAG welcomes the outline of the regional framework for PPMD, based on the experiences of the Philippines. 2. Scaling up PPMD will have a significant impact on increasing case detection. RECOMMENDATIONS FOR THE

WESTERN PACIFIC REGIONAL OFFICE:

1. The Western Pacific Regional Office should further develop and share the framework of PPMD with countries, as part of the strategy to increase DOTS expansion and case detection, including its application to hospital networks. 2. In close collaboration with partners or stakeholders involved, the Western Pacific Regional Office should provide technical support to the Philippines to finalize and expand their national strategy for PPMD. RECOMMENDATIONS FOR COUNTRIES:

1. Based on the “onion ring” analysis, countries should introduce or expand PPMD approach, particularly in countries where the private sector is strong. 3.1.8. TUBERCULOSIS/HIV CONCLUSIONS:

1. TAG commends the Western Pacific Regional Office on finalizing the regional framework, in line with the recommendation from the third TAG meeting. 2. TAG recognizes the lessons learnt from field experience in countries with a high prevalence of HIV and a high burden of tuberculosis, namely Cambodia and Viet Nam. 3. The “3 by 5” Initiative is an important opportunity to further strengthen tuberculosis control in the Region; the Western Pacific Regional Office has a strong collaborative approach with the regional HIV/AIDS programme.

RECOMMENDATIONS

FOR THE

WESTERN PACIFIC REGIONAL OFFICE:

1. The Western Pacific Regional Office should encourage and support the collaborative activities of NTPs with national HIV/AIDS programmes and partners. 2. The Western Pacific Regional Office should organize a TB/HIV meeting for the Mekong region during the first half of 2004, to adopt a joint strategy for implementing a comprehensive TB/HIV care package. 3. In collaboration with the TB/HIV programme, the Western Pacific Regional Office should provide necessary technical support to countries in the implementation of the “3 by 5” strategy. RECOMMENDATIONS FOR COUNTRIES:

1. Countries should finalize and implement a national TB/HIV framework emphasizing surveillance as an essential component and proceed with TB/HIV joint pilot projects. 2. Countries should proactively approach and collaborate with national HIV/AIDS programmes and partnerships, while addressing joint strategy development for “3 by 5” implementation. 3.1.9. JOINT PROGRAMME EVALUATION CONCLUSIONS:

1. Programme evaluations have been conducted successfully in China, the Philippines and Viet Nam in collaboration with partner agencies at country level and have generated increased political commitment and technical support for the NTP. 2. Programme evaluations are an effective means of highlighting key constraints and challenges to further guide the direction of NTPs. RECOMMENDATIONS FOR THE

WESTERN PACIFIC REGIONAL OFFICE:

1. In collaboration with partners, the Western Pacific Regional Office should provide coordination and technical support to the NTP to facilitate the conducting of joint programme reviews. RECOMMENDATIONS FOR COUNTRIES:

1. Countries should conduct a joint national programme review, at least every two years, which includes the participation of all partners, including Global Fund representation.

RECOMMENDATIONS

FOR PARTNERS:

1. Partners should actively participate in joint national programme reviews. 3.1.10. CONCLUSIONS:

GLOBAL FUND

1. WHO provides technical guidance and support to Global Fund projects within the limits of its own resources, both at country and regional level. 2. The Technical Working Groups, which consist of technical agencies such as WHO to advise and guide the PR, are critical in providing technical assistance as required. 3. Further review and analysis of the Global Fund’s country operating mechanisms will enable countries to manage and implement the Fund more efficiently. RECOMMENDATIONS FOR THE

WESTERN PACIFIC REGIONAL OFFICE:

1. The Western Pacific Regional Office should provide technical support to countries, in close collaboration with the Global Fund Secretariat and country coordination mechanisms. RECOMMENDATIONS FOR COUNTRIES:

1. Countries should collaborate closely with Global Fund’s country coordinating mechanisms, to ensure high-quality implementation of the two-year work plans. 3.1.11. COUNTRIES WITH AN INTERMEDIATE BURDEN OF TUBERCULOSIS

CONCLUSIONS:

1. Outcome-based cohort analysis is essential to design interventions to enhance programme performance. 2. Cohort analysis is important at every level of the health service (including the private sector), wherever tuberculosis patients are provided with care. RECOMMENDATIONS FOR THE

WESTERN PACIFIC REGIONAL OFFICE:

1. The Western Pacific Regional Office should facilitate continuous and collaborative external technical assistance to study problems and assist with the implementation of improvements particularly to the countries with an intermediate burden of tuberculosis.

2. The Western Pacific Regional Office should adopt the Expanded Framework for Effective Tuberculosis Control (WHO, Geneva, 2002) as the definition of DOTS for estimating DOTS coverage in these countries. 3. The Western Pacific Regional Office should recognize that cohort analysis is an essential requirement in the definition of DOTS, including a policy that incorporates all tuberculosis patients managed in both the public and private health sectors. RECOMMENDATIONS FOR COUNTRIES:

1. Countries should expand the use of tuberculosis case management using the Expanded Framework, including the application of directly observed treatment. 2. Countries should implement comprehensive cohort analysis of tuberculosis cases, incorporating all TB patients managed within both public and private services of the health sector. 3.1.12. CONCLUSIONS:

QUALITY ASSURANCE

1. External Quality Assessment (EQA) is critical to ensure highquality passive diagnosis by sputum smear microscopy and increase the case detection rate. 2. The TAG acknowledges the Western Pacific Regional Office’s prompt and comprehensive planning to develop and implement regionwide EQA policy, including special attention for the Pacific island countries. RECOMMENDATIONS FOR THE

WESTERN PACIFIC REGIONAL OFFICE:

1. The Western Pacific Regional Office should provide all the technical support required to countries to adopt and implement the Regional Guidelines on Quality Assurance. RECOMMENDATIONS FOR COUNTRIES:

1. Countries should emphasize the importance of laboratory services under the EQA framework and adopt and implement the Regional Guidelines on Quality Assurance, according to country-specific situations.

3.2 REGIONAL ICC CONCLUSIONS:

CONCLUSIONS AND RECOMMENDATIONS

1. Close collaboration among tuberculosis partners at the country, regional, and global levels is essential for meeting the 2005 targets. At the country level, all tuberculosis-related efforts should support the action plan of the NTP. 2. National-level ICCs are generally functioning well. However, it may be necessary to include partners with certain skills and/or funding to address specific priorities of the NTP. 3. Reporting back to partners (e.g. donors, GFATM) on progress based on the NTP action plans is important for maintaining external support for the tuberculosis initiatives needed to meet the 2005 targets. RECOMMENDATIONS TO THE

WESTERN PACIFIC REGIONAL OFFICE:

1. The Western Pacific Regional Office should facilitate information exchange among countries, regional partners, and global partners. RECOMMENDATIONS TO COUNTRIES:

1. NTPs should strengthen collaboration among partners for the implementation of their two-year national acceleration plans to achieve the 2005 targets. 2. National ICCs should continue to coordinate with global and national partnership mechanisms, such as the Stop TB Partnership, Global Fund and the national AIDS programmes, in order to strengthen the efficiency and effectiveness of the partnerships. 3. NTPs should review future resource requirements and inform the Western Pacific Regional Office in advance, so that regional support can be coordinated effectively.

ANNEXES

Annex 1: Fourth Stop TB Technical Advisory Group Meeting for the Western Pacific Region - Timetable, Manila, Philippines, 17-19 November 2003 Anenx 2: List of Technical Advisory Group Members, Participants, Consultants, Resource Persons, Representatives of Partner Agencies and Secretariat Annex 3: Opening Remarks of the Regional Director at the Fourth Technical Advisory Group (TAG) Meeting, 17-19 November, 2003, Manila, Philippines Annex 4: Country presentations - Countries with a high burden of tuberculosis Annex 5: Country presentations - Countries with an intermediate burden of tuberculosis

ANNEX 1 Time

FOURTH STOP TB TECHNICAL ADVISORY GROUP MEETING FOR THE WESTERN PACIFIC REGION - TIMETABLE. MANILA, PHILIPPINES, 17-19 NOVEMBER 2003 Tuesday, 18 November Wednesday, 19 November

Monday, 17 November

0800 0830 -

Registration Opening ceremony

(6) (7) (8) (9)

Summary of poster session (15 min) TB-HIV (40 min.) PPMD (40 min.) WPRO strategic plan 2004-2005 (25 min.)

0800 0940

(16) Summary of HBC session (10) (20 min.) (17) WPRO Quality Assurance Guidelines for (20 min.) (18) Summary of IBC session (12) (20 min.) (19) Summary NTP meeting (14) (20 min.) (20) TB and Poverty (20 min.) COFFEE BREAK

0930 1000 1045

PHOTO SESSION/COFFEE BREAK

1000

COFFEE

BREAK

0940 1010 1100 1100

(1) Aims and objectives of the meeting (5 min.) 1030 (2) Global TB situation and partnership response (20 min.) 1200 (3) Regional Stop TB Initiative:Progress report 2002-2003 (20 min.) (4) Current status of TB control and two-year action plan in seven high burden countries (75 min.) LUNCH BREAK 1300 1530

(10) “Accelerating DOTS” in high burden countries: a. Case finding (90 min.)

(21) Conclusions & recommendations of TAG (30 min.) (22) ICC report and conclusions (20 min.) Closing ceremony

1200 ` 1330 1530

LUNCH

BREAK (12)DOTS in inter1300 mediate burden countries: 1600 a. Applying DOTS in low/intermediate burden countries (60 min.) b. Technical issues (90 min.) Field visit

(4) Current status of TB control and two-year action plan in seven high burden countries (120 min.)

(10) “Accelerating DOTS DOTS” b. Programme evaluation (30 min.) c. Central capacity (45 min.) (11) Global Fund to Fight AIDS, TB and Malaria Malaria (75 min.) COFFEE (13 ) ICC meeting BREAK

1530 1600 1700 1830

COFFEE

BREAK

1530 1600 1700 1830

(5) Progress of TB control in inter mediate burden countries: Poster session (60 min.) WPRO Cocktails

(14) NTP meeting Dinner

(15) TAG meeting

ANNEX 2 LIST OF TECHNICAL ADVISORY GROUP MEMBERS, PARTICIPANTS, CONSULTANTS, RESOURCE PERSONS, REPRESENTATIVES OF PARTNER AGENCIES AND SECRETARIAT 1. TECHNICAL ADVISORY GROUP MEMBERS Dr Jaap Broekmans, Director, KNCV TB Foundation (formerly KNCV), Riouwstraat, 7, P.O. Box 146, 2501 CC , The Hague, The Netherlands; Tel.: 31 (70) 416 7222 / 7245; Fax: 31 (70) 358 40 04; E-mail: broekmansj@kncvtbc.nl Dr Donald Enarson, Director, Scientific Activities, International Union Against Tuberculosis and Lung Diseases (IUATLD), 68, Boulevard Saint-Michel, 75006 Paris, France, Tel.: 33 1 43 299087; Fax: 33 1 44 320360; E-mail: denarson@iuatld.org Dr Michael Iademarco, Associate Director for Science, International Activities, Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, 1600 Clifton Road, NE Mailstop E-10, Atlanta, Georgia 30329, United States of America; Tel.: 1 (404) 639 8120; Fax: 1 (404) 639 8604; E-mail: mai9@cdc.gov Dr Sang-Jae Kim, Scientist, TB Strategy and Operations Stop TB Department, WHO Headquarters, Avenue Appia, CH-1211 Geneva, 27, Switzerland Tel.: 4122 7911626; Fax: 4122 7914268; E-mail: kims@who.int Dr Toru Mori, Director, Research Institute of Tuberculosis, Japan Anti-Tuberculosis Association, 3-1-24 Matsuyama, Kiyose-shi, Tokyo 204-8533, Japan Tel.: 81 (424) 92-4767; Fax: 81 (424) 92 4600; E-mail: tmori@jata.or.jp Professor Ian Riley, Director, Australian Center for International and Tropical Health andNutrition, 45th Floor, Public Health Building, Herston, Queensland 4006, Australia Tel.: (617) 3365 5395; 5280; Fax: (617) 3365 5599; E-mail: I.Riley@mailbox.uq.edu.au Dr Alberto G. Romualdez, Jr., Health Services Consultant and President, Friendly Care Foundation, Inc., 710 Shaw Boulevard, Mandaluyong City 1501 Metro Manila, Philippines; Tel.: (632) 7222993; Fax: (632) 722-2973 E-mail: quasir@mozcom.com; fcfi@friendlycare.com.ph Dr Mitsuhiro Ushio, Director, Tuberculosis and Infectious Diseases Control Division, Health Service Bureau, Ministry of Health, Labour and Welfare, 1-2-2, Kasumigaseki, Chiyoda-ku, Tokyo 100-8916, Japan; Tel.: (813) 3591 3060; Fax: (813) 3581 6251 E-mail: ushio-mitsuhiro@mhlw.go.jp

2. PARTICIPANTS BRUNEI DARUSSALAM Pg Dr Hj Khalifah bin Pg Hj Ismail, Medical Officer, Ministry of Health Bandar Seri Begawan 1210 Tel.: (673) 2 381 640, Fax: (673) 2 381 440 E-mail: c/o int_moh_brunei@hotmail.com Dr Mao Tan Eang, Director, National Center for TB and Leprosy Control (CENAT), Ministry of Health, St. 278 and 95, Boeng Keng Kang II, Chamkarmorn, Phnom Penh Tel: (855) 12 916503, Fax: (855) 23 218090 E-mail: mao@bigpond.com.kh

CAMBODIA

Dr Touch Sareth, Vice Director, National Center for TB and Leprosy (CENAT), Ministry of Health, St. 278 and 95, Boeng Keng Kang II, Chamkarmorn, Phnom Penh Tel.: 855 23 219274/275; (855) 012 833465 Fax: 855 23 218090; E-mail: sarethtouch@online.com.kh CHINA, PEOPLE’S REPUBLIC OF Ms Wan Liya, Consultant , Division II, Department of Disease Control, Ministry of Health, No. 1 Xi Zhi Men Wai Nan Lu, Xicheng District, Beijing 100044 Tel.: (8610) 6879 2364, Fax: (8610) 6879 2279 E-mail: mddc2@a-1.net.cn Dr Cheng Shiming, Deputy Director, National Center for TB Control and Prevention, No. 27 Nanwei Road, Xuainu District Beijing 100050 Tel.: (8610) 6317 1368, Fax: (8610) 6302 9984 E-mail: nctb@chinatb.org Dr Zhao Fengzeng,Senior Advisor, National Center for TB Control and Prevention, No. 27 Nanwei Road, Xuainu District Beijing 100050 Tel.: (8610) 6316 7544, Fax: (8610) 6316 7543 E-mail: fengzengzhao@sohu.com FIJI Dr Wiliame B. Kaitani, National TB Control Officer and Medical Superintendent, Tamavua Twomey Hospital, Ministry of Health, Private Mail Bag, Suva Tel.: (679) 3321066, Fax: (679) 3321559 E-mail: twomey@healthfij.gov.fj Dr Chang Kwok-chiu, Senior Medical Officer, TB and Chest Service, Yaumatei Chest Clinic, 145 Battery Street, Kowloon Tel.: 852 2388 5939, Fax: 852 2374 3575 E-mail: kcchanghome@hotmail.com Dr Naoko Ishikawa, Deputy Director, Tuberculosis and Infectious Disease Control Division, Health Service Bureau, Ministry of Health, Labour and Welfare, 1-2-2, Kasumigaseki, Chiyoda-ku, Tokyo 100-8916 Tel.: 81 3 3595 2257, Fax: 81 3 3581 6251 E-mail: ishikawa-naoko@mhlw.go.jp Dr Phannasinh Sylavanh, DirectorNational Tuberculosis Centre , Ministry of Health, Simouang Road, Vientiane Tel.: (856) 219 078, Fax: (856) 452855 E-mail: ntcplao@laotel.com Dr Soth Bounmala, Chief, Planning and Financing Division, National Tuberculosis Control Program, Dongpalane Thong Road, Ban Phonesinuane, Sisattanak District, Vientiane Telefax: (856) 021 452 855; E-mail: ntcp@laotel.com MACAO, CHINA Dr Chou Kuok Hei, Head, Tuberculosis, Department of Health Special Administrative Region (SAR), Macao Tel.: 853 532196; 853 532225, Fax: 853 530582 E-mail: ctb@ssm.gov.mo

HONG KONG, CHINA

JAPAN

LAO PEOPLE’S DEMOCRATIC REPUBLIC

MALAYSIA

Dr Mohamed Naim bin Abdul Kadir, Principal Assistant Director , TB/Leprosy, Level 3, Block A, Health Office Complex, Ministry of Health, Jalan Cenderasari, 50590 Kuala Lumpur Tel.: (603) 26946601, Fax: (603) 26946404 E-mail: mnak@time.net.my Dr Nymadawa Naranbat, Deputy Director for TB Control, National Center for Communicable Diseases, Central Post, P.O. Box 596, Ulaanbaatar – 13 Tel.: 976 11 451166, Fax: 976 11 450492 E-mail: pnbat@yahoo.com Dr Purevdagva Anuzaya, Project Officer, GFATM, “Accelerating DOTS in Mongolia,” Ministry of Health, 2 Olympic Street , Ulaanbaatar – 48 Tel.: 976 11 311328, Fax: 976 11 326115 E-mail: anuzaya@mongol.net; anuna_chu@yahoo.com

MONGOLIA

PAPUA NEW GUINEA

Dr James Wangi, Acting Director, Disease Control Branch Department of Health, P.O. Box 807, Waigani, N.C.D. Tel.: 675 3013738, Fax: 675 3234515 E-mail: jwangi@health.gov.pg Dr Paul Aia, Specialist Medical Officer for TB, Mt. Hagen General Hospital, P.O. Box 36, Mt. Hagen, Western Highlands Province Waigani, N.C.D. Tel.: (675) 542 1174/542 1166, Fax: (675) 542 2127

PHILIPPINES

Dr Myrna Cabotaje, Director IV, National Center for Disease Prevention and Control, Department of Health, Sta. Cruz, Manila Telefax: (632) 7117846 E-mail: mccabotaje@co.doh.gov.ph Dr Jaime Lagahid, Medical Officer VII and Officer-in-Charge Center for Infectious Disease Office, National Center for Disease Prevention and Control, Department of Health Sta. Cruz, Manila Telefax: (632) 7116808 E-mail: jaimelagahid@edsa.com Dr Rosalind Vianzon, Medical Specialist IV, TB Division, Center for Infectious Disease Office, National Center for Disease Prevention and Control, Department of Health Sta. Cruz, Manila Telefax: (632) 7117808 E-mail: rgvianzon10@yahoo.com

REPUBLIC OF KOREA

Dr Hur Yong, Director, Disease Control Division, Ministry of Health and Welfare, Seoul Tel.: (822) 503 7543, Fax: (822) 504 1100 E-mail: gonie@chollian.net A/Prof Wang Yee Tang, Director, TB Control Unit, Department of Respiratory Medicine, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore 308433 Tel.: (65) 6357 7861, Fax: (65) 6357 7871 E-mail: yee_tang_wang@ttsh.com.sg

SINGAPORE

VIET NAM, SOCIALIST REPUBLIC OF

Dr Bui Duc Duong, Deputy Director, National Hospital of Tuberculosis and Respiratory Diseases, 463 Hoang Hoa Tham Street, Ha Noi Tel.: (844) 832 9229, Fax: (844) 832 6162 E-mail: vnntp_463@hn.vnn.vn; bdduong@hn.vnn.vn Dr Do Chau Giang, Head, Training and Health Education Department, Pham Ngoc Thach Hospital, 120 Hung Vuong St., District 5, Ho Chi Minh City Tel.: (084) 08083479/(848) 8550189, Fax: (848) 8574264 E-mail: giangcb2000@yahoo.com

3. RESOURCE PERSONS Dr Eun Gyu Lee, Section Chief, Epidemiology Research, Korean Institute of Tuberculosis, 14 Woomyundong, Sochogu, 137-140 Seoul, Republic of Korea Tel.: (82) 2 576 4982, Fax: (82) 2 573 1914; E-mail: eg_lee@yahoo.com; Eglee61@kornet.net Dr Jacques Sebert, 29 Square Michelet, 13009 Marseilles, France Telefax: (33) 4 9171 4688; E-mail: jacques.sebert@free.fr

4. REPRESENTATIVES OF PARTNER AGENCIES ASIAN DEVELOPMENTBANK Dr Maryse Dugue, Project Specialist (Health), Pacific Operations Division, Pacific Department Asian Development Bank, 6 ADB Avenue, Mandaluyong City , 0401Philippines Tel.: (632) 636 4444, Fax: (632) 636 2444 E-mail: mdugue@adb.org Ms Myrna Jarillas, Senior Program Officer, CIDA Manila, 11/F Allied Bank Building, 6754 Ayala Avenue, Makati City, Philippines Tel.: (63) 2 867 0139, Fax: (63) 2 810 5142 E-mail: myrna.jarillas@dfait-maeci.gc.ca Dr Michael Qualls, Deputy Associate Director for International Activities, Division of Tuberculosis Elimination, National Center for HIV, STD and TB Prevention, US Centers for Disease Control and Prevention, Atlanta, Georgia 30333 United States of America Tel.: 1 (404) 639 8120, Fax: 1 (404) 639 8604 E-mail: muq1@cdc.gov Dr Guido Groenen, DFB Medical Coordinator for Southeast Asia , DFB Laos c/o World Health Organization, P.O. Box 343, Vientiane, Lao People’s Democratic Republic Tel.: (856-21) 413431/413023, Fax: (856-21) 413432 E-mail: guido.gerda@visto.com Mr James Yue, Executive Secretary, The Hong Kong Tuberculosis, Chest and Heart Diseases Association Secretary General, IUATLD Eastern Regional Office 266 Queen’s Road East Wanchai Hong Kong, China Tel.: (852) 2572 3466, Fax: (852) 2834 0711 E-mail: antitb@ha.org.hk

CANADIAN INTERNATIONAL DEVELOPMENT AGENCY (CIDA)PHILIPPINES

CENTERS FOR DISEASE CONTROL AND PREVENTION (CDC)

DAMIEN FOUNDATION BELGIUM (DFB)

INTERNATIONAL UNION AGAINST TUBERCULOSIS AND LUNG DISEASE (IUATLD), EASTERN REGIONAL OFFICE, HONG KONG, CHINA

JAPAN ANTI-TUBERCULOSIS ASSOCIATION (JATA)

Dr Masashi Suchi, Head, Department of International CooperationJATA1-2-12 Misakisho, Chiyoda-ku, Tokyo 101-0061 Japan Tel.: (81) 424 935340, Fax: (81) 424 928258 E-mail: suchi@jata.or.jp Dr Kosuke Okada, Chief Advisor, CENAT/JICA National TB Control Projectc/o JICA Cambodia Office, P.O. Box 613 Phnom Penh Cambodia Tel.: (855) 23 218091, Fax: (855) 23 218090 E-mail: kosuke.okada@online.com.kh Dr Shinji Shishido, Chief Advisor, JICA Philippines G/F National Tuberculosis Reference Laboratory, Research Institute for Tropical Medicine, Filinvest Corporate City, Alabang, Muntinlupa City, Philippines Tel: (632) 772 2068 to 70, Telefax: (632) 772 2063 E-mail: tbcp@compass.com.ph Dr Tomohiro Shirahama,JICA Expert on TB Control, JICA Philippines, G/F National Tuberculosis Reference Laboratory, Research Institute for Tropical Medicine Filinvest Corporate City, Alabang, Muntinlupa City, Philippines Tel: (632) 772 2068 to 70; Telefax: (632) 772 2063 E-mail: tbcp@compass.com.ph Dr Arthur B. Lagos, Medical Advisor, JICA Philippines G/F National Tuberculosis Reference Laboratory, Research Institute for Tropical Medicine, Filinvest Corporate City, Alabang, Muntinlupa City, Philippines Tel: (632) 772 2068 to 70, Telefax: (632) 772 2063 E-mail: tbcp@compass.com.ph

JAPAN INTERNATIONAL COOPERATION AGENCY (JICA), CAMBODIA

JAPAN INTERNATIONAL COOPERATION AGENCY (JICA), PHILIPPINES

MEDICOS DEL MUNDO

Dr Jose Luis Portero Navio, Research Adviser and Project Administrator, Medicos del Mundo (Spain), 2000 Roxas Boulevard 1004 Malate, Manila, Philippines Tel.: (632) 525 9399, Fax: (632) 711 6654 E-mail: jporteronavio@yahoo.com; mdmanila@info.com.ph Dr Maria Rubio-Yuste, Project Coordinator, Medicos del Mundo (Spain), 2000 Roxas Boulevard, 1004 Malate, Manila, Philippines Tel.: (632) 525 9399, Fax: (632) 711 6654 E-mail: mdmanila@info.com.ph

MINISTRY OF HEALTH, BRUNEI DARUSSALAM

Mr Haji Abu Haji Serudin, Senior TB Visitor Bandar Seri Begawan 1210 Brunei Darussalam Tel.: (673) 2 381 640, Fax: (673) 2 381 440 Dr Charles Yu, Chairman, PHILCAT, Quezon Institute Compound, E. Rodriguez Avenue Quezon City, Philippines Telefax: (632) 7498990 E-mail: cyu@philtips.com; resccy@yahoo.com; choly@eudoramail.com Dr Juan Antonio Perez, Chief of Party, PHILTIPS 1608 West Tower, Philippine Stock Exchange Tower Ortigas Avenue, Pasig City, Metro Manila, Philippines Tel.: (632) 687 7135, Fax: (632) 687 2195 E-mail: jperez@philtips.com; jperes@chemonics.net

PHILIPPINE COALITION AGAINST TUBERCULOSIS (PHILCAT)

PHILIPPINE TUBERCULOSIS INITIATIVE FOR THE PRIVATE SECTOR (PHILTIPS)

Dr Rodrigo Romulo, Technical Advisor, PHILTIPS 1608 West Tower, Philippine Stock Exchange Tower Ortigas Avenue, Pasig City, Metro Manila, Philippines Tel.: (632) 687 7135, Fax: (632) 687 2195 E-mail: rlcromulo@philtips.com SECRETARIAT OF THE PACIFIC COMMUNITY Dr Janet O’Connor, TB Specialist, Secretariat of the Pacific Community, Post Box D598848 Noumea CEDEX New Caledonia Tel.: (687) 260 116, Fax: (687) 263 818 E-mail: janetO@spc.int Prof S.H. Lee, Vice President, The Hong Kong Tuberculosis, Chest and Heart Diseases Association, 266 Queen’s Road East Wanchai, Hong Kong, China Tel.: (852) 2572 3466, Fax: (852) 2834 0711 E-mail: antitb@ha.org.hk Dr Andrew P. Clements, Regional Health and Infectious Diseases Advisor, Bureau of Asia & the Near-East Global Bureau, Office of Health and Nutrition USAID/ANE/SEA/ SPAUSAID/G/PHN/HN/EH, Room 3.07-080B, 3rd Floor, RRB Washington, D.C. 20523-3700 United States of America Tel.: (202) 712 4218/ (202) 712 1083; Fax: (202) 216 3702 E-mail: aclements@usaid.gov Ms Catherine Fischer, Senior Technical Advisor, 8/F PNB Financial Center, Roxas Boulevard 1308 Pasay City, Metro Manila, Philippines Tel. : (632) 552 9800 local 9865 Fax : (632) 551 9081 ext 5410 E-mail: CFisher@usaid.gov WORLD VISION DEVELOPMENT FOUNDATION, INC. Dr Melvin Magno, National KB Project Coordinator World Vision Development Foundation Inc. (Philippines) 55 Maginhawa St., UP Village, Diliman, Quezon City, Metro Manila, Philippines Tel: (632) 927-0676-79, Fax: (632) 921-0195 E-mail: melvin-magno@wvi.org Ms Elaine Martinez-Umali, National KB Project Manager, World Vision Development Foundation Inc. (Philippines) 55 Maginhawa St., UP Village, Diliman, Quezon City, Metro Manila, Philippines Tel: (632) 927-0676-79; Fax: (632) 921-0195 E-mail: elaine_martinez@wvi.org

THE HONG KONG TUBERCULOSIS, CHEST AND HEART DISEASES ASSOCIATION

U.S. AGENCY FOR INTERNATIONAL DEVELOPMENT (USAID)

5. SECRETARIAT WHO WESTERN PACIFIC Dr Dong Il Ahn, (Responsible Officer) Regional Adviser Stop REGIONAL OFFICE (WHO/WPRO) TB and Leprosy Elimination, WHO/WPRO, U.N. Avenue 1000 Manila, Philippines Tel.: (632) 528 8904; Fax: (632) 521 1036 E-mail: ahnd@wpro.who.int

Dr Pieter van Maaren, (Co-Responsible Officer) Medical Officer, Stop TB and Leprosy Elimination, WHO/WPRO U.N. Avenue, 1000 Manila, Philippines Tel.: (632) 528 9706, Fax: (632) 521 1036 E-mail: vanmaarenp@wpro.who.int Ms Priya Goyal, Technical Officer, Stop TB and Leprosy Elimination, WHO/WPRO, U.N. Avenue 1000 Manila , Philippines Tel.: (632) 528 9727, Fax: (632) 521 1036 E-mail: goyalp@wpro.who.int Dr Sumana Barua, Medical OfficerStop TB and Leprosy Elimination, WHO/WPRO, U.N. Avenue 1000 Manila , Philippines Tel.: (632) 528 9709; Fax: (632) 521 1036 E-mail: baruas@wpro.who.int Dr Daniel Chin, Medical Officer, Tuberculosis Office of the WHO Representative in China, 401 Dongwai Diplomatic Office Building 23, Dongzhimenwai Daijie, Chaoyang District, 100600 Beijing, China Tel.: (8610) 6532 7190 ext. 628 Fax: (8610) 6532 2359 E-mail: chind@chn.wpro.who.int Dr Mariquita Mantala, Medical Officer, Tuberculosis Office of the WHO Representative in China, 401, Dongwai Diplomatic Office Building23, Dongzhimenwai Daijie, Chaoyang District 100600 Beijing, China Tel.: (8610) 6532 7190, Fax: (8610) 6532 2359 E-mail: mantalam@chn.wpro.who.int Dr Maarten Bosman, Medical Officer, Tuberculosis Office of the WHO Representativein Viet Nam, P.O. Box 52, Ha Noi, Viet Nam Tel.: (844) 943 3734 to 3746, Fax: (844) 943 3740 E-mail: bosmanm@vtn.wpro.who.int Dr Erwin Cooreman, Medical Officer, Tuberculosis Office of the WHO Representativein Papua New Guinea P.O. Box 5896, Boroko, N.C.D.Papua New Guinea Tel.: (675) 301 3757, Fax: (675) 325 0568 E-mail: cooremane@png.wpro.who.int Dr Ichiro Itoda, Medical Officer, Tuberculosis Office of the WHO Representativein the South Pacific P.O. Box 113 Suva, Fiji Tel.: (679) 3304600; 3304631; 3304635 Fax: (675) 3300462; 3311530 E-mail: itodai@sp.wpro.who.int Dr Pratap Jayavanth, Medical Officer, Tuberculosis Office of the WHO Representative in Cambodia P.O. Box 1217Phnom Penh,Cambodia Tel.: 855 23 216610 ext 205, Fax: 855 23 26211 E-mail: jayavanthp@cam.wpro.who.int

Dr Michael Voniatis, Medical Officer, Tuberculosis Office of the WHO Representativein the Philippines P.O. Box 2932, Manila, Philippines Tel.: (675) 5289767, Fax: (675) 7313914 E-mail: voniatism@phl.wpro.who.int Ms Anjana Bhushan, Short-term Professional, Health Care Financing, WHO/WPRO, U.N. Avenue 1000 Manila, Philippines Tel.: (632) 528 9814, Fax: (632) 521 1036 E-mail: bhushana@wpro.who.int Ms Sarah Coll-Black, Technical Officer, Stop TB and Leprosy Elimination, U.N. Avenue, 1000 Manila, Philippines Tel.: (632) 528 9709,Fax: (632) 521 1036 E-mail: coll-blacks@wpro.who.int WHO HEADQUARTERS Dr Marcos Espinal, Executive Secretary, Stop TB Partnership World Health Organization 20, avenue Appia CH-1211 Geneva 27, Switzerland Tel: 41 (22) 791 2708, Fax: 41 (22) 791 4886 E-mail: espinalm@who.int Dr Léopold Blanc, Acting Coordinator, TB Strategy & Operations, Communicable Diseases Cluster World Health Organization, 20, avenue Appia CH-1211 Geneva 27, Switzerland Tel.: (41) 22 791 4266, Fax: (41) 22 791 4268 E-mail: blancl@who.int Dr Jun-Wook Kwon, Medical Officer, TB Strategy & Operations , Communicable Diseases Cluster World Health Organization 20, avenue Appia CH-1211Geneva 27, Switzerland Tel.: (41) 22 791 3220; Fax: (41) 22 791 4268 E-mail: kwonj@who.int

ANNEX 3 OPENING REMARKS OF THE REGIONAL DIRECTOR AT TECHNICAL ADVISORY GROUP (TAG) MEETING, 17-19 NOVEMBER, 2003, MANILA, PHILIPPINES Distinguished guests, TAG members, ladies and gentlemen: During the first Technical Advisory Group Meeting to Stop TB, which took place in this very room some three and half years ago, the Technical Advisory Group set a very ambitious goal: reducing the TB burden in the Region by half by 2010. In order to achieve that goal, participants at that meeting – TAG members; TB programme managers; partners; and WHO committed themselves to a set of intermediate targets, including DOTS coverage across the Region by 2005. It is very encouraging to note the progress that has been made since 2000. Political commitment to fight TB has increased in the Region, not only in countries with a high burden of TB, but also in Pacific island countries and in countries with an intermediate burden of TB. In this regard, I would like to congratulate Philippines, who achieved 100% DOTS coverage in less than five years, and Viet Nam, who received an award for outstanding progress in TB control from KNCV TB Foundation at its recent centennial celebration. In less than two years, the funding gap between the funds needed to expand DOTS regionwide and available funds has been reduced from 40% to 10%. There has been very strong support from partners such as the Global Fund to Fight AIDS, Tuberculosis and Malaria and the World Bank. Six high burden countries and ten Pacific island countries in the Region all sent successful proposals to the Global Fund. As a result of the progress made on funding, countries are closing in on 2005 targets of the Stop TB programme. For example, DOTS coverage in the Region reached 77% by the end of 2002, up from 58% in 1999. Now that the funding gap has almost been filled, it is time for countries and their partners to focus on the implementation of effective TB control activities. Both countries and WHO will need to step up their efforts if we are to reach the Regional targets in 2005, which is only two years away. This meeting will review the progress made so far, and analyse the current status of DOTS expansion in the seven countries with a high burden of TB. It is clear that, given the current 77% DOTS coverage in the Region, in the next two years the focus of the TB control activities needs to be on DOTS expansion. Based on the 5-year action plans that were developed in 2001, countries have prepared 2-year DOTS acceleration plans that should bring the 2005 targets within reach.

THE

FOURTH

The Regional case detection rate, which currently stands at 44%, is lagging behind the 2005 target of 70%. Most countries represented here today are still far from this goal. This problem can be addressed in different ways. It may be tempting for countries to focus on specific activities that increase case detection. However, it is my conviction that countries, by providing full access to DOTS and improving the quality of DOTS implementation, will experience an important increase in their case detection rates. In addition, some countries may develop innovative approaches to reach population groups at risk, including the poor and vulnerable, and expand strategies to involve the private sector through Public-Private Mix DOTS. Similar to last year’s TAG meeting in Osaka, this meeting will also attend to the problems of TB control in some of the more affluent countries with an intermediate burden of TB. I would like to ask TAG members to review the progress made since the Osaka meeting, and discuss the options for these countries to strengthen their DOTS implementation and monitor TB control activities through effective TB information systems. Ladies and gentlemen, I want to express my appreciation to you, the TAG members. For the fourth successive year, I believe you will make a major contribution to alleviating the TB problem in our Region and will guide countries in the implementation of sustainable TB control beyond 2005. I want to conclude by acknowledging the contributions by partners to the implementation of the DOTS acceleration plans. I would like to thank the Australian Agency for International Development; the Canadian International Development Agency; the Department for International Development of the UK; the Global Fund to fight AIDS, Tuberculosis and Malaria; the Government of Japan; the United States Agency for International Development; the World Bank, and our other partners for their continued support to TB control in the Region, our already strong political commitment and partnership will be further strengthened at all levels to fight tuberculosis and poverty in the Western Pacific.

ANNEX 4: COUNTRIES

WITH A

HIGH BURDEN

TUBERCULOSIS

COUNTRY PRESENTATION: CAMBODIA

COUNTRY PRESENTATION: CHINA, PEOPLE’S REPUBLIC OF

COUNTRY PRESENTATION: LAO PEOPLE’S DEMOCRATIC REPUBLIC

COUNTRY PRESENTATION: MONGOLIA

COUNTRY PRESENTATION: PAPUA NEW GUINEA

COUNTRY PRESENTATION: PHILIPPINES

COUNTRY PRESENTATION: VIET NAM

ANNEX 5: COUNTRIES WITH TUBERCULOSIS

INTERMEDIATE BURDEN

COUNTRY PRESENTATION: BRUNEI DARUSSALAM

COUNTRY PRESENTATION: HONG KONG

COUNTRY PRESENTATION: JAPAN

COUNTRY PRESENTATION: MACAU

COUNTRY PRESENTATION: MALAYSIA

COUNTRY PRESENTATION: REPUBLIC OF KOREA

COUNTRY PRESENTATION: SINGAPORE

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Key facts

Organisation World Health Organization (WHO)

Document type Technical Documents

Adoption date December 31, 2003

Source World Health Organization