WORLD HEALTH ORGANIZATION EXECUTIVE BOARD 114th Session Provisional agenda item 4.9 EB114/14 29 April 2004
Sustainable financing for tuberculosis control Report by the Secretariat 1. A global plan for the period 2006-2015 is being drawn up to achieve the Millennium Development Goal 6: “Combat HIV/AIDS, malaria and other diseases”. Target 8 under that Goal is relevant to tuberculosis: to “have halted by 2015, and begun to reverse, the incidence of malaria and other major diseases”. The indicators for reaching this target are prevalence and death rates associated with tuberculosis and the proportion of cases of tuberculosis detected and cured by directly observed treatment, short-course (DOTS). This report provides a framework for discussing the promotion of, and reporting on, sustainable financing for tuberculosis control within that global plan. 2. The global targets for tuberculosis control set for the year 2000 by resolutions WHA44.8 and WHA46.36 were to detect 70% of new infectious cases and to treat successfully 85% of detected sputum-positive patients. Countries still need to reach those targets and sustain such levels of control in order to achieve the reduction in prevalence and death rates indicated in the Millennium Development Goals. Even though considerable progress has been made, the Health Assembly recognized in resolution WHA53.1 that most of the countries with the greatest burden of disease would not meet those global targets by 2000. It endorsed the Amsterdam Declaration to Stop Tuberculosis, which reset targets to 2005. Many countries have made considerable progress towards attaining these targets: the latest global figures for new sputum smear-positive cases indicate a 37% case detection rate (at the end of 2002) and an 82% treatment success rate (for patients registered in 2001).1 Progress in case detection has been accelerating, but at the current rate of progress the 70% target rate will be reached only in 2013. Although the treatment success rate is substantially below average in Africa (71%) and in eastern Europe (70%), the global target of an 85% rate should be attained by 2005. 3. Drug-resistant tuberculosis and the fuelling of the tuberculosis epidemic by HIV pose particular difficulties in tuberculosis control. Although progress in widespread implementation of the DOTS strategy will help to prevent the further emergence of drug resistance, the application of DOTS-Plus, a complement to the standard DOTS strategy, is necessary to stem the current contribution of drugresistant cases to the overall tuberculosis epidemic. Control of HIV-related tuberculosis depends on collaboration between tuberculosis and HIV programmes in implementing the expanded control strategy, which comprises interventions against tuberculosis and against HIV (and therefore indirectly against tuberculosis) and is adapted to a country’s HIV prevalence.2
1 2
Global tuberculosis control: surveillance, planning, financing. Geneva, World Health Organization, 2004. Document WHO/HTM/TB/2004.330.
EB114/14
4. The progress so far in global tuberculosis control has been based on formation of partnerships, good coordination and improved planning at global, regional and country levels, and on increased financing for implementing the DOTS strategy. More funding, the development of better tools (new drugs, improved diagnostic tools and more effective vaccines) and the application of a universal standard of care hold out the prospect of accelerating progress in global tuberculosis control. 5. Sustainable financing for tuberculosis control is taken to mean the set of financial options that promote equity, achieve efficiency, provide resources in an adequate, timely and reliable manner, are compatible with transparency and accountability, and encourage the highest possible level of financial self-sufficiency. The options available that fulfil these criteria include domestic public funds, domestic private funds, external public and external private funds. 6. At the global level, the Stop TB Partnership now provides an effective vehicle for promoting and coordinating the contributions of a wide and increasing range of stakeholders. The Global Plan to Stop Tuberculosis for 2001-2005 identifies the funding needed for global tuberculosis control (implementation and research), and the DOTS Expansion Working Group, in collaboration with the working groups on tuberculosis/HIV and DOTS-Plus, coordinates the implementation of the DOTS strategy. Progress in the regions in matching these global developments in partnership, coordination and planning has been varied. 7. At the country level, more national Stop TB partnerships are being formed in order to support the implementation of plans for long-term expansion of DOTS through national interagency coordination committees. So far, in countries with high tuberculosis incidence rates, financing of tuberculosis control has come from governmental and other domestic sources as well as external sources (including bilateral, multilateral and nongovernmental organizations and foundations). Now, the Global Fund to Fight AIDS, Tuberculosis and Malaria is beginning to make substantial financial contributions. In addition, in the Amsterdam Declaration Member States committed themselves to ensuring sufficient and sustainable domestic resources; financing mechanisms include poverty reduction strategy papers. 8. Despite recent progress in tuberculosis control, important constraints remain. The six most commonly identified in 2003 by countries with a heavy burden of tuberculosis were lack of qualified staff, poor monitoring and evaluation, inadequate infrastructure, weak laboratory services, the failure of tuberculosis programmes to engage the full range of health providers (including all those in the public sector and private practitioners), and ineffective decentralization. In those countries with both HIV and tuberculosis epidemics, the impact of HIV has exacerbated many of these limitations on tuberculosis control. In addition, despite the mobilization of more resources for tuberculosis control, both existing gaps in funding and uncertainty about future financing continue to impede planning and implementation. For example, recent data indicate that funding falls about 20% short of the total needs for DOTS expansion in 2004 and 2005. The Commission on Macroeconomics and Health in 2001 identified the need to increase spending by on average US$ 1000 million per year over the period 2002-2015 for DOTS implementation (excluding investments in the control of both HIV-related and multidrug-resistant tuberculosis) and research into new drugs, diagnostic tools and vaccines.1 It further stated that this increased funding will need to come from both countries with high incidence rates of tuberculosis and external sources.
Macroeconomics and health: investing in health for economic development. Report of the Commission on Macroeconomics and Health. Geneva, World Health Organization, 2001.
1
2
EB114/14
9. To achieve the Millennium Development Goal relevant to tuberculosis, long-term planning and associated funding are needed for the period 2006 to 2015. To accelerate progress will require broad improvements in health systems, as recommended by the second ad hoc committee on the tuberculosis epidemic.1 Tuberculosis programmes need to work with stakeholders to implement its other main recommendations: (1) to consolidate, sustain and advance achievements; (2) to enhance political commitment; (3) to address the health workforce crisis; (4) to strengthen health systems, particularly primary care delivery; (5) to accelerate the response to the tuberculosis/HIV emergency; (6) to mobilize communities and the corporate sector; and (7) to invest in research and development to shape the future. Plans for implementing these improvements will need to be backed by sound financial planning, supported by sustainable financing to close all projected funding gaps, with coordination between funding sources.
ACTION BY THE EXECUTIVE BOARD 10. The Board is invited to consider the following draft resolution: The Executive Board, Having considered the document on sustainable financing and tuberculosis control,2 RECOMMENDS to the Fifty-eighth World Health Assembly the adoption of the following resolution: The Fifty-eighth World Health Assembly, Having considered the document on sustainable financing and tuberculosis control; Aware of the need to diminish the global burden of tuberculosis and thereby lower this barrier to socioeconomic development; Welcoming the progress made towards achieving the global tuberculosis control targets for 2005 following the establishment, in response to resolution WHA51.13, of the Stop Tuberculosis Initiative;3 Stressing the importance of the engagement of the full range of health providers in delivering the international standard of tuberculosis care in line with the strategy of directly observed treatment, short-course (DOTS); Concerned that lack of commitment to sustained financing for tuberculosis control will impede the sound long-term planning necessary to achieve the Millennium Development Goal relevant to tuberculosis;
Report of the meeting of the second ad hoc committee on the TB epidemic: recommendations to Stop TB partners (Montreux, Switzerland, 18-19 September 2003). Geneva, World Health Organization, 2004. 2 3
1
Document EB114/14. Now known as the Stop TB Partnership.
3
EB114/14
Encouraging the development of a global plan for the period 2006-2015, which will address the need for sustained financing in order to achieve the Millennium Development Goal relevant to tuberculosis, 1. ENCOURAGES all Member States: (1) to fulfil the commitments made in endorsing resolution WHA53.1 and hence the Amsterdam Declaration to Stop Tuberculosis including their commitment to ensure the availability of sufficient domestic resources and of sufficient external resources to achieve the Millennium Development Goal relevant to tuberculosis; (2) to ensure that all tuberculosis patients have access to the universal standard of care that is based on the proper diagnosis, treatment and reporting consistent with the DOTS strategy by promoting both supply and demand; 2. REQUESTS the Director-General: (1) to intensify support to Member States in developing capacity and improving the performance of national tuberculosis control programmes within the broad context of strengthening health systems in order: (a) to accelerate progress towards reaching the global target of detecting 70% of new infectious cases and successfully treating 85% of those detected; (b) to sustain achievement of that target in order to reach the Millennium Development Goal relevant to tuberculosis; (2) to strengthen cooperation with Member States with a view to improving collaboration between tuberculosis and HIV programmes, in order: (a) to implement the expanded strategy to control HIV-related tuberculosis; (b) to enhance HIV/AIDS antiretroviral treatment; programmes, including delivery of
(3) to take the lead in working with partners to devise a mechanism to facilitate sustainable financing of tuberculosis control; (4) to enhance WHO’s support to the Stop TB Partnership in its efforts to achieve the Millennium Development Goal relevant to tuberculosis.
=
=
=
4
WORLD HEALTH ORGANIZATION EXECUTIVE BOARD 114th Session Provisional agenda item 4.9 EB114/14 Corr.1 6 May 2004
Sustainable financing for tuberculosis control Report by the Secretariat CORRIGENDUM The penultimate sentence of paragraph 8 should read as follows: The Commission on Macroeconomics and Health in 2001 identified the need to increase spending by on average US$ 1000 million per year over the period 2002-2015 for DOTS implementation (excluding investments in the control of both HIV-related and multidrugresistant tuberculosis and research into new drugs, diagnostic tools and vaccines).1
=
=
=