Key political commitment documents for tuberculosis prevention and care and their intended influence in the WHO European Region: analytical report

KEY POLITICAL COMMITMENT DOCUMENTS FOR TUBERCULOSIS PREVENTION AND CARE AND THEIR INTENDED INFLUENCE IN THE WHO EUROPEAN REGION ANALYTICAL REPORT ABSTRACT This analytical report reviews and discusses the potential role and influence of political commitment in implementing endorsements and conducting policy in the field of tuberculosis (TB) prevention and care. It promotes discussion by comparing and analysing the extent to which selected international commitments, set out in declarations and other committal documents between 2000 and 2018, may have translated into sustainable action. This reflection is relevant and timely, as the United Nations high-level meeting (UNHLM) on TB recently took place, offering countries the opportunity to take stock of progress made, refocus efforts, and step up global commitments to achieve the United Nations Sustainable Development Goal of eliminating TB by 2030. Literature identified in the context of developing this report (technical reports, peer-reviewed publications and grey literature) recognizes the 2007 Berlin Declaration as a milestone in committing countries to multiply their TB prevention and care efforts, and underlines the key role of political commitment, good governance and accountability in achieving set targets to combat TB. The report offers definitions of these three ideas. To guide countries to a more systematic follow up on their commitments, any future accountability framework, for example destined to facilitate the follow-up of the implementation of the declaration resulting from the recent TB UNHLM should be multisectoral, involving stakeholders across sectors, across borders and across illnesses. It should include existing (often health-related) tools and indicators but also present new monitoring and evaluating mechanisms that focus on the co-determinants of TB infection, allowing countries with different health-financing contexts and at different stages of economic growth to put them to use. Such a multisectoral accountability framework shall be user-friendly, as it is conceptualized to blend with existing country-level recording and reporting activities. Adequate feedback mechanisms at different levels, including national, regional and global, are suggested. Keywords TUBERCULOSIS – PREVENTION AND CONTROL POLITICS INTERNATIONAL COOPERATION PROGRAM EVALUATION EUROPE Address requests about publications of the WHO Regional Office for Europe to: Publications WHO Regional Office for Europe UN City, Marmorvej 51 DK-2100 Copenhagen Ø, Denmark Alternatively, complete an online request form for documentation, health information, or for permission to quote or translate, on the Regional Office website (http://www.euro.who.int/pubrequest). © World Health Organization 2019 All rights reserved. The Regional Office for Europe of the World Health Organization welcomes requests for permission to reproduce or translate its publications, in part or in full. 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. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either express or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. The views expressed by authors, editors, or expert groups do not necessarily represent the decisions or the stated policy of the World Health Organization. Document number: WHO/EURO:2019-3501-43260-60629 page iii CONTENTS Page Contributors ....................................................................................................................... v Acronyms ....................................................................................................................... vi Executive summary ........................................................................................................... vii 1. Introduction and background ........................................................................................... 1 Scope and purpose .................................................................................................... 2 Aims and objective ..................................................................................................... 3 2. Political commitment and its importance ........................................................................... 4 Defining political commitment, accountability and governance ....................................... 5 3. Methodology .................................................................................................................. 7 Search strategy ......................................................................................................... 7 4. Political commitment ....................................................................................................... 8 Existing projects or efforts to measure political commitment .......................................... 8 Challenges and impediments in measuring political commitment .................................... 9 Recommendations for measuring political commitment ............................................... 10 5. Declarations on TB and related documents ..................................................................... 11 Overview of the Amsterdam Declaration to Stop TB .................................................... 11 Overview of the Berlin Declaration on TB ................................................................... 12 Overview of the Joint Riga Declaration on TB and its Multi-drug Resistance .................. 13 Overview of the Moscow Declaration to End TB .......................................................... 14 Overview of the Estonian Senior-level Policy Dialogue: Addressing HIV and TB Challenges and its resulting outcome document .......................................................................... 15 Overview of the UNHLM on TB and the political declaration adopted by resolution at the Seventy-third United Nations General Assembly .......................................................... 16 Key events and documents citing the Berlin Declaration .............................................. 17 Grey literature search results .................................................................................... 19 Conclusion............................................................................................................... 20 6. Mapping exercise .......................................................................................................... 22 Similarities .............................................................................................................. 22 Differences .............................................................................................................. 23 page iv 7. Monitoring and accountability on TB ............................................................................... 27 8. Discussion .................................................................................................................... 29 Acceleration of progress and maintaining political commitment .................................... 29 9. Conclusion ................................................................................................................... 31 The way forward ...................................................................................................... 31 References ...................................................................................................................... 34 page v Contributors This analytical report was written by Ms Sandra E. Roelofs (Consultant), Ms Sabina Safronova (Consultant), Dr Martin van den Boom (Technical Officer) and Dr Masoud Dara (Coordinator, Communicable Diseases and Programme Manager), Joint TB, HIV and viral Hepatitis Programme, Division of Health Emergencies & Communicable Diseases, WHO Regional Office for Europe. Additional technical inputs were provided by the following WHO Regional Office for Europe staff: Dr Soudeh Ehsani (Technical Officer); Ms Vittoria Gemelli (Consultant); Dr Ogtay Gozalov (Medical Officer); Dr Sayohat Hasanova (Technical Officer); Dr Ihor Perehinets (Technical Adviser); and Mr Szabolcs Szigeti (National Professional Officer). page vi Acronyms AMR antimicrobial resistance DOTS directly observed treatment, short course ECDC European Centre for Disease Prevention and Control EECA Eastern Europe and central Asia EU European Union GFATM Global Fund to Fight AIDS, Tuberculosis and Malaria M&E monitoring and evaluation MDG (United Nations) Millennium Development Goal MDR-TB multidrug-resistant tuberculosis MSF Médecins Sans Frontières NGO nongovernmental organization SDG (United Nations) Sustainable Development Goal SMART specific, measurable, attainable, relevant and time-bound TB tuberculosis TBEC TB Europe Coalition UHC universal health coverage UNHLM United Nations high-level meeting USAID United States Agency for International Development XDR-TB extensively drug-resistant tuberculosis page vii Executive summary The WHO European Region has the fastest decline of tuberculosis (TB) incidence and mortality among all WHO Regions. TB incidence and mortality rates decreased from 38 new cases in 2012 to 32 in 2016, and from 4.4 to 2.8 deaths per 100 000 people respectively. This is the fastest TB burden decline of all WHO regions (European Centre for Disease Prevention and Control & WHO Regional Office for Europe, 2018). To end TB as envisioned by Sustainable Development Goal (SDG) 3 target 3, “to end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and combat hepatitis, waterborne disease and other communicable disease (by 2030),” more efforts are needed to speed up the decline in TB rates in the Region. It has been argued that antimicrobial resistance, which is a huge challenge for TB, should be confronted through a combined global effort, championed by high-level political decision- makers such as heads of state and global institutions, and through more far-reaching and coordinated actions by interlinked and synergistic health-sector components adopting a whole- of-society multisectoral approach. A similar approach is required for TB to achieve the objectives, goals and targets set out in TB declarations and initiatives. It has been emphasized that political commitment is essential to developing and maintaining a successful response to the TB epidemic. This analytical report provides a comprehensive, comparative assessment of contemporary declarations on TB and other relevant committal documents, including whether they have translated into political action and to what degree. Findings of this report suggest that due to its multidimensional nature, political commitment/support is a challenging concept to measure through quantitative indicators. It was nevertheless found that political commitment and actions could be measured indirectly through review of statements, adoption of policies and actions taken by the political leaders. Findings also indicate that since the endorsement of the Berlin Declaration in 2007, several events and forums have been established to assess and discuss progress in fighting the TB epidemic. This underscores the initiative exemplified by the WHO European Region Member States and other partners involved in decreasing TB incidence by 2030 and achieving the overall milestones and targets of the SDGs with the WHO End TB Strategy and the Roadmap to implement the tuberculosis action plan for the WHO European Region 2016–2020: towards ending tuberculosis and multidrug-resistant tuberculosis. Despite this advance, evidence indicates that regardless of the policies and endorsements of declarations, all of which represent positive steps towards elimination of TB, they must not be standalone options; more is needed for (higher) impact to achieve the essential targets and milestones. The analytical report has also ascertained that the WHO Global Ministerial Conference on ending TB in the SDG era, which resulted in the Moscow Declaration to End TB in November 2017, and the Estonian Senior-level Policy Dialogue in December 2017 can be considered crucial political milestones in combating TB. These events paved the way for the significance of the TB epidemic and multidrug-resistant and extensively multidrug-resistant TB to be showcased at the first United Nations General Assembly high-level meeting on TB in September 2018. This represents a significant opportunity to sustain and boost the political commitment required to further intensify the battle against TB and put the world and individual countries on the right trajectory to ending suffering from TB and the TB epidemic itself. page viii With regard to the future and the way ahead, it has been argued by several stakeholders (the United Nations Special Envoy on TB and staff, several Member States, four civil society representatives, United Nations organizations and representatives from leading international technical agencies working on TB) that a more systematic monitoring and evaluation/accountability framework needs to be established in/for future declarations, as it would provide built-in/associated tool(s) for better follow up. This analytical report identifies a number of elements that may be missing in existing (accountability) frameworks and monitoring mechanisms, a situation that needs to be examined and considered for the future with a view to improving follow up and translation into action. The report outlines and discusses some such missing elements. The imperative for political commitment and strengthening the coherence of policies, investments and actions across sectors and stakeholders is not only emphasized in the declarations evaluated in this report, but also coincides with the factors emphasized and promoted in the WHO European framework for health and well-being, Health 2020. Reference European Centre for Disease Prevention and Control, WHO Regional Office for Europe (2018). Tuberculosis surveillance and monitoring in Europe, 2018. 2016 data. Stockholm: European Centre for Disease Prevention and Control (https://ecdc.europa.eu/sites/portal/files/documents/ecdc-tuberculosis- surveillance-monitoring-Europe-2018-19mar2018.pdf). Key political commitment documents for tuberculosis prevention and care and their intended influence in the WHO European Region page 1 1. Introduction and background Despite considerable progress in tuberculosis (TB) prevention and care response in the WHO European Region, human suffering and death continues to be caused by TB, multidrug-resistant TB (MDR-TB) and TB/HIV coinfection (WHO Regional Office for Europe, 2016:iv). According to the report Tuberculosis surveillance and monitoring in Europe 2018 published by the European Centre for Disease Prevention and Control (ECDC) and the WHO Regional Office for Europe (2018), the estimated number of TB cases in the WHO European Region has steadily been declining since 2000. The average decline in the TB incidence rate was 4.3% during 2007/2016 and 4.6% between 2015 and 2016, which is significantly higher than the global rate of decline (ECDC & WHO Regional Office for Europe, 2018). Despite this representing the fastest decline in the world (in comparison to other WHO Regions), it needs to be accelerated to achieve the goals and targets of the End TB Strategy (WHO, 2015a; ECDC & WHO Regional Office for Europe, 2018). Currently, the WHO European Region has the highest rates of drug-resistant TB globally and only approximately half of patients with MDR-TB are cured (WHO Regional Office for Europe, 2016:iv). The Region has also witnessed an increase in HIV/AIDS, generating yet another challenge to TB, and MDR/extensively drug-resistant TB (XDR-TB) prevention and care (WHO Regional Office for Europe, 2016:vi). To efficiently respond to the challenges presented by TB, MDR/XDR-TB and TB/HIV, the support and involvement of leaders from all levels of society and continuous political commitment to providing and supporting TB prevention and care are required (United States Agency for International Development (USAID), 2000; WHO Regional Office for the Eastern Mediterranean, 2018a). Political commitment and achievements are difficult to measure through data that are collected consistently (USAID, 2000:4). A so-called Policy Project ran for 11 years (1995–2006), funded by USAID, and was considered a vital resource for improving the policy environment for HIV, family planning/reproductive health and maternal health in developing countries. The project combined several USAID technical assistance areas such as raising awareness, policy dialogue and policy formulations, into one programme (USAID, 2006). There is no single set of best practices that can be put forward to measure the multidimensional concept of political commitment. The measurement can follow different pathways, including both qualitative and quantitative approaches, which can be used in a complementary way. First, direct political commitment can be measured by conducting semi-structured interviews with political leaders, although the validity and accuracy of information provided by politicians needs to be confirmed through other methods. Secondly, it is not unusual for political commitment and achievements to be measured indirectly by examining the public statements of leaders and/or by assessing approved policies and actions that provide evidence of how statements are translated into policy actions (USAID, 2000:5). Finally, a third approach suggests creating a composite indicator by quantifying and measuring the impact of several other components of political commitment; for instance, a composite indicator has been developed to quantify the political commitment of leaders to combating AIDS. This analytical report builds on discussion of indirect measurement of political commitment to provide a more elaborate explanation. Key political commitment documents for tuberculosis prevention and care and their intended influence in the WHO European Region page 2 Scope and purpose Six declarations directed towards further reduction of drug-susceptible and drug-resistant TB have been developed since 2000. These emerged from: ● the Amsterdam Global Ministerial TB Conference in 2000, which led to the Amsterdam Declaration to Stop TB (Stop TB Partnership, 2000a); ● the Berlin WHO European Ministerial Forum, “All Against Tuberculosis”, in 2007, which produced the Berlin Declaration on Tuberculosis (WHO Regional Office for Europe, 2007); ● the first Eastern Partnership Ministerial Conference on Tuberculosis and Multi-drug Resistant Tuberculosis as part of the Latvian European Union (EU) Presidency’s Programme in 2015, in which the Joint Riga Declaration on Tuberculosis and its Multi- drug Resistance was developed (Latvian Presidency of the Council of the European Union & Eastern Partnership, 2015); ● the WHO Global Ministerial Conference “Ending TB in the Sustainable Development Era: a Multi-sectoral Response” in Moscow, 2017, culminating in the Moscow Declaration on TB (Ministry of Health of the Russian Federation & WHO, 2017); ● the Senior-level Policy Dialogue “Addressing HIV and TB Challenges: from Donor Support to Sustainable Health Systems”, which took place in December 2017 in Tallinn under the Estonian Presidency of the Council of the EU and which also issued an outcome document (Council of the European Union, 2017); and ● most recently, the United Nations high-level meeting (UNHLM) on the fight against TB that took place on 26 September 2018 in New York during the 73rd session of the United Nations General Assembly, which issued a political declaration (United Nations General Assembly, 2018). It has been argued that antimicrobial resistance (AMR) can only be confronted through a combined global effort initiated by heads of state and global institutions, and through coordinated action by health sectors (Inoue & Minghui, 2017). The fight against TB, for which AMR in the form of MDR-TB and XDR-TB poses a huge challenge, would therefore also benefit from such a combined global effort. Successful examples of finding effective responses to the HIV/AIDS epidemic that required support and involvement of leaders from all levels and sectors of society could also serve as inspirations in the scale-up of the response to TB. As the high-priority countries of eastern Europe and central Asia experience the highest MDR- TB burden across all regions, both in absolute and proportionate terms (WHO Regional Office for Europe, 2016:2), and lack the necessary funds to address this challenge, the May 2017 meeting of G20 Health Ministers in Berlin committed to increasing efforts related to AMR (Federal Ministry of Health, 2017a). The UNHLM of September 2018 also underlined the importance of AMR and stated that “many of the Sustainable Development Goals may not be attainable if we fail to address antimicrobial resistance” (United Nations General Assembly, 2018:3) It is possible that the upcoming Romanian EU presidency may raise the AMR issue at European level. Mapping of declarations and other committal documents to examine, for example, the extent to which they may have been put into action and with what effects on strengthening TB prevention and care in the WHO European Region, has not been carried out. The rationale for this report therefore was to carry out a comparative analysis of the declarations and other relevant committal documents to heighten understanding of implementation and assess whether, and to what degree, they have translated into political action. This can provide the Region and Member Key political commitment documents for tuberculosis prevention and care and their intended influence in the WHO European Region page 3 States, donors and other relevant entities with a helpful insight into what has been achieved so far and how these political documents have influenced necessary action. Aims and objective The objective is to provide an analytical report that maps out and compares declarations on TB in the WHO European Region and other relevant committal documents. The report aims to: ● support understanding of what else needs to be done for the Roadmap to implement the tuberculosis action plan for the WHO European Region 2016–2020: towards ending tuberculosis and multidrug-resistant tuberculosis (WHO Regional Office for Europe, 2016) to be more efficient and effective by the year 2020; ● provide meaningful discussion on whether the declarations have translated into action (and how) and if any political action has taken place since their endorsement; and ● identify gaps in implementation of commitments into sustainable action. Key political commitment documents for tuberculosis prevention and care and their intended influence in the WHO European Region page 4 2. Political commitment and its importance This chapter introduces relevant definitions of political support and a related concept – good governance – as they relate to the topic of this report. It also discusses why political commitment is encouraged by WHO and by the declarations. Ways in which political commitment can be measured are suggested in Chapter 4. Heightened political commitment is required from Member States and other involved parties to escalate and progress the fight against TB, ultimately ridding the world of the global TB epidemic by the year 2030,1 as envisioned by the United Nations Agenda for Sustainable Development (2030), and 2035, as per the End TB Strategy (WHO, 2015b:vii; WHO, 2017a). The development of a supportive environment for TB programmes involves not only the formulation of appropriate policies (the Berlin or Moscow declarations, or any other relevant TB declaration) and the allocation of resources, but also the mobilization of political parties and social groups to reach political consensus, so that programmes such as the directly observed treatment, short course (DOTS) strategy in 1994, the Stop TB Strategy in 2006 (WHO, 2006), the End TB Strategy in 2015 (WHO, 2015a) and the TB action plan for the WHO European Region 2016–2020 (WHO Regional Office for Europe, 2015a) can have a positive impact on the health care and well-being of society (WHO, 2015b:4; WHO Regional Office for Europe, 2016:29). USAID has been among the first key partners investing in TB prevention and care in eastern Europe and central Asia. The agency states that efficient responses to TB and the MDR/XDR-TB epidemic require the support and involvement of leaders from all levels and sectors of society (USAID, 2000:2) and that political commitment is essential to developing and maintaining an effective response to the TB epidemic (USAID, 2000:3). According to WHO Regional Office for the Eastern Mediterranean and WHO headquarters webpages, strong and active partnership among key stakeholders at country and regional levels is needed to accomplish and maintain the required political commitment (WHO, 2017a; WHO Regional Office for the Eastern Mediterranean, 2018a). This commitment should be connected to long-term strategic planning of national TB prevention and care programmes to address technical and financial prerequisites and encourage accountability for results at all levels of the health system. The requirements for political commitment at national level is described as follows (WHO Regional Office for the Eastern Mediterranean, 2018a): The government considers TB to be a priority for the health system, according to the national TB burden; TB management is included within health policy, with sufficient budget allocation and a suitable structure within the ministry of health assigned responsibility for implementation of the Stop TB Strategy; national TB programmes have developed policy for TB management (including MDR/XDR-TB), based on the Stop TB Strategy tailored to country needs, including guidelines and a long-term (3–5 years) strategic plan to Stop TB, with annual work plans. The Stop TB Strategy referred to above was a strategy/policy initiated to reduce the global burden of TB by 2015 in line with the United Nations Millennium Development Goals (MDGs) and the Stop TB Partnership targets (WHO, 2010a). Since then, it has been replaced by the post- 1 The 2035 targets are a 95% reduction in TB deaths and a 90% reduction in the TB incidence rate, compared with levels in 2015. The 2030 targets are a 90% reduction in TB deaths and an 80% reduction in the TB incidence rate, compared with levels in 2015. Key political commitment documents for tuberculosis prevention and care and their intended influence in the WHO European Region page 5 2015 global TB strategy, the End TB Strategy (WHO, 2015a), with the vision of “a world free of TB” with “zero deaths, disease and suffering due to TB”, and the goal of ending the global TB epidemic by 2035. The principles outlined above are also of relevance for the WHO Regional Office for Europe, as governance aspects apply here as well. One of the End TB Strategy principles emphasizes government stewardship and accountability, with monitoring and evaluation (WHO, 2015a:6). The strategy’s success and efficacy rely on the commitment of Member States and partners (WHO Regional Office for Europe, 2015b:1). In the post-2015 global TB strategy, the term “TB control” has been replaced by “TB prevention and care” (see discussion of this in Chapter 5). Defining political commitment, accountability and governance Two definitions were found following a search in peer-reviewed publications. One describes the concept as “a government that fully defends and supports a service despite other budgetary, epidemiological and technical priorities” (Rodriguez et al., 2017:122). Key elements of both definitions were taken by the authors to arrive at a single definition of political commitment: political commitment is continuous and sustainable support of the political community towards those actors who are trusted or are in charge of formulating and implementing public policies. The political community can include national governments, social partners and international organizations. The scope of the commitment includes not only policies that pursue (despite possible obstacles) consciously selected, usually ambitious and well-defined goals to address policy challenges, but also the allocation of particular attention, visibility and necessary resources to implement appropriate actions. WHO defines leadership and governance, and accountability (WHO, 2010b; WHO, 2014) in the following ways. Leadership and governance in building a health system involves ensuring that strategic policy frameworks exist and are combined with effective oversight, coalition-building, regulation, attention to system design and accountability. Accountability is an intrinsic aspect of governance that concerns the management of relationships between various stakeholders in health, including individuals, households, communities, firms, governments, nongovernmental organizations (NGOs), private firms and other entities that have the responsibility to finance, monitor, deliver and use health services. Accountability involves, in particular: ● delegation or an understanding (either implicit or explicit) of how services are supplied ● financing to ensure that adequate resources are available to deliver essential services ● performance around the actual supply of services ● receipt of relevant information to evaluate or monitor performance ● enforcement, such as imposition of sanctions or the provision of rewards for performance. Governance can work effectively without the appropriate level of political commitment or vice- versa: political commitment might be in place, but good governance is lacking. To move towards the all-sector, all-society holistic approach laid down in the Sustainable Development Agenda and to design a multisectoral accountability framework on TB to that effect means that certain preconditions need to be in place, such as multisectoral policy plans and Key political commitment documents for tuberculosis prevention and care and their intended influence in the WHO European Region page 6 governance mechanisms. This is a challenging first step that may add to the complexity of implementation of existing health governance mechanisms. Key political commitment documents for tuberculosis prevention and care and their intended influence in the WHO European Region page 7 3. Methodology Search strategy A broad strategy was employed to identify relevant literature for development of this analytical report. The initial search began with an online review using the bibliographical databases provided on the WHO Regional Office for Europe website, and the online search engines Google, Google Scholar and PubMed (the last of which gives access to the MEDLINE database of references) to map out the empirical field of the topic. These databases for reviews were based on criteria of relevance, and keywords were used to search them. The search sequence included a combination of the following keywords: [‘Berlin Declaration’ ‘Amsterdam Declaration’ ‘Riga Declaration’ ‘Moscow Declaration’ + ‘TB’ or ‘Tuberculosis’] [‘monitoring and evaluation’ and ‘accountability’ ‘political commitment’ and ‘challenges’ and ‘success’] and [‘technical reports’ + ‘berlin declaration’ + ‘TB’].2 This led to narrowing of the search to peer-reviewed journals and technical reports. The initial search via PubMed came up with eight publications on the Berlin Declaration, whereas online search engines such as Google and Google Scholar revealed 732 000 results, including so-called grey literature. Due to the large number of publications, a selective search was performed through websites of main agencies working on TB in the Region. 1. Key organizations that have a leading role in technical expertise and support (such as the WHO Regional Office and headquarters, ECDC and the Stop TB Partnership) were accessed. Retrieved studies and technical reports were screened initially using the title and abstract and then briefly browsed to establish their relevance. After removing those that did not meet the criteria outlined above, full texts of the remaining studies were reviewed, with only those meeting the criteria and being considered relevant to the empirical study of the report being selected. 2. Twelve organizations that have been active in TB in the high-priority countries of the European Region after 2000 were also accesed. This yielded relevant reports, studies, brochures and meeting documents from five entities involved in TB prevention and care, including NGOs: the KNCV Tuberculosis Foundation, International Union Against Tuberculosis and Lung Disease (The Union), USAID, the TB Europe Coalition (TBEC) and Médecins Sans Frontiéres (MSF). Clearly, these organizations represent only a proportion of the relevant organizations and agencies working in the field of TB prevention and care. What follows should therefore not be considered an exhaustive representation of literature on political commitment in the WHO European Region. 2 As the high-level meeting of the United Nations General Assembly took place very recently, it was not included in this literature search Key political commitment documents for tuberculosis prevention and care and their intended influence in the WHO European Region page 8 4. Political commitment Existing projects or efforts to measure political commitment The Policy Project toolkit (USAID, 2000) suggests that the most direct approach to measuring political commitment is to assess statements made by national leaders by counting the number of positive statements they make, as reported in national newspapers. Leaders who are vocal on the importance of TB express a commitment to the issue and create a climate that encourages solutions (USAID, 2000:4). The fact that the toolkit was published almost two decades ago encourages elaboration on the types of vehicles available currently, as was done in the context of involving communities and civil society in the Roadmap to implement the tuberculosis action plan for the WHO European Region 2016–2020 (point 2E5 on activities related to areas of intervention) (WHO Regional Office for Europe, 2016). Online and social media now reach a far larger audience, geographically and time-wise, than printed media like national newspapers. Statements and posts stay online much longer than a newspaper would be accessible. Online media also offers opportunities for interaction through assessment and feedback and can be augmented by attractive features such as relevant video and/or audio material. Online offerings of governmental entities therefore offer better options for gauging political commitment than printed statements in national media. Different types of input, output, outcome, impact and process indicators exist. For example, government pledges, stewardship or good governance, or advocacy from governmental or society leaders, would typically facilitate budgetary, regulatory or legislative processes and would therefore be appropriate process indicators (although usually they are hard to quantify). If, however, results of political commitment, such as an increased budget allocation, are measured, the higher budget would be recorded through an input indicator, which in turn would probably positively impact on the disease-related outcome indicator. The framework that will be offered as a monitoring and follow-up tool after the September 2018 UNHLM on TB will reflect all five types of indicators. Steady progress made by TB prevention and care programmes in penitentiary settings provide another example of high political commitment. A more than 13-fold increase in funding since 2006 for the penitentiary system of Azerbaijan has been seen as a result of consistent activities that have led to a two-fold decrease in TB incidence, 3.5-fold reduction in prevalence and a more than four-fold decrease in TB mortality (WHO Regional Office for Europe, 2018a). From the example above, it can be seen that one way to measure political commitment is through recording statements or pledges. The Stop TB Partnership key performance indicators reported from the 28th Coordinating Board meeting in September 2016 clearly identify how the indicator provided for its Goal 1, “Advocate, catalyse and facilitate sustained collaboration and coordination among partners in order to achieve the targets under the global plan to end TB 2016–2020 and move towards ending TB” (Stop TB Partnership, 2016:2), could be measured. Subgoal 1.1 indicates the following: “Ensure TB is high on the political agenda through increased dialogue and engagement with political decision-makers and influencers and a strong unified community” (Stop TB Partnership, 2016:2). The suggested measurement means is official statements made by heads of state or heads of government in national, regional or global forums, or as evidenced by signed declarations of commitment at ministerial level (Stop TB Partnership, 2016:2). This concurs with the recommended approach suggested by the Policy Project toolkit (USAID, 2000). Key political commitment documents for tuberculosis prevention and care and their intended influence in the WHO European Region page 9 In relation to HIV/AIDS, the Policy Project has suggested and discussed several approaches on how to measure political commitment. These examples could be of relevance in measuring political commitment to TB; HIV and TB are strongly connected, and they are often referred to in terms of a co-epidemic (Federal Ministry of Health, 2017a; International Federation of Red Cross and Red Crescent Societies, 2018). WHO affirms that TB is the primary killer of people living with HIV (WHO, 2015b:III; WHO, 2018a). People living with HIV are 20–30 times more likely to develop active TB disease than those without HIV. HIV and TB create a fatal combination, each accelerating the other’s progress. The most recent WHO/ECDC TB surveillance report reveals that during the period 2007–2016, the WHO European Region encountered an exceptional increase in HIV prevalence in incident TB cases, from 3% to 12% (ECDC & WHO Regional Office for Europe, 2018:3). In 2016, one in eight new TB patients were HIV positive, and approximately 0.3 million people died of HIV-associated TB in 2017 (ECDC & WHO Regional Office for Europe, 2018). WHO proposes a 12-component method of joint TB/HIV activities, including measures to prevent and treat infection and disease, and decrease deaths (WHO, 2018a). The strong links between TB and HIV justify the use and relevance of approaches on how political commitment can be measured. Measures of political commitment are required as a way of evaluating current levels, increasing recognition of where commitment is strongest and weakest, following the trajectory of changes over time, and understanding trends and whether activities have had influence (USAID, 2000:3). Challenges and impediments in measuring political commitment While the number of statements might seem like a useful indicator of commitment, it suffers from several impediments. For instance, the making of statements is often influenced by special events such as World TB Day or the introduction of an innovative new drug, rather than being inspired by a general commitment. Moreover, leaders may support programmes verbally but then fail to follow through with the necessary action. For these and several other reasons, this indicator is rarely used (USAID, 2000:3). A second approach is to track quantifiable indicators of actions that result from political commitment (USAID, 2000:3). These might include items such as national TB policies, strategic plans, a comprehensive programme that addresses all key aspects of prevention and care, or highly placed government programmes. Whether or not these characteristics exist could be verified by asking the following questions (USAID, 2000:5). ● Are specific and time-bound targets aligned to the strategic objectives? ● Is there a mandated unit for central coordination for the implementation of the national plan? ● Is there an authorized manager for supervising the central unit? ● Is there a participatory organizational mechanism to involve the key government and social partners in an intersectoral collaboration? ● Are all key partners involved in the intersectoral collaboration, including civil society partners, other health programmes and representatives of purchasing agencies? ● Is the plan budgeted, and if so, how is it endorsed, monitored and evaluated? These questions are largely comparable to the indicators used for assessing governance of national TB programmes, on the basis of which targeted policy interventions are suggested at country level. The following questions then arise. Key political commitment documents for tuberculosis prevention and care and their intended influence in the WHO European Region page 10 ● Does the country (or countries) in question have a national TB policy that is approved by the government or ministry of health? ● Do they have a strategic plan? Is there any action plan that details how the strategic objectives can be reached? The question of not just how much funding is made available for TB prevention and care, but also how efficiently it is allocated and spent, also arises. Indicators like these have advantages, as they are considered to be quantifiable and therefore more readily measurable than qualitative indicators, but even though such items are easily traceable, they provide insufficient information about the quality of the policy plan or programme (USAID, 2000:3). Just because a policy exists does not mean it is viable; a policy can be ineffective or may contain negative elements. Recommendations for measuring political commitment It is suggested that a more suitable indicator (of political commitment) is funding for the TB and MDR/XDR-TB programme (USAID, 2000:5). High levels of national funding can result only when the political commitments exist to make TB a priority programme for national resources. Funding can be traced over time and be compared across countries if changed to a standard metric, such as cost per patient in relation to gross domestic product per capita. Information on funding can, however, be difficult to obtain (USAID, 2000:5). Another recommendation could be that a qualitative indicator is elaborated to complement the quantitative indicator discussed above; one could measure political commitment through the level of involvement of high-level officials at country coordinating mechanism or other coordination meetings on TB. The presence of officials is positive in itself but taking into account the habit of busy officials to be involved in mobile online communications during such meetings, the extent to which the official was committed and actively involved in the discussions and proceedings should be objectively evaluated. Taken individually, the existing and/or recommended measurements for political commitment might be suboptimal, but by combining different measurement methods, the data can be considered complementary and give a more realistic reflection of the level of political commitment. Finally, the TB UNHLM in September 2018 was in line with the United Nations Agenda for Sustainable Development and the End TB Strategy, which signifies that human rights, ethics and equity needs will be emphasized in the TB response. Key political commitment documents for tuberculosis prevention and care and their intended influence in the WHO European Region page 11 5. Declarations on TB and related documents This chapter presents an outline of the declarations on TB that have been developed and endorsed since 2000, an overview of key points from their content, and a description of relevant facts, such as where and when the proceedings took place and who attended/participated. The declarations are: ● the Amsterdam Declaration to Stop TB (2000) (Stop TB Partnership, 2000a); ● the Berlin Declaration on Tuberculosis (2007) (WHO Regional Office for Europe, 2007); ● the Joint Riga Declaration on TB and its Multi-drug Resistance (2015) (Latvian Presidency of the Council of the European Union & Eastern Partnership, 2015); ● the Moscow Declaration to End TB (November 2017) (Ministry of Health of the Russian Federation & WHO, 2017); ● the Estonian Senior-level Policy Dialogue: Addressing HIV and TB Challenges: from Donor Support and Emergency Response to Sustainable Health Systems (December 2017) (Council of the European Union, 2017); and ● the political declaration of the high-level meeting of the Seventy-third session of the United Nations General Assembly on the fight against Tuberculosis (United Nations General Assembly, 2018) The Berlin Declaration is explicitly mentioned throughout the Joint Riga and Moscow declarations and related high-level events. Overview of the Amsterdam Declaration to Stop TB Twenty countries convened in Amsterdam, the Netherlands, on 22–24 March 2000 for a ministerial conference on TB and sustainable development. The objective was to examine TB in the context of social and economic development (Stop TB Partnership, 2000b). Participants included ministers of health and finance, development planners and top civil servants from 20 of the highest-burden countries in the world, and high-level delegations from donors and technical health agencies. The WHO European Region was represented to a very limited extent. Countries endorsed a declaration to take action on stopping TB on a worldwide scale. Key attributes of the Amsterdam Declaration The Amsterdam Declaration, to which the 20 highest-burden countries – Bangladesh, Brazil, Cambodia, China, Democratic Republic of the Congo, Ethiopia, India, Indonesia, Kenya, Nigeria, Pakistan, Peru, Philippines, Russian Federation, South Africa, United Republic of Tanzania, Uganda, Viet Nam and Zimbabwe – are signatories, outlines the following priorities (Stop TB Partnership, 2000a). ● EXPANDED coverage of our populations with the WHO-recommended strategy to combat tuberculosis (DOTS) providing for at least 70% detection of infectious cases by the year 2005; ● ENSURING that sufficient human & financial resources are available on a sustainable basis & expanded to meet the challenges of stopping tuberculosis; ● ENSURING that the implementation capacity is developed to utilize these resources efficiently & effectively; ● IMPLEMENTING, monitoring & evaluating our national tuberculosis programmes in line with internationally-accepted WHO standards; ● IMPROVING systems of procurement & distribution of tuberculosis drugs to ensure quality, access, transparency & timely supply; Key political commitment documents for tuberculosis prevention and care and their intended influence in the WHO European Region page 12 ● INCORPORATING basic outcome measures for tuberculosis as performance indicators for overall health sector performance; ● PROMOTING the development of national & international partnerships to stop tuberculosis with all stakeholders in society, including government departments & organizations, private health sector, industry, nongovernmental organizations & the community; ● ACTIVELY participating in the development & subsequent implementation of a global partnership agreement to Stop Tuberculosis designed to foster ownership & accountability. Overview of the Berlin Declaration on TB In 2007, WHO categorized 18 Member States of the Region – Armenia, Azerbaijan, Belarus, Bulgaria, Estonia, Georgia, Kazakhstan, Kyrgyzstan, Latvia, Lithuania, Republic of Moldova, Romania, Russian Federation, Tajikistan, Turkey, Turkmenistan, Ukraine and Uzbekistan – as high-priority countries and introduced a plan to alleviate the situation they faced (Castell et al., 2010:423). The WHO Regional Office for Europe and the German Federal Ministry of Health then convened the WHO European Ministerial Forum on Tuberculosis: “All against Tuberculosis” on 22 October 2007 in Berlin, Germany, to accelerate progress towards achieving the global targets for TB prevention and care in the Region and target 8 of MDG 6, to have halted and begun to reverse the incidence of TB by 2015 (WHO Regional Office for Europe, 2008:5; Ulrichs, 2012:262) . The forum was attended by over 300 participants, including ministers of health and justice and high-level decision-makers from 49 of the 53 Member States of the Region, representatives of United Nations bodies, intergovernmental agencies and NGOs. Ministers endorsed a declaration outlining the main challenges in containing TB in the Region, calling on Member States to increase their involvement in control of TB, and listing commitments for high- and low-burden countries. The declaration ends by stating that progress in fighting TB should be assessed every two years (WHO Regional Office for Europe, 2007). By accepting the Berlin Declaration, countries undertook the tasks of strengthening their public health and social services systems to respond to the TB situation in the WHO European Region, adopting the Stop TB Strategy, and seeking viable funding for TB prevention and care activities. It has been suggested that the Berlin Declaration effectively has reorganized the TB prevention and care agendas across the European Region (ECDC, 2010:6). Key attributes of the Berlin Declaration The Berlin Declaration 2007 outlines the following priorities (WHO Regional Office for Europe, 2007): ● universal access to the Stop TB Strategy should be promoted by strengthening the health sector and involving the full spectrum of health care providers, private and public, civilian and penitentiary, all of whom should follow the International Standards for Tuberculosis Care and promote the Patient’s Charter; ● civil society and affected communities should be considered as important partners in and included into TB control; ● the shortage in funds, as outlined in the Global Plan to Stop TB 2006–2015, should be dealt with properly prioritized funds, enhancement of funds, sustained and targeted local, national and international funding; Key political commitment documents for tuberculosis prevention and care and their intended influence in the WHO European Region page 13 ● TB control should be a high priority within national development plans presented for external financing; ● better use of existing effective tools, and new diagnostics, drugs and vaccines should be developed through research and product development, including by public–private partnerships, private industry and national research institutes; ● TB should be included into HIV treatment and care programmes, since the two diseases present a deadly combination; and ● greater partnership and coordination across the health, penitentiary and social services sectors should be promoted, as well as inter-country collaboration. It is important to clarify that the word “control” was part of the language of describing TB prevention and care activities for many years, being used in international guidelines and published literature (Zachariah et al., 2012:714). Evidence has shown, however, that derogatory language can have damaging effects that lead to stigmatization and prejudice towards patients (Zachariah et al., 2012:714). Several authors and institutions from different parts of the world (Africa, Asia, Latin America, Europe and the Pacific) (Zachariah et al., 2012:714) have argued that from a patient perspective, “control” is considered to be: inappropriate, coercive and disempowering, and at worst they could be perceived as judgmental and criminalizing, tending to place the blame of the disease or responsibility for adverse treatment outcomes on one side – that of the patients. It is claimed that the notion of control is hypothetically alarming because it tends to make the so- called experts seem superior and presumes that they have the solutions to the patient’s health problems (Zachariah et al., 2012:716). It has also been argued that the idea of “control of TB” may unintentionally lead to programmes trying to take control of TB patients by disregarding their rights and independence. “Controlling” may be construed as something done to, instead of for, the patient or client (Zachariah et al., 2012:716). Consequently, it is suggested that the word “control” be replaced with prevention and care, or simply be removed. Prevention and care are considered to reflect more tolerant attitudes and promote the notion of a patient-centred approach (Zachariah et al., 2012:716). The term “TB control” has therefore been removed or replaced by terms such as prevention and care in recent committal documents and international publications. Overview of the Joint Riga Declaration on TB and its Multi-drug Resistance The Eastern Partnership Ministerial Conference on TB and its Multi-drug Resistance took place on 30–31 March 2015 in Riga, Latvia. This multistakeholder high-level conference was attended by ministers and representatives from ministries responsible for health in EU Member States and countries of the Eastern Partnership, NGOs and international institutions (WHO Regional Office for Europe, 2015c). The aim of the conference was to discuss topics such as improving detection and treatment outcomes for TB and MDR-TB patients, enhancing research and development for new drugs to treat TB and MDR-TB, addressing the needs of vulnerable populations and moving towards TB elimination, and expanding patient-centred models of care and shifting from inpatient to ambulatory care (WHO Regional Office for Europe, 2015c). Key political commitment documents for tuberculosis prevention and care and their intended influence in the WHO European Region page 14 Key attributes of the Joint Riga Declaration The Joint Riga Declaration outlines the following priorities (Latvian Presidency of the Council of the European Union & Eastern Partnership, 2015). 1. To implement the End TB Strategy and to do the utmost to reach a 75% reduction in the number of TB deaths and a 50% reduction in TB incidence rate by 2025 compared with 2015 thus progressing towards ending TB as a public health problem in the countries participating in the Conference through implementing sustainable response measures integrated within health systems and involving all relevant stakeholders and supporting TB prevention and control globally. 2. To call the upcoming Eastern Partnership summit in May 2015 in Riga to endorse this aspiration. 3. To target and increase domestic funding as needed, towards more patient-centred care on ambulatory level as a way to avoid hospital-based transmission of the disease and ensure appropriate patient education interventions, especially for socially vulnerable groups. 4. To strengthen the work with vulnerable populations, where social support is essential, by ensuring multi-sectoral collaboration, including civil society and affected populations in the design, implementation and monitoring of national TB response as well as service delivery. 5. To cooperate in cross-border risk assessment measures regarding the spread of tuberculosis and continuity of care for patients in the region through, but not limited to, bilateral mechanisms among the countries and joint actions. 6. To strengthen and formalize regional collaboration on TB and MDR-TB at the highest political level across the different sectors, including civil society organizations and communities. 7. To strengthen collaboration in research and development for new tools and embrace innovative and patient-centred approaches to TB prevention and care. 8. To ensure adequate domestic resources are made available in order to sustain investments in TB, particularly in countries transitioning from donor funded activities. 9. To commit ourselves to closely monitoring and evaluating the implementation of the actions outlined in this Declaration. 10. Welcoming the proven value of the first Eastern Partnership Ministerial Conference on Tuberculosis and its Multi-drug Resistance as a forum for deeper political reflection on the thematic dimension of cooperation within the Eastern Partnership, the Participants have undertaken to meet regularly to review the progress against the actions outlined above and discuss additional measures that would be needed. Overview of the Moscow Declaration to End TB The first WHO Global Ministerial Conference on Ending TB, “Ending TB in the Sustainable Development Era: a multisectoral response” took place on 16–17 November 2017 in Moscow, Russian Federation. The high-level event generated 1000 registered participants, among whom were 79 ministers of health and ministers from other sectors (finance, social development and justice), including ministers from the 40 highest TB and MDR-TB burden countries (WHO, 2017b). One hundred and eighteen WHO Member States participated in the conference along with 122 partner organizations, such as United Nations organizations, development agencies, regional bodies and NGOs, including faith-based organizations, civil society representatives, affected people and communities, and academic and research institutions, philanthropic foundations and private sector entities (WHO, 2017b). Key political commitment documents for tuberculosis prevention and care and their intended influence in the WHO European Region page 15 The aim was to accelerate implementation of the WHO End TB Strategy and notify the United Nations General Assembly high-level meeting on TB in 2018, acknowledging that investments and actions have to date fallen short of those needed to achieve TB targets and milestones set as part of the United Nations Agenda for Sustainable Development and the End TB Strategy. During this two-day conference, 75 ministers agreed to take imperative action to end TB by 2030. Ministers also promised to decrease the risk and spread of drug resistance and to do more to engage people and communities affected by, and at risk of, TB. Key attributes of the Moscow Declaration to End TB The Moscow Declaration to End TB (Ministry of Health of the Russian Federation & WHO, 2017) resulted in collective commitment to raise action on four fronts (WHO, 2017c). 1. Move rapidly to achieve universal health coverage (UHC) by strengthening health systems and improving access to people-centred TB prevention and care, ensuring no one is left behind. 2. Mobilize sufficient and sustainable financing through increased domestic and international investments to close gaps in implementation and research. 3. Advance research and development of new tools to diagnose, treat, and prevent TB. 4. Build accountability through a framework to track and review progress on ending TB, including multi-sectoral approaches. Overview of the Estonian Senior-level Policy Dialogue: Addressing HIV and TB Challenges and its resulting outcome document The senior-level policy dialogue took place on 12–13 December 2017 in Tallinn, Estonia, under the Estonian Presidency of the Council of the European Union. The event brought together representatives of the health and financial ministries of Europe, the Balkan and Eastern Partnership countries, representatives of the European Commission, WHO and other international organizations, and institutions’ and communities’ representatives involved in funding programmes and providing services to challenge TB and HIV (Council of the European Union, 2017). The event outlined the needs, challenges and opportunities and introduced a framework for multisectoral and multi-stakeholder action towards sustainable, resilient and people-centred systems for health that would lead towards the end of HIV and TB epidemics and leave no one behind, in line with the United Nations Agenda for Sustainable Development (Council of the European Union, 2017). Key attributes of the Senior-level Policy Dialogue’s outcome document The Senior-level Policy Dialogue: Addressing HIV and TB Challenges outlined the following objectives (Estonian Presidency of the European Union, 2017). ● The continuation of the discussions on actions towards eliminating HIV and TB in the European region with emphasis on financing of HIV and TB services and guaranteeing their sustainable integration into national health systems. ● Identifying and sharing good practices on overcoming the challenges in transition to domestic funding and sustainable health planning, integration of HIV and TB response to national health systems. ● Identifying the major obstacles, gaps, resources and needs in ensuring sustainable responses to HIV and TB. ● Providing applicable recommendations to other communicable diseases of serious public health concern. Key political commitment documents for tuberculosis prevention and care and their intended influence in the WHO European Region page 16 Overview of the UNHLM on TB and the political declaration adopted by resolution at the Seventy-third United Nations General Assembly Following the UNHLM on the fight against TB that took place in New York, United States on 26 September 2018 – a gathering of unprecedented global dimensions – the United Nations General Assembly adopted a resolution at its Seventy-third session, on 10 October 2018, reflecting a political declaration entitled “United to end tuberculosis: an urgent global response to a global epidemic”. This outcome document recommits to the SDGs, underlines the importance of achieving UHC and urges a focus on multi- and intersectoral engagement and responses that also address social and economic determinants to leave no one behind (United Nations General Assembly, 2018:8). Key attributes of the political declaration on the fight against TB adopted by resolution of the Seventy-third United Nations General Assembly The key issues explicitly mentioned in the political declaration are: ● importance of effective people-centred and community-based prevention, treatment and care, making use of innovative digital technologies; ● importance of the fight against AMR and comorbidities; ● promotion of access to affordable medicines; ● focus on high-risk groups and those in vulnerable situations, especially in developing countries affected inequitably by TB and including reduction of stigma and discrimination; ● coordination and collaboration between TB and HIV programmes; ● rapid scale-up of access to TB testing; ● additional investment in research, development and innovation and improvement of TB research platforms and networks across the public and private sectors; ● mobilization of sufficient and sustainable financing based on capacity and solidarity; ● multisectoral collaboration of global, regional, national and local level, involving all health stakeholders as well as stakeholders from following sectors: nutrition, finance, labour, social protection, education, science and technology, justice, agriculture, environment, housing, trade and development (United Nations General Assembly, 2018); and ● development of a multisectoral accountability framework with implementation ensured for no later than 2019. Together with the International Organization for Migration and the Slovakian permanent mission to the United Nations, the WHO Regional Office for Europe officially launched the United Nations Common Position on Ending HIV, TB and Viral Hepatitis through Intersectoral Collaboration at the high-level meeting, further emphasizing the need to overcome the traditional silo approach. This initiative stems from technical consultations in the regional SDG Issue-based Coalition on Health and Well-being for All at all Ages and puts forward the commitment of 14 United Nations agencies and the Stop TB Partnership to strengthen collaboration beyond the health sector in Europe and central Asia. The Common Position, endorsed by the United Nations Regional Coordinating Mechanism and the regional United Nations Development Group, calls for a sustainable development approach that translates United Nations commitments into more and better intersectoral action. Addressing the different determinants of health and risk factors as relevant in the national contexts is recognized as an effective measure not only to address the three epidemics, but also to build on the synergetic and complementary work of the partners, Key political commitment documents for tuberculosis prevention and care and their intended influence in the WHO European Region page 17 advancing across all SDGs. The Common Position also reinforces the call for effective mechanisms to support accountability across sectors and partners, highlighting how existing mechanisms can provide efficient platforms to connect national, regional and global levels without increasing transaction costs and the reporting burden (WHO Regional Office for Europe, 2018c). Key events and documents citing the Berlin Declaration This section outlines events, peer-reviewed articles and key policy and technical documents that have referred to the Berlin Declaration. Events European Commission/ECDC/WHO Regional Office for Europe Tuberculosis Meeting, Luxembourg, 30 June–1 July 2009 The European Commission, together with the ECDC and the WHO Regional Office for Europe, held a meeting on TB in Luxembourg on 30 June–1 July 2009 (WHO Regional Office for Europe, 2018b). This was the first follow-up meeting on implementation of the Berlin Declaration and took place under the patronage of Her Royal Highness the Grand Duchess of Luxembourg. The meeting included 90 representatives of health ministries and donors, partner and civil society organizations (WHO Regional Office for Europe, 2009a). The meeting addressed achievements and drew attention to persisting challenges, such as drug resistance, prevalence in vulnerable populations, TB/HIV coinfection and gaps in the fight against TB. Participants identified a series of actions for future implementation (WHO Regional Office for Europe, 2009a): ● establishing a mechanism/platform for civil society, nongovernmental and professional organizations involved in TB control across the Region; ● promoting the strengthening of health systems and multisectoral approaches through a high-level forum for policy discussions; and ● revisiting the eligibility criteria for the Global Fund to Fight AIDS, Tuberculosis and Malaria, which should be based on epidemiological burden rather than on gross domestic product. Declaration satellite symposium, Berlin, Germany, 15 October 2009 The satellite symposium was held to follow up on the Berlin Declaration. It focused on raising public decision-makers’ awareness of the importance of TB/HIV coinfection and the obstacles this deadly combination poses to health systems. The event drew specific attention to fighting TB/HIV coinfection (WHO Regional Office for Europe, 2009b). The meeting showed that the issues raised in the Berlin Declaration remained valid and emphasized the demand for experience-sharing and enhancement of collaboration. The recommendations (WHO Regional Office for Europe, 2009b) were to: ● ensure access to correct diagnosis, continued high-quality treatment and effective prevention measures; ● overcome vertical, disease-specific programme structures and integrate TB and HIV care into general health care; and ● address prejudices, discrimination and stigmatization of people affected or groups at risk that constrain prevention and access to care. Key political commitment documents for tuberculosis prevention and care and their intended influence in the WHO European Region page 18 Berlin Declaration of the G20 health ministers, 19–20 May 2017 G20 health ministers convened in Berlin on 19–20 May 2017 to discuss global health ahead of the G20 summit in July 2017 (Federal Ministry of Health, 2017a). It was recognized throughout the meeting that a heightened response was needed to address the global health risks, such as infectious disease outbreaks and AMR. The meeting’s conclusions were summarized in the form of a declaration, “Together Today for a Healthy Tomorrow” (Federal Ministry of Health, 2017b). Outcomes of the event (Federal Ministry of Health, 2017a) were to: ● reaffirm the role of the G20 ministers in “strengthening the political support for existing initiatives and working to address the economic aspects of global health issues”; and ● seek to “intensify global action and cooperation” and reaffirm the G20 commitment to achieving the health-related goals and targets of the 2030 Agenda for Sustainable Development. The meeting also discussed combating AMR, as this is one of the largest threats to global health and affects industrialized and developing countries (Federal Ministry of Health, 2017a). Documents Working through the existing publications for the literature review, it became evident that the Berlin Declaration has played a key role in all committal documents issued between 2000 and 2017; subsequent declarations and initiatives build on the Berlin Declaration’s main directions. The most relevant publications (peer-reviewed articles as well as policy and technical documents) referring to this milestone declaration are shown in Table 1. Table 1. Key publications citing the Berlin Declaration Title Author(s) Publisher Date and bibliographic data Weblink The European health report 2009: health and health systems WHO Regional Office for Europe Copenhagen: WHO Regional Office for Europe 2009 http://www.euro.who.int/e n/publications/abstracts/eu ropean-health-report-2009- the.-health-and-health- systems Knowledge transfer – the new core responsibility of higher education institutions practice and perspectives in Russia and Germany Gorzka G Kassel: Kassel University Press 2012 http://www.upress.uni- kassel.de/katalog/abstract.p hp?978-3-86219-412-4 Public health advocacy for the Berlin Declaration on Tuberculosis in the former Soviet Union: the view of Médecins Sans Frontiéres Healy S, Dietrich S, Roth T, Nyang’Wa B-T, Ducros P European Journal of Microbiology and Immunology 2012;2(4): 282–6. https://www.ncbi.nlm.nih.g ov/pmc/articles/PMC38320 68/ Tuberculosis surveillance and control in Germany – an application of the Berlin Declaration monitoring and evaluation framework Hauer B, Fiebig L, Brodhun B, Haas W European Journal of Microbiology and Immunology 2012;2(4):287 –91 https://www.ncbi.nlm.nih.g ov/pmc/articles/PMC38320 66/ The Berlin Declaration on Tuberculosis and its consequences for TB research Ulrichs T European Journal of Microbiology 2012;2(4)261– 3 https://www.ncbi.nlm.nih.g ov/pmc/articles/PMC38320 71/ Key political commitment documents for tuberculosis prevention and care and their intended influence in the WHO European Region page 19 Title Author(s) Publisher Date and bibliographic data Weblink and control in the WHO-Euro Region and Immunology Best practices in prevention, control and care for drug- resistant tuberculosis WHO Regional Office for Europe Copenhagen: WHO Regional Office for Europe 2013 http://www.euro.who.int/e n/publications/abstracts/be st-practices-in-prevention,- control-and-care-for-drug- resistant-tuberculosis Roadmap to implement the tuberculosis action plan for the WHO European Region 2016–2020 WHO Regional Office for Europe Copenhagen: WHO Regional Office for Europe 2016 http://www.euro.who.int/e n/publications/abstracts/ro admap-to-implement-the- tuberculosis-action-plan-for- the-who-european-region- 20162020.-towards-ending- tuberculosis-and-multidrug- resistant-tuberculosis-2016 Tuberculosis surveillance and monitoring in Europe reports ECDC/WHO Regional Office for Europe Stockholm: ECDC 2012, 2013, 2014, 2015, 2016 https://ecdc.europa.eu/en/ publications- data?s=Tuberculosis+surveil lance+and+monitoring+in+E urope+reports+ Good practices in the prevention and care of tuberculosis and drug- resistant tuberculosis in correctional facilities WHO Regional Office for Europe Copenhagen: WHO Regional Office for Europe 2018 http://www.euro.who.int/e n/publications/abstracts/go od-practices-in-the- prevention-and-care-of- tuberculosis-and-drug- resistant-tuberculosis-in- correctional-facilities-2018 Grey literature search results Progress made since the Berlin Declaration was reviewed at the Wolfheze 2013 workshop jointly organized by WHO Regional Office for Europe, ECDC and KNCV, as described in the workshop report (KNCV, 2013a). One of the recommendations was that the Berlin Monitoring & Evaluation Framework be promoted. Challenges in advocacy work were also mentioned during Wolfheze working group discussions, as participants felt that advocacy is often seen as a task for civil society organizations and that (vulnerable) groups affected by TB were not popular with decision-makers. The participants suggested that a pool of evidence showing the effectiveness of advocacy and which would enable the advocacy communication strategy to be better adapted to current economic contexts should be created, taking into account different national contexts and languages. These advocacy-related concerns were also raised in a country presentation by Stop TB Partnership Romania, which identified the lack of a national advocacy strategy (KNCV, 2013a:16–7; 2013b). Lack of continuity of high-level political leadership in health and consequent lack of policy coherence at ministry of health level was also raised as a concern (KNCV, 2013a:16–7; 2013b). The Union highlights that policy recommendations in a certain context and at a certain point in time should mainly be based on that context’s health system characteristics, government commitment, drug-resistance data and HIV prevalence (Arnadottir, 2009:94). The Union deemed the level of government commitment of a group of countries of the eastern Europe and central Asia region (EECA) sufficiently satisfactory to support the formation, in 2016, of the Eurasian Key political commitment documents for tuberculosis prevention and care and their intended influence in the WHO European Region page 20 Parliamentary Group on Tuberculosis, composed of members of parliament of 12 EECA countries (The Union, 2016:47). TB management is considered more a clinical than a public health issue in the Russian Federation, with the government being responsible for focusing on prevention of (resistant) TB infection. Nevertheless, as mentioned in a USAID project’s evaluation report, TB programmes in an administrative region where local authorities have displayed strong political commitment should serve as examples that can be followed in other administrative regions (USAID, 2009:37– 8). A brochure on AMR issued by the civil society organizations’ network TBEC illustrates how in the field of TB medication, the third sector is expected to lobby governmental structures on priorities (such as ensuring that any AMR action should prioritize TB as a component) at high- level meetings (including the UNHLM), while the government is expected to create mechanisms to support and incentivize research and development into drugs, diagnostics and vaccines (TBEC, 2015:4). In its 2017 annual report, TBEC states that its Global Health Advocates Network had been advocating to the Estonian Government to organize a senior-level policy dialogue on transition and sustainability, which led to the event of December 2017 (TBEC, 2017:13). TBEC also called the UNHLM “an important event” (TBEC, 2017:13) and organized a webinar on the meeting in English and Russian languages, offering a concise overview on what it is and why it is important. In relation to TB, MSF mainly advocates for access to affordable medicines. It developed eight recommended commitments (mostly drug-related) for the Global TB Ministerial Conference in Moscow in November 2017 and the UNHLM in September 2018 (MSF/STOP TB Partnership, 2017:61). MSF has also urged governments to apply “compassionate use” when registering relevant new drugs, making them available and supplying them in a sustainable way, and commissioned medicines manufacturers to ensure their products are affordable, with a transparent price policy for drug-resistant TB medicines sold to all low- and middle income countries, despite some markets being small (MSF/STOP TB Partnership, 2015:48; Treatment Action Group, 2018). Another world-wide initiative worth mentioning is the establishment of the Global Caucus of Parliamentarians in October 2014, a global network of over 2300 members of national parliaments in 130 countries who are united by their shared commitment to end TB, focusing especially on working with civil society organisations (Global TB Caucus, 2018). The most recent Global Fund to Fight AIDS, TB and Malaria (GFATM) initiative (2017), is the Global Fund procurement cliff initiative, which is inscribed in the GFATM’s sustainability, transition and co-Financing policy. It offers mitigation strategies to those countries that find themselves in the challenging situation of prematurely transitioning to national procurement that entails the risk of stock-out of essential TB and ARV drugs (Treatment Action Group, 2018). Conclusion This chapter aimed to demonstrate that since the endorsement of the Berlin Declaration, increased attention to the fight against TB has led to several high-level events and the establishment of forums to assess and debate progress in fighting the epidemic. This underscores the determination of WHO European Region Member States and partners to decrease TB incidence by 2030. Key political commitment documents for tuberculosis prevention and care and their intended influence in the WHO European Region page 21 Undoubtedly, the 2007 Berlin Declaration constitutes a milestone in international commitment to combating TB; all declarations and events identified in this synopsis are built upon it, or have elaborated its main directions (such as coordination of TB care among civilian and penitentiary sectors and public and private care providers, involvement of civil society organizations, better use and further development of health supplies (drugs, vaccines and diagnostic tools), HIV testing for TB patients and the bridging of funding gaps). It is difficult to assess clearly and establish whether these documents and declarations have translated into political action. TB statistics indicate that despite endorsements of declarations, policies, and discussions on TB and the Berlin Declaration in policy and technical documents and peer-reviewed journals, more is required to gain a greater impact and achieve the targets and milestones. Key political commitment documents for tuberculosis prevention and care and their intended influence in the WHO European Region page 22 6. Mapping exercise This chapter describes a mapping exercise that illustrates the similarities and differences between the selected political declarations. The aim is to provide a wide-ranging, comparative overview of the TB declarations, highlighting similarities and differences that focus particularly on UHC, health financing, partnership, political commitment, MDR-TB and HIV/AIDS, and patient/people-centred care but also elements such as gender, migration and TB in penitentiary settings. Similarities All six declarations recognize that a multisectoral approach is needed to deal with socioeconomic challenges linked with TB prevention, treatment and care. TB-related services and efforts cannot rely solely on efforts from the health sector. The partnership aspect is emphasized in all six declarations, each of which promotes the development of national and international partnerships. The Amsterdam and Riga declarations mention this aspect only briefly, but the Berlin, Moscow and UNHLM declarations and the Estonian Senior-level Policy Dialogue discuss it more extensively, indicating that civil society and affected communities should be considered as key partners in, and be integrated into, TB prevention and care. The Moscow Declaration and the Senior-level Policy Dialogue state that civil society and community involvement can ensure that the collective response is informed by the realities of those most affected. At long last, the UNHLM Declaration stresses the empowering of women and girls as a critical part of reaching undetected and untreated people. All six declarations touch upon cross-linkages and interconnections between TB and HIV/AIDS. This is highly emphasized in the Senior-level Policy Dialogue document. It and the Berlin, Moscow and UNHLM declarations clearly outline that TB should be cohesive with HIV treatment and care programmes. As the Senior-level Policy Dialogue states (Council of the European Union, 2017:3): Greater integration of HIV and TB services into health systems can enable a holistic response to people [’s] needs and improve the outcomes of the treatment on the one hand, and, on the other, better pooling and optimized use of available financial, human and other resources for the epidemics, i.e. achieving greater sustainability and resilience in systems. The UNHLM Declaration (paragraphs 17 and 29) underlines the importance of comorbidities other than HIV (such as diabetes and viral hepatitis) and conditions that increase the risk of TB infection (such as harmful use of tobacco, alcohol or other substances, undernourishment, and mental or physical disabilities) (United Nations General Assembly, 2018:4,6). Health financing is cited in all six declarations/committal documents (Amsterdam, Berlin, Riga and Moscow declarations, the Senior-level Policy Dialogue outcome document and the political declaration of the United Nations General Assembly), but more emphatically in the Berlin and Moscow declarations. UHC is mentioned quite frequently and can be considered one of the declarations’ main objectives. If UHC is accepted and adopted by more countries, people across a range of communities will have access to health-care services, ensuring that patients or their families are not exposed to financial hardship. The Berlin and Amsterdam declarations emphasize that limited adherence and substandard devised actions and practices have led to the emergence of high MDR-TB and XDR-TB levels. It Key political commitment documents for tuberculosis prevention and care and their intended influence in the WHO European Region page 23 has therefore been suggested that more focused attention on resistant forms of TB is needed. The Riga Declaration raises awareness of the present reality, that the Region accounts for almost a quarter of the MDR-TB global burden and that prevalence and incidence in many countries are at worrying levels. The Moscow Declaration stresses that MDR-TB should be addressed as a global public health crisis and that higher-burden countries should respond to it as a national emergency; systems should be put in place to prevent the emergence and spread of drug resistance. The Senior-level Policy Dialogue outcome document warns that by 2050, “an additional 2.59 million lives could be lost through MDR-TB alone in the European Union”. The UNHLM Declaration goes as far as stating that the SDGs may not be attainable if AMR is not addressed, which is a global challenge (United Nations General Assembly, 2018:3). The Amsterdam Declaration and Senior-level Policy Dialogue document specify that increased public awareness and political commitment is needed to raise awareness and eliminate the disease. The Berlin and Moscow declarations and the Senior-level Policy Dialogue document accentuate that these declarations/committal documents are formulated to raise and gain more political commitment from Member States and involved parties, so the epidemic does not go unnoticed, and that communication about the impact of action and inaction is sustained. The UNHLM Declaration mentions global collaboration alongside sustainable and sufficient political buy-in (United Nations General Assembly, 2018:4). As Table 2 shows, all declarations endorsed in the past 18 years explicitly mention public awareness and/or political commitment as key factors in achieving the set TB targets, except for the Riga Declaration. It should be noted, however, that public awareness and political commitment are certainly implied by its priorities 1 and 4 (“involving all relevant stakeholders”), 3 and 8 (“target and increase domestic funding”), 6 (“collaboration … at the highest political level”) and 10 (“deeper political reflection”). It can therefore safely be stated that all high-level declarations issued between 2000 and 2018 recognize political commitment as a crucial issue in efficiently fighting TB globally or regionally. Political commitment at global and regional levels is considered a crucial and timeless element in TB responses and is discussed in greater detail in Chapter 5. Differences The Moscow Declaration and the Senior-level Policy Dialogue outcome document contain a new aspect to the overall objectives that seek to elevate and sustain the fight against TB – gender. The Senior-level Policy Dialogue document cites gender identity and sexual orientation as important aspects to consider when offering integrated services. The Moscow Declaration mentions that women and children can be considered as vulnerable groups due to gender- and age-related social and health inequalities, such as reduced health literacy, limited access to health services, stigma and discrimination, and exposure to the infection as carers. The UNHLM Declaration briefly mentions gender when stressing the importance of gender equality in community-based health services. The Amsterdam and Riga declarations do not mention migration, while the Berlin, Moscow and UNHLM declarations and Senior-level Policy Dialogue outcome document all raise migration and/or cross-border collaboration (the latter being briefly mentioned in the UNHLM Declaration) and how migrants, refugees and undocumented vulnerable groups need to have access to adequate culturally sensitive TB care and services. Key political commitment documents for tuberculosis prevention and care and their intended influence in the WHO European Region page 24 In this respect, the multisectoral accountability framework would need to provide cross-border follow-up mechanisms (and indicators) for outgoing migrants, while incoming migrants need to be reached out to, ideally through coordination between the sending and receiving countries/regions. If such seems impossible due to conflict or disaster, an international structure needs to be held accountable for these so-called pockets of infection. A specific focus on TB in penitentiary and correctional facilities was integrated in the agenda of the three most recent meetings, and generally in four out of six declarations. The UNHLM Declaration specifically acknowledges the link between incarceration and TB and reaffirms the 2015 United Nations Standard Minimum Rules for the Treatment of Prisoners (the Nelson Mandela Rules) (United Nations General Assembly, 2018:8). Yet another specific focus was integrated within two of the six political declarations (the Moscow and UNHLM political declarations) – the development of a multisectoral accountability framework. The area of focus was mentioned and described in the Moscow Declaration and further referred to in the UNHLM Declaration, which specified; “the Director General of the World Health Organization to continue to develop the multisectoral accountability framework in line with World Health Assembly resolution 71.3 and ensure its timely implementation no later than 2019” (United Nations General Assembly, 2018:10). The Senior-level Policy Dialogue document differs from the others in that it mainly discusses TB and HIV epidemic management in the EU and European Economic Area. It focuses on endorsing the transition process from donor-supported HIV and TB programmes to sustainably financed services that need to be combined with national health systems, outlining how customarily HIV and TB efforts have been developed as emergency public health responses and, in some cases, through vertical systems. To reach and sustain the ambitious global targets, resilient health systems need to be built, and current resources used adequately. Patient/people-centred care is not mentioned in the Amsterdam and Berlin declarations but is discussed in all others. The UNHLM Declaration mentions the promotion of people-centred health and enabling of integrated people-centred prevention in the context of the integration of digital technologies (United Nations General Assembly, 2018:7). People-centred care can reduce unnecessary hospitalization, improve patients’ well-being, ability to follow treatment plans and treatment outcomes, and lower TB costs for health systems and patients. Enabling patients to stay home in their own communities also means that TB becomes less of a stigma-prone issue or object of discrimination. The similarities and differences are summarized in Table 2. Please note that four or five similar indicators out of five are placed under “similarities”, while “differences” comprise areas of focus with one or two indicators of one type versus three or four of another type. Key political commitment documents for tuberculosis prevention and care and their intended influence in the WHO European Region page 25 Table 2. Mapping exercise summary Political declarations on TB Amsterdam Declaration to Stop TB, 2000 Berlin Declaration on TB, 2007 Joint Riga Declaration on TB and MDR- TB, 2015 Moscow Declaration to End TB, 2017 Estonian Senior-level Policy Dialogue, 2017 UNHLM Political Declaration, 2018 SIMILARITIES AREA OF FOCUS Multisectoral approach ✓ ✓ ✓ ✓ ✓ ✓ Introduction of the United Nations Common Positiona Partnership aspect ✓ Briefly mentioned throughout ✓ Discussed in extensive terms and civil society aspect included ✓ Briefly mentioned throughout ✓ Discussed in extensive terms and civil society aspect included ✓ Discussed in extensive terms with civil society aspect included ✓ Briefly mentioned with civil society aspect mentioned Inter- connection with HIV/AIDS ✓ ✓ ✓ ✓ ✓ Highly stressed ✓ Health financing and UHC ✓ ✓ More evident throughout, particularly UHC ✓ ✓ More evident throughout, particularly UHC ✓ ✓ Emergence of high levels of MDR/XDR-TB ✓ ✓ ✓ ✓ ✓ ✓ Public awareness and political commitment ✓ ✓ X ✓ ✓ ✓ TB and HIV epidemic in Europe ✓ DIFFERENCES AREA OF FOCUS Gender aspect X X X ✓ ✓ Briefly mentioned ✓ Briefly mentioned Migration X ✓ X ✓ ✓ ✓ Briefly mentioned TB in penitentiary X ✓ Briefly mentioned X ✓ ✓ Briefly mentioned Patient- centred care X X ✓ ✓ ✓ Highly stressed ✓ R&D ✓ Briefly mentioned ✓ ✓ ✓ Highly stressed ✓ Briefly mentioned ✓ Highly stressed Digital technologies X X X X ✓ ✓ Key political commitment documents for tuberculosis prevention and care and their intended influence in the WHO European Region page 26 Political declarations on TB Amsterdam Declaration to Stop TB, 2000 Berlin Declaration on TB, 2007 Joint Riga Declaration on TB and MDR- TB, 2015 Moscow Declaration to End TB, 2017 Estonian Senior-level Policy Dialogue, 2017 UNHLM Political Declaration, 2018 Multisectoral accountability framework X X X ✓ Highly stressed X ✓ X: this area of focus is not included in the TB declaration. ✓: this area of focus is included in the TB declaration. a The United Nations Common Position on Ending HIV, TB and Viral Hepatitis through Intersectoral Collaboration (see chapter 5, p. 16). Key political commitment documents for tuberculosis prevention and care and their intended influence in the WHO European Region page 27 7. Monitoring and accountability on TB Monitoring and evaluation (M&E) is an essential part of TB programme management that provides information on the scope, quality, scale/coverage and success of programmes (WHO Regional Office for the Eastern Mediterranean, 2018b; WHO, 2018b). Generally, monitoring refers to the routine collection of information across time and sites to track a programme’s ongoing activities (WHO, 2018b). M&E of TB activities provides the methods for assessing the quality, effectiveness, coverage and delivery of services, while promoting a learning culture in programmes to safeguard recurrent health improvement (WHO, 2009:4). Policy-makers use monitoring to trace health-related indicators, usually without ascribing change to any specific programme or set of programmes. Evaluation includes the collection of information about a specific programme and provides an objective assessment determining the value of a programme in terms of its success in accomplishing predetermined goals (WHO, 2018b). Satisfactory M&E can only be achieved through a well-coordinated plan that includes a framework of the goal, service delivery areas and activities (WHO Regional Office for the Eastern Mediterranean, 2018b). Indicators are needed to measure the performance and progress achieved. It is vital that the framework indicators can be analysed in a critical manner and interpreted at all levels, and corrective action taken (WHO Regional Office for the Eastern Mediterranean, 2018b). It would be important to consider the M&E activities as core activities for a broader framework of performance assessment that includes also other dimensions such as efficiency, responsiveness and assessing financial protection of national TB programmes. Monitoring of TB-specific indicators is well established at global and national levels (WHO, 2017d). For instance, standardized monitoring of notifications of TB cases and their treatment outcomes at global and national levels has been in place since 1995 and estimates of TB incidences and mortality have been published by WHO yearly for more than a decade. This type of monitoring will remain for the duration of the End TB Strategy and the United Nations Sustainable Development Goals (SGDs), together with continued efforts to bolster notification and vital registration systems so they can be utilized reliably for direct measurement of TB incidence and deaths (WHO, 2017d:12). According to the Implementing the End TB Strategy: the essentials report from 2015 (WHO, 2015b), reliable measurement of progress in reducing TB incidence, TB deaths and devastating costs is vital. High-performance TB surveillance within national health information systems and national vital registration systems must be set up to monitor TB incidence and mortality, while special surveys are the most appropriate way to measure catastrophic costs (WHO, 2015b:17). Apart from WHO/ECDC regular recording and reporting mechanisms, WHO also routinely collects data on budget approved and budget executed for TB (as part of the national health budget) (WHO, 2017d) and, through special surveys attached to the regular data collection forms, requests countries and national TB programmes to provide additional information that measures activities and tendencies beyond the disease itself. WHO headquarters has also recently started to gather information on SDG-related TB data. These global data, as well as the country data mentioned above, might serve as (political commitment) indicators in the draft multi sectoral accountability framework. Key political commitment documents for tuberculosis prevention and care and their intended influence in the WHO European Region page 28 After endorsement of the Berlin Declaration, an international task force was established under the leadership of the WHO Regional Office for Europe to prepare an M&E framework (Hauer et al., 2012:287). This framework was put into place to follow up countries’ efforts and accomplishments in the implementation process of the declaration (Hauer et al., 2012:287). It has become an integral part of the annual surveillance and monitoring report produced by WHO and the ECDC, and countries and national TB programme managers are urged to use it (Hauer et al., 2012:287). A report that evaluated implementation of the End TB Strategy was submitted to the Seventieth World Health Assembly in May 2017. It determined that (WHO, 2018c:2): global, regional and country-level actions as well as investments were falling short of those needed and that high-level global support and regional and national commitment were required; and noting that progress is slow on all three targets of the Strategy (reducing TB incidence, reducing TB mortality, and eliminating catastrophic costs among TB patients and their households). Due to the report’s unsatisfactory findings and following endorsement of the Moscow Declaration in November 2017, a Resolution was adopted by countries and partners during the 142nd session of the WHO Executive Board in preparation for the UNHLM in September 2018 (WHO, 2018d). According to the meeting report, the resolution discloses that the WHO Director-General is requested to develop, in close partnership with all relevant international, regional and national stakeholders, a draft multi sectoral accountability framework that (WHO, 2018d): enables the monitoring, reporting, review and actions needed to accelerate progress to end tuberculosis both globally and nationally, leaving no one behind through an independent constructive and positive approach, especially in the highest burden countries, and the independent review of progress achieved by those countries, to be considered by the Seventy-first World Health Assembly in May 2018, and presented at the high-level meeting of the United Nations General Assembly on ending tuberculosis in 2018 in order to secure strong political support. Key political commitment documents for tuberculosis prevention and care and their intended influence in the WHO European Region page 29 8. Discussion Acceleration of progress and maintaining political commitment Given that political commitment plays such a crucial role in “getting things done” and facilitating processes in TB prevention and care, specific output and outcome indicators that combine complementary ways of measuring political commitment need to be identified. The draft multisectoral accountability framework requested by the WHO Director-General needs to accelerate the progress necessary to reach the SDG and End TB Strategy targets for the TB epidemic. The framework that is being developed currently takes into account existing tools and mechanisms, such as the M&E framework of the Berlin Declaration, 3 in which expected outcomes are brought in relation to the six building blocks of a health system (human resources, financing, health information systems, supplies, services and governance). It might seem paradoxical to use the building blocks of a health system in a framework that bears the title of being multisectoral (and not just being health-sector related), but non-health co- determinants of TB (such as social, economic and environmental determinants) always relate to one of the building blocks: introducing a social package or additional allowance for TB-affected families, for instance, affects health financing, and improving working conditions for coal-mine workers reduces the burden of disease, resulting in less use of services and human resources with effects on health financing, just as better housing does. The disease-related (impact) indicators being more or less stable, efforts need to be focused more specifically on finding updated indicators that go beyond the health-care sector, but which ideally can be integrated in existing recording and reporting cycles and structures of the health- care and other sectors. Indicators need to be relevant to the priorities of the End TB Strategy and the Roadmap to implement the TB action plan for the WHO European Region 2016–2020, which are to improve human rights, ethics and equity, avoid financial hardship for affected people, and offer innovative and community-based solutions. The multisectoral accountability framework should be applicable to any Member State irrespective of its level of development or financial sustainability, so indicators should be donor- and development level-neutral. At the same time, indicators should be capable of a certain degree of adaptation at country level, which may enhance country-level buy-in and ownership. The core elements of a suggested regional approach to a draft multisectoral accountability framework elaboration – commitments, actions, monitoring and reporting, and review –can be linked to a new framework and will reflect national, regional and global responses to the TB epidemic. Juxtaposed text sections with additional information will also be used, alongside a concise list of guiding principles that are linked to the SDGs, the End TB Strategy pillars/principles and the Roadmap to implement the tuberculosis action plan for the WHO European Region 2016–2020: towards ending tuberculosis and multidrug-resistant tuberculosis publication’s strategic directions (WHO Regional Office for Europe, 2016). 3 After the UNHLM took place, outcomes that differ from those of the Berlin Declaration can easily be adapted and integrated in the renewed multi-sectoral accountability framework. Key political commitment documents for tuberculosis prevention and care and their intended influence in the WHO European Region page 30 Displaying political commitment and following “good-enough”4 governance practices are particularly important in high-priority countries to save lives, avoid (co)morbidity and make sure families affected by the pandemic(s) are not impoverished (ambitions that are in line with the End TB Strategy challenges). If political commitment decreases, together with the TB burden or level of economic development, it will have a detrimental effect on the building blocks of the health system; TB might then fight its way back, reversing positive epidemiological trends. Not only high-priority countries, but also those in the process of transitioning from donor support or which are already expected to increase co-funding through domestic channels, need to maintain and nurture political commitment and keep alert to the core indicators presented in the multisectoral accountability framework. In this context, the Senior-level Policy Dialogue held in Estonia in 2017 suggested identifying and sharing good practices on overcoming challenges in transition to domestic funding, sustainable health planning, and integration of HIV and TB responses into national health systems. It is also important to note that a specific focus on TB in penitentiary and correctional facilities was on the agenda of most of the high-level meetings and was mentioned specifically in many of the political declarations. 4 The term “good-enough” governance is used here as a compromise, reflecting the significant debate among political scientists about the appropriateness of the term “good” governance. Key political commitment documents for tuberculosis prevention and care and their intended influence in the WHO European Region page 31 9. Conclusion The main objective of this analytical report was to underline the importance of political commitment in responses to TB through mapping the six declarations and other relevant committal documents on TB issued after 2000. The report heightens understanding of implementation and assesses whether, and to what degree, the declarations have been translated into political action and implemented. Political commitment and achievements are challenging to measure, as commitment is a multidimensional concept that cannot be measured solely through quantitative indicators (USAID, 2000:5), but it has been established that measurement of political commitment and achievements can indirectly be achieved through examination of statements, policies, financial allocations and actions of leaders, among other methods. While measuring political commitment and actions related to fighting TB is challenging, it is important to state and acknowledge that considerable follow up has been carried out. As stated above, an international task force was established under the leadership of the WHO Regional Office for Europe after endorsement of the Berlin Declaration in 2007 to prepare an M&E framework to follow up countries’ efforts and accomplishments in the implementation process (Hauer et al., 2012:287). The Moscow Declaration also called for multisectoral accountability to be established before the UNHLM on TB in September 2018; this was substantiated by a resolution adopted by countries and partners at the 142nd session of the WHO Executive Board in support of the UNHLM (WHO, 2018c:2). Several high-level events and forums have been held since the endorsement of the Berlin Declaration, which demonstrates substantial initiative by the WHO European Region, its Member States and other partners involved in the Agenda Towards Ending TB by 2030 and achieving the SDG and End TB Strategy milestones and targets. The ultimate high-level commitment was shown by the United Nations General Assembly high-level meeting in New York on September 26, 2108, leading to the adoption of the political declaration “United to End Tuberculosis: an urgent global response to a global epidemic”. Chapter 4 illustrates the degree to which these declarations have been put into action by providing an overview of high-level events in which the Berlin Declaration was reaffirmed and followed up, such as the declaration satellite symposium in Berlin in October 2009, at which awareness of TB among public decision-makers was also enhanced. The Berlin Declaration of the G20 Ministers in May 2017 was yet another such event, reaffirming the G20 commitment to achieving the health-related goals and targets of the 2030 Agenda for Sustainable Development and, as such, underscoring the intensification of global action and cooperation. It can therefore be confirmed that these events represented some of the ways of evidencing political commitment in an indirect way through the examination and follow up of high-level meetings and actions of leaders. As the comparative overview of the political declarations on TB clearly indicates, the need for a multisectoral approach is emphasized in all six declarations. It was stressed that TB prevention and care cannot rely solely on health-sector efforts. This concurs with a feature of governance that involves government actors, civil society partners and donors working together to achieve the desired outcomes, as was suggested by the high-level events and the Berlin Declaration. The way forward Endorsing declarations and creating necessary policies are positive and necessary steps for an improved TB response, but more is required to ensure higher impact and eventually to achieve the set milestones and targets. The Moscow Declaration, its adaptation by Member States and the Key political commitment documents for tuberculosis prevention and care and their intended influence in the WHO European Region page 32 committal document from the Estonian Senior-level Policy Dialogue were important in showcasing the prevailing challenges of the TB epidemic and MDR/XDR-TB at the UNHLM in September 2018. This meeting provided the opportunity to display some of the achievements accomplished so far in reversing the global TB epidemic and raised awareness that to reach the WHO goal to end TB by 2030, a multisectoral approach needs to be taken, efforts must be intensified, the pace must be stepped up, and successes should be sustained through sufficient funding and efficient allocation and spending. The United Nations Common Position also provides key action areas and guiding principles, channelling political commitments from the United Nations and partners into relevant action across sectors to eliminate TB and end the public health threats of HIV and viral hepatitis. To that end, high-level political commitment and support for TB are required more than ever, particularly in view of other developmental and health-competing priorities. The high-level meeting produced an ambitious political declaration on TB endorsed by heads of state that will further strengthen and elevate action and investments required for the end of TB response, thereby contributing to saving millions of lives. The need for its follow-up was explicitly mentioned in the political declaration itself, which states: “to develop … multi sectoral accountability framework … and ensure its timely implementation no later than 2019” (United Nations General Assembly, 2018:10). It will indeed need to be followed up carefully to ensure sustainable and results-yielding implementation. A multisectoral accountability framework To provide a constructive vision for the future in relation to ending TB by 2030, it is suggested that a more systematic M&E framework is required in any future political declaratory document, since the M&E system enables and provides necessary information that allows programme managers, donors and government planners to track trends and achievements over time and make adjustments in planning and implementation. As was mentioned above, a framework was put in place after endorsement of the Berlin Declaration to follow up countries’ efforts and accomplishments in the implementation process. The Moscow Declaration also specified that reliable data are required to enable collective knowledge to be converted into efficient and timely action so that the overall goal is achieved within the established timeframe. It has therefore been proposed that a multisectoral accountability framework be developed to facilitate the review and monitoring of implementation and deliver a systematic approach to verifying additional actions needed to achieve the SDG and End TB Strategy milestones and targets. It is highly recommended that this accountability framework be developed in such a way as to avoid overlapping or duplicating existing M&E frameworks (Ministry of Health of the Russian Federation & WHO, 2017:6). As accountability endorsed through appropriate political commitment is intrinsic to governance, the Roadmap to implement the tuberculosis action plan for the WHO European Region 2016– 2020 calls for Member States to “improve leadership and participatory governance for TB control” (WHO Regional Office for Europe, 2016). In light of this, the Regional Office action plan envisaged improved technical assistance to Member States to ensure “improved, accountable and effective central coordination of TB control and implementation of results-based management approaches to improve performance (by 2020)” (WHO Regional Office for Europe, 2016). For an accountability framework to be successful and provide the necessary results needed to end TB by the allotted deadline, it is important that its indicators are SMART (specific, Key political commitment documents for tuberculosis prevention and care and their intended influence in the WHO European Region page 33 measurable, attainable, relevant and time-bound). Selected indicators should be goal-specific, not too broad, and relevant to the overall programme/goals, allowing parties to keep track of progress. It has also been suggested that for the accountability framework to be effective and successful, heads of state should be aware of the problems caused by the TB epidemic. Ministers across governments must also participate, preferably through a mechanism that goes beyond the ministry of health, as is emphasized throughout the six political declarations. This multisectoral aspect is vital if the future accountability framework for TB is to be truly multisectoral (Floyd et al., 2018:5). A global consultation meeting took place in Geneva on 1–2 March 2018, with representatives of stakeholders specifically listed in the Moscow Declaration convening with WHO staff from headquarters and all regional offices to assess which elements of a multisectoral accountability framework already exist for TB and what might be missing. It became apparent throughout the meeting that the main elements that appear to be missing in current accountability frameworks are (Floyd et al., 2018:8): ● insufficient funds (a significant funding initiative would be needed beyond the GFATM); ● lack of, or inadequate legislation for, TB (such as United Nations or SDG commitments specific to TB); ● absence of dedicated parliamentary and ministerial structures for high-level review (such as at the United Nations General Assembly and regional meetings of heads of state); ● an independent review mechanism; and ● limited engagement of civil society at all levels of the accountability framework (actions, monitoring and reporting, and review). The outcomes of this consultative meeting on the accountability framework draft was presented at the World Health Assembly in Geneva in May 2018. As a result, more revisions were made and the revised accountability framework draft was presented at the UNHLM in September 2018. The overview of the shortcomings aligns with some of the objectives of Health 2020, which outlines the need for a whole-of-government and whole-of-society approach that creates intersectoral governance structures by emphasizing the roles of the private sector and civil society and a wide range of political decision-makers, such as parliamentarians (WHO Regional Office for Europe, 2012:142). The whole-of-society approach involves supplementary capacity for communication and collaboration and increases communities’ resilience to withstand threats to their health, security and well-being (WHO Regional Office for Europe, 2012:143). Health 2020 nevertheless states that governments must maintain overall responsibility for, and commitment to, protecting and promoting the health and well-being of the people they serve and societies they represent (WHO Regional Office for Europe, 2012:143). 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Key political commitment documents for tuberculosis prevention and care and their intended influence in the WHO European Region page 39 WHO Regional Office for Europe (2018c). UN common position paper on ending TB, HIV and viral hepatitis in Europe and central Asia through intersectoral collaboration. In WHO Regional Office for Europe [website]. Copenhagen. WHO Regional Office for Europe (http://www.euro.who.int/__data/assets/pdf_file/0005/382559/ibc-health-common-position-paper- eng.pdf?ua=1) Zachariah R, Harries AD, Srinath S, Ram S, Viney K, Singogo E et al. (2012). Language in tuberculosis services: can we change to patient-centred terminology and stop the paradigm of blaming the patients? Int J Tuber Lung Dis. 16(6):714–7. The WHO Regional Office for Europe The World Health Organization (WHO) is a specialized agency of the United Nations created in 1948 with the primary responsibility for international health matters and public health. The WHO Regional Office for Europe is one of six regional offices throughout the world, each with its own programme geared to the particular health conditions of the countries it serves. Member States Albania Andorra Armenia Austria Azerbaijan Belarus Belgium Bosnia and Herzegovina Bulgaria Croatia Cyprus Czechia Denmark Estonia Finland France Georgia Germany Greece Hungary Iceland Ireland Israel Italy Kazakhstan Kyrgyzstan Latvia Lithuania Luxembourg Malta Monaco Montenegro Netherlands Norway Poland Portugal Republic of Moldova Romania Russian Federation San Marino Serbia Slovakia Slovenia Spain Sweden Switzerland Tajikistan The former Yugoslav Republic of Macedonia Turkey Turkmenistan Ukraine United Kingdom Uzbekistan World Health Organization Regional Office for Europe UN City, Marmorvej 51, DK-2100 Copenhagen Ø, Denmark Tel: +45 45 33 70 00 Fax: +45 45 33 70 01 Email: eurocontact@who.int Website: www.euro.who.int WHO/EURO:2019-3501-43260-60629