WORLD HEALTH ORGANIZATION EXECUTIVE BOARD 105th Session Provisional agenda item 3.4 EB105/13 7 December 1999
Stop Tuberculosis Initiative Report by the Director-General
BACKGROUND 1. Resolution WHA44.8 set out global targets for tuberculosis control for the year 2000.1 Resolution WHA46.36 subsequently urged Member States to act rapidly to control tuberculosis through introduction of the strategy of directly observed treatment, short course (DOTS).2 DOTS not only drastically reduces deaths by increasing the cure rate of treatment, but also cuts the transmission of infection and prevents the development of multidrug-resistant tuberculosis. DOTS has been evaluated by the World Bank to be one of the most cost-effective of all health interventions, as an investment of only about US$ 3 is required per year of healthy life saved, making it one of the best buys available to health and finance ministries. 2. Since the introduction of the DOTS strategy in the early 1990s, the world has witnessed remarkable progress in global tuberculosis control under WHO’s leadership. Major achievements are outlined below.
PROGRESS IN TUBERCULOSIS CONTROL, 1991 TO 1997 Indicator/year Number of countries adopting DOTS strategy Global tuberculosis patients treated under a DOTS system (%) Average cost of antituberculosis drug regimen, per patient (US$) External support for tuberculosis control in developing countries (excluding WHO input) (US$ million) WHO’s budget for tuberculosis-related activities (US$ million) 1991 10 <1 40-60 16 2 1997 110 16 10-20 Approximately 100 25
Global targets for tuberculosis control for the year 2000 are: successful treatment of 85% of detected infectious cases, and detection of 70% of such cases. DOTS is a management system that assures that persons suffering from tuberculosis are diagnosed, and that health workers are accountable for successfully curing each patient. 2
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3. Although significant, this progress has not been enough. An estimated one-third of the world’s population is already infected with tuberculosis. Each year an estimated eight million new cases are produced from this reservoir of infection, and two million people die of the disease. The poor and marginalized in the developing world are the worst affected: 95% of all cases and 98% of deaths from tuberculosis occur in resource-poor countries. 4. Tuberculosis remains a significant obstacle to human development, especially in poor countries and among marginalized populations. Of cases in developing countries, 75% are people in their most economically productive years (ages 15 to 45). The disease kills more women than any single cause of maternal mortality. It directly affects the development of families, communities and national economies. Families face significant expenditures on diagnosis, treatment and transport, breadwinners face suspended or lost employment, children face suspended schooling, and employers face decreased labour efficiency. In poor countries, a single case leads, on average, to the loss of two to three months of family income. According to recent studies in several Asian countries, the loss to the economy on account of tuberculosis is equivalent to an estimated 4% to 7% of GDP. 5. Although many small and medium-sized countries are likely to achieve the control targets for 2000, most of the countries which account for the world’s highest tuberculosis burden either adopted the DOTS strategy only recently, or have been slow to expand it. As a result, most of them will not achieve the targets by 2000. Unfortunately, global progress depends above all on advances made in the 22 countries that together account for 80% of the global burden. Recently collected data on case detection and treatment success from countries worldwide indicate that, among the highest burden countries, only Peru and Viet Nam have achieved the targets, although Cambodia, Kenya, and the United Republic of Tanzania were identified as other top performers. Resolution WHA51.13 urged Member States, the international community and WHO to give high priority to intensifying tuberculosis control. 6. Reasons for slow progress in many countries are, with few exceptions, no longer technical but of political and economic origin. Like malaria and HIV/AIDS, in many countries the tuberculosis epidemic is viewed as a problem only of the poor, and responsibility for tackling it is confined, wrongly, to the health sector. National health systems are often underfunded. Where resources do exist, drug procurement and distribution systems are often inefficient or nonexistent, implementation is hampered by the lack of managerial capacity, and training and retention of health workers is often a low priority. Underlying all these problems in many countries is the lack of sustained interest in major health issues among politicians, partly engendered by low societal demand to implement and sustain effective disease control programmes within national health systems. 7. The world’s ability to control tuberculosis is at a crossroads, and WHO has acted quickly to mount an effective response. Tuberculosis control is among the highest priorities of the Organization which, during 1999, launched the Stop Tuberculosis Initiative. Stop Tuberculosis is geared to accelerating global action against one of the world’s major infectious killers by working across WHO and the organizations of the United Nations system, and forging new partnerships across health, social and economic sectors. The following goals guide the work of the Initiative: • to ensure that every tuberculosis patient has access to treatment and cure; • to protect vulnerable populations, especially children, from tuberculosis and its multiple drugresistant form; • to reduce the social and economic toll that the disease exerts on families and communities.
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The priority areas of work for the Initiative in 2000-2001 include: • convening the Ministerial Conference on Tuberculosis and Sustainable Development (Amsterdam, 22-24 March 2000) in order to create high-level political support to tackle tuberculosis within the broader context of health, social and economic development; delegations will comprise health, finance or development planners from countries with the highest tuberculosis burden; • exploring partnerships and options for enhanced access of all Member States to safe, high quality antituberculosis drugs; building up capacity within national health systems of developing countries for drug procurement, distribution and monitoring; brokering tender of second-line regimens to equip pilot projects for control of multidrug-resistant tuberculosis with necessary drugs; and promoting the development of new drug formulations.
ISSUES 9. The emergence of drug resistance signals that control strategies employed by national health systems are failing and that urgent remedial action is required. Drug resistance is a major obstacle to effective treatment and control because sufferers require costly treatment that is well beyond the resources available in most developing countries. In the several locations around the world where prevalence of multidrug-resistant tuberculosis is high, the future ability of national health systems to control the disease is severely threatened. These locations constitute international public health emergencies, requiring immediate action to improve control. At the global level, new, additional elements to the DOTS strategy need to be developed in order to identify faster and to treat drugresistant cases – in resource-poor settings. 10. Tuberculosis and HIV have synergistically fuelled each other’s spread. HIV multiplies by 30fold the speed at which a tuberculosis-infected person can develop disease and become infectious. Tuberculosis is the leading cause of death among HIV-positive people, and accounts for one-third of AIDS deaths worldwide. In many sub-Saharan countries, the number of persons with the disease has quadrupled since 1990, mainly because of HIV. Effective tuberculosis control is one tangible intervention that can extend the life of HIV-infected persons. From a public health perspective, it can quickly render individuals noninfectious, and reduce further spread of the infection in regions where HIV is rampant. 11. Effective management of tuberculosis through DOTS is an integral part of primary health care. It is a positive contributor to the overall development of national health systems. It strengthens decision-making, action and evaluation at district level, and can improve the efficiency and costeffectiveness of integrated service delivery for lung health services in general. Reforming health sectors rightly focus on the achievement of measurable health outcomes. The DOTS strategy is one of the few health strategies that incorporates basic recording and reporting requirements and allows for evaluation of individual and cohort outcomes.
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ACTION BY THE EXECUTIVE BOARD 12. The Executive Board may wish to consider the following draft resolution: The Executive Board, Having considered the report of the Director-General on the Stop Tuberculosis Initiative,1 and recognizing the leadership of WHO in tuberculosis control; Noting that the Ministerial Conference on Tuberculosis and Sustainable Development will take place in Amsterdam, in March 2000, RECOMMENDS to the Fifty-third World Health Assembly the adoption of the following resolution: The Fifty-third World Health Assembly, Concerned that the global burden of tuberculosis is a major impediment to socioeconomic development and a significant cause of premature death and human suffering; Being mindful of the fact that most countries with the greatest burden of disease will not meet global targets for tuberculosis control for 2000 set by resolutions WHA44.8 and WHA46.36; Welcoming the establishment, in response to resolution WHA51.13, of a special Stop Tuberculosis Initiative to accelerate action against the disease and to coordinate activities across the Organization, 1. ENCOURAGES all Member States: (1) to accelerate tuberculosis control and to commit themselves to achieving or to exceeding as soon as possible the global targets set by resolutions WHA44.8 and WHA46.36; (2) to ensure that sufficient domestic resources are available to meet the challenges of stopping tuberculosis, and that the capacity to apply them exists; 2. RECOMMENDS that Member States should: (1) participate in the global partnership to stop tuberculosis, and establish and sustain country-level partnerships to stop tuberculosis within the context of health, social and economic development; (2) include case detection and cure rates, the basic outcome measures for tuberculosis, among performance indicators for overall health sector development;
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(3) speed up coordination between prevention and treatment programmes for tuberculosis and for HIV/AIDS; 3. CALLS ON the international community, organizations and bodies of the United Nations system, donors, nongovernmental organizations and foundations: (1) to support and participate in the global partnership to stop tuberculosis by which all parties coordinate activities, and are united by common goals, technical strategies, and agreed-upon principles of action; (2) to increase organizational and financial commitment towards combating tuberculosis within the context of overall health sector development; 4. REQUESTS the Director-General to provide support to Member States through: (1) exploring partnerships and options for enhancing access to safe, high-quality curative drugs; (2) promotion of international investment in research, development and distribution of new diagnostics to speed up case detection, new drug formulations to shorten duration of treatment, and new vaccines to prevent disease, reduce suffering and save millions from premature death.
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