Global Tuberculosis: Burden, Challenges, And the contribution of the private sector Fabio Scano Stop TB Department WHO Geneva TB Workshop Hillbrow, 4 July 2007
I will Provide a summary of the global burden of TB Review the achievements towards the 2005 World Health Assembly global targets Describe the challenges we face to meet the 2015 Millennium Development Goal and Stop TB Partnership Targets Present the role of the PPM and ISTC as component s of the Stop TB Strategy
Millions of deaths in 2002 TB is the biggest cause of death from a curable or preventable infectious disease 3.0 2.0 1.0 0.0 HIV/AIDS Tuberculosis Malaria Measles
The boundaries and names shown and the designations used on this map 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. WHO 2005. All rights reserved 2005 8.8 million new TB cases and 1.6 million deaths due to TB 445,000 cases and 66,000 deaths WPR 22% AFR 28% Estimated new TB cases (all forms) per 100 000 population 0-24 25-49 50-99 100-299 300 or more No estimate SEAR 34% AMR 4% EMR 7% EUR 5%
Global TB control targets 2015: 50% reduction in TB prevalence and deaths by 2015 2015: Goal 6: Combat HIV/AIDS, malaria and other diseases Target 8: to have halted by 2015 and begun to reverse the incidence 2005: World Health Assembly: - To detect at least 70% of infectious TB cases - To treat successfully at least 85% of detected cases
Over 26 million TB patients treated under DOTS worldwide 80 70 60 45% 53% 60% 50 40 30 20 10 16% 18% 24% 22% 18 16 28% 22 32% 24 37% 28 32 37 45 0 199495 96199697 98 199899 01 200002 03 2002 04 05 2004
Case detection rate or cure rate (%) World Health Assembly 2005 TB Control Targets 100 90 80 70 Target cure 85% Target detection 70% 84 60 60 50 40 30 20 10 0 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
Estimated TB incidence/100k/yr Progress towards the MDGs 2015 TB incidence rates per capita peaking? 450 400 350 300 250 AFR SEAR EMR WPR EUR AMR WORLD 450 400 350 300 250 200 200 150 150 100 100 50 50 0 1990 1995 2000 2005
What are the big issues in 2007? 1. DOTS not yet fully expanded and of high quality everywhere 2. TB/HIV, especially in Africa; MDR-TB, especially in former USSR and China; XDR-TB emerging in South Africa 3. Weak health systems and services compromising TB care: need by NTP to get engaged in HSS 4. Outside of NTP staff, not all practitioners, non-state and even governmental, working at high standard 5. Communities un-aware, un-involved, not mobilised 6. Research not yet delivering new tools, and often outside of the interest of TB "controllers"
Issue 1: DOTS quality reasons for failure Reasons for failure: Treatment outcomes are worst in Africa and Europe W Pacific SE Asia Europe Died Failed Defaulted Transfered Not Evaluated E Med Americas Africa 0 10 20 30 40 Percent of cohort
Issue 4: Non-NTP providers (other public, private MDs, academics, NGOs) not engaged
Why work with the private sector? Outnumber public sector providers in Asia and rapidly growing in Africa Manage large proportions of TB suspects and cases, serving even the very poor in many settings For-profit, impose enormous financial burden on patients No mandatory continuing medical education No regulation or monitoring No systematic licensing or re-certification
What benefits for TB control? Improve quality of TB care Increase case detection Improve treatment outcomes Enhance access and equity
Expectations from participating providers Follow basic DOTS principles and use International Standards Undertake the tasks that they can carry out Provide quality assured anti-tb drugs free of charge to their patients Accept supervision by and reporting to NTP
Expectations from the public sector Provide training adapted to the needs and conditions of the providers Provide drugs, equipment and stationary free of charge Coordinate, supervise, control quality
Possible "contractual" mechanisms Informal agreements Memoranda of Understanding Contracting Certification / accreditation Social franchising Reimbursement through TB-specific insurance package Non-financial incentives are as (if not more) important as financial (most TB initiatives have no direct financial incentives to providers)
International Standards for TB Care: available but not yet widely adopted The International Standards for TB Care describe a widely accepted level of care that all practitioners should seek to achieve in managing patients who have or are suspected of having tuberculosis
Why new standards for TB care? There are many guidelines, recommendations, and manuals, but none are supported by a broad international consensus; most present the how of TB control rather than the why (evidence base is lacking); most are viewed as government documents and, therefore not relevant to the private sector;
ISTC: CONTENTS Executive summary (brief background and standards) Introduction Standards for Diagnosis Standards for treatment Standards for Public Health responsibilities Research Needs References
Public Health Responsibilities: Standards All providers who undertake evaluation and treatment of patients with TB must recognize that, not only are they delivering care to an individual, they are assuming an important public health function. Standard 17: All providers must report both new and retreatment TB cases and their treatment outcomes
WHO recommended Stop TB Strategy to reach the 2015 MDGs
In A new conclusion vision New challenges require the new Stop TB Strategy The Global Plan 2006-2015 clearly outlines what needs to be done and the costs
Conclusion Crucial public health role for TB control in the country (major research contribution) How to better formalise collaboration Clear understanding of what are each others expectations.