Financial resources required for tuberculosis control to achieve global targets set for 2015

OBJECTIVE: To estimate the financial resources required to achieve the 2015 targets for global tuberculosis (TB) control, which have been set within the framework of the Millennium Development Goals (MDGs). METHODS: The Global Plan to Stop TB, 2006-2015 was developed by the Stop TB Partnership. It sets out what needs to be done to achieve the 2015 targets for global TB control, based on WHO's Stop TB Strategy. Plan costs were estimated using spreadsheet models that included epidemiological, demographic, planning and unit cost data. FINDINGS: A total of US$ 56 billion is required during the period 2006-2015 (93% for TB-endemic countries, 7% for international technical agencies), increasing from US$ 3.5 billion in 2006 to US$ 6.7 billion in 2015. The single biggest cost (US$ 3 billion per year) is for the treatment of drug-susceptible cases in DOTS programmes. Other major costs are treatment of patients with multi- and extensively drug-resistant TB (MDR-TB and XDR-TB), collaborative TB/HIV activities, and advocacy, communication and social mobilization. Low-income countries account for 41% of total funding needs and 65% of funding needs for TB/HIV. Middle-income countries account for 72% of the funding needed for treatment of MDR-TB and XDR-TB. African countries require the largest increases in funding. CONCLUSION: Achieving the 2015 global targets set for TB control requires a major increase in funding. To support resource mobilization, comprehensive and costed national plans that are in line with the Global Plan to Stop TB are needed, backed up by robust assessments of the funding that can be raised in each country from domestic sources and the balance that is needed from donors.     

Dengue: emergence as a global public health problem and prospects for control

Dengue causes more illness and death than any other arboviral infection: there are at least 20 million infections in the world each year and several hundred thousand cases of a severe, life-threatening syndrome known as dengue haemorrhagic fever/dengue shock syndrome (DHF/DSS). In recent years, the geographical range of dengue has extended and DHF/DSS is occurring in new areas and with increased incidence. The reasons for the resurgence are complex, but parallel demographic changes and reduced efforts towards disease control. Control of dengue currently depends on controlling its mosquito vector. However, development of a vaccine offers greater hope in the long-term. The dengue group of flaviviruses is unique in that it comprises 4 distinct serotypes which have the potential to cause sequential infections with increased severity. It is reasoned, therefore, that any vaccine should induce solid immunity to all 4 serotypes. Knowledge regarding dengue immunity and pathogenesis is rapidly advancing and it is reasonable to believe that this information can be used to devise a safe and efficacious vaccine for dengue, but it seems unlikely that this will become available in the near future.     

BCG vaccination and WHO's global strategy for tuberculosis control 1948-1983

Mass vaccination with BCG against tuberculosis has been one of the major health interventions of WHO since the Second World War. This article traces the history of the controversial BCG vaccine from its adoption by WHO in 1948 up to 1983. In 1948, there was no clear scientific evidence to support the vaccine, and its adoption by WHO seems to have been urged by the existence of the UNICEF funded 'International Tuberculosis Campaign' and a fear of a threatening global epidemic. Moreover, BCG fitted well with the post Second World War perception of public health interventions. The vaccine was not systematically reviewed by WHO until 1959, and this review appears to have been biased in favour of the vaccine. In 1979 the results from the South Indian Chingleput trial, which showed no protective effect of BCG against pulmonary tuberculosis in adults, prompted WHO to change the arguments for recommending the vaccine. Since 1983 BCG has been recommended with specific reference to its protective effect against severe forms of childhood tuberculosis. The story of the BCG vaccine and WHO is a story of medical uncertainty, institutional inertia, strategic obduracy, and not least, hope.     

A method for estimating maternal and newborn lives saved from health-related investments funded by the UK government Department for International Development using the Lives Saved Tool

Background

In 2010, the UK Government Department for International Development (DFID) committed through its 'Framework for results for reproductive, maternal and newborn health (RMNH)' to save 50,000 maternal lives and 250,000 newborn lives by 2015. They also committed to monitoring the performance of this portfolio of investments to demonstrate transparency and accountability. Methods currently available to directly measure lives saved are cost-, time-, and labour-intensive. The gold standard for calculating the total number of lives saved would require measuring mortality with large scale population based surveys or annual vital events surveillance. Neither is currently available in all low- and middle-income countries. Estimating the independent effect of DFID support relative to all other effects on health would also be challenging.

Methods

The Lives Saved Tool (LiST) is an evidence based software for modelling the effect of changes in health intervention coverage on reproductive, maternal, newborn and child mortality. A multi-country LiST-based analysis protocol was developed to retrospectively assess the total annual number of maternal and newborn lives saved from DFID aid programming in low- and middle-income countries.

Results

Annual LiST analyses using the latest program data from DFID country offices were conducted between 2013 and 2016, estimating the annual number of maternal and neonatal lives saved across 2010–2015. For each country, independent project results were aggregated into health intervention coverage estimates, with and in the absence of DFID funding. More than 80% of reported projects were suitable for inclusion in the analysis, with 151 projects analysed in the 2016 analysis. Between 2010 and 2014, it is estimated that DFID contributed to saving the lives of 15,000 women in pregnancy and childbirth with health programming and 88,000 with family planning programming. It is estimated that DFID health programming contributed to saving 187,000 newborn lives.

Conclusions

It is feasible to estimate the overall contribution and impact of DFID’s investment in RMNH from currently available information on interventions and coverage from individual country offices. This utilization of LiST, with estimated population coverage based on DFID program inputs, can be applied to similar types of datasets to quantify programme impact. The global data were used to estimate DFID’s progress against the Framework for results targets to inform future programming. The identified limitations can also be considered to inform future monitoring and evaluation program design and implementation within DFID.

     

Reaching the global tuberculosis control targets in the Western Pacific Region

PROBLEM: In 1999, a tuberculosis (TB) crisis was declared in the Western Pacific Region. APPROACH: In response, WHO established the Stop TB Special Project, which sought to halve 2000 levels of TB prevalence and mortality by 2010 through first reaching the global 2005 TB targets. LOCAL SETTING: Particular issues in the region were low political commitment, inadequate numbers of staff (particularly of adequately trained staff) and a wide variation in TB burden between countries. RELEVANT CHANGES: WHOs leadership (especially the commitment of its Regional Director) and building of regional and national partnerships strengthened political and donor commitment. This accelerated the implementation of regional and national TB control plans, allowing the region to reach the 2005 targets for TB control. LESSONS LEARNED: The experience in the Western Pacific Region demonstrated that WHOs leadership was pivotal in generating the political commitment necessary to accelerate actions on the ground. The regions investment in building partnerships and a motivated workforce was an important contribution towards achieving the 2005 global TB targets.     

Achieving the goal of halving global hunger by 2015

The FAO World Food Summit (WFS) in 1996 set the goal of halving the numbers of the global population suffering hunger by the year 2015, which was later incorporated into the UN Millennium Development Goals (MDG) that commit the international community to an expanded vision of development, and one that vigorously promotes human development as the key to sustaining social and economic progress in all countries. The two targets under the first MDG goal to eradicate poverty and hunger call for halving the proportion of individuals who suffer from poverty and from hunger by 2015. This commitment is another instance of the international community through the UN system yet again renewing its efforts and setting a target and a time frame to deal with the global problem of hunger, poverty and malnutrition. To date, the efforts to reduce global hunger in the developing world have fallen far short of the pace required to meet these targets. There has no doubt been some progress and several countries in the developing world have proved that success is possible. The economic and societal costs to developing countries of not taking decisive action, and thus failing to achieve a reduction in hunger and undernutrition, including micronutrient malnutrition costs, are that every year five million children lose their lives, 220 million disability-adjusted life years are lost as a result of childhood and maternal undernutrition and billions of dollars are lost in productivity and incomes in these countries. Alongside this perennial problem in developing societies are emerging new epidemics of diet-related diseases resulting from the profound demographic changes, urbanization and the economic transition that is transforming and globalizing the food systems in these countries. Thus, many developing countries are facing new and additional challenges of co-existing hunger alongside the emergence of other forms of malnutrition. Meeting the WFS and MDG targets of achieving the goal of halving global hunger is urgent, and the question that needs to be addressed is not whether the international community can achieve this goal in time but whether it can afford not to.     

To control and beyond: moving towards eliminating the global tuberculosis threat

For 10 years the World Health Organisation has had a single answer to the deadly threat of tuberculosis (TB)-provide treatment to smear positive patients and watch them take it. In contrast with confident statements about how global TB would be brought under control when directly observed therapy, short course (DOTS) was introduced, TB continues to rise worldwide. The introduction of selected multiple drug resistant TB treatment programmes, "DOTS-Plus", although important, also focuses on therapy for active TB. HIV endemic countries in particular have experienced tremendous increases in TB despite having DOTS programmes. A critical review of recent epidemiological data and computer models shows that the present international strategy of concentrating on providing treatment for smear positive TB, DOTS and DOTS-Plus, is likely to have only a modest impact on population based TB control. Effective global TB control will require strategies that go beyond relying on treatment of people with active disease.     

Success factors for reducing maternal and child mortality

Reducing maternal and child mortality is a priority in the Millennium Development Goals (MDGs), and will likely remain so after 2015. Evidence exists on the investments, interventions and enabling policies required. Less is understood about why some countries achieve faster progress than other comparable countries. The Success Factors for Women’s and Children’s Health studies sought to address this knowledge gap using statistical and econometric analyses of data from 144 low- and middle-income countries (LMICs) over 20 years; Boolean, qualitative comparative analysis; a literature review; and country-specific reviews in 10 fast-track countries for MDGs 4 and 5a. There is no standard formula – fast-track countries deploy tailored strategies and adapt quickly to change. However, fast-track countries share some effective approaches in addressing three main areas to reduce maternal and child mortality. First, these countries engage multiple sectors to address crucial health determinants. Around half the reduction in child mortality in LMICs since 1990 is the result of health sector investments, the other half is attributed to investments made in sectors outside health. Second, these countries use strategies to mobilize partners across society, using timely, robust evidence for decision-making and accountability and a triple planning approach to consider immediate needs, long-term vision and adaptation to change. Third, the countries establish guiding principles that orient progress, align stakeholder action and achieve results over time. This evidence synthesis contributes to global learning on accelerating improvements in women’s and children’s health towards 2015 and beyond.     

BCG vaccination and WHO's global strategy for tuberculosis control 1948–1983

Mass vaccination with BCG against tuberculosis has been one of the major health interventions of WHO since the Second World War. This article traces the history of the controversial BCG vaccine from its adoption by WHO in 1948 up to 1983. In 1948, there was no clear scientific evidence to support the vaccine, and its adoption by WHO seems to have been urged by the existence of the UNICEF funded ‘International Tuberculosis Campaign’ and a fear of a threatening global epidemic. Moreover, BCG fitted well with the post Second World War perception of public health interventions. The vaccine was not systematically reviewed by WHO until 1959, and this review appears to have been biased in favour of the vaccine. In 1979 the results from the South Indian Chingleput trial, which showed no protective effect of BCG against pulmonary tuberculosis in adults, prompted WHO to change the arguments for recommending the vaccine. Since 1983 BCG has been recommended with specific reference to its protective effect against severe forms of childhood tuberculosis. The story of the BCG vaccine and WHO is a story of medical uncertainty, institutional inertia, strategic obduracy, and not least, hope.     

把握机遇 努力实现降低孕产妇死亡率的目标

把握已在全国 12个省、自治区、直辖市开展降低孕产妇死亡率和消除新生儿破伤风项目的机遇 ,在政府的领导和各相关部门的密切合作下 ,齐心合力 ,解决关键问题 ,就一定能实现《九十年代中国儿童发展规划纲要》中降低孕产妇死亡率和消除新生儿破伤风的目标。     

Financing tuberculosis control: the role of a global financial monitoring system

Control of tuberculosis (TB), like health care in general, costs money. To sustain TB control at current levels, and to make further progress so that global targets can be achieved, information about funding needs, sources of funding, funding gaps and expenditures is important at global, regional, national and sub-national levels. Such data can be used for resource mobilization efforts; to document how funding requirements and gaps are changing over time; to assess whether increases in funding can be translated into increased expenditures and whether increases in expenditure are producing improvements in programme performance; and to identify which countries or regions have the greatest needs and funding gaps. In this paper, we discuss a global system for financial monitoring of TB control that was established in WHO in 2002. By early 2007, this system had accounted for actual or planned expenditures of more than US$ 7 billion and was systematically reporting financial data for countries that carry more than 90% of the global burden of TB. We illustrate the value of this system by presenting major findings that have been produced for the period 2002-2007, including results that are relevant to the achievement of global targets for TB control set for 2005 and 2015. We also analyse the strengths and limitations of the system and its relevance to other health-care programmes.     

Planning to improve global health: the next decade of tuberculosis control

The Global Plan to Stop TB 2006-2015 is a road map for policy-makers and managers of national programmes. It sets out the key actions needed to achieve the targets of the Millennium Development Goals relating to tuberculosis (TB): to halve the prevalence and deaths by 2015 relative to 1990 levels and to save 14 million lives. Developed by a broad coalition of partners, the plan presents a model approach combining interventions that can feasibly be supplied on the ground. The main areas of activity set out in the plan are: scaling up interventions to control tuberculosis; promoting the research and development of improved diagnostics, drugs and vaccines; and engaging in related activities for advocacy, communications and social mobilization. Scenarios for the planning process were developed; these looked at issues both globally and in seven epidemiological regions. The scenarios made ambitious but realistic assumptions about the pace of scale-up and implementation coverage of the activities. A mathematical model was used to estimate the impact of scaling up current interventions based on data from studies of tuberculosis biology and from experience with tuberculosis control in diverse settings. The estimated costs of the activities set out in the Global Plan were based on implementing interventions and researching and developing drugs, diagnostics and vaccines; these costs were US$ 56 billion over 10 years. When translated into cost per disability adjusted life year averted, these costs compare favourably with those of other public health interventions. This approach to planning for global tuberculosis control is a valuable example of developing plans to improve global health that has relevance for other health issues.     

Update: global measles control and mortality reduction--worldwide, 1991-2001

Despite international recognition of the high burden of disease associated with measles and the existence for 40 years of a safe, effective, and inexpensive vaccine, measles remains the leading cause of vaccine-preventable childhood mortality. In 1990, the World Summit for Children adopted a goal of vaccinating 90% of the world's children against measles by 2000 (1). In 2001, the World Health Organization (WHO) and the United Nations Children's Fund (UNICEF) developed the Global Measles Strategic Plan for 2001-2005. The plan's objectives are 1) to decrease the annual number of measles deaths by 50% by 2005 compared with 1999 levels (875,000 deaths), 2) to achieve and maintain interruption of indigenous measles transmission in large geographic areas with elimination goals, and 3) to convene a global consultation in 2005 to review progress and assess the feasibility of global measles eradication. In May 2002, the United Nations General Assembly Special Session on Children also resolved to reduce measles deaths by 50% by 2005 compared with 1999 levels. This report describes progress toward eliminating measles worldwide. Data from WHO's Global Burden of Disease (GBD) project indicate that approximately 1.7 million vaccine-preventable childhood deaths occurred in 2000, of which 777,000 (46%) were attributed to measles. The measles deaths occurred overwhelmingly among children living in poor countries with inadequate vaccination services. To prevent these deaths, stronger political commitment is needed to provide all children worldwide with two opportunities for measles immunization.     

Progress in global measles control and mortality reduction, 2000-2006

The World Health Organization (WHO) and United Nations Children's Fund (UNICEF) comprehensive strategy for measles mortality reduction is focused on 47 priority countries. Components include 1) achieving and maintaining high coverage (>90%) with the first dose of measles vaccine by age 12 months in every district of each priority country through routine immunization services; 2) ensuring that all children receive a second opportunity for measles vaccination; 3) maintaining effective case-based surveillance and monitoring of vaccination coverage; and 4) providing appropriate clinical management, including vitamin A supplementation. In 2005, the World Health Assembly set a goal for global measles control as part of the Global Immunization Vision and Strategy (GIVS): a 90% reduction in measles mortality by 2010, compared with 2000 levels. In January 2007, WHO/UNICEF reported that implementation of measles mortality reduction strategies had reduced measles mortality by 60%, from an estimated 873,000 deaths in 1999 to 345,000 deaths in 2005. This reduction exceeded the goal of 50% measles mortality reduction by 2005 (compared with 1999 levels) that had been set in 2002. This report updates previous reports by detailing 1) measles mortality reduction activities implemented during 2006 and 2) the impact of activities since 2000 on the global burden of measles and progress toward the GIVS mortality reduction goal for 2010.     

Lessons from Africa: developing a global human rights framework for tuberculosis control and prevention

Background

Tuberculosis is a highly contagious disease, and there has been a rise in recent years of drug-resistant cases no longer responding to standard treatment.In order to address this threat and contain possible transmission of drug-resistant cases, some countries have taken strong action, including the compulsory detention of non-adherent drug-resistant patients. These measures have been strongly criticized by human rights advocates, and they raise the question of how to legally protect both citizens and the community.

Discussion

Following discussions with National Tuberculosis Programs in Africa (the continent with the highest incidence rates of tuberculosis worldwide), we show that of all the countries surveyed, all but one (Swaziland) had either no specific policy addressing tuberculosis, or only general policies regarding public health applicable to tuberculosis. Six countries also reported having policies that address non-adherence to treatment with containment (isolation in health facilities or incarceration), but laws are not adequately enforced. If the international community wants to effectively respond to the threat of tuberculosis transmission, there is a need to go beyond national tuberculosis policies and to implement an international framework for tuberculosis control, inspired by the Framework Convention on Tobacco Control, a key model for future public health treaties that address global burdens of disease. The framework, for which we clarify the conditions and procedures in this piece, would define the rights and responsibilities of the different stakeholders involved: patients, doctors, pharmaceutical firms and public authorities. To facilitate the governance of the national obligations under the Convention, a coordinating body should be set up, under the leadership of the World Health Organization and the Stop TB Partnership.

Summary

Successfully implementing policies for tuberculosis that simultaneously address patients’ rights and communities’ wellbeing will have positive implications for those affected by the disease and serve as a basis for other global health conventions to truly ensure the global right to health.

     

Trypanotolerance in cattle and prospects for the control of trypanosomiasis by selective breeding

Tsetse-transmitted trypanosomiasis is one of the major constraints on the expansion of the livestock and agricultural industries in Africa. The disease affects animals and man, with direct and indirect losses estimated in billions of dollars annually. Because of the phenomenon of antigenic variation, no vaccine is available. Current prophylactic efforts must rely on tsetse control by the use of insecticides and on trypanocidal drugs. However, recent advances in our knowledge of tsetse and trypanosome biology are offering hope for alternative methods of trapping tsetse, new drugs and even vaccination. Possibly of even greater significance is the increasing sense that Africa herself might be able to contribute to the resolution of this problem. Over a period of several thousand years, she has generated cattle, such as the taurine N'Dama and West African Shorthorn breeds of West and Central Africa, that are now known to possess a significant degree of innate resistance to trypanosomiasis and several other important infectious diseases. These cattle are extremely well adapted to the environment and are now recognised as having considerable production potential. The ability to resist the development of anaemia in the face of infection, as assessed by packed red cell volume percent (PCV), has been shown to be correlated with the capacity to be productive, thereby identifying regulation of PCV as a key trait of trypanotolerance. Thus, an estimate of the ability of an infected animal to maintain PCV, following either experimental or field infection, could be used as a method for identifying trypanotolerant individuals. This could provide a means of estimating trypanotolerance heritability, thereby permitting rational breeding programmes to be instituted. Africa may thus provide the answer.