Global Tuberculosis: Burden, Challenges, And the ... fileGlobal Tuberculosis: Burden, Challenges, And the contribution of the private sector Fabio Scano Stop TB Department WHO Geneva
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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
TB is the biggest cause of death from a
curable or preventable infectious disease
0.0
1.0
2.0
3.0
HIV/AIDS Tuberculosis Malaria Measles
Mil
lio
ns
of
death
s i
n 2
00
2
2005 – 8.8 million new TB cases
and 1.6 million deaths due to TB
Th
e bou
nd
arie
s an
d n
ames
sh
ow
n a
nd th
e des
ign
atio
ns
use
d o
n t
his
map
do n
ot
imp
ly t
he
exp
ress
ion
of
any
op
inio
n w
hat
soev
er o
nth
e par
t of
the
Worl
d H
ealt
h O
rgan
izat
ion
con
cern
ing th
e le
gal
sta
tus
of
any
cou
ntr
y, t
erri
tory
, ci
ty o
r ar
ea o
r of
its
auth
ori
ties
, or
con
cern
ing
th
e d
elim
itat
ion
of
its
fron
tier
s or
bou
nd
arie
s. D
ott
ed l
ines
on
map
s re
pre
sen
t ap
pro
xim
ate
bord
er lin
es f
or
wh
ich
th
ere
may
not ye
t be
full
agre
emen
t.
WH
O 2
00
5. A
ll r
igh
ts r
eser
ved
AFR 28%WPR 22%
SEAR 34%
EUR 5%
EMR 7%
AMR 4%
0 - 24
25 - 49
50 - 99
100 - 299
No estimate
300 or more
Estimated new TB
cases (all forms) per
100 000 population
445,000 cases and 66,000 deaths
Global TB control targets
2005: World Health Assembly:
- To detect at least 70% of infectious TB cases
- To treat successfully at least 85% of detected cases
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…
1618
2224
2832
37
45
0
10
20
30
40
50
60
70
80
1994 1996 1998 2000 2002 2004
45%
37%32%
28%24%
22%18%
16%
53%
60%
95 96 97 98 99 01 02 03 04 05
Over 26 million TB patients treated
under DOTS worldwide
World Health Assembly
2005 TB Control Targets
0
10
20
30
40
50
60
70
80
90
100
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
Case d
ete
cti
on
rate
or
cu
re r
ate
(%
)
Target cure 85% Target detection 70%84
60
Progress towards the MDGs 2015
TB incidence rates per capita peaking?
0
50
100
150
200
250
300
350
400
450
1990 1995 2000 2005
WORLD
AFR
AMR
EMR
EUR
SEAR
WPR
Est
imat
ed T
B in
cid
ence
/100
K/y
r
50
100
150
200
250
300
350
400
450
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"
Reasons for failure:
Treatment outcomes are worst in
Africa and Europe
0 10 20 30 40
Africa
Americas
E Med
Europe
SE Asia
W Pacific
Percent of cohort
Died
Failed
Defaulted
Transfered
Not Evaluated
Issue 1: DOTS quality – reasons for failure
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 conclusion…
New challenges require the
new Stop TB Strategy
The Global Plan 2006-2015 clearly outlines
what needs to be done and the costs
A new vision…
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.
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