Global Tuberculosis: Burden, Challenges, And the ... fileGlobal Tuberculosis: Burden, Challenges, And the contribution of the private sector Fabio Scano Stop TB Department WHO Geneva

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

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, or

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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

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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.