World Health Organization Regional Office for the Western Pacific The WHO End TB Strategy: Regional...

World Health Organization Regional Office for the Western PacificWorld Health Organization Regional Office for the Western Pacific

The WHO End TB Strategy: Regional Perspective

Dr Nobuyuki Nishikiori, CoordinatorStop TB and Leprosy EliminationWorld Health OrganizationRegional Office for the Western Pacific

The Ninth Technical Advisory Group and National TB Programme Managers Meeting

Manila Philippines, 9-12 December 2014

World Health Organization Regional Office for the Western Pacific

Regional Situation


TB burden in the Western Pacific Region• Since 2000

- 10 million patients treated- 800 000 deaths averted

• On track for achieving the TB related MDGs and other targets by 2015

1.6 million(87 per 100 000)

110 000(5.8 per 100

000)

Estimate number of TB (all forms)

Estimated number of deaths due to TB*

Multidrug-resistant TB

71 000

HIV-associated TB 23 000

All estimates are for 2013.Source: Global TB Report 2014 (WHO)* Excluding death due to TB-HIV co-infection


Changes in TB incidence between 1994-2013

Estimates from Global TB Database


Changes in TB mortality between 1994-2013

Estimates from Global TB Database


The WHO End TB Strategy

X

Challenges and Opportunities in the Western Pacific Region


Challenges

• Still many patients unreached• High-risk and socially vulnerable

populations• Only a small fraction of MDR-TB

patients diagnosed, yet treatment capacity insufficient

• Donor investment shrinking, threatening sustainability

• Health systems in transitions for efficiency and sustainability

• Regulatory approaches not fully utilized


3 qualities of the End TB Strategy

that are of high regional relevance

1. Transcending epidemiological settings with a long-term targets ‘Spectrum’ of TB epidemiologyTB control as a global public good for health


Evolution of the TB control components along with an epidemiological spectrum

Pillar 1. Quality TB services

Pillar 2. Bold support systems (vertical/top-down sustainable & integrated)

e.g. Surveillance: Basic system

e.g. Social protection: enablers income compensation comprehensive health-welfare link

Electronic / case-based system

High burden Low incidence Pre-elimination Elimination

e.g. Basic / resource constraint

* Only selected components are shown for the illustrative purpose.

Comprehensive / fully satisfy the standards of care

e.g. Contact investigation: Facility-based home-based active epi. investigation

Link with lab. info system gene/molecular surveillance

e.g. LTBI: PLHIV/Childhood contacts Expansion to other high risk groups


TB control asa global public good for health

• TB control in one setting will benefit everybodyNo body is prevented from benefiting (and vice versa)– “A classic example of how a health program might be considered a

global public good”

• “Weak link” characteristics—the maximum attainable level of control in any particular country can be impacted by the level of control achieved in the worst national TB control program.

• This principle is a key for continued advocacy and sustainable public financing

Smith R., Beaglehole R., Woodward D., Drager N. (ed.) Global Public Goods for Health: health economics and public health perspectives.





2. Focusing on the vulnerable and unreachedAddressing health inequityRe-tackling TB as a social disease


Pillar 1: Reach the Unreached

( Session 3)Situation• Contact investigation

strengthened in many countries

• Childhood TB Taskforce and national policy development

• Steady progress in TB/HIV• Hospital engagement in

relevant countries• TB screening project and

initiatives to address TB among high risk populations

Challenges• Policy implementation• Prioritization• Sound, regular evaluation• PPM: engagement and

regulation


Pillar 1: PMDT( Session 2 Lab,

Session 5 MDR-TB)

Situation• Significant PMDT expansion• Rapid adoption of new tools• Gradual capacity

development

Challenges• Treatment gap enlarging• Deterioration in treatment

outcome in some settings• Path towards universal DST

Diagnosed and notified

Enrolled in treatment

Gap

MDR-TB notification and enrollment in 8 countries

LFU

Success





2. Focusing on the vulnerable and unreachedAddressing health inequityRe-tackling TB as a social disease

3. Emphasis on bold policies Integration and harmonization with health systems Whole-government and societal approaches


Pillar 2: UHC and social protection

( Session 6: 28-29)

Situation• Increasing social disparity

and health inequity• High economic burden on

TB patients • Various experience in

enablers and subsidies• UHC poses a major

opportunity

Challenges• Institutionalizing good

practices • Options to be explored to

mitigate patient economic burden

• Limited schemes available• Monitoring mechanism


Financial hardship of TB patients and familiesTB continues pushing people into poverty

• Many patients face catastrophic expense due to TB

• A half of the costs before TB diagnosis

• Patients take coping mechanisms that may be irreversible: – 75% of TB patients must take out a loan; – 50% sell household items

• Addressing catastrophic patient cost is essential

Annual direct medical cost spent by households with TB patients.

Unweighted summary of 9 studies in China (Long et al 2011)


Pillar 2: Sustainable financing( Session 6: 26-27)

Situation• Many countries in health

financing reforms• Financial sustainability is

threatened– Shrinking donor investment– Too small domestic fund

• Robust, costed NSPs in most countries

• Success in GF applications

Challenges• Building sustainable TB

financing suitable for each country context

• Protect essential public health functions

• Where applicable, effective integration into general health funding schemes including health insurance


Pillar 2: Drug regulations ( Session 6: 30)

Situation• A critical key for

MDR-TB prevention• TB drug regulation

meeting identified priority actions

• New TB drug introduction and PV

Challenges• Continued dialogue

and collaboration with NRAs

(Islam, T. Tisocki, K. et al. Public Health Action 3, 337–341 (2013).)

Drugs by public procurement

Drug sale in the private market

Notified TB cases


Pillar 2: Patient and community engagement ( Session 7)

Situation• Various experience in engaging

community based organizations in TB control

Challenges• Empower patient and

community organizations for effective engagement

• Expand the area of collaboration: patient support, advocacy, policy processes, etc


Regional document to support implementing the End TB Strategy


Regional Framework for Actionto implement the End TB Strategy (proposal)

Purpose• Facilitate the adaptation and implementation

of the End TB Strategy

Methods / scope • Elaborate policy options:

– Considering region-specific context– Spectrum of TB epidemiology (all countries)

• Major sources:– NSPs, Programme Reviews– Recent meeting findings/recommendations

(childhood TB, drug regulations, migration and TB)– Operational research publications/reports

• Regional experience and case studies• No new targets

Regional Framework for Action

to implement the End TB Strategy


A proposed process

• Dec 2014: TAG & NTP managers meeting– Agree on the scope and overall framework– Discussions and recommendations for each session will be fully

taken into account

• Dec 2014: Establish a drafting group • Feb 2015: First web-consultation • March 2015: Expert consultation meeting (HBCs +

selected IBCs)• (April 2015: Final web-consultation, as needed)• Aug 2015: UNION APR Conference• Oct 2015: RCM


Your comments are welcome!

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