“Challenges of Current TB Problem to Today’s Asia”

Regional Framework for Action
on Implementation of the End TB Strategy
in the Western Pacific Region
The Asian National Stop TB Partnership Forum,
14–15 March 2016, Tokyo, JapanDr Nobu Nishikiori, Coordinator
Stop TB and Leprosy Elimination
World Health Organization
Regional Office for the Western PacificWorld Health Organization Regional Office for the Western PacificMDG6 TB target achieved
REVERSED

43 million
lives saved
between 2000
and 2014

Rate per 100,000 population

TB

47%Mortality

Incidence

TargetFalling 1.5% per year(2000-2014).
18% drop since 200047% decline since 1990

1990

2000

2014

1990

2000

2014

But huge burden of deaths and suffering remains.
9.6 million people fell ill with TB in 2014, and there were 1.5 million deaths

Surpassing MDGs and other targets
in the Western Pacific Region

World Health Organization Regional Office for the Western PacificTB burden in the Western Pacific Region

Estimate number of TB (allforms)

1.6 million(85 per 100 000)

88 000Estimated number ofdeaths due to TB*(4.8 per 100 000)

Multidrug-resistant TB

71 000HIV-associated TB

31 000All estimates are for 2014.
Source: Global TB Report 2015 (WHO)* Excluding death due to TB-HIV co-infection

World Health Organization Regional Office for the Western PacificChallenges
1. Many patients unreached2.

Insensitive diagnostics

3. Vulnerable and high-risk groups

4. Only a small fraction of MDR-TB
patients diagnosed, yet treatment
capacity insufficient
5. Limitations in health systems

World Health Organization Regional Office for the Western PacificIncreasing difficulty in TB diagnosis
All cases identified by prevalence survey

Sm-ve TB
(culture +ve)
16%
Sm+ve TB
14%
Cases identified
by symptom
screening

Sm-ve TB
(culture +ve)
54%
Sm+ve TB
16%

Cases (additionally)
identified
by X-ray(Data from The Second National TB Prevalence Survey, Cambodia, 2011)

World Health Organization Regional Office for the Western PacificNeed for more sensitive diagnostics
More sensitive diagnogostics

LED Microscopy
10,000/ml
Line-probe assay
10,000/ml

LAMP
50-150/ml

XPERT MTB/Rif
50-150/ml
Liquid culture
10-100/ml“Smear-negative”

1

10100

1000

“Smear-positive”

10000

100000

CFU (colony forming unit ) per ml
World Health Organization Regional Office for the Western Pacific1M

via Universal Health Coverage and other Social Protection measures

Financial hardship of TB patients and families~ losing a half of annual income ~•••TB patients
middle-income
countries face
Fallinginilllow-andwith TB often
carries a devastating
expensefinancial
equivalent
more
50% of their annual
burdento
withsocialthan
repercussions
income. On average, TB patients in low-and middle-income
countries
face
medicalexpenses,
costs
ofseeking/staying in care, and income loss equivalent tomore than 50% of his or her annual income *.

A half of the costs are incurred before TB treatment
The financial burden varies between settings, with total
cost in relation to income ranging from 2% to over 300%
across countries with different TB care models, general
health systems and social protection schemes.

Patients often have to resort to coping mechanismsthat may beirreversible:
The financial burden is on average greater for persons–––•

up to 75%of TBMDR-TB
patientsand
mustout a loan;
ill withfortakethe poorest.
up to 50%sell household items; andIncome loss represents on average about 60% of theup to 66%
relycosts
on financial
fromrelatives.
total
faced bysupport
patients,
whereasabout 25% is for

direct medical costs such as tests, medicines andhospitalization, and the rest is for other care-related
costs, such as transport (see figure).

Addressing catastrophic patient cost is prerequisite
average, halfTBof thecosts are incurred before TB
for furtherOn
advancing
control

Distribution of medical expenditures, other expendituresand income loss, before and during TB treatment*

Universal health coverage and social protection
can eliminate catastrophic costs

WHO defines catastrophic health care expenditures
treatment has begun – in seeking diagnosis (see figure).
as direct health care expenditures correspondingto >40% of annual discretionary income (incomePatients often have to resort to coping mechanisms
after basic needs, such as food and housing). Indirectthat may be irreversible: up to 75% of TB patients must
HealthRegional
costs of Pacificcare and income loss are not included.
take Worldout a loan;
up toOrganization
50% sell household
items;Office
and up for the WesternMDR-TB diagnosis, enrolment vs estimatedin the Western Pacific Region
71,00070,00071 000
MDR-TBcases
annually

60,00050,00040,000

Number of MDR/RR-TB cases diagnosed andnotified

30,00020,00013,437
8,725

10,00010,263Only 12%enrolled

8,850

6,412
1,190

2,057

2008

2009

3,773

0
2010

2011

2012

2013

2014

Enrolled

Estimated

World Health Organization Regional Office for the Western PacificTB drugs in the private sector market
Growing evidence on a hugeprivate sector drug marketooo•

Public procurement sufficient for all
notified TB case(Blue bar and line)
Private sector drug sales are almost
equivalent to the notified TB cases(Red bar)
Five times more drugs for initial
treatment relative to drugs for continuous
phase

Reflecting:ooo

A weak notification system
Incomplete treatment in the private sector
Unnecessary patient costs

700 000

Drug procumenet/sales volume(equivalent to a number of pa ents could be treated)•

Private sector drug sales*
600 000

500 000

Procurement by Na onal TB
Programme
TB cases no fied (1-yearoffset)

400 000

300 000

200 000

100 00002007200820092010

2011* Private sales was translated as a number of patients could have been initiated intensive phase of treatment
with 4 fixed-dose combination tablets.
(Islam, T. Tisocki, K. et al. Public Health Action 3, 337–341 (2013).)World Health Organization Regional Office for the Western PacificExternal funds

Rich countries

Investment
National
Programmes••••

Provincial/District
Programmes

Large external funds
Delivery of proven interventions
Quick & measurable health gain
Help poor countries get out of the vicious cycle temporal large investment justifiedInterventions
Services
Health Centres

Consequences• Fixed unilateral aid flow, power imbalance and donor
fatigue• Too much focus on performance in narrow agenda,
less on process and the net social benefit• Inequitable distribution of services within the healthsystem

Health outcomes
Health development model in the MDG era

The End TB Strategy
Draft Regional Framework for Action

World Health Organization Regional Office for the Western PacificGlobal commitment to End TB
Moving from halting TB to ending TB by 2030
SDG 3.3 “End the epidemics of AIDS, tuberculosis, malaria andneglected tropical Diseases”

Health development modelin the context of Sustainable Development

Funds
Revenue(Resources forhealth)

Universal Health Coverage
Health system capacity• Quality & safety• Efficiency• Equity• Accountability• Sustainability and resilience

Health policies,
system & services
Efficient and coherent service
delivery

Healthgovernance

Health outcomes
Non-health sector
policies & actions

Governance
For Health

Sustainable
development andgrowth

Disease control in the SDG era• Disease control efforts:—should support system building—should be supported by boldsystems• System efficiency, equity andsustainability• Strong governance• Multisectoral engagement

Vision, goal, targets, milestones

Vision:A world free of TB
Zero TB deaths,
Zero TB disease, and Zero
TB suffering

Goal:
End the Global TB
epidemicProjected acceleration of TB incidence decline to target
levelsCurrent global trend: -2%/year

Optimize current tools,
pursue universal healthcoverage and social
protection

Average-10%/yearby 2025

Introduce new tools: a vaccine, anew prophylaxis & treatment
regimen, a PoC test

GLOBAL TB
PROGRAMME-5%/year
Average-17%/yearThe End TB Strategy:

3 pillars and 4 principles

Regional Framework for Action
on Implementation of the End TB Strategy
Purpose• Facilitate the adaptation and implementation of theEnd TB Strategy
Structure and contents• Follow the same three-pillar structurewith 7 components• Each component composed of:– Strategy– Regional situation– Proposed actions•

Region specific issues:

Regional Framework for
the End TB Strategy– High risk groups, opportunities for social protection, urban TBcontrol, co-morbidity management

Endorsed by Member States in 66th RCM in Oct 2015
World Health Organization Regional Office for the Western PacificRegional Framework for Action
Pillar 1: Integrated, people-centredcare and preventionPillar 2: Bold policies and supportivesystems

1. Treatment and care for all TBpatients

1. Governance and stewardship•••••

MDR-TBTB among children
High-risk populations (enhancing contactinvestigation)
TB/HIV
Co-morbidities

2. TB laboratory networks
3. Latent TB infection and BCG
vaccination••••

NSP and TB control financing
UHC policy and TB control
Drug regulatory systems
Disease notification and surveillance systems

2. Engagement of public and private
providers
3. Addressing social determinants andsocial protection

Pillar 3: Research– Enhancing TB research capacity

World Health Organization Regional Office for the Western PacificAttributes highlighted and elaborated• Paradigm shift in TB control• Apply health system strategies and concepts• Covering the whole epidemiological spectrum• People-centred care

World Health Organization Regional Office for the Western PacificParadigm shift in TB control

Gradual expansion toadditional services(e.g. radiography)
Free diagnosis anddrugs(in-kind provision)

Elimination ofcatastrophic costs /Harmonization with UHC
schemes

Supportive
supervision andcommunity-based
supportSupervised
drug intake

Patient-centred care

Examples:• “free diagnosis & treatment”
 UHC & social protection• DOT  Patient-centred care

World Health Organization Regional Office for the Western PacificKey areas elaborated• People centered care  Principle– WPRO/SEARO 2007 Policy Document• Co-morbidity management– Link with ageing societies• TB care financing in the context of UHC– WPRO’s policy framework on sustainable financing
for priority health programmes• Social protection floor– ILO Recommendation R202

• Social determinants– HiAP & Urban TB control
World Health Organization Regional Office for the Western PacificChanges in TB incidence between 1994-2013
LAO
MNG PNG

PHL200VNM
HKG

100MAC
SGP

MYS

50BRN

CHN

KOR

20JPN

10NZLAUS

5

Estimated incidene rate (per 100 000)

500

KHM

1001000

10000
Estimated incidence (n umber)

1000001000000
Estimates from Global TB Database

World Health Organization Regional Office for the Western PacificEvolution of the TB control components
along with an epidemiological spectrum
High burden

Low incidence

Pre-elimination

Elimination

Pillar 1. Quality TB services
e.g. Basic / resource constraint Comprehensive / fully satisfy the standards of caree.g. Contact investigation: Facility-based  home-based  active epi. investigation
e.g. LTBI: PLHIV/Childhood contacts Expansion to other high risk groups

Pillar 2. Bold support systems (vertical/top-down  sustainable & integrated)
e.g. Surveillance: Basic system Electronic / case-based system
Link with lab. info system  gene/molecular surveillancee.g. Social protection: enablers  income compensation  comprehensive health-welfare link

* Only selected components are shown for the illustrative purpose.
World Health Organization Regional Office for the Western PacificThree tiers of actions
Spectrum of TB epidemiology
High burden

Low incidence

Pre-elimination

Progressive actions towards elimination

Universally applicable actions for all settings
Setting specific considerations (e.g. Pacific islands, urban areas)

World Health Organization Regional Office for the Western PacificTB control asa global public good for health• Public goods—e.g. safe drinking water, clean air, etc.
• TB control has been regarded as a classic example of“a public good for health”– TB control in one setting will benefit everybody– Collective (global/regional) TB control is impacted by the level of control
achieved in the worst national TB program(the weak link characteristics)• This principle is a key for continued advocacy for sustainablepublic financing as well as cross-country collaboration
Smith R., Beaglehole R., Woodward D., Drager N. (ed.) Global Public Goods for
Health: health economics and public health perspectives.
World Health Organization Regional Office for the Western PacificA vision beyond DOT:
People-centred health care
• Health care that is organized aroundpatients, families and communitiesAction domains• Responding holistic needs ofpatients, rather than the needs ofprogrammes or systems

2. Competent and responsive healthworkers– Medical, psychological, social, andfinancial– Strong service coordination

1. Informed and empowered patients,
families and communities

3. Efficient and humane health careorganizations
4. Supportive health systems

World Health Organization Regional Office for the Western PacificPeople-centred TB careEngagement &Partnership

Community
FamilyRisk group
BCG & LTBI

SocialdeterminantsSocial protection
Patient

Infected and become sick

Treatment and careCommunity
healthworkersCommunity
healthworkers

HealthWorkers
Health careorganizations

Laboratory network

Health system
capacity

Treatment and care for all

Governance and stewardshipWorld Health Organization Regional Office for the Western PacificSummary• Substantial achievement in TB control globally• Remaining and emerging challenges– TB among high-risk and vulnerable populations– Scaling up response to drug-resistant TB– Building sustainable TB control system while contributing to the overall
health system strengthening efforts• The End TB Strategy and its Regional Framework opened up
new era of TB control– From a vertical programme to “an essential health system competency”– People-centeredness as a core principle– All countries to be aligned and cooperate for regional/global TB control

World Health Organization Regional Office for the Western PacificThank you!

World Health Organization Regional Office for the Western Pacific