After the UNGA High-Level Meeting on Tuberculosis—what next and how?
Authors: Suvanand Sahu, Lucica Ditiu, Alimuddin Zumla
Journal: The Lancet Global Health (2019)

Although tuberculosis is curable and preventable, it remains the leading infectious cause of death worldwide. The 2018 WHO Global Tuberculosis Report1WHOGlobal tuberculosis report 2018. World Health Organization, Geneva2018Google Scholar states that, in 2017, an estimated 10·0 million people globally (5·8 million men, 3·2 million women, and 1·0 million children) fell ill with tuberculosis, of whom 1·6 million died. Tuberculosis is also a major cause of morbidity and mortality in people living with HIV infection.1WHOGlobal tuberculosis report 2018. World Health Organization, Geneva2018Google Scholar Multidrug-resistant tuberculosis is now a serious threat to global health security, adding to the growing burden of antimicrobial resistance. In 2017, of an estimated 558 000 people with drug-resistant tuberculosis, only one in four received treatment, with treatment success rates estimated at 54% versus an optimal target of 90%.1WHOGlobal tuberculosis report 2018. World Health Organization, Geneva2018Google Scholar Tuberculosis incidence is decreasing at a slow pace of 1·5% each year. These annual rates of reduction need to rise to 4–5% by 2020 in order to meet the WHO End TB Strategy targets2WHO End TB strategyGlobal strategy and targets for tuberculosis prevention, care and control after.https://www.who.int/tb/post2015_strategy/en/Date: 2015Date accessed: February 1, 2019Google Scholar of a 90% reduction in the number of deaths due to tuberculosis, and an 80% reduction in tuberculosis incidence between 2016 and 2030. To achieve these daunting targets, a major step-change in political will was required to put global efforts to end tuberculosis back on course. On Sept 26, 2018, the first ever UN General Assembly (UNGA) High-Level Meeting on Tuberculosis (UNGA-HLM-TB), with more than 1000 participants from across the world, assembled in New York.3UNGAA/RES/73/3. Political declaration of the high-level meeting of the General Assembly on the fight against tuberculosis.http://www.un.org/en/ga/search/view_doc.asp?symbol=A/RES/73/3Date: 2018Date accessed: February 1, 2019Google Scholar The meeting resulted in the adoption of a Political Declaration on Tuberculosis3UNGAA/RES/73/3. Political declaration of the high-level meeting of the General Assembly on the fight against tuberculosis.http://www.un.org/en/ga/search/view_doc.asp?symbol=A/RES/73/3Date: 2018Date accessed: February 1, 2019Google Scholar, 4Stop TB PartnershipUNHLM on TB Key Targets for 2022.http://stoptb.org/assets/documents/global/advocacy/unhlm/UNHLM_Targets&Commitments.pdfDate: 2018Date accessed: February 28, 2019Google Scholar on Oct 10, 2018, which reaffirmed commitment to end the tuberculosis epidemic globally by 2030 and included ambitious and bold targets for scale-up of tuberculosis care and prevention services, as well as commitments on research for new tools, principles of equity and human rights, and resource needs targets for both implementation and research. A follow-up WHO Executive Board meeting focused on ending tuberculosis re-affirmed targets set for 2022.5WHOExecutive Board 144th session. Follow-up to the high-level meetings of the United Nations General assembly on health-related issues. Ending tuberculosis. Dec 13,.http://www.stoptb.org/news/stories/2018/ns18_072.aspDate: 2018Date accessed: February 12, 2019Google Scholar An unprecedented level of political commitment to ending the tuberculosis pandemic was achieved at the UNGA-HLM-TB.6Zumla A Petersen E The historic and unprecedented United Nations General Assembly High Level Meeting on Tuberculosis (UNGA-HLM-TB)–'United to End TB: An Urgent Global Response to a Global Epidemic'.Int J Infect Dis. 2018; 75: 118-120Summary Full Text Full Text PDF PubMed Scopus (20) Google Scholar, 7Herbert N Sharma V Masham BS Sheehan BS Hauser J Zumla A Concrete action now: UN High-Level Meeting on Tuberculosis.Lancet Infect Dis. 2018; 18: 709-710Summary Full Text Full Text PDF PubMed Scopus (12) Google Scholar Encouragingly, this has continued and remains strong, with some heads of states and most ministers of health personally involved, particularly those from countries that proactively participated in the process before and during the UNGA-HLM-TB. Now is the time to translate this political will and commitments into practical action within the short timeframe of the targets. The Declaration created unprecedented opportunities requiring concrete actions7Herbert N Sharma V Masham BS Sheehan BS Hauser J Zumla A Concrete action now: UN High-Level Meeting on Tuberculosis.Lancet Infect Dis. 2018; 18: 709-710Summary Full Text Full Text PDF PubMed Scopus (12) Google Scholar and raises the questions: what next and how? Three critical components—funding, action, and accountability—will be pivotal to the success of the initiatives of the UNGA High-Level meeting on Tuberculosis. First and foremost, is for UN member states to make available the resources needed. The UNGA Declaration calls for mobilisation of US$13 billion per year for implementation and an additional $2 billion per year for research into new tools.3UNGAA/RES/73/3. Political declaration of the high-level meeting of the General Assembly on the fight against tuberculosis.http://www.un.org/en/ga/search/view_doc.asp?symbol=A/RES/73/3Date: 2018Date accessed: February 1, 2019Google Scholar, 4Stop TB PartnershipUNHLM on TB Key Targets for 2022.http://stoptb.org/assets/documents/global/advocacy/unhlm/UNHLM_Targets&Commitments.pdfDate: 2018Date accessed: February 28, 2019Google Scholar In 2017, less than $7 billion was available for implementation and about $0·7 billion was available for research.1WHOGlobal tuberculosis report 2018. World Health Organization, Geneva2018Google Scholar, 8TAG-Stop TB PartnershipTuberculosis research funding trends 2005–2017.http://www.treatmentactiongroup.org/sites/default/files/tb_funding_2018_final.pdfDate: 2018Date accessed: February 4, 2019Google Scholar Thus, funding for tuberculosis implementation needs to almost double and for research it needs to almost triple. The Global Fund to Fight AIDS, Tuberculosis and Malaria, which is the main external funding source for tuberculosis globally, is going for its sixth replenishment in October, 2019. The tuberculosis aspect of the Global Fund Investment Case for replenishment is aligned with the Political Declaration on Tuberculosis and is for the critical period 2020–22, when most of the scale-up towards achieving the UNGA tuberculosis targets is anticipated to occur.9The Global FundInvestment case summary. Sixth replenishment.https://www.theglobalfund.org/media/8174/publication_sixthreplenishmentinvestmentcase_summary_en.pdfDate: 2019Date accessed: February 4, 2019Google Scholar Several high-tuberculosis-burden countries depend heavily on the Global Fund for their tuberculosis programmes and Global Fund grants have a catalytic and important role in various low-income and middle-income countries. Although a fully replenished Global Fund will be important, national domestic budgets also need to increase significantly in all tuberculosis-endemic countries, and additional sources of funds through loans, bilateral aid, social health insurance, and innovative and impact financing will be required.10STOP TB PartnershipDecision points. 31st board meeting, 20–30 January 2019 Geneva, Switzerland.http://stoptb.org/assets/documents/about/cb/meetings/31/31%20Outcomes/31%20Stop%20TB%20Board%20Decision%20Points.pdfDate accessed: February 4, 2019Google Scholar For research funding, national governments need to commit resources and contribute their fair share based on income and capacity to do so.3UNGAA/RES/73/3. Political declaration of the high-level meeting of the General Assembly on the fight against tuberculosis.http://www.un.org/en/ga/search/view_doc.asp?symbol=A/RES/73/3Date: 2018Date accessed: February 1, 2019Google Scholar, 8TAG-Stop TB PartnershipTuberculosis research funding trends 2005–2017.http://www.treatmentactiongroup.org/sites/default/files/tb_funding_2018_final.pdfDate: 2018Date accessed: February 4, 2019Google Scholar Investing in tuberculosis is said to be one of the smartest investments among the Sustainable Development Goal (SDG) targets, with a return on investment of $43 per dollar spent.11Copenhagen Consensus CenterThe Nobel Laureates' guide to the smartest targets for the world 2016–2030.https://www.copenhagenconsensus.com/sites/default/files/post2015brochure_m.pdfDate accessed: February 4, 2019Google Scholar Second, rapid action by countries, donors, and stakeholders is required for scaling up tuberculosis care and prevention as well as fast-tracking research into the development of new diagnostics, drugs, and vaccines. An estimated 4 million people are currently being left behind without being identified and receiving any quality tuberculosis care. These so-called missing people with tuberculosis need to be found and put on effective treatment for drug-susceptible and drug-resistant tuberculosis.12Stop TB Partnership 201790(90)90: the tuberculosis report for heads of states and governments.http://www.stoptb.org/assets/documents/resources/publications/acsm/909090_PDF_LR.pdfDate accessed: February 2, 2019Google Scholar Century-old diagnostic tools such as light microscopy for tuberculosis diagnosis need to be replaced or complemented with accurate and rapid point-of-care molecular diagnostic tests. Shorter and more effective tuberculosis treatment regimens, including the all-oral drugs treatment regimen for multidrug-resistant tuberculosis, need to replace previous regimens. The expanding pipeline of tools for diagnosis and treatment need increased funding and fast-tracking of development, evaluation, and implementation. Preventive therapy for latent tuberculosis infection needs to be scaled up for contacts (adults and children), people living with HIV, and other risk groups. To achieve this, national tuberculosis programmes will need to change their current mode of operating and mindset, modernising their tools and approaches, incorporating new information technology, and increasing their risk appetite to implement out-of-the box, practical, locally relevant solutions to address any operational problems. Third, a specific independent monitoring and accountability mechanism was absent from the Political Declaration and is essential to hold world leaders, national governments, and stakeholders accountable to the commitments made. The global targets in the declaration are now categorised and delineated by individual country-level targets to ensure that progress by countries can be tracked.13Stop TB PartnershipUN High Level Meeting on TB: key targets and commitments for 2022 and outlined in the UN declaration on TB.http://stoptb.org/global/advocacy/unhlm_targets.aspDate accessed: February 28, 2019Google Scholar Encouragingly, several countries are in the process of breaking down national targets into provincial and state-level targets. The precise accountability mechanism is yet to be agreed upon. It needs to be multisectoral as well as multi-stakeholder and inclusive. Civil society and affected communities need to be part of the accountability mechanism. Accountability should not stop at the level of health ministers but should be at the level of heads of state and governments. This is easier said than done and difficult to implement, but there are examples to follow, such as the Africa Leaders Malaria Alliance (ALMA) score card for heads of state.14African Leaders Malaria AllianceThe ALMA scorecard for accountability and action: documentation of experiences and progress.http://alma2030.org/sites/default/files/initiatives/alma_scorecard_for_accountability_and_action.pdfDate accessed: February 10, 2019Google Scholar The Director-General of WHO is expected to develop the multisectoral accountability framework in line with World Health Assembly resolution 71.3 and ensure its timely implementation no later than the end of 2019.3UNGAA/RES/73/3. Political declaration of the high-level meeting of the General Assembly on the fight against tuberculosis.http://www.un.org/en/ga/search/view_doc.asp?symbol=A/RES/73/3Date: 2018Date accessed: February 1, 2019Google Scholar On March 24, 2019, the world will observe the first World TB Day to be held after the High-Level Meeting on tuberculosis. The Stop TB Partnership, in consultation with Partners and stakeholders, has set the theme of World TB Day 2019 as "It's Time…". This theme has been deliberately kept flexible so that a wide range of views and messages from communities and the global tuberculosis fraternity can be expressed from all continents on World TB Day, to prompt concrete actions and deliverables from governments as committed through the Political Declaration.3UNGAA/RES/73/3. Political declaration of the high-level meeting of the General Assembly on the fight against tuberculosis.http://www.un.org/en/ga/search/view_doc.asp?symbol=A/RES/73/3Date: 2018Date accessed: February 1, 2019Google Scholar The declaration calls for a progress report in 2020 and a comprehensive review by heads of state and governments at a high-level meeting in 2023. These will provide opportunities to hold world leaders accountable for contributing resources, progress, and successes and failures to meet targets. Close collaboration among all stakeholders, including governments of tuberculosis-endemic countries, specialised agencies of the UN, UN regional commissions, the Stop TB Partnership, WHO, UNITAID, the Global Fund, tuberculosis advocates, researchers, community leaders, patient groups, donors, and grant-awarding bodies, will be essential to the implementation and achievement of the Political Declaration on Tuberculosis, and to ending the tuberculosis epidemic. All authors are advocates for tuberculosis and members of the STOP TB Partnership. We declare no competing interests.