Leveraging health diplomacy to end the tuberculosis epidemic
Authors: Michael Reid, Eric Goosby, Sebastian Kevany
Journal: The Lancet Global Health (2019)

In September, 2018, the first ever High-Level Meeting of all UN member states made defeating tuberculosis a global political priority.1Stop TB PartnershipUN high-level meeting on TB–key targets and commitments.http://www.stoptb.org/global/advocacy/unhlm_targets.aspDate: 2018Date accessed: December 12, 2018Google Scholar After years of neglect, recognition is growing that ending the tuberculosis epidemic is now achievable. To capitalise on this crucial juncture will demand both a coordinated, multisectoral response, and a pivot towards undertaking bold antituberculosis efforts that synergise with broader sustainable development agendas. The Lancet Commission on tuberculosis, published on March 20, 2019,2Reid MJA Arinaminpathy N Bloom A et al.Building a tuberculosis-free world: The Lancet Commission on tuberculosis.Lancet. 2019; (published online March 20.)http://dx.doi.org/10.1016/S0140-6736(19)30024-8Summary Full Text Full Text PDF PubMed Scopus (178) Google Scholar highlights the importance of political engagement to secure investment, so as to achieve these goals. Global health diplomacy is crucially important in ensuring sustained political engagement and in addressing the multisectoral challenges that have hampered global efforts to control tuberculosis over the past century. In this context, health diplomacy refers to activities such as formal negotiations and partnerships and interactions between governmental and nongovernmental actors, which are needed to secure financial investment and policy implementation to end the epidemic.3Katz R Kornblet S Arnold G Lief E Fischer JE Defining health diplomacy: changing demands in the era of globalization.Milbank Q. 2011; 89: 503-523Crossref PubMed Scopus (81) Google Scholar Global health diplomacy provides a framework that can motivate innovative multilateral cooperation and investment in global health, ensuring tuberculosis is prioritised in the context of national security, trade, climate change, and migration policies.3Katz R Kornblet S Arnold G Lief E Fischer JE Defining health diplomacy: changing demands in the era of globalization.Milbank Q. 2011; 89: 503-523Crossref PubMed Scopus (81) Google Scholar In high-burden countries, global health diplomacy also has an essential role in shaping the political economy of universal health coverage, to ensure that tuberculosis-inclusive policies are prioritised. The role of global health diplomacy in engaging multiple domestic stakeholders—including patient activists, researchers, the private health sector, industry, and non-health government ministers—is equally essential to creating the enabling policy environment that is needed to implement targeted strategies for diagnosing, treating, and preventing tuberculosis. Recognising that increasing domestic resource mobilisation, rather than relying on donor agencies, should now be the primary driver of investment; global health diplomacy is also essential to ensure that diminishing donor resources are matched to domestic priorities and catalytic of domestic investments.4Pablos-Mendez A Raviglione MC A new world health era.Glob Health Sci Pract. 2018; 6: 8-16Crossref PubMed Scopus (10) Google Scholar In addition, global health diplomacy has several important (albeit underappreciated) functions in the tuberculosis response context, as we highlight. Over the next decade, at least 6 million people are projected to develop drug-resistant tuberculosis.5O'Neill J Tackling drug-resistant infections globally: final report and recommendations. The review on antimicrobial resistance.https://amr-review.org/sites/default/files/160525_Final%20paper_with%20cover.pdfDate: May, 2016Date accessed: March 5, 2019Google Scholar A major obstacle to controlling the drug-resistant tuberculosis epidemic is the high costs of diagnostic and treatment commodities, which are up to 100 times that of drug-susceptible tuberculosis in some settings, and far beyond the budgets of many high-burden, low-income countries.6Vassall A Benefits and costs of the tuberculosis targets for the post-2015 development agenda. Copenhagen Consensus Center, Copenhagen2014Google Scholar In this regard, global health diplomacy has an important role in shaping markets for drug-resistant tuberculosis drugs and providing means for high-burden countries to leverage donor financing, so as to consolidate demand and negotiate lower prices for second-line tuberculosis drugs. Such combined negotiation and public health initiatives will become crucial as high-burden countries increasingly assume cofinancing while transitioning out of donor eligibility requirements, such as those of The Global Fund to Fight AIDS, Tuberculosis and Malaria.7Waning B Tuberculosis market-shaping strategy: overview, updates and priority issues from stop TB's global drug facility. Stop TB Partnership, Montreux2017Google Scholar The UN's Sustainable Development Goals highlight the importance of the broader multisectoral agenda to ending the tuberculosis epidemic;8UN Secretary GeneralProgress towards the sustainable development goals: report of the Secretary-General. United Nations, New York, NY2017Google Scholar ending tuberculosis is predicated on improving air pollution, regulating certain industries, and optimising urban development. Global health diplomacy is essential to ensuring that such links are made, and that partnerships that include stakeholders from the relevant sectors are forged. Global health diplomacy has a crucial role to ensure that the corporate sector recognises the value of investing in tuberculosis programmes as a component of securing the health and wellbeing of their workforce. Corporate health responsibility—when coupled with the urgent and increasing need of traditional actors, such as national tuberculosis programmes and their donor partners, for additional intellectual and financial capital—has already motivated many non-traditional stakeholders to engage more deeply in global health efforts. If this type of collective action is optimised, it can provide business opportunities and establish frameworks for driving sustainable reductions in tuberculosis incidence and mortality. Approaches based on global health diplomacy provide a key platform for such holistic, innovative, and cross-sectoral responses. Understanding tuberculosis as a global health security threat is essential to ending the epidemic. Tuberculosis disproportionately affects marginalised communities most vulnerable to political or other forms of extremism;9Sun N Amon JJ Addressing inequity: neglected tropical diseases and human rights.Health Hum Rights. 2018; 20: 11-25PubMed Google Scholar interventions that address tuberculosis risk in these communities often represent joint opportunities to address social exclusion and inequity, which might also confer both a national and international security dividend. Additionally, cross-border spread of tuberculosis, especially drug-resistant tuberculosis, has substantial health security implications for countries with a low tuberculosis burden.10Dheda K Gumbo T Maartens G et al.The epidemiology, pathogenesis, transmission, diagnosis, and management of multidrug-resistant, extensively drug-resistant, and incurable tuberculosis.Lancet Respir Med. 2017; 5: 291-360Summary Full Text Full Text PDF Scopus (355) Google Scholar Global health diplomacy has an essential role in securing international collective action to address these negative externalities.11Jamison DT Frenk J Knaul F International collective action in health: objectives, functions, and rationale.Lancet. 1998; 351: 514-517Summary Full Text Full Text PDF PubMed Scopus (63) Google Scholar As with HIV and Ebola virus disease, opportunities might also exist for global health diplomacy approaches to help govern the engagement of non-traditional global health actors, such as militaries and defence forces, in tuberculosis efforts, particularly if outcomes of interest to strategic or other agendas can be shown. As the Lancet Commission on tuberculosis emphasises, global tuberculosis efforts are moving beyond traditional siloed development assistance approaches to a new era of country ownership and holistic, multisectoral global cooperation. Global health diplomacy is essential both to motivate these new approaches and to create the enabling environment needed to secure substantive progress towards ending the tuberculosis epidemic once and for all. We declare no competing interests.