How is North Korea coping with TB one year after Global Fund grant cuts?

A general view of the city of Pyongyang. Photo by: REUTERS/Danish Siddiqui

MANILA — Advocates working to address the tuberculosis burden in North Korea are calling on the Global Fund to Fight AIDS, Tuberculosis and Malaria to resume its grants in the country in the next two months to ensure thousands of patients don’t fall out of treatment. The call comes just a few months before the fund's sixth replenishment conference in October.

In less than a year, about 100,000 TB patients in North Korea dependent on Global Fund-financed drugs will be left with no medicines after the remaining buffer stocks run out by June 2020.

“If we want to avoid a stock-out next year, after June ... the Global Fund should restart the work, and then order for drugs should be placed in September this year.”

— Lucica Ditiu, executive director, Stop TB Partnership

There are over 130,000 known TB patients needing treatment in the country, and over 5,000 suffering from multidrug-resistant TB, according to World Health Organization estimates. There is a limited supply of drugs, including for patients suffering from MDR-TB.

This year, the Stop TB Partnership is providing treatments for 1,200 patients with MDR-TB with WHO funding, but the figures are far from the national target of 5,000 patients. Increased food insecurity in the country — resulting from reduced crop production due to extreme weather conditions and limited agricultural input supplies — also threatens to exacerbate chronic malnutrition and stunting among the population, leaving them vulnerable to infections such as TB.

The difficult operating environment and sanctions in place mean that very few organizations are able and willing to operate in the country. There are also very few donors and advocates, so when the Global Fund decided to stop its grant-making in the country, leaving scant resources for TB, it barely caused a stir in the aid community.

“Very few are keen to take on the battle for the people of DPRK,” said Stop TB Partnership Executive Director Lucica Ditiu.

During a trip to North Korea a few of weeks ago, Ditiu said she had seen a lot of effort made to ensure the “bare bones” such as drugs and basic diagnostics are made available for people with TB in the country. Local doctors have also been trying to continue monitoring and evaluation activities in spite of the Global Fund’s absence.

But that can only last for so long.

“There is no shortage of ... first-line drugs right now in DPRK. However, … in DPRK it's not easy to send drugs. So this is not the [case that] if something happened, we can react in a month. It takes in nine to 10 months … to get the drugs in a country,” she said.

“If we want to avoid a stock-out next year, after June ... the Global Fund should restart the work, and then order for drugs should be placed in September this year,” she added. “That's what I hope that the Global Fund will be able to do.”

Reasons for pulling out

The Global Fund closed its grants in the country in June 2018 because the country’s “unique operating environment” had prevented the fund from “achieving the required level of assurance on the deployment of resources and the effectiveness of grants,” said Seth Faison, the fund’s head of communications.

There were speculations that the decision, which many described as “sudden,” was politically influenced by the United States, the Global Fund’s largest donor.

Ditiu is hopeful, noting that there have been interactions between the government and the Global Fund on conditions and implementation arrangements. But Faison only told Devex that the fund is only “exploring options for the possibility of launching a new grant” for TB and malaria in North Korea.

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He gave no other details, other than, “this year, if there are improved implementation arrangements, including better access to program sites and independent verification, we will consider making a new grant,” adding, “we remain committed to supporting the health of people in DPRK.”

Few organizations with TB programs operate in the country. The Eugene Bell Foundation has been operating in the country for over two decades, with programs targeted toward individuals suffering from MDR-TB.

UNICEF, the principal recipient of the now-defunct Global Fund grants, continues to operate in the country, although with very little funding.

“UNICEF, like other U.N. agencies, has faced serious funding shortfalls for its humanitarian work in DPR Korea and this year is no different. So far only 32% of the required$19.5 million has been raised,” Shima Islam, regional communications specialist for UNICEF in East Asia and the Pacific, told Devex.

UNICEF said it is important to raise awareness on child TB in the country. There are currently 5,000 reported pediatric cases of TB under treatment there. However, the United Nations program said North Korea has a “well-working system of household doctors” trained to identify TB cases and supervise treatment.

Bigger problems

A year of Global Fund’s absence in North Korea has advocates worried over its health implications on TB patients. But they highlight the larger issues that exist.

Despite being seen as a major donor in North Korea, Ditiu said the Global Fund only covers a “small portion” of the funds needed to diagnose and treat all of those estimated to have TB or drug-resistant TB.

“Ideally, other donors or governments that are interested should be able to support DPRK’s efforts. Global Fund alone will not do,” Ditiu urged, reiterating that this is not unique to North Korea.

TB receives the smallest in Global Fund allocations. Its recently approved methodology allocated 18% for TB versus 32% for malaria, and 50% for HIV. For many years, advocates have raised the issue that TB has no dedicated fund compared to HIV and malaria.


Ulick Burke, board member of the Korean Red Cross Foundation, meanwhile, pointed to a larger problem — sanctions.

These sanctions prevent organizations from bringing in tools such as ultraviolet germicidal irradiation devices, which can be placed in rooms to help prevent the spread of TB transmission in hospitals, said Burke.

This is the same for diagnostic tools. Ditiu said most hospitals still use microscopy for TB diagnosis as sanctions prevent them from procuring modern tools such as GeneXpert, which can detect TB in as little as two hours.

Even spare parts for vehicles used to distribute TB and malaria supplies to health facilities are sanctioned and require exemptions approval from the U.N. Security Council exemptions committee.

“The Global Fund must return to avert the looming drug stock-out. This is a critical first step. But we cannot keep treading water like this, vulnerable and dependent on ‘heroic’ interventions … [instead of] emphasis on the boring but essential building of health systems,” Burke told Devex, underscoring the need for increased exemptions on humanitarian efforts under the U.N. sanctions and for multiple funding streams to eliminate both drug-susceptible and drug-resistant TB.

About the author

  • Jenny Lei Ravelo

    Jenny Lei Ravelo is a Devex Senior Reporter based in Manila. She covers global health, with a particular focus on the World Health Organization, and other development and humanitarian aid trends in Asia Pacific. Prior to Devex, she wrote for ABS-CBN, one of the largest broadcasting networks in the Philippines, and was a copy editor for various international scientific journals. She received her journalism degree from the University of Santo Tomas.

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