Q&A: What does 2018 hold for the fight against TB?

GENEVA — Advocates in the global fight against tuberculosis are hoping to raise the issue on the political and financial agenda of world leaders at the first United Nations high-level meeting on the disease, scheduled for Sept. 26 in New York.

The goal is to “approve a concise and action-oriented political declaration,” which will be agreed in advance, according to member states.

Behind the push for what is being described as the most significant political meeting ever held on TB is the Stop TB Partnership. Administered by the U.N. Office for Project Services, the partnership brings together 1,600 organizations from over 100 countries, including U.N. agencies, the World Bank, and the private sector.

To mark World TB Day on Saturday, the Stop TB Partnership and World Health Organization have jointly launched a campaign to build up commitments to end TB under the slogan: “Wanted: Leaders for a TB-Free World.”

TB is the top infectious killer in the world, and it accounts for about 30 percent of all deaths due to drug resistance. According to the WHO TB report 2017, 10.4 million people fell ill with TB and 1.7 million died from the disease in 2016. Globally, TB incidence is falling at about 2 percent per year, but this needs to accelerate to 4 or 5 percent to reach the 2020 milestones of the End TB Strategy.

Speaking to Devex ahead of World TB Day, executive director of the partnership Lucica Ditiu pinpointed what she sees as key to making the U.N. high-level meeting a success, and explored priorities in financing, data, and awareness raising as the fight against TB moves forward. The conversation has been edited for length and clarity.

What are the key asks of the global TB community ahead of the U.N. high-level meeting?

Our key asks, which we have just presented to our board, are reaching all people by closing the gaps on TB diagnosis, treatment, and prevention; transforming the TB response to be equitable, rights-based, and people centered; accelerating the development of essential new tools to beat TB; investing the necessary funds to end it; and committing to decisive and accountable global leadership, including regular U.N. reporting and review.

We are now working to establish specific quantitative targets under each of these goals, such as finding and treating all 4 million “missing” people with TB worldwide [those living with the disease who have not been diagnosed, treated or reported.]

Alongside a political declaration, the U.N. high-level meeting is expected to approve an accountability framework. What steps should be taken to ensure accountability?

Accountability is essential, so we want to see regular U.N. reviews, similar to the ones for HIV, noncommunicable diseases and antimicrobial resistance. As long as this U.N. review format exists, why not [hold] another U.N. high-level meeting in five years?

However, the real accountability will take place at country level. Unless [action] stems from countries’ own systems, under the leadership of heads of state, what one does at the international level will not really matter.

In addition, earlier this month, we met with partners in Geneva to address “above country-level” accountability. It is not about creating new platforms, but about including a one-hour session on TB in meetings that are already taking place regularly. For example, the BRICS [Brazil, Russia, India, China. and South Africa] represent 50 percent of the global TB burden, and 60 percent of the multidrug-resistant TB burden. Whenever their heads of state are meeting, they could look at key TB indicators — just a few would be enough — to keep track of progress. That would be a huge step forward.

How can one ensure accountability in data-poor countries?

Countries are poor in TB and in HIV data because it is not easy to find the vulnerable groups. What we now want to bolster is the involvement of communities and key groups, not only in the implementation [of TB programs], but also in monitoring.

Our colleagues in the HIV field started mapping key groups within countries a long time ago. We can learn from them, applying and scaling up the available methodologies. It is work in progress but, ultimately, a lot depends on the willingness of countries to understand the impact of TB [in their territories] and to change the situation.

Concerning resource mobilization, what role should domestic financing play going forward, both at the U.N. high-level meeting discussions and beyond?

Domestic resources will be the future — fortunately or unfortunately. Countries can generate a lot of efficiencies by using their resources in a smart way, and taxation will also play an important role.

Additionally, they can leverage external resources. The Global Fund [to Fight AIDS, Tuberculosis and Malaria] accounts for 63 to 75 percent of overall external TB funding and there are contributions from the United States Agency for International Development and Canada. Development banks or the World Bank could be other options for accessing international funding.

We would like high burden countries — at least some of them — to attend the U.N. high-level meeting not only with commitments, but also with suggestions on what financial tools they are planning to use to close the funding gap.

Ultimately, this is a one-day meeting that will come and go, so what we do before and after it is what matters.

Does innovative financing hold promise as a means to increase TB funding?

Executive Director of the Global Fund Peter Sands says that everyone speaks about innovative financing, but nobody knows what it means, especially when it comes to health — and I agree.

Tools such as social impact bonds and money from the private sector will not be the ones to solve the problem. The biggest chunk of money will come from the budgets of governments and the rest will be add-ons.

Countries should estimate how much money it will cost them to end TB, how many resources they have and what they can do to increase them in a smart way. This sounds easy, but very few are doing it, and doing it through [finance] specialists.

That was clear at the END TB Summit in Delhi this month, where we brought together ministers and experts from both the health and the finance fields for a TB financing dialogue. The way each group spoke about TB finance was so different! That means the arguments of the first group might not be quite resonating with the second.

Stop TB is working on a “Finance for TB” report using publicly-available data. How good is the quality of data?

Looking at finances in TB, even by trying to retrieve TB budgets from individual countries, is not easy at all. What scares me is that when you look at basic data, it is either incomplete or inconsistent, so it is very difficult to build something solid out of it.

We want to analyze data that is publicly available, but when you try to put figures together, they do not add up and this creates a distorted picture. But our team is working on it, and we expect to wrap it up around the time of the U.N. high-level meeting.

You were concerned about the Global Fund’s portfolio optimization policy, which means that countries cannot carry over unspent grant funding anymore. What has been the impact of this policy so far?

Portfolio optimization makes sense, but when applying a new policy, you have to be flexible and I think the Global Fund knows that. Especially at the end of 2017, what happened was that a lot of countries tried to spend the money on commodities and procurement when they realized it was serious.

That created a great distortion: We were flooded with requests for diagnostics and drugs which were just meant to push the money out of the window. On top of that, deliveries were supposed to be done in a very short timeframe. It does not make sense for a country to rush to get the drugs, because they may be expiring later on.

There were a few countries that were big defaulters, but overall it did not look as bad as I had thought. There was a lot of catch up in 2017, but we will have to see what happens from 2018 on.

What measures is the Stop TB Partnership putting in place to help countries increase their grant absorption rates, their capacity to spend grant money?

The factors behind countries’ grant absorption rates are very complex: There is the country, the Global Fund, partners, subrecipients, and so on.

Money is a big bottleneck, but systems also have to be rapid. Very often, legislation and countries’ management and administrative procedures are bottlenecks to implementation and scale-up. It may take months to get approvals or drafts.

We are now addressing the grant absorption issue in two ways: We are analyzing it alongside several partners in our weekly Situation TB Room, and we are working with the Global Fund to create a sort of early warning system. Accessing the data [on absorption rates] early on allows us to be a lot more proactive. We can alert the country program and the Global Fund’s Country Coordinating Mechanism and, if needs be, we can see who can help address the problem.

The Stop TB Partnership works to bring various constituencies on board the fight against TB. How are you engaging the private sector?

We have been working closely with the delivery arm of the private sector such as doctors and pharmacists, and with drug and diagnostics developers. Now, we are encouraging ICT and artificial intelligence developers to enter the TB space, either through project funding or by supporting innovators through our Accelerator for Impact.

As part of our preparation for the U.N. high-level meeting, we are also bringing private sector [actors] together under a dedicated work track.

I am a medical doctor, and, for a long time, we thought we would end TB at hospitals and with laboratories. As the TB community, though, we learned the hard way that was not the case. Many sectors and groups, including civil society and policymakers, must work in partnership to end TB.

This year is key to raising the profile of the global fight against TB. What is your definition of success for 2018?

I would like the U.N. high-level meeting to be attended by at least 20 heads of state of high-burden countries, and to produce a strong political declaration with quantitative targets.

Secondly, I would like the world to detect and treat a total of 7 million TB cases, up from the around 6 million that have been treated annually since 2009. In this regard, we have just launched a joint initiative with WHO and the Global Fund aimed at finding an additional 1.5 million missing people with TB by 2019, and 4 million by 2023.

As long as there are so many missing TB cases, we will not be able to end this disease as a global health threat because transmission and suffering will continue. We will not reach universal health coverage, either, because we will be leaving a lot of people behind.