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Is the global tuberculosis control strategy too big to fail?

 

Tuberculosis is a major killer and will remain so without considerable changes. Recent UN meetings are “déjà vu all over again”.

Progress has been slow. Global tuberculosis incidence has been stagnant for decades at around 2%, despite assurances that the recommended tuberculosis strategy would accelerate its decline. Case detection is also stuck at 64%, only a marginal change from 42% in 2000. Over a third of tuberculosis cases are never diagnosed, causing millions of preventable deaths and new infections in families and communities.

Control of multidrug-resistant tuberculosis is also failing. In 1996 WHO stated that “MDR-tuberculosis is too expensive to treat in poor countries; it detracts attention and resources from treating drug-susceptible cases”. Faith in directly observed treatment, short course (DOTS) slowly eroded, because leaving people with multidrug-resistant tuberculosis untreated was increasingly recognized as being both unethical and a bad tuberculosis control strategy. However, in the decades that followed, there has only been minimal progress in preventing, finding, and successfully treating new cases of multidrug-resistant tuberculosis. In 2008, 29 423 (7%) of an estimated 440 000 new cases of multidrug-resistant tuberculosis were treated with a 60% treatment success, translating into a 4% treatment success for all estimated cases of multidrug resistant tuberculosis that year. In 2017, 139 114 (30%) of 457 560 estimated global cases of multidrug-resistant tuberculosis were treated with a 55% treatment success, translating into a 17% treatment success for all estimated cases that year. Although overall treatment success is rising about 1·4% per year from 2008, this can hardly be called a successful response.

Announcing that tuberculosis has now surpassed other lethal infectious disease, leadership blames insufficient investment and cites a growing US$3·5 billion annual resource gap for global tuberculosis control. From 2003 to 2017, $43 billion were budgeted by international and domestic sources for control of tuberculosis and HIV-associated tuberculosis (appendix).5 Resource allocation data are scarce, so past investments are difficult to match with their effect on service delivery and health. For example, serious doubts remain about the impact of investing millions of dollars to deploy the Xpert MTB/RIF assay to diagnose tuberculosis and multidrug-resistant tuberculosis in endemic countries.6 It is also very difficult to know with certainty what proportion of resources are being used to provide direct services to people with tuberculosis.

Budgeting for ambitious targets makes sense and is necessary to successfully tackle tuberculosis control. However, calling for increased funding for a poorly performing disease control strategy is never easy. Requests for funding should be based on new strategies that review available resources and past returns on investments. There are many hard questions to be asked about strategy, leadership, and longstanding inefficiencies, including wasteful meetings, redundant international organizations, and antiquated, ineffective service delivery. Asking tough questions should not be seen as an attack; it is essential to rapidly learn from past failures and course correct to ensure increased funding and the success of robust tuberculosis control efforts.

 

Source: https://doi.org/10.1016/S0140-6736(18)32751-X

Released: November 01st, 2018 10:14 AM

Author: Reuben Granich

Website: The Lancet Journal