Climbing Mountains Beyond Mountains – the road to end TB
Next year, in 2023, the world will gather for the second UN High Level Meeting (HLM) on Tuberculosis. The first one had taken place in 2018, and had set targets for 2022. GFAN had then supported TB advocates, CSO’s and communities by convening a platform for regular exchange, strategizing and collaboration ahead of the HLM; we had also supported a Communities and CSO Advisory Group selected by the Stop TB Partnership to participate in the organization of the HLM.
The international community will come together to take stock of global progress and renew commitment on TB targets to meet the 2030 Sustainable Development Goals (SGDs). And there will be little but failure to find. Failure to invest, failure to act and failure to meet the commitments of the HLM, which combined into a failure to significantly change the course of the disease.
As the 2021 WHO Global Tuberculosis Report shows, as of last year we were behind on nearly all targets for 2022, especially with regard to prevention targets. The sole exception was the number of people with HIV receiving preventive treatment, where the 2022 target had already been met. A lot of the setbacks seen in the 2020 data can be linked to the impact of COVID-19. Regrettably, their effect will not be temporary. WHO projects the extent of the impact on mortality will only become clear in 2021, and that on incidence only in 2022.
The core of the challenge of ending TB is that each person untreated for active TB has the likelihood of transmitting it to up to 15 others within the course of a year. Which is why finding missing people with TB must be a priority. TB is curable; about 85% of active TB infections can be successfully treated with a 6-month drug regimen, and the treatment success rate for Multi-Drug Resistant TB (MDR-TB), though still lower than for drug sensitive TB, has improved in 2020 despite COVID-19.
TB is both a cause and a consequence of poverty and inequality. The fight against TB and the fight against poverty are closely interlinked, because progress on TB is influenced by the social and structural drivers of the disease, in particular nutrition, human rights and gender equality. Recent evidence has clearly shown that human rights and gender barriers hinder the effectiveness, accessibility and sustainability of TB programs and services. People living with and at greatest risk of TB often live in vulnerable and hard to reach settings where stigma, discrimination, inadequate political will and funding support, and where legal, human rights and other socio-economic and policy barriers inhibit their access to timely testing and treatment. The science is clear: limited access to TB prevention and testing means that fewer people will know their status and be put on treatment – this puts their own health at risk, but also contributes to the ongoing cycle of TB transmission.
A lot of questions have been raised about a potential connection between COVID-19 and Tuberculosis. TB and COVID-19 share similarities: they both attack primarily the lungs and are both transmitted through the air largely through close contact. Though TB is not known to put people at higher risk of COVID-19 infection, it may contribute to more severe symptoms.
We have not reached our 2022 target, in part because of the impact of COVID-19 on progresses made fragile by chronical underinvestment. And, If left unaddressed, the impact of the pandemic on the TB epidemic will compound be felt long after 2022. Domestic resource mobilization efforts are being strained by the economic crisis created by COVID-19, and are unlikely to be able to increase fast enough to meet the challenge – though there is hope that many of the investments made in the fight against COVID-19 can be repurposed against TB and help gain ground back faster. Just as worrying, the war launched by Russia against Ukraine and its ramifications are making more people vulnerable to the disease across Eastern Europe. Displacement creates threats of treatment interruption, stockpiled drugs have been destroyed in Russian airstrikes, all the more heartbreaking considering the progresses that had been made in the fight against TB in Ukraine, with case per capita dropping by 2/3 from 2015 to 2020. The spillover effects of the war, on energy and food prices, will also threaten our progress on the Global Health agenda.
On the road to end TB, international investment still has a pivotal role to play.
Olga Klymenko, chairman of TBpeople Ukraine and GFAN Speaker, in Kyiv
Funding the End of TB
The fight against TB is largely funded – at 80% – through domestic resources. Among international funders, the Global Fund, despite spending under 20% of its resources on TB, represents 77% of all international financing for TB. Low- and middle-income countries, that account for 98% of reported TB cases, saw a nearly 9% decline in TB funding from 2019 to 2020. Most of the decline was caused by a fall in the number of people diagnosed with TB and reallocation of resources to the fight against COVID-19 – but also some changes in the model of care, for example increased reliance on remote treatment monitoring.
We know that funding for essential TB service delivery is what will get us back on track in reducing TB transmission and TB mortality - as will our ability to harness innovations in diagnostics, treatment and vaccine research and development. However, investment is starkly insufficient. In 2020 spending fell 50% below globally endorsed TB targets. This means that less than 50% of resources needed are currently funded, of which 80% is funded through domestic resources. This is despite the fact that investment in TB is a public health ‘best buy’. Studies show a US$ 43-49 return on investment for every US$ 1 spent.
GFAN calls on donor countries to uphold the 0.7% ODA/GNI target to ensure we meet our collective commitment to end TB as a global public health threat by 2030.
Official development assistance (ODA) plays a fundamental role in closing the gap between people who have access to TB prevention, treatment, care and support services, and people who are being left behind. This particularly resonates in today’s COVID world where we continue to see the rapid erosion of fiscal space in many low and middle-income countries.
The Global Fund is showing early success in its work with partners to explore and unlock new funding avenues that go beyond traditional aid. However, because the available resources have never matched the global need, glaring funding gaps were already escalating well before the dawn of COVID-19.
As the primary provider of international funding for TB, the Global Fund has a pivotal role to play in finally closing the funding gap and putting us back on track to end TB. Acknowledging the particular challenges of underfunding in TB, the Global Fund Board recently adjusted the funding allocation formula that would see a slightly increased share of funds above US$12 billion available for TB in country allocations.
In the face of the billions of dollars by which the fight against TB is underfunded, a few hundred million of additional money will simply not be sufficient: to meet the amounts needed in GF eligible countries with the new allocation formula, investments in the Global Fund for the 7th Replenishment would have to go much beyond US$18 billion.
We need bold investment in the Global Fund – and other channels - to stand a chance to get back on track to meet the SDG targets for TB. The newly released Global Fund Strategy (2023-2028) defines the road ahead. Investing in the Global Fund means an even greater focus on issues of equity, sustainability, program quality and innovation. It means firmly rooting communities that are most affected by HIV, TB and malaria at the center of our global and country-level responses with determined action to tackle human rights and gender-related social and structural barriers. It means leveraging the fight against TB to build inclusive, resilient and sustainable health system capabilities. It means funding robust community-led responses to be better able to deliver health and well-being, and to prevent, identify and respond to the pandemics of today, and tomorrow.
And in conclusion, countries will have to find ways to increase funding for TB. Otherwise, we will find ourselves gathering at the TB HLM in 2028 to bemoan our lack of progress, just like we are about to do at the 2023 TB HLM; and in the meantime, millions will have contracted the disease, and died. This will be despite the fact that we have many of the tools we need to do a lot better – but we are choosing not to invest enough.