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The Union – (Way) Beyond TB

The Union – (Way) Beyond TB. North America Regional Conference San Antonio, 23-25 February 2012 Dr Nils E. Billo, MD, MPH. Outline. Little history of The Union Beyond TB t obacco control and mpower p neumonia in children a sthma operational research m anagement education Summary.

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The Union – (Way) Beyond TB

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  1. The Union – (Way) Beyond TB North America Regional Conference San Antonio, 23-25 February 2012 Dr Nils E. Billo, MD, MPH

  2. Outline • Little history of The Union • Beyond TB • tobacco control and mpower • pneumonia in children • asthma • operational research • management education • Summary

  3. Origins of The Union • Paris 1867: first international TB meeting • Berlin 1902: first permanent office • Paris 1920: International Union Against Tuberculosis officially established • Paris 1986: Board decision to expand beyond TB: adding Lung Disease to name

  4. What is The Union? An Institute A Federation • 79 Constituent Members • 22 Organisational Members • 2738 Individual Members • over 30,000 contacts • 14 Offices worldwide • 5 Scientific Departments Tobacco Control Lung Health & NCDs Tuberculosis HIV Research

  5. The Union’s vision and mission today Mission The Union brings innovation, expertise, solutions and support to address health challenges in low- and middle- income populations Vision Health solutions for the poor

  6. Activities of The Union • Founded in 1920 • Up to 1986: focus on TB: mainly Conferences, publications, courses and technical assistance in TB • Between 1978 and 1990: Development of the TB DOTS strategy, mainly in Africa • 1990s: adding asthma, child lung health, tobacco control using TB model • 2000-2012 adding HIV and expanding in TB and tobacco control, adding operational research and management education to portfolio

  7. The Union then and today • 1992: Staffof 12 people Small Federation Secretariat: 1 Executive Director, 1 Scientific Director, admin staff for membership services and Editorial office for Journal, 1 accountant Budget 2 million USD • From 1992 onwards: gradually growing Secretariat in Paris with enlarged focus on Technical Assistance, Education and Research: Institute function added • 2011: about 250 staff and consultants in 14 offices: Budget 50 million USD

  8. The Tobacco Epidemic Tobacco is the leading behavioural risk factor causing a substantially large number of potentially preventable deaths worldwide. The five million deaths translate to an incredible statistic: one death every six seconds. Unless strong actions are taken to halt the tobacco epidemic, 1,000,000,000 people are projected to die this century - we cannot let this happen. I urge all countries to implement fully the WHO Framework Convention on Tobacco Control. Dr Ala Alwan, Assistant Director General , WHO, November 2011

  9. Proportion of TB burden attributable to some major risk factors in high TB burden countries Sources:Lönnroth K, Castro K, Chakaya JM, Chauhan LS, Floyd K, Glaziou P, Raviglione M. Tuberculosis control 2010 – 2050: cure, care and social change. Lancet 2010 DOI:10.1016/s0140-6736(10)60483-7.

  10. Deaths attributable to tobacco (in %)WHO Global Report: Mortality attributable to tobacco, 2012

  11. Exposure to second-hand smoke causes death and disease Source: Office of the U.S. Surgeon General. The health consequences of involuntary exposure to tobacco smoke: a report of the Surgeon General, 2006

  12. Bloomberg Initiative To Reduce Tobacco Use • Grants Programme • Capacity Building • Programme Impact 2011 • Progress of The Union’s Tobacco Control work 2011

  13. WHO MPOWER Package • monitortobacco use and prevention policies • protect people from tobacco smoke (Smoke-free) • offerhelp to quit tobacco use • warnabout the dangers of tobacco • enforce bans on tobacco advertising, promotion and sponsorship (TAPS) • raisetaxes on tobacco

  14. Grants programme

  15. Capacity building

  16. Progress in Tobacco Control * Partially achieved

  17. Reducing childhood pneumonia-related mortality

  18. Pneumonia:The forgotten killer of children New York: UNICEF/WHO 2006.

  19. Pneumonia:The forgotten killer of children New York: UNICEF/WHO 2006.

  20. Child Lung Health Programme (CLHP) MALAWI Making a Difference in Child Survival

  21. Specific objectives • To standardise case management for severe and very severe pneumonia in district hospital paediatric inpatient ward • To reduce mortality due to respiratory disease especially severe/very severe pneumonia in children under 5 years of age • To rationalise the use of drugs for ARI in children under 5 years of age. • To provide uninterrupted supply of essential drugs and oxygen at District Hospital

  22. Enrolment into CLHP by year 2000 - 2005n = 48,365 24 districts Total 23 districts Total 24 districts Total 16 districts Total 10 districts 5 districts

  23. Trend in Outcomes 1 October 2000 to 30 September 2005 % 2000 2002 2001 2003 2004 2005 Months after program introduction

  24. Achievements of the CLHP Malawi • Total number of children admitted 48,365 • between October 2000-December 2005 • Baseline pneumonia CFR 18.6 • Pneumonia CFR December 2005 8.4 • Reduction over the baseline 54.8% • Total number lives saved 2000-2005 4,357

  25. Summary • Implementation of standard case management to district hospitals is feasible and successful • Key elements for success are supply of drugs, accountability and supportive visits • The cost is competitive, facilitating sustainability CLHP Malawi incorporated into the Essential Health Package • Adoption of Child Lung Health into National Planning sector wide approach (SWAPS)

  26. Why Asthma? • Asthma is the most common chronic disease among children. • Asthma affects millions of adults. • 235 million people worldwide suffer from asthma. • Asthma is a non-communicable disease (NCD). • Effective medicines are available. • Unfortunately, for many people with asthma – particularly the poor – these medicines are too costly or not available at all.

  27. Asthma in Children

  28. Asthma in Adults

  29. Essential Medicines: Pricing, Availability and Affordability

  30. A PracticalSolution: AsthmaDrugFacility (ADF) • Provides affordable access to quality-assured, essential asthma medicines for low- and middle-income countries • Promotes a quality improvement package for the diagnosis, treatment and management of asthma In countries, the cost for one year of medicines for a patient withsevereasthmacanbelessthan 40 USD whenmedicines are purchasedthrough ADF

  31. ADF Clients • Countries that have alreadyreceivedtheirorders • Pilot Projects in Benin (NTP), El Salvador (NTP), Sudan (Epi-Lab) • Kenya (KAPTLD) • Burundi (NTP) • 7 orders for a total of €99,826 • Currentorders • Vietnam (CHDI) • Guinea Conakry (NTP) • Burkina Faso (NTP)

  32. Reduction in annualcosts for a patient withsevereasthmawhenmedicinespurchasedthrough ADF(in euros, based on 2009/2010 ADF prices)

  33. ADF Product Prices for 2011Additionalcosts: transport, insurance, preshipment inspection and 10% fees for ADF services *On the 17th WHO Essential Medicines List March 2011

  34. Challenges at country level • Lack of politicalwill, otherpriorities • Guidelines not available or not implemented • Corticosteroidsoften not on the national Essential Medicines List (EML) • Non-essential medicinespushed by pharmaceuticalcompanies and specialists • Lack of trainedhealthworkers • Lack of funds to purchase essential medicines • Restrictions in national procurement system about using the ADF mechanism

  35. The Economic Burden of Asthma Treating asthma entails vastly more than the cost of medicines. It amounts to billions of dollars in both direct and indirect costs.

  36. The Global Asthma Report 2011 www.theunion.org http://isaac.auckland.ac.nz www.globalasthmareport.org

  37. Operational Research at The Union

  38. Centre for Operational ResearchActivities

  39. Support Bold and Innovative Strategies MALAWI HIV testing of all pregnant women and ART offered to all those HIV-positive regardless of CD4 count In 3 months from April – June 2011: 509,645 persons were HIV tested 18,442 new HIV-positive patients started on ART 7524 (88%) of 8525 HIV-positive pregnant women started on ART

  40. The DOTS Model for monitoring Non-Communicable Diseases

  41. Operational Research Fellows • 6 Union-based OR Fellows: Malawi; Zimbabwe; South Africa; India; Vietnam; Brazil • 4 MOU-supported OR Fellows: South Africa (2) and Kenya (2) • Outputs from April 2009 - December 2011 (33 months) 55 research projects undertaken 39 completed and submitted to journals 30 papers in press or published

  42. Operational Research Courses Purpose: To teach the practical skills for conducting and publishing operational research Approach: Product –oriented [a submitted research paper] Participants go through whole research process Milestones must be achieved to stay in course Trained participants become facilitators

  43. Three module – course starting this week in Nepal for Asian candidates • Module 1a:research questions, protocol development and ethics (5 days) – February • Module 1b:Data management and data analysis (5 days) – February/March • Module 2:Paper writing, peer review and policy implications (5 days) – October

  44. Does the Model work? • 7 courses – either underway or completed since 2009 - 86 participants enrolled • 3 courses completed:- • 34 participants enrolled • 31 completed milestones /awarded certificate • 35 papers submitted to journals • 27 papers (>70%) in press or published

  45. Published Papers as a result of training / support from COR “If you do not write about it, it did not happen”Virginia Woolf

  46. RESEARCH TO POLICY • One Expert Meeting 2009 • Two papers in IJTLD • Two papers in TMIH • One paper in TRSTMH • One paper in BMC Medicine

  47. POLICY TO PRACTICE Bi-Directional Screening of TB and Diabetes Mellitus China and India • World Diabetes Foundation Support • National Stakeholders Meeting • Training for implementers • Implementation • Review activities and data • National Stakeholders Meeting

  48. Strengthening Health Systems • The Union’s International Management Development Programme (IMDP) was created to aid countries with the difficult task of operating a national health programme by training health managers in management education. • Its mission is to develop a community of leaders and innovators in public health who improve the quality of services provided to the public through well-managed national health programmes.

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