Report of the 2nd ad hoc Committee on the TB epidemic Dermot Maher Stop TB Department, WHO

1. Report of the 2nd ad hoc Committee on the TB epidemic Dermot Maher Stop TB Department, WHO (on behalf of the 2nd ad hoc Committee) DOTS Expansion Working Group meeting The Hague October 2003

2. 2nd ad hoc Committee on the TB epidemic 1998 1st ad hoc Committee, London 2000 Ministerial Conference for 20 HBCs, Amsterdam 2001 Global Plan to Stop TB 2003 2nd ad hoc Committee, Montreux 2005 WHA targets 2010 G8 Okinawa targets 2015 Millennium Development Goals

3. Objectives of 2nd ad hoc Committee (1) review status of TB epidemic and of TB control efforts (Global TB Monitoring and Surveillance Project) (2) review progress in implementing the 1st ad hoc Committee recommendations (London, 1998) (3) analyse constraints in HBCs to reaching targets (DEWG) (4) make recommendations in defining a mid-term strategic direction for the DOTS expansion movement to speed up progress towards targets

4. Global TB control targets World Health Assembly 2005 to detect 70% of smear-positive cases to treat successfully 85% of all such cases G8 Okinawa 2010 to reduce TB deaths and prevalence of the disease by 50% by 2010 Millennium Development Goals 2015 to have halted by 2015, and begun to reverse, the incidence of priority communicable diseases (including TB)

6. Global TB case finding 1.2 million new sputum smear-positive PTB cases notified by DOTS programmes in 2001 = 32% of estimated incident cases

7. Treatment success by region for 2000 cohort

8. Time perspective of 2nd ad hoc Committee recommendations 2003 2005 2010 2015 WHA targets OkinawaG8 targets Millennium Development Goals Mid-term strategic direction (about 5 years)

9. Process of developing and endorsing2nd ad hoc Committee report June – Aug 03 Mar 03 Apr 03 June 03 Sept 03 Oct 03 Dec 03 DEWG STB Cd Bd 2nd ad hoc Committee secretariat Partners’ forum (New Delhi) STB Cd Bd MDGs 2nd ad hoc committee STAG Consultations 1st draft (constraints identified by DEWG) challenges identified report finalised recommendations report endorsed

10. Assessment of specific constraints in the 22 HBCs(WHO Report 2003. Global TB Control: Surveillance, Planning, Financing) • 5 most important constraints: • lack of qualified staff • inadequate preparation for decentralisation • failure to engage private practitioners in DOTS implementation • weak health infrastructure • lack of political commitment

11. Assessment of specific constraints in the 22 HBCs • 7 other constraints: • financing • access to TB care • inadequate lab network • HIV • limited public awareness • drug supply • recording and reporting

12. Main recommendations (1) Consolidate, sustain and advance achievements (2) Enhance political commitment (3) Address the health workforce crisis (4) Strengthen health systems, particularly primary care delivery (5) Accelerate response to the HIV/AIDS emergency (6) Mobilise communities and the private sector (7) Invest in research and development to shape the future

13. (1) Consolidate, sustain and advance achievements The Stop TB Partnership should (1) demonstrate the effectiveness and added value of the Partnership, GDF, GLC and its collaboration with the GFATM; (2) involve a wider range of stakeholders at all levels; (3) use existing mechanisms at national level, e.g. NICCs, Sector-Wide committees, CCMs; (4) strengthen its relationship with the GFATM; (5) seek enhanced and sustained donor support for GDF; (6) advocate for support for TB activities based on success stories of TB as pathfinder for health system reform.

14. Government warning: smoking may seriously damage your health

15. (2) Enhance political commitment The Stop TB Partnership should (1) explore complementary “top-down” (e.g. lobbying by high-level missions, political mapping and analysis) and “bottom-up” approaches (social mobilisation and communications); (2) seek financial support from a broader donor base; (3) argue the case for increased donor budget commensurate with global TB burden, e.g. GFATM; (4) adopt the 2015 MDGs relevant to TB as impact targets while retaining WHA 2005 targets as process targets.

16. (3) Address the health workforce crisis The Stop TB Partnership should collaborate with governments and international bodies to: (1) develop policies to remove administrative barriers to creating and filling posts; (2) develop policies to promote terms and conditions of service attractive to employees; (3) promote assessment of human resource needs; (4) support human resource planning and training; (5) explore strategies for mobilising human resources from the full range of primary care providers, especially community groups.

17. (4) Strengthen health systems, particularly primary care delivery The Stop TB Partnership should (1) promote reflection of TB control needs in design and implementation of health reform strategies; (2) ensure that TB programmes contribute to broader health system strengthening; (3) foster NTP stewardship capacity; (4) explore strategies for harnessing the contribution of the full range of health care providers; (5) encourage partners in Global TB Monitoring and Surveillance Project to intensify collaboration with other programmes and improvements in accuracy of estimates of progress towards targets. (6)

19. (5) Accelerate response to the HIV/AIDS emergency The Stop TB Partnership should (1) urgently step up collaboration with HIV/AIDS partnerships to implement strategy of expanded scope to control HIV-related TB; (2) support countries in delivering TB care as part of the HIV/AIDS care package; (3) support countries in making progress towards the “3 by 5” goal, by promoting HIV testing among TB patients and referral for ART; (4) support ART programmes in making use of lessons learned from TB programmes in applying public health principles to large scale diagnosis and treatment of a chronic communicable disease.

20. (6) Mobilise communities and the private sector The Stop TB Partnership should (1) intensify efforts to engage the widest possible range of stakeholders to contribute to TB control activities; (2) use the language of the business world and of community development to engage with respectively the private (corporate) sector and with community groups; (3) support the mobilisation of grassroots community groups to voice demand for effective and accessible TB care; (4) promote links with the private (corporate) sector using established activities, e.g. corporate sector activities in HIV/AIDS programmes.

21. (7) Invest in research and development to shape the future The Stop TB Partnership should (1) ensure a framework to support interaction between the WGs on new tools and the WGs on implementation; (2) work with the research community on advocacy for new tools, funding and preparation of trial sites; (3) promote operational research; (4) develop and articulate arguments in favour of increased research capacity building to encourage OECD countries to increase funding for this.

22. Main implications for Stop TB Partnership (1)Speed of progress in reaching WHA 2005 targets now depends on collaboration with other programmes and other constituencies. (2) Need to reach out to other programmes within the health sector, in addressing the key health system issues, e.g. human resources, general health infrastructure, primary care providers, health system reform. (3) Need to reach out to other sectors beyond health, in enhancing political commitment, expanding the resource base, and mobilising communities.

23. Next steps (1) Endorsement of report by DEWG. (2) Endorsement of report by Stop TB Partnership Coordinating Board. (3) Dissemination of report by Partnership secretariat . (4) Working Groups to consider how to put recommendations into action. (5) All partners at the Stop TGB Partners’ Forum to consider how to put recommendations into action (New Delhi, 4-5 Dec 2003). (6) Recommendations to feed into work of MDGs Project and to revision of Global Plan to stop TB.