PHM-Exch> Fwd: Executive Board to review barriers to controlling TB epidemic

[Claudio Schuftan]

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From: Editor <editor at phmovement.org>

Also new strategy to drive research and development for TB

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<https://mailchi.mp/28ab9e5cb98c/executive-board-to-review-barriers-to-controlling-tb-epidemic?e=916df65fd1>
Executive Board to review barriers to controlling TB epidemic Also new
strategy to drive research and development for TB

Under Item 10 at its forthcoming meeting WHO's Executive Board will review
progress in implementing the 2014 End TB Strategy
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=78c954dd5c&e=916df65fd1>
and
fulfilling the commitments in the 2018 UN Political Declaration on ending
tuberculosis
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=092203a6a9&e=916df65fd1>
.

Tuberculosis is the leading cause of death worldwide from a single
infectious agent, one of the top 10 global causes of death, the leading
killer of people with HIV infection, and a leading cause of death due to
antimicrobial-resistant infections. In 2016, tuberculosis was responsible
for an estimated 1.3 million deaths and an additional 374 000 deaths among
HIV-positive people worldwide. An estimated 10.4 million people globally
fell ill with tuberculosis in 2016. Drug-resistant tuberculosis is a
worldwide threat and a crisis in several Member States. In 2016, there were
600 000 new cases with multidrug-resistant and rifampicin-resistant
tuberculosis, requiring treatment of longer duration with more expensive
and more toxic second-line drug regimens. Globally, the tuberculosis
mortality and incidence rates are decreasing annually at about 3% and 2%,
respectively. However, by 2020, these annual rates of reduction need to be
4–5% and 10%, respectively, in order to reach the 2020 milestones of the
End TB Strategy. (EB142/16
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=46f883e336&e=916df65fd1>
)

It is evident from EB146/10
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=95069678a7&e=916df65fd1>
that the End TB strategy is failing. The shortfalls in the targets are
themselves disappointing but in absolute terms the global burden of TB is
static if not increasing:

   - the reduction in TB incidence and mortality is well below the targets
   set in the Strategy;
   - TB households are facing catastrophic health care costs: between
   27-83%; 67-100% for drug resistant TB (or are not seeking treatment);
   - There is an estimated annual gap of around 3m people who are not
   registered and not treated.

PHM's comment
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=0865fad184&e=916df65fd1>
on this item argues that the continuing TB epidemic reflects health system
weaknesses (including huge out of pocket costs for treatment);  failure to
act on the social determinants of the epidemic; and weak accountability for
implementation.
Weak health systems

Weak health systems, in particular weak primary health care, jeopardise
case finding, supportive treatment regimes, and case follow up and
monitoring. Health workforce is critical for the implementation of the
strategy and it is important that WHO gives priority to the strengthening
and equitable distribution of the health workforce. Shortfalls in the
health workforce are not mentioned in the report.

WHO’s insistence, in its UHC rhetoric, that mixed (public and private)
health care delivery and health insurance financing are compatible with
effective health care, in this case effective TB control, is not credible.
The End TB strategy repeatedly refers to engaging the private sector but
implementing a TB control program through the private sector require well
resourced program management, appropriate organisational support and
regulatory capacity which in most cases is just not available. The
preference of private sector providers to cluster in affluent areas is a
major contributor to the poor distribution of health care resources and the
shortages of skilled and motivated health workers in rural communities and
informal settlements. PHM urges the MS to strengthen public health systems
within the context of comprehensive primary health care and improve health
care access.

The other major barrier on the health care side is the cost of medicines
(particularly medicines for resistant TB), whether met through out of
pocket payment or public subsidy. This underlines the importance of WHO’s
work on access to medicines and the culpability of those who continue to
obstruct effective action in this space.

At another level of scale the neoliberal program of small government, low
taxes and austerity is responsible for limits on fiscal capacity, for
either health service development or underwriting the cost of essential
medicines.
Multisectoral action on the social determination of tuberculosis morbidity

The second challenge for the effective implementation of the End TB
strategy lies in the barriers to action on the social determinants of the
TB epidemic.

EB146/10
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=e896ad8bfc&e=916df65fd1>
reports that, of the estimated 10m new cases per year, 2.3m are
attributable to undernourishment, 0.9m to smoking, 0.8m to alcohol abuse,
0.8m to HIV and 0.4m to diabetes; a total of 5.2m. There is no estimate of
attributable fraction due to crowded housing, exposure in prisons, indoor
air pollution or occupational dust exposure, although these are mentioned
in the End TB strategy (and the draft R&D strategy).

Proposed interventions include reducing poverty, ensuring food security,
and improving living and working conditions as well as interventions to
address direct risk factors such as tobacco control, reduction of harmful
alcohol use, and diabetes care and prevention. The strategy goes on to call
for multisectoral action, political commitment and adequate resources.

Many governments, especially in the TB high burden countries, are still
failing to address the basic social determinants of (ill-)health, including
TB, such as poor housing, undernutrition, occupational exposure to dust,
and HIV control, which creates an environment for TB to easily spread.

These risk factors point to the importance of multisectoral action driven
by political commitment, and multistakeholder buy-in as emphasised in the
strategy.

However, what the End TB strategy does not address is the political economy
of poverty, inequality and austerity. The continuing epidemic is closely
linked to the continuing and deepening inequalities between and within
countries. In most of the high burden countries the majority of people live
in impoverished communities including displacement settlements.
Accountability

In 2018 the World Health Assembly noted that;

... global, regional and country-level actions as well as investments were
falling far short of those needed and that high-level global support and
regional and national commitments were required; [and noted] that progress
is slow on all three targets of the Strategy (reducing TB incidence,
reducing TB mortality, and eliminating catastrophic costs among TB patients
and their households). (WHA71.3
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=fa06d45a01&e=916df65fd1>
)

The 'Multisectoral Accountability Framework' was first proposed at the
2017 Moscow
Ministerial Conference on TB
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=88d728c3ca&e=916df65fd1>;
a draft version was considered by WHA71; a revised version was endorsed in
the 2018 UN high level meeting on TB; and the framework was finalised
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=d17ee8ff69&e=916df65fd1>
in April 2019.

The Framework is a brave initiative. It proposes that better indicators,
given higher profile, and reviewed in high level multisectoral forums under
the watchful eyes of 'key stakeholders' will accelerate progress to
achieving the targets of the End TB strategy.

Given the fact that the indicators are almost all TB-specific, it seems
unlikely that this will be enough to drive action on nutrition, housing,
overcrowding, HIV diagnosis and treatment, health system strengthening and
real progress towards medicines affordability.

Liberalised transnational capitalism is widening the gap between those
people and countries who are well placed in global value chains and those
countries and people who are excluded, who continue to carry the burdens
of  malnutrition, poor housing, occupational hazard exposure, and poverty
and the financial and other access barriers which prevent them accessing
care. Neoliberal austerity is restricting fiscal capacity and limiting
health systems investment.

PHM urges the Board to address the global economic and political pressures
which continue to drive inequality, poverty, displacement, and austerity
while protecting the interests of the large corporations, including Pharma.
Draft global strategy for TB research and development

EB146/11
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=b95904870e&e=916df65fd1>
presents a draft global strategy for TB R&D as requested in WHA71.3
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=b4d6c089fd&e=916df65fd1>
(and presented
in full here
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=683f4752bf&e=916df65fd1>
).

The draft strategy acknowledges the existing limitations in R&D capacity
and performance and their significance in the continuing TB epidemic. The
strategy addresses health system innovation as well as the need for
medicines and diagnostics.

Some of the barriers to the needed R&D which are identified in the draft
strategy are:

   - regulatory barriers and the management of innovation in health care
   practice;
   - institutional weaknesses in research capacity and links between
   academia and health service delivery; and
   - lack of funding for R&D.

The lack of funding for TB R&D is attributed to the low priority assigned
to TB in rich country research (where most of the basic research capacity
is located), to the lack of market incentives to encourage research-based
pharmaceutical corporations to invest in TB, and to the lack of public
funding to supplement private sector investment (and provide support for
public private partnerships).

The strategy reviews priorities for the development of diagnostics,
medicines and vaccines and highlights the importance of implementing
WHO’s Roadmap
on  access to medicines and vaccines 2019-2023
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=4980e8387d&e=916df65fd1>
and the Global Strategy
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=4db36bdba8&e=916df65fd1>
and Plan of Action
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=b64c426113&e=916df65fd1>
on Public Health, Innovation and Intellectual Property. Unforunately
EB146/11 does not mention these.

PHM acknowledges
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=b48220d3de&e=916df65fd1>
that
the global strategy on TB R&D will be a very useful instrument. PHM
particularly appreciates:

   - the emphasis on data sharing (including ‘open access to research data
   and IP’ generated through international funding) although the draft does
   not mention the 2019 Transparency resolution
   <https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=7b0d15a969&e=916df65fd1>
   ;
   - the endorsement of  WHO’s Roadmap on  access to medicines and vaccines
   2019-2023
   <https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=720fd520b9&e=916df65fd1>
   and the Global Strategy
   <https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=6cf08f4bc6&e=916df65fd1>
   and Plan of Action
   <https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=353c73989c&e=916df65fd1>
   on Public Health, Innovation and Intellectual Property; and
   - the recommendations regarding capacity building for research,
   development and health service innovations, including strengthening the
   links between research institutions and service delivery programs.

PHM looks forward to seeing the final draft adopted but has concerns about
scope, intellectual property and transparency and urges the Board to
clarify and strengthen these commitments before forwarding the draft to the
Assembly.
Scope

The scope of the draft strategy includes basic research into medicines,
vaccines and diagnostics and operational research into health care delivery
issues. These are all clearly vital. However the draft strategy fails to
fully consider the need for research into the social determinants of the TB
epidemic (including undernourishment, smoking, alcohol abuse, HIV,
diabetes, crowded housing, exposure in prisons, indoor air pollution or
occupational dust exposure). It fails to acknowledge or address the global
economic and political pressures which continue to drive inequality,
poverty, displacement, and austerity (all critical drivers of the TB
epidemic) while protecting the interests of the pharmaceutical and vaccine
manufacturers.

WHO strategies, by themselves, are unlikely to resolve these social
determinants and their economic and political drivers, but the first step
in addressing them is to describe and analyse them and to report on ‘best
practice’ in addressing them.
Research funding and intellectual property

PHM appreciates the clarity of the draft strategy regarding market failure
in mobilising investment for TB research and innovation and the need to
reform the IP based research funding ecosystem. In this respect PHM
appreciates the reference to milestone prizes. However, the absence of any
reference to the recommendations of the UN High Level Panel on Access to
Medicines
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=efb7fcf99f&e=916df65fd1>
is disappointing.

In particular PHM regrets the lack of reference to the need for countries
to fully implement the flexibilities available in the TRIPS Agreement to
improve the affordability of medicines (in particular medicines for drug
resistant TB).
Transparency

PHM recognises that product development partnerships can play a useful role
in promoting research in situations of market failure. However, PHM urges
that organisations funding PDPs make open access publishing and open
patenting conditional upon receipt of such funds.

PHM urges much stronger reference to the need for transparency with respect
to private sector research and development costs. Estimates of R&D costs
published by the pharmaceutical industry are generally wildly inflated and
not accompanied by publication of any raw data. If public support for
private sector research is based on these estimates it will be essentially
contributing to marketing costs and profits.

PHM appreciates the references to open patents and new policies on IP. In
para 86 the draft highlights the patenting of specific medicines as a
barrier to operational research directed to determining the most
efficacious treatment regimes.

PHM urges high burden TB countries to develop appropriate amendments to
both the draft strategy and the draft decision to incorporate these
suggested improvements into the strategy as finally adopted.
More For further links and more detailed comment on the Cervical Cancer
item on the WHO Executive Board agenda see the PHM comment
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=e189ba8dd3&e=916df65fd1>
on this item.

The full agenda for the EB can be accessed through the WHO Tracker at
who-track.phmovement.org/eb146
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=79aa5e658f&e=916df65fd1>,
including PHM comments on most items.

To provide feedback on this commentary please write to editor at phmovement.org
.
Spread the word

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which is a project of the People's Health Movement
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=986747bad6&e=916df65fd1>
in association with Medicus Mundi International
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=456668282a&e=916df65fd1>,
Third World Network
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=6f99dafefb&e=916df65fd1>
and a number of other civil society networks.

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Update Reports from previous WHO governing body meetings and earlier Item
Alerts regarding EB146 are here
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=ef33b7251e&e=916df65fd1>
.
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