RESUMO
A first UN General Assembly high-level meeting on the fight against tuberculosis (TB) will take place on September 26, 2018. It offers the opportunity to forge new concrete commitments and action needed to finance and deliver universal access to care and prevention, to address equity and social determinants of TB, and to pursue robust research and innovation. These are all needed to accelerate declines in TB mortality, incidence, and social and economic burden of the disease. This Commentary looks at leadership precedents in action against TB and highlights opportunities for bolder accountability and collaboration, especially at the country level, to stimulate action and impact.
Assuntos
Saúde Global , Colaboração Intersetorial , Liderança , Responsabilidade Social , Tuberculose/epidemiologia , Previsões , Humanos , IncidênciaRESUMO
Mandatory tuberculosis (TB) notification is an important policy under the End TB Strategy, but little is known about its enforcement especially in high TB incidence countries. We undertook a literature search for selected high-incidence countries, followed by a questionnaire-based survey among key informants in countries with high-, intermediate- and low-TB incidence. Published literature on TB notification in high-incidence countries was limited, but it did illustrate some of the current barriers to notification and the importance of electronic systems to facilitate reporting by private providers. Required survey data were successfully gathered from 40 out of 54 countries contacted. TB is notifiable in 11 out of 15 high-incidence countries, all 16 intermediate-incidence countries, and all nine low-incidence countries contacted. TB case notification by public sector facilities is generally systematised, but few high-incidence countries had systems and tools to facilitate notification from private care providers. In the context of the new End TB Strategy aimed at eventual TB elimination, all countries should have TB on their national list of notifiable diseases. Enhancing the ease of notification by private providers is essential for effective implementation. To that effect, investing in strengthening disease surveillance systems and introducing digital tools to simplify notification are logical ways forward.
Assuntos
Notificação de Doenças/legislação & jurisprudência , Tuberculose/epidemiologia , Saúde Global , Política de Saúde , Humanos , IncidênciaRESUMO
This paper describes an action framework for countries with low tuberculosis (TB) incidence (<100 TB cases per million population) that are striving for TB elimination. The framework sets out priority interventions required for these countries to progress first towards "pre-elimination" (<10 cases per million) and eventually the elimination of TB as a public health problem (less than one case per million). TB epidemiology in most low-incidence countries is characterised by a low rate of transmission in the general population, occasional outbreaks, a majority of TB cases generated from progression of latent TB infection (LTBI) rather than local transmission, concentration to certain vulnerable and hard-to-reach risk groups, and challenges posed by cross-border migration. Common health system challenges are that political commitment, funding, clinical expertise and general awareness of TB diminishes as TB incidence falls. The framework presents a tailored response to these challenges, grouped into eight priority action areas: 1) ensure political commitment, funding and stewardship for planning and essential services; 2) address the most vulnerable and hard-to-reach groups; 3) address special needs of migrants and cross-border issues; 4) undertake screening for active TB and LTBI in TB contacts and selected high-risk groups, and provide appropriate treatment; 5) optimise the prevention and care of drug-resistant TB; 6) ensure continued surveillance, programme monitoring and evaluation and case-based data management; 7) invest in research and new tools; and 8) support global TB prevention, care and control. The overall approach needs to be multisectorial, focusing on equitable access to high-quality diagnosis and care, and on addressing the social determinants of TB. Because of increasing globalisation and population mobility, the response needs to have both national and global dimensions.
Assuntos
Antituberculosos/administração & dosagem , Controle de Doenças Transmissíveis/organização & administração , Países Desenvolvidos , Saúde Global , Tuberculose/tratamento farmacológico , Tuberculose/prevenção & controle , Feminino , Humanos , Incidência , Cooperação Internacional , Masculino , Inovação Organizacional , Tuberculose/epidemiologia , Tuberculose Resistente a Múltiplos Medicamentos/tratamento farmacológico , Tuberculose Resistente a Múltiplos Medicamentos/epidemiologia , Tuberculose Resistente a Múltiplos Medicamentos/prevenção & controleRESUMO
Tuberculosis (TB) remains a major global public health problem. In all societies, the disease affects the poorest individuals the worst. A new post-2015 global TB strategy has been developed by WHO, which explicitly highlights the key role of universal health coverage (UHC) and social protection. One of the proposed targets is that "No TB affected families experience catastrophic costs due to TB." High direct and indirect costs of care hamper access, increase the risk of poor TB treatment outcomes, exacerbate poverty, and contribute to sustaining TB transmission. UHC, conventionally defined as access to health care without risk of financial hardship due to out-of-pocket health care expenditures, is essential but not sufficient for effective and equitable TB care and prevention. Social protection interventions that prevent or mitigate other financial risks associated with TB, including income losses and non-medical expenditures such as on transport and food, are also important. We propose a framework for monitoring both health and social protection coverage, and their impact on TB epidemiology. We describe key indicators and review methodological considerations. We show that while monitoring of general health care access will be important to track the health system environment within which TB services are delivered, specific indicators on TB access, quality, and financial risk protection can also serve as equity-sensitive tracers for progress towards and achievement of overall access and social protection.
Assuntos
Gastos em Saúde , Política Pública , Tuberculose/economia , Tuberculose/prevenção & controle , Cobertura Universal do Seguro de Saúde/economia , Saúde Global/economia , Saúde Global/tendências , Gastos em Saúde/tendências , Humanos , Tuberculose/epidemiologia , Cobertura Universal do Seguro de Saúde/tendênciasRESUMO
In order to inform the development of appropriate strategies to improve financial risk protection, we conducted a systematic literature review of the financial burden of tuberculosis (TB) faced by patients and affected families. The mean total costs ranged from $55 to $8198, with an unweighted average of $847. On average, 20% (range 0-62%) of the total cost was due to direct medical costs, 20% (0-84%) to direct non-medical costs, and 60% (16-94%) to income loss. Half of the total cost was incurred before TB treatment. On average, the total cost was equivalent to 58% (range 5-306%) of reported annual individual and 39% (4-148%) of reported household income. Cost as percentage of income was particularly high among poor people and those with multidrug-resistant TB. Commonly reported coping mechanisms included taking a loan and selling household items. The total cost of TB for patients can be catastrophic. Income loss often constitutes the largest financial risk for patients. Apart from ensuring that healthcare services are fairly financed and delivered in a way that minimises direct and indirect costs, there is a need to ensure that TB patients and affected families receive appropriate income replacement and other social protection interventions.
Assuntos
Efeitos Psicossociais da Doença , Tuberculose/tratamento farmacológico , Tuberculose/economia , Características da Família , Saúde Global , Custos de Cuidados de Saúde , Gastos em Saúde , Humanos , Renda , Modelos Econômicos , Pobreza , RiscoAssuntos
Antituberculosos/uso terapêutico , Erradicação de Doenças , Saúde Global , Acessibilidade aos Serviços de Saúde , Tuberculose Latente/tratamento farmacológico , Pesquisa , Vacinas contra a Tuberculose/uso terapêutico , Tuberculose/prevenção & controle , Descoberta de Drogas , Humanos , Pesquisa Translacional Biomédica , Organização Mundial da SaúdeRESUMO
Weak health systems are hindering global efforts for tuberculosis care and control, but little evidence is available on effective interventions to address system bottlenecks. This report examines published evidence, programme reviews, and case studies to identify innovations in system design and tuberculosis control to resolve these bottlenecks. We outline system bottlenecks in relation to governance, financing, supply chain management, human resources, health-information systems, and service delivery; and adverse effects from rapid introduction of suboptimum system designs. This report also documents innovative solutions for disease control and system design. Solutions pursued in individual countries are specific to the nature of the tuberculosis epidemic, the underlying national health system, and the contributors engaged: no one size fits all. Findings from countries, including Bangladesh, Cambodia, India, Tanzania, Thailand, and Vietnam, suggest that advances in disease control and system strengthening are complementary. Tuberculosis care and control are essential elements of health systems, and simultaneous efforts to innovate systems and disease response are mutually reinforcing. Highly varied and context-specific responses to tuberculosis show that solutions need to be documented and compared to develop evidence-based policies and practice.
Assuntos
Atenção à Saúde , Saúde Global , Tuberculose/prevenção & controle , Atenção à Saúde/classificação , Atenção à Saúde/economia , Atenção à Saúde/organização & administração , Surtos de Doenças/prevenção & controle , Organização do Financiamento , Mão de Obra em Saúde , Humanos , Sistemas de Informação , Inovação Organizacional , Objetivos Organizacionais , Tuberculose/epidemiologiaAssuntos
Antituberculosos/provisão & distribuição , Administração em Saúde Pública , Tuberculose Resistente a Múltiplos Medicamentos/prevenção & controle , Gerenciamento Clínico , Saúde Global , Gastos em Saúde , Acessibilidade aos Serviços de Saúde , Humanos , Automedicação , Tuberculose Resistente a Múltiplos Medicamentos/epidemiologiaRESUMO
BACKGROUND: The End TB Strategy and the Sustainable Development Goals (SDGs) are intimately linked by their common targets and approaches. SDG 1 aims to end extreme poverty and expand social protection coverage by 2030. Achievement of SDG 1 is likely to affect the tuberculosis epidemic through a range of pathways. We estimate the reduction in global tuberculosis incidence that could be obtained by reaching SDG 1. METHODS: We developed a conceptual framework linking key indicators of SDG 1 progress to tuberculosis incidence via well described risk factor pathways and populated it with data from the SDG data repository and the WHO tuberculosis database for 192 countries. Correlations and mediation analyses informed the strength of the association between the SDG 1 subtargets and tuberculosis incidence, resulting in a simplified framework for modelling. The simplified framework linked key indicators for SDG 1 directly to tuberculosis incidence. We applied an exponential decay model based on linear associations between SDG 1 indicators and tuberculosis incidence to estimate tuberculosis incidence in 2035. FINDINGS: Ending extreme poverty resulted in a reduction in global incidence of tuberculosis of 33·4% (95% credible interval 15·5-44·5) by 2035 and expanding social protection coverage resulted in a reduction in incidence of 76·1% (45·2-89·9) by 2035; both pathways together resulted in a reduction in incidence of 84·3% (54·7-94·9). INTERPRETATION: Full achievement of SDG 1 could have a substantial effect on the global burden of tuberculosis. Cross-sectoral approaches that promote poverty reduction and social protection expansion will be crucial complements to health interventions, accelerating progress towards the End TB targets. FUNDING: World Health Organization.
Assuntos
Saúde Global/estatística & dados numéricos , Pobreza/prevenção & controle , Política Pública , Tuberculose/prevenção & controle , Objetivos , Humanos , Incidência , Modelos Estatísticos , Tuberculose/epidemiologiaRESUMO
BACKGROUND: The economic burden on households affected by tuberculosis through costs to patients can be catastrophic. WHO's End TB Strategy recognises and aims to eliminate these potentially devastating economic effects. We assessed whether aggressive expansion of tuberculosis services might reduce catastrophic costs. METHODS: We estimated the reduction in tuberculosis-related catastrophic costs with an aggressive expansion of tuberculosis services in India and South Africa from 2016 to 2035, in line with the End TB Strategy. Using modelled incidence and mortality for tuberculosis and patient-incurred cost estimates, we investigated three intervention scenarios: improved treatment of drug-sensitive tuberculosis; improved treatment of multidrug-resistant tuberculosis; and expansion of access to tuberculosis care through intensified case finding (South Africa only). We defined tuberculosis-related catastrophic costs as the sum of direct medical, direct non-medical, and indirect costs to patients exceeding 20% of total annual household income. Intervention effects were quantified as changes in the number of households incurring catastrophic costs and were assessed by quintiles of household income. FINDINGS: In India and South Africa, improvements in treatment for drug-sensitive and multidrug-resistant tuberculosis could reduce the number of households incurring tuberculosis-related catastrophic costs by 6-19%. The benefits would be greatest for the poorest households. In South Africa, expanded access to care could decrease household tuberculosis-related catastrophic costs by 5-20%, but gains would be seen largely after 5-10 years. INTERPRETATION: Aggressive expansion of tuberculosis services in India and South Africa could lessen, although not eliminate, the catastrophic financial burden on affected households. FUNDING: Bill & Melinda Gates Foundation.
Assuntos
Custos de Cuidados de Saúde , Tuberculose/economia , Tuberculose/prevenção & controle , Doença Catastrófica/economia , Humanos , Índia , Modelos Teóricos , África do SulRESUMO
Mycobacterium tuberculosis has been identified in prehistoric remains of humans. Despite references to TB by Hippocrates and Galen, humankind had limited understanding of and few tools to defend itself against TB until the later 19th century. Subsequently, landmark advances in the 20th century provided the means to control and prevent this disease. At the same time, epidemiological developments and fundamental problems related to human behavior, socioeconomic conditions, and political circumstances continue to thwart efforts to diminish the burden of suffering and death caused by TB. This article reviewed some of these issues including the global failure of TB control in the late 20th century, the worldwide emergence of drug-resistant TB, the extensive spread of HIV infection and its impact on TB incidence; and changing health care and political environments. The obstacles to TB control remain and will remain challenges in the coming years. Still, recent developments in immunology, biochemistry, and molecular biology suggest that new knowledge and tools are just around the corner. These will enhance the ability to conquer this microbe by the end of the current century.
Assuntos
Tuberculose/epidemiologia , Infecções por HIV/epidemiologia , HumanosRESUMO
People with TB and/or HIV frequently experience severe economic barriers to health care, including out-of-pocket expenses related to diagnosis and treatment, as well as indirect costs due to loss of income. These barriers can both aggravate economic hardship and prevent or delay diagnosis, treatment and successful outcome, leading to increased transmission, morbidity and mortality. WHO, UNAIDS and the ILO argue that economic support of various kinds is essential to enable vulnerable people to protect themselves from infection, avoid delayed diagnosis and treatment, overcome barriers to adherence, and avert destitution. This paper analyses successful country proposals to the Global Fund to Fight AIDS, Tuberculosis and Malaria that include economic support in Rounds 7 and 10; 36 and 20 HIV and TB grants in Round 7 and 32 and 26, respectively, in Round 10. Of these, up to 84 percent included direct or indirect economic support for beneficiaries, although the amount constituted a very small proportion of the total grant. In TB grants, the objectives of economic support were generally clearly stated, and focused on mechanisms to improve treatment uptake and adherence, and the case was most clearly made for MDR-TB patients. In HIV grants, the objectives were much broader in scope, including mitigation of adverse economic and social effects of HIV and its treatment on both patients and families. The analysis shows that economic support is on the radar for countries developing Global Fund proposals, and a wide range of economic support activities are in place. In order to move forward in this area, the wealth of country experience that exists needs to be collated, assessed and disseminated. In addition to trials, operational research and programme evaluations, more precise guidance to countries is needed to inform evidence-based decision about activities that are cost-effective, affordable and feasible.
Assuntos
Síndrome da Imunodeficiência Adquirida/economia , Malária/economia , Tuberculose/economia , Atenção à Saúde/economia , Saúde Global/economia , Humanos , Cooperação InternacionalAssuntos
Saúde Global , Infecções por HIV/mortalidade , Tuberculose/mortalidade , Causas de Morte , Infecções por HIV/diagnóstico , Infecções por HIV/economia , Infecções por HIV/terapia , Infecções por HIV/virologia , Custos de Cuidados de Saúde , Humanos , Incidência , Prevalência , Medição de Risco , Fatores de Risco , Fatores de Tempo , Tuberculose/diagnóstico , Tuberculose/economia , Tuberculose/microbiologia , Tuberculose/terapiaRESUMO
OBJECTIVES: Health care delivery is particularly problematic in fragile states often connected with increased incidence of communicable diseases, among them tuberculosis. This article draws upon experiences in tuberculosis control in four fragile states from which four lessons learned were derived. METHODS: A structured inventory to extract common themes specific for TB control in fragile states was conducted among twelve providers of technical assistance who have worked in fragile states. The themes were applied to the TB control programs of Afghanistan, DR Congo, Haiti and Somalia during the years 2000-2006. RESULTS: Case notifications and treatment outcomes have increased in all four countries since 2003 (treatment success rates 81-90%). Access to care and case detection however have remained insufficient (case detection rates 39-62%); There are four lessons learned: 1. TB control programs can function in fragile states. 2. National program leadership and stewardship are essential for quality and sustained TB control. 3. Partnerships with non-governmental providers are vital for continuous service delivery; 4. TB control programs in fragile states require consistent donor support. CONCLUSION: Despite challenges in management, coordination, security, logistics and funding, TB control programs can function in fragile states, but face considerable problems in access to diagnosis and treatment and therefore case detection.