World Health Organization Regional Office for the Western Pacific The WHO End TB Strategy: Regional Perspective Dr Nobuyuki Nishikiori, Coordinator Stop TB and Leprosy Elimination World Health Organization Regional Office for the Western Pacific The Ninth Technical Advisory Group and National TB Programme Managers Meeting Manila Philippines, 9-12 December 2014

World Health Organization Regional Office for the Western Pacific Regional Situation

World Health Organization Regional Office for the Western Pacific TB burden in the Western Pacific Region Since million patients treated deaths averted On track for achieving the TB related MDGs and other targets by million (87 per ) (5.8 per ) Estimate number of TB (all forms) Estimated number of deaths due to TB* Multidrug-resistant TB HIV-associated TB All estimates are for Source: Global TB Report 2014 (WHO) * Excluding death due to TB-HIV co-infection

World Health Organization Regional Office for the Western Pacific

Changes in TB incidence between Estimates from Global TB Database

World Health Organization Regional Office for the Western Pacific Changes in TB mortality between Estimates from Global TB Database

World Health Organization Regional Office for the Western Pacific The WHO End TB Strategy X Challenges and Opportunities in the Western Pacific Region

World Health Organization Regional Office for the Western Pacific Challenges Still many patients unreached High-risk and socially vulnerable populations Only a small fraction of MDR-TB patients diagnosed, yet treatment capacity insufficient Donor investment shrinking, threatening sustainability Health systems in transitions for efficiency and sustainability Regulatory approaches not fully utilized

World Health Organization Regional Office for the Western Pacific 3 qualities of the End TB Strategy that are of high regional relevance 1.Transcending epidemiological settings with a long-term targets ‘Spectrum’ of TB epidemiology TB control as a global public good for health

World Health Organization Regional Office for the Western Pacific Evolution of the TB control components along with an epidemiological spectrum Pillar 1. Quality TB services Pillar 2. Bold support systems (vertical/top-down  sustainable & integrated) e.g. Surveillance: Basic system  e.g. Social protection: enablers  income compensation  comprehensive health-welfare link Electronic / case-based system High burden Low incidence Pre-elimination Elimination e.g. Basic / resource constraint  * Only selected components are shown for the illustrative purpose. Comprehensive / fully satisfy the standards of care e.g. Contact investigation: Facility-based  home-based  active epi. investigation Link with lab. info system  gene/molecular surveillance e.g. LTBI: PLHIV/Childhood contacts  Expansion to other high risk groups

World Health Organization Regional Office for the Western Pacific TB control as a global public good for health TB control in one setting will benefit everybody No body is prevented from benefiting (and vice versa) –“A classic example of how a health program might be considered a global public good” “Weak link” characteristics—the maximum attainable level of control in any particular country can be impacted by the level of control achieved in the worst national TB control program. This principle is a key for continued advocacy and sustainable public financing Smith R., Beaglehole R., Woodward D., Drager N. (ed.) Global Public Goods for Health: health economics and public health perspectives.

World Health Organization Regional Office for the Western Pacific 3 qualities of the End TB Strategy that are of high regional relevance 1.Transcending epidemiological settings with a long-term targets ‘Spectrum’ of TB epidemiology TB control as a global public good for health 2.Focusing on the vulnerable and unreached Addressing health inequity Re-tackling TB as a social disease

World Health Organization Regional Office for the Western Pacific Pillar 1: Reach the Unreached (  Session 3) Situation Contact investigation strengthened in many countries Childhood TB Taskforce and national policy development Steady progress in TB/HIV Hospital engagement in relevant countries TB screening project and initiatives to address TB among high risk populations Challenges Policy  implementation Prioritization Sound, regular evaluation PPM: engagement and regulation

World Health Organization Regional Office for the Western Pacific Pillar 1: PMDT (  Session 2 Lab, Session 5 MDR-TB) Situation Significant PMDT expansion Rapid adoption of new tools Gradual capacity development Challenges Treatment gap enlarging Deterioration in treatment outcome in some settings Path towards universal DST Diagnosed and notified Enrolled in treatment Gap MDR-TB notification and enrollment in 8 countries LFU Success

World Health Organization Regional Office for the Western Pacific 3 qualities of the End TB Strategy that are of high regional relevance 1.Transcending epidemiological settings with a long-term targets ‘Spectrum’ of TB epidemiology TB control as a global public good for health 2.Focusing on the vulnerable and unreached Addressing health inequity Re-tackling TB as a social disease 3.Emphasis on bold policies Integration and harmonization with health systems Whole-government and societal approaches

World Health Organization Regional Office for the Western Pacific Pillar 2: UHC and social protection (  Session 6: 28-29) Situation Increasing social disparity and health inequity High economic burden on TB patients Various experience in enablers and subsidies UHC poses a major opportunity Challenges Institutionalizing good practices Options to be explored to mitigate patient economic burden Limited schemes available Monitoring mechanism

World Health Organization Regional Office for the Western Pacific Financial hardship of TB patients and families TB continues pushing people into poverty Many patients face catastrophic expense due to TB A half of the costs before TB diagnosis Patients take coping mechanisms that may be irreversible: –75% of TB patients must take out a loan; –50% sell household items Addressing catastrophic patient cost is essential Annual direct medical cost spent by households with TB patients. Unweighted summary of 9 studies in China (Long et al 2011)

World Health Organization Regional Office for the Western Pacific Pillar 2: Sustainable financing (  Session 6: 26-27) Situation Many countries in health financing reforms Financial sustainability is threatened –Shrinking donor investment –Too small domestic fund Robust, costed NSPs in most countries Success in GF applications Challenges Building sustainable TB financing suitable for each country context Protect essential public health functions Where applicable, effective integration into general health funding schemes including health insurance

World Health Organization Regional Office for the Western Pacific Pillar 2: Drug regulations (  Session 6: 30) Situation A critical key for MDR-TB prevention TB drug regulation meeting identified priority actions New TB drug introduction and PV Challenges Continued dialogue and collaboration with NRAs (Islam, T. Tisocki, K. et al. Public Health Action 3, 337–341 (2013).) Drugs by public procurement Drug sale in the private market Notified TB cases

World Health Organization Regional Office for the Western Pacific Pillar 2: Patient and community engagement (  Session 7) Situation Various experience in engaging community based organizations in TB control Challenges Empower patient and community organizations for effective engagement Expand the area of collaboration: patient support, advocacy, policy processes, etc

World Health Organization Regional Office for the Western Pacific Regional document to support implementing the End TB Strategy

World Health Organization Regional Office for the Western Pacific Regional Framework for Action to implement the End TB Strategy (proposal) Purpose Facilitate the adaptation and implementation of the End TB Strategy Methods / scope Elaborate policy options: –Considering region-specific context –Spectrum of TB epidemiology (all countries) Major sources: –NSPs, Programme Reviews –Recent meeting findings/recommendations (childhood TB, drug regulations, migration and TB) –Operational research publications/reports Regional experience and case studies No new targets Regional Framework for Action to implement the End TB Strategy

World Health Organization Regional Office for the Western Pacific A proposed process Dec 2014: TAG & NTP managers meeting –Agree on the scope and overall framework –Discussions and recommendations for each session will be fully taken into account Dec 2014: Establish a drafting group Feb 2015: First web-consultation March 2015: Expert consultation meeting (HBCs + selected IBCs) (April 2015: Final web-consultation, as needed) Aug 2015: UNION APR Conference Oct 2015: RCM

World Health Organization Regional Office for the Western Pacific Your comments are welcome!