1. Breaking Silos: TB and Poverty Bobby Ramakant, Rachael Thomson STOP TB Partnership TB and Poverty Subgroup

2. Poverty and health: the links Increased Personal and Environmental Risks Increased Malnutrition Less Access to Knowledge, information Diminished Ability to Access Care Diminished Quality of Life Reduced Productivity Diminished Household Savings Reduction in Household Assets The vicious circle: Ill health leads to poverty Poverty leads to ill health

3. What is poverty? Poverty is more than economic poverty (living on ≤US$ 1 per day) encompasses lack of opportunities, voice and representation, and vulnerability to shocks is a major determinant of vulnerability to disease – especially TB

4. TB and Poverty – Poor and vulnerable people are much more likely to suffer from TB due to socioeconomic factors – The poor face significant costs and delays in accessing TB services. In urban Malawi poorer patients face costs 6 times their monthly income to access a diagnosis from ‘free' facilities In rural Malawi this rises to 10 times – Case detection in many countries is low because the poor cannot access TB services – The process of accessing care is impoverishing – The lack of diagnosis, treatment and cure means the burden of TB in their communities continues to increase – Papers:  Kemp et al. Can Malawi's poor afford free TB services? Patient and household costs associated with a TB diagnosis in Lilongwe. Bull World Health Organ 2006; 85(8)  Nhlema-Simwaka et al. Developing a socio-economic measure to monitor access to tuberculosis services in urban Lilongwe, Malawi. IJTLD 2007; 11(1):65-71.  Hanson C. Tuberculosis, poverty and inequity: a review of literature and discussion of issues. 2002. Washington DC. World Bank

5. The relationship between poverty and TB The poor have higher risk of infection higher prevalence of disease worse outcome of disease

6. The poor have greater health care needs

7. Active TB Symptoms recognised Health care utilisation Diagnosis NotificationInfected Health system delay Patient delay Conceptual framework for improved and early case notification/detection Patient delay

8. What can we do? Break Silos: work together Put health on the poverty agenda Put poverty on the health agenda

9. What is the TB and Poverty Subgroup? Subgroup of the DEWG of the STOP TB Partnership Network of individuals and organisations interested in the needs of poor and vulnerable populations with respect to TB Led by a core team and supported by a secretariat funded since 2007 Vision: "A world where the poor and most vulnerable are protected from TB and have easy and equitable access to quality care“ Purpose: To enable the STOP TB Partnership to achieve its global targets and contribute to its poverty related mission statements. To ensure that every TB suspect/patient has easy and equitable access to effective diagnosis, treatment and cure. To reduce the inequitable social and economic toll of TB.

10. TB & Poverty Subgroup Revised Objectives Support & Advocacy: –To establish a new Subgroup Secretariat in a low-income country that organises communication, dissemination and meetings for the Subgroup –To actively promote the explicit acceptance that diagnosis of smear positive TB disease is an international public good and should be provided free of charge for universal access in all health systems –To identify additional and feasible entry points for TB control interventions addressing prevention and specifically social determinants of TB Research: –To promote implementation of the TBCAP patient-centered approach (Tool to Estimate Patients’ Costs, QUOTE Tool, ISTC, Patients’ Charter) and indicators that NTPs can use to assess equity in access in relation to geographical, social/cultural, health system or economic barriers –To ensure that the needs of the poor are met as new tools are developed and implemented, including work with Introducing New Approaches and Tools Working Group (INAT) and Treat TB.

11. TB & Poverty Secretariat TB & Poverty Subgroup Secretariat is housed in The Union South-East Asia Office in New Delhi, India since September 2010 with a dedicated staff of one technical officer and one communication officer Activities carried out For addressing poverty in TB control, a 2-day consultative workshop was held in Delhi on the 29 th & 30 th October 2010. It involved the NTP Manager from India, Nepal and Thailand, State TB Managers from 8 poorest states of India, and partners for various other organizations like WHO, the World Bank, World Vision, GFATM Round 9 members, Media (CNS, Asia Tribune), National Partnership for TB care and control in India etc. Way Forward Organize a Sensitization workshop for program managers in India on Relationship between TB and Poverty Regional workshop related to issues in Addressing Poverty in TB control Coordinate with the ongoing Global Fund Round 9 civil society project in India and identify opportunities in poor population

12. How can the subgroup help? Guidelines for NTPs 1.Identification of the poor and vulnerable groups in the country/region served by the national TB control programme 2.Identification of the barriers to accessing TB services faced by the poor and vulnerable groups in the country/region 3.Identification of potential actions to overcome the barriers to access 4.Identification of situations and population groups requiring special consideration 5.Harnessing resources for pro-poor TB services 6.Assessment of the pro-poor performance of the national TB control programme and the impact of pro-poor measures http://www.stoptb.org/tbandpoverty/steps.asp WHO/HTM/TB/2005.352 May 2005