1. The Union – (Way) Beyond TB North America Regional Conference San Antonio, 23-25 February 2012 Dr Nils E. Billo, MD, MPH

2. Outline Little history of The Union Beyond TB –tobacco control and mpower –pneumonia in children –asthma –operational research –management education Summary

3. Paris 1867: first international TB meeting Berlin 1902: first permanent office Paris 1920: International Union Against Tuberculosis officially established Paris 1986: Board decision to expand beyond TB: adding Lung Disease to name Origins of The Union

4. What is The Union? An Institute A Federation 14 Offices worldwide 5 Scientific Departments 79 Constituent Members 22 Organisational Members 2738 Individual Members over 30,000 contacts Tuberculosis Tobacco Control HIV Research Lung Health & NCDs

5. Health solutions for the poor Mission The Union brings innovation, expertise, solutions and support to address health challenges in low- and middle- income populations The Union’s vision and mission today Vision

6. Activities of The Union Founded in 1920 Up to 1986: focus on TB: mainly Conferences, publications, courses and technical assistance in TB Between 1978 and 1990: Development of the TB DOTS strategy, mainly in Africa 1990s: adding asthma, child lung health, tobacco control using TB model 2000-2012 adding HIV and expanding in TB and tobacco control, adding operational research and management education to portfolio

7. The Union then and today 1992: Staff of 12 people Small Federation Secretariat: 1 Executive Director, 1 Scientific Director, admin staff for membership services and Editorial office for Journal, 1 accountant Budget 2 million USD From 1992 onwards: gradually growing Secretariat in Paris with enlarged focus on Technical Assistance, Education and Research: Institute function added 2011: about 250 staff and consultants in 14 offices: Budget 50 million USD

8. The Tobacco Epidemic Tobacco is the leading behavioural risk factor causing a substantially large number of potentially preventable deaths worldwide. The five million deaths translate to an incredible statistic: one death every six seconds. Unless strong actions are taken to halt the tobacco epidemic, 1,000,000,000 people are projected to die this century - we cannot let this happen. I urge all countries to implement fully the WHO Framework Convention on Tobacco Control. Dr Ala Alwan, Assistant Director General, WHO, November 2011

9. Proportion of TB burden attributable to some major risk factors in high TB burden countries Relative risk for active TB disease Weighted prevalence (adults 22 HBCs) Population Attributable Fraction (adults) HIV infection 20.6/26.7*0.8% 16% Malnutrition 3.2**16.7% 27% Diabetes 3.15.4% 10% Alcohol use (>40g / d) 2.98.1% 13% Active smoking 2.026% 21% Indoor Air Pollution 1.471.2% 22% Sources: Lönnroth K, Castro K, Chakaya JM, Chauhan LS, Floyd K, Glaziou P, Raviglione M. Tuberculosis control 2010 – 2050: cure, care and social change. Lancet 2010 DOI:10.1016/s0140-6736(10)60483-7.

10. Deaths attributable to tobacco (in %) WHO Global Report: Mortality attributable to tobacco, 2012

11. Exposure to second-hand smoke causes death and disease Source: Office of the U.S. Surgeon General. The health consequences of involuntary exposure to tobacco smoke: a report of the Surgeon General, 2006

12. Bloomberg Initiative To Reduce Tobacco Use Grants Programme Capacity Building Programme Impact 2011 Progress of The Union’s Tobacco Control work 2011

13. WHO MPOWER Package monitor tobacco use and prevention policies protect people from tobacco smoke (Smoke-free) offer help to quit tobacco use warn about the dangers of tobacco enforce bans on tobacco advertising, promotion and sponsorship (TAPS) raise taxes on tobacco

14. Grants programme

15. Capacity building Technical and management courses since 2007 (to 31 May 2011) Number of trainings109 Number of participants2305 Number of countries covered36 Progress 2011 9 trainings held since January 2011 including 5 in March – May 2011 Total IMDP trainings in 2011 – 6 Total technical trainings in 2011 - 3

16. Progress in Tobacco Control Indicator 2011Achieved 2011 Increased Smokefree initiatives in 7 priority countries and 1 country noted for its regional influence. China* Indonesia Russia* Egypt Pakistan India* Bangladesh* FCTC compliant legislation focusing on MOPWER interventions achieved in 2 priority countries and 2 countries of regional influence. Russia Nepal Indonesia* Lebanon Incorporating TC into the broader health agenda in 3 priority countries. Russia Philippines* Indonesia* One recognised civil society organisation and/or government subsidiary takes on tobacco control in 6 countries as its main area of work. Bangladesh India Egypt Pakistan Philippines Lebanon * Partially achieved

17. Reducing childhood pneumonia-related mortality

18. Pneumonia:The forgotten killer of children New York: UNICEF/WHO 2006.

20. Child Lung Health Programme (CLHP) MALAWI Making a Difference in Child Survival

21. Specific objectives To standardise case management for severe and very severe pneumonia in district hospital paediatric inpatient ward To reduce mortality due to respiratory disease especially severe/very severe pneumonia in children under 5 years of age To rationalise the use of drugs for ARI in children under 5 years of age. To provide uninterrupted supply of essential drugs and oxygen at District Hospital

22. Enrolment into CLHP by year 2000 - 2005 n = 48,365 5 districts Total 10 districts Total 16 districts Total 23 districts Total 24 districts 24 districts

23. Trend in Outcomes 1 October 2000 to 30 September 2005 2000 2003 2002 2001 2004 % Months after program introduction 2005

24. Achievements of the CLHP Malawi Total number of children admitted48,365 between October 2000-December 2005 Baseline pneumonia CFR18.6 Pneumonia CFR December 2005 8.4 Reduction over the baseline 54.8% Total number lives saved 2000-2005 4,357

25. Summary Implementation of standard case management to district hospitals is feasible and successful Key elements for success are supply of drugs, accountability and supportive visits The cost is competitive, facilitating sustainability CLHP Malawi incorporated into the Essential Health Package Adoption of Child Lung Health into National Planning sector wide approach (SWAPS)

26. Why Asthma? Asthma is the most common chronic disease among children. Asthma affects millions of adults. 235 million people worldwide suffer from asthma. Asthma is a non-communicable disease (NCD). Effective medicines are available. Unfortunately, for many people with asthma – particularly the poor – these medicines are too costly or not available at all.

28. Asthma in Children

29. Asthma in Adults

31. Essential Medicines: Pricing, Availability and Affordability

32. A Practical Solution: Asthma Drug Facility (ADF) Provides affordable access to quality-assured, essential asthma medicines for low- and middle-income countries Promotes a quality improvement package for the diagnosis, treatment and management of asthma In countries, the cost for one year of medicines for a patient with severe asthma can be less than 40 USD when medicines are purchased through ADF

33. ADF Clients Countries that have already received their orders Pilot Projects in Benin (NTP), El Salvador (NTP), Sudan (Epi-Lab) Kenya (KAPTLD) Burundi (NTP) 7 orders for a total of €99,826 Current orders Vietnam (CHDI) Guinea Conakry (NTP) Burkina Faso (NTP)

34. Reduction in annual costs for a patient with severe asthma when medicines purchased through ADF (in euros, based on 2009/2010 ADF prices)

35. ADF Product Prices for 2011 Additional costs: transport, insurance, preshipment inspection and 10% fees for ADF services ProductPrimary Supplier (Country) Price per unit FCA (USD) Beclometasone 100µg/puff 200 doses, HFA inhaler* Beximco (Bangladesh) 1.28 Salbutamol 100 µg/puff 200 doses, HFA inhaler* GSK Export (UK) 1.08 Budesonide 200µg/puff 200 doses, HFA inhaler* Cipla/Medispray (India) 2.60 Fluticasone 125µg/puff 120 doses, HFA inhaler Cipla/Goa (India) 2.50 *On the 17 th WHO Essential Medicines List March 2011

36. Challenges at country level Lack of political will, other priorities Guidelines not available or not implemented Corticosteroids often not on the national Essential Medicines List (EML) Non-essential medicines pushed by pharmaceutical companies and specialists Lack of trained health workers Lack of funds to purchase essential medicines Restrictions in national procurement system about using the ADF mechanism

37. The Economic Burden of Asthma Treating asthma entails vastly more than the cost of medicines. It amounts to billions of dollars in both direct and indirect costs.

38. The Global Asthma Report 2011 www.theunion.orghttp://isaac.auckland.ac.nzwww.globalasthmareport.org

39. Operational Research at The Union

40. Centre for Operational Research Activities

41. Support Bold and Innovative Strategies MALAWI HIV testing of all pregnant women and ART offered to all those HIV- positive regardless of CD4 count In 3 months from April – June 2011: 509,645 persons were HIV tested 18,442 new HIV-positive patients started on ART 7524 (88%) of 8525 HIV-positive pregnant women started on ART

42. The DOTS Model for monitoring Non-Communicable Diseases

43. Operational Research Fellows 6 Union-based OR Fellows: Malawi; Zimbabwe; South Africa; India; Vietnam; Brazil 4 MOU-supported OR Fellows: South Africa (2) and Kenya (2) Outputs from April 2009 - December 2011 (33 months) 55 research projects undertaken 39 completed and submitted to journals 30 papers in press or published

44. Operational Research Courses Purpose: To teach the practical skills for conducting and publishing operational research Approach: Product –oriented [a submitted research paper] Participants go through whole research process Milestones must be achieved to stay in course Trained participants become facilitators

45. Three module – course starting this week in Nepal for Asian candidates Module 1a: research questions, protocol development and ethics (5 days) – February Module 1b: Data management and data analysis (5 days) – February/March Module 2: Paper writing, peer review and policy implications (5 days) – October

46. Does the Model work? 7 courses – either underway or completed since 2009 - 86 participants enrolled 3 courses completed:- –34 participants enrolled –31 completed milestones /awarded certificate –35 papers submitted to journals –27 papers (>70%) in press or published

47. Published Papers as a result of training / support from COR “If you do not write about it, it did not happen” Virginia Woolf

48. One Expert Meeting 2009 Two papers in IJTLD Two papers in TMIH One paper in TRSTMH One paper in BMC Medicine RESEARCH TO POLICY

49. POLICY TO PRACTICE Bi-Directional Screening of TB and Diabetes Mellitus China and India World Diabetes Foundation Support National Stakeholders Meeting Training for implementers Implementation Review activities and data National Stakeholders Meeting

50. Strengthening Health Systems The Union’s International Management Development Programme (IMDP) was created to aid countries with the difficult task of operating a national health programme by training health managers in management education. Its mission is to develop a community of leaders and innovators in public health who improve the quality of services provided to the public through well-managed national health programmes.

51. Training Leaders in Public Health Participants who attend IMDP courses have the opportunity to become multi-talented managers capable of dealing with complex situations in public health that require multiple skills and competencies. IMDP participants generate greater value for health organisations by being more capable of handling a variety of challenges that health programmes face.

52. Summary Main activities in TB and tobacco control Models ready to be scaled up in child lung health and asthma Operational research critical to investigate new areas of intervention Publish successes a must Management training and Human Resource Development critical

53. Health Solutions for the Poor Technical Assistance – Education – Research

54. Union Values Quality We deliver our services and products to the highest possible standards. Accountability We are responsible stewards of resources and deliver on our commitments. Independence We maintain the freedom to pursue innovation and are guided by the best evidence to improve the health of the poor. Solidarity We stand together as one Union to overcome the greatest challenges to improve health among the communities we serve.

55. Thank you