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Amsterdam Report, EnglishAmsterdam, 22-24 March 2000 Amsterdam Declaration to Stop TB – World TBDay
Agenda Opening Ceremony 19:30-20:00 08:45-08:50 08:50-09:00 09:00-09:10 09:10-09:15 09:15-09:25 09:25-09:30 10:00 10:05-10:15 10:15-10:20 10:20-11:45 11:45-12:00 13:30 13:35-13:45 13:45-13:55 13:55-14:00 14:00-14:45 14:45-14:50 11:30-12:00 15:00-16:00 - Round tables were open to all Conference participants and consisted of short country presentations followed by facilitated group discussions - Finance Track "Socioeconomic impacts of TB and TB/HIV" - Health Track "TB and Health Systems Development" 16:30-17:30 - Finance Track "Options for Financing and Sustainability" - Health Track "Strategies to Cope with the Dual Epidemic" 17:30–18:30 08:45 08:50-09:30 09:30-09:40 09:40-10:50 10:50-11:00 12:45–13:30 13:30 13:35-13:45 13:45-13:50 13:50-14:50 14:50-15:05 15:05 Conference Adjourned Acknowledgements The organizers would like to thank Dr Els Borst-Eilers, Minister of Health, Welfare and
Sport, the Netherlands, and Ms Eveline Herfkens, Minister of Development Cooperation,
Ministry The expertise of His Excellency Korn Dabbaransi, Deputy Prime Minister and Minister of Public Health, Thailand, in chairing the Amsterdam Declaration to Stop TB preparation and adoption sessions is gratefully acknowledged. The contribution of national delegations, government representatives and governmental agencies, international organizations and others is appreciated. The contribution in kind of the DIP Foundation is acknowledged. The Conference was organized by the World Health Organization and the World Bank. Thnaks to the Stop TB team for their valuable review and comments. Project Manager: Heidi Larson Preface Tuberculosis (TB) is a global public health emergency demanding concerted global action to halt its rampage through some of the poorest countries in the world. High-ranking participants at the Ministerial Conference in Amsterdam bore testimony to their collective commitment to take action—and to take it NOW. Partners in the Stop TB Initiative and the 20 highest TB burden countries represented at the Conference spoke eloquently of the need for sustainable financing, resource mobilization and partnership building to overcome this global threat and ward off its devastating social and economic consequences. TB and Sustainable Development—the theme of the Conference—encompassed its aims: to place effective TB control high on the political agenda and to shift the emphasis from a purely technical approach within the health sector to an intersectoral approach, tackling TB from a sustainable development perspective. The grim statistics of TB are only too well known—two million deaths and eight million new cases every year; the scourge of the dual HIV/TB epidemic; and the spectre of multidrug-resistant TB (MDR–TB). The good news is also well known—there is a cost-effective treatment strategy called DOTS that has high cure rates. Currently, however, DOTS only reaches about 25% of TB patients, which means there continue to be hundreds of thousands of preventable deaths every year. The Conference gave delegates the opportunity to analyse country-specific challenges to implementing effective global TB control. It brought together senior ministers from various government sectors and donor agencies, providing an environment in which to address issues of financing and sustainability. The terrible tragedies of TB were heard through poignant personal testimonies and country presentations. But we also learned of major gains through DOTS, of high cure rates and great optimism, given adequate levels of funding and support for TB control. The Amsterdam Declaration to Stop TB is a major cause for hope and optimism. Through this Declaration, the 20 high-burden countries committed themselves to accelerated action against TB and a strengthened Stop TB Initiative. We are inspired by this determination and look forward to building on the momentum of the Conference and supporting the actions outlined in the Declaration. We know that if we embrace our shared goals and vision we can tackle this scourge. Together, we can Stop TB. Dr Arata Kochi List of participants DELEGATIONS FROM 20 TB HIGH BURDEN COUNTRIES BANGLADESH BRAZIL CAMBODIA CHINA CONGO DR ETHIOPIA INDIA INDONESIA KENYA NIGERIA PAKISTAN PERU PHILIPPINES RUSSIAN FEDERATION SOUTH AFRICA TANZANIA THAILAND UGANDA VIET NAM ZIMBABWE GOVERNMENT REPRESENTATIVES AND GOVERNMENTAL AGENCIES Australia — Australian Agency for International Development (AUSAID) ORGANIZATIONS • American Lung Association (ALA) Opening Ceremony Proceedings The Conference opened with welcoming remarks from Dr Gro Harlem Brundtland, Director-General of the World Health Organization (WHO) and Ms Eveline Herfkens, Minister for Development Cooperation of the Netherlands. Both urged participants to capitalize on the opportunity at hand. Dr Brundtland Some occasions provide unique opportunities for change. Such chances must be grasped while they are there. If not, there may be years before the opportunity re-appears or it may never happen again. This conference is such an opportunity for change. We must make the most of it. We should take a moment to remind ourselves that we are sitting in the very part of the world that was ravaged by tuberculosis in the 18th and 19th century. It was a scourge that took whole families in its wave and left many others alone, as their spouses, parents and siblings died of what was then known as "consumption". Then, with the development of new TB drugs and improved living conditions due to socio-economic development, TB disappeared in the lives and minds of many. We thought we had conquered TB—that it would soon be a disease of the past. But, today we are faced with a global epidemic that is killing more people than at any point in its history. This week will be testimony to that. It will be a week to bring light to the gravity of this persisting epidemic, as well as a time to chart our collective response… Minister Herfkens The success of this conference depends on how political priorities are set in your countries with regards to investments in human development and health. … TB control cannot be seen as separate from a country's overall health policy. TB programmes will not work—or will be much less efficient—in countries that lack a decent level of basic health care. Their success depends strongly on the strength of the health care system as a whole.I firmly believe that a sectoral approach will lead to more sustainable TB programmes, with much better coverage. I also believe that it will raise the overall standard of health care policies. I am arguing against compartmentalization and for cohesion, so that TB programmes and the rest of the health sector can benefit from one another. I sincerely hope that this conference will strengthen the global partnership to stop TB. Session 1- Improving Health:a Catalyst for Development Session one confirmed the links between TB and development, ill-health and poverty, and stressed how improved health is a catalyst for development. TB affects the poorest people in the world—95% of new TB cases every year are in developing countries—and their illness tumbles them further into poverty. They are unable to work when sick and families often have to sell what little they own to pay for health care. Research by the World Bank among 60 000 poor people in 60 countries confirms that one critical missing link between poverty and a life worth living is personal security, especially freedom from disease. Illnesses such as TB—and the deadly combination of TB and HIV/AIDS—prevent people from helping themselves out of poverty, compounding the poverty cycle. Improved health through effective TB control contributes to a country’s development. TB control makes development sense Delegates were urged to remember the lessons of TB control in the Netherlands and New
York City. In both places, as TB was brought under control, the facilities and resources
for treating the disease were scaled down. It was assumed TB could be consigned to the
history books. Instead, TB persisted. In New York City between 1979 and 1992, the number of patients with TB tripled and the percentage of patients with MDR-TB more than doubled. By allocating the necessary financial and human resources and designing a comprehensive, integrated TB control plan, the City is winning the battle against TB. A crucial part of the programme is the use of "Directly Observed Therapy", where outreach workers visit patients in their homes and workplaces, in the streets, homeless shelters and subway stations. Today in New York City, TB continues its downward trend. The global response to TB has suffered from a legacy of complacency and neglect. There has been no new TB drug for 30 years. There is no vaccine that truly protects against infectious pulmonary disease. Investment is urgently needed in developing better tools—diagnostics, drugs, vaccines—to guarantee the elimination of TB for good. Speakers stressed the urgency of the problem and the need to take action NOW to apply on a large scale what is known about tackling the disease. Otherwise, the world faces the growing threat of drug-resistant TB and a potentially incurable epidemic. Credit: ©WHO/TDR/Crump Conference speakers stress need for urgency: "We Must Act Now!" 6 Action
points 1. Act now to avoid a more serious and dangerous epidemic in the future. The Honourable Clare Short, Secretary of State for International Development, UK "We can ensure this conference will be a turning point, by developing strategies for sustainable financing, resource mobilization and partnership building. And when we’ve all gone home, translating them into action. Action to tackle TB, action to tackle poverty. We have the potential to consign TB to the dustbin of history. Let’s just do it." Dr Els Borst-Eilers, Minister of Health, Welfare and Sport, The Netherlands "The fight against tuberculosis is a dynamic process that needs to be adjusted continuously. The moment you think you can sit back and relax, TB will rear its ugly head again." Dr Donna E. Shalala, Secretary of Health and Human Services, USA "TB attacks the body and assaults the spirit. It hinders economic development. It holds the poor in the grip of poverty and disease. And none of our nations—north or south, east or west—are immune from its threat." Ms Mieko Nishimizu, Vice-President, The World Bank, USA "Health expenditure to fight such epidemics will force very hard trade-offs in public finance. Every time I look at such financial projections, I shudder. Economists like me are not good at making impossible, unethical, trade-offs. I do not wish such nightmares on anyone, especially political leaders of developing nations. But they will be the reality one day if we do not act now." Source for the four photographs: ©Capital Photos/WHO Session 2: Confronting and Overcoming Challenges Session two examined TB in the context of other infectious diseases—and learned how Bangladesh, Kenya, the United Republic of Tanzania, and Viet Nam have successfully confronted the epidemic and are overcoming particular challenges. All four countries have committed considerable financial and human resources to TB control. Success is attributed to political commitment and partnerships with NGOs, the private sector and international agencies. The importance of community education around TB and DOTS was stressed in discussion. Pakistan recognizes that community education needs in the country must be linked to one phrase—social stigma. Stigma is strongest in countries with the highest burden of TB and is a major barrier to people seeking diagnosis. TB in perspective There are 54 million deaths in the world each year. In low-income nations, 45% of deaths are due to infectious diseases, including TB. Worldwide, premature death from infectious diseases is 48%, of which 90% is attributable to just six infectious diseases: acute respiratory infections, TB, AIDS, diarrhoeal diseases, malaria, and measles. This figure varies greatly from region to region. In the United States it is about 10%, whereas in Sub-Saharan Africa it is as high as 60%. Partnerships between high-and low-prevalence countries are crucial to addressing the TB epidemic. TBand HIV/AIDS HIV/AIDS has fuelled the rise in TB cases at an alarming rate, spawning a lethal dual epidemic. Of the 2.3 million deaths from AIDS each year, one half million is due to TB. AIDS is ravaging parts of Africa, leaving children orphaned and communities destitute. The epidemic is rapidly becoming more devastating than war: it is now an international issue of human security. MDR-TB Amajor challenge confronting TB control is the emergence of multidrug-resistant TB. MDR-TB trends are alarming, and the cost of treating MDR-TB is 100 times more expensive than standard TB treatment. Speakers recognized MDR-TB as a public health emergency requiring a prompt international response, including research. It was noted that MDR-TBis generated by poorly managed TBprogrammes. Several delegates spoke of the problem of drug-resistant TB in their countries. In Tomsk in the Russian Federation, for example, 30% of TB patients have MDR-TB. Globalization, particularly through international travel and migration, contributes to the spread of TB and MDR-TB. "In countries where strong political leadership, openness about the issues, strong community involvement and broad, crosscutting responses come together, the tide is turning and clear success is being demonstrated." Dr Peter Piot, Executive Director, UNAIDS, Geneva - 3 messages 1. Any action that stops the HIV epidemic will also stop TB.
Ministerial Panel Bangladesh Bangladesh has achieved 90% DOTS coverage. Government is committed to addressing TB through partnerships with the private sector, NGOs and international organizations such as the World Bank. Challenges include expanding DOTS coverage to the main cities and to remote populations, women and the poor. Confronting the challenge of TB: Government and NGOs partners for DOTS 500 thanas DOTSin 4 thanas NGOs, Government United Republic of Tanzania The United Republic of Tanzania introduced DOTS as early as 1977. Cure rates of more than 80% have been achieved, with low drug resistance. Strong Government commitment, close collaboration with donors and integration of TB services have been key to its success. Since 1982, the number of TB cases has increased four-fold due to HIV. This has led to an overburdening of the health sector and has affected access to TB services. The challenge is to scale up and sustain DOTS despite the severe impacts of the HIV/AIDS epidemic. The Key to Success Viet Nam Viet Nam was the first Asian country to introduce a DOTS pilot programme in 1989. By 1997, DOTS was expanded nationwide (96%) and global targets of >70% detection rate and >85% cure rate achieved. Strong political commitment, full integration of TB services and strong international support has guaranteed success. Major challenges include the growing threat of HIV/AIDS and the expansion of DOTS to remote and mountainous areas and to vulnerable groups. Reasons for Success Kenya Kenya established a National TB and Leprosy Control Programme in 1980. TB services in public institutions are free of charge. Government recognizes TB control as a public good. These services are at risk, however, because of the rising TB epidemic in the last decade due to HIV/AIDS: a 500% increase in TB case finding between 1987 and 1998. The highest increase is among the most productive age group (15-49 years). Challenges include the development of a joint HIV/AIDS-TB control strategy and further involvement of community care providers. Successes and Lessons Learned Session 3: Taking Action Session three focused The key issues raised in the discussion of the draft Declaration included the reluctance of pharmaceutical companies to develop new TB drugs; a call for access to low-cost drugs; the problem of poor countries having to pay for high cost MDR-TB treatment; the inability of some countries to finance TB control due to indebtedness; and the urgent need for vaccine development. The role of effective TB control in strengthening health systems and contributing to sustainable development was also highlighted, and the consequences of poor TB control were addressed, particularly the risk of increasing drug resistance where TB programmes are ineffective. Expanding coverage of DOTS must involve changing the focus from a purely technical, health intervention to a multisectoral response engaging the commitment of political leaders and civil society. A personal testimony Ram Khadka, a teacher from Kathmandu, Nepal, gave a personal testimony to the misery of
TB. "The organizers, governments, NGOs and WHO who are working together to eradicate TB have to involve people like us who had the bitter and hard experience of TB. The involvement of technical manpower will not be the entire solution to the problem. There needs to be a change in the attitude of people. They must know that TB can be cured. We know it because we have had TB." Mr Ram Khadka, Kathmandu, personal testimony The mission of Stop TB The mission of Stop TBis to ensure that every person with TB has all the necessary information and access to treatment and cure; to protect vulnerable populations from TB and multidrug-resistant TB; and to prevent the unnecessary social and economic tolls of TB. Opportunity for Action Arata Kochi, Director, the Stop TB Initiative: "Why TB?" Challenge Multi-sectoral approach Initiatives for Action * Global Drug Facility * Global Partnership Agreement Session 4: Finance track First round Finance round tables in Session four debated the socioeconomic impacts of TB and TB/HIV, and options for finance and sustainability—supported by country presentations. Socioeconomic impacts of TBand TB/HIV India India carries one-third of the global tuberculosis burden, which affects the most productive age group (15-49 years). TB causes more deaths among women than all other causes of maternal mortality in India. The social stigma associated with the disease makes the situation worse. India recognizes that any TB control initiative has to be implemented in tandem with poverty elimination programmes. In 1993, the Revised National TB Programme based on the DOTS Strategy was started on a pilot basis and scaled up in 1997. Resources were committed and free treatment is now available for a population of 130 million people. Indonesia Indonesia continues to suffer the economic legacy of poverty from the financial crisis in Asia in 1997. In 1996, the World Bank estimated that TB caused 7.7% of the total disease burden in the country. Approximately 75% of cases are in the economically active age group of 15–54 years. Some 60% of TB cases occur among the poor and poorly educated. Indonesia introduced DOTS in 1990. The strategy aims for 70% coverage within five years; currently, only about 51% of health clinics implement DOTS. Despite the economic challenges, TB control is recognized as critical to avoid even more difficult and expensive problems in the future. Uganda Uganda has experienced the dramatic socioeconomic impacts of the dual TB/HIV epidemic for the past fifteen years. Half of TB patients are also infected with HIV. Life expectancy has steadily declined since the onset of the HIV/AIDS epidemic. The socioeconomic impacts of the dual epidemic on households and communities include: • Decreased labour supply; Zimbabwe Zimbabwe has among the highest rates of HIV infection in the world. The TB and HIV epidemics have together contributed to the decline in the average growth rate and the GDP per capita. Debt servicing accounts for more than four times the expenditure on health and education. Some 41% of the population lives on less than US$1 per day. Extended family systems that used to care for orphans can no longer absorb the costs. Resources otherwise available for investment are now used for health care and social welfare, especially care for orphans. Where support for orphans is failing, the phenomenon of street children in the major cities is rising. Life expectancy has declined by 17 years, principally among the most socioeconomically active. Additional country-specific information and indicators can be found in the Country Profiles document (reference: WHO/CDS/STB/2000.3) prepared for the Conference or at www.stoptb.org. Second round: Options for financing and sustainability Democratic Republic of the Congo Despite war, Congo DR has achieved 70% DOTS coverage. TB control is based in 306 health centres around the country. Health centre personnel receive ongoing education. Partners in this work include the Catholic Church. Major obstacles to TB control are debt servicing, epidemics and war. Some 70% of financing comes from donors. The country recognizes the need to mobilize partnerships across sectors and to obtain a constant and regular increase of state budget earmarked for TB. Pakistan Pakistan has the fifth highest burden of TB in the world, causing approximately 26% of all avoidable adult deaths. DOTS covers only 8% of TB patients. Pakistan is planning a massive poverty alleviation programme. Improved literacy, especially among women, will greatly contribute to the efficacy of the TB programme. The programme is based on two guiding principles: self-reliance through regular budget sources and sustainability through integration of programmes with general health services. Government is committed to effective TB control and plans have been made for DOTS to expand nation-wide. All provinces have allocated funds for TB in this financial year. Philippines The Philippines needs at least US$ 60 million over the next four years to reduce TB. Anti-TB drugs are a major cost item. Although the NTP calls for free drugs for all infectious cases, there have been insufficient resources to support this policy until 2000. A multi-year budget has now been proposed for TB until the year 2003. A planned expansion of social health insurance is also under way. Currently, social health insurance pays only for hospitalization of TB patients; however, the inclusion of outpatient TB diagnostic and treatment services for poor people is being piloted. Efforts are being made to lower drug costs and to reform the procurement system. Two major gaps in financing are recognized: measures to address childhood TB and adequate provision for MDR-TB. Russian Federation Government has supported the fight against TB since 1910 by providing considerable resources. Since 1992, however, there has been a significant rise in the incidence of TB, with a major epidemic in the prisons. The increase is due mainly to the rapid deterioration in social and economic conditions, including the flow of refugees. The overall health system has severely deteriorated. Additional financial resources are needed for the education of physicians and the general population, for monitoring TB incidence, for the upgrading of diagnostic facilities and for anti-TB drugs. Session 4: Health track First round Health round tables in Session four considered TB and health systems development, and strategies to cope with the dual TB and TB/HIV epidemics—supported by country presentations. TB and Health Systems Development Cambodia Despite years of isolation and conflict, Cambodia introduced DOTS in 1994 and has achieved 92% treatment success rates. Because of years of isolation and the resulting lack of a health care infrastructure, TB services were implemented in a vertical manner. A reform of the health sector aims at providing a network of health centres run by multipurpose health workers. A pilot programme "DOTS in health centers" begun in September 1999 integrates the already existing TB services. Health sector reform and the integration of TB services have become even more important in the light of increasing HIV rates which, in 1999, has led to a 14% increase of TB cases. Viet Nam Viet Nam has met WHO global targets for national DOTS coverage and TB cure rates. A
major contributing factor is the existing and well-functioning network of health services.
There is a health centre in every commune with dedicated and well-trained staff. Ethiopia Ethiopia's Health Sector Development Programme was launched five years ago and aims at a comprehensive sector wide and integrated health system, focused on family health and communicable disease prevention. The TB programme aims specifically at providing management training for information systems to assure a continuous drug supply and increased quality services such as microscopy, which Ethiopia recognizes are prerequisites for a sustainable health system and effective TB control. The importance of Government commitment and effective coordination within the Government as well as with donors and partners is acknowledged. Challenges are maintaining the decentralization process while coordinating and integrating activities. Philippines The present Philippines administration was elected on the basis of a pro-poor agenda, which included an ambitious health sector reform agenda. A presidential memorandum signed in 1998 made TB control a national priority. Public health reforms support the national TB programme by improving the drug procurement system and ensuring prompt delivery of anti-TB drugs to health centres. In 1991, legal autonomy was given to provinces, cities, and municipalities. A devolved health delivery system makes local Government units critical to DOTS implementation. It is expected that DOTS coverage will increase from 17% currently to about 80% at the end of 2000. A key element for achieving targets is strong collaboration with the private sector, particularly important as research shows that 80% of all TB patients first see a private practitioner. China TB is the main communicable disease in China causing poverty in rural areas, and hampering local economic development. There are at least 1.5 million new cases every year and the total number of TB patients is 6 million. Government has used a World Bank loan and domestic resources to introduce TB control through DOTS. In DOTS project areas, cure rates are above 90%. Successful implementation relies heavily on the development of the health system. DOTS implementation has significantly improved the functioning of the health system and the technical skill and working capability of TB control workers. Second round:Strategies to cope with the dual epidemic South Africa TB and HIV are of the highest priority in South Africa. The rapid progression of the HIV epidemic has fuelled the already high numbers of TB cases. Socioeconomic diversity has translated into an imbalance in service delivery across the country. In an attempt to harmonize TB and HIV/AIDS control, key areas where both programmes could work together have been identified: • Political commitment; Networks of community-based volunteers and lay assessors have been mobilized to provide care for people living with HIV/AIDS and to ensure that TB treatment is accessible. To improve collaboration between TB and HIV/AIDS programmes, pilot sites are being developed in health education, voluntary counselling and testing, treatment of opportunistic infections, care and support, and collaboration between home-based care projects and community-based DOTS projects. Thailand It is estimated that HIV has contributed to 15%–20% of the new TB cases in the country after decades of decline in TB rates. In 1998, 20% of people infected with HIV also had TB. As a result of HIV, TB affects more young people and debilitates more adults in the productive age group than ever before. The dual epidemic has gone far beyond being a health problem: it has destabilized families and impeded economic development. Thailand’s response is to improve TB services at all levels, based on the DOTS strategy, and to integrate TB care with HIV community-based care. Thailand is also drawing from its experience with HIV/AIDS to address the dual epidemic. Government leadership, an inter-sectoral response, education and information, and building networks with patient groups and activists to prevent discrimination are among the strategies being used. Uganda The dual epidemic of TB/HIV is severe in Uganda with about 50% of TB cases being HIV-positive. The national response is to mobilize all stakeholders, particularly communities. The results are very promising with cure rates rising to 87%. Decentralization, integration of TB and HIV/AIDS care into the general health system and community involvement are key to a sustained TB programme. In the future, the participation of communities will be extended to address malaria, immunisation, and reproductive health. Village Health Committees will be set up in every village of 2000 people to mobilize a mass movement to promote health. Zimbabwe A key strategy in addressing the TB/HIV epidemics is the empowerment of communities to get involved and take responsibility. A strategic change implemented in Zimbabwe is that now the health services go to the patient. There is a policy of decentralization to the district and the district health executive is the driver of the health services. The Ministry of Finance now allows district communities to retain the fees collected for health care. Session 5: Investing in Health for the Long-Term Session five considered financing and sustainability options as a means of investing in health for the long-term. Ms Mieko Nishimizu, the World Bank, reflected on the Conference and noted the "wonderful learning" among delegates who shared common challenges and experiences. The impressive collective strength and personal commitment of leaders was commended. It was observed that such commonality stimulates a "virtuous cycle of development partnership"—a cycle that begins through action leading to visible social and economic returns. 5 lessons Ms Mieko Nishimizu, Vice-President, The World Bank, USA 1. In the fight against TB—as in all other development challenges—one size
does not fit all. 10 recommendations Dr William Foege, Senior Health Adviser, Bill and Melinda Gates Foundation, USA 1. We need to be globalists—national boundaries must be forgotten. "Equity is the bottom line." Ministerial panel: Financing and sustainability "The difference between a body of scientific knowledge improving health or not improving health comes down to management." Dr William Foege, Bill and Melinda Gates Foundation, USA Brazil Brazil is committed to sustained TB control. Government spends approximately US$ 23 million a year on TB control—equal to a per capita spending of US$ 0.13—30% more than the level recommended by WHO. The new National Tuberculosis Programme established in 1998 focuses on integrating TB services into other major health initiatives and on decentralization to bring decision-making and care closer to the patient. Challenges include improving management capacities at local level and further improving the laboratory network. Government has increased resources (such as for microscopes and drugs) and DOTS is being expanded and implemented in all 27 States. To increase participation, a bonus of between US$ 55 and U$ 85 is being paid to communities for each cured TB patient. Brazil has committed resources to achieve cure rates of 85% by 2002. China In 1991, the World Bank and the Chinese Government jointly initiated a TB control project. This, in addition to a special Government funded TB control project, reached a total of 700 million people. More than 1.2 million infectious TB patients have now been diagnosed and treated free of charge, with cure rates as high as 90%. TB is the main communicable disease causing poverty. The Government is committed to expanding DOTS to 90% of the population by 2005; it will increase the special budget for TB control and will hold a national mobilization meeting. India Nearly 15% of the population is covered by DOTS compared with only 2% one year ago. It is estimated that DOTS can prevent more than 1.5 million deaths by the year 2010—the largest number of lives saved for a single public health programme. India plans to implement DOTS nationwide by 2005. Priority research areas are to develop an effective vaccine and a new generation of drugs that require only one to two months of treatment. The costs of TB control are currently borne disproportionately by developing countries. The global community must increase its commitment to TB control, both in technical and financial terms. Nigeria The budgetary allocation to health in Nigeria is low at only 2.0% to 2.5% of the national budget. Currently, approximately 10% of TB patients are treated with support from international donors. Government plans to provide treatment services to an additional 20% in the year 2000, however, more resources are needed to address the TB problem nationwide. In order to expand services further, the option of cost-sharing between three tiers of Government—federal, state, and local—is being considered. User charges have been introduced in most health facilities, although TB treatment is free. In order to sustain support for the TB programme, further cost-sharing with patients may be required. Other options to mobilize finances are using the National Health Insurance System, linking with the National AIDS and STI programme and reducing TB drug costs by centrally procuring them in bulk. The establishment of a national Tuberculosis Fund with money raised from public and private sectors has been discussed. In addition, decentralizing decision-making processes as well as capacity building at a local level are envisaged in order to make services more efficient. Concluding session:"Forging New Partnerships to Stop TB" Following unanimous adoption of the Amsterdam Declaration to Stop TB, the concluding session heard statements from two of Stop TB’s partners: UNICEF and Médecins sans Frontières. The case for UNICEF’s involvement is clear. TB is a major threat to the rights of
the child, adolescents, and their families. The potential negative impact on the survival,
growth and development of its mandated populations is extremely grave. Women and young
people Insufficient attention has been focused on the direct and indirect impact of TB in children. The problem is underestimated because diagnosis is difficult. Children also suffer the impacts of TB in families and are often taken out of school—about 300 000 a year in India. Children are inevitably neglected when parents fall sick. The disease renders ineffective the taken-for-granted family coping mechanisms that have been the foundation of community and family care systems for generations. UNICEF called for more research on TB and HIV/AIDS that identifies the special risks to children in conflict situations and to those who are refugees, trafficked, or are in conflict with the law. UNICEF endorsed the need to expand DOTS and urged countries to establish National Investment Plans to complement the Global Investment Plan being prepared by the Stop TB partners. These plans must be multisectoral and involve a broad partnership reaching beyond the health system. UNICEFalso called for more research on TBand children. MEDECINS SANS FRONTIERES welcomed the fact that TB was now on the political agenda. For too long it has been a technical, medical disease. Dr Orbinski, International President, affirmed the need to improve, expand, and adapt DOTS. Accelerated research into new drugs, diagnostics, vaccines, and different ways of using DOTS was called for. These solutions rest on the right to health care for all, on the recognition of equity of access to health care, and on the responsibility of governments and intergovernmental organizations to ensure provision of health care. Dr Orbinski noted that the 20 countries represented at the Conference did not have the financial resources to fight TB alone or to invest in the research needed. Their capacity was stretched to the limit. The market has clearly failed to produce new TB drugs. There needs to be international leadership on drugs research. TB is a disease of the poor, but the poor do not have consumer power. TB control is a public good and any public research and development initiative into new TB drugs must put equity of access as its first goal; access to the drug itself and to the intellectual property rights. A particular focus should be on developing a drug that shortens DOTS treatment to less than three months with minimal dosing requirements. Ministerial Panel—Partnerships for Action 5 action points Dr Gro Harlem Brundtland, Director-General, WHO, Geneva Let us… 1. Make sure TB gets the priority it deserves in budget allocations. Democratic Republic of the Congo For the past decade Government has had strong partnerships with NGOs working on TB control. This has contributed to a very high number of cases being tracked and treated. Challenges now are to improve the expertise of health workers, strengthen the coordination capacity of the programme, prioritize advocacy and social mobilization—and end the war. Indonesia Partnership is a key factor in the success of the National TB Programme. Every day, 500 people die from TB—the country has the third largest number of TB cases in the world. The Gerdunas TB Movement launched by the Minister of Health in 1999 has mobilized political commitment of the highest order. Long-term commitment from donors is essential to ensure the continued success of the movement. Nigeria The National TB and Leprosy Control Programme launched in 1991 promotes the use of DOTS—implemented in 19 of the 36 states. Many activities, such as the provision and distribution of drugs, are carried out by a number of NGOs. In addition, joint action plans have been developed with the National AIDS and STI Control Programme. In order to ensure a continuous supply of drugs a key partner is the pharmaceutical industry. Other sectors that play crucial roles in improving living standards, promoting health and preventing TB are being targeted for collaboration, such as housing, education, agriculture, labour and the community. In order to encourage more partnerships, the Nigerian Government has set aside counter- part funds to support activities by development partners who are willing to invest. 24 March: Launch of World TBDay World TB Day The theme "Forging new Partnerships to Stop TB" is a call to reach out beyond the TB community and to mobilize new TB constituencies such as international agencies and organizations, women’s groups, human rights groups, HIV/AIDS groups, and others to join the global movement to Stop TB. Dr Gro Harlem Brundtland, Director-General, WHO The theme of the Year 2000 World TB Day is "Forging New Partnerships to Stop TB". … We have heard Ministers agree that no one should be denied access to DOTS. This means that DOTS should be available to all who need it, wherever they live—whether they are young or old, man or woman, homeless or housed, jailed or free. We have heard Ministers agree that DOTS gives hope to people with HIV/AIDS. They too should have access to DOTS—without fear of stigma and discrimination. We have heard Ministers stress the need for adequate funding to Stop TB—whether from local government, central government or the international community. We have heard Ministers describe how they have mobilized international resources, and used them in ways that catalyzed a stronger national response to enable more people to access TB treatment. We have heard expression of commitment around the table—to a real increase in global and national responses. I now ask—How can we best grasp the opportunity presented to us these past few days? What will we do differently from tomorrow, after we leave this conference. How can we all catalyze a difference in the lives of those suffering from TB and its devastating impact?… As my colleague from the World Bank has reminded us, we will never realize our dream of a world free of poverty "unless we join hands to overcome major global threats to the poor and the marginalized". TB is such a threat, and we must, as the World TB Day theme calls for, "Forge new partnerships to Stop TB". UNAIDS PRESS RELEASE Contact: Dominique DeSantis UNAIDS SECRETARIAT JOINS "STOP TB INITIATIVE", STRESSES CLOSE LINKS BETWEEN HIV AND TUBERCULOSIS AMSTERDAM, 23 MARCH 2000. The secretariat of the Joint United Nations Programme on HIV/AIDS (UNAIDS) has officially joined the Stop TB Initiative, a broad partnership to halt the spread of tuberculosis around the world. The Initiative is hosted by the World Health Organization, a Cosponsor of UNAIDS. "There is still insufficient understanding of the close links between TB and HIV," said Peter Piot, Executive Director of UNAIDS. "The two epidemics work hand in hand. In some parts of Africa, their deadly synergy has quadrupled the number of TB cases over the past ten years." Dr Piot was speaking on the eve of World TB Day at the opening session of the Ministerial Conference on "Tuberculosis and Sustainable Development" in Amsterdam. "UNAIDS’ participation in the Stop TB Initiative is crucial in order to effectively address the dual epidemic," said Dr Arata Kochi, Director of the Stop TB Initiative. The World Bank - News Release News release No. 2000/254/HDContact: Christopher Walsh TUBERCULOSIS POSES SERIOUS THREAT TO DEVELOPMENT AMSTERDAM—"The unity of purpose among the nations and agencies at this conference is pathbreaking," said World Bank President James D. Wolfensohn. "We know that only through partnerships can countries effectively respond to tuberculosis and other top communicable disease threats. None of us can have the impact alone that we do together." UNICEF - Information United Nations Children´s Fund TUBERCULOSIS NOW A GLOBAL THREAT UNICEF says support of worldwide DOTS system could stave off a catastrophe Geneva/New York, 23 March 2000—UNICEF today called tuberculosis "one of the most seriously neglected and underestimated health, human rights and poverty problems of our era" and said only a concerted effort could conquer a disease that accounts for two million deaths a year, including over 250,000 children. "TB is the globe’s leading infectious killer of youth and adults and a leading killer of women," UNICEF Executive Director Carol Bellamy said. "In a globalizing world, we need a quick, global solution." UNICEF Deputy Executive Director André Roberfroid will underline the agency's concern in an address tomorrow to the Ministerial Conference on TB and Sustainable Development, being held now in Amsterdam. "The cost of inaction is high," Mr. Roberfroid says. "If we accept the proliferation of inadequate TB treatment services and incorrect self-treatment—a real possibility in Asia—we face a rise in the incidence of multidrug-resistant TB (MDR-TB). That would be a humanitarian and epidemiological disaster." World Health Organization (WHO) PRESS Contact: Gregory Hartl DRUG-RESISTANT STRAINS OF TB INCREASING WORLDWIDE New WHO report shows super-deadly TB strain is spreading. Drug resistant cases increase
by 50% Amsterdam—A new report released today by the World Health Organization and the International Union Against TB and Lung Disease warns that if countries do not act quickly to strengthen their control of TB, the multidrug-resistant strains that have cost New York City and Russia hundreds of lives and more than US$1 billion each will continue to emerge in other parts of the world. In response, top government officials of 20 countries meeting today in Amsterdam are expected to announce an ambitious strategy to "turn off the tap" of drug resistance in the worst-affected countries. The focus of these efforts will be the tripling of access over the next five years to a strategy proven to prevent MDR-TB from developing. Press Release WHO/20 WORLD TB DAY: PRESIDENT CLINTON HELPS TB PATIENTS Action brings attention to India's success in treating TB United States President Bill Clinton marked World Tuberculosis Day by administering the World Health Organization (WHO)-recommended DOTS treatment to TB patients in Hyderabad, India. At the Mahavir Hospital outpatient facility, President Clinton participated in the cure of three TB patients, who received their final dose of medicine of a six-month treatment, under the DOTS programme, today. One patient was an 18 year-old woman, the second a 35 year-old rickshaw driver. President Clinton himself administered the dose of three pills to a 12 year-old girl and then signed the TB register documenting her cure.
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