International Development CommitteeWritten evidence submitted by the UK Coalition to Stop TB

About the UK Coalition to Stop TB

1. The UK Coalition to Stop TB (UKCSTB) is an alliance of UK-based organisations who share a commitment to fight tuberculosis (TB)—a preventable and largely treatable disease that kills over 1.4 million people worldwide each year. It was established in 2008 and now has over 30 member organisations, including the UK’s main tuberculosis charities and leading research and global health organisations.

2. The coalition was formed to increase support for the fight against domestic and global TB among influencers and decision-makers in political and policy arenas. UKCSTB subscribes to the Millennium Development Goals (MDGs) and the Stop TB Partnership targets and broadly to the programmes and policies approved by the World Health Organisation (WHO). The Coalition aims to add value and impact to existing efforts to combat TB by harnessing the skills, capacity and impetus of its member organisations.

3. UKCSTB welcomes the opportunity to contribute to the IDC inquiry on the Post MDG Development Goals. This submission will take on a health focus with particular attention to infectious diseases including TB.

Chapter 1: Lessons learned from the adoption of the International Development Targets and the Millennium Development Goals: in particular how effective has the MDG process been to date

4. The MDG process has proved to be very successful at placing poverty reduction, and subsequently health, at the heart of development. It has shown itself it be a remarkably useful instrument to rally stakeholders (particularly at the global level), and has provided a focus for governments and other development actors in both rich and poor countries. It has further increased the flow of financial investments, in particular towards research and development of new tools to combat diseases of poverty and scale-up of access to services for those in greatest need.

5. Health is an important part of the MDGs, accounting for three of the eight goals. Significant resources have been mobilised to help achieve the progress made to date. The MDGs have also highlighted funding gaps and helped create the impetus for the development of global funding mechanisms to increase the flow of resources to address health. These include the GAVI Alliance, UNITAID and the Global Fund to Fight Aids, TB and Malaria, all of which the UK is a significant contributor to.

6. Infectious diseases (including HIV/AIDS, TB and malaria) are now the world’s biggest killers of children and young adults, the vast majority of deaths taking place in the developing world. The inter-linkages of infectious diseases are programmatically and policy-wise very important. TB is the leading killer of people living with HIV/AIDS (it kills one in four); and one of the leading non-obstetric causes of maternal deaths. In 2009, 3.3 million women were diagnosed with TB; 320,000 women died from TB in 20101, with pregnant women and the poor disproportionately affected. TB also impacts considerably on child health and is one of the top ten killer diseases of children; half a million children develop TB each year resulting in 70,000 deaths2. In developing countries, children make up 20–40% of all TB cases, and again, it is those who are orphaned, malnourished and/or HIV-positive who are mostly affected.

7. Investments in TB and progress on MDG 6 have helped accelerate the overall progress of the MDGs, for example, by contributing directly to a reduction in maternal and child mortality, reducing poverty and addressing a major cause of death among people living with HIV. While the MDGs cannot claim full credit for all progress made, they have helped to focus government action and change across these key health areas.

8. Since 2000, TB prevalence has fallen from over 9.2 million to 8.8 million (2010) and new HIV infections have declined by 17% from 2001–20093. Globally, the TB death rate dropped 40% in 2010 compared with 1990, and all regions except Africa are on track to reach a 50% reduction in mortality by 2015. This success should be acknowledged and can in large part be attributed to the focus and catalyst provided by MDG 6 on infectious diseases and an achievable (though some say not ambitious enough), target for tuberculosis.

9. The lack of focus on a human rights-based approach to health in the current MDGs has left many key populations, often those people most vulnerable to disease, unable to access the medical services they need. Social stigma and legislation prevents many migrants, transgender, injecting drug users and particularly women from seeking and accessing life-saving treatment for HIV/AIDS 4 and TB.

10. The current MDGs also do not recognise the impact of the huge increase in mass population movements over the past decade. The UNHCR’s 2010 trends report estimated that 43.7 million refugees and people were displaced within their country by events such as war and natural disasters5. Not only are refugees and displaced people especially vulnerable to infectious disease; their movement can also spread infectious diseases across borders. New development goals must fully consider the range of movement of people, and the interventions and health services that are needed to serve this population and prevent the spread of disease.

Chapter 2: How should the “Sustainable Development Goals” established following Rio +20 relate to the “Development Goals” being considered by the High-Level Panel?

11. There are major impacts on health with regard to access to food, clean water and sanitation and the competition between the use of land for fuel or food, all of which will determine the healthcare that is ultimately required. These also impact on people’s access to primary healthcare since access to energy has an impact on communications (more so now with the wider use of IT and mobile phone technology). Clinics cannot function without reliable electricity and we should not let green development be a reason to deny people access to health.

Chapter 3: The coverage of future goals: should they be for developing countries only or should progress be monitored in all countries?

12. The new goals should apply to all countries. More poor people live in Middle-Income Countries (MICs) than Low-Income Countries (LICs), and even in relatively rich countries pockets of inequality and deprivation exist. The rights-based approach to heath applies equally, globally. On a practical level, infectious disease, in particular, is one example where rich and poor countries need a coordinated response.

Chapter 4: The process: are the right voices being heard? What are the opportunities for and constraints to global consensus?

13. The TB community felt that the MDG process, failed to engage the right national stakeholders (civil society implementers, national experts and affected communities) to adequately define the goals and appropriate metrics for measurement. As a result, the MDGs lacked a critical southern focus and human rights-based approach. This in turn led to targets that were not sufficiently ambitious for countries to achieve the scale of progress and improvements needed, including the building of capacity and infrastructure.

Chapter 5: Targets: was the MDG “target-based” approach a success? Should it be retained? How should progress be measured?

14. The target-based approach has been successful in countries where there is capacity for monitoring and evaluation processes in order to confirm baseline data and track progress. In many instances, this approach has encouraged countries to record baseline data and track progress from that point.

15. It is important to note that the countries least successful in the MDGs are often those without the capacity or resources to invest in this infrastructure to monitor progress. Any future development goals must build into the framework the investment necessary for monitoring and evaluating progress.

16. In the case of TB, the MDG target of reversing TB incidence by 2015 was achieved in many regions of the world by 2008, however 8.8 million people continue to develop active TB disease and 1.4 million people continue to die each year from this largely treatable and curable disease. It is notable that the Africa region will be the only world region not to reach this global target.

17. The imbalance between countries in meeting the TB target, a majority going far beyond its ambitions and a minority not getting close, highlights the need for more nuanced targets. The “one size fit all” approach did not work for the MDGs and would certainly not work for globally applicable goals. Two things are critical for future goals: both a staggered approach where targets are tiered according to a country/region’s current MDG baseline; and a monitoring system which provides for disaggregated data and permits measurement of equality and equity of access.

Chapter 6: Financing global goals: are new mechanisms needed?

18. Predictable, sustainable, long-term funding is required for good development programmes and interventions. In terms of health, there can be greater efficiencies within existing funding mechanisms including UNITAID and the Global Fund to Fight AIDS, TB and Malaria. At the same time, donor funding must be improved by more countries making multi-year pledges, like the UK; and use of innovative financing mechanisms like a Financial Transaction Tax (FTT) and other solidarity taxes such as the airline levy used by France to finance UNITAID.

19. UNITAID, a health financing mechanism financed primarily by a solidarity air travel tax, has played a crucial role in driving down market prices of TB drugs and enabling countries to purchase these in bulk as well as invest in modern tools to diagnose TB and drug-resistant strains.

20. The Global Fund to Fight Aids, TB and Malaria is responding to the need for predictable reliable grant delivery through the development of a new funding model that will be finalised in November 2012. The Global Fund is the largest multilateral funder of global health and channels two-thirds of the international financing provided to fight TB and malaria and nearly a quarter of the international financing against AIDS6. Within the new funding model initial levels of grants will be set according to historical allocations and more than ever, a higher allocation for TB will depend on the strength of country plans and contributions in discussions at country level as well as the ability to generate demand through ambitious and high-quality proposals and strategies.

21. In 2006 the UK government made a 20 year commitment to UNITAID of €60 million per year. Coupled with its on-going commitments to the Global Fund, as previously discussed by the IDC, both mechanisms have the potential to have a huge impact on health outcomes. The UK must continue to invest in the proven ability of UNITAID and the Global Fund.

22. The global recession has frequently been cited as the principle reason for many donors to cut back on investments in international development. More than ever, new innovative funding mechanisms (IFMs) are needed to generate additional resources: A financial transaction tax (FTT of less than half a percent (0.005%—0.5%) on trades in derivatives, stocks, bonds, and foreign currency exchange7 could generate enough resources to invest in both domestic and international development. In August 2012, France was the first country to implement a FTT, with the promise that a proportion of the revenue would be dedicated to funding AIDS research.

23. Future funding architecture must ensure that the funding gap for TB of US$ 3 billion per year8 is closed and not widened.

Chapter 7: The role of the private sector and other non-state organisations

24. To date, the private sector has played an important role in the financing and delivery of critical health services. This includes financial contributions to multilateral grant facilities such as the Global Fund; delivery of key health services for its workforce, and the recognition that the private health sector workforce must be trained to adequately deliver correct treatment to patients seeking care.

25. Many mining companies, whose employees are known to suffer occupational health problems including increased susceptibility to TB and much higher rates of HIV/AIDS, have established targeted health programmes on site which have brought about improvements in the health of the workforce9.

26. TB in the gold-mining industry is the most concentrated TB epidemic in the world. It is a key driver of TB-HIV across the Southern African region and greatly impacts on the likelihood of that area of the world meeting MDG 6. In recognition of this, the South African Development Committee (SADC) signed a declaration in August 201210, which seeks to produce a regional plan of action to inform future TB-HIV interventions. This may include the introduction of regional health passports for migrant workers and the harmonisation of TB treatment policies and regimens across the industry in that region.

27. In some LICs and MICs, private healthcare is often viewed as better than that provided by national government, resulting in many healthcare seekers first approaching private healthcare facilities11. However, cost and quality of service within the private health sector are both under-regulated and often poor quality.

28. Care must be taken when promoting the private sector as a provider. While it may be perceived in some places as being better than public provision, this is often not the case. In Cambodia, for example, the private sector is the dominant provider of TB services, with most people preferring to seek private TB treatment. In 2004, a survey funded by USAID12 showed that private providers lacked adequate knowledge and training to deliver TB care and treatment. The study also highlighted the need for health service providers to give adequate information on TB to patients and clients through education materials and to recognise the impact of stigma on health-seeking clients.

29. As well as healthcare delivery, the private sector also plays a vital role in research and development for new tools. The development of cheap, accurate and rapid Point of Care (POC) TB tests is key to early diagnosis. Shorter regimens of more effective drugs could greatly reduce the risk of drug resistant TB developing as occurs when patients fail to complete their treatment. New vaccines would dramatically change the course of the global epidemic and provide protection for HIV-positive populations. The current BCG vaccine is not safe for people living with HIV and only provides protection against the most severe forms of childhood TB (TB meningitis) until adolescence. It has a variable impact on pulmonary TB, the most common cause of TB worldwide.

Chapter 8: Timescale: what period should the new framework cover? Was the 15-year timescale for the MDGs right?

30. Within the timescale of 15 years it was possible to see progress, with regular progress meetings allowing most off-track goals to be reprioritised. However, many development issues have longer time horizons than 2015, and some goals will only be achieved beyond 2030, due to the nature of the challenges.

31. The Global Plan to Stop TB strategy is an example of a global health strategy with a longer timescale, working to a goal of 2050 elimination. Vital to this strategy and to any new post- MDG framework should be the inclusion of regular and transparent monitoring of on-the-ground progress with country-led targets within the context of a global framework.

Chapter 9: The content of future goals: what would be a good set of global goals? What continuity should there be with the MDGs, and how should the unfulfilled MDGs be taken forward?

32. Future goals should highlight more clearly the inter-linkages between all the current MDGs; unmet MDGs should be carried forward and existing ones strengthened.

33. A good health system delivers quality services to all people, when and where they need them. The exact configuration of services varies from country to country, but in all cases requires a robust financing mechanism; a well-trained and adequately paid workforce; reliable information on which to base decisions and policies; well-maintained facilities and logistics to deliver quality medicines and technologies. Therefore, direct investment into and strengthening of primary healthcare, the first point of access for many healthcare users, will substantially increase access to a number of services especially maternal and child health, HIV and TB. Most critically, effectiveness must then be measured by developing indicators for health outcomes, particularly those relating to the factors which cause the most illness and death amongst the most vulnerable and marginalised.

34. TB and other infectious diseases must retain a pivotal focus in health and future targets for TB should be focused on making substantial improvements towards achieving TB elimination; including universal access to high-quality care for all people with TB.

35. Furthermore, research and development and innovation are a vital part of UK development aid to ensure the most up-to-date, effective, appropriate and high-quality technologies essential to a good health system are available to those who need them. Global health research has already made a significant contribution to global development goals and must be given sufficient priority in the post-2015 era. New drugs, diagnostics and vaccines for TB that have come online or are in development will be essential to the prevention, treatment, control and elimination of the epidemic.

36. Given the last decade of investment in the fight against the three major infectious diseases has shown such impressive results, a failure to sustain these gains through the new framework would contribute to rapid backsliding and increased suffering and costs to control the epidemics.

5 October 2012