So whose Plan is it anyway?
The last twelve months has seen the emergence of a new ‘post-2015’ Global Strategy for TB – one that’s intended to be rolled out over the next twenty years in the hope of seeing the ‘end’ of this pandemic.
Back in June 2013 a high level panel established by the Secretary General of the UN submitted its report to the WHO. It contained its own recommendations for this new plan for TB and the principle of universal health coverage was definitely included within them. Amongst other things this amounts to is the difference between aggressively treating drug-resistant TB (which is so expensive and requires such resource) and not doing so.
During the first phase of this Global Emergency (from 1993 till today) there has unquestionably been a shamefully inadequate response to the drug-resistant part of the pandemic – which is exactly why the problem is now so large. What's alarming us is that we have yet to see one visible target set in this Plan for either MDR- or XDR-TB.
The aims of the new draft post-2015 strategy first showed its face in October 2013. Instead of the previous long-term aim of “eliminating” TB by 2050, it now surprisingly included the more ambitious goal of “ending the global TB epidemic by 2035”, with milestones and targets being set for 2020, 2025, and 2030. Things were starting to look astonishingly optimistic, but it was still intended for the plan to be reviewed by the WHO executive board in January 2014 and then for it to be discussed and hopefully ratified by the World Health Assembly in May.
And this is exactly what happened. The delegates of the 192 countries who were at Geneva in May 2014 unanimously and enthusiastically adopted the Plan and then passed it straight back to the WHO, with half of them surely knowing that its targets were impossible to be met in their own countries given their existing health resources, and surely all of them noting that a Plan which embraced the idea of universal health coverage failed to incorporate a single target for DR-TB that might actually help make this happen.
It’s important to appreciate that it’s the responsibility of national governments and their health ministries for the planning and execution of their own TB programmes at national levels. The efforts of such national TB programs (NTPs) are informed, if not largely directed, by the WHO’s strategies but it’s down to the NTPs themselves to implement them. Ideally these NTPs govern the equipping and functioning of diagnostic laboratories, providing a continuous supply of drugs to treatment outlets which are appropriately available, co-ordinating the efforts and activities of government and non-government health care operatives, and setting national policies relating to TB treatment. But of course we don’t live in an ideal world. We live in one where half of the countries in the world don't have the resource to diagnose MDR-TB let alone treat it at any scale, and without doing so there's not a prayer that TB can be 'ended' by 2035.
So whose responsibility then is this Plan that can't be met, and whose responsibility is it to see this disease being properly treated and the pandemic ended?
Well certainly the UN should put its hand up. After all it initiated the formation of the WHO in the first place, but its specialist committee also submitted its own report on TB to the WHO back in June 2013 which formally started the ball rolling with this new post-2015 Global Plan. The result – the current Plan to ‘end’ TB by 2035. Meanwhile back at the UN that same specialist committee was apparently also concurrently involved in developing the UN’s own Sustainable Development Goal no.3 for Health. This also includes the goal to ‘end’ the epidemic of TB, but this time by 2030, five years earlier than the WHO’s Global Plan!
Doubtless some regrettable semantics exist here, but it’s difficult not to believe that when the SDGs were officially adopted last month there wasn't serious consternation amongst those in the WHO who had worked so hard on their Plan for 2035 – which is ambitious enough after all.
Is this an example of some of the incoherence that appears to be endemic in TB control?
Maybe it is.
But as far as implementing the Plan is concerned (whichever end-date one favours) it still has to be first and foremost the responsibilities of the governments of the countries themselves as part of their social contracts with their citizens. In other words, it actually amounts to the individual responsibilities of exactly those World Health Assembly delegates of the 192 countries who so merrily signed the new Plan in Geneva last year and then passed it back to the WHO before retiring for drinks and canapés. (Or similarly the delegates of the 193 countries of the UN General Assembly which adopted the 2030 Development Agenda titled Transforming our world last month – those SDGs).
But this is a global problem and TB is an airborne disease with no respect for borders, so such responsibility has also to be shared with the WHO itself, particularly if it recognises that its Global Plan simply can’t possibly be met by individual countries without outside help. In fact the WHO accepts this shared responsibility, with the prime responsibility normally resting on the shoulders of the governments themselves – but wherever resources are known to be particularly poor these responsibilities weight heavily in the direction of Geneva.
So it’s also the responsibility of those in Geneva to accurately assess the situation on the ground in each and every one of these countries, not just in terms of the burden of their disease, but also in terms of the resource available to counter it – and not just do this in terms of what the country may be ‘officially’ telling them, but also in relation to what is really happening on the ground because for many reasons this might be different. And they have an army of operatives worldwide to do exactly that.
But even this gets complicated because within Geneva itself there are divided responsibilities with two distinct organisations now working on the case, and they don’t always see eye to eye with each other.
One is the WHO and its Global TB Programme, and the other is the Stop TB Partnership.
The Global TB Programme is a division of the WHO with its own Director, Mario Raviglione, who’s been in post since 2003. They are the normative body who don't generally engage in advocacy but rather develop their general strategies based on the global data, the collection of which is under their general direction. It was the WHO’s Global TB Programme, for instance, which drafted the current WHO End TB Strategy.
The Stop TB Partnership, on the other hand, currently convenes what is known as ‘civil society’ and actively advocates for the disease worldwide, with the intention of accelerating social and political action in relation to controlling the disease. Stop TB has its own separate funding with which to draw together its own plan as well – this one a more advocacy-focused 'five year plan' which takes us from 2016 until 2020. But Stop TB still has to stick to what the Global TB Programme has put into its post-2015 End TB Strategy so the parameters for their own plan are effectively set for them. They then have the challenge of pitching everything in a way that will keep donor governments interested. It's not a simple situation to be in, and it surely helps a little if the picture isn’t too bleakly painted.
But the truth is that things don’t appear to be exactly all a bed of roses in Geneva, and today co-ordination and coherence seems to be on something of a knife-edge. What’s a little ironic is that the Stop TB Partenership was originally conceived back in 1998 in response to a recognised need to co-ordinate those involved in the prevention and treatment of TB. By 2006 the Partnership had even developed muscle enough to launch its own targets for TB for 2015, which were far more ambitious than those developed for the disease before this by either the UN or the WHO.
Was their 2006 Plan an early sign of the tensions that appear to have developed since? It’s hard to say because everyone is so cautious about what they state on the matter publicly. What’s certain is that until recently the Partnership’s secretariat was hosted by the WHO, but they've now moved out. It’s now hosted by UNOPS, with the Partnership officially recognising that “the Partnership in its current form will be better able to fulfil its mandate by moving its secretariat to … a specialized provider of administrative services.” It carefully added however that, “the decision was fully supported and facilitated by WHO”. What’s clear is that members of the Partnership were previously actively involved in drafting earlier global strategies. It’s not so clear how actively involved they are now.
What's acknowledged on the Partnership’s website, however, is that, “the Partnership draws on WHO's expertise, uses its global data and information as the base for its own advocacy material and coordinates its actions and initiatives closely with WHO.” It’s all very diplomatic stuff, particularly because it refers to what may be the root of the problem – the global data – because everyone who knows anything about TB knows that the numbers bear only a faint reflection of the reality on the ground – most particularly in respect to MDR- and XDR-TB.
And it's the WHO that has to accept the full responsibility for collecting the data from the countries themselves and representing it appropriately.
Without any question at all there’s been a desperate dearth of surveillance data in previous Reports, particularly in respect of drug-resistance, and this is unlikely to be different this year. In the last Report there was a “new analysis” of the extent of drug-resistance and as we have blogged already this analysis was unbelievably flawed. But it’s one thing publishing flawed data, it’s another entirely if you use it to inform global policies for the coming two decades.
And this is why we’re so worried about the content of the impending Report.
What exactly is it going to say about the proportion of drug-resistant disease within the wider pandemic?