Tuberculosis (TB) was long underestimated and addressed as an afterthought despite its impact on the poorest and its staggering economic consequences. Globally, in 2015 alone, 10.4 million people developed TB and 1.8 million people, including the 400,000 suffering from the double burden of TB and HIV, died from the disease. Southern Africa is at the TB epicenter, with 134 cases per 100,000 people reported each year versus a global 86 cases per 100,000 people. In 2015, the WHO began to group countries based on their TB, TB/HIV and multidrug resistant TB (MDRTB) burdens; nearly every Southern African country belongs to one or more of these three groups.
In spite of TB’s stronghold in the Africa region, this year’s World TB Day takes place in an era of new possibilities. The stage, in part, has been set by the milestones of the last few years:
- Five years ago the Southern Africa Heads of States and governments committed to the SADC Declaration on TB in the mining sector;
- Three years ago, the WHO approved the End TB Strategy; and
- A year later the United Nations adopted Sustainable Development Targets.
One third of people who fall ill due to TB each year are not reached with proper screening, detection or treatment due to a combination of demand- and supply-side barriers, including household financial constraints, stigma and health systems weaknesses, such as low access to high quality care.
In response, TB Reach, a multi-lateral funding mechanism primarily supported by Global Affairs Canada, has piloted and documented novel approaches to detect TB and to increase case notification, such as use of mobile clinics, improved systematic screening at health facilities and intensified systematic screening for TB among underserved and vulnerable populations, including People Living With HIV/AIDS, contacts of TB patients and people exposed to silica dust, such as miners.
Another new frontier in TB prevention and care is confronting TB at the household level through demand-side interventions. The combination of TB and poverty can mean delayed access to care, resulting in an increase in infections within immediate households. Social protection programs can begin to address household-level expenditures and other socio-economic consequences of TB through complementary assistance to TB-affected households, such as nutritional support. Combining TB, public health and social protection interventions targeting affected households and individuals has been documented in several LMIC settings to generate powerful results, including improved TB treatment completion rates.
While not a silver bullet, Results- based financing (RBF) mechanisms are another promising option. RBF for health links health sector financing to pre-determined results. RBF works to improve supply-side performance of health systems through tools such as performance-based financing. On the demand side, use of instruments such as conditional cash transfers or nutritional support for households can help promote adherence to treatment and screening for TB.
Looking beyond TB diagnosis and coverage of treatment services in the general population, the Southern Africa TB and Health Systems Support project approved by the World Bank last year focuses on vulnerable groups in (i) mining and peri-mining communities; (ii) high TB burden “hot spots”; (iii) border districts with high levels of movement of people and goods; (iv) transport corridors; (v) labor sending areas; and (vi) areas of high incidence of poverty. The project’s regional approach allows countries to reap economies of scale through harmonized efforts, standardization of key high impact interventions, pooling of resources and specialization in service delivery. The project will strengthen laboratories toward accreditation in partnership with the WHO and the CDC; introduce regional peer review mechanisms; train key health personnel; roll out regional quality assurance and accreditation schemes; and promote centers of excellence.
Each participating country—Malawi, Zambia, Mozambique and Lesotho—has a comparative technical advantage, and each is developing and rolling out a regional center of excellence in the management of TB and occupational lung diseases. While each country’s leadership has prioritized an area unique to its context and public health policy priorities, innovations will serve the broader region.
Malawi is committed to community-based TB management and integrated disease surveillance to reduce time between diagnosis and treatment initiation; and improved patient and health records management toward better treatment outcomes. Key to this vision is eHealth, a mobile phone and tablet-based system that will enhance disease surveillance, monitoring and care.
Zambia will address the disproportionate number of TB and occupational lung disease cases in Zambia’s mining districts. Zambia’s Occupational Health and Safety Institute, established in 1945, will undergo a transforming modernization process to align its service delivery with international best practice. The Institute will shift to cutting edge x-ray and lab equipment and technology for improved screening, diagnosis and monitoring; establish electronic data systems for mining sector records management; link databases with compensation systems to enhance service delivery; and improve surveillance systems among mining and peri-mining communities.
In addition to providing world class services in the management of MDRTB and childhood TB, Mozambique’s center for excellence will train public health professionals in these common regional priority areas: (i) case management; (ii) diagnosis and x-ray reading; (iii) community engagement; and (iv) sentinel surveillance with a focus on resistance to drugs and co-morbidities.
Facing one of the highest TB incidences of TB in the region and a low case detection rate of 49%, Lesotho will roll out mobile digital x-ray outreach services to address geographic barriers in accessing TB prevention and care and to improve efforts to test and enroll patients on treatment. Lesotho will complement this effort by expanding a primary care community-based approach engaging ex-TB patients, ex-miners and community-based health workers to promote TB screening and adherence to treatment. This innovation will be anchored in community dialogue on TB prevention and care and mitigation of stigma.
To push the frontiers in TB prevention and care, we must: sustain policy level attention and support towards the TB response; continue to innovate and experiment with models of TB prevention and care that yield better returns on limited available resources and improve access hard to reach populations; and collaborate to scale up promising innovations and promote platforms for joint learning and actions to address the transboundary aspects of this persisting TB epidemic. We are—we must be—up to this task.