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The Director's Corner

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Where does TB fit in the universal health coverage agenda?

Message from the Executive Director, José Luis Castro

According to the World Health Organization (WHO), at least one half of the world’s population does not have complete access to essential health services, and some 100 million people are forced into extreme poverty in order to pay for healthcare.

Appropriately, the WHO is making a major effort to promote universal health coverage, with the goal to ensure everyone can obtain the care they need, when they need it, wherever they may be.

When you consider that an estimated 36 percent of people with tuberculosis (TB) go without diagnosis or care, or that 90 percent of the children who died from TB last year were untreated, there is no doubt that the principles of universal health coverage go hand-in-hand with any hopes we have of ending TB. 

That’s why as our focus shifts towards a comprehensive and equitable approach to health worldwide, I hope that we can boldly accelerate our progress against TB while remembering the mistakes of our past.

I witnessed the effects of those mistakes first hand when I was working in New York City’s Bureau of TB Control in the early 1990s. At that time, the number of people with TB in the United States had been steadily declining, and so were the specialised health services available to treat them. By the late 1980s, the majority of the TB clinics and hospitals in New York had closed and the decaying infrastructure led to treatment failures and relapses, driving up the number of people developing multidrug-resistant TB (MDR-TB).

Then HIV appeared, and suddenly New York was faced with a growing population of people who were highly susceptible to TB and a health system ill-equipped to manage the outbreak.

This occurrence was not unique to New York. Throughout the world, the vertical approach to TB that had seen great success in high-income countries (but was found to be much less effective in low-income areas) had slowly been disbanded, in favour of better integration of TB activities within the broader health system.

This swing towards integrating TB prevention, diagnosis and treatment into the general health systems in the 1970s and 80s – while as strong in principle as universal health coverage is today – provided a misguided justification for dismantling other specialised functions such as TB training, monitoring and supervision that ensured adequate drug supply or allowed us to evaluate case finding and measure treatment success.

In addition, the integration of services in many cases was not accompanied by increased resources. While some integrated services in immunisations, laboratories and drug logistics were successful, the overall result was a gradual loss of expertise in TB management.

This is one of the reasons New York – and cities and countries worldwide – suddenly found itself scrambling to manage an outbreak of MDR-TB that, frankly, we should have been prepared to handle.

We have ended up swinging like a pendulum between integration and specialisation in tragically disorganised succession since the discovery of the first TB drugs in the 1940s. (This history is explained in greater detail in Drs Raviglione and Pio’s ‘Evolution of WHO policies for tuberculosis control, 1948-2001’.)

There is no question that universal health coverage is the only way to ensure that equitable, person-centred care is available to everyone. TB is exacerbated by many other common health concerns like tobacco and other substance use, diabetes and HIV. Without a health system that addresses TB alongside these interconnected health issues as part of a core package of healthcare services provided in all high burden countries, as well as to high-risk populations in countries with a lower TB burden, we will never succeed in ending TB. Providing people-centred care – meaning TB care offered through a primary health care model – is the way to best serve families and communities affected by TB.

At the same time, we must safeguard – and nurture – the knowledge and experience of our specialised TB programmes so we can monitor our progress, revise our response accordingly, and assure accountability for reaching the targets set at the United Nations High-Level Meeting on TB.

We must be ready for whatever challenges arise. As the threat of antimicrobial resistance grows, it is not difficult to imagine a future in which expertise in dealing with challenges like poor diagnostics, surveillance and ensuring appropriate use of quality-assured antibiotics, among others, will be crucial to tackling the next great health emergency.

This time, let’s get it right.